Michael, how are you? Bob, how's it going? Good, I'll try not to pepper you with a lot of questions while you're trying to do this. Okay. Can I ask you one from the start? Sure. What are your indications in 2021 for an open Bankart stabilization procedure in taking care of anterior shoulder instability? Well, in our practice, 90% of our patients have ISS scores greater than 90. So, unless they're throwing athletes, pretty much everybody. So, if it's an overhead athlete or a throwing athlete, we fix a lot of those arthroscopically, but we've had excellent results over the years doing them open. In Tennessee, patients don't mind having an incision. They just don't want to have a recurrent instability. If a glenoid defect exceeds 20% or there's a large Hill Sachs, I start to get a little nervous, but my tendency is not to do a Latter Jay or bone block unless they've had a failure. So, most of the Latter Jays we do are revisions almost exclusively, and we've been doing a lot more remplisage with large Hill Sachs lesions because that's the group that in our series, we found might have a higher recurrence rate. The glenoid defects don't seem to affect our recurrence, and that's not only our literature but previous papers that have been out there. So, you will add an remplisage to your open technique? We do. We always scope the shoulder first, and if we have evidence on our preoperative studies that there's a large Hill Sachs, we have been doing remplisage. We don't have enough follow-up at this point to determine if that makes a difference. I think in our series we had about a 12% recurrence rate with large Hill Sachs lesions. That was not statistically significant, but I think we've anecdotally felt that we have, if there's a group that we could do better in, it's patients with large Hill Sachs. Okay, let me let you get going. Okay. So, in the interest of time, we've made our incision, and normally I would start down here, if I can get my big finger in there, in the axilla, and my assistant, I have Justin and Kelly and Jim here helping me, my usual staff. It's nice, the meeting's in Nashville. So, we find the coracoid process, and we make a incision along Langer's lines. Usually you can identify this by rotating the arm in, and you'll see a crease, and that crease will lead to the incision. This leads to a really nice cosmetic outcome. We made the incision a little bigger today, so we can see. Once we've made the incision, we put a couple of galppies in the top and bottom of the incision, and we create skin flaps. I think this is important and often underappreciated, but we have the assistants kind of raise the skin away, and then using scissors, we'll just dissect down to the deltopectral fascia and raise flaps medially and laterally. And once we've raised these flaps, you guys can rest now. We identify the deltopectral interval with a syphallic vein, and let's have the two Army Navies. And we usually, you know, we dissect this out with mets, and then I just spread down to the fascia, and often we will use scissors just to develop it more, and I'll take the blue handle. Spread that a little more, Jim. So, now we've got down to the deltopectral interval, and we're looking for the coracoid process, which is up here. Usually you need this extra instrument up here, retractor, to identify it. You're a little deep, so relax. So, coracoid process, we identify that. It's right here, and we incise the clavipectoral fascia just along the coracochromial ligament. We actually incise the coracochromial ligament so we can see better to the top of the capsule, and then sharply dissect the muscle away so we're not in the muscle. So, once we've done that, come on out with those. Don't come out with that, Jim. We insert these larger retractors. Again, trying to stay above the conjoined tendon. Come out, Justin. And now we've really kind of got the exposure that we want, and we've got everything freed up, and in an effort to free the hands of the assistants, now we insert some self-retaining retractors, and we use these blades. You can see here we put the convex side down. They're designed to be put in the other direction, but by doing it this way, they get them out of the way better. So we just insert these blades, and then we've already done some work in here, as you can see. I'll take the other ones. And then coming from the medial side, we insert a second set of self-retaining retractors. These have various size blades. You guys support that? This is upside down. Can you switch those blades? Steve, or Mike, I see that you've done a tenotomy. I'm going to let you get in there, and just maybe you could spend a few moments giving us your tricks on how you do the subscapularis tenotomy, and or when you do a subscap split, if you do that. So, you know, I just heard a paper referenced by Nick Mattotti, where he did a nice randomized series, stay above the conjoined