Good afternoon, my dear friends. Welcome to our current session. It's SLARD with AOSSM. Today, we are going to talk about the short-length stability. And we have four speakers from different countries of South America. We have Dr. Felipe Balbuena from Colombia, Dr. Fabricio Favela from Mexico, Christian Lozano from Peru, and Fernando Lozada from Venezuela. They are going to give the experience in South America. I'm going to make some, a little presentation about the bunker repair past, present, and future. As you know, Dr. Pertis was the first physician that describes the capsular shift in shoulder stability. But it's Dr. Banker in 1923, the pioneer of this technique. He established the stability of the glenohumeral joint without sacrificing the native joint movement. As you know, Dr. Banker published his first 50 patients in 1957. He says that 50% of these patients have less than 10 degrees of external rotation deficit. Six years later, Dr. Rowe in 1963, he published three times more than Dr. Banker published. And he says that 90% of these patients have good and excellent results. On the 80s, the open pressures were gone and the inferior capsular shift were well done. That's why the open bunker repair in this time report a success rate more than 90%. As you know, the open bunker has advantages. The access to bipolar defects, low recurrence in high-risk population, but its advantages are incision size, external rotational decrease, and sub-scapular damage. In 1993 is the year that Banker's thoroscopy, as you know, 70 years after Dr. Banker published his first article. Seventy years is a very long time. The thoroscopy Banker has its advantages, improves the vision glenoid level of patient, no sub-scapular lesions, and the incision size is small and only have the disadvantages are the learning curve and the high cost. On the 80s, the arthroscopy procedure had the high failure rate in the early series because the technical modifications weren't done until 2005 with the new devices and the new anchors, as you know. From 2000 to these days, there is a significant increase in arthroscopy surgery. However, you can see that there is a high failure rate after soft tissues bunker repair. It happens that the concept of bunker repair is not the same of labrum repair. Because at that time, they use one or two anchors easily failed or inadequate ligament tensioning. But right now in the present time, we use from three to five anchors and it's a better solution of the patient to repair these lesions. It's in 2007 that Yamamoto Itoi speaks about on-track, off-track concepts. That is a modern way to objectively evaluate the glenoid bone loss and the HHS lesions, which aids in the decision making at the present time. As you know, there is no consensus, but there is an algorithm with surgery to perform. Right now, less than 10% of glenoid bone loss, the indication is arthroscopic bunker. We have a great song, as you know, as you can see in this image, that you can perform an arthroscopic bunker plus re-implicize or open later jet. If you have more than 20% of bone loss, you do it open later jet or open later jet plus bone blocks. The future, as you know, is based on the innovations in surgical decision making algorithms to include virtual simulation models based on individual patient CT scan and MRI data. It's very important to take the development of artificial intelligence. The future of the technique is likely to continue to evolve and improve in a patient benefit way. I want to finish my presentation inviting you to our congress. The regional congress is going to be in Santiago, March 25. We are going to talk about cases for young orthopedic surgeons. And the international congress we're going to have in Lima is going to be on March 26. Thank you. Right now, I'm going to invite Dr. Felipe Balbuena from Colombia. Thank you, David, and thank you to the academic committee for this invitation to talk about anterior shoulder instability and when anthroscopic bandcard is not enough. These are my disclosures that you can see in the meeting web page. We know today that anthroscopic bandcard alone remains with high recurrence in some people. In some studies, it's as high as 40 percent. So we have new surgical methods and new technologies designed to improve these outcomes. On the other hand, the current understanding of critical and subcritical bone loss continues to evolve, and we don't have consensus in the searching or addressing the bone loss in the shoulder. Proof of that is the many papers that have been published in the last 14 or 15 years, beginning with the presentation of the EC score by Pascal Wallo in 2007, and the on-track off-track concept by Giovanni Di Giacomo, Eiji Toya, and Stephen Burkhart. After that, the proposal of how to address this on-track off-track concept in 2014, and then in 2020, the proposal to incorporate the on-track off-track concept in the EC score by the G-team's score. And of course, additionally, we have too many papers that are designed to validate or evaluate these different scales. For example, this is a paper published in 2015, and you can see if you have four or more points in the EC score, you can have a recurrence as high as 70 percent, but also this paper shows that each one of these factors can be a potential independent risk factor for