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AOSSM 2022 Annual Meeting Recordings - no CME
Shoulder Instability: Perspectives from Around the ...
Shoulder Instability: Perspectives from Around the World
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It's from around the world, the AOSSM and ISOCOS Combined Symposium. Really we're going to organize this in two ways. First is the world view, and we're here recording from Madrid, Spain. Case one is a first or second dislocation, small heel sacs, no glenoid bone loss. Second case, multiple dislocations with bone loss, but an on-track lesion. And case three, multiple dislocations with bone loss with an off-track lesion. We have Pablo Nurbona from Argentina, South America, Beno Idesman from Brazil, South America, Giovanni Di Giacomo from Italy, Clara Acevedo from Portugal, and Emilio Calvo from Spain. Trying to give us the world view, and we'll go through with these three cases, looking and discussing what their opinions are. Then Mike Freehill, who's the moderator of the U.S., where you guys are, in Colorado. Steve Weber, Eric McCarty, and Albert Glenn will then take over, and you guys can discuss. So we hope this is helpful, giving you both a global perspective of shoulder instability. Thank you. I think that this is the ideal case to do a bunker reimplacement. For me, it doesn't matter if it's... For me, the bunker reimplacement, nobody talks about the dynamic effect of the reimplacement. And if we do the reimplacement a little bit laterally, and not too medial on the tendon, we are not going to alter too much the anatomy, and we are going to lose external rotation. So I think I would go for a bunker reimplacement in this case. I don't like the bunker reimplacement. I prefer to do the laterger. And mainly in competitive athletes, we publish some papers in professional soccer players, and mainly in goalkeepers. And if you do arthroscopic, you have a lot of failure. And we have another article about bullfighters. And when you have athletes like that, or when you have athletes like, we call, waste of life, like surfers, or paragliding, you should do a latger, because I think it's more safer for the patients. Now we are using just one screw and washer in the proximal aspect of the bone block, and just a screw in this proximal to the tendon, because we studied the finite elements, and when you do this, you have more strength, and you decrease the chance to have osteolysis. No, no, you use two screws. In the first screw, you just screw and washer, and the second screw, you just use just the screw. You have a very good fixation, and we think that because the screw that is too proximal is too close to the conjoint tendon. If you just use a screw, you have a better fixation, you don't have too much motion, and maybe you decrease the chance of osteolysis. Thank you, Gus. So I'm the fifth. We have two supporting soft tissue procedures, two supporting osseous procedures. I will try to give my opinion. So this is a case of a non-track, three-stack lesions with multiple dislocations. Am I right? No bony glenoid defect, okay? So I need more data, because if the patient is a very active patient doing a high-risk activity or sport activity, like contraceptive sport or conditioner sport, this is an indication completely for a lethargy, because the rate of recurrence is very high. But if the patient is, let's say, over 30, not very active in terms of athletic activity, it could be an indication for a soft tissue procedure, and in this regard, my preference would be a conventional bank of repair. I don't see the necessity to do any roentgens, and I don't see the indication for a dynamic anterior stabilization in this population, but if the patient wants to have a very safe shoulder, a reliable shoulder, because they want to practice these kind of activities, it's an indication for lethargy, for sure. Yeah, so let me push back on you a little bit, because I don't know how many patients would come in and say, hey, you know, I want kind of a mediocre shoulder. You know what I'm saying? So, you know, it sounds like you're a lethargy, because you feel that's a safer operation, it's more reliable. Is that true? That's absolutely true. So if anyone says, I want a safe shoulder, I want the best procedure, you're saying lethargy. Well, first of all, I'm going to offer my patient the best procedure, because I believe that a soft tissue procedure can be the best procedure for a patient over 30, with no bone defects, and with a sedentary life. That's it. But if the patient wants to have a really safe and reliable shoulder to practice risky activities, or if he's too young, or he's young enough, it's an indication for lethargy. Going back to the black legend of the complication of lethargy of 30%, probably I know where this figure is coming from, but, you know, there are many publications. We published the series of lethargy, and our complication rate is much lower than that. So it's lower. Of course, there are complications, like with any other procedure, but it's not superior to other procedures. Yep, I pass that over to Giovanni. I agree completely 100% with Emilio regarding the complication. The complication is more or less four or five complications, and regarding the hardware is very surgeon-dependent. If you put the screw, we use a small plate in the right way, and you pay attention, and you have a very nice view during the surgery, and you put the retractor in the right way, you cannot have this kind of problem, even if you have an absorption. And regarding the absorption, you have to pay attention when you don't have huge bone loss. When you don't have huge bone loss, you have to twist your coracoid to have the best fit between the deepest part of the coracoid and the steep, because you don't have bone loss. That's the reason we use a small plate with a wedge that gives an excellent compression. We published a paper last month in Atosubi Journal about a comparison paper between Banco Rempisaz and Latarje. We compared 70 patients for Banco Rempisaz against 188 patients with Latarje, and we really had zero complication rate in Banco Rempisaz, almost 6% in Latarje. And we have better return to sport with Banco Rempisaz, almost 91% against 72% with Latarje. And the recurrent rate was lower in Banco Rempisaz than in Latarje. But we do Banco Rempisaz in a different way than normal do. We go with the supra-spinato and not the capsular on the Hitzad lesion, and we