We have around 10 minutes to go through some cases and then we have a video presentation at the end. Again, my name is Brett Owens. I'd like to share with you some cases. I have three cases. Hopefully, we'll have time to get through all of them. These are all cases that are recent in my practice since November when I was given this task of this panel discussion. So I don't have a long-term follow-up on all of them, but they're all recently part of my practice. So a couple of disclosures, none of which are really relevant to my talk. We really have a fantastic panel that we've assembled here. Lance LeClair is going to end us with a video from the Naval Academy, most recently moved to Vanderbilt and doing great things there. John Dickens also left the military at Walter Reed and now at Duke. And we're joined by Allison Toth also at Duke. And the godfather of shoulder and posterior shoulder and stability, Jim Bradley from Pittsburgh, who's forgotten more about this topic than most of us know. I also like to thank Dr. Taylor for staying on as well. So jump right into the first case. First case is a 17-year-old male lacrosse player. He checked another player and dislocated. He went to the emergency department. They report an anterior dislocation. They do not have pre-reduction films. He thinks it may have gone out the back, but he's not sure. I performed my exam in the office. Again, he's just unidirectional, posterior, symptomatic load shift, posterior apprehension. His anterior and the rest of his exam is normal. His plane images do show maybe a suggestion of a potential reverse hill sacks there. I'll start with you, John. How much stock do you put in the emergency department's assessment or in the patient's assessment? It can be confusing sometimes with a pure dislocation, whether which direction it went. Do you just rely on your physical exam or how do you approach this? Yeah, I mean, I think obviously having some degree of skepticism with this. I think it's hard for patients sometimes to remember or be able to isolate the direction of instability. I've had several similar to this that have had a posterior instability event when they've thought it feels like anterior, whether or not they're told that's the case. So I certainly, your exam here, I would trust that a whole lot more than I would the history from the ER and even kind of what the patient says sometimes. Great. Sam, so HSS, they definitely don't like gadolinium. What is your choice for advanced imaging at this point? A non-contrast shoulder MRI is what typically what we would be getting in this situation. Okay. Well, I got contrast, but so this is MRI arthrogram. These are a little bit of motion artifact here. They're not the best, but these are sequential axial cuts and can show you what you need to see. Usually the kernels are really helpful for this problem, but Lance, what are your thoughts here? Well, yeah, so I think this demonstrates why I prefer gadolinium contrast as well. So, you know, even if we didn't see some of the, you know, the middle cut or the right cut there, you'd be worried about the volume of dye in the capsule, in the joint, and some extravasation, which may be indicative of a posterior or reversed glenohumeral ligament avulsion. At a minimum, you're looking at posterior involvement, posterior instability here, I think. You know, I would also look at the sagittal views very carefully for any glenoid bone loss, but I think we're looking at a posterior instability pattern here with the concern for potential Hagel lesion. Does your radiologist at Vanderbilt ever get this call right, or do you not even read their report? I take a look at it, but I think you have to proceed with a lot of caution. If these are very frequently missed, another helpful view is the coronal view, seeing the dye track down the medial deck of the humerus. I think those can aid in the identification of these, but I think I agree they're very frequently missed by the radiologist. John, I'll come to you quickly. Is there any role for nonoperative treatment based upon the paper you just presented? Not for this patient. Okay. Loving it. Okay. So, we go directly to surgical intervention, and this is what we see. This is a beach chair. Sorry about that, but looking from the top, you can see a posterior tear, as well as this reverse Hagel with a kind of an L-shaped type tear. Jim, certainly, we've discussed this. You have a case you've shown with an NFL player of kind of similar. What's your approach, and is there a particular order you like to address this? Yeah. So, two things. If a player dislocates on the field, and you have trouble reducing him, you better expect to see that capsular tear right there, and the labral tear. They usually come together, and sometimes there are multiple tears in the capsule. The way I do it, first of all, is I close the capsule first, and then I go to the labrum, because I'm afraid I'm going to over-tension the labrum, and then not get the capsule closed. I typically do them arthroscopically, and I take the sutures so that the knots are not inside the joint, all right? And use any device you want, but that's kind of the sequence. Okay. Well, I agree with you. I usually approach this in a similar way, affix the reverse Hagel first. And this one, it was just a really small posterior tear. So, we addressed that with one, I think, a single anchor. Hold on. Let me advance this. There we go. Again, you can see it's sort of an L-shaped capsular tear, a really small labral tear. We're able to address that with one single. If you can advance it to the next slide, please. Oh, here we go. Sorry. Let me show you what we did. So we did fix the labrum first. Um, one simple, and I, and again, I agree with you. Usually it's nice to be able to not over tension it and take up your tension on the, on the, on the glenoid side. But in this case, we put one simple, uh, anchor in on, on the, on the label tear, and then we're able to repair this with a single knotless anchor. And then a couple of side to side stitches to complete that capsular repair. Okay. Great. Okay. Next case, uh, GS 21 year old male who actually is a work comp injury. He actually works on a, on a cruise ship and he had a seizure while at sea. Uh, when they were eventually