Good afternoon, everyone. My name is Gabrielle O'Day. This is Dr. Kevin Farmer And we're gonna be moderating the shoulder session today. We've got a lot of great Talks today with some really talented panelists Much of our talks today are going to be in the instability portion And then there's going to be questions and answers at the end If you want to hold your questions till then and then a case discussion, they'll be moderated by a Dr. Provencher We're gonna start with our first talk today and it is on shoulder instability my lessons learned for a successful arthroscopic Bankart repair by Dr. Jonathan Dickens All right, well, thank you very much and it's a privilege to be here I don't know if I have too many lessons learned most of them are from my failures. So I Want to just acknowledge the military folks that have helped me learn as I made this transition now to Civilian practice no disclosures So it's important that we recognize that if we're gonna do an arthroscopic Bankart We really have to get it right the first time if we don't the arthroscopic revision has a 40% Failure rate even a latter J has two times the failure rate as a primary procedure unfortunately Arthroscopic Bankart repair if we look a little bit longer at our follow-ups more than 10 years For the most part has between 18 and 36 percent But certainly acknowledging that some of these studies are earlier generation Techniques implants and understanding of the pathoanatomy, but why not a ladder J? We know short-term complications and long-term complications are not insignificant 25% short-term complications probably the most important be a neurologic injury and some of these being permanent Long-term complications are also prevalent non-union osteolysis and glenohumeral arthritis So if we're gonna do this surgery, I think we need to have the right patient population For the arthroscopic Bankart and that begins for me with recognizing the impact of early surgery This is a study from the Italian groups that have shown that surgery within six months for the arthroscopic Bankart has 5% recurrence Excuse me versus 12% in the group. That was greater than six months We also know that soft tissue quality is important a first-time dislocator has permanent elongation of the inferior glenohumeral ligament And we know that a Bankart repair with a 10 millimeter capsule labral shift does restore that native length tension relationship We also know that subcritical bone loss is present in the first time dislocator We still don't know the threshold of which that subcritical bone loss is important But six and a half percent bone loss is present in a first-time dislocator now population And we also know that there's numerous athletic and athlete patient factors This is certainly overhead athletes contact and collision athletes and throwers and the arthroscopic Bankart doesn't quite fare as well as Other procedures like the open Bankart in latter J. So we need to be careful in this population So some of my thoughts for this I think the basic training for Bankart repair, so to speak the basics of the technique It's important to look from the anterior superior portal to get that good visualization down the glenoid deck for a general generous labral Preparation we want to see the subscapularis beneath and we want to prepare the glenoid for healing in general I say this is where I spend the majority of my time and I use the idea that the labrum should float up Above the glenoid after a good mobilization. We want to make sure we have good anchor placement Medial anchor placement is going to not recreate the capsule labral bumper Which is an important factor for these we want to use a minimum of three anchors I want to shift the capsule from inferior medial to superior lateral and I like to use a grasper to do this as I'm passing My shuttling device now, how about some more modern techniques if you will so lateral position certainly seems to improve Visualization it's better access for combined lesions There's some systematic reviews that would point to the fact that there's lower recurrence rate As well, but I think if you're trained in both and do a good Banker repair in both positions you can do that. Either way a bump is helpful. It does help improve your your glenoid Visualization and it's important to recognize and treat posterior pathology combined labral pathology So for me everyone gets a six o'clock anchor To recreate the hammock of the anterior and posterior glenohumeral ligaments and we always dress posterior and combined labral pathology recognizing that many of these recurrent instability Patients have a posterior labral extension. So addressing posteriorly is important in my hands in terms of suture configurations There's been a lot of development with technology in this mattress and double loaded anchors are helpful There's been demonstrated improvement in biomechanical strength with mattress sutures Knotless sutures to prevent Knot wear curve drill guides smaller diameter anchors and soft tissue anchors have helped us prevent the Lower the diameter of our tunnels and this may prevent potentially postage stamp type fractures theoretically So I think it's important we recognize that for the bony bank hearts We want to address those early certainly before we allow that bank card or bony bank card fragment to resorb Matt Provencher is going to join us Recently just published this paper for those that have a bony bank cart that approaches the 10 to 15 percent Instead of actually getting overgrowth you might get some resorption of those fractures Converting that on-track lesion to an off-track lesion. So maybe we need to be thinking about that as we consider those patients and then rim plissage John Kelly the master of the rim plissage is has certainly taught me everything I know but we want to avoid medial capsular placation and make our placations a little bit more lateral to prevent the loss of external Rotation and this is this is sort of the landmarks to help do that So the safe zone greater than one centimeter lateral to the chromium three centimeters distal to the posterior lateral chromium In this it the steps for this for me are preparing the labrum then passing anchors Going back doing the repair and then tying the hillsex sutures There's a number of different ways to do this whether it's suture anchors knots or knotless no study for me has really Dictated which way to do this in my hands and then lastly Arthroscopic bone block I think is maybe not modern but future of the the bone block I think Ivan Wong has really kind of led the way and showing us a lot of how we do this But it is an evolving technique for sure autographed and allograft techniques are are helpful here and and this could be the future of how we're Addressing these lesions in the future and then finally with regards to rehabilitation for me the soft tissue Arthroscopic Bankart for me is a slower rehab course So in summary approach it appropriate patient selection no chronic recurrent instability No subcritical or critical bone loss our requirements the modern arthroscopic technique addresses all pathology use mattress sutures small diameter and hopefully knotless suture anchors and the REM plissage For the off-track minimal bone loss case. Thank you All right next we have dr. Albert Lin discussing glenohumeral bone loss What's critical and how should I measure it? Thanks so much for having me for Brian and Mary and Anna and RJ OS RJ OS So, let's see here. All right This one hmm This PC one All right good. So We know that shoulder instability and young athletic populations is pretty problematic and this is particularly problematic in young males collision sports and bone loss which substantially amplifies those risks and So what is critical bone loss in? 2022 so we know that glenoid and humeral bone loss are risk factors for recurrent instability And so what's considered to be too much glenoid bone loss for