Thank you very much, and thanks again for having me. It's humbling to follow Professor Lorraine on the podium. I've been reading his work since 2001 when he published a classic article on arthroscopic bank arts and rugby players, and I thought if I could get as good as him with results in that population that I might be something, and I'm sorry to say that I've never achieved it yet, but I'm still working on it. So Professor Lorraine, welcome to the meeting, and thank you. I get to talk to you today a little bit about the glenoid track and some of the lessons that we've learned about bone loss and how to put this all together. And this is me in 2002. This is one of the early patients that I had, 23% bone loss, and I treated this with a scope bank art and ALPSA. So I thought, I'm well trained for this. This is what we're built for. I can get this thing done, and if you do the arthroscopic bank art correctly, I thought we're going to be successful with these patients. In fact, when I left the operating room, this is what he looked like, and I felt like that was a pretty sound technical answer, and this is what I look like, and I kind of felt like Buddy Savoie, felt really good about how that thing went. Now, unfortunately, this is what he looked like 16 months later when he failed, and this is what I look like, and I didn't feel much like Buddy, to be honest with you. And I think that forced me, that index case forced me to go back and look and say, well, I didn't think I could do that operation better than I'd done it, and therefore, I thought there must be something else going on here. It forced us to go back and evaluate this paper, right? So this is the most quoted paper in the shoulder instability literature. You guys know this paper by heart, I'm sure, 194 athletes, 6.5% failure rate if you don't have bone loss, but if you have bone loss, that failure rate goes to 67%, and if you do bone loss in a contact athlete, their failure rate was 89%, incredibly humbling. So how much glenoid bone loss can we tolerate? That was really the question, and there's two ways to answer this question. You can answer it qualitatively, as Burkhart and DeBeer did, and called it the inverted pair, or you can do it quantitatively. Professor Itoi did this with working when he was at the Mayo, and showed that he did progressive osteotomies and found that at 21% or so, you lost stability with an arthroscopic Bankart repair. Now, why that's so interesting is that's the number. This is the study, back in JBJS, that we get the critical bone loss number from. So this is what an inverted pair can look like, and it can be very daunting to try to take it on. Well, we looked at this, and we knew that 21% was too much, but I was in an active duty military program at the time, where many of you guys and gals have been too, and you realize that sometimes they fail even lower than that. And so we decided to take a look at what we called subcritical bone loss. In other words, we knew 21 was too much, but how much lower than that could you go and safely get away with it? So Jimmy Shehey looked up our results with this, and what we found was, was that if you had 13.5% bone loss, this led to an unacceptable clinical outcome, even if the patient didn't have recurrent instability. So this study taught us two things. The first thing was, is that there was a number of bone loss that was less than 20 that still was important. That was number one. Number two, we learned that we can't just use recurrence as our ultimate outcome measure. Because we'd have many of these guys come back, Rangers, who would come back and we'd say, did you dislocate? No. Are you apprehensive? No. And we'd get their WOSI scores, and we'd say, that's terrible. And we found that even with subcritical bone loss, even if you didn't dislocate, it was still a problem. Well, what about the humoral side? You can look at that as well from a qualitative or quantitative standpoint. The so-called engaging hill sacks, and then Mineachi repeated Itoi's work in the humoral head and found that progressive osteotomy showed that 5H removal was bad in abduction external rotation. But then, typical of Steve Burkhart being ahead of the rest of us and Eji Itoi and Giovanni Di Giacomo, they put the two together and realized that one side bone loss is going to affect the other side bone loss. And they put together this article, which I think was an incredibly important step forward in our understanding of the on-track, off-track lesion. Essentially, you could use imaging to predict who would become that engaging hill sacks if you did it right. Now, I get asked about this a lot, as did the other authors. We did a little method to simplify this. We validated it on an MRI scan, so you don't necessarily need a CT. It's not as easy as we all think sometimes. So this is a very, very simple way to calculate the glenoid track. Step number one, you have to draw a circle in the inferior two-thirds of the glenoid. So that's an easy one. I think most of us are comfortable with that. And then you have to measure the diameter of that circle. And then you have to do one math equation. People all say, oftentimes say, the math is too tough. And Steve Burkhart always reminds us, it ain't calculus, it's arithmetic. So you just take .83 times that diameter. That's it. And then you subtract whatever's left for the bone loss, and that's your glenoid track. So in this case, a 30-millimeter circle times .83 is 25 millimeters. You subtract the six millimeters of bone loss that's there. And you've got your glenoid track at 19. Then you simply go to your axial view, and you draw a line from the insertion of the cuff to the middle portion of that track. That's your pothole. And if your pothole is bigger than your tire, you're off track. And if it's less than your tire, then you're on track. Well, we got interested in this and said, well, that's a really interesting way to think about it, but does it matter? So we went back and applied it to a prospective series of our own patients while I was at Tripler Army. Jimmy Sheahey again led that charge. And what we did was we clinically validated the glenoid track as predictive of outcomes. And this is what we found. And you talk about humbling. What we found was is that if we did an arthroscopic bankart on an on-track lesion, we had an 8% failure rate, which we felt was pretty acceptable. But if we were off track, that failure rate went to 75%. What we also found was that our WOSI score was 450 points worse if they were off track than if they were on track, even if they didn't re-dislocate. Very, very humbling for us to take a look at that. And so what we learned was is that the off-track lesion is not amenable to a simple arthroscopic bankart. If you're off track and you try to treat this with a scope bankart alone, I can promise you you're going to be up a familiar creek without a familiar paddle. You better have a better paddle. So think about other things, remplissage, open shift, laterges along those lines. So putting it all together, please, please recognize bone loss is critical to outcomes. Don't go to the operating room, put the patient in the lateral decubitus position, stick your scope in and assume that you'll make it work, because you'll talk yourself into it. We have to recognize that bone loss is on both sides of the equation and the track is critical. If possible, correct the pathoanatomy and always have a plan and take that aim. Thank you very much.

arthroscopic bankart repairs

shoulder instability

bone loss

glenoid track

patient outcomes