Surgical options for shoulder instability, 2023. First of all, you have to evaluate your options, you know, what we know, what we do, and what we should do with this new literature that's out there. So I'm 31 years in the NFL, we've done 65 shoulder surgeries in the Steelers and many other, and some, a lot from other teams also. Anterior instability, we've done 17 open bank hearts and 17 scopes, we've had open bony bank hearts and an ORIF, we've had bristos and bank hearts, two of those, posterior instability dominates at usually 13. We've had to do slap repairs on three of our quarterbacks. So the problem is recurrent instability, obviously the considerations are age, gender, in-season activity level, time from initial dislocation, ligamentous laxity, bony defects, other pathology, and their expectations. So the options anteriorly are obviously arthroscopic, arthroscopic with REM plissage, open anterior capsular labor reconstruction or this bank heart modification that Job showed me, which is a great operation. Coracoid transfer, which would be a bristo or laterge, and then bone transfers, autografts, which would be distal clavicle, or allografts, which is a distal tibia. Posteriorly, they're primarily arthroscopic in almost everybody's hands. Open is extremely rare, although I've done them, and I've only done a few bony transfers. So posterior, believe it or not, is number one in athletes. Posterior arthroscopic repair in contact athletes has actually better outcomes in return to sport. We've published this multiple times, and it's actually the most common in athletes. So there's a bunch of articles out there, but we just did our recent study of 1,760 consecutive cases that I have done, and 65% of them were posterior in athletes in some way. I always say a little tight is always better than too loose in our contact athletes. So we started in 2015 when Justin Arnott, my partner, helped me. We put 70 American football players, and we had 93% return to sport, and 79% return to sport at the same level, and that's the best I have of any group in my cohort of over 960. We had 96.5% of the football players actually were satisfied with their operation out of these 70. Then we moved on the next year in 16, and we said, okay, let's look at other contact athletes in my group. There were 117 multiple different sports. Once again, we had good to excellent results by ASES score, but remember, ASES score is not as good as the Curlin-Jobes score. That's the better score. Subjective strength was 93, and stability was 94. So then we said, okay, what about our revisions? What will lead us to have a revision for posterior? So we looked at 186 of our athletes. I had 11 revisions. The only thing that mattered, and Dr. Morrow helped us, was that the only thing that mattered was a smaller glenoid bone width. That was it. Everything else did not matter. Gender, cartilage, labral, capsular injuries, level of sport. So our risk was 5.9% at 12 years, which was probably the best, it is the best of any of our groups. Then we said, well, what about long-term? What about long-term posterior? So we just finished this, and Ben helped us. We had 55 shoulders with a follow-up of 15.4 years average. It was 11 to 19 years. And what we found is, at 15.4 years, that actually contact athletes equaled non-contact athletes. Throwers had less return to sport at the same level, which you would think anyway, because they're aging. Non-revisions actually were as good as revisions. That was the first time that happened. So surgery, the surgery was worthwhile, they said, in 89% of the time. The non-contacts said it was 87%. And once again, the contacts, 94% said that the surgery was worthwhile. So it's kind of like this. You know, in football players, we tend to do a big repair and take a lot of tissue, whereas in baseball players, I take like half the labor, and I tend not to be nearly as aggressive. So that's kind of the way I like to see them. Okay, how about anterior instability? All right, so if you look at anterior instability across the literature for recurrent dislocation, just based on age, that's it, nothing else. Your chance of recurrence if you're under 20 is 90%. So that's a lot of kids I take care of. If you look at recurrent instability based on activity alone, no age involved, it's 66% for the high-level athletes, the cadets, the collision athletes, the NFL guys, when you average them all out. So just by age and activity, you can start counseling your patients. And then Brophy and Marks helped us, and they did a meta-analysis on young athletic population. If you did surgery on them, there was a 10% recurrence, and if you did non-operative treatment, there was a 58% recurrence at long-term follow-up. So it's kind of pushing you that way. The interesting thing in that study is the recurrence rate in open, it was 8.2%, whereas 6.4% in the scope. So usually the opens are a little better, but this is when the scope was. So what are the treatment considerations? It's age, activity level, sport, is it on-track or off-track? If you don't know on-track or off-track, that's kind of a big deal now. Percentage of bone loss, associated pathology. Was there a bank heart? Was there no bank heart? Is there a capsular tear? Was there a Haga lesions, which is a humeral avulsion, which is a big deal? And then the patient's desires and expectations, and they have to be kind of realistic. So this is the on-track, off-track lesions. So this is Giovanni Di Giacomo and Steve Burkhart, basically. What they did was they made up this thing called the glenoid track. And if you were on-track, you had an 8% recurrence if you had an arthroscopic bank heart done. But if you were off-track, you had a 75% recurrence. So then, so now the surgical goals that we have are to reduce the rate of re-dislocation, to prevent further pathologic changes with recurrent instability. So when you have recurrent instability, you get progressive bank heart lesions, and you can get bone loss, progressive capsular deformation. Every time you dislocate, the capsule gets plastically deformed, and you have these enlarging heel sacs, which decreases your amount of good to excellent results if you're doing it arthroscopically. So then what about open versus arthroscopic? Well, Tony Romeo and Brian Cole showed us early on