Thanks, Rick, for having me. So the format today, as Rick mentioned, is going to be a couple of quick didactic talks. So I'm going to talk a little bit about applying the glenoid track in this regard, because we've had a lot of experience with this. As you guys know, bone loss remains one of the most challenging aspects in shoulder instability. And you can see this sort of inverted pair concept. So if you're looking from the anterior superior portal, and it looks like that you're looking at a pair that's upside down from superior to inferior, that usually means that you've got bone loss. And if you have bone loss and you do an arthroscopic Bankart, you're going to be in trouble with this. Jimmy Shea is here in the audience with us. And he taught us all about subcritical bone loss, did the lion's share of the work on this paper, which told us that while 20% is too much, actually 13 and 1 1 was a cutoff point for us that shows us that if you're below that, or if you're above that number, what we called subcritical bone loss, that you were going to have a higher re-dislocation rate. But more importantly, even if you didn't re-dislocate your WOSI scores would be in the toilet if you do an arthroscopic Bankart. So we'd see these guys back. We'd say, did your shoulder come out again? They'd say no. And we'd say, well, how's your shoulder doing? And they didn't score very well. And that's one of the great lessons that we've learned from this. And then, as you know, Jujakamo and Eji Itoi, Steve Burkhart, taught us about that this is not just a glenoid-sided bone problem. This also exists on the humeral side. And Nobuyama Moto has been critical in my understanding of this concept, helping us understand that it's on both sides of the joint, and we've got to deal with this. So how do we measure glenoid bone loss in terms of the glenoid track, and figuring out if we're on track or off track? And I think it's really not as difficult as we sometimes make it out to be, right? So you only really have to do one math equation, I promise. And it's just arithmetic. It's not even algebra. So we'll get through this together. But the first thing you gotta do is you gotta draw a diameter. That's the inferior 2 3rds of a circle. I think most of us have software in our institutions that help us do this. So that's pretty good. And then measure that. That's your big D. That's the diameter of the idealized glenoid, okay? And so that diameter in this particular case is 30 millimeters. The next thing you're gonna do is measure the bone loss, and that's little d. And so that's a little blue line here. Also with the same circle, and just measure it in. And in this case, that's six millimeters. Now here comes the math part, okay? So grab your coffee or your beer. But essentially, in order for you to get the glenoid track, it's this one formula. You have to multiply it by 0.83, which is what Nobu and Edgy taught us about how much of the idealized humeral head travels through the glenoid track. It's about 0.83 of the diameter of the glenoid. So you just simply take 0.83 times big D. In this situation, that is 30 times 0.83, and that gives you 25. And then you subtract from that whatever your bone loss is. In this case, that's six. And so you simply go 25 minus six. We now have our glenoid track is 19. That's it. That's the only math you gotta do. Now, we're gonna then go to the humeral side and figure this out. So in the humeral side, we've simplified this a little bit. In the original description, they had you take this heel-sax interval, but you can combine that with other things. So all you gotta do is draw one arrow from the most medial portion of the heel-sax lesion to where the cuff inserts. That distance is your heel-sax lesion. If that's bigger than your glenoid track, you're off track. If it's smaller, you're on track, and those things matter. So in this particular case, the glenoid track measured at 19 and the heel-sax lesion was 15, so you are on track. Now, you'll notice you're on track, but you're only on track by four millimeters. What happens at speed? So I worry about that a little bit, right? So we and others have talked about this near-track concept. And Edgy took a look at this, and we'll talk a little bit about how they define that. When we looked at this, you might say, well, does the track concept matter? And the answer is it does matter in our hands. At least we had three sports surgeons going at this pretty hard, and this is another work by Dr. Shehey that helped us understand this. If we did an arthroscopic bank cart and we were on track, our failure rate was a pretty respectable 8% in a military population. I'd take that. But if we were off track, we had a 75% failure rate. That's brutal, and it was humbling, and really taught us that we had to think about it. And again, in this thing, we learned that even if the patients didn't redislocate, their outcomes were still terrible in an off-track lesion that we fixed with an arthroscopic bank cart, regardless of whether they had recurrent instability. So what we learned from that, that was sort of the come-to-Jesus moment for me where I said, we gotta stop or lie unto ourselves. We all think, oh, that's not been my experience, and we would have said that too before we had this experience with this. Are all tracks the same? Well, the answer is no. The more peripheral or the more central you get, the worse off you are. And so if you get that near-track lesion, if you're within 25% of the glenoid track, you should consider that off-track, even if you're on track. Does that make sense? So if you're near-track and close, you gotta treat that like an off-track lesion. So if you're gonna do it, then how do you fix it? We're gonna spend the rest of the time talking about that today. I think if you have minimal bone loss without other risk factors, I think an arthroscopic bank cart still remains our go-to operation. If you have subcritical bone loss or you're off-track because of a large Hillsex lesion, and really the data is emerging to tell us that almost any Hillsex lesion should do a REM plasage. But of course, if we get to a place where we have more than 20% or significant glenoid bone loss, I think that's the role for the graphs that we're gonna talk about today. So in conclusion, we must recognize the limits of the arthroscopic bank cart. Remember that bone loss is a bipolar problem that can be quantified, and the track concept is validated. It's a validated method in decision-making for the unstable shoulder with bone loss. Thanks very much and good luck.

bone loss

shoulder instability

glenoid bone loss

humeral bone loss

arthroscopic Bankart procedure