I'm going to introduce myself. I'm Dean Taylor. I'm the president of the American Orthopaedic Society for sports medicine I'm honored to have up here on stage with me I'm Peter McDonnell immediate past president of the American shoulder and elbow surgeons, and it's great to be here We have our current president Jed Kuhn sitting near the front, and we're really excited to have this combined session with AOSSM We're the thanks for our program co-chairs Chris Clefton Jarrett Woodmass and Eric Wagner for putting the program together in Angela, Orlando, especially from our office Yeah, and I echo that this is this is a great collaboration between ASES and AOSSM and and we're really excited for what's going to happen The end of this morning and into the afternoon, and I would echo what you said Peter You know Allison Toth John Dickens and Jan Fecke from the AOSSM Have done a great job in working with with your team to create something that's going to be really special So without further ado, I want to turn it over to our moderators for the first session Sarah Edwards and Oceana Quinze so you guys take it away All right, we'd like to invite our first three speakers up Albert Matt and Seng Jin our first talk is going to be Our first talk is going to be to REM plissage or not to REM plissage recurrent instability after primary stabilization surgery Risk tool assesses preoperative failure rates in on track shoulders undergoing primary arthroscopic anterior stabilization With or without REM plissage. Thank you Albert All right, thanks so much, can we pull up the slides thanks Sarah and Oki for having me here and AFCS and AOSSM All right, there you go. Thanks so much again and like to acknowledge my co-authors My disclosures are not relevant. So we all know that arthroscopic primary bankrupt repair still has a pretty high Recurrence rates and this has remained pretty constant over the last 20 years And we are all aware of the demographic and the anatomic risk factors that that Are worrisome for current instability. We also know that there are other Risk factors that have not been studied as much including worrisome on track lesions And these this can be calculated looking at how close in on track lesions becoming off track term these near track lesions Which have also been shown to be a risk factor for recurrence Now, we're in the era of REM plissage Obviously, it's been increasing in popularity a lot of studies demonstrating REM plissage augmentation can decrease the recurrence rates Compared to a bark bankrupt repair alone, but the real question is should we really be doing this for everyone? So the purpose of our study were twofold to evaluate rates of recurrent instability among patients with on track heel sex lesions Who underwent arthroscopic bankrupt repair alone? Versus those with REM plissage and then to create a risk assessment tool for recurrent instability that considers these prognostic factors To determine who might benefit from REM plissage in patients with on track shoulders. We are hypothesized an arthroscopic bankrupt With REM plissage would result in lower rates of recurrent stability, especially among high-risk patients with on track shoulders This was a retrospective review in over an eight-year period of time looking at bankrupt repair alone versus REM plissage inclusion criteria included on track shoulder lesions in a younger patient population and we excluded patients who had off track lesions glenoid bone loss More than 15 percent and less than two-year follow-up Our high-risk patients were considered to have this criteria near track heel sex on track lesions hyper laxity younger age More than one preoperative instability episode contact sports and glenoid bone loss less than 15 Our primary outcomes are recurrent instability Which included both recurrent dislocation and subjective feelings of instability as well as revision surgery And we use standard statistical analysis We were left with 169 patients with 116 in the bankrupt repair alone group 53 in the REM plissage group the mean age of 21 and a half years and a mean follow-up of around five years Regarding recurrent instability our bankrupt repair alone group were eight to ten times more likely to sustain recurrent stability than REM plissage group And for revision surgery that was nine times more likely than REM plissage. So this is the entire cohort in total Regarding our independent risk factors. All of the risk factors identify including younger age contact sports hyper laxity near track heel sex lesions Instability episode more than one event and glenoid bone loss in patients who were non-contact athletes were all independent predictors of recurrent instability now if you look at the Risk factor burden. So the if you look at all of the Risk these independent risk factors with increasing burden There are much higher rates of recurrent instability following a bankrupt repair alone and you can also confer a Greater benefit of a REM plissage when you have increasing risk burden So maybe another way to look at this is if you have increasing risk burden The number needed to treat was less for a REM plissage to be protective in other words If you look at Kaplan-Meier survival curves, if you have less than three the dashed line being REM plissage the solid line being bankrupt alone Greater risk survival with risk factors less than three, which becomes particularly more relevant when you have three or more risk factors You can then take these hazard curves or see these Kaplan-Meier curves and then have a weighted hazard ratios and develop a score using all of these risk factors and they can categorize between low risk moderate risk high risk and Extreme risk and a REM plissage would then lower your score by ten points so if you look at this graphic representation how this helps you is that if you can Sum up the scores you may have a high extreme high risk of 25 and you do a REM plissage It lowers your risk to 15, but you're still in the high extreme risk category. That person really may not benefit from our scopic Approach with a REM plissage conversely of a low risk patient Maybe a score of only one to two that person may not even need a REM plissage To have a low risk of recurrence And then lastly if you say let's say you take a high risk patient as a score of around 12 and use a specific Incidentally tool risk score and you do it REM plissage takes you to a low risk of two that person re may be an on-track Hillside's lesion patient who may benefit significantly from a REM plissage So in conclusion arthroscopic bank or repair with REM plissage reduces the rate of recurrence of billion patients with on-track lesions Observe risk reduction was particularly beneficial for these high-risk patients with the following Risk burden criteria and The pit risk score may help determine which patients may or may not benefit from REM plissage or need a different surgical approach altogether Thanks very much Thank you, that was fantastic Next paper will be from Matt Fury looking at the effect of concavity restoration on glenohumeral Stability in a glenoid bone loss model comparing the DTA reconstruction and ladder shape procedure I told OK, I couldn't touch the computer because I would definitely break it. All right. Good morning. My name is Matt Fury. I'm a shoulder elbow sports medicine surgeon at the Baton Rouge Orthopaedic Clinic and a former fellow at hospital for special surgery. The title of our project is the effect of concavity restoration on glenohumeral stability in a glenoid bone loss model, comparing the DTA reconstruction versus the classic Latter Jay. I have some committee membership and grant funding, but nothing relevant to this talk. I'd like to thank my co-investigators and my mentors for their support on this project. So as we know, a high percentage of patients with recurrent instability have some element of glenoid bone loss, and we have an increased appreciation for the need to address this bone loss when performing our stabilization procedures. And the classic Latter Jay has become the gold standard in restoring bone loss, but the clinical outcomes are far from perfect. There's a high percentage of patients that modify their activities and a high percentage reporting fear of re-injury. It's associated with an increased overall complication rate. And so because of these limitations, there's been increasing interest in the distal tibial allograft reconstruction. As a means of restoring glenoid bone loss and its proponents state that this graph restores the glenoid width and creates concavity in addition to providing an articular surface. However, the effect of restoring concavity has been minimally investigated in the literature. So the purpose of our study is to evaluate the restoration of anterior stability and glenoid concavity after DTA reconstruction when compared to the classic Latter Jay procedure in a glenoid bone loss model. So we hypothesized that for equivalent bone loss restoration, the DTA would better restore the concavity gradient and result in improved stability when compared to the classic Latter Jay. So we took nine fresh frozen cadavers. They underwent preoperative CT scan to assess their native glenoid depth and concavity as measured by the bony shoulder stability ratio, which is depicted here. We then mounted all of the shoulders onto a shoulder table in 90 degrees of shoulder abduction, and we applied force to the rotator cuff tendons to apply a constant compressive force. We used a KUKA robot to normalize our translation force based off of the inherent tissue laxity of each specimen, and a 3D motion capture system was used to measure humoral translation. We performed a student's T-test and an ANOVA with post hoc Tukey test to determine if there were differences in the bony shoulder stability ratio or anterior translation between the two procedures. So a previous publication from our institution demonstrated the importance of restoring 100% of