All right, thanks so much for joining us this morning. It seems like each morning probably less and less attendees and hopefully my voice will hold up the rest of this morning. But I welcome you to this ICO. We all know that we, my name is Albert Lin from the University of Pittsburgh. I'll be the moderator. And we all know that arthroscopic, well that's probably not going to be great for 7 o'clock here. We all know that arthroscopic vanguard is a really popular surgery, and we're all very familiar that it has a high failure rate. And so the goals of this ICO are to talk about all the treatments for this very common scenario. And I'm joined by excellent faculty here. Ivan Wong to the left of me from Halifax. Kat Coyner from the University of Connecticut. Amandouan from Penn State is checking his talk right now, making sure it uploads. And so this will be the format. We'll have some short talks here. I'll initially talk about revision vanguard with or without remplissage, and then we'll talk about some open revision options, including vanguard and Latter-Jay. Dr. Coyner will talk to us about other open revision options, and then we'll hear talks from the expert on the arthroscopic bone block. And then, of course, we'll have some case presentations, where I hope to elicit some of the nuances and difficulties of these cases. We know the failure rate here is high. In fact, I probably should update this slide. The failure rate at 10 years is about 30% for arthroscopic vanguard. And so with all the options in our understanding of what constitutes bone loss, either no bone loss or subcritical bone loss, that adds a different dimension as well to sort of our treatment options. And I think we have to have also a special consideration, not just for the anatomic issues, but also for the demographic ones as well, including what the age of the patient is, what sports they're playing, this concept of what do you do for in-season management, how do you put the glenoid track into your decision-making. And so we'll focus on a couple things, including what some of the pros and cons are under all these options, the risk-complication-return-to-sport profile, and then of course some technical pearls from our experts. So could you load my other talk now? So obviously I think there is a role for arthroscopic revision vanguard, but I think patient selection and sort of when you decide to do that is really important. So we'll talk about first the revision vanguard option and whether or not you include a rump massage. So of course primary Bankart failure remains very high, even at short-term follow-up, even higher at long-term follow-up. And of course you have all these options like we talked about. What is the rationale for doing arthroscopic revision stabilization? So Aman is going to talk to you about sort of the open revision of Bankart. If you look at open revision rates, you have a wide range of failure rates, maybe somewhere even between 8% to 22%, depending on what literature you look at. And so we still often consider arthroscopic revision scenarios. Why? Well, because this has a relatively low risk profile, as we all know. And these are the considerations. So if you're seeing a patient who has failed their initial index Bankart surgery, you look at many things. What did they do at the time of the surgery? Was a rump massage added to this? Often it's not. And we look at other things. How much bone loss was there at the initial injury and how much bone loss has subsequently developed? Is it on track or off track or sort of near track? Is there anatomic issues like hyperlaxity? Are there other pathology that hasn't been addressed like Hagel? Does this person have like a labral tear extension sort of 360 degrees that was never addressed at the time of surgery or has some component of MDI? And some of the historic treatments here we don't see as often. I used to see this a little bit earlier in my practice, but thermal treatment or multiple dislocations. And so maybe the patient had 10 dislocations before their primary surgery and now has very, very poor capsule labral tissue quality. In fact, I would say Ivan probably always sees that in Canada because he's not able to see them for over a year. And then, again, what kind of patient am I really dealing with? Age, contact, sports, or competition in terms of their athletic status. And then you start thinking about technical issues too, right? Was proper technique used? Is all the capsule labral tissue shifted? Do you use enough anchors? Occasionally I'll still see a patient comes in with a failure and had like a one-anchor repair. Was there adequate tissue mobilization? And is all the capsule redundancy addressed? I truly think that when we think about what revisions scenarios we're talking about, we're really in our heads, I think, talking about a risk-benefit ratio in terms of a complication profile. And obviously as the surgeries go from the left to the right on this slide, the risk of sort of complications and sort of the severity of them also increase. And so I think this is a very delicate balance between sort of what we're willing to accept from a complication standpoint, what the patient is willing to accept, and what the benefit in terms of recurrence in their reported outcomes. So the pros of arthroscopic revision bed car, I think all of you probably know this, but you can preserve the subscapularis, you can evaluate other labral pathology, maybe preservation of motion, which can be very important, say, for a thrower. Save the coracoid, low complication profile. And then this thought that maybe it doesn't box you out of other stabilization procedures, although I think there's some data that suggests if you continue failing and then you do a bone block procedure, you may have worse outcomes. The cons, if you add a remplisage, you know, there's a plus or minus. Most systematic reviews now don't demonstrate a significant decrease in external rotation, but there is always this worry about whether or not you can diminish someone's kinematic profile if you do a remplisage. And then there's this thought about a higher rate of recurrent dislocation compared to maybe other stabilization procedures like Latter Jay's. And so the question really is, like, who is the right person that you might be able to appropriately indicate a revision arthroscopic bed car? Again, you pull the literature here. I think even after open stabilization, open bed car, the revision failure rates are all over the place, even up to 50% in one study. So how does the arthroscopic revision bed car compare to this? If you look at some older studies, this is a study from Andreas Imhof. Look at about 50 patients with recurrent instability. You can see that the revision bed car scenario, and this is the predating remplisage, had relatively reasonable recurrent instability rates, about 11%. And relatively good outcomes. But, you know, as you would imagine, lower return to sport. Another paper out of Rush, essentially a little bit older as well. Same type of follow-up, about four-year follow-up. They were able to get recurrent instability at around 20%, which is around the same as a primary scenario in their risk factors for failure, hyperlapse, and the number of prior surgeries. And this is a systematic review, also from the predating remplisages, demonstrating relatively reasonable sort of recurrent rates, recurrent instability rates in return to sport. And so, again, the question is, like, who should you really indicate the surgery? This is a paper we published back in 2018, looking strictly at revision anterior stabilization, no remplisages. This was, again, predating much of the remplisages that are done now. We had reasonable follow-up, about almost six years. And the recurrent instability rate in our whole cohort was about 40%. That's pretty large. It's pretty sobering. But if you tease out certain risk factors, which we determined from a multivariate standpoint, and those risk factors being younger age, less than 22, off-track lesion, and ligament dyslexia, you subtract those out, the recurrence rates can be lowered to about 19%, which is more in line with the other studies that we presented. And so, potentially, in a subgroup category of these patients, revision vanguard repair may be successful. And, again, this is without remplisage. Interestingly, John Dickens did a similar study in his military cohort. They looked at, again, arthroscopic vanguards, no remplisages. And they controlled for things like glenoid bone loss and Hillsex defects or off-track lesions. And in this population, high risk of recurrence, about 40%. They did have a very young age of 23 in a military population. And it's also interesting to note that most of, half of those failures occurred after three years. So there's nothing like long-term follow-up to disrupt your early outcomes. So, again, pulling these data aside and looking at both the open vanguard and arthroscopic vanguard, you can see that the failure rates remain relatively similar of both. What about a Latergé in the revision scenario? Well, there's data that suggests that even if you do a Latergé, it has higher failures compared to a primary situation. And sometimes, and we heard about this in the morning session yesterday, you can do a bone block procedure and still have some issues regarding sort of the on and off-track concept. And so I still