Dr. Justin Arner: Welcome everyone. I'm Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today I have the distinct pleasure of speaking with Dr. JT Tokish, current President of the Arthroscopy Association of North America and professor at the Mayo Clinic in Arizona. Dr. Tokish was the senior author of the paper titled “MRI Analysis Demonstrates Improved Reliability in Measuring Shoulder Glenoid Bone Loss Using a Two-thirds Glenoid to Height Technique Compared to the Best Fit Circle,” which is in press in the Arthroscopy Journal. Thank you, Dr. Tokish for taking time out of your busy schedule and congratulations on your presidency and thanks for joining us.
Dr. JT Tokish: I appreciate you having me. Justin. Thanks so much. It's a busy year and a fun year and really grateful to Justin Makovicka, who was the lead author on this paper.
Dr. Justin Arner: Yeah, that's awesome. I wanted to congratulate you guys on a important study and personally doing these measurement techniques and studies in clinical practice, I was always a little bit skeptical about where do you put the circle, and it seems like the reproducible accuracy maybe is not as great as we once thought. Tell us how you came up with this idea and how this all started.
Dr. JT Tokish: Yeah, so figuring out and calculating bone loss is tricky. And I have a background in the military where we did a bunch of instability, so lots of experience with calculating these circles and over time you realize that the circle is a little subjective. Sometimes you can make that circle a little bigger and a little smaller. And when we start talking about subcritical bone loss, for example, when we say that 13.5% seem to be the critical number where it all fell out to, people reasonably ask, well, wait a minute, what's 0.5% got to do with this? And we're often talking about the difference between two and three millimeters, making the difference between a patient that we should put bone into and a patient that might get away with an arthroscopic bankart. So clearly if the margins are that thin, then I think it's critical that we have accurate measurements of these things.
And I will say that we, with the perfect circle, I can make the perfect circle a little bigger or a little smaller. And so I tasked the lead author on this paper, Justin Makovicka was our fellow, and Justin really ran the ball with this. And I tasked him to say, can you go back and find out where do we get this from? Is this even true or real? And what we found it's one of those many things in the orthopedic literature that's got this cult following or this dogma producing statement that we all accepted but has never really been tested. And so that was the purpose of this study to go see if we could test it and quantify it.
Dr. Justin Arner: Right. I think it's a great purpose and I remember as a fellow, I had the same discussions with my co-fellows about this. What are we really doing here? And as you mentioned before we started talking, bone loss, it's such a difficult thing and a pandemic almost with revision arthroscopic techniques. And you mentioned before we started about you have to make it kind of simple and reproducible. So tell us a little bit about how you came up with this measurement technique, the percentage, how you guys came up with this basically seems like a more simple and reproducible technique to measure bone loss.
Dr. JT Tokish: Yeah, so we're blessed in that I'm in a big academic system with radiologic systems that allow constant measurement. Our radiologists, musculoskeletal trained all one source at least here at Mayo, but we get a lot of them in the community and it's pretty variable out in the community sometimes about either the quality or how they orient the scans, et cetera. And so I think with that variability, it's important to take a look at these measures. We know that the arthroscopic bankart remains the mainstay of treatment of shoulder instability in this country for sure.
And the truth is, in spite of all the papers from the original one in 2000, 2001 with Burkhart and De Beer demonstrating the high levels of failure with arthroscopic bankarts and bone loss, nevertheless, the percentage of patients that do have an arthroscopic bankart remains incredibly high, probably too high. And so if we're going to fix that, we need a couple of things.
Number one, we have to recognize those patients that are at high risk. And so there's cases like methods like the instability severity score or other scores into account that will predict who's going to fail with an arthroscopic bankart that are important. But in order to do that, all systems that are going to give you an idea about what's important and who you're going to have to augment, all of them require an accurate measure of bone loss on the glenoid side.
