Giovanni's slide's up. Carolyn, where do you think we are with REM plasage now? Do we have to do it? And do you think, let me back up to the paper we had from Dr. Stephanie Bowden and the UPMC group. 25% recurrent instability rate, 179 patients arthroscopic, less than 20% bone loss. It's pretty sobering. Do you think REM plasage, based on your view of the world now, helps that? I do think that REM plasage does help. And especially, like I said, the McDonald paper was really eye-opening to me in terms of the benefit that it does provide. I am now much more strongly considering using REM plasage. And again, any patient that has that increased risk file, even if the Hill Sachs lesion is small. So I'm adding it to a lot more of my Bank Heart Repairs. Emilio, the arthroscopic Latter Jay is a humbling procedure. And if you look at LaFosse's lessons on 100, he had very significant challenges, complications, 18%, 20%, depending on what you code a complication as, screw positioning, screw angle, et cetera. Where do you think we're going with the arthroscopic bone block procedure? Well, I think that bone block procedure is going to increase the use of bone block procedures in the future. Of course, arthroscopic, either Latter Jay or free bone block. And we know there are new instruments and new techniques to do these procedures. So we know that with an isolated Bank Heart Repair, the rate of recurrence is very high. We want to do arthroscopic surgery on our patients. And for sure, they will increase the number of bone block procedures. Probably, there is a kind of black legend about the complication of Latter Jay. It's true that it's a risky procedure. It's challenging. But the rate of complication is not so high. Thank you. Yeah. And how many cases did it take you to really get comfortable with it? I mean, clearly from your video, you're an expert. You're comfortable working around the nerve. How many, honestly, how many questions did you stop thinking about at the night before? That's a very good question. Because this is like every surgery. When you do a procedure, you learn, no matter how experienced you are. But we analyzed the learning curve of arthroscopic Latter Jay. And it's identical to any other procedure, like rotator cuff repair or hip arthroscopy. You need to do about 20 to 30 cases to become confident with the technique. So that's good enough. Guillermo, tell us about your approach to remplisage. Every instability patient, 50%, a few select ones, contact athletes. What is your approach and indication for remplisage currently? My indications of remplisage is increasing day by day. Because I think it's a technique to improve the results of the arthroscopic bunker repair. And also for huge, huge such lesions in collision athletes that we do the Latter Jay. I think as we do it in lateral acubitus, it takes us 10 minutes to flip up the patient to the big chair position for the open Latter Jay. But I think it's worthy to do both operations in these very demanding cases. So belt and suspenders, we always have a little bit of a saying in orthopedics, nothing's for free. You get a little more stability, but what are the trade-offs in motion, external rotation losses? If you look at one of the early remplisage papers, and obviously he was very honest about his results, because Pascal Bellot in 2016, when he presented remplisage in JBGS, went from 0% posterior shoulder pain to 30% posterior shoulder pain. We all know that could be a challenge to deal with after remplisage. And I know it's there. I've seen it. I don't want to know what the real number is, but it's definitely there on top of the rotation issues. I think it's a technical issue. As I've shown, the anchor should be very medial, close to the cartilage. And the main error is to grab the capsule close to the glenoid. You need to grab the capsule and the infraspinatus on the humeral side in order to avoid stiffness. OK, this is my case report. And this could explain why in the States there are much more arthroscopic bunker remplisage, and in Europe, more latergé. And why in Italy, we have rules. Sometimes we give rules, but sometimes we don't follow the rules in such a precise way. So this is a professional rugby player. He had in season 3 pure traumatic anterior inferior dislocation. The mechanism of the lesion was all the three times in arbor position. He's a male. He's 24. Competition, the degree. Rugby player. Hyperlaxity, negative. Heel sucks, negative on the X-ray. Glenoid contour, negative. And with the measure of on-off track, he's on track. Returned to sport after first time dislocation. He had equilibrium time. It means the shoulder was dislocated for 30 minutes after first time. And he came back after 36 days. Time between first time and second dislocation, three months. Returned to sport after second dislocation. Second dislocation equilibrium time, 35 minutes. 