All right, thanks so much for having me. I'm really honored to be here and to kind of learn from this really awesome group of people. So, Mike tasked me to talk about an ALPSA in collision athletes, and so hopefully this will be a fun case to talk about. All right, so this is a high schooler, junior, he's 17-year-old, he's left-hand dominated, he's a quarterback. Three days prior to seeing me in clinic, he dislocates, this is his first game of the season after getting tackled, and he's reduced on the field. He's 6'2", 190, he's a little bit undersized, he's a shifty guy, so he's a scrambler. And he's got pretty, you know, he has, at his first visit to me, has actually pretty good motion, he's got good strength, and really the only finding you get is that he has apprehension and relocation. He has no findings of generalized laxity. So a common scenario, I think, that you guys all see. So these are his radiographic, or his x-rays, true AP lateral, or axillary. And no real surprises here. And so we quickly get an MRI non-arthrogram here, and I'll kind of quickly go through this and have you guys take a quick peek. And so he has the typical findings, so he's got the Hill-Sax lesion, he's got the Bankart. He has, I'm going to go back to this again, if you look at his axillary view, there's a hint that he has some potential bone loss in him, but maybe a little bit of scarring of the anterior labrum. And again, no real surprises here. And the sagittal view, you can kind of take a quick peek, but no substantial, I think we all agree that there's no substantial glenoid bone loss here. So if you take a really good look at the spot images here, I'll kind of give you some measurements here. He does have some glenoid bone loss. It's in the sort of subcritical range. If you calculate his on-track, off-track, he's about 10 millimeters, or 9.9 millimeters from being off-track, and we may debate this, but this is a range that we might consider sort of worrisome on-track lesion, or near-track in a collision athlete. He's got a three to six o'clock vanguard tear, and he has a potential question of an ALPSA lesion. And so here's the case summary here. 17-year-old, high-level collision athlete, first-time dislocation, subcritical bone loss, he's got an on-track lesion, anterior labral tear, three to six o'clock, question of an ALPSA lesion, and a couple things to consider or think about. And so JT has written the 13.5 glenoid bone loss. We know that that value for glenoid bone loss may be getting lower, and that 10% range, I think we would still consider subcritical. And then we're talking about sort of on-track versus off-track concept, and sort of whether this is a continuous variable, and some on-track lesions may be concerning, particularly if they're getting close to being off-track. And so we have a first game of the season, subcritical bone loss, maybe a near-track lesion. It's his dominant hand, and he's a quarterback. And so some things worth thinking about. And so I'm going to pose some questions for you, and this will be great to hear from the great faculty we have here. So what do you do right now? Do you rehab him, allow him to finish the season, and do the surgery after a season? There are a couple of references I have up here. JT has taught us in the high school athlete that you can get these guys back to play. Very high success rate without a recurrent dislocation over the next season. Successful return to sport with non-operative treatment, multiple studies, Dickinson bus. But you may have another instability or dislocation event, and if you have that, your chances of a successful arthroscopic repair might be less. And so question one, again, you rehab him, allow him to finish, and if you allow him to go back, how do you determine that? Do you use any kind of brace? What are your criteria for return to sport? If you might decide to rehab him and you do the surgery, if he has a second episode during the season, or three, you just decide, I'm going to just pull you out and take you out to surgery. So that would be question one. And then question two is, if you decide to do surgery, whether it's now or later, are you going to perform an arthroscopic Bancart alone, you're going to do an arthroscopic Bancart with remplissage, or some other type of augmentation like a posterior capsular shift. You're going to do an open Bancart, a Latter Jay, or other bone reconstruction, including arthroscopic versus open DTA, distal clavicle. The faculty here have demonstrated nice arthroscopic approaches to bone blocks. So which one of these are you going to choose, and what's going to be your criteria for return to play? So I'll sort of leave up those two questions for you guys, and then we'll revisit what we did. Is he a senior? He is a junior. Junior? Yeah. And it's his throwing shoulder. It's his throwing shoulder. He's being recruited as a quarterback. He's shifty. So he's an athlete. He's like a fast... Yeah, he's an athlete. But he's small. He's kind of smallish. Yeah. But