All right, welcome to our ICL session here. This session is on Arthur Scott Baker, the failed bank cart repair and sort of the options related to this. I'm Albert Lin, I'm from the University of Pittsburgh and I'm the moderator. I'm joined here by an excellent faculty, Dr. Dewan here from Penn State, Dr. Koiner here from UConn, and we have Dr. Ivan Wong here of the famous Halifax portal. So quick introduction, we do have disclosures which are easily, we can easily look them up. So we know that Arthur Scott Baker Bank Cart is a very popular surgery, but it's still associated with very high failure rates. And so failure, as we all know, is common. We see this all the time. And the question here is what are you gonna do when you have a failed bank cart, especially if you have no bone loss or what we now consider subcritical bone loss. And I think the options really come in a couple of flavors, revision arthroscopy, maybe you can do something different or do it better, open Latter Jay, Europeans love doing this, open bank cart, Aman's gonna talk to us a lot about this, or bone grafting sources of other kinds, osteochondral grafting, auto or allograft, both open and arthroscopic, and we'll hear some really good lectures regarding that. And I think in the background here, there's a lot of considerations, right? Demographics like age, sport, anatomic factors, hyperlaxity, whether you have bone loss, the track concept, and then with these athletes, what are you gonna do with them in season, so beginning season, mid-season, after the season, and I think the focus here will be on outcomes, pros and cons, the risks and complications, and technical pearls, and we'll have some cases, hopefully we can go at the end, we'll talk about it as a faculty to see what we would do. So here's the brief outline, I'll go over revision bank cart, we'll then hear about open bank cart and open Latter Jay, open revision options, or other options, and we'll lastly hear about the revision arthroscopic bone block. So, you know, what are we gonna do, and why is arthroscopic revision bank cart even sort of in the armamentarium, right? So, if you look at sort of the whole open revision failure rates, they can have a large range, anywhere from, you know, eight to 22%, some lower in other studies, and some higher, and why is it popular? Well, because it has a relatively low risk profile, right? And I think everyone here is comfortable with doing arthroscopic surgery. A question is, does it have comparable outcomes to other open stabilization? Here are some things that I consider when I'm really kind of thinking about this. First of all, you know, are there pathology or issues that haven't been recognized? Is there bone loss? What's their track? Is that addressed in the first procedure? What's the hyperlaxy status? Do they have a Ms. Hagel lesion? Do they have MDI or some other component of instability? How about other anatomic factors? What's the tissue quality like? And then what kind of patient are we really dealing with? Is it a young patient, a non-compliant patient? Are they a high-level athlete? Do they participate in contact sports? And then from a technical standpoint, you know, we hear about whether or not, you know, if this is something that you did before, are you gonna do the same thing again? Or if this is something referred to you elsewhere, from elsewhere, and then are you gonna look at other issues? Is it the proper technique? Was there enough anchors? Was there enough mobilization of the capsule? Is all the redundancy addressed? And then I think when we really think about this, what we're really thinking about is what the complication profile here is, right? Can I get a good surgery but limit the risks of complications? And I think as you go from left to right here, the type of complications you experience and sort of the severity definitely increase. So what are some pros of arthroscopic revision Bankart where you can preserve the subscap? You can evaluate other pathology, like SLAP and posterior laboring can preserve motion. You can save the coracoid. And it has a very low complication profile and maybe it doesn't box you out of some stabilization procedures. Whether or not you can still get good outcomes following a failed revision, revision Bankart, it's hard to know. So what are some cons? Maybe external rotation loss, particularly if you're considering remplissage. And what about higher recurrence rates when you consider the other procedures like latergies or open Bankart? And so some of the question here is then maybe who do you appropriately select a revision Bankart for? What are the outcomes of open revisions? Some of the studies are a little bit all over the place, including reasonable failure rates to less reasonable. And sort of how does the revision Bankart cohorts compare? This is an older study from Professor Imhoff demonstrating relatively good outcomes with about 10% recurrence rates following a revision Bankart with relatively good return to sport. Here's a study out of the Rush Group. Demonstrates slightly high recurrence rates, about 20%. And with risk factors, including hyperlaxia and prior surgeries. But high return to sport. An older systematic review, 2013, demonstrating relatively good recurrence rates and high rate of return to sport. And so the question is, you know, with proper patient selection, maybe the revision Arthroscopic Bankart can equal open Bankart outcomes. So who's the appropriate patient? Back in 2018, we looked at this through JBJS, looking at 65 patients, all revision Bankarts. And this was without any augmentation, no remplisages, no posterior augmentations. Recurrence rates, quite humble at 42%. But there were some risk factors. If you look at multivariate analysis and we looked at age less than 22 years old, off-track lesion, ligaments, and you excluded all of those, you could get the recurrence rate down to about 19%, which is comparable to those other studies. And so patient selection is critical. This is a more recent study from John Dickens' group at Duke, or probably when he was at Walter Reed actually, looking at young military population, 2023, 53 revision surgeries. They excluded bone loss and hyperlaxity. And their recurrence rate was a pretty sobering 44%. Now, why was it so high? Probably because their mean age population was 23 years old in an active military group. And so, and just note that many of their failures occurred after three years. And so half of their failures occurred after a long period of follow-up. So then if you look at sort of all of the studies looking at this, comparing arthroscopic versus open, revision anterior stabilization, potentially the recurrence rates may be comparable if you kind of look at the mean recurrence rates in both open and revision bank cards. What about revision latter-stage stabilization? Some studies demonstrating inferior outcomes if you do it after a failed primary stabilization, others demonstrating not the same issues. Maybe the real thing here or the concept here is just picking the right surgery for the right indication and making sure that you do the right one the first time around. So I don't believe an arthroscopic bank card is a panacea. These are situations I think twice in a primary situation about just doing an arthroscopic bank card alone, subcritical glenoid bone loss, near-track or these off-track lesions, contact athletes, multiple recurrent dislocators, patients with hyperlaxity and younger patients. And I certainly think of this in a primary setting where I started to think of the glenoid track or bipolar loss concept as a continuum. And so there are some on-track lesions that I think are worrisome for failure without further augmentation. And so who gets a primary arthroscopic bank card in my hands? Someone who has minimal bone loss, a first-time dislocated and older patient, not a contact athlete, no hyperlaxity in a well-on-track lesion. This is a very sort of select indication. And these are the same things that I think about in a revision scenario as well. Otherwise, I'm probably gonna augment this with something else, including remplisage or consider doing open procedure. So my algorithm for revision bank card, it has to be a distinct event after a significant period of a successful procedure. They're not involved in a high-risk activity like collision or high-level sports. They need some kind of external rotation. They're a little bit older, no hyperlaxity. They have to be well on track. And then I'll consider doing a revision arthroscopic bank card, usually with some kind of augmentation, including remplisage. Now, this is not a revision procedure, but this is somewhat the sequence that I would do for a remplisage. This patient has subcritical bone loss, has pretty chronic tissue, a little bit older. So we first make our portal. This is making an anterior lateral portal. I have passed, actually, initial suture down at the 530 position. We're now going up and fixing posterior labral extension. I'll then go and assess the hill sac's defect at this juncture and start to prepare the hill sacs. I still do the remplisage in this manner. We'll kind of poke on one end, intra-articular, with a sharp choker and drill a standard sliding suture anchor. And we'll repeat that on the other side of the posterior portal to do this all intra-articular. So we're mainly stabbing through the capsule and not so much the infraspinatus. Now that we've put those in, we'll just go back and finish up the rest of the anterior labral repair here using a knotless type mechanism and system. And again, in the very beginning of it, it passed the five o'clock low anchor before doing the remplisage work. And after we fixed everything, then this is usually when I go in and do the remplisage. I still like to do it this way. This is a tied double pulley to kind of put the capsule into the defect. I know there are other