This is General Scientific Session Rotator Cuff 2. Your moderators are Dr. Paul Sethi and Dr. Albert Lin. All right. Still morning. Hopefully everyone's awake. We have an actually really good panel here. It's gonna be fast-paced. Let's go figure it out. Let's get the let's get the debate prompt up. The case is a 52 year old so that as we debate here we all have the same same atmosphere here. 52 year old with a massive cuff tear and debaters, you got five minutes. If you go over you automatically lose your debate. Albert, any other instructions? Nope. I'm with you, Paul. Let's go. All right, let's go. Rob Hartzler, TSAOG, Orthopedics in San Antonio. I'm going to tell you why rotator cuff repair with dermal allograft is the right choice for this patient. Disclosure striker, we sell products for all of these operations. So no intercompany disclosure there. Big disclosure is I wasn't sure if Dr. Burkhart was going to be in the audience here, but I have to win the debate so I can get invited to Cinco de Mayo next year. Elephant in the room, this patient likely will do well with any of these operations. So we got to choose between maybe factors that you wouldn't necessarily think of. The other elephant in the room is this patient likely has a repairable rotator cuff tear. And if you don't believe me, here's the same woman in my practice, 52 years old, bad-looking cuff, repair, augment, and you might say, Hartzler, there's no way that thing healed. Prepare to be amazed. Don't forget about repairing these. In the case of operative irreparability, in our practice, dermal allograft SCR has performed very well with excellent clinical outcomes. Big disadvantages of this operation, technically demanding, expensive, short-term outcomes only. At this meeting in poster form representing midterm outcomes, you do see a little bit of a drop-off in clinical outcome scores. Thanks to Dr. Cognetti, who's in the audience for putting together this data for us, and you see some structural deterioration in outcomes, too. But enough patients like this with a healed dermal allografts at minimum five-year follow-up, I think that we shouldn't be throwing this operation away out of our toolkits. We know from the literature factors that are associated with success in superior capsule reconstruction. Low age, this patient meets that. Good subscap, this patient meets that. Low Hamada grade. Let's look at a little bit of head-to-head literature. SCR versus tendon transfer, data from the Mayo Clinic, Wagner, our alma, where is Wagner? Our alma mater here. Different patient populations, but SCR for the win on pain, forward elevation. Lower trap gets it for improvement in external rotation, but these patients had worse external rotation to begin with. Reoperation there, not statistically significant, but I think we can all appreciate the clinical significance of one-third lower re-operation rate. Both operations are technically complicated. How about SCR versus reverse? This is our data, primarily looking at value. These are two different patient populations, but SCR for the win on ASES scores, major complication rates, and the only disadvantage for SCR in this study is longer surgical time. Let's do a little pre-rebuttal here, take a look at the competition. So Evan's arguing for reverse in this situation as a permanent solution, and you know, in surgery, this is the easy button, but from my standpoint, I mean, you're getting married, Evan, to this 52-year-old woman, and I already have one wife with moderate middle-aged health complaints. I do not want another. This woman's gonna torture you, Evan, for the rest of your career. She's gonna come in at every follow-up visit. What is the bump? Why does it hurt? Why is my shoulder deformed? Why can't I reach up my back? No, thank you. And that's if she doesn't have a major complication with reverse. Joe, balloon. I love balloons for the right patient, but this is an old person surgery. We're talking about a 52-year-old woman here, and the balloon did not get FDA clearance because younger patients actually had better outcomes in the level one randomized clinical trial. Dr. Bonner, half an SCR. This is being billed as a permanent solution. The only thing permanent in my mind are death and taxes. Man, we just don't really know very much about this operation. Early outcomes are promising, no data. I've never seen any post-operative imaging of this operation, so for me, half an SCR is for surgeons with half a skill set. Now, Wagner, lower trapezius tendon transfer. That's intriguing for this. I think, you know, you're the stiffest competition here in this debate. Promising strength, am I right? So I cut up cadavers for six months to investigate the biomechanics of this operation, and the line of pull is right. We know that. But the force generating capacity of the lower trapezius is one-third of the infraspinatus, and you know you're losing a muscle grade on that thing. This patient has a hypertrophy teres minor. Your lower trapezius transfer is going to be like your deadbeat son, living in the basement, playing Call of Duty, eating Cheetos. That ain't doing anything for this patient. So in conclusion, repair this cuff. Dermal allograft SCR, if irreparable. Reverse is too much, balloon too little. Half an SCR for a half-brain surgeon, tendon transfers. It's not the easy button, but not in this case. Thank you. Awesome. So it's hard to follow that, but I'm going to talk to you about five reasons why the lower trapezius transfer for this patient. My disclosure is not relevant to this presentation. But first off, I do argue this is a functionally irreparable tear. If you look at the Rohy index, it says a 38% chance of healing if they work as a desk job, or a 14% chance of healing if they're a laborer, partly from this infraspinatus fat infiltration. And when you look at the other options, both on data out there in the literature, as well as our own data, I'm going to show you at least why I think this is the best option. So in general, we've shown this does very well. In patients that have irreparable tears with fat infiltration, they do have sustained clinical improvements. And this is in converse to data both that we've published here, as well as others, that when you have fat infiltration, the SCR really doesn't have a predictable functional outcome. Furthermore, the recovery curve for the lower trap is better than the latissimus or the SCR. And when you compare it to the reverse, in the restoration of scapular humor rhythm, you can see that the lower trapezius basically restores a normal scapular humor rhythm in converse to a non-anatomic procedure like the reverse. So another reason I think you should consider this is it's actually easier than you think. I know it's not the easy button, but it's not as hard as people I think can make it out to be. So my own personal learning curve was 14 cases that we've sort of published on. I'm going to show you some technical tips that maybe will help shorten your own learning curve. So you harvest the lower trapezius off the medial scapular spine. You transfer the L-graft into the joint using a long hip arthroscopy grasper. I like to preload it in two portals, makes it a little bit easier to anchor it once you anchor it in place. After placing four anchors, really compressing it down, you bring the arm in external rotation, and then you secure the graft with a pulvertaf weave. A couple technical pearls. You want to place the anchors replicating the upper infraspinatus on the anterior aspect of the greater tuberosity. I also like to preload these anchors, making the arthroscopy part a little bit easier. So this kind of shows just five technical pearls for the actual case itself. So one, when you're doing the harvest, excise the back fat. In Georgia, we have a lot of people with a lot of adipose tissue in the back. You can harvest the tendon off the spine, as you can see here. Going right to the spine, you can get a really nice excursion, really nice overall harvest with a pretty good tendon on the back of the lower trap. Then you use this long hip arthroscopy graft to transfer the allograft into place. The allograft has multiple crackout stitches placed in place, and you can kind of see this transfer using the anterior superior portal. You then will anchor the graft into the anterior aspect of the greater tuberosity. So once again, replicating the upper infraspinatus, I use self-punching anchors, preloading them prior to the transfer, making it a little bit easier once you get to the arthroscopic standpoint. I then like to use two other anchors to kind of really compress down on the footprint and help kind of secure. And you can kind of see here the ultimate graft, and you can see here the nice compression that we were able to get on the footprint. You then bring the arm in extra rotation and abduction, and then you will secure it after splitting the graft with a pulvertaf weave. And this, you really want to over-tension it. You can't tension it enough. Placing multiple figure-of-eight stitches, doing this sort of sandwich type of weave over the top, and then ultimately you can see the tension when you bring in an internal and external rotation, as you see here. So you can also add in a biceps SCR if you have something like a large subscap and you're worried about some anterior superior escape with this procedure. And in general, patients tend to really like this procedure. These are two case examples. So 56-year-old, 62-year-old females with what I would argue a massive irreparable posterior superior rotator cuff tear. You can see the fat infiltration in the infra and the supra, and you can see that Terry's minor hypertrophy. So both of these patients did quite well. You can see in this case at 12 months, restored scapular humoral rhythm. The patient-reported outcome measures were basically normal, and when he raises both of his arms, sorry, the video is a bit choppy, but it seems like you can't really tell which side we operate on. And in general, on the little bit older lady, you can see at four years post-op, she basically has normal scapular humoral rhythm. Sorry, the videos don't seem to be playing super well, but nonetheless, she was able to maintain these gains over the long-term. And then finally, at Emory, and this is my own personal algorithm, we like to replace muscle with muscles. When you look at SCR at Emory, when you have low gouttelier, the SCRs seem to do pretty well. When you have higher grades of gouttelier, the SCRs did really poorly, and this is in converse to the lower trapezius, that both from a clinical outcome standpoint and a failure and revision standpoint, really mimicked those that had basically primary repairs. So our algorithm, if you have good tendon muscle, you do a repair. If you have tendon deficiency, you use something like a structural graph to make up for this. And if you have muscle deficiency, you replace muscle with muscle, and you do a lower trapezius transfer. Thanks for your time. Thank you for the opportunity to present. I'm going to raise you a temporary spacer. My conflicts are in the academy website. So the options that have been discussed, superior capsule reconstruction, we know high failure rates, high complications, breaks, you know, bridges, complex procedure. I know Rob is a skilled arthroscopist, and he can execute it, but not everyone can. Partial repair, retear rates high, tendon transfers, very finicky indications, works on some patients, but not often. So it's kind of a unicorn type procedure for me. Permanent spacers, not enough literature, very novel. It's not really minimally invasive in the sense that you're still putting anchors in tuberosity, which really seems to be the pain generator for patients. And then reverse shoulder arthroplasty, too invasive, should be considered last resort. And Evan, you still haven't won a championship with the Suns. So in space balloon, FDA approved in 2021. I've done 121 since the FDA approved it, 10 during the IDE study. And I'll present my overview of the results. So it increases the acromi-humeral distance. It's for me, a rehab accelerator, and alters the center of rotation for the patient. This is the most important slide of this talk, the indications. It's for massive irreparable superior cuff tears, minimal OA, can elevate their arm to 90 degrees, intact subscap, failed conservative management, functional deltoid. I don't use age as a criteria, although that's what it's on label for. My experience, 131 patients so far, with a variety of outcomes from several weeks to seven years. Average age, 65, partial repair in 36, 64, isolated balloon, even split between males and females. You can see the average pre-op ASCS is in the 40s, VAS is six. So adhering to range of motion indication is very important. You can see the average forward elevation pre-op here is 130. These are not pseudo-paralytic patients, not like the Lancet paper, where the average forward elevation was 60 degrees. In my cohort that has one year follow-up, which is 57 at this point, three have been revised to an RSA within a year, so 5.3% conversion rate. 54 have final full analysis. One patient sustained an unrelated proximal humerus fracture. Forward elevation, generally the green represents increase in forward elevation for the 54 patients. Red is decrease, yellow is neutral. So you can see forward elevation generally increased about 23 degrees. ASCS, again, green is increase, red is decrease, generally increased from about 40 to about 80. And VAS generally improved, green is improvement, red is dissatisfaction or increased pain. And you can see the VAS generally went from about a six to about a two. And this is the sort of pattern of ASCS over their follow-up as we document all their follow-up. VAS, similar pattern. There is this phenomenon that we've described now and published the dip that happens sometimes around three months. I think it's related to the resorption of the balloon and probably some interference with the mechanism of compensation that was happening. Oftentimes, I tell them to work through it. They oftentimes will work through that and do very well. I don't bring any alarm bells, don't get MRIs, not really that helpful. So just grind through it. Case example, this is a patient during the IDE. So this was back in, gosh, 2017. I performed research. She's exactly what you described, 54-year-old, right-hand dominant female, left shoulder, had a previous scope, was unable to do anything with it. She came to see me. She had forward elevation in 90 degrees. Active individual. You can see no OA, some proximal human migration. This is her MRI videos. And again, this is a challenging problem in this age group for sure. So this is her static images, subscaps intact, force couples intact. That was in 2018. That was during the IDE. She was the last patient enrolled in the IDE, actually. And this is her five years later. So that's her left shoulder. So doing very well and very happy. So PEARLS for me, it's a rehab accelerator and facilitator. There is a dip that can happen at three months. Don't be alarmed. Coach them through that and tell them about that preoperatively. Safety, no consequences or harm to the joint that I've seen so far in over 100 patients. Pain relief and functional improvement is pretty predictable. Longevity, I've seen patients now up to about five to six years. We've published on the series of five that we've been able to have their five-year follow-up. No bridges burnt. When I revised to RTSA, did not see any scarring or remnant of a balloon. I've done two revisions. Two patients have had bilateral balloons. So it's possible to repeat. Make sure you stick to indications. This is not a hammer and nail situation. Thank you. Thank you. Next up, we're going to talk about temporary spacers. Don't work. Try this, a permanent spacer. And honestly, this talk is meant to be provocative, not for everybody to necessarily go home. My one disclosure that is relevant, I think this is important, is we do a technique patent relevant to this technique. So SCR in the United States, we'll talk about it. So generally positive surgical outcomes. I did this for years, honestly. The results are typically higher level surgeons, right? Technically challenging for the masses. A very high rate of non-healing. And why are they doing well clinically? So if we have audio, you'd hear this guy saying how happy he is. He's doing great. But the issue is, is that he actually failed on the glenoid side. So what several of us have recognized throughout, and I give a lot of credit to Rafi Mirzaian as well, is that when they heal on the tuberosity side, they were doing better. But we had a number of these that did very, very well. This guy was actually now seven years out doing well. So the most common complication with an SCR, and we saw this in ours as well, non-healing rates 20 to 70%. And so in this study, 2021, 62% radiographic failures with SCR. However, the clinical improvement was not necessarily tied to whether or not they healed or not, but multiple people were seeing that when they were healed on the tuberosity side, they were doing better. Here's another study, just the disparity between the radiographic and clinical results of SCR. Very high rates of non-healing, especially on the glenoid side. So the question is, why were they doing so well? This is a very good study done by Albert Lin, who's here, that actually we thought that the SCR was depressing and improving kinematics. This actually shows that that was actually not happening. And the question is, why were these patients then doing better? One explanation is, is the graph simply acting like a spacer? So we published this last year, two years ago now. This is actually a survey study with shoulder surgeons from Anna, and SCR has basically dropped off significantly. Many have become very disenchanted with SCR, and if you talk to a lot of surgeons, including myself, that