Welcome to the American Journal of Sports Medicine's webinar in conjunction with the American Orthopedic Society for Sports Medicine and the European Society of Sports Traumatology Knee Surgery and Arthroscopy. Thank you for joining us. I'm Donna Tilton, Senior Publishing Manager for AJSM, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options on how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching the speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, click in the text box and type your question. When finished, click the send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so please send those questions as you watch rather than waiting at the end. There is CME available for this online activity. Here are the learning objectives and the disclosures for our faculty and organizers. At the conclusion of today's program, we ask that you complete a brief evaluation to collect CME for this activity. Details will be given at the end of the program and in an email to attendees. At this time, I would like to introduce our moderator, Dr. Bertha Boe. Dr. Boe is head of the Arthroscopy Unit in Oslo University Hospital, Vice General Secretary of ESCA, and President of the Norwegian Society for Surgery of the Shoulder and the Elbow. She is also a member of the AJSM Electronic Media Editorial Board and will be moderating our webinar. And with that, I'll turn the program over to Dr. Boe. Thank you, Donna. It's a pleasure for me to be a chair of this webinar. We really have been looking forward to host this amazing faculty. And to introduce them, first, Dr. Clara Acevedo. She is the head of the Shoulder and Elbow Unit in Lisbon Sam's Hospital in Lisbon, Portugal. Welcome, Clara. We also have Knut Beisel from Atos Orthopaedic Clinic in Cologne in Germany. Welcome, Knut. And Manos Brilakis, working in Athens in Brilakis Orthopedics in Athens, in Greece. Welcome, Manos. And last but not least, Dr. Ivan Wang, working at Dalhouse University, Halifax in Canada. Welcome, Ivan. So we would like to have this webinar more like a discussion than several presentations. So I have asked all the faculty for cases, and they have got their task to present a few of the new techniques in shoulder instability. So there are room for questions and there are room for discussion, and we will try to give you the perspectives of all these different techniques, both the new ones and the old ones who have been shown to work very well for many years. So we will start out with the two cases from Dr. Brilakis, and I will start the presentation for you, Manos. Can you see your first slide? Yes, Berte. Thank you very much for including me in this webinar. Thank American Journal of Sports Medicine for hosting this nice event. And today we have two cases. As we can see in your picture, you're also the chair of Athens shoulder course. Yes, and next February is the next version of this. Everyone is invited and welcome to have the discussion in any controversy of shoulder. It's a very great course. So let's go to the cases. Thank you for the kind words. So the first case is a case of a female, 16 years old, is a competitive tennis player, high school student. He has dislocated his right arm, which is the dominant arm. He has three shoulder dislocations in the last nine months, the last one during a tennis match that it was reduced in the hospital hours later from the event under general anesthesia. Nothing special from the medical history, no previous surgery. And we can see the range of motion of the shoulder preoperatively. He has a typical bankrupt lesion from one o'clock to six o'clock. The glenoid defect measured by a 3D CT scan, 3% of the inferior glenoid diameter. There is an on track heel sac lesion and the functional score are the ACE is 80% and the Bayton score is four out of nine. So this is the preoperative case. Do you want to discuss on this case or do you want to proceed with what I did and the result? I showed that you had been operating on this girl, I'm sorry for that, but yes. What are your thoughts about this? So it's a typical bankrupt lesion. We have a young girl that has three dislocations. So he has tried the conservative treatment for the first and the second one, but now I think that it's time that she should be operated. She had an injury which it was reduced easily. So two hours later from the injury, we suspect that maybe has a deep heel sac lesion. However, this is not confirmed by the 3D CT scan. And for me, it's a case of a typical bankrupt repair. However, because it is a young female competitive tennis player, in this case, I also include a remplissage for the management of this case. So it's a soft tissue procedure. It's a tennis player, not contact sport. Would you agree that this is a soft tissue procedure, or would you think for a bony procedure in this young athlete? No. So first of all, good evening, everybody. I absolutely agree with a soft tissue procedure at that stage of the information we have. For me, with 16 years old, if I got it correctly, she had a couple of redislocations. So in my mind, with 16 year olds, I'm even more aggressive in going in there with a soft tissue procedure after the first time dislocation. I think that's where you have the best chances to get a good effect of your bankrupt soft tissue procedure. What I'm thinking in this case, instead of the remplissage, we will probably later discuss that. I think I would rather opt for a seven o'clock anchor. The idea is these ladies have often a hypolexity issue, as Manos has said before. And with pulling up the posterior inferior general ligament, that would be an idea for me to address that rather than going in there with a remplissage. I think that's to discuss. Yes. Thank you. I think most people would agree for soft tissue surgery when there's such a small glenoid defect. In the States and Canada, you have a little bit more aggressive athletes in the contact sport even. Is there any form of sports that you would think that you would go directly to a bony procedure even with this small glenoid defect? Yes. Again, good evening. Thanks for having me here. Sport definitely makes a difference. Contact collision sports are quite worrisome. One of our worst ones are rugby type of players. We do know that even with small amounts of bone loss, especially with a little bit of hyperlexia, we're very concerned with. In those patients, we would actually have a long discussion with them because this, I think, needs their input to go into whether they want a smaller operation, knowing that their failure rate is a bit higher with a