Good, the mic's working. So I want to say thanks to AOSSM and Anna. What an amazing packed house here. It's great to be back and doing this in person. So I do have disclosures that are listed. So I think what we're all hearing here through all the various presentations here is, you know, this kind of key first point. Instability patients are prone to instability. And so when you're thinking about how you're going to manage these patients in your practice, I think the number one goal, and we need to always remember this, is this patient's coming to you to get their shoulder stabilized. And so when this surgery's done or when you're done treating them, they need to walk out of there with a shoulder that's going to be stable. So kind of keep that in mind as you're approaching your patients. And so when I see patients with shoulder instability, I think these two questions. Who's the patient we're treating? And what do they have? And I think the key is to really understand both to a large degree. And so what does the patient do? What are their inherent risks? And then really understanding the pathology allows you to kind of work down an algorithm to get to the right spot. We've talked about this as a three-dimensional on-track, off-track problem. And then we also know that as we've looked more and more into kind of the role of bone loss, that really kind of the kind of historical 20% number is probably not going to be adequate in these higher risk patients. So looking at this as a spectrum, I'm going to show kind of down the line, increasingly difficult problems and kind of how I like to manage them, how I look at them in my practice at this point. So here's a case, a 19-year-old, this is a college football player, had a primary dislocation. This is what Dr. Taylor was talking about, the first time dislocator. Came to surgery at the end of the season. You can see the imaging here. Really not much in the way of bone loss in this patient. Here's how it looked in the surgery. So this is a patient, standard arthroscopic stabilization in my practice. I think you do need to understand that this is a three-dimensional problem. This is a high-risk patient based on the football component. Understand the circle concept. Consider doing something posteriorly to kind of reinforce and give you a little bit more protection on your repair. But this is the arthroscopic patient. Multiple sutures, really try to stabilize them. What about this guy? Slightly worsening circumstance, subcritical bone loss. This is somebody who had an anterior dislocation during spring ball. You can see the x-rays don't look all that concerning, but the MRI is starting to make you wonder, is this something we need to be more cautious with? CT even pushes you further down that line. Small bone fleck. Some subcritical bone loss, but certainly bone loss in this patient that's relevant. So you have some options here. Do you do a standard scope repair? This may be a great option, or a patient for the option you just saw, an open Bankart arthroscopic relatable repair and a REM plissage in the back, or a glenoid bony procedure. Here's what we see when we get in, and scope is joint. So maybe a little bit worse bone loss than we thought. So this is a patient where I treat with a glenoid-based bony procedure. Standard Laterge through a subscap split. Here you can see his post-op x-rays. Similar circumstance, but this patient had a prior stabilization prior to coming into college. And so same position, same age. Some kind of postage stamp type characteristics here. You can see some prior anchors that have been placed. This is a patient where you have the same kind of menu of options. And you can see, again, when you scope it, the bone loss may be a little bit more worrisome than what you thought going in. So again, great opportunity for a glenoid-based bony procedure. What about this guy? So this is a 25-year-old, really, really high risk. So these rodeo cowboy patients, they're going to be somebody where you got to do whatever you can to get them stable. And so you can see here on his x-rays some clear evidence of some bony problem already. You got a bipolar problem. This guy's off track. Some pretty substantial glenoid bone loss. Get into the joint, and he actively engages while you're scoping the shoulder. So a real big problem for this really problematic patient. So here in my practice, this is somebody where I consider converting to a congruent arc type procedure. And you'll hear a research presentation on that coming up. But this extends the glenoid further. It allows you to actually increase the arc. And in a high risk patient like this, may be a really good option to try to correct the bony problem and address some of the soft tissue issues with the conjoint tendon over the subscap. How about this? Maybe not quite as high risk. This is a 28-year-old anesthesia resident, but has had a number of instability events and has just been kind of lax on getting it looked at. MRI shows a labral tear. Not the most concerning appearance, but then you scope the joint, and lo and behold, this guy also engages when you're seeing him. And so you can see not only is there increased glenoid side involvement, but the humerus is a problem in this guy as well. So this is a great option in my practice to use a combined arthroscopic labral repair and add a remplissage. And a remplissage is a procedure that I found myself using more and more as, you know, kind of year to year. Because it's a great option to help you with kind of a belt and suspenders approach in somebody where you think their bone loss is going to be something that's going to cause a problem. What do you do when you've tried a glenoid bony procedure and it fails? This is one of my own patients where he went on to a non-union after a Latter Jay procedure. And so it's a college football linebacker. So what do you do with this patient? Well here's where you start to think about other bony options and where the fresh osteochondral distal tibial graft really can become a really useful adjunct. And so there's some great instrumentation to use this at this point. You can create a wedge that fits your bone defect perfectly. Here's what it looks like arthroscopically when you're done and with a CT scan to verify healing. You'll see there's a number of new techniques on how to fix this being presented here in this symposium, but a great option to have in your toolbox either for large bone loss or for prior failed Latter Jay procedures. And you can see there's great data out there on this operation. What about the massive patients? So this guy is really high risk, both glenoid and humeral-sided bone loss. So here I like to add a REM plissage to a bony procedure. So you can see here with that. So REM plissage first, followed by a distal tibia, and here you go. And then to stay on time, I'll show you this case example was a failed prior procedure. So sometimes a subscap can go in an open procedure. So sometimes you'll add some soft tissue allograft to try to deal with that complication if you haven't. So finally, be wary of bone loss. It's there, even if it's not initially evident. You want to think algorithmically when you treat these patients. Know not only what the problem is, but who it's in. Know your patient. And remember, the ultimate goal is to stabilize the shoulder, and so more is oftentimes better. Thank you very much. Great. Thank you.

shoulder instability

bone loss

treatment options

arthroscopic stabilization

remplissage procedure