We, you know, we only have a few minutes, but we didn't give anyone a chance to talk to Ian about questions. And Pat, that was awesome. I mean, really, right? You can clearly see where you should be going with your reverse here, right? Older patient, pseudoparalysis, boom, reverse. Younger patient, no pseudoparalysis. You got to do something else, right? And you never know if a cuff's repairable until you try to repair it. So in a younger patient, don't give up the ship and say it's not repairable, and, you know, we're just going to do a reverse. As Pat just pointed out, it's a mistake. So questions for any of us? Somebody asked Ian a question. I feel like Pat, like, cut him off. Ian, you know, I think the strength of your talk there really, among many, was just sort of looking at the, you know, the difficult concept of, well, should I do a bridging graft or should I do an SCR? And you know, it's a tough call, right? Because, you know, both of them are technically difficult, and it's sort of an idea of trying to really tease out the specific indications, right? Yeah, and I think the way I do an SCR has changed over time as well. You know, when we did that study, it was all human dermal allografts. However, you know, if I have a younger patient with even, you know, pseudoparalysis, and I really think it's super, super important to make sure their chromohumeral interval is completely restored, then I will do traditional Japanese, in quotes, in quotes, Japanese style with fascia lateral autograft to try to get that person the best chance possible to, you know, restore their chromohumeral interval and hopefully reverse their supraparalysis. I do think as well, like, doing the partial repair is extremely important as well. I mean, it shows that the graft integrity is improved even with human dermal allograft, but also, you know, Mihata just, I think was an AJSM, showed that subscapular integrity was important even for his fascia lateral autografts. So, you know, that's really where I have been evolving now, is I'm doing a lot more fascia lateral autografts than human dermal allografts. If I do do a human dermal allograft because the patient prefers it and or, you know, they have some knee pain, hip pain, leg pain, or whatever, then I'll commonly double up the human dermal allograft. There's a biomechanical study that shows whether human dermal allograft or fascia lateral thicker is better. So, I'll do that. I know the expense increases astronomically, but I feel like if you're going to try to do it, you got to do it. Yeah. Ian, they're coming out with thicker dermal allografts. That's number one, because I think that's an accepted concept that you need more thickness. And I really think, because in the study that you commented on, on SCR versus bridging, you know, a lot of that could be technique, and if you just do an SCR and you don't pay attention to the front and the back of the shoulder and you don't make sure that your subscapularis is repaired, and I know I always put really good sutures in whatever infraspinatus I can get and try to pull that up and then sew the infraspinatus to the SCR graft if I can. So, it's sort of a bridging in SCR. I think that's really the answer to getting really the best of both worlds and maybe getting your best outcomes. Yeah. And you're right. I mean, the human dermal allograft, because it elongates, a lot of its biomechanical integrity is dependent upon suturing anteriorly and posteriorly as well. And so, that tends to stiffen the graft. And so, I totally agree with that. What position do you put the arm in when you tighten your SCR? Like, you know, everybody knows you need fixation on both sides, but like, how much tension do you put on it? I usually do my graft measurement with the arm about traditionally in about 30 to 40 degrees of abduction. I know there are some people, I remember I went to South America and some Brazilians were doing it when the arm up was up in 70 degrees, but I've just traditionally done, you know, 30 to 40 degrees. Me too. Anything else? 8.30. Thank you very much, and thanks for coming to this joint conference on behalf of Sports Medicine Nana.

surgical options

shoulder injuries

subscapularis tendon

autografts

allografts