collision type of athlete versus a much more aggressive operation that has a higher success rate but does have changes that we have to anticipate, meaning changes in their anatomy and changes in potential future surgery if they should so need since they're so young. Yes. So this is open for discussion, but except from the rugby players or very hard collision athletes, most would choose a soft tissue procedure. So that's also what you did, Manos, and you started this month's post-operation. I want to highlight that because of the hyperlexia, I had a replica, even if the kiltsack lesion was not so big, in order to enhance the effect, the result of the classic arthroscopic vascular repair, I used to use an anchor in 6 o'clock or in close to 7 o'clock because I can shift the capsule better. So I think that this is what Knut mentioned earlier. However, in my practice, in my mind, in my opinion, I think that only doing vascular repair, you have greater risk of recurrence. So I think that soft tissue procedure should be augmented. The classic vascular repair should be augmented and probably we have the chance to present it later in the small presentation I have to have. Yeah, we'll move on to your next case. However, six months, I cannot see the slides anymore. OK, can the other in the faculty see the slides? Nope, slides are gone. I'll share again. You can see the slides. OK. Can you see them? Yes. Now we can see. In the previous slide, you see the results six months later from the operation. He has regained all the range of motion and the full function after the rehabilitation and she is ready to return to her sport, to the competitive sport. So the next presentation, the next case is a female, 34 years old. Also the dominant arm, the right arm, he's an accountant, he's a competitive basketball player. He has over 30 episodes and the age of the first dislocation was 19 years old. At the last month, he has dislocated her shoulder three times, many times, and some of them very easy, even she has an apprehension in 20 degrees of external rotation in abduction. No other medical condition and no previous surgery. So it's a different case than the previous. This is the range of motion, which is pretty good. It's the right arm. You can see in the left arm a reduction of the forward flexion, but it's another condition, it's not the shoulder that we discussed. It's the right arm. Not bad functional score in the assets, but Oxford 31 out of 38 and not very laxity. So this is a different case than the previous. In this case, if you want me to start the discussion, I will not consider a soft tissue procedure for this case because of the number of dislocation, because she's a basketball player and also you can go to the next slide because there's the 3DCP. You can see she has not a bony defect, but a bony fracture probably, it's a step. This is why she dislocated her shoulder too easy the last month and the glenoid defect is measured 25% and the heel-toe lesion, which is not so big, but it exists, it's off track. So in that case, I would not consider to do a soft tissue procedure and I will go for a bony procedure. Yes, I think most people would agree to that, Manos. I will proceed your slides so you can also present the technique of your... Okay, in that case, as you know, I'm not so big fan of Lata-Z, which is the classic bony procedure. I do the arthroscopic end-and-heel vignette using an autograph from the iliac spine and also six months post-operatively, he has again the full range of motion and the full function of her shoulder having no application and now also she is ready to return to sport. And you do this bone block technique with screws or endo-button? I use buttons. I use four buttons, two anterior, two posterior and satchels in between. And also a guide for the drilling holes from posterior, right? Yes, I use the guide for posterior because it's more easy to use and more safe. I agree. So you have given us an overview of your decision-making algorithm. I think you have talked about it, so I will proceed so you can tell us about how you perform the replacement. Yes. These are the prognostic factors for recurrence. The age of the patient, the type and the degree of poor participation, the capsular laxity and the patient's hyperlaxity and the proprioception are factors that cannot be addressed by the surgery but they are very important for the patient's selection. This operation is a special topic not for this webinar and the bone effects are the most important factor for decision-making. So we have the cases with no bone loss that we know we should do the bank and repair, the classic lesion of the anterior shortal dislocation and we have the critical size of bone defect over 10% that we all agree that we should do bone procedure and also we know from an article some years earlier published in the journal that hosts today's webinar that the sub-critical size is the size that we also go for bone procedure because the factional scores are seriously diminished if we don't. So between no bone defect and 13.5% bone defect we have a grey zone and this is many surgeons that extend the indication of the bank and repair because of the lower complication rate. If you can go to the next slide it would be good. Many surgeons lower the indication for the lateral zero for the bone procedures because of the lower recurrence rate that they produce. So we speak about augmenting the classic bank and repair, we speak about an amplissage which is the capsulomyotenoidosis of the posterior capsule and infraspinatus tendon inside the heel sac lesion. We can see in the image below and this is proposed by Eugene Wolf and this is the technique we abrade the heel sac lesion and we do some perforation in order to enhance biology. We use the saver or a drill and after this we implant the anchors. I used to do with one anchor but now I use two anchors, one laterally and then we pass the sutures from the posterior capsule and the infraspinatus tendon. There are many techniques, I do it inter-articulately with this view and this is the final result. We reduce the posterior capsule from the left image below to the right image below and we reduce the volume of the posterior capsule and we do the heel sac lesion extra articulately. So the indication, the classic indication is for isolated humeral bone defects but we know that we should combine the bone defects and think about this in combination and this is our experience. We have 65 patients with bancal repair and replacement for recurrent stability without inverted appearance of the glenoid, 