were doing a lot of SCRs five to seven years ago, were doing basically none at this time. And so, again, this was published by Rafi, and we noticed the same thing independently. And then the ultimate question, I think, here is, is the debridement all that's needed? And I think the bar on these things is we do know that debridement and doing a partial repair very often can give a very good result. So for a lot of these cases, I think our bar should be, how would they do if we just did a debridement with an SAD, address their biceps, et cetera? So this is something that myself, my partner published the same time as Rafi. They published it in the same journal, looking at what we call this interpositional tuberosity graft. And honestly, when I started first doing this, I started doing it with a quadricep graft, and then for various reasons, we went back to a thicker dermal allograft. And you can see part of the issue is, giving me a hard time earlier, is it's a lot easier to do, especially sort of for most surgeons out there. If you can do a rotator cuff, you can do this. So you can see it's basically doing the half of an SCR. You're covering the tuberosity. You can do this now in 25 to 30 minutes easily, and everybody can really become proficient. So what are some of the results? And actually, we have a multicenter study that will be coming out with our first group, and it was a multicenter with Rafi, ourselves, and several others. So this is a guy. He's actually a laborer five weeks out. So the benefit is there's no tension on this graft, and they actually can heal very quickly and do very quickly, sooner. Here we have a 55-year-old guy, active duty. It's a guy who we don't want to do a reverse shoulder. He has full but painful range of motion, unresponsive. And so basically, again, irreparable cuff, and we did a tuberosity graft on him. And these people are getting back very, very quickly due to the fact that you don't have to worry about the tension. They heal very, very quickly. And again, I am not proposing that everybody goes out and do this, by the way. This is meant to be provocative, but something we've been doing now for about five years. Here's another one, 53-year-old former college wrestler. We did, again, we abandoned SCR probably about three, three and a half years ago, and we went to doing more of a tuberosity graft on him as well. So we've done quite a number of these. The question is, are these going to ultimately go up and down what's called Scott's parabola, meaning we're talking about this like we're talking about SCR where it sort of goes up and down. So there's a lot of things that we still don't know about this. So I appreciate it. And again, not meant for everybody to go home and do it, but just something to think about. Thank you. Well, this is a talk all of my panelists wish they were asked to give, because I don't think anyone has a question that the reverse shoulder replacement is here to stay, has stood the test of time, has over 2000 papers showing its effectiveness, and works for massive rotator cuff tears. I do have some disclosures that are relevant. When we're looking at these irreparable rotator cuff tears, age probably really doesn't matter anymore. It's trying to find the best operation for the patient. And with better improvement in technique and devices, we've come a long way. So we have our case. And what's really important, and nobody here has talked much about the patient so far. We got to ask our patients what's their goal. They don't want a lot of operations. They want pain relief, functional restoration, return to work or sport. They want predictable outcomes. They want something that lasts for a long period of time. All of these things are nice. I've done all of them. And there is an indication for every one of these operations. But when it comes to predictability, durability, and reliability, it's hard to beat the reverse shoulder replacement. So our patients come to us and they say, Dr. Hartzler, what if my SCR fails? What if my rotator cuff repair fails? My lat transfer fails? Well, the answer is reverse shoulder replacement. So maybe sometimes we should do the second operation first and save the burden of care to our patients and give them something that works. And as we talk to our patients, we really need to make a decision along with them what we do. What's their function now? And what's it going to be after surgery? What's the quality of their tissue? And what do they have remaining? And what's the host like? A lot of these patients are not so healthy. Or even if they are very active, maybe they don't have a good healing commitment. So you want to choose a procedure that has the least long-term restrictions and the best possible durable outcome. We've come a long way from the original reverse we were all putting in in 2004. And with the evolution in design, we have better range of motion, better results, better longevity, less complications. And when we look at the reverse, it's the only thing that really restores the stable, fixed fulcrum for rotation, and that's why it reverses pseudoparalysis predictably. Everything else functions as either a spacer or a restraint to superior translation, and we can get predictable results even in massive cuff tears. We have long-term follow-up. This is 150-month average follow-up with the GERMOD prosthesis, showing implant survivorship greater than 80%. With a lateralized implant and a lower enough shaft angle, we have revision rates at 12 years of 6% for massive rotator cuff repair, and including Dr. Hartzler's mentor who taught him how to do this. I think he would not like that x-ray you showed, by the way. We can get good results long-term. Meta-analysis, you can pick a million papers. There's 2,000 of them out there, showing that for massive rotator cuff repair, we can get good, reliable outcome. What about return to sport? There's a lot of papers out there. People can go back to play golf. They can play racquet sports. They can go to the gym. They can swim. They can work out. They can do it predictably. They're usually back by six months. Some of these operations have very long-term restrictive rehabilitation programs, up to a year to go back to sport, slings for a long period of time, gunslingers, what have you. This is, at most, a couple weeks in a sling, and they're back to their activity. So who doesn't do well? So if patients have preserved active range of motion, maybe the younger patients don't have quite the durability. If they have high functional outcome scores, preoperative and an absent teres minor, then they don't do as well with a reverse shoulder replacement. Long-term follow-up for every operation we talked about, it really doesn't exist. After two years, most of these operations starting to trail off, with the exception of arthroscopic debridement. So what about having an RSA after? Are we burning bridges? Well, the answer is, we might be. RSA after rotator cuff repair, compared to doing a primary reverse, higher complication rate, higher revision rate. After simple rotator cuff repair. RSA after SCR, two papers out there, showing lower patient-reported outcome scores, lower range of motion afterwards. Significant burden of material that you gotta remove from the shoulder. Perhaps there's an infection rate that we haven't understood yet. RSA after balloon. The published studies show increased complication rate, lower patient-reported outcome scores, increased revision rate. RSA after LAT, and lower trapezius transfer. Not a lot of data out there, but also showing a complication rate that's a little higher than standard. So, for massive rotator cuff tears, what's changed over time? We're far down the learning curve. We're familiar with the operation. We know what we can get. We've reduced notching, which was a major issue with longevity. We're getting better range of motion. We have more implant options. We can revise reverse shoulder replacements, which we couldn't 20 years ago. It's durable, it's predictable, and we can get good range of motion out. So, reverse will work for you if you give it a chance. Thank you. All right, awesome debate here. So, who won this debate? We're gonna go down the line here. Rob Hartzler, SCR. Oh, okay. Nobody? Not a single person. Oh, Rob, that must feel bad. Joe Abood, balloon spacer. Oh my goodness, nobody. Paul, can you believe this? I mean, somebody out there. I don't know. Okay. Moen, Moen, who'd you like? I actually like the SCR. SCR, what? SCR. Yeah. All right. Eric Wagner, tendon transfer. We got some tendon transfers here. Oh, a lot of hands. Look at that. Kevin Bonner, we got the biologic spacer, tubroplasty. Actually, people are leaving the room. That's weird. Gia, who'd you like? Oh, everyone. That's a surprise. Very surprising here. And then, the last, but not least, Evan Letterman, reverse total shoulder placement. Paul, I don't think some people raised their hands here. You know, I'm worried. Who didn't raise your hand if you didn't raise your hand? All right, who does that go to? I think it's a split between. Actually, Evan, stand up. Rob, stand up. Guys, hold hands in the middle. Raise them up. Equally inclusive. Gotta get this picture. Hold hands. All right. I mean, that was an awesome talk. I think the real Jedi sense on this is because I suspect all of you on this panel do some iteration of these, is figuring out who needs what. And I suspect that happens not by imaging, but by a careful exam of understanding what that patient needs. And maybe that's the part that I learn when I walk away from this meeting. Not to do each of these procedures, but to learn who and why to pick what and why. Yeah, I couldn't agree more there, Madam Paul. All right, fire away. All right, so, Rachel and Anna, thanks for allowing me to give this talk. We're gonna talk augmentation for massive irreparable cuff tears. My disclosures are on the Academy website. So, we know, like, we just heard some great talks. This is a large spectrum of possibilities. And who does biologic augmentation? We're gonna talk about biologic augmentation, who it might be appropriate for. So, we'll talk about SCR, patch grafting, tuberoplasty, and then biceps, anterior cable reconstruction, or ACR. So, the main cruxes, or just Paul mentioned, is what is your indication? Is this a functional loss problem with no pain? Is this a pain problem with preserved function? Or is this a mixed bag of functional loss and pain? I think we all agree, if we see this, a true anterior superexcape with pseudoparalysis, there is nothing that any of these non-arthroplasty options are gonna work except for a reverse. Well, how about the opposite? Isolated pain, good function. So, preserved elevation, very limited, HAMADA changes, no osteoarthritis. What options are available here? Well, I would argue all. You could probably do anything in these patients, and they'll probably do well. There's Mayo Clinic study, greater recognition C for all non-arthroplasty options, which is essentially neither for nor against. So, my partner and I looked at 3,000 shoulders as a systematic review, and in fact, debridement actually had the best post-operative range of motion and pain scores. And this belies the issue of what is your indication for this? So, the question maybe we need to ask is how do all these treatments, including these novel treatments compare to the gold standard of debridement and partial repair? So, if you have a mixed picture, these are the things I consider. Age, degree of arthritis, goal of surgery, durability of the procedure, and the risk tolerance of the patient. And I find myself asking myself who is indicated for reverse in this situation, or who is excluded from reverse? And probably patient selection, as Evan had mentioned, patient has to be comfortable with the risk of reverse. A patient has to have advanced age or cuff arthroplasty in this scenario with regards to their function, and they desire a predictable outcome with durability. So, pain relief, functional restoration, or both. And so, these are the people that I would consider for a reverse. Who's not getting biologic augmentation? Probably these three categories for me. Somebody with advanced arthritis, loss of exonotation as their primary or main isolated complaint, and again, the pseudoparalytic patient with anterior superexcape. So, let's first talk about pros and cons of SCR. Now, Mahad has demonstrated excellent five-year clinical outcome, but this is autographed. Remember that these graphs are seven to eight millimeters in size. The Rush Group has recently looked at this as systematic review. More tempered outcomes, good outcomes, but high failure rates both with allograft and with autographed. This is a study that Kevin had mentioned. We looked at in vivo kinematics following SCR to look at whether they would have changes in kinematic function after the SCR. We did it through a biplane fluoroscopy. We were able to then model these with 3D bone models, and so we could really accurately see what was going on. And again, much to our surprise, we didn't see any change in kinematics, and there was actually no correlation with the patient-reported outcomes and graft healing. But despite that, all of these patients did very, very well and went well beyond MCID with improvement in their scores. The grafts also stretched beyond their intraoperative length, and they stretched well beyond the failure strains. And so, if the SCR isn't doing anything in terms of a kinematic standpoint, then the question was, what is it actually doing? And so then we hypothesized, well, this was really a pain-relieving spacer, and hence, the concept of maybe a tuberoplasty could actually do the same exact thing. Now, who can an SCR actually be indicated for? This is a multicenter study that we did with Ruth Delaney, and we looked at SCR versus margin convergence. We were able to achieve excellent outcomes in both cohorts, but in particular, with the patients who had pseudoparesis with elevation less than 90 degrees, the SCR actually significantly improved that motion, and margin convergence did not. So, SCR take-home points, I think it still can be a viable treatment option, particularly in patients with pseudoparesis. There are some studies showing durable outcomes up to five to 10 years. There's no effect on in vivo kinematics, and thicker grafts appear to be better. So, if this is a spacer effect, then what about this concept of a biologic spacer or tuberoplasty? And for those haters, how is this really any different than a subacromial balloon? And so, there is some biomechanics that support this. This is from Ty Leasod, demonstrating tuberoplasty can improve superior translation, subacromial contact characteristics, and acromial humeral distance. And clinical studies presented by Rafi Mirzayan and others demonstrating good improvements with patient-reported outcomes, and other studies demonstrating that patients would actually have the procedure again. So, Kevin, I think you might still be onto something here. So, systematic reviews recently demonstrated 2024, good clinical outcomes, significant pain relief, but with variable reoperation range. So, take-home points of tuberoplasty, some biomechanical evidence that supports it. Tuberoplasty, I think, can be considered in the same vein as a subacromial balloon spacer, but questions regarding durability and what will happen with these over the long term. But the issue sometimes is cost. An L-graft is costly. This is a study from the Mayo Clinic demonstrating an SCR was actually more expensive than a reverse or a tendon transfer. How about just using the biceps tendon? Biceps is a local graft. It's cost-effective. If you use it as an SCR, you can achieve similar outcomes compared to allograft. If you use it as a patch graft, you can also have similar good outcomes lowering the re-tear rates, but probably further studies are needed. What the hell is an inter-cable construction? Many of these patients have a loss of their rotator cable, and oftentimes you can only repair the posterior aspect. And so this is a concept in which you take the biceps tendon to reconstruct what you've lost with that rotator cable. And there's been many techniques described, including leaving it intact distally or tenonizing or tenodesis and taking the proximal stump and securing it to the humerus. ACR outcomes with the use of biceps can diminish the re-tear rates of partial cuff tears and also can also improve acromial distance, at least according to this Korean study. There are some biomechanics that support this as well. This is also from Tai Lee Zab using a semitendinosus allograft, but they've been able to demonstrate that it can improve superior translation, subacromial contact characteristics, and range of motion. Lastly, what about bridge allograft? Ivan Long has presented this great paper as a RCT looking at bridge allograft versus repair. And in his cohort, the dermal allograft bridge group actually had less re-tear rates and excellent outcomes compared to repair alone. And why is this good compared to sort of the other literature that's available? If you scrutinize this technique, the re-tear cuff cable is either intact or it is restored. And so it absolutely needs to be restored for this to be successful. And the re-tear cuff needs to be there rather than just bridging the gap. So take home points on biceps and ACR and bridge allograft. Using the biceps is cost-effective with reasonable data for use in SCR or ACR. ACR may be a promising option, particularly in combination with partial posterior cuff repair. And patch grafting can still work, but you must restore the anterior cable. This is my evolving algorithm. If they have full motion and pain is a primary complaint, don't forget about just debriding it, partial repair, margin convergence. If the biceps is there, I use it. If there's no biceps or margin convergence, I tend to use a tuberoplasty. True