And so about 10 years ago, one of the authors on this paper is Jimmy Shahe, when he was a resident with me, he actually took on the process when we were at Tripler Army Medical Center, we actually had a failure rate that was higher than I was comfortable with. And so I said, "We should go back and take a look at this." And so that was the paper when we published on subcritical bone Loss. We let the data fall where it would. Separated people into quartiles. And once it finally fashioned itself out, we realized that it was far less than the 20% of so-called critical bone loss that was used, and it was a lower number than that. Now we can argue about 15, the data says 13 and a half, but it's probably somewhere between that 10 and 15% of patients that are going to need to be done.
The problem is is that depending on where you draw that circle, a little bigger, a little smaller can take 13 and a half and turn it into 17 or can take 17 and turn it into 13 and a half, and then that's the first problem. The second problem is is that many, in fact, most of the practitioners out there that are doing arthroscopic bankarts don't have access necessarily to PACS machines and accurate drawing of circles. In fact, in our city here in Phoenix, if we have our local guys do it, great, but if I get it from an outside institution, in fact, we have two big radiology places in the valley here, and one of them allows you to make a perfect circle on your PACS images, but the other one does not. And so what happens to all those people out there who don't have the ability to draw a "perfect" circle, even if it is accurate, they don't have access to that radiology films. And we thought, okay, is there a simpler way that we can do this? And is two thirds even accurate?
Dr. Justin Arner: Yeah, that's great advice and great point. Yeah, I thought it was interesting. I recommend the listeners look into basically that 67.8%, the glenoid height and basically it's just a more reliable technique to measure to the base of the coracoid. And like you said, I've had the same issue. So you mentioned a little bit about the imaging and I see these three Tesla MRIs. Can you just talk to us about a little bit about CT versus MRI and 1DCT and just your thoughts and Gestalt certainly you're an expert on this field and the best techniques that way?
Dr. JT Tokish: Yeah, I remember, gosh, many years ago we had our musculoskeletal radiologist at Tripler where we defined a lot of this work. We were getting CTs and MRIs on everybody and he used to come back. His name was Ken Lindell. He's a phenomenal musculoskeletal radiologist. And he came back and I said, "Ken, is there a difference between the MRI and the CT?" And he said, "No, the MRI is equally equivalent." And then of course we had a series of studies that came out that showed that CT scan is "the gold standard" because of bone, and that's fine. Certainly, all of us would agree. You can see the bony contours of a CT scan a little bit better than you can see on the MRI. That's true. I think Ken was right too though in that the way he did his MRIs and the way he set up the protocols for the MRIs, they were so consistent and so good that we had a very, very high insured observer reliability.
But that's not the case in the real world. Not everybody's out there is a Kin Lindell and not everybody out there controls their entire healthcare system where every radiology tech is trained the same way, et cetera. So we have to account for that variability.
What we found was was that if you really do have a very standardized way to go about this, that the MRI is as accurate, but the CT scan too also remember they have to orient it along a certain plane. And there've been several studies now one by us, one by others, Matt Prevention published on this as well, that if they go back and reformat the CT and they're off in terms of where they, not necessarily off, but if they just format it in such a way that's not truly perpendicular to the face of the glenoid, it can really over call and under call bone loss. And so what we want is the MRI is nice because it's a little bit more standardized in terms of how the formatting gets done post study. And so if you've got that MRI, it's a pretty reliable way to be able to say, yep, we can get this. We can get it every time. We believe the MRI is the better measure for this, not because it's necessarily more accurate, but because it's as accurate and doesn't have the radiation potential of the CT scan.
Dr. Justin Arner: Yeah, that's for sure. I did a posterior instability project with Dr. Bradley and Dr. Provencher, found the same thing. If you reorient the image, you get a total different reading and getting the 3D models are nice, but sometimes in our system it's difficult to measure like you mentioned on the 3D model. So it's a good point. The other thing I saw you mentioned in your paper, which is pretty interesting, if you have a substantial amount of bone loss inferiorly, it's really hard to even know where to put that circle in, which I think is interesting. Tell us a little bit of how you evaluate bone loss. You're the guru of this. Do you use this two-thirds technique clinically or has it changed your practice?
