I have friends here, enough for stepping up and giving world-class talks, and we're gonna make this interactive a little bit. I have some, I'm the outlier. You know, I'm the guy with the frontal lobe issues and think outside the bun, and JT knows I'm getting in trouble with the boundary thing, but I'm here to tell you what works for me, and full disclosure, honestly, I don't have all the answers, I don't. I'm not pushing any technique here, but I can tell you, in Philadelphia, where not only you get sued BID, it's fiercely competitive, and I have to thank the Lord of Thriving Practice because what I do seems to work. I'm here to share what works for me, and I wanna thank Heather and Nathaniel here because this has been absolutely seamless. You guys rock, man. Hey, you guys are good, man. All right, to know this guy, I still love him. I just can't tell you, I was his mentee, or he's my mentee from ANA, which is a wonderful program. We're starting with AOSSM as well, and those of you who haven't signed on for the mentor program, please do. It's one of the most rewarding experiences you can ever have, and he has taught me so much, as this guy has not only cured my slice this day, but the more I know about this guy, the more I just revere our friendship. There's no finer person, I think, in the cosmos than Colonel Tokish. Honestly, I say that, and I got the rosary in my right pocket, and I'm waiting for the nun to slap me if I lie. So every procedure has pros and cons, so we're trying to crystallize what we heard this morning, and it's individualized treatment, discussed over a patient, but you also think about long-term, and this is what we call in Philadelphia, Peter Arthur, and Arthur's got a brother named Ritus, right? So we can debate, till the cows come home, whether L'Atelier, I'm trying to talk like Christian Gerber, causes Arthur, and it's hard, because mostly people have had dislocation arthropathy when they get to your office, but I do think there's something to be content with. So when in doubt, I believe, and this is just the frontal lobe, out of bounds take, least invasive option, and do what best restores anatomy. So, restore the labor bumper, we're gonna talk about that, shift the capsule, address the whole sex, I'm already feeling guilt, because JT's gonna say, sir, the capsule doesn't matter, sir, it's a bony procedure, sir. Whenever he calls me sir, I get nervous, because he's gonna call me out again, but address the glenoid bone. So, we don't talk about this much, but there was some studies done in the University of Washington that increasing labile depth up to two millimeters increases 50% stability ratio. This is real data, you know, the recitals, and Doug Harriman, God rest his soul, talking about labroplasty, I do this whenever I can. Increasing labile width does matter, and Bob Burks, who was a mentor to me as well, with Pat Grace, showed that if you take out the labrum, you increase contact pressure. This is one of my pleas against the open bank cart, because we don't restore the bumper as well. I do a lot of hip arthroscopy, and you know, the suction seal's important in the hip. Labrum was given to us by God for a reason, and it does significantly diminish contact pressure in the joint. And the suction seal, I had a great talk with Ben Kibler yesterday, and the concavity compression of the shoulder is very, very important. And the only way you can get concavity compression is with a good bumper, all right? And I believe, and Decker gives me a hard time with this, that I'm not a big knotless fan, full disclosure, because I do think then this fellow named Hagstrom did this wonderful study with Ty Lee, by the way, that the best bumper is a horizontal mattress. I learned this from Buddy. And when you do an open bank cart, you nuke the bumper, and I think the horizontal mattress is, and Buddy taught me this, is the tool in my hands I use the most. And there's several papers showing that labral height matters, and that the lower the labrum post-op serial MRs, the higher the recurrence rate. So I think the highest bumper wins. And this is something that I learned from Greg Bain, who is an absolute genius. He's almost as smart as JT, but the inferior labrum is a fixed organ of compression, and it edge loads. And the superior labrum, we talk about the thrower's talk sometime later, but it's mobile. But the inferior labrum is a fixed organ of compression. And you need to have that ledge, that edge, as you see here. Look how anterior that labrum sits. So we have to restore that edge. And I think we can talk about the capsule we want, but people