Good evening. Thank you for joining us tonight for the AOSSM Fellows Webinar, Shoulder Instability with Bone Loss. Tonight's presenters are Dr. Peter Chalmers, Dr. Michael Pagnani, Dr. Steven Perota, and Dr. Matthew Preventer. To submit a question on the GoToWebinar panel on your screen, click the questions drop-down arrow on the right-hand side of the panel. The slide shows where you input your question, then click send. I will now turn this over to Dr. Preventer for formal introductions. Great, Meredith. Thanks so much and welcome to the AOSSM Fellows Webinar. These have been a fantastic addition to the AOSSM educational curriculum and tonight is going to be a real special treat. We really focus on shoulder instability and we have some experts around the country that really need no introduction but I will introduce anyway. Dr. Pete Chalmers at Salt Lake City, Utah. Great to have you. Steve Perota, Augusta, Georgia. And Mike Pagnani, Nashville, Tennessee. So we're very honored to have this group and we're going to get right into it. The format will be we all have a short presentation. Please send your questions in. We will try to get these during the presentations and also during the end we'll have some time for cases as well as Q&A. Pete, take it away. All right, well thank you again for inviting me to do this. I've been tasked to talk about bone loss, how much is enough, and how do you measure to begin with. And these are my disclosures, none are relevant to this particular talk. So this is when we talk about bone loss, this is the patient we're talking about. The person whose shoulder comes out so easily they can shrug and get it back in. Usually they've had multiple, multiple episodes of instability or multiple subluxation episodes. And if you catch this acutely, so if you catch the first time this happens, then oftentimes you get this where you see a glenoid fracture, a bony bankart. If you find this acutely, then really you should fix it to try and restore as much of the osteosurface as you can. And usually that can be done arthroscopically assuming the piece is amenable. But the problem is when this becomes chronic, and this can become chronic because you have a fracture and the piece goes away or because of a traditional bone loss with multiple episodes. And the issue here, of course, is that we're missing that inter-inferior glenoid. And there's a couple of different ways to measure this. And I think most people are familiar with this, but there's an area measurement where you take the area of that orange light that's missing as compared to the total glenoid. But the most common way to measure it is these linear measurements. And I just want to go through this real quickly because this is the way that most people will do this and most of the literature is based on. The idea is this, you put a circle around the glenoid and you best fit it around the inferior posterior, try and get that circle to match as well as you can the rim. Then you take the diameter of that circle. And then you take the width of the measure of the missing bone loss at its widest point. And you divide one number by the other to get a percentage. So that's basically the linear measurement in the area measurement. And those are basically the measurements that you're going to make on your 3D scans. And the reason you'll measure this, of course, is because if you're missing enough bone, then you take this piece of coracoid and you shift it down here, which as we all know works pretty well in the vast majority of cases. But you don't want to do if you don't have to, because when this goes wrong, it goes very wrong. Screws in the joint or graft in the joint or the screws pulling out or the graft that doesn't heal. Everyone's had the latter day that turns into a disaster. So certainly you only want to do this when you need to, again, because you worry about these complications. But if you're going to have a shoulder that's beyond stable, you want to know when to do this. So the question then becomes, when do I need to add bone? And you don't want to find that out now. So the last thing you want to do is put the scope in the shoulder and say, God, I'm missing a lot of glenoid. I didn't expect to see this. So this is a problem. You want to make this diagnosis before surgery. And you generally can't do it with just this. So if you're looking at x-rays and thinking you're going to diagnose bone loss, generally you're missing the boat. And you also generally can't do it with this. So if you take your CT slices that are in whatever planes the tech chose for them, you'll often be missing your bone loss. So the first thing you need to do is this. Get a 3D reconstruction of the scapula. Subtract out the humerus. Get it so that you can rotate it to get an on FOS view of the glenoid. Now, this is not in the plane of the body. It's not at the plane of the scapula. It's looking directly laterally at the glenoid itself. And then you'll be able to make those measurements that I showed you earlier. The problem, of course, is that most of the patients are going to come into your practice already with an MRI. Can you use that MRI? If you have the MRI, should you make the linear measurements I showed? Or if you could make area measurements, should I make them? And to me, we did this study to answer this question. So we took a group of patients that had both MRI and CT, and we looked at the comparison between the two. But then we also looked at comparison between linear and area measurements, because I really wanted to know what was better. And here's the basic answer. On CT, the measurements you make are about 3% greater than MRI. So for me, if I get an MRI and it's clearly greater than 20% bone loss, as in it's not going to change my management, there's no reason to get a CT. If I get an MRI and there's clearly no bone loss, as in less than 5% to 10%, then I'm not going to get a CT. But if you're anywhere in that questionable zone, so somewhere in the order of 10% to 20%, you should seriously consider getting a CT and not making measurements on MRI, because they could be off enough to change your management. And that gets me into this next topic, which is where do you draw the line? So how much bone missing is too much bone? And there's been a lot of biomechanical research, axonal biomechanical research, for instance, that form by Itoi to answer this question. But I think the best studies performed so far is the study that Tokush did, where he looked at dividing the patients into different quartiles and what the instability failure rate was. And the basic outcome from the study is, if you have under 13% bone loss, the failure rate remains the same and low at about 5%. If you have over 20% bone loss, the failure rate is unacceptably high with endoscopic labor repair at nearly 30%. And in the in-between range, the 13.5% to 20% range, the failure rate starts to go up. So for me, the value here is this is how I draw the line. If you have greater than 20% bone loss, you should seriously consider doing something other than an arthroscopic labor repair. And you probably need to add bone. And we'll talk later in the webinar about different ways you can do that. If you are in the subcritical phase, if you're in 13% to 20%, you need to assess the patient's risk. If that patient is 14 and headed back to high school football, that patient gets a Latter-day. If that patient is 33 and has had maybe two dislocations, that person is someone you can really seriously think more about, could you just do an arthroscopic labor repair? OK. But this is where it gets even more complicated. That's just the glenoid side. You also have to measure the humeral side and then combine the two. And the best way to do this is these measurements made by Yamamoto. In the study they did where they showed where the glenoid articulates with the humerus depending on what degree of extortation you are. You can see there's this tract, there's this band on the glenoid, posterior superior that articulates with the glenoid, on the humerus, it articulates with the glenoid. And you need to know how wide the hill sac is. If the hill sac is medial at that point, then once the arm gets that rotation, the arm will dislocate. And that's when you need to consider adding this rempelsage. And the rempelsage, it's relatively straightforward. It takes another 15 minutes in the operating room. You scuff up the hill sacs, you put in some anchors, you tie the infraspinatus into it. But certainly you wouldn't want to do this if you didn't need to. But you want to know when to do this. So that's basically this formula. So you take the width of the glenoid, you measure the width of the bone loss, you measure the width of the hill sacs, you multiply the width of the glenoid by this