Dr. JT Tokish: I actually do every time. I calculate bone loss in every single patient that comes through it, we did a paper which validated the on-track off-track method. I got interested when Di Giacomo and Bradley and Eiji Itoi, three of my heroes sat down and said, Hey, we realized that bone loss is bipolar. They wrote that up as you know back in 2014, I think. And that changed the world in helping us understand it's not just the glenoid side, but we have to be able to calculate a track. So then we were in the midst of all this bone loss stuff and thought, gosh, does this matter? Does the track matter or is this a cool radiologic measurement?
So we went back and looked at our patients at Tripler with three of us that were pretty busy sports surgeons doing lots and lots of these bankarts, and we found that the glenoid track actually was a very good predictor. I think what we found was that if we were on-track that we had about an 8% failure rate and if we were off-track, it was five times higher than that, four times higher than that. So from that standpoint, we said, and gosh, this is very important to be able to calculate that.
In addition to that, if you were off-track, you had a really high chance of having a poor outcome even if you didn't redislocate. So it was even more important than just figuring out recurrence was to figure out whether these patients did well. So when you ask a soldier who was out there and we'd say, Hey, have you redislocated after this? And they'd say, no, I'm okay. And we'd say, well, let's take a look at how you're doing. And we'd measure their woe and they were doing terrible almost as bad as somebody who had recurrent instability. And so we realized a couple of things then.
Number one, you can't use recurrence as your sole measure of outcome after shoulder instability surgery because they just never got to this position and to the abduction and external rotator position. So that was number one. And then number two, we found that the glenoid tract actually is a very good predictor of who was going to do well and who was not going to do well in that population. And of course, therefore you have to have accurate measurements of these things.
So we went ahead and said, "Okay". I tasked Justin and a couple of our other folks, Jimmy Shahe on this paper too because he became our fellow, but they went out and took a look at a whole bunch of our own ones now here at Mayo and said, first of all, number one, is there a flection point at the base of that coracoid? In other words, is there that posterior superior glenoid tubercle?
So we made sure we blinded everybody to that. Some of the people that do these studies, they take a snapshot of the ideal shot and they put it in a PowerPoint, and it's a little bit of a cheat code, to be honest. We did not. We had have to go through and look at these themselves so that we couldn't cheat and pick the one image that everybody say, okay, that's good because that's part of the deal is can you go through the image and are we all talking about the same flection point in image? And so they were very, very close in terms of their reads. The inter reserve reliability was very, very good in terms of that even better than the two third circle method.
And so now for me, when we come through bone loss is one measurement. It's not the only measurement, but it is the hammer, right? So if you've got a bone loss that's above a certain amount, you're not getting an arthroscopic bankart for me, it's just not happening. And because we know the failure rates are 30, 40%. People say, "Well, that's not my failure rate." And I'd say, have you followed your patients two years? Have you followed your patients four years? Because I used to say the same thing and I've learned this the hard way over the years, and these patients are just getting shuttled from one surgeon to the next sometime.
And so I would tell you that if you have significant bone loss, forget about any of the rest of it, that's enough to tilt you over to do something else. Now, whether that's something else is a remplissage or that's something else as a glenoid bone graft or it's a latter J, I think that remains to be seen and remains to be determined. And we can get into that discussion if you wish, but I think for now, just an arthroscopic bankart, we've got to know better and we've got to do better than that.
Dr. Justin Arner: Yeah, you're right. Like you said before making this easy for all of us to measure and evaluate is important in busy clinical practice. Talking about the humeral side sided bone loss, tell us how you measure this. Are you doing the on off-track? And it seems like the more we learn, the more we realize that it's probably more complicated. How wide, how deep, how long? Tell us your gestalt of what you're looking for when you see these humeral sided bone loss and what do you do about it?
