We're going to talk about some of these options. It's funny how things come full circle every decade or so as you keep reviewing the literature and seeing where we're at with this. So we're going to talk about some of these biologic options, Achilles, Fasciolata, Shoulder Capsule, Lateral Meniscus Allografts, Dermis, Xenograft, Intesina. I've used almost every single one of these except some Xenograft stuff and they're good but not perfect. So when you're looking at these biologic options for young patients, I really like to think about how we're doing these lesions. It matters if it's unipolar or bipolar, but at the end of the day, many of these are bipolar lesions. And when you're looking at these palliative treatments, Brandon really nicely showed arthroscopic debridement, et cetera, maybe there's some incidental findings there. Maybe it's just capsulitis. Maybe it's early arthritis. Deconstructive biologic resurfacing and bipolar lesions, well, we've got small lesions, large lesions, small lesions, maybe we start thinking about microfracture. It's not a bad option. Restorative osteochondral plug transfer, it's there. And then very large is maybe we're doing a chondrocyte implantation. I've done that. We've done certain things, especially on the glenoid with that. And then bulk osteochondral allograft. So the best success with low demand patients, capsule release, glenoid plasmas, T, biceps, everything else we talked about here. But sometimes we're combining this with a microfracture. So that's a biologic option. And arthroscopic debridement plus microfracture is a very viable option. And we have all these microfracturals. I don't particularly like those. I like ones that we have a much smaller drill hole, if you will. And really like, as Tony just pointed out, it's super important. Patients have pain if they have shoulder loss of motion. If you have good shoulder motion, they can still have issues and pain, but getting their motion back is the number one priority in the shoulder. You got to get the motion back and then you can assess everything else. Here's the CAM, the recent one just out of our facility, and it's a bridging procedure. So what happens when that bridging procedure fails? We start talking about reconstructive. And so when you go back to this, here's Mike Worst's paper, 30 patients, age 15 years or younger, with a transplant. And so meniscus allograft transplant, we thought this was a really good option. I put a ton of anchors in here, six, seven, eight anchors all the way around the periphery, a center anchor, lateral meniscus is generally what's been used. Why? It's got much bigger coverage, as we know from the knee. And they actually did okay. But 30% reoperation rate, and this is absolutely a bridging procedure. And what I say to these patients is, you're going to need a tune-up. If we do this and do a biologic resurfacing, you're going to need a tune-up down the road. And that could be three, seven, 10, 12 years. And then let them assess the risk profile. Here's another one looking at Dermalmatrix, and this is from Buzz Burkhead, where he had 55 patients actually did not only the glenoid resurfacing, but also a hemiarthroplasty in many of these patients. And you can see they actually did pretty well in overall satisfaction. Again, joint space matters. Just like in the knee, even though it's a quote-unquote non-weight-bearing joint, many of these patients are actually doing weight-bearing across this joint all the time. They quote-unquote walk on their shoulders. And that's an issue that you have to think about. Here's another study looking at 268 shoulders, and many of these were looking at the systematic review in meniscus allografts, Dermalmatrix, Achilles tendon, shoulder joint capsule, fasciolata. Subjective outcome scores, they did okay. Again, you're going to be about a third needing revisions within a few years, 36% complications. Most of these complications were loss of motion, it wasn't actually nerve or bigger things that we're really worried about. It was really just continued pain, stiffness, and other problems. Looking at this one, humeral head arthroplasty with biologic resurfacing glenoid with an allo-achilles tendon. Biologic resurfacing, rheumatoid arthritis, but you're dealing with a very bad population here. This is kind of a biologic resurfacing, but you can see a very, very tough population. This would generally just be a reverse in most of my hands when you automatically have an inflammatory arthropathy patient. It's automatically a reverse for the most part. But you have some young patients sometimes and otherwise, but you have to be really careful with some of these patients. So what about reparative options? We know from back in our knee days and dog model that these microfracture can help this. And so here you can see these vertical walls that we're trying to obtain. But keep in mind, this cartilage on the humerus is very thin, 1.1 to 1.6 