Thank you, Brian. Thank you, Rachel. It's great to be here this afternoon. And what better way to start off a shoulder instability symposium by introducing Stephen Schneider and such a thought leader. So we have five questions. I'm going to have a brief, just a little brief, my perspective on Steve. So he was clearly and is one of the original pioneer thought leaders in shoulder arthroscopy without question. He's a premier educator. As a resident in the mid to late 80s, when you saw Steve Schneider's name on a podium presentation, if you saw him involved in a cadaveric dissection or a cadaveric surgical demonstration, it was a go-to event. It was a must-see event. You had to be there because he was such a phenomenal educator. And I mean that sincerely as a young resident, it was without question a go-to spot. He's clearly developed multiple things along the course of time. We'll hopefully touch on the Alex the shoulder professor. He's developed the class at SCOI, the Center for Learning Arthroscopic Skills. And he's been an innovator and inventor throughout his career of over three decades, going back to suture anchors, cannulas, instruments, suture shuttling devices, braces, arthroscopic arm support devices, you name it. And this was at a critical time in the infancy of shoulder arthroscopy. So we had no way to do these procedures. And it was thanks to Steve that we really got here. So we all owe him a huge debt of gratitude. But what we really want to hear now are the questions. So there are five questions. We're going to start with this one. Steve, what are your three key concepts related to shoulder instability? Thank you, Frank. Three key concepts. Well, I think number one would be what Rick Ryu teaches us so well. And that is a complete exam of the shoulder from both the anterior and posterior portals. So we know each and everything that may be related to the patient's anatomy. That includes looking down the subscapularis recess for loose bodies, looking down the anterior labrum to assess the quality of the tissue in the labrum, and looking from front to back to assess the quality of the capsule. From the back of the shoulder, we look at the heel-thacks fracture, and we watch the translation of the humeral head over the front edge, number one. Number two, and I think equally critical once we've got our diagnosis, is to plan our repair and always, always mobilize the tissues anteriorly before we do anything else. So often, if you're looking from the front of the shoulder and you see the head sitting out the socket, once you mobilize the tissues, and that is, I'll give you a little clue on this, and Ivan knows it very well, or all my fellows. The best instrument you can use in the front of the shoulder to mobilize the capsule in the labrum is what we call a Tommy bar. And what it is, it's a heavy-duty Steinman pin with the tip blunted. And once we use our liberator elevator to release the tissues, we put in this crowbar or Tommy bar, and we literally force the capsular tissues away from the front of the glenoid so that there's not a bit of scar tissue that will resist your translating the tissues back up to the labrum, so there's no tension on your sutures at all. The third thing I would say, again, there's a whole list of these things, but I think soft anchors have been a wonderful godsend. I've had problems with every kind of hard anchor in the glenoid you can think about and seen lots and lots of young people damaged permanently from those. So soft anchors are the key, whether you use single-loaded or double-loaded. I think that's a big gift that we got from industry and certainly helps us out. Those are great thoughts, great concepts for everyone in the room. In terms of the visualization, which was point one, have you found 70-degree lenses to be useful? 70-degree lenses? You know, I don't use it very often. If I had it built into my scope so I could have the option, I'd probably use it a lot more, but no, I don't use it too often. Then on the third point, when you talk about soft anchors, are you excluding peak anchors, which are not bioreactive? They're non-metallic for the audience, but they are rigid anchors. I've had cartilage beat up pretty bad with peak anchors. I don't like anchors that I don't know where they are. I don't know why somebody in industry doesn't develop a biologic anchor made of human dermal allograft. It's just a perfect idea. Put a little titanium thread deep in the anchor inserter so you can see where it is, and then you'd have a perfect anchor that would fill in. But short of that, they call them all suture anchors, so they're not really sutures, but I think they're wonderful. I haven't had problems with cysts. I use double-loaded anchors, Frank, and I use two anchors on every instability, two double-loaded anchors, that's four sutures. My theory was always it's not the anchor that holds the tissue, it's the suture. So if you've got four good sutures and you advance your capsule and attach your labrum, that's the best you can do in the front. Great. Thanks so much, Steve. So the next question, and it really begins with this landmark article. Again, during my residency, I heard Steve present this paper, and then it was published a