have a really very strong Banco repair. So I think the modern technique for Banco Rempisaz, for me, is a great option. I think that the problem with Latarje is not so much the 30% question. It's that we know, anecdotally, that there are devastating complications with Latarje that we see when we discuss with colleagues around the world. So this makes this procedure not the ideal procedure, because the ideal procedure is one that is highly reproducible in anyone's hands. So the problem here is this, is that the reason why there are surgeons looking for alternatives is that there is a learning curve for the Latarje, and if you use the Latarje judiciously, considering glenoid bone loss, you won't have a high volume of Latarje procedures. If you approach it like the French do, they do 70% of the French surgeons do a Latarje immediately after the first dislocation. They have high volume, so they have a low rate of complications, because they do it every time. But if you do it judiciously, you will have complications. When you have complications, they may be devastating, and when they are devastating, they are in young people, 19-year-olds, 20-year-olds. I think this is the main question surrounding Latarje. One possibility to save the Latarje for me is the hardware-less Latarje. I think that's the future. Not using hardware, maybe then we'll find a place for everyone to do Latarje without devastating complications. Okay, and then the final case would be multiple dislocations, bone loss, off-track lesion. I don't think this will be hard. Well, off-track, no, it can be hard, because there will be some discussion, of course. I think this is an indication for a bone block procedure, of course, because an off-track probably some people will think of recommending amputations for these patients. But so far, it's been demonstrated that Latarje is an excellent alternative for patients with off-track heel sac lesions. We recently published a paper in the American Journal of Sports Medicine trying to assess the capacity of Latarje of restoring the glute tract in patients with off-track heel sac lesions. We found that it could be very efficient, of course, in restoring stability, but also in restoring the glute tract. However, in patients with very large bone defects, probably the cortical process is not thick enough to restore the glute tract. And there's a small percentage of patients that this is 11% in whom we should do something different, probably like an electrical bone graft or even something different, or even a Latarje plus a Ramprissage in the specific population. So, going back to this case, indication for Latarje unless it's very large bone defects. I do a Latarje. We did a study that compared Bristol and Latarje, and the results of Latarje is much better. You have more problems with the Bristol. But when you do like the last case, when you talk about arthroscopic procedures, in my hands, when you have a patient that you do a Boncar procedure after some dislocation, you never had a pre-initial negative after that. If you examine the patient, they used to have some symptoms of instability, and when you do a Latarje, they feel very comfortable, they feel very safe. So, I think in this case, I do a Latarje, and in my hands, they can return to sport much earlier than Boncar procedures. I'm allowing the patients to return around 3 months follow-up. Live or dead spots, maybe no, but if they are professional soccer players, I think they can return after 3 months. If they are goalkeepers, maybe 4 months. And maybe if they are surfer or maybe another sport that has some risk, they can return after 4 months. Because you have a bone healing, and after that you have a good proprioception, you have a strength, and I think you can allow to return after 4 months. I'm not in a hurry to go back to sport after a big procedure. It doesn't matter if you go back to sport in 4 months or 6 months. But anyway, for this case, we are talking about a glenoid defect bigger than 20%. What about an off-track lesion? Okay, if an off-track lesion and a glenoid defect less than 20%, I will go for Boncar replacement. But if the glenoid defect is bigger than 18-20%, I will go for Latarje plus Remdesivir. I think the dynamic effect of Remdesivir is very important to have the sensory human head. Nobody talks about the dynamic effect of Remdesivir. When the infraspinatus gets contracted, the human head is really sensory on the glenoid side, so it protects the head for a Latarje or for a Banco. So how do you do the Rempissage with a Latarje? I go for arthroscopy, I always do an arthroscopy diagnosis before Latarje, so I put the anchor for the Rempissage, I prepare all the heat solution, I put the anchors, then I go to the subacone state, I pass the suture, but I don't tie the sutures. Then I go back to the open Latarje. If there is a really big defect on the glenocyte, I will go for an arthroscopic Latarje, I can do it, but with a regular glenodefect, I will go for an open Latarje, do the Latarje procedure, and at the end I just blind the cloth for the Rempissage. So as I said, if it's subcritical glenoid bulmos, 20% or less, I'll go for the dynamic anterior stabilization. If it's more, the Latarje. But I think Benno focused on a very important question, which is if the patient wishes to return to sport early, dynamic anterior stabilization is not a surgery for them, because they'll have to wait six months to return to sports. So if that's the case, then I'll have to do the Latarje. Of course I would do a Latarje, but I would like to give two messages. The first message is because we are in an international setting, so we speak very often about Latarje, but we don't know how it works. We don't know how the Latarje works, because most of the papers are in vivo, are not in vivo, are on specimen, because it's very very hard to study the movement of glenohumeral joints in vivo after the Latarje. We are trying to do this, but we don't know exactly how the Latarje works in vivo. The second message is, even if I am maybe one of the first fans of Latarje in the world, pay attention to do the Latarje in the dominant arm of a hereditary sport man, like a tennis player, a high-level tennis player. Fortunately it's very rare, because they don't have dislocation, but you can have a good tennis player with dominant arm, or probably in any kind of throwers, because it's not anatomic, and in my hand is very very difficult, they go back at the previous