Hello, my name is Michael O'Brien coming to you from Tulane University in New Orleans. I want to thank our course chairman for the opportunity to present to you. I'm going to be talking about when is the soft tissue Bankart not enough in factors to consider. These are my disclosures which are also listed on the Academy website. So the short answer is an arthroscopic Bankart is not going to be enough when you have significant glenoid bone loss. It's the most common cause of failure. So glenoid bone loss over 40%, bipolar defects, especially with an engaging Hill Sachs defect and in the setting of revision surgery. It's also something to consider in the setting of an ELPS lesion where the outcomes are a little bit worse with repair. A Haggle lesion which needs to be addressed, collagen tissue disorders which might require some sort of allograft augmentation and ligamentous laxity as well. But we're really going to focus on those top three because they're the most common. Anterior instability with bone loss is a difficult problem to treat and sometimes it's hard to determine when you should scope, when you should open and when you should bone graft. So we're going to try and go through an algorithm to make this a little more simple. In general, glenoid bone loss less than 10% can be treated very successfully with an arthroscopic Bankart. 10 to 20% is that subcritical bone loss that we've learned about and that's kind of the challenging area. 20 to 30% is probably more reproducibly treated with a bone augmentation procedure such as a Latter-Jay and even the Latter-Jay has upper limits. So once you get to 30 to 40% bone loss, that might be too much for a Latter-Jay and then you're going to consider a distal tibia allograft or possible iliac crest allograft. So for the purpose of this talk, we're really going to focus on that subcritical bone loss of 10 to 20% and a lot of that's going to be determined if your lesion is on track or off track in regards to the Hill Sachs defect. As we all know, recurrence rates can be very high after an arthroscopic Bankart repair and this is most at risk for young males that play collision and contact sports. Those are the ones that have higher failure rates after an arthroscopic soft tissue repair. Burkhart and DeBeer showed us that the inverted paraglenoid is a risk factor for failed arthroscopic soft tissue stabilization. So when you have significant anterior inferior glenoid bone loss, they add up to a 67% recurrence rate with a soft tissue repair alone. Pascal Boileau also showed high failure rates with greater than 25% glenoid bone loss, hyperlaxity and the use of less than four anchors and especially in the setting of bone loss and hyperlaxity has a very high failure rate. So these are things you want to be thinking of in terms of when do I need to add something in addition or in place of my Bankart repair. So how much bone loss is significant? So Guy, Boileau and others have showed that it's often present, almost universally present in the setting of recurrent shoulder instability. Burkhart showed that 25% glenoid bone loss was the cutoff for a failure of a soft tissue repair. Itoi's cadaveric study showed 21% glenoid bone loss was a setting for soft tissue repair and recently JT Tokish has even showed that 13% glenoid bone loss can set you up for failure of an arthroscopic procedure. Tokish described this as subcritical bone loss and bone loss as low as 13% led to a worse clinical outcome with worse WOSI scores even when someone did not re-dislocate, their outcome scores were worse and it doubled their recurrence risk. Yamamoto also looked at this and found that 17% glenoid bone loss was what he considered subcritical bone loss with a subgroup of Bankart repair patients with between 17 and 25% glenoid bone loss, 17% glenoid bone loss had worse WOSI scores, the subgroup also again showed that males had worse outcome scores than females and contact athletes performed worse than non-contact athletes. So this reinforces some of those same principles. The keys to your decision making are really going to be based on the history exam and your imaging. I think the keys to history are how long has your shoulder been dislocating, has it been coming out for 12 months or 12 years, how many times is it dislocated, 2 times or 20 and what are you doing when it dislocates, does it only dislocate in an athletic position up overhead when you're playing sports or does it pop out when you're reaching over for the alarm clock and finally what are your hopes and aspirations, are you a rugby player or are you an office worker because that may determine the treatment that you receive. I think the most important aspects of the physical exam is apprehension at low