think our ability to address that remains a little bit challenging, even with these bone block procedures. I did not put our recent study on this, but we actually looked at revision vanguard with Remplisage and compared to the Latergé recently. This was published in JSCS and actually with new techniques of Remplisage, I think Larry Field also mentioned this as well, our failures are actually the same. So there is, I think, a cohort of patients that you can do a revision vanguard with the Remplisage and still get similar outcomes to the Latergé. So in my opinion, who gets an arthroscopic vanguard alone now? I think very, very, in a primary setting, I think pretty limited indications. Somebody has subcritical glenoid bone loss, or sorry, these are patients who I would not just do an arthroscopic vanguard alone. Subcritical glenoid bone loss, near-track or off-track lesions, contact athletes, multiple prior dislocations, hyperlaxity, and younger age. And I think as we continue to think about sort of bone loss concepts on bipolar end, both on the glenoid side and the humeral side, I think we need to think about this in more of a continuous variable, such that there is an on-track lesion that is worrisome, which we would consider a near-track. And so we look at this as more of a continuous variable rather than a binary concept. So again, the patient who would get a primary vanguard now, and sometimes this is just an indication regarding sort of if you do the right surgery the first time around, for me, these indications are becoming more and more narrow. For me, it's somebody with less than 10% glenoid bone loss, a first-time dislocator, an older patient, no contact athlete status, no hyperlaxity, and they have to be very, very well on-track. Pretty much everything else I'm considering doing a remplisage. So here's my algorithm for when I would consider a revision arthroscopic stabilization. I think they have to have a distinct event of a successful procedure. What I mean by that is patient did really quite well. Maybe they're a football player. They did well for a number of years, and they have a distinct event. They got tackled, and they dislocated. For me, it's a distinct event following a successful procedure. They're not involved in collision sports. Maybe they need some external rotation. They're older, like older meaning older than 22 years old with no hyperlaxity, and they have to have a pretty well on-track status. So my indications are somewhat narrow for this, but I do think there's a population that would be successful, and if they have all of these criteria, then I'm considering an arthroscopic revision bankart and probably doing a remplisage. You guys all know how to do the remplisage here, but this is a case that's sort of illustrating that. This is a kid who had multiple dislocations. This is not a revision scenario, but this is just to show the sequence. This is from an ASL portal in the left shoulder, and we put our first suture around the anchor first in making our ASL portal, and then we go back and finish up the posterior labral tear. I do think in scenarios where you're doing a lot of work, I think it's, for me, easiest to put the remplisage anchors in in the beginning so that your space does not enclose after you do the bankart repair. So here we're pulling the cannula out and basically jabbing on both sides of the portal to place our remplisage anchors. We also heard some talks about where to put these anchors. I think if you have a reasonable-sized heel sex lesion, you're probably putting on the medial margin, as you see. And then we go back and just finish up the rest of the bankart repair. And this person's tissue quality definitely looks pretty chronic to me. And then at the very end, we'll go in and use a double pulley to tie those in. You can do knotted or knotless technique, but that's sort of my sequence for doing a remplisage. Thanks very much. So the next talk we'll have up here would be Aman's talk on open bankart and open Latter-day. All right, thanks, Albert. I'm going to talk to you about, I know this is an arthroscopic meeting, but I'm going to talk to you about a couple open techniques here that are, should keep in your armamentarium for these particular situations in which you have a failed bank card. So, we talk about revision after failure of arthroscopic stabilization. Dr. Lynn just talked to you about a revision arthroscopic stabilization with or without augmentation. And then, we're going to talk in a bit about arthroscopic bone block procedures, but you should know that there is another option, and that's the open bank card. And I know this is kind of losing popularity, I think in large part, because people are less familiar with this technique, whether it's in residency or fellowship training, you don't see this a whole lot. There's an argument to be made that if you're going to open, why not do a bone block procedure, such as a Latter Jay? And then, if you're just managing the soft tissues, why not do it arthroscopically? So, we're going to address these. If opening, why not do a Latter Jay? Well, if we're honest about our complications with this, they are probably more frequent than we'd like to admit. There's a whole host of both minor and major complications, including hardware breakage, malunion, nonunion, nerve issues, infection, that I think we really need to be honest with ourselves and admit that this is probably not necessarily a risk-free surgery. And that complication rate, depending upon what you believe, can be fairly high. And if you're thinking about doing a revision arthroscopic procedure, understand there's some things that you can do with an open technique that you just really can't do arthroscopically. And specifically, managing capsular volume really is much more, you have much more ability to manage the capsular volume, as well as the thickness, instead of just pleading as you do arthroscopically. And I love this quote by Dr. Warren, and I think we all are at risk of thinking this sometimes, that especially if it's not your own surgery, that failed on the index procedure. But don't just assume that you can do better than the last surgeon. If there's something specific that you can address, maybe number of anchors, knotless anchors, position of the anchors, capsular mobilization, haggle lesion, something like that, you know, that may be a candidate for an arthroscopic procedure. But if not, you're doomed to fail again if you just basically do the same procedure over. And what does the data say when you talk about open bank cards for these revision situations? Really, the data is fairly convincing. Several studies have looked at this and demonstrated very low risk of recurrences with an open bank card after a failed arthroscopic index surgery, including with fairly good outcomes. So who would benefit from this surgery? I think the two or the three big ones in my practice, patients with hyperlaxity, I think, again, your ability to manage those soft tissues and especially double the capsular volume, I think, is really beneficial for those patients. People with a Baten score of over five, really a very on-track lesion or no, Hill-Sachs, very minimal glenoid bone loss. Those are all patients that I think really would benefit from this technique. Who would I consider for another technique? Obviously, patients with an off-track or near-track Hill-Sachs, patients with significant bone loss on the glenoid side. And then if there's a specific technical factor that I can correct with an arthroscopic revision. So how do I do this? I do this through a deltopectoral approach. I think most of us are fairly familiar with a subscap split. But understand, if you don't do a lot of open bank cards, you may want to do an L-shaped subscap tenotomy, really. Visualization is key. And if you don't do this procedure a lot, you really want to do it correctly. So I'm going to show it using a L-shaped tenotomy here. Either way, whether you do an L-shaped tenotomy or a subscap split, I start medially. It's a lot easier to vet out the capsule from the subscap if you start medially and work laterally using nail scissors and a cob elevator. So essentially, the deltopectoral approach, again, starting medially with the subscap split, I use a sponge to really kind of open up that space that can be very adherent, particularly in the patients with multiple dislocations and previous surgery. And obviously, we're talking about a revision situation. I'll tag in a little bit of a visualization of the subscap splint. So I'll start with the subscap splint. Obviously, we're talking about a revision situation. I'll tag it with sutures. And then, as opposed to my laterges, I do a laterally-based T capsulotomy in my open bank cards. I think it gives you a lot more flexibility as far as managing the capsule, what you want to do, how much you want to overlap it, and how much you want to bring that up. So I do a laterally-based T capsulotomy with those. And then, again, just like your arthroscopic technique, I use three anchors. I do use a pigtail passer. I had an issue once using a free needle, and it broke, actually, because you're putting so much torque on it. And that took about an hour of my time and about 10 years of my life trying to retrieve that. So use a pigtail catheter. It's a lot less sensitive, and it's got a lot more robustness in terms of passing. And