lively discussion on subcritical bone loss. Thanks. All right. Well, it's a pleasure to be up here, Gene, from our Army colleagues coming in a little bit late, but that's all right. So we have a really fantastic panel. As you can see here, Michael Fu from HSS, Corey Edgar, UConn, Gene Paskowski, San Antonio, and Joe Eichinger from South Carolina. So we're going to tackle subcritical bone loss, and we're going to have a little bit of a case discussion here, hopefully a lively one. So we're in Vegas. We can go ahead and get our betting odds out. And we're going to take a little bit of a different approach to this. We're going to have folks take a stand on their cases. They're going to tell us in two minutes or less, and we're going to time this, why they should want to do their particular procedure, and maybe why they would not do the opposing procedure. So this is our bracket. You can get your odds ready. And we're going to start with this case. So this is a 16-year-old high school junior football and track athlete. We're at the end of the football season. He's a defensive back, and he's had two years or two seasons of instability. He hasn't reported it and just had increasing instability this last season. He comes in after the season, three self-reduced dislocations, he describes, five subluxation events, apprehension positive, no mid-range instability. He's got a positive anterior load shift that's asymmetric from his contralateral side, no posterior clinical exam findings. And this is his imaging here. So we'll take a look at these. Hopefully they'll scroll through here. So sagittal and axial cuts here. From the panel, Joe, why don't you take this? Do you see anything here that concerns you? What is your initial thought? And then what might you do next with this imaging finding here? Well, clearly he's got some anterior glenoid bone loss, and I'm guessing that's somewhere around that critical number. So to me, this is something that I think doing a Latter-day is the way to go. When you think about what this kid is going to be doing with his arms as a defensive back, even if he's a player from UConn, he's going to get his arm in a position that's going to put him at risk again and again and again. So for me, this is a no-brainer. This is a Latter-day, all day, every day. Are you getting any imaging further than an MRI here? Would you be getting advanced axial imaging like a CT? What would be your next imaging sequence here, if any? You certainly can. I think that in reality, looking at this, he's going to be probably close. I don't see a big heel sack, so he's probably going to be an on-track lesion, I think, if you crunch all those numbers. So you could get the CT, but I think, for me, it would be a little bit of an academic exercise at this point, given all the other considerations we talked about in terms of the position he plays, the sport he participates in. So I don't think it's necessary, but certainly if you were on the fence about the approach you wanted to take, I wouldn't hesitate to get it otherwise. Corey, do UConn football players, do they get a CT in this situation? Absolutely. We're a state institution, so we spare no cost on our football players. Yeah, but I think a CT scan gives me a little bit more information as I'm going through my decision tree. So this is the CT, 3D reconstruction here. And we'll show you, you know, it's 9% glenoid bone loss. So on-track, if you measure it here, we'll just do that, 19.5, Hill-Sachs lesion is 13.8. So on-track, and not on here, but just to give you a little bit more data, quick math, if you were to look at the distance to dislocation that was described by Albert Lin and the group out of Pittsburgh, you know, just under 6 millimeters distance to dislocation. So Corey, open Bankart. Tell us why, what do you think, what should we be doing this, why are we doing this in this athlete? Yeah, I think this is a great example of somebody to strongly consider this. I mean, fortunately, at UConn, we know how to do open Bankart, so it's something that we have in our armamentarium outside of other places. So in our situation, I think with that athlete, one, you can address, it looked like there might be a little bit of residual bone that's there. So we typically still do it through subscap splits, you don't have to worry about that. He does have a little bit of patchlessness inferior, so we can carry that extension posterior. So the hope is that we can not only tighten the cap, so we can reduce some redundancy and stop some of that inferior shift. So we stop a little bit of that translation, but we're also able to restore the Bankart. And it's definitely a different repair, it's open, you're passing the suture, you can basically do a double repair. If there is any sort of bone stock that there that looked like might be in that CT scan, you can certainly incorporate that and maybe salvage a little bit of that glenoid. So I think for me, this is definitely a case for open Bankart. Wait a second, did I hear subscap split? Yeah. You're not taking down the subscap, is that how Bob taught you? Yes. Is that how he does it? Yeah, actually. Well, that's impressive, because I think trying to go through a subscap split for an open Bankart is pretty tough, but that's impressive. So it's inferior two-thirds, and you basically will take it down maybe a couple millimeters of the inferior part of the subscap, and you can- So you are taking it down. Less than 10%. Okay. So, Joe, Latter-Jay, why are we doing the Latter-Jay, or tell us, what are your tips and tricks with the Latter-Jay as well? Yeah, I mean, I think for me, it is a Latter-Jay just because of that bone loss. And like I said, the position this kid plays, and all those other factors that Kevin was talking about. I do like to split the subscap, though, for the Latter-Jay. I don't want to take down the subscap if I have to. I pretty much use the technique that Joe Walsh espouses. I spent some time with him, and I think that that's really the technique. I think I do an open Latter-Jay. For me, that's the go-to procedure for this. Any concerns about Latter-Jay in a contact collision athlete? I think Matt Provencher described a high rate of incoming