But I'll go ahead and kick us off. So my name's Adam Yanke. I'm at Rush University in Chicago, Illinois, and I'm excited to be part of the first installment of the Anna Industry Learning Vault series. This is a webinar series that's new to Anna that is sponsored by different industry partners to try to help engage learning for surgeons both in the U.S. and abroad. It's great to see that tonight we have almost 20 percent of our attendees are from outside of the U.S. with interest in allograft. So we're excited to have a great crew here, and thanks to JRF for sponsoring the first of these. These are going to be available online on the Anna website that's going to be revamped and will be available tomorrow. And so these are going to happen approximately once every two weeks or so, and there's a few others already scheduled, including another one by JRF as well, the use of allograft throughout sports medicine and starting a practice. And then there's another one coming up on investments and investment-based webinar to be very helpful as well. So we're excited that Anna put this together, and thanks again to JRF for being part of this first one. As we go through this, please put any questions that you have in the chat. I think Matt put that already in the chat, but there'll be an active Q&A component to this. And so if you have questions as Dr. ProVenture is talking, I'm happy to help field them and we'll bring them up, or I'll cover them at the end depending on the relevance to what we're going through at the time. If we have some time, there's potentially some cases at the end as well. So without further ado, I'd like to introduce Dr. Matt ProVenture. Captain ProVenture is a mentor, a friend, and colleague now at this point. And I've been lucky to know him for the last 20 years or so. He's been in practice in 20 years, both in the civilian and in the military side of things, working with the Navy SEALs. He's been ranked consistently one of the top surgeons in the country and has had the opportunity to work with high-profile teams and is now a clinician at the Stedman-Philippon Research Institute and does both research and clinical care and really is a clinician scientist. He's also the Assistant Editor-in-Chief for the Arthroscopy Journal and has published over 250 articles and many textbooks. So we're very lucky to have Dr. ProVenture here, and he's going to be talking with us about the use of allografts about the shoulder. So thanks very much, Matt. Adam, thank you. Yeah, two kind of an introduction. Really appreciate it. It's been a great, great journey we've been on in this orthopedic world. It's amazing. And I, first of all, want to thank Anna for putting this on, because a great series to help us connect all of our surgeons and patients to help with our patient care and help with excellence in our patient care. And I think that's certainly what Anna is all about. And I also want to thank JRF, David Wilkie, and Keith Byers, among others, for helping sponsor this, but also helping take this journey with us. And we can't do it alone. We can't do it without our industry sponsors to help us innovate and develop things. So with that, I'm going to share screen and kind of kick this off. Yeah, feel free to put some of the stuff in the chat. And Adam, please just interrupt me. So we're going to talk about shoulder tonight, and shoulder and how we've really extrapolated the use of grafts and tell a story in terms of how we came to this. But one of the things we realized a long time ago was the glenoid doesn't take a joke. And if you have some amount of bone loss, and it doesn't have to be much, you could have four millimeters, six millimeters, of course, this is more of an egregious example, but you can see maybe about eight, nine, 10 millimeters in this patient from the bare spot. And you can see the significant inability of that shoulder joint to remain contained. So it's not just the glenoid, it's a bipolar problem. And our critical size, and JT Tokish, we've researched this, Craig Batani, so many others have helped us understand this, including the glenoid tract, that you really start after thinking about bone grafts, in my opinion, we're now at about 10 to 15%, because that's about four, five, six millimeters, depending on the size of the patient. Keep in mind that every 1.5 millimeters is about 5%. So if you have three millimeters of bone loss, that's about 10%, four and a half, five millimeters of bone loss, that's 12, 15%. So it adds up really quick. We know that stabilizations and failures are much higher if you have this bone loss situation. Well, you can definitely predict bone loss from just doing a good orthopedic history and a good examination. And that's the beauty of orthopedics, is we're able to tailor that to the patient and not just be only radiologists about it, although we use our radiology colleagues extensively to help us understand this better, and we're getting much better at modeling this in terms of how to really look at these bone defects. But the biggest thing is it just starts in clinic. And you can predict if they have bone loss by this instability in mid-abduction. This patient is unstable right there. He did not need much abduction. We don't need much external rotation. And if they have ease of recurrence, it now dislocates in my sleep, it dislocates when I put my head over my pillow, it dislocates when I sneeze. It's not like they have a psychiatric issue. It's because they have significant loss of the static stabilizers of the shoulder, which in general is the bone. So how do we best address this? Well, x-ray we thought was superior, but now we got much better with them. Our orthogram helped us a lot. You can see here how nicely an orthogram can help us look at the differential. But really when we're looking at things, it's the CT scan, the three-dimensional CT scan with the humeral head digitally subtracted, which you have to ask for. And that inferior two-thirds of the glenoid is well-conserved circling. You can see here's more of an acute type of fracture that was actually a postage stamp fracture. You can see some of the anchors positions there on the left side, but on the right side, you can see this patient had been coming out for four or five years, four years plus of instability events. That's more than half the glenoid missing. That's a pretty significant attritional bone loss situation. So as we add this up, it adds up quickly. We do this millimeter kind of quick look at this in clinic, but as we're kind of studying it, we do our publications on it. We really look at the surface area model for this to see how this looks. And we know that, again, from history, it predominates. If you have more instability events, guess what? You've got four times increased chance of having more bone loss. And the issue is more instability, more duration of symptoms, and younger age. So it's not just age. Near and row were absolutely correct. Young age is a problem. But now there are many other factors, and that's now been explored quite well, looking at chronicity being more than three months, multiple instability events, probably more than two or three. Well, what else happens with instability? And this is some of the things maybe we can solve with a cartilage graft. And to put the JRF spin on this a little bit, we do get a lot of other things. We get more off-track lesions. We get more GLAD lesions. We probably get more arthritis. And that's been pretty well borne out in the literature that more instability events leads to more arthritis. It's just like the knee. More instability of the knee leads to more arthritis, more meniscus tears. It's the same concept. And we know very clearly, and this is now very well in the literature, we've published a ton on this among others, some really good stuff, that more recurrence, more instability events, longer time of instability, guess what? You're