I think you have a lot more maneuverability with it. So if you do have a situation in which the capsule and subscap are very adherent, which often happens in these situations, you can take them off together from laterally. And then, basically, when you do your... After you place your anchors on the glenoid, you can pass those through in mattress fashion, just basically inside your flap, a Hawkins technique. And that works very well also if you're really having trouble separating those layers. And then, finally, capsular management. I think it depends upon the patient's age, the patient's athletic endeavors. If they're a collision athlete, obviously a thrower, you want to be a little more careful about how much you're overlapping that capsule and how much you're tightening. I bring the arm into abduction and external rotation about 30 and 30 before I do that. Well, what about if there's patients who have an off-track heel sacks or a near-track heel sacks or significant glenoid bone loss? Well, I do an open Latergé, and it's not that I think arthroscopic techniques are fantastic, and again, we're in an arthroscopic meeting. But just because you can doesn't mean you necessarily should. And I think you have to decide that in your own hands what's best. In my hands, I feel like I can do the carpentry best. Open, I can play golf in a lightning storm as well, but I choose not to, and this is kind of similar. So principles of procedure, patient positioning. I do this beach chair. I have them not quite as sat up as I do with my arthroscopic shoulder surgery. I think it's really critical, put a couple towels behind the medial scapula. You really want to try to get the trajectory of your screws as parallel to the glenoid as you can, so you really need to flatten that scapula out. So putting a couple towels, as you can see in that top-left picture, behind the medial scapula really does a very good job of doing that. We talk about soft tissue management. I do leave a little cuff of my CA ligament attached to the glenoid. The few challenges I've had with my latter Js have been generally stiffness, and those, for the most part, absolve that. So I leave about six to eight millimeters of CA ligament to attach to my capsule medially afterwards, and that seems to help prevent that. Your bone harvest, you really want to try to get as much of that coracoid as you can. Can you go back one? So this one's not working. I don't know why. So when you take your coracoid, you really want to take as much as possible. Obviously, you want to get back to those CC ligaments. It's perfect if you get that little spike of glenoid on there. I think that helps. Obviously, we'll need to machine that down in your prep before you actually place that onto your glenoid, but it's perfect when I know I get that little glenoid spike. It's about 16 millimeters in width, 12 millimeters in height, and about 28 millimeters, or about 25 millimeters in length. If I get that, I feel pretty comfortable with it. And then you have to decide on your orientation, whether you want to do this congruent arc or you want to do it classic French technique. French technique, essentially, that posterior edge of your coracoid is now up against your anterior glenoid, as opposed to essentially flipping on its side where that inferior edge now is on your coracoid. And both are valid ways to do it. Arguably, the congruent arc gives you a little bit more bone volume in terms of width and glenoid reconstruction. However, if you believe that the sling effect is most important biomechanically, in my hands, I do this traditional French technique. My biggest concern as far as this bone block is getting it to heal and preventing malunion or nonunion. And so I do this classic French technique to really give me as much bone possible for that healing surface. Decorticating, and we were talking about the carpentry before, this is why I do it open. I feel like the carpentry, at least in my hands, I can do it far better with an open technique, decorticating both the inferior surface of that coracoid graft, as well as on the glenoid side, which really is critical in terms of preventing nonunions or hardware complications with this. And then depending upon the specifics of the patient, if you have a patient that's hyperlaxed, you can really make your split in your subscap a little bit more superior as opposed to your traditional superior 2 3rds, inferior 1 3rd, to give you a little bit more inferior subscap in terms of that sling effect, and that can be very effective. As opposed to your open bank card, like we talked about, where you do your capsular management laterally, for my open latergies, I do it medially. Prepare your glenoid, be careful with rotatory burrs, obviously, near the axillary nerve, but I think doing something, whether it's burr and or osteotomes, I think is critical in terms of really prepping that anterior inferior glenoid for your recipient place. When I used to place these, I used to try to get them as low as possible, much like your anchors for an arthroscopic bank card, but actually you don't wanna get that low. You wanna put it right at about four o'clock. If you get this bone block too low, you actually can jump the graft. So four o'clock is really perfect. If you're not trying to put it at the five or six o'clock position, you really wanna put the middle graft about the four o'clock position. You don't want it too low, your wrist dislocation of your graft. Two screws, non-cannulated, I use 3-5 cortical screws. They end up being somewhere around 36, 38 millimeters, and you really wanna get them as parallel to the glenoid as you can. That's critical in terms of your outcomes, as well as preventing non-unions. Be careful of small caliber, less than 3-5 screws or cannulated screws. These have been shown to increase your risk for complications of a hardware bending and or breakage. So you won't really wanna be attentive to that. And then finally, capsule management, several options. You can use anchors immediately. You can attach it to your CA ligament like we talked about before, or you can do nothing. There are surgeons that do nothing with a capsule and have very good outcomes from this surgery. They obviously lose one of the aspects of the triple blocking effect, but again, it's probably the least important of the three. Make sure when you're managing that capsule, you really bring the arm into abduction, external rotation before you close that. Again, my biggest complications from this have been stiffness. And when you're closing, you're obviously tired, you're finishing the case. Often it's your resident or a fellow that's doing this. So be a little attentive with that to prevent that significant complication. What does the data say on this? I think it's fairly convincing that a letter J procedure in the revision situation can be a powerful tool for this with a low risk of recurrent instability, at least compared to an arthroscopic revision procedure. And I guess something maybe we talk about during the questions and or case presentations is there's some data out of the military that demonstrates if you're talking about letter Js, they really are more effective in terms of outcomes and recurrent instability if done primarily versus in the revision situation. So really, should we be doing more of these in the primary situation? Something to discuss. So in conclusion, I think we talked about a couple of procedures here, both open. Don't forget about an open Bankart reconstruction. Often many of us are not familiar with this procedure, but there's really things that you can do with that procedure that you can't do arthroscopically, particularly managing capsular volume and capsular thickness. You don't always need to risk the complications of a letter J. Open Bankart is literature supported. It's ideal for patients with minimal bone loss, hyperlaxity also is an indication in my hands. And then when patients with osseous concerns, either an off-track or near-track lesion or significant glenoid bone loss, in my hands, an open letter J through a subscap split is my preference. Thanks, guys. Perfect, so I have sort of the grab bag of all the other bone procedures that are open, so distal tibial, iliac crest, and distal clavicle. Some of this, obviously, they've already stalled the fire on a lot of this, but we'll sort of go through it. I think the big message that we all know and sort of all try to achieve is try to get it right the first time. You know, when you try to do a revision arthroscopic Bankart, you know, you're approaching a 40% failure rate. And then he just mentioned this study, but in a Latter-day Primary situation, you know, you have about a 9% failure rate. But if you do that in a revision setting, that increases to 20%. So getting it right the first time is most important. We do need to recognize, you know, why are we having such poor outcomes? And this is really, with an arthroscopic situation, you can see these ranges that we sort of talked about in other studies, that they're really high. And in my hands, at least, there's not a lot that I would do a revision arthroscopic, except for sort of the indications that are clear-cut. I think just like a primary situation, we really need to recognize where that bone loss is, how much it is, and is it bipolar or not. So even in the historical literature, we've, you know, been talking