arthroscopic stabilization is shifting based on the recent literature And in addition our understanding of bipolar bone loss and a going to track continues to expand it's well known the glenoid bone loss scores up to 90% of patients with recurrent anterior instability and We all know this paper of the classic Burkhardt and DeBeer study Substantial bone loss a risk factor for failure foreign arthroscopic stabilization So two-thirds of patients failing arthroscopic stabilization if you reach the inverted pair and that amplifies over 90% in a contact athlete And then we know based on work the classic work from a toey in Gerber that there's probably a little controversy that when you reach the 20 to 25 percent glenoid bone loss, this is a What we'd consider more of an absolute threshold for bone reconstruction But then you look at the recent literature And this is just at this threshold for critical bone loss is probably evolving and now something in the subcritical range Maybe anywhere between 13 and a half to 17 percent and in this range You know, you not only get biomechanical alterations with arthroscopic stabilization and high recurrence rates But outcome scores are significantly lower even if you don't have a recurrence and that that's what that's from studies that JT Tokish has Has published and so how do you measure glenoid bone loss was the guy in the early 2000s described a perfect circle method on A 3d reconstruction to quantify the amount of bone loss and I won't belabor this slide too much But there are multiple methods that's been described and almost all methods use some kind of a perfect circle or quantify some type of a ratio I think it's important to know that some studies demonstrate a unilateral method will overestimate bone loss compared to a bilateral area Pico method And then some studies demonstrated a 2d CT scan can overestimate compared to a 3d And so when you combine the two together you do a 2d unilateral estimate Which is the most common method of calculate bone loss on the sagittal CT This may actually double overestimate the amount of bone loss. And so I think the main thing is there's no true gold standard, but most are reliable and if you decide to choose a method make sure you understand what the limitations are and that the Measurements are reproducible in your hands. So we're familiar with the glenoid track and our understanding that bone loss is a bipolar Concept and the jock Motowin Burkhart recently further Characterizes as on-track versus off-track concept of bipolar bone loss Developing equation really to predict whether hill sex lesion will engage and so it's important to note that if you have more glenoid bone loss That'll make your glenoid track smaller and the hill sex lesion more likely to be problematic Now if you have an off-track lesion, we know that if you add a remplisod to that that will decrease your risk of failure pretty substantially But what about this concept of maybe a near-track lesion? So at our institution we found that there was a threshold of distance Between being an off-track lesion somewhere between zero to eight millimeters that was associated with an increased risk of failure With an arthroscopic Bankart alone and we termed this a near-track lesion in addition The threshold seemed to be decreased for age And so I think this makes some intuitive Senses most of us would probably think twice about an arthroscopic Bankart alone with the up when the on-track lesion is just Millimeters from being off-track and a more recent study we looked at two millimeter decreasing increments from being an off-track lesion in all patients and who are on track and are with an Arthroscopic Bankart alone and we found that the probability of failure exponentially increased the closer We got to being an off-track lesion and that inflection point was around ten millimeters And then interestingly if you look at our collision athletes These were particularly problematic and this figure here depicts that the surgical failure rate in our contact athletes here In the orange line remains substantially high even when the shoulders were really very well on track So our findings suggested it matters how far an on-track shoulders from being off-track and then arthroscopic Bankart alone and collision athletes Even if they're well on track may not be a suitable treatment So the implication of on versus off-track may well go beyond a binary concept And what about adding REM plasage for just an on-track shoulder? We compared our patients with on-track shoulders who underwent an arthroscopic Bankart With REM plasage and compared them against a control group and Who did not and we found that the rate of the recurrence significantly decreased in our REM plasage group And this was particularly pronounced in our high-risk athletes And so while there's no difference in the PROs the addition of REM plasage actually lowered the risk Substantially by about 99% so we may want to rethink about whether REM plasage is useful adjunct for on-track shoulders Particularly for near-track lesions or contact athletes So many of us are familiar with this treatment algorithm the question posed in 2022 include What is the level of critical bone loss to consider arthroscopy? What is the role of REM plasage for a near-track lesion and is this algorithm even? Relevant for contact athletes. So if we're talking about critical bone loss, I think 20% remains the textbook answer However, a critical bone loss in 2022 may be anywhere between 13 and a half to 20% So you might want to rethink whether an arthroscopic Bankart surgery is the right thing to do in this range And lastly bone loss is a bipolar concept We may want to rethink whether a near-track lesion are Problematic and whether the track concept is appropriate for our contact athletes If you look at the treatment algorithm from an American standpoint with no critical bone loss Most of us are doing some kind of soft tissue stabilization with critical bone loss greater than 20% We're doing a ladder J or some kind of bone reconstruction But then that's not always clear and then it's even more gray when you look at the subcritical bone loss Region you can see that the treatments really get pretty quite complicated and maybe all over the place and if you're European That is easier just doing a ladder J So I want to put in a shameless bug for the Oasis trial It's a multi-center study initiative at Pitt and Walter Reed and John Dickens here We just gave the great talk as one of the PIs and we want to answer the question of what is the best treatment for subcritical bone loss by randomizing our participants to Orthoscopic Bankart versus open Bankart versus ladders a in situations of 10 to 20% going on bone loss And I hope that the results of this study will allow us to define what the best treatments are for gray zone scenarios And so in summary the treatment algorithm 2022 for anti-instability may look like this first understand what the patient's expectations are second Understand the risk factors third factor in the bone loss and I think scenarios of subcritical bone loss the near-track lesion Contact athletes those are gray zones in which I think we need some further studies Thanks so much We're gonna skip ahead briefly and our next presenter is is dr. Ivan Wong who's going to talk about arthroscopic bone block The time is now to transition Wonderful, thank you very much So we'll talk about arthroscopic bone block For Glennard reconstruction my disclosures again, we just talked from heard from Albert talking about his his algorithm again I'm going down somewhere around 10% when they start considering using this bone block or a bone block for a shoulder instability because we do Know that latter J is considered the global standard for shoulder instability with bone loss It can address it, but it's non-atomic has a high potential complication rate can progress to osteoarthritis And it makes revision