millimeters. It's really thin. The glenoid's about two millimeters. So here's a microfracture. All you can see that this does actually do a reasonable job. Maybe you stop at the line. You might have to go a little bit further, but I actually even use a K-wire these days, another longer wire that's a small one, like a 0.045 to get even deeper. So we're really getting into the marrow elements. We get some of that marrow stimulation going. We do the capsule release. Tony taught me this trick a long time ago, which is doing a capsulectomy. I really like using a basket. You can see the basket here is actually removing about three millimeters of tissue. It's not just using a radiofrequency hook type wand. I don't like those down inferiorly. There are case reports of axillary dysesthesia and axillary burning sensation with radiofrequency wands that are used inferiorly. So be a little bit careful with that. So now we have some other options. These are actually really my workhorses these days, and sometimes combining it with either a dermal patch on the glenoid or lateral meniscus transplant. Patient selection is critical. And just like Mattson's popularized the Riemann run, the patient selection is absolutely critical. And so here we're doing a fresh allograft for high-demand isolated focal defects. We've also done ACI and ACI transplantation, and now MACI with a cartilage sheet. And we actually had some reasonable results with these on the glenoid. And so what about this osteochondral? This is a study out of China. And these were actually frozen osteochondral allografts. So keep that in mind. It's not the fresh. It's overseas. 43% graft resorption rate, which I have not seen using fresh allografts in the shoulder. It's a very high number. But they had some reasonable improvements and statistically significant improvements. Another one looking at 20 patients, OCA was a viable option with isolated humeral chondral injury. I like these headless compression screws. You can see just like they're used for scaphoid fractures. So these are all available now with a headless compression variable pitch, which are really nice. You recess the screws underneath. And I have these in my operating room almost at all times just because of their ubiquitous nature. This is another one where we're really looking at how to reconstruct glenoid defects, but also extrapolate this to glenoid and humeral head arthritis. So we know that the distal tibia fits the glenoid really well. And now the talus, we've really got a bunch of studies now in the literature looking at how the talus nicely fits the humeral head. And so we were looking at bulk allografts. You saw some of those bulk allografts were actually a humeral head that was matched and frozen in that prior study. The problem here in the United States, it's really hard to get a fresh humeral head. Why is that? It's graft donor concerns. It's harvest concerns of the graft companies. You have to understand that if there is a contamination, meaning a level three contamination, clostridium, et cetera, in any of the allografts that are harvested, all 180 musculoskeletal lots or 180 barcodes that come from a donation of life of one body, 180 barcodes. So all of those will be invalidated if there is a positive level three contamination. And when do you get the contamination? If you harvest more center to the body. And so that includes humeral head, it includes pelvis stuff, things like that around the belly, the intestines, the lungs, et cetera. And so part of that has been a business decision from the graft companies. And so we said, and that's how we came up with the distal tibia, is we couldn't get fresh glenoids. We couldn't get fresh humerus. I know many of you out there may have had these on order for a long time. And you said, well, the distal tibia fits really well, let's substitute that. Those are external. They were producing a lot of talus for our colleagues in the foot and ankle world for talus plugs. But we were then able to bring in the concept, well, you got these available within a week and the availability of these grafts is highly available. And now we can steal from the foot and ankle surgeons the talus to use in the shoulder. So it's actually some really good, when you're doing Hill Sachs lesions or mapping of the humerus or flat humerus, you can see that these tailor plugs and the radius of curvature almost matches perfectly. The cartilage thickness differences that we just also submitted for publication is within 0.3 millimeters. So here's just a couple of cases, 24-year-old male, he's a Navy parachuter. He was three years after an instability repair and pain and mechanical symptoms. And here you have to be really cognizant and really watch your x-rays. And certainly this was referred to me, but when you're watching these x-rays, you've got to really watch that right side where you have that inferior osteophyte. You see the arrow there, but you can pick