Dr. JT Tokish: Yeah, the problem with the Hill-Sachs lesion is it doesn't read the book, right? So glenoid bone loss is usually fairly standard. It's fairly parallel to the long axis of the glenoid. So you don't get it in different shapes and sizes per se, very much. It's usually right along that long axis. The humerus is an entirely different thing. It depends on what position the arm was in at the time of that initial dislocation. So Di Giacomo and Maddie published this too, where they looked at the difference between what they called an abducted Hill-Sachs lesion and an ad ducted Hill-Sachs lesion. And actually what they found was the ad ducted lesion was probably a little bit more common. So that's the linebacker who's not up in the outstretched up position, but he's down with his arms at his side and then has an arm tackle and that guy rips it out and he gets forced external rotation.
That one's tough because the Hill-Sachs is lesions still there. It can still be engaging, but it's not amenable to that standard remplissage that we all do. So not all Hill-Sachs lesions are amenable to those. So when you've got the big Hill-Sachs lesion, what we would say is we rely on on-track off-track for this a lot. And there's a couple of really good papers out there, one by Peter Millet that I would call everybody's attention to, and that is this. Peter, when he was doing Latarjets, did a really elegant study of looking back and finding out when he did his Latarjet, did he take them rather from off-track to on-track, right? That's our goal.
And so when you add that bone to the front of the glenoid, you extend the arc, you make the bike tire bigger if you will, and then hopefully it doesn't fall into the pothole. But in Peter's cases, there were many of his cases where he did not, he left them, even though he did a very beautiful Latarjet, he still left them. They still were corrected and they were still off-track. And guess what? What he found was no patient in his series had a good or excellent result if they remained off-track after surgery.
Now, our European colleagues are so aggressive with the Latarjet that they do it with no bone loss, and in their case, they almost never have an off-track lesion when they're doing it or often don't have an off-track lesion. But the caution I would have for folks is if you're doing this in Latarjets in the setting of bone loss, usually in that 20 to 25, 30% range, if you don't correct that to the on-track method, that guy's going to still engage and you still have a problem with outcomes.
So how do we approach it? Well, the remplissage has changed a lot. I will be honest. When it first came out, I thought the remplissage was going to be a flash in the pan. Here's why. It's simple, it's slick and you can bill for it. And so when you've got those three things in the hands of us as orthopedic surgeons, Katie, bar the door, we're going to adopt that thing and run it up the flagpole. We're going to tell everybody how great it is and it's awesome because I can do it. And as you know, we do these in very fast time, very efficient, and now I've got a bill for it, let's go. And that's a problem, I thought.
But in truth, the data has come out. And in 2015, I think Boileau published the first large scale series of this, and that was very good. But then Neuroscience comes out with a paper shows one third of patients still have posterior shoulder pain, and then John Kelly, God bless the right Reverend John Kelly, he's as big a proponent of the remplissage as there is anywhere. And actually did a number of the critical studies to bring this up, he with Grant Garcia. And what they found was return to sport was a little sketchy, 68% I think in basketball or football. So it was that two thirds to 70% of patients that did not return to sport after that.
So what about direct head-to-head studies with that versus the Latarjet? And I think our best data, at least right now, comes out of Bob Arciero's group and Yang is the lead author on that. And they did a series comparing Latarjet to remplissage, and they found that equivalent results. And there's lots of studies out there showing equivalent results except for contact athletes where 30% of the remplissage is failed or revision surgery where they and others have showed really high failures in revision, not revision remplissage, revision surgery. So be careful. If you've got a contact athlete, somebody who's got a revision or somebody that's got bigger bone loss, your remplissage does not perform as well as does the Latarjet of the bone blocks.
So how do we employ it now? Well, if the data is getting pretty clear, you ask, well, which patients would you do a remplissage in? I'd say, well, any patient that I'm doing a bankart in, you might even say patients, people tease me about this because I've made a couple comments in this regard. Well, what about a patient who doesn't have a Hill-Sachs lesion? And I say, "Well, I make one." And I say that tongue in cheek. But the truth is, yeah, it's not a bad idea to go up and just roughen it up next to that area because the truth is is that the data is really clear in almost every study that's been done across the board. You're playing for a tie, you're hoping to get as good a result with a bankart as you get with a remplissage. So who would I not do it in? I wouldn't do it in a throwing athlete. I think that's a tricky one. So that patient can't have it. Now if you've got a throwing athlete with a big Hill-Sachs lesion, good luck, buddy. That's a big problem.
