I'm Albert Lynn from the University of Pittsburgh. I'd like to thank Anna for allowing me to give this talk. Talk to you about my algorithm for management of primary and recurrent anterior shoulder instability as well as open treatment of lab fractures. My disclosures are not relevant. Here's my algorithm, how I think about this. After a first-time dislocation, I consider what's important, either return to play versus recurrence. I then think about if we're talking recurrence, immediate surgery is probably recommended for a high-risk patient. Tips three and four are the type of surgery that depend on both glenohumeral bone loss. Critical glenohumeral bone loss remains a moving target. The glenotrach and concept of a neotrach lesion is also a moving target. And I would say, be flexible. Our scopic background alone is not always the right choice. If we're talking return to play, non-op can be successful, but if recurrence is your outcome, you're rolling the dice if you leave it alone. It's probably coming out again, and there are obvious consequences. Tip two, immediate surgery is substantially better across the board. When's the best time for surgery? Well, it's now. Is there really a debate regarding when to do surgery? At least four RCTs, including a 10-year follow-up study, demonstrating immediate surgery is better. Our group also looked at the specific scenario stabilizing after a second dislocation, which is a common practice, and found that a second dislocation increases the risk of failure substantially. So there's overwhelming weapons that should you fix immediately? Yes. It's the other stuff like eligibility, scholarships, coaches that complicates the decision. If you fix it later, understand your outcomes are worse, and your surgeries may need to be more aggressive. Tip three, evaluate bone loss and know that critical thresholds for glenoid bone loss are trending lower than the traditional 20%. And recent literature suggests that the threshold for critical glenoid bone loss may be anywhere between 10 to 20%. So critical versus subcritical bone loss remains a moving target. Tip four is that in the year 2022, bone loss is a bipolar concept. We're all familiar with the glenoid tract, but not all on-tract lesions are created equal, and a near-tract lesion is described as an on-tract one, close to becoming off-tract. We've published that near-tract lesions predict failure following an arthroscopic vanguard alone. When we added a REM plasage to our on-tract shoulders for high-risk subjects, the risk of recurrence was lowered by 99%. This is a familiar treatment algorithm. The question posed in 2024 include, what is the level of critical bone loss to consider arthroscopy? What's the role of REM plasage for near-tract lesions? And is this algorithm valid for certain demographics and risk factors? Finally, tip five is that the arthroscopic background alone is not always the right surgery, and we're all familiar with the three major categories for stabilization. And while arthroscopic vanguard is an excellent surgery, you may want to think twice for these particular categories, subcritical bone loss, near-tract or off-tract lesions, contact athletes hyperlaxes, and those with multiple recurring dislocations. So who's getting arthroscopic vanguard alone in my hands? Those with minimal bone loss, a first-time dislocator aged more than 25 years, not a contact athlete, no hyperlaxy, and those with an on-track heel-sex lesions who are not near-tract. Otherwise, I'm adding a REM plasage or doing an open procedure. The latter, Jay, clearly has excellent results, but we tend to shy away in the U.S. to the high rates of complications. And perhaps due to this concern, DTA, distal clavicle autograph, in arthroscopic bone block techniques appear promising, particularly for situations in which arthroscopic vanguard failure is a concern and more research will be forthcoming. Ivan Wanek certainly presented on arthroscopic bone block procedures with excellent outcomes compared to a vanguard repair alone. And lastly, I would say, don't forget about the open vanguard. We went from A, arthroscopy, to C, coracoid transfer, and forgot about B, open vanguard altogether. These are long-term studies with low recurrence rates. And I think still an excellent option, particularly for patients with less than 10% bone loss, particularly in a contact athlete, off or near track lesions, and acute bony vanguards, particularly in athletes. So which surgery are you gonna choose? Well, it's not always clear, particularly in subcritical range, and further research is necessary if you're a European. The choice is typically easy. You're doing a latter, Jay, and remember to factor in the following risk factors. Here's a case. A D1 receiver dislocates his shoulder in the second game for the first time. It was reduced by the medical staff. What did our college kid decide? Well, he's a freshman. He's got a lot of career left. He wants to play, but he knows he'll come out again, so he chose surgery. Which surgery will we choose for our wide receiver? On evaluation of glenoid, it's got no significant glenoid bone loss. He has an anterior and posterior labral tear. He is on track. He's a football player, so he needs something extra. He undergoes an arthroscopic back heart posterior labral repair, and we augment it with a REM plasage. A quick illustration of our technique. This is a curved guide. He's putting a 530 knotless anchor with a tensionable knotless anchor. We pass a suture. The stay suture, we put it through the knotless mechanism. We don't tie. We fix the posterior labrum. Then we prepare the Hill Sachs lesion. We then poke on either side of our portal site from intra-articular with traditional suture anchors, which are double loaded. We then finish up the rest of the back heart repair, including tightening up with the initial 530 anchor that we placed, and at the end, we use a double pulley technique to work from inside the joint, intra-articular to fill up the REM plasage. What if your back heart fails? What are you gonna do? We know that this is a common scenario, and we know all typical options for revision. Look at systematic reviews and weighted averages for open back heart in the revision setting versus arthroscopic back heart alone okay outcomes with arthroscopic back heart, and perhaps potentially better outcomes with an open revision back heart. The question sometimes for me is who's gonna be indicated for an arthroscopic revision back heart? We've done a study demonstrating that as a whole, recurrence ability rates can remain quite high, but if you're very selective about the patients, you can definitely get the recurrence rate much lower to a reasonable level of around 19%, and our predictors were age less than 22, off-track lesions and ligament dyslaxia, and if you have any of these criteria, I would consider doing something else. More recent study with Dr. Dickens demonstrated a pretty similar recurrence at around 44%, which is quite high, and