All right. Thank you very much. So I want to start by commending our military colleagues as much of the information that I discuss here is through their hard work, and so certainly very honored to be involved in this panel. So Kevin Farmer, University of Florida, these are my disclosures. Shoulder instability is very common. We all deal with it on a day-to-day basis, especially in contact athletes. 2005 NFL Combine, 14% of the athletes by the time they arrived that already had instability surgery. Having just come back from the Combine, I can assure you that number is much higher now. If you have an athlete that has a first-time dislocation or any patient of the first-time dislocation, who's at risk for recurrence? I think we see several things that come up time and time again. This study looking at a thousand patients, younger age, male, hyperlaxity. Again, this study looking at 15 level 1, level 2 studies, males threefold odds ratio. A male less than 18 has a 12 or 13 fold odds ratio with a nearly 80% recurrence risk. Taiwan, again, thousand dislocations, young age, male. Poland, male, younger age. Again, you see this kind of recurrent theme, males, younger age, contact athletes, higher risk for recurrence. NFL data shows that return to play after an instability event is 92%, but a 60 or 55% or 60% recurrence at about three weeks. College data, 45 athletes, 73% return after an instability event. Median day was five days, but a 65% recurrence rate. It's important to remember that you keep the plan. This study looking at addressing an in-season instability event with operative repair postseason found that if you convince yourself that if you make it through the season and you do well and decide not to fix it, there's a 60% recurrence the following season. But if you fix it afterwards and address it in the off-season, there's a 90% success rate. So it's important to not kind of assuage your plan that you made during the season. Is there a downside to waiting in that population? The answer is yes. This study looking at D1 athletes, 23 patients, found that after a first time dislocation, about a 7% bone loss, but that number jumped to 23% after a second dislocation. So there are downsides to waiting, and those need to be discussed with the patients, the families, the coaches, and the athletic trainers. If you decide you're going to move forward, what's the best surgical approach? We have some tools to use. This unfortunately labeled ISIS score, the instability severity index, looks at risk factors, but let's take this through a little trial here. So let's say an 18-year-old's high school football player walks in after an instability event, young age, contact athlete, you know, higher risk, their ISIS score is 5. If you look at the outcome studies, ISIS score less than 3, 94% success rate of bank cart repair, 4 to 6, it goes down to 86%, and less than 6, only about a 50% success rate with a bank cart repair. Again, this study, 300 patients, the ISIS score less than 2, very low recurrence rate, but an ISIS score of 3 to 4 is up to 36%. So these athletes, by definition, are already at high risk compared to normal population. We know that the outcomes are variable. This study out of Japan showed that 24% recurrence rate, but that number was less than 5% if the bone loss, sorry, 8% if the bone loss was less than 5%, and was up to 38% if bone loss was greater than 5%. We know through meta-analysis that we can get that recurrence rate down to about 8% if we kind of control the most highest risk factors. How much bone loss is too much, this is a moving target, but more and more data is coming out to show that less than what we previously thought, around 13.5% appears to be the inflection point for a good functional outcome. The idea of the glenoid track has sort of changed our approach. It makes us realize that the bone loss on both sides are additives. If you have bone loss on the glenoid and bone loss on the humeral side, the outcomes were basically a lot worse. So 8% failure with an on-track lesion for arthroscopic repair, and a 75% failure for an off-track lesion. If you look at systematic reviews, who's at risk for failing arthroscopic Bankart repair? Again, young age, contact athlete, bone loss, these are things that we see time and time again. ISIS score greater than six. The idea of a Bankart Plus has been kind of my approach to these high-risk athletes. In this case, you want to maximize the number of anterior anchors, maximize the spot welding. Certainly we know from Pasco below that greater than three is preferred. Four or five is my preference. The smaller the anchor, the better. I think that it minimizes your risk of fracture. You want to make sure you maximize that inferior to superior capsular shift. Obviously, based on their position and all these different aspects, that can lead to poor outcomes if it's a player that needs to maintain the range of motion, whereas somebody that maybe you're less concerned about, you can even do more of a capsular shift. I like the idea of including the posterior band in these high-risk athletes. I think this circle concept of the hammock approach to retighten both anteriorly and posteriorly are important. I think you should have a low threshold for a remplissage. Outcome studies show minimal loss of motion, minimal poor outcomes, but decreased recurrence rates in those athletes. Have a low threshold for a bone graft procedure in high-risk athletes. Again, showing good outcomes. So let's summarize. Who should we think about repairing? Males, younger age, contact athletes, hyperlaxity. Who should we think about a basic Bankart repair? Bone loss less than 13.5 percent, non-contact athlete, older patient, female, on-track lesion, ISIS less than three. Who should we do a Bankart plus? Bone loss 13.5 to 20 percent, contact athletes, age less than 20, males, off-track lesion, ISIS greater than three. And who should we do a bone graft procedure? Bone loss greater than 20, ISIS greater than six, and a severe off-track lesion. Thank you very much.

shoulder instability

management

contact athletes

recurrence risk

return to play rates