about this for probably decades at this point, that bone loss matters, but how much bone loss is that sort of critical factor? And I think that continues to get smaller and smaller as we get better with our techniques. The glenoid track obviously provided a lot of information with on-track, off-track, and has given us some guidelines of when to add a remplissage. And that will be interesting, you know, 10 years from now, when we have this data on our previously 10 years, you know, where now we're doing remplissages. I think the one thing that, you know, I hear Bob Arciero talk about all the time, and we're actually looking at his long-term outcome of his open vanguards, is he's shocked of how many people come in very late. So you know, we think we get to the three-year mark, five-year mark, maybe we've even changed practices at this point, all our patients do well. But if you actually stay one place and follow these patients, which is hard to do, those outcomes aren't as great. And I think, you know, Tokish and everybody has really sort of brought us attention to subcritical bone loss. This is a study that Gus Mazzocca did at our lab at UConn, and really showed the additive effects and the bipolar effects of this. And with a two-millimeter glenoid bone loss, which sort of represents around 8%, with a small Hill Sachs, you compromise your Bankart by 26%. You increase that glenoid bone loss to six millimeters, and now have a medium-sized Bankart or medium-sized Hill Sachs, and you compromise your Bankart by 50%. So we really have to look at that glenoid bone loss. And what is that critical? You know, historically, it's been 20% or 25%, as Tokish has sort of showed us, that recurrence may not happen at 20%, but even at 13.5%, their outcomes are much worse. So distance to dislocate is also sort of, if you're not doing that, I would definitely suggest to start doing that on all your primary and revision situations, and really trying to determine this. Because if it's less than 10, you have a 12 times more likely failure risk with a Bankart repair. And in your contact athlete, that distance can be 24 millimeters, and you're still going to have an increased risk. So those patients probably are going to need to be added something else, whether that's the open Bankart, whether that's the Ripple Sach, or even now sort of something more bone block situated. So, oh, so let me go back, sorry. This is a good study from Dickens. He basically took a look at his military cohort, and prior to anybody having a shoulder injury, they got MRIs, you know, sort of prophylactically. And what they found is after the first instability event, they had a 6.5% glenoid bone loss. So at the second instability event, they had 22.8%. So if you're addressing a revision situation where that person had at least two, you know, you can almost count on the fact that they probably have glenoid bone loss, and if you don't see it, you should probably look a little harder and make sure you're getting all your studies that you, you know, can evaluate that appropriately. I think similar to what other people have talked about, when somebody fails, you know, I sort of try to figure out that why and what factors played into that. You know, did they have a new trauma, or was this just that they have sort of a subclinical failure where they're just not happy, they feel unstable in that abduction external rotation. What's their age? What's their activity level? What do they want to go back to? What side is their dominant arm if they're an athlete? What position do they play? Do they have a Hill Sachs? How big is it? You know, do we think that's off track or on track? What's their percentage of glenoid bone loss? What's the quality of the tissue? Was it an error in indication? Did somebody, you know, if you weren't the original surgeon, or even if I was, I try to critically look at, you know, was the right surgery picked, and then was it done technically well? So we sort of looked at this already, but, you know, the results of arthroscopic revision and Bankart are a wide range, but can be approaching 50%. You know, do we just say, hey, I can do this operation? I think it'll be good. Hopefully, they, you know, go someplace else if they dislocate. But I really think that, you know, if you look at the return to play, really only less than 50% return to their pre-injury level. So I would argue that we can definitely do better than this, and we should be doing better than this for our patients, which sort of leads us to this bone augmentation. And there's lots of different choices. Well, that's an open Latter-J, arthroscopic Latter-J, distal tibia, distal clavicle, iliac crest bone graft, and then addressing the bipolar bone loss with the humeral head when necessary. We sort of talked about the Latter-J with the sling effect. You can do this open or arthroscopic indications, sort of greater than 20% of bone loss. And obviously, there is some trends in some parts of the world that this is happening for first-time dislocations. You know, this has historically been the gold standard, and you can sort of see why. The overall return to sport rate was near 85%, which is excellent. But if you look at, you know, these are my partners and two of the most honest guys I know in Bob Arciero and Gus Mazzocca, and, you know, these are expert surgeons, and you can see that they had similar recurrence rates, which were pretty high, as well as high complication rates. And there's a significant learning curve. If you haven't done, you know, many Latter-Js, you know, the learning curve is supposedly about 22, where an arthroscopic Latter-J is even double that at nearly 40. So I think there is a learning curve, and we have to decide what we're going to do to do that. So we talked about the sling effect. Biomechanically, it probably does make a difference. However, clinically, that hasn't really been borne out, whether when we're comparing a Latter-J to, say, a free bone block, whether that's open or arthroscopic. So that's just something to consider. So why not a Latter-J every single time? And I think the complication rates are high. You know, it's anywhere from 15% to 30%, but if you look at the studies where there's neuromonitoring, 77% of them will have an event, and then 21% will have a deficit post-op, and 5.3% are permanent. So if we can avoid that and get the nerve out of the sort of question, I think we may be better off. There's also defects that are too big for a Latter-J. So these, you know, there's some that we can't make it to an on-track lesion due to the glenoid or due to the humeral head. And in those cases, there's a four times higher rate of failure. So if you take a Latter-J and still, it's an off-track after you've operated on it, you have a 33% failure rate in comparison to a 2% if you made that an on-track. So paying attention to this as you choose your grafts are important. So what's the ideal solution? Well, obviously, we want to try to restore the anatomy. I do think having cartilage there could be important, especially with larger bone deficits. If we can use autograft, especially in areas where allograft isn't as readily available, and it should be easily accessible and available, the cost shouldn't be prohibitive for some of our underinsured patients. And then donor site morbidity. So here are all sort of a table from the TAN Journal. But iliac crest, distal tibia, distal clavicle, scapular spine are pre-shaped. They all have their pluses and minuses. But really, it doesn't appear that in many of these, there's much clinical difference in head-to-head. So the distal tibia has an advantage. It does. The curvature really matches. The thickness of the cartilage closely matches the glenoid, which makes it nice. And it preserves the coracoid. So if you do have to go back as an arthroplasty surgeon, you're going to have an easier dissection, hopefully, and potentially less invasive as you've preserved the conjoined tendon. So the disadvantages are, obviously, it's costly. If you get a fresh graft, it can take some time. In some places, allograft is not available. There's some short-term data that say we're doing pretty well with this. But we still, obviously, need to follow this from a long-term perspective. Distal tibia, with fixation, with the ladder J, you do worry about sort of that non-union. Or if you look at your CTs, not many of them, or some of them, will have suggestions of lysis around your screw heads. This one, with the distal tibia, at least in the study, it was about 89% healing. And one of the sort of technical pearls is to angle your graft less than 15 degrees that showed better alignment. So this is looking specific at ladder J to the free bone block. And really, again, it's dealer's choice. There wasn't a lot of significant difference with failure rates. So I think it's a little bit what's comfortable in your hands. This looked at results of the free bone blocks that are non-ladder Js. And really, again, the pooled recurrent rate was about 3%. Distal clavicle, I personally haven't used it, but I know people definitely are. It's locally available. It's osteochondral. It's cost effective. And there's minimal donor site morbidity. However, there is a size limitation. Anything over probably 25% to 30%, it's not going to be a large enough piece of bone. It's also variable quality. And if you do over-resect, you can