Essek, thanks to our first set of debaters. We're gonna move on to the shoulder panel, so if we can get the instability panelists to come up. And I would like to invite President Tokic and Giovanni Di Giacomo to moderate the panel. Thank you so much. I'm grateful for you voting the remplissage, the winner on that one, only because it would have set a hell of a dangerous precedent if you show up with no slides and kick the hell out of the guy that you're debating. So, and Emilio, you damn near pulled it off, so that is, in fact, a flex well-played young man. It's my pleasure to introduce, this panel needs no introduction, but we're gonna talk a little bit about cases. We've got three of them that we're gonna go back and forth with, and I'd really like to welcome the mayor of Rome, Giovanni Di Giacomo, or as we learn, GDG. That's what they all call him out there. One of the slickest surgeons on the planet, and he's gonna take us through the first case. Giovanni, welcome, sir. Thank you very much. I really appreciate to stay here with you, my friends. These are two unusual case in my practice. It's very rare that I can see something like this. I presented two cases that I faced maybe four, five weeks ago, more or less in the same week. It's unusual because it's a traumatic subluxation. These are two different patients, and you can see that, of course, there is a bone loss that unusually, almost in my practice, is free, or it seems to be free into the glenohumeral joint. So my question to you will be how is important a free fragment, and how do you detect from where is the bone fragment? This is the first case. It's a male, 57. Just few weeks ago, he had a ski accident, and he referred subluxation to the shoulder. He came to me with this X-ray. So it seems very clear. According to Christian Gerben, there is a loss of the white sclerotic line that for me is very, very important. In X-ray, true AP, in my practice, is one of the key point when I face this kind of pathology. But you can see on the right side, posteriorly, there is a bone fragment that seems to be free. So what do you think about this from here to lateral? Gene? From where is the fragment for you in this case? Are you sure where the fragment is from the heads, from the glenoids, from other place, or you need some other image? I certainly wouldn't be sad to have additional imaging, because no, I wouldn't make a confident statement on this. Certainly the anterior inferior glenoid has compromised bone, but whether or not that's attritional I think is a little bit difficult. It's hard to imagine that that piece would be so free of tissue that it was able to go around posteriorly. So I'm worried that one, this isn't this guy's first injury, and two, that that could be coming off of the humerus as well. Okay, going on. Can help this axial view, please? If you give a look to this axial view CT and you see this posterior fragment, what do you think about this? Michael. I think it's most likely anterior glenoid defect that's migrated, but it could be posterior. Even when we do open procedures, we always look in the shoulder arthroscopically first, so we would have a pretty good idea from our arthroscopic exam, but I would definitely like to get more imaging and see in more detail what we're looking at. Please, go on. Always on the right side, please. Patrick, what do you think about this? The first thing I would have thought it was greater tuberosity. So I have to say, I've never seen this. This is really indeed from the anterior shoulder, so I would want an MRI to look at the cuff as well. So let the record show that Giovanni showed something that Patrick Denard has never seen. We are in rare waters, ladies and gentlemen. Rare waters. There is another issue always going on. You can see the tuberosity. There is a tuberosity fracture. This is our measure, of course, we always use to measure the glenoid tract. Just a fast message. I wrote a paper on the glenoid tract, but the glenoid tract, keep in mind, is a concept, is not a number. I cannot decide how to treat a patient 12 versus 13. For me, it's a mistake. The glenoid tract is a concept that we have to improve in the next years. Stop. Giovanni, you worried about posterior bone loss here? Your circle's funky. No, this is easy. So what do you think about this, Ivan? From where is the bone fragment? See, we got the smart guy and the drunk uncle up here, so we're just gonna keep doing this all day. So this is obviously worrisome. The CT, biggest thing, I see there's an MRI, but most of the information I think I can get from a CT, the MRI really looking at the capsule, you have a GT fracture that's not displaced. I don't think that plays anything into it, but when you have a CT, you can get the DICOM images and with free software, we can do the 3D segmentation as well as removing the humerus. That gives you a lot of information about what to go because if you look back on your sagittal views, we're already looking to see hisochromia is very low posteriorly. So this is gonna be a very tough operation if you're gonna treat this in one go, but this is one that I'd be very happy to go look at because with a loose fragment inside, we can do everything together to remove and then reconstruct and rebuild that foundation. So if you would treat this