going to have more bone loss, more heel sacks, and you're going to have basically what we found here in R. This is a group of about 250 CT scans. They had acute injury, less than 5%. They had this nice bone fragment. Maybe you could figure out a way to put that back and arthroscopically fix that. Most of it was in this attritional range, which is in the middle. That's generally where they had two to seven episodes. And if they had more than 10 episodes, they were in this attritional range. That was a pretty big number as well. So one of the things we did, and the Latter Jay is great. The Iliac crest was great. And you have to understand, back in the 2000s, we were looking, the early 2000s, late 90s, early 2000s, bone loss was a very new concept. So this is still evolving. And one of the things we asked was, how do we treat this better? We have Iliac crest, but the best article on that was JP Warner's with 11 patients in AJSM, 11 total patients with the Iliac crest. There was a military medicine one that had 15 patients. We're talking less than 30 patients in the entire literature treated with Iliac crest autograft for bone defects. Good graft, autograft does well, a lot of donor site morbidity. And actually the story goes back to a great friend of mine, John Sakia, who was in the Navy with me. He was at Michigan. He's retired now, but he and I started on this journey to ask for, let's reconstruct the anatomy. And so we asked our graft companies, let's try to reconstruct anatomy. Guess what? A humerus with a humerus and a glenoid with a glenoid. Well, one of the things that was very hard to get was a fresh glenoid. The issue with that was there is a higher contamination rate when you start harvesting body parts from the cadaver and you get a higher contamination rate. You have a just much harder ability to harvest this. And it sort of changes the equation for our graft harvesting or graft procurement agencies, which are in all these major cities to obtain allografts that we use every day in orthopedics from bone, tendon, bone, to semi-tealografts, to TibAnts, to cancellous chips. All of that is obtained from our donor agencies and then processed by companies like JRF. So we had a really hard time getting fresh glenoids. We had a really hard time getting fresh humerus. And so one of the questions he asked, well, what don't you use? And a friend of mine who at the time, before JRF was even started, had worked for Allosaurus, which was the fresh company at the time, but now is all run by JRF. But a really good friend of mine, he was with me in a case and I said, I need a different graft. And he said, well, let's start thinking outside the box. And so we did. And we started thinking about using the distal tibia, very nice, dense corticocancellous bone, really good, nice cartilage. And I said, well, maybe that'll fit the humerus on some level. And you can see that, you know, from our picture here and great credit to Lance LeClair and Jimmy Bailey for this when they were my residents. This is literally in 2006 or 2007, maybe, as we were starting to study this, that this is an unmatched humerus and distal tibia. And you can see sort of a law of nature now that we now have well investigated, it's been investigated, that radius of curvature is preserved up to a certain amount across all of our joints. And so we really liked this initially to start. We did a lot of studies on it. No donor morbidity, could really think restore the mechanics of the glenoid, could restore, at least initially, we thought these large defects, things we were doing iliac crest for, or we didn't think a Latter Jay could be enough for. And then we did a lot of initial just biomechanical testing, cartilage thickness testing, cartilage viability testing, the physiology of the cartilage. It actually was very similar to the glenoid, almost statistically, or I don't think even clinically different. And these are the options we have. They work really good overall. But we think that some of the, you know, now the evolving indications for me, certainly youngerish patients with almost 10, 12 percent bone loss. We do we do know that equation. And maybe adding rhombosogen is the answer that those results are more encouraging, of course, and helping to resonate a little bit better in the literature. But I'm now starting to use this more and more and use this more orthoscopically to use this even mini open because I do see so much utility in being able to reconstruct the anatomy. Certainly a failed situation, postage stamp fracture, attritional bone loss, other situations. These are my main indications. And I'm going to take you through a little bit of the steps here in terms of how we do it. But it's really the ability to understand what's going on preoperatively. A lot of times I'll use 3-D models to see how the bone integrates. You can see this is after a failed Latergé. You can see the two screw holes in the front of a prior piece. You can see that the coracoid there is very short in this model. This is actually a patient that had a failed Latergé and we're looking at revising it and kind of demonstrating where that humerus comes down anteriorly and inferiorly, where it was this patient was subluxing anteriorly and inferiorly, actually over the coracoid graft or just inferior to it. So sometimes, you know, just a 20, 22, 3 millimeter graft is not enough from the coracoid, but the coracoid still remains a very good graft. I just think this one provides a really nice option without any of the non-anatomic issues, the ability to really reconstruct the joint well. And this is how we basically do this for glenoid reconstruction. And this is a patient that had numerous instability events and traumatic dislocation. You can actually see the patient's 45, super young for me. MRI had about a pretty significant amount of bone loss, had some attritional fragment here, a larger fragment. Certainly an argument can be made to maybe fix that, maybe put that back. But when we measured it, it's certainly quite a bit of, you know, attritional loss there, but the interface maybe could fix this. But at the end of the day, we opted for a distal tibial holograph to reconstruct the joint, just given the severity of the bone injury. We basically take this down through a delta pectoral approach, what I'm showing there with the ruler, back up just a little bit. What the ruler is, that is the top of the rolled edge right there at the top of the ruler. And it's right about three centimeters, two and a half to three centimeters down. So we split it two thirds, one third, or something like this. It's three fifths, two fifths actually. The three fifths from the top is where we put it. You see, I love a needle tip bovie. We're just gently dissecting through. You can also use a knife here where you can finish that up. And then we use a deep galpy. I put this deep galpy medially. And what you see usually is the capsule that's there. And you can see up here in the upper left, that's the L-shaped capsulotomy that we make. I then love just using blunt dissection. A cob is really nice down here to be able to elevate up the fragment or any small bone fragments. We then increase the size of the cob. We use a high speed burr and rasp. You can also use mechanical rasp, which I generally use. But keep in mind, this bone is super hard. Now, this is a set from Arthrex that partnered with JRF to help develop this. And full disclosure, I did help develop this. So if these things come loose a little bit, I apologize. You just have to keep tightening them at times as you're kind of sawing and drilling through here. But it is a nice way to be able to reproduce a very reliable graph. The way we designed this was with three different, well, really six different sizing blocks, 7 millimeters and 10 millimeters of surface reconstruction. And then we also did 5, 10, and 15 degree angle. Why do we do 5, 