say, well, I do an open banker because I can take care of the capsule better. Me, in my humble hands, I can shift the capsule much better with a scope. Johnny Sakia years ago told me, he's a Navy guy, by the way, if I'm not happy, take more tucks. I just take more tucks. Instead of guesstimating in the open. And that poster band, the IG shell is very important. Ben Kielbo taught me this. So that's the front, the back, if the poster band's lax, the circle concept is important. I know this is soft tissue, JT, but it does matter. So let's talk about what I see are options for hill sex. Peter mentioned allograft, it's open bank cart, which really works because it makes you stiff, in my humble opinion. You can leave it alone if it's small, if it's a very lateral. Hemicap, I don't think so, a young person. And remplisage. And I think that open bank cart, and JT, we're friends, but we can open up the discussion here. I think it works because of scar. I think that, and this is Burkhardt's paper. It prevents engagement because it restricts extronotation. So that's my take. And Arthur moves in when you restrict extronotation. This is a tokish open bank cart two years out. So as my brother lawyer would say, no further questions. We talked about the glenoid track. It is important, but it's not my end all be all. But again, I'll repeat what Peter Mill had found, that you can enlarge the glenoid track with latrage, but sometimes that coracoid, as JP Warner would say, process, he says process to sound cool. It's coracoid process, JP, okay? You can enlarge it with a latrage, but sometimes the coracoid is not big enough. And whether you do congruent arc or pate, it's dealer's choice. I think congruent arc gives you a little more bone, but it's thin and it gives me the heebie-jeebies because I can crack those screws. So here's an example on the far right where the coracoid process is just too small. What are you gonna do? Address the anatomy. So you get these big honkers like this, Colonel and Major, and you gotta do something. And the replosage, again, JT mentioned some of those lesions are very low, and I gotta tell you, JT, I don't do every lesion, especially if I have a big bridge of articular cartilage, I'm not gonna sacrifice that. So I do microfracture. It's maybe a sissy way of treating it, but I do do something to that lesion. So they engage because they happen, whether it's in lower abduction or high. And this was taught to me. This is not my technique. Eugene Wolf, who is a very, very avant-garde surgeon, and it prevents humeral head engagement. But as JT mentioned, it also pulls the head posteriorly. I asked a question the other day in the session. I asked Albert Lin from Pittsburgh, who knows more about this than I ever will. So why does a replosage prevent apprehension in an on-track lesion? And he says, because it just pulls the head back. Makes sense. So it does pull the head back, and for that reason, it's physiologic, unlike the dog smoking. The allograft, as most of us would take down the subscap, I'm not as good as Bob Rossiero, where you can do it through an infraspinatus split, but that's a big hit to the shoulder. And it does pull the head back. And it makes the bancard easier. Geoff Ravens taught me a nice little trick. When I do a replosage first, I hold the strings, and I can actually pull the head back further, which makes my bancard even easier. Anybody know Italian? Capisce? How am I doing Han so far? Okay, so I prepare the labrum first. I do a replosage before the bancard. Eugene Wolf taught me this, it's not me. I put my anchors through the posterior portal, I retrieve through a seven o'clock portal. And the reason I do that is because I wanna get tendon. I don't wanna do a musculodesis, I wanna do a tenodesis. And there's literature that knotless is better than double pulley. And I repair the labrum first, looking for the front, work from the front. But this is Grant Garcia, what a brilliant medical student we had at Penn years ago who became on Rush, HSS, and his career's taken off in Seattle. And he taught me this, that the safe zone is lateral. And if you're gonna go posterior, you better go at least three centimeters to get tendon, so you don't get a musculodesis. This is very important work. So I think that, again, they all engage, and whether or not, if it's a big cartilage bridge, I don't do it, I just do a microfracture and say, hey, I'll marry you. But I think preparing is very important, very important. A microfracture, and I make sure I get a crit. And one of my pearls that Matt Ramsey taught me, I use a little dye on my punch. And I