text:
Spare Parts: Four Undocumented Teenagers, One Ugly Robot, and the Battle for the American Dream
Davis, Joshua
Annotation: Tells the story of how, with the help of two inspiring science teachers, four undocumented Mexican immigrants in Arizona put together an underwater robot from scavenged parts and went on to win the National Underwater Robotics Competition at UC Santa Barbara.
Genre: Engineering
Format: Perma-Bound Edition
Publisher: Farrar, Straus, Giroux
Pages: xii, 224 pages, 8 unnumbered pages of plates
Dewey: 629.8
Robotics. Competitions. United States.
Remote submersibles. Competitions. United States.
Mexican American boys. Education. United States.
Mexican Americans. Economic conditions.
Phoenix (Ariz.). Social life and customs.
*Starred Review* Reality is complicated, notes Wired magazine contributing editor Davis in this powerful chronicle of four West Phoenix teenagers who proved they knew more about what to do with "spare parts" than the leaders of the country they called home. In 2003, Lorenzo Santilian, Oscar Vaquez, Christian Arcega, and Luis Arranda had been all but written off by Arizona's educational and political systems. Children of Mexican immigrants who had been brought into the U.S. illegally, they found themselves attending a severely underfunded barrio school. Yet in 2004 they scraped together used-car parts and created a funny-looking but impressively functional underwater robot that won first place d national recognition the prestigious, NASA-sponsored Marine Advanced Technology Education Robotics Competition, overcoming competition that included MIT engineering students. All things being equal, these four engineering geniuses should have been able to write their own tickets to the best universities in the country. But all things are not equal. Far from it. Davis pulls no punches as he describes the grim sociopolitical atmosphere that allows the oppression of talented people for no morally acceptable reason. The four young inventors and their struggles helped spur the DREAMers movement, and their story will also be told in a forthcoming Hollywood movie. This is important reading.
Starred Review ALA Booklist (11/1/14)
Interest Level: 7-12
Accelerated Reader: reading level: 6.9 / points: 10.0 / quiz: 180664 / grade: Middle Grades+
LORENZO SANTILLAN had always been different. It might have been his head. When he was a few months old, his mother dropped him on a curb in Zitácuaro, a town of about 100,000 people in the Mexican state of Michoacán. He already had an odd, pear-shaped head, but now he developed a lump on his forehead. Laura Alicia Santillan was worried. She decided that he needed better medical attention than he was getting in Mexico, so she began the long journey to the United States, eventually slinking through a tunnel under the border with Lorenzo in 1988. Lorenzo was nine months old. She was motivated by a simple desire.
"We came to the U.S. to fix his head," she says.
She found a doctor in Phoenix who agreed to examine her son. The man said that surgery could realign Lorenzo's skull, but with a significant risk of brain damage. But, as far as the doctor could tell, Lorenzo was doing fine. The surgery would be strictly cosmetic and was otherwise unnecessary. Laura took another look at the bump above her son's right eyebrow and saw it in a new light. From that moment on, she told Lorenzo that the bump meant he was smart. "Your extra brains are in there," she told her son.
Now that Laura and Lorenzo were in the United States, there were reasons to stay. The family had barely been getting by in Mexico. After slicing off half of his right index finger in a carpentry accident, Pablo Santillan, Lorenzo's father, fed the family by disappearing into the forest for days on end with an ancient musket. He would return with skunks, squirrels, and iguanas slung over his shoulder. Laura dumped them into a stew, added some tomato, chili, and onion, and called it dinner. She was only fourteen when she married Pablo (he was twenty), and neither had made it past sixth grade. There weren't a lot of opportunities in Zitácuaro, but in the United States, Pablo had a shot at making five dollars an hour as a gardener. It seemed worth relocating.
The family moved into a two-room apartment near downtown Phoenix. A block away, prostitutes offered their services from an abandoned building. Drug dealers worked the corners. It was starkly different from Zitácuaro, where Pablo could search the forest for food. Now they lived in the middle of a big city and it wasn't possible to hunt for dinner. Laura got intermittent work as a hotel maid, and Pablo worked landscaping jobs throughout the scorching Arizona summer.
Before coming to the United States, Laura had given birth to two children: Lorenzo and his older brother, Jose. When she crossed over to the United States, she was pregnant and soon gave birth to Pablo, Jr., on U.S. soil, which meant that her third child became an American citizen. Yoliet and Fernando, a daughter and a son, were also born in the United States. The three American-born siblings would go on to have significantly more opportunities to live and work in the United States than the two who had adopted the country as their new home.
For Laura, Mexico soon became "an erased memory." But Pablo never forgot the solitude of the Mexican forest. A quiet, stoic man, he wore cowboy boots and sported a handlebar mustache so thick, it hid his mouth. He had the hard-drinking, solitary nature of a cowboy but now found himself in a vast urban desert with five children. It was a heavy load to bear. At night and on weekends, he often bought a twelve-pack of Milwaukee's Best and started working his way through it. As Lorenzo tells it, when Pablo was drunk, he became emotional. Sometimes he told Lorenzo that he loved him, other times he snapped. On one occasion, when Lorenzo was in middle school, Pablo asked his son to clean up the living room. When Lorenzo refused, Pablo grabbed an electrical extension cord and went after him.
School wasn't much better. As Lorenzo got older, his jowls bulged out but the top of his head stayed comparatively narrow, giving it an egg shape. Kids mocked him for his misshapen head and, once he got to middle school, they laughed at his unibrow. "I didn't understand why people would do that," Lorenzo says. Many days, he came home crying.
With little choice, Lorenzo decided to embrace the fact that he was different. While the other kids at school had short hair and nice fades, Lorenzo went the other way. His mother cut his hair—they couldn't afford a barber—so he asked her to only trim his bangs and let the rest of his hair grow out. Soon, he had a mullet.
"It looks really nice," Laura told her son.
His classmates were less supportive; the ridicule was frequent and varied. Sometimes they called him an egghead; other times, he was referred to as El Buki, after a long-haired Mexican pop singer. When students called him a woman, he fired back that he was more of a man because he could take all the insults. "I don't want to be like everyone else!" he yelled back, and tried to pretend it didn't hurt.
In seventh grade, a friend asked him to carry marijuana for Sur Trece, a local gang associated with the Crips. He agreed and was entrusted with a pound of weed, which he stashed in his backpack. Eventually, he was instructed to leave it in a hole on school grounds. He did as he was told but was terrified the whole time. "I could get my ass kicked at any moment," he kept thinking. He realized he wasn't cut out to be a criminal and refused to do it again.
Instead, when he arrived as a freshman at Carl Hayden Community High School, he decided to join the marching band. To prepare him, his mother found a piano program offered by the Salvation Army and managed to get a free upright piano (though it was missing a number of keys). She set it up on the back patio so he could practice. Lorenzo learned how to play pieces by Debussy ("Clair de lune"), Erik Satie (Gymnopédie no. 3), and Chopin (Sonata no. 2). Lorenzo could listen to the music a few times and then play it back. He figured he was learning enough that he could wing it at band practice.
Unfortunately, band practice is not a place where winging it works. The first problem was that the band had no piano. The closest thing the music teacher could come up with was the xylophone. Next, Lorenzo had no idea what to play since he couldn't read the sheet music.
Nonetheless, as Christmas neared, the teacher handed him a uniform and hat and told him to get ready for the annual holiday parade. Lorenzo dutifully donned the outfit, strapped the hulking xylophone to his body, and marched alongside the rest of the band as they paraded down Central Avenue in downtown Phoenix. He knew the songs they were performing had big parts for the xylophone, but he couldn't play them. Every now and then he would try to hit a few notes, but they were always wrong. As the parade streamed endlessly through downtown Phoenix, he kept wondering when the humiliation would be over. The best he could do was keep his legs in time with the others as they walked.
"It was a walk of shame," he says.
He returned the xylophone and never went back to band. He felt that he didn't belong anywhere, though he was desperate to find friends, or at least people who wouldn't mock him. But it was high school and he looked funny. He had also been held back a year in first grade when he was still learning English. As a result, he was a year older than his classmates, which suggested he had flunked a grade.