he's a 190, I think, is what I said. All right. So discuss, and then we'll talk about sort of what we did. Perfect. So before I show you what we did, let's talk about ALPS a little bit. Higher risk of recurrences has been reported recently by Justin Arner, who's Jim's partner, and Peter Millett over at Vail. Much higher, 30% versus 13% of recurrences, standard Bankart. Prevention has shown it's at a higher risk of glenoid bone loss. This is usually associated with a higher number of preoperative instability events and recurrent episodes. And so some of the themes of ALPS are typically early diagnosis and treatment to prevent sort of these chronic issues from developing. And what about this question of a remplisage and an on-track shoulder? Now this is a little bit controversial because it's his throwing hand, but if you really look at sort of, you know, Peter McDonald's done a RCT looking at sort of Bankart versus no Remplisage versus no Remplisage, but didn't really look at sort of the track concept. His study, definitely there was a diminished risk of recurrence. And then Pat Denard and I took a look at this sort of multi-center study looking at, you know, we excluded patients with glenoid bone loss more than 50% of any off-track lesions, and we looked at sort of the risk profile of those cohorts. And if you look at sort of a high-risk cohort, which we defined as a contact sport athlete or somebody who had a near-track lesion, and you added a Remplisage, you could diminish the risk of recurrence very significantly, from 4.2% to 2 out of 3. Bob. You know, Remplisage is, there's no question, has gained tremendous foothold, at least in this country again. But John Kelly, who's a big Remplisage guy, reported that only 50% of his overhead athletes got to the same performance level when they did a Remplisage. I think it would be, I would be incredibly, maybe even do a mini-Remplisage if it's a huge lesion, but I'd be really cautious. You thought it was a mini-Remplisage? I don't know. I've got no clue. You? No, but I'm just saying that. Right. Can you tie up that infraspinase? So, it also depends a little bit on, probably, and I think that may depend, and I think that's true, but if you look at sort of literature looking at external rotation loss, it is not always apparent that you have external rotation deficits. But you have pain, they can, they'll have some pain. You can, and some of that also may be technique related to where the heel sac lesion is, how medial you're going to put that, how much of the infraspinase you're going to dunk in and where of the infraspinase you're going to take, or you're going to take mainly capsule. And so, no, I'm not pushing Remplisage, but I'm saying that it is becoming increasingly popular for instances in which you feel that there's a high-risk episode that an alloscopic bank loan might not be the right thing. And so, that's, you know, what the sort of the background for this. We let this kid play out and try to see if he could go, because it was, again, I ran mentioned it was really important for him. But as Jim mentioned, he couldn't throw. He was too unstable to do it. And so, we ended up having to take him to surgery. And so, what we did, this is. Probably about six weeks later. Yeah. So, we gave him a good trial. No. No. He was just rehabbing and he just couldn't throw. Yeah. And so, this is his intraoperative photos, obviously, in a lateral decubitus position here. We were able to mobilize the labrum so it's nice and kind of floating back up. We put the first anchor in. We did do, we decided to do Remplisage on him because I thought he was, you know, even though he's a thrower, a high-risk scenario. And we, I kind of do the technique that, you know, JT has described in the past, which I don't really go up into the subacromial space. And I just, I take the candle out and just literally punch through the capsule. So, I think I get very, very minimal infraspinatus into the Remplisage. And then we finish up the rest of the Bankart repair and then do a double pulley technique to interpose the Remplisage. Just a few words here. So, you know, we can kind of discuss this too. Criteria for return to sport. Everyone does this in the ACL. This is not talked about much for instability, though I think this makes some sense. And I was sitting in the physical therapist table and they also kind of mentioned this actually right off the bat. And so, we at Pitt have been using sort of Validate Return to Sport Testing, which I, which we did with Adam Popchak. And we've actually been able to show that with criteria-based testing, if you test these athletes that look great and physical exam at six months, a good majority will fail some component of this test, whether it's a kinetic, whether it's strength testing or functional testing. And then we also looked at sort of patients who underwent some kind of criteria-based testing for clearance, whether or just six months and you're good to go. And we were able to demonstrate, at least