It's just going over and cuddle or something. Just kidding, I'm kidding, of course, Mike's awesome. But that's, if you wanna go check something out, you have some specific interest, feel free to do that and come back and forth. At 6.30, after these are over, we're gonna have a concurrent session where everybody, both in the shoulder and elbow side, are gonna come together for the throwing athlete. So that'll be really fun until seven o'clock tonight. So a couple other things I wanted to say. The faculty here, they're all volunteers. Nobody gets paid for anything. They put us up in that amazing Hampton Inn. That's about all they do for us there. But they're here and they're really wonderful people. And so lean on them, ask them anything. Also, I think, oh yeah, and I wanna make a special thank you to our master faculty, Brian Waterman and Michael Bryan, who are here, who are really wonderful, experienced, innovative doctors, and they're gonna be participating today and tomorrow. So anything that you need to know, they're a great resource for you as well. So with that said, I wanna turn the floor over to Rob, and we're happy to help him any way we can. Larry, thanks. I do echo everything that you said, Larry. I don't know how that happened, though. I was in... First off, I just apologize for my voice. I'm not actually currently sick. I was a little under the weather last week, so my endothelium is still reconstructing itself. So I've had the opportunity this last week to practice my Lego Batman voice, which is going really well. So I apologize about that. I actually have two sessions, so you're gonna have to listen to this raspy thing for at least almost an hour today. I'd like just to emphasize what Larry said. Thanks to all the faculty members. It really is just a testament to everybody's dedication to our craft and our profession and the Arthroscopy Association that everyone's here. Thank you so much for everyone who's traveled a long way. And welcome to the course participants. Again, just to emphasize what Larry said, we're here for you these next two days. Please ask questions, grab us in the lab, get out of the course everything that you want to. Can we switch over to my... My fault, okay, good. Okay, and then let's have... Okay, so let's get started. Let's have Justin Arner, Chris Bokabla, and Andy Sheehan come up as the first panel. This is a case-based discussion. We have 25 minutes on shoulder instability, no bone loss. So all of these are case-based discussions, open discussion, I will call on the panel here, but audience, please participate. So let's talk about arthroscopic bank heart repair and additional procedures, when and how. Maybe we'll get to some posterior instability and maybe some weird cases. All right, so smashing you in the face here, faculty diagnostic arthroscopy. A left shoulder from a posterior viewing portal. I'll give you some demographic information and history here in a second, but I just want you to kind of get the lay of the land from a diagnostic arthroscopy standpoint. You can tell this is baby cartilage here, a young patient. This is an anterosuperior view. So most of my instability cases are gonna be this anterosuperior view. It's kind of a top-down view. So at the top of the screen is actually the inferior aspect of the glenoid. To the right is anterior. There you see an anterior cannula coming in and you see the condition of the anterior soft tissues. Here, we're going back to a posterior view, showing a nice, juicy Hill-Sachs lesion. So the question for this case is, should we reemplisage this Hill-Sachs lesion in 2024? So here's the case, 15-year-old, young man, linebacker, one-time dislocation, had to be reduced in the emergency department. He's asymptomatic now, finished out the rest of the season, no problems. He does not have hyperlaxity, normal exam except for anterior apprehension. Some x-rays, no bone loss. Everybody in agreement with that? Some advanced imaging. Maybe helpful, maybe not, now that you've already seen the scope pictures. Pretty typical findings for first-time anterior instability. You see the Hill-Sachs lesion looking fairly acute-ish there. Okay, so let's go to the panel. Maybe Justin, we'll start with you down there. So many factors in decision-making here. Is this somebody you're offering surgery to right away, or maybe even insisting in 2024 on surgery, pushing for surgery? What do you think about that? Yeah, I would insist, especially with the linebacker, and I've definitely gotten more aggressive over the last two, three years about reemplisage and these people. It's a little bit controversial. I do worry a little bit about what happens long-term to the cuff in these reemplisage kids, but with such a big ALPS lesion like that, I worry, you know, J.P. Warner described that, I think, in the early 2000s, and when I was a fellow with Millet a few years ago, we looked at all of his patients, and they still fell at a higher rate despite kind of knowledge of the ALPS lesion and really elevating that. So I think for sure, reemplisage, and I think really would talk them into surgeries. Cartilage looks pretty