From around the world, the AOSSM and ISOCOS Combined Symposium. Really we're going to organize this in two ways. First is the world view, we're here recording from Madrid, Spain. Case one is a first or second dislocation, small heel sacs, no glenoid bone loss. Second case, multiple dislocations with bone loss but an on-track lesion. And case three, multiple dislocations with bone loss with an off-track lesion. We have Pablo Nurbona from Argentina, South America, Beno Idesman from Brazil, South America, Giovanni Di Giacomo from Italy, Clara Acevedo from Portugal, and Emilio Calvo from Spain. Trying to give us the world view and we'll go through with these three cases looking and discussing what their opinions are. Then Mike Frijo, who's the moderator of the U.S. where you guys are in Colorado. Steve Weber, Eric McCarty, and Albert Glenn will then take over and you guys can discuss. So we hope this is helpful giving you both a global perspective of shoulder instability. Thank you. I think that this is the ideal case to do a vascular implantation. For me, it doesn't matter if it's... For me, the bancal remplisage, nobody talks about the dynamic effect of the remplisage. And if we do the remplisage a little bit laterally and not to medial on the tendon, we are not going to alter too much the anatomy and we are going to lose a strong rotation. So I think I will go for the bancal remplisage in this case. I don't like the bancal remplisage. I prefer to do the laterger and mainly in competitive athletes. We publish some papers in professional soccer players and mainly in goalkeepers. And if you do arthroscopic, you have a lot of failure. And we have another article about bullfighters. And when you have athletes like that or when you have athletes like we call risk of life, like surfers or paragliding, you should do laterger because I think it's more safer for the patients. Now, we are using just one screw and washer in the proximal aspect of the bone block and just a screw in the proximal to the tendon because we studied the finite elements. And when you do this, you have more strength and you decrease the chance to have osteolysis. Almost the first time. No, no. We use two screws. In the first screw, you just screw and washer. And the second screw, you just use just the screw. You have a very good fixation and we think that because the screw that is too proximal is too close to the conjoined tendon. If you just use a screw, you have a better fixation. You don't have too much motion and maybe you decrease the chance of osteolysis. Thank you, Gus. So I'm the fifth. We have two supporting soft tissue procedures, two supporting osteo procedures. I will try to give my opinion. So this is a case of an on-track tri-cycle lesions with multiple dislocations. Am I right? No bony glenoid defect, okay? So I need more data because if the patient is a very active patient doing a high-risk activity or sport activity like contraceptive sport or political sport, this is an indication completely for a later stage because the rate of recurrence is very high. However, if the patient is over 30, not very active in terms of athletic activity, it could be an indication for a soft tissue procedure. And in this regard, my preference would be a conventional bancal repair. I don't see the necessity to do any OMPSAS and I don't see the indication for a dynamic anterior stabilization in this population. But if the patient wants to have a very safe shoulder, a reliable shoulder, because they want to practice these kind of activities, it's an indication for a later year for sure. Yeah. So let me push back on you a little bit because I don't know how many patients will come in and say, hey, you know, I want kind of a mediocre shoulder. You know what I'm saying? So, you know, like I'm talking to you. So it sounds like you're a later J because you feel that's a safer operation, it's more reliable. Is that true? That's absolutely true. Well, first of all, first of all, I said I'm going to offer my patient the best procedure because I believe that a soft tissue procedure can be the best procedure for a patient over 30 with no bone defects and with a sedentary life. That's it. But if the patient wants to have a really safe and reliable shoulder to practice risky activities, or if he's too young, or he's young enough, it's an indication for a later J. Going back to the black legend of the complication of later J of 30%, probably I know where this figure is coming from, but, you know, there are many publications. We published the series of later J and our complication rate is much lower than that. So it's lower. Of course, there are complications like with any other procedure, but it's not superior to other procedures. Yeah. Do I pass that over to Giovanni? I agree completely 100% with Emilio regarding the complication. Our complication is more or less a 4-5 complication and regarding the hardware is very surgeon dependent. If you put the screw, we use a small plate in the right way and you pay attention and you have a very nice view during the surgery and you put the retractor in the right way, you cannot have this kind of problem, even if you have a reabsorption. And regarding the reabsorption, you have to pay attention when you don't have a huge bone loss. When you don't have a huge bone loss, you have to twist your coracoid to have the best fit between the deepest part of the coracoid and the skip, because you don't have bone loss. That's the reason we use a small plate with a wedge that gives an excellent compression. We published a paper last month in Atrocity Journal about a comparison paper between bancal reprisage and LATR-G. We compared 70 patients for bancal reprisage against 188 patients with LATR-G and we really had zero complication rate in bancal reprisage, almost 6% in LATR-G. And we have better return to sport with bancal reprisage, almost 91% against 72% with LATR-G. And the recurrence rate was lower in bancal reprisage than in LATR-G. But we do a bancal reprisage, I think, in a different way than we normally do. We go with a supra-spinato and not a capsular on the Hitzad lesion and we have a really very strong bancal