20 days after the second dislocation. Then he got the third dislocation, and we decide for surgery. So if you give a look to this score, or GTM score, he has three points. So he would be ready for Zen boat, for arthroscopic. For arthroscopic back repair. So rugby player, on track. Heel sucks, nine millimeters to dislocation. Bone loss, 15%. Here's his score, three. GTM score, three. This is the X-ray. This is the study of the glenoid track. And as I told you, he's on track lesion. But we did a La Trajet technique. Differently from other authors, of course, we do the split from lateral to medial. And we don't perform the capsulotomy from north to south. But once again, from lateral to medial. I call this like a retractor surgery. And you need a very, very good exposure. This is the glenoid bone loss of the patient. And we enjoy to use two skew with a small plate with a middle wedge. That is especially important when you don't have a huge glenoid bone loss. This is the plate. And it's very easy. It's a very reproducible technique. Because it's impossible to be wrong. Because you have two holes on the glenoid, two holes on the coracoid. And the plate is ready with two QI that guide you exactly where you want. This is the final step. This is the X-ray. And this is the picture of the CT and face view at one here, where you can see exactly. There is a very good osteointegration of the graft. The best part is inferiorly. And we can ask why. This is interesting that show to you why we trust that the plate is important. The less bone loss you have, the more important is the plate. Because we have a steep glenoid. And this video can show to you how it's easier to perform a later jet technique when you have a huge glenoid bone loss, like 20%, 25%, because it's flat. So we enjoy to use the plate, especially when there is a steep glenoid. And regarding the complication that are described in later jet, of course, as any surgery, you have to pay attention. And as I told you, the later jet is a retractor. And the position of the retractor on the most lateral side and on the most middle side, of course, are one of the key points to avoid complication in this kind of surgery. Thank you. Awesome, Giovanni. Thank you very much. Thank you. Mary Mulcahy, what's your subscap split best pearl? Well, in terms of, yeah, I mean, splitting basically 2 thirds, 1 third is what I tend to do. And I think that that tends to be most helpful and still gives you the access that you need on the antero-inferior aspect of the glenoid. John Dickens, 100% toughest part of the later jet case for you? You know, I think the, maybe not the toughest, but the part that I pay the most attention to is in the technique that we were just asking. I like to use the curved MEOs and make that split in the muscle belly, as opposed to dissecting off from lateral to medial. Instead, going from medial to lateral to have that subscap split and visualize the capsule. Yeah, that nerve, as Giovanni nicely showed, comes into play very quickly as you get through that muscle of the subscapularis. Emilio, talk to us about congruent arc or traditional later jet, especially your experience outside the United States. What should we be doing? When do we consider flipping the coracoid around 90 degrees? That's a great question, because with a congruent technique, you reproduce more easily the concavity of the glenoid. So theoretically, it's a more anatomical technique. Having said this, I think you have to flip the coracoid 90 degrees. And the original technique is with the coracoid in front of the glenoid neck. So I think we should prepare both surfaces, the undersurface of the coracoid and the glenoid rim, to obtain a good contact between both of them. And this will increase the surface of the coracoid, will create a good sling effect. And we don't need to do this congruent arc technique. John Dickens, there's a correct answer to this question, by the way. Free bone block technique for shoulder instability and bone loss. Never heard of it. Iliac crest, distal tibia, distal clavicle. We can be agnostic. Is this indicated in a contact athlete? Yeah, I think, well, first, I think we have to be careful as a whole with free bone blocks or any bone block procedure, depending on the sport. Matt, your paper looking at combined NFL athletes, a lot of complications. Screw pull out, broken hardware, graft non-union. I think it was 50%, maybe more, in that population. So I have a lot of reservations about that in general. Free bone block overall, I think, for me, the attraction to that is maybe the evolution towards an easier arthroscopic approach. Awesome. Well, thanks, everyone. Thanks to our great papers, our panelists, great video, great kickoff to this session. Thank you.

surgical techniques

shoulder instability

Latter Jay technique

remplisage

bone block procedures