That's it. You know, I'm going to run some cases for that. I'm going to tell you some very fascinating cases. JT, can you lead us off, please? And then I'll let you sort of moderate the discussion. Do you want me to present the whole case and then talk about it? Or do you want me to stop and ask questions? Just stop and ask questions. So one of the things we don't talk about very much is post-human stability, especially with the challenging ones. And so this one is my case. All the mistakes made here are mine. And so I'd love to get your guys' thoughts and the panel's thoughts, because the story might not be over with this one, but probably the most challenging posterior stability case I've seen to date. My disclosures are available. So this is a 13-year-old female. And I was called by our pediatric orthopedic surgeon in town. She's incredibly talented. And she said, hey, we've got this kiddo that keeps coming in. And they can't keep the shoulder in. She's been to the ER four times. It keeps falling out. There's not really been any trauma. She's been placed on narcotics. Gabba Penton presents with several weeks' history of this, out several times a day. The family can sometimes get it reduced. But it drops back out. And most of the time, maybe two, three, four times a week, she's having to go to the emergency room, go under a narcotic and a sedation, and get it done. So the MRI, gets the MRI and presents to me after about 30 more dislocations. So Rick, what do I do with that? Non-op, runaway, MDI, we might call it, et cetera, right? So this is a fascinating case. And what I'll tell you, obviously, this is a CAPS. This is basically a soft tissue pathology, number one. There may be some version issues with the glenohumeral joint. What's interesting is the positioning of this patient, which they call you every day, is a paradox. When I see these coming out the front, you want to put them in a sling. That's what the ER doc does. They put them in neutral rotation. They're coming out externally rotated when it's out the front. In the back, your option is you do the exact opposite. So you put them basically in a position where you think it makes the capsule lax, but actually, muscularly, it helps them hold it in. So when they keep calling you, they're putting it in the wrong position. It's the exact opposite of what you should do in an acute case when you have these patients with really poor tissue. So Rick takes the typical cop-out position of don't touch it, run away from it, and I understand that. Mark, you got to operate on this. You leave it alone. Yeah, I'd like some additional views. I mean, on that one AP x-ray that you're showing, she's got a hypoplastic glenoid. I mean, you don't really see any glenoid neck at all, and on the one cut, you're kind enough to show us down below. It looks like there's some engagement there, but I think her glenoid's a whole lot worse, and this is challenging. So there's her glenoid. That's the sagittal view that we get on that. So this is between now March and August of last year. She's out several times a day. She's wearing a sling full-time. When she wears the sling and relaxes, it does stay in, but it will come out almost without her even trying it. She gets a little spastic as well. Two to three ED visits per week now when the family can't get it in, and so there may be a little bit of a spastic component here. So, Rach, do we continue to turn our head here? Do we do something for surgery, and if so, what? Well, this is way too complex for Colorado. This has to go to the Mayo Clinic, JT, so I'm just not sure. I think something needs to be done for a 13-year-old girl. Number one, the cat's out of the bag. She's going to have glenohumeral chondrosis at an early age just from instability arthropathy, but regardless of that, we need to get a stable shoulder here. This is one where I would like 3D reconstructions on a CT view just to look at the morphology of the glenoid, but I think this is one where I'm not sure if you mentioned her Baton score, but even if she had a relatively normal Baton, given the quality of what's sure to be that posterior capsule, I don't think any soft tissue procedure here is going to be the winner. I don't think you'd be faulted for trying that in a 13-year-old as a first attempt, but I do think we need, even though it doesn't look like there's a significant amount of bone loss per se, that posterior glenoid doesn't look normal. Again, I'd love to see that 3D, but I think you're looking at a bone procedure here simply to keep the golf ball in the golf tee. Yeah, so we did do the 3D recons, and this is what you get. So she's 13. She doesn't have a 30-millimeter glenoid, right? But she's not a 25-year-old guy. She's a 13-year-old girl, and her glenoid's 21, and it's not clearly inverted pair or anything like that. Mark, is this a bone procedure for you first time, or are you going to give it a shot with that soft tissue procedure? Yeah, I'm anticipating soft tissue. I mean, if you look at it, I'm assuming this is GAD or some type of fat set, but if you look in the back, she's got an enormously patchless capsule there, posterior inferior. There's just nothing there, so you can't even see the capsule at the edge of that. So, you know, I think you're going to be doing a huge advancement in plication. But yeah, I like that approach. So here we are, August of 2021, exam under anesthesia. Easily drops out the back. She's asleep. She's out. I can put it in, drops right back out. And so you can see what I did here. I elevated the back side. Maybe I should have done bone on this one. We did a