magic number of 0.83. And the magic number is how much the glenoid rides up onto the cuff attachment. And if those numbers are greater than the hill sac's width, then you need to add a rempelsage if you think you don't need to also do a lateral J. Okay, here's the problem with these measurements. In our study, we looked at agreement and reliability for this measurement that I've shown you right here is not great. So even on CT, there's about 20% disagreement between surgeons as to whether or not you are on or off track. Even with that reliability, there's not necessarily great accuracy for this. So this is a study we haven't published yet, but we have completed and will be publishing, where we looked at where the cuff attachment is on the humerus. And to do this, we had to do dissections and put metal fiducials onto the cuff attachment. And then looked at varying degrees of where your axis is on your CT scan. And the reason we did this is because it makes a big difference. So if you look in the upper right, generally the axis of your CT is going to be where this red line is. But this measurement is designed to be orthogonal to the cuff where the black line is. So then you need to reorient, and there's no clear process for how you do that. The other problem is that often the widest point of the Hill's axis you see here on your measurement I've shown you here doesn't even intersect with the cuff attachment. It's above the cuff attachment. We've all had this image where you're like, well, this is the widest point of the Hill's axis, I don't even see the cuff. The even bigger problem is that the Hill's axis is a bony phenomenon, and the cuff is obviously a soft tissue structure. So you somehow would need to merge together your MRI and your CT to be able to accurately measure this concept. So the reason I'm telling you this is because I think this conversation about how to measure this is not over. And there's going to be a better way in the future that's going to somehow take into account all these factors that I'm showing you in these images. Now, the reason why I say this conversation is not over is because this particular measurement in our practice has not been perfectly reliable. So this is the outcomes of a study we published this year where we looked at recurrence rates comparing on-track versus off-track with arthroscopic labor repair. And we had a higher recurrence rate in the on-track as compared to the off-track, and none of these patients received rempelsage. So to me, that doesn't make any sense. And that suggests that somehow we're not measuring what we think we're measuring because the underlying concept is clearly valid. So this is my overall paradigm. If you're a high-risk patient and you have a first-time dislocation, then we do surgery. If you had recurrent dislocation or if you have a bony bank cart, then we should do surgery. And if you do surgery, then you need to determine whether or not there's bone loss. And I told you already how we determine whether or not we need a CT. If you are in that greater than 20% range, you get a Latergé. If it's 14% to 20%, then you get a Latergé if you're high-risk. If there's less than 14% bone loss, but you have an engaging heel sac, and as I measured, we have some disagreement on how to measure that, then you also add a rempelsage. And if you don't meet any of those criteria, then you can have an arthroscopic labor repair. Or if there's a haggle, then you would need to add repair that as well. I want to get you a little bit into the future here because I think that what I've talked about is a little bit the past, and there is more to come here. So this is from a study we did where we took CT measurements and we made 3D models. We took those 3D models and then put correspondence points on them. And the beauty of this is then those correspondence points can be made into 3D positions like coordinates, and you can then take those and statistically analyze them. And those can be used for this thing called statistical shape modeling. From there, we compared control to instability scapulae. And the reason we did this is because there actually is a lot of variation in the shape of the scapula. So this is from the National History Museum here in Utah. We've got a lot of great dinosaur bones here in Utah. This is a brontosaurus. This is an allosaurus, the younger version of a T-Rex. And you can see how different the scapula looks. And in our research, what we found is that there's a huge difference in the shape of the scapula between patients who have instability and those who don't. And it's not just the glenoid. It's also the coracoid, and it's also the scapular spine. So overlaid here, you can see the big differences. And this is the video. So this is what normal looks like. And this is moving towards instability. It looks like the video is not playing, so I apologize about that. But you can get the idea from here that as you move towards instability, the coracoid moves up and back, the scapular spine moves back and down. Everything changes. It's not just that. It's also the glenoid itself changes in terms of how much of a cup it is. And this is from Philip Moroder's study, where he showed that in patients with instability, the glenoid itself has less of a dished cup. It's more shallow. It's also been shown in some work that Brent Owens did that the glenoid is taller and narrower before the dislocation. So what I'm trying to tell you here is that what I've shown you in terms of bone loss measurements is probably only one piece of the puzzle. And in the future, we're going to have to consider all of these other factors to really understand the overall contribution, the morphology of the scapula and humerus to the recurrence risk when it comes to instability. Thank you. Pete, thanks so much. We're going to now move on to Mike Pagnani. He's going to talk to us about his arthroscopic and open decision making and how he does it. Mike, welcome. Thank you, Matt. That's a great talk, Peter. Can you guys see my slides? Looks good. I can see them. Yep, all set. All right. Well, I've been asked to talk about arthroscopic and or open Bankart repair in patients with bone loss. Arthroscopic Bankart repair, in my opinion, has been plagued by unacceptably high recurrence rates in several populations, but particularly in patients with bone loss. So we all know the classic paper by Burkhardt and DeBeer where they had a huge recurrence rate in contact athletes who had either an engaging heel sacs or an inverted paraglenoid. And this has sort of evolved into assessing engaging and non-engaging lesions and on track and off track. And I think what's important is the high failure rate associated with bone defects has been erroneously attributed to open Bankart as well. And we'll talk a little bit about what the literature really says about that. So, you know, our technical abilities to do things through the scope have increased dramatically since I started doing arthroscopic stabilizations 30 years ago. And our equipment and our devices are so much better. But unfortunately, despite modern technology, we really haven't improved in our rates of recurrence over the last 20 years. And that really surprised a lot of people, but there are two recent meta-analyses that show this. And I think it's been my experience too, that while we can make it look better and we can try new things, we're still having failures in these high group patients. So the patients that I would consider an arthroscopic repair in with a bony defect are pretty limited. They would be low demand patients, those with a smaller defect, an acute glenoid fracture. You know, we have used the bony Bankart bridge that Peter Millett has popularized. And we also will do it in a patient who simply says they want it done through the scope. And they understand that in our opinion, the recurrence rate is going to be higher if we fix it through the scope. When we find a Hill Sachs arthroscopically, we do rump massage. We've been using this knotless anchor technique where you pass the repair suture of one anchor through the shuttle suture of an adjacent anchor. And we've been very happy with how that's made it easier. And our technique seems to lead to better results. And this is just a Hill Sachs lesion we did recently. And these are two knotless anchors that we put in the defect. And then you shuttle the passing suture, the repair suture from one through the subtle future of the other, and then reverse it after you poke through the capsule with the suture. And here we are tightening it down and here it's almost down. And that's what the finished product looks like. So we're also, and I'll explain in a minute, doing this more in patients that we do open. So we often are doing an arthroscopic rump massage