techniques now where you can pass using bridging techniques and knotless mechanisms, but this is a little bit what it looks like. All right, thanks very much. Thank you. I loaded them with you, don't you remember, we were just in the room. Okay, we have Kathy go and I'll come to the back and, okay, yeah. I saw him in there too, if you need to trust that he was there. Well, I get the difficult one, just the other. So open to be allograft and distal clavicle potentially. So my disclosures and I think we sort of talked about this, but recognizing glenoid bone loss, but also the fact that in a primary situation, these are primary failures and the obvious is significant. When you haven't recognized glenoid bone loss, your rates of failure go very high. And this is obviously about sort of subcritical bone loss and again, this is a primary situation and I would challenge that it's even more important in the revision situation. So this says that at 13.5, the clinical outcomes are worse. So our subcritical bone loss less than 20%, especially if they've already failed a primary procedure, I would definitely want to think about that. The glenoid tract has obviously gotten a lot of play and we better understand this and creating on-track lesions are very important from the revision situation and really addressing that bipolar bone loss is something else that we didn't touch upon necessarily, but looking at the humeral head in that revision setting as well. So a lot of this is, we've sort of talked about it, but Bankart in a primary situation sort of at 11% recurrence rate, open repair is about 8%. And if you looked at the arthroscopic with all suture anchor, then it was about 8.5. Return to sport is adequate, 87 to 90%. It's good, but not perfect, I would say. So similar, my approach is to say, why did this fail? Was it a true dislocation after multiple years of successful treatment? And I think having the ability to be partners with Bob Arciero, we get to talk about this a lot and what he'll tell you is that the longer you follow them, the higher failure rates you'll see. So even with a new trauma or not. And then the other one is about sort of not a recurrent dislocation, but is it a functional deficit? Do you have a thrower that has two loss of external rotation because somebody did a remplisage and they're just functionally not happy? You have to think about that situation as well. What's their age and activity level to determine sort of their risk profile? Do they have a hill sax that you need to address? Is there bone loss and how much, on track, off track? What's the quality of the tissue? Because if you're trying to do a revision arthroscopic repair, you've got to really be able to assess that preoperatively or at least be able to have a secondary option to go open if you need to. Was it an errant indication? Did somebody do an arthroscopic when there was actually bone loss and maybe something else should have been addressed? Or an errant technique? So again, the failure rate of revision arthroscopic approaches are probably not great. I would say that we're not very good, even if we think we are. And the return to sport rate, obviously very variable, but not what I would want for patients that I treat. And then looking at the results of all arthroscopic revisions, almost 26% had recurrent instability. So I would challenge that we can probably do better. Obviously, Latter-day has been the gold standard with an overall return to sport near 85%. But again, with Dr. Mazzocco being here and Dr. Arciero both previously being at UConn and these guys are the most truthful guys I know, and even in the hands of experts and wonderful surgeons, the complication rates are real, 25% with similar recurrence rates. And that's with or without more or less than 25% bone loss. So you really have to ask yourself about the ability to do a Latter-day and to do it safely. If you look at the learning curve of both open Latter-day as well as arthroscopic Latter-day, it's approaching over 20. I would challenge that people in the community, you're probably not doing 10 to 15 a year. So what's that learning curve and what's that look like for you? So the talk that I was assigned to give is these other options and are those safer potentially? So the other argument with without doing a Latter-day and doing other bone block procedures, are you missing the sling effect? So biomechanically, I think that the studies are definitely supportive that that does matter. However, clinical results haven't really showed a large difference with bone block versus Latter-day. So why not a Latter-day every time? And I think mainly the comment is about complication rates. You know, it's controversial, but anywhere from 15 to 30%, the studies that show neuromonitoring, 77% had some sort of alerts with 21% having a deficit post-op with five of those being permanent. So, you know, every time I do a Latter-day, I definitely think about that and it worries me. And, you know, there are some defects that are too big for a Latter-day, especially in the revision setting, and they don't restore that on-track status of the glenoid, which I think is super important. And in those cases, the revision instability was four times higher. So the distance to dislocate if it's greater than basically 7.5 and have a persistent off-track lesion that had an increased failure rate. So what's the ideal solution? I think there's lots of them, but the goal is to restore anatomy. Another proponent of sort of the distal tibia in comparison to the Latter-day is that, you know, you really have an osteochondral problem. You don't just have a glenoid bone stock problem. So being able to replace the osteochondral surface of the glenoid is potentially more appropriate. Autograft uses the own tissue. It also is more available, cost-effective from that perspective, availability, you know, it should be easily accessible, should be, you know, not cost prohibitive, and then donor site morbidity. So I like this comparative chart. This is out of the JAOS journal article from Tokish, I believe, and it really goes over all of those in regards to iliac crest, distal tibia, distal clavicle, scapular spine, and then pre-shaped ones. So, you know, you can review this, but there's lots of pluses and minus to all these different graphs. So what are the advantages to distal tibia? Well, there's a low risk of complication. You don't have to, you know, find the musculocutaneous nerve and worry about that. So you have lower nerve injuries, fewer instances of grafts or resorption, and you're also reproducing that osteochondral surface. You know, it actually articulates very well with the humerus, and there's been some studies showing that there's more appropriate joint contact forces, which may lead to lower rates of arthritis. You preserve the coracoid and potentially less invasive. You don't have to do the subscap split from an exposure standpoint. The disadvantages are, like many allografts, you know, it's a significant cost. There's a waiting period in order to get these. In other countries, they're not available, and, you know, I would say that we're still working on those longer-term outcomes to be able to comment that, you know, they have decreased recurrence rates long-term. But here's a study from Tony Romeo and Preventure looking at distal tibia with bicortical screw fixation, and really they showed that the healing was about 90%. One of the surgical tips or angling your graft less than 15 degrees showed better integration with the native glenoid. This is looking at a Latter Jay versus a free bone block, and rates of recurrence of instability was basically no different where the free bone block was only 3%. So you know, with arthroscopic bone block, which Dr. Wang will definitely touch upon this, but there's lots of different options from that standpoint as well. And you know, really the results of the non-Latter Jay, if you want to approach it like that, you know, with allograft or autograft, the pooled recurrent instability was only 3% and the arthritic progression was evident in 11% of autografts versus allografts. So distal clavicle, probably a lesser used bone graft, but it is also osteochondral in nature and it's obviously readily available. It has close proximity here. It's cost effective, and then there's minimal donor site morbidity. However, it is size limited in the fact that, you know, your distal clavicle is not as large as what you can get a distal tibia, so you can really only get about a 30% glenoid defect. It would be, you know, maximally the largest defect you could treat. Also the quality of the bone is variable, and especially if a patient has AC joint arthrosis, you're going to have more difficulty harvesting an appropriate distal clavicle. And then also if you over-resect, you may lead to AC joint instability. So I think the graft choice is maybe less important than the optimized technique. The latter J is always nerve wracking as the nerve is in play. Is there a better way? Is this open arthroscopic? Again, Dr. Wong will sort of talk about the arthroscopic approach, takes the nerve off the table. And looking at head-to-head comparative studies with fixation, screw versus button, the screws show lower instability but higher reoperation rates, and the outcomes were the same. With bone integration, the bone block actually showed less osteolysis than the latter J. Button showed less osteolysis than the screw, so all things to take into account. So I think important in regards as you approach this from an open, you know, bone graft of the other model of latter J is, you know, correct the bone loss if it's a bone problem. The latter J is still effective, but it's definitely limited by the risk and the technical demands. So I think your preferred technique and just a little bit of a surgeon comfort level, I think the arthroscopic is technically challenging, and, you know, we're