8 years of follow-up, we have a recurrence rate of 5.6%, we have high satisfaction of the patients, 70% return to the sports at the same level and we have no restriction or minimal restriction in external rotation and in the activity of daily living. If you see the literature, you can see many clinical studies and systematic reviews that show the recurrence rate is almost 5.5 or 6% and some cases speak about a small deficit of external rotation, we can discuss about it if you want, and a lower complication rate. So for me, the role of RempliSAS in now 2023 is pure math, due to indication, we should respect the indication, so a 25 years old recreational tennis player with 3 recurrences and glenoid bone loss lower than 10% is a good candidate for augmenting bancal repair with RempliSAS, but an 18 years old player, competitive handball player, over 20 recurrences and glenoid bone loss over 10% is a bad candidate for bancal repair plus RempliSAS. So the important thing, like you have pointed out here, is to pick the right candidate and then you mean that RempliSAS is a great additional procedure to the Vanguard. So I would like to welcome Klara into the discussion as well, is Vanguard something that's also in your toolbox or are you concerned about less external rotation or other things using the RempliSAS, Klara? Hi, good evening. Thank you for the invitation. I'm very happy to be here, Berte. That's a very good question. I think you have to think about the issue with external rotation is mainly a concern when the anterior glenoid bone loss increases, because as the anterior glenoid bone loss increases, if you do a bancal repair, you're pushing the head posterior inferiorly progressively more, and this will lead to the loss of external rotation. This is why it's not a good indication when you have subcritical anterior glenoid bone loss. For me, in my algorithm, the isolated bancal repair as a surgery is no longer a consideration because when patients have a surgical indication, they usually have other lesions that need to be addressed. And I agree with Manoj Relakish that the heel sex ramp massage is a great augmentation procedure for these patients. If the patient has nothing else, usually if it's a first duplicator, I would try conservative treatment before an isolated pancreatic surgery. Thank you, Clara. I will let you proceed with the new procedure. I know you like, and you have also presented a nice case for us. So please take us through your case. Yes, this case I think will generate much discussion and controversy. So this is a guy who's 24 years old when he presents to us, and he practices Thai boxing. So Muay Thai and soccer, but at the recreational level, and he wishes to continue. And he has had one traumatic dislocation during Muay Thai. And these three months after the dislocation, he has, of course, a loss of strength in abduction, a very high AWASI score, so he's very poor at this moment, low release score, and this subjective shoulder value is very bad. And he's in a lot of pain. So you can go ahead, Berthe, please. And this dislocated is right dominant shoulder, which is at this point stiff. So this is active and passive as well. And he wants to be able to practice this type of sports comfortably. And he asked me to treat him in the way that I would offer him the least risk of redislocation with the least risk of complications. So, but Berthe has been going along with the exam. So I use, in my practice, I usually use the MRI because I have very young patients and I'm afraid of ionizing radiation in these type of patients and it has been shown that MRI has the same value to assess the glenoid and urinal bone loss. So as you can see, the patient has a clear his heel-sex lesion, which is lateral, and he has a Benkert lesion with some glenoid bone loss that we measured, and it was actually 14 and a half percent of anterior glenoid bone loss. And the heel-sex lesion measured, I think for 15 millimeters and the glenoid tract was larger than the heel-sex defect, so it's a non-tract lesion. So I think we could discuss what each of you would do if Berthe thinks it's appropriate, or I'll go ahead and show what we're talking about in this case. Yeah, for you, Clara, I understood that this is a soft tissue procedure. I guess this is a kind of sport that some else would have think that maybe you should go directly to a bone procedure. That's to be debated. Yes. Do you want to comment on it? Yes, I mean, these guys are a bit crazy. Martial arts athletes are always challenging. And in fact, that's a patient... I'm a little bit curious if the bone loss of 14% on the glenoid after first time dislocation is really real. I think that brings us to the other topic, like Manos had 13.5% as his cutoff. I think we are not so good in measuring bone loss. I think we have wide variability of a couple of percent. So I think we are on a wrong way to try to define bone losses by 1.5 or 2.5% as a cutoff. I think it's more like Manos said, the gray zone where we are. And that's the same thing for the bone loss. So in my experience with the martial arts athletes, these are the ones that have so much impact on their shoulder with the forces they generate, especially if they throw a punch and they don't hit, that they manage to damage the soft tissue procedures. And in this case, it's a kind of, I wanna make this shoulder more stable than it has ever been, or than it has ever been anatomically. So in this case, he would be a candidate for Latache in my opinion. But I would discuss the problem of following bone loss of my graft, because due to Wolff's law, he will later on see a bit of bone loss, but on the other hand, we have good data that these patients get very happy with that procedure. Well, I think that, sorry, Berti. I just want you to present your technique because you chose a procedure, but as we now illustrated, it's debatable for such a patient. Yes, because they're crazy as well as to go ahead and do the sports earlier. And I'm more afraid of an early complication of a bony procedure in these crazy guys than of a soft tissue complication. So it goes both ways. So this procedure that we elect for this type of cases, after of course discussing the advantages and disadvantages that I will say in the end, we do a dynamic anterior stabilization. In our case, we use an onlay technique. So what we do is we do a long-headed biceps tenotomy, and you can go ahead to the other slide. And the aim of this procedure is to transpose the long-headed biceps to the anterior glenoid. In this case, it's in an onlay fashion. So