and then doing an open procedure. So I just want to bring up this case quickly. This is a recent patient that we saw. So it's a 54 year old sedentary male who had this horrible fracture, showed up in the office three weeks after his injury after seeing someone else. And I think the guys who know me on the panel would be surprised at what I decided to do with this. So this is what we found when we got in the OR. We always scope the shoulder first before we open. And I was prepared to fix this open, but I was really worried about the axillary nerve. He's not a very active patient. So despite my reputation, we ended up fixing this through the scope. And I think that the point I want to make is open's not for everyone. You have to make your decision on how you're going to treat someone for instability based on the patient, what their goals are. This guy had an axillary nerve injury. He's actually doing very well. He's a little stiff, but he's got his nerves recovering. And he really wasn't a good candidate for a big traumatic recovery. So we're very happy with how this turned out. So I just want to review what's called the injury severity index scale. This is a 11 point scale. And almost all my instability patients are under 20. Almost all of them are contact over at athletes. Almost all of them play competitive sports. And some of them have bone defects as well. So when you get to the bone defects, all of them are in the ISS score greater than six. And so that's most of my patients. And nowadays, if you have ISS score greater than six, the common recommendation is to do a ladder J. But I'd like to have you young guys realize there's an intermediate option, and that's point B, an open Bankart. Open Bankart has been consistently effective in reducing instability with very low postoperative recurrence rates. And it should be noted that these are generally in unselected populations, including contact athletes and patients with bony defects. But if we could do a show of hands here, often if I ask how many orthopedic surgeons under the age of 40 have been trained well to do this, it's often just a smattering of hands. So in the results, despite what's been reported for arthroscopic stabilization for open capsule repair with bony defects are quite good. Carter Rowe had a classic paper with a 2% recurrence with bony defects of the glenoid. In our paper, we had no recurrences with glenoid defects, just doing a repair of the capsule into the defect. The results with humeral head defects are also quite good, although maybe not as good as glenoid defects. And for this reason, we're doing a REMPLISAGE more often just to try to get these numbers lower in our practice. Overall, with all HILSACS lesions, we had a 4% recurrence rate. And with large HILSACS lesions, which we measured as 2 centimeters deep and 2 centimeters wide, we had an 11% recurrence. And I would remind you that the latter j does not really address a HILSACS lesion. So it's not really an anatomic way to address that. So we always scope the shoulder first. When we do an open procedure, we place an armboard at the side of the table and we tape sheets to that so that when we are ready to convert to open, we just pull the armboard out, sit the head down, and we're ready to go. We make our incision on the interaxillary crease. This leaves a very nice cosmetic result. And this is just an examination of an anesthesia. Young man's shoulder is clearly loose. We scope the shoulder, pull the armboard out, pull the arm out, put the head down, and we're ready to go. There's the incision again. We use two assistants, develop skin flaps, find the deltoid pectoral interval, identify the cevallic vein, develop the deltoid pectoral fascia, find the conjoint tendon, and release that. And then we use two self-retaining retractors of this type, which allows us to work through a fairly small incision with excellent visualization. So we've released the clavipectal fascia. Now we take down the subscap and we really try to preserve the superior and inferior attachments. We basically pry the subscap off with a combination of blunt and sharp dissection. And we put modified Kessler sutures in, which are a very strong suture. And to my knowledge, we've never had a subscap rupture post-operatively. I know it's been reported, but I think it has to be exceedingly rare if you take care of the subscap. So now we're working under the subscap. We put in our glenoid retractor. There's a huge rotator interval lesion. We always close this first when we do them open. If you close them arthroscopically, they'll never actually rotate again, but the mechanics are different when you've freed the subscap from the capsule. Then we do a transverse horizontal capsulotomy, and this allows us to see the joint and really decide how best to approach it. We insert a humeral head retractor. You can see this large Bankart lesion with some bone loss. We generally use three anchors. We roughen the glenoid if it needs to be. If it's eroded, sometimes there's bleeding bone to work in, we usually use three anchors. I still use these old metallic anchors with Ethabond because they've always worked for us, and I like to know where the anchors are. So there we filled in the defect. We shift the inferior capsular flap up and slightly laterally with these mattress sutures from the anchors from inside out. We pass all three pairs and then tie them with a head reduce. It's important to make sure the humeral head is reduced when you do this or you'll leave the shoulder loose. So our assistant is putting posterior pressure on the shoulder, and he's maintaining 45 degrees of external rotation, and we'll dial that out a little bit in certain patients and dial it in in people that are really high risk. And we use those same sutures and pass them through the superior flap. So we're doubling the thickness of the capsule as we're repairing the Bankart lesion. So those are the three sutures passed, and then we tie them down, and then we have this transverse area. If there's less than five millimeters of overlap, we just placate this. You can see how much redundancy there was in the capsule here in addition to the Bankart. Tie these down. If there's more than five millimeters, we'll actually shift the capsule laterally with a T-plasty technique. So there's the redundant capsule, and we're going to use that. So we've thickened the width of the capsule in addition to repairing the Bankart lesion. And you can see with no posterior stress, the shoulder is stable. It's very important to meticulously repair the subscap. So this is what it looks like when we put it back, and there it is. And you close the skin, and that's what the incision usually looks like. That's what the incision usually looks like. So I rarely do a Latter Jay. I've seen too many pictures that look like this. We did an observational study of patients that were referred to us a few years ago, and we just saw a lot of problems. I mean, the experts seem to be able to do this with low complication rates, but it seems that the community orthopedist that tries to do it has a lot of trouble. And one thing we noticed is that when the coracoid process doesn't heal or the screw breaks, a lot of them are not unstable, which makes you wonder what the bone block's doing anyway. Anyway, thank you guys for your time and look forward to the other speakers. Hey, Mike, thanks a lot. That was great. Let's move on to Steve Parada. And then participants, please type in your questions on the control panel, and we'll get those. Thanks. Well, that was great. That was great to hear and fantastic to see. And I agree. I think we don't do a great job of teaching open bank cards. And so certainly seeing it well done like that is fantastic for all the fellows who are watching and for those of us on the panel as well. So I'm going to be talking about Latter Jay and other bone graft options, including DTA. I do have disclosures available at the Academy's website. We'll try to make those not pertinent to this talk. Obviously, we have lots of bone graft options, but for the sake of time, we're going to stick to the Latter Jay and the DTA and go through kind of techniques for doing that. And you'll hear from the panelists. Obviously, we all have kind of different opinions on kind of when to do this and other options. But as far as the techniques for doing that, that's what I'm going to focus on here. So we're going to start with the laser jet, as my patients like to refer to this as. And I think for positioning, for me, I do this just open. I don't start with the scope. Very lazy beach chair just for ergonomics to kind of look down on it. I do use an ET tube, allow paralysis. I think that makes it helpful, especially in very muscular patients. This is kind of my drawing. I'm