tenon, and he did all his cases through a subscap split, and really that's the only report that has a high recurrence rate with open stabilization. So, we rarely do a subscap split. When we do it, and we rarely do this, it's usually in a thrower that has failed an arthroscopic stabilization. Is that because you can do a better job of capsular shifting? Right. Do you think? We can see the rotator interval, and we can do a better job of shifting the capsule, and we can more easily double the thickness. So, it gives us exposure to the entire capsule. We can see the rotator interval, which typically if a patient has one, we would close at the beginning. This patient doesn't have one. So, we generally find the bicipital groove. Can you rotate, Justin? So, the bicipital groove is right here, and we identify that. Jim, you've lost it three times. Go ahead. All right. So, and we've identified the bicipital groove, and I'm just going to try to improve our appearance here a little bit. You've lost it again. We're trying to get the conjoined tendon out of the way. It's a little harder on a cadaver than on a live human. So anyway, here's the subscap, and we identify the bicipital groove, which is over here, and then we go a little more than a centimeter medial, and we take this off with a combination of sharp and blunt dissection. And what I think is really important here is we really are working under the subscap. We're just detaching it laterally, and then the rest of the work is done under it. So, we usually take a BOVI, and we detach it, start it here, and then take a scalpel, and you can see transverse fibers of the tendon over here, and as we get to the bottom of the transverse fibers, you can see the actual capsule, and then we develop this with scissors, elevator, and we just work under it. So, if you see here, the superior attachment is still intact. The inferior attachment is still intact, and we're working under it, and we're really working to get down to the glenoid, and so, you know, sticking a finger in there, you can actually feel the edge of the glenoid when you get to the right point. So, once we've got, and we've placed modified Kessler sutures in here, which are very strong grasping sutures, and at the conclusion of the case, we'll just use free needles and use these sutures to repair the subscap. And to my knowledge, we've never had a subscap rupture, although it's been reported. There were a couple of reports, you know, 15 years ago. Prior to that, it was a case report, so it's exceedingly rare in our experience. Is the horizontal limb of the tenotomy inferiorly immediately above the vessels? Yeah. So, somebody asked me this recently, but often we're above the vessels, so I used to routinely ligate the vessels, but we just don't get down there that far anymore. We stop here and leave them intact and work under them. Okay. So, let's have the three-prong retractor. So, once we've gotten the subscap free, then we insert this glenoid retractor, and we're going to hook that. Take the blue out. We're going to hook that over the edge of the glenoid. Push the head back. And if you notice here, Justin is controlling the arm position, and that's really important for us to be able to see. I'm in the joint. There we go. So, now we've inserted this retractor. I know you guys are having a hard time seeing, but we haven't gotten to the seeing part. Let's see. So, once we… Then we do a transverse capsulotomy. So, this is a… We've already cut the capsule here because we had to create a Bankart lesion, but here's the top of the capsule, here's the bottom, and we've just incised this from medial to lateral. Would it be possible, Mike, for the cameraman to come sort of over your left shoulder a little more to look down into the wound? So, here's the superior… There. That's a little better. Right. Here's superior, and we've put a stitch in the inferior capsule to see it, and the orientation is a little hard to see here, but that… It's a transverse capsulotomy, right? So, we've incised it. I'm trying to look at the video at the same time. Our incision is from… Oh, this is not easy. From here to here. Okay? So, we usually start laterally, and pretty tough to show you this, and incise it this way. Would you say that that's about at the mid-equator of the glenoid? Yeah. Probably the middle… The ideal position is probably middle… I'm sorry, the bottom third, upper two thirds, but the middle is fine. So, once we've done that, we're going to insert our glenoid retractor, Facuda. All right. And that's not hooking on the back of the glenoid, Justin, so relax. There we go. All right. And I'll take the two-prong retractor. So, once we've gotten the glenoid retractor in, we are going to replace the larger glenoid retractor with a smaller one. Put your hand up higher, Justin. There you go. Take that out. Can you push that down? Do you paralyze your patients for this