probably at this point transitioning to that, but that's sort of, you know, that's an emerging trend that's still yet to be determined. And then also we still need sort of advances in fixation, advances in delivery, the graft availability. So ultimately, bone needs bone. Make sure that you're making these lesions on track. The glenoid side is most applicable, but if you have a large humeral head deficit, you want to make sure that you correct that bipolarly. And then open and arthroscopic are both reasonable options. Thanks. Thanks so much. Mon, you ready? I'm ready. All right. We'll see. How many in this, as they pull it, how many people in this group have done a open tistal tibial allograft within like the last six months or a year? And how about an arthroscopic bone block procedure? Open Bankart? Nice, love it. How about an open Laterge? There we go. And arthroscopic Laterge. Where are you from? Brazil. Brazil, yep. I didn't think it was an American in here, so. That's the one. You need to be patient. Well, maybe I can ask Kathy, well, Amon is pulling this up. Out of all those bone blocks, have you done, you know, I think it seems like you've done the DTA. Have you done any of the other grafts like distal clavicle autograft and et cetera? I have not done any distal clavicle. I think that's a preventer, you know, or tokish. You know, they do more of that. I think distal tibia is what we sort of tend to do. I mean, iliac crest as well, from a hospital perspective. I think there'll be some data from Joe Abood soon. He's looking at the distal radius as a matched graft for this that might be able to match more planes in the distal tibial allograft. And so I'd be interested in seeing more data in the near future regarding that. Cool, all right, so without further ado, I'm gonna talk to you a little bit about a couple options here for failed arthroscopic anterior stabilization, specifically that for open stabilization, open soft tissue stabilization as well as open Latter-J. So in the armaterium of revision options after an arthroscopic failed Bankart, you know, we've talked a little bit about revision arthroscopic procedures as well as, and you heard a little bit about arthroscopic bone block procedures, which Ivan will talk some more about as well. But kind of the redheaded stepchild, if you will, is open Bankart reconstruction. And essentially, this is a procedure that unfortunately, this is decreasing in frequency. I think there are a lot of reasons why, but probably the largest of those is we just don't see it as much. We don't have as much experience with it, especially during training, residency, and fellowship. Many of us have that mindset. If we are opening, maybe we should just go ahead and do something osseous, and we'll talk a little bit about why that's perhaps mistaken. And then if we're just managing the soft tissues, why not do an arthroscopic? So we'll address those. So I think Kathy talked a little bit about this. You know, I think we're honest with ourselves. Latter-J is really not as benign as we think. The more that any of us have done these, I just had one about three months ago, two weeks after post-op, he had his first seizure, his first seizure ever, and pulled his bone block off with bent screws, now problem. I had one about two years ago where about six weeks, maybe eight weeks post-op, he fell down some stairs and then broke his bone block, screws still retained, but now bone and conjoined tendon down in the axilla. So these things happen. And if we're honest with ourselves, these things probably happen more often than we think. Sometimes the patient can do still fairly well with a fibrous union, but oftentimes not. Oftentimes we don't see those complications. So I think we need to be honest with ourselves in terms of really is it worth doing a Latter-J every time? And why not do it arthroscopically again? Well, some of the things that we do with an open procedure, and we're gonna talk about how to do these, you just physically cannot do this arthroscopically. When you're managing a capsular volume, you can pleat arthroscopically, but you really can't fold the capsule over itself. You can't increase the volume, especially in diminutive tissue like in revisions. And then I love this quote by Russ Warren. And often when we have patients that come to us that need a revision procedure, we were not the primary surgeon. Sometimes we are, but many times we're not. And if they failed the previous arthroscopic procedure, you may wanna consider doing something else with a revision. Don't just assume that you can just do better than the last surgeon, all right? So and I love that quote, and I think it does pertain well. What does the data say? Well, multiple studies, this one out of Cleveland Clinic, up top by Morgan Jones and Dr. Mineachi, demonstrated a three times lower risk of recurrence with an open Benkert versus an arthroscopic stabilization. And especially in patients that you would expect, the ones without bone loss and without significant Hill-Sax lesions, those especially can do very well with an open Benkert. Other advisors published their series up to 10 years of follow-up, also zero recurrences. Dominic Sisto, again, very low risk of recurrence, zero out of 30, and improved row scores. And then this study out of Korea, which demonstrated very low risk of recurrence. And the ones that did, the three patients that did, those are ones that you would expect to with significant osseous challenges that probably needed a different procedure in the first place. So who would benefit from a open Benkert? Well, this is what I look for. Essentially, patients who I think have hyperlaxity without bone loss or without significant on-track Hill-Sax lesions, I think, are really setups for doing well with an open Benkert. And who would I consider for another technique? Well, obviously, the other patients. Significant bone loss with a critical amount, as I defined, about 15%. We can debate that. And off-track Hill-Sax lesions. And I think as Albert showed earlier, if you have something specific that you can go after arthroscopically, if the original one did not have enough anchors, or if there was something clearly technically done differently or wrong or incorrectly, that may be a patient that may benefit from doing an arthroscopic technique. But I think if you're gonna go back to the same arthroscopic technique, just because you think you can do better, I think you gotta think twice about that. So how do I do this? Deltapectoral approach. Prefer to split the subscap. If you don't do this a lot, and I would say I don't even do this a lot. I do this about twice a year in open Benkert. Don't be afraid to do an L-shaped subscap tenotomy. It's important to see appropriately. If you need to do that for the first couple times you get back to this, then so be it. But there is some benefits in terms of muscle strength, as well as patient-reported outcome scores if you do a split versus an L-shaped tenotomy. So the hardest part about this is developing the interval between the subscap and the capsule, I think. All right, so once you get past that, really it's the same surgery as an arthroscopic technique. So a little tip that I got that I still use is I find that interval medially, more towards the musculotendon junction, muscle belly. You can split that with your Mayo scissors. And then you can actually put a ratec in there. So you're seeing that in that third video there. But you can put a ratec in there that kind of expands that space between the capsule and the subscap, and really then makes it very easy to follow that out laterally, and then create the rest of your split. Or if you need to do a full tenotomy, that's fine too. But if you find that medially and then work laterally, it works far easier. I use scissors, and then I'll stuff a ratec in there, and then I'll use a Cobb elevator to essentially create that separation between the two. I do a laterally-based capsular shift. I think it really helps you in terms of titrating your volume. You can double the thickness of the capsule with pants over vest suturing as you're closing on your way out. And then standard technique that you would otherwise. You use anchors. It's a lot easier to get down to six o'clock, obviously, open versus arthroscopically. I still use a pigtail passer. I find that it makes it a lot easier as opposed to free needles. And I think it's a lot safer. I once had a needle break on me years ago. It's a lot safer than trying to torque a needle in a very obscure angle. So I still use a pigtail passer. There's a number of different commercial designs of that, but it does make the surgery a lot easier. At least three anchors. You usually don't have a problem putting as many as you want when you do it open. Sometimes it's difficult to tease that interval between the subscap and the capsule, especially in a revision situation, as we talked about. If you do, you can use this Hawkins technique, which I've done a number of times as well. Essentially, you take the capsule and the subscap down together laterally, and then you work inside out. You work inside that curtain, and essentially you work inside out in mattress fashion, passing your sutures. And so you actually don't even need to tease the two away if you don't have to. This technique actually works quite well. And then lastly, you tie them down. I work from medially to laterally when I titrate my capsule volume, pants over vest medially, and then depending upon if they're a contact athlete versus one that's a contact athlete and a throwing athlete, something like quarterback or something similar, you may want to titrate a little bit less volume, but essentially you work medially to laterally. I put anchors laterally, ultimately to repair that final T for my capsule. But what if there is an off-track lesion of the hillsacks or significant bone loss greater than 