healthy right now. Chris, what do you think? Let's say he is 18, and he's done with football. So Justin said the linebacker position's important. He says, I'm just gonna be a normal college kid now. I might go to the weight room, but what do you think about reemplisaging him, then, 18-year-old, one-time dislocator? You wanna give him a chance with the old isolated arthroscopic vanguard repair? No. With an ALPSA? No, I don't know. No, I would definitely add. Or how about it, let's throw out, would anybody go for bone reconstruction, Laterge on this? So I don't think it's unreasonable to consider a Laterge. If you think about what 18-year-old college students do, most of them are in collision sports, I think if we remember back to our college days. And I would argue there, it's not a huge amount, but I do think there is, looking at the arthroscopic views, especially the intra-op video you showed, it looks like there is a small amount of anterior glenoid bone loss, and certainly that Hill-Sachs lesion is a significant injury. So if I'm doing the surgery arthroscopic, it's gonna be a Bankart-Remplissage, but I don't think it would be unreasonable to consider an 18-year-old who's very active, it sounds like this is probably an athletic kid to begin with if he was a linebacker, to consider a Laterge as well. Would you get a CT on him? Do you get a CT routinely on all anterior instability patients? Not on all, but recurrent. My practice is a high percentage of revision. I'm in a community setting, so my partners will do all their arthroscopic Bankart. So I typically do get a CT because it's usually recurrent instability. Okay, nice. Andy, all these scoring systems, ISI, on-track, off-track, does it matter anymore? I mean, are we just... For me, it really doesn't matter. This guy gets a Bankart-Remplissage every time. Okay, great. Is this a preoperative decision? Raise your hand if this is a preoperative decision based on clinical patient factors or is intraoperative. Justin says pre. He's just... You can see it on the MRI, right? I find it hard, though. I don't know what everyone else has experienced. Sometimes it really can be an issue with insurance coverage, with it being a non... Some people, like J.T. Tokish, he's been told to build it as a rotator cuff. At my institution, it seems to say that's not the right thing to do because there's not really a diagnosis code for it. So I think that's been a challenge. I wouldn't personally do an open Bankart, but I don't know if anyone else would consider an open Bankart in this kid, too. I think about it in a kid this age that plays football. What I struggle with is I bet if we look more closely, he's got a fair amount of pathology percolating down around up the back. And so then maybe we can talk about what Bankart remplissage plus means. Because to me, it means Bankart, remplissage, and at least two or three anchors come around the back. And so there's a logistical issue with trying to do all those anchors in the back. I do a lot of cubitus and then flip them and put them up in the... But I have done open Bankart in the past for these collision athletes before. The hillsacks, are we gonna talk about how to do the remplissage? I do have a case that's got a lot of technical kind of, yeah, good. Or be it for me trying. Let's go one more. Rob, can I ask a quick question? So if there's no hillsacks, do you ever create a hillsacks to do a remplissage in a high-risk patient? Me too. I've done that a few times. Yeah, so I just, I think for me, the indications for an isolated Bankart are shrinking by the day. I think that Patrick Denard's paper that was published in Arthroscopy Journal two or three years ago, demonstrating essential equivalency between Bankart remplissage versus Latter-day. It was a very compelling thing for me. I don't think that the loss of external rotation is something that I think historically had been a concern. I think if you do the remplissage correctly, you don't put that too medial and you don't get into the myotendinous juncture or anything like that. You cure at that cartilage job, you take it right off and you put your anchors right there every time for me. It's usually dinged anyway, a little bit, even if it's not a real hillsacks. How about exam under anesthesia for these folks? Does that, does it matter? I mean, if he just falls out and you've got to pull him back in or if they kind of just barely sublux and it's like, this isn't like a real deal recurrent 20 time dislocator exam. Does it matter? I had a kid about two weeks ago that didn't have a great story and his MRI was impressive. And his exam was so kind of overwhelming that I did a remplissage that I hadn't really planned on. I talked to them about it, but told them it would be a really low risk, but doesn't, I don't think impact me often, but sometimes you're surprised how much instability they have. Sometimes they almost have no instability, right? And you're like, why are we here? But then they, so, okay, good, okay. Yep. I actually have a case like that in the weird stuff section at the end. So I don't think we'll get there, but it matters to me and