level. So just to finish up, we'll start with you Giovanni. Why don't you give us the top three kind of pearls or facts that you have in your experience in treating shoulder instability? Of course, you know, I wrote a paper with Steve Onishi on the groin track, so the bipolar bone loss is one of the key points, but the second step, maybe probably more important than bone loss, is the age. So first of all, I give a look at the age. The younger they are, the more I pay attention to give the best information to the player, to the family. The second factor is the bone loss, and the third is what kind of sport they play, and where they are in the field. Goalkeeper. The goalkeeper, I can promise that he is coming back in three months after the Latter-day Saint, but as he said, I wait most of the time, like a rugby player, five months. In a midfielder, soccer player, first division Italian team, three months they can go back to play. So there are many factors that are related to the indication and expectation of the athletes. For me, it's very important to do a correct preoperative study. This is mandatory, and it's not frequently done. We should really assess the glenoid bone loss and the iliopsoas defect, the iliopsoas interval, and determine whether it's on track or off track to discuss with the patient. The other aspect is what are the patient goals, so the type of sports, if they wish to continue to do the same sports or not. Sometimes patients are fixed, and if it's a recreational sport, maybe they can change the sport, and they don't have to have an aggressive procedure. For me, this is very important. And another aspect is to always assess systematically hyperlexity. I always do the weight and score in each and every patient, and I think sometimes this is overlooked, and this can be one of the reasons of some failures, even after La Targée, because the La Targée fails, and sometimes has to be revised with soft tissue procedures. And this is not very frequently discussed, and it's a problem, and it's related with preoperative assessment. Do you have a certain score when you do something different? Well, yes. When a patient is really young and female and has like 9 or 8 out of 9 of the weight and score, I try to avoid surgery. I try to exhaust every possibility with rehabilitation, because there is no perfect procedure for these patients. So, this is a lesson. We see catastrophic results in very young patients, because they were treated aggressively, very young, and this wasn't taken into consideration, and bony procedures were used, and then there's no solution for these patients. So, this, for me, is a failure. I really agree with Giovanni, that there's so many different types of patients, and so many factors in each individual patient, that to find the right surgery for each patient is really difficult. But I'm sure what I'm not going to do, never, is to use a glenotechnique to treat the hemorrhage problem. For example, to do a lathargic to treat the really big hits of lesions. I will go to treat the glenotechnique problem for a side and a hemorrhage problem for the one besides. I think the first lesson is to treat the first location. I think it's very important. I think you should treat surgically the first location, mainly in sports, mainly in athletes. The second, I think that you should treat your patient, not should treat your exam. And the third one, I think you should do the procedure that you perform the best. I think the best procedure that you know, and sometimes, like in Brazil, sometimes you don't have too many anchors. Sometimes you have problems with the anchors. We have the problem to have absorbable anchors and sometimes we need to do a lathargic procedure. But I think you should do the best procedure that you can do. Thank you. I think what I've been saying is true. Keep in mind, first of all, that the key issues or the key factors to keep in mind, we published it many years ago, is bone defects, age, sporting activity, and hyperlaxity, as they pointed out. Having said this, second take-home message is that bunker alone has an important recurrence rate. So we should do something different to that. Probiamplicides is a good option. Probi-lathargic is a good option. We need to tailor the specific treatment to each patient. Our patient for lathargic, our patient for amplicides, and we need to figure out which is the perfect patient for the procedure. And finally, we need to tailor, and this is very important, the specific technique for the activity the patient wish to perform. Because it's different, somebody who needs a very safe shoulder like a climber to a thrower is completely different, and this is very difficult. All right. I want to thank you all. We'll give this over to Mike Freehill there in Colorado in the AOSSM meeting. This is us from Madrid, Spain, and the ISOCOS team here coming to you, to Colorado. So thank you for having us. All right. Can we get Drs. McCarty, Weber, and Dr. Lin up and then go to the last session? So while they're coming up, I want to send a picture. So I want everyone to wave on three and we'll send it to our colleagues. One, two, three. Yeah. Okay. Thank you. All right. So sorry for some of that audio, but I think that that's really valuable to get the insight from all over the world like that. So we have a couple cases here. We're going to tweak it a little bit because I think it's exciting to not just talk about the primaries that haven't had surgery before, but let's start talking a little bit about when someone's had a surgery. So our first case here is a patient who's had a surgery. So we're going to take a look at So our first case here is a 28-year-old female had an arthroscopic vein cart repair five years before and still pretty involved with swimming and surfing and those types of skiing. Can you turn the microphone down just a touch? So let's start with Eric. What are your thoughts with that history and just the images that we have there? The minimum of three anchors, four anchors to prepare the vein cart for stabilization. So for me, you know, I see a couple issues. I don't see anything specific about it today. I would like to know the type of vaccine sort of base or that will be helpful. You know, I think you could probably go ahead and do a vision vein cart in your preferred method of calling it four or five anchors. I'd like to start as I mentioned before around seven o'clock. However, I do also like to do the right massage, so I'd like