surgery like this failed one very difficult So latter J trades a decrease in recurrence rate for an increase in complication rate and and more difficulties with future revision surgeries as compared to arthroscopic Bankart repair We've actually done arthroscopic latter J's and we find that it has not taken up in North America specifically for these reasons It's have has a very high learning curve. It doesn't address the capsule in its technique It's still close to the neurovascular area to give you the same inherent risks of having neurovascular injury You still have to split the subscap to do the arthroscopic latter J and failure of that procedure still makes revision surgery very difficult The distal tibia is an ideal graft choice It's been developed by my preventer as an open technique with screw fixation and we do know that if you can recreate the glenoid Bone stock you do not need a sling to get both Radiographic and clinical excellent outcomes. That's the same as a latter J from this level one study with two-year follow-up here We've published our technique of how to do this arthroscopically The biggest thing is doing it arthroscopically. You do not have to damage that subscap at all You don't split it you go through the rotator interval We've shown that the learning curve to do this through that interval through the Halifax portal is shorter, right? It's only takes nine cases to get you always in the right position and probably the reason why is on the left You can see all the portals for the arthroscopic latter J on the right That's the anatomic glenoid, which is the same as a regular Bankart procedure with one extra portal done in this way and using a 3d Models, we found that really helps you identify where you want to put this It also allows you to address the capsule on the left You can see the end of the arthroscopic latter J the humeral head will sublux over that coracoid You see there into the muscle belly of the subscap. So you're really Depending on that's a conjoined sling to hold it in Whereas on the right is the end of the anatomic glenoid you saw the distal tibia being put in there and the bank Arts being repaired on top. So the shoulder is stable right at time zero We've published this paper in 2018 to show that the Halifax portal is safe outlined in the green through the rotator interval The conjoined tendon and the subscap is what keeps you away from the nerves and vessels Whereas the subscap split is the nerve is always within the split whether you see it or not You are retracting it and this is what it looks like in real time So this is not sped up switching say peril to glenoid superior to subscap right there. There's lateral to conjoined We slide the switching stick over we push from back to front and we can create this in less than 30 seconds We were getting excellent clinical radiographic outcomes. This is a one-year follow-up. You can see this is a Semi pro hockey player in Canada third surgery. We did anatomic glenoids. We've got full range motion back We're not having the same perioperative complications. We've published our two-year outcomes in a GSM in 2020 Showing no redislocations one subluxation. We just finished presenting our five-year outcomes of the same patients here at the Academy Just yesterday showing the outcomes have been maintained 94% of these patients maintaining MCID for five-year time point and we'll keep following them and again It doesn't have to be distal tibia We've published our outcomes of Iliac crest now just last year showing the exact same functional outcome The the CTS in fact look very similar to the distal tibia So they do heal the same and we've done our economic analysis, which shows that at every Cost that the payer is willing to pay you are getting substantial benefits. So this is always Economically feasible to do this rather than a bank card and wait for it to fail. So how do these look postoperatively? That's what we always get asked. This is just an example of this this is 32 year old female who had a dislocation they can see the CT here has a subcritical bone loss in the front and Because in Canada waited nine months afterwards had several had several different episodes after that you can see she still had a little Inverted pair measured 18 millimeters from anterior to posterior when you measure the glenoid So I'd like to put that distal tibia graft in front and why I'm trying to show you this is we want to show You what looks like afterwards watch where we put this. So the graft is in there subscap We pull back over the top so we didn't damage the subscap. You can see the graft is in the right place We can see that the measurement now has gone back to 30 millimeters. And then we're going to repair a bank card Soft tissue repair on top and this is the superior anchor when we got it up there You can see this is double loaded anchor blue suture. And at that time this was in 19. Sorry This was in 2015 when we did it We got it repaired to that spot because what happened was she got nice and stable postoperatively But six years afterwards and no instability just some aching pain with internal rotation You can see the subscap is completely intact where those screws are and did want to try get those screws out I want to really want to see what it looked like. So this is what it looks like afterwards You can see, you know, we didn't do a rump massage at that time We did do it this time when we came in to try get the screws out You can see the rotator interval is actually healed in after we resected it We actually have to puncture through and then when we move over to the front You'll be able to see that the bank cut repair that were repaired over on top of the graft making it extra articular has Completely healed in all of that Bankart is actually healed over so the graft is completely extra articular So in this case what we want to do is be able to take away those screws So unfortunately to take away the screws We actually have to create a Bankart tear to find the screws again And why that's important is because right here. This is where that suture is You saw that blue double loaded suture that is where it is We're going to take a traction suture to be able to visualize this better Grab it Split it down to an episiotomy and this is where you get the visualization of what it goes through and when we can be able To see it. We're going to look right down on the at that suture anchor Which we know is that anterior superior corner of the previous graft six years ago So if you look at it, this is how the bone remodels and we talk about resorption But really it's healing and then remodeling of the bone. There's the anchor everything anterior to the anchor That's all new bone remodeling So it heals back in this triangular pattern and then when we free this all the way up down below you can see it You know, we have the fibro cartilage that cartilage that was there from this frozen graft is still intact So it's giving some protection onto that glenoid before Or sorry glenoid after and now you can see that afterwards the glenoid looks like the shape of a glenoid is rounder in the bottom It's bigger in the bottom. It's no longer in inverted pair. So what's the future? How can I learn something like this if you want get into the process? Well, you know doing these different talks you and see edited videos It does look pretty easy and trying it, you know, you can do it But trying to learn all the tips and tricks we can actually broadcast this out You know since since kovat happened We've been broadcasting to be able to show it so we can see all the anatomy as we go and have discussions We also can do these virtual teaching labs now where we can actually do augmented reality. This is a surgeon down in Texas He's doing a cadaver I'm marking on the screen to show him where to cut how to move this using multiple camera feed We can be able to annotate draw on top identify exactly how to create that