Thanks to the program chairs for including me, disclosures are in the app. I'm going to talk a little bit about the forgotten surgery. Despite popular opinion, there is another option besides a scope repair and a ladder J and just try to make the case that there's still a place for an open repair with a capsular shift. So indications in my practice for this, an athlete, especially a contact athlete that has a bit of labrum injury, but also ligamentous laxity, I define ligamentous laxity as it has a Bayton score of at least four, a failed scope repair without significant bone loss, bony bankart injuries, haggle injuries, all good ways to approach open. So what's the advantage of doing it open? You can mobilize the capsule from the subcap, which is much more difficult through the scope. You can eliminate this medial capsular recess we often see on the MRI. We can tighten the axillary recess. We can repair bony fragments. We can directly treat the rotator interval. The capsule can potentially be imbricated, pants over vests, to double the thickness and we can directly repair some cartilage lesions on the anterior glenoid. It's a harder operation, so you need at least one, if not two, assistants. Case that this will be the video case, 17-year-old right-hand dominant volleyball player, traumatic first-time dislocation, three recurrences, committed to play D1 next year, five over nine Bayton scores. She has an MRI with a labrum injury, no significant bone loss. 45-degree beach chair position, an arm holder is really helpful. We'll start just lateral to the coracoid, down toward the axilla. Here we found our subscap. We want to find the musculotendinous junction in the lesser. Always peel up this nice little layer of bursa that's on there. We deal with the subscap. You can either do a tenotomy, which is my preference, a lot better visualization in my experience, or we can do a subscap split. I like to do the tenotomy a few millimeters away from the musculotendinous junction. It really optimizes your ability to find that plane between that capsule and the subscap. As you get lateral, that's much harder. If you do a split, you want to go right in the middle or slightly inferior to the middle. Here we're elevating up the lateral stump of the subscap. You can see a big defect in our rotator interval once we get down to this area and some laxity of the capsule. Then we peel the capsule right off the anatomic neck. Again, a big part of this is not only repairing the labrum, but doing a direct, powerful treatment of the capsule. The further down we go on the anatomic neck, the more we can shift and tighten. Here's our labrum tear that we can see once we've got our retractors in place. We can mobilize this, prepare the glenoid. It's actually easier to use the arthroscopic instruments at this point in time. Mobilize the tissue, especially if you have an ALPS lesion and such. Get a rasp in there. Get things kind of nice and ready to go. Anchors of choice. This is a nice place to use anchors with needles. It makes it certainly easier to pass things. Usually three or four anchors along the anterior edge. Part of this will be to place our sutures in a vertical mattress fashion right out through the anterior capsule labral tissue. You can see we've got a DERA retractor in there. The hardest part of this procedure is catching your needles as you're passing them. You can use some arthroscopic instruments that will facilitate this a little bit. Once we get our sutures passed, we create some anterior mattress sutures. This is how we eliminate this medial capsular recess that we often see. I like to use an arthroscopic knot tire just to get knots down in there tight. You can see a nice repair of our labrum. There's our sutures outside the capsule. Now we're going to do the second part of the operation. For me, this is not just a labrum repair. This is a treatment of the capsule. We're going to place our anchors along the anatomic neck. Three to four. If you leave a little stump of tissue here, you can do tissue to tissue. Certainly saves on costs. Here we've got our anchors. That's where the capsule would have gone. Here's where we're going to shift the capsule up and lateral. This is how we address anterior and inferior laxity in addition to our labrum repair. Here we've got our capsule tied down. Here's our rotator interval defect. Sometimes we have extra capsule left over. You can vest over pants that. You can excise it. We'll close the rotator interval. Got to take care here to not over tighten the shoulder. So arm position is important. I'm usually in the 30-30-30 position. So if we've done a subscaps tenotomy, now we've got to do a very aggressive and robust repair. So that's number two sutures and modified Mason-Allen configuration for me. That's usually five or six. Here we've got our sutures placed. Here we've got our sutures tied. And I'm a bit OCD, so I do another running baseball stitch right over the top of this. We can't have a subscap failure because that's a disaster. So here's our subscap repair. Sling immobilization. The rehab is very similar to a scope repair. I actually let them go a little quicker because I'm more comfortable letting them get their motion going. The gold standard with this was Mike Pagnani's study. He's 15 years old now, but he had some bone loss in this group. Over 100 patients. These were mostly young athletes and a 2% recurrence rate. So just remember there is a third option. That's an open Vanguard and addressing the capsule open as well. Thank you very much.

open repair

capsular shift

shoulder injuries

scope repair

ladder J techniques