Good afternoon everybody, I'd love to say top of the morning, I'm sure John would like to hear that, but unfortunately it's a bit late for that. So I've been asked to talk about Rompasage and it's a great pleasure to be here and we'd like to thank John Kelly and Lewis McIntyre for inviting us and to the ANA for having us as well. It's very daunting to follow a man like Steve Schneider, so hopefully I'll deliver some reasonable information to you now. Thankfully we have no disclosures on this. So we know that shoulder instability surgery, both open and arthroscopic, has evolved quite a lot over the last 20 years or so and I think the reason for this is improved techniques but also better understanding of our patient factors and also the pathology factors that have helped us to treat these patients, I think, better over time and of this, heel sac lesions are certainly a component that we need to evaluate and to consider and in recurrent instability they're there nearly all the time and it's important that we address these particular issues. So I suppose initially when arthroscopic techniques were evolving, the debate between arthroscopic and open procedures in terms of recurrent instability following surgery were strongly in favour of open techniques, but I think this has changed over the years and several authors have published recently of varying levels of evidence but nonetheless a trend towards at least equivalent if not better outcomes for arthroscopic stabilisation and I think part of that is because the techniques that we have have improved and that's also led to the increase in the usage of arthroscopic techniques for dealing with instability and I think part of that has been the evolution of rhompus age and the understanding of heel sac lesions and how they affect instability. There is a bit of debate happening at the moment about whether or not we should be doing bony procedures or arthroscopic procedures with rhompus age but in my mind they're not mutually exclusive, I think they're part of the spectrum of instability and it's important that we're able to deal with all these aspects of instability in order to deliver the best outcomes for our patients and I think a lot about what we do with instability really is an a la carte treatment plan and we should have all these options available so that we can treat them adequately. My own view on rhompus age is that it's a relatively risk-free procedure with minimal downsides to it, I suppose there are concerns around limitation of range and while throwing athletes really aren't that big part of our practice at home, I have noticed that it's been a significant element of discussion while we've been here which is something we'd definitely be bringing back with us I think but it has had an effect on recurrence rates and recently Andrew Wallace has published a paper looking at elite contact athletes and it's definitely reduced the risk of recurrent instability in that group which applies to our players as well. The concerns around neurovascular injury and infraspinatus weakness really haven't been reported so it's really with regard to external rotation loss which seems to be the biggest concern around rhompus age but in broad terms what I find is that my patients don't really complain about it but if you measure it, it's there. So my indication for rhompus age in general is a large engaging heel sac lesion in any athlete really up to elite level who has a minimal bone defect anteriorly or a soft tissue defect only so we're not really talking about off-track lesions here, we're talking about relatively well-preserved glenoid bone stack. I typically set my patients up in the lateral position, I like to use bolsters posteriorly so that I get good support in the scapula in particular for glenoid drilling and I use control cannulae front and back and then stab incisions for the suture passage for the rhompus age. The most important thing about performing a rhompus age to make it easy for yourself is that you do it in the correct sequence because nobody wants to be sitting at the football match and not be able to see the game so if you obscure yourself by doing your rhompus age too early, you will not be able to complete your surgery. So for me, I like to introduce the diagnostic arthroscopy from the posterior aspect to decide what needs to be done inside the shoulder and then reintroduce the camera from the front, prep the heel sac lesion using one or two anchors and then deliver the sutures outside the posterior cannula then deal with the remaining pathology viewing from the back and leave the rhompus age to be tied at the end. So this is a typical lesion, so a large heel sac lesion engaging with both the superior and anterior labral tear. So hopefully this will play for me. So effectively the tools I use for this are standard tools that we all have in most sets for arthroscopic stabilization. I don't use anything fancy, this is a straightforward 15 degree elevator and I then use a rasp just to try and trim the surface of the heel sac lesion to expose the cancellous bone and after this then typically just form a small number of microfracture holes using the same instrument that we're going to be using to insert our anchor posteriorly. This is all viewing from the back. I do find that on occasion, depending on the position, the heel sac lesion can be helpful to look for an anti-superior port but in broad terms, it's usually just a straightforward anterior viewing port with a 30 degree scope that gives you this view. After that, we insert our anchor and I use just a straightforward cross crew anchor for this, a 5.5. What I would say to you is that in this bone, in athletes, it can be frequently very, very hard so it's worth tapping before trying to put your anchor in because what you don't want to be doing is finding it stuck halfway. Then I position my retrieval instruments using a straight forward spinal needle. Typically I find one of them is going to be through a Wilmington portal and the other is going to be coming in through a stab incision just inferior and lateral to your posterior viewing portal and then you retrieve your sutures in this way and you see it's quite powerful in terms of its ability to reduce the humeral head inside the glenohumeral joint. So this is what you'd see if you then reintroduce your camera from the back. You're looking at the heel sac lesion which has been debrided and prepared and your anchor is sitting there with your sutures well positioned. After this, I then again, viewing from the back, complete the remaining part of the instability surgery so reducing your IGHL and the rest of the labor repair. Then after that, then I back the posterior cannula back out and then try and dial it back in a little bit so as to trap the infraspinatus and capsule between it and the humeral head and retrieve my sutures then exteriorly through the cannula. So frequently that can be tricky to do just using a standard grasp but what's a useful trick for that is to use a knot passer to try and to root your sutures back out through the cannula. For knot tying, I usually use a fisherman's knot. I found that using an SMC knot can mean that you lose the ability to then re-tension if you lose your tension when you tie it down first of all so a sliding knot rather than a sliding locking knot I think is a better option and then you see that as you start to stack your half hitches after the fisherman's knot has seated, you do get increasing improvement in the engagement of the posterior capsule into your heel sac lesion. This is what it typically looks like at the end where you have a well-imbricated posterior capsule and a well-centered glenohumeral joint thereafter. From the point of view of the rehabilitation, I don't really do a whole lot different. I put them in a standard sling, not an ABE or sling. I know there is some debate about that but to be honest I haven't found it makes a difference for our patients and it avoids confusion with the therapists but what I do look for is for the therapist not to engage the rotator cuff in the first six weeks postoperatively so that you don't tear your rampus out of its fixation point. What that does mean for elite athletes is that their ability to accelerate their rehabilitation program and shave a couple of weeks after their return to play is not possible because they won't have the adequate rotator cuff activation in time to do that so that's one downside I think for rampus as I guess. I usually give the patients the standard safe zone so whatever you identify as being the safe zone for the labor repair interoperatively is what I apply in postoperatively in terms of passive range of motion. So in summary I think rampus as is a worthwhile addition to optoscopic stabilization. I think if most of us are really engineers at heart and I think if there's a big hole in the middle of the road you've got to fill that with something in order to avoid accidents and I think it's a useful adjunct to stabilization surgery. It's not really that time consuming, it's of relatively low risk and it has good outcomes. So thanks very much for having us and we'd like to invite any of you who have time to come to Dublin next year.

Rompeage

heel sac lesions

shoulder instability surgery

arthroscopic stabilisation procedures

recurrent instability cases