bone graph to get that excellent fit and where to put it and He's able to actually put this into the glenoid to make it perfectly parallel at the end of the surgery So hopefully we've been able to show you that the evolution of that anatomic glenoid is really Evolved from the arthroscopic ladder J Now you can get the same benefits of a ladder J with a risk profile of an arthroscopic Banker repair faster learning curve Cost-effective repairs a capsule safe doesn't damage subscap and anatomic. Thank you All right, awesome job now we have dr. Matt Provencher you can discuss glenoid augmentation reign supreme open ladder J and DTA Yeah, Kevin, thank you, thank you program I have no idea who set this meeting up and put these rooms so far apart so We're gonna. We're gonna work on it Vegas is gonna be better. I promise you okay So thanks for a flexibility and we got my talk up, please So Ivan I want to thank you for help helping take this to the next level from our 2006 first description of the DTA but I think it's gotten us to rethink all of the bone graphs and everything that we are doing in terms of In Terms of bone grafting the arthroscopic technique is I think gonna reign supreme here in the next several years as we continue to refine this Bill Veen and I were just doing an ICL where we went over this extensively, and I think Augmentation whether you do it open and transition in arthroscopic get in the open down first I think it's important Then you able to transition to the arthroscopic and this is where we certainly started our journey When you look at the bony augmentation when to consider we know this but four millimeters is a lot of bone loss every 1.5 millimeters Approximately based on the size of your patient is 5% so every 1.5 million is 5% so if you're on three 3.2 millimeters you're at 10% you're at four four and a half millimeters or 15% so we're really starting to think about these four millimeter lesions, and so this is what we're looking at This is how bone loss occurs in general It's parallel to the long axis of the glenoid and when you look at our failures at 13.5% really gets us down quite a bit on the WOSI scale for whatever reason and it's probably because their shoulders not Stable enough and they feel like they're going to sublux and so treatment decisions really to start in the clinic Examination and history and physical are the most important If you see this which is a very extensive and at least 25% bone loss with an attritional fragment This is what it looks like arthroscopically and between four to six millimeters Anterior granite bone loss you know can amount to 20 to 25% and that's very significant Next slide can you play that video next slide maybe? There we go so when do I had to use ladder J versus DTA well pretty basic ladder J multiple Recurrences if you ask Christian Gerber he'll tell you all the time you Americans need to get smarter Because if you have more than one Instability event you just do the ladder J. It's a very simple discussion That's forget all these algorithms forget all this other stuff Exam instability and mid abduction if they're a contact athlete and then certainly imaging off-track 12.5% more glenoid bone loss, but it could even be a near track or an on-track lesion which we're learning much more about The ladder J procedure when we looked at this this was Tim Malone myself We went back to my alma mater at the Naval Academy and found mean follow-up these patients that had the Bristow done by Jay Cox He was there in the 1970s a great surgeon followed these patients up at 26 years You know we found about 14% recurrence the ladder J is not perfect And if you look at the ladder J the recurrences are real and can happen and you look in the literature It's anywhere from 8 to 14 percent if you add in recurrent subluxation There's a lot of steps to it and happy to have you have this talk when you look at it But the biggest thing is subscapularis you have to split this in line with the fibers Generally two centimeters above and two and a half centimeters below you can split that down a little bit lower We then harvest the coracoid we use a saw we want to make sure that we get enough of this about 22 to 25 millimeters Depending on the size of your patient, and then we're gonna put that graph between three and five o'clock with two screws about one Centimeter apart, so here's a case an 18 year old male quarterback highly recruited to multiple d1 schools in game shoulder dislocation Guess what they do they go back and complete five more games. You got to get more game film for all the recruits and They have more subluxation so before you know it you don't even need imaging They have more bone loss by definition just because they went back to play so if you make that decision They're gonna get more bone loss, and they're gonna get more attritional bone loss which you see here There's that tiny fragment is not enough to reconstruct the glenoid And that's a big problem and 3d CT remains supreme to really help us differentiate this as you can see the latter J We're able to put this in repair it And we also take care to do the capsule I do an L-shaped capsulotomy And we get good outcomes at by three to four months most these patients are back to full activities Maybe the highest level of contact I'll wait for four and a half months But they're usually pushing you and that bone-to-bone healing is very nice And if you look at LaFosse's arthroscopic latter J work at two to four weeks people are getting back to full activities But the latter J is not perfect these are either my own cases or others Pulled off conjoined reserves in a bone plot It all exists screw prominence and bending arthrosis problems all kinds of things can happen here, and if you look at the overall outcomes Even in Pascal's in 2006 at three-year 15% experience recurrent instability Pascal below 2006 recurrence is related to presence of a bone defect very interesting Shaw overall complication rate 25% now some of these complications were smaller But there were some real ones in there plenty here one stability after a latter J 8% So I don't know we're getting this one two three percent from I think that's a myth I don't think that's a hundred percent true So we I think we have a lot of evolution to do here in terms of the latter J Being the gold standard and if you look at the best study out there and O'Neilly is following his patients for a long time 319 shoulders 15 years one or more subluxation is reported in 13% So I'm still trying to find that one two three percent article out there. I haven't seen it yet 2011 Article when you looked at this revision procedure, and you can see this Mean graft osteolysis from the Giacomo 59% of the latter J resorbs, but the patients were doing well So if you look at your x-rays you look at your CT scan a bunch of that coracoid goes away So what about the DTA history multiple recurrences again? It may certainly a failed stabilization I would consider it when I think about it more as a cartilage or a concavity problem. I would do it Instability and mid-abduction maybe an overhead athlete or potentially even a contact athlete that Conjoint tendon puts a lot of force across those screws And I do not think is benign when we looked up our combine results at the NFL combine We had a 60% complication rate, and that was the real deal So I when I really say is when I want to reconstruct both the cartilage bone and anatomically fix it And then also do this much more arthroscopically distal tibia has been a big workhorse for us We've still done this fresh although I know they have a special of frozen lake up in Halifax where they have special processing up there I think there's some special juice in the lake that keeps these graphs good, and I like it I would I haven't gone to the frozen yet but Ivan is showing us the ropes on doing this which would make this highly available and off-the-shelf and Really a nice way to do