Well, I think we do. We should. And the reason for that is that because it allows you to estimate, to properly estimate the amount of bony lesions that you have in that specific shoulder and also to estimate and assess the glenoid tract for that particular shoulder. And what's the utility of this? If you have a non-tract lesion and if you have a glenoid bone loss that is below 25% or whether it's 25% or 10% or maybe 17% according to different authors, where the bottom line is if you have a minor glenoid bone loss and a non-tract lesion, maybe that patient will do well with a simple bunk heart repair. Whereas if you have an off-tract lesion, then you probably should add something else like a remplissage. On the other hand, if you have a major glenoid bone loss, probably it should go for a latage or some kind of bony augmentation. Now what do you have in the literature concerning comparisons between bunk hearts and remplissage? We know that overall or in average, the rate of recurrence may be kind of similar. Apprehension and revision rates are also kind of similar. But one must bear in mind that there are large variations in the literature. There's also selection bias in the articles. So we have to be judicious when reading these articles. This is a very classical report, long follow-up, 17 years follow-up from Ovilius that showed clearly that the latage does better in terms of recurrence rate, patient satisfaction, and also clinical scores after a long term. Likewise, this six years follow-up also showed recurrence rate after the latage that was much better than after bunk hearts. Furthermore, the latages fail in the first two years. So they keep stable after that period, whereas the bunk hearts keep failing after that period. So this is an important point one should consider as well. And it also means that if you're into soft tissue procedures, you should probably add something else like a remplissage, dynamic anterior stabilization with biceps, or some sort of subscap augmentation. And these kind of additional procedures may lead to better clinical results in the near future if you're going to stick to soft tissue procedures. But what do you have in comparisons between remplissage and latages? This is a laboratorial study that clearly shows that the stability is similar in specimens with 25 percent of glenoid bone loss. And this is a clinical study. It also shows that in primary cases, the results are similar between the two procedures. However, in revision cases, the latage appears to work better. So the rationale behind surgery in this case should be something around this. If you have no bone loss, then you may restore the anterior capsule and labrum with a bunk heart repair. If you have a umbral bone loss, you should go for the reduction of the posterior capsule volume with a remplissage. If there's anterior soft tissue deficiency, hyperlaxity, or hegel lesion, or minor glenoid bone loss, you should reinforce the anterior structures like subscap augmentation or dynamic anterior stabilization, or even the latage if there are other risk factors associated like contact sports or whatsoever. And if there's an important glenoid bone loss, then some kind of bony augmentation to the glenoid should be the choice. Now this is an interesting study from a group of surgeons that showed that the recurrence was common after an isolated bunk heart despite subcritical glenoid bone loss below 15 percent. So they stated that the remplissage may be considered even in on-track lesions. So for this group of surgeons, there's hardly any room for an isolated bunk heart repair. Now this is the way I do a remplissage. So after a few years, you kind of start making it as simple as you can. So it's just a placement of a couple of anchors, titanium anchors in the heel sex lesion. I place them closer to the cuff insertion. Then as you notice, I got rid of one of the sutures. These are double-loaded anchors, but I get rid of one of those. And then using a double pulley mechanism, I just tie the knots between two of the limbs, pull on the other limbs, and close the gap and fill the void like so. And I tie the knots blindly in the subacromial space. And this is another interesting study from a group of experts, but again, bear in mind this is a level five evidence expert's opinion, but still it's important. It's an expert's opinion. They tried to reach a consensus around this topic. And in fact, they got unanimous or strong consensus regarding most of the statements, but there was no unanimous agreement on any aspect around the latage or the remplissage. So there's clearly a lot to know around this topic. And considering that remplissage is best for glenoid bone defects under 10% and large half-track lesions, these authors proposed in limited glenoid bone defects below 20% offering something that could give the sling effect and also the hammock effect like the latage, but using the long biceps instead of using the contouring tendon, which is the dynamic antistabilization with the biceps. And there are several ways of doing it. This is the way I do it. In this particular case, you can see there's a slap lesion over here. So something would be done to the long biceps anyway, then fixation in the inferior part of the labrum. So you could see a taut anterior part of the inferior ligament. And then subluxing the long biceps by primarily tech-stitching it, then cutting the transverse ligament and dislocating the long biceps anteriorly. Then preparing the split in the subscap like so, then automizing the origin of the long biceps, and then using the sutures tech-stitching the long biceps to pass and transfer the long biceps through the subscap split from anteriorly to inside the joint with a rasper and using the sutures and pulling them from posteriorly. Then grabbing the sutures through the canal line, the rotator interval, and the next step is just fixing that long biceps in the right location using a punch-in knotless anchor. This is an anchor that allows you to estimate the tension that you can use, if you wish, for a Bankart repair. And as you can see, that's reduction of the long biceps to its location, to the desired location, and finalized with a punching in of the anchor. And final result, you will have the long biceps through the subscap split and a plication of a capsule more inferiorly. So as final messages, the recurrence rates vary widely in the literature, so one must not forget this. Do not underestimate the importance of the bony lesions. We know today that the Lat-Ager is more reliable and remains stable after two years. And we also know that the choice depends mainly on surgeon's preference or training, and it's largely based on extrapolated scientific data. However, newer techniques we have available today may change the rationale for decision if you're into soft tissue fixation and reconstruction. Thank you.

bony lesions

glenoid tract

shoulder injuries

Bankart repair

remplissage