Good morning. While they're bringing that up, basically, this is meant to be interactive. So we're going to present some cases to you, the stuff that you see in your office, not every single day, but often enough, and you're sort of torn with what's the next step. And I will tell you that there's a lot of controversy. I'm not sure there is a next step that we would all agree upon. So we're going to kind of have some of those discussions now, so maybe you're better prepared in terms of what you might consider down the road. And I see a lot of people with a lot of shoulder experience in the audience with Mauricio and Dan and Gus. So hopefully, you'll chime in with your experiences as well, and I think it'll help all of us. So with that, we're going to talk about anterior posterior bone loss and revision cases. This is my disclosure. I really have just an outstanding faculty and all very, very experienced in the shoulder instability and not only successes, but complications and failures, especially Dr. Tokish. So he's going to give us a talk on the failed Latter Jay, which I think will be very insightful. Format, case presentation, and then we're all going to discuss it. What do you do? And again, we'd like you to share your experiences with us, and then we'll have the presenter present their solution. What did they do? And we'll try to get through at least three or four cases in this session. So very informal, step up, make sure that you get your questions answered. That's the reason for this particular format. So with that, I'm going to introduce Dr. Paskowski, who's going to lead off this morning. Jean. Good morning, and thanks, Rick, for setting this up and for the invitation. We'll load up. Perfect. So it was originally case four, but then Dr. Ryu said we didn't want to have Michael O'Brien present. So now I'm up first. I apologize. All right. So we have in the emergency department a 24-year-old male with a known seizure disorder who had been seizure-free since February 2022. He'd already had multiple episodes of anterior shoulder instability, and the year before had underscored an arthroscopic bank heart. So of course now he's back. It's May. He undergoes closed reduction with the residents, but he's reporting daily subjective subluxations. He's dislocating in his sleep. He's getting the dead arm sensation. He's wildly apprehensive. And so these are our dislocation films in the emergency department. So we can already see the suggestion of a very large Hill-Sachs lesion. This is after closed reduction. Here's the CT scan. So evaluating here, we can see his prior anchor tracks, and we can perhaps make the suggestion that maybe there were some signs of struggle here. Maybe we're a little bit high, putting some anchors into no man's land. Did you say there are CT signs of struggle? That's awesome. I'm going to write that down for you. I just want to say when I look at my own CTs, no, no, a hundred percent. Just suggesting that maybe we're a little bit high on some spots. All right, fine. I'll take it back. I've insulted two people so far. One is anonymous. Okay. That's what happens when you become a full colonel in the army. That's the kind of language you have to use right there. It's called being diplomatic, JT. All right. And as we come down through his axial views, we see that that Hill-Sachs lesion is definitely kind of on the order of that shark bite that we see typically with these high energy seizures. Representative MRI as well. We don't really see too much of an anterior inferior labrum. And so he comes back for his preoperative appointment in September. We're really excited. We're getting this guy in the books. He forgets one dose of his seizure medication, and we reset the clock, unfortunately. So the neurologist decides to make quite a number of adjustments, and so we wait. And it happens again and again and again. For the most part, he's having instability events on a daily basis, typically more than once. His family, when he does formally dislocate, is able to reduce most of them, but he's still in the emergency department every so often. But he's at least stable on his medications. And so we come back. Now we're ready to go. We offer him the full buffet here of surgical options, listing arthroscopic Bancart at this point only to condemn it. He's already been through that once. There's clearly some, at a minimum, Hill-Sachs lesion that's significant. Glenoid bone loss didn't look horrible, but it's probably starting to impinge upon that subcritical at least. And so we talk open Bancart. I'm not too confident at this point that there's any viable soft tissue left, so we really do just discuss the bony options, be that Latter-J versus a different bone graft and then the addition potentially of a remplissage. And after all is said and done, we decide upon the open Latter-J. So as we take him back to the operating room, he dislocates three times during the surgical prep, and it's about 15 degrees of abduction when he starts to go out. It actually gets harder and harder to reduce him at that point. So I do like to scope for my Latter-Js first to see if there's any posterior pathology that we need to address at the same time, and again, if we're going to contemplate remplissage. And here's what we see in the front. So we have old suture just kind of floating out in space. We don't really see much of any viable soft tissue there in the front, even looking from anterior-superior lateral down. There's just nothing. It's not an ulsa. It is effectively just completely eradicated. We look down the back and find this staring at us. So here's his Hill-Sachs lesion. And then with a graduated probe coming in from the front, he has about 18 millimeters from front to back of glenoid bone. And here's him in the neutral position looking straight down. This is before an arthroscopic load and shift is actually even performed. So the question is, now what? All right. Anyone from the audience have any suggestions on how you might want to manage this? Don't be shy. Anyway, so can I ask, so I think what we're talking about is, you did a latter J, open latter J, and it was still unstable, so you took the biceps, the dynamic stabilization, brought that through the same defect to the subscan, or how'd you bring the biceps in? I have not heard that procedure and he stayed in, so he stayed in, he was stable and he's been successful. Yes. Wow. If I go back, I will do any form graft, it will be much better for the patient because the methodology was too small for this defect. So, Daniel, what are you going to do? Would you go to the back of the shoulder? Can you stand as loud as you can please? maybe and then the scare of you know with the allograft compared to bone on the back. One thing you can do pre-op too in these is when you have a huge, a large amount of glenoid bone loss, you can measure your distance to dislocate. And then on your CT scan, you can check the diameter of your coracoid and see if that's going to get you there, which you all probably know. That's one thing you can do on your pre-op films to give you some ideas. Latter-day are going to give you enough of a track. So can I ask, do you ever do a congruent arc where you turn your coracoid so you get a little more width? I would not. I worry that it's going to be narrow. With that, with that. I stay on the European, I keep the European. And then I wanted to ask, for you all, do you worry about Latter-day incision disorder simply because you're going to pull that thing off possibly? And is that a reason not to do it? 100%. There's good data in the literature that looks at people that have Latter-day incision disorder. And the answer, the bottom line on those papers are that they still have seizures, but it does decrease the instability. That being said, we've all seen those cases of bent screws, broken screws, and everything else. So if you're going to do a bone block in the front, and I think in this case you must, I would strongly ask you to consider doing that without screws and considering a button kind of construct, or cerclage, or whatever it is that you're of choice. Because when they do tonic-clonic, that sling effect is hurting you as opposed to helping you in this situation. Because that thing kind of wants to pull and pull off and pull off. Sure. So if you want to, you can kind of finish your work in the front. It's a little bit annoying, but that does work. I've done that in future cases. This is a great case for a 3D printing machine, whereas addressing the phone graph, I think that. I think the only thing with that, Rob, is with the 3D printed models, I think it's a great idea with these. So are you, do you size more though? Because like when that bone is kind of compacted and kind of crushed in, by the time I'm done like preparing the defect, the defect is always bigger than like what I measure on CT scan. I always need like a couple of millimeters on each side to kind of get that compacted bone out. How do you do that with the 3D model? Yeah, I'd say I think the bone graft is tricky with the large humeral heads. I think I'd do the same thing, Rob, I'd get a 3D CT and kind of fiddle with it and I think the carpentry is actually a little bit more challenging than that. Yeah, I wish they'd print the graft too, that won't do that. I totally agree with you, it's that finicky part of getting it a perfect wedge and once you get it prepped you can take bone wax and make a mold of your graft and then on the back table you can try and cut it to that, but it's still kind of finicky. Very shallow. Yeah. I will say that for me, goals on this case are, I want to finish this case and leave and be done. So for me, this is a great case for a metal hemi cap on this. And that would be my choice in this one because when I leave the operating room, we're finished. There's no healing. There's no resorption. There's no nothing. That metal is done and he's finished with it. So that's something to consider. So you're doing full resurfacing? No, I just do it. Well, it depends on what the defect is. On this one. This one is, I think a hemi cap will work in it. Yeah. And you'll get it. The hemi cap doesn't, you can cut it to fit. So it'll match nicely, but that's a massive defect. I would encourage you, you do a REM plasage in this. That's going to be out in the recovery room or certainly when he does his first seizure sometime around. Question? Yes. Sure. Correct. What about the soft tissue at the front? Because those pictures, the one at the front. Looks like garbage. The soft tissue's just. It's awful. Yeah. So, are you going to think about trying to augment that soft tissue at the front? Because with