this arthroscopically, but this is what you feel like after you put this in it's very nice It's a good concavity when you look at our outcomes overall very good We got CT scans on everyone our WOSI scores went down to 11% We have to look at interface graft healing Ivan bill and others and myself have been working on this. It's not just lysis What do you mean by lysis? How much did it heal between the native glenoid and the bone? And that's what we really have to be talking about. We had overall 90% healing rate top to bottom medial lateral in that graft. What about revision? This is really only a large-scale failed Latter-day study out there. And we had a bunch of patients that did very well. This is a very tough case, but we had complete union in about 90% of patients with the DTA. We did have a couple of failures, but overall very good outcomes in a very challenging cohort. So good luck on your glenoid bone loss journey. Thank you. Our next talk we're going to start talk about the back of the shoulders. So this is Dr. John Kelly talking about don't forget the back, addressing posterior shoulder instability. Thank you very much. I want to thank Brian and Mary for the opportunity. And as the father of an orthopedic resident, Anne-Maria, I want to thank Mark Gettemann for his leadership in this whole endeavor. So these are my disclosures. And what I've learned over the years, 31 years doing this, is that pain may be the only presentation of posterior instability. The scope works most of the time. Bone loss and anatomy do matter. The glenoid osteotomy should be reserved for master surgeons. And no joke, but I'm a big believer in reverse shrimp plissage. I learned a lot of these pearls from Jim Bradley and also Brett Owens. I want to give him a shout out. Posterior instability can be traumatic or nutritional. We see bench pressers, linemen. Now the lead shoulder in a batter, look at this. So anytime you ad-duct and internally rotate with a posterior moment, it can happen. So these are factors. Anatomic factors matter. Glenoid hemoretroversion, chondrolabel retroversion, reverse hillsacks, the concealed Kim lesion, and the reverse Hagel can all be present. So posterior acromial anatomy also matters. A wider posterior acromia potentiates the risk of posterior instability. And don't forget scapula dyskinesis, which is an ever-present issue in many of our patients. Throwers are a special breed. If you have GERD, as you go into extantation or intrantation, you can literally rip off the PGI gel because of the GERD. I see this all the time in throwers. So morphology matters. Jim Bradley, a leader in this, did 118 MRIs and looked at bone width, labor width, many, many metrics, and he found that only bone width predicted recurrence, including metrics of chondrolabel retroversion. He repeated this study, it was in 2021, where Arner looked at this more closely and he did the same measurements and again found that bone loss was a big deal. In fact, at 15% bone loss, you roughly increased your risk of failure arthroscopically 24-fold. However, retroversion does matter. Brett Owens, a genius, did show that for every degree of retroversion in the West Point study, you increase your risk of posterior shoulder instability by 17%. So retroversion does matter and Brett also showed in the lab that it also potentiates instability, less force required to dislocate. But how much bone loss is too much? Again, let's go to Brett. Biomechanical study, the critical number in his hands was 20%. After 20%, you saw a precipitous decrease in stability, as shown in this graph here. So that's analogous to the anterior shoulder. Travis Decker, another, I want to shout out our military heroes here, did another study showing that the bone loss was really posterior inferior, about 30% off the long axis. And John Dickens, if you don't like John Dickens, you got personal problems, but he showed that more bone loss correlated with retroversion and again, that critical number, 13.5%, just like anterior, he had a 44.4% reoperation rate, analogous. John also went on to say that retroversion predicted bone loss and also more bone loss correlated with a more robust jerk test. So great work, John. So non-op treatment works about 80% of the time for posterior shoulders, but beware of these anatomic lesions, including the reverse hill sacs. I'm a lateral-to-cube guy. I like to look from the front and like to work in the back and work from the front. I use the Porter-Wilmington off for my anchors, and Jim Bradley showed us that, use an anchor, when in doubt, use an anchor. You'll lower your recurrence rate precipitously. So here I am, looking from the front, working from the front, prepare. I learned this from the Korean specialists, and I also do my anchors percutaneously. Porter-Wilmington often works, and I also shuttle percutaneously, and that way I can get around the shoulder anywhere I want, and I'm a big horizontal mattress person. I think there's some biomechanical data saying it works, but the labor height correlates with recurrence. You get the best labor height in my hands with a horizontal mattress. How about bone grafting? I've never done this. Maybe I should. There's a lot of case series, and I think it is indicated. I haven't seen it, but Lauren LaFosse has the longest follow-up. No recurrence, but 37% of the time I had to go in back in again for screw irritation. Glenoid osteotomy. Christian Gerber, one of the world's greatest, had recurrence of only 86%, so what's that gonna make me? However, more recent studies show that you may be helping patients, but there's a considerable fracture risk, and this is a meta-analysis showing 22% recurrence. Not great, but again, Brett Owen showed that a glenoid osteotomy does help biomechanically considerably, so it's reserved for masters. How about reverse soul sacs? Well, if it's big, the best is an osteochondralograft, but for smaller ones, I like reverse remplissage, and I think in my hands it's helped many, many patients. So how can you push the envelope? You can. This is a 3.5 week out dislocator. It comes in my office, and one thing for the younger folks, they cannot do this on exam. Remember that? And here we go. I call the priest in, but there's the reverse soul sacs, so what do they do? A good bumper in the back, reverse remplissage, and there's actually literature on this. 12 patients Romano, chronic dislocators, you can help them, but also in humility, you have to know your limitations. This person came in my office about six months ago, 14 months out. I called Buddy Savoie. He says, well, Sonia, you can do it with a cob elevator. I did that. I got it reduced, but I don't think it stayed in. I was trying to be probably an ego attack, so know your limit. I think he's perched, so I have to open this guy up. So no limitations. Posterior disabilities common. Retroversion, bone loss matter. Most cases can be treated with a scope. Osteotomy should reverse for master surgeons, and reverse remplissage may help. And a plug for the Learning Center. You want to operate like a champ, go to the Learning Center. Thank you. All right, next we have Dr. Julie Bishop discussing posterior augmentation. I'd like to thank the program for having me. My disclosures are available, and I think my most important disclosure is that I'm no Ivan Wong, and that means that if I can do posterior arthroscopic augmentation, so can you. And I think we need to realize that posterior bone loss is uncommon, but when it's present, as Dr. Kelly was showing us, we need to address it. A military study looked at 43 arthroscopic repairs, and those with greater than 13 and a half percent bone loss were less likely to return. The cadaveric study that he also just mentioned showed over 20 percent bone loss were likely to fail after an arthroscopic repair. The old way we did posterior bone blocks, for me the old way was big kid, big incision, and the concerns of this is that