the glenoid width when performing a Latter Jay procedure. So our goal for our study was to restore 100% of the native glenoid width with both the Latter Jay and the DTA. So the way that we did this was in a patient specific manner based off of their coracoid anatomy. So we would harvest the coracoid and prepare it as if we were performing a Latter Jay. And once we prepared it, we measured the thickness. So for example, we would say 10 millimeters for this specimen. So therefore a 10 millimeter bone defect would be the greatest defect that we could create where the Latter Jay would restore 100% of the width. So we'd go to the glenoid, we perform our osteotomy to create our bone loss model, and then we created a DTA with similar dimensions as a coracoid. So we tested the intact condition, we performed a Bankart lesion, and then we created our bone loss model and performed a DTA reconstruction. We then removed that graft and performed a Latter Jay, and we tested with a conjoint tendon loaded and unloaded to evaluate the sling effect. Then all specimens underwent post-op CT scan to measure the bony shoulder stability ratio. So when you look at concavity as measured by the bony shoulder stability ratio, the concavity was greater after the DTA than after the Latter Jay. It was 0.45 versus 0.35. And when you look at the effect of the concavity alone, so comparing the DTA versus the Latter Jay without the sling, maximum anterior translation was significantly lower after the DTA reconstruction. However, there was no difference in anterior translation between the DTA reconstruction and the classic Latter Jay when the sling effect was applied. You can see this graphically here with the DTA having less anterior translation compared to the Latter Jay without the sling, but then the application of the sling effect neutralizes this. So the limitations of our study, the cadaveric age was older than our usual instability cohort. We performed an LTO to access a glenohumeral joint to create our bone defect, but there's been studies in the lab that have shown no difference between a repaired LTO and a subscap split. Importantly, this is time zero biomechanical testing, so we're unable to account for soft tissue adaptations, for graft remodeling, or in vivo physiologic changes. And we compared this to the classic Latter Jay, not the congruent arc, so it may not be generalizable for surgeons performing that procedure. And importantly, this is a unipolar bone loss model, so it may not be valid for bipolar bone loss scenarios. So to conclude, when addressing bone loss and glenohumeral instability, there are additional factors besides the restoration of glenoid width that contribute to stability. The concave reconstruction as produced by the distal tibia allograft decreases anterior translation when you compare it to the flat reconstruction produced by the classic Latter Jay, but there's no difference in translation between the DTA and the classic Latter Jay when the sling effect is applied. So the DTA reconstruction provides an alternative to the classic Latter Jay procedure with equivalent biomechanical properties. Thank you. Thank you for that. Our next paper, arthroscopic double row bridge fixation provided satisfactory shoulder functional restoration with high union rate for acute anterior glenoid fracture by Sangjin Shin. Thank you, Chairman. The treatment of anterior glenoid fixation, various fixation methods using screw, endobutton, and suture ankle fixation have been introduced. In arthroscopic suture ankle fixation, most surgeons prefer the single row fixation. However, the single row fixation, especially for the large bone fragment, could not provide sufficient contact area and compression and may cause tilting or toggling of the fragment. When we compare the single row and double row repair technique biomechanically, double row repair technique showed reduced fracture displacement, improved fracture reduction, and superior stability at time zero. So I modified double row fixation for acute glenoid fracture. I call it double row bridge fixation. Which characterized by these, the suture anchors are inserted separately on the medial and lateral margins of the fracture site. Medial suture anchors are inserted parallel to the glenoid surface through the subscap tendon. Sutures compress the fragment firmly onto the glenoid bone bed, and a large contact area is created, which provided better rotational control. The purpose of this study is to introduce a novel surgical technique of arthroscopic reduction and double row bridge fixation using trans-subscap portal for acute anterior glenoid fracture, and to evaluate clinical and radiological outcomes of this technique. 26 patients with acute anterior glenoid fracture and who underwent arthroscopic reduction and double row bridge fixation were enrolled in this study. These are the inclusion and exclusion criteria. And then clinical outcome was assessed, and then radiological assessed was performed on 3D CT. So fragment size was calculated by the ratio of the fracture fragment width and the glenoid width on pre-op CT, and then articular step-up and the medial fracture gap was measured on pre-op and immediate post-op CT. These are the videos. So 41-year-old right glenoid fracture. From anterior superior view, we can identify the fracture fragment. Usually inferior to the fracture fragment, I performed a conventional Bankard repair using all suture anchors. Through the subscap tendon, I inserted a single row medial suture anchor and then passed a labrum, which is outside the fragment, but the suture should pass below the fragment. And then the fragment size was so big, so I put one more double row suture anchors. In the same manner, I passed the sutures through the labrum and then below the fragment. After all sutures are passed, I tie the sutures inferior first, then superior, then medial part for later. So using those medial sutures, I connected to knotless suture anchors, and then I put knotless suture anchors in the medial side of glenoid surface, like that. So I made a suture bridge configuration to make a firm fixation. So that's a post-op CT. So order of fixation of fragment, I put anchors inferior, medial, superior, and knotless anchor. But I tied inferior and superior, then medial anchors. So pre-op fragment size was 25.9%. Clinical outcome was improved, and then there is no stiffness after operation. Articular step off was improved from 6 millimeters to 1.1 millimeters. Medial fracture gap was improved from 5 to 1.9 millimeters. So 91% has a complete union, but two patients has a partial union. Four patients has a post-op trauma arthritis, but without any symptoms, and then with a low grade. So strong points of the blow fixation, a bridge fixation, is a minimal injury to the fracture fragment, and then we can obtain the sufficient strength enough to achieve the firm fracture union, and then combined injury can be treated. So conclusion is the arthroscopic reduction and double-low bridge fixation using trans-sub-scale portal is more suitable for arterial glenoid fracture with a fracture fragment size more than 15%. And then arthroscopic reduction and double-low bridge fixation using a trans-sub-scale portal for acute arterial glenoid fracture to achieve satisfactory clinical outcomes and anatomical reduction. Thank you for your attention. Thank you. Now we have some time for questions. So we'd like to invite people to the mic that have any questions about the talks. I can start. Do you have a question? Well, I can start with Dr. Shin, a very elegant technique. What do you think the biggest advantage of going trans-sub-scale is? Is it to make it easier to get around the piece? I know usually when the piece is very large, it can be very hard to get around the piece for a double row, but for you, what's the biggest advantage of going through the sub-scale? So usually arterial glenoid fracture, even though the carticular surface is large, but the below that is very narrow. So screw fixation or other fixation is not enough. And then as you said that the passing the sutures below the fragment is the most tricky part, and then we need some kind of technique for that. But for me that I use the curved suture hook, and then I pass the labrum and then release the shuttle relay that it will be bounced up from the sub-scale and it will become up between those gaps. So that's my technique for the passing the sutures. Awesome. Dr. McDonald? Yeah, just a question for Albert. This is a great talk and thanks for creating this score. With the patients who are at very high risk, would you go then to a bony procedure or would you stay with a rhombosarge? Yeah. So, you know, what we're trying to figure out is, you know, who is a person that a rhombosarge might not even be beneficial for. So I would say, you know, we still need to validate that score, but let's say you're at really extreme risk and you can use that score and say rhombosarge is not going to diminish your risk. Yeah, that's a person that I would go to something different altogether, probably an open approach, probably a bone grafting approach or something other than arthroscopic Bankart with rhombosarge. Thanks. Okay. Ivan, and then Dr. Romeo. Yeah, thanks. Matthew, that was a fantastic study. Obviously it looks really good. There's very little literature on the concavity. My question, and I might've missed it because you're going so fast. I'm trying to understand. Did you measure the amount of translation before you even did the osteotomy of the glenoid to find out if distal tibia or latter-J work? Because it seems like you said distal tibia and latter-J with the conjoined are exactly the same. We did. We measured the intact state and then we created a Bankart lesion and then we created our bone defect. We didn't measure again at the bone defect state. We just applied our two surgical techniques and then measured from there. And that was actually equivalent