recurrent dislocations, meaning that maybe if you have one of these recurrent risk factors, you can have a recurrence as high as, say, 60 or 70 percent, and maybe you need to go for another surgery, like artery surgery. So when is satroscopic bunker enough? This question is another concern, because there is a problem to define it is enough for what. It is to prevent new dislocations, or to prevent instability symptoms, or maybe to improve satisfaction scores, or just to support return at the same level. And we know today that there are associated factors, and you can split into different groups. One of these is the patient characteristics, like age, sex, hyperplasticity, and the participation in sports, and on the other hand, the anatomic status of soft tissue injuries, and the bone loss of glenoid, the heel sacs, and bipolar lesions. Let's see this paper. It is a systematic review and meta-analysis of more than 4,000 shoulders evaluated in 29 studies. In all of this group, the recurrence was 17 percent, but you can see in the right side of the slide that the first plot favors the presence of independent risk factor, the age below 20 years, the participation in competitive sports, the glenoid bone loss, and for more than one preparative dislocation, also the heel sac lesion. Besides the off track, the ALPS lesions, and a delay of more than six months to surgery after a first time dislocation. But also we know that there are other related factors, like dominant arm, hyperplasticity, the slab and rotator cuff there, and the presence of less than two anchors in the surgery. But maybe this relation is not as strong as we thought before. And we also know today that collision athletes is a high risk group. For example, these two papers recommend that in this case, maybe you need to go for another surgery, like an open bunker. Because with the open bunker, instead of an arthroscopic bunker, you can get better outcomes with increase of sports return, and you can diminish the recurrence rate and reintervention rate. Also, these are two papers published last year that recommend that in this case, special consideration in overhead and collision athletes, you can go with additional re-emplisage to the arthroscopic bunker, and you can improve rate of sports return at the same level. Now, how much bone loss is considered too much today? This is a case control study presented last year, and you can see in the recurrence group and the failure group, that the volume of the glenal bone loss was 9%, meaning that maybe we need to redefine the concept of subcritical bone loss. But if you add a re-emplisage to the arthroscopic bunker, you can reduce rate of recurrence and reinterventions in bunker procedures, like this randomized control trial demonstrates. Also, re-emplisage benefits in engaging heel sacculations, I mean, the off-traculation. You can see in this meta-analysis that in the forest plot, there is a favor to the bunker plus re-emplisage to diminish the dislocation rate and the recurrent instability. But if you don't do re-emplisage, you can have a 4.5-fold higher risk to have a recurrent instability after the surgery. Also, re-emplisage benefits on track and subcritical bone loss. And this paper demonstrates that you can reduce sense of apprehension and increase the rate of return to sports. You can see that the group of bunker plus re-emplisage don't have re-dislocation rate after final follow-up period. And there is a new concept in the last years. There's a near-track relation. You can see in this paper that with a value below 8 millimeters could be a predictive of failure. But in this case, you can go with a re-emplisage plus the artesuco with bunker. You can see in this paper, again, published last year, that in the group of bunker repair with re-emplisage, you can reduce the failure rate from 66% to 4.2% with a DTD, distance to dislocation below 10 millimeters, and in the contact athletes. This year, we have a new concept is to redefine the critical humerus bone loss. It is recommended to not only assess the heel sacs in the medial to lateral position, but also to the cranial caudal position and in the inferior extension. And maybe you need to draw two different angles, the lower edge angles and the sagittal midpoint angle. If you have more than 90 degrees and 60 degrees respectively, you can have a OATS radio, 4.8 and 3.3 respectively, to be a record in shoulder instability after surgery and include even in the daily living activities position. And if you, in this case, have also glenoid bone loss near to the subcritical bone loss, your records will be as high as 70%. So when is artescopic bunker not enough at 2024? Definitely in competitive sports and in collision athletes, in the bone loss with glenoid more than 9.4% in the heel sacs lesion, maybe in the any size, in the off-track lesions, in the on-track with DTD below 8 millimeters. And in this case, we should consider the following, or a remplaceage or DAS, or maybe we need to go for another surgery like open bunker or an anterior bone block or a lateral jib. Thank you. Thanks, Dr. Valbuena. Right now, we invite Dr. Cristian Lozano from Peru. He's going to talk about complications of lateral jib. Okay, thank you for the invitation. We are going to talk about the complications of LaTarGET, how to avoid and