posterior reconstruction. Interestingly, she did not have a positive sulcus sign. She didn't even really have a big sulcus sign for laxity, and she certainly wasn't symptomatic. Anteriorly, she was kind of loose but pretty symmetric to her other side. And I said, well, I think she's got unidirectional instability with multidirectional laxity. We performed a five-anchor, knotless, all suture, suture-anchor repair. Rick, what do you think? Just, you know, the smell test here is no trauma, no injury, and she's loose and coming out. So if it happens enough times, you'll get labral pathology. But this is a capsular issue, and this lesion you're seeing here, I think is a result of being out so many times. But it's not the true pathology. That's my opinion of this. So I probably would have disagreed and said this is a secondary rather than the primary. I would have gone MDI is my primary and Ehler-Danlos type. And I would have said that this is something we can treat, but the Ehler-Danlos part had to be addressed. How do you treat Ehler-Danlos? Well, I'm talking Ehler-Danlos type of approach to instability, which is you can do capsuloraphies, you can, you know, whatever your algorithm is for that, you know, what you believe. So you would have gone pan-labral? I would do tests. Tighten the hell out of it. I'd be testing her, all these things in advance of surgery to make sure she's a collagenopath or not. And then if not, then we're doing basically a 360. Yeah, I think that's a good point and probably a mistake on my part. This is her post-op course from August 21 to January of 22. She feels like it's trying to come out, you know, after these five anchors are put in. And she feels like she has this kind of interesting spasm. She feels like her spasms are getting worse by January. She says she feels it's out again. She's back to the ER one to two times per week. This is her CT scan from January of 2022 where it shows a moderate posterior subluxation. She feels like this is out. She also has a thumb MCP that's now dislocated. So to Rick's point about something else going on. And her folks come back and they say, well, we have her on gabapentin. Have you ever heard of gabapentin causing spasms? So my answer to that is nope. So called our neurologists at the Mayo. Their answer was nope. But mom is pretty like many parents. But this particular mom is just a tremendous human being and really smart. And so she goes, well, I don't think you guys know what you're doing. So she goes to the literature and finds a study and takes her off of gabapentin. And five days later, her spasms cease and have not returned. And so as it turns out, this is actually reported in the literature. So for those of you out there with these kind of these weird ones, if you have a patient on gabapentin and they have spasmodic situations, it is rarely reported. But there is a little bit of this in the literature. So I'm thinking, great. Maybe this was the problem. Maybe this is why she failed. I've got the spasms now under control. She hasn't had a spasm and to date still hasn't. So we've got her out without problem. But now, of course, I got bitten by that. I should have waited or I should have known more about gabapentin. And I didn't. That's on me. And so we've got that problem figured out. But her shoulder is still out. And so as Rick says, by March of 2022, she's miserable. No spasms. Brief periods of improved stability full time in a sling. Now she has an elbow contracture, 90 degrees. She wears a thumb in the brace full time. The MCP is out. I sent her to our hand surgeons. They said send her to OT. Thanks. She's still in terrible pain. And she is now – and, I mean, this is an open discussion. Parents are citizens. They're the best people. And so is this girl. This little girl is just a dynamite kid. And they're at wit's end. I mean, can you imagine you taking your child into the emergency room three times a week for sedation and then home on narcotics? It's the only thing you can do. So what do you do? Well, I think maybe, like Rick would have done it correctly the first time, you do – I probably maybe I missed something in MDI. I should have tightened the hell out of her. So I take her back to the OR. This is last March. And the old repair, I look at it, it's not retorned. It looks pretty good. And I'm looking at it and I'm going, shit, I mean, I felt like I did the best repair I could. And I got back and I was pretty happy with it. But I said, okay, you want to test me, baby? I got you. I can make this pancapsular flication. There will be no chance of you putting this thing out. And I did. So this is her kind of coming around the front. This is around the backside after the revision. I think I did 11 acres. These are all knotless, so they're smaller. But if there was a way to flicate capsule, I did it. It's almost a soft tissue fusion I made it so tight. By May 2022, largely unchanged. She says it's shifting out. There's less dislocation, but the pain from it going out is hard. I get a CT. And if you look at the bottom, that's the biggest I can find that's her glenoid. And that's now 18.7. And I probably did this to her. Because remember, she started out at 21, 22. So I've at least cost her 4 millimeters of glenoid in that. And in her, that's an 18-millimeter glenoid. And that's a really small gulp teeth. So is it the anchors? Did I do it with some of the anchor repair? I probably did. Is it erosion? She's negative for infection. I got that going for me. So now what? Graft? Fuse it? Fuse a 13-year-old girl? I'm not doing that. Do a reverse? I'm not doing that. Rick, you do