So a throwing athlete, I don't do it in, I don't trust it in a revision case, and I don't trust it in a major contact athlete person there. In those patients, I think you have two choices. For me, I actually do a bone graft on the glenoid side and I tell them, I make the dance floor so big that they can't dance off of it. So that's a distal tibia or an iliac crest or whichever your graft dejour to choose. I don't use our distal clavicle graft for those big ones because it's not a big enough graft. So for small subcritical bone loss, I'll use distal clavicle for bigger ones. I think Matt's graft with the distal tibia is an excellent choice, and I think even frozens as Ivan Wong has shown us is a pretty good choice too.
Dr. Justin Arner: That's a great synopsis. Banking off your discussion about graft size, certainly with your experience, it's interesting for me to know. You hear all these stories about resorption and screws and buttons. Have you seen resorption in Latarjet, DTA? Does it matter of the size? Tell us your thoughts about resorption of the grafts.
Dr. JT Tokish: Yeah.
Dr. JT Tokish: Well, I'll tell you, it's a hot area right now. So for young surgeons that are out there that are looking to start doing some studying and looking at a topic that is unsettled, look into this topic. The truth is I've seen every graft resort, all of us have. The classic study was by Di Giacomo where he took a look at the Latarjet afterwards and he found, I think it was 57%. Don't quote me on that number exactly, but 57 ish percent of the superior half of that graft went away. And that's concerning because what's left there is a bare screw, right? And I would say that some of my distal clavicle grafts, we've done a number of those, we'll see a little bit of milder resorption. I see less of it as a percentage, but it's usually a smaller graft. I've seen distal tibias that melt away.
So with all due respect to some of the studies that are out there, anybody that's done a bunch of distal tibias, we haven't figured that out yet either. Many of those get away and go away. I've also seen distal tibias that don't move a lick. I've got probably got 15 or 20, I CT all of them and I've got 15 or 20 of them that it looks as good as the day it was born in there.
Now, how to fix them? I think we must move away from screws and put in buttons or some sort of equivalent with that. And the reason that I say that is not because it's superior yet, but because nobody's going to adopt the screws. So what happens is people come out and they go, I don't want a Latarjet. Why not? Well, because there's a not insignificant risk of injury and the case is hard. So most people are not comfortable with doing those and therefore they don't do them. They go back and they do another arthroscopic bankart, which then of course, unfortunately fails.
So we have to teach either teach more Latarjets, which is what our European colleagues tell us to do, and that's one way to do it. Alternatively, however, we should maybe make this procedure simpler. So we and others have developed different techniques about how do we make that bone block work and how can we do it? The problem is from the front, you can't put screws in a bone block unless you go all the way to the medial, the Halifax portal, if you will, with Ivan Wong's technique. It's doable, but you're making a big hole in the pec, doesn't seem to be a problem. So I think Ivan's a genius and I think his technique is excellent. I don't think it's ideal yet. It's not optimal. And the reason is is that it's dependent on the graft guide that you use, and that guide can't put the bone in on foss, it has to put it in like it puts it in which burrows a pretty good size hole in the soft tissues on the way in. So ideally, we'd like to change that.
So the technique we've described and a few others are doing is we can put it through the interval. So a couple of the key procedures here, number one, the graft should be able to be done arthroscopic because most of our surgeons are not going to convert to open surgery. That's just the truth of it. So we have to make it easy enough for the arthroscopic surgeon who's not comfortable open, will do this arthroscopically. Perfect.