pseudoparalysis, I think a reverse is the right option. A mixed bag of pain and functional loss. If you have minimal arthritis and pseudoparesis in a young patient, I would consider biceps ACR. If not present, bridge allograft or SCR. In an older patient, biceps ACR. If not present, balloon or tuberoplasty. If the patient wants a one-and-done, desire a one-and-done procedure, then I think a reverse is the right bet. And if ER loss is the primary complaint, then tendon transfer is the way to go. I think these newer options need to be, we need to ask, are these options better or more cost-effective than gold standard or partial repair? And definitely high-quality comparative studies are necessary to make sure that we're comparing the right indications. Very quickly, this is a 67-year-old who's had multiple years of pain, has very small, very minimal harmonic changes, irreparable supra-infra with excellent, well-preserved motion. He had no biceps. We had no ability to do a margin convergence. We ended up doing a tuberoplasty with a partial single-row repair of the posterior cuff. He's one year and doing well, but who knows what the durability of this procedure is. Thanks very much. That was a great talk. Clear as mud, unfortunately. I mean, as we leave here today, I'm hoping that this panel is going to give you some guidance on what you do on all those cases in the middle. Does anything work? Is anything durable? Is it all going to go back to reverse? We'll find out. All right, so good. So we're going to go through some cases here, and we have our esteemed panel here to get to go through this. So I'll highlight this as a 52-year-old. This guy actually works as a PT tech with me, so I see him all the time. So I better do the right thing, otherwise he's going to torture me forever. He had a fall eight weeks ago. He can't lift his arm at all, so this is an acute injury. He's very, very active, and you can see his motion. He's got 60 degrees of elevation. He's got a positive drop arm. He has an external rotation lag sign at the side as well, and he's quite weak. These are his x-rays. I'm not going to trick you with any of these, but here are his imaging findings. So there's coronals, which we'll kind of spin through here a little bit. So, Eric, let's jump to you right away. Look, this guy was normal. He's 52. He clearly, his shoulder had no issues before this fall, and now you have this MRI. What makes you nervous? You got 30 seconds, by the way. All answers, 30 seconds, otherwise you might forget. What makes you nervous? What makes you excited? Yeah, the only thing, if I could see a sagittal just to see the muscle quality, but I mean, it's a massive retract tear. The tending quality looks pretty small. I can't really see the muscle quality. I mean, if the muscle quality is good, I mean, it seems like an acute setting. Why not repair it with a structural graft to augment the tendon? I can't really tell on that sagittal what the muscle quality is, but if there's fat infiltration, in my mind, this is a active patient who has weakness. If you try to repair it functionally, that's not gonna be a normal muscle that's gonna power the shoulder. Why would you not want to sort of make up for that muscle deficit? So it all depends for me on the, on whether I feel like the muscle makes it repairable or not. We'll keep going. All right, so muscle quality is totally normal. Very retracted tear. Tendon quality looks a little iffy. He has acute pseudoparalysis. Muscle quality's not normal. There's atrophy there. It was a shitty sagittal, but it was there. All right, well, let's say he has a little bit of fat atrophy. Joe, Albert asked questions. You don't ask questions. Yeah, yeah, thanks, Paul. All right, so Eric said repair with potential grafting, right? Right. So these are some of the options here, and there may be more here, but rotator cuff repair alone, biceps ACR augmentation, rotator cuff with a patch or biologics, and then perhaps what's in your toolbox, and what do you have available if you can't fully repair this? Can you tell me? So for me, that's an at least acute on chronic. He has a traumatic. He has good muscle function. It's a massive tear, but usually they fall up in the back, so if you pull them in front, you get them back. So from the healing criteria, the massive tear is the most rational criteria for problems in healing. He is a guy. He has good bone. He has good muscle. So I'll go for a repair, and I would augment it because of the massive tear with the biceps in an ACR fashion. This is your editorial. Finally, something good about the biceps tendon. Didn't you write this editorial? In fact, I did the same development like you did, like I told him this morning. I love to use the biceps to augment my repairs. Gia, is Knut wrong? The answer is yes, but tell us why he's wrong. Well, for me, I think if you have the biceps there, and it seems to be repairable. I am worried about the length of the tendon there in the magus, so I think the biceps is interesting to try to improve your repair and the thick of the tendon repair. What happened in this case, Albert? So when we went in, obviously, as you guys alluded to, a very retracted tear. His biceps was still present, and so I've become a believer in keeping the biceps. It's a local graft. I think it's an excellent kind of augment, and so we were able to kind of suture the graft, the biceps. I left it intact, just sutured the biceps through the medial, anterior medial row anchor, and then passed the sutures through a standard double row type technique. Rob, you were tough on everyone this morning. Was Albert a half a surgeon on that or a good surgeon? Looked like it. You repaired that completely, correct? Yeah, it was a complete repair. Yeah, no, looked good. I'd go after this one. That's it? Yeah, augment with dermis if it's not looking good. You're so tough. All right, so here's a video demonstration of this technique. You can see this is a pretty bad looking biceps, right? You know, a lot of people would not look at it. Oh my gosh, it's vascular, though. It's got blood better than all these grafts. Subscapularis, there's a partial tear. That's gonna get repaired. The biceps gets released out of the tuberosity on the lateral side here. You look at the tear, try and get your anatomic reduction of the tear. But in this case, I think the tissue quality's lousy. You saw the MRI. We're gonna bring the biceps out of the groove and translocate it up onto the tuberosity. Where you translocate it really depends on the degree of tearing, I think, and how you choose to fix this, whether you're a single row or double row person. You know, why don't you start talking, Kevin? Talk us through this as we're watching the video. Yeah, I would try to do a double row. I think, regarding the biceps, Larry Field has written on this with very good results, and we've been starting to use it as well. The question is, where do you put it, as you said? But I would try to do a double row repair. Augmenting with the biceps, I think, makes sense, but I would certainly try to fix it. Moen is a frugal Canadian who doesn't want to use grafts irreverently. Are you gonna use grafts? Are you gonna cut the biceps? Is this gonna cause stiffness by leaving it attached to the supraglenoid tubercle? Yeah, I don't know. I would probably do a tenotomy or tenodesis with the biceps and repair the tendon if I felt that it was kind of crappy. Tenotomy? Yeah. What? Yeah. They're Canadians, Paul. You know? Joe, do you ever do this procedure? Biceps ACR? Yes. Yeah, would you do it for this case, too? The quality of the biceps there is pretty poor, but it's a good argument. It's cheap, it's there. The research that's been coming out is promising, so it seems to be that we're switching our pendulum to the other side of the biceps now. Instead of cutting it and tenodesing all of them, now we're using this graph. So I guess we don't know what we know. Yeah, Rob, what do you think? To me, this one is one that I would not do this technique because you're placing that biceps onto the greater tuberosity somewhat. You moved it over, correct? So where there's perfectly good supraspinatus tendon that I want to heal onto that bone. So for me, I'm not sure what you're doing here on this one. Good, I like the criticism. So with responding to the quality of the biceps, I think that if you're worried about a lousy quality biceps, I would submit that it's better than any dead dermal bovine, any graph that you could put in. You've got live tenocytes. Whether you need it or not, I think you make some preoperative assessment, rohe, fatty infiltration, and Rob, to your point, I don't think you can actually look at tendon and know what you're looking at. We wrote that study and it histologically had surgeons grade the tendon quality and then looked at what the Bonner score was, and they didn't correlate at all. So when we think we know what we're looking at, I would submit that be cautious. Knut, any final insights on this, because we want to get to the next case. Well, I also agree, and I think that even if the biceps looks such disastrous, we have very good results in transposing it. Johannes Barth has shown very good results, even if it really looked torn, and you can still use it and augment with it. What about not introducing it distally or proximally? I mean, do you need to cut it to superglenoid tubercle? Do you need to release it below to prevent stiffness? Well, I do cut it distally, but basically you don't have to. Yeah, you know, I mean, whether you cut it or not doesn't seem to really matter, and I would be interested sort of in future sightseeing whether that really even makes a difference, but since this is a conference, I have to not show a shitty video. All right, so case two. So this is a very healthy 63-year-old carpenter. He's a nonsmoker, very, very active. He had acute injury. So this is a two-part. Basically, he had a cuff tear. We did a double-row repair, subpecting adhesives. He did great. I lost some follow-up after about five months and then about a year after his follow-up he had a new sudden injury and now has a Active elevation of about 70. So he has a acute change in function and this is his post-operative MRI So Kevin, what do you what do you think of this? Yeah, it's Obviously not going to be as easy as the first time it's somewhat retracted But honestly with his acute injury even after a repair I would try to fix this and I think it'd be perfectly reasonable to have an augment something to augment it as well But I would personally try to fix this Eric How do you know that this this is an acute re-injury versus failure failure to heal at a year? Like how do you decide that? Yeah, I mean that's hard a couple things one the muscle by muscle quality looks good We know no after tears. It's about a year or so of great of good talia So that gives you some insight to the tendon quality actually looks pretty decent still. It's not a type 2 tear It's not a muscular tennis tear So there is some tendon to repair now that it's not going to be normal biology on the true on the on the durocity But nonetheless, I do think you can get reasonable quality tendon And then you just have to decide how you want to try to get to heal this this time around So Kevin had mentioned an augment here. We didn't really talk about biologics Anyone in a revision scenario, you know would consider doing like PRP or ACP maybe just a Raise of hand. So anyone supplement this with PRP Audience are you gonna is anyone gonna add PRP to their revision a Couple handfuls so this is what you encounter intraoperatively, so Can you what do you think of this? So, I think I think that that is a repairable re-rupture for myself so I would go for repair and I would Augment since we are not so much patch augmenting I would augment with minced borsa, but it's just to have a little bit of feeling of putting something in there additionally Which is you go, but I think this is repairable and I would do a repair basically a single row in this situation Gia In this situation because you can improve your healing chances graft So Rob when you have an intra tendons component like this, how do you fix this? I mean, there's a large clump of tissue on the tuberosity Just technically. Yeah, if that's good If so, I'm like if you remove all of it, you're gonna have nothing left Yeah, the million-dollar question for me is just is that good that that lateral tissue? So, you know if I interrogate that really thoroughly it seems good. It seems like tendon then I'll do it's DS Yeah, it's decent. Okay good. So I'll do a meat. I'll do a medial row I'll do an anchor base basically like transcendent is repair. So one or two anchors At you know at the medial aspect of the greater tuberosity pass the sutures through the cuff through the Residual lateral tissue tie down and then probably in this case since it's a revision do dermis on top of that whole thing Okay, do you should hang on we have to stop here You remember in trauma you had to have your synthese little thing and draw out your plan As it turns out we went into sports medicine. So didn't we have we didn't have to do that This is actually Albert's plan he drew it and for like an uber bright super how is that your handwriting? I'm Asian, you know, I Was thinking that but I couldn't say it no, so You know, it's a I mean, no, I can barely read my own handwriting so but the the picture basically just depicts that we put a bunch of side-to-side sutures to kind of hold the kind of pull The tissue down and then we you know supplemented with the double row repair technique But you know rather than you know, kind of just that what we talked a little bit about biologics here And so what are we gonna do here? How are we gonna augment this? And and so, you know, maybe a Moen like, you know, if you're gonna supplement this with a biologic patch, what are you gonna use here? And why? Yeah, I would use either any of these patches I think I don't know if you know evidence is stronger for one versus the other but I would try to augment it whether a Slayer doing an olograft or something like something like a regenitin patch a sailor general olograft Joe intuitively Does it make sense to do an emphasis augmentation below the cuff or something on the superior aspect of the cuff? We don't want to say both because that doesn't seem you know responsible in a way, but how do you think about that? I mean intuitively it makes sense on the bottom side of the cuff just because tendon and bone are going into each other Versus adding biology on top of it. That's intuitively but I'm not sure Does the rest of the panel agree that it makes Joe says it makes more sense to to put an emphasis repair But all of you on the panel are talking about over the tops. Is that right? No, you spent like two years in the lab. I mean, come on Let's give you some stuff here. That's well exactly the thought. I mean we tried to We looked at to put collagen patches on the emphasis compared to dermal patches on top So on top if you integrate it into your double row you have a little bit more about biomechanics stability, of course But the healing you want to have in the anthesis, but at the end of the day now 2024 what we see is that these Biologic patches seem to do something just by laying on top of it. So that kind of brings all that upside down Yeah, you know Paul if I back this up Can does all this the entire panel are they gonna put a patch on here like so is that even debatable? So if we have a raise of hands whoops putting a patch in this scenario. Oh Only half only half half surgeons, I mean it really depends on the quality for repair and the tissue I think I mean you could have it there available, but I think that's a game day decision Honestly, I mean, I think we are able to actually get a pretty good repair on this So but so if you if that if you got a good repair that you would leave that alone So Kevin, what are the results of revision rotator cuff repair? Just done doing the same thing over again Not even close. Yeah, it depends on your tissue quality. Honestly, as you know, it really depends on what it looks like They're clearly not as good as primaries. Everybody knows that but they're all not the same There's a spectrum and it really depends on the tissue quality just like Alberts on that case If you can get a nice repair without it, especially if it's not a type 2 failure You can actually have very very good results and then you get in there in other cases the tissue is awful and you're like Why am I here? So, you know, it's a spectrum. So it's not they're not all the same Rob You're gonna mention something here I was just gonna say that I mean I think there's a lot more data in the primary repair situation for augmentation and revision and for me It's doing it's doing something just based on let's do everything We possibly could for a young patient rather than really what's in the literature I just don't think we know very much about revision rotator cuff repair augmentation So I augmented this repair with a dermal allograft and I and Paul can kind of take us through this video Yeah, actually, let me walk back here All right. So here's a previous previous surgery important to net recognize the subscaps in the anchors are out. There's there's a tear There is decent tissue I'm trying to switch over to a different style anchor a smaller body anchor and actually I do think I got reasonable tissue I'm very careful on this medial bridge not to over tighten or over constrain to create a type 2 Re-injury, but I want to get as many bites as I can but nonetheless this is sort of it felt Okay, but I wanted to do a little more in this case. I chose to use the dermal graft I think you have a lot of choices on what grab to use and then technical features of it It just has to be easy Joe. You said this to me before it has to be easy and efficient I choose to use a posterior insertion point that