it matters what kind of thrower they are. What do you guys think? Thank you, Theo, for busting my chops. Not every time. But I also haven't seen that many overhead throwers where this is, you know, it's their dominant extremity and they're also in contact. Yeah, I feel the same way. And also when I'm in there, I'm addressing instability primarily. And so, you know, most of the studies don't show a huge loss in external rotation. So for me, it's why am I doing the surgery? It's for instability. All right, so here's some repair video. Went by kind of fast there. What do you think about, let's see if I can get back to the, okay, I can see it there. Was this tissue, does that tissue look any better than you thought it might be from the? Oh, yeah. You did a really nice job elevating it and it floating free there. It was hard to do. Not bad, right? Looked better than. I like the move too about taking two, you know, a couple of millimeters of cartilage off right there. Yeah, I was gonna ask everybody about that. That was Dr. Burkhart's practice. Instead of placing the anchors kind of onto the face into the cartilage to create a little bone shelf there. In a couple of randomized controlled trials, I think there was a little conflicting evidence about whether that matters or not. I didn't do the remplisage. This case was about five years old and at that time, I was really following on track, off track, you know, pretty by the book. Although, we looked up the rate that Dr. Burkhart actually used that and it was only about half the time. About half the time he went to the next higher level of constraint. So, he wasn't really religious about it. So, I actually fixed this kid's dad's distal biceps a few months ago, so I got follow-up. So, he actually did fine with just isolated arthroscopic Bankart. He changed positions. He wasn't a linebacker anymore, but played the rest of high school. So, got away with it on this one, but I think we've all pretty much moved to, this is a mistake, not addressing the Hill Sacks. Fair to say, panel? He was one of the lucky 70% of the patients. And five years out, I mean, he's still got a couple of years, statistically, to still recur before I really got away with it. Okay, good. Thoughts, audience, questions? Case two, rim plissage techniques. Okay, right to video panel. Bone loss measurements intraoperative. This was Dr. Burkhart's gold standard. This is where he made the decisions. I think that the basic science doesn't support that. Who's measuring bone loss using the bare spot, measuring the Hill Sacks, doing the calculations? Does this matter? Does this influence the surgical decision-making in 2024? For me, I'm not, because I've already made the decision before I got to surgery. So if I'm in the shoulder, I'm arthroscopic, I'm doing a Bankart rim plissage. You ever look at the soft tissues and convert to Latter-Jay? I have not. Justin? Yeah, I agree, same. All the decisions are pre-op. Andy? Pretty much, yeah. Okay, Bankart rim plissage, a lot of steps. What order does everybody like to do things? Is it a little bit of capsule labral repair, then go to the Hill Sacks, then back? Do you put in the Hill Sacks anchors first, then do the labrum? What's the order? Chris? So, diagnostic arthroscopy first. Immediately, I'm looking for the Hill Sacks, because I know I'm gonna do the Bankart, and I'll prepare the Hill Sacks first. And I actually, I'll put my- Viewing, how do you view anterosuperior? Okay, lateral position? All instability, including bony, if I'm doing a DTA. So, I'm gonna prepare it first, before I even touch the Bankart, and then I'd make a little stab incision off the posterior lateral aspect, almost like a seven o'clock, and I shuttle those sutures out quickly, so that I'm not, nothing's in the way. So, you prepare it, put your anchors in through the posterior portal? Correct. And then you shuttle them back out? Just a little stab incision. So now, when I'm doing my Bankart, it makes it a lot easier, because now they're extra cannular. And so now, I'll go do my Bankart, because when you have that in, it gets a lot harder. If you elevate it the way you did, which looked nice and high, it actually gets much tighter in the back. And so, it's much easier to do the Bankart, than tighter- It gets swollen, if you, yeah, yeah, agree. Any other thoughts? I think, I like to do the Paul Brady. So, I'll have two long, 14-gauge angiocasts. I'll put the anchors in, in the defect here, like you've done through that cannula. And then, I'll put the 14-gauge angiocasts in percutaneously. Take the needle out, lasso in, retrieve the lasso through the cannula, and then shuttle the stitches. So then, I have two, I have the sutures parked in the angiocasts. Because then, I still like to go up in the subacromial space. Yep, there's a subacromial space picture there, so that we can talk about that, too. The point about viewing from the front, doing it before you do the Bankart, I think, is really important. Because I think, if you've done your Bankart well, you should be able, that should result in that kind of recentering of the humeral head. And it's real