Many thanks for the opportunity to present today. For those of you I have not met, my name is Brian Waterman. I'm at Wake Forest University School of Medicine and Wake Forest Baptist Health in association with Atrium Health in Winston-Salem, North Carolina. Many thanks to our course directors, Jonathan Dickens and Patrick Denard, as well as our full complement of ANA faculty and staff. This should be a great learning experience with the ANA Advanced Shoulder Course. We hope you avail yourself to all the expertise in this field and really come home with a lot of great pearls and techniques to improve the outcomes of your patient. Our disclosures can be found online in the AOS website. Disclosures database as well can be shown here, none of which are relevant to the content of my current talk. I will submit to you that I am definitely a beneficiary of the long gray line of Army sports medicine. Having done my training within the military, many of our pearls of wisdom are really drawn from the source. And that's John Fagan, who's an intrepid leader within sports medicine, largely headquartered out of West Point and then subsequently at Duke and Vail. He really has contributed immensely to our field. And I continue to look to him as an example not just my professional conduct, but personal life as well. He has inspired a whole host of leaders in this specific field of shoulder instability. And there's a long standing military heritage here. So when I look at things that we should do for the more complex cases that we might encounter in the shoulder instability realm, these are the individuals I talked to. And they have subsequently contributed and poured their knowledge into my contemporaries. And there's many folks that are carrying the flag now within the Society of Military Orthopedic Surgeons. So a quick plug for them, as well as our subspecialty organizations. So thank you to these leaders in the field. We'll buckle up. There's a lot of knowledge to take in in a very short period of time. And this injury pattern is certainly fraught with a high risk of failure and recurrence. So let's dive in. What we know about anterior shoulder instability that even with first time shoulder dislocations, there's a high preponderance of bony involvement, be it the labrum and or anterior inferior rim of the glenoid. There's a high risk of heel sac lesion up to 64 to 100%. There can be propagation to the superior labrum 10 to 14% of the time. And the sad facts are that 80 to 90% of these young athletes, particularly those under 20 in contact athletics, do recur. Our surgical treatment can decrease this risk of recurrence quite dramatically, resulting in improved quality of life and likely improved cost effectiveness as a treatment strategy relative to non-operative care. When we look at the goals of any of our shoulder stabilization procedures, it's to minimize the risk of recurring instability, as well as to facilitate that return to pre-injury activity often sports in these patients. But to know where we're going, we need to know what we're currently doing in 2021 for shoulder instability. This large private payer database study performed by Andy Riff and colleagues really looked at two trend lines that are consistently still seen within North America for treatment of anterior shoulder instability. And that includes, there's still a high preponderance of individuals performing that arthroscopic traditional Bankart repair. And like our European colleagues, there's increasing utilization of these bone block procedures, particularly Latter-day for treatment of glenoid bone loss. The question remains, and it's one that's often debated within our meeting venues, is capsule labor repair still an option? Is that traditional arthroscopic Bankart something that burns bridges? Or is it something that provides value to our patients while decreasing the potential morbidity of the stabilization procedure? Very often our European colleagues are suggesting that this should be abandoned in favor of the Latter-day or other bone block procedures. But I submit to you that there's no bridges burned. If you use the appropriate technical pearls learned in this course, you can result in significantly improved outcomes for our patients as well as low rates and acceptable rates of recurrence. One of the topics that should be consistently debated throughout this course, and as well moving into this next generation of arthroscopic Bankart repair is the utilization of knotless, potentially retentionable technology versus traditional knotted fixation, which is version 2.0 of the arthroscopic Bankart repair. Many thought leaders would suggest that there's a high preponderance of evidence that knotless anchors can provide more consistent performance versus a manually tied anchor, irrespective of experience and anchor type. And so that's one that really dovetails in with two core considerations. One is this concept of trust, that your anchor tension will be preserved using knotless technique. And that certainly was an impediment for me to get over when considering utilization and deployment of this technology in the OR. The other is one of operative time. There may be some operative time considerations and potentially benefits to our patients, both in terms of the cost and time spent in the operating room, as well as the time under anesthesia for our patients. When examining the available literature, this great systematic review, looking at