to consider that on this, even despite the fact that I'm not sure if it would be the first time. And we'll move on to Albert. How important is it or how often? I mean, you published recently on a great, great study on the near track, not off track, not on track, but near track within eight millimeters and then being at extremely high risk. How often are you making the measurements? Are you doing it on every case, Albert? Yeah, sure. I did a lot of track measuring on every one. You know, there's measurement error, but it's like anything else. But it gives me a quick sense of sort of how, how, how off track or how on track the shoulders are. I think the interesting thing in this case, right, is we find out that Eric, we're going to do since there's just two anchors here, but there doesn't seem to be like, we're going to go along. She's not capable of getting up for application. She's 28, she's trying to be like 16. And as long as she's on a type of relax, I think you really, you know, could do a good job with her vision and her therapy. And I would, I would not recommend that in an integration scenario. I would probably just go ahead and do her massage. Today, a few years ago, we looked at her vision. Today, in front of her therapist, without her massage, there's a risk factor, a real risk factor for a just appointment, I would not see an off track vision, because I don't think she needs to do anything. So I, for me, I think it would be reasonable to do her vision for better documentation. All right. And, and Steve, just your thoughts here. You've spoken a lot about open Bancart procedures on various panels. Do you think that there's a place for that here? Number one, and then number two, you know, with that being said, what, what would you do? Well, I just did a paper way back in the dark days in 1993. I think that the guy that's covered with open Bancart is just because he's kind of open and observant. And we've been looking at a lot of, mostly contact doctors that are covered with open Bancart machines. And our results were much better with open Bancart. All you can say, Dr. Gutierrez, is that that's what he likes to do. Okay, so from our expert faculty here, we have Eric, arthroscopic Bancart revision repair with Remplissage, Albert, and Dr. Weber, you're going with the open Bancart revision. Okay, so you guys picked up on some interesting things of why I thought this was a fascinating case. I agree with Albert that 28, you're a little bit out of that really acute period, but this is a really active export doing all the crazy stuff on the water. She had re-dislocated doing surfing, and she's going to go back to that stuff. So I think that that lowers her years a little bit in my mind. I think that it's important to remember, I agree with you, the joint is very concentric, but you picked up on the fact that there's two tracks. And again, as Dr. McCarty pointed out, it's been shown in the literature that you need at least three, and that's probably the preferred number when we're talking about the anterior based instability. Not only that, are there two tracks, the position of those tracks I don't think are in the best place. It appears the lowest one is maybe at four o'clock. So more than likely, probably didn't get that axillary pouch closure. And when that does start to stretch out, which we know does occur with time, probably slipped under that. The hillsacks and why I think Dr. Lin's work is so important with that near track is there is measurement error, but when you measure, remember it's not the depth, it's the width of that hillsack. So when you can find that widest spot, and you start getting into, you know, eight millimeters or less, and you start getting into collision or very active patients, you know, my thought on this, even though I think you could revise an arthroscopic bank heart capsulography, I think you've done some damage to that capsule once it's failed once, and you need to add something to it. So my thoughts on this were an arthroscopic bank heart revision with a remplisage as well. Before we move on, next case, I'd love for, we have some experts in the room, Dr. Arciero, Dr. Burks are here. I'd love to get some insight and ask our faculty some burning questions. I would just ask, does double loaded anchors, you know, I mean, Boileau and some other people have talked about you got to have three or four, but those were all with single anchors. So does double anchor, I'd like to ask the panel, if double loaded anchors make a difference to you, and that's why I think it's important to get the op report, and also the actually the position of the inferior anchor. If the surgeon grabbed the capsule very, very low and reefed it, sort of a pinch tuck with that anchor position, you can re-tension the anterior inferior glenohumeral ligament. It just depends on how you handle the capsule. And so I want to ask that question. And then I'm just going to make a comment that I agree with Steve Weber. I would do this open, except for one thing that makes me think of revising with a scope is the scope bank worked for her for five years. It wasn't like she had an early failure. So I might be tempted to do that, and the way that I would sort that out is an exam under anesthesia. If she had a two plus load shift, I think I might do it with a scope. But if she was three plus and I dislocated her, there's no question I'd do what Steve said. But what about double loaded anchors? Boy, Bob, you had a lot of statements and questions in that. So let me, we can attack it one at a time. So you know, I think it's interesting about the double loaded. We actually, we recently did a biomechanical study looking at double loaded versus single loaded and found that there wasn't a great advantage to the double loaded. But your technique of doing the double loaded may make a difference. You're not just putting them around, you're doing kind of a mattress and a horizontal and something else. So that may be different than the way we looked at it. My preference is single loaded. I prefer more points of fixation rather than trying to pull it up or knowing that if I can get it down and pull up the tissue down to seven o'clock, to six o'clock, to five o'clock and pull it around, I have much more comfort in knowing that that tissue is going to heal. Al? Yeah, I mean, I know double loaded can be, you know, you would think that kind of wrapping it twice would kind of give it a stronger construct, but I think it matters