these up quite early if you're really scrutinize a true AP x-ray. And now you're developing a B2 type of glenoid, posterior subluxation about 75%, and pretty significant narrowing of the joint and deformity of the humeral head. And this has sort of a anchor arthropathy picture written all over it. This should not happen in three years. And many of these can happen in six, nine, 12 months. And here you can see the interoperative findings. We're going to do a lot of what Brandon nicely showed in terms of how he managed to start the scopic. We do the biceps tenodesis. You can see the prior anchors. You can see what we call linear stripe wear. And that linear stripe wear is on the humerus. You can see it just above the probe, but it's that linear stripe right there that is the culprit and the start and usually some type of anchor. Now it's extremely hard to comment on where the anchor was left, where it was put. Who knows what happens post-op day zero, post-op day one. I never comment on it because it's really hard, but usually it's some level of culprit. We've seen this even with not arthropathy, which is going down significantly now that we're in a knotless configuration for many of our constructs and labrum repairs. But this linear stripe wear is a real deal. And don't ignore pain after an arthroscopic labrum type of procedure. You've got to be really cognizant of that. And I have a low threshold to put an arthroscope back in. So this is what we did in this young patient who's 25, did an open osteochondral allograft and mostly was on, as you saw, the humerus. Fortunately, even at three years, still was reasonably early and we put two fresh osteochondral plugs from the talus, I'm sorry, this was actually a fresh humeral head, I'm sorry, to here and we were able to put this in. I thought it was just going to be too big, so I did get actually a humeral head. But I think now I would just do talus for this or even off open order to talus to make sure I have enough bone. You can see, you know, the problem is, and, you know, Tony taught me this quite well is, sorry about the blue thing, yeah, he's a good dude. You can see he did, you know, it's not going to be perfect, but you know, he's gotten reasonable. Maybe he's hiking a little bit there and not quite that same total arc of motion there, Brandon, that you're measuring on the baseball players. Not bad, you know, maybe a little bit of difference there. The good news is a lot of pain resolution, but he's going to last six, seven, 10, 12 years and he's going to need something else that Sam Taylor is going to show us. Here's another case and this is just another concept, but this is how well these fit and to get creative in your practice when fixing, this is a female, she's 35, she had a posterior shoulder dislocation, mountain biking in Vail, presents, this is just a little aside, presents in a sling and the problem with this is, this is actually one of the higher litigation things out of the emergency department because it's missed. Why is it missed? Because the patients are very comfortable just sitting here in a sling in internal rotation. The shoulder is really nicely settled right there and so this is what she had, they got the CT scan in the ER while she was still dislocated, got it reduced and the problem with this one is, it's not quite arthritis yet, but the arthritis is coming quickly. Why? Because a reverse heel sacks is all cartilage. I think reverse heel sacks is a terrible name, we've done a ton of work on this, versus a regular heel sacks, heel sacks is mostly bare spot, unless it gets really big, unless there's a certain size to a regular posterior heel sacks, it doesn't get any cartilage. This reverse heel sacks is all cartilage, even if it's a small reverse heel sacks, so I don't think it's a good name because it behaves totally differently, it's a big impaction fracture and it impacts on average about 38 to 45 degrees of the arc of the humerus. And so, you can imagine what we did here, there's other, you know, McLaughlin, you can do tenodesis, the reverse remplissage if you will, but that's been around forever. And so, here's the osseocondal graft that we obtained, which was a fresh talus, and here you can see the procedure. I try to preserve the vessels and only take down the top three centimeters of the subscap, and Tony and I talk about this all the time, you only get so many chances at the patient's subscap, so you've got to be really careful with that, and that's going to come into the discussion in some of the cases, like do you just do the right thing first for the patient and try to give them the most longevity, because that subscap is the real deal. And so, here we're measuring it, we do a saw, you do a burr, you do a rasp, high-speed rasp, a power rasp, but in general this is the shape of an orange slice in your kid's lunch. Here we're doing a little bit of Woodshop 401, I do a lot of 3D printing with this, I have