10, 15 degree angle? Because we wanted to restore the concavity of the shoulder joint. We just don't want a top to bottom match, which we get questions of. But we also want the ability to create that anterior concavity of the shoulder. And you can see here, you can get 23 millimeters or an 18 millimeter, 18 millimeter for a smaller patient. I almost never use that. I'm almost always using the 23. But you can also slide this thing left and right or just do a freehand cut if you want a bigger bone. And you can just template that on CT scan ahead of time. We then do a generous pulse lavage. If you have PRP, you can soak it in that as well. We don't have any evidence that shows that's any better in holographs, maybe. But I try to do it if we can. And I don't charge a patient anything for it. I just try to do it as a value add, try to get as best healing as possible. You can do two of these ahead of time. You can also use commercially available fingers and inserters. And in general, I use two solid screws. This is a suture washer that has a suture integrated. And you can see how the suture slides around the washer. I really like that to be able to help repair the capsule in the front or any labrum tissue. And you can see how that suture washer has a suture integrated. I really like that thing to be able to tie down the capsule. And I use two solid 4.0 millimeter screws. You can use cannulated. And here you can see the nice conformity match. We angled this one up about 10 degrees to get some anterior. And you can see really nicely how this comes together at the end. And then at the end, all you have to do is repair the capsule. Oh, I didn't show that part, unfortunately, but capsule and then the subscap, subscap repair. This is the overall outcomes of this we looked at very closely and really wanted to scrutinize this with CT scans when I helped sort of start with this. And John Sakia was certainly a partner in crime on this with me at the initial start, we got CT scans. And we were both in the Navy, we were able to get some pretty good CT scans, usually around four to six months or so, and even up to multiple years. Now we follow these patients out multiple years. And what we really started commenting on was the interface healing rate. The bone maintained a very good density. We felt that these actual images were probably the gold standard to be able to show us how things were healing. Not all were perfect. We did have what we call a little bit of allograft lysis. I'm a little concerned about the term lysis. We throw it around quite a bit, but keep in mind that a coracoid, this is your own coracoid in a Latter Jay, Giovanni Di Giacomo has shown us that 59.5% of the coracoid undergoes lysis still with good outcomes. So we're dealing with something that has 40% of the bone left. So we know on some level, there's some kind of remodeling going on. So we have to be careful about that. So we really talked about the allograft healing rate and we call this 90%, meaning there might have been an on average up to 10% of the graph just wasn't fully integrated. Maybe we found that to be just like Giovanni did most most deep and also most superior. So more medial and more superior was the area where he didn't always see 100% of the healing rate. But we kind of scrutinize those CT scans to make sure we were getting we were getting good healing over the first six, eight years of this procedure. And in fact, I was deployed several times. The Navy stopped the procedure for a while and just continued to collect our outcomes. And here's another one where you can see that massive bone loss and able to reconstruct that. And so I really think the restoration of the anatomy is key. You can see this if I scrutinize myself a little bit, I'd like to have that maybe two millimeters superior. And that would be something something a little bit better. You can see you're right here. I mean, one, maybe two millimeters superior. But in general, that's how bone loss happens is this line that's almost parallel to the long axis of the glenoid from 12 to six. And that's what we're reconstructing. But a patient like this does excellent because we've taken care of the instability issue, which is from that four to six o'clock position or six o'clock to eight o'clock position. Well, we then started going on a path of, OK, we've got this for not just primaries or big or big defects, but primaries. But what about some of these failed procedure? And we thought that there would be certainly some the story here, certainly some aspect of the story that we see all the time, a scope that's failed, a latter day for whatever reason that's failed, pulled off bone graft, the conjoint pulls off, et cetera. These are either my patients or patients sent to me. The hardware issue, if you look at that picture, please do not use partially threaded screws. These are the ones that I see bend the most often. So if you're going to use screws, please do a solid full thread screw. You can use cannulated, not a huge problem. Just make sure it's big enough diameter, probably 3.75 or above, but please make sure that threads are a full thread. So we basically looked at a lot of these patients. You can see here a failed Latter-J with screws. These cases can be very hard. We found a ton of graft resorption, actually more than Giovanni DiGiacomo did. We found 78% of the graft was resorbed based on what was taken from the coracoids. We based our CT scan analysis on that. And we said, look, I think the DTA could be good for revision. We had traditionally done this, the Eden Hibernate, the Iliac Crest, and overall we found some really good outcomes. It wasn't 100% perfect, and we're dealing with a tough situation, but there was not a lot of literature until this article, a few handful of case series of some Iliac Crest, handful here and there, but this was 30 plus patients. Now we have hundreds of patients treated with this quote-unquote failed Latter-J for a variety of reasons now with distal tibia, and the outcomes have been actually really good. This was the original study, and now we've got a few others that are in submission right now, now with over a hundred patients, but 31 patients, all of these happened to be male. Mean bone loss was 30%, so it was a lot of bone loss. They probably had more, because once that coracoid pulls off, you get more bone loss because the humerus is just rubbing against it. So we didn't have any cases of recurrence. I actually want to retract that. We've had one now. They actually showed up about eight years later for whatever reason, but the tibia graft did well, and I actually just went back and did an arthroscopic repair of the labrum and capsule, and the patient did great, and it was awesome to have the video of the tibia. The cartilage on the tibia was actually better than the native glenoid, as you can imagine from someone that had a lot of instability events. There's a lot of glad lesions and other things. So we conclude this is an excellent option for revision. Again, not 100% perfect, but then we also started delving into posterior, and how we can put this graft in posteriorly. Again, dense corticocancellus. This is really where I started my arthroscopic journey with this, and now I do a lot of these arthroscopic and arthroscopic assisted after we learned how to do this open well. And now we're not even just using screws, but now also buttons and cerclage with the keys there, I think, really making sure that we're tensioning it to at least 60 to 80 newtons. You can see here a very big defect, about 35, 40%, and you can see these screws here. These are fully threaded cannulated, as I'm sure you can see. So I do use cannulated posteriorly, and this actually works pretty well. You can see how the humerus, and this patient did excellent after a very challenging situation. Last thing I want to cover, and we can certainly do some questions, is the hill