the configuration that you do it. And I'm with Eric, I actually, I like just multiple, I use smaller anchors to get more multiple points of fixation. So that's what I would prefer to do. I don't have any experience with double loaded anchors for bank cards, but I think the idea that you have more points of fixation is probably valid, but I'd love to see the papers looking at the bench for this stuff. Those are great questions, Bob. I like the double loaded. I like to, I think that you get the best of both worlds depending on how you utilize those. You can get a horizontal repair to bring your labrum up, but then you get the added benefit of doing the simple, not passing one of them. So you get a vertical and horizontal, I call that a modified Mason Allen. I like that. Oh, speaking of special guests. Speaking of court jesters, it's a great case, Mike, I was curious, you said that you're in your hands, you'd maybe do a remplisage on this. It's a revision, right? So the one study that looks at revision, remplisage has a 36% failure rate, and Buddy Savoie, that's his data with Mike McCabe. So I just wonder, does revision change your mind about remplisage? Will you do revision remplisage or remplisage in the setting of revision? And if so, what are your indications? And are you nervous about that or do you think it was just a one-off? Awesome question. And I agree with you 100%. I think that's why a lot of times I'm going more to remplisage on the primaries, because the work out there shows you, Buddy and numerous authors actually have shown that, that your failure rate is higher with remplisage and revision. In this case, the things that were pointed out by the faculty, I think changes it a bit. A little bit older, not done probably fantastic the first time, although it did hold up for five years. So I think that was my thought, I could go with just the remplisage versus increasing it. I liked your talk, by the way, JT, that was very good. And so, you know, you do ACL surgery like I do, and, you know, we've come across the lateral extraticular t-edesis, utilizing that, and I almost see the remplisage in a very similar fashion, right? Okay, somebody's got hyperlaxity in their body, high baiting score, we're thinking three plus Lachman, okay, I'm going to add a LAT, all right, same thing with the remplisage, three plus, maybe he's got a baiting score of eight or nine, I'm going to add a remplisage, where previously I didn't, and that's in a primary. Also looking at revision ACL, LAT, revision banker, often using the remplisage. So it's really interesting how the concept of remplisage has gone, and I like what you said, I had a primary care doc that was sitting in the audience, didn't know all the things that we know, but was very smart, he said, doc, you know, why aren't you just doing remplisage in everybody if the stability's better, and he said, that's a good point. Can I ask one more question, if you mind? So you guys made the comment that you like multiple points of fixation, so you're saying three, four, so in this case, there is some lysis in the glenoid, and so if you put three or four more anchors along that rim, does anybody concerned about a postage stamp fracture? I don't know if this is truly lysis on here, because it's not the same kind of enhancement that you see on the T2, where it's completely fluid. That would, I think, make me a little bit more worried. I think these are tracks, and yes, they're a little bit expanded, but I'm not really sure, you know, I'm not really sure that that, you know, would be a cause for a postage stamp, in my opinion, here. I'm curious, Steve, maybe you can answer this, or I'd love to know the faculty's thoughts. In this day and age, when we're getting imaging, a lot of different cuts, and almost always doing calculations, does everybody still do an exam under anesthesia? And I know that that's, you know, we're trained to do that, to do that, but we're all, but I also know that you barely put the rasp on that, and you're losing a millimeter of bone, two millimeters of bone, are you chipping away cartilage? You already have the calculation. Does everybody in the room do an exam under anesthesia still? Well, if you're asking me, yes, I think it's still, you get more information from that than anything. And, you know, when you're in private practice, the quality of your imaging is tremendously variable, and you can't keep ordering scans because you don't like the scan that you got from, you know, Hopetown, USA. So that exam under anesthesia is critical, and I've had at least two patients where I thought I knew what I wanted to do, did the exam under anesthesia, stopped, woke them up, went back to the family and said, you know, I thought it was going to be this, but it's this, and the right thing to do now is this. In fairness, I had one, I remember very well, a guy had a greater tuberosity fracture dislocation of his shoulders in his 40s. I did an exam under anesthesia, went right out, I couldn't get him back in. I had to open him to reduce him, and this was at 10, 30, 11 at night, so it did not make me happy. So that happened to me once, but for the most part, I would continue to do that exam under anesthesia. Mike, I do an exam under anesthesia, but I think it's more rare for me to change my operative plan, unless something like that, very dramatic like that, were to happen. And I think, you know, as you alluded to, doing a lot of the measurements ahead of time, but I do think, you know, obviously if you get a 3 plus that's locked out, that's a very different scenario, and it can change, but I think that's more infrequent. And I just wanted to comment quickly on JT's comment on Buddy's paper. We're familiar with that, and I think it's a great paper. The only problem when I read that paper is that it's really underpowered. There's like very, very few patients, and so we take that as, oh, we shouldn't do remplisages in the revision scenario because of the 36% failure rate, but there was only like, there was a very, there was like only four patients, I think, or something pretty small, so yeah. So it's, you know, and I think it's, I think it's important to know that, but I think in these scenarios, you know, there are other ways to augment as well. You could certainly put in the posterior anchor and also include the remplisage, so. Quick show of hands. So who would do an open Bancart? Who would do an arthroscopic Bancart capsuloraphy revision repair only? That