how to manage the complications. My disclosures. So when we talk about LaTarGET, we are going to talk about instability. This is a procedure that we can perform by two ways, open or arthroscopic. So in both cases, we have many complications and the complications that we have in both procedures are recurrent instability, hardware related complications, graph related complications, nerve palsy, infections and hematoma, and intraoperative fracture of the bone block. So we have to talk about the complications in the short term and the long term. So in the short term, we can identify two types of complications, basically in the open LaTarGET and the arthroscopic LaTarGET, and both are graph complications and hardware complications. But in the arthroscopic LaTarGET, the graph complication and the hardware complication are similar. So we can say that in both cases, we have nearly 6% of complications in both procedures. And in the long term, we have different complications. If we talk about this study, it's a review article that more than 10 years follow up, and we have three types of complications. Residual pain, and the other one is arthritis of the glenohumeral joint, and finally recurrent instability. But if we talk LaTarGET, LaTarGET is a good option for instability with bone loss, and if we talk LaTarGET in both ways, so open surgery and arthroscopic LaTarGET, in both cases, most of the patients can return to the game, even in 85% of them, and 75% of the persons that was performed with the LaTarGET procedure, open or arthroscopically, return to the sport even in the same way that they have before the accident. So after the if we talk the the major complication of the LaTarGET in the long term, we have four scenarios that we have to keep in mind to resolve them. They are that we have a good graft that we have to refix it. We have the other scenario that is a no, the bone block is in a bad condition, so we cannot refix it. The other scenario is that we have a persistent instability, and the last one is hyperlaxity of the patient even when we have performed the LaTarGET procedure. So how can we solve these scenarios? The graft failure is unsuitable for repositioning due to no known fracture or resorption. The free bone block is a good option for this type of complication. The other scenario that we have a good bone block that is in good condition, we can consider refixing it. The persistence of a possibility of track lesion, heel sac lesion, the bone block, free bone block is a good option, but we have to keep in mind that in this case, we have to add a replacement procedure too. And finally, when we have hyperlaxity, the soft tissue procedure such a capsular labral repair and capsular application have been used in the setting of a failed LaTarGET, but in most of the cases, we have to add a soft tissue reinforcement of the anterior capsular with tendon allografts. So to take home messages, records of anterior shoulder instability after a failed LaTarGET procedure can be successfully treated by specifically addressing the cause of failure. The correct repositioning when we have a good bone block the free bone block even adding even it is a good option when the coracoid cannot be repositioned or the glenoid tract has not been restored due to a large or middle of track heel sac lesion. An extracticular capsular reinforcement with an allograft for the patient with hyperlaxity is a good option in bone defects. Thank you. Thank you, Dr. Lozano. Right now we invite Dr. Fernando Lozada from Venezuela. He's going to talk soft tissue augmentation techniques in anterior shoulder instability. Hello, everybody. Thank you for the invitation to discuss topics, interest topics, around shoulder instability. We're going to speak about shoulder instability treated with dynamic shoulder stabilization. My disclosure, what is DAS? DAS is a tenodesis of the long head of the bicep to the glenoid defect through a sub-scalp split to treat shoulder instability with subcritical bone defect. We know that bancal remplisage in the long-term follow-ups have shown a high rate of failure can be between 15% and 25%. And we know that patients with glenoid defect around 13.5% have worse outcomes with bancal remplisage. On the other hand, we know that Latarjet can be an effective procedure to treat glenoid defects, patients with glenoid defects. But also, how Christian said, have a high rate of complication between, depending on the hardware, with the hardware, with the graft resorption, and doesn't have, is about the learning curve is still with this paper from Mauricio Largarcha, we can show a complication until 11 years after of experience. So, we can have some group of patients that can be a candidate for treating with DAS. Patients with glenoid defect between 15% and 10% and less than 20%. And when we think that bancal can be, maybe not be enough, but a bone graft procedure or Latarjet can be too much. So, why DAS? DAS, because you still can do a bancal repair. You can treat a slab at the same time. You can avoid scapular dyskinetic cutting, cutting the pec minor. It's still an all arthroscopic technique. You don't use hardware. And you keep the sling effect. Why the sling effect? Because it's demonstrated that it's a powerful effect that for stabilize your shoulder. This technique has popularized