Thank you very much. I'd like to thank John Kelly. Terrific program this morning. Thanks for making me give the open bank card in a room full of arthroscopists, so I'll do my best to defend it. I guess my job here this morning is to scare the hell out of everybody, because I'm actually going to talk about the science and the data that compares open and arthroscopic bank cards, and I think that we have to be a little bit careful about having one size hammer that fits the whole world's nails. My disclosures are available in the book. So if we take a look at the incidents and sort of what you guys are all doing out there, we all leave these meetings and everybody goes, yeah, bone loss, I do a Latter-Jay. I do an open bank card whenever. And then you all go home and you do arthroscopic bank cards. And the problem is, is 18 months later, a number of those things fail, because we're not paying attention to the literature and the data that's out there. Over 90% of stabilizations were done arthroscopically by 2009, and that continues to rise. But the results of the arthroscopic bank card may not be what they appear to be, at least in the populations that we're looking after. So let me just tell you. It's a little bit like, for me, like the siren song. When you begin just out of training, the arthroscopic bank card is absolutely irresistible. You have to tie yourself to the mass not to want to do it. It's slick, it's easy, it's open, it's very quick, and it's awesome. And the problem with that is for orthopedic surgeons in the U.S. is that we are, it's like catnip for us. We can't get it. And then about, you know, first couple years out in training, you're living in ignorance, ignorant blissfulness. It's just amazing. You never have one fail. I remember going home and telling my wife, I had been 18 months in practice. I had not had a single arthroscopic bank card failure. And then I went to work the next Monday and I had three of them. And I came home and I said, listen, if I ever come home and tell you I got something figured out again, I want you to kick me in the crotch. And she's been doing it every week for the last 20 years. Amazing. The problem with the arthroscopic bank card is that as you get more experience and as you read the literature, it often will leave you like this photo, abandoned and drowning. It's super alluring at the completion of your training. Great operation. It satisfies almost every need that you have, whether you are a big fan of K-pop or J-Lo. Either way, you think it works in all cases. But if we take a look at the level one data that's out there, and this is excluding the bone loss and just talking about what we're going to see off the street. Open versus arthroscopic bank card by Nick Mattotti and the group up in Canada, 23% recurrence rate with the scope, 11% with the open. And it doesn't get any better if you take a look across the literature. So if we take a look at scope bank card recurrence in young athletes, collision athletes in particular, you're looking at failure rates at around 35% and the average across the board is one in four. None of us want that. If you take a look at comparing open bank card versus arthroscopic in the literature and then analysis, this comes to us from Lenters, JBJS 2007, less recurrence, less re-operation, better return to work, better return to sport. Josh Harris gave us this from 2013 showing that revision surgery, don't miss this, revision surgery, if you follow these up long term, arthroscopic surgery, 57% open, 19%. So after reading the literature a little bit deeper, you gain some experience. The siren begins to lose his or her allure just a little bit. You're a little less enamored with it. It's still hot, but not really exactly what you're looking for anymore. And that was with all comers. What about populations where it matters in, like the contact athlete? Well, two great studies in the literature, Cho and Rhee, both showed us that if you take a look at contact athletes, that the arthroscopic rate of failure is much higher and if you compare it to versus open, it's often triple the rate of recurrence. But the siren sings on. In fact, some of the sirens sitting in this audience singing about new words like remplissage. But just be careful when you read the remplissage literature. Take a look at Boileau, outstanding surgeon, does this operation very well. Only 68% of his patients return to sport. If you look at Berlakis, Kesta from 2014, only 71% got back the same level. Even the right reverend John Kelly himself, probably the biggest proponent of remplissage in the US, when he published his data, he had a very low recurrence rate, but only 50% of his patients returned to football and baseball and 69% to basketball. It's not where we want to be. I remember doing an international forum and so just to understand, there's different perspectives out there. So I had R. Ciero on the panel, I had Laurent Lafosse, and I had Giovanni DiGiacomo, and I asked him, what are your indications for remplissage? This is just within the last few years. R. Ciero, none. DiGiacomo, Nusuno. Lafosse, none. They don't do it at all. So just to understand that while we jump on this, and here's again the problem, it's slick, it's easy, it's fast, you look cool doing it, and that's irresistible for us as American surgeons. Contrast to this in the open Bankart and the athlete and look at Pagnani's results, 103 patients, you say, well that may be not collision athletes. Yeah, 85% of his patients were collision athletes. 84% of them had a heel sax, and they had on average around 14% bone loss, so the subcritical bone loss that we're worried about, and found out at 103 patients, only two recurrences. So when should we do an arthroscopic Bankart? You're familiar with the ISIS score as well. When Pascal originally published this, he said if you had greater than six, you had a 70% failure. But if you take a look at more recent data, AJSM 2019, hot off the presses, an acceptable ISIS was considered two, 10%. If your ISIS was three or four, so this isn't big bone loss, this is just being under 20 in a contact athlete, their recurrence rate was 36%. So I said to the French, I said, well wait a minute, that means that anybody who comes through the door is going to get a Latter Jay, and they said, oui. So if we take a look at this, the siren begins to show her true appearance, this is what Kelly looks like from a podium when you're actually talking about literature, he gets all constipated, he gets all weird, but what you learn when you look at this stuff is that the open surgery, we've lost this as an art, and this is my plea to you, it's okay if you want to do an arthroscopic Bankart based upon the indications, but let's not forget what our masters have taught us over the years about doing a good arthroscopic Bankart. But still the siren sings on. It says, somebody may say, well it may do fine, and even if it does fail, you can always get a do-over and do a revision, but the truth is there are real consequences to failures of Bankarts, and some things you just can't do over. The results of resigent stabilization, 25% failure rate. So in summary, arthroscopic Bankarts can be a siren song in the treatment of instability. Indications should be more narrow than are out there, be careful in the young athlete, bone loss and revisions. Please don't do an arthroscopic Bankart because that's the only trick you know. Learn them all and apply them appropriately, and remember that the calmest waters aren't always the best seas. Thank you very much.

arthroscopic Bankart procedures

failure rates

remplissage

literature

treating instability