procedure? Typically, yes. Although, we've done them with a patient awake. So, typically, we do paralyze them, especially in a big guy. It just makes it easier. Pull up on these. All right. There we go. All right. So, sorry for the... Can you guys come a little more over the top? Yeah, it needs to come over the top, like right where you're in the line of your scissors, if possible. Can you come in closer? We're kind of limited by just wheels and stuff. That's improved. Right. So, we had to create a Bankart lesion in this patient, and this, you can't quite see it. If you can get to the tip. Can you see the screen? Can you see the screen? If you can get to where the tip of my scissors is, otherwise, nobody's going to be able to see. Right. Well, this is the front of the glenoid right here, and the Bankart lesion is right here. So, we just can't see it on the camera. Justin, can you duck under that, and can you scoot that to the left? So, if you can see the tip of my scissors, that would... Sorry, guys. Go ahead and load up the anchor. Ah, there we go. All right. Better, better. Good. So, we didn't have very good instruments to make the Bankart, but typically, the Bankart would be there. We would debride the anterior glenoid neck to bone with a burr, and then we're just going to... We're going to put two anchors in here for demonstration. Normally, we would put more, but here we are with a glenoid exposed. Anchor. Mike, did your capsulotomy go all the way through the medial part of the labrum, or stop just short of it? Well, usually, if they have a Bankart lesion, it kind of extends itself. And actually, sometimes, if the Bankart lesion is smaller, and we think there's a big capsular stretch injury, we will extend it medially just because it makes exposure and mobilization easier. All right. So, we've got two anchors. These do have needles on them, right? Needle holder. So, can you guys see the anchors in place? Yeah. So, we've got our two anchors in place, and we're going to pass the inferior anchor through the inferior capsular flap first. This may be a little tough with our visualization here. And then we're going to pass these same anchors a second time through the superior flap, and that will double the thickness of the capsule, which you can't do through the scope, and mobilize the capsule. Let's have that wide one for him. So, Jim, I'm going to put you right here. Just keep that capsule out of the way. Okay. Lift your hand up. All right. Like that. Okay. Good. All right. So, I've taken the liberty of putting a... This capsule is a little beat up, and I've taken the liberty of putting a stitch in it so we could try to keep it together. Pickups. So, Mike, we are going overtime, unfortunately. After you pass this stitch, could you just sort of verbalize what you would do to wrap it up? Yeah. Can you get the light in there? So, we would... Come out, Jim. So, we would pass these stitches through the capsule, find them on the other end, and then pass the next stitch that goes with this anchor. And then, one of the key points here is we have Justin, who's my physician assistant, reduce the shoulder during that portion of the operation. So, we've got one pass through. These are mattress sutures, so I don't want to take too much more time. And it's a little tough. That's a pretty good visualization. But we're going to pass both these through this inferior flap and retrieve them. That didn't cut through. Sorry. Push that back. Alright. So, we'd pass both flaps through, just in the interest of time, and we would tie these to the... Take that out. That's part of the problem. So, we would pull the inferior flap up. This would be a mattress suture. And we would do this again with the second anchor, mobilizing it up as far as we can and making sure Justin's putting posterior pressure on the wound as we reduce the head. If you tie these knots with the head out, it's going to be loose. So, then once we've done this, we take these same two pairs. Normally, we'd start on the superior flap with the superior anchor, and we would take And we would take that superior flap, which is right here. And this one's kind of in the way now because we haven't passed it, but we'd pass this through, which will be a little easier to see. Pull up on the suture, Jim. Mike, we're going to have to leave you at this point. There we go. I apologize. Yeah. Sorry, guys. But we get the idea that you're going to shift the capsule inferiorly. Right. And then at the end, just for... We'd have a double thickness repair here, and then we would imbricate this part of the capsule to eliminate any redundancy, and Justin would keep the arm in 45 degrees of abduction and 45 degrees of external rotation as we were tying the capsule down. Thanks for your time, guys. Thank you, Mike.

open Bankart stabilization procedure

anterior shoulder instability

arthroscopic surgery

glenoid defect

Hill Sachs lesion