sacs. And this has been a conundrum. We've had a hard time sort of classifying it, diagnosing it. We've really started working on some better three-dimensional grading scales of this, really to make it easy, how medial it is, the angle of the hill sacs, some of these other things. I don't want to bore you too, too much with that, but when it looks bad, it's probably bad, and you probably need to do something about that. And what we've found is the traditional and the reverse are much different. We'll show some examples of that. The traditional doesn't involve cartilage unless it gets really big. It's there, the traditional hill sacs, almost 90, 100% of the time, even if it's a small scuffing. And the reverse hill sacs can be there in posterior dislocations. But the problem with the reverse hill sacs, I think it's a bad term. I think we should get rid of it because it's all cartilage. It's a completely different animal, a completely different lesion because it's all cartilage. And so we need a cartilage and bone solution for both of these, because if you're thinking about doing a regular hill sacs, it's usually big enough that now the cartilage is involved, and you're thinking about doing a reverse hill sacs, that's 100% cartilage. And we know that combined defect, I did this with Gus Mazzocca or Ciaro, myself, and many others. I took 144 CT scans of patients. I had kind of created a 50% bone loss model of the humerus and glenoid, and then plus or minus a couple of standard deviations and did a lot of mechanical testing on that to see what we could reproduce in a bipolar model with 3D printed models that exactly reproduced the bony lesions. And you can see at four millimeters of bone loss of the glenoid, plus just an average run of the middle hill sacs, we could never get stability back. Now, this was done a long time ago. Remplissage was not even really popularized by Gene Wolfe and others at that point. So we wanted to go back and relook at this, but at the end of the day, you're thinking the mechanics are really altered when you've got this four millimeter lesion plus a hill sacs and these bipolar issues. Guess what? Just like glenoid bone loss, there's more hill sacs, deeper hill sacs with more instability events and much higher recurrence if you have this hill sacs that's especially medialized. But lastly, what about these treatment algorithms and what to do? Well, when you got Giovanni's done some really nice work and great pictures and videos on this, this is a bipolar problem. We got to think about this together. This is the future. We got to do better on this. We're getting there, but the glenoid track has helped us, but keep in mind, this is a cadaveric model that designed this, that tested it. Yamamoto and Itoi did an amazing job on this, but it still is reasonably clinically validated. Now with some near track stuff and some other things, we did a study in 2013, looking at the clinical application of this and actually found that it was pretty good. We can actually predict success and failure when looking at our glenoid track. And that has been born true in the literature overall. It's a little tricky to measure and whether you're doing it on CT, MRI, but basically if you have less than Giovanni and put this out in Itoi, and this is pretty reasonable. These numbers are continuing to evolve and 25% bone loss I think is a little bit much, but if you're basically less than 25% and on track arthroscopic, maybe a REM plasage, off track, probably got to do some more for sure. Because what if you're at 22% and you're off track and you've got a big ill sex? Now that for me is probably a bone graft to be honest at this point, but this is a study that's now about eight years old and then 25% bone loss on track, later J and off track. Now you're thinking about other bone graft type of options. So at least a framework, but I would caution you that these 25% numbers are an evolving concept just like the title. And these numbers for me are now in the 10 to 15% range based on JTs and other work. So when you're looking at the Bankart, the recurrence rate with REM plasage goes down. It's a good procedure, no question. Later J recurrence rate, it's actually when you really distill down the literature, it's not perfect. And if you're looking at arthroscopic Bankart, 19.5%. So this is a pretty significant systematic review out of your institution Adam. And I think it's bears out the same numbers basically in my practice. So we wanna do better than 19.5%. I wanna get that down to three, four, 5%. So I said, how do we do the humeral head better? It's very hard to get a fresh humerus, same reasons why. What else can we use? So again, if the distal tibia fits the glenoid, maybe the talus fits the humerus. And it actually does quite well. We did a bunch of studies looking at this and the talus again, very nice cortical cancellous bone. I wanna thank Steve Parada and his colleagues. We've been on this journey a lot together among many others. It's a very viable for humeral head and bipolar bone loss and up to about 40 millimeters of graft is pretty good. We've done a lot of computer modeling on this now in terms of where we put this and how we find out what the best way is to reconstruct this. But at the end of the day, you can probably get about 40 millimeters of articular cartilage length reconstruction when you're doing this. So kind of keep that number in mind. We've now really started looking, how do you do this easier? Do we always need to put in a lemon wedge or an orange slice, which we'll show you? But now we're really starting to look at computer modeling, which is what we first started with to be able to look at filling this hillsacks with cylinders. And we were able to find out that off-track lesions are easily able to convert to on-track hillsacks in a usual size was anywhere around eight, 10, maybe a 12 millimeter bone clog depending on the size. So it's really been my go-to humeral head graft, a combination of these plugs, as you'll see here, the Muse 3D CT scan, started this cadaver model again, and you can see how these plugs, you don't have to think perfectly reconstruct the whole hillsacks defect because as long as it rolls over it, it's almost like a cattle guard gate or a drain cover that's got holes in it. You don't really need to have everything completely covered because the humerus just needs to glide over and you can keep some areas free. So you don't have to do the, you can do a snowman technique, not necessarily the MasterCard technique where you have to integrate the plugs into one another to get perfect coverage. You think you need enough just to fill the defects. So this is really where the future is. We've done a lot of work on this with these plugs and getting the augmentation really helped us restore the congruity of the shoulder from a, not just a testing standpoint, but also a mechanical standpoint. Well, what else are we working on? The distal tibia has been great, but now we have the subtalar area and the subtalar joint. We have the talus, but is there a way we can not only just use the talus, but also the subtalar joint? And it's amazing how, again, the subtalar joint is very well, very well approximated to the glenoid, especially the bottom two thirds, which is the area we are obviously interested about. And we found there's a subtalar joint on the left, almost looks like a glenoid, and there's the reconstruction on the right. There's a little, the distal tibia is probably a little bit better for longer defects above 22, three millimeters we found, but can be another viable option. And we've done this clinically in patients as well, very super dense corticocancellus and really good cartilage basis to be able to reconstruct this. So some new horizons with subtalar joint. And then, you know, those of you putting your thinking caps on in the webinar, like, okay, that's pretty cool. I