NFL combine folks with Latter-Jays, screw complications, bone resorption, broken screws, screw back out. Does the type of sport or position of sport change how you might be thinking about this? Yeah, certainly you have to be careful of over-tightening somebody, but you can over-tighten somebody doing any procedure. I think with the Latter-Jay, obviously, it's technically challenging, and you have to do a good job with it. Obviously, there's complications associated with it, and so it has to be done well. You have to make sure that whatever screws you use, you've got to make sure you get that graft compressed. I mean, that's critical, and you've got to get that thing to heal. If it doesn't, then you're going to have problems, for sure. And for the audience, feel free. You guys can come up at this point. We have plenty of questions that we have for our panel, but we want to make sure that we get the audience questions as well, so come on up to the mics, and we'll get your questions in here. Corey, for these patients, open bank heart, do you worry about bone loss? I mean, why not do a Latter-Jay if they have bone loss? Is an open bank heart sufficient? What's our evidence here? Yeah, so I think, obviously, if you're getting towards the 20% or an off-track, larger heel it may not be enough. I think, I certainly agree with Joe, I'd switch over towards the Latter-Jay, and I typically do it open. Also, I think, really, the issue is, if this does go on to failure, you still have options. I also think that in a contact athlete, you're worried about injury and screw breakage or pull-out, I think, so there's some options there. I think you do have the ability to tighten them up, and the open bank heart, as Bob has shown, is just a different procedure than the arthroscopic bank heart, which I wouldn't even consider in this athlete. Great. Okay. And then, why don't we go down, Travis, down at the end there. What do you think about maybe a different approach? Would you consider something like a arthroscopic bank heart and REM plissage in this patient? Is that another option for us? I think it's an option. I think in the setting of a contact athlete, though, with a high-functioning football player, you have to really consider and be careful with your options at that point. Okay. All right. So, quick survey from the panel. Open bank heart for this patient. Who's doing an open bank heart from the panel? Corey. All right. Who does open bank hearts from the panel? All right. And who's doing a laterge for the panel from this patient? From the audience. This patient. Open bank heart? So about a third. Laterge? About a third. Undecided. So still out there. Still unknown. All right. So this is him. So this is a 16-year-old. And he's now 8 weeks. And this is his motion. So probably non-compliant, probably very non-compliant. That's his motion. And he wants to go back to sports. So he's 8 weeks. He wants to start track season is coming up. And he wants to start track. Who's from the panel? How are we making return-to-sport decisions? Kevin, you take care of Florida and see a lot of athletes. What goes into your kind of algorithm or thought process for when we return these patients to sport? What are you looking for? Well, certainly time is important, minimum four months typically, ideally six if you can push it. But that's often hard with the way seasons kind of unfold. We often do a biodex to try to look at strength symmetry, obviously negative apprehension. And then imaging, in this case, making sure you're I wouldn't necessarily get a CT scan, but x-rays, making sure you feel like that things are healed. You could probably with the latter, Jay, push it a little bit earlier than four months. But for me, a bank card typically is minimum four months. Are you getting a CT scan in these folks? Should I get a CT scan, a repeat CT scan in the 16-year-old now? I would not personally, long clinically they're doing well. I would not because often I find that I get information that becomes very challenging to deal with. If he's doing great and it's 40% healed, I mean, how do I use that information at that point? So I would not get it unless there's an issue. Okay. Jean, what do you think about return to sport testing? Should any thoughts or criteria that you use or like to look at? So I agree with the rest of the panel in terms of imaging and clinical exam. But I think in this case, if he's trying to go back to the track season, I think it also depends on what part of the track season is this guy running 100-meter hurdles, is he doing the pole vault? And so if he's otherwise doing okay, I might let this guy go back to running activities but maybe not necessarily field events just yet. Joe, for you, what do you think about if we have to push this patient, want them to get back to or have something they want to get back to, does that change your thought process about the type of surgery you might guide this patient towards? Open bank cart, RIMPLISAGE or LATERGÉ? I think if time is of the essence, I think the LATERGÉ is probably the quickest to come back from because once the bone heals, I think you can really sort of push it. And so if time is a consideration like that, then I think the LATERGÉ is probably the ideal operation. All right. Great. All right. So this is our next patient. So this is an 82nd Airborne, 21-year-old, wants to go to Ranger School in five and a half months. He's had dislocations starting in high school. So a wrestler in high school was his first instability event. He's continued through the military, no surgeries. Most recent event, two months ago. He's not going to get through Ranger School. He comes in and he needs to get this fixed, and he's got a time-sensitive nature to it. His anterior apprehension, 2-plus load shift, no mid-range instability, no posterior symptoms. And here's his MRI findings, and we'll see if we can get both of these to go through here. A little bit fast, but Michael, what do you think? What do you think about this, the imaging here on MRI? Are you getting anything else after this MRI, or do you have enough to make your decision on what to do? Yeah. I mean, I think the bone loss on this MRI, at least, is less than the