that, you're going to lift. I do. I augment it with bone. Yeah. Just put the bone in and leave the soft tissue. Well, I probably would, you know, we'd put some sutures against the bone to do it, but that's, for me, that's going to be a congruent arc DTA and bring the ramp up on the front there. So you can make the argument if you make your front porch long enough that you don't have to worry about it sliding out without soft tissue reinforcement. But I would tell you that whenever I can repair soft tissue, I will. Because I think it adds something in the abductor external rotator position. In 45 degrees of flexion, it's. But my question is how much I think that's a great question because I think some of the early experience here with the DTA was people were having subscap issues by making the graft so big and of course we also worry the bigger the graft the more that we're going to have potential later resorption that will challenge your fixation and so good yeah I agree with kind of what JT said before I think we've we've spent so much time worrying about glenoid bone loss now we're recognizing humeral bone loss is a huge problem so I think in a case like this you have to address both yeah and so you have to do something to the hill sacks other than remplisage to fill it in which will also decrease your your distance to dislocate one last question you can do it you can do it yeah you just have to spin it out you got to take a complete subscap all the way off like you do a shoulder exposure you got to externally rotate but if you're doing a posterior approach as well if you're gonna do the ladder yeah if you're gonna do the ladder J then I don't think you should take the subscap completely down and so but because I think it's really hard to repair around your ladder J once you've taken the subscap completely down but if you're this is one though I would do from the back and if you're going to do surclosh fixation you need a posterior incision anyway so when you're open in the front you just take us a switching stick and you slide it along and then you know exactly where your deltoid split is going to be you know where your cuff split is going to be the hardest part is on the humerus if you're trying to do it through a cuff split it's really tight where you need to make the graft much easier to do go through a cuff split to get to the glenoid in the back on the humerus it's hard and if the Hill sex is really superior then you really have to play around with the position to get the exposure but for me that's what I would do with this I would use frozen femoral head to repair the allograft through the incision in the back and then do a ladder J with surclosh from the front yeah So I think I've got to get on track plus 10. That's sort of the mantra that I'm using now. So that doesn't mean 10 millimeters of bone loss. That means I restore the on track situation plus 10 millimeters. So if my, when I do my combined measurement of glenoid and humeral bone loss, if the Latter J gets me to that, great. If a DTA, I need it to go out and it needs to be 15, 18 millimeters, that's no problem with me. But for a guy like this guy, even if you put an 18 millimeter graft on this, she just told us that his glenoid width, the remaining glenoids, 18 millimeters. So you imagine you put a 12 on there, you're still going to be off track or barely on track. So that's the one I say, if I can't get to plus 10, then they get bone on the humeral head. I do 30%. You know, if your humeral, if your Hillsex defect is approaching one third of your humeral head, then I will fill it with something structural. Yeah, I think this is hard to, I think we all have like a different system that we use, but this is hard. There's so many different systems out kind of, you know, in the literature about how to measure these. And it's not something that we universally agree on. So we use degrees or depth or width. There's a lot of different things that we're looking at. And then we just kind of, everybody's saying like this one, I would, this one I wouldn't, but just like Rob was saying, a lot of times then you go in and you're like, well, this doesn't look so bad. It's a lot more shallow than I thought it would be. So I think the depth matters as much as anything else. In the last note, I have been including a repoussage with a number of my Latter-Js on a routine basis. So good or bad, but I think that in the past I've really had a big issue, but all the data I'm reading, it seems like adding a repoussage with a Latter-J just may help you. Can you talk about your sequence of that? Like the sequence of the steps? Yeah, so I start the Latter-J, I'm done at the back. I do everything in a Latter-J cube. So then I'll flip them. Then I do a, I set them at 45 degrees and I turn the table so that it's up movements where I can do the repoussage at the back. Then I just undo the beanbag and they flop down and I do one Latter-J. Okay. Okay. So this, for me, ended up being a very good case of you were not prepared enough before you stepped foot into the operating room. And so that was a lot of self-reflection in that moment of panic, kind of staring at this, because realistically that CT scan that we looked at before was from that initial presentation. And so a solid nine months had gone by with continued dislocation. So I really had needed to repeat those images before going back. I agree with the concepts of not doing the Latter-J in the seizure patient. And that's also where I have some questions about doing a repoussage, because do we then, through the next seizure event, potentially give him a devastating infraspinatus tear? But can I ask you a question on that, Jean? So do you think that if you do a DTA and this guy seizes, he'll be fine? You think the dislocation isn't what hurts the bone block? It's just the pull of the conjoint? No, not necessarily. But I think I needed to restore both sides. I've got several patients who've had big DTAs and seizure patients who seized afterwards. In fact, they all seized afterwards. And I think of the three that I can think of, two of them had no problem. One of them had a little bit of displacement, maybe three millimeters down, where she collapsed a little bit. And we watched her and she did fine. So I do think there's something to the soft tissues pulling on that. The problem is you get something and you break a screw. Now you've got a big revision. So I love your thoughts about going with the cerclage from the front and using the switching stick technique too. That's what we do as well. And so knowing that I did not necessarily have available in the OR any of the things to mitigate against my poor planning, I decided to run away, fight another day. Had a awkward conversation, put my head down, talked to the family and said, hey, I can't do the operation that your son needs today. And so we came back. I figured the Latter-day was not enough. We did some rapid public math calculations to determine that exact thing. I wanted to do a bipolar bony reconstruction. And so I ordered a humeral head osteochondroallograft as well as a fresh DTA. We could have done either one of those frozen, but I wanted to see if the Venn diagram would work out. And we actually got very fortunate on that and had two fresh grafts that expired within one and a half days of each other. I did go posterior for this because I wanted to have really good access to the entire length of the humerus. And I wasn't confident that I would get that. It probably could. And it sounds like I think it's just a matter of more experience coming from the front. But I did just want to have a very direct, clean approach. I did this with plugs as opposed to a wedge. You can find multiple reports of doing it with many different techniques. I love the idea of 3D printing, Rob. I think that's a great thing to incorporate the next time this comes around. And then went to the front, did a distal tibia allograft. I did use screws. So far they're holding. I also like to use these suture washers, which go around. So whatever residual soft tissue he did have, knowing that we really didn't have any labrum left to repair, I did incorporate those into the repair with the sutures coming out of the washers. Here were his post-operative films. Immediately we liked our restoration. And I think when we look at coming down to the seat, and this is the three-month CT scan, so fairly decent incorporation right through there, still had a little bit of healing left to go. But he was doing very well clinically at this time. I think with those plugs, I think we got something that was better than where we started. Probably not the normal contour of a humeral head, but I think enough to get him back to that on track, and hopefully plus 10. So he was seizure-free for the next 18 months with no dislocations or subluxations. He was pain-free with what we would hope for as a normal motion arc. Maybe not all the way up to 90-90, just shy of it, but he was doing very well and actually training for the police academy. He came back at that point. He's still doing fantastic. He loves everything about his shoulders. I just don't love the fact that his washers are starting to move, suggesting that there probably is some resorption slash remodeling, depending on which camp we want to take on that for that anterior glenoid bone block. If they're yours, it's remodeling. If they're Rick's, it's resorption. Okay. Perfect. So we're all clear. Perfect. Yeah. So here's the best side to side. When you're in a military hospital, you can't get the same x-ray twice. So this is about as good as it would get for that, but you can definitely see that there's several millimeters of difference and some creep in those washers. So I think we've talked about a lot of these things at this point, so I won't take up too much more of your time, but I think, again, that point of when does a humeral head need a graft is very well taken, and I think that's another... That's probably an area in the literature where we could stand to do some more intense research to really try to knock that answer out. And then, of course, I think through the retrospective scope, we talked about better preoperative planning for me, and then certainly just really how much we need to hang our hat on that six-month seizure-free window, because we really did burn a lot of this guy's time, and I wonder if, you know, did we necessarily need to wait that long? And I don't necessarily know the answer, but I think I might be tempted to flirt with that a little bit more if we have somebody whose instability is this severe. Of course, re-imaging fresh versus phosion grafts. And then, again, I