repair. So I think the modern technique for bancal reprisage, for me, is a great option. I think that the problem with LATR-G is not so much the 30% question. It's that we know, anecdotally, that there are devastating complications with LATR-G that we see when we discuss with colleagues around the world. So this makes this procedure not the ideal procedure because the ideal procedure is one that is highly reproducible in anyone's hands. So the problem here is this, is that the reason why there are surgeons looking for alternatives is that there is a learning curve for the LATR-G and if you use the LATR-G judiciously, considering planoid bone loss, you won't have a high volume of LATR-G procedures. If you approach it like the French do, they do 70% of the French surgeons do a LATR-G immediately after the first dislocation. They have high volume, so they have a low rate of complications because they do it every time. But if you do it judiciously, you will have complications. When you have complications, they may be devastating and when they are devastating, they are in young people, 19-year-olds, 20-year-olds. I think this is the main question surrounding LATR-G. One possibility to save the LATR-G for me is the hardware-less LATR-G. I think that's the future. Not using hardware, maybe then we'll find a place for everyone to do LATR-G without devastating complications. Okay. And then the final case would be multiple dislocations, bone loss, off-track lesion. I don't think this will be hard. Well, off-track, no, it can be hard because there will be some discussion of course. I think this is the indication for a bone block procedure, of course, because in off-track sex probably some people will think of recommending amputations for these patients. But so far, it's been demonstrated that LATR-G is an alternative for patients with off-track heel sac lesions. We recently published a paper in the American Journal of Sports Medicine trying to assess the capacity of LATR-G of restoring the glenal tract in patients with off-track heel sac lesions. We found that it could be very efficient in, of course, in restoring stability, but also in restoring the glenal tract. However, in patients with very large bone defects, probably the corticoid process is not thick enough to restore the glenal tract. And there's a small percentage of patients that this is 11% in whom we should do something different, probably like an iliac bone graft or even something different, or even a LATR-G plus a RAMP process in the specific population. So, going back to this case, indication for LATR-G unless it's very large bone defects. I do a LATR-G. We did a study that compared Bristol and LATR-G, and the results of LATR-G is much better. You have more problems with the Bristol. But when you do like the last case, when you talk about arthroscopic procedures, in my hands, when you have a patient that you do a bunker procedure after some dislocation, you never had a pre-initial negative after that. If you examine the patient, they used to have some symptoms of instability, and when you do a LATR-G, they feel very comfortable, they feel very safe. So, I think in this case, I do a LATR-G, and in my hands, they can return to sport much earlier than bunker procedures. I'm allowing the patients to return around three months follow-up. Three months to, as you call it, life or death spots? Life or death spots, maybe no, but if they are professional soccer players, I think they can return after three months. If they are goalkeepers, maybe four months. And maybe if they are surfers or maybe another sport that has some risk, they can return after four months. Because you have bone healing, and after that you have a good proprioception, you have strength, and I think you can allow to return after four months. I'm not in a hurry to go back to sport after a big procedure. It doesn't matter if you go back to sport in four months or six months. But anyway, for this case, we are talking about a glenoid defect bigger than 20%. We're talking about an off-track lesion. Okay, if an off-track lesion and a glenoid defect less than 20%, I will go for bunker re-message. But if the glenoid defect is bigger than 18-20%, I will go for LATR-G plus re-message. I think the dynamic effect of the re-message is very important to have the sensory human head. Nobody talks about the dynamic effect of the re-message. When the infraspinatus gets contracted, the human head is really sensory on the glenoid side, so it's a protected effect for a LATR-G or for a bunker. So how do you do the re-message with the LATR-G? I go for arthroscopy. I always do an arthroscopy diagnosis before LATR-G. So I put the anchor for the re-message. I prepare all the heat solution. I put the anchors. Then I go to the subacone space. I pass the suture, but I don't tie the sutures. Then I go back to do the open LATR-G. If it's a really big defect on the glenoid side, I would go for an arthroscopic LATR-G. I can do it, but with a regular glenoid defect, I would go for an open LATR-G, do the LATR-G procedure, and at the end I just close, like a blinding close for the re-message. So as I said, if it's a subcritical glenoid bone loss, 20% or less, I would go for the dynamic anterior stabilization. If it's more, the LATR-G. But I think Benno focused on a very important question, which is, if the patient wishes to return to sport early, dynamic anterior stabilization is not a surgery for them, because they'll have to wait six months to return to sport. So if that's the case, then I'll have to do the LATR-G. Of course, I would do a LATR-G, but I would like to give two messages. The first message is because we are in an international setting, so we speak very often about LATR-G, but we don't know how it works. We don't know how the LATR-G works. Because most of the papers are in vivo, are not in vivo, are on specimen. Because it's very, very hard to study the movement of glenohumeral joint in vivo after the LATR-G. We are trying to do this, but we don't know exactly how the LATR-G works in vivo. The second message is, even if I am maybe one of the first fans of LATR-G in the world, pay attention to do the LATR-G in