15%? Then you got to think about doing something open. And in my practice, that means, or you have to think about doing something with bone. And in my practice, that means an open latter J. As you know, the triple blocking effect, osseous restoration of the glenoid, capsule repair, restoration, and obviously the sling effect. So let's go through this real quick. I do this in a beach chair, head up about 45, 60 degrees, arm holder versus a mayo. If you do use arm holder, flip it around so it's not just constantly banging against you. If you put it up at the head of the table, it makes it a lot easier. Stabilize your scapula with two towels. This is a big tip that I learned from Matt Provencher. I think it helps a ton. It gets your screws so that they're actually parallel to your glenoid. And then you don't have to worry so much about divergent screws. It really flattens out that glenoid for you. Watch your perineal nerve, especially if you don't do this a lot, and the patient's going to be in that position for a little bit. In terms of soft tissue, adduct the arm to take your pec minor off the medial coracoid. I leave a little stub, about three to four millimeters of my CA ligament to tie back into at the end. And then ultimately for your bony harvest, you want about somewhere around a 28 millimeter graft, essentially where that coracoid goes from horizontal to vertical. When you take it off, if you get a little spike at the end where it goes into the glenoid, that's actually perfect. And it ends up being right about 28 millimeters. You protect your undersurface with Adara. I do a right angle 90 degree saw, and you can actually do most of it, essentially 270 degrees for medially, superiorly, and laterally with that, and then just take the rest off with your osteotomes. When you decide how you're going to actually place your coracoid against the glenoid, you got to make some decisions whether you're going to do this the traditional French way, or the congruent arc Burckhardt way. I personally pick the French traditional technique. Why? Well, if you think, if you believe the data that suggests that the sling effect is the most important part of your Laterger procedure, then essentially you're getting that with either technique. And then I want to try to maximize healing and decrease complications of the surgery. So everything I can do to maximize my contact, my bone of my coracoid to my glenoid, which when you do a traditional French technique way, where the undersurface of the coracoid sits up against the glenoid, you're really maximizing that contact, maximizing your ability for healing and decreasing your potential complications. Coracoid prep and glenoid prep, I think are the keys to this surgery. I think all of us would do this perfectly if we were doing it on a saw bones. Is there anyone that thinks that they wouldn't? I think it would be a very easy procedure if you do it on a saw bone. So why do we have difficulty? Well, it's usually because we don't have the ability to prep the coracoid and the glenoid like we normally would on a saw bones. It's typically because of visualization or because of access. So take your time, make sure you have the access you need, make sure you prep the coracoid, the back of that should be absolutely flat. Split your subscap if you can in a hyperlaxed patient, instead of doing one third inferiorly, two thirds superiorly, I do half and half, give you a little bit more of that sling effect, a little bit more subscap for the conjoined tendon to work with. Capsular management, a T or L tenonomy again. And then again, glenoid preparation, your bony preparation is key. I think this part actually is more key than the back of the coracoid. So really flattening that glenoid, anterior glenoid, getting all the previous anchors down, really getting all that previous soft tissue and all the healed osseous elements off that medial neck all the way back to where the glenoid comes off is really critical. So I think preparation and carpentry of your coracoid and your glenoid are really key to success with this surgery. Placing the graft, you can actually place it too low and have your humeral head at risk for jumping the graft. So you really want it at about four o'clock. You have it, so it's part of your graft, and most 28 millimeter grafts will actually be slightly above the equator. It'll look a little funny, perhaps, for those of you that put it really low, but that's ideally where you want it. If you get it too low, you can get humeral head jumping over the graft, which is obviously a problem. Using solid screws, non-cannulated screws, preferably 4-0, Malleolar, or 3-5 Cortical. I use 3-5 Cortical. You wanna really get these colinear with the glenoid. Be careful using small caliber or cannulated screws. It will bend and or break, so be wary of that, and that is a pain in the butt. Lastly, capsular management. Lots of different things that you can do with this. You can do nothing. There are some surgeons that leave it completely alone. I was certainly a lot more aggressive with my capsular management in my first couple years out of fellowship. I'm less aggressive now. I do attach it to my CA ligament remnant, and I do loosely so, because I had some problems with stiffness early on. You can attach it to your CA ligament, in which case your graft is now intra-articular. You can attach your capsule back to the actual native glenoid and make your graft extra-articular. I don't think one way's been shown to be better than the other, but be leery of the second way. It can create a lot of stiffness issues. Put your arm in a little bit of external rotation, and if you want a slight bit of abduction and forward flexion to really prevent that as well. I do it adducted to the side at about 45 degrees of external rotation. And then subscap closure with your subscap split is just essentially closing the epimysium with non-absorbable stitches. So what does the data say? Well, essentially, as you would expect compared to arthroscopic revisions, open Latter-J shows a significantly decreased risk of recurrence of instability as well as improved patient-reported outcome scores. So there are a number of studies that have demonstrated this. I think something for discussion, and we don't have enough time for this particular talk, but Albert referred to this earlier, the Army Boys, Kilcoyne and Dickens, demonstrated that primary Latter-J does have a lower risk of recurrence as opposed to revision or salvage Latter-Js. I know some other data has perhaps suggested that that may not be the case, but it does make some sense. And then it does perhaps bring up a topic for discussion, which is, should we be doing more of these primarily? So I'll leave that for maybe discussion. Ivan says no. So in the end, in conclusions, don't forget about open Bankart reconstructions. Everyone wants to talk about kind of new sexy procedures that we're doing, arthroscopic this, arthroscopic that, and those are great procedures, no question. But I think open Bankart reconstruction, I think, does have a role in very select patients, so don't forget about this. I think it's kind of the OG of these procedures, so just keep it in your armamentarium. You don't always need to risk applications of the Latter-J. An open Bankart is supported by the literature over an arthroscopic Bankart. It's ideal for patients with minimal bone loss, even with hyperlaxity. When you do have patients with a bone loss over the critical 15% or an off-track Hill-Sachs lesion, you can do a Latter-J different ways. If you don't do these a lot, think about doing them open initially, make sure you can visualize appropriately, and don't forget, really, really be precise with your carpentry. Thank you. Really nice, Iman. As they're pulling up Ivan's talk, who is your perfect open revision Bankart candidate? So mine is kind of what I was talking about earlier with less than 15%, preferably less than 10% bone loss, a very minimal, very on-track Hill-Sachs, not even at risk, and then, you know, obviously, they don't have to have hyperlaxity, but many of them do, but that's not an issue for me, and in my practice, I think those kind of patients actually can do quite well in that situation. And if they have none of those things, then open Latter-J, open Latter-J, okay. Well, it's a treat to have Ivan here. He's arguably the leading expert on arthroscopic bone block procedures in the world here, so Ivan. Hey, thanks, Albert. No, my honor, actually, to be here to tag along with this fantastic crew. So we'll talk about arthroscopic bone block, and hopefully by the end of the session, you'll be more familiar with options for treating failed Bankarts. The pros and cons of using button versus screw for an arthroscopic approach to this, as well as why AAGR, at least with screws in my mind, is the way to go currently. So you've heard all these. These are really great options, and I'm gonna reinforce this at the very end. There is no one-way option afterwards. The Bankart Rump Massage, you saw, great early outcomes, minimal complications, and the whole point of this is this is in our comfort zone. We do know long-term outcome is not as good, but honestly, after this lecture, you guys are going home, a majority of people are gonna still do a Bankart Rump Massage for a failed Bankart procedure because that's in our comfort zone and I recognize that. What we're trying to do is expand your comfort zone. There's long-term outcomes of a Bankart repair. This is my colleague Ian Lowe in Canada. Again, very good arthroscopic surgeon. 