think you can get to it to the front. I was just a little bit nervous to do it in this guy, and I felt that coming through the back... I was in beach chair anyway. I had perfect access to it. I thought it was very, very straightforward to get back there. Thank you. Great stuff. Thank you. I'll run away. I have a quick question, though, for the panel. I'm just a little bit worried about if you had to go back and take those screws out that are cancellous screws. Would anyone use solid screws for that? I know it's the one that you're using, but... Well, the cancellous screws have a couple of benefits. One is that they're cannulated, so getting in there and getting... I said cancellous, and I... Okay. Yeah. So, cannulated screws, right, are a little weaker. But if you take a look at the true torsional strength of those versus solid screws with the ones that are normally available, as long as you use similar size, the strengths aren't that different. But if a broken screw is a broken screw, and I've taken out broken screws in both cannulated and non-cannulated settings, right? But I do think you're right. I'll tell you what I worry about is sometimes the cannulated screws, especially if you're using a certain company's 375, when you go in to take that off, if the screw bite is good, you'll often find that you pop the head off. Always. And if you pop the head off, you got a problem, right? So that troubles me a lot. And if you do that, you just make sure that when you go to the operating room, you've got a coring reamer, because that's your only option, right? A little bit of remodeling helps with that. That's right. Yeah, you get them out a little bit. Yeah, man. Yeah. I don't think the cannulated part... That doesn't bother me. I don't worry about it being cannulated versus solid, but I want a 4.0 screwer bigger. Yeah. So at a minimum, it's a 4.0 cannulated if you're going to do that. Yeah. And the other is, there's a company, and I have nothing to do with them. They're called Oscio. They have basically wood screws. And Mike Freehill at Stanford has a series of, I think, 25 lattice gates using wood screws that incorporate. And that whole hardware issue is just much more of an issue. So it's a very interesting concept. And you might want to look at that for yourself. And we're looking at it because it will solve that problem for us. Yeah. So, anyway. Steve's going to talk about something that we probably... Yeah. Thank you so much. Great to be here. I do have some disclosures. This is our patient. This is a 16-year-old. He's a weightlifter, and he's really big, 6'3", 230 pounds. He's already undergone a posterior labral repair four months ago and then had an injury. He tried to catch a freezer that was toppling over and dislocated. And now he's having daily posterior instability events. And so he has a medical history. He's otherwise healthy. He just had this remote history of a Burkitt lymphoma. And so in the clinic, he only will bring his arm up to about 90 degrees because then he'll actually dislocate out the back. And he can dislocate and then just pull it right back in clinic. And so no scapular winging. And I think if you get these patients, look at their scapula, do a good scapular exam for sure. But there's nothing else I'm trying to trick you with. Here are his radiographs. And I think the first thing we see on these x-rays is something looks abnormal about the glenoid. And so... And that's common with these patients. And so this is the MRI from before his surgery, and you can see his posterior labral tear, but also some abnormality about the posterior glenoid. And then we get a CT scan. You can see his anchors, but now you can really appreciate that he does have some dysplastic changes of his glenoid. And so this is what his glenoid looks like. And I think this is a common picture for these patients. You get a really abnormal looking posterior glenoid. Oops. What did you do? Yeah. I was going to do the rest with hand gestures to show you. So interpret dance. Best fit circle on these patients I think is difficult because we don't know enough about the dysplastic glenoid, and maybe the best fit circle is not really what they started with. And so it's hard to... I think it's hard to measure and appreciate the amount of bone loss in these patients. And so here's our assessment is this patient, now he's 16. And so I'm wondering what our panel would like to do with this guy. Different posterior instability with this kind of quasi-dysplastic appearing glenoid and he's already failed a soft tissue procedure. Mike O'Brien, your revision posterior labral repair, do a reverse O'Brien. Every day of the week. Yeah. I think Jim Bradley has published a lot on the posterior labrum and showed that, and this is a different animal than that because this is a hypoplastic posterior glenoid. But even in his series, he showed once you get over 10% posterior glenoid bone loss, that they have a higher failure rate. And I totally, I don't think we know the answer to this. And I think this is what some people would term the B0 glenoid, where this is going to go on to arthritis at some point, and probably nothing we do will change that natural history. But the only thing I would offer him would be a posterior DTA, because in my mind, everything else will fail. And I think that will hopefully re-center the head. I don't think it's going to prevent him from getting glenohumeral arthritis. Will you do that open or will you do that through the scope? I would do that through a scope. And I would say, one of the things you can take, I looked at the original images on the CT scan. It looked like there was one anterior anchor and one posterior anchor a little bit. No, he was done by a good surgeon. I saw his pictures. One of these things about hypoplastic glenoids is they usually have a hypertrophic posterior labrum. And that's something you can often take advantage of. So if the first surgery was done as technically well as you think, then I'd say, okay, can't bet on that. I will say that while the posterior DTA is easier technically, my complication rate and failure rate with posterior big bone blocks is higher than my anterior rate. And it gives me great pause because I leave the operating room super happy, think it's really slick. And then I've watched several of these where I'm like, you have got to be kidding me. So I'm on high alert with this one. Yeah. So does that change your graft choice? Do you think that's a fixation issue or do you think that's a graft issue? So for me, I'm thinking about arthritis down the road. It may be a graft issue, but I don't want to use screws because if I'm leftover on this, so this is definitely one, I don't want screws in the area. The only other thing I do is a full infection workup on this guy, because don't ask me, I know that. But if he had a failure and things like that, and he's got any C acnes in there and that causes future problems, you're looking at arthroplasty in a young person with a challenging glenoid at that point. Absolutely. I don't think it's a graft choice either because I've done it with Iliac crest and watched those resorb over time since I cry into my coffee. And I don't know if it has to do with the graft density, that a DTA is thicker. And so if they're wanting to ride on that a little bit, is that causing the Iliac crest to dissolve away? I don't know, but I don't think it's graft choice. Do you think it's loading? Yeah, exactly. Because we don't put it down inferior enough. We kind of shoot inferior to superior for fixation versus straight across. I think it's loading. Straight across is not, you know, the wear pattern is close to your injury, so when you're done, they have to be angled where you actually have, I think, the loading pattern you're looking for. Totally agree. I think it's the loading, not the graft. I have a weird question, but I've had a case similar to this, and I used a pacemaker for rehab. And I got to tell you, amazing result. Absolutely. Now this is a series of one, but stimulated correct muscles, sometimes these things, it's amazing that you get enough stability where you can bypass major surgery. Yeah, I haven't been able to bypass surgery, but I think, and certainly as a post-op rehab protocol, Philip Maroder is one of the smartest shoulder surgeons in the world, and he's come up with this pacemaker introduced to me by Rob Hartzler at a course, and then I talked with Philip a lot about it, and we've used it on a handful of our patients, especially these kind of patients in the post-op setting. I used to put these patients, I would get them fit for a scapular brace pre-op and have them go in that, because I felt like they all had this wacky scapular mechanics, and we were trying to correct their dyskinesia before we let them move, and I think the pacemaker helps a lot with that, but I haven't been able to avoid surgery. I've also done two cases of glenoid osteotomy posterior to try to correct this, and I would not recommend that. How about acromial osteotomy? Gerber's idea is that people have this horizontal acromion that's too short in the back, and that's maybe, you know, they need this. Or even acromial grafting, right? Like you take a wedge of the scapular spine and move it over the acromion. I have no experience with that, but I think it's very intriguing. But I think it's interesting. I mean, we do, you look at the pelvic osteotomies that they do, and those just look insane, right? And when Gerber kind of described his kind of triplane scapular osteotomy, we were all like, that sounds crazy, but I think, you know, I've let people break and reshape my knees, and it worked out okay. I thought it would be somewhat doable, and one of mine that's like this that failed three times, and I actually got with Dr. Gerber and sent him the imaging and everything else, and I thought it would be sort of a simple kind of take it and teach me how to do it. It's not. They 3D print it, and it's a pretty involved thing. And at the end of the day, his advice was, well, I don't know that we can do this across the continent. He'd have to kind of come out here, and the kid didn't do that. But it is no small undertaking. But the idea of that, of the angle at which that comes off, if we can modify that, is probably reasonable. Maybe room for an implant on the backside of the spine that will block that would be an interesting idea for you young innovators. For those of you in the audience who are not aware of this, so if your acromial morphology, if it sits high and it's sort of sitting straight up, it's potentially a risk factor for a posterior instability pattern versus being tilted back and