All right, I'm going to ask the next panel to come up. As Janet said, Dr. Tokash is a little-known story about how he got into the Army. Well, we found out from John that there was very specific and rigorous PT tests that he had to pass. And he failed the Air Force test, but I guess we found out that the Army test was OK. So we're glad to welcome him to the Army. Appreciate it. What an honor to be here, and congratulations, Jim and Ken, as well as Michael and Scott. What a great program today. We're going to talk a little bit about when it all goes wrong in this critical bone loss issues. The disclosures are available for all of the panel in there, but this is an intimidating topic for us, many of us. But this group is not intimidated. We got Seth Gamrat. He's used to being on television. He's got his own weekly show. He's so good looking that LA media can't get enough of this guy. Rachel, she operates so fast, she's got to wear Breathe Right strips when she goes to keep all the oxygen going in there. Ivan's already solved this problem, and he's just shocked that we're even talking about this. Why don't we just end this discussion already, because he's already got it. And then Mike Freehill was supposed to be here, didn't make it. But professional baseball player and pinup model is going to add his steely-eyed perspective with this. So we're going to get after it. This is first cases. We got three of them to try to get through here. This is a 17-year-old, plays junior hockey, has had three dislocations, had a scoped bank cart. He re-dislocated at nine months. He was sent to me after four more dislocations, but now hockey season's over, and says, fix me, and I need to get back to play next season. Seth, tell us, this is a quick view of the x-rays. Obviously, we'll give you more imaging, but do you see anything here that's a little concerning? Yeah, two things I don't like about this x-ray. Number one, you can see the Hill-Sax deformity on the AP image. And number two, you can't really see it that well on the axillary lateral, but you lose the contour of the anterior glenoid rim on the AP. Yep, additional imaging, Rach? Yes, by the way, I'm sorry for sending this patient to you. Sorry for setting you up for success here. Yeah, additional imaging in my hands. This is a CT with thin cuts, reconstruction views, as well as an MRI. Okay, so we do get the CT scan, and this is what we get just in the interest of time. Show you the money views here, if you will. There's a bony fragment. This is critical bone loss at 25%, but there's a retained fragment. So, Ivan, what are we gonna do with this? Yeah, this has been multiply operated on. I'm really worried about the healing potential for that bone fragment, so to me, I'm looking at more of a bone grafting procedure. Travis, if this is an early dislocator and a cadet up at the Air Force Academy, and you've got this bony fragment preventer, and Maddie has shown us that you can incorporate this fragment, any role for that in this guy? In the multiply operated on patient, I don't believe. No, if it's the first time, though. I think that in that situation, You might throw it down. Incorporate the bone, yes. Jen, do you trust this bone fragment? Is it gonna heal? Are you expecting this to be soft? Is this something that we can go into and probe and see, and if it feels good when you're in there, can you go ahead and incorporate this and go, are we stuck going elsewhere? I'm gonna use more of a timeline, so depending on how far out he is from injury, this is several months, six months plus. I'm gonna ignore the piece, and I'm gonna move forward to a different procedure. Okay, well, so we did wanna calculate a glenoid track, and so rather than go through it, I'll tell you the track was about 17, but then take a look at this Hill-Sachs lesion, right? So you don't see that on, even on the CT, and sometimes the MRI shows you a little bit more about this. His Hill-Sachs lesion is 26, so we've gotta get this thing. In order to restore it, we need 10 millimeters back. So, Rachel, what are you gonna do? I'm augmenting with a bone block. I don't think, I think even if that bone, and I love arthroscopic revision repair, but I think in this case, the sport that he plays, this is a bone block in my hands, and in terms of choice of bone block, I think I would do a Latter-Jay, and I would ignore the Hill-Sachs. I just wanna push you a little bit. You said you love arthroscopic revision repair. John Dickens' group published this month an arthroscopy of 44% failure rate with arthroscopic revision repair. What are you loving about it? Look, so if the first surgery was done poorly, I like the opportunity to go back in and fix that if there's viable tissue, especially if there's bony fragments. In