can maybe get one bone graft for the humerus and one bone graft in the subtalar joint. We think that's going to be pretty close. We don't know if we're going to be able to use both on, meaning we use just the talus for both the humerus and the glenoid, because just harvesting that graft can be an issue. And these are a lot of our studies that we start with mechanically and then tested and put this through the robot and really help test this, not just with tech scan, but also mechanical data. So Adam, I've got a few cases, but happy to entertain some questions. Thanks, Matt. There are some questions, some from the attendees, and I have a few for you because I can always learn from you as well. First one, I think, is just a good question, a nuts and bolts question about, just clarify again, is this fresh or frozen tissue? Because I think some people get confused. You didn't use the term, but some people say fresh frozen, which is an oxymoron. And if you could just talk about that as well as your process of getting them availability, scheduling, insurance approval, and that pathway. Yep. So, yeah, I apologize if I wasn't clear on this because I think this is important. I have used fresh the whole time. And I know, let me just stop this. I know that Ivan Wong in Canada, his bone bank is actually at his hospital and he has frozen distal tibias. Now he's gone through a journey where he did screw fixation, then button and suture fixation, and back to screw fixation. But his screw fixation, CTs, his numbers, I've looked at them, have been very good on the frozen graft. I have been reluctant as of yet to go down that path, but just for what we've had and the results we've had and the healing rate we've had has just been so good. But we've got other pioneers in this field now, like Ivan Wong and Albert Lin and many others who are now testing the waters using even different grafts and certainly frozen grafts, which have, again, shown good efficacy. I have used fresh the whole time. How hard is it to get in a private practice setting? It's easy, very easy. You know, David's here and he can certainly answer some of those questions, but I found it very easy. The beautiful thing is, you know, we can't get glenoids. It'd be on order for nine months, a year, and problematic. I can get a fresh glenoid in a week or two, you know, almost, well, faster than I can get to the surgical schedule. So they're very available from distal tibia. The talus is the same way. I can usually get these in a few weeks. David, I don't want to throw you under the bus on this type of stuff and then, you know, weeks and others, but in general, that's been the time. I mean, if there's a little bit of a lull or, you know, a certain time of year or season can be maybe a little bit longer, but we're dealing with weeks. This is not a months type thing. And usually it's faster than you can, the graft availability is faster, I've found, than you can usually get them on the surgery schedule. Yeah, I think you should remember that you're not, you know, you're not in isolation. So companies like JRF and other allograft companies are there to help you with the process too. So if you have questions about what you need to do, do you need sizing x-rays? What type of information you need to send? And in this setting, you don't, but for some other allografts, obviously you do. So in this case, and Matt, you can correct me if you do something different, but most people don't order a specific size for a patient based off any preoperative imaging. So you don't have to worry about that component as much. And I think most of us will typically schedule these cases out for maybe a month from when we see them in the office with a hope that, you know, we will have the graft and insurance approval leading up to that time. But again, you know, in this setting, obviously JRF would be happy to help interface with you at your specific location, find out the success people have had at your institution, or if not at other institutions they've worked with. Yeah, I think the biggest thing is telling JRF that the window for surgery on my availability and the patient's availability is this. And if you can give them that, they work their hardest to accommodate that window. So it's not, it's really not JRF's window I found. I found the same thing in the knee. You can give JRF a window of, hey, I need this knee thermal condyle, whatever, ME condyle or fresh plugs or whatever else, or I need this tibia or talus, this will tibia or talus during this window. I mean, as long as it's not in the next few days, they will do their best to accommodate. They like the window, they know when the patient will be available, they know when you're going to be available and they know when you can accept the graft. So that's what I found to be the key. And so my team's got that pretty dialed in in terms of this patient's ready for surgery anytime after X, or this is a great window for this patient. Yeah, and then in the chat, David confirmed that, he said, don't worry about the timing, they can get these quickly. And I think, Matt, that's one of the best parts of the, there's lots of great aspects to the DTA, but the ankle, luckily when this tissue is harvested, is just not as arthritic prone as the knee and other parts of the body. So luckily it's pretty resistant, which maybe helps the grafts too. Less, yeah, there's less waste for sure, I think on JRF's end, because you're not getting rid of the grafts due to cartilage blemishes or other things. I mean, they're as strict as they can about it. I mean, you still obviously want to respect the gift of human life and we have to be certainly super respectful about that. But at the end of the day, I have really not had any tibia with a cartilage injury that I can remember, maybe one tiny scuff, but it was way over near the medial malleolus where I wasn't even going to take the graft anyway. The other thing is I just do male to male, female to female, but I don't even know if that's necessary with Steve Parada's recent work, but I've just done male to male, female to female. And that's it. That's my only ask for sizing. Yeah, that's an interesting- How sure are you with that? Yeah, we tried to look at that in osteochondral allografts in the knee and there's one paper in the knee that says that it matters and we did another paper that shows that it doesn't. So I think the jury's still out on that one, at least in the knee. But I think it's a point that we still have to look at because we want to stop resorption and if resorption has anything to do with the host seeing the donor as foreign, then that's obviously something that we want to minimize. And some of that has to do with prepping the cancellous component with either a high pressure CO2 or with a pulse lavage irrigation, or like you said, maybe the addition of a biologic, which at least doesn't have any level one studies in the shoulder yet at this point. Matt, to the kind of the points of having an articular surface, fresh versus frozen, we have autograft, allografts, there really are a lot of different options. If we just distill it down to, if you're going to use a graft, it would be a distal tibial allograft and if you're not, you're going to use a coracoid for a latter shape. Do you put both of those intraarticular and what do you do specifically at that interface that's different between those two to help people understand that maybe used to Latter-J but not distal tibia? Yeah, this is evolving. And if you talk to Hawk back in the day, this is the hardest part of the Latter-J is managing capsule, managing how you do this, the CA ligament off the coracoid, what do you do with that CA ligament? Do you dye into it? Do you not? Do you use those suture washers? Do you use anchors? Do you make it extra articular? There are a lot of ways to do this. I don't think we've number one, solved the right way. My