clearly not an artist, but in the beach chair, if you've got this bird's eye view, this is the angle we're trying to get to the anterior glenoid. And you can see with a patient who's very muscular, or if you are using arthroscopy and kind of sliding the back of the table out of the way, that's going to cause some scapular protraction. And that's going to make your angle very difficult if the patient has big pec to try to get out of the way. And so Dr. Walsh has kind of talked to us about posting the medial scapula. And what that means is we just want to bring that scapula back into retraction to facilitate making that angle getting to the anterior glenoid a little easier. And so this is something that I do just with using a couple of folded up pillowcases so that I can bring the scapula back a little bit and, you know, give myself a little better angle to get to the front. Just like you guys heard, that vertical instability incision is key. And so, you know, definitely don't want to be lateral to the axillary crease when you're trying to get to the anterior glenoid. And so just like you just saw in that great video, it's still the same delta pectoral plane, but certainly the incision does not have the obliquity as if you're doing work like arthroplasty or humeral head work. And so I also see a lot of x-rays that, you know, look like that one on your right. And when most of the time when I see an x-ray that looks like that, it has a very oblique incision and you just wonder how they could ever get that nice view of the anterior glenoid that we can get with a vertical incision. And so when I'm doing a Latergé, I like to use this rigid 90 degree angled saw blade. If it's not rigid enough and it's flimsy, as you put pressure, that blade will just kind of deflect out and won't, you know, give you that nice cut across the coracoid. It can get a lot deeper on you. Obviously though, the depth of the cut is the depth of the blade. So in a large male, you have to realize your saw may bottom out and you may have to finish with an osteotome. You want to free up the graft enough so you can reflect it outside of the body. And so when you're able to reflect it outside of the body to work on it, you know, you've got it freed up enough from the attachments. We're going to drill holes in the graft. Obviously those holes are going to be dependent on your hardware that you're planning on using. There's a lot of different opinions about that. I do a subscap split always for these. And so you kind of mark out your split in the subscap, usually right at the equator. There's, again, a lot of people will advocate kind of going a little bit inferior. If the patient has a lot of ligamentous laxity, we can make that a little bit more superior to try to tighten that up a little bit. And then we're going to work on exposing the anterior glenoid neck here. And so you can kind of see the glenoid face, the anterior neck. When we get that cleaned off, that's what we're looking at. You can see this case, the bone loss that's evident. The location of the graft is something that again, different people will have different opinions, but I think if you put it too high or too low, you risk still having patients being able to become unstable, either above or below it. And so I think when you look at that best fit circle that Dr. Chalmers talked about, we want our graft in the location where it's going to make up the most of that best fit circle. And so the location of the graft, again, is going to be based on our judgment of the center of the glenoid. We're going to measure the offset of our drill hole, just with a ruler, through the coracoid. That's usually about six to eight millimeters from the center of our hole. And then I measure the same offset on the glenoid face. And this is my plan spot for my inferior screw. So I'm going to go ahead and mark that and then drill that hole. I'm going to add in the depth of the coracoid. That's usually about 12 millimeters. So that screw is typically about 34 to 38 millimeters in an adult male. We're going to put the screw through that inferior hole, the coracoid. Now we have the coracoid fragment kind of on a joystick. We're going to start advancing the screw through the inferior hole, but we're going to keep this screw loose. And so we're advancing this down. With this screw loose, we can still adjust the coracoid. So I typically over-reduce the coracoid. And then with my finger or a retractor like a cob, I can push it back and make sure it's completely flush or slightly medial to the face, wherever you'd like to position that. And then holding that in place, I'm going to use the hole I've already drilled in my coracoid as a drill guide. And I'm going to drill through this into the glenoid. Now I'm going to leave that drill in place. I just leave the drill bit in place. And now I'm going to tighten the inferior screw. When I tighten the inferior screw, that's going to secure the graft so it doesn't rotate. If you leave that loose, sometimes your graft can kind of shift and rotate, making it hard to find that superior hole again. So now that I've tightened that inferior screw, now I can remove my drill bit and go ahead and place my superior screw. And so when I'm done, I like to take this CA ligament remnant and sew that into the capsule. And I like to keep the graft intra-articular. That's certainly another point of this case that a lot of people have different opinions about. And so you can see with our immediate post-op x-ray, we want to see that graft nice and flush and in the position of height that we wanted it at. I think early in your career, a CT scan post-operatively is a good way to get feedback and make sure this graft is where you wanted it to be and your hardware is where you wanted it to be. If you are going to obtain a CT scan, waiting at least four months will really give you feedback so you can judge healing. We're looking for that osseous integration there on orthogonal views. And of course, if we do this correctly, we do not expect loss of external rotation. We don't expect any loss of motion. If you do a second look arthroscopy for any reason, usually that's for screw removal if they're proud in the back, you can see that piece has nice fibrocartilage fill in over it. And again, I've left that piece intraarticular on purpose by sewing the ligament into the remnant capsule. And so we're going to kind of try to cover DTA as well. I think, you know, we obviously, we have the creator of DTA on this as our esteemed panelist and creator here. And so everything we know about the DTA kind of goes back to the advancements that Dr. Provencher has made. And so we've kind of learned everything from him. I use non-laterality, non-size, non-gender matched graft. And it's important that it's fresh and never frozen. So we have live cartilage. This is the information that you'll get from the graft company. You'll get this nice bird's eye view. And they'll tell you if there's any kind of articular cartilage defects. We've looked at a lot of distal tibias on MRI. And we found that, you know, almost all of these will have a straight or nearly straight lateral border, which lets you keep that lateral cortex for your graft when you're advancing the screws. And so, but you can see there's a lot of variability in the shape of the distal tibia at the articular surface and where you're going to harvest that graft. You can see some of them, you're going to be able to retain lateral cortex and some you won't. We've looked at this biomechanically and we found that the addition of washers matters more than the retention of the cortex. And so now based on this, we'll really use any graft, even if we have to keep a completely cancellous graft like in this one in the corner, knowing that our washers will make up for the difference. And so there's a very nice commercially available graft prep station designed by Dr. Preventure. And I think if you have access to this, this is really a nice, it takes a lot of the, you know, futz out of this of trying to hold this with towel clamps and, you know, not cut your fingers off. And so for me, graft preparation starts before the patient rolls back to the operating room. I know the size of my graft based on my preoperative templating. I use a separate back table for setup and I'm usually finishing up the graft by the time the patient rolls into the room. We've already talked about it ahead of time. They love this, they roll in and they're, you know, they'd say, doc, is that my graft? And they're all excited about it. And at least in my institution, this is a way I can help offset the cost by decreasing my OR time. Obviously you have to pay for this graft. So we harvest a piece, we compare this to our template for our radius of curvature and the