just, for those of you starting to do this, I use regular knots, but the colonel taught me to do it knotless, which I do now. And make sure you retrieve widely. You don't need four sutures, just do two. But I retrieve the seven o'clock portal, and I now use a penetrator versus this flimsy device. And retrieve wide, and I threw this portal, Wilmington, roughly, is where I end up retrieving this. And it's very important when you do this to have your resident or your fellow push the head back as you tie, very, very important. And it just pulls the head back. And we did some early MRI studies. It does turn into fibro, fibrous tissue, and they're hoping that maybe some metaplastic changes occur. Maybe it becomes fibrocartilage. I don't know the answer to that. I applied for a grant, got rejected, but I think they'll get that long-term visualization of these. I think there's some metaplasia that does occur in time. That's what it looks like. So, then I do a vancart, and I get a nice bumper. And the colonel, I've been adding a subscapularis buttress effect, and people are really, really unstable, as taught by others. So, JT taught me this, and this is his way. And I do it a little differently, JT. I know you put it through the post-lateral portal. I tend to put the anchors through the posterior portal and retrieve the knotless. Okay, this is JT's knotless technique, which is wonderful, folks. As he said, it makes it easier. And I'm a little lazy. I don't look in the subacromial space. Peter, I just tie it blindly, lathe. I don't, and the second anchor here. You can comment, JT, anything I'm missing here. What it avoids is having to do any passing. So, you never have to go into the subacromial space. You never have to pass a suture. It's frighteningly easy. So, this is just it on a bone model where we're demonstrating it, and then you pull out the slack. You simply put one anchor through a direct percutaneous portal, you do another one, and you flip it into the other anchor, and you're done in five minutes. Scary easy. So, we're gonna take the gloves off here. So, JT, who's really been a mentor to me, and Jimmy Shea, he did this study, which we all quoted, we all know about. But they didn't do remplissage. This was just a regular Vanguard. So, critical mass, 13.5%. No remplissage. But Travis lived this too. This was Marcus Scheibel. It depends on the geometry. So, not all bone loss is equal. And what he found was that the edge, the leading edge is the most important part of this. So, if you have a flatter glenoid, bone loss matters less. So, not everybody's the same. So, bone loss matters more in some individuals than others. But the edge is the most important part. Once you lose that edge, you lost a lot. So, the Latrage, it is the gold steering in my hands. I'm doing one now on Tuesday, because it failed my procedure. You gotta, you know, one to hold them, one to fold them. But look at all these origins of muscles. It's not a free ride. Cogabriela, C. eleva, pec minor, short of the biceps. And I end up nuking the capsule. I'm not as good as these guys. I had to take a lot of capsules, get exposure. And Ian Hurley, Ireland's favorite son, did a great study. 38% arthritic changes. Some of that could be cuff, you know, instability, arthropathy, it's hard to say. But MAP prevention, this is a small study. 100% of ZNFL candidates who had no Latrage had Arthur on their x-ray. So, there's no free rides. There's, in addition to neurologic, we talk about, you know, the resorption. Ivan Wong, who's an absolute genius, too, does the distal to the allograft. JT did that for a while, I know. And he's gone to the clavicle for good reason, because you get long-term resorption. And Joe Torgut always tell me, we don't know about disease X. What's disease X? We don't know it yet. We don't know what we're putting in that patient's body. I love that, disease X. But here's where I'm getting outside the bun here. I still do this, because Peter, or Sagaia Peter, did this study years ago about how, if we fix a bony back heart under compression, it hypertrophies. I think we sort of lost this brilliant idea. And he looked at post-CT, five years out, small bony back heart, and under compression, Wolfie's Law, had hypertrophy. So I took this idea, and I just, for the last three or four years of doing this, I've been taking some cancellous bone at the time of my remplisage, and I'd like to hear what Peter thinks of this. And then I deliver it under the glenoid. So here he is, I just take an OATS plug through a standard post-treatment portal. I gotta get at least 20 millimeters in length. And