actually for me makes it just a little bit easier I really want to be careful to line this up over over my repair I don't want to get too medial into the muscle belly it I want to just augment what I'm worrying about here And then there's lots of ways to fix it This is this is one technique where you can use these pledges and sort of affix it into two points on the medial aspect Use a couple of these medially maybe two sometimes three and then laterally I'll fix it down on top as well I don't know. I don't know if anyone has a strong opinion Rob, do you have a strong opinion on what the graph should be in this case? What material I? I Just said we didn't know anything about it. Yeah I mean and I guess we do have some data that suggests that this is gonna reduce retail rate whether that's from California or somewhere else in this case I had to go back in and put one more pledge it in to sort of seal it down into place and to be quite Honest with you. I am gonna you'll see at the end a spinal needle slide underneath the graft I'll evacuate the joint at the end and then I'll inject Biologic du jour and and again, I'm not sure but perhaps I am taking that kitchen sink approach And I don't know if that's the most intellectual, but I don't want to lose a second time So you've gone from a tear to a primary repair to a grafting situation? You didn't like what I did last time parts there. Be careful. I love this Actually, I love the postural lateral viewing portal with the graph coming in posterior and then working lateral. That's really good I love that. Yeah Bonner. I was gonna say let me ask you cry No, we're supposed to but let me ask because I think it's important rehab What are you doing for rehab because I need it's very important, especially in these revisions How slow or how aggressive are you being? Are we letting him sit for six weeks? Are we starting Gia in the moment you answer those questions? I wait Four weeks for everything and two weeks with a slim but passive motion and no strength until three months Always so nothing for four weeks and then and then strengthening at three months. Anyone's substantially different than that The strength for me is very important. I talk with a physiologist because they try to go really fast and I don't like Nothing else Paul does it matter what side that graft is on? So it looks like the dermal side is actually down on this video. I Don't you should tell me I don't know. Yeah, does it matter what side the graft is? Brian Cole it might You want the reticular side does that market are on the graft to no reticular Oh Rough rough is reticular. It just looks bad if you're rough sides up You know a few Brian Cole All right, one one very quick case here and and this this goes to a quick debate here So this I got this case from from Rob here 78 year old retiree has good motion failed PT injection She has very minimal hamonic changes these are the MRIs which essentially demonstrates supra in irreparable supra infra Really no other major issues and this is what you see intraoperatively All right, so we have the conundrum of a well-preserved motion pain is the only complaint Can you what do you think of this I Would go for a reverse in that situation. I mean I even a great motion Showing here. She's showing you a scope video She will not like the discussion she will not like it, but whatever You do in this lady will kind of fail and then she will come after eight months and tell you you didn't told her that She will rerupture so I would try to go for a reverse in her. Okay. Okay. We got one reverse here Kevin This is a perfect person for a tuber plastic. You think no. No, honestly, I've been doing my tuber plasies in younger people Who I don't want to be do reverses on what would it maybe decided me and this was in the history I had my other cuff fix and it was the worst year of my life Okay, and then for that reason with that bad tear in a 78 year old I would push her towards doing a reverse Joe reverse here. Tell him the truth space there. Yeah, I mean if she's functionally over 50% Sane score I would not do a reverse I mean a reverse is a serious operation and we can all make jokes But there are a lot of complications the reverse and a 78 year old with good motion. It's got perfect motion Perfect motion. She's gonna be disappointed with that operation and you're exposing her to chromium stress fracture balloon every day and twice on Sunday I just want one word answer. Yeah. I'm yeah, I said I do bloom preserve motion Non-functional deficits. I did one moment Whoa, you actually read Albert's papers, huh to breathe it works And then Rob I know I know what you did here but it was Sunday so we did two balloons So we have 10 seconds left Does anyone on this panel other than our friend from Canada actually offered to readmits and a regular do the briefness raise your hand? Readmits partial repair. No. No, I didn't say that That's a repair When you get in there, you can fix something you could always read me the bereavement alone. Raise your hand on the panel Mo and you said you do you got us? Well, I do it with a tenotomy or something else. Ah, okay audience Are you still doing to breathe mitts on anyone? Is this? Anyone with gray hairs raise their hand it seems like it's a good idea. That's pretty good All right, that concludes our session. Thank you so much. Thank you so much to the faculty panel Please welcome to the stage. Dr. Mark Gettleman I'll do a brief introduction. All right Thank you, I Appreciate this opportunity to be back at the podium today to update you on an initiative that began during my presidency Havana in 2021 Diversity inclusion and improving and impacting the racial and gender disparities that exist in orthopedics more than 90% of you orthopedic surgeons in the United States are male and 85% of orthopedic surgeons are white and this statistic underscores orthopedics as the least diverse medical specialty in the nation Not a title that we wear proudly but one that is dedicated to changing Collective strength yields greater impact and in alignment with this principle Anna forged a strategic partnership with diffuse synthese a partnership rooted in shared values and a unified vision Together we are committed to creating a more diverse and welcoming community for orthopedic surgeons Out of this partnership came a series of courses called future scope Introduction to arthroscopy and orthopedics impacting DEI and inspiring the future future scope addresses its fundamentals of an orthopedic practice as well as offering professional insights and opportunities within the field first and second year medical students learn from several renowned orthopedic surgeons many of whom are here today as They dive into a day in their lives here how they got started in orthopedics and so much more Future scope courses have been held twice a year and in 2022 and in 2023 We completed those and continue later this year as well So far a hundred and ten medical students that would not have otherwise been exposed and given the proper experience with orthopedics That wouldn't have otherwise been given the appropriate guidance and mentorship have been influenced. Thanks to Anna and diffuse synthese These numbers are just the beginning of our impactful story And we will continue to follow these medical students through their journey Which hopefully leads them to an operating room in our hospitals one day soon It's rare that an organization can say with certainty that we impacted every single person in the room But look at that number a hundred percent of attendees indicated that they have integrated skills at the course That impressive stat is thanks to the dedicated faculty that understood our mission Embraced our vision and with laser laser focus shared their passion for orthopedics with these hundred and ten medical students 59% of medical students don't feel that they receive appropriate mentorship in a medical school setting after attending future scope 94% feel that they are better equipped to obtain a mentor and 81% have already pursued mentorship six months after the course Mentorship is important and imperative to guiding these medical students towards a future in orthopedics So did we do it? Did Anna and diffuse synthese move the needle? Well, it's too early to tell right now But there's a hopeful sign that we're accomplishing the goal A hundred percent say that we successfully contributed toward their career path Additionally a hundred percent of the attendees strongly agree that representation with orthopedics and access to courses like future scope are the primary drivers of eliminating the under representation barriers Finally I'd like to thank the few synthese for the opportunity And their contributions to this very important program that we continue to grow into the future. Thank you very much No VOG, right It's I think it's coming but if we We can hold on the VOG the voice of God Good morning, I'm Brian Cole from Chicago former and a president and I'm delighted to participate and moderate this session this legacy session Which every program chair has sort of a brainchild and I know that she and JT went back and forth and this is Rachel's brainchild so you can either credit her or blame her after the session But I would say she'll do deserve much like the entire program a lot of credit So it's a I think it's a wonderful idea you're gonna be hopefully inspired by some individuals who Rachel has impacted and take a little bit of a different bend on things that we don't traditionally take through didactics and case-based learning So I'm privileged to be partnering with Rachel and Rachel. I'm gonna let you take it away. Well, thank you. Dr Cole can I invite our additional speakers on up to the podium? Miranda and Hannah as they're making their way up When JT and I were going over the blueprints for this program we kind of started a little over a year ago in New Orleans phenomenal program then and He told me take a little time during the meeting for something that's important to me And I said JT this meeting is not about me. This is about you This is about Anna, but he said do something that's important to you And so I started to think what should I do perhaps another session on shoulder instability? We can't get enough You know, how many times can we debate bone blocks or perhaps a cartilage session? You all know if you know me how that gets me going. I love cartilage and could talk about it all day But then I really started to think I started to think about JT about this meeting what Anna means to me and what I think of when I think of Anna and what I think of or who I think of when I think of Anna and An idea came to mind and it was so obvious But then also potentially so cliche and you all might think it's cliche and then we'll spend the next 20 to 30 minutes kind of sitting here together but for me, this is what I think of when I think of Anna and when I think of who makes up the heart and soul of Anna and Especially when there are so many other arthroscopy focused topics that we can focus on. This is a little bit different So I pitched this idea to JT and to my surprise he was actually all in and so here we are in 2024 with a new session that maybe will continue maybe not but we're calling it the Anna legacy session What does this mean? Why are we here? Why are we spending the time? It's because we have an impact we have an impact on others our Patients every day the actions that you do or don't do they're watching. They're listening. It impacts them We have an impact on our trainees our students our residents our fellows and the legacy we leave with the decisions that we make Our everything and even when we're just doing our jobs. We came to work. We saw patients we operated and we went home That leaves a mark that leaves an impact We're doing what we signed up for but it's the little things that leave a legacy To help tell this story. I'm gonna come back to the podium in a little bit but I think there's two people here who could do a better job explaining what I'm trying to talk about and Those two individuals are here at their first ever Anna meeting and they're here to tell their stories Miranda Manfrey and Hannah Cardenas both Miranda and Hannah work at our CU sports medicine program as research fellows But that's not how they started They've each had a rather unplanned journey kind of like my unplanned journey into where I am today And they're gonna tell a little bit about their story And I think you'll get a view for what I feel the Anna legacy is all about so I'd like you to give a warm very welcoming welcome to Hannah and Miranda for coming to tell their story and We will start with them. Thank you all very much Hi, I'm Miranda and it's truly a privilege to be here with you all today I'd like to thank Anna the program chair and my co-speakers I Also have no disclosures So a little bit more about me I graduated from the Colorado School of Mines in May 2023 with a degree in applied math and I'm currently applying to medical school I'm here today because while I was unfortunately injured during my collegiate track and field career I was extremely fortunate to meet. Dr. Frank is both the surgeon who fixed my knee and as a mentor for my future career in medicine Growing up I played all the sports soccer flag football, basketball, you name it. Then, towards the end of middle school, I fell in love with running. I competed in track and field throughout high school, and I ended up being recruited to run at the Colorado School of Mines, specializing in the 400 and 800 meter distances. My freshman year, I was thriving. This was the first time I had a preseason that was not just playing basketball, and I even started strength training. I put up some of the fastest times I'd ever ran, and I was setting a new school record with my four by 400 meter relay team almost every week. Unfortunately, I'd always had some off and on knee issues prior to college, and with the increase in training, they started to get worse and much more consistent. I soon started waking up with my knee already achy and swollen, and I distinctly remember standing on only one leg during my three hour chemistry labs in the hopes of preventing further swelling since I had practiced in the afternoons. Nothing seemed to help, and I ended up being sent to the doctor. For all the athletes in the room, you know that this is literally one of the worst things you could ever hear. Leading up to the visit, I was sick with apprehension. I spent nights in the library googling my symptoms instead of studying, and I walked in expecting runner's knee, a bad case of IT band syndrome, or at worst, a chronically torn meniscus. I could never have imagined the true diagnosis, osteochondritis dissecans. My visit with the first surgeon was difficult. It felt rushed, and I was told that I was unlikely to return to running even after undergoing two surgeries, and I left feeling devastated. My coaches and athletic trainer recommended I obtain a second opinion, and I found Dr. Frank, a retired collegiate athlete herself who could empathize with what I was going through. The entire process felt like a dialogue. She provided realistic prognoses while also recognizing my need to return to high-level athletics. She also met me where I was at and took a stepwise approach to my care, making me prove that I needed the larger osteochondral allograft transplant and later a second look scope. She even indulged me in discussions about treatments, adjuncts, and ideas for further research. I felt like an active participant in my care, and it worked. In my first season back, I matched my pre-injury 800-meter PR. This is a photo with my team after we won the first conference championship in our school's history. And this past fall, I even completed a trail half-marathon. Now, when I zoom out and reflect on this experience, it's clear that it has had an undeniable influence on my desire to be a physician. It marked a period where, as a patient, I was able to personally measure the effect a doctor can have. Dr. Frank made me feel heard and had the technical expertise and knowledge to fix my knee. I longed to one day have that same impact. Fast forward to the start of my gap year, and I reached out to Dr. Frank to see if I could shadow her again. She did me one better and offered me a job as a research assistant inscribe. Now, I'm going to make some assumptions here, but I feel like she recognized my desire to learn more in our interactions as patient and doctor and took it upon herself to foster that curiosity and give me a hand up into the world of medicine. Again, this is just an assumption, but she really has done just that. In addition to getting to know the fabulous team of PAs, athletic trainers, and administrators who played a pivotal role in my care, I had the opportunity to observe her perform the same osteochondral allograft transplant on another patient, which truly was a full circle moment. Dr. Frank has also shown me the ropes of doctoring, so to speak, and has provided numerous opportunities for professional development. This, for one, the opportunity to attend and speak at a conference before even getting to medical school, is something once unimaginable that I know will only benefit me in the future. I've also had the privilege of working with amazing med students, residents, fellows, attendings, and other providers through research, and I even got my first first author publication this past fall. It's crazy to me that if I hadn't gotten injured, I wouldn't have met Dr. Frank, I wouldn't have gotten this job, and I wouldn't have obtained all this new knowledge and experience. So, it's obvious that this impact, this experience has had a monumental impact on me. Recovery reiterated the importance of time management as I attended every practice and meet with my team while also balancing a full course load and, of course, physical therapy. I also grew to be