difficult to go. I've been a part of some Remplissage misadventures, where I fixed my Bankart, something happens with the Remplissage, and I say, well, I'll just go try to redo it. And you can't, you can't really see it, so. Okay, this, I prepared and placed a couple of anchors for the Bankart repair first. So, right shoulder, anterosuperior viewing portal, working through an anterior cannulated portal, mobilize labrum, prepare the little shelf of bone, like you saw in the other case. This is all before doing anything on the hill sac. So, it is, if you work efficiently, it's possible, and I still, I think, got a reasonable view at the hill sacs. So, definitely possible to do a little bit of anterior work first. An argument for, it's still possible to do that work first. So, couple anchors in there. Let's talk a little bit about technical, on the capsule labral repair, these bites. So, how are you titrating that in? Justin, you want to talk about that? Are you happy with? Your view is beautiful. Are you happy with this? Are you happy with that view? Yeah, happier than what I usually can view. Okay. It looks really nice. Okay. Well, this shoulder's real loose. So, I mean, this is a bad one. So, yeah, this is like multiple recurrence. Okay, so. Yeah, it's so hard to know how much to grab, right? Isn't it really hard? I mean, I still am kind of like, especially those low anchors. I have gone to the tensionable type like you have. Initially, I was skeptical. It's just kind of footsie, feel like it takes longer. But being able to re-tension them at the end, I think is nice. I tend to grab more capsule, which it seems like you do like on your first case. So, sometimes I feel like my bumper isn't as beautiful as some people that are just grabbing only the labrum. But to me, I feel like the capsule is really what matters. So, I try to pay attention to the inferior glenohumeral ligament and try to really grab that with the first two anchors and try to significantly pull it up. Honestly, it's just as much tissue as I think I can get around the passer is how much I grab. Okay, great, great. So, pretty much max. Okay, good. All right, so, Andy. Anterosuperior view, there's the hillsacks. This is gonna be your more inferior anchor. A, B, C, or D. And you can even do halves if you want. I like this, this is fun. I would do B and a half. B and a half, okay. Yeah. The more D you put, the more medial it is. Right. The more you're gonna exclude the lesion, maybe less. Yeah, I think it's a mistake to put your anchors right up against that articular margin. If you're going into this thinking, okay, I'm gonna render this thing truly extra-articular. Okay, all right, here's where I put it, B and a half. This is also something that each time I'm like, I don't know what to do. I don't know if we have anything to guide us on this. What do you think, Chris? Yeah, so, I've looked at this because I do a fair amount of rempassage, and there's nothing that, I've seen a lot of opinions, but I haven't seen anything where people have looked at them and said, this contributes to instability or not. In other words, the position. I try and put it centrally within the lesion, if it's one or two, depending on how big it is. But I try and do it. Does centrally mean you don't care about excluding the defect? Completely. Right. So I don't put it on the edge. So I put it on the edge of the cartilage, okay. Okay, how about the superior anchor? A, B, C, neither? B and a half? B and a half. I think around there in the central portion. Okay. Rob? Yeah. Just a comment. What if it's a deeper hillsex? Does that change your positioning of your anchor at all? It makes it a lot. So for me, it makes it a lot harder. It makes it almost mandatory that you do this technique with the anchors posterior and then reshuttle the sutures. Because if it's a more lateral lesion and definitely more superior too, then you can put the anchors in percutaneously, which is helpful. But yeah, depth. I mean, and sometimes they're so deep that you need to really reconstruct that bone instead of just doing rumpless arch. Yeah, I guess my point was if it's a deeper hillsex, exact same position as the one you had on the last one, but I'm personally aiming more for C rather than B and a half. I'm going, I want to exclude a bit more of that just so I feel better about that. But again, it's not based on anything, just personal preference. Bill? I think that next slide was kind of key. So even if you have to go a little bit more now to the anchor, it's really the position of where you rest the suture is really what I'm really looking for. Just, you don't want to go really for this. Do you think that if I'm gonna interconnect those anchors, do you think that's in tendon, capsulotendin, or capsulomusculo? Is it a capsulomusculodesis or a capsulotenodesis at that location of passing? This one had a pretty good bridge, a little bony bridge. What do you think, Chris? I think it is, you know, obviously the further medial, but yeah, it could be musculocapsule, not tendon. We think that remplisage is free, but I actually treated a patient that I think had a