to the native state. Correct. Correct. When you go deeper down the analysis, yes. Thank you. Dr. Romeo. Yeah, it's a question for Dr. Lynn. You presented a lot of variables, but one factor you implied is the same and that's arthroscopic Bankart repair. Can you describe what you meant by arthroscopic Bankart repair? How many anchors, where you put them? Yeah. So, I mean, these were, you mean the Bankart repair alone group, right? Yeah. So, I mean, if you're doing an incomplete Bankart repair, then additional fixation is definitely going to make a difference. So the question is, are you coming up with some sort of threshold of what you defined as an arthroscopic Bankart repair? Cause you use that term as if it's exactly the same every time. No, good, good. A good question. It was, so one is it's a pulled, it's, it's pulled from many surgeons. So there is some, I guess, external that maybe add some, some kind of, it adds a mix of, of surgeons. And so, but what I would say is that three or three or more anchors were used. So we exclude anyone who had in, you know, in, in inappropriate technique for it. And I'd have to look back and see if there are anyone who had, you know, we, we would include anybody who had some posterior extensions too. So it isn't just everyone who was just left with isolated anterior labor repairs. Yeah. I think the variability between surgeons is probably higher than you might expect. And so that would be another thing to look at carefully, but thank you. It's a really great paper and I really liked the risk scale that you've developed. Thanks. Yeah. Thanks, Tony. And, you know, Albert, I, I sort of had a similar question. Obviously this is a great study and informs us very well. I think, you know, when we have a number of surgeons with different techniques, you start wondering how that factors in and if the surgeon is doing the remplisage may have been more experienced and may have in fact done a better Bankart plus the remplisage, but I know that that's probably a more RCT type study. But can you explain the similarities in contact athletes? You said you didn't know the difference in contact athletes with one versus the other. How would you explain that? Well, I think, I think just being a contact athlete increases your risk factors to a point where it actually washed out the glenoid bone loss problems. So in our, in our, I was, I was actually thinking that bone loss is going to be a significant risk factor, but we only saw that in patients who were non-contact athletes. So I think the risk of just being a contact athlete, which is so much higher that it essentially washes out sort of the other things that you're looking at. Awesome. Thank you. All right. So moving on, our next speaker will be Dr. Peter McDonald. He's going to speak about Bankart and remplisage, when to employ and how to succeed. Thanks very much, Sarah. Thanks to the program co-chairs for inviting me to give this talk. My disclosures are listed here. They may be relevant in that some of the anchors I show are companies that I consult for. So the objective, object of the talk is to go over instability and bone principles and best indications for remplisage, the remplisage procedure and the technical nuances and the results of our randomized clinical trial. And we're all aware of shoulder instability and how it's common in our practice and how it can be a devastating injury for some athletes. So this is the most, one of the most quoted papers in all of shoulder literature, the Burkhardt to Beer one, most of you are familiar with it showing that the increase in risk of recurrence of instability with the increasing bone blocks or bone loss. John Dickens and others such as JT Tokish help redefine what bone loss is and the level of what is critical and so-called subcritical. And we were able to draw the line at 13.5% reviewing the literature as being subcritical bone loss. And then there's the glenoid track as described by Yamamoto, which is a little bit complicated until you look at it for a while, but then it's talked about in other presentations today, but the Hill sacks larger than 0.8 for the glenoid width is a risk for engagement. So Laterge we feel is a better option for critical bone loss of greater than 15% of greater than 15%. So we designed our study around that. And we thank Eugene Wolf for really modernizing the Rompelsage technique, which is a French word meaning to fill. And there are a lot of naysayers to Rompelsage, I must say. And initially when we began doing this studying this procedure, a lot of people were saying, well, you know, it's probably not going to work. It's a soft tissue operation. It's not durable. It's not going to stand up and contact athletes. There's going to be posterior superior shoulder pain. There's going to be loss of range of motion. So there are a lot of naysayers and we had low expectations for the operation when we started out studying it, but we're pleasantly surprised at the results and the durability of the operation. So that's kind of one demonstration of how you can do it. We, we tie the anchors blindly, if you will, by not going to the subacromial space, we started off going to the subacromial space in transition, but I'll go into that later. And of course you can now with modern anchors do this very quickly and relatively easily, easily with all soft tissue or all suture anchors that are fed in a ripstop technique technique from one to the other to to do this quickly and effectively. So it can become a five to 10 minute addition to your regular bank card operation when you do this and get good at it. So our study, our initial study published in 2021 was a kind of a minimum of two year follow up. And the technical sequence was post scope, post your established the pathology, elevate and prepare the labrum scope, enter superior, put the rampasage anchors in, but don't secure them. Then the scope post your do your anchor into your bank card repair. And for Tony, the anterior bank card repair did not include posterior inferior anchors is three to four suture anchors on the anterior labrum and scope enters superior and then complete the operation by securing the rampasage anchors. Recently, we've done a medium term follow up, which is not yet published. Jarrett Woodmass, one of our program co-chairs today has led that and it actually shows that the results of the initial study are durable. The failure rate in terms of dislocation in the no rampasage group was 22.8% or 22% versus 8% in the rampasage group and recurrent instability, which is not a dislocation, but or one dislocation or two subluxations goes from 30% to 10% in the rampasage group. So and even if you look at the high risk group, just to refer to Albert's work the operation did work very well. The no rampasage group in the failures being 27 versus seven in the rampasage group and recurrent instability 32% in the no rampasage group versus 9.5 in the rampasage group. So the operation, if you look at survival curves is holding up over time. It's definitely showing us highly significant difference favoring the rampasage operation. So we feel that it's a good operation. It's one that it should be in your toolbox for instability. And there's been other articles, not just ours, looking at this and in terms of results, similar results to ours and systematic reviews, similar results to ours and fewer complications, low recurrence rate compared to a Latergier across a wide spectrum, a postoperative glenoid bone loss. And then if you look at this other systematic review and meta-analysis by Abdul Raymond's group, similar results and Egan Hurley's publication here showing in another systematic review that meta-analysis that the results are also very good. So the summary of our work and our feeling is that recurrence rates are lower with a rampasage versus a no rampasage in arthroscopic Bankart repair. And that's the Hill-Sacks lesion of any size. But we did exclude glenoid bone loss of greater than 15 percent. We feel a bony operation is better in that situation. In patients who play contact sports, from what we can decipher, it's still a good operation. And the time to recurrence was earlier in the no rampasage versus the rampasage group. And there's lower rates of revision or re-operation in the rampasage versus the no rampasage group. And a less than 15 percent glenoid bone loss situation, a rampasage works well with and Hill-Sacks lesions, we feel even up to 25 percent. So thanks very much and thanks for the honor of giving that talk. Thank you, Peter. That was great. So should we be doing rampasage on everyone? Are you doing it? Pat Denard at Anna this morning is doing it with everyone. If there's a Hill-Sacks lesion, I'll do a rampasage. Okay. All right. Thank you. Our next speaker, Eric McCarty from Colorado, talking about instability in the athlete. What to do and when to do it. Thank you. Thank you for the course chairs for having me present. So let's go back to start a little bit too soon. So shoulder instability can happen anywhere and at any time. And that is going to happen in our rodeo athletes. It's going to happen in if we could advance the slide or play the video, please. Thank you. So you have to be aware it's going to happen at any time and be ready for this to happen any time. And it can happen in any athlete, no matter what they're doing. And it can happen in any direction. As this athlete, a nice check there, and then his left shoulder goes out in a posterior dislocation. It can happen at any age. A 55-year-old mountain biking in Colorado, and it can even happen in a celebration after a key home run. It's embarrassing. I know. So Cody Bellinger had a key home run, dislocates his shoulder as he's celebrating after getting this home run in the critical playoff game. Now it also can be chronic and can be subtle. All right, so what do we do? And when do we do it? So first we've got to understand and define the instability, the severity, the