plus a remplisage arthroscopic? Latter-Jay? Okay. I wasn't going to say it's a cross-section. We're not taking that picture. This is what I have to, this is what's great about it. We have the two very different viewpoints for the most part. JT, we're here for the video. Yeah. Yeah. Okay. So case two, 25-year-old male had a previous Bancart. This held on for nine years, had a re-dislocation, playing basketball, active and recreational weightlifting and playing basketball. So limited images we have here. With these particular images, let's start with you, Eric. What are your thoughts here and what are you ultimately going to do? I'd get new imaging. Did that come from Stanford? Or was that? You know, yeah, really. I mean, I'd like to have a little more information and, you know, it's, this is one I'd probably give a CT scan on. I'm not confident in what I'm seeing. I wouldn't get a new MRI. I'd say, okay, I got some information on MRI, but I would go for the CT scan with the thin cuts and 3D reconstructions. So are you worried about bone loss? Yeah. So Mike, the question that Bob had asked earlier, I think this is a different scenario. So if you look at the fluid sensitive sequence here, there is fluid that's basically tracking through those suture anchor tracks. So I'm a little bit worried that I'm not getting the best image here. And I think there might be some bone loss here. So I definitely would get a new image, particularly a CT scan before I make a call on this one. Steve? Well, I mean, I'm still a little nervous with young people and CT scans because of the radiation exposure. I know that's not a popular opinion. It's always good in these panels to ask for more images because it puts off the answer for another couple of minutes. Assuming we get what some of the guys do to you and say, this is what you're stuck with, make a call. I can't see enough bone loss that would make me change my mind about doing some type of bone augmentation procedure. So if my exam under anesthesia confirmed what I expected and I'm stuck with these images, then I would do an open bank card. Yeah. Well, you brought it up perfectly because we are stuck with this and we need to know what you're going to do. Well, so as opposed to the other case, it looks like there are an appropriate number of suture anchors kind of going from, you know, down below, up superiorly. And let's say for the sake of argument that that picture that you're showing, the sagittal, is representative of some bone loss. It doesn't, to me, look like what I would consider critical bone loss, kind of, if it were to be the case. And for me, I think that's actually a really, for me, I would do an open bank card and probably if there is a sliver of bone to incorporate, I would incorporate that into it. So thanks for leaving us with poor images. But based on this, again, looking at it, it looks like all these anchors are placed anteriorly. You know, I would do exam under anesthesia, do the same things that I talked about, approach it very similarly. I'd have no problem if they're, you know, one, two plus to do an orthoscopic with a remplisage. And if there's not a Hill Sachs, JT advocates for creating the Hill Sachs. That's not exactly how he put it, but he said buff it up. And I'd have no problem doing that, just, you know, looking at this. And for me, the open would not gain as much for me. But I'm not as good as RCR. So. Steve? No, I agree. I would do this, assuming there are no surprises. I would do this open. Even if there's modest bone loss, I think open bank cards can do okay. I know Mike Pagnani and I had a bromance moment a couple years ago at the academy where we both agreed on something, so that's probably where I'd leave it. All right, let me throw this out there. I'd love to get Dr. Arciro's two cents on this. So held on for nine years, still young, still active, now has gone on to have another event. Do you get plastic deformation with that amount of time? Has that been slowly building and eventually you hit a critical time? And now, saying open bank card, which even though I do think it's good to talk about, how many people actually, it's kind of like the double bundle to me. We like to talk about it, but how many people are really doing it, you two excluded? Do you go in with an open bank card? How are you gonna do it? Are you splitting the subscap only? Because if you take that down, they've already had one repair. Now you're doing the open bank card if you have to bail back to a Latter-day for whatever reason. Then my last question would be, if you have plastic deformation, you can really tighten that enough that you'll keep them stable, but is that anatomic? Or are they gonna go on and have a capsulography and Dr. Lin's gonna be doing an arthroplasty at some point? Just. Wow. Wow. Oh. I thought our CRC only wanted to ask five questions. I'm kidding. So I'm gonna take what you gave us, Mike, okay? We don't get a CT scan, all right? So this might be that intermediate, I'm just gonna say it's intermediate bone loss, 10 to 20%. So I think that there's no data to prove anything. There's no data to prove anything, I'm gonna tell you, honestly. But if this kid was really hyperlaxed, I would do a Bayton score and I would look at things like his sulcus sign and his load shift and try elbow hyperextension, get an idea of is he a mesomorph like me or some really wiry, skinny, loose kid, 25 years old. 25 years old. So I would take the subscap down if he was really loose and I think, and I would do an open Bankart on this and pass, it is totally, it depends on how you do it. It's totally different than a scope Bankart, passing the sutures all the way through the laborment capsule and plastering it on the net and then imbricating the capsule and then repairing the subscap with four non-absorbable sutures and a O-Vicryl running stitch and hold him so that that heals. If he's a mesomorph like me, I would probably split it. And by the way, you can still do, if you had to do a Latter Jay someday, even if the subscap healed, hopefully it healed, you could still do a split on it. But that's how I would approach this guy. I wouldn't jump to a Latter Jay on this. I probably, because he's 25, I would have, and he doesn't really have it, I would have more confidence in a open Bankart with a capsulorophy for the next 25 years. Okay, so let's take a, let's just see a show, oh, Dr. Burks. Well, I, I will say I totally agree with your comments on the Latter