the comparative outcomes in both Bankart and flap repair, suggests that while patient reported outcome measures and revision rates likely may not differ, the operative time for knotless technology may be significantly less. And so that should be considered as we continue to compare an apple to apple assessment here. What we also know about traditionally tied constructs is that this can result in knot migration. Even the best of our arthroscopic colleagues have some loss or migration of these knots that can become in contact to the humeral head, particularly as you move further above the equator and the labrum. And this can have important risks of not just mechanical symptoms, but articular cartilage where iatrogenic damage and then ultimately potentially early arthritis. Another debate is the utilization of all suture anchors, which we've continued to see involved to more smaller constructs. And they can be inserted with curved guides for greater access, more orthogonal positioning. It can be bone preserving in nature, and they're often conducive with postoperative imaging versus some of our other anchors. However, arthroscopic bank or repair, whatever anchor you choose, technique still does matter. This excellent systematic review was really a call to arms for those utilizing modern surgical techniques. When you pull the existing data of all contact or collision athletes, you can see the failure rate is about 18%. When we do and we apply what we think are really best practice standards, no significant bone loss, a minimum of three anchors or points of fixation, and that performed in the lateral decubitus position, you can see the failure rate results in nearly halving of the rates of failure, which is about 8%. Now with that, we need to really critically consider what is critical or clinically meaningful bone loss. You can see that our algorithm continues to march down in terms of the percentage glenoid bone loss that is deemed meaningful and predictive of recurrent or patient-reported outcome. You can see my algorithm, and this is my suggestion, is that whenever you get to anterior bone loss of about zero to 7.5%, sometimes up to about 10%, I'm really increasingly using more points of fixation, double-loaded anchors, incorporation of any bony fragment, and utilizing this posterior inferior anchor, as I believe in the hammock construct of re-tensioning that IGHL complex, both anteriorly and posteriorly. When you move up to these more mid-range, the subcritical zone, as defined by Tokish and Chehey and other colleagues, you can see that increasingly I'm using a humeral head adjunct, that remplissage, in order to try to re-tension that humeral head posteriorly and prevent anterior translation. This may also be a site for intervention with the open traditional Bankart repair, with or without bony augmentation. And as you get greater than 15 to 20% increasingly for that higher-demand patient population anterior bone block procedures, always while incorporating these other adjuncts that we've mentioned. So that yellow, green, red is an important algorithm in which to interpret glenoid bone loss. And that really is only paying attention to the glenoid, and increasingly we're looking at the humeral head, which is continuing to be a black box for these on-track, off-track, and now newly defined near-track lesions. Clinical validation of this off-track concept, which shows where the hill sac engages in that subcritical bone loss, and essentially that humeral head falls into that divot, that's that off-track lesion, is really meaningful. As you can see, the rates of recurrence or failure, much lower for these on-track lesions than off-track. And so that can have an important predictive capacity when identifying patients ideal for arthroscopic bankart repair. What about a roadmap to success? These are really the careful stepwise process that I encourage you to go through for all your patients in order to make sure that you get the most reproducible outcome possible with your arthroscopic bankart repair. And it starts with a careful examination under anesthesia. I'll perform this in a supine position after they've gone to sleep in order to assess their uninvolved and involved side. And then I'll position them into the lateral decubitus position, stabilize their scapula on the beanbag, and then provide that same anterior and posterior load shift to really reassess the nature of that glenohumeral joint. This is accompanied with a further arthroscopic evaluation. You can see as the scope is inserted through the posterior superior portal, you can see hemorrhage, capsular injury, this ALPSA-type lesion with potentially a GLAD component. You can see that small stump of residual labrum. And this is a difficult problem for a patient that has significant shoulder instability. For me, this is now done in a lateral decubitus position with the dual suspension shoulder positioner. This is something where I roll the patient back on a beanbag, I carefully position them, I apply tape in order to make sure that the beanbag doesn't deflate mid case. I also use this distraction and traction device. And when needed, utilizing this, what I call the jelly roll, which is just a little bit of co-band around some blue towels, and that's placed underneath the armpit in order to allow for distraction during the critical portion of the case. This is something that I initially trained in a beach chair position, but found it much more