Lorenzo tried to reason with his hecklers. When he mispronounced a word in English and kids laughed, he pleaded for some sympathy: "Why you gotta make fun of me for something I meant?" That only produced more laughter.
Lorenzo's anger mounted and he started picking fights at school. He ended up bruised, scraped, and in the principal's office. He was on track to be expelled. In an effort to turn him around, the school counselor assigned him to anger-management class. He learned that his anger was explosive, the most dangerous type. If he didn't rein it in, he would self-destruct. The counselor showed him how to calm himself by counting backward from ten. The problem was, he wasn't sure he wanted to calm himself. It was hard to ignore all the teasing.
After school, Lorenzo started helping his godfather fix cars. Hugo Ceballos lived with the Santillan family and had set up an informal business in their driveway; anybody with car problems could pull in and Hugo would pop the hood, figure out what was wrong, and fix it right there.
Hugo wouldn't let Lorenzo do much more than clean the tools with a rag damp with gasoline. It gave Lorenzo an excuse to stand beside the cars and watch. He learned that when you jack up a car, you should position a tire on the ground beside you when you slide under the vehicle. That way, if the jack fails, the car will land on the tire, not you.
That's a badass idea, Lorenzo thought.
Lorenzo wanted to do more, but Hugo didn't let him. So Lorenzo hovered on the periphery, cleaning the occasional tool and watching closely as Jose, his older brother, helped. Hugo explained to Jose that it was important to keep track of all your parts. "Anything you take off a car, remember where it goes," he told Lorenzo's brother. When Hugo installed a rebuilt engine, Lorenzo stood a few feet back and listened as Hugo showed Jose how to use a torque wrench to tighten the bolts. Lorenzo listened carefully and tried to get as close as he could to the car. He had to be careful though; if he got in Hugo's or Jose's way, he'd get yelled at and told to go inside.
The chief lesson Lorenzo learned was that it was important to be creative. Hugo wasn't running a normal mechanic's shop, with a wall full of tools and shelves filled with supplies. He had little money, a small set of hand tools, and his ingenuity. To survive, he had to come up with fresh ideas and adapt.
Lorenzo took that to heart. He didn't fit into white American culture and couldn't find his place in the immigrant community. Even band—the standard home for high school misfits—didn't work for him. But his days looking over Hugo's shoulder in the driveway had taught him to think outside the norm. In the driveway, an unusual idea wasn't necessarily bad. In fact, it might be the only solution.
AT ONE TIME, Carl Hayden was a well-regarded school; it even had its own off-site equestrian program. Students could ride horses in an indoor facility so they wouldn't get too hot in the desert heat. The school district even built a rodeo ring for teens. It was meant to be a school for white kids.
It's not that way anymore. Now the neighborhood around the school has an abandoned, overlooked feel. Some of the roads are still unpaved dirt. Junk-food wrappers and diapers lie in the desiccated weeds on the side of the road. At the school entrance on West Roosevelt, security guards, two squad cars, and a handful of cops watch teenagers file past a sign that reads, CARL HAYDEN COMMUNITY HIGH SCHOOL: THE PRIDE'S INSIDE.
There certainly isn't a lot of pride on the outside. The school buildings are mostly drab, late-1950s-era boxes. The front lawn is nothing but brown scrub and patches of dirt. The class photos beside the principal's office tell the story of the past four decades. In 1965, the students were nearly all white, wearing blazers, ties, and long skirts. Now the school is 92 percent Hispanic. Drooping, baggy shorts and crisply ironed denim shirts are the norm.
The current student body reflects the transformation of Phoenix. The city was founded in 1868 by Jack Swilling, a morphine-addicted former Confederate officer. Swilling had come to Arizona seeking gold but ended up falling in love with a Mexican woman instead. Trinidad Mejia Escalante, a seventeen-year-old from Hermosillo, Mexico, was visiting relatives in southern Arizona when she encountered Swilling. Escalante's mother didn't approve of the drug-addled soldier, but the young lady was smitten and eloped.
Soon after their marriage, the Swillings built a canal near the Salt River, a meager flow of water that spills out of the burnt-umber Mazatzal Mountains into a broad, flat valley. They planted corn, sorghum, and even a vineyard and discovered that the land was productive. The winters were warm and the soil rich. Before long, the Swilling Canal drew other settlers, one of whom dubbed the new community Phoenix. This referred to the ancient, ruined Indian canals that still ran across the land, the remnants of a lost civilization that was now rising again as a result of the marriage of an American man and Mexican woman.
In 1870, early Anglo immigrants to the region named the town's east–west streets after U.S. presidents and labeled the north–south roads by local Indian-tribe names. It seemed like a fitting compromise, given the history of the region. But in 1893, the town council decided that the Indian names were too hard to remember and renamed the north–south roads with numbers. The new names also helped Anglo immigrants feel that the land was more fully theirs.
As the city developed, tax revenue was largely allocated to infrastructure for the neighborhoods settled by Anglos. The white neighborhoods got water lines, sewage pipes, and paved roads. The barrios where Mexican immigrants settled got almost nothing. In 1891, the Phoenix Chamber of Commerce published a pamphlet touting their achievements. "Here are none of the sleepy, semi-Mexican features of the more ancient towns of the Southwest, but, in the midst of a valley of wonderful fertility, has risen a city of stately structures, beautiful homes, progressive and vigorous."
When World War Two brought a boom in wartime manufacturing, factories were opened in West Phoenix, away from the pretty citrus groves and canals of East Phoenix. To house workers, companies such as Goodyear and Alcoa constructed small villages near their factories. The housing attracted working-class whites, who built a community in the area. Carl Hayden Community High School was meant to serve that population.
But in the sixties and seventies, as the factories expanded and pollution increased, the working-class whites in West Phoenix migrated out of the area. Leukemia outbreaks among children were reported. In many cases, the housing was poorly built, as it was meant to be only temporary. "Anybody who could afford it moved to the East Side," says John Jaquemart, a historian for the City of Phoenix, who grew up in East Phoenix during that time. "At the least, you moved somewhere else."
At the same time, the population of the region was exploding, driven by a boom in agriculture and high-tech industries. In 1950, the city had 106,818 residents, making it the ninety-ninth-largest city in the United States. Over the next ten years, the population quadrupled and added hundreds of thousands of residents every decade after that. By 1990, Phoenix had a population of almost a million people and was the sixth-largest city in the United States.
The population boom led to a ripple effect across the region's economy as relatively wealthy, newly arrived residents needed a variety of services, from landscaping to cleaning. The spike in demand for labor was met in part by immigrants who streamed across the border illegally, all of whom needed somewhere to stay. West Phoenix was the prime choice. It was cheap and close to downtown, and whites were abandoning it because of the potential health problems and poorly built, decades-old temporary homes.
The changing demographics of the city posed a challenge for school administrators. A 1974 Supreme Court ruling prohibited busing between districts, which meant that white people in the suburbs could stay in their own schools, while minorities in the city center were left with the facilities abandoned by their predecessors. Nonetheless, in 1985 a federal judge ordered the district to desegregate. With few options, administrators tried to entice white students into the inner city. In the mid-1980s, Carl Hayden became a magnet specializing in marine science and computer programming. The thinking ran roughly along these lines: white people like the ocean and computers, so if there's a school that offers specialized classes focused on those things, it'll attract white people.
It didn't work. No amount of computer programming or oceanography curriculum was enough to entice white families, who fled to the suburban neighborhoods surrounding Phoenix. While tony districts such as Scottsdale and Mesa filled with white students, Phoenix grew increasingly Hispanic. Finally, the district just gave up. There was no more diversity to balance. In 2004, Carl Hayden was 98 percent Hispanic—pretty much all the white kids had left—so in 2005, the federal court lifted its two-decade-old desegregation order. Administrators and some teachers tried to put a sunny spin on it. "From school to school, we are equally balanced," announced Shirley Filliater-Torres, the president of the district's Classroom Teachers Association. She didn't point out that the schools were equally balanced because they were nearly completely filled with one race. "We have probably done as good a job as we can to desegregate, given our student population," she said.