musculotendinous rupture from a remplisage. Almost nobody talks about remplisage complications. All right, there's a subacromial view. So this is a paper that we did showing the knotless tensionable anchor interconnected was a little bit better than tied sutures across the remplisage. So that's, I like that technique. What do you think? Final shots there? Everybody happy with that one? It's really nice how it centers the head. It's so powerful. Yeah, it's really a powerful technique. I think it's, that's a hot one. That's one to keep, right? Why do you think that? Why do you think it's better than tying knots? Because if one knot fails, then the whole thing fails. If there are two interconnected sutures, the whole, the anchor has to fail for, or both sutures have to fail for the interconnected knotless anchor technique to fail. It actually depends on the mechanism of failure more than the strength of the construct, so. Rob, is this the the Hartzler special three anchors plus remplisage? Triple-double technique? No. Okay, we got four minutes left. Should we do posterior instability? Okay, 16 year old football player, weightlifting, something happened, weightlifting, then he kept hurting it, kept playing, multiple instability events, x-rays, show some bone loss. Here, I'm gonna go fast. MRI doesn't help you. There's some CT. Anybody scared? Everybody scared? Is that a soft tissue case or a bone case with what you see? Here, I'll give you, oh, there's a 3D. Justin? I'm not jumping to a bony case. I don't know if that's the right answer. All right, good. Anybody else? Bone? Audience? Bone? Anybody doing bone there? Probably not for a first time, right? It's hard, anyway. Okay. There's a little, this is something to practice in the lab, like really. This is, if you don't do anything else, practice making percutaneous portals low on the glenoid. So we can help you with this. Spinal, it's, they're like weird places sometimes, especially a seven o'clock portal. And even without a fancy cannulated technique, you can, you can bring your anchor guide, you know, carefully through, just in the same line as your spinal needle. And posture instability is really fun because you can just make percutaneous portals to your heart's content and get the right angle at everything. So, thoughts on that, guys? The angles, I mean, angles in arthroscopic surgery are a big deal, but if you have the right angles and if, for someone that I have a low, you know, low threshold for putting anchors in the back, I cheat my, and I do all my cuff stuff in the beach chair, but I'm doing lateral instabilities, I cheat that posterior portal more lateral because I find that it gives me more of this angle here. If you make your standard beach chair posterior portal, you're gonna be really medial and you're not gonna be able to put the anchor up on the face and you're gonna have to use all the percutaneous techniques like you talked about. All right, is that low enough? I was reviewing, when I put this together, these are old cases, when I put this together I was like, should have made that lower. It needs one right there. Should have gone lower, right? Depends where you grab it. Yeah. I think insufflating, like Andy said, before you make these, make your posterior portal can help bring that capsule more full and you can get more lateral. And I think you shouldn't be afraid to, if you're so medial, to pull your cannula back and close it and then replace your posterior one where you want it. I used a knotted technique here, double loaded suture anchors, two points of fixation per anchor. You think that helps? Is that a good thing to do on maybe a high risk linemen with recurrent posterior instability? Does it matter? Andy, you're still doing knotless, hard body. Still? Yeah. I mean, I understand the argument for the double loaded anchor, but I don't think that the literature has borne that out. All right. And I worry about the knot stacks. I worry about even the best of hands, those knots over time. Not bad though, right? No, it's time zero, it looks excellent. It would have gone lower though. Yeah. Posterior portal closure, mandatory. That's another good thing to do in the lab. If you don't know how to close the posterior portal, we can show you that, right? Here's one way. Did I use PDS? PDS. Go. We're all done. One minute left. Always close posterior portal on posterior instability. I like doing AO. Okay. Does it matter? Is that just something we do because Jim Bradley and Steve Burkhart said to, or is there some science behind that? I don't know if it matters. I don't know if anyone's written up anything where they can... Larry, do you close the posterior portal? No, it's a waste of time. Thank you, Larry. Sexy though. Okay. Good. Thanks guys. Let's change panels. Next up we have Bill Ciccone. Bone loss. These better all be bone loss cases, Bill. Do we have bone loss? Sure. Bone loss as far as I can see. Okay. And then Bogdan, Mike O'Brien, Waterman, you're up. Thanks. Always a hard act to follow.

shoulder injuries

throwing athlete

surgical approaches

shoulder instability

Rimplissage technique

posterior portal