in the anterior instability setting, that we were able to reduce that rate of recurrence by four times just by having some kind of objective measure of being able to clear them. And so, you know, we're familiar with this concept. I think, you know, there are a lot of questions currently right now, so what is this critical threshold? And if you look at the literature, it might be anywhere from 10 to 20%. What do you do with sort of this gray zone on track lesion where it's not clear, it's on track, but it's maybe close to being off track or determined near track? And how does all the other risk factors that we talk about, contact athletes, hyperlaxity, multiple preoperative dyslexia, and remplisage? How does this all kind of go into our thinking about what we should do or what type of surgery we should do? And if you look at sort of the treatment algorithm for this, again, much of this is due to sort of risk factors, what your bone loss is, what your track concept is. But I think, you know, we still don't really understand, I think, what subcritical bone loss is. What do we do with these near tracks, at-risk shoulders? And then who do we do a remplisage on? It's very popular to do this, but what are the ramifications of doing that over long term? So we recently presented this at Herdicus, and not just to kind of go over sort of what maybe we might be thinking about, sort of how to risk stratify or how to understand sort of what we should do. And so we were able to look at a cohort of patients, we did remplisage and non-remplisage for on-track shoulders, and then come up with a kind of a risk score assessment for various risk factors, including what the patient age is, what their distance to dislocation is, what their risk factors are, their near-track, on-track lesion, laxity, preoperative instability episodes. And based on that, be able to risk stratify them to low risk, moderate risk, high risk, or extreme risk. And if you add a remplisage, you can diminish that risk or that score by 10. And now we're still working on this, so there's some other variables. But ultimately, you know, we're thinking about doing something in which we can say, okay, if you have a score that's at an extreme risk and you include a remplisage, you might be able to diminish that risk into the high risk or moderate risk category. But you might still be at a category where it's still unacceptable for an arthroscopic approach. And so maybe you have to think about doing something open or something else. Alternatively, you could be at a very low risk category, at which point you could say, you don't need to add a remplisage because your risk of recurrence is low to begin with. And I think all of these algorithms in the future probably, there's gonna be some component, I think, of AI ability. I think you input these things in an AI algorithm because there's so many variables now we're trying to understand. And I think, ultimately, that's maybe where we're trying to go with this, where we say, okay, input all the variables and then figure out what the percentage risks are and sort of what the best options available are. And so I'll end with this slide. You know, this was published in NeurCircle a few years ago in JSCS. And many of the individuals are in this room. And so the consensus for reaching recommendations for surgery using a Delphi process, only 5% for recommending surgery and only 14% consensus for recommending non-operative treatment. And so all this to say that I think the entire spectrum of instability remains right now a huge area of continued study and research. And I still think if you get all these experts in the room that don't agree more than those three that Jim was mentioning, then, obviously, there's a lot that needs to be done. So questions or comments from any faculty? What is near-track injury, what percentage? Tell me my definition of a near-track. So we all know how to calculate the glenoid track and just take the on-track, off-track. Glenoid track, subtract the Hill-Sax interval. And if that value is between 0 to 10 millimeters, that is considered near-track with arthroscopic banquet alone. And as the closer you get towards being off-tracked, the failure rate exponentially increases after 10. All right. Good. Thank you. All right. Really quick. Has anyone ever done a remplissage, not a football thrower, but in a baseball player or a baseball pitcher? I'm just curious. I did one at the beginning and did not make it back. Okay. Interesting. All right. Next. So the question was whether you did a remplissage in a pitcher. I actually never touched the infraspinatus, but I had a high school pitcher right when we first started talking about doing it, pretty big Hill-Sax, and I did an infraspinatus, transferred into it, never made it back to pitching, became a hitter, actually became a first baseman. So I've never done it since. Let's see. How do I get to... Oh, that's so cute, Albert.

shoulder dislocation

surgery

ALPSA lesions

Remplisage

shoulder instability