then I'll put my remplisage anchor into that hole, which recesses it further. You get a little better feel, by the way. And then I'll just take, and there is the completed recessed remplisage. And I prepared the, remember, I prepared the labrum first. And I'll deliver this OATS plug. And then I'll just tap it into place, JT. And I think, since you're smarter than me, you can figure out a way, maybe, to deliver this with a knotless, perhaps. But I just tuck it underneath, using Sagaia's principle. And then I just cover it over, under compression, with anchors. And there's the finished product. And this is not snake oil. I've done this in people that, again, I get in the OR and like, and then I add this subscap capsulodesis, which has been described by a few authors at this point, for the really unstable. And this is just, JT on a golf course goes, do you have any post-op CTs, sir? And I said, no, I don't. I really don't. I have clinical data, but I don't have much imaging. But I think we can talk about rhombosage literature, as Peter and Denard and others have shown. Some studies show 7%, seven-fold higher complication rate with LaTorge. And Ian Hurley, in another wonderful systemic review, 0.5% complication rhombosage, 8.6% with LaTorge. And young girl, Ree, he's one of the most honest people in the cosmos. In his own series, he had a 14.3% complications with LaTorge and rhombosage 0%. Now there's only about maybe 13% bone loss, not really big players, but the recurrence rate was the same in both groups. So again, there's this factor X. I don't know what it is, but some of these people with larger bone loss do quite well and some don't. And I don't know whether it's glenomorphology or maybe it's the seating. So what I do, and this is, you're gonna run me out of town here, JT, but I'll take up the 30%, if they have a bony fragment. Because I believe in SIGAI's work. I repair the under tension. And if they don't, I add a little bit of a Father Kelly homeopathic seating. But one thing I wanted to share with the audience is that Alex Lee is a wonderful med student. He looked at our patients and said, if you add rhombosage, the critical doesn't become so critical. Now, I'm not proud of this, that the overall recurrence was 9%, but the critical bone loss with rhombosage, we had just as much recurrence in over 13.5%. Now we did not do OC scores, we did pen shoulder score and ASC scores. So I think adding rhombosage in some ways nullifies that bone loss effect. And then in 77 cases over two year follow up, I've had one revision rhombosage, one letter J and one revision elsewhere. So I'm hanging in there. So again, this is my take. Horizontal mattress capture with rhombosage, glenoid grafting, I do the seed grafting now, more readily in 20%. So, Colonel, what would you want for your loved ones? I know you have some very treasured children. This or the Decker open bank card? Would you want this or the Decker open letter J? This is the coracoid harvest here. So Heather, there should be some sound, but that's okay. So let's go to some, and these guys are my brothers, and I just can't tell you how happy I am they agreed to do this. So before we get to questions, I want to do a couple of questions, make this interactive for the audience. And I just love these guys to death. So please don't take anything personally, okay? All right, my disclosures. 18-year-old scoped bank card for recurrence stability, and he was sent to me by a very good surgeon. And I don't have any CINI MRIs, but I have this. Oh, I do have one. Okay. Anything grab you on that there, Travis? He was done by a very, very good surgeon in town. How about the coronal? Anything grab you? Heavy hint, look at that capsule. It didn't see that the hillsex was addressed in the initial procedure? It wasn't. Anything you see about the capsule kernel? Yeah, I mean, he's got a little, maybe even a little hagel down there, down below. That's right, and you know, usually we see that little like flop sign, it's there, right there. And you know, it's easily missed. So don't forget the hagel lesion. And so what are you gonna do next? You wanna do an open bank card with this a la Decker? You wanna use the captain's frozen tibia, JT? Do you wanna get a train ticket to Phoenix? I love that smirky. Or do you wanna call Father Kelly? There's a Father Kelly, he's a singer, by the way. I looked up a picture of Father Kelly, and there he is. So JT, as always, you're on the mark. This is the deck open back part again, just to. So what do we do here, JT? How do you approach the Hegel lesion? Do you open? And by the way, don't get confused