patient, for example, with lateral glucose, are you to make, for example, a bone block or to do a bunker repair, bunker remplisag, are you afraid of the lateral decubitus because the tuberosity fracture? No, so lateral decubitus, I don't think that it changes anything at all. We just have the arm in a balanced suspension, with the arm straight. We don't have any tension. We actually take the tension off with slight abduction on the arm. So I'm not really concerned with the tuberosity. This is the scope that I performed. The fragment was exactly between the cartilage of the humerus and the tuberosity, so it was not from the glenoid. The fragment was from the human head. This is another video. You can see very clear here the footprint of the fragment. If you click it around. Yeah. Exactly. And it's very, very unusual. So I decided to do what I do most of the time in this kind of rare patient. I did the scope to understand exactly from where the fragment, which is the next step. After removing the fragment, always from right to the left, please, what kind of treatment do you do in this patient? Do you stop and you wait? Do you do a bunker repair? Do you a bunker re-emphasize? Do you a bone block? Do you do a lateraje in this case? Or do you stop here and you speak with the patient and you wait to look what happened because he had only subluxation, first time subluxation? I think in a patient like this, who's 57, I would probably err on the side of taking that piece out, doing a little bit of debridement and letting him see how he does with non-operative treatment. Please, go on. Yeah, I think his age and activity would probably determine how aggressive he would be. But at his age, I would tend to do whatever I did arthroscopically and not subject him to an open procedure just because at his age, his recurrence risk is probably lower. So I would address the fragment and consider doing an arthroscopic Vanguard if he was at high risk. And I would think at his age, although the failure rate, in my opinion, of arthroscopic Vanguard is unacceptable in active populations that at his age, it would probably be a reasonable option and probably have a good outcome. Please, go on. I agree, I think you could excise the fragment as age and just go from there. Please, what do you think, Seth? I agree, I think that at age, I like what you said earlier, Pat, where you said above 35, Bankart and Remplisage is gonna get it done with most patients, even if there's bone loss. But I would let this guy chill out. I've been really impressed at how stable the 57-year-old or the above 50 patient with a dislocation gets. And there's a fair bit of stiffness in that group as opposed to a recurrent instability. So I would take the fragment out, let him heal, rehab him. If he's unstable, then Bankart, Remplisage. Especially the GT fracture is gonna be stiffer as well. So I guess I'll take a different take on this. If I look at his cartilage, it actually looks pretty good. I don't think he had any shoulder problems beforehand. You look at this on that axial view, that's a very large cartilage chunk. If you just try to take that out and just let him be, I think we're gonna condemn him to arthritis and he will get that next operation for a total shoulder. The other part is, is I do know we can take that out, replace it with a distal tibia, and be able to get him stable and then hopefully pain-free so we don't have to do another operation. John, what kind of treatment would you do? So at 57, with a fracture of this, I think you could make a case for doing nothing. Let him move early, protect the fracture. And if this becomes something that is mechanical later, it probably gets out into the periphery and you could leave it alone. I think for my first option, I'd do a reverse shoulder arthro, just kidding. You're in the wrong specialty day if you think that's a good option to go with. And that's the question, right? Can you fix this back? And this guy's got a big risk for stiffness. I do worry, I put him in lateral traction pretty good. So I think your point about the tuberosity, when we bring him up into traction, stretching on the cuff, I'd sure hate to feel a little pop when I put the traction on that bad boy. So that does make me a little nervous. But I think you can get him stable with a little limited, not a big shift, but a Bankart repair, excise the fragment and go on from there. Yeah, great case. Okay, anyway, this is the fragment. And because I was afraid of the Lennard-Bond loss, you can see on the left the magnification. I decided, I am very close friend of Emilio. I decided to perform Latage with the plate that we use that has a way to improve the contact bone to bone on the most medial part. And we do, of course, through the split. And we are very confident with the Latage. I perform more or less 2000 Latage in the last 15 years and the rate of complication in our hand is very, very low, is very far from 30 report in the literature. So this is our case, thank you. That's a great case. So this morning we've taken you through, we've taken you through no bone loss, a little bit of bone loss. Now we're gonna kind of get to the end of the road with this one. This is a patient of mine, a 31 year old female with a six year history of left shoulder instability. And the first thing