more resilient and adaptable. At the start of it all, we were hoping that one simple scope would do the trick. Having to plan for and undergo another surgery on not one, but two more occasions, forced me to focus on the long game. These qualities help me now, in my everyday life, but will benefit me as a future physician. I'll also be able to better empathize with patients, especially other athletes, as I've been in their shoes. I know what it feels like to have that pressure to return to your sport and the feeling of isolation associated with injury. Now, I wouldn't be a true mathematician unless I incorporated at least one theory into my talk and I think my experience being an injured athlete is well described by the butterfly effect. This states that a small change in initial conditions can have big effects later on. In the grand scheme of things, my injury was relatively small and non-life threatening, but as a result, I met Dr. Frank and she changed my trajectory. As a surgeon, she made me feel heard, enabled me to return to sport and saved my collegiate career. As a role model, she demonstrates the impact I want to have on future patients and students and as a mentor, she provides opportunities and advice for not only getting into medical school, but for my future practice. In closing, I'd once again like to thank Anna. Attending this conference, I've been able to see how they champion innovation in arthroscopy and support further education. As a patient, I've benefited from Anna's mission and legacy and I look forward to one day contributing to it. Thank you. Hello everyone. Let me just take a quick second. There we go. Hi, my name is Hannah Cardenas and it is a great honor to be up on the stage in front of all of you. I would first like to take some time to thank everyone here, especially the Anna committee, my co-speakers and our program chair, for allowing me to be here in front of all of you and to share my story. My goal with sharing my story is to highlight how my injuries during my collegiate career shaped my passion to be in the medical field due to the interactions with various medical professionals along my time. I truly believe I owe my success on and off the soccer pitch to these individuals. So I know I have no disclosures. My passion for the game first started when I was five years old and my parents signed me up for AYSO soccer, or basically bumblebee soccer where you just kick in everybody's shins. I had attempted many other sports like softball and dance, but soccer proved to be my one true passion. Through many years of dedication, hard work and grit, I worked through the ranks and competed at the highest level known as ECNL. This conference was a well-known hotspot for college recruitment. As a little girl, I always dreamed of playing collegiate soccer and attending a great academic institution. It wasn't until 2013 when I received the opportunity of a lifetime by, as you can probably guess, the University of Colorado, when they reached out and showed interest in my talents. At the age of 14, I went on to my first unofficial visit and fell in love with everything Boulder had to offer. Shortly after, I committed to CU and never looked back. In 2017, I left my quaint home in Southern California and started my collegiate career at CU. As a freshman, I was terrified of the unknown but excited to start this new chapter in my life. Through workouts, practices and games, I had earned my spot as the only freshman to start on the starting 11. With a successful freshman campaign, I recorded 22 starts, including 1,928 minutes under my belt. I was blessed to continue my success on the pitch when I got called up to multiple U-20 national team camps and further my success by being included as part of the squad that played in the La Magna tournament in Spain. Hoping to build off my success from my freshman year, I was excited to start my sophomore campaign when I suffered my first season-ending injury. As you can see, my collegiate career was plagued with multiple injuries which required multiple surgeries. As you can tell from the long list on the slide, my career was nothing short of frustrations and pain. As someone who had never suffered a major injury before, I was petrified and unsure of my future. For the fellow athletes who have experienced a similar fate, you know that the path being able to walk, run and function as a normal human being, let alone a D1 athlete, is a rollercoaster ride of pain, emotions, frustrations and humiliation that many have not experienced. Rehab is often painful and slow and the invisible struggles with these injuries are often more detrimental than the physical ones. I didn't realize this at the time, but I was extremely fortunate to have Dr. Frank and Dr. McCarty as my surgeons. They were instrumental in guiding me through my recovery process. Looking back now, I can admit I wasn't always the easiest patient and my patience was not my virtue. Sorry, Dr. Frank and Dr. McCarty for that. I had a tendency to push the envelope with my rehab, but my main goal for the end of my collegiate career was to make it to my senior season and my senior game. I wanted to end my career on my terms and know that I gave it my all so that in the future I would look back at my time at CU and live with no regrets. In looking at the surgical interventions necessary for all my injuries, Dr. Frank and Dr. McCarty were methodical, detailed and thorough in explaining what my options were to help me achieve this goal. This was especially evident with my third ACL, when options were very limited. They both had multiple meetings with me in which they had fully disclosed that the path back to playing my senior season was unknown, but they would do everything in their power in order to get me back on that pitch. We discussed that my ACL needed to be fixed for obvious reasons, but informed me that a high-tibia osteotomy would be necessary for my return. Ultimately, through the support and care of athletic trainers, physician's assistants, surgeons and various other individuals, I was able to have my senior day and celebrate with my loved ones as pictured. It has been no easy feat, but my injuries have taught me perseverance and resilience through times of adversity. At my time at CU, I graduated my bachelor's in integrative physiology and psychology along with my master's in integrative physiology. After completing my master's, I was fortunate enough to continue my relationship with Dr. McCarty and Dr. Frank, but luckily this time not as a patient. I currently work as a scribe for Dr. McCarty, and the amount of knowledge I have gained not only in orthopedics but in research will definitely help me further my career in medicine. I always knew I wanted a career where I can make a difference in others' lives, but it wasn't until after my first ACL that I knew for sure I wanted to be a medical professional. The care I received from the medical staff at CU was top-notch and they truly made a difference in my life. They not only healed me physically, but they gave me a hope and a future. It was at this point I knew I wanted to be a physician's assistant. As a future PA, I want to emulate the same exact excellent patient care and kindness I received from Dr. Frank, Dr. McCarty and various other CU medical professionals with my future patients. With that being said, Dr. Frank and Dr. McCarty had a profound impact on my life, and I want to continue that legacy and hopefully inspire future medical professionals for years to come. Thank you. How about that? First time ever at a podium at a meeting like this with a crowd like this. Let's give them another hand. Unbelievable. So the reason I had Miranda and Hannah come up and you guys all have patients like this. You've all had patients where you've impacted their careers just because you did your job and you were a good doctor, a good surgeon and you did the right thing. But not all of us have had patients that then decided I want to do the same thing and I'm going to do the same thing. In my career to ortho and through ana and arthroscopy and sports medicine started in a nearly identical fashion. And it really took some reflection when JT asked me to think about what I wanted to do for this session to think, oh my gosh, this is the legacy of ana. This is the legacy of what we do. My background is very similar to their backgrounds. I started as a really a dorky high school athlete, but then a collegiate athlete, had a couple knee surgeries. We all know this story, lateral meniscus tears don't do well. And then I suddenly needed a lateral meniscus transplant. Luckily I got introduced to Dr. Cole and Dr. Cole was my inspiration to do what I'm doing right here, right now. And so he performed a meniscus transplant, had another surgery. You guys all know the story. These things happen. I then went to med school and I had the opportunity to do a research year. I had no experience with research. My CV to that point was a page and on that page it listed big 10 like athlete of the week. So really not much of anything that would qualify for anything that they would want at Midwest. So I thought, why not? Let's do some research. I did some research. So we did a research year and that was the year that changed my life. I worked with Dr. Nick Verma, Dr. Brian Cole, Dr. Tony Romeo and all of their colleagues, learned how to do research and learned what the research that had led to the innovations that were put into my knee allowed me to do as a functioning person, let alone getting back to soccer. I got to meet some great colleagues, do some animal surgeries, publish some papers. And then I also continued to be a knucklehead and use my meniscus transplant to do stupid things like this and complete triathlons, which then led to more surgeries and more surgeries and more surgeries all with Dr. Cole because I trusted him and trusted his hands and trusted his abilities and ultimately became an orthopedic resident. These are my four classmates, my brothers from another mother, graduated. We all looked a little tired, a little bit more gray, but still standing. Did my sports medicine fellowship and then after fellowship or during fellowship, learned how to operate independently. But here it is. I got to operate alongside my surgeon. I got to do cartilage transplants with my surgeon. I got to do for others what was done for me and there's no better feeling in the world. And then I got to get on the podium and talk about these things and do the research and publish and spread the knowledge and spread the innovations to others. I started my practice thinking life's going to be amazing and then you get into practice for all the young surgeons out there, you know exactly what I mean when you see this. It's not so easy that first year and I had people I could rely on like Dr. Cole. I could call him and say, I've got this thing. What do I do with it? And he said, just do what you normally do. And now this is what I do today. I'm an associate professor at the University of Colorado. I take care of teams. I'm a teacher, an educator, a researcher, and my practice, not at the same level as Dr. Cole, but mirrors what Dr. Cole had. And that is the legacy of Anna. I get to, again, do these things as a team doc, be up on the podium, etc. But most importantly, I get to operate and do the things that he taught me. And again, I met him because I was his patient, but he inspired me to become something more, to use my experiences as a patient to then translate that into hopefully helping other patients and still staying active. Now, I don't run anymore. I kind of learned my lesson after surgery number seven, but I do ski at this really high level. You'll notice this video is in real time, not slo-mo. And I can thank Dr. Cole and his surgeries for giving me that speed in my knee. When we think about the word legacy, there's a lot of definitions. If you Google it, you'll see some different definitions, but this is one. The story you leave behind for others to tell the impression that you make on the next generation, not comprised of money or material things, but of character, conviction, and compassion. Dr. Cole's legacy spreads to me. And then I had an unknowing, I just showed up and did my job. And quite frankly, Hannah, Miranda, and I have all by definition had multiple surgeries. We've not necessarily had a one and done back to sports situation, yet we're still here and we're still here talking about our experiences. And now their legacy is going to be something you'll see over the next five to 10 years. Their next time at Anna will be on the podium presenting a paper and then presenting a lecture and then presenting a keynote 10, 20, 30 years from now. When we think about the mission and vision of Anna, Anna is all about educating the next generation of excellent orthopedic and arthroscopy leaders. When we think about the Anna legacy with a president like JT Tokish and the over 5,000 members, including all of you here, what is that legacy? What are people like Miranda and Hannah and all of you going to do with the lessons and the tools and the teachings that Anna gives you? I've experienced this. So many of us have experienced this. And for that, I'm just so grateful. So your legacy is every life that you've touched. We touch people with our actions, with our words, and really just by showing up. And that, to me, is the legacy of Anna. We show up and we choose excellence. And it really opened my eyes when I saw Hannah and Miranda choose to now pursue a career that they had no idea that they were going to choose simply because we all just showed up and did our jobs. So with that, with the last couple of minutes, Dr. Cole, what are your thoughts on this whole picture? Because it's hard. It's hard to hear. It's hard for me. It feels great, of course, but also hard to hear someone talk about you, and I just talked about you, and Hannah and Miranda just talked about me. And we don't like to hear those things. What does this mean to you in terms of the legacy? Well, the first thing I would say is whether people are saying good things or bad things, it's always hard to hear people talk about you. And that's just sort of how we're built. That being said, thank you. The one thing that even in learning about this session that you came up with as a concept is that there's things that are still blind spots for me. And you and I have had over the years the opportunity to speak about the impact that's had on you. And honestly, I didn't know the dimensions until even most recently, right? Like you had a lot of blind trust, 11 surgeries over with the same, not all with the same surgeon, but several with the same surgeon. You obviously had a lot of blind trust. And that means an immense amount to me. And I think the thing that we continuously underestimate is the impact that we have on people that is just even unintentional, good or bad, right? So trying your best to be a good role model and be thoughtful and intentional and being present are not easy things, especially given all the distractions we have. When I was president, one of the things in my speech that I wanted to bring across was this story that I had heard on NPR about this kindergarten teacher who was in her late 80s and ran into, some of you may remember I told this little story, she ran into one of her former students. He was in his 60s and she was in her late 80s who came up to her and said, look, I remember you as my kindergarten teacher and you had the biggest impact on my life. And I've never had the, I didn't think I'd ever have the opportunity to tell you that. And she literally just broke down in tears. And this is part of this episode. She says, look, nobody in my entire teaching career ever came up to me and complimented me on my teaching. I didn't know I was missing it, but once I heard it, I just, it just made me realize that it gave me a sense of purpose and helped me understand the impact that I can have on others and that I did have on others. And you just, I think the take-home is that if you think it, you know, don't save it for the eulogy, do it now, right? And I've often thought, why are we doing these eulogies when people are going, they don't have the opportunity to hear it, right? We should probably make a practice of doing a eulogy while people are awake, alert, and actually mobile can be around to understand it. So at any rate, Rachel, I commend you and Hannah and Miranda. You guys were awesome. Both of them, I think their first time speaking publicly in this setting, right? So think back to when you guys had that opportunity to do it. It's really special. And you guys knocked it out of the park. And Rachel, look, I think you were provided opportunities and then you just, that's all someone needed to do for you is to be a good role model, provide your opportunity, and then you took it from there. And I think those of us who are in this position to mentor others, help them maximize their opportunity and be supportive and show them what can be done and then lead by example. And that's the, I think that's the best we can do. We have to, a lot of us get asked, what's the mark we're going to leave? What is the dash going to say? I think most of us who are committed to teaching, which is why I actually gravitated towards Anna, is that it provides an opportunity for people at every level of training. I don't think there's another organization that actually does that. And that's why I've committed my career to Anna. And that's why many of you in this room have done the same. It's much different than lots of other societies as you get to know some of the people in this room. So finishing up, Rachel, you're to be congratulated. Best program I think I've ever been to. And thank you for your words of kindness and appreciation. It means a lot to me more than you may ever know. Thank you. All right. Well, thank you, Dr. Cole. Hannah, Miranda, thank you very much. In