Ladies and gentlemen, please welcome your moderators, Drs. Carolyn Hetrich and Brett Owens. Hi. I'm Carolyn Hetrich. I just wanted to welcome you guys to the meeting on behalf of myself and Brett Owens. Just wanted to remind everybody about using the app. You can see the schedule and pick out the current session, look at the handouts if you would like, and do any polling if desired. You can also ask questions through the app. All the disclosures can be found on the AOSSM website, and so I'd like to go ahead and start off the meeting then with our first paper of the session, and it's looking at arthroscopic bank care repair for anterior instability by Dr. K. Hi, everyone. Thanks for having me today. My name is Jeff K. at McMaster University in Canada. I'd like to thank my co-authors, Drs. Bayworth, Bay, Coker, Malewski, and Kramer from Boston Children's. So we know that adolescent athletes that experience a primary anterior glenohumeral dislocation episode will have a high rate of recurring glenohumeral instability following nonoperative management, and evolving evidence on the topic has led to increasing rates of arthroscopic stabilization over the past two decades. However, the timing and role of surgery following a single dislocation episode still remains one of the more controversial topics in orthopedic sports medicine. Therefore, the purpose of our study was to identify prognostic factors that are associated with subsequent recurrent instability that require revision surgical stabilization following arthroscopic bank care repair in adolescents, and we paid a particular attention to the number of dislocation episodes sustained prior to the index surgery. In terms of the methods, the study was a retrospective review, including all adolescent athletes 12 to 21 years of age who had an arthroscopic bank cut repair for anterior glenohumeral instability over a 20-year period. Our event of interest was recurrent instability that required revision surgical stabilization. The data were analyzed using a survival analysis methodology with cost-proportional hazards regression modeling and Kaplan-Meier curves. Overall, there were 488 adolescents that met the inclusion criteria. The mean age of these patients was just under 17 years, and they were predominantly male. And what we found was that 86 of these patients required revision surgical stabilization for recurrent instability. These revision surgeries are depicted with their proportions on the right, and the procedures occurred at a mean of just over two and a half years from the index surgery. Kaplan-Meier curves were used to assess the cumulative rate of recurrent instability at each time point from the index surgery, with the rate being less than 3% at one year, up to over 15% at four years. And for those that had the long-term follow-up at over 15 years, it was 20% of cumulative risk of recurrent instability. After assessing numerous patient radiographic and surgical factors, there were five factors that met our criteria to be included in the final model, and these are the five factors. After running the model, the number of dislocation episodes prior to index surgery was the most important factor, both in terms of magnitude of the association and level of significance, with two dislocation episodes conferring a more than seven times increased risk of recurrent instability, requiring revision surgical stabilization compared to just one episode. And those at three or more dislocation episodes had an almost 11 times greater risk, both highly statistically significant. This translated into a 3% risk of recurrent instability for those with only a single dislocation episode, a 24% risk in those with two or more dislocation episodes, and a 33% risk for those with three or more dislocation episodes. The next most important factor was the presence of a Hill-Sachs lesion, and patients with a small Hill-Sachs lesion had a 2.5 times greater risk of recurrent instability compared to those with no Hill-Sachs lesion, and those with a medium to large Hill-Sachs lesion had a more than four times greater risk of recurrent instability. This translated into a 9% risk for those with no Hill-Sachs lesion, 22% risk for those with a small Hill-Sachs lesion, and 33% risk for those with a medium to large Hill-Sachs lesion. Age was statistically significant as well, with each one year decrease in age conferring a 20% increased risk of recurrent instability. And participation in contact sports was the last statistically significant variable, with those that participated in contact sports having an 80% increased risk of recurrent instability. Therefore, in conclusion, we found that the number of dislocation episodes was the strongest risk factor for recurrent instability requiring revision, surgical stabilization in adolescents, with a seven-fold increased risk for those with two dislocation episodes versus just one. The other significant risk factors was the presence and size of a Hill-Sachs lesion, younger age, and participation in contact sports. Therefore, our two clinical take-home points for consideration