the dominant arm of a hard sport man, like tennis player, high-level tennis player. Fortunately, it's very rare, because they don't have this location, but you can have a good tennis player with dominant arm, or probably in any kind of throwers, because it's not anatomic, and in my hand, it's very, very difficult. They go back at the previous level. So, just to finish up, we'll start with you, Giovanni. Why don't you give us the top three kind of pearls or facts that you have in your experience in treating shoulder instability? Of course. You know, I wrote a paper with Steven Nishi on the groin track. So, the bipolar bone loss is one of the key points, but the second step, maybe probably more important than bone loss, is the age. So, first of all, I give a look at the age. The younger they are, the more I pay attention to give the best information to the player, to the family. The second factor is the bone loss, and the third is what kind of sport they play and where they are in the field. Oh, goalkeeper. The goalkeeper, I can promise that he is coming back in three months after the lottery, but as he said, I wait most of the time, like a rugby player, five months. In a midfielder, soccer player, first division Italian team, three months, they can go back to play. So, there are many factors that are related to the indication and expectation of the athletes. For me, it's very important to do a correct preoperative study. This is mandatory, and it's not frequently done. We should really assess the glenoid bone loss and the ill-sex defect, the ill-sex interval, and determine whether it's on track or off track to discuss with the patient. The other aspect is what are the patient goals. So, the type of sports, if they wish to continue to do the same sports or not. Sometimes patients are fixed, and if it's a recreational sport, maybe they can change the sport, and they don't have to have an aggressive procedure. For me, this is very important. And another aspect is to always assess systematically our prolixity. I always do debate and score in each and every patient, and I think sometimes this is overlooked, and this can be one of the reasons of some failures, even after lottery, because the lottery fails, and sometimes has to be revised with soft-tissue procedures. And this is not very frequently discussed, and it's a problem, and it's related with preoperative assessment. Do you have a certain score when you do something different? Well, yes. When a patient is really young and female and has like 9 or 8 out of 9 debate and score, I try to avoid surgery. I try to exhaust every possibility with rehabilitation, because there is no perfect procedure for these patients. So this is a lesson. We see catastrophic results in very young patients because they were treated aggressively very young, and this wasn't taken into consideration, and bony procedures were used, and then there is no solution for these patients. So this, for me, is the total. I really agree with Giovanni that there are so many different types of patients and so many factors in each individual patient that to find the right surgery for each patient is really difficult. But I'm sure what I'm not going to do, never, is to use a glenal technique to treat a hemorrhagic problem. For example, to do a lavalier to treat a really big hip adhesions. I will go to treat a glenal problem for a side and a hemorrhagic problem for the one besides. I think the first lesson is to treat the first dislocation. I think it's very important. I think you should treat surgically the first dislocation, mainly in sports, mainly in athletes. The second, I think that you should treat your patient, not should treat the exam. And the third one, I think you should do the procedure that you perform the best. I think the best procedure that you know, and sometimes, like in Brazil, sometimes you don't have too many anchors. Sometimes you have problems with the anchors. We have the problem to have absorbable anchors. And sometimes we need to do a lot of procedures. But I think you should do the best procedure that you can do. Thank you. I think what I've been saying is true. Keep in mind, first of all, that the key issues or the key factors to keep in mind, we published it many years ago, is bone defects, age, sporting activity, and hyperlaxity, as they pointed out. Having said this, second take-home message is that bunker alone has an important recurrence rate. So we should do something different to that. Probiamplicide is a good option. Probi-Latter-Jay is a good option. We need to tailor the specific treatment to each patient. Our patient for Latter-Jay, probably our patient for Amplicide. And we need to figure out which is the perfect patient for each procedure. And finally, we need to tailor, and this is very important, the specific technique for the activity the patient wish to perform. Because it's different, somebody who needs a very safe shoulder, like a climber, to a thrower. It's completely different. And this is very difficult. All right. I want to thank you all. We'll give this over to Mike Freehill there in Colorado in the AOSSM meeting. This is us from Madrid, Spain, and the ISOCOS team here coming to you to Colorado. So thank you for having us. All right. Can we get Drs. McCarty, Weber, and Dr. Lin up and then go to the last session? So while they're coming up, I want to send a picture. So I want everyone to wave on three, and we'll send it to our colleagues. One, two, three. Yeah. Okay. Thank you. All right. So sorry for some of that audio, but I think that that's really valuable to get the insight from all over the world like that. So we have a couple cases here. We're going to tweak it a little bit, because I think it's exciting to not just talk about the primaries that haven't had surgery before, but let's start talking a little bit about when someone's had a surgery. So our first case here is a 28-year-old female had an arthroscopic vein cart repair five years before and is still pretty involved with swimming and surfing and those types of skiing. Can you turn the microphone down just a touch? So let's start with Eric. What are your thoughts with that