Thank you Rachel and JT and Mark, very compelling talks and I'm going to kind of finish off with the DTA and bone blocks, free bone blocks for instability and then we'll start with our cases and it's Ryu, go to the top one please, go to the top one. While they're pulling that up, can I ask Rachel a question? Please. You just told us about the triple blocking effect and how important that sling effect is and yet you're the one that published the first critical study with DTAs versus Latter-Jay with no sling effect on that showing equivalent outcomes. So do you really believe that or were you just required to do that because Professor Ryu over there made you? You know it's a great question. I was tasked with the talk of defending Latter-Jay. Which question, whether you believe it or whether Rick Ryu pressured you? They're all great JT, they're all great. What I would say is you may have not heard me mention the words DTA or distal tibia allograft at all in my talk so that I could avoid this exact question, but I would say the sling effect is real and it works, but all of the options that you've heard and you're about to hear are great for the right patient. So I do believe in the sling effect, but I don't think it's the only effect and we're going to hear about how just a bone block in and of itself can provide equal, if not I would say equal, stabilization. Rachel, that was artful. I'm going to say it was the Middle East that solved some problems there. That was outstanding. So here's my disclosure. In fact, we're going to go through here. So this is where we're going to talk about now the thing, just kind of the new topic and that's basically bone grafts. And we talked about the bank card as being a suspect and Rachel referred to the high recurrent instability, again the consequences, you know the banquet of consequences that we all get doing surgery. Why do they fail? Well, that's been, I think, elucidated by everyone on the panel. And how much is too much, we can debate that, but I'll just tell you when you get to over 10%, you got to start thinking that you may have to do more than a soft tissue procedure. And on and off-track lesions, easily identified now. We do it routinely. My radiologist gives me a report every single time and it's very helpful. I just don't get surprised in the operating room anymore. I used to say, oh gosh, I didn't realize so much bone loss, but that just doesn't happen anymore. So how do we solve this? Well, the rep massage that Dr. Gettleman has mentioned, no question that it has a role. And this is, again, the Delphi panel, the international consensus. So off-track or engaging heel sacks without severe bone loss, you can make the argument that this would be a bank card and a rep massage. Why not perform a Latter-day? Again, the virtues of it have been discussed, but again, for many of you who might do maybe three or four a year or maybe one a year, this can be a problematic procedure because of complications that can occur. And most of those are all from JT. So thank you, JT, for sending those to me. Now, this is another paper that I'm going to bring up that JT was part of. And this was the Latter-day paper here showing that nearly a quarter of patients had recurrent instability and a third had persistent pain at two and a half years. Now, JT was part of this, so it's not that surprising. But that said, the Latter-day is not a panacea. So the next step may be a distal tibial allograft. And again, subscans bearing arthroscopy-assisted, it really has... Hey, Rick, what were you doing with your ink there on that distal tibia? I mean, you marking the outlines on a Rorschach test? Just kind of spreading it around. Okay. Yeah, right on. This is my signature. That's good looking right there. And then this is the Morota paper. So this is one that got me very interested. This is a Level 1 RCT Latter-day versus bone block. And at the end of the day, and the J graphs are a little different, but at the end of the day, no clinical or radiographic difference. So, again, we started thinking maybe this is an alternative. Now, this is a paper that JT was trying to embarrass Rachel with. She had a very nice paper, 50 in each group DTA, matching cohorts. And at the end of the day, no difference between Latter-day and a DTA. So, again, there's evidence out there. This is a technique. This is a right shoulder. And you're looking at basically suture. This is a failed Bankart. We're coming back up. This is about 10 years after the failed Bankart. So number one is, technique-wise, you must go past the 6 o'clock position, and you must be very generous in mobilization. You will not get your bone block in if you don't. You just have to make this thing very mobile. Then we put a 3 o'clock notch because that's our orientation. And then we come in, put a 6 o'clock anchor in, and we'll pass our sutures, but we won't tie them. And as Mark showed, we'll do kind of a hospital corner type, 6 o'clock anchor, not tying. And then you take down the labrum. It kind of breaks your heart a