a reverse on her, man? Is that what you're doing? I started with that. I mean, damn. Right? Okay. So let me ask that question. Let's say we get to a place we cannot control her. You fuse her? Yeah. You would. Before a reverse? Oh, yeah. What? Absolutely. The fusion in that age group, they'll do well. What are you going to fuse to? An 18-millimeter ball? We didn't say it was going to be easy. Oh, God, sorry. That's what I said. And then it's solved. Yeah. You reverse on her, and that's just a lifetime of misery. Yeah, that's a tough one for sure. All right. So here we are in May of 22. So now, Rach, what do I do? Make that golf tee bigger. Make the golf tee bigger. And so could you just run that video, please? So you can see this is me viewing from the back. This is a shaver coming in. You can see she's already got changes on her head. I take her out the back. That's her posterior repair, and that's all the glenoid she has left. So you can see that she hasn't completely failed that thing, but here we go. So one of the tricks is coming in from the mid-glenoid portal here with your more bent liberator because that's a really good way to get it. You've got to widen this thing out pretty wide. Then I'm taking a burr from the backside. Normally I drill across the glenoid, but in the back it's much easier because you can come in. And so now I'm measuring the distances down here, and I've got to get this right because I want a flush graft when it's all said and done. I've got her posterior capsule widely elevated. I'm measuring the dimensions of what I want here. I'd like to give her back at least 10 to 12 millimeters of bone because we start with 18, and I'd like to get her there from that standpoint. Now this is an all suture suture tack that's knotless and kind of a pulley system gig. We're going to put two of these guys in here. Once they're in, the surgery becomes simple. One of the things that Rick showed earlier, which I think this one is really helpful, look at this big cannula. It's a 16-millimeter cannula. We call it the Hulk because it's big and green, and it allows you to introduce your grafts whether you're from the front or from the back without having to mess with that soft tissue, which can be really tricky. Now we just simply load the graft. This happens to be a distal tibia, but I could have used distal clavicle. I just wanted a bigger graft in this case. Now you just simply load the two of those, and then you pass one limb, the working limb of one suture, through the loop of the other and vice versa. Now we can slam it down home. There's the graft coming into place. There's your two holes that you can put in. The key here is this is self-locking. You bring this down, and you want to kind of get it close. And then once you get it close, you can fine-tune it with a spatula and then kind of continue working on it. So I've got some slack to get out. Here comes our bone block. We put this guy down, not quite flush yet, but now I can kind of suck that down, and now I've got her flush, and then I can make the final fine-tunings, tighten it up some more in that regard. And so you can see now that we're finished with that. And then this is where I say, Rick, where I don't redo the capsule except down below we'll do the capsule, but then I'm going to tie that capsule into the outside of the bone graft because I think I'd over-tighten it, and she'd by definition fail. There's the tightening mechanism on the outside. I wanted to show you that. And then there we are looking from the back and across with where that graft is over the top. We've now shown you that we've given her back, I think, 12 millimeters, so 12 plus she's now 28 millimeters in her graft. And then you can see now we're passing the sutures that were on the backside of her graft through the native labrum here. And now we've gone ahead and reconstructed that. So now we'll have to see how fast this resorbs and how fast she fails again and see what happens from that. So that's our posterior case. And I don't know how she's doing. That's this month. May of 22. I promise I'll report back, and God bless this little girl. We have some questions from the audience. Yeah, questions on this? I'm telling her to do nothing until she turns 21. Yeah, that's what I tell my own daughter. Yeah, Jimmy. So a question and a comment. The question, these spasms, were these subscap spasms pushing her out the back? Yeah, we went down the rabbit hole with it a lot. We had our neurologist take a look at it. They thought it was something to do with a sort of central nervous system thing. Jimmy actually looked at it for us and found a couple papers with, like, violin players sometimes get this. Jimmy can do weird stuff, man. He'll find articles, and he'll be like, dude, what sources are you looking in? It's weird. He's a deviant. Anyway, so we thought about that for a while. We sent her for cortex mapping, et cetera. We sent her for Botox. Anything we could do to get the spasms under control. Yeah, I mean, we couldn't figure it out. Once she stopped the gabapentin, gone. And then just a comment about this technique. We'll see. We actually changed the technique, right, because we've done ten of them now, so we have to change something, right? That way, when they fail, I can say, well, that's not my latest technique. I'm really doing a good job now. But we're going to add an extra anchor at the bottom and an extra anchor at the top. The two sutures on the back side, you can actually refeed them through these anchors, and so we're going to turn it into cargo netting, and then we'll have four points of