Jay, or excuse me, the Remplissage failure paper that Buddy did because I was gonna bring it up to Mr. Literature over here. I guess, you know, these are ones that I think are a little bit tough. I don't like to look at that humeral head. And so, you know, we're sitting here saying, oh, do you do bone, do you do open, do you do whatever? That's not a good looking joint to me. And so when we go back to the imaging and everything, you know, it's a young guy. And so what has maybe happened in this duration that this person's been stable? And so that kind of concerns me. And I guess I'd raise the question that, let's just say it's a little more advanced than you might like to see. Does that tip you more to a Bankart as opposed to a Latter Jay? Because maybe in the near future somewhere his, he may need more. And I know that there are some who would say that having the Latter Jay there might complicate other things. Maybe the open Bankart doesn't, but I'd kind of like to want to get some information on what that looks like. Maybe it's gotta be a scope, but I'm not happy with a 25-year-old with that. And much like the remplissage literature, you know, the Boston Shoulder Group also put out literature with athletic populations. If you don't go to, if you go revision one after an arthroscopic Bankart failure and do a Latter Jay, pretty good results to get people back. They can be active, collision athletes, et cetera. When you fail twice and then go to your Latter Jay thinking that's your bailout, the results are like 50%. So there's, that's why I think that these cases are so excellent to talk about, because once you get to this revision point, all right, so show of hands, who would do an open Bankart? All right, pretty good number there. How about an arthroscopic Bankart revision capsuloraphy alone? How about arthroscopic Bankart capsuloraphy revision with remplissage? And how about open Latter Jay? How about arthroscopic Latter Jay? How about anything else I missed? Mike, you've presented. JT. This is a clavicle? Yeah, I think this is a perfect case. If I buy that lower right image there, and we call that, as Bob said, maybe separate the bone loss, then I would make the argument that an arthroscopic Bankart here's gonna fail. I don't know enough about the bone trauma to the remplissage. It might work, we don't know. Or going around seven o'clock, we don't know. But I know that there's, if that's bone loss there, there you get subcritical, which is only three to four millimeters. That's too much. So for me, this guy, if he were considering doing a bone grafting procedure with physical tibia or physical clavicle, it's subcritical to just allow, it's more than subcritical to use. Now, you're saying a bone block that you're putting in arthroscopically through the interval, so you're not gonna play with the subscapital? Correct. Okay. Do you agree with the examination under anesthesia that doing that could cause, just as you said, three millimeters of bone loss? What's that, 6%, 5% you've just lost? 4%? Yes, we do. Yeah. I think the examination under anesthesia is important. I don't want to put them out necessarily to prove it, but I do think the laxity, I think that's one of Bob's really, thing that he's taught us really was, the laxity and how much that thing translates, because I think that helps us understand how big of a tux that you're gonna take if you're gonna do an arthroscopic, whatever. Are you gonna go posterior? Does this guy go right out the back of the posterior limb and shift? How much room do we have in terms of that laxity in tightening them up? So I think that's the art of it. But no, I don't think you should be showing your fellow, hey, watch this. Stop this crime, watch out. Dr. Lynn, Eric, Steve, how about drive-through sign? Dr. McFarland described that years ago, and you'd go in, if you could drive right through. Is that real? Does that make an instant decision change that you can do that? Does that have to do with how much weight you have on the arm if you're doing it in lateral, in beach chair? Is it just how strong your resident or fellow is? I believe he described it in the beach chair, and I do these lateral, and so I don't use it. And I think it does make a difference how you have the arms, particularly lateral, but I don't use it. Yeah, I don't use the, I don't find the drive-through sign helpful for me. You know, you asked sort of, are we missing anything? And I wonder, you know, I know JT, I know you've presented on these. I wonder if this is the case, Ivan Wong has presented on arthroscopic bone blocks. I wonder if this is a case where, you know, that might be a good indication for this. Well, both of us know Dr. McFarland well, so I don't wanna cast any aspersions. I don't use it. I think the drive-through is pretty dependent on how hard you push, more so than anything that I'm really measuring. All right, we have about six minutes left, and if anyone has a question, please come up. But until then, I'll throw something, Dr. Burks. So I kind of always struggle with when we have bone loss, and we call the Latter Jay a bone operation. You know, Gilles Walsh has done more than anybody, and he'll say one or two millimeters medial to the glenoid is acceptable. Well, that's not really filling bone where there's bone loss. So to me, the Latter Jay is magic. You know, it's the sling. It's all this other stuff. And so the interesting question is, how does Latter Jay compare to when you really do replace just bone? Because they're, you know, why should they both be good? I mean, they do totally opposite things. And so I think it's not a bone operation so much as it's a bony soft tissue attachment that gives us some advantages. So I'd be just interested in what everybody thinks. Thank you. There's three studies in the literature that look at that. Brought up in the 2019 year where it was a bone blocker versus Latter Jay, no difference. No sling effect in the bone blocker. And then Romeo's group with prevention, trying the same thing, right? And another study out of Germany, same thing. So I think, were you calling into question the sling, or were you trying to advocate for it? Neither. Were you just confused? Neither, I'm always confused. No, I think the issue is we heard this morning where you were that, oh, a small amount of bone and we still might do a Latter Jay. We heard earlier, Emilio Calvo, you know, with a small amount might do the Latter Jay. And we know in France, everybody