anecdotal concerns are if you posteriorize the capsule too much, I think that's a problem. Meaning, okay, I put a bone graft, now I made it 100% extra articular because I put some now anchors at the interface. Depending on the amount of bone loss, I can bring that, drag that capsule pretty far posteriorly. Now maybe you've got enough length on it and the labrum's going there, but I generally don't see that per se. So I worry about posterizing the capsule too much. I generally make, the coracoid for me is a partial articular graft because I work it around the CA ligament. And our studies have shown the CA ligament kind of, it doesn't come off at the top of the coracoids, it kind of blends in the middle or there's maybe about a third or half the bones sort of exposed. But we want a smooth bone interface and I don't hesitate burying down a coracoid if there's any prominent bone to make that super smooth and confluent with the glenoid. The distal tibia, for me, is an articular graft. Makes sense, it's reconstructing. I used to do much bigger, okay? If you had a, you were measuring, okay, you think to reconstruct that circle, the biggest diameter is, you're missing seven millimeters. I would put 10, 12, 13 millimeters in because I thought I needed a big graft and didn't want to have a big platform. Well, guess what happened to that extra four or five millimeters? Gone. Yeah, exactly. So the body's telling us something. In addition, it's only gone, or two is I've seen, and these are my own patients and others that get sent to me, is the subscap rubs against it. Subscap and the screws, and if it's too big anteriorly and they do, patients do not like that. It's the same as screws out the back and hence why buttons and suture and these other things are really, I think, going to be the future. It's really coming along with the technology there, but the screw irritation and the infraspinatus is also an issue as well. So those are all real things and things you don't want to miss and let your patient know about. They may need to do artery removal down the road after this heals or put some anchors in down the road. I tell all my patients that, because sometimes that just happens based on how we do. So I really try to anatomically reconstruct this. That's just another, I guess, segue on that question. Yeah, well, then when I started doing these, I got CT scans post-op to see how they were healing and I would cross my fingers to see how close I got to the spinal glenoid notch with my screws and I was like, I'm just waiting for one of them to be directly in the notch, but so far they squeak, squeak right by. You know, I think that you hit on a point that's really important and maybe you don't have more to say there, but I'm just bringing it up specifically in case you do. You know, the sizing that you're doing to try to prevent resorption, whether it's a coracoid or a distal tibia, you know, what is your recommendation? Because I think that as you make them small, they feel structurally maybe a little less intact because the amount of cortex that you have is at the surface. You're screwing into cancellous bone as opposed to a coracoid where you have a little bit more cortical bone. So have you ever run into problems by trying to make them smaller, arthroscopic approach, having them crack, or how do you get the porridge just right? Yep, I've been there. I've been there when I've cracked it. Fortunately, the distal tibia is forgiven. I've gone and harvested a second piece of bone and you can get two grafts out of one distal tibia. So that's a bailout. Had to do it once, maybe twice in 15 years. I remember the case as well, of course. You always remember those one or two. But what I try to do is keep the cortex on the tibia. I like having that nice cortex. I don't cut a lot down on the cortex atom. The cancellous bone is the deeper bone where you make that second saw cut. I try to really preserve the cortex where I'm putting the screw as best as possible. However, Steve Parata and I did a study looking at exactly this, cortex or just cancellous. If you just used a screw and a standard screw head, and you just had cancellous bone, we studied this mechanically, it was not very good. Once you added a washer, it was equivalent to cortex though. So I think you're okay either way when we looked at this mechanically, but I just try to keep cortex. There's a lot of other things going on. I wanna try to minimize the other variables. Yeah, for sure. One of the questions we have from an attendee is just curious if in your experience in both the civilian and the active duty sectors, do you feel like you've seen a difference in how you've managed the problem in those two different populations? Does it affect your graft choice rehab? Can you speak to that in general? I think it's just been a continuum of the journey overall, whether it's military or civilian. For me, it's just been more learning. Our teams continue to learn on it. I've learned from many others now that have now really honestly taken the baton and the torch with this entire concept and grafts around many joints in the body, not just the shoulder. So I'm very humbled by where this is going, but I also know we need to do some more work. But for me, it's just been, I didn't really think about it that way. It's kind of the same for me, whether it's military or civilian, it's really what's the patient's demands? Where are they at? What do they need? What's been our success rate with these? And our outcomes, again, have been very good, especially when you compared Latter-day and distal tibia in our 100 patient each study, that was a very solid one to look at the outcomes. And it was a very good study that another one of your former colleagues, Rachel Frank and I helped put together. Yeah, that's awesome. Okay, this one's a question for me because this is where I need to learn from you. When I first did a distal tibia, I was kind of asking myself, why do I feel like things are a little tighter? Why do I feel like my exposure is not what I was used to with the Latter-day? And then kind of the dummy aha moment was, well, I don't have the coracoid out of the way when I'm trying to put it on. And unfortunately, I had actually a brachial plexus traction injury from that patient from trying to retract so much because I was so worried I wouldn't get a good enough view to get it in fear and have it creep onto the face of the glenoid. Luckily it recovered, but it was pretty stressful two months. Do you have any tricks or pearls on your exposure for DTA compared to coracoid? Yeah, it's a great question. And it's good to know we've both been there. Suffering on the shoulder just happens. Good news is almost universally they recover. It's not knock on wood. It's not that we're lacerating structures. It's a neuropraxia and fortunately the body's very forgiving. So that's what generally what I've seen six to eight weeks, be patient, don't necessarily need an EMG, watch it, recover it, go from there. But yeah, the conjoint is the real deal. So in that exposure, well, first of all, I've kind of taken this down to an arthroscopic type approach at the state. You know, I didn't show it all today, but they have gone almost to an arthroscopic, cerclage button type of approach. And there's a bunch of videos out there for that. The open approach with an intact conjoint tendon atom is all about arm positioning, bringing it in, internal rotation, relaxing it, or even a little bit of flexion. You know, a lot of times I would challenge you to look at your arm positioner. I've had a lot of times, because I come into the room, my fellows of getting things positioned, and I come into the room and it's in 20 degrees of extension. It's classic because you're only up 40 degrees, head of bed, 45, maybe 50, 60, whatever, however you position beach chair. But your arm's in 20 degrees of extension. I want you to go