size of our distal tibiala graft. The key and cell aside is going to go up against the glenoid neck. And when we can retain that cortex, we're going to use that as the side for our screws. We think pulse lavage is key. This is going to remove the marrow elements, hopefully decrease any type of an allergenic response and really help this incorporate. And then I'll also use some type of biology to make this more likely to incorporate. So if the insurance company will allow, I'll use PRP like in the bottom left here. And if not, then I'm just going to aspirate iliac crest. I'm not going to use it concentrated. This is a very low cost alternative. We're going to do this before sitting up the patient into the beach chair position, so do this while they're supine. Now, there's been some recent literature that really calls both of these practices into question. And so, these are obviously, these are from knee studies. So, do these apply to our DTA graft? Really, we're unsure. And so, the graft certainly will visibly look different after you pulse lavage. And maybe the geometry of our graft being more of a rectangle and not a cylindrical plug makes a difference when we're doing this. So, more to come on that. So, we've harvested our graft. It's gonna be the same setup, the same positioning, the same incision, the same approach. I'm still going through a subscap split. In the revision setting, I'm gonna use a split just above their previous split so that if there's any conjoined tendon that's still scarred in, they'll still have the benefit of this. So, I go through my split. Here I am, I've got my retractors in place, I've exposed. You can see the previous screw holes after I've removed their failed laterge. We're gonna create our flat bleeding bed of bone on the glenoid neck. I'm gonna mark out the position of those previous holes on the glenoid face with a marker so I can avoid those old holes with my new screws. And you can see kind of the excellent congruency of that graft, which is again, non-sized match, non-laterality matched. But it just fits the glenoid like it was made to be there. If you have a lot of more considerable bone loss, then we're using a larger graft, which means a larger height. Typically, our typical graft height is about 22 millimeters. These can get up to about three centimeters. If that's the case, we'll kind of put these joystick small K wires in and then use that to provisionally fix the graft before we place our screws across. And again, our goal is to reconstruct the glenoid in both the axial plane and the coronal plane. There's a lot of talk on always making sure your screws are completely parallel to the joint. Well, in cases of considerable bone loss, you may have to change the obliquity of the graft, which is gonna change the obliquity of your screws. So be cognizant of that. I do use a cannulated drill, but then I'm always using solid screws. And again, based on our biomechanical study, we always use washers. These washers can have embedded sutures for capsule repair if you wanna do that. And again, a CT scan will give you excellent feedback about graft incorporation, graft location, and healing. And so in summary, I think these techniques are great ones to learn in labs and courses, and then practice so that you have that in your tool bag to give to your patients. Exposure is gonna start with the incision and the proper positioning. Glenoid preparation is key. These cases are such a great blend of mechanics and biology. And the outcomes Matt's group has shown, outcomes can be as positive as a Laterge, even when done in a revision setting. That's an incredible statement. And really, I'm obviously just a simple shoulder surgeon. I'm not a sports surgeon like some of our other panelists, but I don't know of another surgery that you can fail a Bankart, have another procedure Laterge, fail a Laterge, have another procedure like a DTA, and we're not just in salvage mode, you can still have amazing outcomes. That doesn't happen a lot in sports, if you're talking about ACL or meniscus or hip scopes or anything like that. And so these are powerful surgeries to have in your toolkit. So thank you very much. This is great to be a part of this. I really appreciate it. Steve, excellent. Thanks so much. We really appreciate it. I'm gonna roll in. We'll get the questions going here. Steve Parada, what amount of bone loss would you say is too much for a Laterge to handle and require crest or DTA primarily? Yeah, great question. And so I think, just like Pete was talking about, there's a lot of different ways we talk about this. And I think a lot of times when we're talking, we're probably not comparing apples to apples, but for me, with the way that you and I kind of do these measurements using a CT scan, using surface area-based, not linear percentage-based, I would say over 30% I think is hard because when you start looking at taking the dimensions of your Laterge and making up for that best fit circle, you start, you're really giving up a lot of area. You're not making up that area anymore. So I think for me, over 30%, I template that out. And most of the time I'm choosing to go something more than a Laterge. Yeah, I think that's been a go-to number. You know, it's hard though. What's 28 versus 31 and 25? And you have to put the whole patient together. Mike, what do you think? What have you done? Well, I rarely do a Laterge as a primary procedure. And when I do it, it's usually in a revision and often after somebody's had previous operations. But I have to say, I get nervous about not having some kind of phone support when you get to about 30%. That's kind of been my cutoff. And I think that's what the literature supports. But we've done open bank cards in people with 20% and had good outcomes. Yeah. You have to keep in mind, depending on how big the patient is, every 5% is anywhere from 1.4 to 1.6 millimeters of bone. So going from 20 to 30% is maybe 2.8, 2.9 to 3.2 millimeters of bone. Pete, what do you think? I was just gonna say, I think instead of having a percent in your mind, you can actually take your CT scan and measure how big your coracoid is. And then you can see what it's gonna look like when you put it on your glenoid. Because there is actually variability in the thickness of the coracoid. I'm sure you've seen this, you've had this experience, Steve, where you cut the coracoid off and you bring it out and you're like, God, this graft isn't as thick as I thought it was gonna be. I hope this is gonna work. So I definitely have taken it on my Latergé patients to analyze in the coracoid more, to look not only how thick it is, but also how much variability is there on that lateral edge. So that if I put it down, am I gonna have a wavy edge? It's not gonna look like that beautiful scope image you put up. So I think that's another layer, when you do bone grafting, is to look not just at the recipient site, but the donor more specifically before you do the operation. Yeah, that's excellent. About 15 years ago, we published on what you can get from the congruent arc in an average number of patients, male versus female, what you can get from a traditional coracoid in terms of bone reconstruction. You wanna exactly reconstruct, or sometimes people like putting a few extra millimeters. Still a lot to work on. Well, in the interest of time, I'm gonna start my presentation just on the failed Latergé. Keep the questions coming, folks. My disclosures are in the AAOS disclosure database and also shown here on the talk. So why does it fail? And I think anytime we talk about a failure, whether it's a knee or an elbow or a joint or a hip, it's not just that it comes out again, but you could also have stiffness and you can have pain. You could also have weakness. Mike mentioned axillary nerve injury or other injury. That's, a patient might not have instability. They might have dynamic instability because their muscle's not working well, but their shoulder's not gonna be working well if you have an axillary nerve issue after a instability case, and that's cause for failure. So we just can't get wrapped up in just recurrence, although it's the thing we always like to talk about. So what about the management of an athlete with failed instability? JP and Winston wrote this up. Pain, stiffness, weakness can denote failure in an overhead athlete. It may not just be overt dislocation, but it may be recurrent instability or their shoulder just not working right. And we've actually published on that quite a bit based on what type of instability. We've talked about the different bone graft options. The latter is not perfect. You can have a pulled off conjoint. You can get resorption of the bone block. This does exist. We know from Giovanni Giacomo's work that on average, 57% of