chronicity, the direction. And then what's the impact on instability on the athlete? How does it affect the athlete? Is it just a little bit, a little bit of subluxation, or is this dislocation? And when is it an issue? Is it an issue just like once a season or does it happen every game? And then what are the potential consequences of another instability event? Well, if a golfer has his shoulder come out, the consequences are low. But if a kayaker or a mountain climber has their shoulder give out while they're in one of their sports, that could be life-threatening. And then we have to remember, is this a recreational or competitive athlete? So if it's a recreational skier, that's a little bit different than a competitive hockey player. And then what part of the season does it occur in? Is it in the in-season or is it in the off-season? So we've got to examine and remember all those factors. We've got to define instability, what's the impact of the instability, the consequences of another instability event, is it a recreational or competitive athlete, and is it in-season versus off-season? So what do we do and when do we do it with a recreational athlete, as you see in the slide above? So the recreational athlete, the treatment and timing is certainly based on the individual. Physical therapy is often a very good option depending on the severity of the instability for this athlete. Now, if we go to surgery, the surgery type is dependent on all of the previous factors that I just mentioned, as well as the sport and the bone loss. The anterior instability with minimal bone loss in this recreational athlete, an arthroscopic banker, is probably going to suffice. We're probably going to consider the remplissage in a more aggressive recreational athlete that is going to be falling on their shoulders or doing some activities that they need to have that shoulder instability, even with a minimal bone loss. And then for anterior instability greater than 15%, we're going to consider some type of bone augmentation procedure, whether that's open or arthroscopic. Now, what about our competitive athlete? There's more factors to consider. We have to look at the off-season versus the in-season. In that off-season competitive athlete, we can treat the instability with whether it fits the pathology and the impact it has upon the athlete. The timing in the off-season is ideal for recovery for that athlete prior to the next competitive season. Now, what about in-season? So that in-season athlete, is it recurrent instability or is it a first-time event? Look at this guy who has recurrent instability. He pops his shoulder right back in on the field and continues playing. His recurrent instability is a little bit different than a first-time instability event. So recurrent instability, if recurrent, then how much does it affect the athlete's ability to compete? Well, for that guy, not much. He just pops back in and goes back. If it significantly affects ability, then you fix it during the season. If able to continue participation, we really want to consider fixing it at the end of the season. And remember, we have to match the surgery with the pathology and the sport. Baseball player's gonna be a little bit different than the football player. Now, first-time dislocation in-season, not recurrent, but first-time dislocation in-season with a competitive athlete. Now, there's a lot of factors in the management of this. Counseling of the athlete is critical and we need to understand, well, can this athlete return to play with what this athlete has just incurred? So there's a lot of factors we have to look at. We have to look at what sport they're playing. What timing is in the season? Is this in the very beginning of the season or is this at the very end of the season? That's gonna change maybe a little bit how we're looking at the management. And what's their year in school? Is this a freshman in high school or is this a senior in high school? Last year, this kid ever gonna play high school competitive sports or freshman when he's got a lot of sports to play? And what position? Is it a linebacker putting his arm out or is it gonna be a lineman putting his hands right in front of himself? And what's associated pathology? Are there fractures or is there anything else? And then more important, certainly with these college and high school athletes, what does mama think? Because that's gonna make a big difference. And so return to play considerations. We need to understand and understand can they safely return? Is it possible to? Is there a risk of further injury? Can the athlete protect themselves? And do they meet ideal criteria to return to play? And so the ideal criteria to return to play is there little to no pain? Of course, that can be very subjective and that's gonna depend on the type of athlete. How about normal range of motion, normal strength, normal functional ability, normal sports specific skills and other intangible factors? So return to play, we want full motion. We want normal strength and we want no apprehension. But the reality is the season's often over before we get that ideal criteria and we achieve that ideal criteria. So then the question is, can the athlete return without achieving this criteria? And the answer is yes, they can return. And they can return with near full motion, near full strength, maybe some mild apprehension. There is some limited data on return to play and the recurrence rate. And these are some nice studies that were done. Dan Buss did this in 2004 and then John Dickens with the military population in 2014. In-season athletes can return most of the time. Two-thirds are able to return and finish the season. However, 40 to 65% of those will have recurrent episodes. So if recurrent episodes occur during the same season, we recommend fixing during the season. Go ahead and get it done. If there's no recurrent episodes, then the recommendation is to fix at the end of the season, even if the athlete has, as the athlete has future competitive seasons ahead. And even if the athlete feels good, he says, Doc, I feel good, I'm fine. Why would we fix it at the end of the season if he feels good? The risk of recurrence is very high. Best time to recover from the surgery is in the off-season. And if you don't fix it, and he goes to the next season and has recurrence, then the athlete's mad at you and then you got your coach looking at you and he's looking at you cross-eyed and say, why didn't you fix it? So best for all parties involved. Get that fixed at the end of the season. Take out the whole off-season recover. So decision for surgery is made. Bankart, no bone loss. What to do? Well, in the non-contact athlete, we're going to arthroscopic bankart. In the contact collision athlete, recommend arthroscopic bankart plus REM plissage. Heard some nice papers already about that. Pete McDonald's done some nice work. That is my go-to for my contact athlete. Why can we do arthroscopic surgery in the contact collision athlete? Real nice study from Rush. Look at his meta-analysis of a lot of athletes. Rugby, the most common sport. Only 7.9% failure rate in studies using modern techniques and excluding bone loss greater than 20%. So it does work. Need the right patients, the right bankart repair, Tony Romeo, minimum three to four anchors, treat the path of anatomy, recurrence is low. Now what about bankart and bone loss? Open bankart or arthroscopic bankart plus REM plissage for bone loss than 15%. And then bone augmentation, whether it's open or arthroscopic for bone loss greater than 15%. So in summary, important factors, treatment of the shoulder instability, got to define the instability, impact of the instability, consequences of another instability event. Is it a recreational or competitive athlete? In-season versus off-season. A lot of facets to consider in the in-season athlete. Remember, there's no cookbook. There's a lot of individuality to this, but refer back to the basic criteria that we talked about. And if there's repeat dislocation in the in-season athlete, go ahead with surgery. Do surgery at the end of the season, no matter what, even if they say, I feel great, doc. And then for surgery, arthroscopic stays and works in the contact athlete preferences, arthroscopic stabilization with REM plissage and bone augmentation considered for any athlete with a bone loss greater than 15%. Thank you. That was a great talk, Eric. Our next speaker will be Ivan Wong, who's gonna share technique video, arthroscopic anterior instability bone block. Thanks so much. I really appreciate the invitation. Thanks to ASES, AOSSM. I know John Dickens and Jarrett are working so hard behind the scenes to make sure all these are working because I'm getting these texts on these videos working. So top things I've learned doing these techniques, we're really just going on techniques. Exposure, go big or go home. You gotta create a good graft. The shape is key. We gotta insert it. And what it is is a subscap to make it low and the conjoint to make it parallel and then do the Bankart and REM plissage on top. So this is, oh, sorry. This is the technique hopefully we're gonna work on. Our positioning is kind of lateral, slight posterior. We gotta make the portal perfect. And that's really superior so that we can get it parallel to the bone loss and parallel to the glenoid face because we now go out anterior to this. We always look at the REM plissage or the Hill Sachs to do a REM plissage and we do take care of that at the same time. The first step, we again, view from posterior, is we have to be able to open up the rotator interval. And this is a big opening. We wanna essentially excise it. We see the interval. We see the CA ligament. That's the first anatomical landmark we look for. Once we see the CA ligament, we actually wanna go past there and identify the intersection between the CA ligament and the conjoint tendon. This is anterior to subscap. And that is