Number two, we have to be able to introduce the graph through the interval because splitting the subscap always puts the nerve at risk and it's hard. So even after 80 arthroscopic Latarjets, you still run the risk. That nerve is right there. And so if you're a wizard, great, do it and you can get that thing and set it apart and it's beautiful. The problem is is that the vast majority of these are not going to be done by Pascal Boileau, Laurent Lafosse are some of the people in our country that are doing them. The vast majority are going to be done by people who say, I'm not even going there. So it has to go through the interval. We have to get secure fixation. Can't do that from the front with screws, so they have to be either drilled from the back or we've got to change the technology. I think with the emergence of some of the suture buttons and cables and a couple of the things that are just on the horizon, we'll have that problem solved.
Now, the challenge is is Ivan Wong has done a study, a comparative study where he's looked at his comparing buttons versus screws, and what he found was that the buttons had a pretty high failure rate, and then people have argued, well, you don't use fresh distal tibia, you use this frozen stuff. But he was pretty good in that study. I think anybody that hasn't read it should go back and read it. Ivan did a really nice job of removing variables, and that's the best data in literature, so we should be nervous about that a little bit.
The other thing Ivan says, which I think is really smart, is that I tell you that I've got these great CT scans at three months and six months, but he's got his now, some of them out at five years, and the remodeling process continues to take effect there. And so who knows? I will say this, all of them remodeled, and so if you've got, well, I think one of the reasons the Latarjet still works is you still got a screw there, but it's also the reason that we have to go back so often and remove screw hardware for painful issues after Latarjet.
Dr. Justin Arner: And certainly that's not benign, going back into that scarred mess to remove a screw is not fun for anyone. So you alluded to this. Tell us a little bit about how you're approaching it in these critical bone loss, 15%. Are you using your elegant distal clavicle graft, more revisions, DTA? I know I've seen some great talks from you, especially at this AANA annual meeting and how you use the basically suture anchors as buttons. Tell us a little bit about just your typical thought process with these different cases.
Dr. JT Tokish: Yeah, so I would say that with all those principles in mind, having to do it arthroscopically, having to do it through the interval and not through a split through the subscap, having a big enough graft to correct the bone loss and then making a simple and safe and reproducible method, the first time, I think Pascal Boileau deserves a lot of credit because he's the first one to say, you know what? I'm going to use a suture button. I did suture anchors when we originally described the distal clavicle, I put two suture anchors and used a double pulley technique to slam it down, and the truth is it works. There's another study out of China in 2000, I think it was 2017 maybe, that showed that too. They did it and it worked.
And so I thought, okay, that's reasonable, just suture your anchors, and then you could put two holes and double pull it and slam it down. The problem is when I was really being honest, I could still wiggle that graft a little bit and I didn't love it. It works and it's good, but I thought, gosh, these patients are, I want something better.
So when Pascal came out with his button, I thought that was a pretty good idea. Well, we were very comfortable with ACL tightrope fixation and with syndesmosis screw fixation now with these adjustable buttons, and so I went to one of the companies and said, Hey, I want to see if I can use your syndesmosis fixation, which has buttons on it for me to do this with bone loss.
So we went to the lab and originally they were too short, and so we had to figure out how to lengthen it by hand. And so we did. We made that work. My first probably five or six cases was me using that. We watched them very closely. We're very careful about how we did that. We did CT scans at three months and then MRIs not much, and I thought, well, that's pretty good. Wouldn't it be nice if we could remove the buttons altogether? So there are an emerging group of companies that will create all soft tissue buttons. Wouldn't it be nice ideally if we have no metal in the shoulder and we can still do these things? So now there's soft button constructs out there.
We started doing soft button constructs with that, and that was actually even better. There's a circlage technique out that I've also used. That one is good. I worry a little bit about it eroding the bone in between. So I believe that we should be doing longitudinal compression only and not across the bone compression, but it can work very well, especially if you leave the cortical edge of a bone on there.