little bit, but we take down the anchor, superior labrum, like an episiotomy, so we can open this up and pass our graft. It makes a huge difference. We put the guide in. It's based off the glenoids, so, you know, you never worry about where your screw placement might be. This is the inferior sleeve coming through. And now you can see that drill hole you see there was at 3 o'clock. We're going to come in just below it so we know our graft is between the 3 and 5 o'clock position where we want to be. And, again, the sleeves are in. And at this point, we're going to drill our anchors for the bank art repair because with the sleeves out, you can cut the sutures out. And you can ask me why I know that. And then we take out the rotator interval, the critical step. Then we put in basically a sled, and we'll go ahead and slide our graft down once we have our passive sutures. Now it's just suture management. The graft goes down, and it should be trapezoidal. The base should be wider than the superior surface. Otherwise, it tilts, and if it tilts, then we're in trouble. So we want this to be flush, so the base has to be wider. It tends to basically dig into the glenoid. It keeps you sort of flat. And so we're settling it, and from the back, we have a nice surface. Jeff Abrams calls this the ice rink. I like that term. And then we tie down on the back side with two buttons. And then we do our bank art on top of this. This is going to be an extra articular bone block, and we won't worry about a fresh graft. This is frozen, very affordable, whereas fresh might be $8,000 to $10,000. And because it's extra articular, I'm not worried about sell viability. So, again, you won't break the bank doing this operation, at least if you're using frozen allograft. And then we simply do a knotless technique, again, to bring our bank art over our bone block, and then we're done. So Ivan has reported on this, and he reported earlier today regarding the results, which are pretty impressive. And this is when he was using two screws. Unfortunately, he also told us today what happens with the buttons. And now I think all of us, myself included, are a little bit concerned because I have basically three-year follow-up to date, but I'm a little concerned, and I might have to bring some folks back in. But the buttons may not be good as the screws, and we can discuss why that may be the case here. So AHER is a preferred technique for me for going to bone loss if you have good soft tissue and you can do a bank art and a rump massage. Sub-scalp sparing and anatomic, safe and easier to revise. I think the results, at least so far, are as good as the latter day. Targeted therapies, in my beliefs with arthroscopy, are always better than shooting fish in a barrel. And then screw versus button technique is worrisome, and we have to learn more about this. So with that, before we get into the cases, are there any questions from the audience regarding any of the talks that were given thus far so that we are all on the same page when it comes to language, concepts, or what have you? Anybody? Any questions? Go ahead. Please. Yes. Was there a question back there? Can you stand? Do we have a mic by any chance? We're going to hand you a microphone so that everybody can hear your question. But no pressure. It's not being recorded. Is there a situation where you've regretted rump massage, or is it something where it's not going to be a loss? Speaking of regrets, I'll turn it over to JT. Go ahead. Yeah, I think there's some of the data out there would suggest that there's one-third of patients have posterior pain. So Neurosoft published that paper, and I've seen that. So they're especially in the throwing shoulder. So what do you do with that patient who's got a pretty good-sized heel sacks, and they're an overhead athlete, tennis player, et cetera? And so a little bit of those times, and I wonder if I could have gotten away with something else or expanded the glenoid track a little bit with a bone graph, which we're becoming more aggressive with. So, yeah, I would say it's not a panacea for all patients. The recurrence rates are good. The other thing is that we're all really excited about rump massage now. But if you take a look, and we'll talk about some of this data in a little bit, but if you take a look in specialized populations like contact athletes versus Latter-J, the recurrence rate is still very high. And so in those specialized populations and with more than subcritical bone loss, the recurrence rate is still two to three times higher than a Latter-J. And I've made that mistake where I've thought, ah, I can do it. It's such an easy operation. I've fallen into that trap. So, yes, I have regretted it a few times. So a question for a couple of speakers, actually. Graph resorption, this became a big part of Ivan's talk today. And as you know, graph resorption sometimes then leads to hardware complications and maybe some predictive degenerative arthritis of the joint. Have you thought about, after Ivan's talk today or in your