lower where it may be a buttress. So that's what we're talking about in terms of shaping the acromial tilting height. It may have an impact on posterior instability. And you can see this one would be one, and usually if you, if it looks like you could do the arthroscopic DTA very easily, you know, that's like, that's why. Because it should be hard to do an arthroscopic posterior DTA if their acromion was kind of down and blocking it. But that's how these patients become unstable. Sir? Just a thought for you. You're fighting the biology here. Yeah. This thing wants to sit out the back. Could this be subtle brachial plexus instead of the brachial plexus? Because we did a whole bunch, I worked for a nerve unit about 20 years ago. We had a whole bunch of kids and they looked like this. Yeah. And we did a whole lot of posterior bone blocks. And they looked fantastic for about a year. No, it's an interesting, it's, yeah, it's an interesting thought. What do you do, what do you do that's modifiable in that though is the challenge? Yeah. Yeah. Remember, the spoiler alert is he has this on his other shoulder as well. So I think that's a, you know, very interesting point. So I think, you know, these are surgical options. We've heard about all these now from our panel. And so final vote, O'Brien says posterior arthroscopic DTA. JT, you're undecided or? No, same. Same? Yeah. Gene? Same. Same. Dr. Rhea? Same. So we're all saying that. Reluctantly. Yeah. I decided to go open. And I think because these dysplastic ones with the 30 degree scope, I've also, just like JT is talking about, I've had problems with resorption. And I feel like if we, when I'm having problems with resorption, I worry it's because of my surface area contact. And so I'm worried about getting the articular surface perfect in somebody who has a very irregular surface to begin with. And so for cases of the retroversion like this, I think it's just easier for me to see. And I was also worried about that really unusual kind of posterior contour that you can see there. And I was worried about, you know, how much I was going to have to take that down. I think that's hard to do through the scope. And like JT mentioned, they have a huge posterior labrum. Yeah. So it can be a little tricky because you've got to get that big fat thing out of the way to try and do it arthroscopic. Absolutely. So this, you know, this incision, a little bit more medial when we're going to the glenoid. I shift this a little bit more lateral if I'm doing like the Hillsex grafting that I was talking about. I do these in beach chair. And I do these in beach chair when I do them arthroscopic, just because I think that helps me kind of go back and forth. I do the rest of my instability lateral. But we do a posterior split. This guy's a giant guy. You're not going to be able to move this deltoid completely out of the way. So you put some type of retractor like a cobell in there through your posterior split. And then next you have your infraspinatus. And you can feel that. And then we're going to make our split through that and carry that, you know, very far laterally into the actual tendinous portion so you can get good mobilization. And then you can get very medial where you need to be on the glenoid for these. And we're using most of our same retractors just from the back. So deep bent gelpes, humeral head retractor. And once you play around with this to get to the glenoid, this exposure becomes very easy. To get to the humerus for a humeral head grafting I think is a lot more challenging. But so here's our exposure now. And now you can really see that irregular contour there. And I'm like, I think that would have been hard to balance a graft against that through the scope. And so I'm smoothing that out. I like to pin. I don't like to pre-drill my graft for these because I worry with these dysplastic ones, if you pre-drill those holes in your graft and then line it up, that might be a much different angle than you want your screws to be. So I like to use these small little joystick pins outside of where my screws are going to go and pin this. I did this with screws. Now I think I would try to do this with cerclage. And then just like Gene showed, I like to be able to repair the capsule. The capsule repairs very well. You close the layers on the way out. And you can get a very nice capsular closure and cuff closure there and then even loosely repair the deltoid on the way out. And so I was pretty happy with my reconstruction of the contour there. And again, I'm going to kind of get through this just because I want to get to some more questions. So his motion does great. This kid is so happy. He's like, please do my other side. He's also failed a labral repair on the other side already. His other side almost looks the exact same. It's incredible. So I do the other side. He was involved in a car accident at eight months. And he really, he didn't have any instability events, but we got a CT scan. We saw a little bit of graft remodeling, just like Gene talked about there. You can see my washers aren't right up against it in a couple of those cuts, but the graft does look healed even though he has some of that resorption. But I'm starting to worry a little bit. The kid actually is now gonna apply for PA school. So he comes back and now he's in my clinic. And so he's shadowing me in clinic. And I mean, this is a win. I'm high-fiving. And of course, in the military, when I was in the military, by now either I would have moved or he would have moved, and this would have been a happy ending. And now that I'm at the same place and I've been in the same city for like 11 years, now trying to see these patients back for follow-up where they can just keep finding you is a little bit, it's sobering. So, but wait, there's more. So three years post-op, he starts saying he's having some sharp posterior pain and he feels a click. He says he feels like something clicking in the back. He was trying to go to EMT school and it became too symptomatic for him trying to lift patients. And so now it's affecting his, you know, what he wants to do. He's tender. He feels this click. So we talked about hardware removal. He had actually already came to me with this on the contralateral side. I went back in, I took the screws out and he was like 100% better. And he's like, I've got 100% shoulder on his other side. His other side looks like the mirror image of this. So I take him back to do a hardware removal, just like JT was talking about. Both the heads popped right off. And so both the heads popped right off. I got the heads and the washers out. The graft was stable. The graft looked fine. And he's not happy. And so same side, his other shoulder, he says he feels like he has about 100%. This one he says, I mean, I got an email from him last week. Here's an MRI with a hardware subtracting MRI. And you can see the contour looks pretty good. He looks pretty balanced. But he says, as soon as he does anything where he needs to use his shoulder, it feels painful. It feels tired. When I took the screws out, we did a biopsy, which was negative for infection. I think it's a good thought to be thinking about that. How does Cartilage look when you took the screws out? It looked good. It looked good, but he's not happy. And again, I think the, just like JT was talking about these patients, like when you put in that stability, we could probably put a piece of wood back there and they would feel great post-op. They just feel great to be balanced. And so I think initially they feel great. And it's easy to think that these are a win. And like anything, we start following these out. We get these patients out past two years and we get them to three years. And especially in these young patients, I have now had a lot of these in these young patients that are starting to get graft resorption and they're starting to be very unhappy patients. And I think this is a real challenging problem. And so I'm curious if anyone else is having that experience. JT, it sounds like you are. What are you doing for those patients then? I've revised a couple of these to Iliac Crest, but I just think now we start going down a road that's hard to stop. And I mean, this kid's only 20 now. I share your pain on some of these. What do you think his pain generator is? He doesn't look like he's got a ton of arthritis. No, he doesn't. So I guess that's where I'd focus my efforts would be interarticular injection. Does that solve his pain? And if that's the case, then I'll assume and it probably it is, right? We injected his biceps because he was having some symptoms in the front. So we injected his biceps and he was like, it didn't really help. He's not like non-compliant. I think early on, it's quick to blame the patients for all these things. This guy's non-compliant. He's stopped going to EMT school. He wants to be a PA. He's not doing lifting. He's built like the Incredible Hulk, but he's not trying to, he's not doing those things. Is he out a little bit on the scan? Is he sitting out? I mean, it looks like he's kind of balanced over his new glenoid, but I mean, certainly his humeral position, if you go back to his original CT scan, that's where he lives. And I feel like early on for me in my learning curve, I was trying to take that bone block and try to guide the humerus back in. And that does not work. They will rough up against that. And I had to go back and do some resurfacing arthroplasty on those patients. Is he symptomatic when you push him posterior, push pull test, load and shift kind of stuff. Do you sense it's coming from posteriorly and in the joint? Honestly, I can't recreate on exam the symptoms that he's telling me because he's like, during the day I get tired. And as soon as it gets tired, it hurts. And then I'm sore for like three days. Sharp pain's gone. The click is gone. So I think that was the screw heads after we got a little resorption, maybe though, or the washer, but I can't recreate this on exam now. Get a nerve study on him, I suppose. Look at his suprascapular nerve just to make sure. I mean, I don't think it would be that, but. That's a good, yeah. That's a good thing. Doesn't have any muscle changes, right? What about his hypersomatism teres? Yeah. Do they look okay on their, like on the sagittal cuts? No, that's a great, that's a great point. When we go through the, when we go through the cuff and do a cuff split like that, that is something I worry about. I've had small females that I do this and they actually, my posterior split of the deltoid, they get like denervation there. And so I think for me and a small female now, I try to go completely under the deltoid