there's morbidity of the approach. You have to detach part of the deltoid more the bigger the kid is, and there's all these are always big athletes. The cosmetic results are poor, it's a deep hole, and it's hard. Did I say hard? And prior to distal tibia, we used to do iliac crest. So imagine prepping them out and prepping their hip and taking their iliac crest and then doing this big surgery. And big open surgeries and big patients takes a while and is technically difficult. And the final pictures also, you know, we would go back in and put our camera in to get a picture of our graft, and they're just not as pretty for your presentation. So that's another reason to convert. And the arthroscopic techniques, as Dr. Kelly was saying, are gaining popularity. There's more and more studies detailing how to do these surgeries. And a systematic review looking at the complications showed overall for posterior bone block, about a 14 percent complication rate. Most are hardware complications. And you think the devices and the ways we do this arthroscopically are getting better and better. I think that's going to minimize the hardware complications. Less hardware complications, better fixation, less bone resorption, and hopefully less recurrent instability. So I decided that it was time and that if I could do this arthroscopically, I might have more control. So it was time to make this my way. So this is our first patient here. He's 17, football player, and he had a direct blow and a fall last season, recurrent instability. His full motion and strength, 2 plus posterior translation. And the MRI shows that there's some concerning bone loss. So we went with the CT scan, which shows he has a malunited, medialized, reverse bony bankart, and about 15 to 17 percent posterior bone loss. For me, lateral is the way. It's more comfortable. It's easier, better access. If you have to convert to a mini-open, I think it's a lot easier. Initially, we look from posterior. The anterior structures are intact, and then we can see our posterior lesion. And then we are viewing anterior superior. I do the entire surgery anterior superior. We're probing posteriorly, really getting a good sense for our lesion. And then we are doing all of our viewing anterior superior. Our anterior portal is a little lateral. We're coming in with the bovie, freeing up the labrum and the capsule off the entire posterior scapula. And you continue this until you really see it mobilize, and you see the underneath rotator cuff fibers. A traction suture is really helpful to pull the labral capsular complex out of the way, so you can access the posterior scapula. And then we can see it really well. And you see here the malunited, medialized, reverse bony bankart. And you see the muscles of the posterior cuff. You want to see those muscle fibers. And then we come in. Again, we're coming in posterior. I'm coming in under the capsular labral complex. And we're burying down that old bony bankart, so we have a nice flush surface. We preoperatively measure on the CT, and we confirm that with our measuring device interoperatively for our bone graft size. And then most important is we decide where our little mini incision is going to be. We come in with a spinal needle, because you want a straight shot down. If you're too angled laterally or immediately, you're going to really be torquing on your graft to get it flush. And then we dilate the entry point with your finger. So you've got the scope in your right hand, and that's your finger. And you can feel the trajectory down. You can dilate with a snap. And it really helps you, in your mind's eye, understand how that graft is coming down in. We go to the back table. We cut out our graft. The system we used allowed us to pre-drill, helps the screws be parallel. And you can put top hats in, which really helps, because this device gives you good, firm security and easy maneuverability of the graft. The metal trocars go through the delivery device and lock into the top hats. And so you can bring that in, you can line it up, and you can really crank on it safely to get it lined up. And then you drill your K-wires, you over drill your screws, you take the metal top hats or the metal trocars out, and you can watch yourself go back and forth, tighten the screws until you watch your bone graft be compressed, which is really helpful. So here's your final construct. And the bone graft is nicely compressed, and you have a lot of control over that. And you can look around the corner while you're doing this as well, because your traction stitch is pulling your labrum. And you can see that your screws are down, and you can watch yourself compress nicely. And then to finish, we do a little bit how Ivan does it for the arthroscopic anterior bone block. We percutaneously place an anchor inferior to the bone block. We percutaneously place one superior to bone block, pass a suture around the labrum, and tie that. So we're bringing our capsular labral complex back up to the glenoid face, and recreating that bumper. And here's our final construct with a capsular labral complex re-approximated, and our graft firmly secured. So thank you very much. So we're a little pressed for time, but we've got a couple more minutes for questions, if anybody has them. My first question is actually going to go back to Dr. Lin. You showed on your algorithm, you know, different options in terms of arthroscopic Bankart repair. You did mention open Bankart as well, and then bone block. What's your threshold in patients with some level of either subcritical bone loss, where you're going to do an open Bankart repair? Where is that, where does that have a role in your practice now? I think that open Bankart still has a substantial role. I think the reason why it's been out of, gone out of favor, is that all the literature seems to suggest that open Bankart equals arthroscopic Bankart. I'm not really sure that's true. I still think there's a group of patients when you have maybe about 10% bone loss in a high-level contact athlete, who may not have had a lot of dislocations, so that their tissues are still reasonable. I think that is a good person to do an open Bankart. All right, I think we're going to go to our cases now with Dr. Provencher and Dr. Levine moderating. All right, good afternoon everybody. I'm Bill Levine from New York, and live from that side. It's live, yes. So we've asked everybody on this panel what they would like to be called. We're all going to be called by our first names, with the exception of Father Kelly. So he decided that he cannot be called by his first name, but everybody else will be by first names. So we're going to start out, am I using the Mac one guys? The PC, thank you. This is my disclosure, nothing should have any impact on this case. What an awesome panel that's going to help share our learning here for everybody this afternoon. So this is a case ones of a 15 year old playing football, has a first-time anterior dislocation. So before we get into all the other stuff, I just want to hear what everybody's thoughts are, and we'll start down on the far end. Is that Jen or Gene? I can't see who's there. Okay, go ahead. Let's start out with first-time dislocation in a 15 year old. You're going to operate, not operate, timing, scope versus open. What are you going to do? And we're going to assume for the sake of this argument, there's no significant bone loss. First time dislocation. Sure, so I think that if this is somebody that wants to continue playing football, especially at a competitive level, that trying to non-op this one is probably not going to work. So I'd probably offer him a surgery. I think, again, we know that if they continue through the season, they're going to continue to develop additional injuries and potentially worsen any existing bone loss. And so I would prefer to get to it soon, especially since he's 15. We're not looking at a senior season. I would probably