year or so later, and it was very intriguing for all of us because we typically talked about labral tears below the equator. We never really thought about labral tears above the equator. Now, there might have been someone along the line who talked about that in throwing athletes, but much like the Vikings finding North America, it wasn't until Columbus landed on our shores that we actually opened it up to the rest of the field. So you did that with this paper. You classified 27 slap tears, and they were identified within a cohort of more than 700. So you made a very important point that there were less than 4% of these at that time during routine shoulder arthroscopies. So we're going to come up with four questions, sorry. So what is a real slap and why is it important? And then we can touch on how should we fix them, why should we fix them, what about the types threes and fours, and what about the young overhead athlete for which we seem to have no solution? Yeah, a real slap lesion is any symptomatic superior labral pathology, period. The superior labrum, a real slap lesion, always includes the anchor point of the biceps tendon, but superior labrum from anterior to posterior, which is the name of the slap, just means anything bad that happens up on top, and it's so much correlated with the patient's age and activity. A type, what we call a type one slap lesion, which is really degenerative changes of the superior labrum, just like a little fraying on the meniscus, it's no big deal. We just trim it off. It may be a normal aspect of aging, but when you see it in a 14, 15-year-old kid, it may be a sign of some pathology. Type two slap is the one that gets all the press. It's often associated with instability, and truly it's the way you diagnose it is you grab hold of the biceps tendon and pull it away. If the tension that develops as you pull that biceps anchor north away from the joint is visualized in the middle glenohumeral ligament, you know that it's loose and part of the pathology. Threes and fours are no brainers. They're just like bucket handle tears the meniscus. You can take a three out unless the front of the slap is attached to the middle glenohumeral ligament, then you have to fix that ligament back, but you take out the bucket handle and fours, you treat it as a biceps problem. Okay. Great. What about the overhead athlete? They don't seem to do well with labral repair or with biceps tenodesis. Yeah. You know, I don't take care of a lot of throwers, so I'm really talking out of class a little bit, but early on when people started reporting results of slap lesions, there were really a lot of bad results, and I couldn't figure that out because ours didn't seem to do that. And I think like every operation we do, just because you do the operation and then you report on it doesn't mean you do it well. And people that I saw were putting three or four anchors to try to fix a little tiny biceps attachment where one anchor would be just fine, and they'd close the anterior sublabral hole, this famous Buford complex that Donnie Buford gets grief for all the time. People were fixing those, and we had to take a lot of those down so people didn't understand that the biceps anchor is a discrete attachment point, and that's what you fix. Great. Thank you. So question number three, I believe, is surgical pearls. What have you, what have been your most significant surgical pearls in the last 30 years performing shoulder instability repairs? I think we have to go back to the diagnostic thing. I mean, really, when we started doing these, we just couldn't see. We only looked from the back of the shoulder. We didn't mobilize the labral tissue, and we didn't advance the labral tissue. Anchors were tough because we started out with four millimeter metal anchors. We got some trouble with those. So there isn't really one thing, but I think recognizing all the pathology and then applying your best, honest effort to repair that pathology is good. There isn't just one thing, Frank. And we have MDI. Ah, my favorite. What has been your most successful and gratifying treatment? MDI is the best operation I've ever, ever done. And nobody knows anything about how much fun we have with that. If I have a young woman, a swimmer, tennis player comes in whose shoulder's loose and she's crying, I can fix her with no scar and essentially guarantee she's going to be normal for life. I have long-term follow-ups. Nobody does it the way we do, except Ivan and a few of the fellows, because we don't make a big deal of it. We published a paper, and then everybody else started using anchors. But what we do is a special kind of stitching. We do a pan-capsular plication, which is five figure-of-eight sutures around two in the front, one in the bottom, and two in the back of the shoulder using ethamine and no anchors. I have a 17-year follow-up patient with MRI scan. I've got visual follow-up in people who've developed SLAP lesions afterwards, and it's a wonderful way to do it. I wish I had time to show you, because it's an underused but highly gratifying way of taking care of a symptomatic MDI. Thank you very much. Thank you, Dr. Snyder.

Brian

Stephen Schneider

shoulder arthroscopy

suture anchors

cannulas