And congratulations, Albert and Carolyn, on a great session. My task today is to talk a little bit about the remplisage technique, decision making and technique. I'm J.T. Tokish from the Mayo Clinic in Arizona. I do have some disclosures available in the coursebook and at AOS.org. And the second one is I think I may owe the remplisage an apology because when this first came out, I said, well, geez, usually if something is really slick, really easy, and you and I can bill for it, we're going to abuse the hell out of it and oversell its importance. And I believed that for a long time. But the data, as it turns out, is actually pretty darn convincing. So if Gene Wolfe is out there in the audience, thank you for helping us with an innovative technique. And for those of you that have done this research and continue to do this research, thank you for kind of helping us understand where the limits are. So this is a surgeon's evolving understanding of the arthroscopic Bankart. If you take a look at it, you can take a look at this in terms of a siren song. When we first graduate from fellowship and we get out there and we've done our first 50 arthroscopic Bankarts and you're six months in and none of them have failed, you think this is the most beautiful thing in the world. And so she starts singing to you about that arthroscopic Bankart. And then, you know, a year into practice, I mean, you're all in. Your arthroscopic Bankart's still doing really well. The siren continues to sing. And then around 18 months when they start to fail with arthroscopic Bankart and bone loss, the siren has abandoned you and you're drowning in the water. In 2000, we learned from Burkhart and DeBeer about the upside down pair and critical bone loss in this regard knowing that 10 times higher failure rate when we're talking about arthroscopic Bankarts in the setting of bone loss. And we know that bone loss is the single biggest risk factor for failure after treatment for anterior instability. And so how much bone loss is critical to outcomes? We were concerned about this because we'd see patients that didn't just quite do very well after an arthroscopic Bankart, even when they didn't re-dislocate. And so we looked at this and thought, is there a subcritical level? And we found that this 13.5% level led to an unacceptable clinical outcome, even if the patient didn't have recurrent instability. And that was a big revelation for us and very humbling. Around that same time out came the concept that we can't just look at it on the glenoid side. We have to look at this in terms of a bipolar construct. And Giovanni and Eiji and Steve have taught us about these things. And we decided to look at that in a clinical setting. And what we found was we were able to validate this on-track, off-track concept, noting that if we did an arthroscopic Bankart on an on-track lesion, we had an 8% failure rate. But if we did it on an off-track lesion, our failure rates went up by a factor of 10. And again, this was irregardless of whether the patient had recurrent instability. So that's what we know, that scope Bankarts are ineffective for off-track lesions or even near-track lesions as Albert has continued to teach us. Okay, so if we're going to fix this, how should we fix it? And I would say that the algorithm looks something like this. If your glenoid bone loss is less than subcritical and you are on-track, then this is a great case for an arthroscopic Bankart. So the first-time dislocator, this is a really good option for this. But if your glenoid bone loss is less than 13.5% and you have a large Hillsacks lesion, especially one that takes you off-track, then I would say to you that a REM plissage is proving very effective for this central cohort. And of course, if you have glenoid bone loss that is bigger than that, greater than 20% and off-track, then I think this is the role of either distal clavicle osteoautograft or distal tibial allograft or Latter Jay. So then why should you add the REM plissage and when should you add the REM plissage? And I think we could almost make the case that you should do this always. And the data is emerging in this regard. You take a look at the studies that are out there. When you compare those studies that have compared Bankart versus Bankart REM plissage, take a look at the recurrence rates. It is clear and really if you're just doing an arthroscopic Bankart, you're playing for a hopeful tie. Every study in the literature that has come out so far has shown that the Bankart always does worse than a Bankart REM plissage in those settings. So one would argue that you should probably always add a REM plissage when there's a Hill Sachs lesion present in that regard. Well, what about versus bone blocks? We certainly have this controversial talk when we're debating our European colleagues about running right to a Latter Jay or for those of us that are doing bone blocks arthroscopically to sort of change this. What about the studies that look at this? So I'd call your attention to two studies. This first is a systematic review of 145 studies, Bankart REM plissage versus bone blocks. And what they found was is that the results are variable in both groups, but the recurrence rates tend to be a little higher with the Bankart REM plissage all comers and the complication rate though also tend to be higher. I think one of the best studies in the literature comes to us by Bob Arciero's group and Dr. Yang where they compared Bankart REM plissage versus Latter Jay for off-track lesions. And their recurrence rates were really not that different. Their complications, however, were quite different with Latter Jay having a much higher complication rate. Now these are all comers. And when you selected it out for different groups such as collision athletes, we found that those data did not, that sort of equivalence did not hold up in