it's fixed to the four and five o'clock position with two ulcer tranches with four knots. And this will provide a sling and a hammock effect much like the laryngea. And it's an augmentation for a Bankart or in patients who don't have Bankart, you can use this because the onlay effect is a mini labralplasty effect. And nowadays, we're actually adding the ilfector amplissage as well. So in this case, we would have done an ilfector amplissage as well. In this case, we didn't. Can you go ahead? So one of the disadvantages for these patients, you can see in this image, is if you have a competitive athlete, which is not the case, this is a recreational one, they will want to go back to sports early. And with this technique, we don't allow them. So they cannot go to contact sports until six months, much like every other soft tissue procedure. And in the beginning, most of the rehab is focused on protecting the healing of the longheaded biceps. So this is what you've seen on the left, from the first to third week, and from the third to sixth week. Main concerns are with the strengthening of the biceps that is avoided. So we only start strengthening the biceps from six weeks onward. The rest is equal. So what we're seeing here is we've studied in the beginning, these patients, we have very good results in patients with less than 20% of anterior glenal bone loss in recreational patients. Mostly, we have a considerable follow-up now. You can go ahead, Roche, with the slide. Sorry. So what I was going to tell you is that we have a low recurrence rate, but still there is a recurrence. But I have to highlight that this was a very severely hyperlexed patient, where we sufficiently addressed inferior glenohemal ligament. So the discussion in the case of Manos is very significant for this subject. And we've modified this technique in terms of tips and tricks that we have published recently to make it easier. Nice publications there, Clara, both of the results and of the technique. Can you go ahead, Barte? Go ahead with the slide. I just wonder if you could tell us what's the difference of onlay and inlay and why you have chosen to do it onlay? Of course. Well, actually, originally, the technique that I learned first about this dynamic anterior stabilization had been described by Oleg Milin and Embruden Toussaint, who did it in a non-lay fashion. What does this mean? This means that the long edge of the biceps is transposed to the anterior glenoid wing and not to the glenoid neck. So you are mimicking the effect of the lost glenoid anterior inferior labrum. And this is maybe interesting in patients who have several dislocations and who have completely lost or destroyed their labrum, where it's not possible to use this as an augmentation for a vanguard repair because the vanguard is no longer possible. So it seems to be meaningful that you reproduce the labrum with the long head of the biceps. When you do an inlay technique, you're transferring the long head of the biceps a little more medial to the glenoid neck. Usually you use either an interference screw like Philippe Collin and Alexandre Lalonde described, or you can use a tunnel and use the system that you use for the laterger with the endo button, but you're a little medial. And here you really need to do a vanguard. Otherwise you may risk more recurrences. And this was what happened in the beginning in the technique of Philippe Collin and Alexandre Lalonde. Then they changed it to fix it a little more lateral. And so this mainly is the difference between inlay and onlay, per se. With the onlay, you create more like a bump anteriorly, like the bump we want to the labrum. Yes. Yes. And you maybe reestablish more the concavity of the glenoid. Yeah. So here in the end, so I wanted to highlight the effect of long head of biceps in front of the humeral head as a sling in the first degrees of abduction and sort of rotation, actually in the higher degrees of external rotation and abduction in the beginning, it's the hammock effect. The long head of biceps pushes the subscapularis down. So much like the latissimus dorsi. Apparently in the biomechanical studies that are published today, which are many, there seems to be no loss of external rotation produced by this effect of the transposition of long head of biceps. And it has been shown to decrease significantly the anterior glenoid mode translation in anterior glenoid defects ranging from 10 to 20%. So the gray area seems to be the indication for this technique. It allows you to deal with a SLAP lesion. So in patients where you find that you have a SLAP lesion in addition to the anterior instability, you're kind of feeling two needs with one deed. You do a tendon disease of long head of biceps to treat the SLAP and you do the transposition to treat the anterior instability. In our case, we use all suture anchors. So there's no hardware involved, which is interesting in terms of the post-operative study with no artifacts from metal that you need for most of the techniques described for bony procedures, but we have new techniques, of course. And there's no problem with Wolff's law issues where you have bone resorption and then you have metal inside the joint, destroying the joint. And there's no neurovascular complications involved in this procedure because first you're not using the conjoined tendons and you're not placing traction on the musculocutaneous nerve. You're transposing the long head of biceps, not the short. And also you're more lateral. So you don't risk causing a lesion to the axillary nerve and you don't have to do such a big split. So the risk of neurovascular complications is less. And in our technique, we use only three arthroscopic portals. We do this all arthroscopic. And another advantage is when you, sometimes you measure and as Newt said, sometimes the sensitivity of the measurement is kind of questionable of the bone loss, either on humeral head and the glenide. And you can find yourself with a patient that actually has an off-track lesion and you find that the soft tissue procedure you had elected to do intraoperatively is insufficient and you want to have something else and you don't need to request for more instruments. Clara, you seem quite enthusiastic about this new technique. And I know there has been several publications from Europe. So I want to ask Ivan, if this is something you have adapted in North America, is this a technique that you have started to use or are you considering to start using it? What's your experience? Yeah, so obviously Clara has done wonderful work kind of promoting, describing