is does the size and location of the Hill-Sachs lesion impact your decision in doing, or your technique in doing the REMPLISAGE? And my research plug is, we're doing a large multi-center randomized control trial looking at subcritical bone loss comparing Benkart REMPLISAGE versus Latergé. We're looking for more European sites, so if any of you are interested in participating, we'd be loving to have you guys on. Want to answer that or do it? So for me, definitely the position of the humeral bone loss, it's very critical. So as I said, if it's too medial, I'm not going for REMPLISAGE because stiffness is a big concern in these cases. So in these cases, if it's an on-track lesion, then I'm doing a Benkart procedure plus an augmentation with the subscapularis. If it's more than, if it's an off-track lesion, if it's combined with a glenoid bone defect, then I'm doing a Latergé. So I wanted to compliment you on the bone block technique. Really nice developments and much simpler technique, I think. My question is, do we still need to do a REMPLISAGE on patients with a Hill-Sachs with a bone block, or do you restore enough of the glenoid that it's not necessary? Good question. No, you don't need to do a REMPLISAGE because the bone block actually covers the off-track positioning of the Hill-Sachs. Of course, since my philosophy is to do an anatomical reconstruction of the shoulder, I think the next step is to fill the Hill-Sachs with bone, not with, I don't know, infraspinatus, capsule, or whatever. Yes, I also have a love treasure to do the REMPLISAGE in bunker's procedure, but not to medial, like Michael mentioned. But for the Latergé, I think for most of the procedures, the Latergé will take the shoulder from being off-track to on-track with the bone block. So I hardly ever do REMPLISAGE in combination with Latergé. Yeah, I'd just like to add a comment, actually, that can fit both of the questions, both of the previous questions. I think the idea between, before bone block augmentation is kind of turning an off-track lesion into an on-track. So probably there's not much sense in doing the REMPLISAGE, but that's, well, my opinion. Regarding the location, yes, it's true that if it's more medial, the risk of redislocation is larger. And like Berta said, well, probably in those cases, I would not consider a REMPLISAGE. So I would go for a bony augmentation or a Latergé. Hi. My compliments to the panel. Outstanding session. As someone who does a lot of arthroscopic Bankart and open Bankart and open Latergé, and looking and getting towards the end of my career, I really do think that a real anatomic solution arthroscopically is what's gonna happen. And so I'm a little bit more in line with Dr. Taverna. But my, and that's a comment, that we will be shuttling bone in and repairing it anatomically. We won't have to do a Latergé. I think it will become obsolete. And I do a lot of them. I do a lot of open Latergés. I like the operation, but there's a steep learning curve. That's one comment. The other comment is we're not quite to Dr. Taverna yet because it's not really a transportable technique yet. He's an incredibly skilled, you all are very incredibly skilled surgeons. And so there's a lot of people in the United States that do instability surgery, and they're still doing too many arthroscopic Bankarts. I do a lot of revisions in that setting. My question though, and there's just comments, my question is no one talked about open Bankart in this group. And it's an entirely different operation than an arthroscopic Bankart. And you can do it with a subscap split, and you can also do it with a tenotomy and repair it, and you can do a beautiful capsular shift on it, the Bankart, and you can address subcritical bone loss with an open Bankart very, very effectively. So I do think personally, and I know that in this country, people are revisiting open Bankart for that subcritical bone loss patient, would not disagree with you at all about 17, 18, 20% about putting bone down, but it's that in-between group. And I'm just curious, do all my European colleagues hate the open Bankart? I know that Philip Moroder is still a strong proponent and had a beautiful 20-year follow-up in his patients. So that's my question. No place for an open Bankart, or is there? I think I'll start, if you don't mind. I think it's an invaluable comment you just made. I think it's very, very interesting, that comment you made. I think that depends a lot on the habit you have and the school you have. Everyone knows that in the US, it's more common, and the tradition is to do the Bankart repair. You all started with the open repair and then moved to the arthroscopic. It's true that it's a different procedure. You can easily correct a Hagel lesion if it's present, unlike in an arthroscopic procedure, which you can use for the correction of the Hagel lesion as well, but it's not as easy and straightforward. So it's definitely very