based on these data is that this may lend some indirect support towards the growing trend of recommending, or at least considering surgery for adolescent first-time dislocators, and that we may consider the role of the REMPLISAGE procedure or other adjunctive techniques in addition to the arthroscopic Bancart in the setting of these adolescent high-risk patients with Hill-Sachs lesions. Thank you very much. Thank you. Next, we're going to hear from Dr. Hintz, and looking at 20-year follow-up of Bancart repair. Dear Chair, dear auditorium, thank you very much for the opportunity to present our outcomes for 20 years after arthroscopic Bancart repair. I have nothing to disclose. Anteroskeletal instability, as we all know, is a common pathology, and especially in young patients due to the high rate of instability recurrence, surgical treatment is indicated. Following arthroscopic Bancart repair, the instability rates have been reported as 7% after short-term, mid-term follow-up, and as high as 31% after 12-year follow-up. There exists, however, a scarcity of data on outcomes exceeding 20 years. That was the aim of our study, to evaluate the clinical and functional outcomes, minimum 20 years after Bancart repair, and to compare these outcomes in the same cohort that was previously evaluated after a minimum follow-up of 10 years. We hypothesized that there would be a good functional outcome, but there would be high rates of revision surgery, instability recurrence, and re-dislocations. We included all patients who underwent an arthroscopic Bancart repair for the treatment of anterior shoulder instability between 1996 and 2002. All patients had to have participated in the previous study, and again, the minimum follow-up was 20 years. Patients with voluntary shoulder instability, bi- or multi-directional shoulder instability, neurological disorders of the upper extremity, or co-combined rotator cuff tears were excluded. We evaluated the rates of revision surgery, as well as dislocation and instability recurrence at follow-up, and in patients who did not undergo revision surgery, we also evaluated patient-reported outcome measures. Of the previous cohort, we were able to evaluate 83 patients, of which 16, so 19%, underwent revision surgery and were excluded from further analysis. The patients at the time of surgery were 28 years old. The time until follow-up was 23 years at median, and about one in five patients had a preoperative hyperlexity defined as a positive sulcosign. Surgery was performed after first-time dislocations, and only one-third of the patients, which is certainly something that's different today, and about 16% of patients had a previous surgery for shoulder instability. In patients who did not undergo revision surgery, the instability recurrence rate was 15%, and the re-dislocation rate was 11%, which increased from the 10-year follow-up. The first re-dislocation occurred six weeks postoperatively, and the latest first re-dislocation even occurred after 21 years, which is something that we didn't expect. The constant Murli score declined between the 10- and 20-year follow-up, but was above the age-adjusted normative value at both time points. The ASES score was excellent at both times. Comparing patients with and without re-dislocations, we realized that patients who had a re-dislocation had a slightly lower number of anchors that were used for the repair, and had patients suffered from a re-dislocation, the VAS for pain at rest was a little bit higher, and they had higher instability during activity and were less satisfied with the postoperative outcome. In a comparison between patients with versus without instability recurrence at follow-up, we saw that the patients with instability recurrence were slightly, the follow-up was slightly shorter. They more often had hyperlexity, and they more often had a previous surgery. Regression analysis showed that only preoperative hyperlexity was associated with postoperative instability recurrence, and that was with an odds ratio of almost seven. Limitations I would like to note is that preoperative imaging was not available, so we could unfortunately not evaluate glenate bone loss or Hill's X lesions. We only had the operative reports available who mentioned that bone loss was not apparent or minimal. Further, we could not assess the onset or progression of osteoarthritis, but as pain levels were low at follow-up, we assumed that even if it was present, it might not have been, like the patient didn't feel it or it wasn't significant. We could not evaluate the number of preoperative dislocations due to a recall bias, and the reason for and type of revision surgery were unclear. And last, there is a limited extrapolation of that data to current techniques because, of course, it was developed since. We have techniques available for atheroscopic remplissage, and also anchor systems improved tremendously. I would like to conclude that 20 years after atheroscopic bankout repair, nearly every other patient either underwent revision surgery, suffered at least one shoulder re-dislocation, or