history and just the images that we have there? Is the mic working? Yeah. So the images are very concentric points. There's not the parameters to be following, so I can see the thickness of the trachea is this. That in surgery, it looks like there's, I see some tracts or anchors, but I don't see any tracts. And so that's number one. You know, it's all for the low torque that the minimum of three anchors, preferably four anchors, to prepare the vein for stabilization. So for me, you know, I see a couple issues. I don't see any reason to evaluate. I would like to know the epilepsy sort of base for that would be helpful. You know, I think you would probably go ahead and do a revision. I think there would be a preferred method of calling it four or five anchors. I'd like to start, as I mentioned before, around a seven o'clock position to go around. However, a revision, I do also like to do the right massage, so I might be willing to consider that on this, even despite the fact that, you know, I'm not sure if it was, if it was direct the first time. And we'll move on to Albert. How important is it, or how often, I mean, you published recently on a great, great study on the near track, not off track, not on track, but near track within eight millimeters and them being at extremely high risk. How often are you making the measurements? Are you doing it on every case, Albert? Yeah, sure. I do a lot of track measuring on a free run. Now, there are, you know, there's measurement error, there's something like anything else. I think it gives me a quick sense of sort of how, how off track or how on track the shoulders are. I think the interesting thing that this case started is we find out, Eric, we're going to do this since we're doing this year, but there doesn't seem to be, like, the fact that we're going to go along. She's been able to get her applications from the age of, you know, 16, and as long as she's not hyper relaxed, I think you really, you know, could, you know, be in trouble with her provisional therapy and I'm not going to take any of the risks there. I'm just going to enjoy the massage. So, you know, a few years ago, we looked at revision, bank card repair, because without that massage, there's a risk factor, a real risk factor for age less than 20, hyperlaxing, off track, because I don't think she needs to spend any time, so I, for me, I think there's a big reason for the revision, repair documentation. All right, and Steve, just your thoughts here. You've spoken a lot about open bank card procedures on various panels. Do you think that there's a place for that here, number one, and then number two, you know, with that being said, what would you do? Okay. Okay, so from our expert faculty here, we have Eric, Arthroscopic Bancart Revision Repair with Remplissage, Albert, and Dr. Weber, you're going with the Open Bancart Revision. Okay, so you guys picked up on some interesting things of why I thought this was a fascinating case. I agree with Albert that 28, you're a little bit out of that really acute period, but this is a really active export doing all the crazy stuff on the water. She had re-dislocated doing surfing, and she's going to go back to that stuff. So I think that that lowers her years a little bit in my mind. I think that it's important to remember, I agree with you, the joint is very concentric, but you picked up on the fact that there's two tracks. And again, as Dr. McCarty pointed out, it's been shown in the literature that you need at least three, and that's probably the preferred number when we're talking about the anterior based instability. Not only that, are there two tracks, the position of those tracks I don't think are in the best place. It appears the lowest one is maybe at four o'clock. So more than likely, probably didn't get that axillary pouch closure. And when that does start to stretch out, which we know does occur with time, probably slipped under that. The hill sacks, and why I think Dr. Lin's work is so important with that near track, is there is measurement error. But when you measure, remember it's not the depth, it's the width of that hill sacks. And when you can find that widest spot, and you start getting into eight millimeters or less, and you start getting into collision or very active patients, my thought on this, even though I think you could revise an arthroscopic bank heart capsulography, I think you've done some damage to that capsule once it's failed once, and you need to add something to it. So my thoughts on this were an arthroscopic bank heart revision with a remplisage as well. Before we move on, next case, I'd love for, we have some experts in the room, Dr. Arcio, Dr. Burks are here. I'd love to get some insight and ask our faculty some burning questions. I would just ask, does double loaded anchors, I mean, Boileau and some other people have talked about you've got to have three or four, but those were all with single anchors. So does double anchor, I'd like to ask the panel, if double loaded anchors make a difference to you, and that's why I think it's important to get the op report, and also, actually the position of the inferior anchor, if the surgeon grabbed the capsule very, very low and reefed it sort of a pinch tuck with that anchor position, you can re-tension the anterior inferior glenohumeral ligament. It just depends on how you handle the capsule. And so I want to ask that question, and then I'm just going to make a comment that I agree with Steve Weber, I would do this open, except for one thing that makes me think of revising with a scope, is the scope bank worked for her for five years. It wasn't like she had an early failure. So I might be tempted to do that, and the way that I would sort that out is an exam under anesthesia. If she had a two plus load shift, I think I might do it with a scope, but if she was three plus and I dislocated her, there's no question I'd do what Steve said. But what about double loaded anchors? Boy, Bob, you had a lot of statements and questions in that, so let me, we can attack it one at a time. So, you know, I think it's interesting about the double loaded. We actually, we recently did a biomechanical