first case, but the Hill Sachs appears to be a little more prominent. I do get a CT with 3D reconstruction for most of my instability patients. Any cutoff for that? What makes you decide, I'm going to get a CT scan based on your MRI? If I'm worried about the degree of bone loss, and I want to get a more accurate measurement, and to get a better assessment of the Hill Sachs interval and the glenoid track. OK. All right. So here's his CT scan. I don't have the 3D recons for you, in the interest of time. Here's where he is. So he has glenoid bone loss of 10%. His glenoid track, 20.9, Hill Sachs interval, 19.6. So in this case, bigger Hill Sachs lesion, still on track, distance to dislocation, essentially 1. So panel, Jean, Latter-J, tell us, why are we doing a Latter-J in this patient? Yeah. So I think this is our most high-risk patient right here. We have a young male who's active duty, wants to go into airborne ranger operations. So I really can't think of a more dangerous occupation than all of that for shoulder instability. And so while that glenoid bone loss is very minimal, the Hill Sachs lesion is relatively large. I think just based on what this individual wants to do, I really have to think of those consequences. So, you know, Bankart-Remplisage, clearly versus an isolated arthroscopic Bankart, we know that the Latter-J is going to have decreased risk of recurrence, probably better functional outcomes and patient-reported outcomes. Bankart-Remplisage may be a little bit less clear in terms of that comparison. But my concern with this guy is, if I do something less than that Latter-J, and I put him out the back of an airplane, and anything goes wrong with that, then that's not just him losing a scholarship or his inability to play, and not to downplay those things. But this is that guy potentially dying on that operation or having such a severe injury that he has to be evacuated by his teammates off of the landing zone, which then also puts these other people at risk. So in my hands, I think just with this patient's circumstances and those particular imaging findings, this is a Latter-J. Okay. Michael. Bankart-Remplisage. Yeah. This is a great case because there's so many different options. So I would go with a Bankart-Remplisage for a few reasons. So number one is, as we know, Latter-J is a technically challenging surgery. So there's a potential for some real complications like neurovascular injury, infection, hardware issues, graft resorption. And so generally for me, Latter-J is reserved for revision cases or cases with a little more bone loss. In addition, we know that patients that have recurrent instability are already predisposed to developing arthritis in the future. So this patient, there's a not insignificant risk that he's going to need arthroplasty someday. And so as you can imagine, arthroplasty in the setting of previous Latter-J is very challenging due to scarring, altered anatomy, hardware. And there's a paper in JSCS in 2018 by Dr. Sanchez-Sotelo that demonstrated that arthroplasty in the setting of a previous Latter-J or Bristow has a 30% revision rate. So you're taking a surgery or shoulder arthroplasty that's very reliable and predictable and turning it into something that might have a much higher revision rate than average. And then finally, there's a lot of data coming out to your point in the last year or two looking at Bancart remplissage versus Latter-J demonstrating similar outcomes and redislocation rates. Obviously, longer-term follow-up is needed. And the paper you referenced earlier from Albert Lin demonstrated that patients that are technically on track but are near track are still a significantly higher risk for redislocation. So for me, the decision of whether or not to add a remplissage is not strictly based on on-track, off-track, but more of a general gestalt of the patient's risk factors. So based on all those reasons, I would do a scope Bancart remplissage for him. So we talk about doing a Bancart plus, getting a good number of anchors in there, a posterior inferior anchor. Do you worry about anything doing that with posterior inferior labral repair and a remplissage? Are you doing both of those? Are there any concerns there? Is it one or the other for you? What's the thought process there? It's not one or the other, actually. So for higher-risk patients or if they have a more lax EUA, I will add a 7 o'clock portal and do a posterior inferior anchor. And then I do like the more modern anchors that are sub-2 millimeter in size, and I'll do four or five in the anterior inferior labrum. And then with respect to the remplissage, in terms of the concern for overtightening, I do watch out for not over-medializing where I put those anchors in through the posterior capsule and the infraspinatus. So there's some data looking at sort of the safe zone, so making sure lateral enough to not be in the muscle but in the tendinous portion of the infraspinatus so as not to over-tighten them. Great. Dr. Rodia. For the panelists that want to do a LIDER-J with 9 or 10% glenobone loss, I'd be interested in your thoughts. I know some data demonstrating resorption of your bone if you don't have much bone to replace. That may be a reason for some of the screw complications. So that's one thought. The other is, how about an open bank cart with arthroscopic remplissage here? Yeah. Great. So, Corey, are you doing open bank carts and a remplissage? Why don't you tackle that one? No, I think that's a great comment. And it's not that bad, especially with some techniques out there for the remplissage. You can certainly start with the scope, put the anchors, you don't tie them down, you do your open bank cart, and then you tie them at the end. So I think, you know, this is definitely somebody, if I was going to do an open bank cart, I agree with Dr. Rodia, that's something that won't take you that long. You scope it first, you put that in the back, and then you go do your open bank cart. So I think that's a great option here. Great. Thank you for our panel. Great discussion. And we'll turn it over back to our moderators.

subcritical bone loss

shoulder instability

treatment options

Latarjet procedure

open Bankart repair