with the terminology, because, you know, and it's been described since 1942. And Bach, Bernie Bach, of all people, described it further. You can have a floating glenoid or a floating capsule. You can have it on both sides of the joint. Larry Field described that. And it can occur after a successful bankrupt, which was happened here. So what do you want to do, Colonel? You know, it's a chip shot open. It is. Yeah, I think it's a wonderful thing. If you do open surgery for this, this is a great procedure. You don't even need to take down the tendon, so it's a subscap sparing. Go right below the three sisters, take down the muscle, and you're staring at it. Which is awesome. And it'll allow you to go to the six o'clock position and even posterior. So the challenge with these arthroscopically is if it's three to five, no problem. It's not a very difficult procedure to do. And if it's on the backside, seven to nine, no problem as well. But that six o'clock anchors a bear and can be tough to get into. So for me, I want to know how far it extends around. I'll take some time looking at the sagittal images. But if it goes to that six o'clock place like that one might, then I might just open him up. So Travis, after three Hail Marys, two Our Fathers, and Peter, I didn't consent him for an open procedure late. I just did the five o'clock portal and hit the hill sacks. And he also had a bank card with that. It was a floating capsule. So I addressed this. And there it is. There's it pulled off the bone right there. And in my experience, audience, you don't need a lot of anchors. Usually one anchor low works for me. So I did the bank card first in the front, which might have been not a good idea. But I figured, I'm there. I'll do that. Then I'll pull this other capsule up. You did the bank card first? Yes, sir. So the challenge with that, I think, is that if you do the bank card first. I know, but I did assess the tension. At least, I think I did, because I got it back. Then I did a rump massage. I just think it makes it hard. I know, but I'm getting old. I like challenges. You're just that good. I love it. No, no, I'm not that good. You do a percutaneous anchor right here, excuse me. Then you use one of these retrievers outside the cannula. And then it becomes just pulling back, almost like a rump massage, and you tie it. And thank the Lord. Literally, this person did very well. But beware of the missed haggle. This was a very good surgeon in town. So I just want to get you guys your money's worth. So let's do rabbit fire. This is a 48-year-old who dislocated their shoulder. Major Decker. And look at this. Look at that labrum. Have you ever seen that before? What's going on there? And this woman had a locked shoulder. Couldn't have abduct. Could you go a little faster through the MRI screen? Yeah, I just wanted to wake people up here. Travis, look at that labrum. What do you think? Have you seen that before, son? I have not seen that before, but bucketed. It's like a bucketed labrum. She had limited, she had like 0 to 30 abduction. So JT, you're going to open this? You're going to end up in a big, big Hilsaki virus? Yeah, 48-year-old female is going to get stiff. If I open, I'll go to great lengths to try to do this arthroscopically. Well, this is what it looked like inside the joint. Literally, Travis, you're absolutely right. Bucket-handled tear of the labrum. It was a chalk block. And once I reduced this, and thank God in my favor, I don't think I covered this fully, but she was 48, lower demand. Got to reduce it. And the teachable moment here is really use the 7 o'clock portal and the trans subscapular. This is low, low. And I'm sure JT's taught me this at one point, but I think it was Tony Romeo years ago as a young guy taught me the value of the 7 o'clock portal. And you really can get down low as you want. You can shuttle the sutures in the front. But to me, this is how you get low with a 7 o'clock portal. And for the anterior inferior, I go trans. This is my needle through this trans subscap. So I think the teachable moment here is like lateral cube gives you a wonderful access. 