All right. Good morning. My name is Rick Ryu, and I have the pleasure of moderating this session. And so thank you for being here. I know it's early. And I think we're going to present some very interesting cases for discussion. And we very much enjoy your participation in some of the discussion. And I'd also ask that at the end of this, we'd ask you to please take the time to go online and do an evaluation of this ICL. So thank you in advance for that. Does he advance the arrow? What do I need to point it at? There we go. We all have disclosures, and you'll see individually. Now, what I wanted to do here, and I can't get this to advance there, is I really want to have the very best faculty possible, and none were available. So I had to invite Dr. Patskowski, Tokish, O'Brien, and Parada. So you'll have to go with the B team here. No, all kidding aside, they really weren't my first choice. So here we are, and we're going to talk about, as soon as I get this back, we're going to talk about some interesting cases. And these are ones I think that kind of, thank you, stymie all of us. And this is the format. Short presentation, discussion among all of us, and then we're going to ask the presenter to tell us what they did, and then we'll basically try to get to at least four good cases. So Dr. Tokish can't be here right now, and I can't tell you why. My guess is he has another obligation, but I'm sure he'll be here shortly. And for that reason, we're going to jump right past him, and we're going to jump into Dr. Parada, who is going to take us through a very interesting, let me get through this here. Here we go. Thank you very much. Thank you, and thank you to all of you guys for being here. And so my name is Steve Parada. I'm from the Medical College of Georgia down in Augusta, Georgia. And so I do have some disclosures. We'll try to make them not irrelevant to my talk. So our history, this is a 16-year-old. He's a weightlifter. He's a pretty big guy. He's got right shoulder pain instability, and he undergoes a posterior labral repair about four months ago. And then a month ago, he, a freezer was tipping, and he catches it, and so he has a posterior force on that operative arm, and now he's complaining of actual daily dislocations. And he can actually self-reduce these. Medical history, he just has this Burkitt lymphoma that he's been cleared for for years. So on exam, he gets up to about forward elevation of about 90 degrees, but then he stops due to this apprehension, but then he can dislocate in clinic. And he's not a volitional dislocator. He's just a positional dislocator. He gets up past 90, and he just falls out the back. No appreciable anterior translation. This is unidirectional. Good strength in all planes. Sir? Good morning, sir. I'm a couple minutes late. I got caught up just a little bit coming up. Not a problem. No scapular winging. He's nervoscularly intact. Sit me next to O'Brien. I don't want to sit. Jean's too smart. She hits me when we're talking. So nothing. We're trying to trick you on physical exam. These are his images. You can see, again, how young he is. This is, axillary radiographs are tough to get in my clinic, and so this is admittedly not a great axillary radiograph. And so this is his MRI that he brings with him that's before surgery. And so you can see his posterior labral tear that was there before surgery. I got a CT scan, and so here's his current CT scan. You can see his anchors, and you can see his glenoid version. And so when we're looking at this, I think 3D CT scans are very helpful whenever we're looking at bony anatomy, the morphology of the scapula, and glenoid. And so as we look at this, a lot of times we talk about the best fit circle. The best fit circle, you know, in a case like this may not help us as much in a case like this. So this is a dysplastic glenoid, and so maybe this is an incorrect assumption, and that's hard because that's our first assumption that we make whenever we're trying to measure bone loss. And so assessment on this patient. How would you, in your mind at this point, O'Brien, what do you, how would you describe this guy, what he has? He's got, as you said, a very dysplastic glenoid. And so can you go back to your x-rays for a sec? You know, when you see on the AP x-ray, you can even see it on that CT cut. He's got no glenoid neck, you know, and so he's got no glenoid neck, and he's got a hypoplastic retroverted glenoid. So he naturally wants to shift out the back. And usually I think these guys present a little bit later because when I see this, I'm worried because this guy's going to end up with arthritis. And there's nothing that I know that we can do to change that natural history, but maybe we can buy him some time. So then if you go to your CT cuts, you know, he's got a recurrent posterior labral tear and fragmentation of his glenoid in the back. And so this is something that if he's ready to proceed with surgery, which it sounds like he is, he can't raise his arm up above 90 degrees, I would think about a posterior bone block, like a posterior DTA, distal tibia allograft. But I kind of lay a lot of crepe with these, especially when these guys, it's hard at 16 because he's not going to listen to anything you say. But when they come in and they're in their 20s, you're like, this is a bad player. You know, I've never done a glenoid osteotomy for something like this. So that is not something I'd be comfortable tackling, but I tell them like this shoulder is going to give you trouble in the future. Yeah, I think it is tough because we don't have great known natural history on how often this is out there and not seeing us. We just know the patients who come and see us. And I agree, 16 is very early to have this present. And I do, like you, I worry about these guys, like what happens in the long run with them. And so again, he's, you know, we have kind of that absolute number of 25 degrees in the literature, after which we call something retroversion or call that amount of retroversion dysplasia. But there are certainly patients who have dysplasia, even if they don't have 25 degrees. And this is this guy's, and again, percentage of bone loss, I think really hard to quantify JT. Do you have, do you, when you look at this, are you trying to calculate percentage of bone loss in this patient? Are you, does that factor into your, to your equation? Yeah, we looked at this and tried to do it with perfect circles. Adam Hines is the lead author on the paper and found that subcritical bone loss didn't matter so much in terms of dislocation stuff, but it did matter in terms of return to duty. The challenge with these guys is that I think it's a different animal posterior. It's not the bone loss as much as it is the retroversion and the slipping off. And one of the things that's really concerning about this guy is the amount of subluxation he has posteriorly. Now, when you do the labor repair, you may well be able to center that, but that labor repair will sag. So I think you're right. I think sometimes this is a making the dance floor big enough where he can't dance off of it. And then the other thing you notice is that gouge in the front. So this may be a rule for a reverse rim massage. You know, if you're going to do an all soft tissue, the concerning part about this young fella is he's young. If they're 25, you can say, well, this is the way the good Lord made him and he's done pretty well up until this time. So let's do a, you know, Hawk used to say small problem, small operation, big problem, big operation. This kid's 16. He hadn't even made it through sophomore year of his high school. It's a big problem, big operation. He lifts weights. He's like 6'3", 240 pounds. He's a big dude too. And in the beginning, you missed the beginning, but he's already failed a posterior labor repair as well. And so, and again, this abnormal bone ridge, I have a, when I see something like that, I have a hard time, you know, thinking that that is, that he's getting much stability from that. So even though he has that bone there, that's almost like that medialized bone that we see, like with a bony Bankart, that even if you can see it, I'm not sure it's still offering him any, any help. So these are the surgical options, you know, typically that we would think of. You could revise his labral repair. He's had a good repair done by a good surgeon. Open posterior labral repair, glenoid osteotomy, like Mike talked about, or bony, or bony reconstruction. And so Gene, is there anything on the other for you? Obviously you're still active duty. You see a ton of these guys with instability and you see them early. And so are there any other treatment options that you have that, that you consider or, and is one of these your go-to? Yeah, I would say for this, that the bony posterior reconstruction is probably going to be my go-to for this. I think that there's not necessarily something else that I would jump to that I would say has a lot of evidence, evidential support for it. Because, and I think you really have to just be careful with the capsule here, because like you said, someone's already been there. We know that the posterior capsular tissue is very thin to begin with. So I'd anticipate you'd put some stitches in, it would look great, and it would immediately fail. I think that this person is probably likely to continue to lift weights. If they're like my population, you're going to tell them to stop and they won't. And so usually I try to get them to say, can you at least stop doing one rep max bench press competitions? And maybe I can succeed in that space, but that's about it. So I do think bony augmentation is going to be necessary here. I think it's a good choice. For our audience, how many of you have done like a bone block procedure in the back of the shoulder before? And of those, how many people have done that through the scope? And so mostly open in the back. And so how about for our panel? So everybody on the panel is picking a bone graft for this patient? Yeah. And so let me ask, what graft are you using then and are you going to do it open or through the scope? You can start, Mike. Yep. I would do a distal tibia allograft and I would do it arthroscopic, lateral decubitus position. The key in doing this arthroscopic is you have to make, you really have to elevate the labrum up to get your bone block in. So you'll have to kind of elevate that labrum excessively anterior and posterior, almost 12 to six. The thing that's a little bit easier about a posterior one compared to anterior is once you lift that labrum up, you can bring the bone block in under the labrum and the capsule. So you're lifting it up to get it lined up perfectly and then you can either repair the glenoid, repair it back to the native glenoid or to the bone block. But I use screws for this with one of the commercially available systems. Posterior approach under the labrum, two screws for the bone block and then repair the capsule in the labrum back to the native glenoid. You put in a, you pay $7,000 for fresh cartilage and a DTA and then you cover it back up? Yes. Why do you do that? I'm not sure it's the right answer. To get a little extra tightness of the posterior capsule and IGHL to try and shift the anterior. It's early to dig in like that, Steve. I mean, 7 a.m. and you, yeah, I mean. I know, it's tough, it's tough. It's like right at it. There's accountability right there. 