I'd say is, Ivan, what do you think? Yeah. You noticed the x-rays, huh? Those look painful. Right, so this is the thing, right? We always say, because Gil Walsh's video says, just use a 34 screw. These are 34 screws. We know, those of you that have been here before, and we're all laughing with me and not at me, I hope, because you've been there too. You're all lying. We've all been there where you put that 34 and you get that post-operative x-ray and it looks a little bit like this. So sometimes the 34 isn't a 34. So just be a little careful. The other thing, Seth, is talk to me about where that bone is in the front. Well, I would say that I like the fact that it's low, but it looks a little bit medial. So this could be someone that could dislocate despite having had this procedure done. Over the top, yeah. And then we don't see, I'll show you a CT in a minute, but if you take a look here, we're not exactly seeing the most robust of bone blocks here, right? So this idea of osteolysis, and we can debate this about what the Latter Jay does and doesn't do versus bone blocks does and doesn't do, a little tricky. So she had, but in fairness, right? So for you arthroscopists out there, she did have a scoped Bankart in 2016, and this failed. She had a revision scoped Bankart in 2018, and that failed. And then she did revise to a Latter Jay in 2020, and while they are rare, she did have a musculoskeletal nerve, or a musculocutaneous nerve injury. It was 10 months, it did resolve, but 10 months, she couldn't flex her elbow. So she was pretty miserable, and you can understand pretty careful about this. And unfortunately, to Seth's point that we worry just a little bit about recurrent instability in this, maybe you could argue a technical point. I think this is funny, right? We oftentimes say, well, we shouldn't do Latter Jay because the complication rate's too high. And so therefore we shouldn't do them. And I think our European colleagues make a great point, the ISSACOS side of this, to say, no, it's the reason you have complications because you don't do them. You need to do more of them and then we won't have these complications. Giovanni, have you had nerve injury persist? Have you seen it? It is very rare, to be honest. Clinically, it's very rare. I never did a study with the EMG to see if there is some clinical, just maybe some transient. But the main complication that we have is some hematoma after the surgery. And we used to removing 3% of our patient, the plate and the skew, because they have some persistent pain around the shoulder. How many of you in the audience do rimplessage as part of your surgical armamentarium? How many of you? So the word has gotten out, right? So that's a 90% answer on that, I think is pretty good. Well, now she's got a chief complaint of pain and instability and a SANE score. And you can see, this is the typical procedure of these. And maybe, let me ask you, Pat, what makes you nervous about this one? A lot makes me nervous. Obviously, you have so many bone holes that the bone quality is gonna be a significant issue. And you also have the significant Hill-Sachs lesion. There's sublux, it looks like, on that axillary view. We need more views, but. Michael, thoughts? Yeah, what surprises me about this is that she's unstable, because a lot of times you'll see osteolysis, broken screws, no bone plug, and they're stable, which makes me question how the Latter-J really works. I think it's a poor man's Bankart, often, just a ball of scar in the front of the shoulder. Ladies and gentlemen, you heard it here first. The Latter-J is a poor man's Bankart, by Mike Pagnani. So I think this is a challenge, and she's got bone loss, and even radiographically appears to be unstable. So things start getting complicated. This might be the one patient in 1,000 that I actually think about doing a Latter-J on, because of the complex nature of the injury, but we just haven't found it necessary, as practitioners of open Bankart, to do Latter-J, because bone loss hasn't affected our outcomes, particularly glenoid bone loss. We have a slightly higher recurrence rate with large Hill-Sachs lesions, and we've actually been doing arthroscopic ramplissage in that population before we do the open Bankart, to try to get our recurrence rates down to the one or 2% that we have experienced. I should just point out who this is that's sitting in front of you, and why we pick him for the podium. So this is Mike Pagnani, and Mike has published several of the sentinel articles on the open Bankart. So while we argue about one millimeter and two millimeters, and a little bit of on-track, off-track, this is the guy that published the seminal articles on open Bankart, taking care of contact athletes, moderate bone loss, 2%, even in collegiate athletes. So this is a guy that we should be listening to an awful lot about what we do, and how we make our decisions in this regard. Now though- I'm glad we're not voting, because the opens haven't done so well. You just didn't give your slides yet. But as he mentioned, one of the risk factors, if you're an open surgeon, and I would love to claim to be an open surgeon as well, the one challenge with that, even if you go back to the row papers in 76, et cetera, the one risk factor that you have to be careful about, is that