abduction angles, so external rotation at the side if they're feeling instability that is going to signify significant bone loss in the shoulder and also look for hyperlaxity, so hyperlaxity in all three planes trying to determine which is the main direction of their instability. We'll always start with standard radiographs and we like to include this Bernoulliot view on the bottom right which helps give you a good view of the glenoid and this has been shown in studies to be as predictive of glenoid bone loss as a 3D CT scan. On your AP radiograph you want to look for loss of that anterior glenoid sclerotic line which will indicate some anterior glenoid bone loss. Here's a picture of the Bernoulliot view which we have this in our radiology suite so we get this on every instability patient that can get their arm in this position and it has been shown to be a predictor of glenoid bone loss as accurate as a 3D CT. The Stryker Notch view can also give you a good view of glenoid bone loss as well as a good view of that Hilsack's defect. So once you see bone loss on your radiographs then I encourage you to get your three-dimensional CT. So a CT scan with three-dimensional reconstructions, humeral head subtraction, and three millimeter cuts is going to give you the best view of your glenoid bone loss. Sagaia showed that the bottom hemisphere of the glenoid is a circle that goes from three o'clock to nine o'clock and that's going to help you determine the amount of anterior glenoid bone loss that you have. There's multiple ways to calculate your glenoid bone loss. All of these areas are pretty comparable, measurements are pretty comparable, and you can see that they're all better than an arthroscopic determination. So just estimating an arthroscopy can overestimate the amount of glenoid bone loss. So you want to determine this preoperatively based on your CT scan. I like to use the AP distance to the bare area, which is a very simple technique. You can use this on your 3D CT or even just an on FOSS view of your sagittal cuts on your MRI. So you're going to get that perfect cut of the on FOSS view of the glenoid. You measure your circle of the bottom hemisphere, measure the defect A, measure the diameter B. A over B times 100 gives you your glenoid bone loss. So it's a very simple and reproducible way to estimate your glenoid bone loss. We're all familiar now with the concept of the glenoid track. So the glenoid track by DiGiacomo, Itoi, and Burkhart helps us understand the influences of bipolar bone loss and how this can influence your surgical decision making. So the glenoid track, DiGiacomo has some wonderful videos on this on how to measure this. The glenoid track is the width of the glenoid that comes in contact with the humeral head and the abducted externally rotated position. So you measure your glenoid track and then you measure your Hill-Sachs defect. If the glenoid track is wider than the Hill-Sachs defect, it's an on-track lesion and the Hill-Sachs defect should not engage. If the glenoid track is narrower than the Hill-Sachs defect, then this is an off-track lesion and likely the Hill-Sachs defect will engage. So more significant bone loss. So what will you choose to do in a 17 year old football player with 17% glenoid bone loss? I would suggest these are the options that you have here. And this is one where 17% glenoid bone loss, probably you need to do more than just an arthroscopic Bankart alone. So when we look at our subcritical bone loss category here with an on-track lesion, you can have good success with an arthroscopic Bankart plus or minus a rump lesage based on the size of the Hill-Sachs defect. When you have an off-track lesion with an engaging Hill-Sachs defect, then you're either going to want to add a rump lesage, add some sort of bone grafting procedure, and don't forget about the open Bankart, which we'll discuss briefly. Is rump lesage the answer? So the rump lesage is a posterior capsulotinodesis of the infraspinatus and posterior capsule into the defect. So this was repopularized by Eugene Wolf in 2008. And many studies show that when you perform a rump lesage by tying the infraspinatus and posterior capsule into that defect, it dramatically reduces recurrence rates down to 4% to 8% instead of that 18% to 20% that we've seen in some of those previous studies. This systematic review that was published in 2018 showed that a rump lesage in the setting of recurrent instability with subcritical glenoid bone loss reduced the odds of recurrent instability compared to the isolated Bankart alone. And so all of these studies are looking at subcritical glenoid bone loss with an engaging Hill-Sachs defect. There was a reduction of external rotation at 90 degrees of 