true program chair format, we're going to stay right on time. In closing, I want to thank all of you for sitting through these 20, 25 minutes and getting ready for the main event. Dr. Tokish and his presidential address. There is no one better to talk about what Anna means to him and the legacy of Anna than Dr. Tokish. And I'm just so honored that I could be part of this journey with him. I want to thank Dr. Cole for everything he's done for me as my physician, but also as a teacher, mentor, colleague, and friend. And to Hannah and Miranda, we wish you and expect from you big things. Thank you all very much. Please welcome to the stage your first Vice President, Dr. Alan Curtis. Ladies and gentlemen, make some noise for Miss America! Off we go into the wild blue yonder Climbing high into the sun Here they come Zooming to meet our thunder At'em boys, give her the gun Down we dive Spawning a flame from under Hops, we're gone And the boys... Sorry I'm a little late. I'll be right there. Boy, that commute was a bitch. Jesus. All right. Sorry. Rachel, don't start the clock yet. All right. So in the next few minutes, I have the distinct honor of giving you a glimpse into my good friend J.T. Tokish's life. So John was born in Guam to Lynn and Wanda Tokish, the youngest of six siblings. He moved to Seattle in the eighth grade, so he obviously developed his cool island vibe there. Moving to Seattle, though, he was a star football player. He was a linebacker, and he graduated as the valedictorian from Blanchard High School. He was a diehard Seahawks fan, and he told me I'm not allowed to say that name. From there, he was highly recruited. And after meeting the coaching staff at the Air Force Academy, he decided to go there and to set him on the path that brings us to today. There, he excelled again as an academic All-American and the captain of the football team in his senior year. From there, he chose medicine, moved back to Seattle again, and was at the University of Washington Med School from 91 to 95. From there, he made a great decision going south to enjoy the weather and do his orthopedic residency from 96 to 2000. There in his first year, he was very fortunate to be wandering the hallways, and he saw this lovely nurse named Beth Brown. A few years later, on Cinco de Mayo, a brilliant choice by his wife so that J.T. would never forget his anniversary, he married his lovely wife, and they are a beautiful couple. In June, he finished up his residency and moved on to the Steben Hawkins Sports Fellowship in Vail, Colorado. By all accounts, that was just an amazing year. They were newly married, they learned to ski, he learned to scope, and he started his publishing career. Publishing on the liftoff test for subscapularis tears, toward all use in athletes, and the wonders of thermal capsularity for anterior instability. Well, two out of three is not bad, John. In May of 2001, they welcomed their firstborn, John Jr., our toke to the world. A few months later, in August 2001, he got his dream job. He was actually stationed back at the Air Force Academy to be a team physician and an orthopedic consultant. Couldn't have been better. Unfortunately, three weeks later, everything changed for the toke, as it did for all of us. On September 11, 2001. Shortly thereafter, John was deployed for six months to Afghanistan conflict, and believe me, he was right in the heat of it. He redeployed to Baghdad in 2006. In between, though, it was basically good life at the Air Force Academy. He was the chief of sports medicine and the head team physician through 2009. They welcomed the lovely Mia in June of 2003 and A.J. in August of 2004. After a short stint back in Arizona, they actually had this really cool opportunity to renew J.T.'s island vibe, and they went out to Tripla Army Medical Center, where John served as the residency director, and during that period he was also the president of SOMOS. In 2014, J.T. left active service. And when I tell you this guy was highly recruited, there's probably 50 of us in this room that would have hired him in a heartbeat. But instead, he chose to renew his relationship with Dr. Hawkins at the newly formed Stedman Hawkins Clinic of the Carolinas, where he served as sports medicine and research directors. In 2017, though, another opportunity arose, and after years of travel, there was this chance to move home. And after talking to his wife, they jumped at it. So he became a professor of medicine at the Mayo Clinic and the director and actually instigator of the Sports Medicine Fellowship, which he continues to run today. He also serves as the team physician of the Arizona Coyotes from 2018 to 2023. Academically, he has few peers. I mean, he's really quite amazing. He's edited three texts, which you can see they're on the right. They're all available on Amazon. Make sure you click the Anna discount. You get another 10% off. He's edited 50 book chapters, 200 publications. He's basically given 500 worldwide lectures, and it continues to grow. He's had incredible leadership roles in Anna, ASSCS, AOSSM, and many other societies. But to do this, the guy has to have just a gift. He has to be able to multitask. And so these are some films that we found from vintage Air Force days back in his early career, where he demonstrates his ability to multitask. So there's JT. He's basically getting his normal daily workout. He's helping his buddies park planes so he can make a little extra money on the side, and he's testing out the new number nine fiber wire to check out its tensile strength. Best view. Come on, best view right there. Just a legend. So in conclusion, though, family is first with the Tokichs. John Jr. graduated from ASU, and he's preparing to join the military. Mia is studying nursing at Grand Canyon University, and AJ just completed his first year at ASU studying biomedical engineering, and he's hopefully heading off to medical school in the future. So with that, I ask you all to rise and welcome our 42nd president, JT Tokich, to the stage. Let's go. Yo. His palms are sweaty, knees weak, arms are heavy. There's vomit on his sweater already. Mom's spaghetti. He's nervous, but on the surface he looks calm and ready to drop bombs. But he keeps on forgetting what he wrote down. The whole crowd goes so loud. He opens his mouth, but the words won't come out. He's choking. How? Everybody's choking now. The clock's run out. Time's up. Over. Plow. Snap back to reality. Oh, there goes gravity. Oh, there goes gravity. Choke. He's so mad, but he won't give up that easy. No, he won't have it. He knows. His whole back to these ropes. It don't matter. He's told. He knows that, but he's broke. He's so stagnant. He knows. When he goes back to this mobile home, that's when it's back to the lab again. Yo. This old rap said he better go capture this moment and hope it don't go. You better lose yourself in the music, the moment. You own it. You better never let it go. You only get one shot. Do not miss your chance to blow. This opportunity comes once in a lifetime. You better lose yourself in the music, the moment. You own it. You better never let it go. You only get one shot. Do not miss your chance to blow. This opportunity comes once in a lifetime. Holy smokes. Thank you for that kind introduction. Pause. Wait for applause. Sorry. There's no teleprompter. I just thought presidents are supposed to do that. We're going to get the talk pulled up. The title of my talk this morning is to tell you a little bit about Anna, some of the things that you learn when you're a young military guy in a military family and some of the analogies, you see what I did there, that might apply to this organization in our lives. You know, I played football for one of the greatest coaches in history, Hall of Fame football coach, Fisher DeBerry, and you had a four-year education and a little bit of it was about football. And after every game, he would sit us down, and every one of the thousand young men that were trained in his program could recite you his three rules. At the end of that, he would say, Fellas, don't you ever do anything to dampen the image or blacken the eye of this program. Number two, tomorrow's the Lord's Day. You get your butt to church, and you thank him for giving you the opportunity to be a fighting falcon. And three, call your mama, and you better thank her for the immense privilege it is to be part of your family and the opportunities that she's given you. And if something ever happened to you that was good, like today counts as good, with all the young people that are in the audience and all of you that have been kind enough to come listen to the old guy, when something would happen to you, and maybe you were elevated a little bit, coach would find a way in front of your teammates, and he'd say, J.T.? He was from Cheraw, South Carolina. He had a little South Kakalaki draw. He'd say, J.T., you ever seen a turtle on a fence post? No coach, hadn't seen a turtle on a fence post. He goes, I'll tell you what. You seen a turtle on a fence post, I'll tell you one thing about that turtle. He didn't get there by himself. And ladies and gentlemen, that is a perfect example of me standing in front of you here today. That begins with Rich Hawkins. I call him coach. You heard from him yesterday. You can see why he is so immensely revered by over 200 of us. He's got his own society named after him. And there isn't a week that goes by where my fellows or my students or my residents don't hear a quote or a story or a lesson that he taught me. For me, in orthopedics, he is the standard to emulate. On my best days as a teacher, there's something of him there. Coach, thank you so much for teaching me about the journey. He also built one heck of a team. Out in the middle of Greenville, South Carolina, after leaving Vail, there's a number of our team up there. You can see Ellen and Chuck. Chuck's in the audience today, and they are fellow seekers and researchers. Their physical therapists and an unbelievable part of the team have taught me a ton about asking good questions and then working like hell to find the answers. Teamwork is unbelievable, and I'll tell you, this is where we talk about analogies. When I was a freshman at the Air Force Academy, we had to memorize a whole bunch of quotes, but I don't think any of them were more important than this guy's. This is General George C. Marshall. He was the top-ranking officer in World War II, and many of you don't have a big knowledge of him. He received the Nobel Peace Prize, and he's outshined by some other guys with bigger egos, but he ran the whole show. And the quote that we had to memorize from him was, there is no limit to the good you can do if you don't care who gets the credit. And there are many of you in this audience who absolutely emulate that. But the analogy, if you look at this, comes from ANA itself. See, about 10, 12 years ago, I was the president of ANA, and Rick Ryu came up to me, and he said, I can't believe that military surgeons don't get a routine fellowship. You don't have the opportunity to do that. That was true. And he said, well, we're going to change that. So with his effort, and a whole bunch of other people, he created this course, along with Matt Preventer, and created a military-specific course free of charge. Fifty military attendees, free plane flight, free hotel, free weekend in the lab, about $5,000 a piece, all written off. And over the years, ANA spent over a million dollars in doing that. Over 500 military attendees have been included in the course. There's been over 100 attendees that are in this audience today that have been teachers in that and volunteered, including, now don't miss this, every single member of the ANA presidential line since 2010 has served as an instructor. If you've done a long day in the lab or a long weekend in the lab, we've got past presidents out there. It's an amazing thing. And there's been an equal number of military instructors that have dedicated their time, many of whom, including myself, have gone on to serve at the ANA's board. What an opportunity for a young military surgeon to be able to sit with some of the masters of arthroscopy and learn our craft, and the opportunity that is opened up by those relationships to go forward. And I'm so grateful for it. But it's become so much more, because I told you, there's no limit to the good you can do when you don't care who gets the credit. Rob Hunter is in the audience with us. He attended one of those meetings as an instructor, and as time went on and the military support started to fade from industry, Rob stood up and said, I'm going to find a way. So Rob, Uncle Rob goes to Washington, engages a lobbying group, and starts what becomes MAST. Now MAST is the true story of the fact that success has 1,000 fathers and mothers. What he did was he was relentless and went out there, and I'm proud to tell you that that's turned into what we call the Military Advanced Surgical Treatment Program. From 2020 to 2024, we've been able to get direct funding from Congress for over $10 million. And it's just an astounding thing. It's opened up the mission capabilities of ANA beyond anything else that we can do, and it's become one of the most important programs. Now you might say, well, it's closely kind of aligned with this. What about the general membership? Well, everything we do in the military is in the active athlete, but nothing has a more direct correlation to a civilian application than the program that we've put together with this. You want to teach a surgeon how to operate, send him or her to war. You want to teach a sports surgeon, put him in the military for a while, where it is an absolute pandemic to see ACLs and shoulder instability and all the things that we try to teach our fellows as we go. We shouldn't separate the military from the civilian in this regard. For as Thucydides said, the society that separates scholars from its warriors will have its thinking done by cowards and its fighting done by fools. This has developed into an unbelievable collaborative, and these are just some of the programs that you see up here that were begun and now are being carried on by members of this organization as you go. And I'm proud to announce that this year we've added a new program, the first ever combined military-civilian registry and biorepository for orthobiologic treatments. We have a tremendous interest in trying to get the warrior back on the battlefield as soon as possible, right? But in order to do that, that's no different than the athlete trying to get back out onto the field as soon as possible. Both will sacrifice personal health and individual goals for the sake of their team. So there's nothing more important than a collaborative that can answer those questions and then have it apply across the board to a wider gig. One of the other programs is called the Masked Visiting Professor Program. This is where a senior ANA leader gets to go out to a military treatment facility, or MTF, and exchange thoughts, have journal clubs, meet residents, and gain, I mean gain, from the experience of those young people who are out there. I've done it. John Kelly's been out to San Diego, Kevin Plancher, Joe Toro, and many, many more. And all of us will tell you it is one of the truly great experiences and how humble for those young people. For those of you who are worried about your country today, come visit Walter Reed with me. Come visit Tripler Army Medical Center with me. It will have your faith restored in who these young people are. We also have developed out of this, also paid for by MAS. No funding comes out of ANA for this. A traveling fellowship program. This is Joe Galvin. Joe Galvin served first as a regular company commander, Army officer, out in the wars, before he ever did medicine, then went back and did medicine. This is him out in Arizona trying to teach us not how to die out of a hot air balloon. And then this is the famous waste management hole where everybody throws beer at you if you get it. I knocked mine on the green, he missed it, I was super happy, and then that little jerk chipped in for a birdie and I missed my putt, so there you go. What about the importance of research? Any impact program, anything we do has gotta leave a lasting legacy. How do you leave a lasting legacy? Well, you gotta do something with it. Well, I'm proud to talk to you about Joe Toro today and Greg Nicandri, they're in charge of trying to figure out how do we use technology to change the next generation? We see the goggles, we get it, we see the really cool simulators, but do they work? We gotta ask fundamental questions, crucial to teaching surgeons. The role of simulation in surgical education, is technology king or is surgery irreducibly complex? Haptics and buzzes on a handpiece ain't gonna do it. So we've gotta figure out where that investment should be made and that takes data, time, and I'm gonna tell you, it's also applicable to our civilian counterparts. It's been an amazing process. Another mass research program that I wanna talk to you about is led by Kelly Kilcoyne and none other than Rick Angelo, the inventor of this whole process himself, on surgical skills degradation. The question we ask is what happens when a surgeon deploys and does no advanced arthroscopy techniques in maybe six months or maybe 12 months? This is my crew playing combat poker in Iraq. The red chips here are worth 5,000, the whites are worth 10,000, and the blues are worth 25,000 if the bomb hits and we all die. And if the bomb doesn't hit and we wake up to next morning, it's a nickel, dime, and a quarter for those same chips. So there you go. But I will tell you, we know in pilots, skills degrade. In any profession where you gotta use your hands, skills will degrade over time. This is applicable in civilians too. What about when you go down playing your basketball game and you tear your Achilles tendon? You gotta be