have, then, an AC issue. Also, this lacks long-term results. So really, I think it's less important about what graft you choose, but making sure you optimize your technique. The ladder J always has the nerve in play. So is there a better way, which, obviously, we're going to hear about soon arthroscopically-wise. So I think if you have bone loss, you have to replace that with bone. So revision instability with bone loss needs bone. We need to make it an on-track lesion. And I think we have recognized that. And how you do that in your hands is going to be variable, given the patient. We always address the glenoid side, but I think not forgetting about the humeral side and the bipolar bone loss and putting a humeral head allograft when needed. And then I think both open and arthroscopic bone blocks are reasonable options. I've historically done a lot of ladder Js, have now done free bone blocks. And even Ivan, you'll be proud of me, I've done one arthroscopic bone block. So thank you very much. Thank you. There we go. That's good. Okay. Probably if I play golf, it'll feel like a lightning storm. We'll talk about revision arthroscopic bone blocks. So thanks for having me here. Disclosure. So by the end of the session, you'll be more familiar with options for treating a failed bank card, the pros and cons of using button or screw fixation, and kind of why AAGR, at least with screws, for me is the way to go. So really to improve outcomes, we really got to assess. We heard this already. If there's bone loss, we really got to address it. And sometimes it's more subtle than we think. We heard more than one dislocation. You really should start looking at it. So this one does have a bone loss. I see a previous instability attempt in there. So I want to be more careful with this. And what I did learn doing this is we got to measure the glenoid. So the perfect circle is one thing. We do that. That's the best study technique. But I find it very difficult to measure. What we did find is the two parts I can measure are the superior and inferior aspects of the glenoid. And when I do that, we actually have a very good correlation between the two, which, again, could be a much shorter algorithm than the one we created here. So this is our publication on this of how to do this. But the best or the quickest way to measure is I get superior to inferior. I just multiply it by 78% or 0.78. And that gives you the anterior to posterior width, a very, very quick, easy way to do it. Philip Marauder and their team is very good at describing why this is actually more important. So we measure typically on face view, looking at the anterior to posterior dimension. But what we're actually really trying to do is recreate that concavity of the glenoid, that dish shape, because that's where it actually gets the stability from. And it's the most important part is those last millimeter or two that gives you the most stability of here. So a couple of millimeters off in glenoid bone, that's a very big deal. It's not like we need more than five before it becomes a big deal. We heard about Latter Jay's gold standard. No questions. This has stood the test of time. We need to compare all of our bony reconstructions to this as the lowest dislocation risk. But it is more difficult, at least for me, to do it open than arthroscopic, because I can't get the graph lined up perfectly. I can't see down through this deep, dark hole. I can't deal with the hill sacks. I can't deal with the slap. I can't measure the glenoid defect. I can't align the graft appropriately. And of course, x-rays like this scare me. Revision surgery is also very difficult with something like this. So Latter Jay trades a decrease in recurrence rate for an increase in potential complications, an increase in future revision surgeries, and for me, more difficult surgery. This is a nice comparison. Our rush group looked at their outcomes of open DTA versus open Latter Jay, and what they found is they get fantastic results in these patients. What I did learn from this, though, is our best surgeons here also get the biggest complications rates, too. So you look at these two complications they're looking at. These are permanent nerve injury, permanent subscap failure. And this is probably why not everyone is doing a Latter Jay right at the beginning. We talk about the ideal surgical technique. We want something to be as safe as a bank card, so low complications. Something you do arthroscopically that we're comfortable with, preserves the subscap, safe from the nerves, has a short learning curve. But we also want something that is like the Latter Jay, with a decreased recurrence rate that you can replace bone, have good outcome, and obviously something that's teachable. And this is where you kind of have to get out of your comfort zone. So if you don't want to play golf in an electrical storm, you try to do this indoors. We published our technique in 2015 of how to do an arthroscopic anatomic linoid without a subscap split. And it's grown since then. And the unfortunate part is when you're trying to do a new technique, a new thing, you really focus on outcomes. And that's all we focused on. Now we're focusing on how to teach this. So how do you get the graph low enough? And most people talk about this. And how do you do that? Is you depress the subscap instead of splitting the subscap. This actually has to take your open techniques arthroscopically. You got to do all the releases you did for your Latter Jay, but you got to do it arthroscopically. And we try to teach that and how to do this depression. And you can actually get the depression of subscap so low that you can miss the inferior screw. Okay. So if you can't do that, we haven't done enough of a release. And the whole point of this is if you do the Halifax portal, you're through the green, the rotating interval, it is completely safe. All you have to do is identify the conjoin and stay superior to subscap and you cannot hit the nerve. If you don't identify it properly, then yes, you can. So once you get the anatomy, just like open surgery, it can be safe. We've shown the learning curve is shorter than the arthroscopic Latter Jay. That's a very difficult technique to learn. This one, the technique, once you identify those two structures, it's actually very easy to do. The hard part of this technique is get the graph where you want, and anyone who's tried this, I've actually seen several in the room today, we've had lots of discussions over this week to talk about it. The difficulty is getting low enough and parallel enough, and these are all just about releases and how to get it. And it takes about nine cases to get that way, and we can speed that up as well. We do think distal graph, again, I'm not a basic scientist, I'd go with all the other graphs. There's lots that you can use. The only one that I know that has a lot of data on this right now is distal tibia and iliac crest, and they definitely work well. And why I do like it is you really can recreate any amount of bone loss. You literally just draw it onto the graph, and you go as much as you have. We've actually replaced half the glenoid before quite successfully when you have very, very large bone loss pieces going on in there. And the way I like doing it is using a cannula to be able to control exactly where the graph goes on the inside. Those that don't have access, we actually have the same data using iliac crest. So when we didn't have access to distal tibia, we use autograft iliac crest. The outcomes, the remodeling, all the bone reconfiguration and stability are all the same. We're very careful looking at what latter J or arthroscopic latter J compared to distal tibia look like. And essentially, they have the exact same union, healing, size, and resorption of that bone when you look at latter J versus anatomic glenoid. The only thing different was the step formation. When I did the latter J, I could not line the graph up as perfectly as the distal tibia, mainly because distal tibia, I just put a switching stick across, and I make sure the cartilage lines up. Trying to figure out where the bones meet is a much more difficult option. So what are the advantages I have learned with the AAGR versus DTA? Well, I learned, it's very humbling as you look back on your previous data. So these are usually six, seven-year patients out doing CT scans. Resorption is not resorption, it's remodeling. So if you try to make a supersized, and again, when I started doing this, we tried to make supersized glenoids because we thought that was stable. We don't have to deal with heel sacks. What happens is it remodels back to a normal size, but the screws don't remodel, so they stick out, and they can irritate the patient. So this is an example of one, right? On the left, you have the pre-op. So if you look at that, some people actually say there's not much bone loss. But when we do the measurement, it should be 24 millimeters. That's six millimeters of bone loss. And the six-year CT scan, you can see in the very middle, the remodeling after six years looks almost exactly like the native glenoid. The normal side is on the right-hand side there. So you can see what happens over time. And if you put too big a bone graft in, those screws stick out and can become irritating. So I actually want to go through this patient with you because this is part of the learning process