7 a.m. on Friday, let's get to work. Come on. Yeah. If you're going to cover it up, then maybe a graft that you don't need the fresh cartilage. I mean, for the DTA, right, we're paying for the cartilage. That's the cost is we want live cartilage cells to put in there because we think that's the important part. But if you don't need that, is there other graft, you know, that you could use or? The other reason I choose the DTA is the density of the bone, you know, and it's a big graft so you can cut it wedge-shaped so you can get some of that natural concavity of the posterior glenoid and then you don't crush it with your screws. But I still cover it up. Jean, do you do anything different than that, hopefully? A little bit, oh jeez, okay. They called me the mean one. Should I scoot down a chair? Let's just go back a couple minutes here. Should I go down there? Yeah, no. So I will do this case in beach chair and I will also scope it first, I would almost say more arthroscopic assisted and kind of a mini open delivery of the graft. I like to use the arthroscopic instrumentation to do all that labor elevation and prep and I think the other thing that can be really hard, especially these post year ones, is that a lot of the commercially available systems and the jigs are really designed to give you that anterior graft, which doesn't always sit as well post yearly, especially in the setting of a dysplastic glenoid. And so trying to use your instrumentation to figure out when do you actually have that right slope to the area that you've prepped, that part can be tricky. And so sometimes it looks good right on that joint surface, but as you track medially, there's a gap there. And so for me, I've just found almost just doing that standard arthroscopic coming from my anterior superior lateral portal and just coming down to such a nice angled approach to do a lot of that prep, that I can save a lot of that work by doing arthro, or save time by doing arthroscopically. Yeah, that's a great point. J.P. Well, I think this is a hard case. And I think the reason it's hard is because you gotta commit. So when you make your recipient site on the glenoid side, you're gonna be removing a lot of bone in order for the carpentry to match. And that is sometimes breathtaking, the amount of bone that you're gonna remove volumetrically to do that. A couple of things, one, couple of tricks. One is view from the mid glenoid portal. And if you're gonna take a burr to it, take that through the anterior superior portal. It's magic how parallel you are to the back. So that's one little trick to make sure you're getting a parallel shot down the back. Number two, we will use the low profile reamers. And after we've drilled our pins from the back, we'll take the low profile reamer and bring it in and create a concentric circles, which will give you a perfect routing on the back so that graft is flush. So that's two. The third thing is- You're doing that, can I ask you, you're doing that from the back, not like when you're doing it from the front where you come in post earlier to do that. Right, yeah, we can't get the angle from the front in order to get parallel. Right, so we would do that. We would do, if you're working from the back, we don't do a flip cutter. We just take just a low profile reamer. Now you're not trying to drill a tunnel. You're just trying to flatten that bone and then you get two concentric circles and that's how we get the carpentry. What size is that reamer that you use? 13. 13. Yeah, so usually if you get 13, concentric circles, it'll give you 25 by 10 by 10. That's what we're looking for. That's great. And then a couple other things. One is that people say, well, I do it arthroscopically, but if you do it with screws and you just stick it, you're putting a big hole in that muscle. So I believe strongly we put a portal in the back and we have to put it in on FOSS and then we have to flip it. So how do you do that? You put a suture anchor in through the hole, pre-drill your graft through the hole so you put it in. And then once you get it in, then you can take a wire and place shish kebab in it. And once you've got that, then you're down. And I've done it both ways between soft tissue and screws back there. The screws are easy because it's, again, straight line and a good way to go. And so I think I would say at this point right now, I would say I prefer screws, but I think we're gonna get there with the soft tissues before we go. No, I think those are all great points. And so I went open. And I think part of the problem for me in these real dysplastic ones is I worry about matching that. Of course, we're not trying to, in that axial plane, we're not trying to bring that glenoid bone block to kind of block or push the humeral head. We're trying to extend it out. And that gets very medial in these patients. And I think that's hard to see with a 30-degree scope. Can I ask you on that, though? Yeah. So there've been a couple of procedures that have been out there to consider. And the fact that when we first started looking at posterior bone loss, we noted one of the procedures that was up the back as a true block. Yeah. The other thing we now know, some of the work by Dickens and the guys out at Reed have shown us that if you have a low angle of your posterior acromion, you don't get posterior instability. For sure. So I wonder, we all talk about these beautiful reconstructed dance floors and everything else. We make them look perfect at time zero. Yeah. But I wonder if that block concept of a big bony block, i.e. the acromion, or maybe something else that we put back there, maybe we should be doing something like that to give that a little bit of a push. I think, for me, my experience is however the humeral head looks on their preoperative CT cuts, that's where the humeral head stays. And so I've gotten aggressive early on with trying to kind of recreate the contour of a normal glenoid in these patients who probably never had a normal glenoid, and try to really bring my graft in to kind of replicate that concavity and watch them grind down their humeral head on that block. Yeah, I'm gonna put our fellow on the spot here because we're working on something right now. The problem with the concavity is it's in the wrong direction. The distal tibial allograft, anyway, is beautifully concave, 90 degrees to where we need it to be concave. So Alex Hoffer, who's here in the audience with us, is working on the congruent arc DTA. So I hope we, now we're on the clock, buddy, because now everybody's gonna go home and go, holy crap. So, right, so we all want that thing to go, and we all, you guys have all seen the video, and I love Matt. We see the video, and you got the distal tibia hanging out on that humerus, and it fits perfectly, and he says it recreates and matches the radius of the curvature. Well, who gives a damn about the curvature of the humerus? We're trying to match the radius of curvature of the glenoid, which it does not do. What we want to do is bring that, we want to bring that thing the other way, so maybe we need to cut that distal tibia graft 90 degrees to where we're cutting it, so you do get that slope that you're talking about. Otherwise, you're getting an up and down slope, superior to inferior, not medial to lateral, anterior to posterior, which is where we need it. Interesting. I have a question for you, JT. Don't tell Matt. The idea about that posterior hang of the acromion providing some stability is really interesting, and some people will take their bone graft from the scapular spine or posterior acromion, so is that a bad idea? In a patient like this, because you might be destabilizing it further. The Tedger-Rottel? Pardon? The Tedger-Rottel, the reverse Latter-Jay? Yes, yes. The Tedger-Rottel. Well, you know, for the audience, so Christian Gerber has talked about the acromial morphology and if it's high and flat, the instability is a risk, and if it's low and squat and tilted, it actually blocks you from dislocating posteriorly, so you have to look at acromial morphology and whether or not that may be a contributing factor to these instability cases. The other one, this is a tough case, but in standard recurrent posterior subluxation, and you fix it, and all of us do that, and we get a good result, those results are not durable, and you can tell your patient, hey, listen, for three to five years, you're gonna do pretty well. At 10 years, is it 30 some percent are pretty dissatisfied? That's a big number. So, you know, we're kind of talking about a very tough case, but just for