7 o'clock inferiorly, trans subscap for, of course, Rachel Frank, the brilliant, showed that trans subscap didn't matter. But I think in this case, I just figured it was a better thing to do. And she did very well. I did the labor repair. I think just reducing the chalk block on her. But have you seen that before, JT? It's the first time I've seen that. Yeah, I mean, sometimes you'll get those that'll wrap all the way around and bucket up into it. I think those are much easier arthroscopically. So that's a good one. Peter had a question. Question about the 7 o'clock portal. I love that anchor that Tony Romeo taught me as well. Do you ever do that plus a rampassage? I worry a little bit about stiffness when you're doing both of those. Good question. If I see postural laxity, maybe it's because I'm getting older, and then the words of Jamesh, hey, just sometimes run out of gas. I don't, if I do rampassage, because rampassage, to me, is sort of like a poster inferior buttress. It's a very good question. If I have a poster label tear, I will address it, a Kim lesion. I'll do that, and then do rampassage. But for poster capsule laxity, I feel rampassage addresses that. So it's a wonderful question. JT and Major Decker, any comments on Peter's question? I don't think it's the same operation. I wonder where the actual sort of sweet spot lies. I think that when we do rampassage, it's generally up at that 9 o'clock to 12 o'clock position. And when we do the posterior inferior anchor, it's down at 7 o'clock. So I don't know of a biomechanical study that compares them. Peter, you guys could do it. I'd love to do it. But I think it's an unanswered question about when we should, which is better, what conditions matter. I think that's an unanswered deal. Rapid fire. Let's go to the treatment of the first time dislocator. So Travis, this is a 22-year-old low-demand medical student coming to my office with this big Hill Sachs lesion here, but no glenoid bone loss. And first-time dislocator. So what's your thought process, Travis, at this point? Low demand. Her hobbies are basket weaving and studying biochemistry. In her examination? Good question. She did have appreciable apprehension, appreciable. How long ago was the dislocation? As every car kernel, it was maybe two months ago. But Travis is on the mark, as usual. So were you going to rehab, scope anchor at Remplissage, or are you going to go to a Latourget, Travis? You want to tell her to take up backgammon, which she already does. I think she's 22. I think I just talked to her about her risk of at least redislocation. If she wants to attempt rehab, but at least let her know that she's still at her age, relatively high risk of redislocation. But I'd be doing this. She had a relatively, she had a moderate-sized Hill Sachs lesion, so if I was going to be doing the procedure, it'd be at Banker Remplissage. She actually played right into JT's brilliant paper. She did not like this position. I'm seeing another all-star, Jim Gehr, who's taught me a lot. Thanks, Jim, for coming. Did not like this position. She said, you know, Doc, I just, I can't do this. So I was, I didn't drink the Kool-Aid for years, because I had wonderful mentors, Ray Moyer Temple. I virtually never operated on a first-time dislocator. And Buddy would say, we operate on disability, not instability. And all that was in my mind. But she didn't like this position. So she's a first-time dislocator that I operated on. And don't forget the man scan, woman scan, as Travis indicated, especially in Loutre, if you have someone with apprehension and Loutre's abduction, they need an operation. And they need to have the bone addressed. So I used to examine a lot. I've covered enough sideline games where, you know, I've had kids sublux and maybe dislocate, quickly reduce. And three weeks later, they come in your office, and you're cranking the heck out of their arm. And they have minimal bone loss. I let those kids play. And guess what? I've been blessed. A couple of them have had zero, a few. Most of them do have issues, but they're able to return back to season. So Bushnell, as Travis mentioned, is more reliable, the apprehension, lower abduction than the x-ray. So she had minimal glenoid bone loss, large, large hill sacks. Colonel, even in a young female, would you consider Loutre here? No, I don't think so, I mean, especially low-demand like this. I think this is the perfect case for a Benkert rump massage. And thank the Lord it was. It's big. It's huge. Huge. I had to get that low. Huge. So Rachel Frank also showed us that if you do these cases, and I'm not dissing beach chair preventability, look at the recurrence rate, much lower in Loutre cubitus. So that's meaningful data. So I prepared the labrum first, as I showed you earlier. And I did the rank on rump massage. And she did very, very well. So no further questions, Your Honor. Can you stay categorical? You are fake news. I'm sorry, I had to put this for JT. Sir, can you stay categorical? Fake news. Volume, Heather. You, Travis, you got a gift. You got a gift, my friend. You got a gift. He