by Alex Leatherman and Philippe Collin. And they have demonstrated that the DAS has a very powerful posterior hip translation. So, cannot be indicated in patients than bone defect more than 20%. Because it's going to put your head too much posterior. So, this kind of technique, DAS or Latarjet, doesn't have to compete for the indication concerning to the glenoid defect. Or indications, anterior shoulder instability, glenoid defects between 10% and less than 20%. Slab associated is very important. It's a good indication patient with a slab, hyperlaxity patient, and moderate activity level. There is many ways of doing it. You can do it with all shooter technique, all arthroscopic technique, like the group of Clara Campos Acevedo. It's only reconstruction. You can do it with button, like a technique from Jose Carlos Garcia. And you can add remplissage if you have a heel sacs. We're proud to be a part of the surgeon that are trying to provide this technique for this kind of patient with glenoid defect around 13%. And we learned the technique directly from Jose Carlos Garcia in Sao Paulo, Brazil. We developed instrumental, especially instrumental with adjustable button. So, I can show you a little, quite rapid, the technique. You can identify, you have to identify, like always, your bank relation and prepare your glenoid defect. From anterior portal, standard portals are used in this technique, all inter-articular. You use three portals. You identify how you're going to be the split on the subscap. And you don't have to be like a formal split. You just open it at the level, at the medial level of the subscap. You can secure your path of the tendon with radiofrequency device. You take down the rotator interval and make sure that you cut all the liberate or the bicipital groove. And you make sure that your tendon can go medially freely. After that, you take your tendon and do the biceps tenotomy and take out and prepare it like a standard way of preparing. You measure your tendon. You can put the cannula in the anterior portal. You pass the guide. You drill a bone socket of 20 millimeters because it's an inlay technique. You pass your button to the posterior cortex of the glenoid. And you feel it when it's posterior. You take inside the tendon. And you can help it with any kind of instrumental. And that is going to look like that. When you are in this path, you can go internal and external rotation. And the split, it goes a little bit open. After that, you can do a standard bunker repair. Sometimes you can put an anchor superior and one anchor inferior. You can follow your patient, we follow our patient with ultrasound and we can show how the tendon goes immediately through the split of the subscap and insert the glenoid defect in the anterior inferior part. This patient, you saw that we did a remplisage too, and with this technique we think that the tendon is a very rigid, strong fixation. You can move the scapula when you pull out the sutures. For our trend, a bunker remplisage for patients with less than 5% glenoid defect. That's a remplisage for patients with between 5 and 10% of glenoid defect. If they have a slab, it's better for us. And open lateral with glenoid defects more than 20. You have to take account in the activity level and if there is hyperlaxity. Thank you. Thanks, Dr. Lozada. And now we invite Dr. Fabrizio Favela from Mexico. He's going to talk about failure-shortening instability surgery, causes and treatment. Hello, good afternoon. Thank you for having us. It's an honor to be here. All right, I'm going to talk about failed shoulder instability surgery. My name is Fabrizio Favela. I'm coming from Monterrey, Mexico. I have nothing to disclose. So I want to start with a definition of what is failure in shoulder instability surgery. It's the recurrence of glenohemeral instability after vascular reconstruction. Patients with persistent apprehension and those with pain in the throat movement can be included. Two main causes of failure can be identified. One lack of understanding and recognition of the structural injuries, and because of this, we made a wrong procedure. In the 90s, vascular rectoscopic repair became the standard of treating this instability. But in recent years, we have realized that on its own, it cannot stabilize all injuries. Because revision surgery has a poor result, we must focus on preventing failure. This paper from Pascal Ballot and his group, Risk Factors of Recurrence of Shoulder Instability after a rectoscopic vascular repair from 2006, Level of Evidence 4, they studied 91 patients treated with reinsertion of capsular-labral complex with anchors. Three to six months of average follow-up, they found 50.3% with recurrence of instability at 17.6 months, and they found that the risk of recurrence were related to bone defects. And the combination of bone defects and hyperlapsity increased this risk to 75%. In the patient history who had recurrence, the average age of patients with recurrence instability is 23 years. Patients over 40 years, we must suspect for rotator cuff tears. It's very important the type of the sports, the level of competitions, and if they have previous surgery, because we can find weak deltoid and loss of capsular structures. In the physical examination, we must look for signs of hyperlapsity. For example, in