that I went through, right? So 32-year-old female had a dislocation a few times, and you can see the bone is kind of a little bit more medial there. You can see something going off. If we do a CT scan, you can see, look, the bone is actually a little bit off there. There's enough going on, and we decided to go do a distal tibial holograph. So I just want to go through this technique here because you can see where the first surgery looks. So we measure the glenoid. We can get all the way across. We actually have no tissue in the very front. So we free up all the tissue. We get the graft in, and this is the original screws. You can see the screws actually stick past the graft here, but that's a pretty big graft. What I want to show here, though, is we can actually get a switching stick all the way across. So we're recreating the concavity. It doesn't stick up. It's not angled huge amounts. My posterior aspect of that switching stick is actually, or probe, is a little bit lateral to the glenoid. So it's pretty parallel. And this is a double-loaded suture to be able to repair the bankart back to the aspect of the graft between the graft and the native glenoid to repair the bankart. And why that's important is that is actually the location of where we can identify what's new bone versus not. So post-op, looked fine. Patient actually did extremely well. Didn't see those, you know, saw them for two years, and then kind of disappeared. And then five or six years, like, you know, I can do everything. Doesn't feel unstable at all. It's just this little achiness feeling up there. So we ordered, again, anytime they'll let me do a CT, I'll try to do a CT after the two-year mark. So I got a CT, and this is what happened. The glenoid actually looks the normal shape. And if you measure anterior to posterior, hopefully I showed you already, it's actually equivalent. It's identical to the other side, except the screws are long because we made a humongous glenoid because I didn't know what to do with the heel sacks before. So remodeling over time, normal glenoid, second picture, you have a bone loss. Third picture, we put a big bone graft in. Fourth picture, it remodels over time. So this is what happens over time, but it's not just in the sagittal plane. It's also in the axial plane. So on the left, normal glenoid, middle, you have bone loss. We add a rectangular bone graft in because that's how we hold the screws. That's how we make sure we get good contact with the native glenoid remodeling. But over time, it's going to become triangular and anything anterior to it will have screw prominence. So this is what this one looks like. We come back in, even though I opened the rotator interval, there's interval tissue growing back in. Again, the shoulder is stable. It's still in the right spot. And when we look at it, we view it from the anterior superior portion. You can see switching stick from the back. The labrum Bankart repair on top of it is actually completely continuous. You can actually see where middle glenohumeral ligament continues to go down. And the shoulder is actually balanced over the graft and the glenoid. So we actually have to make a Bankart tear in this. She doesn't have instability, but we find those sutures. And those are the sutures at the junction between the graft and the glenoid initially. So this is roughly about three o'clock position. So we have a traction suture in there to be able to open it up. We have to do a labral transection here to be able to see down the anterior glenoid neck. And that traction suture is just anterior, just as lateral to that double loaded suture anchor. So as we free up, this is the double loaded suture anchor. Everything anterior to it or to the left of it is a bone remodeling. Everything to the right is a native glenoid. You can kind of see that on the cartilage. So this kind of replicates exactly what we saw on the CT scan. It's no longer rectangular, right? So people may call it resorption. I think it's remodeling. That's cortical bone on here. We have to actually release this all the way back down to six o'clock to be able to see this in its entirety. And I'm going to show you all the screws again. The screws are actually inside the subscap. You can see it through the muscle fibers. It's not causing damage. It's just I could see where it could be irritating. But the shape of this glenoid now looks exactly right. And if we measure this, it's actually 24 millimeters again. It's what the patient has on the other side. So learning from this, I'm realizing we don't want to make this supersize. We don't want to change the anatomy. We want to make it back to normal so it can remodel back to normal. So this is my normal algorithm now to do this. Essentially, when I can measure bone loss, when there's two or three millimeters that I can actually see and be able to fix and make this concavity back, I'm going to try and make that bone better because I can get them stable. I don't want to do it as a second operation. I want to do it the first operation. I want to be the one to be able to make everyone stable and be able to fix all the problems, not try it the second time. So if you want to make this leap, I really do think everyone can. We've seen more and more people who actually asked to do something like this. We teach this all the time. You don't have to travel anymore. COVID has been wonderful to be able to do this. So this is actually a virtual teaching session. I'm sitting in Halifax. One of the people, one of the other surgeons are actually in their hometown at their own lab, and I'm drawing on the screen. And the benefit is we have cameras all over the room. And now that we've learned how to teach these with Zoom, we can have multiple cameras. They didn't understand where to put their bone graft. So we're actually drawing on the screen, orient the graft like here. These are the two holes that you actually want to drill across to be able to get the graft in the right place. If you don't understand that, we actually show a video of it at that time to try to replicate this and all the nuances of how to get the graft exactly in the right place. And so far in every one of these labs, this is what the end result is. You know, a surgeon who's never done it before, who actually may not have even met in person, can do this procedure, getting the graft low enough, parallel enough to be able to do this procedure. So I encourage you, don't avoid doing a procedure because you think it's hard. Spend the time to learn it if you want to do something like this. So AAGR has the stability of a ladder J, but with the ease and safety like an arthroscopic bank card, and now can be taught virtually. Thank you. Amazing. Those are really, really wonderful talks. Can you pull up the first, yep, you got it. So we're going to go with some cases here and hopefully we can get maybe two. All right. So this is a pretty typical scenario. 17-year-old high school hockey player. He presents four days after his dislocation, playing hockey, reducing the ER. This is a first-time dislocator. Got good motion. He has no baiting, so there's no hyperlaxity. These are his radiographs. And the only finding he really has is a positive apprehension and relocation. So maybe question one, this is, I know this is not sort of a primary situation, but is this an automatic MRI for you, Aman? Yeah, absolutely. And usually if it's within the first two weeks from injury, I don't order it with contrast, mostly because accessibility for MRIs, at least at my institution at Penn State, is much easier and much more efficient without a radiologist having to administer contrast. So I can get a normal MRI of the shoulder without contrast that night, whereas with arthrogram it might take two to four weeks. Yeah. I haven't noticed I didn't ask you. No, but I mean, there's always a question about sort of how soon can you get an MRI sort of in the first dislocation for the hematoma to act as a contrast. And we actually published some studies that the magic time seems to be about two weeks. Once you diverge from two weeks, the lack of arthrogram seems, or if you get an MRI plain, the sensitivity tends to go down in sort of accuracy of your reads. And so I think if you can get this within two weeks, you most certainly, if it's a true dislocation event, have the same thing as a arthrogram. So, Kat, if you look at these images, anything that jumps out at you? Yeah, sort of some edema at the heel sacs, but small. It looks like he has an anterior inferior labral tear with some periosteal stripping, sort of almost like a lopsa. Let me just look at the sagittal. Can you play the middle image again? Sure. Just looking at that briefly, it doesn't look like there's a lot of glenoid bone loss. I would say that, you know, I have a low threshold to get a CT scan because I feel this is a good sagittal, but our sagittals are always off plane. So if I have any question, I think the other point about this is it's a shared decision making. I would like to know a little bit more, you know, is this a senior hockey season? He has three games left. You know, is he playing collegiate hockey? Is he really a basketball player? Some of those questions I think matter in treating patients like this. So, yeah, I mean, I think those are all great points here. Sort of what their activity level, we know he's a high risk status. This, you know, I