out of surgery for a while. What happens to you? Well, your skills will degrade, but nobody's ever quantified that in surgeons. Well, we're gonna do that. And then we're gonna figure out, can we measure it? Can we prevent it? And if you get it, can we restore it? Absolutely critical. Can we use MAS to innovate initiative funding and relevant competitive grants? Because the ideas come from all over the place. So this is what we did for the first year. We had our first annual MAS summit. Anna Somos and the AOSSM got together in Denver and we had our first one. And we had a competitive grant said, tell us what you think we need for relevance in terms of returning. It was a competitive process. I took the presidential lines from all organizations out of it. We put it in the hands of the research people. We said, let the chips fall where they may and where it goes. We know that the importance of collaboration with other major stakeholders. Anna and Somos have a definite voice in this. And I'm proud to tell you that this year we awarded our first $200,000 grant. Andy Sheehan, who's an active duty, brilliant military surgeon, and will be president of something someday, has gotten an award for defining the impact of general mental health, resilience, and pain catastrophizing on return to duty and clinical outcomes after ACL reconstruction. Critical to the soldier, critical to the athlete. Collaboration, Anna, Somos, AOSSM, the importance of us getting together as teamwork when you have a shared mission always beats competition, right? I learned this early because when I was deployed to Iraq, this is us, if you had a holiday, you sometimes could get crab legs thanks to you guys sending your support out to Iraq, we'd be there. But next door to us was a group of Brits. These guys are tough and they are grizzled, but you're eating a dog's breakfast when you go over with the Brits, I'm just telling you. So they were coming over to us going, hey, how's it going, can we have a little breakfast with you? We're like, sure, come on in, because general order number one over there says that I cannot have alcohol. It is a court-martialable offense. But the Brits brought their beer and they still get a daily rum ration. So if you don't understand the importance of collaboration, son, you are missing out. Well, where's the analogy here? Well, Anna and AOSSM. We look at the shared vision and shared mission that we have an opportunity to come together with, right? And so Dean Taylor is the president of AOSSM now, but there's an entire presidential line on both sides that are team players. Collaboration always beats competition. So the analogy here is we got together and said, gosh, where can we collaborate? And in truth, we've done this before on a project level. We've done the ski course together, which is insanely effective in the wintertime. We've done specialty days together. But honestly, the first sort of example to teach us about program collaboration is Brian Cole, who's in the audience. Now you guys all know Brian Cole, but he is a gifted communicator. And COVID came along and our meeting was canceled. Now, if I'd have gone in, probably everybody would have said, well, sure, JT, pay your money. You can come in and attend our meeting. But when Brian Cole walks in the room, it became a combined meeting. And thanks to our staff, Laura Downs and her staff, that became a collaborative meeting and one of the most successful meetings we've ever had. It was well-received by UR members in surveys as well as industry. And Dean Taylor, other than the fact he's a West Point, he's not a bad guy. And so we've continued to try to work together on this. So I'll tell you some of the things we've done. In examples of ways that we can collaborate, well, what about the fellowship? You know, in the past, we've had two different fellowship administrations. We've had two different certificates, two different everything. The other thing is right now it's a sports medicine fellowship, right? We're sports medicine trained, but we're arthroscopists. That's a skillset. And lots of people around the country and other groups are trying to claim the importance of that. That's our bailiwick, that's Anna. So how do you collaborate? Well, I'm proud to announce to you that as of 2024, Anna and AOSSM have come to a memorandum of understanding that there will be one fellowship certificate and the fellowship will now be named the sports medicine and arthroscopy fellowship beginning this year. It'll be signed by both presidents on a single certificate. And I think rightfully so, AOSSM has pride of place. This has been their baby since day one. And I think it took a lot for them to come to the table and say, you bet, we wanna combine with you. It's a big deal. Well, where else? We then recognize as their critical skillset and what we bring to the table as well. We are no stranger to fellowship education. But what about the other side of it? Critical to us is surgical skills and Rick Angelo's in the audience. He's placed us on a 10 year journey to get better about surgical skills and how to train it, how to teach it, how to validate it, right? That's our bailiwick, it's his bailiwick. Both Anna and AOSSM recognize the need to ensure we graduate fellows with adequate or we'd like to say excellent surgical skills. This is based on Rick's work and the goal is a valid and scalable skill assessment program that we have. What about practice management? Five years ago, if you would come to this meeting and there's a business session, it was crickets. Now it's cicadas. The storm's coming, they are packed. Everybody wants to know, what do I look for in a job? How do I find it? What's the best way to go? And through efforts with Kevin Bonner, our treasurer who is as business savvy as it comes, he's led us through a series of webinars and most of the people that now come to us and talk to us say, hey, can you talk to me about how to find a job? What's important in all that? It's a critical skillset. How do we run the business? More important than ever, what should I look for in a job? And how should we advise our fellows, residents, and even colleagues in where they should go and what they should do? It used to be the four bigs, right? Money, geography, type of practice, and autonomy. Does that still hold true? Well, if you want to answer that question, you go back to General Dwight D. Eisenhower, the creator of D-Day, if you will, freer of the known world, said, in preparing for battle, I have always found that plans are useless, but planning is indispensable. So you gotta learn to be rigid in your objectives and flexible on the tactics. Well, if you're gonna be rigid in your objectives, you better define them. And that brings me to a project that we've been doing this past year called the Anna Happiness Project. We sent out a survey to all members of Anna, and we asked them to try to determine our objectives. We want to know what our drivers are. So we developed this survey, sent it out in the literature, and I got a data from a variety of sources. We didn't just willy-nilly pick questions. I wanted to find people who could get in the literature and find questions that have already been defined so we don't waste time and re-go over old ground. And I will tell you that a number of people that helped me see blind spots, including Mary Mulcahy, Todd Tucker, who's in the audience, George Branch, Jimmy Sheahey, and of course, Rachel Frank, all took a look at the survey and made valuable inputs to make sure that we were asking questions that would be relevant to all of us, not just some of us, and try to help us understand where those blind spots lie. So here was the premise. I asked you one question. How happy are you in your job? 100 is perfect. Zero is I'm out. It's one question. It's called a SANE score. Now you might take a minute and think about what your own SANE score is now because I'm gonna share some data with you, and I might depress some of you, or I might make some of you really happy. But we asked you that one question, and then we said, that was the anchor question, then we asked a bunch of other questions, and we sent out a big marketing campaign with this. We wanted as many people to answer it as possible. We sent it out with a picture of me and a video that was attached, and I got an overwhelming response. Some of them included like, JT, with your picture, this should be called the Unhappiness Project. How about renaming it the Hangover Project? Dude, did you score a zero? And this one, of course, was Uglier Risk Factor for Unhappiness. That was Burks. I know it was. It's anonymous, but I know Burks did that to me. Well, 706 of you took the survey, okay? And here's what we did for you math geeks out there. Here's some things to note. The mean happiness is 80. You're a pretty happy group. That's good. The standard deviation's about 10. So here's what we did. I took the standard deviation on one side. I killed all that. If you were above one standard deviation over here, we called you happy. If you were below one standard deviation over here, so that means you scored less than 70, we called you unhappy. Now, there was a small group that we could compare that were happiest versus unhappiest, and these are the emojis, so stay with me on this because I don't have all that much time. I tried this for the unhappiest emoji, but I got censored by the Anna staff, and then I tried this one, but I couldn't figure out whether that was the happiest or the unhappiest, so I threw those out, so we're just staying with the four. So some quick results. Age matters. Those in the happy group averaged age 50. Those in the unhappy group averaged age 45, and that was statistically significant. Got you, Burks. Sleep matters. Lack of sleep costs you. You heard this yesterday from Dan Rooney. This I found super interesting, and I'll tell you why. If you sleep less than six hours a night, you are three times more likely to be in that one standard deviation unhappy group versus the happy group. Now, you think, well, that's a lifestyle thing. That's cool. Well, interestingly, exercise and diet didn't. When we looked at are you on an exercise program, how much do you work out, how's your diet, what are your, blah, blah, blah, all the questions they ask us in the military about health and life, those didn't matter, but sleep did. So if you ain't getting enough sleep, I just tell you, stay out of my damn suite at night because it's been really tough to get any sleep this week with all you knuckleheads drinking all that beer up there. Oh, speaking of beer, what about alcohol? Well, I'd like to tell you, and I'm proud to report that there's no difference between drinkers and non-drinkers. There is an equal distribution of happy and unhappy unless you drink more than 10 servings a week, in which case you are five times more likely to be happy. What about money? Now, this was surprising. I did this before, and it didn't matter, 15 years ago. It didn't matter a lick, and it does now because something's changed, especially at the upper ends of the income. So it's getting tougher, and this is what I'm talking to you about about business. It's a harder deal now to make a living at that level than it was before. You are mildly more likely happy than unhappy at lower incomes. Now, this is me in a private jet, and believe me, this is not the Tokish jet. I was flown up to the bubble when COVID happened by my hockey team. They did that because it would avoid me from having to sit in quarantine and have them pay my employer for my time out of work, so it actually saved them money for me to get on the private jet there. So then we won the series, but then my time was ready to go back home. Same hockey team flew me home by coach, three stops, middle row by the crapper. We call that the Memorial Tokish seat. We don't have, we've missed the boat on the money stuff. Sorry, honey. And as my mom said, I should have been born rich instead of so damn good looking. What about time with spouse? Well, if you spend less than 90 minutes a day with your spouse, you are three times more likely to be unhappy than happy. I told that to my wife. She goes, wait a minute, let's clarify. Are you sure about that? So then I realized that different spouses may have different answers to that question. It brings us to the married question. If you're married, you are twice as likely to be happy as unhappy. You're also twice as likely to be unhappiest than happiest. Do you have a pet? 100%, more than twice as likely to be happy than unhappy if you got it. You look at that little fella's smile to greet you when you come home, you're gonna be happy. I didn't separate out dogs versus cats because I know you cat people are not happy, but the dogs are. What about job factors? A lot did not predict happiness. Income from passive sources. Passive income, don't go chasing that. It won't make you happy. Time you leave work each day surprised me. Not happy. Things are changing. Number of hours worked. Weeks of vacation a year did not matter. Until you get to eight, then you're seven times more likely to be happy than unhappy. So this is my most practical thing for you right now. You better get your eight weeks. Seven times the happiness love on that, right? So let's get after that. But some things did. Academics and salaried physicians were two times more likely to be unhappy than happy. Surprising no one, unhappy surgeons spent five more hours a week on administrative tasks than happy surgeons. So it's not all beauty. And this next one I'll tell you about. How efficient is your clinic? We want to be efficient. You think it's important? The statistically most powerful thing was if you rated your clinic as efficient or if you rated your OR as efficient. Look at this. This is a P times 10 to the negative 12th here. If you're more efficient in your OR. This is actually a picture of one of my anesthesiologists from my OR fast ass asleep during one of my cases. Now his happiness is pretty good because he's getting his six hours. But my happiness isn't so good because my efficiency isn't very good. Now I thought about leaving this one out because this is not good news. And it was the most surprising thing I found in the study. And I thought, wow, this is supposed to be kind of an easy light kind of talk. But I'm gonna tell you, this one really concerned me. I went back, we looked at the data again and again and we're just starting to figure out. But if you're a female orthopedic surgeon and you responded to this survey, there were 90 of you that did. Four of you were happy. 34 were unhappy. If you're a female orthopedic surgeon and you took this and you responded to our SANE score, you were eight and a half times more likely to be in the unhappy group than the happy group. And ladies and gentlemen, we are spending a lot of energy on young people and specifically young women to recruit them to come into this field. I think we need to spend a lot more time on retaining them. I will tell you, I don't know all the details behind this, but I am committed to you. I will get to the bottom of this rabbit hole and we'll try to figure it out. And in programs like Future Scope, we're gonna try to expand for our colleagues who are already there so that maybe in five years or three years, we can report back to you and have that number be equalized from the top. That's my word to you and I'll come back to you on it. We don't know why yet, but what we've learned so far from this project is this. We're not looking for less work. We wanna do it efficiently. Life outside of work is a big driver of happiness and how do we optimize this myth? Well, Sun Tzu taught us this and this is another military analogy. Strategy without tactics is the slowest route to victory, but tactics without strategy is the noise before. It will not happen passively. You need protected time to do this. If you think you'll get to it, you won't. You've got to block time for the big things. Only you can defend this because there's all these little rocks coming at you from all the other places. You've got to find time structured for this. But the analogy here is you better be flexible because as the great philosopher Mike Tyson once said, everybody's got a plan until you get punched in the mouth. This is me in August 2001. There's my beautiful wife and that little toe head at the bottom there, that's Toke, that's me and Hawk, and we're leaving to go back down to the Air Force Academy as was mentioned. Hot new sports job. I'm raising a dog. Look at him, the mean kid right there and living the dream. And six days later, this happens. And they said, hey, FNG. Some of you know what that means. The N is for new guy. You're the new guy. It wasn't because of any talent. But five weeks out of fellowship, sports fellowship, and I'm on the plane, this is our C-130 as we took off. And I was gone six months. Now, we were ill-prepared to say the least. I was ill-prepared. Please note, I'm going to the deserts of Afghanistan and I'm in jungle camo. Some people say military intelligence is an oxymoron. Right? But it happened so fast, we didn't even have time to prepare and we weren't prepared. We didn't know much about the blast wound either. The transition though wasn't that different from my fellowship. At the end of fellowship, Dr. Steadman gave us a jet and let us go to Vegas on it. So we took this private jet and we went to the desert. And seriously, two months later, I got another private jet and I'm going to the desert. So it's not all that bad. Now, this was our team loaded. We had a five-member team, a general surgeon, orthopedic surgeon, anesthetist, an OR doc, or a nurse rather, and an ER doc. And the pack there had 70 pounds of equipment enough to perform 10 life or limb-saving operations right there in the backpack, in theory, as long as I could pick the cases. But unfortunately, you couldn't pick the cases. We didn't have