useful. But again, it's a question of being used to it or not, and your school. I can talk for myself. I did my training in Portugal and also in France, so I'm probably biased. And I feel, I don't know if it's unlike you or not, but I feel that the Lataget offers an excellent solution to the patients. I mean, the rate of success is very high. It's true that there's an important learning curve, but it's a successful, very successful procedure. So we may have different points of view according to your previous habits, but thank you for your comment. And I, if, am I allowed to make one more question? This is for Dr. Taverna. So you've gone to Xenograft, and I'm impressed at the union rate and the incorporation. And do you have any explanation why Xenograft would be favorable? I would think it would melt away. Good question, and we were very much surprised about the equine bone we are using for this, because there is no resorption. Even if you're no good and you don't compress properly the Xenograft against the glenoid, after one year, you do your CT scan, and the graft is still there, 100%. Two years, it's still there. If you use another, any other bone, even autograft, they will be fully resolved after one year. The explanation is that probably the equine bone is not attached by the enzyme, human enzyme, and so remain there as a biological prosthesis to support our soft tissue repair. And just, Bob, if I can say something about the reproducibility of the bone block, I would say that all the people who are coming to visit and they want to do that at home, we have a very high percent, close to 100% people who are able to reproduce it, and not necessarily are surgeon that they are skilled and used to do a lot of the procedure. So actually, the bone block is not really not reproducible. You have to learn only one thing, to place properly the guide, and then everybody can do it. Thank you. John D. Kelly, I had a, it was a wonderful session, obviously. I've been torn at the idea of using knotless anchors, shuttling bone, Dr. Deverna, antegrade. Have you thought about that? Is that crazy? Is it fixation too weak? Instead of going transglenoid, has anyone on the panel thought of that idea of taking a bone substrate and just using knotless antegrade? You mean not using any anchor? Yes, there is the possibility to do the circulation, to do that. I think there are some advantages and some disadvantages. Disadvantages is that you want to fix properly the graft against the bone. You have to pull on those sutures so much that you can easily break the graft, more easily than using the buttons. And so that's my choice for the button. Gracias. Frank Cordasco, New York. Really a fabulous session, and the wonderful interaction internationally. I think we all grow from that. So I appreciate all of the presenters and speakers, really thoughtful, thoughtful work. I wanted to follow up on Dr. Arciero's comments because in this country, if you look historically from 1990 through to the present, there's been a groundswell of enthusiasm for arthroscopic techniques. And for those of us who trained earlier, we learned the open technique first. So I'm just gonna frame this comment. It's a comment, not really a question, to give you some sense of my own situation. So in 2022, 69% of my cases were performed arthroscopically for stabilizations, and that included advanced arthroscopic techniques, posterior inferior capsule labor repairs, double row anterior suture fixation, and REM plissage on occasion. The vast majority of those cases, I added a posterior inferior labor repair. There were some REM plissages. 22% of my cases were bone augmentations. The vast majority, coracoid transfers, classic Latter Jay, some distal tibial allografts. And then 9% in the middle were open stabilizations. So it wasn't the majority of my cases. And as Dr. Arciero said, I do a lot of all of those cases, but I still have a place for open stabilization. And I just, I'm stating that because I think it helps both to do the medial capsule labor repair and the lateral capsular shift. And I was taught by Dr. Neer and Dr. Villiani and others, and I still think that there's a role for that. So I'll give you one simple case. Cornerback in the NFL, they play on the defensive side. Maybe they have one frank dislocation in preseason. They play through the season with a harness or without a harness. They have two additional subluxations, not frank dislocations. They come to you at the end of the season to be repaired. Minimal bone loss. We would all agree that they do not reach a meaningful level of bone loss either on the glenoid or the humeral side. So for me, that case is an open stabilization. Cornerbacks hit people very hard with high velocity. And you can try and do an arthroscopic procedure and throw everything at it. Arthroscopic remplissage, multiple anchors anteriorly come around the back. In my view, and this is experiential, I think