because I think if you're doing a deltoid split and only leaving like this much in the back, it's hard for them to kind of recover from that. You're also really close with the nerve on the backside of the, of the, you know, the drop-off is there, but the nerve is right there too. And you're, we're closer than you think. Yeah. One little comment. What if this problem was not a form loss, but was a problem of version of the hemorrhage? Yeah. Like the relation with flow of an atrium. So excessive version, that's what caused your instability in the spine. And if you ask for steel form, it will not solve the problem. Just, you have to adjust the position of the hemorrhage. It's difficult because I did the exact same procedure on his other side. And he feels like that shoulder is 100%. He's got, you know, he has a- But that was six months later, so wait six months. Yeah. Come on, man. Well, so I think one of the issues here is, this is obviously an ongoing issue right now. Yeah. I get that from my personal experience. I can make anything worse. If I don't know exactly what I'm going to go do, there's a good chance I'm going to eff this thing up. So I would tell you cannabis is really my solution for this problem. For me or for him? Yes, for you. For me. Yeah. A little of both. A little of both. Yeah, because I think this is the, these glenoid version problems, as JT alluded to, I don't think we have an answer for it. And this is an early B0 glenoid, where if you do nothing in however many years, he's going to have a B2 glenoid riding out the back. So there's some folks that say, don't do anything, ride it out until he's ready for his reverse, which might be when he's 28, which is crazy. Yeah. But I think we need a better solution for this problem. Well, and I think the caveat is, I've presented this case at so many conferences as a win, and now it's not a win. And so be careful of the things you hear us talking about. Just take out those last three slides and then it's still a win. Oh, we're short on time. Thanks very much for your attention. What I loved about your post-op imaging is you saw his screws went inferior to superior, which I think is exactly, so when I do it open as well, because I'm very worried about- Wait, you voted for arthroscopic on this guy. No, no, I thought you meant bone block. Okay. Yeah, open bone block. Because I think if it's just transfer of screws, that is not the way the glenoid work pattern is, so they ought to be looking inferior to superior if they're not, I think it's malposition. That's it, no, I think that's a great point. And I think that's tricky. Arthroscopic posterior DTA is my go-to when it's not a glenoid that looks like this, but I think it's a very complicated procedure. But as you commented on, it's a commitment. In order to prepare the posterior glenoid to get the carpentry right, you have to take an L-shaped cut out of the back of that glenoid. And if it fails, man, you wanna talk about glenoid bone loss. So it's a big commitment to do that. I trained with Frank Jobe, and Frank was kind of like the, just nothing bothered him. We'd be doing these incredible cases and just nothing bothered him. And then the glenoid osteotomy would show up, and he'd actually sweat in osteotomy. And when he started sweating osteotomy, I said, that's an operation I'm gonna stay away from. So do you have experience with osteotomy? I do, well, not a big one, but enough to know that I don't like it. But yeah, I've seen it work. In all honesty, you could say that this is a guy that might benefit if you could do it well and you're good at it. Well, I mean, getting it to heal, you've still got a bone block to heal and everything else, you're wedging it up, it's flimsy. So you're really worried about, you think, oh, I'm gonna osteoclase this, and it's just gonna hinge on the anterior stuff. And that's what you're hoping it will do. But I will tell you, be careful, because if you break one of these, and you've got a thin sliver of bone now that's free, don't ask me how I know this, it's a dogfight. All right, so with that, you typically say best for last, but that's not the case here. JT, can you come up here and give us your case? Yeah, it's a pleasure. I've seen a ton of moderators over my career, and Rick is certainly one of them. Can we go to that? There you go. So this is a 31-year-old female with a six-year history of left shoulder instability. And I mean, listen, I'm not throwing stones. This comes from the outsides. It's one of my patients. But this is what you and I see in our clinic, right? You see those screws in the back, and you're like, well, they weren't short. You didn't have any problems with that. The other thing is, Burkhart's published on the importance of trying to be parallel to that. And you can see that these aren't. And I will just tell you, getting parallel is tough, especially if you're doing Travis Decker's deal, and that chest sticks out to here, man. It is tough to get those things flat. We can talk about technical tips to kind of get better. Radiographic evidence of struggle. Yeah, that's right. So she had a scope Bankart in 2016. That failed. So that's how her journey started, like it does with many of our patients. She had a revision scope Bankart in 2018, and that failed. She had a revision to a Latter-Jay in 2020, and she woke up with a musculoskeletal nerve injury, or musculocutaneous nerve injury, rather. So couldn't flex her elbow. And that was for 10 months after the Latter-Jay was done. And then in 2021, she underwent recurrent instability as well. Now she has a chief complaint of pain when she presented to me with a SANE score of 20. These are her presenting x-rays in that regard. So these are the money shots on your CT scan, and this is pre-Latter-Jay. I was able to get her imaging before the Latter-Jay because she was done in my city. And so you can see that there's a litany of, it looks like a landmine, a landfield in there. And then she has a pretty darn large, pretty darn large Hillsex lesion, though not terribly deep. So here's her CT scans after the Latter-Jay. So you can see again, screws are pretty long. Maybe that's a source of her pain. Lots of resorption here. If you take a look here on the right side, you'll see that Latter-Jay is not doing much. It's resorbed down. So the idea that it's allograft, autograft, that's what I spend my time thinking about why I can't sleep at night, is we got to figure out the resorption or the remodeling problem. Because when those go away, they're left, you know, stuff's left behind. If you're using buttons and soft tissue like I do, well, then you're worried that you don't have anything to support it. If you're losing, using screws, you might still have rebar that supports it, but then you got your own problems with that. So that's where we are with this regard. Now, what 31 year old female, field three surgeries, failed a Latter-Jay, still remains with pain and instability. And I guess that's what I'd like your opinions on. So I think this person, you want to make sure you see that all those changes from the anchors, you want to make sure she's not infected. And then it's tough because if it was just pain, then I would start with just a hardware removal. But if her complaint is pain and instability, then I think you have to address both. Tell me what your infection workup is with her, right? Because that's tricky too. You're going to take her all the way, everything from getting an ESR and CRP to arthroscopic, you know, aspiration, to doing the scope, to opening and taking five samples. Where do you stand on that? Well, previously it's been, you know, scope, five samples, but now, you know, these companies are getting better and better. Now they have like a dipstick that you can get, you know, you can get a, just take fluid and put it in, and in like 30 minutes get a readout on whether or not it's C-acne. And so our hospital is kind of just after that. Yeah, and so I'm looking forward to hopefully being able to avoid these scopes. We're going to do both in the beginning and make sure it's the same. I've been through it. I do a lot of shoulder arthroplasty, and we're with a bunch of joint guys that do hip and knee, and they are like, they snuggle their synovia sure at night and they just think that's the greatest thing in the world. And I'll tell you, I'm at a complete loss at diagnosing C-acnes in the shoulder in terms of being accurate enough to make solid decisions on it. And so then the other problem with me is this, if the C-acnes workups comes back negative, well, we're going to surgery. And if it comes back positive, we're going to surgery. So then I wonder, should I just be a nihilist and not do it? I don't know, what do you guys think? Well, I think if you knew it was positive though, you wouldn't put bone graft in, especially not allograft in this patient. Well, you would take her, you would take the hardware out, you'd put 12 liters of fluid through her and give her antibiotics for six weeks. Would you do that anyway, maybe? Third time failure already? Potentially, I haven't staged that before, but I've also not ever had one of these that I've been able to prove failed because of infection. It's probably happens more than we think of, but it hasn't. And then just to push you on this, right? If we think of this as analogous to a shoulder arthroplasty, we wouldn't necessarily do a stage procedure for that. We do a single stage revision in most of our arthroplasty patients with better data than the two stage revision. So I don't know what to do on that. But I did think about that in her and thought, man, but I thought, man, she's been through so much already. If I can get in one shot, I don't know. I don't know the answer either, but just like you mentioned, if you look at the data on infection with single stage arthroplasty, if it is C. acnes, which is most likely, it's a low virulent organism. So you can do your one stage, take your cultures. If it turns up positive, then you get her a PICC line and get her into CID. Although then she has allograft bone in her, but I don't know the answer either, but I've never taken somebody back for this to do synovial biopsies before the final procedure. Okay. I have just to diagnose it because we don't have this amazing test that I'd love to have, but it doesn't look like anything has done, been done to the humerus at this point. And it does look like she has a small hill sax. Would it be unreasonable if you're going back to obtain those cultures, do your synovectomy, maybe start on prophylactic doxycycline and do a remplisage while you're there? Yeah, that's a good point. One could consider