Johnstown, Jim, I'm from a small town in Pennsylvania and we have some idiosyncrasies that John likes. I have nothing to disclose. I'm trying to teach you the 10 lessons I've learned over the last 28 years of research in post-year instability. The first thing is it's usually a combination of the above. All this is in the handout so you can look at them. The recurrence rate, we found out that from Jimmy Taboney and Lee Kapton and I, we looked at it over the years and found out that the mechanism in overhand athletes is usually an indirect mechanism. The mechanism in contact athletes is usually direct. First thing I'd like to teach you is the ideology of overhand athletes is frequently different than contact athletes and so is the treatment. If you look at throwers, Andrews' deceleration, eccentric overloads, one mechanism, post-year capsule contracture, Burkhardt-Morgan, slap extension, Kibler and Eletrage, and then dynamic post-year instability is Johnny Conway and myself. Second thing I want to tell you, there's a few things on physical exam that don't do well without surgery and one's a circumduction test. The other one is a load and shift, oh I'm sorry, a load and shift test that's a plus three and then a dynamic post-year instability. Hyperlaxity states, you want to beware of them. I'll diagnose three-year-olds with Danlos every year and what you got to do is you treat them a little differently so beware of that. Beware of bone loss but how much bone loss is too much, well actually the literature can't tell you but I can tell you that our paper says is that of the 200 repairs we looked at for this that decreased bony width, not bone loss, bony width was what we were worried about. I call them the military mafia, JT and the boys tell us that even they believe that, that 69% of their people had bone loss, 22% was greater than 30, 13.5 but yet reoperation rates, complications, patient reported outcomes were not different between the bone loss group and not bone loss group. Watch for excessive retroversion, the literature won't tell you what's too much, what's too much that the MRI you see there is a tight end from a large school in Ohio that plays in the NFL now and all we did was fix the labrum with that amount of retroversion. It does seem, Brett Owens has shown us, it does seem before surgery, it's a risk factor but once you have surgery, it doesn't seem to be a risk factor. We looked at that and increased retroversion was not a predictive value. There are certain things at MRA we want to look at, glenoid dysplasia, post-year humoral head subluxation and increased capsular volume on MRI are all independent risk factors for post-year instability. Beware of scapular dyskinesis, Ben Kibler taught us this but unfortunately sometimes the dyskinesis is protecting the shoulder from going out the back and you have to fix the shoulder before the dyskinesis goes away. Sometimes in throwers, this scapular problem is very common, we studied this but sometimes it's normal in throwers so don't be afraid in throwers if they have some protractions kind of normal in them. Third thing I want to teach is labral tears and retroversion, both bony and chondral labral are common, they're not rare as the literature says. Of our first 100 cases, we had 57% of them had some kind of labral tear so be expecting them. Chondral labral and glenoid version are going to be statistically significantly increased in all my patients and we did post-year instability and of the whole group, the pitchers were actually the worst, they had 11.5 versus a control of 5.4. Fourth thing I want to teach is post-year pathology is rarely isolated, it always comes with something else, slaps, post-year cuff tears, raggles, post-year glenoid DJD. So my group now is 620 we've operated on in a prospective study, 35% of them had some additional pathology that we had to address. Concomitant pathology, raggle lesions, this is an NFL linebacker in Florida and if we don't know ahead of time that this is a raggle lesion then you're going to get into trouble when you get in there so just look ahead because there's other things too, capsular rents, so the baseball players, thermals, football players, every time I go in there a lot of times I don't realize that they have these even in the MRIs and then of course revisions become a big problem. Also these type 8 slaps, we've been seeing more of these where they start at the top and throwers and then they kind of go down to the bottom. My first group of those we did pretty well in and then we looked at them again in long term follow up and what we found is consistently throughout my studies is that throwers have greater pain, decreased function and poor return to play at 6.6 years with these but they had, for some reason they had pretty high satisfaction. Posterior instability and rotator cuff tears are not the same as posterior instability in slaps so as opposed to slaps, posterior instability with a partial cuff tear they don't do nearly as bad as slaps do. The fifth thing is overhand athletes have poor outcomes and poor results, you've got to tell your patients that so my first group of athletes I looked at we had 27 throwers and 55% of them were less likely to return to their preoperative level. In my next group of 200 we have 56 and the one thing I can tell you is please use suture anchors. So in the suture anchor group we had 70% return to sport at the same level, my sutureless anchor group I only had 22% return. We looked at this in cage match controls and sure enough the throwers and the non-throwers were kind of equal in return to sport but look at the same level. So returning to a thrower, especially a pitcher at the same level with posterior instability is a task. So in the end the take home message is a little loose is always better than too tight in overhand athletes. The sixth thing I want to tell you is that contact athletes have better outcomes in return to sport. We had 117 in my first group and they had 93% good decks and results and in fact of that group the American football players did the best. So we had 93% return to sport and we had a 96% rate of satisfaction. So in the end in contact athletes too tight is always better than too loose in contact athletes. Arthroscopic treatment is better than open especially in overhand athletes and quite frankly the reason is because you can treat all the other pathology, the partial cuff tears, the slaps, the capsular tears and the haggles. Lastly your options, you have multiple options when you do an arthroscopic but please don't use electro thermal. Don D'Alessandro and I's paper kind of showed us that there was a 40% failure rate. So not to disrespect the other speakers, I'm going to stop right there. I think that's enough. Thank you very much.

post-year instability

overhand athletes

contact athletes

physical exam findings

electrothermal treatment