The transformation was complete. West Phoenix was Hispanic. And while that population worked downtown or in East Phoenix—cleaning the city at night like ghosts that disappeared at sunrise—the doctors and engineers in Scottsdale and Mesa rarely ventured west. Various reasons were given: it was dangerous, it was dirty, it was hot.
"We looked with nothing but contempt at anything west of Central Avenue," says William Collins, a historian with the Arizona State Historic Preservation Office.
According to Jaquemart, the City of Phoenix historian, East Siders claimed they could never live on the West Side because the sun would be in their eyes as they drove downtown to work in the morning. Jaquemart's geography professor at ASU put it more succinctly:
"There's nothing worthwhile there."
Copyright © 2014 by Joshua Davis
Excerpted from Spare Parts: Four Mexican American Teenagers, One Ugly Robot, and the Battle for the American Dream by Joshua Davis
All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
In 2004, four Latino teenagers arrived at the Marine Advanced Technology Education Robotics Competition at the University of California, Santa Barbara. They were born in Mexico but raised in Phoenix, Arizona, where they attended an underfunded public high school. No one had ever suggested to Oscar, Cristian, Luis, or Lorenzo that they might amount to much - but two inspiring science teachers had convinced these impoverished, undocumented kids from the desert who had never even seen the ocean that they should try to build an underwater robot. And build a robot they did. Their robot wasn't pretty, especially compared to those of the competition. They were going up against some of the best collegiate engineers in the country, including a team from MIT backed by a $10,000 grant from ExxonMobil. The Phoenix teenagers had scraped together less than $1,000 and built their robot out of scavenged parts. This was never a level competition - and yet, against all odds . . . they won! But this is just the beginning for these four, whose story - which became a key inspiration to the DREAMers movement - will go on to include first-generation college graduations, deportation, bean-picking in Mexico, and service in Afghanistan.


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Two Irishmen arrested over assault of 66-year-old in Australia
Two men from Ireland have been arrested and charged over an alleged assault in Sydney, Australia this week.
Christopher McLaughlin, 24 and Nathan Kelly, 21, both from Donegal were arrested near the scene of the incident in which a 66-year old man was assaulted.
The victim is said to be fighting for his life.
Police in Australia said that McLaughlin and Kelly were charged with grievous bodily harm and affray after the man was found with critical injuries on the side of the road in Summer Hill.
The victim, who has not yet been named, was treated at the scene for his injuries before he was taken to Royal Prince Alfred Hospital where he has been described as being in a critical condition.
The men appeared before Parramatta Bail Court yesterday.
According to Independent.ie the pair did not apply for bail and are due to appear before Burwood Local Court on 9 January.
Tags: Arrested, Assault, Australia, Irish
School of Rock actor arrested for stealing guitars and an amplifier
US man arrested for grooming children on Fortnite
By Ian Mangan / 1 year ago
Tourist faces 10 years in prison for vandalising ancient wall in Thailand
Man arrested over attempted child abduction outside a primary school
Man (39) arrested after allegedly mugging 100-year-old woman who broke her neck during attack
Funeral of Paddy O'Donnell, who was viciously assaulted, to take place tomorrow in Cork

redpajama_set_name: RedPajamaCommonCrawl


The vets team (over 40s) start from 17th May. If you qualify and are available to play, please contact Russ Longhorne (tel 07960 886 215 / email rlonghorne@btinternet.com).
Semi Finals either 5th or 19th July and the final is on 26th July.


Tomorrow will see the first rugby fixtures of the season for the Rugby Club Luxembourg (RCL).
The day will kick off at 12:00 with a match between RCL U14s and Ardennes/Walferdange. Next up, at 14:00, the RCL will go head to head with German team SC Frankfurt 1880, followed by a match at 16:00 between U16s Lux Derby RCL and CSCE.
For more information, email info@rcl.lu.


Is my mobile phone compatible with Wireless Qi technology?
Technology evolves at a vertigo speed. Sometimes, too fast for society to follow on time. One clear example is the wireless charging with wireless charger. It is a type of charger that was created about 10 years ago but until this day did not have too much use. Do you know what Wireless Qi technology is? Is your phone compatible with this type of wireless charging? All this and more we explain it below.
Wireless charging or Wireless Qi is not a recent technology. In fact, a few weeks ago we already talked about what are wireless chargers and how they work? This time we will go into detail in this Wireless Qi technology that seems to be in rise again and is stronger than ever.
This type of technology allows the charging of devices without cables at a distance no greater than 4cm. The operation is simple despite the complexity of its structure: It generates an electromagnetic field that emits energy to capture the energy of the other side. We translate! The electromagnetic field is generated by wireless devices and the one that receives the energy on the other side is your smartphone. We told you, its operation is really simple!
Now, you're probably wondering, and how do I charge my wireless phone? This is the easiest thing in the world of technology. The methodology goes like this: you must leave your Smartphone on the Wireless Qi charging device and your phone will start charging immediately. That easy? Yes! But pay attention because no mobile device is compatible with this technology.
Is my phone compatible with Wireless Qi technology?
Although this technology was created in 2008, it was not until 2012 that the first mobile compatible with Wireless Qi was launched. These were the Lumia 820 and 920. If you're from Android you'll be interested to know that the first Android phone with this technology was the Nexus 4.
Therefore, you already know that not any mobile can be charged wirelessly. Compatible phones are distinguished above all by incorporating glass back covers instead of metal. In fact, the majority of high-end mobiles that came on the market from 2017 on brands like Samsung, LG, Xiaomi, Lenovo, HP or Apple incorporate this technology. Finding it in mid-range or low-end terminals is more difficult because it increases manufacturing costs.
In recent years, many wireless chargers with Qi technology were launched. Which one is the best? The chargers work in a similar way and what we should worry about in this case is quality. In YupCharge we have chargers without cables with fast charge and integration of Qi emitters. You can integrate it in any type of furniture without any problem. We are talking about the Yupwireless Dual, which although a wireless charger also incorporates USB ports for those devices that still do not support this type of load.
On the other hand, we recommend for the more sophisticated the Yupwireless Qi a charger without cables, with fast charge and that integrates a standard Qi transmitter. This type of charger has two possibilities, the visible or the invisible, which is integrated below the furniture and cannot be seen.
And, is all this possible in a single charger?
In YupCharge everything is possible. We integrate the wireless device in the furniture of your business so that you give a value-added service to your customers.
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Thank you to everyone who attended our Introduction to Fundraising workshop at Stirchley Baths on Wednesday 19 September. We hope you found it useful and that it will inspire you onward with your plans.
Feel free to send us your feedback, and do look out for other events and surgeries we're holding in the coming months.


Ever since I started blogging one thing that has changed in my life is my new found love for skincare products. Never before have I taken so much time cleaning and protecting my skin in the hope that I can achieve a better complexion and delay the signs of ageing in the process. As with any good skincare regime the key is to start off with a perfectly cleansed face before applying all the lotions and potions to it.
Eucerin Dermo Purifyer Cleanser is designed for blemish/acne prone skin, containing Salicylic Acid ( a well know spot fighting ingredient) that helps de-clog pores as well as neutralising bacteria, one of the main causes of spots and blemishes. The gel formula, which is soap and fragrance free feels light, and the smallest amount is needed to cleanse your whole face ( I realised this after the first use, as I resembled a foam monster! lol note to self... a little bit goes a long way!). Some gel cleansers can leave the skin feeling tight and dehydrated but this is designed to absorb excess sebum while still leaving the skin feeling clean and supple, which I can say it definitely did!
I have been using this as my second "wash off " cleanser at night and in the mornings to clean any dirt and products from my nigh time routine, and I can say that my skin was left feeling squeaky clean, (I use that as a term of phase and not in the literal sense) and refreshed.
As for fighting spots and preventing blemishes I think I can say that it has helped a little, but in all fairness my skin and I have had a major fall out recently and we are still not on speaking terms so it would be unfair to say this doesn't work as I'm yet to find anything that does work!