doing that. I did not do that, but yeah, that's a good idea. I was thinking the exact same thing, Jean, because I think for this, like I would do a DTA in the front open, but I would do an arthroscopic remplisage. So if you were going to stage it, do the remplisage, treat it, and then bring her back for an open DTA. But talk to your ID people because doxy is not what we, doxy is not the best med for this. And most of them don't need a PICC line for C. acnes. It's penicillin. And so you put them on amoxicillin and it has great bone penetration and it's got great bioavailability and they can just take three pills a day and that's their treatment for six weeks. And so, and that does great for C. acnes, especially in a healthy host. Well, what do we do? So I think in her case, I worry about the subscap taking all that stuff down. So I thought, well, we'll do this. This is a little bit, you can take these out arthroscopically. I think the tip here is, as you can see, I'm pulling out the screw from the front. These were cannulated, which is an advantage here. I did not pop the heads off on this one, thank God. She was loose anyway. And so you can take these out coming from the front, but I wouldn't continue to take them all the way out the front because you have the chance of losing them into the anterior soft tissues. So I take them out just until I can remove the pin and then I'll slide the entire screw into the joint and then take it out from the back. And that's my standard go-to method. Now, if you finish with this, you can look down, there's her conjoined tendon. It's still attached, but she hadn't gotten any bone. And so now we've got to revise this to play with this. So you can see how much glenoid bone loss she's got. That's a ton. So this is me coming from the back with a drill guide. I use flip cutters because it allows me to get the carpentry just right if I use them as routers. So I have parallel flip cutters coming from back to front. That's the inferior one. Then I've got to match the other one. We flip it back, take it out, and send it down the other one with a guided pin system here. We mark our spot so we don't lose it. Now we're coming through the parallel, hopefully parallel shot that's coming through. Here comes the drill guide here. And we do, those of you that use flip cutters in your life, this is pretty straightforward in terms of its ability to come back. And then you're under direct visualization, just kind of coming back and using it as a router. And then you've got two overlapping ovals, if you will. Now, this is a mid glenoid portal. So the same portal you and I use every day. There's two passing sutures. So same techniques that you and I use every day. And we slide this out the front. This was probably, this case was probably, gosh, four or five years ago now. And so we were still on a previous generation of how I do fixation, but pretty easy fixation. And so now you just slide that thing down like you normally would, and you've got to fiddle with it just a little bit. A lot of times these patients have some arthritis in the glenoid. So sometimes it's tricky as to where to stop because you can really take a lot more glenoid. You can see centrally, she's got a little defect here. I left that alone. And so now we're going to put this into place. I've got a soft tissue fixation in the front. You can see the loops there. And then when you're finished, you can see we can get quite a bit of bone put back on top of this deficient glenoid to where we get it. So what's it look like? The current evolution is just a little bit different from this. We use a similar technique. The only difference is, is that we do a cerclage technique. We were a little concerned. This one worked fine, but, and this is not her, but the current technique that we do, I was a little bit worried about those buttons not having enough compression strength. And so the cerclage actually has solved that for us. I think we're one step ahead of that now, but it's yet to be released. So again, using those flip cutters and getting a good carpentry on the front side, same principles apply. Two grasping stitches out of here. And then this is us loading the graft with a cerclage kind of construct. It comes out the one tunnel, back down the other tunnel, dip it back down the backside of the, of the graft and then slide this guy in. So this is again, not hers, a separate patient, but demonstrating sort of our current evolution and pretty straightforward. You can see a little bit of flipping in here and kind of getting this knocked down. Once you're down here, this graft is really, really solid. One of the things we've learned with the buttons is it's really hard to tension them enough, the current available ones. So these tensioners here, this is, this is going up to 50 pounds of force, which is quite a bit. After that, you can jump up and down on this thing. And I show myself spanking this thing with a spatula. You want it to be nice and solid, and then we can repair it and hopefully get something like this. So this is what she looked like. I get a CT scan at three months on everybody. I want to know that my position hasn't changed. And then it's before it's resorbed enough for me to get really nervous. So I like this window and, and pretty happy overall with the, with the ability to restore this overall. You can see how much bone we put into this lady. So that was three months status post. And then she came back at six months and was really nervous and worried about it. And so you can see, we did another one with a 3D reconstruction and you can see she's not started the resorption process here, which I know unfortunately is coming. But I would tell you for me at this point, I was super happy. At this point, she's now four years out. She works around our hospital. So I've seen her and, and she's hanging tough. She feels great. No apprehension. SANE score is maintained at 95. So for me, this is a win. I will worry about what that will do over the course of time. What about the large heel sacks? Well, we've talked about that a little bit in this regard. I'll show you one of the things we're working on. We love the Remplissage just like you guys do, but there, there is some ability maybe to bone graft those. So what do we, what do we do when we don't want to do these big open ones? And I'll tell you, I don't, because of the big exposure, the subscap takedown and the resorption in these. So you can see what we do is we just place a, we just place the simple Remplissages like we normally would. And then underneath that, we place this bone graft. And we got a little bit of a, can you run that video? So these are the pre-placed sutures on the, on the Remplissage. And you can see, we clearly need to get a little slicker about how we do this in terms of the technical side, but this is the bone graft that I put in by hand. And then you can put this flexible bone graft up into and underneath my Remplissage. We call it bone graft Remplissage. It's coming out. So if you want to see the technique in A-Tech here pretty quick, but we'll put that graft in it. And usually it can come in various sizes. You can actually cut this graft. And then once it, once it dries out a little bit, then that becomes solid and strong. And that's been our approach. So just to show you what we have here on these guys, we three months CT these guys and ask our radiologists to say, look, are we incorporating? Is it working? Or is it just resorbing away? We've got eight patients so far, no recurrence yet. I don't know whether this is the answer. So there may be, you know, structural bone graft, but the idea is if we can pack something in there minimally invasively, and then put it under compression with the Remplissage that we already do. It, it, it's been promising, at least in my practice, but like anything else, stay tuned and I'll show you my failures next year. And we'll go from there. Thanks very much for your attention. JT, are you using, did you use, do you add any biology? is that, that was fresh graft? Yeah, it's a, it's a proprietary graft, but it's a, it's flexible. No, for the, for your bone graft, that's a DTA, fresh? Yes. Yeah, and do you add any biology, or are you adding, are you taking crest? I do, I soak it in PRP, I do a little chicken bones around it, there's a little voodoo doll that I stick in the back of it. I mean, I don't know what works in that, but yeah, we do soak it in PRP. I mean, my system patients would have to pay out of pocket for any of those things, none of it's covered, and so I have a hard time selling that when we don't have, you know, data on that yet, and usually I'm just doing iliac crest, non-concentrated iliac crest aspirate, because I can do that just for the cost of the bone marrow biopsy needle, but are you, are you, are you going further than that, are you spinning that down concentrated, or are people paying for that? Interestingly, normally we get it pre-approved, and normally it's approved, and if they, if they're not approved for it, then we talk about, you know, other options, but normally it's kind of a package thing in our system where it seems to work out. This one's not as hard, because I don't have the option of Latter-Jay, and our insurance companies haven't figured out that iliac crest would be another option that they could do with less whatever, so I think in this case, and we're pretty good about getting DTAs sort of approved. I don't know if fresh DTA works better than frozen, and in fact, there's some evidence, at least coming out with Matt Preventer and Ivan Wong, where they've compared the two results, and it doesn't seem to matter, at least if you do it like Ivan, and so, you know, maybe at the end of the day, we can do this with a much cheaper graft, and maybe the cartilage doesn't matter, but these patients are often in their mid-20s, and so if the cartilage will heal, I want real cartilage that will heal over time so that you don't have, and you guys have done this too, on second look arthroscopy, the cartilage doesn't, you know, sometimes you go back on OTAs, back in the old days with the knees, and the cartilage is all sloughed off. I have yet to see that on a second look DTA, although my numbers are limited in that regard. Yeah. The other is, in this case, you left it in particular, correct? I do. You put a Vanguard over it. I do around it, yeah. Yeah, so cell viability. versus allograft, no difference. And to your follow-up, so I think there's some evidence that you might be wrong. The only challenge is I don't think that you pointed this out yesterday in an ICL, which I think is exactly right. There is in my mind, as Burkhart