gets it. Well, they're not replacing bone, and yet it works. And so is it maybe better in a high-end athlete who needs the extra that some people talk about where you get maybe a little bit of bone, but you also get a sling effect. And if you had a 2% bone loss, are you going to put a distal clavicle in and say, I'm good? Is it the same thing? How do you start choosing? So that's why I'm confused. Bob, you confused us. You weren't confused, but I think it's a great question though. It really is. And I love JT's thoughts on it because I know you've done a bunch of both and this distal clavicle, I really like it. And I think that's important because there is a real complication rate with the Latter Jay. And that, you know, they talked about it, maybe it's not as high as 30%, but it is real. And when you have it, it is devastating. And the distal clavicle, JT, I mean, you don't have that same issue, correct? So if you have equivalent type of results, you know, why not something like that, right? You know, it's interesting, the results, JT, as you said, they're equivalent, right? You know, and why is that? But the other issue though is the demographics. You know, there might be a difference in demographics too. And I think anybody who is doing DTAs to a high degree, push them on, are you gonna do that as your primary procedure for your football player? And most of them say no. Like most of them have not jumped to that yet. I don't know. Or maybe JT, or have you jumped to that? Yeah. I think you either believe that you're giving a restoration of anatomy, or you don't, right? And so I think that a bladder jay is an excellent procedure, but I agree with Eric. And you know, if you all have these patients in your clinics, like I do, with broken screws, or displaced screws, or even just well-placed screws with resorption, and head damage to the head, God forbid a nerve injury, which, you know, the follow-up study still shows 3%, even when they take all the precautions. And so if you're doing 100 instabilities a year, and you see three complete permanent nerve injuries, that's a non-starter, which is why you'll never catch on. Agreed. Yeah. So we have to find a way, I think, that is anatomic, and we can do those things. So to your point, I would say yes. We've moved to where we, I'm not gonna say it's dead. Bladder jay's not dead, but it's on life support. We have one more question. Hi, for this case, or even the previous case, does, can you just comment on index, at the index surgery, the quality of the labrum tissue when you're trying to predict going back and revising that tissue and trusting it, in either this case or the previous case? Does that play a role in your decision-making on what to choose for these patients? Yeah, so it's a great question, and I think that if there are cases of yours, and they come back, a lot of, you know, a lot of us usually will see patients that have failed from another place. Not always, but I think it gives you a lot more information if you did that index. These particular two cases were both from outside, so that makes it a little more tricky because you don't know the quality, and you don't know some of the, that information. But what do you guys think? Makes a big difference, your index, knowing how good that tissue was. Steve, you wanna answer that? Well, no, I think it's all part of the picture. If you're on the fence about whether to go orthoscopic or open, and you put the, because I scoped all my open repairs anyway, so I didn't miss anything. But if you look and it's a terrible labrum, you might say, well, I'd better do something else. Or another thing that I saw a lot of, you kind of poke around a little bit with your scope, and that capsule is just completely not mobile. I mean, it's just scarred in from what may be the prior procedure. In my era, we saw a lot of thermal capsule orifice, and it was routine to see a horrible capsule after those were done. So I think it's part of the algorithm, if you like, that you're gonna use to make a decision about how to proceed. I mean, sometimes you can judge a little bit of the quality on a good MRI. The other things about history, how many times has this person dislocated or subluxed in the interim, I think is important, because if they've dislocated several times, you know that, you know from all the studies that the capsule, there's gonna be plastic deformation in the capsule, so it may, kind of the pieces of the puzzle kind of, you know, kind of, you sum them up, and you say, okay, maybe this would be better suited for, let's say, an open or something more robust. So that's sort of what I would use to judge that. Okay, we're gonna close it down now. So thanks to our North American faculty, Drs. Riccardi, Lynn, Weber. Special guest faculty, Dr. Arciero, Tokush, and.
Video Summary
In the video, a group of surgeons discuss three different cases of shoulder instability. The first case involves a patient with a first or second dislocation and small heel sacs. The surgeons debate whether to perform a bunker reimplantation or a laterjet procedure, taking into consideration the patient's age, activity level, and desired outcome. The second case involves a patient with multiple dislocations and bone loss. The surgeons discuss the possibility of arthroscopic bankart revision repair with remplissage or an open bankart procedure, depending on the severity of the bone loss and the patient's laxity. The third case involves a patient with a previous bankart repair and a recent redislocation. The surgeons debate whether to perform an arthroscopic bankart revision repair with capsular plication or an open latterjet procedure, considering the presence of bone loss and the patient's laxity. The surgeons also discuss the use of double-loaded anchors and the importance of preoperative imaging and examination under anesthesia. Overall, the surgeons take into account the specific features of each case and the patient's individual circumstances to determine the best course of action. No credits were mentioned in the video.
Asset Caption
Michael Freehill, MD; Benno Ejnisman, MD; Clara Azevedo, MD, PhD; Giovanni Di Giacomo, MD; Emilio Calvo, MD, PhD; Michael Freehill, MD; Eric McCarty, MD; Albert Lin, MD; Stephen Weber, MD
Keywords
shoulder instability
surgeons
dislocation
bunker reimplantation
laterjet procedure
bone loss
arthroscopic bankart revision repair
remplissage
capsular plication
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