an arthroscope in that pack though. That made me very unhappy. So you got to redefine and you got to make a new plan. But I figured at the time, I'm like, hey, look, I'm a board-certified orthopedic surgeon, trauma trained, level one trauma center, fully trained and prepared, right? Until something like this happens. Three nights into it, mass casualty comes in and the backpack is quickly overwhelmed, as is the facility, and you discover a self-critiquing experience that you are overwhelmed and underprepared. How do you respond to that? All of us have had that. And there's lots of way to respond. And I will just tell you, cases that made me nervous in 2001, when I got out of my fellowship, I was still pretty nervous about a multilig knee injury. That one made me nervous. And in November, this is my multilig knee injury. How do you respond with rigor? Well, the first thing you got to do is admit it. We have plenty of us in the ORs. Walk in, these are the best of hands, right? We all walk in, we got to admit it. You got to get comfortable with being uncomfortable. All of us are on a journey with some surgical procedure, some way to teach, something going on. You will not get better at it until you admit that you're uncomfortable and you got to avoid avoidance. Secondly, you got to model it. What do I mean by that? You got to find somebody better than you or somebody that's doing the same thing and collaborate. The history of Anna is Steve Burkhart and Steve Snyder and Jim Esch calling each other, going, I put the thing in the shoulder again and I don't know what the hell I was looking at. And pretty soon you have this collaborative group and we did the same thing, partnered with Stryker Trauma. And we put together this and this is the share. We codified the lessons learned, good and bad, for the benefit of the coming later. Well, what's the analogy here? Well, the analogy is what Anna is doing with case-specific courses. We did our first one last year under the leadership of Rick Ryu and Nick Scaglione, both former presidents. They don't have to do this stuff anymore. So, the difference here is we're not teaching you basic arthroscopic skills. You say, look, I admit that I'm not comfortable with a Latter Jay or an SCR or a lat transfer. And you got paired up with somebody who's done a whole bunch of them, came out and did it and just measurably got better over that weekend. And that's the model, thanks to the leadership of JK and Josh, that we're now moving to. Our courses are going to become procedure-specific, drill down to exactly what you need so we can meet you where you are. Admit it, model it, share it. That's how you respond with rigor. And I'm proud to tell you, did we do it? Well, the course had 52 spots maxed out. That's not surprising. We do that a lot. We had a 29-person wait list. That's Anna members responding, admission, modeling. So, I would tell you here, you got to embrace imposter syndrome. We talk about it like it's a bad thing. I am a more than happy imposter. I promise you. I'm not lying about this. And I want to be an imposter. It's the best thing I got. I want to coach and teach like a hawk. I want to approach problems and innovate like Steve Burkhardt. I want to be a friend and a source of encouragement like John Kelly. I want to be someone to look up to for advice like Jeff Abrams. I want to inspire you, almost compel you to be your best like Rick Rioux does. I want to connect and communicate like Brian Cole does. I want to have attention to detail and master the art of the upgrade like Jim Stone. I want to see things from all perspectives like Mark Gettleman does. I want to enjoy the journey for what it's supposed to be like Alan and Julie Curtis. I want to have the sheer presence and honestly, I'd love to have the engine of a Rachel Frank. And I want to flat bring it every time I come someplace like Bob Burks does. I am a proud imposter and I would encourage you to become the same. Find it, admit it, admit that you're not that, try to find someone to be like and do it and be an imposter. Now that comes by pretty honestly for me because I have a long history of impersonation trying to be somebody that I'm not good enough to be. In the audience today is my big brother Len Tokish. He was my first hero. He's the guy I was trying to be like and the man I'm still trying to become. I pray that you have or find someone in your life like him. I will say this, four of you have come to me who were in our suite last night because he was pouring drinks and come up to me this morning and go, you're not half the man your brother is. You're not even close. You're not even the smartest guy in your own family. I go, tell me about it. It's terrible. Why can't you be more like your big brother? I'm trying. I'm trying. I promise. Now we're getting older and we have the immense privilege of being drunk uncles or what they call drunkles to these 12 incredible people. His kids, my kids, my sister's kids. And it is one of the great honors of our life to be able to do this. These dozen cousins as we call them have already surpassed anything we could have ever hoped them to be. And I just want to speak just for a second about three of them. The knuckleheads sitting in the audience down here in the front. My own kids. Here in the audience are John Jr., we call him Tok, Mia, and AJ. You know, I can't tell you how proud I am of each of them. They are young people of faith, commitment, and purpose. They are so far ahead on this journey of where I was when I was a decade older. They understand what is truly important in life. And I sometimes marvel at how it could have ever happened, honestly. Except this is exactly how it happened. This is my wife, Beth. This beauty is a woman of deep faith and substance. I recognized it early, and I got my hooks in her 24 years ago this week. We celebrated our 24th anniversary. I am convinced, I tried to convince her, and was successful at least at one point, that life was going to be one big party. It was going to be set up, working out with galas and spa visits, and this was going to be our life together, baby, come on for the ride. Instead, I only baited and switched her into a life of helping me with my work, holding rat rotator cuffs, feeding and caring for a mob of hooligans, and being buried under chores, laundry, and dogs. She is my pearl of great price and great worth, and I'm grateful to be on this journey with her. Thank you, baby, for putting up with all of it. So finally, after 21 years, three deployments, four time zones, eight schools, she finally got back to her beloved Arizona, where we have found a home. We've become part of a team, and we've started being part of a group that's trying to build something special. Our fellowship is young, but we have a gifted and committed team. These are young fellows, many of whom are in the audience, and I'm so grateful for you guys coming back, leaving your lives for a while. I know how hard those first few years are, and to take time and fly across the country, some of you across the world, has been incredible to me. That team begins with one member in the audience who's here, and one who isn't, Cassie Smith is my PA. Cassie, are you in the room? Yeah. There she is. Cassie is the engine behind our practice. She can outwork and outthink any of our residents, any of our fellows, and their attending. I once asked her, I said, look, you've got to slow down, you've got to pace yourself, because I need you for 20 more years. And she looked at me, and she goes, you think you've got 20 more years in you? That's faulty. But I'm going to tell you, she is technically gifted. And that other woman right there, Kristen, she's the conductor that keeps our engine running as our liaison and our scheduler. She's the face of our practice, and her kindness and attention to detail ensures that every patient feels valued and prioritized. Build a team like this one, and you can't help but find the greatness. A few special thank yous. In the audience today is Todd Tucker. Todd was my first partner. In residency, we shared every other night trauma call at a level one trauma center. You learn a lot about a person when you share that kind of deal. He has an unbreakable spirit. He has a clear sense of how to weed out non-essential things. I'll always respect him for that, and is the best friend you could ask for, in the rain or in the sunshine. Brother, I know how difficult it is for you to be here today. And I'm grateful for you being here. And this is Ben Cam. Ben is also here with his wife, Mako. Ben was my classmate at the Air Force Academy, then my partner, and now like a brother to me. He's been a voice of wisdom and guidance when life's noise has gotten out of the way, and he has a remarkable sense of recognizing the importance when life gets too loud. I'm so grateful for your friendship, brother, and thanks for being here. To the fellows in residence that have been kind enough to spend all the hours listening to me drone on, like you guys are beginning to do now, thank you. Thank you for the immense pleasure and honor of being able to share ideas with you. Thank you for challenging me, and thank you for making me better. Well, when you enter the board of this organization, it can be pretty intimidating. Look at this. They call themselves the Rat Pack. Right? You walk in, you think, you look at those that come before you, and it'd be easy to think that you don't belong. And it's true that our past presidents and current executive committee, that we are surrounded by an amazingly group, amazingly talented group of people, including our executive board, Kevin Bonner, Joe Toro. But that's nothing compared to Anna's future. Here are just some of the leaders that are putting us in good stead going forward, and I'm telling you, we are poised for sustained excellence in this organization. The next 10 years will be like nothing we've ever seen. I promise you that. Which brings us to our next analogy from George Patton. No army is better than its soldiers, and the analogy is Anna's army. This is led by Laura Downs, our CEO. She is our captain responsible for the whole deal. Times come and go, and she has to deal with each one's personal quirks and pathologies. She possesses wisdom, grace, and a team building sense that any leader would be envious of. You want to know about Laura? She begins with yes, and works backward to wherever your problem is, and then helps get you back to where yes is. That's what I can say about her. She has a gifted team of professionals with her who deserve mention, so you're going to have to forgive me. I'm going to go over just a little bit with this, but these are super important people. We're sitting in that upper left corner with Alex Andrick. Alex is in charge of all surgical skills courses. If this is one of Anna's core competencies, then you might say that Alex is at the core of the core. Terry Bruce is in the other corner up here. Terry runs our educational foundation, which includes corporate partnerships, fundraising activities. She's the reason you get ice cream when you come to Anna, let me just tell you, in many, many ways. Carrie Corona handles all of the nuts and bolts of the finances. When I was treasurer, she told me which checks to sign and why I couldn't write them to myself. It was really strange. Adam Foltz is our IT director, second from the right. Adam, when all of you show up with your half-baked talks and your videos that you swear were running on your computer properly but don't work because you didn't put in the time, Adam's the guy that saves your bacon. He's so important that we left him back in Rosemont. He's still in that same damn room making sure that all the talks run over the internet as we broadcast this live. Thank God he's with us. Vicki Markhart, those of you who are at Specialty Day who have been here, she's been right there in that seat the entire meeting, not missing a single moment to make sure that everything rolls smoothly and kind of comes forth the way it's supposed to. Matt McNutt, you see him just below Laura on the left there. Matt's in charge of all online learning activities. He edits our podcast. By the way, our podcast, 3.6 million hits last year. Matt McNutt is responsible for that. And our fellowship curriculum, Christine Nogle. Christine Nogle sang our National Anthem. You heard her earlier. Christine is our Chief Operations Officer. Oh, by the way, she runs our entire marketing campaign and, by the way, somehow finds time to run the Biologics Association. She embodies both the nerd side and the glamour side of marketing and data like nobody I've ever seen. She's irreplaceable. Fran O'Malley, you see up top in the hat, she's the person getting you to the bus and getting you to the right places at the right time with the right sort of attitude to go. She is pure sunshine, and we're grateful to have her as well. Next is Frances Park. Okay, I just want to pause here. This is Frances' picture. She runs every detail of this meeting. I have never seen anyone as good at their job as she is at her job. I hope Anna keeps her forever. She is the reason that this thing runs like a well-oiled machine. She's got a sense of style that the presidential line certainly doesn't have. I wish she'd run our country, and I may write her in anyway later on this fall. Lindsey Ruiz. Lindsey runs the branding campaign here, and I just want to pause here about Lindsey. You notice outside the program is a work of art. That's her artistic work. The big cutout, we're taking our pictures in the Anna cutout world. That's all of Lindsey's artwork. She's taken all the dry stuff that we as surgeons do and turned it into an artistic experience. Kim Santanello. I mean, where do you start? She runs our whole education program. She's one of the most dedicated and committed people I've ever watched. She may be the happiest staff member that I'm becoming after my presidency, honestly. She's elevated our education programs and has been a vital partner. The success of this annual meeting is due to her ability to multitask and her ability to collaborate and work with people. I can't thank you enough, Kim, for what you've given us. Nick Sautter down here is our new research guy. All that stuff you saw from the Happiness Project was me hammering him daily. Hey, I need it redone. I need the analysis redone. Are you sure? Let's look back at it. He's been a great addition. Then, I think Dennis Sienna. I've got to show you Dennis. Dennis volunteers as a volunteer member of the Sheriff's Department, but he is our chief of finance. I'm going to just tell you, this organization is a $20 million organization. When you step in to run it, there's some blind spots, especially for me. I'm the Labrador. That thing where they say, hey, who's in favor of spending all the money right now and having a big party? I'm the guy going, yes, and Dennis is the guy keeping me online. I'm grateful for you, buddy, and thanks for all of your assistance as we've gone. Beatrice Vasquez. Beatrice runs communications at Anna. When you call with a problem and an issue, there's a good chance she's the first person that answers the phone. Her kindness and her ability to communicate with you is the reason people leave Anna with such a guided first impression. Melissa Villegas. Melissa, she is the do-everything, everything person. She manages all the details of our board meetings, committee organization. She's often the board's corporate memory. When we all forget what was said, she's got the notes. She ensures all the half-baked ideas we have come up with are followed and enacted upon as we go forward. Ladies and gentlemen, I'll just say for one second, if I could, could you give a round of applause to our staff? Thank you guys for your incredible commitment. Nothing is as strong as the heart of a volunteer. That's Jimmy Doolittle. My prayer for all of us is that God might lead us into service beyond ourselves and to the grace of self-sacrifice. There's no one that I've come into contact with in this career that has a bigger heart of a volunteer than Rachel Frank, our program director here. Rachel, could you stand? Where are you at? Please stand. What an amazing, amazing job. She has been a complete inspiration to me. She's brought all these things that you don't think about, like the legacy session. I was late because I was sitting in the front row because I couldn't take my eyes off of the program. It was just that good. She's been responsible for everything. When she points the laser in a direction, you better get behind her. Incredible, incredible leadership. As next presidents, I'm just going to tell you, I'm leaving you in great hands. These are men of style and substance. Now, Kelly, I do not know why you are scoping naked at the OLCB under that gown, man. We'll have to get to it. But I'm just going to tell you, these are men of great talent. I mean, an incredible skill set, and they've become dear, dear friends to me, and I've been lucky to be part of them. Anna gets an upgrade tomorrow afternoon. I promise you that. The best part about this job is that it has allowed me to get to know hundreds of you, literally hundreds of you really talented women and men all over the world. And to learn a bit of your story, it has deeply enriched my life as a surgeon, as a teacher, and as a person. The worst thing about this job is that it spreads you pretty thin. So unfortunately, I don't know hardly any of you nearly as deeply as I'd like to. And for that, I hope you'll forgive me. But I intend to spend the rest of my time on God's green earth in this organization learning your stories and helping you tell them. Thank you very much for your attention. Thank you.

Dr. J.T. Tokish

Guam

orthopedic surgeon

educator

academic excellence

sports excellence

leadership roles

extensive research

medical societies

family

mentorship

innovation

challenges

teamwork

work-life balance