Notes from Singapore and Sydney: biology, bone loss, and peptides.
Three weeks. Two countries. Two courses. Three takeaways that change what I'll do in clinic next week.
The last fortnight has involved more aeroplanes than anaesthetics. It started in Singapore, at the Smith+Nephew Medical Education Inspire Shoulder course — three days on advanced arthroscopic technique for glenoid bone loss and tissue augmentation in rotator cuff pathology. From Singapore to Sydney, for a faculty-excellence course and a day with a group of fellows and consultants working through every difficult shoulder one of us could put on the table.
The faculty was practical, opinionated and useful — Chris Peach, John Trantalis, Alan Wang, Ian Lo, and Fay Leung between them have a few decades of complex shoulder mileage. Three takeaways I'm bringing home and into clinic.
1. Biology is the next frontier of cuff repair — and it's earlier than I thought.
For two decades the rotator cuff conversation has been about technique. Single-row, double-row, suture-bridge, transosseous-equivalent. We've moved from re-tear rates that were genuinely poor to a contemporary baseline that is defensible. But the technique has hit a ceiling, and the ceiling is the biology of the tendon being repaired.
What that means in clinic, starting now:
- Pre-operative nutrition matters. Patients with poor protein intake, deficient vitamin D, or uncontrolled metabolic disease heal worse tendon. We are going to have an honest conversation about this before any elective cuff repair — not after.
- Metabolic optimisation is not optional. Smoking, uncontrolled diabetes, and severe vitamin D deficiency are modifiable pre-operative variables. The data is no longer subtle.
- Intra-operative augmentation has a real role. The conversation around REGENETEN (a bio-inductive collagen implant) and the newer ENFIX-class technologies is moving from "novelty" to "standard option for high-risk biology." I will be augmenting more often — particularly in re-tears, in larger tears, and in patients whose tissue biology I don't trust to heal a bare repair.
The shoulder you need back is the one that heals, not just the one that gets repaired. The field has finally caught up to that.
2. Lower threshold to augment glenoid bone loss — and a new technique I'm taking home.
The decision between an arthroscopic Bankart repair and a Latarjet has been the central question of instability surgery for the better part of a decade. The threshold has typically been around 15–20% glenoid bone loss; above that line, Latarjet has the better re-dislocation profile and gets used.
That threshold is moving. The data is suggesting the line should be lower than we have been using. And there is a third option — one I had not seen demonstrated properly until this trip: arthroscopic distal tibia allograft for anterior glenoid bone loss.
Ian Lo's technique is elegant. The distal tibial allograft has bone stock and a cartilaginous surface that matches the native glenoid better than a coracoid transfer — and the entire procedure is done arthroscopically. For young patients with significant bone loss who want to avoid the open Latarjet, this is now a serious option.
The plan: cadaver-lab work this month, then offering it as an option to suitable patients in the months that follow. More on shoulder instability and bone loss.
3. Peptides are everywhere. The data is not.
Almost every consultation in 2026 now includes some version of: "What do you think about peptides?" BPC-157, TB-500, the GLP-1 family — patients have read about them, friends and gym contacts are using them, and the marketing has run several steps ahead of the science.
My honest position. The orthopaedic evidence base for peptide therapy in tendon healing is thin. The safety data is thinner. The Australian regulatory picture is unclear, and recent TGA scheduling changes have shifted access models. I am not prescribing peptides for tendon healing. I am also not dismissing the question, because patients deserve a serious answer rather than a brush-off.
Where this needs to go: properly designed clinical trials, with proper safety endpoints, properly registered. The pressure to move on this is real, but the answer has to come from data, not anecdote. I would like to be part of that work — the University of the Sunshine Coast research partnership is where I would start.
Acknowledgements.
Thank you to Chris Peach, John Trantalis, Alan Wang, Ian Lo and Fay Leung for the faculty teaching. Thanks also to the Smith+Nephew team behind the week — Anahy Wilde, Ella Post, Ben Williams (Queensland State Manager), and Jenny Wong.
On reflection, I might have thought about wearing the Dodgers jersey around Ian. I will wear something different next time. The technique is being taken home regardless.
— Joe