1 to 11%. We looked at our series here at Tulane, and when we had subcritical glenoid bone loss with an engaging Hill-Sachs defect, we had zero failures when we performed an arthroscopic Bankart plus rump lesage in the primary setting. However, in the revision setting after a previous failed scope repair, we had a 36% failure rate. So I think it's good to remember that the rump lesage probably works best for your primary procedure and in the revision setting, you may still have recurrent instability. It's also not for everyone. Multiple studies have shown you can lose 5 to 10 degrees of external rotation, so this may not be ideal for the dominant arm in your pitchers or high school quarterbacks, and you want to make sure you're passing the sutures in the safe zone, getting the sutures more in the infraspinatus tendon and not in the muscle belly. How about comparing Bankart and rump lesage to Laderge for subcritical glenoid bone loss? This study by Young-Girl Ray in 2016 compared 37 rump lesage to 35 Laderge found no significant difference between these groups with pain scores, range of motion, strength, and patient reported outcomes. The recurrence rate was very similar, however, they found a much higher complication rate in the Laderge versus the rump lesage. This study by Mazzocca and Arciero also looked at 98 patients with rump lesage compared to 91 with Laderge. All of these were subcritical glenoid bone loss with an engaging hill-sex lesion. Similar to our study, for a primary repair, they found no difference in patient reported outcomes, revision rate, or recurrent instability. The Laderge had a higher complication rate than the arthroscopic rump lesage. In the revision setting, the rump lesage did worse. So these authors conclude that Laderge appears to be a better choice in patients with revision instability surgery, collision and contact athletes, and those with 15% or more glenoid bone loss. This was another systematic review and meta-analysis in October of 2020 published in JSCS. They looked at four studies, 380 patients. They found no difference between recurrence rate, row scores, pain scores, and range of motion, however, a higher complication rate in the Laderge. And finally, this was another systematic review published in Arthroscopy in September 2020, looked at 145 studies, four of which were comparative between rump lesage and Laderge. Similar recurrence rates, higher complication rate with any bone block augmentation, and they concluded that a Bankart plus rump lesage was best when you have less than 10% glenoid bone loss with an engaging Hill-Sacks lesion, and when your bone loss was greater than 10% than a bony augmentation may be better. So most of these studies show for that subcritical bone loss, Bankart repair plus rump lesage is a good option unless it's a revision surgery. And in the US at least, there is a higher complication rate with the Laderge. Don't forget the open Bankart. So this is a 16-year-old male who dislocated in a football game with a large bony Bankart. This was treated with a primary open Bankart repair with good success. Many studies have shown that the recurrence rate after an open Bankart is less, about half that compared to an arthroscopic repair, especially in your contact and collision athletes. Robert Neviser published his work on 10-year follow-up of failed arthroscopic Bankarts, 30 patients at 10 years follow-up with no failures. So don't forget the open Bankart, especially in the setting of a failed previous arthroscopic repair with minimal glenoid bone loss. The new kid on the block is the arthroscopic anatomic glenoid reconstruction. So this is an arthroscopic bone block reconstruction without the Laderge. The benefits of this, it's a bone block introduced through the rotator interval. So you preserve your subscapularis. There is less risk of nerve injury because you do not have to dissect out the axillary or musculocutaneous nerves. You reconstruct the bone loss with distal tibia allograft or distal clavicle autograft, and it can be secured with metal buttons instead of screws. Pascal Boileau has showed us in a landmark study that dual fixation with metal buttons is as secure as metal screws. So that eliminates some of the hardware complications we can see with screws. Then the labrum is repaired around the bone block. J.T. Toka showed us that the distal clavicle is an excellent source for autograft bone. The cartilage on the distal clavicle and curvature can match your area of bone loss. So you can take a distal clavicle autograft and then insert that arthroscopically for your reconstruction. This procedure has really been championed by Ettore Tverna and Ivan Wong, and they've done some excellent work on these studies