interestingly, most of these occurred after three years of follow-up. They controlled for risk factors and still had a high failure rate, and I think this is because of their very young military population, so again, patient criteria and selection is critical. What about lateral? You can still get good results, but there's been recent data demonstrating that failure rates are higher in the setting of a failed primary back heart, so sometimes, maybe the issue is to really just get it right the first time around if there's any question at all going straight to a lateral shape. My personal algorithm for who I decide are revision back heart. They have to have distinct event after a successful procedure. They're not involved in collision sports. They need some kind of external rotation. They are over the age of 22, and they don't have any hyperlaxity. They're well on track, don't have a near-track lesion. Somebody then I might consider doing arthroscopic revision back heart, usually with some augmentation, including a rump massage, but again, I think the indications for this are becoming pretty narrow in my practice. My algorithm for open revision stabilization, pretty much anyone who's a contact athlete, young, has hyperlaxity, multiple preoperative dislocations, and is off-track or near-track. If they're zero to 20% bone or bone loss, they may be indicated for an open back heart in certain circumstances, otherwise, a lateral or a DTA, and if they're over 20% bone or bone loss, they're getting a Latter Jay or an osteochondral allograft or iliac crest bone graft if they have a very large defect that I can't convert an off-track to an on-track lesion, and then, in these circumstances, I might be advocating a rump massage if there's an extreme high risk, such as a seizure disorder patient. I'm gonna switch gears and talk really quickly about mid-shaft clavicle fractures. There's been recent evolution of a trend towards operative management of these fractures. We know that, historically, these have been treated gold standard with non-operative treatment based on older studies from Sarmiento and NIR, demonstrating good outcomes with non-operative treatment. However, since those studies, more recent studies have demonstrated about a 15 to 20% non-union rate with non-operative treatment, particularly with worrisome fracture patterns, including those with shortening more than two centimeters or greater than 100% displacement. The initial enthusiasm for operative management really started from this randomized controlled trial from Canada in 2007. I actually remember this when I was a resident, demonstrating better outcomes with ORAF with superior plating versus non-operative treatment for displaced mid-shaft clavicle fractures, demonstrating lower rates of non-union and lower rates of non-union in a shorter time to union. But if you look at recent studies, looking at all of the studies regarding surgical treatment versus non-operative treatment, what you'll find across the board is that with surgery, you get a higher rate of union and a faster rate of union, but with surgery, you also get higher rates of secondary surgery. And so the question may be, who's at risk of getting a symptomatic non-union that you might want to consider surgery? There's been some studies looking at this, some demographic risk factors being lack of cortical apposition, female sex combination advanced age, and fracture displacement in addition to smoking. But if you look at more recent studies, there may be less enthusiasm for direct operative treatment in all of these displaced fractures. And some of these studies have demonstrated no significant difference in patient-reported outcomes and higher rates of secondary operation with surgery. Even a recent study in Bone & Joint Journal 2019 essentially made the statement that in order for this to be cost-effective, that we need better selection of patients to undergo surgical treatment for displaced fractures. What about surgical techniques for displaced fractures? Well, they usually follow in three categories. You can do plating, whether anterior or superior, IM rotting, or dual plating. We looked at the risk of complication following ORF or mid-shaft clavicle fractures and found the rate of complication to be quite high at 23.7% and the risk of operation almost 10%. And the worrisome patients that we found to have a higher rate of overall complication included smokers, obese patients, and those with transverse Z-type fractures. And interestingly, patients who underwent reoperations were found exclusively in single-plating ORF constructs. So in patients who are high-risk, which we would consider smokers, those who have obesity, transverse Z-type fractures, there's a significant risk for overall complications and I would consider non-operative treatment if all things are equal. And if surgery is opted, dual plating may be favorable for high-risk patients and single-plating opted for low-risk patients with oblique fracture patterns. Recently, we published a study in AJSM looking at the types of surgery for fixation, including superior and anterior plating and dual plating. And we found that dual plating, compared to other treatments, had nearly an eight-fold lower risk of reoperation along with lower rates of non-union. From a cost perspective, we performed a cost-effective analysis that was also recently published in JBJS. And it appeared that operative management of displacement Jeff clavicle fractures with dual plating was found to be more cost-effective compared to single-plating. What's my thoughts on displacement Jeff clavicle fractures? Non-operative treatment still remains historically a gold standard, but there's higher rates of non-union rates than the classic studies. ORIF lowers the rates of non-union, no doubt, compared to non-operative treatment. However, functional outcomes may not be different between the two groups. And so the question is, are we doing too many of these ORIF surgeries? There's definitely a higher rate of secondary surgery with ORIF, and this can be up to about a fourth of all ORIFs. I think ORIF is likely a better option for patients with high risk of non-union, and we may need to do a better job identifying who those patients are. Multiple studies at the current time are tempering initial enthusiasm for surgical treatment. In high-risk patients, I would consider our smokers, obese patients, those with transverse and Z-type fractures. And in this cohort, because of the high rates of complications, if all things are considered equal, I would strongly consider non-operative treatment. And finally, if you're gonna choose surgery, I think recent literature suggests that dual plating may lower the reoperation rate by at least eight times, and the rate of non-union rate while remaining cost-effective. Thanks very much.

shoulder instability

clavicle fractures

arthroscopic bankart repair

remplissage

dual plating

labral fractures

immediate surgery

glenohumeral bone loss

revision surgeries