this technique. I've seen her present it. It's very intriguing. At our latest meetings, we've had a few surgeons try it in North America. It really hasn't taken up that much yet. I know they're still interested in the Bankarta and Remplissage and trying to figure out where that fits, as well as all our other modified boning procedures. So there's, again, there's a lot of space in this area that's becoming very interesting. Time will tell to be able to figure out what is important, but all these things we're obviously trying to address. We need to make a nice safe option for surgeons to be able to offer. Yes, I agree. This is very interesting to see how we end with this. Well, I think we'll have to move on. And the next cases is from Knut. So Knut, can you please present this first case? Yeah, so this is, again, a collision overhead sport athlete. So a handball player, 19 years old. He is playing not, well, he's actually playing, he has been playing on a national level. So he has a history of two arthroscopic stabilizations performed arthroscopically previously, which both failed. Here we, again, have the problem of about 15% of genoid bone defect and an off-track sac lesion. And this patient here, you see, I'm with Clara. I'm also using the MRI for measuring my defects because the Rush Group has shown that it's very comparable to the CT scans. And the important part is that you place your planes correctly into the glenoid. Here you see a small video. We do 3D planes. And with this, I'm able to really adjust my plane and get the on fast view. And I think that's very, that's the important part. It's not so much about a CT. And just another thing of topic on the lower left, you see some of the new MRI capacities because the MRI will in future be able to be CT-like sequences. So I think in the near future, we will not need the CT scans to evaluate the bony effects of this. So this guy then was sent all about Germany. There were little discussions about it, which way to address this guy. And especially in concerns of his age with 19 years. Should I go now with the next slide? So basically, that's what I ended up with this guy. So for me, handball is kind of a collision sports. It's not so much overhead. It's really collision what they do. I didn't see any option with another soft tissue procedure. However, in his case, there was no ramplissage done and no additional treatment. The placement of the anchors and the previous surgeries was okay. Not perfectly, but okay. But in this situation for me, he is a candidate for lethargy. He's now three years out with that surgery. Full back to handball, full back to playing at his level. So that's like the martial arts athlete we have seen before. A candidate for me for the lethargy. And yeah, I mean, it's an open discussion. Important points from you here, Knut, is the measurements. That if you don't do it the correct way, there's uncertainty. There could have been 10%, there could have been 20%. If you didn't measure it correctly. And also that the traditional open lethargy is a very useful procedure with good results. And this is the procedure that you prefer to do in such cases. Yes, it's really the point for me is all the other options are very attractive. Clara's technique is really great thought and very good. But at the end of the day, lethargy has 30 years of clinical experience. We have really good data on that. So in my opinion, if you go on the safe side, a secure technique, that's the way to go for me right now. I'm really open for the other techniques, but that's the way to go. And on the other hand, the topic of the measurements. So for me, it's really like managing the more competitive, the more collision athletes we have, the less bone loss I tolerate. If this guy's only playing EA sports on his computer and he has 18% of bone loss, I might get away with the soft tissue procedure with the ramp massage, because he's not going out on the field. And on the other hand, as Manos said, is if he has, or like this guy here, about 10%, 10 to 15% and he's collision athletes and I'm more aggressive on the side. So this is a very important part for me, mixing all these things and they add together that I'm more aggressive or less aggressive on the body side. How about this is the third operation for instability? Would you try to do the soft tissue procedure for a third time? No, but I can tell you there were a lot of other surgeons involved in that story. And it was a hot discussion. And there were other colleagues who absolutely suggested soft tissue procedure again. I know it's always when we are in these webinars and we are putting together our ideas, we don't have to forget that. I think Ivan, is it the North American data, 80% of shoulder stabilizations is the arthroscopic bank cut. We have to be clear on that side that that is the working horse and that's used thousands of times. And also a lot of surgeons have very good experience. Also myself with a nicely done arthroscopic bank cut in the right patient. You have a wonderful full result and then you have an easy, quick surgical procedure which can be done by a lot of surgeons. Yes, I agree with you. And I think all the panelists and including myself are from countries where we do a lot of bank cuts. So we don't have any French surgeons here today but they would probably go earlier for a lot of shame. So I think we'll proceed with this case. Also very interesting. Please tell us a little bit about it, Knut. That was an interesting case. So it's from Europe, it's an Irish guy. So this guy, 25 year old male, he had already a history of tuberculoma fracture which was treated with osteosynthesis as you see there. And the basic problem in this guy was that he is a seizure patient. But he was perfectly on medication with his seizures and I think he didn't have any seizures since six years. Well, now the fact that it's an Irish guy. So he had a big night drinking out there and forgot his medicaments. So he got a seizure again and dislocated his shoulder again. So here you see the x-rays. And the next slide, you see the problem we have. Now we have to deal with bone loss, significant bone loss on both sides, even rather more on the his sac side. So in my opinion and this, sorry. Before moving on, I want to hear both from you but also from one of the others in the faculty. What are the concerns about these patients with seizures? Would you always choose screws because that seemed like the more solid procedure or were you considered to use endo buttons because you are afraid of breaking or bending of the