critical because that is where we're gonna make that Halifax portal. Once you open that interval though, it makes it really easy to get your anterior superior portal and then the rest of the operation, you're really viewing from the anterior superior portal. That posterior portal, we check again. Again, our confirmation of good posterior portal is something that's parallel to the glenoid and at around the 50-yard line. So we start off with the traction stitch. And the traction stitch is gonna do two things. One, it's gonna do our inferior to superior capsular shift like a Bankart repair, more similar to an open technique. And the second thing it's gonna do is allow us to view that anterior rim of the glenoid very clearly. And with that traction stitch, that luggage tag stitch, we can then do an episiotomy of the labrum. So we're gonna split that labrum. We're no longer gonna leave a continuous between the traction stitch and the biceps without destabilizing the biceps. Once you do that, you can actually free up all the tissue all the way to the coracoid and then inferiorly. And where we work from is we work from medial to lateral. So you take the tissue and the periosteum. So your capsule labral complex shift is gonna have better tissue than you start with every time, even in revision cases. This we find actually works good even when you don't do a bony procedure. We do all this anterior soft tissue harvest for every case we do with shoulder instability. We gotta make sure we take it past. And here you can see where it's seeing how the tension goes. That's the tension to shift the tissue. And we absolutely need to make sure we can shift it. And honestly, this way we can measure the amount of shift that we want as well. We mark where we think the 50 yard line will be where half of the graft will go. Because after you get the graft in, it takes up a lot of room and sometimes it's hard to adjust. And very commonly people may, doing this arthroscopically, may put the graft a little bit higher. So now, unfortunately, it's a little bit of freehand work. Really important to get the anterior glenoid rim ready for fixation. So you want this to be 90 degrees to the anterior aspect of the glenoid. And nice healthy bleeding bone, about 15 millimeters of free bleeding cancellous bone. This is really important. We gotta do a coracohumeral release. This is underneath the coracoid. Everything's upside down in the lateral decubitus position. That's the tissue with the switching stick pushing inferiorly on the subscap. That's the tissue between the subscap and the inferior aspect of the coracoid. If you do not release this, the graft will always look superior. So any of the post-op x-rays or CTs you get, if you don't release this, that was the difficulty of getting the graft low enough. When you release it, you can tell because we can get the switching stick pushing the subscap past six o'clock. Essentially, there's so much room in here and the subscap is moving freely that we can do anything you want anteriorly. You can actually put it too low. Then we want the Halifax portal. This is the switching stick from the posterior portal, parallel to glenoid, lateral to conjoin, and we want it at about the 50-yard line, and you can see we push from posterior to anterior to get this, open it up with an incision with a couple half pipes, and to be able to dilate this up using a channel dilator. I know I'm talking fast, going fast. I'm trying to give you all the highlights, but this is the difficulty of trying to do something like this in 10 minutes. On the back, we will then prepare the glenoid graft. We measured the amount of bone graft. We used to try and make a supersized glenoid. We no longer do that because of all the data we've received about the remodeling, so it will always remodel back to a normal-sized glenoid, and our goal is to get the graft within one millimeter of the normal-sized glenoid. That's looking at the other side. We also have an algorithm that we've actually published to be able to know what the normal size is, to be able to make this preoperatively to guess. I also make this trapezoidal because the cancellous bone of the distal tibia is more compressible than the cortical bone, so because we're going to use screws to do this, we are going to get fantastic compression. I want this to be primary bone healing. I do not want a gap in there. You can hear this with the Latter-day Surgeons, that they do not want space in there because that's how you get non-unions. That's how you get things that resorb. Now, the cutting is actually more difficult than I thought to be able to teach this and to do this consistently, so this is where marking is important. Pre-templating is a detail, and everything is based off the cartilage surface, so it's really important. The cartilage surface is where you start with, and the whole point is you want those screws parallel and perpendicular to the cartilage surface and the bone loss region. I found that using my assistant holding the drill is a much more effective way at getting these two to line up to be perfectly central in here, to have that 7-millimeter offset, to have it consistently drilled and top hats placed in here. This way, with a small bone graft, it's really hard to do freehand. As you can imagine, even putting the screws in freehand, the graft wants to move around with you. Once you have that together, you can now place this onto this cannula, and really, this is the part that makes it better because you have ability to control the graft inside the shoulder because it's a very small hole. From the same Halifax portal that we had with the half pipes that's opening it up, we do know that we have a nice straight line coming through lateral to conjoin, superior to subscap. The switching stick is still holding subscap down. That's why we actually got lots of room in here. The biggest difficulty is getting it lateral to conjoin, and we use finger dissection to make sure there's enough soft tissue released so you can easily go over subscap or lateral to subscap to get it down. Once you have it into that space, again, the more bone loss you have, the more space you'll have to be able to do this, now we translate it inferiorly. So the very first thing we do is work on getting the graft inferior enough. So that switching stick from the back shows me that I'm down at the six o'clock position. I'm happy with the inferiority of the graft so I can get 1K wire through to temporarily hold it in place. I'm trying to demonstrate to you. After that, I can do rotation of the graft to micro-adjust it to make sure it lines up with the articular cartilage. When it lines up appropriately, then we focus on the angle. So now we just depress it, push against the conjoint, and you can get this to line up perfectly flush. So hopefully you can see here, we're trying to recreate, just like Matt said, recreate the concavity. We want the switching stick with that 15 degree angle of that tip of the switching stick to recreate the glenoid concavity so we get stability afterwards that we can be comfortable with. In fact, I actually bury those screws because I do know remodeling is going to happen. That's what bone healing happens. So I bury them so that later on, remodeling will not cause this to irritate the subscap. And honestly, in the past six years of surgery, we have not had to remove one more set of screws. They're all my early set. And then we do a Bankart shift. So this is that tissue. With the traction stitch at three o'clock, we pull on it with the arm and external rotation you can see here. We are getting better tissue than we first started with. And that's because we shifted both the periosteum, capsule labral tissue, up to the six o'clock position. And finally, with that traction stitch, the luggage tag is now being put into a suture anchor at the 12 o'clock. And so we can measure our shift was approximately two centimeters from inferior to superior. Learning for us for your practice, I know 10 minutes is hard to get all those tips and techniques, but there's numerous courses to be able to learn how to do something like this. There's also virtual observations. By doing virtually, you have more timing closer to your case to be able to do it. It's actually very appropriate for refreshers, training your team, training your assistants, training your trainees, and having little tips and tricks to become more facile with this technique. How you want to do this is be able to go through it in detail, not a 10-minute talk, but really being able to have a conversation through an entire surgery. So if you're going to have to do something like this, I'd use a lot of augmented reality so we can go through the 3D anatomy to show. We use a lot of cameras. Why I'm showing this is you see all the cameras in the background, so you can see it from every point of view. And having augmented reality really allows you to line up that graph to exactly where you want, and so everyone in the room knows what you're about to do, how you're going to do it, and how this makes it safe. Because if you follow the tissue planes, again superior to subscap, laterals conjoined, you will be completely safe doing this technique. Then we can flip everything around with a virtual cadaver lab. So we take all those cameras I showed you in my operating room, we send it to your local lab with your local rep, with your local assist, with your regular scrub techs, and then everyone can learn the technique, and you can feel every piece going through. And we use augmented reality to draw on top of your cadaver. This is another surgeon learning how to do this in a beach chair position, trying to understand the different portals, and I'll tell you, this type of learning has been more successful in my hands than even cadaveric surgery, cadaveric labs. We have all these surgeons sending things back. In fact, just last night I received this message back. You can see the date