What I can say is that my problem is with cyst like spots which don't really relate to the bacteria type spots like white/black heads, the types that have pus drawn up to the surface (I know TMI!! lol). Since using this I haven't had any of these types of breakouts and the ones I do get seem to get dry up a lot quicker then they used too and I think this has something to do with it!
If you're interested in trying this or any other French skincare brand, Ecsentual currently have 1/3 off throughout the whole of June, so grab yourself a bargain while you can!
We do like gel formula products :-) Heard so many great things about Eucerin brand.


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Verizon Digital Media Services today announced it has added a round-the-clock managed cloud security offering as part of its global Cloud Security Solution. The managed cloud security component provides access to expert security professionals who monitor and proactively take corrective action against the latest security threats, no matter the time of day. The addition of this offering complements features previously available within Verizon Digital Media Services' leading Cloud Security Solution, including a dual web application firewall (WAF), distributed denial-of-service (DDoS) protection, bot management, and real-time analytics and reporting.
The managed cloud security offering provides continuous security support from a dedicated Computer Security Incident Response Team. Based in Verizon's Security Operations Centre, the team provides 24×7 monitoring and mitigation. Additionally, the Cloud Security Advisory Team from Verizon Digital Media Services, which manages WAF and HTTP Rate Limiting configurations, provides planning support and recommendations to ensure maximum protection throughout web application changes.
Real-time analytics and reporting to monitor and deliver alerts on live threats and attacks within seconds of occurrence.
Verizon is a recognized leader in the 2018 Gartner Magic Quadrant for Managed Security Services, Worldwide. To learn more about the Cloud Security Solution from Verizon Digital Media Services, visit www.verizondigitalmedia.com/cloud-security/.


A recent Native Soil Chief installation popped up near Winston & Main Street in Downtown Los Angeles. Recent articles on LATACO.com (click here) and LAist.com (click here) are bringing much attention to the Autry Museum and it's handling of the Southwest Museums operations. Photographer Erwin Recinos sent over these photos of the latest statue near Skid Row. For more information please visit FriendsOfTheSouthwestMuseum.com.


© 2017 Yates et al.
Defects to the articular surface of the humeral head have been known to be associated with shoulder dislocation since the 19th century. It wasn't until 1934 that the first description of the ubiquitous compression fracture of the posterolateral humeral head that occurs with traumatic anterior instability appeared. From 1940, this defect became referred to as a Hill-Sachs lesion after the investigators who reported the condition. The significance of, and therefore treatment of, these and other such bony defects around the shoulder joint has been hotly debated.
We reviewed the available current literature to determine and report on the most up to date concepts and treatment techniques being used to manage bony defects of the shoulder.
Numerous surgical options have been proposed to manage bony defects of the shoulder, including a variety of defect-filling procedures, with good outcomes. However, the small numbers and diversity of case mix makes for difficult comparisons.
We are currently developing a greater appreciation of how both the humeral and glenoid defects interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. More research and collaboration is needed to determine the optimal method of assessing and managing these patients.
Keywords: Hill-Sachs lesion, Shoulder dislocation, Glenoid defects, Shoulder stability, Glenoid track theory, Shoulder surgery.
Defects within the humeral head have been known to be associated with glenohumeral dislocation since the 19th century. It wasn't until 1934 that the first description of the ubiquitous "compression fracture of the posterolateral humeral head associated with traumatic anterior instability" appeared . From 1940, this defect became referred to as a Hill-Sachs lesion (HSL) after the investigators who had first reported it . Glenoid defects, when deemed appropriate, are usually addressed through the open Latarjet procedure, also known as the Bristow-Lartarjet or Bristow procedure . Numerous options have been proposed for HSLs managed surgically, including a variety of defect-filling procedures. We are currently developing a greater appreciation of how both the humeral and glenoid lesions interact and therefore should be assessed and addressed simultaneously in order to improve patient outcomes. This review will look at the current theories adopted and novel treatments suggested for managing these lesions.
In order for any bony defect in the glenohumeral joint to become clinically symptomatic, it must first cause an abnormal interaction within the joint. The engagement of a HSL with the glenoid depends on its size and location relative to the glenoid. The average size of HSL is 22mm in width and 5mm in depth . The critical dimensions of HSLs suggested to cause instability are those which are 4cm long by 0.5cm deep (a medium lesion) and 4cm long by 1.0cm deep (a large lesion), greater than 20-25% of the humeral head surface, deeper than 16% of the humeral head diameter and with a volume greater than 250mm3 or 1000mm3.  Biomechanical studies suggest that HSLs as small as 12.5-25% with concomitant glenoid bone loss can affect shoulder stability. They found that shoulders with large HSLs (37.5-50%) may benefit from allograft transplantation to restore shoulder stability . A more horizontal orientation of HSL on CT scan has also been shown to predict the likelihood of engagement of the HSL .
The incidence of HSLs appears to be directly proportional to the frequency of dislocation. Incidence has been observed to raise from 65-67% after a primary dislocation to 84-93% after a recurrent dislocation . Its detection is reliant on the imaging modality used since small HSLs might be missed on plain radiographs, which may be seen on a magnetic resonance imaging (MRI) scan. The prevalence of symptomatic HSLs following unilateral recurrent anterior shoulder dislocations has been found to be around 7% .
Fig. (1). Glenoid track, engaging and none engaging HSLs.
The upper and most left image shows the shoulder joint in neutral and then, on the right, in abduction and external rotation. The shaded area on the humerii shows the glenoid track. The lesion within the humeral head in the top image can be seen to engage the glenoid as it moves parallel to it as it is more medial than the glenoid track. The lower image demonstrates how this is much less likely to occur in a more vertical orientation and with the lesion sitting within the track i.e. a none-engaging HSL.
The HSL occurs when the humeral head dislocates from the glenoid, engaging the relatively harder glenoid rim leaving an impression fracture on the humeral head. Two main factors which determine the severity of the resultant HSL are the frequency of episodes and the force generated upon dislocation. In addition, the position of the humerus at the time of dislocation is important with regard to location, depth, and orientation of the HSL. The capsule and labrum become increasingly attenuated with each episode contributing to recurrent instability and HSL. Dislocation can occasionally lead to injury of the subscapularis tendon or an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion . One must be mindful of the bipolar phenomenon, where there are defects formed in both the glenoid and humeral head as both must be addressed to achieve overall stability.
The concept of an articular arc deficit explains why some patients feel their shoulder is subluxing or dislocating when it is not clinically. The mismatch created by bony defects between the humeral head and glenoid alters their normal articular arc length . HSLs that engage the anterior corner of the glenoid with the shoulder in 90° of abduction and external rotation are termed "engaging HSLs". None-engaging lesions can cause symptoms in non-functional shoulder positions  (Fig. 1).
With respect to HSLs, any coexisting glenoid defect will undoubtedly affect management and prognosis. The concept of the glenoid track is based on the orientation and location of lesions that lead to an engaging HSL . The glenoid track is essentially the contact zone which occurs as the glenoid shifts along the posterior margin of the humeral head. (Fig. 1) This occurs when the shoulder is in 60° abduction and full external rotation and moves along the end range of motion. The glenoid track takes into account both glenoid and humeral defects. The track has been measured to be 84% the width of the glenoid, which is the distance from the contact area to the medial border of the rotator cuff footprint . Therefore, if the measured width of HSL is larger than the glenoid track size then it is high risk for being an engaging lesion or "off-track" lesion. An off-track when compared to an on-track HSL does appear to be a significant risk factor for recurrence of symptoms and need for revision surgery after arthroscopic Bankart repair . Biomechanical studies on cadavers support the glenoid track theory and also that a Bankart repair alone is unlikely to fully address the defect . Clearly, treating lesions outside the glenoid track requires prevention of engagement to prevent instability. It has been suggested that this may be addressed at the glenoid side through a Latarjet procedure or on the humeral side through a rotational humeral osteotomy thereby moving the track position altogether . The rotational humeral osteotomy whilst a well-established treatment for osteoarthritis can in itself cause osteoarthritis and so more work is needed to determine the exact risks of this in this situation. Understanding of and the utilisation of the glenoid track theory in both classification and in treating patients is currently under investigation.