this case, with his risk factors for recurrence, even though I love, I should say I love arthroscopy. I love the ability to go in and fix things arthroscopically, but in this case, this, you know, I don't, it's hard to say how the first surgery was done, but I would say that this is a bone block. I mean, this, and you can pick your bone block, but this is a bone block. Seth, in your hands, Latter-Jay, bone block, open bank cart, what are you gonna do? Definitely a Latter-Jay in my hands. Latter-Jay. I like autographed. I like that it's vascularized. I like the sling effect. Yeah, so Ivan is, here's a good question then. Can the defect be too big for the Latter-Jay? Oh, so for me, I think lots of things can be too big for the Latter-Jay. Yeah. Lots of different reasons that I would move on to a bone block, and I agree with the whole idea of arthroscopy. My preference always is to do arthroscopically, whether you're gonna do a bone block with a distal tibia or other type of holograph versus a coracoid. Yeah, it's interesting. You know, there is data out there. The first one, Peter Millett, up in Vail, showed us that when he would do it, he went back and looked at it, and some of his Latter-Jays, he was not able to restore the on-track status. So you'd look and you'd say, well, that's okay. I'm gonna do it because it has this beautiful sling effect and everything else, but unfortunately, in those cases where he couldn't restore it back to the on-track status, his instability revision was four times. Emilio Calvo looked at this, a brilliant surgeon from Spain, who does this arthroscopically, and what he found was that if your distance to dislocation is greater than seven and a half, you're not gonna convert this back to an on-track lesion, and if you don't convert it back to an off-track lesion, you're gonna have a 33% failure rate with that Latter-Jay, so tricky. So in my case, we're gonna breeze through this a little bit, but this is my sort of approach on a bone model, if you will. I take this and we'll drill pins through here, standard equipment that we use, and I use a little kind of a flip cutter technology here, and the reason is I think we have to prepare the recipient site and get that flush, and if you use these two flip cutters, it will allow you to create these intersecting circles, making a big oval to be able to get a really flush cut on the front side of that glenoid. Once you've done that, we take advantage of some of the knotless technologies and cables. This is us passing, or this is the idea of what we're hoping this will look like in surgery, and so then you can kind of crank this guy down and get yourself a bone block that would then kind of restore it and be able to restore any size bone defect that you have. This is what it looks like in this particular patient, so we put a little traction stitch in here. I've sped this up just a little bit to Rachel Frank speed here, and I put a little opening in the back of the capsule back here. I use a standard offset guide, Latter-Jay offset guide here. From the back, we drill our two pins. Once they get in, we've got our drill. There's that flip cutter that I showed you earlier. The first one's done, and we mark our spot. Now we're bringing in the second one. This is so that we can get an absolute flush cut on this area, if you will. There, now we're flush. Once we've done that now, we've gotta just prepare our graft. I'm pretty graft agnostic. I don't really care which one you use, but it needs to be big, and in this case, I want some cartilage, so I think distal tibia is great. It's gotta fit through that big cannula. We soak it in a little PRP, and so now we're coming back in. That's that big cannula. Now it's simple, because now we've got it all prepared. We simply take a stitch from the bottom, stitch from the top, loop that, retrograde past those FibroTac tails, and then through this large cannula, you can see that we can bring the bone down. Then you gotta fiddle around with it, tighten it down, and then kinda cover it up. This is what he looked like. So his three-month CT scan, so Ivan's shown us that we should be a little bit nervous about patients who have soft tissue or FibroTac buttons or the like with this. At three months, I'm pretty happy with this, but Ivan, you've got reason to believe that I shouldn't be so happy about this, yeah? So I agree, that looks fantastic. I love the three-month view. This looks like it's healing nicely in there. The only thing I'm looking at is, you can still see most of that structure is cortex on the sagittal view. The coronal looks fantastic. Or sorry, the axial looks fantastic. That's actually the view you wanna see. Once you start getting remodeling, where you get that triangular formation, then you