screws? Did you understand my question? Who wants to answer? So first Knut, what's your consideration screws or ender buttons in such cases? So this case is about five years ago. Basically that was a bit before the hype or the or let's say the different way around. The last four years the non screw fixation procedures for the adenovirin etc. really evolved. So five years ago we have not been so good to do a boning procedure without screws. But the thought is correct in this situation the thought is for me this is not a candidate for later shape. So in seizure patients I'm not opting for later shape because in these patients I'm really afraid because a seizure situation will throw out everything you do in there. And with the later shape I think I'm at risk to damage the sling effect and then have a broken later shape etc. So in these patients I opt for iliac crest. In that situation I use it with screw and we also comment from Manos as well. Do you have any thoughts of screws or ender button in these patients with seizures? I totally agree with Knut that the last few years the evolution of ender buttons and the strong orthopedic sutures have given us many strong much more strong fixation than almost screws. So always in that cases I consider the next step and in this case the next step the next injury the next dislocation is possible. So I would like to fight with a small button and not with a large screw that probably can be broken or it can be exposed and produce more problems than it solves. Let's see what you did. Your comment Knut? Yes so in this situation we know from Bob Asiero that with adding bone on the glenoid we can get compensated a big bunch of Hilsax lesions and also I mean the atheroscopic colleagues could also add one plisage. In this situation the Hilsax lesion was too big in our opinion so I thought that I add on both points. So I have bone loss on the glenoid and I have this huge Hilsax lesion. So I did it in a in a stepwise procedure. So I did a posterior approach to address the Hilsax lesion first. I fixed that with the screw. I had no Herbert screw at that moment. I did patients before with just impacting the graft into the Hilsax lesion and that didn't work so fine. So we opted for screws for the primary fixation and then I did the second step where I addressed the anterior part with an AB heavy net with an India crest and as I said for me screws open procedure is well the pragmatic quick one but absolutely agree with Manos that if you go in there with the suture button devices or the saclage devices that's absolutely comparable. Yes and these patients they most of them have new seizures. How about this one? Yeah that that was the story. I mean he really was good with this medication and it was really this one-time drinking event. He got a bit more normal and not so much drinking anymore. So he took more of his medicaments and and that worked out fine for him. Good for you as well. So you sent me well this is the results from this operation first and then I think we would like to proceed for the young lady you also sent me. You want to tell us about her? Yes so yeah so this is a 21 year old female tennis player and she has this story of coming to you into office and she has since three years pain with his shoulder and you've seen she wasn't able to lift her shoulder more than 90 degrees and she as you all I think know that had the history of run through multiple physiotherapists etc and the pain got worse and the problems got worse and the MRI I'm showing you if you look in the lower left she was sent with the idea that she had a Hagel lesion out of this after MRI and with the history of her with you see hyperlexity signs that was something we were curious about but again you are standing there and they tell you the radiologist tells you there's a huge Hagel lesion and what we found later on was that you have to be careful if they inject intra-articular contrast agent in the inferior recesses and they have too much pressure then it runs out there so you have to be aware that you can be false positive with these MRIs so in her situation no so it was no Hagel lesion it was a hyperlexity and a multidirectional instability we tried again to go for a first round of conservative treatment today I'm working with EMG biofeedback so we have great physiotherapists here who use it's not like the pacemaker it's the other way around by showing them the EMG activity of the muscle you can give them biofeedback and they can get a lot of control back but in her situation we failed with that and was really a problem of a kind of micro-directional multidirectional instability so we solved that with with an arthroscopic procedure with the 270 degree stabilization here you see the rather problem of the hyperlexity not so much the clear Bankers lesion although you see a little bit of cliff phenomenon and then at that time point still we worked with suture not with not less anchors but we did the 270 repair and with that we got her back into playing tennis and into all her sports and right motion of her arm so her case that would be the next light I think so her case okay so her case is an example for me of the proprioceptive function of the capsule I think these patients really they are not the contact athletes they profit when their proprioception gets a feedback by the capital I shift that the rotator cuff can work again correctly in this situation yes so this is a nice example that even though we really try to treat many of these hyperlex patients conservatively sometimes we end up doing surgery and they're doing well even though yeah thank you for these nice cases and we will proceed to dr. Wong you have also sent us a really nice case and you know that most surgeons when they have done the latter share they have kind of ended what they have in their toolbox and if this face they really don't know what to do further so please help us out of this yeah so this is a 24 year old male he had a skiing injury in 2017 dislocated the shoulder and had a bony bank card type of thing and then when the upper extremity surgeons was able to see and was able to do again it was a bony piece that they saw and they wanted to do a latter-day so they did a latter-day you know young male and then he re dislocated it the year later playing baseball so we'll go next so it was an open latter-day you can see here with the re dislocation looks like he has dislocated the metal anchor that is anterior with that blue arrow there and you see one of the screws of the latter day that's broken we'll go next slide so this is a CT