study looking at double loaded versus single loaded and found that there wasn't a great advantage to the double loaded, but your technique of doing the double loaded may make a difference. You're not just, you know, putting them around, you're doing kind of a mattress and a horizontal and something else. So that may be different than the way we looked at it. My preference is single loaded. I prefer more points of fixation rather than trying to pull it up or knowing that if I can get it down and pull up the tissue down to seven o'clock, to six o'clock, to five o'clock and pull it around, I have much more comfort in knowing that that tissue is going to heal. Al? Yeah, I mean, I know double loaded can be, you know, you would think that kind of wrapping it twice would kind of give it a stronger construct, but I think it matters the configuration that you do it. And I'm with Eric, I actually, I like just multiple, I use smaller anchors to get more multiple points of fixation. So that's what I would prefer to do. I don't have any experience with double loaded anchors for bank cards, but I think the idea that you have more points of fixation is probably valid, but I'd love to see the papers looking at the bench for this stuff. Those are great questions, Bob. I like the double loaded. I like to, I think that you get the best of both worlds depending on how you utilize those. You can get a horizontal repair to bring your labrum up, but then you get the added benefit of doing the simple, not passing one of them. So you get a vertical and horizontal, I call that a modified Mason Allen. I like that. Speaking of special guests. Speaking of court jesters, it's a great case, Mike, I was curious, you said that in your hands you'd maybe do a remplisage on this. It's a revision, right? So the one study that looks at revision remplisage has a 36% failure rate in Buddy Savoie. That's his data with Mike McCabe. So I just wondered, does revision change your mind about remplisage? Will you do revision remplisage or remplisage in the setting of revision? And if so, what are your indications? And are you nervous about that or do you think it was just a one-off? All right. Awesome question. And I agree with you 100%. I think that's why a lot of times I'm going more to remplisage on the primaries. Because the work out there shows you, Buddy and numerous authors actually have shown that, that your failure rate is higher with remplisage and revision. In this case, the things that were pointed out by the faculty, I think changes it a bit. A little bit older, not done probably fantastic the first time, although it did hold up for five years. So I think that was my thought. I could go with just the remplisage versus increasing it. I liked your talk, by the way, JT. That was very good. And so, you know, you do ACL surgery like I do and, you know, we've come across the lateral extra-articular t-edesis, utilizing that. And I almost see the remplisage in a very similar fashion, right? Okay. Somebody's got hyperlaxity in their body, high Baton score. We're thinking a three plus Lachman, okay, I'm going to add a LAT. All right. I'm going to do the same thing with the remplisage, three plus, maybe he's got a Baton score of eight or nine. I'm going to add a remplisage, where previously I didn't, and that's in a primary. Also looking at revision ACL, LAT, revision banker, often using the remplisage. So it's really interesting how the concept of remplisage has gone. And I like what you said. I had a primary care doc that was sitting in the audience, didn't know all the things that we know, but was very smart. And he said, doc, you know, why don't you just do a remplisage in everybody if the stability's better? And he said, that's a good point. Can I ask one more question? Of course. If you don't mind. So let's just, you guys made the comment that you like multiple points of fixation. So you're saying three, four. So in this case, there is some lysis in the glenoid. And so if you put three or four more anchors along that rim, does anybody concerned about a postage stamp fracture? I don't know if this is truly lysis on here, because it's not the same, you know, kind of enhancement that you see on the T2 where it's completely fluid. That would, I think, make me a little bit more worried. I think these are tracks, and yes, they're a little bit expanded, but I'm not really sure, you know, I'm not really sure that that, you know, would be a cause for a postage stamp in my opinion here. I'm curious, Steve, maybe you can answer this, or I'd love to know the faculty's thoughts. In this day and age when we're getting imaging, a lot of different cuts and almost always doing calculations, does everybody still do an exam under anesthesia? And I know that that's, you know, we're trained to do that, to do that, but we're all, but I also know that you barely put the rasp on that, and you're losing a millimeter of bone, two millimeters of bone, or you're chipping away cartilage. You already have the calculation. Does everybody in the room do an exam under anesthesia still? Well, if you're asking me, yes. I think it's the, you get more information from that than anything, and you know, when you're in private practice, the quality of your imaging is tremendously variable, and you can't keep ordering scans because you don't like the scan that you got from, you know, Hopetown, USA. So that exam under anesthesia is critical, and I've had at least two patients where I thought I knew what I wanted to do. Did the exam under anesthesia, stopped, woke them up, went back to the family and said, you know, I thought it was going to be this, but it's this, and the right thing to do now is this. In fairness, I had one, I remember very well, a guy had a greater tuberosity fracture dislocation, his shoulders in his 40s. I did an exam under anesthesia, went right out, I couldn't get him back in. I had to open him to reduce him, and this was at 10, 30, 11 at night, so it did not make me happy. So that happened to me once, but for the most part, I would continue to do that exam under anesthesia. Mike, I do an exam under anesthesia, but I think it's more rare for me to change