had a feeling of shoulder instability at follow-up. Patients who did not undergo revision surgery, however, had good to excellent shoulder function and low levels of pain and instability. A lower number of anchors was used in patients who later suffered a shoulder re-dislocation, and the presence of hyperlaxity was associated with an almost seven times higher risk for postoperative instability recurrence. I would like to thank you for your attention and would like to invite you for our course in Munich later this year. Next, we'll hear from Dr. Wong, looking at five-year outcomes of atheroscopic anatomic glenoid augmentation. Thank you so much. So we'll talk about five-year outcome of Bankart versus AAGR. So we just heard two very good talks about Bankart, some mediums and long-term outcomes. It's definitely the North American standard, got minimal complications, but long-term outcomes may not be as good as Latter-Jay. We do know that Latter-Jay is the gold standard for shoulder instability with bone loss, but it has other problems as well. AAGR, we've published our two-year data in 2020, has first 73 patients with minimum two-year follow-up and had very good outcomes, recurrence rates similar to the early results from Latter-Jay. And this was with our critical bone loss, suggesting it's as stable as a Latter-Jay. So we wanted to find out what the midterm outcomes of patients with subcritical glenoid bone loss would be compared to the arthroscopic Bankart repair. Our methods was a retrospective chart review. We looked at the recurrent shoulder instability with anything less than 25% bone loss treated with AAGR or Bankart with minimum five-year follow-up. Our primary outcome measure was the re-dislocation rate. We also looked at post-operative complications, revision surgeries, radiographic outcomes and reported measures. So all our patients from 2012 to 2018, 308 were considered. We analyzed. You can see why we excluded these people, but AAGR, 41 patients and Bankart of 31. Our patient demographics were actually very similar between the two groups. Biggest difference was glenoid bone loss. So more glenoid bone loss in the AAGR group, less in the Bankart as well. More revision cases in the AAGR group, as you can imagine why, and Bankart is less. Our results for re-dislocation, so this is five-year minimum, AAGR re-dislocation that first row shows 2.4%. In terms of Bankart re-dislocations after five years is 17.8%. And year on year, you see that down below is more and more dislocations in the Bankart group. In terms of complications, complications actually very similar except for hardware irritation. So AAGR group had five patients with hardware irritations of the screws, but no instability from that point of view. In terms of radiographic outcomes, we looked at the post-op glenoid AP diameter after five years on a CT scan showing AAGRs had remodeled back to a normal anterior to posterior dimension of a glenoid where the Bankart stayed roughly the same. In terms of progression to osteoarthritis, both groups were exactly the same with no further progression. For patient reported outcomes, the AAGR group and the Bankart group both had improvement in outcomes, but when you look at the percent that met MCID, those with an AAGR had more percentage that met MCID compared to those who had a Bankart repair only. Those who did not have a meet MCID for the AAGR group were really from hardware irritation because they had a revision surgery using AAGR or they had a recurrence afterwards. Those that did not meet MCID for the Bankart group really was mostly from a recurrent dislocation after surgery. So for discussion, when we compare this to other studies that have a five-year follow-up from Bankart versus really it's Latter-day because there's no other AAGRs out there, this is one of the ones published in 2022, 242 patients, mostly in Bankart group reported no report of bone loss, but the dislocation rate afterwards is very similar to what we report and improvement in patient reported outcomes also very similar to what we report. Two other studies, one by Boileau in 2014, another European group in 2016 also showed the longevity and failure rate over time comparing Bankart to Latter-day, again, very similar trend where our trend was 40% of dislocations happened after the first five years of follow-up for the Bankart group, similar to these two other studies. In terms of remodeling, we actually did show our data on remodeling. It takes about 6.9 months after you use screws with distal tibial holograph for a final remodeling of it. And this does show that at five years, our glenoid dimension is exactly what we expect at 30.7 millimeters from anterior to posterior. And you can see initially we tried to make supersized glenoids right when we started doing this distal tibial holograph technique. So that's why you have screws sticking out and that's why you may have some of these irritations. Since that time, we've actually done our anatomical study to show how big the glenoid should be is about 0.77, the height of the glenoid. And since that time, we