scan that was ordered before sending so this is a 2d CT scan and I know there's radiation going in here we choose radiation or I choose this because I like having 3d models to go through after and we don't have the software in our MRI to be able to model this this way so in the 2d you can see it's difficult to get the on face view we'll go next slide but then the 3d scan you can see where everything went so it does look like the latter-day pulled off from anteriorly broke off from where it was so at least the inferior part is pulled away the superior part still looks together and then there's both this anterior rubbing off now where that screw is as well as the hill sacks that's there from previous so we go next slide so we go and on to go fix this and to fix this I know we've been publishing our technique for arthroscopic anatomic glenar reconstruction or a AGR and the whole point of doing something like this is to be able to get access inside the shoulder without damaging the subscaps since the subscaps already been violated so first thing we're viewing from posterior portal we're doing a lateral cubitus we're opening up the rotator interval and we would usually do this to be able to see both the conjoint and the CA ligament but obviously from a previous latter-day that's not the same so this is a failed latter-day we took out the screw we're viewing from the oh sorry we can go to the next next one so we're viewing from the anterior superior portal now and the first step of doing something like this is put a traction stitch you can see that traction stitch at the three o'clock position and we do a release here of the labrum so this is the difference from a normal Bankart repair we release the labrum and follow it down to where the coracoid should be and in this case there's no coracoid there because they would osteotomy and have a latter-day so we actually go to where the graft is and by having the traction stitch we're going to be able to locate where the labrum is and what we're going to do with it so we go next slide so the first step of something like this and the failed latter-day you can see we outline where it is in the outside view of how big the incision is we'll try to remove this piece and everyone gets worried about screws in the shoulder and it breaking and things like that so you can remove this this is just an osteo osteotomy that we have before we'll to break the screw and be able to remove these completely arthroscopically using the the screw broken screw removal set so these will fit Arthur's again through the regular portal so this is the anterior inferior portal that we put in through the rotator bull and be able to remove them and now that we measured how big it is my preference is to use the distal to the holograph I know some people use it Iliac crest going through but distal tibia adds cartilage going in especially and more importantly the bone quality is fantastic the metastasial bone is exactly what we want it to be and we can fashion it in a way that Iliac crest doesn't quite go in so I can make this trapezoidal shape to represent exactly what's going on and be able to make sure that it's exactly the right size so using an assistant we can be able to make sure the the cuts are parallel and be able to get the screws perfectly parallel to the bone loss area we can get to this Halifax portal so this is a way that we get the the graft into the shoulder you see my switching sticks from the posterior portal on a green cannula there aiming right down the axilla so that graph that portal is superior to subscap and lateral normally conjoined is there but we're getting it as lateral as possible and everything is split bluntly so it's a switching stick so there's no sharp dissection no chance of injury to nerve we glide this in using two half pipe cannulas we can position this perfectly to make it match the the the glenoid doing go to the next slide and by putting it in with two screws we can get excellent compression he's actually only two weeks post-op we did this with our visiting ASES traveling fellowship surgeons here so we showed him how to do this and go to the next slide and really find that using this a AGR is really beneficial anytime we have concerning bone loss and right now the more that we do realize that anything more than 10% or measurable bone loss is something that I consider doing a bone grafting procedure for now that we can do this safely and we can teach this next slide please we really find that it's much beneficial so we can do a AGR because we already have five year data showing that and show and presented at AOS as well as Anna to show that it's effectiveness just like a ladder J it has a safety profile just like the arthroscopic bankrupt repair we publish over 24 papers in the last decade on the technique outcomes whatnot five-year follow-up demonstrates 2% redistribution rate and our only dislocation has been from seizure patient we've actually had quite a few seizure patients that have not dislocated but the only dislocations have been from a seizure patient and now we've been able to teach this over kovat even remotely so this procedure is safe enough that we can teach us using augmented and mixed reality remotely and this is actually a demonstration so if you got one minute left there's a one minute you we use augmented reality so again we use the CT with 3d recon really not to show you with a bone loss but show you where the portals are because portals are the key success if you're going to do this arthroscopically and over coven we've done a multiple camera visualization so again I tend to wear a hologram to this to get a first-person surgeon view as well as having that mixed reality in there we can actually size up the graft and get a good idea where we need for the switching six how we make it parallel how we get it all the way across having overhead view having zoomed out view so you understand how the room is set up be able to show you how we can get a portal all the way across but more interestingly is we can then send our cameras over to a learning surgeon where they can do their cadaver lab and then we can use this extra screen you can see here and use drawing on top so augmented reality on top we can guide surgeons who do beach chair position to show you where the portals are and then they can follow these you know it's like follow the dot exactly there's the dot for the anterolateral aspect and now we're getting these emails back with all these surgeons who have never met before showing me their post-op x-rays of doing this anatomic glenar