for having me, and Matt, good to see you virtually. You look great, the bouffant fits you nice. So we're gonna keep this moving and try to make up some time. So I'd like you to kind of maybe start with the operation and then we can kind of pepper you with questions while you're working and make you super nervous. Perfect, thank you, Joe. Good morning, everyone. Welcome to Nashville. It's a great pleasure to be here and be backing everyone in person. First of all, I wanna thank the Orthopedic Learning Center staff and this incredible new mobile lab. You have to check it out, it's up on the third floor and it's a really cool setup. So Lise and her team have done an incredible job. I wanna thank our industry partners as well, and also my current fellow, Bob Waltz, who's gonna be helping me from Vail, Colorado. So we have a little bit of a surprise and I mostly added this in for Rick Ryu's benefit because he says I talk a little fast. We're gonna bring up some picture-in-picture slides in all seriousness to help walk through the steps of this and talk about some of the relevant anatomy. I also wanna thank Jorge Chala for some of his incredible work on some of these drawings. So let's talk about patient positioning and setup first. Next slide. It's really important. This is where the procedure really starts and I use two towels behind the back of the scapula, right on the medial border, so that you're really allowing this to position. You can use a commercial arm holder or you can use a padded mail stand. I use both and most frequently just a padded mail stand so I can move the arm around freely and not put it in positions that may be a little tough on the patient. If you put your arm in extension a little bit, that's a lot of pressure on the front of that shoulder. So then we're gonna start with our approach, the delto-pectoral and Mike showed this very well. It's our open Bankart approach. You can take the cephalic vein laterally or medially and we're gonna get right into it here for our approach. So you can see we've already done our Bankart approach here. It's an open Bankart. I've identified the coracoid. Let's get a pointed homin in here. I generally use a pointed homin right at the top and what you'll see, next slide, is the anatomy of this coracoid and what we actually found, and this is a paper we published, is two bands of the coracochromial ligament and we're gonna see that right here and I'm gonna take that about a centimeter away from the coracoid itself and that's if you want to be able to repair the capsule and so once I've exposed that, I'm gonna incise these two bands of the CA ligament that you can see nicely there in the anatomic picture. You have the conjoint tendon nicely approximated here. I've also put a mark or you can use a small bovie tip mark when you use this in the OR to mark the front edge of the acromion. The other thing you have here is a nice separation from the pec minor and you can see the difference here and this is really key. Here's the tendon of the conjoint and then you get really into this muscle area just like we've shown on this picture and so I'm gonna take that off. I usually take it off subperioste, you can use a bovie, you can use a knife and I also use a cob elevator and you just have to be careful here because next slide, as you go medially, the nerves and vessels are right in this area here so you have to be really careful as you're approaching this medial. Next, we're gonna now work on taking this and harvesting the coracoid. I generally put a cob here medially and hold that there. Here's a cool little trick here in this next slide. Most of these saws that are at 90 degrees, if you look at this, this is 25 millimeters right here. I don't know if the camera can zoom in a little better but you can see that's about 25 millimeters right here on the ruler and from the hub to the edge there and so you know you're getting right around 25 millimeters and so in males, it's 28 millimeters to those ligaments. You wanna stay away from that. In females, it's about 23 to 24 millimeters so you have to be cognizant of it. I generally start with a curved blade and I start medially and then roll it around this way. We're gonna cut. We've already marked it out and you can see the ligaments right behind me and you don't have to complete it with a saw. Many times, I just start the top vortex, roll around and I like this roll technique because that's very helpful and it protects the structures inferiorly very well. You can then take an osteotome. A lot of times, you just need to just use your hand. You don't even need a mallet and then we're gonna look at this here, coker, and make sure that we harvested enough and you know you've harvested enough if you have right here through the elbow and so you see this piece of bone which is actually into that elbow or curved area of the glenoid base. Now, we're gonna peel this up and prepare this. Do you release more from lateral to medial? Do you spend some time trying to find the musculotaneous nerve at this point? Absolutely, that's exactly what we're gonna do right now so as soon as I get this kind of freed up, again, we've got about a centimeter of our tissue right here on the CA ligament. You can see those two bands. There's the front band and there's that posterior band. We subperiosteoly, Joe. A lot of times, you have a few remaining fibers of the pec minor attached