2021 Annual Meeting Shoulder Access Pass-Questions and Answers: Instability: It's Not Just the Anterior

Video Transcription

Yeah, this is for both Justin and Jim, actually. So you have this nice little exponential linear type graph that shows risk of failure 10 times higher  with 11% bone loss, 25% higher with 15% bone loss. So how has that changed your indications for surgery as far as timing, first time, post-treatment stability  events, and number two, has that changed your technique?  I'd certainly defer to the masters on the panel here and in the room, but I think the first paper showed us some good insight, and same with the anterior.  Letting these people dislocate more and more, I think, is an issue. So certainly getting to them earlier, and hopefully with more recognition,  it still seems like posterior instability recognition is lacking but improving. So I think that's one way, but as Dr. Bradley mentioned, once you start getting to 15%,  maybe we should start thinking more about bone grafting, and I think it probably depends on the quality of the soft tissues posteriorly, too.  So I'm gonna fix them the way I fix them, even if it's 15%, because I've only got a 25% failure rate, and then if they fail that, then I'm gonna go  to Matt's technique of a distal tibial allograft. I don't like, or you can use the iliac crest, but man, that really hurts. I just use a distal tibial allograft.  But they're few and far between,  even in my revisions that I've done, they're very uncommon, believe it or not, because I do mostly athletes, and athletes, they tend to sublux first,  and they don't get huge amounts of bone loss, but once they get around 10%, I ask them, please, we need to operate on you. Do you try to take any more capsule,  do any more of a capsule? Yeah, put it up on top. So the linebackers get this a lot, and what you do is you take it and you put it up on the face more.  So it's supposed to, where the labrum lives on the top is on the side, it's two or three millimeters off the side, and you don't put it on the face once you get above the equator,  but below the equator, it lives four millimeters on top of the face. And you can look, when you go back down and look at a normal one, it's sitting on top.  So I will pull that right on top of that bone loss thing and run it right along that corner. I've had some pretty good luck with that, I really have.  It's a great point, and something that Jim's mentioned before, not in this talk, but I think if you have isolated posterior instability for you guys in the audience,  you need to be sure and close your posterior portal, because that's essentially like a capsular tear, capsular wrint, so something that I don't do,  the anterior side, because you're working through the rotator interval, on the posterior side, you need to close that portal.  Yeah, the reason I did that was when I first started doing, because no one liked to do posterior in the beginning, and I liked them because I didn't want to do the,  I preferred them because no one did them, and then I would look in there, and I'd walk in there, and there's big holes in the capsule. I'm going, that's a stress riser.  So every one of those, I started closing. They're easy to close, the way you close them is simple. You unscrew your cannula, you take a Spectrum,  RealPass, whatever you're gonna use, pop it through, put your suture inside the thing,  and then take a penetrator, all right, and pull it through the other way, just pull it out. You can tie it right down to the muscle,  because you know that the cannula's protecting you. So they're very easy to close, and the reason you should learn how to do that is, because when you go in there,  and there's a posterior haggle, and you don't know it, that's an easy way to fix them too. We had one other question come through from the audience,  and that is the utilization of MRI in this setting. So both the first studies, maybe you can comment on this, the authors, so many people talk about bone loss,  utilizing CT, both of your studies were based on MRI.  Do you find the quality of the MRI mattered? Was it hard to draw that circle? Do you have to tell anything special to the centers that are doing these?  T1 imaging, is that important? Maybe just address the utilization of MRI, perhaps.  Yeah, so I think one of the studies, there has been a study that showed that 3D CT was a little bit better than MRI, but I think the way the other group did it,  getting a 3D recon, being able to get to the sagittal, the correct sagittal plane that gives you that en face look is very important, and I think even in ours, we didn't do that,  but we did look at our sagittal en face images, how far off were they from being perfect, and it was two degrees off on average, so I think that as long as you have that,  that's probably enough, but obviously, 3D CT would be the gold standard, but then you have the risk of radiation as well, coupled with that.  And just remember, posterior instability is pain. It's not instability. Anterior instabilities, they complain of instability. Posteriorly, the athletes complain of pain.  Very important point. Thank all the panelists for participating. Thank you guys for coming. That's the end of the session. Thank you.

Video Summary

In the video, the speakers discuss the impact of bone loss on surgery indications and techniques. They mention a graph that demonstrates a higher risk of failure with increasing bone loss percentages. The speakers emphasize the need to recognize and address posterior instability, especially in athletes. They also discuss the use of bone grafting when bone loss reaches 15% and mention the potential use of a distal tibial allograft. The speakers touch on closing the posterior portal to prevent capsular tears and stress risers. They briefly discuss the use of MRI for evaluating bone loss, mentioning that 3D CT scans may be the gold standard, but have the drawback of radiation exposure. The video concludes with a reminder that posterior instability causes pain, unlike anterior instability which leads to complaints of instability. No specific credits are mentioned in the transcript.

Asset Caption

Michael Bedrin, MD; E. Lyle Cain, MD; Justin Griffin, MD; Justin Arner, MD; James Bradley, MD; William Ciccone, MD; Ivan Wong, MD, FRCSC, MAcM, Dip. Sports Med; John Tokish, MD; Brett Owens, MD

Keywords

bone loss

posterior instability

bone grafting

MRI

3D CT scans