patients with EC anterior subluxation or persistent sulcus in external rotation like in this photo. You can see in the left the sulcus, and it's persistent with external rotation. Also in the wrist and the elbow, we can look for signs of hyperlapsity. In the X-rays, we can find bone loss in the glenal side and the humeral side. For example, in the image of the right, you can see the huge heel subluxation. And in CT scan with reconstruction, we can find bony bunkers, and we can measure the length and the depth of the heel subluxation also. And we can know if this heel subluxation is engaging. So what about bone loss? We know that the incidence of bone loss is around 60% in the physical dislocations, and it's raised up to 93% in cases of recurrent instability. We have 20% recurrence after arthroscopic bunker in the presence of less than 50% bone loss, and 0% recurrence if we do bunker plus remplisage. So what treatment options we have in heel subluxation of tract lesions? We can ignore the injury, but this leads us to failure. We can do non-anatomical procedures. We talked in the previous lecture, later yet, we can do remplisage, rotating osteotomies of the humerus, tightening anterior structures, or anatomical procedures like osteoarticular allograft. Heel subluxation and arthroscopic solution for the engaging heel subluxation, initially described in 2008, is an advance of capsule and infraspinatus designed to fill with capsule and tendon to prevent hooking, to prevent engagement. Fixing with anchors, and always, always is a complementary procedure, never is performed alone. So we started doing it in 2009 with the original technique. First we started in beach chair, and now we prefer lateral decubitus. So we start exploration under anesthesia, like these examples. And then we make an exploration intra-articular, so we can define all the lesions, and we can see how in external rotation and abductions that heel subluxation engage with anterior rim of the glenoid. So we start with vision in the anterior superior portal, and with canula in the posterior portal, we start putting our anchors, we put one anchor inferior, and then another anchor in the superior part of the heel subluxation, double loaded. And then we recover these sutures through the tendon, it's very important to make sure that we have tendon, not only capsule. And then we go in the anterior aspect of the lesion, so we perform a traditional banker repair. Then when we finish the banker repair, we finish the procedure, tighten the posterior brain plisage, like in these videos. We have this study, Recurrence of Shoulder Instability After Orthoscopic Surgical Stabilization with Brain Plisage and Banker Repair. This is a study conducted by Dr. Daniel Figueroa, ex-fellow in San Pedro Garcia Nuevo Leon, in 2020. It's an intervention, prospective, and longitudinal study, 11 patients from November 2018 to December 2019, follow-up one year in lateral decubitus, two double suture anchors, and our conclusion was no recurrence of instability and no external rotation deficit. So to take home, let's add brain plisage to the banker, it works, reduces the recurrence, low complication rate, and minimal loss of movement. And we need to focus on preventing failure. Thank you so much. Thank you. Now we are going to have the moment of questions and answers. I invite all the speakers to come here, please. I would like to start asking Dr. Lozada, why do we have to do that technique, that DAST technique? Why? What's different from the techniques that we are improving, we are doing right now? Like you said, David, in your conference, there is a gray zone. In patients, we'd have like 10% of glenoid bone loss, then the studies in the long-term, you have a high recurrence rate. So with this technique, biomechanically, the head goes posterior in a dynamic way. So it can be a technique that is or arthroscopic, you don't use hardware. If the patient have a slaughter, you can treat it at the same time. So have benefits from the bunker. I understand that we need more long-term follow-ups, but it shows that the patients that have no recurrence, this patient have five years of follow-up, but we have some groups that have more patient with more follow-up, and the results are pretty good. And there is another term that it goes pretty well in patients that have hyperlaxity and patients with moderate activity level. If the patient, for example, is a collision athlete, have glenoid defect near 20%, I do a lot of it without thinking, but that's my focus. Okay. Dr. Favela, in your talk, what's that difficult that you find when you improve your technique that you described a minute ago? The first thing that we realized was the steps of tying knots in the lesions. There's one time that we start doing the remplisage and then tying the knots. But when you do that, the remplisage makes the space anteriorly less. So you need to first put the anchors in the remplisage, not tying, and then you need to fix bankart, tying, and then go back to tying the remplisage, and that's the finish. We find that in the hard way. Some questions of the audience now? Dr. Lozano, what's the most common complication in the latter-stage surgery? As I told you in the presentation, recurrent instability is the most common in the long-term. But if we talk recurrent