here. We did the cadaveric surgery in June of last year, and he's already written back yesterday saying he's done five already. He's having a little bit of trouble introducing the graft, but it's more consistent and wants to get a refresher on this to make it more fluid. So hopefully, through teaching AAGR, I've learned how to utilize planning with 3D modeling, achieving success requires significant exposure, the shape of the graft is critical, and soft tissue repair can enhance your procedure. Thank you. Thank you, Ivan. We'd like to invite our next, Albert and Dr. Savoie up for our case discussion. So it's my distinct pleasure to do this with Dr. Savoie, who has so much wealth and knowledge in this sphere, and to have this great faculty panel here as well. So I'm gonna go to, we're gonna skip this one here. All right, so this is a case I think we see frequently. It's a 17-year-old right-hand dominant. He's a high school hockey player, dislocated shoulder, four days playing hockey, four days prior to visit playing hockey. It's a first-time traumatic dislocation for him. He's a reasonably sized kid, no hyperlaxy. These are the films that you get in clinic, and his only exam finds he has apprehension and relocation. So, you know, Sarah, when you have somebody like this, you know, this is somebody that you're getting a study immediately, right away. You know, do you get an MRI? Do you wait? He feels pretty good. You know, on his x-ray, it doesn't appear that he has a bony defect, so I don't typically order an MRI right away, unless he wants to have surgery. So I would have the discussion. I do believe in trying to fix a traumatic dislocation earlier rather than later. So I would talk to him about surgery, but I wouldn't routinely order the MRI. Eric, this is a, you were, you know, you had to give a great talk about in-season management of this. You know, is this, we have a lot of data showing, you know, RCTs demonstrating first-time dislocators do much better with immediate surgery. Their parents are looking at you. What do you, what do you say to a high school athlete like this? And he, you know, he may or may not be playing hockey into his future. No, I always get an MRI on something like this. I like to know what the pathology is. I want to know, is it a Banker lesion? Is it a Hagel lesion? What else is going on? Is there cartilage injury? So because I want to be able to counsel that player and that family as to what the options are. And so that's going to be my first step. And then potentially if it's a simple Banker and he's not relaxed, then we're going to talk about what his goals are and what he wants to do and potentially let him go back. Maybe this is his last year of playing high school or hockey in general and he really wants to play for his team. So we're going to, we're going to talk about that option. Peter, what do you think about that? You do a lot of hockey players, you and Ivan in Canada, but you're like a head team doctor for pro hockey. What is your thought on these young hockey players? Yeah, I'm similar, Eric. I would probably be more aggressive than Sarah getting an MRI on most of these players. And I always counsel a family that it's an easier operation, more reproducible and better results if you do it right away or, you know, within six weeks or so. The only downside I can see that is the increased risk of stiffness, which is kind of like an acute ACL. You have to let the joint settle down a little bit, but I'm more aggressive in doing them right away if they want to go that route. So since this is going to be a multi kind of step case here, and so what I'm going to tell you is that his MRI shows a standard Banker tear. There are no tricks with this. Standard Banker tear, small heel sex lesion, very on track. And, you know, we have the extended discussion that both Eric and Peter mentioned, and the patient and the family they want to go for surgery. So everyone on this panel here, you know, is this somebody, you know, so bear in mind this is a patient I saw maybe like more than ten years ago before we were talking a lot about rump lasage and on-track lesions and all these other studies. So is this a person that you would ever consider doing an arthroscopic Bankart alone, just given that information? So Sarah, you said Bankart alone, no rump lasage, no augment with the rump lasage. I mean, that's what we've done for years, right, with a fairly good success rate. I think knowing what we know now, I would be more inclined with him being a contact athlete to offer rump lasage at the same time. Okay. Oki? Yeah, no, I agree with that. I think that normally this is an arthroscopic Bankart done very well. If it's a small heel sacs, that's on track. Certainly the literature is driving us towards doing more rump lasage. So as of now, I would consider it, but normally this would be something I'd just do arthroscopic Bankart for and feel like that's a good outcome. Okay. Dr. O'Donald, probably a rump lasage for this kid? Yeah, if there's a heel sacs lesion, I'll do it most times. The only downside I can think of is the stiffness part, which I just alluded to, but if there's a heel sacs lesion, we're more aggressive about doing rump lasage. Eric? Yeah, I've certainly changed over the years as I've learned from everybody and this guy would get a, he'd get a rump lasage now. And even with very minimal heel sacs, I've even had to create a little bit of a, you know, roughing up the bone. JT has talked about that, creating a heel sacs and putting putting one in. Yeah, at least creating a little rubbing of the bone and then put some anchors in there. All right, Ivan? Yeah, I think for me, an MRI just is not as helpful for me because we already know he has a Bankart tear. I'd actually go straight to the CT scan because I see a couple things I'm really worried about right here. If you look at his corcoid on his axillary view, it's actually very medial. It doesn't stick out very lateral even though the the perfect AP looks like it's a bit lateral. That makes me concerned. So if we were going down the surgery route, which I still think is the right idea, his glenoid is very shallow. So even a tiny little smidgen, not even talking about 10% bone loss, he's gonna lose his rim. It's gonna be much worse. I want to make sure that this is absolutely perfect for him, give him the best chance if we're going down an arthroscopic surgery. Because even minimal bone loss, I still agree Bankart rump massage is key, but I want to know how detailed or how little bony anatomy he has to help himself. So let me push you on that a little bit. 4% bone loss. I just made that up. I'm not really sure what it is on him, but 4% bone loss. Would you soft tissue or would you AAGR? So I'll tell you right now, with the numbers that we have, I still go soft tissue, but I look at everything else. There's more than just the glenoid, right? So you show very clearly the hillsacks has a huge part to do with this. So I need to know how much that contributes to it. What we do not have data on right now, which I'm sure you're gonna go do for our next meeting, is gonna be the coracoid. Because I'll tell you, the coracoid anatomy changes so much. And I only started paying attention to this after doing a lot of AAGRs because it makes it difficult to put the graft in. That said, the people who dislocate often with low bone loss have a coracoid that's actually quite medial. It makes it very easy to put bone graft in, but it's very hard for them to keep it stable even with a soft tissue repair. Interesting. Buddy, anything to add to this? Would you do a REM plissage if you're doing a Bancart repair? I agree with what everyone has said. Okay, so I'll show you what we did. So they decided on surgery, you know, standard Bancart 2-6. No real labral tear extension, no real, you know, major bone loss. He gets a four-anchor repair. We thought it looked, you know, standard. And then, as all things, you know, you recommend surgery, they get surgery, he goes back, first game, and then re-dislocates it again. Alright, so here is what we're dealing with here now. So, Oki, what do you think here? Yeah, I mean, it looked like a good repair. Maybe he certainly has some bone loss or some bone remodeling on the axillary. This is definitely one I'd get a repeat MR arthrogram and also a CT scan, with a concern that the patient might have at least some critical bone loss and possibly the hillside defect being larger. Show of hands on the panel, is everyone here getting a MRI? Okay, Ivan says he's just getting a CT scan, right? Is everyone getting MRI and a CT scan here? And so, Eric, you raised your hand, so why get both? You know, I'm still really like the information I get from the MRI. I'd like to see the soft tissues. I'd like to see any associated pathology that may be there. And then I really want the CT scan, really more for the bone. You know, it's funny. You see this kid, and he's back in your clinic. He actually has a really, really benign-looking exam. He has a terrible-looking imaging. He has a benign exam. Buddy, does that matter in any way? Does it, you know, does this inform you in any way? I think your clinical exam is always the best evidence of what you're doing. And so, you know, either you can be, he may be a little apprehensive, but it also points you maybe in a different direction. So if you've failed a bank card and you re-dislocate, usually there's a lot of damage to the tissues in there. And you, you know, sometimes you can get a haggle lesion. Sometimes you can split the interval. I know Ivan cuts it out, but, you know, sometimes that's a part of stability. So I think more imaging, CT orthogram, MR orthogram, really help you find this associated pathology that could be there. You know, so it was quite interesting, this kid. I remember putting him, his arm in almost 110 degrees of external rotation. I couldn't listen to a apprehension sign. It was actually kind of