personal practice, what you're going to do about the size of the graph? So Rachel, coracoid transfers, you're getting resorption, you're not getting resorption? Or particularly with the distal tibial allografts, anybody can answer. Are we going to change the angulation of the graft? Is there a reason? And the last concept would be the French have sort of popularized not closing the capsule down. And we close the capsule down, or some people do. Do you think that may play a role on whether or not the humeral head is articulating with the fragment enough to allow for Wolf's Law or resorption? So good thing, bad thing, closing capsule, not closing capsule. And then have you adjusted the operation for bone resorption? Mark, what do you think? So in terms of bone resorption, I'm all in on distal tibial allograft. I've kind of switched over to it almost exclusively. I don't like failure, so I use screws. It's harder. It's technically a much harder operation than using the buttons and drilling from the back. Two things, I do try to tailor the size of my bone to what I think is bone loss. So I'm not necessarily always taking one centimeter by 1.5 by two. I may make it a little bit smaller because I think what Ivan has taught us is that it does tend to go back to that perfect circle. So you need to potentially put in less bone. And I think if the capsule is good, to me, it's a better operation because I can go in, as Rick said earlier, with a plan to do an arthroscopic operation. If I get in there and I feel like the bone loss is too much, I just switch to the distal tibia. It's not like I'm going to change and now have to do an open latergé. So yes, adjust your bone block, and I still want the capsule over the top. Rachel, what about resorption? This is a real problem for us because resorption is a common phenomenon. If you look at papers on latergés, resorption could be in 100% of cases, but in most cases it does not have an impact on outcome. So we're going to expect resorption from Wolf's Ball. We expect it around a square bone block, kind of fill a circle. So we're going to expect it. The issue is when it's too much, too much, and why is that happening? Yeah, I think it's a great question, and I think that this is something that as younger surgeons go through their learning curve, as in myself, you start to learn that more is not always better. Bigger is not always better. Size does matter. And I think in this case, I've learned just through my own cases, but also through work by Giovanni Di Giacomo and others, that you do see resorption even with surgically kind of perfect techniques. So I do think because of Wolf's Law and just kind of common sense-wise, you shouldn't necessarily just try to make the glenoid tract as big as you possibly can. I think you need to recreate the anatomy. I also think the critical component to this is ensuring that your bone block, whether it's Latergier or distal tibia or iliac crest or autograft clavicle, you need to make sure that the surfaces of your graft and the surface of your anterior glenoid are going to be flushed so you can get good compression. So this, you know, oftentimes we take our bone block, whatever it might be, and we just kind of fidget it with our hand or with a guide if you're doing it open with a Latergier or even arthroscopically, and you just get it to match up where you think it's okay, and then you rely on your screws or button to do the rest of the work. But we have to remember fracture 101. We need to get the bone surfaces to really oppose each other so that your fixation device can go perpendicular to the fracture line. So I think that's one of the critical steps. Early on, I didn't necessarily pay as much attention to preparing both the glenoid and preparing the bone block to make sure I had good compression. And I think as I've gotten better with that technically, resorption has gone down. That being said, it is ugly to look at those x-rays when you see screws in nowhere, and that may be where it's more attractive to potentially use a button, but either way, resorption may potentially become a symptomatic problem, but not always. This is one of the reasons why removal, screw removal in a Latergier is so common because you'll resorb where it doesn't move, and then those screw heads can be prominent. So, you know, resorption isn't always a bad thing. It's kind of a natural occurrence. The question is when is resorption too much? And if so, how do we control resorption? And I'm convinced now we're all neurosurgeons, we're all scientists. If someone says my bone graft is healed, it doesn't matter about this fixation. The fixation becomes irrelevant. But clearly with buttons, something's happening. So I don't think the healing is occurring that we think is occurring that we get with the screws. And it's not just a rebar effect of the screws with the graft because many of the grafts that are healing with the screws are the exact same alloprath material. So I think the fixation isn't as established. I think the healing that we think