start arthroscopic, just depending on what the advanced imaging shows from a bone loss perspective at that time. Okay, keep going. Yeah, I agree. I'm going to, you know, have a very thorough conversation with the parents and make sure that they kind of understand what their options are, but I would be pushing pretty hard for treating this operatively sooner rather than later. Ivan, anything different? No, not a whole lot other than imaging and counseling about ideal to do it sometime before the second dislocation. Are we worried, Father Kelly, about the age of 15 and the higher failure rate with arthroscopic instability repairs? Does that make you listen to Dr. O'Day and say maybe we should do an open Bankart, God forbid, after only a first-time dislocation? I don't like that word, but this is my senior, Kelly. By the way, I rely, with my colleagues, I just rely on my exam. A little disagreement here. If they have apprehension and lower-degrees abduction, then I would recommend surgery, but I usually give them a trial of non-op. You would give a trial of non-op? Sir. Julie? I think a trial of non-op is very reasonable, and a lot of times the patient really wants that trial of non-op. I think that that is okay. With a brace, it's not going to stop the second dislocation. With a firm understanding that if you sense apprehension, subluxation, then you need to be done. So, Julie, we know that you can get 13.5% critical bone loss after one dislocation, and we certainly know from our friends at UCSF and others that you can definitely get it after two. So, are you condemning this 15-year-old to a different type of operation by letting them have number two? I think you need to take that into account with the discussion, but I would say I've had so many of these discussions with so many families, and so much of it is driven by what the family wants, and I think a lot of them do want to try to play, but I think you have to warn them that that is a risk, but I don't think I'm condemning them. Okay. Albert? Yeah, I think I'm biased towards recommending surgery for this just because of, you know, sort of the natural history of what we know happened in all the studies that demonstrate that if you get to this quick, there's a much lower recurrence rate. I probably would include a remplisage on this even if this was not off track. Okay, and John, you get to finish off. Yeah, there's no right answer. It's early in the season. It's August. There's a long season to go. I'm sure that this patient is probably looking forward to playing, but I think the discussion has to be made with the patient and the family. For the long-term health, he's got several years left in his high school career, maybe longer. You have to present the data. I think it's hard to... Certainly, a non-operative period is reasonable. Unfortunately, if you give them a non-operative period in two, four, six weeks, they're going to be feeling fine. They're going to want to go play, but their risk of recurrence is still the same, and so I think that's the hard part, but I think the shared decision makes it important. All right, so I think we've gone over that pretty well. This patient did have an arthroscopic bank card. Just to... let's quickly go over this. How many anchors should we use in this 15-year-old? Should we use three, four, eight, 22? What's the right number? Start out, John. We'll go this way. Yeah, I think minimum of three. It just depends on the location of the tear and how many. I think, as I mentioned earlier, I think the smaller diameter sutures are helpful. Mattress sutures are helpful. These all get a six o'clock. I find that the majority of these do have some posterior extent. I would do a rim plissage if he had a hillsex that was off track or near off track. Does anybody want to go against Monsignor Kelly saying that we have to do mattress sutures? Ivan's getting ready to go at it. I wouldn't say go against, obviously. I trained at SCOE. I do circumferential sutures for everything. It just seems to hold nicely. I really do focus on an in-period of superior shift. I really do think that you can get this. If you grab the tissue at the 3 o'clock, you can use a knotless anchor right at 12 o'clock to replace it. You shift the tissue from 3 to 12, just like you would in open. Great. Had his first dislocation. Gets a SCOPE Anchort on November 4th, 2019. Three months later. Has three anchors. Returns to football and suffers a recurrent dislocation in March of 2020. Here's the CT scan. Here's an MRI. Jen, what would you like to do? I couldn't really see if there was significant bone loss, but can you go back to that? Yeah. Yeah, I measured 18% bone loss. Yeah, I'm gonna push to doing a LATERGÉ for this. I think that even though you see a little bit of that bone that's there, it's medialized and it's not effectively producing any stability for him, so I'm gonna jump to a LATERGÉ for this. I do open LATERGÉs, not SCOPE. Jean? I would do the exact same thing. You have to think alike. We're in the military. Military people. Anybody in the military panel not going to do a open LATERGÉ? Dr. Provencher? This is an open LATERGÉ. You could consider an open Bancard. There is some evidence, I think, to think about just an open Bancard repair for this, even with 15-18%. Open LATERGÉ or potentially a distal tibia. Okay, Ivan? Yeah, this would be a distal tibia for me going in there, and definitely, you know, it is bone loss going. I can model it exactly where we want. We're having good results that way, but again, we'd measure for bipolar bone loss to be considering doing a REM plasage with that at the same time. Monsignor, have you been elevated above the Monsignor level yet? Not after last night. Okay, what are we doing, John? In my hands, I make sure I get adequate capture tension. I would do REM plasage, and I do some like Oates bone grafting with my REM plasage, and I seed the glenoid. I would not do a LATERGÉ yet. Yet. Julie? Open LATERGÉ. Open LATERGÉ. Albert? I would do an open Bancard and incorporate the piece that you can see there. It's a pretty meaty piece, and I think you'd get a pretty good shift with that. Love that, Albert. John Kelly, you're doing the same thing again. Is that what you said? No, in my hands. See, this time I would do the capture tension right, and get a good bumper. You're doing the same exact procedure again. We can finish this outside prevention. Hey Matt, do you like it when surgeons say, in my hands? Whose hands are you going to be using? It's kind of politely respectful, but really disrespectful, is what we're saying. John, what would you do, John? Probably a LATERGÉ. I don't think you're wrong with an open Bancard, and I think Ivan's DTA is on the horizon, I think. John, would you do it open or arthroscopic? I don't do an arthroscopic LATERGÉ. Audience, who would do an open LATERGÉ? Who would do an arthroscopic LATERGÉ? A few brave souls. Who would do an arthroscopic DTA? Dr. Abrams, of course. Love it. Okay. Ivan, we knew what you would do. Open Bancard, anyone? Open Bancard. My mentor, John Richman. Richman, there we go. I love it. How many of the young surgeons in this audience have never seen an open Bancard? Oh, my heart is aching. Oh, John, what are we going to do? You trained at Columbia, obviously, or was it? Oh, no, I'm sorry. Oh, that is just cruel. That is cruel. All right. So I did do a revision open LATERGÉ. It was a couple of years ago. Sling for four weeks, no PT initially. Slow, steady return to activities. Are you going to change your return to activities, Ivan, if you had done an open LATERGÉ because of some crazy thing, because of his young age, because it's a failure and it's a revision surgery, or are you doing the same rehab as normal? Well, we're changing the procedure. So when we started using the conjoint and bone block, as long as it heals, I would use my normal LATERGÉ procedure post-op. So what criteria do you guys all like to