home or try it right now and put your arm in 20 degrees of extension relative to your thorax and see how comfortable that is. And we're doing that to a sleep patient. So be very careful with that. It's one of my absolute pet peeves. So flexion, adduction, a little internal rotation absolutely help relax that conjoint. The other thing is I don't use a commercial arm holder doing these. I do it all in a Mayo stand and I drop the Mayo stand, bring it in, bring it over, flex it up a little bit. Sometimes just bring a Mayo up, pop the elbow up a little bit. And then that absolutely helps a ton. Commercial arm holder can be a little bit of the enemy here, to be honest, in terms of getting the graft in the right position. In a big patient, it can be a challenge. I have taken a couple of conjoints down. You're like, oh, I take the conjoint down. Actually, not that. I just went back in with a couple of anchors and anatomically repaired it medial-lateral or just did a 475 anchor right in the center and used some tape suture. No problem. So, you know, we look at what we do to the conjoint now as it is. It's like we move that thing all over the place. And so don't hesitate to take part of it down. You can take the lateral half of it down. You can take the whole thing down if you need. And then just repair it with an anchor. Tag it. Yeah, that's excellent. I would just also reiterate, you know, your evaluation comments. You know, one of the systematic reviews you showed, I think, was from a couple of years ago. And then we did one in 2022 in AJSM, looking at the risk factors. If you stack the risk factors for shoulder instability, for all the studies that report on different issues, and then you look at the ones that control for the most factors, the number one factor that every time somebody looked at it had a significant association with recurrence was on or off track lesions. And so there's yet to be a study, at least as of 2022 at least, that has looked at that, that showed it wasn't significant, even when you control for as many other factors as you can think of. And to compare that to glenoid bone loss, only 80% of studies showed that glenoid bone loss was significant, which seems kind of crazy, but it's exactly the issue that you bring up, where you can have glenoid bone loss that's marginal, and then you add some ligamentous laxity, you add a large heel sacs, and now you're in a different category. And then the other stuff beyond that was younger age, sports participation, and the things that we see in the ISIS score, which also was ISIS score was about 75% of studies. So I think that it's just something important to keep in mind. I think that, like you said, it's not the easiest thing to calculate the off track where people may not be used to it or familiar, but there's lots of great resources out there to help with that. And I think it's pretty useful and needs to be part of your armamentarium if you're treating this stuff. Totally agree, great points. But all those things that have come along over the last really 15 years, 18 years, it hasn't been long, has just helped us do a better job recognizing it with a good history, a good objective and good imaging. So maybe just a couple of cases we can kind of rip through these. 26-year-old male, we know the story. Scope Bankart, billed for instability in 15 months. Someone that fails pretty quickly. Guess what they've got? Bone loss. Latter Jay, presented with shoulder just kind of slipping, mild crepitus, just almost engaging on the rim, instability on exam or surprise, relocation, et cetera. Here's the imaging. It's got screws, hardware, cannulated screws, but full thread, not bent. You can see there, down at the back, maybe that's tickling the subscap or the infraspinatus a little bit, but not the main issue. And you can sort of see the bone and medialization going. So here you can see the humerus and with this, this one I actually took the top two thirds of the subscap down. And that's another thing that can really help you. With this, I try to do this through a subscap split, but you can absolutely do this with taking part of the subscap down. We've done it in open surgery. We do it in instability. And then we just gently chip this down right at the bottom. My retractor is the axillary nerve. And then the musculocutaneous is not far away. I'm gonna remove these screws. Hard to remove from priors. Sometimes a washer with it. Make sure you get that as well. I've left that behind without realizing it. So make sure you get that washer. You're right, I'm looking at it. But yeah, a good, reasonable cannulated screw. And you can see that the humerus, there's the chip of bone. Now, what do you do with that conjoined tendon? This is super controversial. I actually tag it. I'll take the bone off. So here I'm gonna tag that conjoined just to see if I wanna, and a lot of times I'll integrate the conjoined into the screws or an anchor that I repair in the front of the glenoid or use some type of anchor type system to put that back in place, the conjoined tendon. But it's not mandatory. I don't think you have to do that very carefully as long as we got that out of the wound enough and away from the axillary nerve. We got my needle tip bovie taking that off. And then we're going to then start with the preparation. Here's our workstation. What I'm showing here, I think is important in the workstation is this thing's got six degrees of freedom. So what I'm doing is making sure it's parallel to the ground because that's everything there. So those two purple lines, left, yeah, right there, I wanna make sure I'm center and I wanna make sure that this thing is flat to the ground. This was a huge bone loss situation. So we got the 10 millimeter surface. I made it 10 degrees for the angle, but you could definitely do 15 degrees. You gotta bring this down. You just gotta watch these screws here as they can loosen up with your sad saw. So I just hold it in place. I use some fresh irrigation. Now here, Adam, what you were talking about is removing that front cortex. I kind of made this flush, but I try to preserve that cortex if I can. You can pre-drill this with this commercially available guide. You don't have to, you can do it after. But for me, it just helps put the graft in place. The other thing is if you pre-drill this, Adam, to your point of managing the conjoint, a guide can really help you get around the conjoint and just gently move that over with a guide. So this patient also had a massive hill sacs. And so now we've got the talus and we're showing the difference between the talus and hey, there you go. There's the subtalar joint right up against the distal tibia. I've got my light shining on it there, but you can see how amazing that is and how well the body is conserved. It's a law of nature. It's crazy. And the ability to have this and think outside the box, I think is just so cool. I'm doing this freehand because I need a bigger graft than 23 millimeters. So it's about 27, 28 millimeters, and that's a pretty big chunk of bone there. We're gonna prepare that. And then this is the hill sacs. And the reason I took down that subscap is that hill sacs was really big and we're doing some measurements now and gently externally rotate this. And now we're gonna look at the size of the talus here. You can see I can probably get 40 millimeters up to about three centimeters there. And we're starting to mark this out. This is kind of Woodshop class 401. If you have 3D printed models, that's actually super helpful to be able to do that as well. And now we're able to do some fast cuts. I saw this fast in real life and we're able to create this kind of orange slice. But this is Woodshop class 401. I put some small K wires into it here on the side, bring it back into the body a bunch of times and fix it, retool it, reshape it. I always make it too big at first because it's not that