got to port, they, they went sent, he went to two emergency departments. Uh, they both mixed missed his posterior dislocation. Uh, he actually went to a primary care, uh, sports medicine physician who actually sent him for an MRI. Uh, and then called me when he got this, uh, emergency call from the radiologist. He's dislocated as you can see here in the gantry. Um, his exam, he's got very limited motion is neurovascular intact. Fortunately, uh, we don't have a lot of time. So I'm going to rapid fire, go down through, uh, what, what's the, what's the approach here? Anyone want any, anything, any additional studies, or are we going to go right to the operating room with this? Well, I'm going to, I'm going to reduce it. I'm going to look at the size of the defect and I'm trying to probably do a REM plasage in the front. Um, and if it's really bad, I would take the lesser tuberosity and put it in there like I used to do in the old days. John, anything different? Uh, yeah, same, same thing. I'd, I'd plan on going straight to the OR to the reduction since it sounds like it's been there for some time. Same. I agree. Good illustration of, uh, the difference between a regular heel sacs and a reverse heel sacs lesion. This is all articular cartilage. So I have to think about that potentially long-term. Would you try tamping it out if there's a nice cartilage there? With this size of a defect, I would not, but if you're 40% or more, I think I would consider something, uh, certainly if it's central in the humeral head, I would think about something for the articular cartilage. Anything different, Allison, Sam? I think that just that question of whether or not to get a CT scan and try to like look at that bony defect a little better and multiple, uh, cuts and try to figure that out ahead of time, how large that defect is, that may help in that planning pre-op. I, I agree. I'd probably get a CT and I would consider an OC allograft potentially. Okay. Well here, here's, let's jump right to what we saw. Uh, this is, we were actually able to get a very easy, uh, uh, closed reduction in the operating room. You can see it's a pretty beat up shoulder, really scarred in posterior, uh, periosteal stripping. Here's that, that reverse heel sacs defect, no articular cartilage on it. It's again, not as big as maybe we had worried about. The patient was fairly compliant and not trying to move his shoulder. We've really locked him down beforehand, able to do a, a posterior repair. These are some stills of a, a double anchor reverse remplissage, uh, tying that down on the other side of the, uh, of the subscap. Do you routinely use peak anchors? I do like peak anchors. Yeah, I'd had some, I started with some biocomposites and, uh, I've, I've been pretty happy with the peaks. Uh, anyone, has anyone moved to all, all soft tissue, all, sorry, all suture type anchors, or I'm still a hard guy right now. Anyone soft? Uh, I think some of the, uh, all suture anchors with curved drill guides can help in some positions getting a little bit lower. And then in the posteriors, um, I, I can avoid, uh, some additional, uh, portals using the flexible drill guides, but, um, I use these anchors. Great. Well, here, here he is, he's six months out and doing very well. Um, really had, had no issues. So again, don't have long-term follow-up, but he's done very well. And, um, I've got, I'm going to go really quickly on the last case and then we're gonna jump into Lance's video. Okay. So we'll go kind of go rapid fire on this is a 42 year old active duty Navy, uh, service member. He's had chronic pain. He doesn't describe instability on exam. He comes out with forward flexion. These images show pretty advanced, uh, glenoid dysplasia. There's some concerns, there's some potentially maybe the start of an inferior spur on his, on his, on his humeral head. Um, uh, what are your thoughts here? We'll go quickly, Jim. Um, it's all depends on the bone on the back. So if the bone on the back, you think it's okay, then what you do is you simply repair the labrum and I've had good luck with that. If the bone on the back's a problem, then what I do is I use John Conway's technique. He taught me where I use these small bony, they look like little toothpicks. We get them from the tibia, make a picket fence in the back, fill it with bone and repair the labrum. John. Uh, if he was army, he would not have been able to last for 42 years, uh, on active service. Um, he has a hypertrophic labrum, no prior surgery. You could consider fixing that arthroscopically. I might tend to, um, favor, even though he hasn't had prior surgery, a bone block procedure. Same. I would just add Joe Ekinger has a nice, uh, series of active duty patients that had equivalent outcomes with glenoid hypoplasia, dysplasia, uh, with arthroscopic repair. So it is possible to get a good outcome with these arthroscopically. Okay. 10 seconds. Yeah. I, I agree with the panel. I would just say that, uh, thinking about doing a bone block or something very hard with, there's still a little glenoid there and even an osteotomy, uh, even though that's not gained much popularity, that's really difficult when you don't have much, you don't have much medial room. Five seconds. That guy's sitting out the back. If you do something with bone, he's going to become arthritic fast. I'd inject this, um, and treat his pain and then consider an arthroscopic procedure. Okay. Yeah, I agree. He, again, he had done well for 42 years, not complaining much instability. You can see he's got a little bit beat up, uh, posterior inferior, uh, glenoid articular cartilage, but, um, we did a, uh, a very, a very fast repair. Um, that's all I have time for. Thank you very much. We're going to end with, uh, with Lance Leclerc's, uh, video. I like to, again, just share with the, with the audience here is that this was submitted, uh, with many other, uh, videos on posterior shoulder instability. His was selected as the winner. Uh, all of these videos are going to be available for, um, uh, for our review, either through the society, uh, website or through VJSM. But again, I'd like to thank Dr. Leclerc for submitting his video and, uh, Lance.

shoulder injuries

ER assessment

treatment approach

posterior dislocation

arthroscopic repair