my operative plan, unless something like that, very dramatic like that, were to happen. And I think, you know, as you alluded to, doing a lot of the measurements ahead of time, but I do think, you know, obviously if you get a 3 plus that's locked out, that's a very different scenario, and it can change, but I think that's more infrequent. And I just wanted to comment quickly on JT's comment on Buddy's paper. We're familiar with that, and I think it's a great paper. The only problem when I read that paper is that it's really underpowered. There's like very, very few patients. And so we take that as, oh, we shouldn't do remplisages in the revision scenario because of the 36% failure rate, but there was only like, there was a very, there was like only four patients, I think, or something pretty small, so yeah. So it's, you know, and I think it's, I think it's important to know that, but I think in these scenarios, you know, there are other ways to augment as well. You could certainly put in the posterior anchor and also include the remplisage, so. Quick show of hands. So who would do an open Bancart? Who would do an arthroscopic Bancart capsuloraphy revision repair only? That plus a remplisage arthroscopic? Latter-Jay? Okay. I was going to say, it's a cross-section. We're not taking that picture. This is what I love too. This is what's great about it. We have the two very different viewpoints for the most part. Jay T., we're here for the video. Okay. So case two, 25-year-old male had a previous Bancart. This held on for nine years, had a re-dislocation, playing basketball, active and recreational weightlifting and playing basketball. So limited images we have here with these particular images. Let's start with you, Eric. What are your thoughts here and what are you ultimately going to do? I'd get new imaging. Did that come from Stanford? What was that? Yeah, really. I'd like to have a little more information. This is one I'd probably get a CT scan on. I'm not confident in what I'm seeing. I wouldn't get a new MRI. I'd say, okay, I got some information on MRI, but I would go for the CT scan with thin cuts and 3D reconstructions. So are you worried about bone loss? Yeah. So Mike, the question that Bob had asked earlier, I think this is a different scenario. So if you look at the fluid sensitive sequence here, there is fluid that's basically tracking through the suture anchor track. So I'm a little bit worried that I'm not getting the best image here and I think there might be some bone loss here. So I definitely would get a new image, particularly a CT scan before I make a call on this one. Steve? Well, I mean, I'm still a little nervous with young people and CT scans because of the radiation exposure. I know that's not a popular opinion. It's always good in these panels to ask for more images because it puts off the answer for another couple of minutes. Assuming we get what some of the guys do to you and say, this is what you're stuck with, make a call. I can't see enough bone loss that would make me change my mind about doing some type of bone augmentation procedure. So if my exam under anesthesia confirmed what I expected and I'm stuck with these images, then I would do an open Bankart. Yeah. Well, you brought it up perfectly because we are stuck with this and we need to know what you're going to do. So as opposed to the other case, it looks like there are appropriate number of suture anchors kind of going from down below, up superiorly. And let's say for the sake of argument that that picture that you're showing, the sagittal, is representative of some bone loss. It doesn't, to me, look like what I would consider critical bone loss, if it were to be the case. And for me, I think that's actually a really, for me, I would do an open Bankart. If there is a sliver of bone to incorporate, I would incorporate that into it. So thanks for leaving us with poor images. But based on this, again, looking at it, it looks like all these anchors are placed anteriorly. I would do exam under anesthesia, do the same things that I talked about, approach it very similarly. I'd have no problem if they're one, two plus to do an orthoscopic with a REM plasage. And if there's not a Hill Sachs, JT advocates for creating the Hill Sachs. That's not exactly how he put it, but he said buff it up. And I'd have no problem doing that, just, you know, looking at this. And for me, the open would not gain as much for me. But I'm not as good as RCR, so. Steve? No, I agree. I would do this. Assuming there are no surprises, I would do this open. Even if there's modest bone loss, I think open Bankarts can do okay. I know Mike Pagnani and I had a bromance moment a couple of years ago at the academy where we both agreed on something. So that's probably where I'd leave it. All right. Let me throw this out there. I'd love to get Dr. Arciro's two cents on this. So held on for nine years, still young, still active, now has gone on to have another event. Do you get plastic deformation with that amount of time? Has that been slowly building and eventually you hit a critical time? And now, saying open Bankart, which even though I do think it's good to talk about, how many people actually, it's kind of like the double bundle to me. We like to talk about it, but how many people are really doing it, you two excluded? Do you go in with an open Bankart? How are you going to do it? Are you splitting the subscap only? Because if you take that down, they've already had one repair. Now you're doing the open Bankart. If you have to bail back to a Latergé for whatever reason, then my last question would be, if you have plastic deformation, you can really tighten that enough that you'll keep them stable. But is that anatomic or are they going to go on and have a capsulography and Dr. Lin's going to be doing an arthroplasty at some point? Wow. I thought our CRC would be willing to ask five questions. So I'm going to take what you gave us, Mike, okay? We don't get a CT scan, all right? So this might be that intermediate, I'm just going to say it's intermediate bone loss, 10 to 20%. So I think that there's no data to prove anything I'm going to tell