reproducible, requires less hand. It really offered me 360 degree access for approaching these involved often bi-directional injuries. Well, portal position continues to be one of the most critical, if not the most critical part of this case. It starts for me with this posterior superior portal position as described by Romeo. It's approximately one centimeter down and one centimeter in. It allows me to be a little bit more thoughtful about placement of my posterior inferior seven o'clock portal. I do also establish this mid glenoid and anterior superior portal. The mid glenoid is placed approximately just at that top board of the subscapularis to allow me adequate access to that inferior most margin. And if that allows me adequate access, I can often obviate the need for the five o'clock or trans subscapularis portal, which is about two centimeters down from the top board of the subscapularis. I will also use this anterior superior portal, and this can be really directed on either side of the bicep tendon, avoiding that supraspinatus leading edge. And that can be really helpful for visualization during the entirety of the case. That's traditionally where I'll park the camera. A diagnostic evaluation is really key, and that's applying various different tensions and degrees of abduction. You can see this posterior inferior labrum, which is an important part, which shows weakening in almost a chem type lesion as you evaluate this anterior clinically symptomatic shoulder. You can also look at the Hill-Sachs lesion. So we start by looking at the AI and PIGHL through that posterior portal. And then you want to take the shoulder throughout a range of motion in order to make sure you identify the extent of that Hill-Sachs and see whether it's amenable to REMPEL-SACH. I will often present, I'm sorry, perform my preparation of my REMPEL-SACH at this juncture in time. I'll use either a curette or a shaver and burr function in order to create a nice bleeding bed that's to remove all the interposed scar tissue to drape the rotator cuff out of the way. And this is often with the tension let off the distraction in order to allow me to work through this fairly tight space, relatively low suction, want to create a nice bleeding surface so that hopefully gets an incorporation of this capsule tendinous tissue into position. At this point in time, then I would perform one of two constructs. I've increasingly utilized this knotless construct, but I do still tie, either interlacing these anchors together, oftentimes using just a standard label suture anchors, but sometimes screw in rotator cuff style, depending on the level of bony fixation. These can be passed in either mattress fashion or tied in a parachute type fashion in order to bring that tissue back together. But I will pass these using combination of suture passing device or a percutaneous spinal needle shuttle with a PDS. And then I will park these extra capsularly for later tying often in blind fashion. It's also important when you do this to make sure that you're placing your anchors and passing through tissue laterally as you do not want to fall at that myotendinous junction, which can contribute to rates of stiffness and failure. So don't tension these. These can be utilized for applying traction to the humeral head and exposing that anterior inferior quadrant as is. As I alluded to, you can see the accessory percutaneous portals are critical. You can see the seven o'clock portal coming down right at that cracking of that chem lesion. So I'm trying to make sure that I can get access and appropriate angle for drilling. I use these dilators in order to access it over a nice Wissinger rod. And then you can see the five o'clock portal, which is performed here and trying to make sure that we can get to appropriate angle to avoid, again, those postage stamp fractures where our anchors converge or the dreaded in-out-in where our anchor can get compromised fixation as a result when trying to do everything through that anterior inferior or mid-glenoid. Labral mobilization. This is a critical part, often one that I think gets a little short-sheeted at various different stages. You want to spend at least 50% of your time. And I elevate from the anterior superior and often the mid-glenoid portal as I'm working that around towards the back. Use these elevators. There are a wide variety of them out here. You can see where we're trying to remove any residual scar. We're trying to allow this to float up. When you apply suction, you should see it really elevate towards the lateral aspect of your field. And for those ALPS, more chronic type lesions are one that are really scarred down. It's really critical that you see the fibers of the subscapularis and you distract this so that you can pull this laterally like the hood of a sweatshirt. For me, this also starts with placement of six o'clock or seven o'clock anchors. You can see the angle of entry for that drill guide. You can see I'm allowing my anchor to get really fully seated in bone. My preference is to be right on the rim. I don't advance this centrally as you see with many of the anatomical constructs. I really want that to be right on the rim so not in compromised bone. If there is a nice bleeding area there, then I can really lever my hand up with this more rigid drill guide. And then the anchor is impacted in position. You can see we're performing shuttling. I typically will use a 90 degree suture passing device