now do our AAGRs in an isolated fashion where we have no more irritations than the past three years of reconstruction. Our strength of the study, it's a comparative cohort with midterm data. Limitations are of a retrospective design, missing midterm data, as usual for retrospective type of views, and our future directions for a randomized controlled trial, hopefully be able to present to you next year from AAGR to Bankart. So in conclusion, AAGRs at five years have a redistribution rate similar to a Latter-J. It has more stable than a Bankart repair at five years. Most common complication is hardware irritation, but most don't need surgery and can be mitigated with a custom graph size to represent normal, and there's no progression to arthritis similar to a Bankart. Thank you. Our last paper of the session will be from Dr. Hurley, looking at open Latter-J procedures in athletes. Thank you. My name is Owen Hurley. I'm a resident at Duke. I'm originally from Ireland, and I did this work in combination with Hannah Mullet and John Dickens, and that was a really fun talk by Evan Wong to follow, considering I'm also talking about five-year outcomes. So the open Latter-J procedure is a coracoid transfer, and it's been shown to result in high rates of return to play, low rates of recurring instability. As Dr. Wong said there himself, it's the gold standard for shoulder instability. But it is still unclear what factors are associated with long-term satisfaction following the procedure, as well as what patient's perception of their function is. So the purpose of this study was to evaluate the functional outcomes and recurrent instability of athletes five years after undergoing the open Latter-J procedure, and to evaluate what factors were associated with satisfaction and shoulder function as defined by SANE score. Our hypothesis was that they would have good outcomes, low rates of recurrence, but return to play would be a big factor for satisfaction in this patient population. So we did a retrospective review of patients who underwent an open Latter-J procedure in Dublin, and we looked at return to play metrics, as well as patient-reported outcomes. Of note, this procedure was performed open in all patients, and two-screw fixation was used. Multilinear regression models were used to evaluate factors affecting post-operative SANE and satisfaction levels. So overall, we had 143 shoulders, five professional athletes, 115 competitive athletes. The majority of these were playing rugby or Gaelic football, which is another high-level collision sport. Mean bone loss about 17%, about half had off-track lesions. So when we look at complications, firstly, 4% had recurrent dislocations. All of these were due to traumatic events, with four of them being tackling while playing rugby, and two of them in wrestling. Then the further re-operation is actually quite similar to what Dr. Wang showed with the DTA graft. We had some patients with stiffness. The one thing we noted in our series previously was hematoma was a problem, given these were big, well-built athletes. But this changed after we incorporated TXA into the practice. So when we looked at survival analysis for re-dislocation, about half of them occurred within the first year, close to the year mark when they were just getting back to returning to play. And then it showed to be stable over time. The return to play rates were high, 92%. Most of them getting back to the same or higher level, comparable to that found in the literature. And we had good patient report outcomes, low VAS score, high SANE score. Most patients had a high SIRSI score, indicating they were confident in their ability to return, and satisfaction was high across the board. So when we looked at single versus recurrent dislocation, we found no difference. But when we looked at primary versus revision stabilizations, we found a huge difference with revision stabilizations being associated with worse outcomes across the board. When we looked at satisfaction itself, we found pain and patient report outcomes were associated with it, as well as return to play, recurrent instability, and re-operation, indicating those who weren't able to return, those who had a recurrent instability event, or had a re-operation, were less satisfied at five years. Similarly, similar factors were found to be associated with SANE score and patient's perception of function, whether they felt they were good enough to go back to sport, how their pain level was, as well as were they able to return to play. So even something that happened, you know, four years ago or four and a half years ago in most cases, were they able to return still had an effect at five years, whereas recurrent instability didn't affect their own perceived function, but sleep disturbance did. So what we kind of said was recurrent instability factored into satisfaction but not perceived function. And it's an important return to play metric for these patients. And I also put up these outcomes compared to our arthroscopic bank heart repair series just so we could show a similar kind of