know that things are going the way you want. So this looks great. My only concern with doing things like this with a all-suture or a suspensory type of fixation is trying to get that angle formation. Philip Marauder talks about this critical size, so not just anterior to posterior, but medial to lateral. You wanna get about a four-millimeter depth of the glenoid to recreate that anterior lip. And if we don't get that, whether we get it too much, so for screws, that's the difficulty, is getting it too much, and you have too much of an acute angle, it will wear out. If you get it too little, and using suspensory fixation, I have a very difficult time controlling that, that will also go away. Is this gonna remodel to where it's gonna fail down the road, though? If I get another CT at 15 months or something like that, is it gonna look like hell? It's okay to be honest. I'm concerned. Yeah, so he's published this paper, very concerning, but guess what? He returns to hockey, 40-plus games. He says he's perfect, so I'm the man until game 45. And then he gets hit in the back, and dislocates again, so I get new imaging. And this is what's really interesting. This is his new imaging. The radiologist says the glenoid is, quote, normal without bone loss. So it did its job, and yet he failed anyway. But he's still got that big heel-sax lesion, so Jen, now what? Now I'd go to a Latter-Jay. Now you're gonna do a Latter-Jay with this one? Even though there's really no bone loss here, Travis, same thing? Yeah, Latter-Jay with you guys. So, Rach, we got this, but here's the problem. We've got a Latter-Jay. We can probably put him back to on-track, but there's now that big issue here. Should we remplisage him, Latter-J, bone graft? How are you gonna fix this? Quick question. Why not consider the remplisage at the first case? Even though you fixed the track, you got him under 10. Is there any downside in that case? No, this was early on in my bone grafting arthroscopic deals, and I did not remplisage him. I think now every single one of these gets a remplisage from me, and it's arthroscopic, so you're already there. You're already there. I don't know about you, but maybe I should've done that. So, I'm with Jen on this one. This guy gets a revision with a Latter-J and remplisage, which is reported in the literature, but not terribly high. Okay, let's move on now. We've gone from the junior Varsity case. Now we're going to the Varsity case. This is our 31-year-old female, Seth. Somebody was smart enough, took your advice, and did this gal's Latter-J. She has a six-year history. She failed a scope Bankart back in 16. She failed a revision scope Bankart back in 18. She had the Latter-J back in 2020 outside. She had a musculocutaneous nerve injury, so she couldn't flex her elbow for 10 months. It did come back. So, for all of you Latter-J proficionados out there that say, don't worry about the nerve injury, I guess you don't have to, because it came back, but it was a year where her arm was flaccid. Okay, so now 2021, she has recurrent instability, and she comes to see me now with pain and instability. Her SANE score's 20. What do we do? Well, these cases are really difficult, because she's already failed three operations, and you could probably criticize those screws a little bit, but I worry in this case. For being too short? I, yeah, I worry in this case about some sort of a hyper laxity situation. So, obviously, we need some three-dimensional imaging, but you start thinking about, you know, revision DTA with a remplisage. This was her before the Latter-J, Rach, and then this is her CT scan after her Latter-J. So, this is where we are currently, and she's got a 22-millimeter Hill-Sachs lesion, and she's got about 18% glenoid bone loss. We talked a little bit about these reasons for failure. So, let's go back here. Now what? Yeah, I'm sorry you keep getting all my failures again. JV surgeon for a varsity panel here. This is a tough scenario. I don't love the look of that glenoid. Obviously, the screws make this even more difficult. One of the screws maybe looked a little bit bent, which can make taking this out when you do your revision a bit difficult. I think you need revision bone graft augmentation, and with that Hill-Sachs defect, I'd probably go on both sides. Seth, are we doing this arthroscopically, you doing this open, getting the screws out? Are there tips that we can do this arthroscopically, or is this an open procedure? Yeah, for me, it's an open procedure. I would do the remplisage first arthroscopically, not tie the knots, then go open, take out the screws, revise it with a DTA. So that would have been smart on my part. I didn't follow that exact advice, but I will say there are some things about screws. I think they