with very good outcomes. This is done all arthroscopically to reconstruct your glenoid bone loss with dual metal button fixation. They found in their studies that the arthroscopic anatomic glenoid reconstruction is faster and safer than an arthroscopic Latter Jay, and they are able to get better graft position in their hands by getting the graft a little bit lower on the face. I've discussed this with both of these surgeons, and they feel that this is a great option when somebody has had instability events for less than two years. So that means that their labral encapsular tissue is still quite robust, so you can add the bone graft and repair the labrum and capsule around it. If their instability events have been going on for greater than two years, they worry that they have capsular laxity, and then a Latter Jay may be better with the sling effect. Once you get above 20% glenoid bone loss, especially 25% glenoid bone loss, I feel the Latter Jay is still probably our best bet. It restores glenoid bone loss and, most importantly, provides the sling effect to keep the humeral head in place. It widens the track, so your Hill Sachs defect is no longer engaging. The concern is the U.S. is that we have less experience with this than our European counterparts, so there is a higher complication rate, especially with nerve injury. So I think the Latter Jay is an excellent procedure. Be very cautious with identifying your nerves, whether you're doing this open or arthroscopic. Finally, once you get above 30%, 35% glenoid bone loss, this may reach the upper limits of the Latter Jay, so then I think it's good to consider a distal tibia allograft. So in a case like this where you see 40% to 50% glenoid bone loss, it's going to be best to go with a distal tibia allograft. That you can cut a little bigger, and as Matt Provencher has showed us, the curvature of the distal tibia matches that of the glenoid, so it's an excellent reconstructive option to reconstruct large amounts of glenoid bone loss. Finally, when you have combined bone loss on the glenoid and a large Hill-Sacks defect, a combined procedure is an option, such as a Latter Jay in the front and then humeral head allograft on the humerus side. So in summary, I think where we are right now is subcritical bone loss with an on-track, non-engaging lesion. I think most commonly folks will still perform an arthroscopic Bancart plus or minus a remplissage based on the size of the Hill-Sacks defect. With an off-track lesion and an engaging Hill-Sacks defect, then you definitely want to add a remplissage, and multiple studies have shown that this is an effective way to get our patients stable and give them good outcomes. In the future, I think we're going to see more and more arthroscopic bone block, like Dr. Taverna and Dr. Wong. So this can be an arthroscopic bone block with a Bancart repair performed around it, and you can still add a remplissage for a large defect. So I think we'll be seeing more and more of the arthroscopic bony augmentations for subcritical glenoid bone loss. Once you get above 20%, then I encourage you to consider the latter shade. So remember, an arthroscopic Bancart is not enough when you have glenoid bone loss over 20% and engaging Hill-Sacks defect or in the setting of revision surgery. I think it's important to make your pre-op plan and stick to it. Rarely make adjustments for intraoperative findings because your arthroscopic assessment of glenoid bone loss may be flawed. The best treatment for recurrent instability is prevention. So I encourage you to recommend surgery after the first time dislocator. Tell them if it comes out a second time, you need to fix it. So Owens in 2015 showed that those treated earlier did better. The magic number seemed to be three. Once patients had more than three instability events, they had worse WOSI scores and worse SANE scores. So recommend early fixation. When you do an arthroscopic repair, start low, use your seven o'clock portal, and try and get your first anchor at six o'clock or around the back at seven o'clock to start your shift and take it forward. Instability with moderate bone loss, your best treatment option may depend on your Hill-Sacks defect. So consider the REM plissage or an arthroscopic bone block based on if your Hill-Sacks defect is engaging or not. Greater than 20% glenoid bone loss and revisions consider a bony augmentation procedure because a revision arthroscopic repair will likely fail. And again, don't forget the open bank card, especially for your failed arthroscopic repairs with minimal glenoid bone loss. Thank you so much.

glenoid bone loss

arthroscopic Bankart repair

soft tissue Bankart procedure

bone augmentation procedures

recurrent instability