started with this only because it's such a common scenario. It didn't look like a crazy heel sacs deformity, have your typical bank cart. He wants to play, but he wants to play sort of recreationally given sort of what we know of the literature now regarding sort of the need to address things more aggressively. Hypothetically, I mean, if you're able to see this person, let's say in Canada, is this somebody that gets a surgical treatment right away in your opinion, or should they be, or is this a, you know, let's just wait and see. Yeah. So I think no matter what it is, it's always a shared decision making option. They, you know, some people have a lot of different thoughts on it. They just have to know what the consequences are. And just like you mentioned, you know, every time they dislocate, there's more bone loss. You may change the surgery right now. To me, at least it looks like a soft tissue repair could be it with the current stuff that we have. Obviously, I'm still worried about the capsule on the other side, if there's any haggle in there too. But as long as they know every different aspect of it, they probably good to make a decision. Yeah. I mean, there's a lot of data. I mean, you look at RCTs, looking at first time treatment for initial treatment for first time dislocation, there's no question that if you're talking about just an arthroscopic surgery, your success rates are much higher, low recurrences if you treat this early. But, you know, life gets in the way and there's always a different number of circumstances. And I think the patient and family have to understand that there are consequences. The consequences can lead to different surgeries with different outcomes. I want to ask you guys, let me just say yes or no. So if you saw this patient and recommended surgery and arthroscopic approach, and you have such a small heel sacs lesion or defect here, is this somebody that's getting a rump massage? Or what if you go or let me just say, let me before I ask the second question. So would every one of you guys do a rump massage in this instance? Amman says yes. Yeah, I was going to say. Kat says yes. Yes. Okay. What if you don't have a heel sacs defect? Now, Tokish has talked about making one and do you guys do that? And would you guys augment this in any other way? Post your capsulography, et cetera. So, yeah, no, I remember John talking about that he makes a heel sacs defect to do a rump massage. I have not done that. You know, I think it's a novel concept, but I have not gone to that. I would also, if I change the scenario a little bit and this wasn't a contact athlete, I'll be honest that I might not do a rump massage like out of the gates. I would be prepared to do it. I would look at it. And then, you know, sometimes I do a posterior flication of the posterior inferior glenohumeral ligament instead of that. But I think you just have to sort of evaluate it. So, yeah, if there's no heel sacs, I don't do I don't make a heel sacs to be able to put it in. But we actually saw lots of capsular redundancy in the posterior aspect that glenoid posterior band. So I would make sure that I do enough of inferior to superior shifts. Right. So we can do a very similar arthroscopically with the traction stitch at three o'clock. And this one, I would want to put almost past 12 o'clock because I think we could move that tissue that far. Yeah. Yeah. All great points. I mean, Tony Romeo actually will talk about addressing posterior capsular if you're sort of or not insufficiency, but sort of the redundancy with a seven o'clock anchor. And he actually thinks that this may actually do exactly the same thing as a rump massage. So it's something worth considering if you need something to augment sort of a high risk scenario. So so we discussed, you know, what the family what they wanted to do. Ultimately, they decided on doing surgery. And this was a number of years ago. So this is maybe about 10 years ago before the rump massage craze. And so as you know, as Kelly mentioned, actually, we just did a standard bankrupt repair for anchor repair. You know, we thought it looked nice. And as all things, you know, this hap, you know, always happens. He goes back basically about a year later to participate in a very first game. He goes in, he redislocates. So now he's 18 years old. This is what you got. Okay. Cat, anything jump out at you here? Yeah, I mean, you can see here, obviously, I don't know what anchor you use, but you see some lucency in your glenoid on the grassy view. And then on ice, it looks like there's some bony abnormality on the anterior front of the glenoid. Yep. You know, to be fair, this is a person that definitely would augment at some with something at this, you know, at the first index procedure, but that's not where I was thinking at that time. But it's a it's kind of interesting comes back sees us and he actually looks quite good on exam. I can't even actually elicit an apprehension sign on him. And I don't know whether or not that matters, but this is now his these are his new MRIs. Okay. Let me see if I can go back here. All right. Ivan, what do you think here? Yeah, there's a lot of stuff going on. So that capsule labrum periosteum anterior inferiorly looks like it's off. There seems to be some phony part to that as well. Maybe a postage stamp. Posterior inferiorly, I'm worried on the humeral side because there's some fluid going in there as well. So, yeah, is this a can you do you feel like you can estimate bone loss on MRI? I can estimate that I want a CT scan. And is everyone getting a CT scan here? So if you see something like this, OK, it's so interesting. You know, we all get all these referrals and they always come with an MRI, you know. And and then you just, you know, you feel like, OK, I want to estimate the bone loss better. And they end up getting a CT. And it's interesting. You might start with that first and just get a CT scan, because, you know, I don't know how much more an MRI offers, to be honest. But here are the CTs. And this is your classic what we call postage stamp fracture here. And so I thought I was being clever and putting them as many anchors as I could. These are two nine anchors, actually. So probably would use lower profile anchors now. But he has a redislocation and now he's got like a postage stamp fracture through the anchor sites. So I'll give you some measurements here, because we've been sort of talking about this a little bit. And just for completion sake, it's about 14 percent glenoid bone loss. So it's not, you know, it's not quite sort of your critical 20 percent, obvious critical. And he's got like a near track lesion. His hillsides is actually not that large. And so, Aman, what do you think here? Is this a person that you would consider doing an open bank card repair? I think with the amount of bone loss that he has and a near track lesion in a hockey player. And granted, you know, it sounds like he wants to only play rec. But I don't know how much you know about rec hockey. It can be actually more violent than competitive hockey. But I would do a ladder J in this. Ladder J. OK, Kat, what are you thinking here? Yeah, I mean, I have similar concerns with that. I think, you know, one of the nice things I would have historically probably done a ladder J. I don't think that an open bank card, unless you scope a shoulder first, do a rump massage and then do the open bank card, which is not, you know, sort of the standard working order. I would have historically done a ladder J. However, now have done an arthroscopic free bone block. I think you could address that hillsides and put the arthroscopic bone block. So I think it's dealer's choice what you're comfortable with. And so what? So you would do a new arthroscopic bone block with a rump massage. Is that what you would do here, too, Ivan? Yeah. To me, I think that bone loss is actually more than 14 percent. So it depends on where you want to count that bone. If I measure superior to inferior and I'm trying to look at a 90, like a exact perpendicular line in that CT on face view scan, where are you going to put that anterior measurement? Are you going to put that in that little fleck of bone where the bone or the postage stamp is? Because if I do it there, I think that's where the 14 percent comes. If you go on the other side of the previous anchors, I think it's actually significantly more than that. And then this is an estimation. Try to figure out what that bone is going to be like, where we previously put anchors in. So my concern is I think this is more than that. I want to be able to anatomically size a bone reconstruction. So, yeah. And that way we can do the soft tissue. Because I think there's a lot of soft tissue damage in here as well. Let me ask you this. So if you put a bone block here and you kind of do your measurements, it's probably going to create an on track lesion here. I think. Would you still address the the hill sacks? It's your data that I'm using to choose hills. I'm serious. I find it so so I know very little. And this is why I really enjoy coming here, because I can measure any glenoid I'm looking at it. I've been looking at it so carefully. But what I have not spent enough time to understand is the hill sacks. I really do think that is the critical step now to figure out. And even though here it looks small, I'm already thinking I want a 3D of the