does, guys. Don't forget that name, Travis Decker. He's going to be running every organization in about 10 years. And last, this is a 22-year-old colonel, former slap repair. Now, Arthur came and made a visit. We see that. But look at that, Hill Sacks. How many people in the audience have seen Second Opinions and had a slap repair, and they have huge instability? Right, Lathe, have you seen that? And again, this is why I'm a horizontal mattress fan. One proud suture can trash your shoulder, believe it or not. But JT, look what we got here. Have you seen this one, kid? This is kind of a Haggle hybrid. High Haggle. High Haggle. So Travis, what do you think? I mean, you're in how many years of practice? Four. Four. Are you going to tackle this arthroscopically? Are you going to get the Lathe Jesuari Hotline? What are you going to do? I'd definitely use the Hotline, for sure. But you're doing it arthroscopically. I called you, so I'm probably going to do this over. Call JT like I would, but what's next? Full mobilization of the capsule. JT, what do you think here, buddy? I'm still a little confused. Is that subscap that we're staring off into the interval there? Yes, sir. And the biceps is on your left there? That's just capsule on my left. We're not seeing the biceps, Colonel. OK, so you're lower than that, then. I think it depends on how mobile that tissue is. Can you bring it back up to the humerus? In which case, I think you're fine to do it arthroscopically. If you can't, there's a number of options you can do with this. If you've got deficient capsule in the front, one would be a Lathe Jesuari, of course. One would be a DAS, or a Dynamic Anterior Stabilization, where we take the long head of the biceps, put it through the subscap, and then fix it down there as well. And then, as you demonstrated earlier, Mayotte's technique, where you do a subscap tenobesis would be an option here, too. OK, so I'm a thick-headed Irishman that I am. And don't forget, it was worse with benching it. I get a little comedic relief here. I decided to incorporate that into my anchor. And I was able to close, fix the bumper with, and close the interval. I did a couple side-by-side. And I did my subscap tenobesis, as well, with a Remplissage. And again, thank the Lord, this patient did quite well. So I was able to address that with incorporating my sutures. And I think I'm going to stop here, but this wonderful panel, I'm sure you have a couple of questions here for JT and Travis. And please take all the time. We'll hang out, get to be somewhere, Colonel? Not till now. OK. Questions for our distinguished panel? And some people in the room are lost for me. Leif, Jim Guerra. On that case, addressing the biceps as a source of this pain, JT brought up, by doing that dynamic sling, it's almost like it's essentially a tenobesis as a pain generator. Any thoughts on creating more instability, getting rid of the biceps? Well, you're talking to the wrong guy, because I am not a biceps killer. And I've been blessed to work with Ty Lee. And he's got a recent study coming out showing, and it was actually Josh Stein's paper showing an increased poster instability. And Ty Lee and a guy named McGarry, a woman named McGarry, showed that it really does help center the head. So the biceps, I think, is underappreciated. It's an unsung hero. I'm not a biceps killer. I think it's like a meniscus. We take it out, we feel better. Long term, it may not be so good. So I'm not a biceps killer. I would defer to these geniuses here. But I don't like these slings and harvesting the biceps. Craig Wharton called the biceps the ACL of the shoulder. So I'm not a big biceps killer. That's my point. But JT is going to. Ty Lee has a new study coming out. Just stay tuned. Another question there, sir? Yeah, good morning. Thank you. Can you guys just comment on the remplisage? I think, JT, you showed that only 60% of them with remplisage went back to sports. Do you know why that is? Mostly because they have pain. It takes away the instability for sure. It takes away apprehension in most cases. But Neurasat showed one third of his patients still had pain. Even John's data shows that those patients still would not return to sport, mostly because of posterior pain. So why is that the thing? I think we're still learning about that. But you change the cuff dynamics for sure. And we say, oh, John's got a brilliant paper with Garcia that talks about the safe zone where you're going to put it through the tendon. But in truth, that only works in the lab because you're going to put the tendon into the heel sacs lesion, which means