a 3D printer, I'm sorry, I have a 3D printer in my clinic where we actually do 3D printing, and you can also do reverse molds with bone wax, you can put bone wax in this lesion and get a couple packs of bone wax to reverse mold so that you have it on the back table, but in general I'm just kind of going back and forth. This, you can get quite a bit of coverage from a talus, it's about 40 millimeters top to bottom, 38 to 40 is what we found, so you get quite a bit of coverage, you get quite a few large plugs, and the nice thing is the radius of curvature is almost a perfect match, and when you put it all together, you've got these headless compression screws, I'd use anywhere from four to five headless compression screws, recess them about two to three millimeters, the headless compression screws are generally a 3.5 millimeter, I don't use the smallest ones, which are generally 2.0 or 2.5, and then we're going to repair the subscap very meticulously. And so here you can see the reconstructed look, especially on the axillary, it almost looks like a native humerus, there might be a little step off on the front, I don't really worry about, and I shave down the front anyway because that's where the subscap is going to be attaching, and here you can see now at 18 months, you get this really nice consolidation and really no resorption, that's been my experience in allografts around the shoulder, especially the fresh allografts, is just very little resorption, as long as you follow good allograft preparation principles. So in summary, evidence is still lacking, but we continue to revisit these procedures. I do want to make one additional comment, when we had all these pain pump situations, we had quote-unquote chondrolysis, Tony and I would see these patients, it was an epidemic of early arthritis, and it's actually interesting, some of these patients are still presenting 6, 8, now 10 years out, 12 years out, most are not used, and hopefully never used in the United States anymore, these interarticular pain pumps, but it was a really bad situation, and these were the ones where we were really trying to figure that out, but that's a different patient, because it was so inflamed, they didn't have this very quick onset of arthritis, but it was a very rapid dissolution of the cartilage, a very rapid onset of their inflammation, and that's just a different patient, and so we can talk about the chondrolytics, they're kind of mostly gone away, although I just saw one last month in my clinic, she was about 9 years out, and the biologics continue to evolve, but when we did all these biologics for those type of patients, they didn't work that great, and we got to what Sam Tiller is going to teach us about the gold standard for arthroplasty, early wear is a concern, and I tell all my patients again, these are challenging, and it's going to be, you're going to need to tune up at 5, 6, 7, 10, 12 years, depending on where they are, and how this is going to go, but I tell patients, you're going to have to start living your life in those type of increments to try to get some improvement, and then we'll do the next thing. Thank you. Thank you, Matt. Matt, real quickly on the graft coverage of the glenoid, there's been some separation suggesting maybe if you were able to take down the bone spurs, and just put a graft on the glenoid, but no humor replacement, they may work better than doing a hemiorthroplasty with a graft, do you have any experience with that? Yeah, so it's kind of... Just a resurfacing of the glenoid. Yeah, just resurfacing the glenoid, or an open cam procedure, plus resurfacing the glenoid, and you're talking a reaming of the glenoid, or... No, just Burkhart, and some others, Buddy Savoie, others have reported that in the past. Yeah, they've had some good outcomes, and Buddy's had really, really good improvement with his study, and about 90% improvement with that approach, with taking down the cam open, and then doing the glenoid resurfacing. At the end of the day, those patients are good, but the durability is 5, 7, 10, 12 years, so they're good, but it's not the be all, end all. All right, thank you, Matt. Thanks, Tony. All right. Yeah, in terms of what's actually valuable in terms of healthcare economics, they talk about the quality of life years, and typically, for a procedure to really make a difference in terms of avoiding the final treatment, it should be about a 10-year success rate. So if you're getting two to three years, you're probably wasting healthcare dollars, and not really making that patient's overall life better. So that's what we really have to look at, is five to 10-year results, and to really say that this is something that's helpful. So still a lot to learn, and then if we do have a chance to perform these procedures, or they're too far gone, then arthroplasty is the answer.

biologic options

shoulder injuries

arthroscopic debridement

graft coverage

long-term outcomes