can be challenging. This is doing it arthroscopically. We're lucky these are cannulated screws. One tip, if you're gonna take these out arthroscopically, take the screw out, get it done, and then don't try to take it out the front because you don't have anything connecting the screwdriver to the screw, and you're gonna lose it in the front. Don't ask me how I know that. So better off to take the screw this way like this, and when you get close, watch, I'll bring a little kingfisher in. When you get close, use the kingfisher to pull the screw right into the joint, and then take it out the back portal, and you never lose sight of this. So in this particular patient, there we start. There's her conjoined tendon from the old Laterge. That's still hanging in, but the bone's still gone. You can see about 35% bone loss on her once we get started, and then I used a similar technique with flip cutters that we talked about here. You gotta go through a whole bunch of stuff, and then in the interest of time, I'll just show you what she looks like post-operatively. This is her three-month arthroscopic, after an arthro DTA, and we've been able to kind of restore that, and you can see this is a big bone block in this case, and so Ivan's points about remodeling and everything. This is fresh. Maybe that's different. Maybe it's not, but I am concerned. We're not using, quote, rigid fixation because of these things, so that's a little tricky, and you can see that's a pretty massive bone block. I did, I was nervous enough about her that we brought her back at six months. This is her six-month CT scan, and you can see for this patient, she has not remodeled. We're in pretty good shape in that regard, and then if we take a look from here now, she's 15 months out or 14 months out, SANE score 95, so so far so good, but I'm nervous about this, as Ivan says with that, so I think those are a couple of examples of really bad ones. We're not gonna have time to get into the third one, but just to introduce this kind of case, this is where it goes from the ridiculous to the sublime. You've got a 25-year-old female, grand mal surgeries two to three times a year or a month, 44% glenoid bone loss, but I think this is an option, so just to kind of talk to the panel here just a little bit, maybe I can ask you, Seth, what do you do here? Well, I think the key in this patient is getting good seizure control. They gotta be seizure-free, and then you hit them with your best operation. So first of all, is that a lie? Because every one of these kids lie to us, right? Oh yeah, my seizures are in good control, right, and you do it, and then pretty soon, next thing you know, they seize again. So I'm not sure that even exists. That's like a unicorn thing for me. In this person's case, she's in-house, and she's got no insurance, so they say, look, while she's in-house, you can operate on her. So I'm like, well, I don't wanna put screws in her. I don't wanna do something, because we got a problem. That's her bone block, and it's on the right side of your screen. It's more bone graft than she has it, so we add a little cargo netting to a similar technique, and I'm pretty happy about the way it comes out here, if you will, but of course, then post-op day number one, she has a grand mal seizure while she's in-house. Now, right now, I'm like, well, thank God, at least I didn't put screws in her, because they'd be broken, and now we got a problem, and so we get a CT scan, and you can see her CT scan on post-op day one. It's hanging in there. Now, none of us look at that bone block. It's huge, and you look at it, and you go, well, it's staying, it's hanging in there in good place, but I'd sure love rigid fixation across that. Ivan, what do you think? Absolutely. So, we have had a few seizure patients that we did screw fixation on. I'm very happy that we didn't use a coracoid for that to pull it off, because they have survived the early seizure. So, and the screws hold tight if they have seizures afterwards, so there's something to be said about that, but broken screws. This is her at six months. You can see she's leveled out and remodeled just a little bit. Her seizures are under better control. She seized a few times since surgery, but has not had her shoulder come out. She feels like she's functional. She's unable to follow up with us at this point, but she said, don't worry, because my other side's just as bad, and I'll come back to the ER when the other one comes out. So, I think a couple of examples. I think we're out of time. In the interest of time, we'll move on. I want to thank the panel very much, and wish you all the best of luck on your instability journey. Thank you.

shoulder instability

panel discussion

medical professionals

cases

Dr. Tokash