31% of his will fail regardless of bone loss and 36% will develop osteoarthritis. So don't forget these patients are young to begin with. We're going to have another surgery on them. They are going to need an arthroplasty sometime in one of our colleagues lifetime. So you need to plan for that next surgery. Our North American algorithm talks about the amount of bone loss and then deal with it and really it's based on our comfort zone. Less than 15% we do arthroscopic Bankart repair or open Bankart repair. More than 25% Latter-day. But these numbers need to dwindle because we just finished hearing bone needs to be treated with bone. So what about revision? Well this is a great study looking at it. We heard many so the cost of revision when you fail Bankart and you treat it with Bankart again or even with Remplissage, it is significantly worse than what we thought before. So it's not even that way. So to improve outcomes we need to start stepping out of our comfort zone. We saw how many people do open Latter-day. That's great. That's really fantastic that we have that in our momentarium. There's no question it's the gold standard. This is what we should compare everything to. It has definite benefits. You've heard about them but there's different problems. So what if we can take those benefits and not have the problems, right? What if we don't have to figure out how to revise something like this that the anatomy is all changed and the nerve scarred in. Latter-day trains that decrease in recurrence rate for an increase in complication rate, right? So your second surgery because these people you got to remember young will get arthritis, a good portion of them will need aperture surgery. What type of approach are you going to use then? So this is what I go back to. I just look back to the giants of this this procedure. This is Rachel Frank, Brett and Cole looking at treating Latter-day and open distal tibia. And why like this? It shows that both are the same. And that's what most of us get out of that. But if you look at it, this is some of the highest volume in the country and they get musculoskeletal nerve injury permanent. How much does that cost your practice? How much does that cost your life? They get subscap failure, complete dehiscence. How do you deal with that one? We talked about other bone blocks, you've heard different things. What's the ideal technique? Well I think something that is safe, like a Bankart repair, so low complication, something arthroscopic, preserves the subscap, safe from the nerves, short learning curve. And something that's as stable as a Latter-day with decreased recurrence rate. You can replace the bone, you can have good outcomes, but you got to have it teachable. So when you get out of your comfort zone, that's where the magics happen. We started publishing this in 2015. So these are the steps. You can look at it online. We have their presentation. But this is really where it does. We change where we put our portal. We depress the subscap. We do not split the subscap. So we go through the rotator. And why that's important is because if you keep subscap, you keep conjoined, and you stay in that rotator interval, you're completely safe. You're four centimeters away from any neurovascular structure. And because of that, the learning curve to this is way different than a Latter-day. Way different than anything else. If you're going to pick up a new skill, this is going to be faster than anything that, if you're good at arthroscopy. And it's ideal graft choice. I'm not a basic scientist. All these other surgeons have actually gone to say distal tibia works. It does cost more. We do not use a fresh graft. We use a frozen graft. It costs $800 in Canada. So by using this with screws, with other techniques, we can replace any type of bone loss. We make it bigger if there's more bone loss. We make it smaller when there's less bone loss. But you got to make sure we're only replacing the bone that's gone. You do not want to replace extra bone because then you have excessive screws. If you don't have bone, you don't have distal tibia, I use Iliac crest. We get the exact same outcomes. They just hurt in their hip. Their shoulder feels amazing. Their hip, not so much. We compared our data looking at Latter-day. So I did arthroscopic Latter-day, open Latter-day. We compared our healing data compared with the distal tibia and everything is exactly the same except I'm better at positioning the graft when there's distal tibia because there's articular cartilage. You just make it perfectly flat. And outcomes. We've actually got out to five-year, minimum five-year outcome. We just presented at Academy looking at distal tibia arthroscopic outcomes and we're getting exactly the same recurrence rate. I think we only had one failure so far. And our latest patient, you know, we're actually starting to get past 10 years now. Our return to sports are superior in our AAGR group. We can't seem to get our American return to sport group but we do know we have a lot of instability before they even come see us. So it's a very different population than what you see. But our AAGR group with even more bone loss than that are getting back to sport better than our arthroscopic pancreatic repairs. So what else have I learned during the time that I've built up doing AAGRs? Well, this is actually the poster award here at Anna. We've actually learned how the remodeling happens. We've looked at all our data now with all our CTs and realized it takes 6.9 months to remodel. This is an example of six years. So take a look. Pre-op on the left, six-year post-op CT scan. It's healed to the point that you can't actually see the definition between the graft and the glenoid. But I put a huge graft in thinking that we can ignore the hill sags. So don't do that. These are the mistakes. I'll try to show you all my mistakes. Here's an example of one. 32-year-old female had a dislocation. So a CT does show a little bit of bone loss. She was in a study. I'm just really showing you this to show you what it looks like as a second look. So this is the view. I find this view easier to look at than look doing a ladder j. I can assess where the glenoid is. I can assess where flatness is. I can assess the graft being parallel to it. I can make sure the subscap gets reduced on top of the graft. This is the original size screws. You can see they're actually quite prominent there, but now they're better. But I can actually put a probe across to know that the graft is perfectly recontoured. I want this slight concavity shape in there. And why I show you this is because this is a double-loaded anchor at the top of the graft, right? This is the front or this is the edge between native glenoid and graft because I want to show you what the six years out looks like. So post-op, six years after surgery, I had made a supersized graft in there thinking that I can ignore the hillsacks. She has no instability, complains a little aching in the front. And you can see when the bone remodels, the screws are prominent. It's a big screw to begin with. So that instead of being a rectangular graft, it's now round. Instead of being a rectangular graft in the axillary plane, it's now triangular. And this is six years afterwards. I had excised the rotate interval. That tissue grows back in, right? So we have to open that up again. So the first step of this is to open up the rotate interval. I view it from the top. And the Bankart's still there. The tissue is sewn down right to that edge of that glenoid. You remember I had a little gap in there to try to get it healed to the bone. I don't always do that. And now I actually have to expose. I actually have to do a release of that Bankart to find where that anchor is. So there. There's a first edge that you can see of that double-loaded Bankart repair. So my trick to this, I got to use a traction stitch. I got to actually release this. I got to take this down. And what I really want to do is be able to see how much of the bone is remodeled, right? Because we put the Bankart repair on top of the graft. We made it extra articular. As we free it down, we're going to see both the screw and we're going to see the graft. So the graft was rectangular, right? If we look at it here, everything anterior to that suture is new bone formation and new bone remodeling. That's now triangular. That cautery is five millimeters, five and a half millimeters in size. So we're getting about five millimeters, maybe six millimeters of bone forming, right? It's not rectangular, right? If you're talking about, did it resorb around the screws? Yeah, it resorbed. It remodeled. But it's the same shape as a normal glenoid if you look at it. If you look from the top down, the shape now is a pair. All that fuzzy tissue, right? That's the capsule in front. That grew back six years later. So it looks like a normal glenoid. In fact, it measures to be the same size as the other side now. So we've done, or we have done, we've looked at systematic reviews looking at this. The screws actually do quite well. I thought it would be easier to teach because obviously teaching is an important part. We learned about this new button fixation from Boyleau doing Latter-day and we tried it in this because I'll tell you it's way easier to teach, but we got longer, higher failure rates. So the healing is very different. Screws and buttons are not the same when you look at a free bone graft. In fact, we got that award in 2022 at Anna. In 2023, we actually analyzed the surgical technique of each of the failed ones to see if there's any difference. This is our fellow that did that and they won the award that year too. And we have not figured out why a suture fixation is not as good as a screw fixation when you use allograft bone. So our current algorithm is this. When there's no bone loss, I do soft tissue fixation, bank repair, rump massage. When there is bone loss, I do the AGR with bank repair and rump massage when appropriate. And then when there's no capsule or soft tissue, we do a Latter-day because now we have replaced that as well. So something like this, failed Latter-day, looks scary. What do you do? It doesn't heal, non-union. So you can actually replace this, revision to an AGR. It's