the routine posterior labor repair, the result's great for the first few years, then it drops off, and you have to look at your acromial morphology. One of the things that we're learning about in the front anyway, right, is the role of remplissage. We're all still trying to figure out exactly where that role, do you guys, do you see, let me just ask you, Steve, do you see a role for reverse remplissage, and if you've done a bunch of them, has it equaled its results on its anterior counterpart? I have not done a bunch of them, certainly. I've done maybe, you know, a couple times. That's usually, obviously in the front, we're trading articular cartilage, you know, most of the time to put that in, and so I've not done that, but I bone graft pretty aggressively on the humeral head for those, you know, for those reverse Hill-Sachs lesions. Steve, can you take us through this, your technique, because I want to get the gene. Absolutely, so again, open for me, again, I've had some of these patients that are 40 degrees retroverted, 45 degrees retroverted. The angle is so incredible. You have to do, just like JT was saying, you have to do a lot of sculpting, and that can be hard to do arthroscopically sometimes, and just hard for me to feel like I do it perfectly, so when they get real retroverted, I end up doing them open, and I just think it's easier for me to put that graft exactly where I want. That open approach, we don't do it very often, but it's, honestly, it's not hard. You can see it's medial to the posterolateral corner because of the retroversion, and so if you're doing it through the scope, you can easily drive a switching stick just all the way across the joint, and then you know exactly where to make your approach, exactly where the deltoid split and the cuff split is going to be. Otherwise, you kind of get used to it just based off your pre-op template of where the glenoid face is in relationship to the posterolateral chromium, so vertical split through the fibers of the deltoid, horizontal split through the cuff, trying to save capsule, and when you have your retractors in, it's just basically the reverse of your retractors from the front, like you're doing a Latter Jay, and then you get this visualization, and you see just that irregular contour of the posterior glenoid there, what we're looking at, and again, I think that's hard to manage through the scope, and so practicing in labs, for sure, after we rasp and prepare that, we bring the angle in. I use washers with these screws, so I don't mind which end of the tibia fits best. Before, we always used to try to save the lateral aspect for our screws. Now we know, we've done biomechanical studies, if you use washers, that's better than retaining the cortical bone, so I'll do whatever it takes to match the contour and then use washers. A lot of times, just like JT was saying, there's kind of mismatch of too much concavity here, so we'll use a fresh 20 blade to come in and just kind of sculpt that cartilage a little bit and make that fit perfectly. Sculpt the cartilage? Yeah. Just to hold you accountable, since you were teasing him about covering the cartilage, you're making the problem, and now you're taking it away. He's just taking it away. I'm way out on the end. You make the problem go away. I'm a skeletal cosmetologist, JT. And so, I've got my screws, I've got my washers, I've got sutures there to repair the capsule. I bring the capsule back and then close the cuff over that, and then after you've closed the cuff, you can repair your deltoid split as well. And then we get them moving passively very quickly because we don't want this to all scar in. And so, get my radiographs afterwards. I use metal screws as well. Again, I'm not really trying to bring that up like a block. There's a lot of controversy about that just because we don't know. Three months post-op, he's doing great. He says his shoulder feels like a normal shoulder. He wants me to do the other side where he has the same thing, less symptomatic. He hasn't had a labor or repair. Eight months post-op, he gets involved in an MVC. And so, he gets a CT scan in the ER. He wasn't really having any symptoms, but it was cool. I don't routinely get CT scans on all my patients now like I did when I was in the Army. It's just a little harder. But you can see, we talk about all the time the glenoid wants to go back and look like a glenoid. And so, the lysis around the superior screw is something that we see. But again, maybe we need to be crafting these grafts to look more like an oval and not a block out there on the far side because we do get the lysis. But I think he's, I would say this is healed. One of the things I think is hard is to say when a graft is healed. We did a study where we tried to look at our healing rate and no one could agree on what that meant, healing rate for these. But he's two and a half years out now. Now he shadows me in clinic because he's applying for PA school. So we got him to stop doing all those things he was doing. So I guess my last question, if we have a second, starting with you, Dr. Ryu, is would you take the screws out prophylactically in this patient at this point? Do you worry about leaving those screws in there? I know that superior screw, the head is, you know, with that graft lysis he's had is a little prominent. Do you do that routinely? If he's asymptomatic, I'd leave him alone. Leave him alone? Yeah. Is that across the whole thing? His young age, even though he's two and a half years out, he's like 18 and a half now. That's why you want to open up the genie box again. You got a home run, leave him the hell alone. Don't poke the bear. Yeah, that's right. Mike, I'm gonna have you do it from there. Hey, that's a great case. That's a tough case. That's it. I think that's as difficult as you get. And I think your open approach, you know, I think JT was referring to it as well. Steve, the bone loss on the backside is not parallel. In the front, it's parallel. It's easy to do a sort of zero degree scope and get it right. In the backside, it's at an angle. So when you take the bone down, you're taking down a lot of bone and you start to doubt yourself like, man oh man, am I making this a whole lot worse? So when you're there, know that everyone's there, but you're taking a lot of bone down. John Conway? Yes. Go back in there, you're trying, you didn't have to sleep. I don't think you can. I don't think you can't tip it up the way you are thinking. In other words, unless you shape your graft in a very particular way, you are essentially extending the back porch or the front porch so it can't slide out. That is all you are doing. This is not restoring a normal anatomy. This is basically adapting your anatomy to prevent recurrent post urine instability, but I agree with you. Or we cut it 90 degrees. I use 3D models, so I haven't created a 3D model that I can work off of. It is very, very helpful. If you cut it 90 degrees, then your slope does come medial lateral, so your slope does come like this. That is what we are fooling with with the congruent arc now. You can actually build up the natural slope of the glenoid to do that. That is one option. Then, I guess, if you are really concerned about it, you could leave your graft proud, which is always, of course, a no-no, but if you are going to put your sutures and your capsule over it anyway, then you have got a little bone, and that is that little bone block construct. Christian Gerber actually does an acromial osteotomy now to bring that down, to block that in the back. That has nothing to do with bigger surfaces or anything like that. He is just trying to create a mechanical block because he believes so strongly that the angle of that acromion blocks you anyway. There may be truth to that. I think that these are sometimes the most challenging when you have a posterior, especially in a 16-year-old. I applaud Steve for taking on and sort of being as aggressive as you were, but I don't think any other procedure would have done it. With that, we are going to pass over to Mike. Mike, can you? I think we are going to move ahead a little bit and try to get the rest of the cases in. Yes. I am not nearly as skilled as Steve Parada, so this is a much more straightforward case. Revision Bankart makes sense sometimes. These are my disclosures. This is a case that you have all seen. This is an 18-year-old right-hand dominant high school wrestler. I did an arthroscopic Bankart on him one year prior, returned to wrestling, and in the state tournament, he had a traumatic subluxation. He finished the tournament, comes back in, but he still feels unstable. Now he is a couple of weeks after the tournament. He claims he no longer plans to wrestle. His wrestling career is over. He is going to college just to be upright. Never trust no one. He feels unstable anteriorly. He is about two weeks after his subluxation, and it was, in his mind, a subluxation that didn't come all the way out. No one had to reduce it for him. He has got full range of motion, normal rotator cuff strength. He has got apprehension way up high, so he can get his arm up overhead, but he has got apprehension. Positive load and shift with his arm up overhead, negative jerk test. So these are his radiographs, and I made little outlines of where his previous anchors were. So he had a three-anchor Bankart labral repair that was from about, you know, 3 o'clock to 6 o'clock roughly. J.T., when you look at these, this x-ray on the right is a Bernoulli view, so the middle one is lateral. Do you appreciate any bone loss? Your Gracie view, it doesn't have the little convexity that I'm used to seeing, but I'll be honest with you. I think the x-rays are, I'm not going to say useless, but almost useless to me. Yeah. Sorry. Fair. There's a gigantic hill sack sitting up there that sometimes keys me in, but again, I'm getting a, especially a revision, I'm getting a CT and an MRI on every one of these, so. So here's his MRI, and the axial cuts you can