A thorough history and examination are needed to fully comprehend the characteristics of any bony shoulder instability and hence plan appropriate imaging and subsequent treatment.
Patients with instability will often complain of deep shoulder pain with mechanical symptoms such as crepitus, catching and clicking. The mechanism of injury and position of dislocation help delineate the type of dislocation and possible related soft tissue and bony injuries. Activities that place the shoulder in abduction, externally rotation and often with an extended arm and axial loading can lead to indirect anterior glenohumeral instability (e.g. in rugby players). Any high energy dislocation with recurrent episodes of instability associated with minimal force or in the mid-range of shoulder motion should be suspicious for bony deficiency . With multiple dislocations, the history should focus on the force required to dislocate, the frequency of dislocations, method of relocation (self-reduction or attendance at a hospital) and the length of time from last dislocation. Dislocations that recur progressively easily on daily basis are likely to have large HSLs and combined glenoid defects . Factors and activities that increase the chances of recurrence should be identified and reduced. Seizures, recurrent falls, alcoholism, drug dependency and activities that require arm abduction and external rotation are all known risk factors. The patient's occupation often dictates the goals of treatment in terms of functional range of motion for his or her occupation. Any previous surgical intervention should also be noted .
Clinical examination consists of checking the range of motion, power of deltoid and rotator cuff muscles and special instability tests. There may be reduced range of motion due to apprehension and there may be reports of pain secondary to arthritis or instability. Bony defects are more likely if a positive apprehension test occurs in mid-range. During the apprehension and relocation test one may also feel crepitus . This grinding sensation may also be noted during the load and shift test (a modification of the shoulder drawer test), suggesting that the normal smoothness of the glenoid lip has been lost. There will be decreased resistance during translation showing a defect in glenoid cavity. This translation test also helps delineate laxity . The presence of a sulcus sign suggests inferior instability. One must perform a thorough neurovascular examination and also rule out other injuries e.g. rotator cuff tear, bicep tendon pathology, superior labrum anterior-posterior (SLAP) lesions, axillary nerve injury or vascular injuries. In all cases, an examination under anesthesia precedes the actual surgery to confirm the clinical findings and imaging studies as well as to assess range of motion and document the pattern of instability without muscle guarding and apprehension.
Patients with shoulder instability should have at least three plain radiographs, including a true anterior-posterior, scapula lateral and axillary views. The Stryker notch and the internal rotation views are the most accurate radiographic views for diagnosing HSLs. The West Point view is useful in detecting glenoid rim lesions. However, these views may still not be sensitive enough to detect small defects . One study looked at the inter-observer reliability in diagnosing osseous lesion in 10 patients with primary anterior shoulder dislocation. They compared plain radiographs with computed tomography (CT) scans . The study concluded that radiographs are inferior to CT scans for assessing osseous lesions. The authors suggested performing a CT scan of the shoulder after primary dislocation to apply the correct treatment early potentially avoiding further dislocations . Another study compared ultrasound (US) with CT arthrography (CTA) and that with arthroscopy in 92 patients. US showed 94% (81 of 86) accuracy when compared with CTA and an accuracy of 91% (79 of 86) in CTA when compared with arthroscopy. Ultrasound is therefore a valuable diagnostic tool in detecting HSLs, with several benefits including low cost and the ability to obtain dynamic, multiplanar images. Limitations include a dependence on operator experience and limited visualisation of intra-articular structures . MRI (or MR arthrogram) has the advantage of detecting soft tissue pathology that may need to be addressed during surgical intervention and can certainly be a tool in approximating the amount of bone loss. In a double-blind, prospective study by Denti and colleagues, MRI showed accuracy of 87% when compared to arthroscopy. This is lower when compared to CTA as mentioned above . A study looking into MRI evaluation of bone lesions on both the glenoid and the humerus showed an accuracy of 84.2% in predicting engagement of that lesion when compared to arthroscopy . CT scan with digital subtraction remains the gold standard for the evaluation of a HSL as it allows the most accurate measures of location and size of lesions. However, Pagnani et al did show that the measurements made by CT are no better than those made during arthroscopy and there is also the tendency for CT to overestimate the size of larger glenoid defects .
Hill-Sachs lesions are classified into mild, moderate and severe groups i.e. mild, 2.0cm long and 0.3cm deep; moderate, 4.0cm long and 0.5cm deep; severe, 4.0cm long and 1cm deep. Patients with a moderate or severe lesion are considered to have "large" defects. Whilst this system was not developed for arthroscopic evaluation, it was easily extrapolated for such use . Flatow et al. suggested quantifying the humeral bone loss as a percentage of involvement of the humeral head i.e. less than 20%, 20 - 40% and greater than 40%. Lesions >40% are clinically significant . There have been numerous attempts at further classifying HSLs. However, the rarity of these lesions makes it difficult in applying and validating classification systems as well as gaining consensus by majority of surgeons.
Management of these patients remains controversial and is based on numerous patient factors including activity level and chronicity, anatomical features and surgeon factors. A trial of non-operative therapy is warranted in most patients, including immobilization before the initiation of physical therapy focusing on the dynamic shoulder stabilizers. This normally allows time to further investigate the instability associated pathology and surgical plan. For elderly patients with large HSLs who are high risk for complications following surgery and anaesthesia or low demand individuals, the best option usually is conservative management via extensive physiotherapy. Their rehabilitation program must focus on improving deltoid and the rotator cuff muscles function, as well as the scapular stabilizers.
The aim of surgery is to reduce instability through the least invasive method. Many of the surgical procedures are technically challenging and carry a risk of morbidity. There is also the risk of hardware failure and a reduced range of motion. The least invasive procedures are therefore growing in popularity.
Prior to considering surgical options one must look at many factors. These include the size of the lesion, location, the patient's age and expectations, whether the lesion involves both the glenoid and humerus or not, bone quality and any previous shoulder stability surgery.
Arthroscopic Bankart repair alone has been effectively used to treat humeral head defects involving 20% of the articular surface. Larger defects involving around 30% of the articular surface have been addressed with humeral rotational osteotomy, osteochondral bone graft and arthroplasty. For those lesions more than 40% of the humeral head, anatomic reconstruction or arthroplasty is indicated depending on patient's age. For patients with bipolar lesions one needs to determine the relative contribution of each lesion and address the most problematic lesion or both as required . A 2016 survey of the American Shoulder and Elbow Surgeons showed consensus between surgeons in their surgical treatment for the above HSLs on initial presentation but less so when revision was required .
Currently, the two general ways of achieving stability in patients with HSLs is to either reduce the range of external rotation or fill the humeral head defect. The former includes anterior soft tissue shortening or rotational osteotomy of the humerus. The latter includes bone grafting or soft tissue disposition into the defect or percutaneous transhumeral headplasty. Techniques can also be divided into anatomic or non-anatomic techniques .
The Bristow-Latarjet procedure of surgically transferring the coracoid process to the anterior glenoid effectively lengthens the articular arc preventing engagement of the HSL. There is excellent long-term data supporting this procedure . Disadvantages of this technique include the loss of external rotation, coracoid graft osteolysis and glenohumeral arthritis. The procedure is technically challenging and produces a non-anatomical repair and a complicated revision surgery should it fail. Furthermore, the data is from a non-homogenous population as surgeons have different operative thresholds with respect to bone loss. A recent study also observed the direct link between compensation claims with ongoing instability in patients who had undergone a previous Laterjet procedure .
In 1984, Weber et al described a rotational osteotomy in the proximal humeral shaft. This increases the retroversion of the proximal humerus redirecting any defect more posteriorly preventing engagement . Rotational osteotomies are associated with a 5.7% re-dislocation rate with 90% of patients having a good to excellent result. 59% required second surgery for removal plates after 1-2 years .