really, really big ill sex lesion, and hers is really long. Okay, so I showed you all this stuff. We talked about reasons for failure. Okay, now what? So now we get to the, the rubber's gonna meet the road. So Jean, let me ask you first, 31 year old female, failed three surgeries, including a Latergé. What's her surgery? So I think at this point, I don't trust her residual soft tissue. I think she clearly needs bone. I would do distal tibia allograft, and I would also do a rumpel sage. Michael, this one, I think this is gonna be really interesting. What do we do here? Yeah, I think I would, I would, she's already had her corcoid used, so I would probably consider some sort of glenoid allograft reconstruction for this case. Patrick, anything on the humeral side? Yeah, I think you would, I think you would consider it, because just the size. The other thing, I think, you know, Ivan really talks about this really nicely, is thinking about not just the fact that graft is medialized, but thinking about your contour, kind of restoring that, that shelf. But just not to get too dogmatic on the non-operative, you gotta be careful when people have recurrent instability, because sometimes they mistaken their instability for actually other issues, like just pain, or it's actually arthritis down the line, so you wanna ensure that that's really the case. Could I make a case for going in and just removing the screws and see how she did? If it was just pain, and they weren't apprehensive, I think you could, absolutely. Can you tell the difference in clinic, right? I bring her up here, and she's like, don't do that anymore. It's tough sometimes, it's tough. But I think you wanna entertain her. But here we are, so are you taking out her screws and stopping, or are you going and taking her down and pulling on it? No, I think in this one, I think she looked subluxed on that CT, so I think you're gonna assume she's unstable, so I would do both. Got it, Seth? Yeah, I agree. I mean, these are some of the toughest cases. The female's multiply operated, you start to suspect Ehlers-Danlos. She's probably got a bad Baden score. So in this case, two advantages here. Number one, she's got a little tiny coracoid that's healed at the bottom of her glenoid, and number two, the screws aren't broken. So take the screws out. I would do arthroscopic REM plasage first, then layer flat and do distal tibia allograft from the front. And I would soak the DTA and bone marrow. I would do everything I can to get this thing to heal, perhaps Forteo, because you don't wanna end up having to operate a fifth time. Yeah, either. Yeah, I think this is the trouble with Latter-day, but the only good part of this Latter-day is that you actually got bone healing. So that looks nice and solid immediately. It's actually gonna be partly out of the way for a distal tibial allograft, so it allows me to do it arthroscopically even better. The Halifax portal allowed me to take those screws out. Nice part is, was we're gonna get a distal tibial allograft with a conjoined sling. So this is one that I would love to save and show, because we'll have a sling on top. But that said, I am still concerned about multiple entries into this. I don't know what the capsule's like. We do know there's a large Hill Sachs, would put a Remplissage in there, but this is one that I actually would go even further on, because I agree, I don't wanna come back into this too. If the capsule's bad, I'll reconstruct the capsule and do an anterior capsule reconstruction at the same time. Okay, so everybody's open? No, all arthroscopic. All arthroscopic. Anybody else arthroscopic? Everybody else open? Yeah, so. Well, so I think I might be in the minority here. This is her case. And so this is one thing that I might say. So this is taking out her screws. We can take them out arthroscopically, especially as long as your angle is north and the Halifax portal has taught us that, Ivan's excellent work. I think one little trick with this is, don't try to take them out from the front because you can't connect it. So put that little K wire in. We're lucky because it's cannulated. Put the little K wire in. Then once it's close, take it out and pull it out from the back. Don't ask me how I know that. If you get it lost in the soft tissues, this becomes an open procedure. So in terms of little tricks in getting it out, that's the way. You can see her conjoined tendon right there. The bone is gone, conjoined tendon wise. And then you've got, now you have just a very large bone loss thing. Her cartilage is actually pretty good. This is the way that I do arthroscopic bone grafts. I use a flip cutter here to route the area. I use it as a router so that I can cut a flush cut. I think many times our geometry's off on the recipient side, not necessarily the donor side. So I like this double flip cutter that overlaps itself. So then we mark it with a little shot here. You can bring in your second drill and pop through. And then we will match that a little bit again with this flip cutter construct, back it up with a little router here. And now I've got hopefully a beautifully flush area here. The flip cutters, we need to make them just a little bit bigger so we can get a little thing. Then we use this standard portal that you are all used to using. We