see, he's got a recurrent anterior labral tear. The other ones I included on the bottom right, he does not have a haggle. He does not have a rotator cuff tear. And you can see not much bone loss, so less than 10 percent bone loss on that axial cut. Jean, would you get a CT on this? I still would. I think that the resolution Yeah. Parata, anything to add? No. No. I always get a CT as well. Yeah. So I did not on this one. Did you do REM Passage on this? No. I did not. So this was a pure soft tissue anterior vein cart. Okay. So Mike, 3D MR versus 3D CT for bone loss difference? I don't have 3D MRI. So the data supports that 3D MRI can be as accurate as 3D CT. We don't have 3D MRI. Yeah, read by a good MSK person, the 3D MRI will bypass a 3D CT if you have it available so you can at least cut some of your costs. Yeah. And so that might be nice and we might be seeing more of that because you always worry about the radiation, you know. So I think the options for this going forward, you could do a revision vein cart. You could do an open vein cart. You could do a bone block. You could do a Latter Jay. Did I miss anything? So if you were to do a 3D CT, what would you do for this with the limited information that you have? Yeah. So revision, I think he's a contact athlete wrestler so an arthroscopic vein cart alone I think is tricky. And for me, this guy gets a Latter Jay. Yeah. Jean? I would love to have the CT scan to know for sure. I think I might be tempted to try a revision vein cart if I did a REM Passage at the same time, but I think with a low threshold to convert to Latter Jay. Steve? Yeah. I mean, so for me, I do instability lateral and so I can't convert intra-op, you know. So I'm going in with a plan and then executing the plan, but I don't remember the last time I've done a revision vein cart of a well-done vein cart. I think every once in a while I'll see a vein cart that has like two anchors that are both above the equator and I think maybe they just didn't have a true shot at doing well from a vein cart. But that's rare. You know, in our town, we have a lot of ex-military folks that do a great job doing those, so I'm doing something bony. Yeah. I think that's a really great point because one of the things you want to think about is why did this fail, you know? He did have a traumatic injury wrestling, but you want to be really critical of the workup. Bone loss is number one. Second would be an inadequate reconstruction, so too few anchors, anchors not low enough, anchors not in the right place, or was there a missed haggle or a rotator cuff tear? Rick, what would you do for this? You know, what I wanted to point out is that the bank cart is a terrible weapon if it's used improperly because everything you're going to hear is if your bank cart fails, all your alternatives afterwards, you're kind of screwed. Your Latter-J, if you do a primary Latter-J or you do a Latter-J on a revision basis, it's twice the failure rate on the Latter-J if it's a second procedure. The revision bank cart after a bank cart, the failure rate is somewhere between 35 and 45 percent, and I think, I mean, not JT, but I think Slavin and Dickens got rid of the, eliminated the bone loss factor, and their failure rate was 42 percent. So going after a failed bank cart, whether the bank cart, even if you have a remplisage, you're in trouble. In Mike's paper, Mike, did you do that with the buddy? Yep. That failure rate, if you added a remplisage to a revision bank cart, it was 36 percent. In the primary group, 0 percent. So adding the remplisage early on, yes. So my message to you is if you're going to do a bank cart, know that it's the right patient and you got to do it really, really well because if it fails, that person's in a lot of trouble. So here we are, you got to do it right in this case. So I would not do a Latter-J. I'm a non-Latter-J guy from the standpoint of if you have decent soft tissue because it's a deforming operation and long-term consequences of OA, arthroplasty, all those are problematic. Return to sports, throwing athlete, problematic. For me, this is a DTA on a revision basis and I would basically DTA, remplisage and fix the bank cart so the bone blocks extra-articular and then that gives me the best chance of restoring anatomy and not subjected to a Latter-J in this setting. So probably the most common reason I do a DTA is a failed arthroscopic bank cart. Do you, Rick and JT, do you worry about the amount of bone you would have to take away? So for your Latter-J or your DTA, he's got a pretty normal contour of that anterior inferior glenoid and my concern was I'd be removing a lot of bone to add bone. So you certainly worry about that because, in other words, if it's a normal glenoid or relatively normal glenoid, let's say 10% and you're adding a big bone block on, it's non-anatomic. So number one is I could take, I feel comfortable taking a little bit of bone away, maybe two or three millimeters and my bone block is a little bit less wide. So I try to make it so that there's less presorption, so to speak. JT? Yeah, I think you're committed. I think in order for the carpentry to work and for you to get that allograft to heal, you have to have a flush surface and that requires a volumetric just explosion sometimes and that's troubling to me. So if it's got normal bone, that's why I said Latter-J. Secondly is I just don't have, I don't think we have enough data on contact athletes. We do in the Latter-J. We know what the return to sport rate is, which is not perfect but pretty good and we know what it is after, in the setting of revision arthroscopic bank cart. We just don't know in the contact athlete with the DTA remplissage, which is my natural thing that I want to do in everybody, but I just, you know, this is an 18-year-old kid. He's already lost once. He's got one more shot. I have an operation today right now that I don't have to validate. We're working on the validation of the other one, but just today as we speak, that's where we are. Yeah. Okay. Pull the audience real quick. Recurrent instability with 10% clonide bone loss. Who would do a Latter-J? Most. Who would do a revision arthroscopic repair? Just you. Rick's going to yell at him. You're the only one. And who would do distal tibia allograft or some other sort of free bone block? Mostly Latter-J. So many options. Revision bank cart can be successful, but in 2024, I think as Rick mentioned, you need very tight indications. So as you're about to see, that's what I did. Minimal bone loss. If there's missed pathology, a previous inadequate repair, or a new traumatic injury, which I would consider in this guy. So this is the guy. So we're lateral decubitus, reviewing from anterior superior. So there's his recurrent tear. I added a remplissage. So I did a double-anchor, double-pulley technique. And here I'm freeing up his tissue, and you can see he failed right through his previous sutures. So did it just not heal all the way? I'm not sure. So I took out the previous sutures, made sure I released this around the bottom to about 7 o'clock. It looked to me like he had adequate tissue, and he actually had a little bit of bone in that anterior fragment. So we're going to start in the back to shift everything around. So this is a 7 o'clock anchor. In this case, I like to use horizontal mattress sutures to recreate that bumper, but also really tighten up the IGHL and that inferior pouch. So we're putting our sutures at about 6 o'clock and 6.30. So one suture goes through the capsule, one suture goes through the labrum. So here's our horizontal mattress sutures. So we tie that down in the back at 7 o'clock, and then we'll start to work our way around the front. So the next anchor goes at about 5 o'clock. And here we're trying to get as low as possible. So he's got a little bit of bone in that labrum there. So I'm getting around the bone with one pass, and then through the labrum with the second pass. And then we're going to finish it with two more anchors up top. So four anchors, three in the front, one in the back, and he's got a little bit of a deficient anterior superior labrum. So first we place our remplissage sutures, fix the Bankart, and then finish off the remplissage. So this is the double pulley technique. And I do that last, and I do that blind. I don't go up in the subacromial space. So there's our finished repair. Revisioned Bankart, in the setting of subcritical bone loss, can have a failure rate that approaches primary Bankart repair. So in this study, their overall instability rate was 18%, where 7% ended up having an additional surgery, and 10% had subluxation that did not require surgery. So revisioned Bankart, in the appropriate setting, can approach primary Bankart repair. Sorry, it's not advancing. I'm stuck. There we go. And so this is a meta-analysis and systematic review. So you can see failure rate after revision arthroscopic labral repair approaches 10% to 15%. Instability after open repair can be from 0% to 12%, but two studies had 0% failure. The Novisor study was 0% failure at 10 years. And these are a couple other studies looking at revisioned Bankart. So overall, the failure rate's 15% to 20%. As Rick mentioned, we looked at ours at Tulane, and we found that when we did Latter-Jay for primary, we had zero failures. In a revision setting, it was 33%, but that was with patients with 15% to 20% bone loss. This last study compares Bankart to Latter-Jay, and it shows that the recurrence rate was the same in this study. So recurrence rate after revisioned Bankart was 11%, 12%. Revision rate after arthroscopic Latter-Jay was 18%. And they had a same return to sport afterwards, post-operative activity level. So I think the point of this case, it's very controversial, especially in 2024, because maybe I did the wrong thing. And I think you need to be really critical of redoing an arthroscopic Bankart repair after a failed Bankart. I think that's a great message, but again, I would stress that you have to do your primary