like to thank ASSM from my side as well for this kind invitation. So my role is to define if arthroscopic bungalow repair is still an option for shoulder instability or not. So these are my scientific disclosures. As we all know, anterior shoulder instability is mainly a traumatic event in almost 100% of the cases, and it affects almost 25 cases per 100,000 people. It's mainly a traumatic event that occurred during athletic activities. And of course, after a shoulder dislocation, you have a classical bunkers lesion. But in addition, you may have the heel sac lesion, the bony bunkers lesion, a glenoid bone loss, and of course, humeral avulsion of the glenohumeral ligaments sometimes. So all of these lesions may take place during first shoulder dislocation or when you have a repetitive shoulder dislocation. And of course, the classical operation which performed all these years between 1995 and I would say 2015-2010 was the classical arthroscopic bunker operation, which consists of preparation of the glenohumeral ligaments and reattachment of the labrum and the glenohumeral ligaments to the glenoid. And sometimes we did the so-called 180 degrees operation in order to address the inferior part of instability as well. So the question is, is this operation worth well for this kind of lesion? Based on the results from the current literature, we may see that this operation has a high failure rate based on this publication from Christian Gerber Group. As you can see, 41% of failure rate, which is of course unacceptable, but take into account that all these operations performed between 1998 and 2007. The same thing from this publication from the group of Pascal Boileau, the failure rate was close to 22%, which is a high failure rate once again, but operations were performed between 2001 and 2006. This is very important to remember. The same things from the Imhoff Group, failure rate close to 20% and the re-dislocation was higher if there were more one dislocation pre-op. These are our results from our group. We reported around 11.5% of failure rate from a group of recreation athletes and laborers, not so high demand population. Some of these patients around 20% developed mild arthritis during this long-term follow-up. This is another publication which reports a similar failure rate, close to 20%. So the question is, why we had so high failure rate after this operation? Probably because in these years between 1995 and 2005-2010, we apply this operation for every patient, irrespectively of glenoid bone loss, irrespectively of heel sac lesions or the quality of the labrum, the quality of the ligaments. So most probably, this was the reason for this high failure rate. Then came this publication from Berhart and De Beer who reported that it was really very important to address the glenoid bone defect and we started to pay attention on the glenoid bone defect and the humeral side bone defects. It came the glenoid track concept published from Yamamoto and his group who reported that it's very important to take into account if the heel sac lesion is on track or off track and address this accordingly based on the radiological measurements that you have to do pre-op. Based on the glenoid track theory, these are the recommendations to do a bone cart repair. If it is less than 25% of glenoid bone loss, which is too much to my perspective, then you have to apply a bone cart repair. If it's more than 25% and it's off track, then you have to do an arthroscopic bone cart plus repair, as we call it. In the other cases, you have to do a bone block procedure like a lateral Z procedure or a nalograft bone block procedure. Probably the 25% is too high and based on the current recommendations, you have to apply an arthroscopic bone cart repair when the glenoid bone defect is less than 13% and you should probably augment your bone cart repair with another procedure, the so-called arthroscopic plus bone cart repair. The thing is that all these years, we learned that we have to evaluate very carefully pre-op all these patients with a CT, a 3D CT or MRI and to apply the heel sacs concept and the on track and off track lesion. Then based on these measurements, you have to apply the correct method. Based on all these assumptions, it is recommended to apply an arthroscopic bone cart repair when the glenoid bone loss is less than 15% and when the heel sacs lesion is on track. You may do an arthroscopic bone cart repair, but in most of the cases, probably arthroscopic bone cart repair is not sufficient and you have to augment your repair with the so-called bone cart plus procedure, which means that you have to do a Riemplisatz procedure, a NASA procedure, or a DAS procedure. If you apply all these principles, then according to the recent publications, as you can see, when you carefully evaluate these patients, if they're on track lesions and you do an arthroscopic bone cart repair, then the recurrence rate is just 5%. And of course, when you have off track lesions, the Latter Z procedure is very efficient with an almost 0% of recurrence rate. The same conclusion from this publication, which reports an overall failure rate of close to 20%, but when you're filtering the studies that excluded athletes with significant bone loss and performed surgery in lateral adjubate disposition and using minimum of three anchors, the failure rate dropped to 8%, which means that the bone cart or the bone cart plus procedure has really worked well. So this is another publication with 100 patients treated with arthroscopic bone cart repair, and as you can see, the revision surgery was required in just 6% when you had an on track lesion. In contrast, when you had an off track lesion, this raised up to 33%. So it's very important to take all these considerations into account, but probably this is not the only critical factor, the radiological measurements, and you have to take into account, of course, the number of preoperative dislocation, the IC score, and other factors as well in order to address all these patients. So probably the instability severe index score is something that you have to apply in these patients in order to decide what operation you have to apply in all these patients. So then the question is, since we have a high failure rate with a bone cart procedure, why not the Latter Z procedure for everyone, even in primary operation? However, we should not forget that the instability, the shoulder instability, and the procedures that were applied to address this problem, it's not all about the dislocation. It's anatomy. Bone cart operation is an anatomical operation. Latter Z is not an anatomical operation. We have to take into account complications, which is much higher with the Latter Z procedure. Arthritis, the same thing, and cosmesis as well. So in our days, the question when to perform an arthroscopic bone cart repair is you have to choose the right patient. You have to deal with a minimal glenoid bone loss, less than 10% ideally, at least this is my perspective. The humeral head lesion should be on track, of course. No more than two preoperative dislocations. Surgery in young male athletes after the first dislocation, which is very important. And of course, if you do your surgery after the first or even the second dislocation, the tissue quality is really very good. However, you have to always remember that there is a cost to waiting on surgery after the first dislocation. And according to this publication from Pittsburgh, from the group of Albert Lin, as you can see, there's a big and significant difference if you operate patients after the first dislocation in comparison to operate patients after the second dislocation. As you can see, there is a high difference between the patients who have been operated after the first dislocation in comparison to patients that have been operated after the dislocation. So in conclusion, what to expect and when to do an arthroscopic bone cart repair, you have to follow the criteria and indication and you have to select the patient. This is a key point. Then you have to you have to accept and wait a recurrence rate between 5 to 10 percent. Return to sports, it's really very high, more than 80 percent. There is a low risk of arthritis in the long term, which is a big concern, especially for young patients. And as John Lennon said, give bone cart or give this a chance. Thank you for your attention and we're looking forward to see you in our next ESCA Congress.

arthroscopic bungal repair

shoulder instability

anterior shoulder instability

glenoid bone loss

glenoid track concept