actually easier arthroscopically because I do it all through the interval. It's less scary. And in fact, everyone worries about this big incision. You can see the two incisions. That white outline, that's the incision. That's the biggest incision we use for the Halifax portal compared to the big open Latter-day. So how to make this leap? Sorry, one more slide. I forgot about this. You can now learn this virtually. So the whole point of this is, you know, learning arthroscopic Latter-day takes a lot of work. But learning AGR, we can actually teach this virtually because as long as you know the safe places, go superior to subscap, lateral to conjoined, you can take your time and do this. We can show you a whole way of learning. So this is a broadcast. So you can see live surgery. We do this every week where surgeons can view from start to finish, talk to me through the whole case. We show you using augmented reality because then you can actually see all the nuances of why we put the graft in a certain way, how we model the graft, where we put it, what angle, why, all the nuances, the Halifax portal to align it perfectly. We do all that. So you can see every nuance and talk about it and discuss it. But even better, we take all that technology and we send it to a lab near you. And I can say in Halifax and kind of connecting the dots, I can draw on your screen to guide you through those exact same steps, piece by piece. And this happened all because of COVID. This is a person who wanted to do it in a beach chair position. We can show you all the positions, why we want to do it there, how we want to do it there. And we've got over a hundred times that we've done this over COVID and more than half the surgeons are able to do this already. They're sending me pictures. You can see comments coming down. We get this almost on a daily basis. I love these interactions, a way we can teach and how we can move forward during this new age. So hopefully you've seen that this is not the only way. This is another tool in your toolbox. But if you have all the tools, you can make the right decision for the right case. Thank you. Amazing talk, Ivan, as usual. I have a question maybe for you. Can you pull up my initial talk there? So we often talk about sort of the track concept and restoring it with this bone. And you have demonstrated some very convincing data that if you take a very, very large chunk of bone, that it resorbs back to the glenoid size. And when it resorbs, it may actually become off-track again. We think we can do a big bone graft to make it an on-track lesion if we care about that type of thing. But then it resorbs and now it becomes off-track. So you know, is the remplisage the right thing to do in these situations, you know? Or as Kathy had mentioned, do we need something else here? Like are we in the era where we need to think of bone grafting to fill sort of the the hill sacks? So I think that's a fantastic appreciation of this. Because I didn't appreciate. I was taught that, look, if you make the glenoid big, you'll never have to worry the humerus. Hopefully now we're showing that that's not the case. And that those are the only times that Woolsey changes. I don't know is the answer. I think you treat everything in isolation. Meaning everything is an a la carte problem. If you got glenoid bone problem, you treat glenoid just like it is. So I fix the glenoid to make it normal. If there's a Bankart tear, I fix the Bankart tear to make it normal. I do the shift. If there's a hill sacks, I treat the hill sacks so it doesn't engage anymore. Whether it's a remplisage or whether you have to use an allograft. I don't think we have that answer yet. That is, I really do believe, the next thing. I do think we have many options now that are quite promising to fix that glenoid bone side. Yeah. You know, I think a lot of Ivan's work has made me, I used to think I'm just going to put a big bone chunk there, right? Just to make it large so we'll never dislocate. And the arc is so large that you never have a dislocation. But I think you've shown some pretty convincing data that over time, that's probably why we get these screw issues, graft resorption, and then quote unquote prominent screws when really it's just that the bone graft has been resorbing over time. So we have some time here. So I'd like to get through some cases. And I think these are cases that we typically see here. So this is multiple years ago when I started practice. This is a 16 year old. He's a high school football player. He's a D lineman. He's a pretty big guy. He's 6'1", 240. He had an index arthroscopic Bankart tear outside hospital about a year ago at the age of 15. And then he's playing football and of course he has an episode. And he comes in and he doesn't have hyperlaxity and he has sort of your typical apprehension kind of findings. And so these are some spot images here. Kathy, anything that you see on here that concerns you? Yeah, I guess I'd first just go with the history, right? He's only 15. He's already had a failed Bankart that failed pretty quickly at less than a year. So you assume that he didn't even get through a full season of play on that saddle. It looks like he does have some bone loss. I'd like to be able to characterize that a little bit bigger, better. You know, small size Hill sacks, not something that I'm thinking about an allograft, but a young person with a revision that failed, you know, I can't really tell him the anchors they use. I do always try to get the the right. The light's not coming out. I think I might just let you go out on that one. Okay, perfect. Perfect. Yeah. So, you know, I always try to get the op note to see where they put their anchors or how many anchors, what type of anchor, because I don't wanna be surprised from that standpoint, but those are my thoughts. We often get MRIs here. Is there anyone here looking at this that would be fine just with the MRI here? Or would you... How many people would get further imaging here? Okay. And how many people would not and just stay with the MRI? Okay. Ivan, can you discuss this? Because in Canada, it's very difficult to get an MRI. In fact, how long does it take to get an MRI in Canada? Well, I don't know. My fellows are here too. So I may order an MRI if I know I wanna follow up two years before I want it. So it is... And so you'll see our studies too, right? You're wondering, why is Ivan not have all the MRI follow ups? Because I ordered it two years ago, I still haven't gotten it yet. But this is our system. We have problems, so everyone has a different system. My concern... So which is also why I switched to CT, and I get a lot of data from CT. This one actually concerns me a lot, because he had a failed bank card, but if you look at the soft tissue anteriorly on that glenoid, it looks like it's attached very well. It's got a very, very thick bumper. So now I'm actually quite concerned for the humeral attachments, whether it's in the front or the back, but a raggle or a haggle or something else going on for its instability, this is something I'm just quite concerned about. It almost looks like, Albert, on that, the one at the... The picture at the end, this could be a postage stamp fracture. Obviously, that's just one cut, but that would also push me towards a CT scan a bit. Alright, so here is your CT scan here. And so what do you think of that, Amon? So certainly there's some anterior inferior glenoid bone loss. There's some blunting there as well. So not only is there bone loss, but then the cavity compression is compromised there. But I certainly would be concerned about that. I agree with you. He has that blunting right there. And it's interesting, when you get an MRI versus a CT, you look at this MRI, you don't really see... At least in my opinion, and these are spot cuts here, but didn't really see any crazy heel sac defect, to be honest. And then you look at this, it looks to me, at least based on the axial sequences, that he actually has somewhat of a broad heel sac defect here. And so you're kind of entering the potential realm of whether this is truly on track. And this was years ago before we were kind of considering this as a near track or a worrisome on track lesion. So bone loss of about 10%. So what do you think? Right at the cusp. Yeah, I mean, I don't think this one works. But I think, yeah, because it's a 10%, but like you said, it's most bipolar, right? So even with bipolar bone loss, I would address it with some glenoid bone probably. I personally would probably do an open Laterge on this, because he's a contact athlete, he's 15, and he has bipolar bone loss. Yeah. I mean, I think if I polled everyone here, I think, judging by the fact that so many people are doing open Laterges, I think that is maybe sort of the preferred approach. But I'd like to get Aman's thought here. So 10% bone loss, no hyper laxity. Is this a guy that you would consider an open bank card in? There's certainly been really great studies from Pagnani and others, and the visor, doing a good open capsular shift can diminish your recurrence rates pretty significantly. Is this a good candidate for this or no? So, I mean, I'm sure you calculated the on track, off track on this. What was the... You said it was on track, but what's the jump distance? Near track. It's like three millimeters, four millimeters. Yeah. So that would concern me about doing an open soft tissue procedure alone. I think if we're getting closer to the centimeter mark, I'd feel a little bit better about that. But at two, three millimeters, we're talking about a very small jump distance, and I think in my hands, I'd be an open letter doing it. Ivan, you kind of presented a really nice algorithm. So your algorithm goes from zero to 10%, and that's sort of your arthroscopic bank card with remplisage. Would you do that in this kid? So I disagree that this is a 10% glenoid bone