call this the Hulk because it's big and green. It's the mid glenoid portal, just like everything that you and I do already. So it's actually a fairly simple procedure. And bringing it in, and now here comes the big distal tibial allograft. This is 35% of her glenoid width. So you can put in very large allografts through these anterior portals, and then you can get this put down. And then I think some of the techniques that have been developed out there, Dr. Taverna's in the audience here today has really taught us about arthroscopic bone grafting with different grafts. This happens to be a distal tibial allograft. I've used autograft. There's xenograft options out there in that regard, and so you can take a look at this. And then I always add a remplissage. So this is our conversion. All I do is take it from the lateral position, and then I just bring the arm up into a abducted position, and then we protect it. We do this, I'll skip through this in the interest of time, but the secret is just being able to get through one skin, so I never go in the subacromial space. You accomplish your remplissage with your percutaneous stick through here, then it becomes two anchors, and then you just slam that down. So this is her three-month removal, screws, arthroscopic DTA, and you can see we put a massive bone on the front. Very happy with that, and I think Ivan was one of the ones that taught us how to do this in that regard, but he's also the one that scared the hell out of us because he told us that it's gonna resorb and remodel as that, so I did ask this woman to go ahead and get a six-month CT scan from where she's at. Now, fortunately for us, she's 14 months out with a Sena 95. She doesn't have apprehension and doesn't have further instability, so Ivan, let me just ask you now, in a year, is that gonna look significantly different? I don't have the data on that yet, so we just finished looking at the data on screws and when remodeling stops, and so we're actually very confident now with our numbers to show that remodeling with screws and allograft distal tibial frozen grafts is at seven months. We're just starting to look at our button data to know when it stops remodeling. Yeah, so seven months is about the remodeling time for this thing, so should we be getting CTs on everyone at six? Do you think it's at nine? What do you think? Or should we not? I mean, the cancer risk, et cetera, should we just leave well enough alone? I think cancer risk is so low that we're doing something new. Before advancing the field, it's our duty to be able to look at these and be able to tell patients what they're gonna be like and as well as other surgeons, so I would say at least nine months. Patrick, help me understand where you are in terms of the role between, you've done a lot of great work on Bankart-Remplissage and Latergé. Where's the sweet spot there? Tell us what the difference is between who you're gonna move over into the Latergé versus the Bankart-Remplissage. I think, again, it's an individual patient that you have to assess. If it's less than 15, it's basic, in a primary case, it's always gonna be Bankart-Remplissage to me. And do you ever do just the Bankart, or is it always a Remplissage? Almost never. Almost never. Over 25, first-time dislocation, I may consider, but otherwise, I'm adding Remplissage. If it's over 15% bone loss, I go case by case. If they're a 20-year-old football player, I'm gonna do a bone block type of procedure. If they are older, I'm gonna go Remplissage. Last question to you, Gene. So you've, Gene happens to be the chairman and sort of runs sports medicine in the U.S. military right now. She is the real deal, I'll just tell you, and has as much experience with instability as anyone in this audience. So in this young, active-duty population, which is your sweet spot now, when you have somebody with, let's call it, subcritical bone loss in a Hill Sachs, is it Latter-Jay, is it Bankart-Remplissage? That's a great question. I think part of it depends on what they do, right? So if it's a young- So if it's a Navy football player, lower activity level, et cetera, and if it's an Army- If it's an Air Force football player, then absolutely. Easy. You're getting a lesser operation, but that's for different reasons. So, no, I think that a lot of people in our population can do very well with the Bankart-Remplissage for that subcritical bone loss. Some of them also get incredibly nervous with that restructured anatomy piece, and I think that for some of our more consequence athletes, we get into that conversation of, if it fails, because nothing that we do is 100% successful, would we rather be having you fail and dealing with the broken hardware, or would we rather still have that open bone block augmentation procedure ready, and we kind of have a native plane for that? So I think in many cases, I do lean more towards Bankart-Remplissage in that population. That's awesome. Well, I think we're out of time. Thanks very much for an engaging discussion by all our panel. Thank you, Giovanni, for teaching us, and we'll move on to the next panel. Thanks. Thank you. Excellent panel with some very challenging, difficult cases.

shoulder instability

traumatic subluxation

bone fragment

treatment options

Bankart procedure

remplissage procedure