Bankart really, really well. I think that's where you want to focus. And we do a Bankart, and we all do them. It can't be sloppy. You've got to do all the things Mike showed you on that revision. And I'll use a traction stitch in the most anterior or superior aspect of the labrum. So I'm pulling on that. So when I'm suturing down below, I'm shifting tissue, because I think a lot of failures occur because we don't address that capital deformation in the revision setting. So you've got to do it right the first time. Do you guys have any experience with it? The only thing I'd add is that not only do you have to do a really good Bankart, you probably better do a remplissage with it. Now the data is almost undeniable in that primary case. There's no study that shows that arthroscopic Bankart—that I'm aware of that shows that arthroscopic Bankart is a better operation or even an equal operation to arthroscopic Bankart plus remplissage. So if you're going to do an arthroscopic Bankart, please learn a remplissage technique, because your failure rates go from 22 to 4 or 31 to 7 or something like that. So in that primary setting, it worries us all in the revision setting, and we don't know where the sort of limits are yet, but that remplissage is critical. I couldn't agree more. All the data, the RCTs, everything. You add the remplissage to a Bankart, your failure rate is what? Maybe— Less than half. Oh, even greater. Maybe 10 percent. Yeah. So let me ask on the panel, when you do a standard Bankart, are you now adding remplissage pretty much for every Bankart that you do? Yeah. People ask me, what happens if they don't have a Hilsax, and I say, I make one. I don't want to get you walking away thinking I'm too cavalier about that, but maybe you make a little bit of a—just kind of roughing it up there so you get something to kind of put it to. But yeah, we're very, very aggressive about that. Audience-wise, remplissage routinely with your Bankarts? Yes? No? Okay. Well, I hope for those that aren't doing it, you may want to consider adding that when you do that Bankart. One other thing about the remplissage, it's not a difficult operation, and most everybody from the podium, I will tell you, says, like Mike did, I freshen up everything, I put my anchors into the remplissage, then I go down and I do the Bankart, and then I go back up and I finish the remplissage. And I will tell you, I never do that. And because I wasn't smart enough, I was already doing remplissage by the time Burkhart, who came out and said, this is what I do because it's important, and I think we've taken that on dogma. I just go and do the Bankart, and then I do it in the lateral decubitus position, and then all we do is we change the weight off the traction here and put it up here and just slightly abduct the arm, and so I'm finished. The hard part about doing it the other way is it's really futsy. You've got to be down here to do your, or you've got to be up here to do your remplissage prep, then you come down here to do your Bankart, or you kind of leave it up, then you've got to go back and you're fiddling with it. So I would just tell you that, at least in my experience, and we've done a lot of these, that you can do the Bankart first very safely, and then just go up and do the remplissage without penalty on it. I think that is way harder. You lose so much space. Like, it's really straightforward. So we'll put our anchors in. Your lateral. Take the cannula out, lateral. I leave my arm in the same position. Okay. But I think to do it your way, it's tricky, because you lose so much capsular volume once you do that Bankart. So I've tried it that way, and maybe I'm doing it wrong, but for me, it's a lot easier to place the remplissage, anchors don't tie, pull out the cannula, put the cannula back in, then do the Bankart and finish the remplissage at the end. Fair enough. You know, I could agree with JT, but then we'd both be wrong. So, no, I like Mike's. I do agree with JT. I agree with JT. So, if you don't mind, I'm going to ask Gene to answer the one on the 6 o'clock anchor. Gene, what do you think about that and the REMPLISAZ 6 o'clock anchor? And then I'm going to ask Steve to answer on the open bank card. Sure. So, I have not gotten as aggressive as JT and started to make Hill Sachs lesions if they don't exist. I might. Just rough it. Just rough it. Just, just, just. No, he creates one when he puts the scope in. You know. It's called a gouge. It's a little, is it conjural cosmetology that way? I don't know. So, I think, though, sorry, Chad, I can't see you, but I think that if the Hill Sachs is there, I do the REMPLISAZ 100%. And then I probably am less likely to put that 7 o'clock anchor unless there's a crack in the labrum there, too. And then I think it needs it. It needs all the things. But I think for the ones where I'm not making a Hill Sach or I'm not doing the REMPLISAZ, then everybody gets a 7 o'clock anchor. Great. Steve, on the open. Yeah. Open in my hands is really, it's pretty limited. I do maybe like one or two a year. Maybe a big bony Bankart or the last one I did was like a college offensive lineman who also had a cartilage lesion and we needed to do that. And so I did an open Bankart. But otherwise, I just don't, that's not, that's not something I do routinely in my practice. So, just because I think when I'm, most of the time I'm going open, it's to address bone loss for me. And then I just do a bony procedure. That's what I would have, that's what I would have considered and was considering and am still considering should I have done that. And same, it's a couple a year for me. But I think with less than 10% bone loss in a failed Bankart, I think open Bankart's a great surgery. Yeah. In the primary setting. In the revision setting. Chad, you know, I mean, we're still looking at 22, 24% in the published literature, right? That's our Sierra's, you know, Bailiwick. So, I love the open Bankart. We don't do them very much anymore because, you know, but, man, it's a great operation. But in the revision setting, all of these are tough. And I will say, and I'm not a Latter-day guy, you hear me all day talking about the evils of the Latter-day. But I'll tell you what. In the data and the literature on revision cases, Gerber and Schmidt, Pascal, you know, Emilio Calvo, et cetera, series after series after series, revision Latter-day instability rates are in the 5% to 7% range. And we don't have a surgery that matches that on the other side arthroscopically yet. And we're working. All right. Good. Any other questions from the audience regarding this revision Bankart case treated with another – Treated wrongly? No, no, no. I'll say, one thing I found interesting was that you did both the 7 o'clock anchor I saw and the REM plissage anchor. And there are some people that would argue that you're sort of now tethered both ends of that and did you see stiffness with that or too over tightness? So, I guess the question for you guys is, if you do a REM plissage, do you always, never, or sometimes add that 7 o'clock anchor? We know it's different. It's a different area of the capsule probably, but it depends on the hillsacks. So are you worried if you do one, then you shouldn't do the other or always do the other? How do you guys approach that? I always do the 7 o'clock anchor. Like we always, I think that might just be something in the military, but it just seemed like a bigger tear, a more traumatic tear, like, you know, those ones we used to see. And so I just always come across 6 o'clock and feel like you stabilize the IGHL by kind of like advancing it on the posterior side and then you can really fix it anteriorly. And then because I'd always done that when I added a REM plissage, I still always did that and then added the REM plissage. No. Same. That's helpful. Thanks. Well, one is that, you know, I do a 6 o'clock anchor because a 6 o'clock anchor addresses labral pathology. Now, you can do a little bit of capsulography on the backside with your REM plissage by tightening up a bit, but I think it's more translational control than it is a shift, at least the way I would think I'm doing it, and I go very, very lateral. But a 6 o'clock anchor, you know, Waterman's study, there were all these studies. If you're going to do a Bancart, you've got to add a 6 o'clock anchor from the standpoint of failure rates, strength of your repair, and the other is, and I'll ask the panel, I do mattress sutures. I alternate mattress and simple sutures with double loaded anchors because there's no question that a mattress suture will give you a better outcome, I think, than a simple suture. Sorry. Mattress. Yeah, I know. I'm not questioning what you said. Oh, okay. I'm questioning why you said it because is there data? Yeah, there are a couple of papers showing that return-to-contact sports, those athletes that had mattress suture configuration had a greater likelihood of returning to a contact like football versus simple sutures. Higher height restoration of the labrum, the mattress suture. Oh, sure. The mattress is beautiful. You take it, and then lots of studies show that you come back in a year, and that height is just now gone. It's like sleeping on your bed, buddy. It goes back after that big body of yours lays on it for a while. I'm not familiar with that work. I just worry that we talk about my technique and my, and this is how I do it, and it's beautiful in that way, and I would say be careful. It's not labral height. It's kind of like a rotator cuff where you're doing a single row and a simple suture versus doing a mattress and pulling it down. This is compression of that tissue against the glenoid face, where you're getting good compression. Then I do a simple that basically brings it down so you can't keep pushing it off, but at the end of the day, that compression, I think, makes a difference. And that paper's Ozurk and Russ Warren, and clearly showed return-to-contact sport greater with a mattress suture. So I'd encourage