the coracoid is resorbed with still excellent outcomes. And that's probably some remodeling laws according to Wolf or others, or the shoulder may be even different, but we still don't know all bone grafts resorb. And I think we have to talk about interface healing, not lysis, not amount of resorption, but interface healing is what we have to talk about between the native glenoid and where the bone graft is interfacing, how that healing looks like. You can see in these cases, almost no interface healing. As Mike pointed out, a lot of hardware failure, screw prominence, bending, arthrosis concerns. I always use solid screws. Minimum 4.0 is what I generally use. When we look at the Latter-day literature, it's not perfect. Everyone talks about being the gold standard, but it really, I'm not sure it is. If you look at it and really dissect down, you look at stuff even from France and Pascal, Pascal reported overall occurrences in 2010 of a large group of Latter-days at 11 to 12%. That's not that good. And that was instability recurrence. So this is a good Hobelius cohort. He's followed hundreds of patients now for more than 20 years. And he had moderate dislocation arthropy in 14% of shoulders, 35% of mild, and 83% recurrence on the graft was positioned in not in a good spot. So what we're hearing more and more is position of graft and dislocation may just be enough to produce osteoarthritis down the road, but certainly surgery may take a toll. This is a great study by Christian Gerber that had prior stabilization other than Latter-day. And if you had preoperative pain before you went into the next surgery, you had a lot of problems with post-op pain. So patients presented with pain prior significant decreased outcomes. We looked at patients back at the Naval Academy, Jay Cox was doing the procedures back in the 1970s, and we followed these folks about 26 years. We found recurrence about 15% over that time period and was dislocation or subluxation. And we had about the same homilious amount of arthropathy in the mild to moderate range, about 20 to 25%. What does this presentation look like in the at-risk population? All of those things, recurrence, stiffness, loss of motion, joint pain, and onset of glenohumeral OA. And we have to be cognizant of all of this. Latter-day is a great procedure for very good stability. It's not perfect, but you can have complications. Here up to 30% dislocation and subluxation was most and all depends on how you define this. And this is almost 8% after a Bristol-Latter-day overall non-union rate, which was a complete non-union of 10%. So there are real issues you have to take care of here. And these are many of the types of patients you're having a challenge with. And I can tell you getting some of these screws out and dealing with this hardware, very medial, just like Mike showed that fracture case, there's a lot of high-risk structures here medially and makes a significant issue when you're trying to revise these and a significant risky case. If you're not familiar with the anatomy and going in on a case like this, I'd be very careful practicing the lab first. So who are these patients? Risk factors, graft placement, recurrent instability, presence of hill sacs, and then revision with Latter-day, still a challenge. After you have operative repair, you can still have issues. So even if you have arthroscopy, you can go to a Latter-day, you can still have problems. Our go-to is either Iliac crest or distal tibia. Pete showed a very similar algorithm on whether or not we treat the remplissage or just go right to a bone graft. And these have all been previously published. Steve showed nicely how the distal tibia fits. And this is just certainly one graft. We've done a lot of Iliac crest. This was circa 2005 when one of my residents at the time, Lance LeClaire and I were down in the lab fooling around and we sort of just came across this, that the tibia and an unmatched specimen fit the humeral head. So what about the management of the failed Latter-day? And there's not a lot of literature on failed Latter-day. Although Christian Gerber published on failed arthroscopic to Latter-day, there were probably less than about eight to 10 cases in the literature on failed Latter-day. We published recently on 31 patients, recurrent subluxation. The prior resorption of the graft was almost 80%. So 80% of that Latter-day corchoid went away. We went on to a distal tibia. I generally take cultures if I'm worried or there's other concerns, or there's a lot of cystic or other changes, not at the surface, but other places. I may do a stage procedure and take cultures. Or if the patient just had a lot of surgeries, I may do a stage procedure, but you have to always be careful of P. acnes and other infections. And this is what we had. We had complete union, meaning what we define as 90% more of interface healing in 28 out of 31 patients. So overall it was excellent. And even before that final evaluation was very good. I wanna show one case study here. It's a 23-year-old male, snowmobiling, had several surgeries, including a Latter-day, positive relocation, apprehensions, not really a pain type of picture, no issues unless was doing activities. And you can see here on some of the imaging, well, it's not playing, but had significant bone loss. The inferior Latter-day screw was bent, significant fragmentation, 85% lysochloroquine. The screws were really not holding any of the graft. You can sort of see that here in the CT scan. So we proceeded to a distal tibia. We prepare this. You can do it freehand or use a holder if you want. And then this is sort of what we get at the end, five months post-op. I generally get a CT. Some of this is also for learning curve experience to make sure that this was gonna work. And so a lot of these cases I wanted to get a CT scan on. And overall have shown very good union if this with the techniques that Steve showed. So I am going to, there's another question here. I'm gonna switch over to some cases here. Question on traditional versus congruent arc. Steve, why don't you tackle this one? Yeah, I think there's definitely two schools of thought. And I think a lot of that is like a lot of what we do, kind of who you trained with. And so where I trained, it was all traditional. And it was learning from Dr. Walsh, the way Dr. Walsh teaches it is traditional. And so that's really my only experience. I've only done congruent arc in the lab. And so I think it is a little bit more difficult with your screw placement if you're doing congruent arc, but certainly there are people who have had great results with that. Yeah, it's interesting. I was doing a traveling fellowship and had the opportunity to go to South Africa and meet with Joe DeBeer and watch him do two to three cases. He was actually one of the pioneers of this. And what he says is as he flipped the coracoid, he actually takes about 30% of it off, meaning he takes away 30% of it. So he tried to decrease the lever arm. He was mostly using it because of the concavity not for more bone reconstruction. So it's pretty interesting, but he would not do it in patients again, where he thought they had a thinner coracoid, but he did it probably 60% of the time or so. And certainly as Pete pointed out very well, you can now look at this nicely on CT, especially 3D and get some images. Mike, question on your open bank card. You mentioned taking down the capsule off of the humerus. Only in certain situations. Most of what you showed, you kept the capsule on the humerus. Tell us about that. Right. Yeah, so if we make that transverse capsulotomy and if they have a bank card lesion, which typically they do, that gives us enough room to get in the joint and we do all our work medially. And then as we shift the two flaps, we look at the amount of overlap. And if there's more than five millimeters of overlap, at that point, we will tee it laterally, not really on the humerus. We leave about a centimeter to the humerus and then we just shift it laterally instead of medially. Right? So we probably do that, you know, 5% of the time. Yeah. So very, very infrequent. You're keeping that intact. Obviously the subscap comes down, but. So it's more frequent that we would do the lateral Pplasty in a multidirectional patient with no bank card lesion, right? No bone defect. Pete, quick question. We're gonna do a couple of cases here. CT or MRI in clinic? What if they come with an MRI? What are you doing? And you're worried high risk patient. Bone loss is somewhere in 13, 15, 18% something on MR. The first thing I'm doing is I'm often taking the MRI and importing it into a software so that I can readjust the gantry angle to get a perfect on FOSS view. I do that. If they come up with a CT that doesn't have 3D recons, I'll do