cohort, although with less bone loss, just to kind of follow with what Dr. Wong already showed in terms of how they compare. There were some limitations. It's retrospective. There wasn't a control group, though we showed some at the end, and a lack of pre-op outcomes to compare the MCID. So in conclusion, there was a very high rate of satisfaction with excellent patient report outcomes, low rates of recurrent instability, and a high rate of return to play. SIRSI score, VASc score, RHO score, and ability to return to play were associated with both satisfaction and SANE score. And lastly, I'd like to thank my co-residents. Many of them are here today to support. So it's awesome working with you guys. Anyway, thank you very much. Thank you. Well, thank you very much. Four fantastic papers. Please come up to the microphone if there's any questions. We do have just a couple of minutes for questions. We're trying to get back on schedule. You can also ask questions via the app, so we've been checking that as well. So while you are all putting those in, I'll start with Dr. Kay. You reported on, I applaud you on your paper. You report just shy of 500 instability repairs over 20 years at a single institution, and that's spread amongst five surgeons. That's fewer than 25 a year spread amongst five surgeons. It's pretty low volume. Did you consider looking at surgical volume and how that impacted potentially the outcomes? Yeah, the volume was definitely impacted by the years. So the volume was quite low in the first 10 years of that cohort, because there was only two surgeons doing it in the first 10 years, and then that increased to five in the later 10 years. But there wasn't any difference in terms of the re-dislocation rate by the time. So the first 10 years was no different than the second 10 years. Yes, sir. Question to Ivan Wong. May I make a question to Ivan Wong? Hi, Ivan. Excellent presentation. According to your data, we have seen better results comparing bomb block procedures or bankruptcy compared to isolated bankruptcy. So according to your data, what do you believe today are the indications for isolated bankruptcy? This is my first question. My second question is that, do you believe that because of this osteolysis, there could be a risk of impingement with the head screws, or should we move to a different system of fixation? Very good questions, Emilio. So your first question, what is my indication for an isolated Bankart? For me, it's some isolated anterior labral pathology, because the Bankart does a very good job in doing that, ideally for a first-time dislocator. And your second question, am I worried about osteolysis around the screw heads? Yes, absolutely, I'm worried about the osteolysis around there. Hopefully I was able to show, but I think I was not able to explain it well enough. The first bit when we tried to do distal tibial allograft, the thought was the bone block, the larger the bone block you put in, the less chance of dislocation. And that's guaranteed the case. We had zero dislocation in the first five years, in fact, with zero irritation either in the first five years. But as the bone block remodels, what we found was everything remodels back to the native glenoid size. And I was trying to show you that in our five-year data, it shows that the glenoid goes back to roughly a 30-millimeter average. And if you put a supersized glenoid in, you can imagine those screws don't follow the bone as it remodels in, so those screws stay long, and that's what can irritate. Now that we've resized our glenoids to what they anticipate to be the same size, same as the other side, we have not had any of those problems anymore. Thank you, Ivan. One final question for Dr. Hurley. These all healed by x-ray. Did you ever get CT scans? Is that not part of your protocol? And then the second question would be, three required revision stabilization. What was the technique that was used for those three? So firstly, they were all x-ray. There wasn't CT kind of done as standard of care, but those were x-rays at six months post-op. And then secondly, allograft is harder to get in Europe. So while DTA is an amazing option, it's just not something that's really feasible there yet. So it was an Eden-Hemine procedure with iliac arrest allograft, which is extremely painful at the hip for those patients. So it's definitely not the ideal answer, but we just can't use DTA there as freely. Thank you very much. Well, put your hands together for this panel. Really fantastic talks. Thank you, gentlemen. Okay, so next we have two technique videos. The first is going to be Ivan Wong, who's going to share his arthroscopic DTA. Thank you very much. I'm privileged to go over this. So we'll talk about distal tibial allograft technique that we just finished talking about the outcomes. Sorry, it's not working. Thank you. Next slide. It should play automatically right after this. Okay. So theoretically, this is playing right now. I do this in the lateral decubitus position. That posterior portal is the most important thing to start off with. I really use a 3D