All right, so switching gears, we're going to go back to the front here, same disclosures. So our first patient, this is, you'll see, 10 years ago, 18-year-old, right-hand dominant male, prior history of left traumatic dislocation at age 16, managed non-operatively and did okay until he falls and dislocates again, now two years later. This time he's now working at UPS loading trucks and is out on disability and it's a work comp injury in an 18-year-old, which is always fun. He's not an athlete in any way, shape, or form. He has full symmetric range of motion. He's got a positive apprehension and relocation test, four over five, you know, you could get him to the edge. I couldn't really get him to completely dislocate. No signs of hyperlaxity, no baiting issues, no surprises here. So pretty normal looking x-rays. I didn't appreciate any bone loss. I can't see his Hill Sachs lesion really to speak of, so no real concerns from me there. So, you know, this was back in the day when Balo talked about the instability severity score and, you know, I kind of calculated it. I'm like, I got to figure this out and, you know, what are the numbers and where do we go? And so he's not athletic, does occasional exercise, he has no hyperlaxity, his x-rays are normal, so he's got a score of two. So does he need a Latter-Jay, JT? No. No. Okay, good. All right. So do we want any additional imaging? You know, back in the day, MRI versus CT, so here's his MRI. Rachel, any concerns? I have lots of concerns. I always have concerns, not specific to this case, just in general. I don't love the look of his Hill Sachs. I don't... I also, and maybe it's just me and I'm terrible at reading MRIs, but I have come to get CTs on almost every patient now just to better assess the glenoid morphology and that anterior inferior glenoid rim, just to have a feel for what I'm getting into. But yeah, and so I don't love the look of his bone, but it's not that alarming where I'm worried about restoring the bone on the glenoid side. Rick, are you going to get a CT on this guy? Would I get one? Absolutely. You would? Yeah. I mean, it's based on that, you know, again, you get fooled and I would just tell you that his situation or a comp, you know, you get one shot at this. And so I would get a CT. I didn't. So here we go. Arthroscopic exam, lateral of the cubitus, you may want to turn your head sideways. But here's what we're looking at. Here's his head. I'm not impressed with his Hill Sachs lesion per se. I'm really impressed with his. What does it take to impress you with a Hill Sachs then? I mean, I don't want to see a Hill Sachs, I mean, that was pretty shallow. So posterior looking from the front, I mean, that's what it is. It's that little divot. To me, I mean, I think anybody who's come out is going to have something like that, but not too bad. So here's what I ended up doing. I did a six stitch, three anchor repair with a six o'clock anchor all the way down to the bottom and felt pretty good. So arthroscopic approach, I felt at the time was acceptable, but it's too easy. The story can't end. So he's noncompliant. He takes off a sling at two weeks post-op. At seven weeks, he says he fell, but he was okay. He's lost a follow up. He doesn't come back until his adjuster demands that he returns for reevaluation to be considered permanent and stationary or maximally improved. And he says, well, yeah, I haven't been working. I've still been out on disability. And then he says, you know, I kind of got high and I was at a concert and I jumped into a mosh pit and dislocated again now at 10 months post-op. So here's his x-rays now, you know, head still there. You can see he's got a funny looking inferior glenoid. Now what? What are we getting next? All the things. All the things. So he's got this little bony bank card, probably a little postage stamp from what I did. So we got another MRI scan and a Hill Sachs lesion is a little bit bigger. Inferior labrum, certainly patchless and not very happy. And now he's got a bigger Hill Sachs lesion there. And here we are on the glenoid side and not quite to seven o'clock, but I think my six o'clock anchor is pretty low. Am I okay there, Rick? I love it. Jake, he's got a problem with it, but I love it. All right. So that's what we have. And then you kind of see a little bit of this bony deficiency on the glenoid side. And here's our big D, little D. Can you do the math quick, JT, there? Are we okay? Yep. All right. So instability repair failures are going to occur. What about value of arthroscopic repair after a failed arthroscopic repair? We've got some data from years ago that looked pretty good. Sometimes you can do good surgery and then it's kind of up to your patient and you can't necessarily fix who your patient is. And so that's kind of the problem. So what do we do now? How'd you get that picture of Rick from college? That was awesome. That was last week. So anybody going to do a revision scope? Probably not. Not on this time. How about scope, bank card, remplisage, open bank card, bladder shea, scope DTA, or just send them away? Rick, what are you doing now this time? I'll be honest with you, you actually have some real choices here. But with the history you're giving me, I'm going to ladder shea. Open. Open ladder shea. Rachel, same? Open ladder shea or scope DTA. Yeah. JT? Yeah, I think so. I think we ignore the revision remplisage data from McCabe and Buddy Savoie with that 36% failure rate. That's just too much. So I don't like the scope remplisage in a revision setting. And so he gets a bone block. All right. So we're going to move on. So that's what I did. Here's his surgery. And it looked pretty good. Case two. 18-year-old right-handed male, hurts his shoulder jumping off a roof into a pool. Plays high school lacrosse and pales pain while he's couching. He's never had a dislocation. He's recruited