loss. I think it's more than that. And this is the thing. I really think... I'm doing this with my fellow, and we say, look, if we do a perfect circle method, I could ask to do it several times, and I get a different number. So I have a really hard time doing that. We've actually switched to a superior inferior measurement to predict our anterior posterior, and we're finding that's more consistent when you compare that to the side. I actually do a CT scan of both sides, and I compare it to the normal side. But there's other factors involved. There's version, there's strength, there's a whole bunch of other things. So in this case, when I see bone loss, I wouldn't deal with bone loss, right? So in this case, in my gut feeling, before I do a measurement, I'm like, I wouldn't do bone. And then the other part I'm looking at is, ooh, I don't know if something's just erased, but that coracoid looks small. And small coracoids, you know, we talk about this two-finger tight, if you're using one screw or two screws, and this is a 16-year-old kid, and I'm starting to get nervous for a latter day just because that's gonna be technically demanding. Yeah, I mean, one of the things that Ivan just mentioned here, which I think is worth thinking about when you're calculating bone loss is that there's no gold standard of calculating. And so there are methods of calculating, 2DCT, 3DCT, and some of them actually greatly overestimate more than others, and most of them have an overestimation error, of which the greatest overestimation is a 2D unilateral perfect circle. And so if you do that method, understand that when you do calculate that, you're probably gonna overestimate the amount of bone loss. It also gets to the question of when we have all of these studies that are calculating bone loss and the outcomes are based on that, how accurate is it? Because there is a certain error bar because there's no real gold standard of being able to measure. So it is an important thing to think about. I think you have to understand the limitations of estimating the bone loss and then choosing your treatment options based on that. So a quick poll here. So who would do an arthroscopic revision Bankart with or without remplisage? All right. Who here would do an open Bankart repair in this cohort? Or in this patient, sorry. Open Latter-Jay? Okay. Arthroscopic bone block? Love it. And then how about an open distal tibial allograft here? You know, so it's interesting to me, right? If you look at literature, looking at DTA versus Latter-Jay, there hasn't been shown to be a lot of difference, whether it's open or arthroscopic. And yet in this type of setting, everyone is gun-shy of doing a DTA. And I actually even asked Matt Preventer this, the DTA guy, and he said he is still gun-shy doing this in a contact athlete for his NFL players. And so I think we need more data here. I think- Did he say why? I think it's one of these things. I think he says his name is sort of attached to this procedure a little bit. And I think despite sort of the literature that's out there, I think he is worried about if he has increased failure regarding that. So because the open Latter-Jay still very much remains the gold standard here, as you can see. Actually, if you can comment on this before the next case, Ivan. You are doing a study comparing Latter-Jay versus arthroscopic AAGR. Yes. And what have you found so far? Oh. So yeah, we're doing a randomized study, Latter-J versus AGR, multi-center, all the way across Canada. I found I really hate doing open Latter-J. Because I can't see as well. So this is the trouble is, I remember doing Latter-J. I did a bunch before. I can't see as well. So I'm not as comfortable being there. So I get my post-op x-rays. I'm actually less accurate at getting it in. But overall, I'll tell you, the patients, they can't tell the difference. In follow-up clinics so far, they're like, yeah, feels great. So both groups, exactly the same. I'm just a lot more nervous doing Latter-J. Yeah. You know, this was many years ago. I did an open Latter-J on this kid. And he is about eight years, maybe nine years out. And he's doing well. He's graduated from college. All right, this gets a little bit tricky. We now have an adolescent contact athlete. So this was also maybe eight, nine years ago. This kid's 13 years old. And about 15 months prior, or a year and a half ago, he underwent an arthroscopic bank run and a slap repair. It occurs that he's a football player. It's very popular, Western PA, Pittsburgh. Recurrently dislocates playing football. Smallish guy, 5'7", 138. No hyperlaxity. He's got apprehension. No other sort of crazy findings on exam. So, Aman, what do you think of this? 13 years old now. Yeah, so, I mean, that age is obviously concerning how young he is. So his CT scan would suggest he does have some anterior bone loss as well. Did you do the index surgery? I did not do the index. Okay, so I can say whatever I want now. Yeah. Yeah. Even if I did, it would have been a shitty surgery, right? I mean, the anchors are a little bit on the face, a little bit on the articular surface. So that's gonna make any revision situation a little bit concerning. And arguably, that bone that is peripheral to that anchor is probably of little utility. So I think you gotta think about these things. Okay. Kathy, what do you think here? So does it matter that he's 13? Does it make you wanna pull the trigger on things like open laterally less? I don't think there's any contraindication from that perspective. But what I worry more about his age is sort of what we talked about, is he's gonna have a higher re-dislocation rate even after a failed. So you wanna get it right this time. I wouldn't be less aggressive because he's gonna have an increased rate of failure. So I would be aggressive to try to do the right surgery the second time because I agree that those are very malpositioned. And I worry about even what they look like if you're gonna be seeing an anchor in the articular surface there. Do you think this is enough bone loss to be concerned about? You say loss of bone requires bone. Do you think this loss of bone requires bone? I mean, doing the measurement, I would probably guess that's less than 15%. But I agree that with those anchors in regards to the previous situation, I would be worried about the quality of bone. You know, I don't know about his capsular tissue. That's the other thing that I would wanna sort of have a better sense of. But I don't think there's a, there's a small Hillsex there. But again, I would assume potentially that's an on-track lesion if you measured it. Yeah, so it is an on-track lesion. And there is some bone loss, but it doesn't look dramatic. And, you know, I would say certainly not 20%, and it's probably not 15% here. Ivan, what do you think here? Yeah, so I like all the comments about, you know, we need to do the right operation now. I would do a bony procedure. There's no question, because I do see some bone loss in there. My only concern is, again, he's so young. When you do a revision-failed Bankart, you are going to have more arthritis. The cartilage is gonna change more. And at 13, you know, we're gonna expect another 70 years of life in here. Somebody's gonna have to do an arthroplasty in here. I, you know, going in after a previous Latter-day is very scary. There's a lot of other complications that go on. I think, at least to our data so far, we're getting similar results with a good bony reconstruction. It doesn't sound like the soft tissue's gonna have trouble. So I think, for me, I would do the arthroscopic distal tibia with a rumpelstoch. But if you look at that, and you say the anchors aren't in a great position, is there any thought that maybe the surgeon didn't do a good soft tissue procedure to start with? And that, you know, does that come into your thinking? Well, maybe I can ask this question, too, because this kind of goes along with you. So where is the ideal position for this? So there's plenty of surgeons that actually put the anchor right up on the face. Maybe they do it with one to two millimeters up on the face so that they can actually curl the capsule and the labrum up. In fact, I do that a little bit, too. And this is not my case, but, you know, I think if I looked at all my ICTs, they might kind of look like that. So where do you guys think are the ideal places of putting these anchors, if we're talking about technical kind of pearls? Yeah, I mean, I try to get as low as I can. You know, if you want to, you know, typically with the curved guides, you can get pretty low. And then, you know, marching up the face, you know, maybe one right at the equator at three o'clock. But so, you know, yes, he had a slap as well. So you can assume maybe one of those superior anchors are from the slap. Again, I wasn't there, you know, so it's hard to tell. But I try to get below the equator. I guess what I'm asking is, if you have the corner of the glenoid, are you putting it right on the corner, or are you putting it up on the face? With the fish mouth guide, I usually put it right on the corner. On the corner. How about you, Elman? Yeah, so I put it on the corner, but I think you're getting at how divergent you want it to the face. And I want it as perpendicular to the face as I can, but on the corner. Got it. So it can create issues, especially as you get down really low, because you can be in, out, in. And so, especially with the all suture anchors, you do have to be a little bit careful about your trajectory. But I think this one is, I mean, you might have some interoperative pictures, but it looks like it would be actually on the condor surface there. Yeah. Ivan, how about you? Yeah, I'm on the face. Mainly because, especially, I've switched all to all suture, and the drill, the trouble with all suture is the drill is longer. You have to push that anchor deeper, and then it has to ball