used to say, I would have to suspend my disbelief if I thought that that capsular repair over these large DTAs stayed intact. It can't, right? So as you pointed out yesterday. So therefore, once that thing fails in continuity or whatever it does, I worry what's that surface going to do to the humeral head over the next 15 to 20 to 25 years. Maybe nothing. Maybe nothing different than the fresh. So that's, I don't know what the answer is there. But when that Bankart fails, and it will, it'll be a controlled failure sitting between your native glenoid and the DTA, that that actually will be a buffer between the humeral head and the articulating surface of that bone block. Maybe so. Because if you go back, if you go back and you look, you'll see that it's not gone. It's just attenuated. But it's still sitting between that bone block and your humeral head. But if your soft tissue injury was so bad that you really just at the end of the case have nothing that will hold a stitch to put over that, does that change which graft you want? You're in trouble at that point. Yeah. So that would be a big issue. Yeah. But I still think that if you can make it extra articular, I think you're better off in the long run. And I think using, and even though it's going to fail over time, I think the fact that you can use like a graft that's like $800 versus one that's $15,000 has to be timed, it's a big advantage. A hundred percent it is. Yeah. So that'll be where we should all watch the data to go. Do you want me to keep talking or, because otherwise Mike's going to present a case? Oh my God. Yeah. I forgot. Okay. You know what, I forgot about him. Time to go on to the case presentation. Before we go any further, are there any questions about, can I ask, is anybody here would do it for a failed latter J? Let's just say for whatever reason, is your go to the DTA pretty much? Yeah. And is it allograft or is it, do you go to Iliac Crest? For me, it's DTA. I've done Crest a couple times, but I feel like we, you know, when I was a resident and especially a medical student, we used to take Crest for everything. And I think now we're, for me, I'm certainly not as good as taking Crest. And so I think that's something we have to continue to probably to work on and to teach. And I've had one patient who then avulsed his ASIS post-op after taking Crest, a little skinny kid. And that was miserable complication. I have to do like a hundred more to get my complication right back in an acceptable percentage now. I think they hurt. The Crests always hurt. And you know, it's like when you used to take hamstring grafts, they never hurt unless you took a hamstring graft for like in UCL and then they fricking hurt on their knee all the time. So the donor site morbidity is no joke. It was high in Marotor study, et cetera. So, and he does them all the time. So that's my reluctance with that. And so less. Would you ever take scapular spine? Would you ever take distal clavicle? I do a lot of distal clavicle grafts. And in fact, the very first, when we described the distal clavicle graft, it was for a posterior one because I was, I didn't have a Latter-Jay to do right. So that's where we sort of said, oh, this makes a little bit of sense and called up Buzz Burkhead and said, you ever done this? He goes, yeah, I did one back like 25 years ago. So I said, all right, well, then it's not completely crazy. And so that's, that was our very first one in the back and that graft works well, but it's a little bit more brittle at the time we were trying to put screws in and it doesn't hold screws. Well, so then I went to buttons and the buttons actually, I think it brought that back for me, but it's for subcritical bone loss. It's not a big enough graph for us to use in, in masses. Yeah. I still like having the cartilage. Yeah. Yeah. Mike, this is a Rick knows I'm not nearly as good of a surgeon as he's master surgeon. So he gave me the first time shoulder dislocation that will unfortunately go through. Um, this is first time shoulder dislocation, uh, right shoulder and a right hand dominant quarterback. So it's midway through his junior year, maybe like four games left. Uh, he got sacked after throwing the ball. So his arm was up over his head when he hit the ground and the trainer got out and pulled his shoulder down and felt a clunk. So it may have been almost like an inferior dislocation, first time, shoulder dislocation in his throwing shoulder. He comes in two days later. Uh, nothing surprising on the exam. He's very guarded. His passive motion is pretty good. He's got a lot of apprehension, uh, and he's got an anterior load and shift, and he does not like an inferior load and shift at all. Negative in the. back doesn't seem like his posterior labrum is involved. And I think his rotator cuff is fine. He's just kind of guarded and apprehensive. So in the sake of time, I'll tell you, there's nothing really that concerning on his radiographs, right? So we usually like to get a Bernoulli view in clinic, but we couldn't in this guy because he was too apprehensive. So that's a standard axillary in the middle and not a visible Hill Sachs, nothing too concerning on the glenoids. So what do you do, Gene, for this guy when he comes into your clinic? Do you get an MRI every time? You talk to him about, these are your options. You want to watch it? You want to fix it? Yeah, so I'm fairly aggressive with the first time dislocators. Obviously most of my patients are military, but I think with this person, if football's his passion, if, and this is the question, do you want to play past high school? I think his odds of being able to successfully complete the follow-on season are a lot higher if we fix him early, or he's almost at the end of it. I'd say skip baseball in the spring, get the surgery now, and then be back in the game for your senior year. I do get an MRI for every one of these. I think there's a lot that we can see. I don't necessarily get a CT scan for every person unless there is some suggestion of bone loss on that initial MRI. If we can get to him early and we don't need dye, that's great. I've probably mostly moved away from arthrograms, but I think in this case with that kind of odd mechanism, at least with having the arms straight up and maybe this potentially being true inferior dislocation, I'd want to know about the status of the capsule. So I would probably get dye if a little bit of time has passed. That's exactly what we talked to him about because he, football is his passion. He plays center field, but he's like, I'm willing to miss baseball to be back for football. And of course he wants to play at the next level. I don't think he's the caliber of a D1 athlete, but you never know, you know? So we got an MRI and part of it, I think, is just to know what the labrum looks like. And really in 2025, people expect it, you know, when they come in with a shoulder dislocation. This is a non-arthrogram. And so we got this pretty quickly. So I figured we'd still have some blood in the joint to serve as contrast. So there's the axial cuts and here's the coronal cuts. So his cuff looks okay. I don't see a haggle. So here's some still shots. So JT, what do you see there? Well, he's got quite a bit of stripping down the front. The heel sex is, it's hard to say because it lights up on the MRI. It doesn't look massive. It's pissed at you, but it doesn't look massive. But a lot of stripping kind of down the front side. I was worried about a haggle when you originally showed this, but I don't see it either. And yep, so he's got a bit of his labrum stripped. So I think he's probably got an ELPS lesion and I would say less than 10% bone loss. So this was an outside image on a CD. So I couldn't make the fancy measurements, but we'll say less than 10% bone loss. So. Oh, go back just one. I'll show you a paper by McEvica showed that if you don't have fancy stuff to look at and stuff, cause we all get stuff from outside. If you draw a line from the bottom of the glenoid to where the glenoid inflection point is, which is really hard. I think Marina Rodriguez is in the audience. Marina is the co-author of the paper. But they showed that if you draw that line straight up and hit the top of that, two thirds of that is your circle. And it's every bit as accurate or more accurate than the perfect circle technique. So for those of us that get outside MRIs that don't have the fancy software, this is a very reproducible stuff. And Marina deserves great credit for doing that work. Absolutely. That's a great tip. Great study. So Parada, what are you going to tell them? Yeah, I'm going to tell them in these, in these young kids, we think the labrum can heal, but it's not going to move back. And so, you know, we kind of show them this MRI and say where yours is, it's not going to move back. The only thing that can move it back is surgery. You're going to dislocate again. And he probably, if he's a, as a quarterback, I, you know, if he's unstable, if he's apprehensive in your clinic, I think that makes it a lot more real for him because there's no way he's going to be able to throw a football. He won't be able to get in that position and that might make it easy. If somehow by the next week he can, I don't try to talk these patients into surgery. I feel like this becomes a very easy decision when he goes back to practice the next day and dislocates the first time he tries to throw. And then I let him come back, but. That's exactly what happened. So he's, I'm a junior. I want to try and play. He tries to go back. He couldn't. So he couldn't throw. Yeah. I might take that. How long did you give him? A week. Oh, that's, that's good. Good, solid try at non-operative management there, Michael, nice work. It was probably two, two weeks. The reason I bring it up. The reason I bring it up is. Three days later, he couldn't throw. So we fused him. You gave him a football and said, throw it. Yeah. Now the reason I bring it up is, is our physical therapist when I was with Stephen Hawkins is a woman named Ellen Shanley. And Ellen and I have had a thousand discussions about these things. And she said, with this exact patient, I had the exact same approach. We got to fix them. She said, JT, you're not even seeing these cats. And I'm like, nah, come on, Ellen. They all come to us. We're first time to blah, blah, blah. She goes, you're not even seeing them. So I said, prove it. So we took the Greenville, South Carolina healthcare system, high school system. And we looked at these kids that sustained dislocations. And then she followed them for a year and said, number one, did they get back to play? And if they got back to play, did