that open historically had lower recurrence rates, but as we got better with our arthroscopic technique and the newer anchors, the newer knotless anchors, the suture tape, those type of things, so arthroscopic doesn't violate the subscap. It has the ability to treat other pathology, like you can treat the front and the back, better range of motion in multiple studies, contraindicated for bone loss, significant bone loss in the glenoid or humerus. That usually stops us. But with modern techniques and no bone loss, arthroscopically should be better or equal to open surgery. So what if you look at open versus arthroscopic in the literature, across the literature? And the last study we had was in 22. There was actually no significant difference if you look at them, using today's techniques. So arthroscopic repair. It's the workhorse of recurrent instability in the correct patient. Who is the correct patient? We're gonna talk about that. And how is failure defined? Repeat surgery, repeat dislocation, subluxation, or subjective instability. So I go through the literature and I can tell you this. Arthroscopic repair is successful in contact athletes. And we have multiple papers that show that. Arthroscopic repair is successful with decreased recurrences as we go through the literature. This is from 2012 to 2018. So it works and you have decreased recurrences using modern techniques. So when is arthroscopic taboo? I think in young contact athletes, maybe depending on their tissue, too much bone loss for sure. An off-track lesion you gotta be careful of. And in my hands, I can't do anterior haggle lesions arthroscopically well. I have to do them open. So bony defects matter. 2000, Steve Burkhart and DeBeer, they did a classic article said that in contact athletes, if you have bony deficiency, or they call it engaging heel sacs, you had an 89% recurrence. If you had absence of deficiency, you had 6.5% recurrence. So Preventure showed us early on in 10 that 25% bone loss is a problem, requires a bone block. Then J.T. Tokich with the Military Mafia said about 13.5 anterior bone loss was unacceptable, OC scores. And then Dickens showed us that 13.5% had showed more instability in football players. So around 13.5 is where we're kind of looking now. And then Pascal Beaulieu showed us the risk factors, bone loss greater than 25%, larger engaging heel sacs, significant instability or stretched IGHL, anterior capsular laxity, or less than four anchors. When we moved on and then he made this instability severity index score, which I don't really agree with, because what happens is if you have six points or lower, or lower than six points, it's good for arthroscopic. But if you have six points or greater, it's unacceptable when you do open surgery and they push them towards doing bristos. So any of my guys that are young and in a contact sport, they're automatically gonna be above six. So I tend to use this system. I can't go through it for time reasons, but the glenoid track instability management score is a better score. Because what it does is the instability score of Beaulieu, they use plain x-rays and parameters are only used, whereas it had predicted a two-fold increase in recommending a later J using this system versus the glenoid track instability management system. So that's kind of the system I use to pick what I use. Matt Preventer has shown us that glenoid bone loss greater than 15, there's recurrent instability and yet with outcomes of arthroscopic bank heart. But there are non-modifiable factors such as age less than 20 or greater than five months of symptoms. So what about open bank heart? This is my preference. If I have a 10% bone loss greater in a contact athlete with multiple dislocations and poor tissue quality, the problem is kind of a lost art. And the residents and fellows don't get trained it. We recently looked at arthroscopic with REM plissage and it's shown that arthroscopic repair with a REM plissage, meaning to fill the defect in the back with the infraspinatus, was best for lesions under 10% bone loss and off track. So coracoid transfer, there's bristos in their bank hearts. I'm kind of a bristo guy because I like a one screw, but there's papers out there that show that in the latter Js, and even in good hands, there's a 16% complication rate, sometimes up to 30%. And there's possibility of this devastating hardware complication. So if you're in the combine, I'd much rather see a good bristo than a bank heart that's poorly done, or excuse me, than a latter J that's poorly done. So my approach is early aggressive for appropriate patients. Patient factors are paramount, less than 20 years old, greater than 30 years old, activity level, arthroscopy in the right patient, open in many contact athletes. These are the things you worry about. The contraindications, relative, young contact athlete, dominant arm overhead, glenoid bone loss of 10 to 13.5%, multiple recurrences, off-track lesion, and a large capsular rent. Those are the ones you can kind of go either way. So my thought process is this. If they're less than 10% and they're on track, they get an arthroscopic knotless repair, sometimes open, depending if they have an apsal lesion, a big one. If they're less than 13.5, on or off track, I use an open bank heart, or I'll use an arthroscopic with a REM plissage. And the ones between 14 and 19%, it's kind of a tweener. You gotta decide what you wanna do, what the tissue looks like. To me, it all depends on the tissue and what the bone looks like. If they're greater than 20, I give them, in my hands, I do a Bristow. Okay, and the conclusions. Arthroscopy is the workhorse in the correct patient. Significant bone loss is contraindicated for arthroscopic surgery. So my algorithm is less than 10% arthroscopic, less than 13.5% on track. It's either an open bank heart or it's a REM plissage. It's all based on what the pathology looks like. Between 14 and 19%, it's a flip your coin in the air. And finally, after it's 20% off, and it's off track, I do a Bristow. I'd ask you to look at this glenoid track instability management system, because it's a better system than the instability severity index score. Thank you very much. Thank you.

shoulder instability

surgical options

arthroscopic repair

posterior instability

patient factors