is there isn't really as robust as we think, and these changes occur over time. Because if it were truly healing, who cares about the hardware? You fix a hip, you're not relying on your plate and screw anymore, right? It's healed. But here we are relying on hardware so we know that maybe the healing we think isn't as robust. With that, speaking of, go ahead. Rick, one quick question. I don't have the technical wherewithal to do this arthroscopically. So my question to you, Rick, if anybody's doing this open of the target and you tie the capsule back to the rim of the glenoid rather than the remnant of the CA ligament, do you think you might be over-tightening the capsule or the front of the shoulder because you're repairing it back to a narrowed glenoid? Oh, there's absolutely no question. That's the advantage of sewing it to the CA ligament? Yes. Every centimeter is about 30 degrees of external rotation. And if you sew it to the CA ligament, which is attached to the corporate block, less so. The graft is incarticular. But if you do, let's say, the congruent or you happen to lay it down in suture, make it extra articular, I think motion loss is actually quite common. On the panel, would you agree? I don't repair the capsule back to the front for that reason. You just leave it there? No, I actually attach it to the edge of the bone block. So you make it extra articular? No, it's intra-articular for me. And then I don't repair it over the top of it. I repair it to the outside of the block after I put it in. Because if you think about it, you're right. We're talking about 25%. When you're doing these big distal tibias and distal— by the way, I think the distal tibia needs to be redone. It's too concave. You guys know this, right? The graft is—it doesn't match the glenoid. It's dipped. So you're either too prominent on the top and bottom or too dipped in the middle. So something like the distal radius is a really nice choice for this. I think we're going to move on to other grafts. But regardless of that, I think you'll find that. And you're exactly right, Steve, I think, that if you're talking about a centimeter or 12 millimeters of bone loss and you're putting your capsule back up onto the face of that, only one of two things can happen. You're either going to be so stiff or you're going to tear it. And if you do repair it and you don't re-tear it, you're never going to engage that bone. And then we all talk about Wolf's Law because it's convenient, but nobody's proven that. I have no idea if it's Wolf's Law. Wolf's Law applies to bone. What he's putting in is dead, frozen something. What do you mean what I'm putting in? You're putting the same stuff in. No, mine's live. Is it live? Yeah. But— Well, that's right, you're cameo. Well, we'll do distal clavicle. We'll do distal clavicle, which is an autograft choice, which is live bone, right? And so—and he may be right. So we tease each other a lot, but it may be that it's not necessarily that it's Wolf's Law or that it's the fixation. There's something going on, but it could be graft-specific. It could be the fact of what Rachel talks about. How planed are you? The technique that we use requires a router because we want that thing— I want 100% sort of overlap. And if you've got two or three little points because our glenoid side is really rough, you know, maybe that's the reason that we're seeing these things. So who knows? The other thing, I think my bank card for these is a control failure. I would not expect my bank card to be holding up a year or two late if it wanted to look. I think it fails slowly and you still load that bone. But, you know, I think it's unrealistic to think my bank card in that capture situation is going to hold up and the bone block doesn't load. The bone block loads, and I think that tissue will fail slowly. That's what I think. Yeah, and I think, you know, I've been shown on second looks, though, that there is capsule that stays on top of that bone. So there's something there. Whether it's your actual true labrum or scar, new capsule, it's hard to know. But I think you are getting something there. And I think that's one of the advantages of having the distal tibia right now, too, is the cartilage there is protective. So to JT's point, if it's not exactly perfect, you know, by the concavity, that's cartilage still. And so you're probably still safe. And I think tipping it a little bit, you know, you don't want to be problematic. But just like you talked about earlier today with a bony bank card, tipping it a little bit to see a little bit of stress, you know, kind of matching that glenoid concavity makes sense. And, you know, I think it's sometimes like we go look at our cuffs and it's a failure in continuity, that it's there, but it's really not the good stuff. I think the bank card, you go back and see it, but it may not really be the robust tissue you're looking for. That may not be the real reason for the split.

surgical techniques

bone grafts

distal tibial allografts

graft resorption

bone blocks