you to think about that mattress suture. I know Buddy does it routinely. I know I do. So a lot of people I know who are very successful in the operating room with bank or repairs are using that mattress. And so aside from what J.T.'s telling me, I don't have the evidence that J.T. wants, I would tell you that you should think about a mattress versus just a simple stitch, which I don't think is good enough. I don't know. Jeannie, are you doing simple or are you doing a mattress? I'm doing case four. I'm sorry? No, I'm just kidding. She's doing case four. Case four, all right. That's good enough. That's a good answer. With that, we're going to kind of go to case four, and Jeannie, take it away. Okay. All right. So I don't have any financial disclosures. So we have a 24-year-old male with a seizure disorder, fairly severe. He comes in and sees us in May of 2022, completely dislocated, unable to be reduced in the emergency department, so we have to do it under general anesthesia. Of note, he has already had established recurrent instability. He's undergone an arthroscopic bankart of June of the year before, and he's been seizure-free for about three months at the time that we've seen him. He does have daily subluxations. He also dislocates in his sleep, and he has a positive apprehension on his exam. So these are the images. I apologize for the no title. That was a screenshot problem. As he comes into the emergency department, and then this is status post, our closed reduction, and so we can immediately see that there's certainly a Hill Sachs problem in this individual. Here's a CT scan from his prior arthroscopic bankart, and I think that in this setting, we can certainly throw a couple stones here. I would argue that we really only have those two anchors that are below that equator position, one in the front, one in the back. Those top two probably are not doing him much in the way of stabilization. And then as we go through, top left is superior, down to inferior in the bottom right, just going through kind of the history, as we can see, of this Hill Sachs lesion, so certainly getting a little bit more medial and a little deeper as we go inferior. Here's his MRI, the same thing, and I think we look to the anterior inferior glenoid. We really don't see much in the way of labral tissue whatsoever. Posterior also looks a little bit askance, and then, of course, our Hill Sachs is well shown once again. So he comes back to us in September 2022 for his pre-op, the weekend before he misses a dose of his seizure medication and has another full seizure. The neurologist is adjusting his medications, and so we wait. Six months later, he's been stable on his current medications, but he's subluxating daily. His family is reducing the majority of his outright dislocations, but he does still have an occasional ER visit. And so we circle back now to talk through his OR plan. Here's the buffet of options available to you. I would say that I listed arthroscopic Bancart here, only in this setting to condemn it. Open Bancart, perhaps a role for it with a remplissage, but I was not really thinking that anything soft tissue was going to work on this guy, and so we plan for an open Latter-day. I started to get a little bit nervous, though, when he dislocates three times during examination under anesthesia and the prep, and I'm the only one in the room that can get him back in to include the chief resident. And like all my Latter-Js, I do scope them first. And so we see some not unexpected findings here in the front. We have loose sutures, capsule labral tissue looks absolutely terrible. And then we look at the back, and this is where I start to get a little bit sad. So here's the Hill-Sacks lesion. I would say that probably a far bit more advanced than it was reported on that CT scan, and with the measured probe in, we see that we've got about 18 millimeters of glenoid bone inferiorly from front to back. So I think the question, and sorry, and this is our view, kind of that, we call it a West Point, the 50-yard line view here looking down. This is with no force applied to the shoulder. This is his resting state in adduction. West Point's never gotten to the 50-yard line. How do you, why do you call it that? I don't know. You played there, JT. That's what I heard yesterday. Touche. Touche. Well played. Very good. All right. So I guess now the question for the panel is, now what? You're in the operating room. You're under general anesthesia with a person who's been seizure-free for six months, and you're consented for a Latter-Jay. Do you still go for it? I mean, for me, this is a bipolar bone problem, and so I'm going in doing a bipolar surgery, and so with that size of a Hill-Sacks, I'm always doing graft for that. I don't use fresh graft. I don't think you need fresh graft. I think there's tons of literature showing that if you just fill that with any type of bone. So I use a frozen femoral head. Humeral heads are really hard to size. A femoral head, you can always get kind of the, you know, match the contour, and then I do that with metal screws, and so I would do that at this point, and so if I wasn't consented for that and he had family, I would talk to him, and I would do that, and I would do that through the back. I think it's way easier than having the arm facing backwards and trying to do it through your anterior incision, and so I do that same incision in the back, split the deltoid, split the cuff. When you go through the front and the back, the cuff takes a hit, and they kind of, you know, kind of sit inferior for a while, so we don't start any active motion until that goes away. With PT, we let the shoulder kind of re-stabilize before we start active motion, but that's what I would do in this person. Do you have those grafts readily available? Frozen femoral head, there's probably one here in the freezer. You can always find a frozen femoral head. I've got one in my room. Yeah. Yeah, for sure. I think we all learned a lot just there. You can always find a frozen femoral head. That's really creepy. If Steve invites you to a room for the whiskey, can they ask you if you want one cube or two? Just take it neat, okay, just saying. Don't take the one big white cube. Yeah, right. Yeah, I agree with you, Steve, and I think in this one, because of the size of that hillsex lesion, I would plan to address both right off the bat. Measuring your hillsex defect, I think, is really hard, you know, and so I kind of split the head into thirds, and once the hillsex defect has reached one third, especially in a guy with seizure disorder, I would probably address it. I've always done it all through the front, and to do that, you have to do a full subscap takedown, because you have to externally rotate the arm 180 degrees, and then I would do a frozen humeral head autograft with headless screws. Still do a Latter Jay, and you can make a split in the subscap, bring your coracoid through the subscap to finish the Latter Jay, and then repair the subscap back, so you can still get the sling effect by bringing it through the subscap. Let's say you don't have graft available, and you consent for a Latter Jay, kind of where you are right now. Are you going to forge ahead, or are you going to stop and order what you need? And we usually have one in the freezer as well, so, but if I don't have one in the freezer, I would do an arthroscopic remplissage, and then proceed with open Latter Jay. I would do an open Latter Jay, because, again, for me, I'm going to do that through the back anyway. You could come back and do that whenever you wanted, and I don't think it would change anything. I think, and that lets me avoid taking the full subscap down. I think that makes the rehab a lot quicker for this, because you're just split in the front, split in the back, and you can see, it's so easy when you look at the back, the arm's just resting there, and then you can make the articular surface perfect without having the arm going way back. I think that's hard to match up. What about if you rotate your coracoid, and you do a congruent arc, so that you might get another, let's say, three or four millimeters in the length of your coracoid by turning it 90 degrees, it's obviously wider than if you just put it down flat. Is that enough? Do you think that's enough to overcome the, you know, this is borderline to me, where I wouldn't bone graft it, and a third is kind of the rule I use, and this might be right there, and I've done these where I've just done the Latter Jay, but rotated 90, so it's a little bit longer porch, and I've been very happy with that. So I don't know. I might have just rotated that coracoid and said, I'm good here. You know, reported literature of a Latter Jay in the setting of seizure disorder is actually quite good, and so you're in good stead, I think, just going forward from that. I think there are a couple things to consider here. I think that if you're going to do a bipolar approach, which I think is the right answer in these, because of just the massive size of this, the challenge is, is if you do it all from the front, it's been suggested, you've got to take down the whole subscap. And then when he seizes in the postoperative recovery area, and he's going to seize really soon, and if he pulls off that subscap, which he may, because it's not a split, right? If you're doing a Latter Jay, most of us will do a split on that, okay, that'll survive. If you've taken down and done a big one, and you've done a repair, and he pulls that thing off, and you've got a subscap deficiency in a 24-year-old home mama, that's a bad situation. So I think maybe advantage goes to the idea that we're going to do a subscap split in the front, and then do a split in the back to be able to graft it, so that you're not risking that subscap off. Secondly, when people seize, remember that the conjoint tendon seizes, too. And so I think you can make a strong case. My approach to this would be a DTA in the front, a large graft DTA in the