And then I want small holes, so these can be done because they're not 4, 5 or 40 screws. We can use 2.75 suture buttons, et cetera. You can actually do these through a one millimeter or a two millimeter drill hole retrograde so the button can't come back through, but the rest of the suture material can come through. So imagine now we've got a drill that goes through the glenoid that's no bigger than two millimeters to three millimeters compared to having to do a 4.75 or something like that. I think we preserve that glenoid bone across there, and now that's what we've done. We've probably got, I don't know, close to 50 now with these various difference, and I'm still evolving in how we do this, and I would say I've had one failure. Actually, I've had two failures that I know of. One was a college wrestler, so that's on me and ended up wanting to go to MMA, so we fixed him. He failed on that one. It toughed me.
And then the second one was a hockey player. That was a really interesting story. He failed two arthroscopic bankarts. I did an arthroscopic DTA on him. He came back after playing 50 games or 40 games, and then he was hit again and redislocated. I thought, oh my God, here we go. So we went and found him. We re-scanned him. His glenoid bone loss was gone. He had remodeled his graft, a big graft into his shoulder, and he had a perfectly circular glenoid. So now I got a problem. I'm like, well, he doesn't have glenoid bone bone loss. It's gone because we grafted it, but he's recurrently unstable. And so then there was this argument, should you try to do another arthroscopic bankart? And I said, no way. We're doing a Latarjet and remplissage. We throw the book at him.
So certainly have had a few failures, but I'll tell you with this one, I've had some incredible results. Some seizure patients, for example, and this is one that I really like this application for. If you get a seizure patient and they say, the neurologists always tell us, oh, their seizures are controlled, don't worry about it, and then they're going to have a seizure right after you do that operation. It's like the Murphy's Law. So with seizures, imagine, now you've got those screws in and now they've broken those screws or bent those screws. We've all seen those cases. Those are disasters. They're hard. You got to go in and bear out those things, and it's a rough day.
So now the buttons happen, and let's say you have an all suture suture button that you go in and you treat somebody with that. Let's say they do have a seizure, and let's say they break that stuff down, you're dealing with broken stitches. That's a fairly easy thing to go in back in and fix without all the destructive nature of that. So eventually, I think we get to all soft tissue buttons. I think they have to be shown biomechanically equivalent and clinically equivalent, but if we can do that and make this thing easy, then I think that surgeon who's comfortable with the arthroscopic bankart, it's not that big a jump to move from that to an arthroscopic bone graft.
Dr. Justin Arner: Yeah, it's an elegant technique and like I mentioned, there's some good recordings from the AANA meeting that you're showing your technique and some nice arthroscopic techniques, ATech techniques about it. So appreciate it. Awesome discussion. I know you have a lot on your plate today, so I don't want to take up any more of your time, but really appreciate your explanations and sharing your results and pushing the envelope. We certainly owe a lot of gratitude to you to make this difficult situation better, so thanks for your time.
Dr. JT Tokish: Well, I'm honored, and Justin, what you guys are doing with the podcast and you in particular is really taking us to a new level, man. So as AANA's current President and the guy that they've given the keys to the car with, I just want to thank you personally for the work that you and what Matt has done on this. I think getting the ability to have conversations like this and to be able to bring in this interactive nature between surgeons I think is really helpful for all of us, especially for the young folks. So we're in your debt, my friend, and look forward to many more to follow.
Dr. Justin Arner: Thank you, Dr. Tokish. Appreciate those kind words. Dr. Tokish's article titled MRI Analysis Demonstrates Improved Reliability in Measuring Shoulder Glenoid Bone Loss Using a Two-thirds Glenoid Height Technique Compared to the Best Fit Circle is impressed in the Arthroscopy Journal is available online at arthroscopyjournal.org. Thanks so much for joining us.
This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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The information and opinions discussed herein, including but not limited to text, graphics, images, and other material contained in this podcast and its referenced paper are for informational and educational purposes only. No material in this podcast or its referenced paper is intended to be a substitute for professional medical advice, diagnosis or treatment. Specifically, all content and information in this podcast and its referenced paper does not constitute medical advice. Always seek the advice of your physician and/or other qualified health care provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen, and never disregard professional medical advice or delay in seeking it because of something you were exposed to from this podcast or its referenced paper. The information discussed in this podcast and its referenced paper may not apply to every individual and may cause harm.