the same thing so that you can get a better view to understand how much going to bone loss is. Cause if the gantry angle is wrong, you won't really be able to see it. If I look at that MRI and I think it's questionable, I'll send the patient for a CT because as I mentioned, if it's gonna change your mind, you wanna know that. I got a question for Mike Pagnani. How do you manage the sisters when you do your procedure? Do you tie off the sisters or you're always working above the sisters? Have you ever had cases where you've avulsed the sisters? We used to ligate them. I mean, when I trained with Russ Warren, we ligate them on every case. But now generally I don't get that low. So we just keep them and work around them. So remember, instead of taking the subscap off and peeling it back, we're kind of lifting it up and working under it. And usually my subscap anatomy is just slightly superior to him. So I see him and try to stay above it, just work under it. Yeah, Pete, that's a great question. I do the same things. Mike, I try to preserve these if at all possible. Sometimes it's hard, but I really try to preserve it. Just out of curiosity, Peter, what your concern was just its effect on arthropathy down the road? I never really thought much about it. I don't have any concern. I think you could take them down with no consequence, just to the listeners here. I mostly want it because the first time I did the procedure, I got to the sisters and I thought, I watched the video and I don't remember the sisters. And now I've always wanted to ask you that so that it can be documented for the listeners. The first time you do this, you could take down the sisters and it doesn't matter, but you should try and stay above it if you can. Yeah, Russ did it on every case and it's not really something that I did consciously. It's just sort of evolved that we just start. I think maybe we're just not taking it down as inferiorly because we're not just peeling off the subscap. We're kind of working under it. And so we try to maintain those inferior and superior connections to the degree we can. If we need to get to the top to close the interval or something, we will take it, kind of do an L-shaped tonotomy rather than just work under it. Just take that part of it off, yeah. You know, Pete, we looked at that exact gantry angle because I was tired of getting crappy CT scans and you're like looking at the sagittal oblique. But the problem is when you're sitting in the gantry, you're off axis about 32 degrees. We published this in Shoulder and Elbow maybe about eight or 10 years ago and it's about 32 degrees off. And unless you correct that, your sagittal oblique looks terrible, both on MRI and CT scan. It's just how you sit in the gantry. And it's correctable either with software or you can correct it through the tech if you have a good tech there. So definitely work with that because that helps you a lot to get a nice on-face view. Why don't we, I'm gonna work on those cases. Well, certainly for the ones that are at my place, we've done that exact same thing. I've talked to all the techs. Yeah. But the ones that come from outside, they're all over the place. Yeah, you can. Critical issue, yeah. You can reformat it. You can use some commercial software to help reformat it for you. There's free ones. I won't say them. Yeah, but that's what I'm doing. They're available. So let's do this case. So maybe we get through one or two here. So we're talking a little bit more about instability. Okay, obviously we're talking about the rib massage, this, everything else. This patient had a slap and kind of an anterior bank cart repair, a slap plus, if you will, a slap five. You know, the slap tear plus anterior extension. He presented about one year out. Now he had this done overseas. He had a lot of pain, a lot of pain in the biceps groove. What he mostly complained about was just aching in the shoulder. And he was about a year out, 29, no issues with shoulder prior. Only surgery he had, flexion 145, abduction 85. His total abducted arc was 55 degrees. His other side was about 170. Steve Parada, thoughts? I can't wait to see how you bring this back to glenoid bone loss. I'm confused so far, but yeah, no, I mean, I think, you know, anybody with a slap repair, you're worried about instability. And so when somebody has slap plus and something was tight, you know, I always worry about when I see pictures of things getting tightened down when people didn't have instability. And so this makes me worried that they've been iatrogenically over-tightened. I think, you know, in the shoulder, anterior instability is the easiest thing we deal with as far as making a diagnosis. Your patients will come in, they'll tell you they're unstable. They'll tell you when it happened. I mean, in two sentences, you'll get everything. So if you're ever doing a scope and you think you see a Bankart, don't fix it because you will know ahead of time if they had a problem with instability. And so that would be kind of what I'm thinking as you're talking about that history. So, you know, as you were talking, I brought up this X-ray and this was taken one year out from his procedure. And I can tell you what I have circled here was not on his original X-ray. And this is where you see some of the earliest degenerative changes or the earliest changes. That should not be there in a 29 year old with a little bit of a small inferior osteophyte. So sort of to cut to the chase, Steve, you sort of hit on it here. Failed, you know, we've kind of termed this failed slapped syndrome. We've written on this a little bit. Capsulitis, shoulder stiffness, loss of motion. You have to be real careful about, you know, where to throw the quote unquote blame, but we really call this post-instability arthropathy or, you know, after you've had an instability case, could have been a Laterge, could have been an open Bankart, could have been whatever. What you'll see here, I think, is the culprit and, you know, if you look at the right panel, you can see, you know, it looks like to be a non-absorbable inert type of anchor. It's sort of there. Got some loose sutures here. So here's what we termed this kind of failed slap syndrome type of stuff. I'm going to move through this pretty quick. You can see, you can see this kind of peak anchor that we're going to almost a spike. That we're going to take out. And this is what I think is important. This is what we have to realize. And so this is what we call linear stripe wear on the humerus. And this is the real deal. And you can see the amount of inflammation and synovitis in the capsule and super stiff and a big problem and implant related arthropathy. But again, it's really hard to say when it started. In general, I do a tailored capsular release. I did remove his biceps, but we do a tailored capsular release, mostly using a basket and right up the capsule labral junction, just because he's just so unbelievably stiff, really thick, but you can tailor it to really where their motion's deficient, whether it's anterior inferior, posterior inferior, et cetera. Mike comments, you seen this? Yeah, unfortunately I had a professional hockey player who was in camp with us who had the same problem. And I had not treated him. He came from another country north of the border and he had metallic anchors and I got a CT scan and they looked like they're in the joint. He was kind of a tryout player. The team sent him back, went back to the doctor who did it, who said, no, they're definitely not in the joint. I'm not going to touch it. And they were in the joint. So it was disastrous, yeah. And there was- Yeah, I think what we learned on this is just being diligent, knowing if they've got a lot, 29 year old shouldn't have that tight of motion and stops and problems and they're painful. The MRI will under call it. And a lot of times you just got to put the scope in and bite the bullet and take a look and don't be afraid. Let's do this last one, just a couple more minutes. Go ahead. I was just going to say, back in the day, everybody put metal in and you could see it. And one of the advantages of non-radio opaque implants is you can't see mistakes anymore. They're invisible. Absolutely right. So this is a 35 year old female, presented to the ER after a mountain biking accident, fell, landed on a left arm, direct posterior blow. Actually was taken to the OR that night for this problem. So closed posterior dislocation with significant reverse ill sex was reduced. Just one caveat, the problem with these injuries is these patients are super comfortable in a internal rotation sling, just a sling at their side, right at their stomach. And this is actually in terms of musculoskeletal, one of the top three closed claims medical legally is a missed