In this technique the glenohumeral joint capsule is surgically tightened through either open or arthroscopic approach. The tight capsule stabilizes the joint by limiting the external rotation and anterior translation . Capsular plication techniques in conjunction with Bankart repair are among the most commonly performed procedures for anterior shoulder stabilisation. However, it doesn't provide an anatomic solution. The engagement of the humeral head is avoided. The HSL may still rotate to an intraarticular location but will remain stable through a functional range of shoulder motion . A recent retrospective study found a recurrence rate of 13.2% after arthroscopic Bankart repair and capsular shift . The estimated probability of recurrent instability within the first two years after arthroscopic Bankart repair and capsular shift showed that in patients with engaging HSLs and glenoid bone loss of 0-5% was between 12-38% (decreasing with age) . The risk of recurrence was independently predicted by the patient's age at surgery, the severity of glenoid bone loss and the presence of an engaging HSL . This is again similar to what other studies have found with contact sports and hyperlaxity. Loss of more than 25% of the glenoid bone was also significantly associated with recurrence . Open capsular repair showed similarly low recurrence rates but with a restricted external rotation and risk of developing secondary osteoarthritis .
In 1972, Connolly described this open procedure, which involves transfer of the infraspinatus tendon with a portion of the greater tuberosity into the humeral head defect. This filling of humeral head defect converts them into extra-articular lesions . Wolf and Pollack were the first authors to use the phrase "remplissage" (French for "filling") . This involves arthroscopic posterior capsulodesis and infraspinatus tenodesis by applying sutures in the muscle belly to fill large Hill-Sachs lesions. These structures then provide a mechanical block to instability . This technique was shown to provide effective treatment for HSL in combination with less than 25% glenoid deficiency . In 2009, Koo et al modified this technique further using the double-pulley suture technique. They tied two anchor sutures over the infraspinatus tendon rather than the muscle, thereby obtaining a more physiologic and mechanically sound construct, specifically by providing a large footprint of fixation. This eliminates the risk of muscle necrosis due to strangulation by sutures . Remplissage is successfully performed with Bankart repair in patients with moderate to large HSLs associated with glenoid defects of less than 20-25% [36-38]. Many other studies have analyzed the outcome of the remplissage procedure on shoulder stability and range of motion. They concluded that remplissage prevents engagement and enhances stability in lesions as large as 45% defects, but with some loss of shoulder movement [36-38]. Other studies have proved the loss of external or internal rotations to be statistically insignificant when compared to pre-operative range of motion or with Bankart only procedures [39-41]. They describe 68-80% of patients returning to the same level of sports, including those involving overhead activities [39, 42, 43]. A recent case series looking at large engaging HSLs treated with remplissage showed 65.5% of patients returning to throwing sports complained of a decreased range of movement but overall there was a redislocation rate of 11.8% at 5 years . This same study showed a return to full sports at 7 months in 95.5% of patients . More long term studies are required to assess the development of osteoarthritis post-procedure within these patients.
Osteoarticular reconstruction of the humeral head is performed by filling in the humeral head defect with osteochondral allograft. This restores the humeral head anatomy preventing the osseous engagement on the anterior glenoid rim. Multiple surgical approaches have been employed: arthroscopic, anterior deltopectoral only, combined arthroscopic and posterior. There are few published clinical reports of this strategy in HSLs with or without glenoid bone injury. The advantages of this technique over others include restoration of the articular surface and a mechanically stable joint without significantly altering the joint kinematics. Furthermore, future prosthetic reconstruction may be less challenging and more of a suitable option than if a non-anatomical reconstruction was used.
The challenges associated with this approach, however, include an extended deltopectoral approach requiring a subscapularis tenotomy and capsulotomy. In addition, there is risk of cyst formation, graft resorption, nonunion and hardware failure . Miniaci et al described a reconstruction of the humeral head using size-matched osteoarticular allograft . At 2 years follow up, there were no recurrent instability and patients had returned to near normal activity. The excessive rotation of the humerus and retraction of local soft tissues required intra-operatively may increase the risk of avascular necrosis and therefore also cause further morbidity. Two out of 18 patients required screw removal for undesired symptoms . Chapovsky and Kelly reported a single case of arthroscopic allograft mosaicplasty of the humeral head in a 16 year old male with a large HSL whose previous arthroscopic anterior repair had failed . Three 5mm plugs where placed along the HSL. He remained asymptomatic post-operatively and returned to basketball at 1 year post operation . Whilst this technique is less invasive it would be limited by the size of the HSL. Use of multiple plugs would limit the biomechanical stability particularly to shear force and there would remain defects between the plugs.
Kropf and Sekiya described another technique of anterior arthroscopic osteoarticular allograft reconstruction of the humeral head . They proposed performing arthroscopic Bankart repair and measuring the humeral head defect. It would be at this stage the surgeon could either stage the procedure or proceed there and then to reconstruct the humeral head. In a staged procedure the patient can return 6 weeks post initial Bankart repair for allografting . Through a posterolateral deltoid and infraspinatus split, the plug is placed in a prepared socket and tapped flush into position. They presented a single case where this staged technique was performed in an active 19 year old enlisted US Navy seaman, with excellent short-term results with the patient returning to active duty by 1 year . The advantage in the staged technique is the limited posterior approach preventing excessive anterior structure sacrifice and excessive humeral head rotation reducing the risk of vascular compromise . As shown in other studies discussed, early intervention in the appropriate population is encouraged to prevent arthritis and maintain function. Further biomechanical studies are underway looking into which size of defects should be treated this way .
Kazel and colleagues described a technique termed "humeroplasty" to either decrease or correct the size of a large HSL in a cadeveric model . It involved disimpaction of the HSL and elevating and supporting the remaining bone with bone graft. Additionally, Re et al and Mehta demonstrated how to reduce the HSL lesions through the humeral head with tamps using a deltopectoral approach [50, 51]. Mehta was able to reduce a chronic HSL with good early results . Sekiya et al equally used the same technique through an anterior cortical window . This cadeveric work concluded that complete correction was not possible and one could only convert large defects into smaller defects . Another cadaveric study, created HSLs on 18 cadaveric shoulder models and then performed balloon humeroplasty . The average pre-reduction HSL volume was 1515.5mm3 and average post-reduction lesion residual volume was 31mm3 demonstrating a 99.3% reduction of the original humeral head volume . The presumed advantages of percutaneous technique included it being less invasive compared to the techniques previously described, restoring humeral head concavity and articular arc length without altering the anatomy to prevent engagement of the humeral defect by either rotating the humerus or over constraining the soft tissues affecting rotation and it does not rely on healing of bulk osteoarticular allograft or transposed infraspinatus tendon. Its potential limitations are that it may not be suitable for sufficiently large humeral head defects or for those patients with significant osteopenia where subchondral support is lacking [52, 54]. Other potential complications include further damaging the articular surface, fracture, axillary nerve injury and even compartment syndrome due to the high balloon pressures [52, 54].
Defects greater than 40% of the humeral head can lead to recurrent or permanent dislocation so one must consider prosthetic replacement as an alternative for reconstruction of the proximal humerus. There have only been a few case reports of resurfacing of the humeral head and either hemiarthroplasty or total shoulder arthroplasty in the setting of HSLs or glenoid defects in association with dislocation [55-58]. Hemiarthroplasty or TSA is best suited to older patients with preexisting glenohumeral osteoarthritis and osteopenic bone, who will not benefit from reconstruction and instead may achieve greater postoperative motion and pain control with a replacement procedure.