right here and then some, this fat below the coracoid. So then, we're gonna take that scissors and I usually use some mats here where we're actually starting to free this up and I like freeing this up. This is a trick that Arciero taught me a long time ago but I like freeing this up to make sure that this is dissected down. Let's make sure we can see that. I can dissect it down from the pec minor area and so you can just gently do that with your digital dissection or use Metzenbaum scissors and then here, we're gonna see the musculocutaneous nerve coming in. That looks nice, yeah. Right there. That's beautiful. You don't wanna pull a lot on it. Obviously, a cadaver, I wouldn't do this a lot in the OR but you do wanna free this up off the posterior aspect of the muscle. You have to be really careful with that but then we put it right here. I'll usually put a blue towel and then finish our preparation. At this point, are you feeling again for the axillary nerve or you're pretty comfortable with where it is and you're just gonna protect it? Yeah, pretty comfortable with where it is. You wanna make sure it's not under tension. The musculocutaneous is not under tension, Joe and here, you can feel and I'm palpating the musculocutaneous nerve just where we know it always is in the inferior part of that subscap through that fleshy portion of the subscap muscle inferiorly so you can do a couple things here now. You can then prepare this with a commercial holder. You can take this spike down to help make it a little easier but the bottom line is we're just gonna start with a saw here, Coker and hold this in place and then hold that there, Bob, thanks. And now this, we're gonna do the traditional technique so let's go to the next slide. Do you typically do it with a saw or a high-speed burr? I typically just lightly recordicate with a high-speed burr. Yeah, no, I think either's fine. I've traditionally just used a flat blade but either is good. The goal here, no matter what, is you really want this nice flat surface and here's a good picture of the congruent arc versus the traditional. Sometimes, you'll have some of the back of the conjoint muscle here attaching and that's okay, you can take some of that off but that's the piece we wanna take off. You can then use a commercial holder and there's a variety of these available and then use this to pre-drill your holes if you want. I generally put it on this side so we're gonna do the traditional technique so the top part then becomes the most anterior and the inferior side will then be up against the glenoid. Now, when you're using this, you gotta make sure that this is flush here and that this is reasonably flush here and that it's not angled any way so that it will sit flush with the glenoid but you can always alter that at the end. Just gonna reposition this here so we've got. What size driller are you gonna use? Yeah, so this is a 4.0 drill and so right here, I'm feeling to make sure that this is nice and flush and there's my CA ligament. I just leave that just in case you wanna repair your capsule and again, there's a million different ways to repair and handle the capsule. Jeez, I got the skin in there. That's not a good thing to do. And there's a bunch of different ways to do that. So, I need the CA. Show of hands from the audience, how many repair the capsule with the CA ligament at the end? Looks probably like 20%. 20, yeah. So, you can use anchors, you can ignore it. Jill Walsh style, you can use anchors, you can do a lot of different things. So, I've pre-drilled that at this point. We're gonna leave that alone. This is ready to go. Again, we're just checking the nerve, make sure everything's looking good here and we're gonna tuck this back in place. Now, we're gonna come to the interval here. It's our time. Where do you split your subscap? Can you talk? Yeah, we'll go to the next slide, please. So, the subscap is about five centimeters in length and here you can see the vessels and the top to bottom from top of rolled edge to the vessel about five centimeters and I usually take it, keep going to the next slide, I usually take it about two, two and a half centimeters above about halfway or just a little. Next slide. Keep going. So, here's our subscap split part, step number five and so there's the two-third, one-third that we like to do. Now, Jill and others and Pascal would say in a hyperlaxed type of patient, you might wanna bring that up a little higher and maybe do that by a few millimeters if you have someone with a big sulcus. The reason we split this is it's much better in terms of patient outcomes and that's been shown again and again in numerous studies for the subscap split. So, we get through that split right here, we protect the biceps, we've done the split and then what I've shown here is the separation of the capsule and it's really easy to find when you're in this muscle belly here, the subscap. Here's the capsule layer and I've already taken it down but it's really easy to find it here. You can use a cob dissector to take this down and then bring it back this way where the capsule and subscap are much more well attached. They're better annealed out here than over in this area. So, then we have the capsule step next. Next slide, please. What's your sequence of retractors here? Obviously, you have great exposure. This is probably one of the harder aspects of the case