amazing. But he has this, which is, which is a very clear postage stamp fracture. We've all had this. You guys have, you know, Dr. McDonald, any tips regarding how to prevent this from happening, these postage stamp fractures? Well, I think anchors that you use, the smaller anchors you use, the less chance of this happening. If you're using the bigger width anchors, there's like, obviously, the distance between the anchor holes is smaller. So it's, it's more apt to happen. We're transitioning now to smaller all suture anchors, which I think would lessen the risk of this. So this is what we have here now. So Eric, what do you think about this CT scan? Yeah, it clearly shows the, the quote, postage stamp fracture. And I, you know, my comment on that, too, is I, you know, we were getting kind of over the edge and put them more medially or more posteriorly along the glenoid. And, and I think that contributes to when you have a lot of little, little, little stamps into the, into the glenoid, it creates these perforations, just like a stamp. So I go more on the edge, and it does look like there's been some, some, the, the areas where the anchors are, they've enlarged. So, so you've got an issue there that you're going to have to do and, and treat this. And, and, and for me, what I would do is some type of bone augmentation, whether it be arthroscopic or open. So, Sayers, now he's 18. He actually does not plan to play hockey next year. He's got this postage stamp fracture. He's got subcritical bone loss, 14%. And he's got, you know, an on-track lesion, but it's actually kind of close to being off track here. What do you, what do you think in here? Yeah, I think, I think there's a few appropriate options here. I think you could, one, tackle again arthroscopically, go in and capsule, or grab that bony Bankart lesion as well as you can, and revise the Bankart and add a hillside, or I'm sorry, add a remplissage at that time. So that's option number one, or two, like he just said, adding some type of bony block in the front at this point. Does anyone on this panel, you know, so we'll ask sort of what everyone will do here, but does anyone routinely diagnostic scope these? So go in and just say, okay, I'm going to diagnostically scope and then make a determination after that. Is there a role for that at all? Okay. And so is that what, so you're thinking maybe try to revise, or try to revise this, or incorporate the acute bone fragment and then add a remplissage? Yeah, I think, good luck. I think when they do have a bony Bankart fracture, they tend to stiffen up a little bit more, so I would potentially go in, fix that arthroscopically, and then put the checker in the back with a remplissage. Buddy, I was hoping you would make a comment. So you have this, you have the study demonstrating, you know, revision Bankarts with remplissage has, you know, didn't have great outcomes in your hands, but this is, is this the same scenario, or this is a different scenario? I think this is a completely different scenario with a bone block like you have, essentially is what you have. You have a bone, it's an autologous bone block, but it's still a bone block there, so it depends on your ability to fix a glenoid fracture. We just heard, you know, 30 minutes ago, a great technique for fixing glenoid fractures, which I have not done, but maybe tomorrow. So I think that I would treat this as a fracture and then do supplemental fixation. So make a comment. So I completely agree with the fixing a fracture. I do think fixing a fracture is great, but you got to remember, a postage stamp is not a regular fracture because you've already lost all that bone from the drilling out. When we drill those anchors out now, especially the all suture anchors, we're actually removing more bone than some of the bigger anchors that we had before. Perfect. So, you know, I think we're kind of alluding to the, these are the options, you know, you do some, you fix it, you fix it with a remplissage, you do an open Bankart, you do an open Latter-day, or you do, actually I did not put an, I said open bone grafting, we could do an arthroscopic bone bone grafting as well. So can we just go down the panel in here and just say what, what each of you guys would do here? So I think Sarah mentioned the option two. Oki, what would you do here? I'll do a arthroscopic distal clavicle bone graft augmentation. Oh, distal clavicle. So why the distal clavicle here? Well, I've had good results. I mean, I think certainly that's one. Number two is, you know, the data was sort of say that for smaller defects, you know, when you're somewhere between 15 or less bony defects, that a distal clavicle provides sufficient augmentation based on sizing, which we know from multiple studies is similar to the coracoid, not the congruent R coracoid, but a traditional coracoid with similar length, similar width. It's an autograft. So that's what I do in a case like this. Does anyone here have experience with distal tibia or distal clavicle autograft? All right, Oki, you got it. I'm all alone. I love it. Dr. McDonald. Yeah, in my hands, I still do an open lateral in this situation. I think the bone loss is getting to be, or it's close to being critical. It's a revision situation. So I tend in revision situations to be more aggressive about doing a bony procedure. I think if you're good at Ivan's technique, that'd be a perfectly good alternative. Eric, how about you? Yeah, no, I'm the same as Pete. You know, taking care of these footballers and these hockey players, open lateral, very consistent. It's a good surgery and I have to get a lot better at doing the arthroscopic like Ivan, or else I think that's a great option as well. Ivan, I know what you're gonna do here. Yeah, just a couple comments on that. Fracture cases are also different. So if this is close to the time of the fracture, or this one I'm actually more concerned about, if it's broken through our previous anchors, the bone there tends to be very soft. And when they're very soft, when you start freshening up that area, you're gonna lose more bone than what you measured before. And my only problem with doing open lateral jays is I can't measure the amount of bone loss. I do know that there's a limit to the amount of bone loss you can do. I just have significant concerns with revising open lateral jays before, right. The failures of those are really difficult to do. Doing an arthroscopic version with a distal tibia, really you can adjust to any type of bone loss at that time. And then Buddy, what would you do here? I'd vote for number two. And if I was concerned about the bone, as Ivan said, I would take a little piece of the scapular spine and add it in with the inside the suture to put it between the two. Ooh, scapular spine, very sexy. Okay. All right, so let's, you know, it's very interesting here. You know, we have an expert panel here, and we have like a pretty divided treatment options here in terms of what everyone picked here. So let's just poll the audience here. So who's going to just do option one, no remplisage, just redo it? Okay. Option two, redo it with arthroscopic, Bankart with remplisage. Anybody doing open Bankart in here? Dean, I love it. Can you just just maybe chat a little bit about what, you know, why and sort of what your thoughts were? Actually, if I do an open pancreatic, that's this is actually one of my more favorite indications to incorporate a bone fragment open latter J All right, and then another open or arthroscopic bone block So, you know, I It's it's a little bit of everything And this is what we did. We actually did option two. I went through all the options with him The bone piece actually was quite good and we got to this very acutely And we you know, it's a standard repair incorporating the bone fragment and his brother ended up working with us And so I've actually been able to see him more than six years follow-up and each time I just I crossed my fingers They have you dislocate your shoulder again, and he says no so far I Think there's one right answer And and sometimes we get in these debates and we say oh my way is better than your way I think it's good to have lots of tools in your toolbox and and all of you have helped us with that So, thank you. Yeah, I agree with Dean I think it's boils down to what you're good at like Ivan is so good at that technique. He can do a Reproducibly and be aggressive about doing it Some of us have not gotten there yet. So you do it Whatever you're good with or good at and whatever you're comfortable with. I think To follow on that. I actually think That you should fit the correct operation for the patient Not the one that you do maybe not the best but the best operation that fits that patient at that time I think that's how things tend to work out better. So this one It's a little quicker Let's see All right, so I have an 18 year old male seizure patient Very poorly controlled seizure patient has had multiple instability episodes not always associated with seizures. The first few were These are our x-rays when he came in this is about a year and a half ago and so the question We just go with one. I guess start with Sarah because you're here and How do you approach these patients seizure patients with instability and clearly starting to have some bone problems? Yeah, this is a real challenge because it looks like he's already Got some medial erosion and potentially early away from all the dislocations. Is he coming out the back? Or out the front. Is he is he dislocating posteriorly or at the front? He's apprehensive anteriorly He's a very apprehensive anteriorly posteriorly actually, I think he sits more anterior and So you can if you try to shift him foster There's a little bit of a shift but doesn't bother him at all at this time And are his dislocations documented like he has to go to the ER and have him put back in there about 20 of the 30 he's had to go to the ER. Okay. So yeah, these are