up to give you the cortical contact. And if you go right on the corner, my trouble is, I've burst out the anterior edge and caused bone loss quite a few times. So I don't like that at all. I want to be on the face. I don't want to ruin any bone that I can have, because we also do know, bankers, our type of bankers that you do, if you put anchors in there, it will remodel, and you'll lose bone, right? So if you do a revision, you're gonna have less bone. So that's an issue, and yeah. Yeah, so I think it's a great question, because I think if you believe that this is a technical error, then the thought here is that, with minimal bone loss here, or what we consider sort of not critical bone loss, maybe there is a opportunity to kind of redo a Bankart in this scenario. And so I'm curious here, this may be a little bit of a different scenario. Even though it's a football player, he's a lot younger. He has what appears to be actually still Bankart tissue there. It doesn't look like there's attritional sort of soft tissue loss, or a significant amount of bony defect here. So how many people here would choose to do a revision arthroscopic Bankart with or without a remplissage? Okay. And then, how about an open Bankart in this young kid? Yeah, I think this would be the one that I. Yeah. I think this would be the one that I would certainly consider it on. And why this guy and not the other guy? So why this 13-year-old and not the 16-year-old that we just presented? So it's kind of what Ivan was getting to before, is based on his age and activity level, the likelihood that he's gonna need a revision surgery, and that it might be an arthroplasty in 20, 30, 40 years, is very high. And the more that we do, we know open Latter-Jay, or Latter-Jay procedure in general is a non-anatomic procedure, and is going to increase your risk of degenerative joint disease, beyond that of the chondral shear forces from repeated dislocation. So I think, in my mind, that's what would make me a touch nervous in a 13-year-old. And Kathy, you also said maybe an open Bankart here too. Yeah, I mean, I think you can make an argument in the index procedure, depending on what position of football he played, you could maybe even make an argument to do an open Bankart at that index. Okay. All right, Tom. Are any of you, at this point, are you strongly encouraging the family to find another sport? Is that part of your equation with them? I know that we're not supposed to do that, but you tell them a 13 has come out twice, you make him run, like he's got that shoulder for 70 years, is that part of your account with him? Yeah, it's always a hard conversation, right? He's 13, he lives in Western PA, you know, all his- You're not in Western PA, you're not. You know. All his friends play football. Football life. You know what I mean? And so, yeah, the time I usually have that conversation, and these guys can weigh in, is usually after their second revision. So, they had another procedure, and they failed that again. Well, then I was like, I think we need to have a serious talk here, because whatever you have here has got to last you. So that's usually, I think I'll give him another chance, because, you know, this is sort of the dream, or sort of the goal. But I think it depends on the scenario too, the massive amounts of bone loss, maybe we're having a very different conversation. Open Latter-Jay in this kid. Very interesting, okay. And how about a arthroscopic bone block procedure? And then Ivan, what were you gonna do here? Sorry, so this is with no bone loss, you said? This was in this kid. Oh, and 13% bone, well, yeah, yeah. So in bone loss, again, I treat bone loss with bone, soft tissue with soft tissue, so yeah. Okay, so we, I ended up doing a revision arthroscopic band card in this kid. And so we did a revision arthroscopic band card, we did a REM plissage along with that. I actually incidentally saw him many years later, when I was still doing some knee surgery. He came in for his ACL, and actually had not dislocated his shoulder. But that's when I started having conversation with him. I said, this is your third surgery, and you're only, you know, 15 or 16 years old. All right, I want the faculty here to just give their one pearl about something that they do now with revision instability that maybe they didn't do about five or six years ago, or a thought about this that they would like to share. Oh. Yeah, sure. So I thought that everyone else couldn't do a band card as good as I could do, because I got trained at SCOE. And I learned that really the hard way. So this is why when I hear the story of, yeah, maybe the person did it first, I can analyze this. I wasn't there in surgery. And honestly, everyone in North America is being trained really well arthroscopically, that I need to anticipate that they did it well. I should assume that first, and make sure there's not anything else that I can deal with. Aman. So yeah, I mean, it sounds simple enough, but it never fails to surprise me how key visualization is. And I think Ivan was talking about this when he was talking about for his study when he's doing open versus arthroscopic. I think in our quest for everyone to do a subscap split, I think many of us do not see the way we want to see. I think the details of carpentry are really, really key. And to do that well, you have to be able to see. I mean, you can't prepare the glenoid appropriately if you can't see. So really taking your time, if you're gonna do a subscap split using Steinman pins on the glenoid, superiorly and inferiorly to hold that split open versus retractors, making sure that you get medial enough on the glenoid with preparation on your laterges. If you're doing an open bank cart and you haven't done this a whole lot, doing it with an L-shaped tonotomy on the subscap to make sure you really affect the capsular volume like you want to do it. But these little steps in terms of visualization, making sure the patient has muscle relaxation on board, making sure that you have towels behind the medial scapular border, I find all these little details. When I said, I obviously train residents and fellows, but when we do a laterge procedure, I set the patient up. And so they'll set it up with me, but if the patient's draped and then I come in, which is so often the case with all my arthroscopic procedures, it's hard to go backwards. Starts initially with positioning, right? Kathy, any pearls? Yeah, I think for me, the open bank cart isn't dead and it was intimidating through residency. I never did one, actually, even though I trained at Duke with Dean Taylor, I don't recall doing one for the first five years I did. And then when I came to UConn with Mazzocca and Arciero, just understanding that it's not as intimidating as what you think. And I think there are people that can benefit from that. And as long as your visualization is appropriate and the positioning is very key, I think that it's an easier operation than we ultimately think when we think about it. And it's not that intimidating. So I think having that in your toolbox is important. Excellent. We had a question here. As I can see, you put in an algorithm that you are reserving out of date procedure for those patients with some soft tissue damage. But sometimes I'm dealing with some patients like soccer players or Michel Martial, or some of our athletes that when we do the latergy, they usually tell us that it's stronger than the other shoulder after the latergy. So is there an indication for the latergy just because you don't look at the image just because it's for or contra athletes? What do you feel compared to the pre-ball graph? So I'll tell you that I would agree the French have it right. If you want one algorithm and you want to do one operation and you're for all instability, latergy can be it, right? We went to ESCA a couple of years ago and their answer was latergy for any bone loss, whether it's there or not for any shoulder instability. And for any failed latergy, you do another latergy, somehow that you revive the craft. But there is no question, it is the gold standard. So hands down, you guys, people are doing it. It's fantastic. But there are problems. That's why we're talking about it. There's scary parts. I don't do it all the time. I'm nervous. That operation, I'm there, just like you mentioned. I make sure we're positioned. I make sure we go through. I'm also there positioning for AGR, don't get me wrong. But that one scares me because I don't think I can be as good at that one. And I honestly don't want to be as good at that one because the next operation, I don't do arthroplasty. My colleagues do. And they look at me, they go, no, we would rather you do AGR all day long than do a latergy. Because at some point, they're coming to our clinic. We actually haven't had one yet. And I'm actually, I want them to have some. They've had failed latergies that they had to revise. They don't like that. Yeah, I mean, I do arthroplasty. Post-arthroplasty latergy is a difficult, I think, a difficult surgery. I think my sort of last prediction or sort of pearl here, I guess, is I think the things that we're hearing about with arthroscopic bone block because of the ability to kind of address bone anatomically and be able to repair the soft tissues, I think if they can find a way that people can reproduce outcomes like Ivan or other techniques that people are very comfortable with, I think we're gonna see a wave of that in the near future. So that's what I think. But I really want to thank you all for your attention. I want to thank the faculty. And hopefully this was helpful for you. Thanks very much. Thank you.

ICL session

failed Bankart procedures

Arthur Scott Baker

Bankart repairs

open Bankart reconstructions

arthroscopic bone block procedures

bone loss considerations

revision surgery

shoulder instability

surgical options

long-term implications