they miss a single day from their shoulder? So we had all that records and we'd set up a nice system. They didn't. So Jean's point earlier when she's saying they won't get back, that's in a collegiate population. And in fairness, that Dickens study is based on 10 patients. And that's okay. That's good. That's the best data we have in the collegiate population. But we have the study in the high school population, which suggests the opposite, that these kids will get back and complete the next season. Now he's a quarterback and it's different and blah, blah, blah. So I would be a little contrarian here to say that this kid has a, at least based upon that data, has a actually a very good chance of completing his entire next season without it, without doing surgery. Now the con to that is the whole, and JT's paper on that, I think is not liar, but it's a very good paper and eyeopening. But think about this. First time dislocation, I think it's analogous to like the ACL. You have a second episode, you think bad things happen. So for us, it was, if you had a first time dislocation and you did a stabilization, could you get the same result and it's a high success rate if they did it a second time, is the result as good? Because if it is, you can say, okay, go ahead and play. If it happens again, no downside. But there is a downside. Albert Lin's paper out of Pitford says, if you dislocate twice and do a stabilization, it is a lower number in terms of the higher recurrence rate than if you do it the first time. So there are prices to pay along the way. And let's remember that you do a bank card and it fails. Now you're down a path where the Latter-day as a revision has a higher failure rate. Everything is affected by it. So I believe it or not, 25 years ago, I debated Toro on this topic of first time dislocation. And I've been a big proponent of taking care of this early because I think if you intervene early, your success rate is the highest. There may be kind of like the appendectomy thing where you may do some that didn't necessarily need it. But in the big picture, I think intervening early in these young athletes and profiling them into the high-risk category, I think you're doing them a favor than letting them play, have them dislocate a second time and not run the risk they're on the wrong track for the rest of their lives. But that's just me. Yeah, and we had this exact discussion. And I said, I think you should have surgery for this. I put the ball in his court, like Parada suggested. And he came back early because he said it doesn't feel right and so then they wanted to do something. So what would you guys do? So he's got an ELPSA, higher failure rate with an ELPSA. He's got less than 10% glenoid bone loss with an on-track pill sacs defect and an ELPSA. So Rick, what surgery would you suggest? Bankart remplisage. Gene? Bankart remplisage. Yeah, JT? I would really be nervous about throwing a remplisage in this kid because of the fact that this is dominant arm and a throwing shoulder and the results on that with throwers are not terrific. And so I'd look and stare longingly at it. I wouldn't say I wouldn't do it, but in this kid, I'd love an open bankart for this, but in a dominant throwing shoulder, this is the one situation where I might be tempted, especially if that hill sacs is really small, to do just a arthroscopic bankart. Yep, Parada? Yeah, same. I would do just an arthroscopic bankart and I would do it the way JT and others taught us in the military. I'd come all the way around to the posterior band of IGHL, make that my first anchor. And so this is gonna be like a five-anchor repair, probably at least. Maybe more than that. Yeah, it's like the posterior's involved a little bit. Posterior wasn't bad. And so once I started kind of probing it, so it's got an ELPSA, it's way medial. There's his hill sacs. It's not horrible. You kind of got to look around the corner to see it. His labrum's way down medial, as you would expect. It definitely goes around the bottom. I think it stopped at about seven o'clock or so. And so this is the case. It's teasing this labrum off. And so it's way medial. So I get an elevator in there and I start up high and you're just trying to peel the labrum right off the glenoid. And you're just trying to get in there. So separate the labrum and the capsule from the glenoid. And then you got to work your way all the way around the bottom. So you spend a lot of time mobilizing this. And so I go back and forth between using an elevator and a shaver. And when I use the shaver, I run it on forward with no suction. I don't oscillate because I don't want to suck that labrum in and suck it away. So now we're getting around the bottom. I'm back to the elevator and it's back and forth, back and forth. You really got to release till you see the muscle fibers of the subscap. There I'm getting around the bottom. And until that labrum starts to float back up. So the majority of this case is mobilization. So here I'm running on forward. I don't have the suction on. I'm just trying to debride, kind of abrade that medial glenoid neck a little bit. And to get around the bottom, I like to use the shaver because it's more stout than the elevator. So I'm using the shaver to push the humeral head out of the way. It's running on forward, no suction. And I'm just trying to elevate that labrum up off the back because I want to mobilize it all the way around the back. So- Did you do a rental massage you did? I did not. And we're going to talk about that. So- So the Japanese would say, maybe you take a curette on top of that and remove a few millimeters of cartilage, right? We all said, oh no, my gosh, you're creating bone loss, but you're really not. Have you done any of that? Or do you just, you feel like the neck is enough? I have not. And I'll use the shaver to just remove a little bit of the cartilage. So I stay on the neck and I try not to remove much of the cartilage. If there's a loose flap, I'll take it out, but I haven't gone to a curette. Okay. So we're starting in the back. So this is a seven o'clock anchor. So I'm using double loaded suture tapes here. So we put a double loaded anchor at seven o'clock, kind of pass the stitches in mattress fashion at six and 6.30. And then my second anchor is trying to go in at about five o'clock. And so I'm trying to get mattresses in that inferior capsule. Is that equivalent to rump massage? That's my question. No, no, that was my question. Yeah. So that's what I wanted to ask the panel because, and then I like these vertical mattress sutures because it helps me tighten up the capsule a little bit and shift it up onto the glenoid face a little bit. So I did not do a rump massage because I was worried that he's a thrower and can five degrees of external rotation loss affect his throwing motion? And I intentionally added a seven o'clock anchor to tighten up that posterior capsule. Is that enough? I think in these cases, you have to do a Bankart Plus, you know, and if you can do, if it's not a thrower and your plus is a rump massage, then perfect. But if they don't have much of a heel sacks, but they still have this big of a labral tear, you have to do more than just our standard Bankart. I think your Bankart Plus is coming all the way around to the, you know, the posterior band of the IGHL. And I think that's, I think that's good. I think what we've learned is just a Bankart doesn't work in these patients, you know. And this was four anchor repairs. So double loaded anchors, trying to keep them all below the equator. He went from this to this. So I felt pretty good about it. He was able, this is the seven o'clock portal. So you just come off that posterior lateral acromion and it drops you right down to the posterior inferior labrum. This is the results on Alps lesions. So we know that Alps lesions have a higher failure rate. So I think you do have to do something more than just your standard Bankart. This is Pete McDonald's two year data on Bankart remplisage that shows a one third of the failure rate when you add a remplisage compared to Bankart alone. So 22% failure rate with no remplisage, 8% failure rate with remplisage. This is at four years. And I just wanted to jump ahead to this. So this came out just this year, 2025. And Pat Denard showed no difference in external rotation loss after Bankart or remplisage, but there is a difference. So it's not statistically significant, but the mean difference loss of external rotation was about six degrees. So even though it did not reach statistical significance at 0.13, so the title of the paper is no difference, there is a difference. And so that's what I worry about. So, and I did this case about three years ago. I might add a remplisage now, but I didn't then. And he made it through his senior season. Can I ask, is he a quarterback or a pitcher? Or what is he? He's a quarterback and he's a center fielder, but he wants to play quarterback. I'm gonna tell you 5.9 degrees in a quarterback won't make a difference. In a center fielder, it won't make a difference. If you're pitching for a living, 5.9 degrees makes a difference. Excellent point. I don't think in a quarterback. And I think now with this newer data in 2025, I probably would have added a remplisage for this guy, but this case was three years ago and I didn't and got lucky so far and he's not playing in college. So maybe it'll survive. The other is that, how many of you, we can use a mattress suture in your bankrupt repairs. Mattress, how many use just a simple stitch configuration? I think you have one. I would say I have one. I think the mattress is really the way you recreate the stability you're looking for. And you're able to push that up and hold it there and actually sort of compress it to a phony surface. The loops I think are better than mine, but I think that they don't give you that in a real restoration. But I think you'll find that using a mattress, you may be a little more impressed by how robust your repair is. And I alternate the mattress in a simple stitch on double loaded angles so it looks better because I can roll the edge down, but that mattress is a go-to stitch for me. And I would strongly encourage you to consider that in your bankrupt repairs. With that, first of all, I want to thank the faculty, the best of the best. Thank you guys. You guys are awesome. Thank you all for attending and I hope you enjoy the rest of the meeting.

shoulder instability

case management

complex revisions

anterior-posterior bone loss

revision surgery

Latter Jay procedure

humeral bone loss

3D printing

acromion morphology

shoulder dislocation

Bankart repair

remplissage