I'd invite any folks with questions to come up to a microphone and certainly we can entertain them. We have about five minutes for questions and answers. Maybe I can get us started. First off, many thanks to our authors for their elegant, well-done studies. I'd like to just start with Dr. Voloshin. These are really, really good talks and very interesting. I think you confirm what a lot of us initially suspect, which is that you probably may obtain time zero better fracture fixation strength, but it may come as a cost. We know that from our SLAP literature with the chondral damage. What are you doing now with this data and do you think there's a role for this SAGAYA type technique where you're penetrating through? Are there any ongoing efforts to evaluate that as well? Yeah. I'll tell you, this was very alarming when we saw these defects on the humeral head. That suture is basically like a cheese cutter just cutting the cartilage. In all samples, it went to a great full lesion. At this point, I choose the lesser of two evils. I would rather I put a stitch on the bottom of the fragment, on the labrum, and on top of the fragment, on the labrum, and so basically the bony fragment is just approximated anatomically biomechanically. It's certainly not as stable as the techniques I described in my presentation, but to me, I would rather protect the shoulder longer and let that fragment heal. To me, that's a lesser of the two evils than have a cartilage damage that I observed in this cadaveric model. That's what I do right now. Many people probably are familiar with the drilling of the fragment technique and I've tried that and I will tell you, it is a fussy technique and you actually have to peel that anterior capsule off that fragment in order to get your sutures retrieved. And I think that capsule has a role on that fragment, so I think we certainly have to figure out how to do this well without leaving suture on articular cartilage. To me, in my hands, what I do now is basically stitch on the bottom, stitch on the top, and protect it a little bit longer, hopefully the fragment healing anatomically less stable, but to me, lesser of the two evils. To Dr. Pautzenberger, where is this fitting into your armamentarium now and how do you decide between this versus a biologic option with bone and cartilage? Also, did you stratify your data to look at underlying condition, be it avascular necrosis or other secondary causes versus primary degenerative or traumatic pathology? Yeah, so thanks. Good, obvious questions, I would say, that come to mind. So it's certainly part of a spectrum. So we didn't really, to be honest, stratify the patients that much because it was our first series, we tried it in a lot of patients. So we found out the glenoid side should be in pretty good condition, otherwise it does not work. So in our spectrum of, or in our armament of surgical techniques, we're trying to, up to two centimeters in diameter defects, we're actually trying microfracturing, it's fast, easy to do, and works well. I think we just submitted a paper with 12 to 15 year outcome of microfracturing in the shoulder, which works fine. So for the smaller defects, we're using microfracturing. And if it's bigger than two centimeters, we're going to the partial humeral head resurfacing. And yeah, that's our current strategy. Certainly, and that's obviously a good point, we tried it in a lot of people in the beginning, I'd say an actual severe osteoarthritic shoulder is not, that's not the right indication. So if it has a central defect, you can address the defect, but you're not addressing the disease. And as I was briefly saying, we were a bit concerned in the beginning with the fixation, but now we tried it, especially in patients with avascular necrosis, because that seemed like an ideal indication. And thankfully, it seems they are holding it in that maybe not optimal bone as well. So, but we see that's early data, we'll see how that goes. Yeah. Great. Thank you. To Dr. Freehill real quick. I'm very interested in this and was not familiar with the PECS block until coming to Wake Forest. So your legacy continues on there. How prevalent is this among our anesthesia colleagues? And is there any added time or costs that's transferred over to the patient? Yeah, that's a good question. And Brian had mentioned that too. I'll tell you that at Michigan, we don't do that. So the axillary pain will still come about. Are they doing it at Wake routinely? Or are you having it done? Only on request, but I wonder about the relative value versus just a local field block. Yeah. And that's the question. It'd be interesting to ask them what, if they're charging additionally, or if this is bundled. Yeah. You know, to Dr. Forsythe, just in brief, this is an incredible study, and I look forward to looking at the onlay versus the interference screw fixation, because I think those are all very popular and well accepted techniques. Any insights you can offer based on your limited clinical experience? Insights as far as the screw versus the suture? My suspicion is that with a suture anchor, that you'll see a little bit more slippage at one week, because it may have less construct stability. The biceps tendon itself is comprised of mostly longitudinal fibers and a few transverse fibers. And if you've ever run a whip stitch through a biceps, you'll note that it slides through longitudinally. So the screw, I think, obviates that problem. And the screw is not without its own intrinsic difficulties. People have reported truncation with the screw or over-tensioning. But I think the take-home for me from all of this is that there's quite a bit of remodeling, and we're not even sure if it occurs through the tendon or through the muscle belly, but I suspect much of this is sort of muscle remodeling and potentially a minute amount of sarcomere length change. So that is the next phase. Hopefully, we'll have those results soon, comparing screws to pec buttons and suture anchors. Well, many thanks to Dr. Campbell as well, and I appreciate all our authors for staying on time. In the interest of getting on to the next session, maybe we can give a round of applause for our presenters.

SAGAYA type technique

cartilage damage

shoulder

microfracturing

PECS block anesthesia technique