Thank you, and I just want to say how humbled I am by that wonderful opening ceremony. Thanks very much, John and Anna, for involving me in this program. My topic is to deal with shoulder instability and why I use allografts for getting the anatomy right and discussing what the major issues are with regards to this. My disclosures are in the AOS handset. So talking about shoulder instability, you're going to hear a lot of things and the shifting questions that occur, whether we should be doing open or arthroscopic repairs, what's the best. And the most important thing, really, is what factors are involved in successful surgery. And I think that we're all figuring those out. And the biggest stride that we've had over the last 20 to 30 years is the fact that we recognize that bone defects, especially on the glenoid and humeral side, are significant issues. I've got to give credit to Steve Burkhart and Joe DeBeer. Their landmark paper back in 2000 talked about failures of their arthroscopic repairs. And they noticed a high incidence of glenoid-type lesions, and they suggested that perhaps there's a certain subpopulation of patients that need to have bony type of reconstructions as opposed to soft tissue repairs. ETOI classified that and said that anything greater than 20% of the glenoid would cause instability issues. And we also, at the same time, reported problems in patients who had Hill Sachs lesions, especially if they had humeral head defects, greater than about 25% on the humeral head. So it raised the awareness that bone problems were a significant issue with regards to instability, instability of repairs, and some of the failures of repairs. Over the years, I have a great interest in this and done a lot of biomechanical research trying to figure out what and how much we need to fix and when to fix it. And to look at this, on the humeral head alone, if you look at it, the number seems to be about 25% to 30% in terms of isolated defects. And on the glenoid side, ETOI has talked about 20%. But what we also learned is that these combined defects could be smaller. And in combination, these smaller defects could still give you instability problems. And that's led to the concept of the glenoid tract, so that we understand now that fixing both humeral head and glenoid may be an issue with these patients. So what do we do? What are our treatment options? And remembering the combined lesions, so that depending on where you're going on the glenoid or on the humeral side, there's a number of different types of procedures. Buddy's going to talk about rhombosage on the humeral side. On the glenoid side, the Bristol-Latter-Jay has seen a big resurgence over the last number of years. And those numbers are increasing. And some of our colleagues, especially across the pond, would say that you can do a Bristol-Latter-Jay procedure for humeral bone loss for these type of situations. The problem is, what you've got to understand, this is a study showing that stability can be restored with the Latter-Jay repair. But the problem is, if you combine it with a Hill-Sachs defect, what you see that once that number gets over about 25%, that the repair of a Latter-Jay for something which is a big Hill-Sachs, even if you've reconstructed the glenoid side, it doesn't necessarily reconstruct the humeral side. And that can give you significant problems in terms of failure, stress on the response, and failures as you go forward. In addition, the Latter-Jay is not without its complications. And a lot of these are related to the surgical dissection, the significant problems that we can see with neurologic injuries, specifically musculocutaneous and axillary nerves. So we're all seeking and searching for a different type of option. So allografts have been around for a number of years, different types of allografts coming from the iliac crest, from the humeral head, from the tibia. And I've got to give credit to MAT Prevention, the group out of Rush, who have been the strong proponents of distal tibial allografts for this type of problem, showing us excellent results at both two- and five-year results with good healing, reduction of recurrence of instability. But they also noted some problems in terms of the delivery of the hardware, putting the graft in, not angulating it. So I thought that while fixing the glenoid is obviously a great idea, is there anything that we can do to reduce the complications, reduce the surgical prep time, give us a reproducible technique, and then giving us an anatomical reconstruction so that over the last few years, I've used an allograft, but we also have a technique to be able to put a guide, do a reproducible, accurate reconstruction, and get ourselves a flat surface with an allograft which is already prepped for you so you don't have to do that in the operating room, and put it onto the defect. So this is an open procedure, obviously. There's a guide that you can put a couple pins in. It's a very simple technique where we ream down the front so you get a flat edge for the allograft to sit against. And then you use these guide wires also for your screw holes. This is a distal tibia or a distal femoral allograft, cortical on the outside, cancellous on the inside. And then when you take the pins out that you've used to prepare the front of the glenoid, you put your screws in as you go forward. So what about the Hill-Sachs lesion? Don't ignore this. When it's greater than 20 to 30%, we've already discussed that. And there's now some studies, this is from Nick Motade showing that it's actually the independent variable is the Hill-Sachs lesion. You can have glenoid defects and not have recurrent instability, but if you have a Hill-Sachs defect, the chances are very high that you're going to recur. So over the years, I've used this anatomic reconstruction model since 1993. I've had matched allografts for these patients that we sized and side-matched. I do this through a deltopectoral approach, and this is the kind of exposure you get. And then what we do is we fix the humeral head defect with this type of reconstruction we reported on this with no recurrence of instability after fixing this Hill-Sachs defect in these patients with these complex instability problems. So in summary then, you can get excellent clinical results using allograft both on the humeral and on the glenoid side with very low recurrence rates. Anatomical reconstructions of these patients have improved range of motion and function. Obviously, issues like grafts, resorption, and healing are issues that we need to improve and some of the biologics are going to help us do that. But certainly, we see a lot of reduced complication rates with excellent anatomic reconstructions with good functional results. Thank you.

shoulder instability

allografts

anatomically correct repairs

bone defects

recurrence of instability