Thank you, Lou and J.K. and the program committee for inviting me. My mandate is to talk about the bank card, and we're going to try to make it great again. And this is my, let me see here, my disclosure. So we know the modern suture anchor technique has a few problems. These are some of the recurrence rates posted over the past decade, and you can see a Ferguson study out of the U.K. had a 51% recurrence rate. These numbers are probably unacceptable to any of us. However, I think we don't want to go to the new ISIS score from Europe, which is if you have a Pulse speak French, spell croissant, or you know someone who once played rugby, you get a Latter-day. I think we want to avoid that if at all possible. So perhaps we can go back to the bank card. So critical step patient selection, and it's pretty simple here. Number one, you know your risk factors for failed bank cards, and if you have too many risk factors, you have to start thinking whether or not a soft tissue intervention is really appropriate. And then the on and off-track lesion, Steve Burke, R.D. Toy, D.G. Ockham have really been outstanding in helping us understand this. Your radiologist can clearly determine whether you have an on or off-track lesion. If you're off-track, that is the pothole is bigger than the width of your tire, you have to start thinking about something other than a soft tissue solution. Can we improve our arthroscopic bank card technique? Well, the answer is I think so, but this is how we do it. This is how we're all taught. We do generous tissue mobilization, and we're going to see the subscap, and we're just so happy and everything's going well, and we put our anchor in, and this is a single loaded. I come below it, I grab tissue. This is a little older video. We come through, we lift, we put through a PDS, we retrograde our suture through, we tie our knots, and after we have three of them in and we re-tensioned it, it's Miller time, and we go, hey, look at re-tension, it doesn't come out. This is great. And the answer to all this is this just isn't good enough. We need some advanced techniques to get the results we're looking for. Number one, lateral decubitus. There's at least one study showing it has a higher success rate. You can access the inferior capsule and ergonomically a better position. If you're not doing it, please try it. Every bank card ought to have a six o'clock anchor through an accessory post-rata portal. Remember that instability is inferior as well as anterior. Here we are directly addressing the inferior capsule. We'll put in a simple suture here first, and then after the simple suture, we're going to basically put a mattress suture on either side of it, and you see we bring it up. We get a nice re-tensioning of the inferior capsule, and then we zip up the front. And this is, I think, something we should do routinely, that six o'clock anchor. Bony bank card lesions, it is an indication to intervene early. We know the problems if we don't. You can use a bony bridge technique described by Peter Millett. But I like to tilt the fragment. So we're going to place an anchor in the medial neck of the glenoid. We're then going to pass a suture around it, and then drag our sutures around the bony fragment, and then we basically, you can use a bone bridge technique here, but I prefer tying knots. I'm going to tilt the fragment while I tie, and that can lead to hypertrophy by loading. So by loading this fragment, you can actually get extra bone. And this is what it looks like here in this particular case. And so you may say it's a mal-reduction, maybe, but there's definitely more bone from loading that particular fragment. Heel sacs lesion, you had a great talk by Buddy on how to do this, and I would tell you throwers, you have to be very, very careful. Garcia's study shows us that. But all significant heel sacs lesions ought to be treated with a rent blissage. Like Buddy said, do not go to the articular margin. You will not only limit external rotation, you will limit internal rotation. So stay in the middle of the defect. All you're trying to do is make it extra articular, control translation, and there's probably some element of a posterior inferior shift. We have the first study, the review back in 2014 showing that with this, there was a very good reduction in our recurrence rate. In this most recent out of the arthroscopy journal, 2019 systematic review, again, pretty much every metric you want to measure, things were better other than range of motion as you might anticipate. Here's something that you should be aware of because a year from now, this is what we'll be doing. Instead of the ladder J, which is too broad a brush, this should be targeted treatment. So if the ligaments are okay and you have bone loss, you can put bone in. This is a distal clavicle graft, an autogenous graft. We're coming through the subscap for a five o'clock anchor. We'll place an anchor and then we're going to go ahead and run our graft in with a button on it and we'll go ahead and place it. And you don't want to oversize your graft because it's simply resorbed. So we try to make it the exact size in terms of bone loss. Once we have the piece of bone in, we're going to go ahead and do a rent blissage and we'll also close the labrum over the bone block. And this is trying to restore normal anatomy. So instead of a ladder J, and sometimes it's indicated, I think this is what we'll be doing down the road. Finally, real quick, this is the lowest tech thing of all. Just hold them a little bit longer. Young male athletes, hold them. They don't get that stiff. As long as they're not throwers, it's not going to be a problem. I try to get 90% of range of motion at three months. So I go slowly and I think my results have been better because of it. So we can have a few conclusions. One is let's mitigate our risk factors, both intrinsic and technical. The intrinsic risk factor mitigation really is avoid borderline bone loss cases. Young male contact athlete, hair on the back of your neck ought to be sticking up, so you have to be thinking twice. And multiple risk factors, think about something other than soft tissue. Modern techniques, ladder to cube, anterior superior viewing portal, six o'clock anchor, adjunctive rent blissage, three or more double loaded suture anchors, alternate simple and mattress. Incorporate bone whenever you can and do it early in these acute cases. Autized bone grafting is what we'll be doing a year from now versus ladder J. And immobilize a little bit longer in your young male contact athletes. And I think overall, you'll be much more happy with your results. Thank you very much. Rick, don't go anywhere. We're on time, so we actually can ask a couple of questions. I didn't hear you talk about knotless anchors at all. I thought that we weren't any good at tying knots. What do you think about knotless anchors? Should that be part of the modern technique for arthroscopic bankart repairs, or should we still be using knotted anchors? There's some, there's literature out there is I think a little sparse on that, but the bottom line is I think the knotless anchors can give you results that are comparable to tying knots. My concern at this point really is with the suture based anchors a little bit, it depends on where they deploy. But if they catch deep, you'll get a cheese wiring effect and you'll basically get medialization of your labor repair. So be very careful when you're looking at the all suture anchors, where does it deploy? You want to be a sub cortical deployment. So the amount of suture in the tunnels, the minimum amount, but I don't think there's a big issue. I think it's dealer's choice. I like tying knots and so that's why I do it. I try to keep my knots away from the articular surface, but I think a knotless technique would work just fine. Thank you.

bank card repairs

suture anchor technique

patient selection

bony bank card lesions

autogenous grafts