that group overall. Their WOSIs and SANEs were equivalent when you compared those two groups. So certainly I think the Bankart REM plissage is making a case that in all comers across the board, it's a pretty solid procedure. When you take a look at REM plissage versus Latter Jay in the setting of primarily humeral bone loss, so that's that middle column I showed you earlier, this study by Cho and Yongguo Ri taught us some interesting things. It compared these techniques for a large engaging heel sacs but minimal glenoid bone loss. In our results, it's about 35 or 40% of the population that you're gonna see in an active population. And they found that very similar outcomes in terms of recurrence rate, less than 6%, but the higher complication rate in the Latter Jay persisted 14% versus 0%. So if you've got a large heel sacs lesion and a small glenoid bone loss, maybe you should think about this procedure. So what are the indications for REM plissage? Well, I might make the case to you that based upon current literature, we would say that all on-track cases with a heel sacs lesion should be considered strongly for REM plissage. And I might even suggest to you that if you don't have a heel sacs lesion, maybe you should make one. And by that, I mean, don't dig a hole, but maybe just freshen it up back where the bare area is. And in fact, for those of you that always go around and put a seven o'clock anchor back in the back and tighten up the piggle, the posterior inferior glenohumeral ligament, maybe you're doing the same thing. And maybe that's why that little additional technique, a reverse REM plissage, if you will, has had the increase in stability that we've seen over time. Secondly, maybe all off-track cases with big heel sacs lesions and minimal glenoid bone loss, that's certainly what the data would tell us right now at a REM plissage. But beware in the collision athlete, beware in the setting of revision, and beware in the setting where your glenoid bone loss is large. Okay, so if you're gonna decide it, how do you do it? Well, we prefer this technique. You'll notice there's one spinal needle coming in. And the key to this is that your portal is variable. But the key is, is that wherever you put that needle, it has to reach both the front and the back of your heel sacs lesion. So once I'm happy with this, and it's not always in the same place, I make sure I'm good. That allows me to do one skin incision, and then I just put a little skinny switching stick, and we drill our anterior anchor here. You see, in this case, we're using a screw-in anchor. We now use a all-fiber anchor, if you will. And you put this in, and please notice, it goes through the anterior cuff or capsule anteriorly there. We simply repeat that process now once we finish with our first one, and we just come posterior. So it's through the same skin incision, but it comes through the cuff at a different place, and you just have to pierce it. And that takes care of all of your suture passage and all of your suture management. So then we just repeat that second anchor in the back of the heel sacs lesion, and when we're done with that, you have two anchors, one in the front, one in the back, equidistant from each other in the front and the back heel sacs, but also equidistant across the capsule and cuff, like you see here. Well, this is a knotless construct, so what you can do is take the working stitch of the posterior ankle and pass it through the looped end of the anterior anchor. You can then pass this through, creating a mattress stitch from the posterior anchor to a linked anterior anchor. So you can see us doing this. We've got it looped through. This is the posterior anchor in the anterior loop, and you can see that we can just pull the other end of the loop, and it'll transfer that, creating a single mattress stitch with a sort of double pulley technique modified, if you will. And then all we have to do is repeat that through the second tie. We never have to go through the subacromial space. You never have to pass a suture through this cuff, and you can see the effect on the humerus. With tension, it slides the head back. With relaxed tension, it lets the head slide forward. And then once you're finished with that and happy with your position, you simply push these down. The technique is actually quite quick. You can exclude the Hill-Sacks lesion out, and more importantly, I think, translate the humeral head posteriorly so that it doesn't engage. Well, what about the evolution of acceptance? I remember we did a ICL in 2016, and these are legends, three legends in the world of instability and me, Bob Arciero and Laurent Lafosse and Giovanni DiGiacomo, and I asked them in front of the panel, what are your indications for doing remplissage? Arciero said none. DiGiacomo said nessuno. Lafosse said akun. None of them were doing any of them. Well, fast forward just a few years, and all of them have published on the topic with their indications for remplissage. So I think like all of us, folks are coming around to realize that this has a role, if you will. So in conclusion, I would say, we must recognize the limits of the arthroscopic Bankart. Ladies and gentlemen, I think we're lying to ourselves because we're grossly underestimating the number of times that we need to add something. Bone loss is a bipolar problem. It exists both on the glenoid and the humeral side, and humeral bone loss can be addressed in most cases with a remplissage technique. We need more data on its limits, and we need more data when it's in a direct comparison with the Latter Jay and other bone block techniques, but it's a very promising intermediate choice in shoulder instability with bone loss. Thank you very much for your attention and good luck.

remplisage technique

arthroscopic Bankart procedures

shoulder instability

bone loss

glenoid bone loss