you, honestly. But if this kid was really hyperlaxed, I would do a Baten score and I would look at things like his sulcosign and his load shift and try elbow hyperextension, get an idea of is he a mesomorph like me or some really wiry, skinny, loose kid, 25 years old. So I would take the subscap down if he was really loose and I would do an open Bankart on this and pass, it depends on how you do it. It's totally different than a scoped Bankart, passing the sutures all the way through the labrum and capsule and plastering it on the net and then imbricating the capsule and then repairing the subscap with four non-absorbable sutures and a O-Vicryl running stitch and hold them, you know, so that that heals. If he's a mesomorph like me, I would probably split it. And by the way, you can still do, if you had to do a Latter Jay someday, even if the subscap healed, hopefully it healed, you could still do a split on it. But that's how I would approach this guy. I wouldn't jump to a Latter Jay on this. I probably, because he's 25, I would have, and he doesn't really have it, I would have more confidence in an open Bankart with a capsulorophy for the next 25 years. Okay, so let's take a, let's just see a show, oh, Burks. Well, I, I will say, I totally agree with your comments on the Latter Jay fail or excuse me, the Remplissage failure paper that Buddy did, because I was going to bring it up to Mr. Literature over here. I guess, you know, these are ones that I think are a little bit tough. I don't like to look at that humeral head. And so, you know, we're sitting here saying, ah, do you do bone, do you do open, do you do whatever? That's not a good looking joint to me. And so when we go back to the imaging and everything, you know, it's a young guy. And so what has maybe happened in this duration that this person's been stable? And so that, that kind of concerns me. And I guess I'd raise the question that, let's just say it's a little more advanced than you might like to see. Does that tip you more to a Bancart as opposed to a Latter Jay? Because maybe in the near future somewhere his, he may need more. And I know that there are some who would say that having the Latter Jay there might complicate other things. Maybe the open Bancart doesn't. But I'd kind of like to want to get some information on what that looks like. Maybe it's got to be a scope. But I'm not happy with a 25-year-old with that. And when, much like the remplissage literature, you know, the Boston Shoulder Group also put out literature with athletic populations. If you don't go to the, if you go revision one after an arthroscopic Bancart failure and do a Latter Jay, pretty good results to get people back. They can be active, collision athletes, et cetera. When you fail twice and then go to your Latter Jay thinking that's your bailout, the results are like 50%. So there's, that's why I think that these cases are so excellent to talk about. Because once you get to this revision point, all right, so show of hands, who would do an open Bancart? All right, pretty good number there. How about an arthroscopic Bancart revision capsulography alone? How about arthroscopic Bancart capsulography revision with remplissage? And how about open Latter Jay? How about arthroscopic Latter Jay? How about anything else I missed? Mike, you've presented. JT. This is a clavicle? Yeah. I think this is the perfect case. Yeah. I know we're right in this area. We call that, as Bob said, maybe subcritical bone loss. And I would make the argument that an arthroscopic Bancart here is going to fail. I don't know enough about the bone trauma to the remplissage. It might work. We don't know. Or going around 7 o'clock, we don't know. But I know that there's, if that's bone loss there, or even subcritical, which is only 3 to 4 millimeters, that's too much. So for me, this guy, I think we're considering doing a bone grafting procedure with this one. To the other four, if it's a clavicle, if it's subcritical, then it's a clavicle. It's more than subcritical. Now, you're saying a bone block that you're putting in arthroscopically through the interval, so you're not going to play with the subscapital? Correct. Okay. Do you agree with the examination under anesthesia that doing that could cause, just as you said, 3 millimeters of bone loss? What's that? 6%? 5% you've just lost? 4%? Yes, you mean. Yeah. I think the examination under anesthesia is important. I don't want to put them out necessarily to prove it. But I do think the laxity, I think that's one of Bob's really key things that he's taught us, which was the laxity and how much that thing translates, because I think that helps us understand how big of a tux that you're going to take if you're going to do an arthroscopic or whatever. Are you going to go posterior? Does this guy go right out the back of the posterior lobe and shift? How much room do we have in terms of that laxity and tightening them up? So I think that's the art of it. I don't think you should be showing your fellow, hey, watch this. Stop this crime. Watch out. Who are you? Dr. Lin, Eric, Steve, how about drive-through sign? Dr. McFarland described that years ago, and you'd go in, if you could drive right through. Is that real? Does that make an instant decision change that you can do that? Does that have to do with how much weight you have on the arm if you're doing it in lateral in beach chair? Is it just how strong your resident or fellow is? I believe he described it in the beach chair, and I do these lateral, and so I don't use it, and I think it does make a difference how you have the arms, particularly lateral, but I don't use it. Yeah, I don't find the drive-through sign helpful for me. You asked sort of are we missing anything, and I wonder, I know JT, I know you've presented on these. I wonder if this is the case. Ivan Wong has presented on arthroscopic bone blocks. I wonder if this is a case where that might be a good indication for this. Well, both of us know Dr. McFarland well, so I don't want to cast any aspersions. I don't use it. I think the drive-through is pretty dependent on how hard you push, more so than anything that I'm really measuring. All