A case series of 11 patients with fixed anterior shoulder dislocation were treated with either hemiarthroplasty (6) or TSA (5) . Four of the hemiarthroplasty group had a combined anterior glenoid reconstruction. Eight patients reported excellent or good outcomes with the remaining three reporting it to be fair. During the follow up of four years, seven complications in five shoulders were observed. Due to glenoid loosening, four cases had recurrent anterior dislocations. Removal of metalwork and removal of the glenoid component were performed in two separate cases . Whilst a reliable treatment for shoulder pain, limited functional results can be expected from arthroplasty. For younger patients with greater than 40% HSL there is an option of humeral head resurfacing. Raiss et al reported 10 patients with traumatic fixed anterior glenohumeral dislocation treated with the cementless humeral surface replacement arthroplasty (CHSRA) for a mean follow-up of two years . Good clinical outcomes with a moderate complication rate was observed. No signs of implant loosening were seen although sufficient bone stock is required for stability. Bone defects of more than 45% of the humeral surface is suggested to be the limit for this procedure and when one should consider a hemiarthroplasty. The authors suggested that younger patients i.e. under 50 years would be more suited to humeral head preserving surgery techniques . Focal resurfacing of the defect with an implant is another option for younger patients. In a case series of two patients, Grondin and Leith used a HemiCAP metal implant to cover large HSLs. However, they had to perform a Laterjet procedure to help stability as both patients had associative bony Bankart lesions. They reported good functional outcomes . Benefits included the preservation of bone stock, which makes future revisions easier and restoration of the normal articular surface without the technical difficulty of precisely matching osteochondral grafts to the articular curvature. More long term follow up results are needed as the long-term survivorship rates are not known.
Kyphoplasty, more often seen in reducing vertebral compression fractures, has recently been used to reduce HSLs in cadaveric studies almost achieving an anatomical correction . This could be a better option for HSLs reducing surrounding tissue damage that can occur with other minimally invasive techniques. This new technique might behave differently when performed on normal individuals .
Posterior shoulder instability is uncommon, since it accounts for less than 5% of all episodes of instability. It is associated with bony or ligamentous disruption [62, 63]. Approximately 30% of posterior dislocations lead to an anterior impression fracture of the anterosuperomedial humeral head, termed the reverse HSL [62, 63]. In these patients the damage is a lot more extensive than seen in anterior dislocations. These dislocations are usually secondary to high-velocity trauma, falls, epileptic seizures and electrocution. In patients with epilepsy, the relatively stronger internal rotator muscles contract and overpower the weaker external rotators . Patients may present with a locked irreducible posterior dislocation in which the humeral head engages the glenoid rim. The patient therefore holds their arm and shoulder in internal rotation and there is a marked loss of external rotation [64, 65]. AP and lateral radiographs classically show a "light bulb" sign and possibly the reverse HSL. Imaging such as CT or MRI is often crucial in detecting associative injuries [64, 65]. After reduction, if the remaining lesion is less than 20% then the shoulder joint can be initially managed non-operatively either by immobilisation in neutral or preventing external rotation for around four weeks . Elderly and low demand patients with chronic dislocation may cope well with minimal pain and just enough shoulder mobility to perform activities of daily living . As with all dislocations, recurrent instability necessitates surgical stabilization. Repairing just the capsule and labrum is not enough, especially if the shoulder is locked posteriorly . Reoperation rates are as high as 20% in many series . Lesions up to 50% of the articular circumference have been treated with anatomical reconstructive techniques whilst lesions larger than this may require arthroplasty . For small impression fractures traditional treatment involves detachment and transposition of the subscapularis tendon (Neer's modification) and or the lesser tuberosity (McLaughlin procedure) with transfer into the humeral defect using an open anterior approach. Successful stability has been achieved with these procedures . They are less successful for lesions between 20- 40% [68-70]. The complications of Neer's procedure include altering the anatomy in such a way that can lead to subscapularis dysfunction and if required, a more complex arthroplasty surgery . In 2006, Krackhardt et al described an arthroscopic subscapularis tendon transfer to the defect using suture anchors. This treated the defect and prevented extension during internal rotation avoiding redislocation. Twelve of these had been reported without any major complications . Rotational osteotomy has similar results for posterior dislocation as for anterior. It allows for improved shoulder range of motion, but does limit external rotation. Concerns due to its technical difficulty and increased risk of devascularization have meant it is rarely utilised . The posterior bone block is a good treatment option for posterior dislocation and has good short-term results with low recurrent dislocation rates despite the increased risk of glenohumeral arthritis [73, 74]. Osteochondral bone grafting can also be considered for patients with medium to large reverse HSLs i.e. 20-40%. Femoral head allograft to fill large reverse HSLs have showed good functional results with no instability. Diklic et al presented thirteen cases with chronic unreduced posterior dislocations of the shoulder with associative humeral head defects i.e. 25-50% of the articular surface. They reconstructed the defect with femoral head allograft. Patients reported good pain relief, stability and function at a mean follow up of four and a half years. The drawback with this technique is that it requires good bone quality of the humeral head and no glenohumeral osteoarthritis . In a more recent study, two patients had their impression defect (less than 35%) elevated and then filled with allomatrix bone graft putty. This construct was then stabilized with raft screws and so it can only be done to none fragmented lesions. After initial bracing for four weeks to prevent internal rotation they were then allowed full active range of movement. At two years functional results were excellent. The authors proposed that this technique can be used in patients with medium sized (20% to 40%) reverse HSLs . In a recent study, following posterior shoulder dislocation (seven to eight weeks), six men underwent allogenic grafting with humeral head contouring of medium sized (40%) reverse HSLs . By four months, all patients had returned to their occupation. Three patients had an excellent clinical outcome matching radiological observation. One other was 8 years post-surgery who developed osteoarthritis and went on to have arthroplasty surgery. The final two suffered collapse of the graft requiring arthroplasty .
Arthroplasty should be reserved for dislocations associated with large humeral head defects, severely damaged humeral heads or osteoarthritis of the humeral head. Gavriilidis et al performed arthroplasties in patients who were symptomatic with greater than 45% damage to the humeral head articular surface. Ten patients underwent hemiarthroplasties and two had TSAs. At a mean follow up of 37.4 months, function and patient satisfaction had improved with no recurrence of instability. One patient required revision at 36 months with polyethylene insert exchange. Two patients developed migration of the humeral head but neither required revision .
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 Elkinson I, Giles JW, Faber KJ, et al. The effect of the remplissage procedure on shoulder stability and range of motion: an in vitro biomechanical assessment. J Bone Joint Surg Am 2012; 94(11): 1003-12.
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 Park MJ, Garcia G, Malhotra A, Major N, Tjoumakaris FP, Kelly JD IV. The evaluation of arthroscopic remplissage by high-resolution magnetic resonance imaging. Am J Sports Med 2012; 40(10): 2331-6.
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 Matsoukis J, Tabib W, Guiffault P, et al. Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation. J Bone Joint Surg Am 2006; 88(3): 547-52.
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Madan Krishna Shrestha & Haribamsha Acharya* invite you to an exclusive charity show "NEWAR BAHADUR – BAHUN BAHADUR" "नेवार बहादुर – बाहुन बहादुर" in support of Spinal Injury Rehabilitaon Centre (SIRC).
Kamalmani Theatre, Rato Bangala School, Patan Dhoka.
The production "Newar Bahadur – Bahun Bahadur" is a satirical commentary on the challenges facing our citizens, from load-shedding to corruption, ever-lasting constitution-writing, political herapheri and the 'Ma-pa-se' drive. The show sold to full houses at Academy Hall in April and is being staged again on public demand starting 13 July. Enjoy this exclusive opportunity to enjoy Maha Jodi's latest production. All of your contribution will go to the Maha Patient Support Fund at SIRC, which subsidises the stay and rehabilitation of poor patients. * Both Madan Krishna Shrestha and Haribamsha Acharya are members of the Executive Board of SIRC.


Since 1971, Memorial Day has been celebrated as an extended weekend away from work–and the unofficial start of summer. It's time to get that grill going, dust off your patio set, and break out the white jeans you've had stashed away all winter.
Q: I'm ready to buy a new home and I'd rather not wait until spring. What do I need to know about buying a house during the winter?
Buying a previously owned vehicle can also be a great way to save big on one of your most valuable possessions.
Q: I need a new set of wheels and I'm wondering if it's better to spring for a new vehicle or to go the cheaper route and buy a used vehicle. What do I need to know about each kind of purchase?


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Combat Troops Have Been Complaining About The M4 And M16 For Years. Now The Pentagon Is Doing Something About It
For decades, troops have been complaining about the limitations of the M16 rifle and M4 carbine, both of which are...