reconstruction, a 3D model to go through. The view from the anterior superior portal is the key. I actually stay in this zone to look at the rhomphosage, to look at the hillsides, to figure out rhomphosage, and to do everything else. So when you first start with the surgery, we got to open the rotator interval. This is the difference with what goes on. We're actually doing a deltopec from inside out. So rotator interval to open, you want to see CA ligament that you see directly anterior here, and you want to see the conjoined tendon. So you can see we go past the subscap. Now if we pull the head back, we can actually see the conjoined. Once we open that up, we now want to be able to isolate our anterior superior portal. So this is the viewing portal, and this is the thing that we're going to do all the measurements from. The posterior portal should be nice and parallel to the face of the glenoid, because to be able to get the graft in from the front, we need a direct straight line. We're going to grab a traction stitch at the three o'clock position. This is going to hold our anterior labrum away and not get trapped in our graft. So the traction stitch at three o'clock also allows us to identify how high of a shift we're going to do with a bankart repair on top of the graft. Then you saw us do a liberating cut. We do an episiotomy of that labrum between the traction stitch and the biceps tendon, and then we free up all the tissue like we normally do with a bankart tear, except I free it from the medial side. Instead of with a bankart knife, I free it from the bone against the subscap muscle belly and free it all the way down to seven o'clock position. After we free it down to the seven o'clock position, we will be able to see how much shift we can get with that labrum. So you can see here, this is peeling it all the way down to six o'clock. Now I'm going to pull on that traction stitch, and you can see that traction stitch, because it's a recurrent dislocator, all that soft tissue is very soft, I can pull it all the way up and be able to identify if it's a one centimeter or two centimeter shift. I'm identifying where the middle of that glenoid bone loss is now. So I made just a slight mark on the anterior rim of glenoid, and now the goal is to make a perfectly flush line between the anterior rim of glenoid and the front face of the glenoid. We want nice healthy bleeding bone to accept the distal tibial allograft. Once that's freed up, we can do the releases. So these are the most important parts to be able to do this graft transition without doing a subscap split. And that's the benefit of doing this procedure, is we're not going to split a subscap to be able to get a graft into the anterior rim of glenoid with two screws. So here we go, we can free this all the way up to the base of the corcoid. You would do this when you're doing a Latter-day Procedure, when you exteriorize the corcoid, you have to take off all that soft tissue on the base and undersurface the corcoid. This is just the same way we do it arthroscopically. And it's cleared as done when you can get a switching stick on top of subscap and push it down so that you can reach six o'clock. Now that switching stick is superior to subscap and there's lateral to conjoined tendon. Once you can do that, you now have a straight line access from posterior to anterior to get what we call that Halifax portal in, and that's that anterior portal. The anterior portal is actually in the axillary fold, so it's very cosmetic to be able to get into that spot. Now we've got to get a graft prepared, and this is the benefit. We just talked about how important this graft preparation is because we want this graft to be exactly the same size when you match that up to the glenoid you're trying to reconstruct to be a native size glenoid. So this is sped up by 1.5 times so you can see, but we make those 90 degree angles. We want to drop this down to be 1.5 millimeters, sorry, 1.5 centimeter meat needle to lateral graft so you cannot fracture it. You got to make a nice size glenoid bone for it to remodel. And you saw me draw this trapezoidal shape because the whole goal of this is to get bone in contact from the medial side all the way to the other edge so that you have lots of bony contact for reconstruction. You make sure you do these saw cuts in here to be allowed to have this perfectly rectangular shaped graft to have those two screws placed in there to be able to make this parallel to the face of the glenoid. And again, all these cuts allow you to have the cartilage side of the graft perfectly parallel and flush with the native glenoid. This guide allows you to be able to hold it and control it inside a shoulder because you're going to put this through a three centimeter incision and it's going to be quite deep. The larger the patient, the deeper this gets. So this guide allows you to have full control intra-articulately even though you have a very tiny hole on the skin in the axillary fold. So once you put these top hats on, these are allowing to have a washer to be able to distribute those