that you don't get to determine where the heel sacs is repaired. The heel sacs gets to determine where the heel sacs is repaired. So it's awesome if you can go three centimeters in one and avoid the muscle and all that stuff. And that's only if you get to design where the heel sacs lesion is. But unfortunately, we don't. So you're going to put it across from wherever it is. And by the way, that depends on whether your arm is here, or here, or here. And so that leaves you even less sort of variability. And I think if we capture that cuff, I think it becomes a real problem. It's funny you mentioned that theoretically, you should lose internal rotation if you're doing an infraspinatus tenodesis. Now, us, maybe it does stretch out. We have not seen any depreciable motion deficits. But it's been described in literature, loss of external. But when you think about it. Stretch out might be a euphemism for fail. But hey, you know, I mean, what could it be? Yeah, it's like a seroma, right, for infection? So again, I don't have all the answers. But we have not had stiffness as an issue, I think. But for the overhead athlete, that was an issue. They just couldn't. They were stiff for that. Other questions? Actually, I had a question for along the return to sport line. So Denard's study recently, 90% return to sport. Sure. Is that just because he's technically brilliant? No. I mean, this is not a difficult operation. So he's not doing anything. I mean, Pat is a beautiful surgeon. But it has nothing to do with the, this is not, you know, microsurgery. It's a remplissage. So the reason his paper, if you take a look at it, why their patients got back at 90%, is this is a very broad population of people that when getting back to sport was, hey, did you get back to sport? And if I'm playing recreational basketball a couple nights a week or whatever, you know, that's not your population. Right? You're not talking about cadets that have to pass a test in order to get their college degree. You're talking about people that are playing rec league soccer. And they got back to sport. So it's not a fair option. But his arthroscopy article did talk that contact athletes come back equivalent. Sure. So the contact athlete, though, again, you got to define what that contact athlete means, right? And I mean, we showed non-operative management got back at 89%. Non-operative management, so if you do nothing, they get back at 90% of the time if they're high schoolers. I have a question for JT, because Jim Garrett and I, who's a fantastic surgeon in Naples, Florida, JT, why haven't you tried knotless technology and going anti-grade for your bone block? Why does it have to be transglenoid? Yeah. So the problem with knotless is you've got to go bicortical. Right? So if you put the knotless anchor into, if you come from the front, what you can do with knotless technology, you either have to leave it in cancellous bone, so put it in the glenoid. And then you're going to be pulling down that bone block. And you're trying to get compression across it. And unfortunately, that'll pull out of cancellous bone. So the best way to do it, and you can do it, is that you can drill it all the way across and go bicortical to the back. The problem is if you're even 15 degrees off, which is very easy to do, then you're heading right at the suprascapular nerve. And so you can get lucky and do it. We've done it in the lab a bunch. And most of the time, you miss, but not always. So eventually, we'll get to a place where you can just dot it from the front, and we don't even have to drill from the back. Exactly. Because I use the, to do hip arthroscopy, I use the knotless. I guess it's harder bone in the acetabulum, because it's worked very well for me. Well, but you're not putting bone graft into that thing. So if you're fixing labrums down, sure, no problem. But if you're trying to get a bone block to heal, and one of the things, you know Ivan Wong's data shows that screws have worked better for him than the soft tissue sort of fixation. And we believe part of that is that we haven't gotten to a point yet where we can tension or compress that bone block enough. And if you do that with soft tissue anchors, and you pull it, it fails at about 80 newtons. 80 newtons ain't enough to give us the compression that we need. Jim Geer, have you done some work at the Arthrex lab? Did you try that? And what's your experience? In the lab, you had the same issue. You really can't control the anchors with the screws.

shoulder stabilizations

surgeon

labrum repair

glenoid bone loss

remplissage

Hill-Sachs lesions

biceps tendon