reconstruction learning all around the world so thank you thank you this is very impressive and it's it's really interesting that you could teach people like sitting on the other side of the Atlantic Ocean and and be able to teach them this way so I have to admit I'm a little bit curious about this Halifax portal that you do and the direction of the of the glenoid so to be in parallel with the joint surface you must probably pull this scapula very much posterior to get the right direction or can you explain that to us absolutely so the most difficult part of doing it in heaven yet when you leave the coracoid in place the conjoined tendon and then most people do it either subscap split or subscap takedown so what we do instead is we go superior to the subscap so we do all the releases that we have so that we can get a switching stick from posterior to anterior to slide the subscap all the way down the anterior face of the glenoid and the only other difficult part is the conjoined tendon so we show you what we do is same as an open release that we release it all the way down hopefully you saw the open incision in the axillary fold that's where we get to get the exact inferior to superior guidance and you can do this completely safe so as long as you get a switching stick superior to subscap lateral to conjoined and do all the releases we can show you how to do this completely safe again that's why i use the 3d models to show you this because most people when they first hear about this or watch a presentation they go that's not possible our anatomy that we've always been taught doesn't make sense you can do this without a subscap split or taking down the conjoined what we've learned because we do the 3d modeling is this is definitely possible soft tissue we can move and by moving in certain ways and keeping things safe then we can actually teach this to anyone as long as they follow those principles yeah this this is very interesting absolutely have you any thoughts about enderbutton compared to screws because i know there's there's a totally different situation when you use the guy that you show those and you can put in the screws you can by yourself decide the direction of the screws while while you're using enderbuttons you are a little bit you have to accept the way the bone block is placing itself because it will place it according to the surfaces of the bone but with the screws you can more decide the direction have you any experience with the button have you any thoughts about using screws or buttons and especially in patients with seizures absolutely so so we actually have quite a bit of experience starting about five years ago the buttons became available and we started doing a switching over because we did remove the first few screws we did when we started doing this agr we use huge bone grafts because we thought that if we take them completely off track we can ignore the heel sacks and the shoulder will be stable and that was very true shoulders are stable you make the glode noise super large the trouble is is bone remodeled just like the newt mentioned it goes back to its normal size and the screws become exposed we have to remove them so when the buttons became available we started using buttons thinking that this is going to be a much better way so we get less revision surgery and just like you said uh bertie when you put buttons in you're 100 at the mercy of how you shape that bone because whatever that bone fits into the anterior glenoid that's how it's going to hold there's no uh no support like the screw does and what we found was we had a 40 failure when we would use buttons compared to screws so we presented our data at anna at aossm so i no longer do buttons uh for an allograft procedure i know boilo has great details on his success rate with the autologous coracoid we've had some failures with autologous iliac crest so again i no longer use buttons for that fixation screw fixation is just so secure and we can we can align it so well now that that we're staying with that yeah yeah that looked really nice and actually we have got one question from one of one of the participants and the question is how do the patients respond to donor site morbidity of autograft iliac crest so i guess i will turn that question to your manos because you are doing a lot of bone blocks with iliac crest yes um if you i think that you should do a conversation with the patients to and explain that there will be a donor site morbidity however i think oh no i think my experience says that after some minor problems for the first 10 or 15 days there is not a serious problem in the donor site so if the patient has been informed before the surgery he awaits to have some pain in the iliac crest and he can accept this yes and for many europeans the the fresh frozen holographs is not an opinion so i guess we will have to use autograft for in many countries is that the situation in greece yes but also there is the option of using xenograft and in my in in my cases the cases with xenograft there was a very low absorption of the bone graft lower absorption than the autologous graft and it was impressive yeah so you recommend autograft anyway yes okay um then it reminds for me to thank you all the faculty this have been a great experience for me and so many interesting cases i wish we had one more hour so we could have discussed all the cases into detail but we will try to stick within an hour plus a little bit and thank you all for being a part of this webinar and i think donna or christine have some closing remarks yes i'd like to give a big thanks to all our panelists and presenters for their work on tonight's webinar on behalf of eska and aossm we hope you enjoyed this webinar and that you were able to attend other educational programs coming up in the future and thank you attendees for your participation if you're interested in cme or would like to review the recording of this webinar please go to education.sportsmed.org log in click my click on my resources and then click the course title you can then complete the evaluation for cme or review the recording which will be available by friday this information will be emailed to you in 24 hours so please don't worry about remembering it all we thank you for your participation and have a great rest of your night thank you everyone

surgical procedures

shoulder instability

Bankart lesion

soft tissue procedure

remplissage

bony procedure

arthroscopic Latarjet procedure

arthroscopic anatomic glenoid reconstruction

autologous graft

bone loss

advanced imaging techniques