to play D1 lacrosse at a Pac-12 school. Here's his x-rays. So funny-looking inferior glenoid there, right on the bottom left. We're not going to spend a whole lot of time here. Some would say D1 and Pac-12 is an oxymoron. It's not Colorado. It's a real school. It's a real Pac-12 school. So this happens to be the younger brother of case one. And their father had an unstable shoulder and had an open bank cart repair in his 20s and re-dislocated after his open bank cart repair. So sometimes you can't really predict how the two brothers are going to get along and how they're going to treat. So the older brother was non-athletic and was a partier. This guy is an athlete. He's competitive. He has a little bit of bone loss, and his severity score was a seven. So here's his MRI. Rick? Well, I mean, he's got some bone loss, there's no question about that. And I think he's got the heel sacks, again, from these angles, hard to tell, but not as impressive. And then, you know, soft tissue bank cart, big bank cart. And he's got a bank cart lesion. He's got a little loose body there on the bottom left. You can see a nice loose body there. His glenoid doesn't look too bad. I mean, you know, and not really much of a heel sacks lesion there on the axials. And, you know, I tried to get all three sequences, but not a whole lot from a bone loss point of view. And then here's some coronal sequences, and he's got this big loose body. Now, again, he says he's never come out, you know, he's never had a problem. He's getting catching and pain, and he's getting ready to go play his freshman year this season. So are you going to operate on him, JT? What month are we in? It is July or August. So he finished high school. He finally said he should probably get this checked out before he leaves for school. Well, if we operate on him, he's probably missing that first developmental season. So I would say in this kid, I'd say if you can play, play. We'll fix it later. All right. So it's July. He's leaving for school in five weeks. Let him play. He's a goalie, so he's a lacrosse goalie. Any benefit of a brace? Would you put any kind of brace on him? No, we publish that. It doesn't work. So he elects non-operative management. During fall training, his shoulder locks twice. Mom calls and says, be prepared to do something over winter break. We've got to fix him. So what are you going to do, Rachel? I think this is the classic case of shared decision making. So I think if you could do option number one, if it's truly mechanical in nature and he's not coming out, and it's locking and mechanical, you could say, I'm going to scope you, clean this out, and see how you do. I don't think that's going to be successful. And I think what I say to patients is, if I had a crystal ball, I think you're still going to have problems. And so we have to decide, do we want to get you rocking now with a definitive surgery? I think the big question in this case is, what is the definitive surgery? For a lacrosse goalie, which is more or less a contact sport, but not like football, I think your options here are open, kind of wide open. In terms of if they want to play that coming season, meaning four months from your operation, I'd probably tell them, I can't predict that you're going to play if we do any sort of stabilization. But a bony procedure might give them the quickest return to play. So no real bone loss, that little loose body, you're going to tell them a Latter-Jay? I'm going to put that on the table. And the reason I put that on the table is the data from around the world. So you can do, and people do do, a Latter-Jay without bone loss in these athletes for this exact reason. And that's because soft tissue procedures sometimes, or many times, fail in the contact athlete. So I would put that on the table as a procedure. Now there is, and I don't mean to prolong this answer, but there is an ongoing randomized clinical trial that's multi-center based out of Canada called the STABLE study. We're a part of that, trying to answer this exact question. Patients with minimal bone loss, first time surgery, scoped stabilization with Remplissage and Bankart repair, versus Latter-Jay. And that's the kind of data we need for this particular procedure. Ice is a seven. Seven. Yeah. It's real. It's real. You know, this is a real challenge. This is kind of like, everyone comes to the right lower quadrant pain, you take their appendix out. You know, you can't just do a Latter-Jay on everybody that shows up your front door. The fact that I've had a goalie in lacrosse who's in an incredibly physical position, quick movements, very sharp, very sudden overhead. So you know, this is a guy who said, listen, you want one operation that works, but it, you know, these are the, and he says, yeah, doc, one operation, and I don't want to worry about it again. He's going to get a Latter-Jay. If I said, I can get you close, but you have a slightly higher success rate, I would do the Remplissage and Bankart. But a lot of these guys, goalies, what have you, polo, they say, hey, you get one shot at it, and it'll never happen again, no matter what I have to go through, one shot. So that's what we did. And very happy, except the story continues. The younger brother returned to the team, played the following season, did great. Very happy. Bound the big brothers back. He went back to work after his Latter-Jay, but remember, you know, his favorite pastime. So here we are, while swimming in the ocean, he gets caught in a riptide, and he's fighting to get out of the riptide, and dislocates again. This is older brother. Older brother. Revision Latter-Jay. Revision Banker-Lazard Latter-Jay. It's his other shoulder. It's like, you know, a story for Hollywood, or what is this, you know? It's his other shoulder, at least. So again, X-rays, normal. I mean, really not much going on. I know it's his