for people. What's your sequence of retractors here to get the exposure of the capsule, then the head, et cetera? So, I use a Cobell retractor out here. Then the next thing, Joe, is a subscap split retractor which is usually just a deep gelpy. And so, these are really nice to have and I put this in the subscap split. So, this helps me manage the capsule. And so, I usually put this medially. You can even tack it down to the drape with a towel clamp and that's really nice to do here. I'm attaching it to the specimen holder and you can see now we've got and can easily deal with the capsule. We got the subscap split and this will just be repaired at the end with some sutures lateral to the conjoint. So, here's our capsule. Next slide. And you can see some of the anatomy that you were dealing with here that there's a lot of nerves and vessels that are not far away once you take this coracoid down. Next slide. And so, here's our capsule management. Next step here. And we're gonna take down the capsule. I usually do this L-type takedown. So, you can see we've got this L here and then off the glenoid. And then I tag it right at the apex of the L with a suture and then we have the glenoid nicely exposed. So, after I've got my deep gelatogel back to the retractor and I have the capsule down, then I put my Facuda retractor in and that nicely brings this up. The other thing you do is a anterior glenoid retractor and there are two 2.1s or 1.1s or 3.1s. Depending on the size of the patient, I'll use a variety of these retractors in the front of the glenoid. Yeah, Jill Walsh used to describe using a Steinman pin up there, which I've used but I've gone away from it a little bit. Yeah. Right there. Yeah. Yeah, right up there. And that's especially in a bigger patient. That's a great point. These muscles can be very big, very well-developed and sometimes putting a big 1.6 or 2.0 Steinman pin up here can help you facilitate exposure. So, I've already done the preparation. This patient's already had a number of shoulder dislocations. And once we have this prepared, the key is making sure that you have well-decorticated bone, you have nice cancellous exposure. You can actually see some good ooze and bleeding, but this is gonna be very dense and you've got to take this down. Otherwise, we may not get the healing we wanna get when the coracoid is put in place. And so, you can use a variety, a sag saw, you can use a 90 degree, you can use a straight, you can use a high-speed burr, you can use a rasp, a power rasp type of device. But we're preparing it so we're having about 25 to 28 millimeters. Next slide. So, we got that capsule done. You're doing great on time. You have two minutes, but you're doing great. And so, now we're gonna bring in the coracoid. And this is always the tricky part of the procedure is finding the coracoid after you've dunked it in. Where'd that thing go? And what we're gonna do is bring the coracoid up with this. Can I get the holder? And you can use a holder to help facilitate it if you want. And so, here you have a holder that actually goes in here. And generally, what I'm doing is putting this between the three to five o'clock position and then very flush. We're gonna then fix this with some K-wires. Temporarily. You can also put another K-wire on top of it. You can pre-place a K-wire. You can put a K-wire outside the holder like this. You can put it inside. There's a lot of different ways to do this, but I have numerous K-wires ready to go. And then we make sure this is flush. One of the things you have to watch here is the rotation. After you put one of these in, and that's really key. So, this is rotated a little bit. That can be proud, superior, inferiorly. We then measure, and we're gonna measure it through here. The depth, and we want bichortical. And we're gonna put in, I generally use solid screws, four O-millimeter solid screws. I employ a Kancellas type of screw or a cortical screw in a bichortical fashion. And we'll put the screw in. Here's a screw and a washer construct. We actually found better compression. I know what Bob said, but we found better compression in a study when we actually added washers in. And this is actually a little nifty thing here where the suture actually slides through the washer. And so, you can repair the capsule down to that if you want. But we found good results with the washer biomechanically. But you don't have to use it depending on what type of screw you have. And certainly a larger malleolus with a larger head can be part of that. So anyway, we're gonna fix that there. You use a titanium screw usually, stainless steel? I use either. I usually use titanium now, a 4-0 solid with a washer. So that was great, Matt. We're just at time now. I think you've really given us a great demonstration here. Thank you. Any last words you wanna share with the audience? There it is. There's a last. Let's go to the next slide. We'll just show that last. And here's our capsule coming up here. And you can repair that capsule very nicely here. You can use a suture anchor. You can tie it in. You can tie it into the suture washer here. And then basically, you're done. You close this down and you're done. You close this down and case is over. Beautiful. Thank you all. Thank you. Appreciate it. Good job, Joe. Thanks.

Latarjet procedure

shoulder stabilization

patient positioning

coracoid

surgical site closure