front, because when you seize and everything contracts, nothing's going to try to pull on my graft. And then I would add to that posteriorly, and we're working on, as a lot of people are, arthroscopic bone grafts in the back of the shoulder for that knee, for that shoulder right now. I think that's a little tricky, so I would do a little bit of a mini open split to get that contract. But then, seize all you want, buddy. I've got you covered, and we're good on day one. I never have to worry about it. And we've looked at this, and you can get both those grafts from a talus and use the Taylor dome for the humeral head, and then the sub-Taylor joint also lines up really well on the glenoid. And so there's not a lot of room for, you know, it's tight to get them both, but you can do it even on a large shoulder. There's some literature published recently on Botoxing the muscles around the shoulder girdle in these seizure patients. Has anyone tried that? Preoperative Botox to paralyze the muscles. Does anyone have any experience with that? Oh, to help you with the surgery or to treat the patient? To treat the patient to prevent post-op seizure. No, but as a skeletal cosmetologist, I'm interested in adding Botox to my repertoire. So Jean, why don't you show us what you did? Okay, and so I showed this case as not only an example of complex shoulder pathology, but also kind of a failure on my part, I think, for the patient. So I think I chose that day to run away. So full disclosure, and I'll say that we did not have those graphs readily available, and I didn't think that what my plan was was the right thing to do when I got in there. And so there's a couple of reasons for that. Just doing a quick on-track, off-track calculation. I felt like the latter day was wildly insufficient. He did need a bipolar bony reconstruction. And so I ordered a humeral head and a DTA. So good news for us, those graphs came in very quickly. I did order both of them fresh. I think that's another point of discussion that's already come up. The Venn diagram of the expirations of those two graphs lined up nicely, so we got very lucky. From that, I did do the humerus first. I did it through a posterior approach, just like Steve has shown previously. I chose to do a snowman technique. I think there's a lot of things that you can do here, and we'll get into that in a second. And then went to the front through a delta pectoral approach through the distal tibia allograft and seeded that down. Here's post-operative x-rays. You can kind of see on the right side, even those two plugs lining up down the line of the Hill-Sacks defect. And then the graph's sitting, I think, fairly reasonably there. The CT scan, I did get this at about three months to see how he was doing. I liked where the graph was sitting. It looked like it was starting to show healing across those interfaces. Gene, what was the depth of those plugs you used? The depth of the plugs, those were about 15. 15. Yeah, so 20 by 15. No, I'm sorry, 20 by 10. 10. Yeah, not terribly deep, thankfully. And so I think as we look at the top of the Hill-Sacks on the left side, I think we got a little bit of the convexity that we wanted there. Again, this was just such a wide defect, I knew it wasn't gonna fully cover it, so I think we went from a shark bite to something that, at the worst extent, inferior perhaps is a little bit more of a flattening. And I think just with that and the DTA, I was fairly satisfied with that result. He's been seizure-free now for 18 months. No dislocations, no subluxations. He has no apprehension. He's pain-free with a normal motion arc, and he's training for the police academy, which is great. However, on his last couple images, I think we see almost the same picture that we saw from Steve's case, right? As you further along with these guys, you do start to get that resorption versus remodeling, whatever our word we want to call it, and you see that your washers are starting to walk. That's why you don't use washers. That is an indication to not use washers. That's an excellent point. But I do like to use those for the capsular repair at the end, so I do favor them. But I think when you look at the screws, is this the screws migrating or is this the bone? And I do think that the screws, for the most part, obviously these aren't the exact same projection, but I think the screws, for the most part, are pretty stable, so I'm not going to go chase these at this point. So I think just, we've talked a little bit about this so far, but how much is too much for a Latter-J? Again, I didn't feel comfortable doing it at that point. I also do have concerns, as JT just mentioned, about doing Latter-J in the setting of a seizure disorder. And then when the humeral head needs a graft, you have a lot of options for graft shape. You can do big wedges. You can do sort of a mosaic plastic called rocks in a stream. You can do the snowman technique. You can do an arthroscopic. You can do it open, like he's heard here. You can do it through an anterior approach as well. This is a fairly thin guy who's been on seizure medications for a long time, so I was also concerned that the position that I would need to put him in was potentially just a little bit dangerous for maybe an intraoperative fracture, and maybe that's just me being a chicken, so welcome to my world. And then again, I think just as we look through the retrospectoscope, did we really need that six-month seizure-free window? That put this patient through a lot of additional instability events, which I should have re-imaged him because of, and probably would not have found myself in that place, in the operating room in the first place. We've talked a little bit now about fresh versus frozen grafts, and perhaps fresh ones aren't necessary. We were fortunate enough, I think, probably if too much time had drawn on, I would have just gone to frozen to avoid trying to having to wait for the freshes. So, and then of course, doing some of these things arthroscopically, be that the humeral head, or doing an anatomic arthroscopic glenoid reconstruction, and I think that that would be an excellent choice in this case as well. I think that's a great case. I think we take care of a lot of seizure patients, and I think it's so interesting that what we get told depends on who's on call from neurology, and there's no, and I'm like, well then help me write a review to teach orthopedic surgeons. I'm like, because we don't understand this, and they don't have data. They don't have literature. It's not like a cardiac event where the risk of anesthesia really causes a big problem, and so we've started to get really aggressive and fix these, like do things right away with them, because there's not really data to suggest that a general anesthetic is gonna trigger another seizure. You know, they're gonna have another seizure, or they're not. Some of these patients come in, and unlike this, they just had one seizure, and they're 42, and they had one seizure, and this happened, and their risk of a subsequent seizure is very, very low, but we have people waiting six months, 12 months to get this seizure-free window that doesn't exist anywhere to tell us like that's something we should do, and you're right. They go through tons of morbidity while you're waiting. You know, I had a patient with bilateral humeral fractures, and they, you know, and one of the neurologists told me to wait six months, and I'm like, this is a normal 40-year-old lady who now can't use either arm, like wait six months? Well, and your point's well taken as it's changed. Now, I've been in the situation where I have, almost to your case, not been a greater tuberosity fracture when they dislocated again. I've also had the latter day where my screws bent three months post-op, so the bent screws bothered me a whole lot more than the tuberosity fracture, so I'm real careful about jumping in until someone says to me, we're good to go. We've had patients seize in the post-op recovery room after a big DTA and CT immediately, and they hang in there, and we've had them do it a couple of weeks later, and they seem to hang in there, so that's, I think, why, that's one option for thinking about that. Tough case. That's a great case, by the way. That's a great case. This is a, let me go back here, a young guy who dislocated his shoulder mountain biking. He had surgery four months later, and then re-dislocated when he came off his bike again. Two more episodes. He had an MR elsewhere. He's got a recurrent Bankart, a large heel sacs, no appreciable glycemic bone loss, and again, markedly positive apprehension test, positive O'Brien's. Does positive O'Brien mean he had a revision arthroscopic Bankart? You're right. Okay. Exactly. Yeah. And so, you can see in the current copy of the MRI, he's got an alpha lesion. You don't want to debate a guy who keeps fresh frozen allografts in his hotel room, man. He's coming for you. And he's got a, you can see on the MR, again, the chart, and then I got a CT on him, and you can see here that he is on track. He's not engaging, but he's got a heel sacs lesion, and he's failed the Bankart. If we look at it here, you'll see, again, on the views here that there's not a lot of anterior glenoid bone loss. He's got the heel sacs, and this might be one where Mike would say, you know, this is perfect for another revision, arthroscopic Bankart, but given the fact that we know that it's probably not the right choice here, we're looking at these others. Open Bankart, Latter-J, DTA, plus a Rhemplisage, and in this situation here, we're taking a look, and what you can see is that we're looking, and we see the heel sacs lesion, and a little patchless capsule. This is what we call the near track, so it's not completely off, but it's very, very close, and from my standpoint, this is the same thing as an off track when you do this dynamically. We're gonna put our Rhemplisage in here, and we're gonna do it the way Mike described, where we basically plant our