other shoulder, but like Abrams, did you take the opportunity to operate on the first shoulder, again, just because? Is Jeff still here? He's in the back. He couldn't handle it. He's in the very back. He couldn't take it. Sorry, buddy. All right. So MRI, little bony, little bank heart. You know, again, shallow Hill-Sachs lesion. Not anything too bad. No messing around time, too. That's right. So that's the end of the story, at least at this point. The younger brother never popped out his second side, at least as far as I know. That's a great case. Great. Thanks for sharing. No, stay up there. Any questions on Mark's case? Those are, I think, a lot of important points about decision-making. And I think Rachel hit on it. This is a shared decision-making. Many of you sit down with the families and the athletes, and it's just so hard to impose your will because there's no right answer oftentimes. And clearly, everyone has sort of different goals. And if you get the family involved and the patient involved, no matter what happens, everyone can accept the consequences. I think when you tell someone, this is what you have to do and it doesn't work, you're in hot water. So I think the shared discussion is important. I think it'll be interesting in three to five years to have a similar ICL and see. All of us, I think, are favoring bone blocks. And all of us, I think, were excited about the Latergé in those cases that were just presented. But will that shift to arthroscopic free bone block transfers? Will that be the gold standard for these patients in three to five years? And I don't think we're going to know that until we get that longer-term data about resorption, recurrence, complications, cost, et cetera, all the things that matter. But I'd be very interested in this same conversation in five years. I wanted to ask from the audience, any questions about any of the topics or cases that have been presented thus far? Yes, we have a couple here. A lacrosse player. Did you scope that? Did you have a full inferior glenohumeral ligament avulsion all the way around or just coming out because of family problems? No, no, no. So he had a minimally displaced Bankart lesion, but I ended up having to scope him because he had that loose body. And I never know that I'm going to find that loose body when I do it open. So I actually scoped him first, took out the loose body, and then went ahead and did an open Latergé. And he did have a Bankart lesion, but I ended up doing that and he was fine. And like J.T., I don't put the capsule back. I just did kind of a classic Walsh-style Latergé. Great. Can I ask the panel, do you guys all scope every Latergé? No. I do. What are you finding? Do you want to do a REM plasage with it? Yeah, I consider REM plasage in some of the Latergé cases with the bigger Hillsex lesions I'm worried about some of the data that's been presented. The other is obviously if you have a labral pathology, extends up to the 12 o'clock position, you can't get at it through an incision. So I'll put that slap lesion, so to speak, down. And I know Tony mentioned something about why do we use slaps, whatever. The biceps has been shown on a number of occasions to be a very important stabilizer of the shoulder. That is one role that's been clearly identified. So if you have instability and you have a slap, and you're trying to fix that problem, that slap has to be in the equation. I saw that you did the slap repair for the instability with the posterior suture. And we've been taught to go away from the anterior part. Would you consider going all the way, like a sling for the entire biceps? Certainly, you can be more aggressive on that side as a non-throwing athlete. We're talking about stability. But at the end of the day, if I can accomplish that by putting it on the backside of the lesion as opposed to in the front and avoid getting too tight or overly tight, then I think I'll choose that. Yes? For me, no. So I do all my work on the latter of the cube, but I've got to flip them. I used to do the latter J arthroscopically, and I've just got to tell you, I do it better open, and so I turn them over. I'm sorry? Yeah, they're supine. I have to actually change and drop them down and re-drape. Yeah. If it's just to take out a loose body, then if I'm not planning anything else, then I would consider scoping them in a beach chair position and then going right to my latter J to save some time. But if I really feel that there may be superior labral pathology or something, I'm going to be much happier doing it lateral of the cube first, and then I'd open them and do the latter J reposition. Great. Yes? Can you turn the mic on? Where is it? Hello? Yes. While we're on the topic of lacrosse, I know it's a contact sport, but what you need to know is the goalie probably has the least amount of contact of any player on the field. No, I'd agree, but what they have to do with their arm in terms of defending that goal is very sudden, sharp motions up, down. So there's a tremendous amount of, I think, episodes where they can dislocate or at least have that dislocation mechanism come into play. That's why we at least let him try to play that season as a goalie because I felt he may be able to do that and he might be just catching on that loose body but it didn't end up working. You know with that we're up against a hard deadline here. I want to thank you all for being here today. I hope we've answered some of your questions. We're here to answer any more as we come off the podium or if you have questions. I want to thank the faculty. They're just not only great surgeons, great minds. They're the most wonderful people and I'm honored to be part of this. So thank you all and I hope you enjoy the rest of the meeting. Thank you.

orthopedic surgeons

shoulder instability

traumatic dislocations

arthroscopic repair

shared decision-making