You guys, great presentations. I'm completely confused about which way to go now. So. No, you're not. No, I'm not. Actually, I'm not. Dr. Murthy, with a very large portal, accomplished exactly what he wanted to do. One thing that was a little concerning listening to both of you, though, is that although the absence of recurrent instability was obvious, the return to play rate was lower than one would expect, especially in the throwing athlete. Does that concern you in this situation? Would either one of you have contemplated treating this non-operatively initially? Ana? Yeah, I mean, this is obviously a first-time dislocator. I think it was his non-dominant arm, too. That's not non-dominant. It was his dominant. You know, if he's really gonna play in college, I think you wanna push him to get it repaired, but if he wasn't, he was a younger or weekend warrior kind of player, I might have tried non-op there, too. Entering his senior year, mom says he's gifted. Need the money, need the scholarship. Mary, what are you gonna do? You gonna ruin this kid's chances? I mean, it's a difficult situation for sure. We have lots of evidence in the literature now, I think, to support operating on a first-time dislocator, although I think just in general, we don't always pull the trigger after the first time, but we certainly have good evidence. In throwing athletes in a pitcher, definitely a little bit more of a complicated situation, but I agree, I do agree with Dr. Murthy here in that sense that just given his aspirations, like, that it would try, like, he's having these issues and that it would move forward with operative intervention. Feel free, if anybody has questions, to jump in, please just step up and to the mic there. Guillermo, what are your thoughts? Good question. If they operate on all the first-time dislocation that played baseball and the dominant arm, or they have some issue with the MRI, look into the labrum, look into the capsule, or some decision-making criteria for operate on or not in this scenario? For first-time dislocators? Yeah. I mean, I think they always, at that point, have come in with an MRI, especially if it's displaced hill sacks, that's gonna be engaging. I would, you know, we can push people to what we think they need, and those kind of patients, I would push towards doing it the first time, at the first dislocation. They're reticent, if they're not gonna play in college, you have to put kind of their goals along with what anatomical problem they have as well, like the surgery surgery, especially if it's on your kid, so I put all that into the basket before I make that decision, but they usually have come with some type of imaging at that point. Yeah, I agree, take all those things into account, have a very in-depth discussion with the patient and their family so that they understand the injury, they also understand the natural history, and then we make a decision together. And at the end of the talk with the patient, you say, without the operation, your recurrence rate is perhaps 100% basically. 100%, basically. And with my operation, how much is it? Mary can go first, Mary can go first. You need to give the mother of the player two numbers. Yeah, I mean, it's much lower, 8%, 9%, like, but there's still a risk, right? We can't make it zero, but it's a much, much lower risk from 100%, you know, dropping that way down. Yeah, I would just tell them that arthroscopic Vanguard is lower than open Vanguard, purely with recurrence. I didn't say return to play. Because arthroscopic Vanguard is the way in this 17-year-old picture. Nah. Yeah. Can I ask a question? Alan, do you have an answer? No, I don't have an answer. I'll know the answer. How many people in the audience have done an open stabilization in the last year? Non-Latter-Jay. Oh, look at that, dropped down. See, it's pretty low, it's pretty low. How many people trained when they were residents saw an open stabilization? Interesting. Thank you. Not terribly common, though. How about post-op, what are you gonna do? How long are they in the sling? When do you allow them to be touched by a physical therapist, Anna? With open, they're in a sling for six weeks to protect the subscap. They start their motion at three weeks, getting all their flexibility back, and then once that's back out of the sling at six, and begins isometrics and then strengthening. Amir? For the arthroscopic Vanguard repair in a sling for four weeks, I have them start doing very basic things at home, like about 10 days after surgery, just like shoulder shrugs, scapular retraction, and then physical therapy starts at four weeks. And when do you let them start playing? I tell them around four months. I mean, it's also gonna be based on their progression. Rhino? Same, it's different that it's not a true contact sport, but I want their strength to be equal. I usually have their therapist do some measurements in the office of making sure that they're equal in strength and that their motion's back. Awesome job, any other questions? Dr. Kelly, this is your baby, you're a baseball nut. What would you do? Come on, John. I need a minute to sober up. That'll take more than a minute. I really think that if you do a, yeah, thank you. I resent that remark. I think that you just holistically approach a thrower. You don't make them too tight, you restore the bumper. You do less is more on the cuff, but I do think it's very hard to throw a game with an unstable shoulder. So if you fix it anatomically, and as we say in Philly, don't make them too tight, you'll be all right. Arthroscopic or open? Arthroscopic, 100%. Oh my God, there's a vote. And please, do not cut the biceps in a thrower. That's my last plea. There you go. All right, so we're gonna do some voting there. Who made their case? Unfortunately, non-op is not one of the options. Let's vote. Dominated. Women, domination. Oh, it's coming up and down. Do it one more time, do it one more time. How many times can I hit this? How many times can I hit this? Oh, just one, okay. Oh, there we go. Looks like the stock market for me last week. On the scope side, yeah. All right. I'm surprised I even got near 20. It was really close. The deck was stacked. Mary squeaked it out. Yeah, the Republicans wanna recount. Okay. Thanks guys. Thank you very much. Congratulations, Mary. Congratulations.

shoulder dislocation

young athlete

operative approach

non-operative approach

arthroscopic repair