posterior dislocation. And that's because they're very comfortable with the sling and their arm right at their stomach. So be careful of that. Pete Chalmers, what are you going to do? Yeah, they are now. Yeah, I mean, this is a difficult one. There's definitely a substantial amount of humeral bone loss here. And obviously it's hard to tell from this one image just how much is missing, but I would tell you there's almost certainly a posterior labral tear as well. And I think your two options here are, all right, we're cutting ahead. We've clearly put some bone back in. Your two options are arthroscopy. Sorry. Arthroscopy, prepare the labrum and do a reverse remplisage, or with one this big, you're definitely going to lose internal rotation to that. And I think you would consider doing some bone grafting at the front. Yeah, that's exactly what we did, Pete. I actually, so I did this in the lateral decubitus because I can do posterior and inferior labrum work much better laterally. And then just lie the patient back and did an open bone grafting. The problem is, you know, this reverse Hill-Sachs is a, I don't think is a good title, is much different than the Hill-Sachs. Pete, you showed it very nicely. The reverse Hill-Sachs is almost 100% cartilage involvement. It's just by definition. You can get away with these if they're small, but the problem is if you come up to a certain amount, biomechanically, it's been shown it's probably in the 20 to 25 degrees. This was a 40 degree defect out of about 170 or 180. So it was pretty significant. So what we've done with this is, you know, we've already done the posterior labrum repair. There was a big pulps labral periosteal sleeve avulsion, and you basically have this. And so if the distal tibia works, why not the, why not the talus? And we've found this to work up to about 40 millimeters in diameter. So we've fresh talus and you can get this very readily. Our foot and ankle surgeons use them all the time. You can get these within a week. You do not have to wait for a fresh humeral head, which I was doing for years and years and years, waiting for months and months and months for a fresh humeral head. And they would just take a very long time for a variety of reasons. And you kind of do wood shop 401 here and Paul Sauvage, and then you end up with something like this using headless compression, titanium screws, and then repair the subscap. And this is kind of what you end up with at the end of the day, that kind of same, same type of allograft distal tibial healing and really good interface healing, but you're able to reconstruct that arc. And she did, she did really quite well, but it took, it took a while. These are big injuries. It probably took her a good eight months to start turning the corner. Thoughts, Mike, what have you done for these as well? How old the patient was she? She was 30, 35. Super active. Well, I mean, I, it depends on, you know, the activity of the patient. I would definitely, I mean, recurrent posterior dislocations are unusual in the absence of, you know, electric shock or seizure disorders. So I think it would, you'd have to individualize it to the patient. I mean, I have, I've done posterior labor repairs and grafted anteriorly. I still know how to do the McLaughlin procedure, which, and I have started with smaller defects doing sort of a reverse rempellage, which I just call an arthroscopic McLaughlin, just a different name for the same thing. But I think again, if it was a low demand patient, I might just sit on it. And because the odds of them re-dislocating posteriorly are pretty small in the absence of certain disorders. Yeah, absolutely. Big, big trauma. These are, these are pretty big trauma injuries to get something like that. Yeah. We've got one more question just in the interest of time. Meredith, we'll do one more question and then we'll go to our outro here. So Pete, this is for you. Any concern that remplisage reduces joint space over-constrained shoulder, causes rotator cuff issues, other pain, et cetera? Yeah, that's a great question. I think the first, the first thing to say is that we've often considered remplisage to be something you could get for free. You hear people talk about that on the podium all the time. Say, oh, you could just add a remplisage, no big deal. There's definitely costs to the remplisage. It's harder to recover from for the patient. There's more pain and there are complications specific to it. I have seen the deltoid remplisage onto the humerus. I have seen a rotator cuff tear after a remplisage and we don't know if down the road you're gonna see more cuff tears in these patients. That being said, the published outcomes with remplisage are excellent. There's a very low recurrence rate. The cuff does reliably heal into the defect and the extra rotation is good and that's been my clinical experience. I've had very good results with it but I don't think you should consider it as something you get for free. There are complications with it specific to it. What are your thoughts, Steve? One thing that I worry about is 10 years from now, what is arthroplasty gonna be like in patients who have had a remplisage? And I think when we're teaching arthroplasty, we teach very specifically, hey, you don't make your cut all the way back to the infraspinatus or else you're really gonna be changing the normal humeral version. You're trying to leave that normal kind of bare area in the back. And so, especially some of these medialized lesions that people are getting a little bit more aggressive with doing a remplisage. And if you have the infraspinatus tethered a centimeter from its insertion into the humeral head and now you're going to do an arthroplasty, are we just gonna leave the version where it is? I mean, I can't imagine we're gonna dig stitches out of the infraspinatus. I don't even know how you could do that through a DeltaPEC. And so, I'll be curious. I haven't had to do it yet. And I've asked a bunch of people and everybody says, oh, you're being crazy. That's not gonna be a problem. But I imagine it's gonna make arthroplasty more difficult. Mike, you showed some nice remplisage pics there. Well, I think it's a good point. I mean, I think I was slow to adapt to it and I've sort of become a believer, but I had a lot of concerns about putting stitches through the cuff and through the capsule and around. I think the one thing is it's hard to know what your depth is when you're passing the sutures. And I usually, it's painful to go in the subacromial space and clean all that up and do it directly. So, it's a learning curve to do it and not tie everything else into it. It's not, I mean, I actually think learning it was somewhat challenging to do it well, but I do think the double pulley technique has made it a lot easier. And the more you do, the easier it gets, but I think it's a valid concern. Like a lot of things that are new, they seem like a good idea. I'm a slow adapter of new technology. I hope I haven't taken on something. You know- Metal anchors, I mean, come on, that's not, I mean, you got some time, another 10 years maybe. When you guys have done something for 15 years and proven that you're still happy with it, that's when I start doing it. You know, it's interesting, when you look at one of the first publications on this, Pascal Below published in JBJS, they had patients present with a longer term follow-up, more than two years, 30% of them, posterior superior shoulder pain. That was a direct complaint, 30% in his article, one of the pioneers of it. So yeah, nothing's for free. It works, probably works well. We still have some work to do on it. But with that, we are over time, everyone. I'm going to turn this back to Meredith. I want to thank our panel, Pete, Steve, Mike, outstanding talks, great job, you know, getting all this in just over an hour. Fellows and everyone else who joined us this evening, thank you so much, we really appreciate it. Staying connected during this time. So look forward to seeing you all soon, hopefully this summer, the OSSM meeting. Meredith. Thanks guys, this was great. Thank you. Appreciate it. Thank you very much. OSSM Fellowship Committee and the professional team would like to thank the panelists for their time and their preparation for tonight's webinar. OSSM would like to thank Darisol for their support of the Traveling Fellowship Program. Info on their upcoming Fellows Program is found here. Next month's OSSM Fellows webinar will take place on December 8th. See you then. Thank you. Thank you. Thanks everybody. Thank you. See you soon.

Shoulder Instability

Bone Loss

Webinar

Dr. Peter Chalmers

Arthroscopic Repair

Open Bankart Repair

Latarjet Procedure

Distal Tibia Allograft

Accurate Diagnosis

Surgical Techniques

Graft Incorporation