big. When I look at our study and look at this thing, this thing is big. We're gonna cut that down. I use headless compression screws. But what I'm most interested in here is the articular match. It's probably about 30, 35 degrees. And now I've just kind of shaved off the back of that. You can see that there where I started, but shaved off the back to make a really nice rounded area. We then put the distal tibia in place, measure this. These are generally 36, 38, 40 millimeters around there. Screw and washer. You can see we got the suture washer construct on there. And you can see how much a nice visibility we have because we took the subscap down because we were doing the talus to the humeral head. And then we're gonna untangle this. You can see how this slides. It's pretty cool suture washer concept. Now you can tie a capsule and a bunch of other things there. And so now you've got this nice big reconstruction. I think anatomically putting that back. One more case here, mountain bike, shoulder injury. This was at a female. And, you know what, sorry, wrong one. I wanna get through this one. This was a big, this was a big, big hill sacks here. Same concept with the talus and distal tibia, but that's the type of hill sacks we're putting. Sorry, this is the type of hill sacks that I think needs a graft. It's very medial to do a rempissage in that. Probably get away with it depending on the patient, but this was a super active contact, 22 year old female. We did combination bipolar grafting on this. And so here's another view of the talus that we're now through again. I'm kind of measuring this again. You can also use a bone wax. We got a couple of packages of bone wax, put it in the defect and then sort of fix this and put this in place. But you can see, guess what? I always make it too big to start. It's too big. Well, you can see how nicely that articular cartilage is. It doesn't have to be perfect to start with, but what has to be perfect I think is an articular match. And then we shave down the back here and you can see now we've got a pretty nice humeral head with a talus, pretty cool setup there. And then we're going to go back and fix the glenoid. And same concept with that. And so here you can see the distal tibia, the foreheadless compression screws, and you can see the axillary there nicely showing the graft in position as well as the distal tibia position, a nice centered humerus over the glenoid. And I think reconstructing the anatomy, and this is what these technology really, I think has allowed us to do. This is the mountain biker one. I'm sorry, I was just a little out of order. A 35 year old female, left shoulder pain, classic, went to the ER. They got a CT scan because the x-rays didn't look right, but at least they got the CT scan and knew it was dislocated. But this is, FYI, I talk about this on the podium a lot, it's the number one closed claim in the shoulder world and upper extremity world in the ER and clinics, urgent cares, et cetera. Why? Because you're super comfortable with a sling in internal rotation. This arm loves being in internal rotation. They're like, yeah, shoulder's doing fine. I can move it a little bit left and right. It's sore, I dislocated it and jacked it up. But you can see the issue with this, and this is why I don't love reverse Hill-Sachs, it's all cartilage. And we've looked at this a lot in all reverse Hill-Sachs, there are about 38 to 45 degrees of cartilage missing. It's a lot. And so we need a cartilage and osteochondral solution. Here we did the, in this patient, I actually did lateral first, because it's a huge labrum tear and capsular injury and repaired all this arthroscopically. And there you can see there on the left image, that massive Hill-Sachs that involves the, reverse Hill-Sachs that involves the cartilage. And I actually just lean the patient back and just gently re-drape the shoulder and open it up in almost a modified beach chair position from the bean bag. So I go get a quick cup of coffee for about 10 minutes. Really, my team puts a patient back in and we're able to, after arthroscopically doing this, you see this situation here where that's all, that's the lesser tuberosity there, where I've kind of just peeled down the top, maybe centimeter or two of the subscap, just kind of peel that down a little bit, but that's the tuberosity that's exposed. We've got a 16, 17 millimeter depth lesion, which is pretty typical, about 35 millimeters or so. We're going to prep this with the similar techniques we showed. Again, my graph's always too big to start. We're trying to fashion this angled lemon wedge. And there is a little bit of a, there is a little bit of an art to this based on where you put these angles relative to the cartilage face, because you want to reconstruct the, you want to reconstruct the cartilage. This is super dense bone because it's been compacted, but you get it close enough, you do a final pulse lavage, like you talked about, or a CO2 type system, and then we're able to put that in place. And you can see how nicely that fits with the headless compression screws. We fix the subscap at the end. And this is the type of imaging we see at the end of the day for this reverse Hill-Sachs, really nicely approximating up, again, right up against the lesser tuberosity. These reverse Hill-Sachs doesn't involve the lesser, it just involves all cartilage. And so you can see it's really nice, good, dense reconstruction. And that's what the Talus has allowed us. We have one more, one last question. We're a little bit over, but we probably have time for this. You touched on it briefly, but can you give a sense, are there certain times when you're preferring a suture, cerclage type fixation versus screws, or you're just kind of working through the evolution and don't have like a good sense of when one's better than the other, like bigger graft, gopher screws, smaller graft, suture, or can you talk about that briefly? It's, yeah, I think you hit the nail on the head both times, Adam. It's, we're in an evolution of this, trying to figure this out. The cerclage and button system really intrigues me, again, taking screws out of this. For a bigger graft, for bigger problems, I've opted for screws. I think cerclage and certainly an orthoscopic technique, especially from the front, is going to be here to stay as the technology and instrumentation and techniques continue to evolve. So I really think over the next several years, that's going to replace screws as a standard fixation of any bone graft in the shoulder. Yeah, I think it's just like any fixation. We have an orthopedic screws, which immediately provide very good compression, which is probably a good thing. But also if you put it in tight and you do it wrong, you make it proud, you get the angles wrong, then you're probably worse off than having used a more forgiving system. So I think it's just one of those balances of if you're going to do something less forgiving, you got to be a little bit more accurate probably. And ultimately it'd be great to have something that's forgiving and accurate that has more healing, which is what everybody's working towards. But well, thanks so much, Matt. That was awesome and a master's class in distal tibia. Well, it's been a great journey, team effort. Thank you all. It's been a pleasure. Thank you. Yeah, thanks to Anna and to JRF again for sponsoring the webinar. Again, this was part of the Anna Industry Learning Vault series. And these will be available online on the Anna website starting tomorrow. And again, there'll be several more in this series to come. So thanks again to everybody and thanks for your involvement and questions. Cheers. Thanks everyone. Have a great night. Thank you all.

Dr. Adam Yanke

Rush University

webinar

Anna Industry Learning Vault

JRF

Dr. Matt ProVenture

allografts

shoulder reconstruction

glenoid bone loss

Hill-Sachs lesions