fixation. But your point is exactly right, that we worry about that stability. Yeah. JT, my concern is the inferior capsule. So, you know, building the porch out is great, and you have a wonderful job, as usual. The question is the inferior capsule. How much are you, I mean... That was surgery number two, as you saw it. That inferior capsule, it doesn't exist anymore. It's so tight, there was nothing to get through. I had a gal, very similar to one JT presented, so bad that when she first came to see me, she had a diaphragmatic pacemaker in, so that when she would sleep at night, her skull would come off her C1, and she stopped breathing, and then her pacemaker would pick in, so she could breathe through the night, and she came in with this shoulder, exact same thing, in the ER every night, whatever. And so these people exist, and I got to tell you, we did a, eventually, I got someone to do the anesthetic, and we went ahead, and she had her C1 occiput fusion. They left the pacemaker in, and then she came, we went and did a pancapsular, and I mean, like you said, the varsity type, where we, I took up every millimeter of slack, and she actually has done okay, but I'm going to tell you, the amount of tightening we did was pathologic, thinking that, you know, this is, no one ever does this, and we did it, and you know, I just knew she was going to stretch it out, and she's actually, she's probably now five or six years out, and she's actually still doing fairly well, so I think doing that pancapsular aggressively from the get-go, buys you some time, but obviously... The problem is, I got, the Mayo has this huge population of analysts, people, it's not because of me, it's because they have these GI problems, and the vascular problems, and everything else, and they're like, oh, by the way, we got this shoulder guy. I'm like, son of a, you know, don't send that to me, but we have a big population of these, and honestly, my results with Ehlers-Danlos are shockingly good, you know, five years, four or five years out, and you're like, yeah, you're doing pretty well. Occasionally, they have a little subluxation, they're a little loose, but they're not as symptomatic, I don't know. Jeff, I'd love your thoughts on this. Do you have a microphone for Dr. Abrams, please? Does anyone have a microphone? Well, he's getting a mic. We now all know where to send our EDS patients to. This is all I could do just to tell you guys about this one. Sorry about the therapy. You can lay down on the couch for this one, if you want. In the beginning, let's just go back to history a little bit. So, you wonder about voluntary, and you wonder about whether the component is just learned, and it's not positional. She's falling out, even with her elbow at the side. This is back a ways when we're dealing with it. So, I think going through just comments about the potential for voluntary, even the potential with seizure. I wasn't sure what was the cause of an effect. Does her muscle activity cause her subluxation dislocation? Would Botox help you in the diagnosis, maybe not possibly in the treatment? So, we did it, and when we started, your point was exactly right. I thought, man, maybe this is just spasm-induced stuff. So, can we get that under? So, we talked about Botox. I was going to do the Botox, and it's actually, in the literature, pretty good, and it's been shown in CP kids to do pretty good things. So, we were very prepared to do that, and I was trying to get my head around whether the spasm caused that dislocation. In fact, I decided after that, once she was asleep, for example, where there's no spasm in the shoulders out the back, I'm like, no, we got bigger mechanical problems than that. But then, when I did it and she failed, I'm like, well, it must be the spasm. But then we fixed it by getting her off the gabapentin. Well, her mom fixed it by getting her off the gabapentin, and then it didn't solve her instability problem still. So, if we gave you the story of 50 subluxation dislocations at the front, you'd know that a standard capsule labral, just by the people who used to say five and more is too much, 50 and more must be way too much. So, my comment would be, those who were familiar with thermal capsulography learned that sometimes we had to go back and do some shoulders that had either very poor capsule or no capsule. Did you ever have an experience of doing a posterior stabilization soft tissue with doing a remplissage against the glenoid as opposed to a remplissage against the Hill-Sachs lesion? I've done both the remplissage, you know, tightened up on both sides, the humeral and the glenoid side. I did not do that in her, but I think that's a viable option in some of these patients. Her capsule was actually pretty high quality when we got in there. This is not an Ehlers-Danlos patient that's just lost off into the wind, but it's a good point. So, on revision cases, I've actually grabbed the infraspinatus with the capsule as opposed to trying to purely take the capsule and the labrum back to the posterior glenoid. I've gone into the subdeltoid space and literally captured the infraspinatus along with the capsule, not unlike a latter shave from the front. You do sort of a medial plication that includes the muscle element from the back just to give you more tissue and push up against it. Once you get bone loss, I don't think it's an option, but in the first stages, you might have had a chance. Well, you know, JT, thank you for sharing. We appreciate that, and we're expecting an update next year on her next surgery.

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