these are real challenge one I mean is is Consulting with his primary care neurologist to make sure that they get that under control because obviously I'm always anxious to take someone to surgery like That knowing that it's not under control. So I would make sure that happens before I'd tackle an operation So this is just apprehension And low-level apprehension. He's on multiple medications still seizing regularly And then he went snowboarding and had his most recent one, which is why I came in So We already talked about I'm gonna try to study it see what happens So what we did at that point was I put him in a Sully brace And send him to physical therapy talked to his neurologist exactly like you said said this is a very difficult case But cannot control his seizures right now. So I said we'll come back once your seizures are under control Okay, very reasonable thing not reasonable. No, absolutely reasonable. It's exactly what I do. Okay So I was kind of worried about it But a quick question The we always talk about sort of seizure control and all of us have a different threshold, you know Six months a year, you know sort of I don't know if there's great, you know data to sort of guide us And so what was your kind of your cutoff for the seizure control? So I if I Basically for me and be interesting to see what everybody says I'd like him to not have had a seizure for at least a couple of months I mean he has regular seizures on a weekly basis not always grandma where his shoulder dislocates, but it's very frequent And it's breakthrough seizures. He's on a lot of medicine So I would say for me if I can get two months and think I could get a window I'd be happy but because I'm worried about the amount of bone loss and if there's no bone loss and there's no permanent damage then I can wait on that so Anybody would operate quicker on no, everybody's here. All right, so we've all agreed This is standards who we're all taught right? Don't operate on a seizure patient because your surgery is gonna go bad and he's gonna have another seizure and mess it up So he came back a year later Seizures are still not controlled This is a burner Joe view. And if you look we now have a giant osteophyte on the head anteriorly He's missing about two-thirds of his glenoid He's had multiple Additional dislocations now is having quite a bit of pain Before he was unstable his shoulder went out now. He's painful and it's lost motion So this is where we are here And if I don't think that shows up on there doesn't all right, so we're missing quite a bit of glenoid This is another way to look at it. This is his glenoid and you can see this big osteophyte So basically the head is sitting in a dislocated position up a budding on the coracoid It's again, he's missing almost 50 to 60 percent of his glenoid not a great deep Hill Sachs lesion, but a big osteophyte So his neurologist did me a favor and ordered an MRI scan so that we can tell what was going on So, you know in the u.s. No offense to Ivan and Pete that means we can't get a CT scan because you don't actually need more imaging Because you've already had an MRI scan and we all know that that's the right thing to do But you can sort of get a sense of the three three views that it's a very deep Hill Sachs Or in a lot of bruising with it and that's our glenoid on the middle and Bottom right view. So Pete this one's going to you. What are our options now still having seizures? We're all taught don't operate on him. He's having seizures Yeah, again, you want to go back to the neurologist try and optimize that but he's gonna need something Obviously at some point in time, you don't want to be caught Planning for an operation and then having him make the situation worse while he's waiting for the operation having more bone loss Which I've seen happen, especially in our system CT scan would be very helpful to quantify that. I think you're going to be looking at a an open procedure In my hands with an open glenoid bone graft and probably the same time going Posterior or anterior if you're more comfortable and doing a graft to that Hill Sachs lesion as well bony graft Eric anything to add No, I agree. I probably I may even fill that That Hill Sachs in with the little metal Hemicap or something like that and do something exactly what Pete would do with the glenoid Ivan yeah, so I think this is the one that I'm really worried about if you go back to that MRI some things that really Concerned me. So the you see all the marrow changes on the humerus So it means that you know, he's had a dislocation, but you don't see that marrow changes on the glenoid So we're gonna get a lot of sclerotic glenoid on there So healing if we do a bone graft is going to be very difficult and troublesome The only good part is there's a lot of bone that's actually medial to this So we have a better chance as we're kind of decorticating this to get healthy bleeding bone for an allograft Again, I want to do a distal tibia. I can do it arthroscopic in the second thing is this one for me even I know They have an MRI I would still be requesting a CT because I want to know how the cuts are going to go Importance is this is not gonna be a 90 degree cut compared to the glenoid. This is gonna be off at an angle So this is gonna be a different type of solution This is where the 3d modeling the augmented reality will really help to reshape that bone because you want those screws to be nice Parallel or perpendicular rather to the bone cut and that depends on what we see at that current time And I'll tell you sometimes on the CT is very different from when you get inside because more dislocations happen, especially with these these Seizure patients and this is also the difficulty right? We have a different time frame for when to do these seizure patients Again, I use six months. You can see arthritis is your deadly component if he's only 19 right now We are really running out of time. So you got to balance this So I guess this is the one-off shot to see if we can get this to get stable Even though we can't solve his arthritic pain, so you would do this one arthroscopically as well. I'm better arthroscopic than okay The tips to to get a bigger bone graft in like you open up the interval even more No, so I'll tell you this one is gonna be your slam-dunk easy time. You got so much space in the front There is no bone there Really when you go in there you free it up with your your finger the bone graft The bone graft is not really bigger medial lateral superior inferior The bone graft is bigger anterior posterior, which is the same as your portal and because you got so much space in there This is actually the easiest Bone arthroscopic bone procedure that you will have and if you're learning this technique You can actually switch it to open at any point in time And that's why you know, if you're going to do something like this, this is the ideal one to do All right, Sarah, okay, and then we'll show You know, I know I know we can we're talking about technique But I would still not operate on this patient because then you're gonna have fractured screws. He's gonna dislocate I think it's still a disaster until he is controlled. I have I practice here in San Francisco Sometimes these people that the neurologist can't get under control are actually actively using drugs. He needs to be drug tested There's there's a problem there. And if you you're just kind of a failed operation Drug testing was clean. We've done a lot of work on him. So that's a great point. You do want to do that? Okay for me if I was gonna operate It'll be Iliac crest because it a large bony defect and I'd use buttons I'm not putting screws in this guy if it's having seizures I'm gonna fix it with an autographed Iliac crest doesn't get a large piece of bone I'm gonna fix you a bicortical buttons for and then I'll do a ramp massage on top of that and I'll do it arthroscopically So we did There we go, so this is the open I did it open I've been apologies you're better than I am and The piece you see to the on your picture to the left. That's a giant ossified on the head when we measured on the burner Joe view the Depth we needed to try to equalize to the other side is neither as coracoid nor as clavicle would fit I mean I need more bone than that And so we got a fresh we happen to get a fresh osteochondral graph and so then we got in here and we had this giant piece of bone because we were gonna use part of that to fill in the Hill Sachs defect like Pete said and so what we ended up doing was taking a Big osteochondral graph, but that big osteophyte happened amazingly enough match exactly the Hill Sachs defect Talk about blind luck, right? So sometimes it's better to be lucky. And so so that's what we did We took that osteophyte off with an osteotome Did the graph for the glenoid and then so the two screws you see that's the osteophyte on the head filling in the Hill Sachs Defect I usually use cannulated screws like Ivan was showing I switched to solid screws on this one and a little bit bigger than we usually do To try to get that input washers on the screws to see I have a question though We have 20 or never mind. We only have 20 seconds left. So any comments? Sorry He's now three months out did not have a seizure in the first 12 weeks. So again blind luck I just I didn't have any bone left after a year to work with so I've made that made that call It looks great The only concern of course as we alluded to is the long-term arthritis and the progression of that At some point in time, he's gonna need an arthroplasty in his lifetime. But hopefully seizures Stay away and he stays in joint Hopefully season, New Orleans Thank you guys everybody for all your help

arthroscopic anterior instability bone block procedure

exposure

bone block graft shaping

subscapularis

conjoint tendon

Bankart procedure

REM plissage

patient positioning

portal placement

open surgery

autograft bone graft

shoulder instability