with a passing suture. And then performing that preliminary tension, which I will revisit at various different stages if coming back at the end of the case after placing my additional anchors. So you can see I'm using that tissue grasper device in order to allow for us to see how we need to tension that posterior inferior labrum. And it just delivers that tissue nicely in a fairly low profile construct. So what about anterior and inferior anchors? You can see in this case, we've placed an additional 5 o'clock anchor, and that's working around that 6 o'clock position. You can see, again, using a suture passing device, you obtain that passing suture, perform provisional tensioning while delivering that labrum anterior superiorly, which I'll even do for my tied constructs. And you can see, just perform provisional tensioning. We'll then come up to the 4 o'clock and subsequently the 3 o'clock position. And very often, I'll use this, quote unquote, pinch tuck type technique with passing through a pleat of tissue, and then coming back through and grasping that labrum. That allows for us to accordion that tissue together and really deliver that nicely and re-tension that construct through the lower degrees of mid-abduction and external rotation. This is then provisionally tensioned, again, at various different stages. You can see in the bottom right, as these anchors are sequentially being tensioned into position. And I will generally avoid doing too much in that anterior superior margin, as I think this can result in over-constrained stiffness and pain. However, that tissue will often be debrided to a more stable base. Well, the 3 o'clock anchor is subsequently placed. You can see, as shown here, we're, again, passing our sutures about an hour down on the clock face in order to re-tension that tissue back up into position. You can see that is using tactile feedback to course right up against the glenoid. You'll see that poke through. Poke through. You'll obtain that night and all passing loop and then shuttled in traditional fashion. This is just shown in that last slide, but just in more focused fashion. So at this point in time, when using a knotless construct, final tensioning is then performed. I will traditionally go from back to front and just sequentially apply tension to these suture anchors and then subsequently using a flush cutter through whichever angle is going to provide me the best degree of access. And I will often let down a little bit of the distraction and traction in order to make sure that I can deliver maximal tension to this new tension IGA complex. As an adjunctive approach, I will often use a posterior portal closure suture. This is done with PDS. I'll usually introduce either a tissue penetrating device or this suture passing device. That will be on either side of this posterior inferior 7 o'clock portal. I don't want it to be a stress riser when patients begin to initiate some of this forward flexion and posterior capsular loading motion. And so you can see, we will withdraw these through and then subsequently tension and tying in the cannula backed out outside the capsule. And careful not to over tension this as that suture is a little bit more friable than your non-absorbable sutures and can result in breakage. So you can see, we're incorporating this case on the bottom right video, a little bit of that capsule labrum in order to just re-tension that tissue just up a little bit more. This is another way to kind of titrate in just a little bit more tension if your exam shows a slightly asymmetric laxity versus the other side. So then the final repair construct as is shown here, you can see tension is let off. You can see it's a very low profile construct. You can see we're performing anterior and posterior load shift. We're assessing for the anterior superior labrum, all of which appears nicely intact. No additional loose bodies, no iatrogenic cartilage damage, and one that I think will result in an excellent outcome for these patients. Well, what about the bony bankart? This is something that sometimes gets the short end of the stick when assessing this at the time of these conferences. So let me talk to you a little bit about KCB, which is a case of bony bankart in somebody with a seizure disorder. You can see this bony fragment that's shown on the images, advanced imaging, which you can appreciate here, is one that shows this bony bankart lesion. You can see it strips all the way to the medial aspect. And when you look at it on these sagittal images, again, you can appreciate this significant, probably 15% to 20% bony lesion. So for that, I've really used this bony bankart bridge approach. And that's popularized by Peter Millett. This is our approach for assessing it. You can see the concept of a traditional single row approach oftentimes is one that treats it like a soft tissue lesion. Circulage is these bony fragments. But the reality is it often results in tilting of the bony fragment, inadequate compression, and ultimately susceptibility to micro-emotions of failure. So the two-anchor construct really maximizes osseous contact. It compresses between two points of fixation. And it facilitates anatomic reduction. With high rates of return to pre-injury activity, upwards of 75%, you can see the satisfaction quite high in this small series from Godin and Millett. You can see diagnostic arthroscopy. This is real-time speed for those. No, just kidding. You can see the loose