humerus. As well, I want to know that superior, inferior dimension going on, because I really think my problems of the remodeling, I'm not trying to make a supersized glenoid anymore. I'm trying to make a normal size because I'm looking at I want 10 year outcome. Perfect shoulder to make a 10 year perfect shoulder. I need the perfect glenoid, but also need the perfect humerus. And then some will be able to be fixed with a hillside. Sorry, a rump massage. And some won't depend how inferior it is. And I really think this is where we talk about how do we make the hill sacks appropriate enough? And where is it acceptable enough? Yeah, it's really interesting. Just this conference, Scott Feely from the military presented a paper on latergies and post-op latergies having basically being a near track lesion. And those patients actually had a much higher failure rate. So I don't know that we truly understand sort of the hill sacks defect. Right now, we address it with rump massage. But there's probably also a range of hill sacks defects that can't be addressed with a rump massage as well. As Kat pointed out to those may require anatomic bone reconstruction of the hill sack. So here are your options here. Maybe we could pull the audience. Is there anyone who would treat this as a acute bony Bankart fracture and treat this such that you could do an ORF rather open or arthroscopic? Is there anybody who would do that? OK. How about an open Bankart? Who might consider an open Bankart here? OK, nobody. Who's doing an open latergy or an arthroscopic latergy? OK. Oh, Emilio's here. He probably would have just done this in the very beginning. He's like these Americans. OK. And then who's going to do some form of an other bone graft, either an open or an arthroscopic DTA, distal clavicle, et cetera? All right. Love it. Well, I did what nobody else here wanted to do. So I did an arthroscopic revision Bankart and then we incorporated the bone. So I actually kind of treated it like a bony Bankart fracture and acute one because we got to it actually relatively early and actually able to incorporate that into his repair and just added a rump massage. So he has many years out. I think this is seven years and probably 10 years out. Probably what saved me, though, is he didn't really return to like a very high level. A competition. And so I actually have seen this family for different issues. So I always ask about him because I'm always waiting for him to tell me he failed. But he's still he's actually a graduate from college and he's he's doing stuff like rock climbing. And he actually had a pretty good outcome. So, you know, just goes to show you sometimes you can get lucky. OK, maybe one quick case here. All right. So actually, let's not do this one. Uh, this one is crazy. Sounds like fun. All right. Let's do this one real quick. All right. So I'm going to I'm going to go through some of the his some of these failures, because this is a not uncommon scenario. 22 year old seizure, history, dislocation, high school, undergoes the arthroscopic Bankart rump massage. Then he's seven months out, fails. OK. I know that was really quick, but a failure from a seizure and let's presume that he's, you know, done the neurologic workup and he's, you know, he's seizure free. Thoughts about sort of what you would do here in a primary or in a revision scenario. And you can see it clearly has bone loss here. I mean, I think the first thing was what you were alluding to, which is to make sure they're seizure free. I think that's critical. I wait six months and absolutely want them to see a neurologist. Often the anti seizure meds have to be titrated. And so, you know, I wait six months. I don't know if that's right or wrong, but. I would say that's step one. OK, presuming that's all kind of under control, what do you think you would do here, Amman? Is this an open Latter-day for you? This is probably a I think, again, not having measured it, but my suspicion is that Hill Sachs is going to need to be addressed with bone as well. And so for me, this is a open humeral head allografting with DTA on the glenoid. DTA, why DTA? I think once I'm using allograft at that point on the humeral head, I just go ahead and use allograft on both sides. But no, no great reason for it. OK, how about Kat, would you do the same, something similar? Yeah, very similar. I would like to see a CT scan just to better quantify, you know, what that glenoid is. But I agree that Hill Sachs, I don't think, is going to be addressed with just a remplissage. So I would do a DTA depending on the glenoid situation, how big it is. Can I ask you guys, do you guys have experience with Latter-day in seizure patients, whether in your own patients or somebody that was referred to you? And the reason I ask this is. The the chondroid remains attached to the coracoid, right? And in a seizure patient, I get a little bit nervous doing a coracoid transfer a Latter-day sometimes because of that issue. I don't know. Just anecdotally, I feel like that is sort of a recipe for a failure, particularly if they have not incorporate the bone within three months before having another seizing event or even if they do seize. But I don't know that for sure. So I just Ivan, do you have similar thoughts or? Yeah, actually, I have a few referrals from previous Latter-day had a seizure and then, you know, essentially broke off or was nonunion because it was relatively early. And that's actually my whole reason why I think that's probably if you can avoid it, it's the right thing. This is the indication to avoid doing Latter-day in something like this. This is actually really interesting. So I also think that this is also a reason not to do an open surgery in something like this, because if you open the subscap, do a tenotomy like that subscap failure waiting to happen just as much as a conjoined or coracoid being pulled off of your anterior rim. This is where the bone block really shines, is that you got a piece of bone you can fix very securely on there that has no muscular attachment, that this is the one that I will actually supersize because I want time zero stability, not have to deal with the heel sacks. I want to heal scar in. In fact, that little irritation in the front of his shoulder is probably going to be helpful for him. And we actually have a reasonable sized series of seizure patients now with bone blocks. Not that I'm trying to do those ones that are I'll send them all. I'll send them all to Canada. I'll actually pay for their ticket. No, that's that's I mean, I think these are really insightful comments, honestly, and in my opinion, and this is not my case, but I thought it was a great illustrative case. This is one I definitely would consider DTA because of those issues, because I feel like I've I've seen. So this this kid ended up actually getting a latter day and. Predictably. This is what happens. OK, so he has another seizing event and and there you go, and I feel like I see this scenario actually more frequently than not, and I've been really hesitant. Actually doing latter days in seizure patients because of this, because of this issue. So now, you know, there is a CT scan here showing, you know, obviously a coracoid, basically a nonunion or it's fractured off and you have a really large hill sack. So, you know, I guess sort of in the interest of time with the robust discussion you guys did, probably I would say he probably should have had both sides maybe addressed at the time. He ended up getting an iliac crest, actually, and a in a bone grafting on the humeral head. But, you know, sort of insight, very insightful comments from from all you guys. Quick question for the panel. When you do a humeral head allografting, do you do bone only? Do you do osteochondral either or? Yeah, I do osteochondral, so I get a humeral head, try to match it like almost like an orange shape, create the hill sacks into like an orange slice and then put that in with two headless screws, three sometimes. So so how do you do the approach? Or how do you put it in? Spin it through like the same as a latter day delto pack and then try to spin it with external rotation to be able to get good access to be able to put screws in. Yeah, I've never done one. Sorry. So so I've made the glenoid bigger was my initial case. Now I do rumblissage in there. So I have not gone to open. I'm not as good at that's lightning storm. So, you know, it's interesting. I, I do the same way that Kat just described as sort of a lemon wedge, although talus has also been described. Actually, talus can fit pretty well in the back. The one thing is it is actually still very challenging. Even if you hyper externally rotate to sometimes get the trajectory to put your countersunk screws. So I actually have in the past even done an open window from the back to to grafted if I if it's a really large defect. And it's really challenging, honestly, to put the screws in. But any questions or comments from audience or. All right, so I really appreciate your participation this morning. I want to really thank our awesome faculty here. Thanks. Thanks so much. And have a great rest of your conference.

arthroscopic surgery

vanguard surgery failures

Albert Lin

bone loss

revision options

open Bankart

Latergé techniques

bone augmentation

distal tibia allograft

arthroscopic anatomical glenoid reconstructions

treatment modalities