that patient is going to do much better with an open stabilization the way Neer, the first three presidents of the ASES, Neer, Rowe, and Jobe all taught us how to do great open stabilizations. So I think you're right. Part of the onus is on us to educate our trainees how to do that operation, but we shouldn't throw the baby out with the bathwater. I think it does play a role. Once again, fabulous work. I also agree with what Dr. Arcio said. I think ultimately we will move to bone block fixation to be performed arthroscopically as we get better and better with instrumentation. I know some people here, J.T. Tokish and others are working on cerclage or metal list fixation. So it's really a wonderful field and thank you all for allowing me to make some comments. Thank you very much for your comment. And I just wanna say that of course there is a place for open bunker. The shift you can do open to the capsule and the ligament is not the same you can do arthroscopically. I just think that in many patients that there is some overlapping of the techniques. In some patients it's good bone block in Latentia as well. Some other could be a good open bunker and maybe bone block, or in some cases maybe still bunker repair arthroscopic is a good one. So definitely there is not consensus on the techniques today, but we're trying to improve. So one final question or comment. No, it's gonna be a question, it's not a comment. It's not gonna be a litany, sorry about that. So I was intrigued about the biceps transfer or sling. How many cases have you done? And I have two questions. And have you had anybody have biceps pain or biceps issues after that transfer? No, in fact I only have a follow-up of one year or so, less than 10 patients. There are several techniques that can be used. So probably those cases of long biceps pain can occur depending on the technique and also on the length, the distance to which you free the long biceps. So it should go as far down as you can, close to the pec major or close to it to avoid tensioning the long biceps. So that's the main concern. In my cases, despite the short follow-up, I have had no major issues, no major complications and no re-dislocations. But it's a new technique. There are only two reports as far as I know on clinical results. One of them with one year follow-up of 15 cases with a 6% re-dislocation rates and another one on 22 patients with a 13% re-dislocation rates from the authors of the report. Authors of the, well, not really authors, but some that made it an established technique from France and from Switzerland. So there's still a lot to know about this, of course. And I must say that I'm a Latage fan and this is just for specific patients and the indications are still unclear. I've used it in the last two years. Definitely there are no patients which reports patient because of the biceps fixation. My main indication is when the anterior soft tissues are not of good quality and there is no major bone loss. And I think it's really very useful in order to reduce the recurrence rate. But definitely no pain after this operation. So I will make one comment. This is something I've learned from my European colleagues. You definitely look at the soft tissue quality. Exactly. Okay, we don't tend to look at it. I mean, we'll say, oh, gee, that labrum doesn't look so good. But you really look at it. And I have learned that from you guys to actually look at the quality of the labrum in the capsule because, as you know, they can be really different. This is a subjective, let's say, estimation definitely, but you can evaluate and estimate the soft tissue quality between patients who had 10 dislocations in comparison to patients who had just one dislocation and you can estimate the difference. So in cases that the soft tissue quality, it's really not good, it's a good indication to augment your Bankart procedure with the biceps. The other question I have is again for Dr. Taverna. So you do a Bankart repair over the bone block, that you repair the labrum and capsule on top of it. How do you be sure that when you put your anchor in that you don't cut those button sutures that are going out the back? It would seem to me that that could happen. Oh, that can happen very easily. That's why we do, we place the suture anchor before we take off the metallic sleeve. So if you touch the sleeve, you know that it's in a good position. So you change, you put all the suture anchor, now I'm using only soft anchor, so I retrieve the suture out of the posterior portal and then I go on. And then at the end, I just use this. Okay, this was a final statement. We have to finish now because you're slightly over during the session, but thank you very much to all the speakers and to the audience as well for the really nice discussion and enjoy the rest of the Congress. Thanks a lot.

REMPLISSAGE technique

Hill-Sachs lesions

shoulder instability

bone blocks

soft tissue quality