By Jeff Schogol February 28, 2018
For decades, troops have been complaining about the limitations of the M16 rifle and M4 carbine, both of which are hindered by the same flawed operating system that makes the weapons jam easily. But after years of ignoring small arms in favor of expensive aircraft and warships, the Pentagon is taking a long, hard look at how to give the Army 11 Bang Bangs and Marine grunts a better weapon.
Defense Secretary James Mattis has ordered the creation of a task force to make American small arms more lethal to give infantry soldiers and Marines an extra advantage in the close fight, Pentagon personnel chief Robert Wilkie said. It has been decades since the Pentagon last looked at the combat effectiveness of small units.
"We don't want any more fair fights," Wilkie told Task & Purpose on Wednesday. "We want to overmatch any adversary out there."
Related: The Army Says Its Next-Generation Assault Rifle Will Pack A Punch Like A Tank's Main Gun »
Close combat, in which opposing troops are no more than 600 meters from each other, accounts for up to 90 percent of U.S. casualties, Wilkie said, and America's adversaries have made advances in this type of fighting in recent years.
The Israelis had planned to destroy Hezbollah using airpower in 2006, but they found themselves in close combat with a conventionally trained force that lured Israeli tanks and infantry into kill zones.
"The bottom line for us is we don't want that to happen," Wilkie said.
To ensure that U.S. troops can annihilate any enemy in the close fight, the new task force will look at how to update troops' training and equipment based on lessons learned from special operations forces, he said. One aspect of the review is whether infantry soldiers and Marines need a new rifle, he said.
When asked if the Task Force's work could result in the Army and Marine Corps fielding a new rifle, Wilkie said: "It could. We just haven't gotten to that point yet.
But Wilkie stressed that the task force's focus is to make sure that infantry troops have the training to be dominant in the close fight, adding that discussions about how soldiers and Marines are equipped "will flow from that."
Mattis has said that he wants U.S. troops to experience 25 simulated battles before they get their first actual combat experience, Wilkie said. To accomplish that, the task force will look at expanding the use of simulators that are currently in the works at Fort Benning, Georgia, and Camp Pendleton, California, he said.
Related: The Army Is Testing A New Rifle With Better Range And Accuracy Than The M4 »
Over the last 70 years, small infantry units have done most of the fighting and dying in America's wars, but a Pentagon Cost Assessment and Program Evaluation review recently determined that infantry troops get less than 1 percent of the Defense Department's resources for training and equipment, said retired Army Maj. Gen. Robert Scales, who was an advisor to the CAPE review.
Meanwhile, any U.S. casualties can have strategic implications, Scales told Task & Purpose on Feb. 23. For example, the deaths of four soldiers in Niger in October 2017 has led the U.S. military to rethink its entire posture in Africa, he said.
"We're very, very sensitive to casualties," Scales said. "So, it make sense to me that the nation should do more to keep alive who are most likely to die."
While small arms and other infantry equipment cost far less than the Defense Department's modernization programs, they have not been a top Pentagon acquisition priority.
For decades, expensive weapons programs like the F-35 Joint Strike Fighter and Gerald R. Ford class aircraft carrier have eaten up a large part of the Pentagon's budget, but Wilkie said the task force will now look at whether the Defense Department needs to spend more money on grunts.
"The focus for this secretary will be on the point of the spear where the most of the casualties occur," Wilkie said. "We are going to determine whether or not we have devoted sufficient resources to that fight. My view is, yes, we will be spending more money on that."
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Noor van Boven shares experience and insights from her career in Recruiting and Human Resources. In this episode, Noor shares how her Father influenced her career, taking time off to travel, why she prefers "people operations" to "human resources", the key ingredient that separates good from great companies, managing people operations in aa global organizations with 38 nationalities represented, time management and productivity tips, how SoundCloud uses it's platform for recruiting, and what music you'll find in her home.
Sree Sreenivasan shares experience and insights from his career spanning Journalism, Academia, and the Arts. In this episode, Sree walks me through where his passion for technology comes from, his 30 year love affair with the Met, the museum of dead technology, learning the value of new technology during a military coup in Fiji, how living in different countries stoked his curiosity, what it's like to run a 70 person startup in a 100 year old company, Tradigital journalism, attention as currency, the biggest competition for museums, where he goes to keep up with emerging technology, why LinkedIn is the most under-appreciated of all the social networks, and where he finds inspiration.
Best Part Of My Job Podcast Ep.5: "From The Goonies 'Chunk' To Hollywood Dealmaker"
Best Part Of My Job Podcast, Ep. 1: Jennifer McClure (@JenniferMcClure), Founder of Unbridled Talent.
Jennifer McClure, Founder of Unbridled Talent, shares stories from her career in Recruiting and Human Resources. In this episode Jennifer shares how she knew when it was time to leave the corporate world, where she finds inspiration, why leadership coaching is so important to her, public speaking and conferences as an introvert, where her love of horses comes from, and more.
I'm excited to officially introduce the new Best Part Of My Job podcast! The "Best Part" podcast is weekly exploration of the world of work. Each week, we'll interview professionals in different fields to learn more about their experience, career path, and what it's like to do that job.


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See more Tsukineko Memento Ink Pad.


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Halo 5's Biggest Problem?
Games Halo 5: Guardians
Gurantulaa April 21, 2016, 5:34am #1
Halo 5: Guardian is a good halo game. The introduction of Warzone, an innovative forge sandbox, and competitive arena modes are the steps in the right direction. But what holds this game back?
What is it that the Xbox One's Flagship game is missing?
Halo 5 Guardians has great music. GREAT MUSIC. The return of some classic soundtrack favorites is great. However, there is little "Epic" songs. Every part of the soundtrack is subtle and seems more like menu music. We need more High Tempo music similar to Halo 2 Mjolnr, Halo 3 Finish the Fight (music like that). But this is not the biggest problem…
Halo 5 has poor custom games support. The few Gamemodes really are starting to be apparent, I am constantly playing an honor system mini game of a traditional Arena map. There also few custom game options (but have mostly been added through last update). This is still not the biggest problem…
Halo 5 has poor theater mode. Glitchy mess! My crossair is 10 feet from where I shot. I will kill someone and I will almost have my back towards them in theater mode. This isn't the biggest problem.
Halo 5 Requisition System. Plz 343, reduce the RNG aspect of requisitions. We need to be able to have some control of our REQs and Armour. Once again, this still isn't the biggest problem (but it's close)
Halo 5 Campaign.
The biggest disappointment in Halo 5: Guardians in my opinion. Go back and play halo 1,2,3, and even 4 to some extent, then come back and play halo 5's. The introduction of 4 Player "Squad" Mode, The lack of diversity between battles, and Most importantly the Actual Campaign (excluding Gameplay). The actual campaign had out of play music, a poorly told narrative, and VERY poor Mission design. Halo 5's mission formula seemed like it consisted of this: Small Room then a Large room then an Even BIGGER room (or area). There was no Diversity once so ever. I think of The Storm from halo 3, You went from area to area with different objectives, not just kill enemies move on, kill enemies move on, Warden fight, Move on. The mission design is a big one. The narrative for Halo 5 is rough, with cheap Trailer Dialogue and poor character development. Halo 5 suffers from an overpopulated character pool. THERE ARE TOO MANY CHARACTERS to develop. It would take several games to develop every single one of the 10-15 characters. Reduce the main character pool to make it easier for you 343. The music seemed odd especially on parts that were ominous or dark, wasn't really any music at all. Think of the Oracle and The Arbiter missions from halo 2 there was a spooky and interested background music to complement the setting and skybox of the mission. Lastly, halo 5 Guardians Campaign does not need the squad system. Halo should be a game that supports either Solo or Co-Op ESPECIALLY In the campaign. I only seem to enjoy Halo 5's campaign with friends On legendary. If I'm solo the campaign feels more like a chore.
Please keep in mind i explain what I don't like about halo 5 because I love halo, not because I hate it. I want it to be the best it can be! So please 343, listen to our community about what to improve upon.