use for return to play? Give me some objective criteria. John? Yeah, well, for the LATERGÉ, I would get a CT scan between three and four months to assess healing. But for return to play, I think actually the PET group, at six months, more than 75% had not met either strength or functional requirements. So using a time-based requirement is, I don't think, satisfactory, although that's what the majority of us use. So I think functional testing, return to sport testing, is important in these patients. Albert, can you comment on some functional return to play criteria? Educate us. Yeah, so we've been using a protocol that's very similar to what we do with ACLs, and they go through isokinetic strength testing, they go through some functional testing, and we basically use it as a gauge at six months. If you pass everything, I'm comfortable allowing you to clear. If you fail one component, we'll have you do more PT, just concentrating on that deficit for four weeks before return. If you fail two, you do PT and then you have that test again. So I think it's been helpful for us because at times, at six months, everyone usually looks pretty good. And I agree with John, and for the latter day, I would look at a CT scan as well to assess for healing. Anyone on the rest of the panel have anything else to add differently than that? Can I ask a quick question to Albert? Because here's my question. What do you do at six months when your CT scan shows you have a non-union, but they're doing wonderful? I was going to say, there's literature to say fibrous unions do quite well. I wouldn't expose them to radiation, I wouldn't. Yeah, I mean, that's a great question because you see it, right? I don't know that I would do anything different if they... Okay, great. Thanks for that answer, Albert. All right. So at 13 months post-op, we let him go back. We did go slowly. He goes back, he tackles a guy, he gets a recurrent dislocation. I would just like to say a very provocative thing. The latter day is not a gold standard. There is no such thing in orthopedics where we say a gold standard has 20 to 25% complication rates and recurrence rates. I will let everybody just sit on that for a bit. That being said, it has been the gold standard because we may not have had a really good alternative. So he gets a recurrent dislocation, he splits his coracoid, he bends his screw, and there he is. So now what do you do? Timing, procedure, non-op. What the heck are you going to do with this? We'll start down there. Jen and Jean, you two go first, please. So I think this is where I start to just really wish that they stopped playing football. But I think to some extent, the writing, I think, is clear, right? This guy's not really probably proceeding with a professional career. And I think from an expectation management perspective, it's important to have that conversation and be honest with this patient. However, we still need to do something to stabilize this shoulder. So I'm probably going to err now on the side of doing a revision of the DTA. I think it's a great procedure. Are you doing that through the scope or open? I'm sorry. In my hands, it's probably open. Okay. Not in John Kelly's hands? Because they're the only ones I have. I'm going to tell you something. Good answer. I'm going to tell you something. Go to the lab, and you're never going to do it open again. I promise you. You're a skilled surgeon. You'll never do it open again. Okay, next. Well, I'm going to say the same thing. I do an open. Okay. I know what Ivan's doing. Monsignor, what are you doing? Remplissage. Remplissage. Wait, wait, wait, wait, wait, wait, wait. And then I would do a scope DTA and this, because I'd have to, because you've mutilated the shoulder now. Okay, Julie, what are you doing? As I said, I'm not Ivan, so I'm going to do an open. Okay, Albert? Open DTA. And John? Scope DTA. The only issue would just be- So I'm just going to go a couple quick steps to show you. The graph prep is beautiful. You can make two different size graphs, seven or 15 millimeters by one by two. It's really awesome. Capsule labral release. This is the first important difference than a typical arthroscopic instability repair. You really need to release the entire capsule labral tissue so that you can pull it out of the way and retract it to be able to get the glenoid bone block in. When you hear people say they didn't have labrum after they went to try to repair it, it's because they incarcerated the labrum when they put the bone block in. I can assure you. So you have to do that. Purse string suture placement is awesome. So whatever technique you want. Here I'm using one of the commercially available sutures, but this is going to be used not only for retraction, but for help in repairing your capsule labral reconstruction at the end. So two for one. Screw removal is the most awful thing on the planet for these, especially when they bend 45 degrees and have every single instrument in the operating room available because this may be the longest part of the operation. In fact, it often is. Interval excision. This is totally different from any other arthroscopic repair. You saw Julie show the finger test on the posterior bone block. I use the finger test on the anterior bone block. You have to be able to get that bone graft in. So it's very different. The Halifax portal. Thank you to Ivan. You can use these. These are from the hip scope set. These are the sleds that you can see. So we're going to put two of them in and this is going to help to dilate your passageway so that you don't get hung up. Once you've done all these other steps, you don't want this to hang you up when you just want to bring the bone block in and put the screws in. And the delivery device that you saw from Julie posteriorly is the same device we're using here anteriorly. Graft placement. So here we go. We're going to bring that graft in on the introducer and we're going to bring that in right to where you want. The only issue you have to really keep in mind is you have to get inferior enough because of the subscap. That's the one thing that you'll have to challenge. And you see right there I'm really pushing to get it at the inferior aspect. And then after that this is just drill and fill. So this device is beautiful. You can put two cannulated screws in and you can see we've got the switching stick from posterior to make sure we've been flush all the way along the way. And then capsule labor repair. We're going to just take the suture that we used in the beginning and I put it right between. We've marked where the midpoint is between your two screws. So we know exactly where we want to put the anchor and bring the capsule labral reconstruction back down. Now Ivan also showed you a superior anchor. You can also do inferior. Depends how elegant you want to be with your reconstruction. And then here he is three months post-op showing you that he's getting ready to try to dislocate a fourth time. So that's great. I mean you basically put all that cartilage in and then just covered it up though. I know it's kind of a very elegant procedure. It's a very elegant procedure where I did just cover up all the cartilage. I do acknowledge that. And Bill, in all seriousness I do want superior and inferior. But I mean there probably is some credence to that. It probably holds in really nicely and folds a nice capsule to help that heal in better on some level. You might be on to something. He's going to see Dr. Dickens in three years for his suture orthopathy. Is that all our time Brian? Thanks everybody. Thanks everyone. Great job. Appreciate it. Awesome job. We're going to transition to our innovations lecture moderated by Dr. Gittleman.

shoulder instability

surgical techniques

arthroscopic Bankart repair

patient selection

glenohumeral bone loss

glenoid reconstruction

distal tibia graft

glenoid augmentation

posterior shoulder instability

functional testing