instability, we have to recognize, as I told you, four scenarios, that you have a good bone block, a bad block, you have off-track heel sac lesions, and the other is that you have a patient that has a prolapsity that you did not recognize during your exam, and you have this problem, and there's soft tissue around the joint that does not help you to maintain the joint in its place. So you have to recognize that four scenarios. Okay. The question for all of you, what's the time that you make your rehabilitation? Because it's very important, the rehabilitation. Dr. Lozano, how is your rehabilitation when you make the later-stage technique? For the later-stage technique, I prefer to wait usually one week after the primary surgery, keep the arm in a sling, and after that, we start the rehabilitation, yes, passive motion, and after the six weeks, you can do whatever you want, but strength after the three months. Dr. Lozano? Three weeks with a sling, and passive for around six weeks, and three months for strong, and return to sports six months. Okay. Dr. Felipe Valbuena, how do you make your rehabilitation in your patients? You mean in an arthroscopic bunker, do a strong massage? Yes. Yeah. We try to put the patient in a neutral sling for three weeks. After two weeks, we can begin with the passive motions of shoulder, elbow, and the wrist. Maybe begin with the strong forces after six weeks, but maybe we need to consider to evaluate the patient with some specific tests previous to the sports return. Dr. Favella, do you have something different? No, pretty much the same, yes. Four weeks in a sling, and then start six weeks active movement, yes. Okay. When you have a patient with a shoulder dislocation, and it's athlete, that's the big problem that most of us, we have. Do you change your technique, or the bone, the glenoid bone loss is important for you? Dr. Favella? It's very important, the bone loss, because it depends how much bone you lost, the procedure that you are going to do. So, if you have less than 20%, I can do the bunker repair and re-emphasize, yes. It's very important, the bone loss. Dr. Lozano? Yeah. It really depends on if the patient is a collision athlete or not collision, and if they practice overhead activities. Maybe I would perform a latargete, or maybe at the block in the instability problem with less than 15% even, because the major problem that we have is the recurrence. So, the soft tissue isolated is not enough. Dr. Lozano? If you have a patient with glenoid bone loss 15%, do you make DAS, or maybe another technique? We have to take in account the activity level, what kind of sport you do, but we start to do in this technique of DAS, and we can elevate the tolerance of the glenoid defect, and not over, under my perspective, over indicate the latarget procedure. This is still an arthroscopic technique. You can call it a bunker plus if you want, but it biomechanically can add something strong to establish a shoulder in a sport activity patient. Okay. Dr. Valbuena? Okay. In the case of 50% of bone loss, maybe I prefer to go for anterior block because of the size of the defect. Maybe latargete could be a good option, but it depends of the size of the coracoid process of the patient. Maybe I prefer to go for anterior bone block. Okay. In the audience, how many of you do the DAS technique? Something? Some of you make the DAS technique? Raise your hand. Nobody? Okay. Why we have to change our mind, Dr. Lozano, to use the DAS technique? I'm not the best person to say it. I know I don't have a high volume of patients, but I already discussed that directly with, for example, Alex Leatherman. You know the latargete have some complications, and bone block procedure have some complications. It's already demonstrated in the literature that bunker have a high rate of failure. So, biomechanically, it can be an option, but I am waiting for more long-term and more group of patient. Because of that, we try to do all our patient that has heel sash lesion, we add rample sash to our DAS. That's our perspective. It works for you. Good. Yeah. Okay. Dr. Felipe Agüero, in your practice, how do you assess the bone loss? How do you do? I prefer to use CT scan with 3D reconstruction, and I use best circle proposed. And if I need to measure the heel sash lesion, the heel sash interval, I prefer to use the concept of DiGiacomo, Egitoi, and Stephen Brugger, and summarize this measure. Okay. Some of you still use the ECS score? No? No? G-TEAMS? No? G-TEAMS, yes. G-TEAMS. Yeah, yeah, yeah. Done by Dr. DiGiacomo. Yeah, yeah, yeah. Do you use? No? Dr. Lozada? I prefer to use ECS score. ECS score? Dr. Lozada? G-TEAMS? Yeah, because the ECS score, it recommends more doing later yet, yes. So the G-TEAMS, less later yet, yes. I think so. Some of the audience use G-TEAMS score? No? ECS score? Nobody? Okay. Thanks a lot for the audience to be here this afternoon. This is a good experience for all the people that came from South America to give their experience. Thanks a lot. Thank you.

David Torres, MD

Felipe Valbuena, MD, MEd

Christian Lozano, MD

Fernando Lossada, MD

Fabricio Fabela, MD

shoulder instability

Bankart repair

arthroscopy

glenoid bone loss

Laterjet procedure

Dynamic Anterior Stabilization

surgical complications

artificial intelligence

patient-specific approaches