forces. These are screws to be able to hold this onto this cannula to place it in. And then we follow that same cannula trajectory all the way inside the shoulder to be able to get it into the right place. And when we follow those in with the half pipe cannulas to open up that space, you can see it can slide over the conjoined tendon. This is into that space, that's the switching stick is holding the subscap inferiorly. Now we can use that cannula to guide it into the exact right spot. So the manipulation of this, you only have to control the vertical alignment. So how inferior you translate it because subscap is going below there. And then how lateral it translates by rotating your hand. And you can alternate your screws to be able to make sure it well aligns perfectly and recreate that contour from anterior to posterior. So you can see I'm just rotating the hand just to be able to demonstrate to you how that happens. These all come with cannulated screws. So we drill over the top. As you drill it, you can get a measurement of how long those screws are. Once you have them all the way in, they'll compress and you can see with screws, you're able to compress away all the bone from the allograft bone to the native glenoid. There's absolutely zero space. And if you watch medially, there's no gap between the bone and the graft. And as you compress it, you can actually get it so that you can watch the cancellous bone compress. Now that it's all together, there's no gap between the graft and the glenoid. We can reduce the Bankart on top of the graft to be able to get a soft tissue fixation just like you normally would if you didn't have a bone graft. So this is just a regular Bankart repair on top. Three anchors, one inferior, one middle, and then one superior, a knotless anchor superior to be able to reattach the labrum that we had transected to be able to allow the graft to be inserted as well as to allow us to be able to have great visualization. Hopefully that makes sense. If you're interested in doing something like this, I'd like to invite you to the AOSSM Surgical Skills Course coming in October, Global Innovations in Complex Shoulder Surgery, where we're going in detail on catabaric specimens. Thank you. Thank you very much, Ivan. Nice technique. Next up is Peter Millett. He's going to talk about open Latter-J. Great. Thank you very much for the opportunity to present. My name is Peter Millett. Welcome to everyone to Colorado. Thanks to the program committee for allowing us to present our work on open Latter-J. And I'd like to acknowledge Max Hintz, who you heard from in the prior session, who helped put this together. My conflict of interest disclosures are on the website publicly. So anterior shoulder instability, obviously, as we've heard about in this session, there's a variety of different factors that play a role, injury-related factors, patient-related factors. And it's always important to look at the bone loss. So when you're dealing with bone loss, Latter-J or distal tibia allograft is a great option. In some cases, even bipolar bone loss can be a problem, and it's important to consider maybe addressing the humeral side as well. The case that I'm going to show today is an 18-year-old male. He had traumatic anterior shoulder dislocation playing lacrosse three years prior. He's had recurrent instability and dislocations during ADLs, no prior surgery. He'd failed non-operative treatment, highly apprehensive during his physical exam, but intact strength. And you can see his sagittal oblique view here demonstrating bone loss with a predicted glenoid tract that would be off track. Here you can see the calculations for the glenoid tract. And we also do what's called a projected glenoid tract, where we look at what the glenoid tract will be after the Latter-J is performed. He's projected to be on track after a Latter-J. So the surgical technique I use, beach chair position. Here you can see the examination and anesthesia. We always perform an arthroscopy about a third of the time. We found that we find some pathology which was not present on the preoperative imaging. Here you can see his large heel sac defect. You can easily dislocate him out the front. And he's missing large amounts of bone and bipolar lesions. We usually reprep with some betadine at this point. I like to use a standard deltaperectal approach because many of these patients down the road will require revision surgery, and it's just easier to revise it through this approach. You can also do it through an axillary split. We'll find the cephalic vein, bring that medially, and then we'll dissect out the conjoined tendon and free that up. And then we'll make sure that we can adequately see the coracoid. So we'll find the pec minor, the CA ligament laterally, and the pec minor here medially, and the conjoined tendon. This is with a three-pronged Bankart retractor on the coracoid, superiorly, and just retractors pulling medially and laterally. Release the pec minor. And it's really important to do a really good soft tissue release around the coracoid so that once you