bodies. And this is an expedited image to show what that arthroscopic image looks like. You can see letting down of tension, assessing the humeral head, looking at that rotator cuff attachment, squeezing around posteriorly. You can see some of that remodeled greater tuberosity and posterior humeral head. We're assessing this chondrolateral area of separation and a pretty rigidly adherent bony banker that's in a medialized position. Very carefully, this is prepared in standard fashion, very similar to the soft tissue approach that we've shown previously. We really want to mobilize this even more elegantly and make sure that we have full preparation. You can see this little divot in that mid-glenoid portal that corresponds nicely with that fragment that's being mobilized here. And again, you just want to maintain that nice tissue and visualize the layers of the subscapularis, which are shown inferiorly within this slide here. The medial anchor placement is often done after the inferior and superior anchor. This is placed pretty far down on the medial neck and then those sutures are docked and they will be subsequently retrieved around that bony circular fragment. You can see the superior anchor is being placed now here and subsequently tensioned into place. You can alternatively retrieve those prior sutures that are in the top part of the visual field here. In this case, we're performing a two anchor kind of a ripstop configuration where these will be performed in mattress fashion, which is shown here. And once those are retrieved, the sutures will be removed in order to prevent bunching. This mattress suture will be tied into position and then these sutures will be retrieved past in a circlage fashion to really allow for that tissue on the north and south end of that bony Bankart lesion to be tensioned into place. And then it's a matter of obtaining final compression of that more central anchor, which will be placed now. Here's shuttling. This can be done alternatively before you tension your inferior and superior anchors. As I mentioned, you can see I'm tempting fate here close to compromising the suture, but I found that I can get in a little bit easier when there's slightly less wiggle room of that bony Bankart lesion. And once the bed is obtained, I will retrieve those anchors and then our final fixation is performed here. You can see that exposed osseous bed. And then this knotless construct is inserted flush and fixation at a greater than three years post-operative assessment. This patient specifically has been both seizure free and recurrence free. That's the bony bank bridge. For me, when is an open procedure indicated? Well, that's for individuals that have failed arthroscopic stabilization. Those with critical glenoid bone loss or combined subcritical bone loss. Those with subcritical glenoid bone loss and significant at-risk activity. And really those contact athletes that may be at higher risk. Those are also ones that you'll consider an open Bankart repair or cat's shift. Bony glenoid augmentation options. Matt Preventer has popularized the use of fresh distal tibial allograft, which I'd encourage you to check out the study if you've not seen or had any experience with it. You can see the tricortical iliac crest has been a workhorse in Europe for many years using this J-shaped or tricortical wedge with fixation and traditional technique. And then also JT Tokish has popularized the use of the distal clavicle autograft as another readily available source for reconstitution of that anterior inferior glenoid dock. So in conclusion, arthroscopic Bankart repair and capsule labor reconstruction with or without reemplisage can really result in a high rate of return to contact sports. It has modest rates of recurrence, not negligible, but they can be minimized using these effective techniques. You wanna have low rates of short-term complications when you utilize these technical pearls. And we avoid any subscapularis violation seen with a capsule or shift or sometimes with a bone block procedure. Technique does matter. For me, I like to perform this in the lateral decubitus position with orthogonal axis that allows me to ensure anchors get placed solidly within bone. There's limited convergence or stress risers for subsequent fracture or compromise. I ensure we get three anchors below three and often four with that posterior inferior anchor placement. Liberal percutaneous portal should be used. They should not be wedded to the angle of approach. This can be fraught with danger in placing it in a prominent position, which is difficult to recover from. And you should incorporate any and all bony fragments and liberally use that humeral head-based techniques that we'll talk about. Knotless suture anchor placement has reproducible biomechanical performance, comparable patient reported outcomes, and it can result in glenoid bone stock preservation, greater circumferential access and decreases suture abrasion related to those knot stacks. And it may have increased cost savings due to decreased OR time, although these need to be followed at longer term outcomes. So thank you. I welcome any of your questions, thoughts. Don't hesitate to contact me via email. My contact information is shown here, and I wish you good luck with the rest of your course. Thank you.

arthroscopic Bankart repair

shoulder instability

surgical treatment

knotless anchors

portal position

bony Bankart lesions

operative time