right, we have about six minutes left, and if anyone has a question, please come up, but until then, I'll throw something. Dr. Burks? So, I kind of always struggle with when we have bone loss, and we call the Latter-Jay a bone operation. You know, Gilles Walsh has done more than anybody, and he'll say one or two millimeters medial to the glenoid is acceptable. Well, that's not really filling bone where there's bone loss. So, to me, the Latter-Jay is magic. You know, it's the sling. It's all this other stuff. And so, the interesting question is, how does Latter-Jay compare to when you really do replace just bone? Because, you know, why should they both be good? I mean, they do totally opposite things. And so, I think it's not a bone operation so much as it's a bony, soft-tissue attachment that gives us some advantages. So, I'll be just interested. But, everybody, thanks. Neither. I'm always confused. No, I think the issue is we heard this morning where you were that, oh, a small amount of bone and we still might do a Latter-Jay. We heard earlier Emilio Calvo, you know, with a small amount might do the Latter-Jay. And we know in France, everybody gets it. Well, they're not replacing bone, and yet it works. And so, is it maybe better in a high-end athlete who needs the extra that some people talk about where you get maybe a little bit of bone, but you also get a sling effect? And if you had a 2% bone loss, are you going to put a distal clavicle in and say, I'm good? Is it the same thing? How do you start choosing? So, that's why I'm confused. Bob, you confused us. You weren't confused. But, I think it's a great question, though. It really is. And I love JT's thoughts on it because I know you've done a bunch of both. And this distal clavicle, I really like. And I think that's important because there is a real complication rate with the Latter-Jay. And, you know, they talked about maybe it's not as high as 30%, but it is real. And when you have it, it is devastating. And the distal clavicle, JT, I mean, you don't have that same issue, correct? So, if you have equivalent type of results, you know, why not something like that, right? You know, it's interesting. The results, JT, as you said, are, they're equivalent, right? You don't see, you know, and why is that? But the other issue, though, is the demographics. You know, there might be a difference in demographics, too. And I think anybody who is doing DTAs to a high degree, push them on, are you going to do that as your primary procedure for your football player? And most of them say no. Like, most of them have not jumped to that yet. I don't know. Or maybe, JT, have you jumped to that? Can I ask a question? Yeah. Yeah. I think you either believe that you're giving a restoration to that or you don't, right? And so, I think that Latter-Jay is an excellent procedure, but I agree with Eric. You know, if all have these patients in your clinics, like I do, with broken screws or displaced screws, or even just well-placed screws with resorption and back damage to the head, probably the nerve injury, which, you know, the follow-up study still shows 3%, even when they take all the precautions. And so, if you're doing 100 instabilities a year and you see three complete permanent nerve injuries, that's a non-starter, which is why you'll never catch on. Agreed. Yeah. So, we have to find a way, I think, that is anatomic and we can do those things. So, to your point, I would say yes. We've moved to where we're not going to say it's dead. Latter-Jay is not dead, but it's on life support. We have one more question. Hi. For this case, or even the previous case, does, can you just comment on index, at the index surgery, the quality of the labrum tissue when you're trying to predict going back and revising that tissue and trusting it in either this case or the previous case? Does that play a role in your decision-making on what to choose for these patients? So, it's a great question. And I think that if there are cases of yours and they come back, a lot of, you know, a lot of us usually will see patients that have failed from another place. Not always, but I think it gives you a lot more information if you did that index. These particular two cases were both from outside, so that makes it a little more tricky because you don't know the quality and you don't know some of the, that information. What do you guys think? Makes a big difference, your index, knowing how good that tissue was. Zeke, you want to answer that? Well, no, I think it's all part of the picture. If you're on the fence about whether to go arthroscopic or open, and you put the, because I scoped all my open repairs anyway, so I didn't miss anything. But if you look and it's a terrible labrum, you might say, well, I better do something else. Or another thing that I saw a lot of, you kind of poke around a little bit with your scope, and that capsule is just completely not mobile. I mean, it's just scarred in from what may be the prior procedure. In my era, we saw a lot of thermal capsule orifice, and it was routine to see a horrible capsule after those were done. So I think it's part of the algorithm, if you like, that you're going to use to make a decision about how to proceed. I mean, sometimes you can judge a little bit of the quality on a good MRI. The other things about history, how many times has this person dislocated or subluxed in the interim, I think is important, because if they've dislocated several times, you know that, you know from all the studies that the capsule, there's going to be plastic deformation in the capsule, so it may, kind of the pieces of the puzzle kind of, you know, kind of, you sum them up and you say, okay, maybe this would be better suited for, let's say an open or something more robust. So that's sort of what I would use to judge that. Okay, we're going to close it down now. So thanks to our North American faculty, Drs. McCarty, Lynn Weber, special guest faculty, Dr. Arciero, Tokish, and...

arthroscopic vein cart repair

re-dislocation

remplacage procedure

open vein cart revision repair

open lateral jay procedure

bone loss

CT scan

basketball

treatment recommendations