anchors, pass our sutures, we put two of them through, and we're not gonna tie these till the end of the case, and then hopefully it's a controlled translation and rotation a little bit. Here we are coming in, you can see the sutures from the previous surgery, and the key to this doing an arthroscopy is you gotta go past the six o'clock position, because you have to slide your block in. We go ahead and put in this six o'clock anchor, we pass our sutures, but we don't tie this until after the bone block's down, and this is a key step. You have to take down the labrum right adjacent to the biceps, and this is basically a relaxing type incision that allows us now to open it up. Once you do that, you can see here we're just drilling through with a guide. This is from one of the companies, and then this is the next step. You gotta take out the rotator interval. So take the interval out, this is a finger test, and my finger matches the size of the block, and then we go ahead and take these passing sutures that are going through, essentially, the two drill sleeves that are through the glenoid, and then we simply slide our block in, and this is a relatively simple operation to do once you've done it a couple of times in the lab. We seat it. Now, what I'm gonna show you here is that we use two, and you can see it's tilted. So I did this a little wrong in terms of what happened. The bone collapsed, and it tilted. Now we do the Bankart on top of it, so I use frozen, I don't use any fresh. It's much less expensive. And then when we're done, the head is centered here, and we then go ahead and do the brunt massage. And so, again, this is a relatively simple technique that most of the room here can learn fairly quickly. Now, here's the imaging part that was kind of interesting. I tilted that fragment, and that fragment, as you can see, is not anatomic by any means, but the part that I found very interesting is the Japanese talk about bony Bankarts and tilting the Bankart lesion, the bony Bankart, and it hyperkaphes. You actually get a wider glenoid when you tilt the fragment. So this was tilted inadvertently, but this is one of my cases where I got very little resorption other than the most inferior aspect of the graft, and so it makes me think this patient is more coming out straightforward versus more anterior-inferior, and I think that may account for some of the differences in resorption. But again, this is a standard double-button technique. I think we can have a big debate about this, but I think it was poo-pooed as a double-button, and the screws were felt to be better. There's now some literature saying less resorption, and the results are equal using cerclage techniques, and J.T. has done that, double-button techniques. So I think the jury's out on how to do this, but there are some reports that a double-button technique was associated with a much higher failure rate, and I actually stopped doing this operation for nine months till I got two-year follow-up on everybody, and my results have actually been much, much different than what's been reported in literature. So I still stick with this, but just know that the screw technique is also, I think everyone, buttons here or screws? No, not screws. No screws? Screws for, let's say, DPA? Nope. Sorry, but I'm still doing it. All right. Mike, it is. There's several systematic reviews now that are comparing them. You can find, I mean, you can find data for anything you want, but there's several that show that actually, that soft tissue fixation now is improved compared to complication rate, even resorption rate when they take a look at healing rate and resorption rate, that the data's showing that the soft anchors, as we've moved along, are better than the screws are for these things, so. If you use this particular device, it has a tensioner on it, and the key to this operation, ask for two. So when you put down the first set of buttons, you leave the tensioner on, and then go to the second set of buttons, it's night and day. If you don't, you get a little bit of play in the front. So two tensioners when you use this particular device. With that, I wanted to, I think we're kind of budding up close to the end. Are there any questions that you have regarding anything you've heard this morning to anyone of the faculty, this is the time to ask. Yes? I'm not familiar with the Botox. In terms of, is that something you inject in certain areas, pre-op or post-op? Pre-op, and they inject all of the periscopular muscles, and so you're trying to knock out the pec, the deltoid, the latissimus, all of the big contracting muscles that might dislocate the shoulder if they have a seizure post-op. So it's done pre-operatively, before they even go to the OR. I've never done it, and so there is a study showing that it can be successful to limit seizure activity after instability surgery. How long does it last? I think in that. I think it's about two damn long. Yeah, yeah, yeah. I mean, you're in there fiddling around with those nerves, and that patient wakes up with no deltoid, you got some, you have some courage in you, young fella. You'd be scared, yeah. Whew. There you go, Mike. He said that it's irreversible in some people. Oh, yeah, so then maybe don't do it. That sounds bad. Any other questions? I think the other thing when we talk about, especially with posterior, there is just such an associated amount of scapular dyskinesia, and so I think, you know, you fix the problem, and then there's still a lot of rehab to do, and, you know, Philip Moroder's Pacemaker device, I think is very helpful. We use that. We try to get that on our, you know, our posterior instability patients, or even some type of, like, a scapular positioning brace, but they get scapular dyskinesia, especially when it's been chronic and going on for months and months. It's a hard thing to correct post-operatively. You know, commenting on that posterior instability, and you have to look, and there are a lot of these classification systems, and there's a functional instability like you were showing, but it's also mixed with some, obviously, anatomic pathology, but, you know, as you raise your arm and it drops out, sometimes that's more muscle firing at the wrong time, and so the Pacemaker that Moroder's described can be very, very helpful in that young person who's subluxing out the back, and their posterior deltoid is firing, and their external rotators are not, and it makes a huge difference, so if you put them in PT, and they really haven't done anything, add the Pacemaker, and I've had three or four cases where it's been miraculous, where the Pacemaker solved the problem. You just kind of muscle the way to education, so consider that you're a calcitrant, younger people with some subluxation that you don't want to necessarily operate on. Mike O'Brien taught me how to do it, so I do it blind. Yeah, we do a, you never have to either. So we do it with a knotless trans cuff technique that is, it's almost so silly easy, it's just funny. But you just do a percutaneous anchor, stick it in, you go through the same skin incision, just go through a different incision or different spot in the cuff, poke it in, and then you just loop one and loop the other, zip, you're done. It's almost frighteningly easy. When you tie it at the end, you can tie it just percutaneously without going up into the subacromial space, or Larry Fields will pass the remplissage sutures back through his cannula, put the cannula through the deltoid, wiggle it around to make sure you're in that subacromial space, and then tie. So I've done it both ways, but you can do it through a cannula, just to make sure you don't wrap up any deltoid fibers. You can withdraw your cannula, right? Then that cannula sweep the back of the capsule, so that the muscles also at the right layer, then you penetrate through. But you'd like not to capture deltoid or other, so you can just sweep it off and then puncture through like JT was telling you. Now, I will tell you that I've used some of the commercially available, and you can pull out some of the self-tying suture base when you start yanking on that. So we go to a 3.9 corkscrew type device for purchase, because it's just a suture base. When you start pulling, it can sometimes pull right out. I've had that fail a few times. So just be aware of that on the double-pulling technique. I've also had the corkscrew fail when it comes out, and it's certainly a lot harder to fish that out than to get the sutures out. But some of the commercially available percutaneous anchor insertion kits, will come with a small metal cannula, that basically will allow you to take just a very small ring grasper down. So then instead of having to put in like a big seven millimeter cannula, you can use that instead. Then as your first sutures come out, you just take that tiny little night knoll down, pull the cannula out, sweep your sutures off to the side, put the cannula back down. Then that really facilitates it, while still being able to maintain the super small hole muscle. If you go on A-Tech, and look at the rent massage, they're going to be like 40 different ways to do it. They're all pretty slick, and they're all variations of what you're hearing up here. Any other questions that we might answer for you regarding some tough topics here? Well, I think we're butting up to the end, and so it's a hard stop. I wanted to thank you all for coming. I want to thank really an outstanding faculty, and please fill out the evaluation. It means a lot to all of us at ANA. Again, hope you enjoy the rest of the meeting. Thank you very much. Thanks, Rick. Master moderator. Awesome job. Awesome job. Yeah, so I was looking at it, you know, at the end of time, I was like, how is he going to do it? I'm sorry, I got held up.

shoulder instability

young athletes

surgical techniques

individualized treatment plans

bone loss assessment

arthroscopic surgery

revision repairs

Bankart repairs

remplissage

Hill-Sacks lesions

Botox injections