osteotomize it, you can free that up. The coracohumeral ligament tends to be the thing that restricts you the most. I use a 90-degree oscillating saw and then an osteotome and really try and get the full thickness of the coracoid, and then we'll mobilize that, exteriorize it. Be careful to protect your musculotaneous nerve. Take the soft tissue off the deep surface of the coracoid, and then freshen this up so we have a nice bleeding bone surface, so we have cancellous bone against cancellous bone so we don't get the problem of a nonunion. And then what I'll do is I'll take a DERA retractor as a backstop, and I'll drill typically two 3.5-millimeter drill holes. I like to drill them by hand because the size of the coracoids vary, so I can place them exactly where I want them. And then I'll use a lag by application technique. At this point, we'll then protect the axillary nerve medially with a COBRA retractor, split the subscapularis muscle, as you can see here, and then we take care to carefully dissect out the capsule underneath. Now this is a primary case, so it's pretty easy to get a nice interval in it. In a revision case, it's a little bit more difficult. Then you can either incise the capsule vertically, although I like to incise it horizontally. I feel like it gives me less risk of loss of external rotation. Place a Fukuda retractor laterally, and then place a Bankart retractor medially. And then this 764 Steinmann pin goes superiorly to retract the subscapularis, and then you can expose the front of the glenoid, as you see here. It's important to try and get your screws as parallel as you can to the glenoid, as you heard from some of the prior talks. We'll measure the depth of the glenoid, and then we'll use our screw, actually, to reduce the coracoid in place. We'll add the total length, the coracoid plus the glenoid. This is a 3.5 millimeter solid screw we've drilled with a 2.5 millimeter drill on the glenoid. Place the screw in, and then secure it down, and we can rotate the glenoid. Now this is kind of just like what Jill Walsh taught us. We can rotate the coracoid until it's perfectly flush on the glenoid, and then we'll place our second screw. This is, again, with a 2.5 millimeter drill, creating a lag by technique process. What you can see is here, with the greater surface area, with the classic technique, it's more stable versus a congruent arc technique, and typically you can place these anywhere from 3 to 6 o'clock, but the 4 to 6 o'clock position, as we showed in the lab with my partner Matt Preventure, really restores the stability better. Then we'll secure these, and finally with a hand fixation, remove our retractors, and then I used to close the capsule in all different ways. Now I just close the capsule side to side, with the arm in 30 degrees of external rotation, 30 degrees of abduction, and 30 degrees of forward flexion, and I find that the capsule actually reconstitutes, and it leads to less external rotation loss. Here's the post-operative x-rays from this case. Ideally, I like these screws a little bit more parallel to the glenoid, but sometimes when they have a big muscular patient, particularly NFL players, it's difficult to get that angle because their pec and their chest is in the way, so don't be too critical. Our post-operative rehab, 0 to 3 weeks, we avoid external rotation, we avoid loading the conjoined tendon, and after 3 weeks, we start them, weaning them from a sling and start letting them go to full passive motion, and then start strengthening around 5 or 6 weeks out. Typically around 4 months post-operative, we can get them back to activities. We've looked at our outcomes, this is my series, which is similar to the series that Owen showed from Dr. Mullett, 119 patients, ASES scores were very high, return to support rate was 97%, return to the same level was 74%, and a revision rate was less than 5%. This has also been used in revision settings, and this is a systematic review that we did looking at this, which showed good outcomes for this. With the elite athlete, there's various phases of return to play, we published on this with a milestone-based approach, but typically it's about 4 months that they can get back to play if they need to, and in our pro athletes, we had a 95% return to competition at a mean of 4 months, and this is an NFL linebacker that I fixed a few years ago, he played for 5 years in the NFL after a Latter-Jay procedure. So I'd like to thank you for allowing me to present, hopefully that gives you a little bit of insight into the technique of open Latter-Jay. Thank you very much, fantastic videos, we'd like to remind everyone to complete the session evaluation as well on the app. Thank you.

Carolyn Hettrich, MD, MPH

Brett D. Owens, MD

Jeffrey Kay, MD, MSc, FRCSC

Maximilian Hinz, MD

Ivan H. Wong, MD, FRCSC, MAcM, Dip. Sports Med

Eoghan Hurley, MD, PhD

Peter Millet, MD, MSc

anterior shoulder instability

Bankart repair

arthroscopic anatomic glenoid reconstruction

Latter-Jay procedure

surgical techniques

prognostic factors

recurrent instability

contact sports