University of Virginia, so we're going to switch gears a bit. Overhead sports is the title, but this is not a true overhead athlete, but it's an interesting problem we see in younger athletes, so kind of switch it up a little bit here, my disclosures. So this is a football player, good, that's projecting well. So he's a safety, let's see if we can get this to play, there should be an arrow, so it's this guy right here, okay, and so you can see, he engages, follows out, and he's laying there. So you'll see another view of it, he'll come into play, he's over kind of on the right side, and he lands kind of awkwardly in that right arm. All right, so we go out and look at him, this is an away game, his shoulder is anteriorly dislocated, and so we bring him in the locker room, we reduce him, we get some x-rays on site, and here are the x-rays that we have here. All right, so you guys see those okay? All right, so we're talking first time dislocation, you got anybody history in a high-risk athlete? All right, anterior dislocation. So first of all, everybody gets imaging in this setting, anybody not get an MRI in this setting? So good, so we get back into town, we get an MRI, here's his MRI, so thoughts on this MRI? Andy, what do you think? We got two cuts. Two cuts. On the x-ray, it looks like he had a bone implosion at the bottom. Yeah. So that would be nice to have. Yeah. You know, posterior limb looks okay, don't really see a big Hill-Sachs bruise, which is interesting. I would expect him to see that, at least a lot of edema in the bone. Do you think that's a Hill-Sachs right there? I never can tell on those, I mean, it looks a little indented, but you don't see the reaction of the bone medial to it. Correct. You don't see a lot of edema in the bone. So then you wonder if he's done this before, and it's that old, and didn't really play a role in this at all, but if he was dislocated on the field, then you've got to pop it back in. So the corona, I think, will help more, or you've got to cut further down on the labrum. Yeah. I don't see a haggle. You have edema on your axillary going lateral, but I don't see it pulled off. Yeah. So the axial there, I thought was kind of a stripped anterior labral tear. You did have a little fleck on that APX ray, so probably a little bit of bone inside that as well. All right, so what do you do at this point with this guy? So this was probably game three, maybe, game three or game four, and to give you some context too, and this is, I don't want to disclose too much, but this is a guy who, he's actually still on our team, and he's nearly 24, 25 years old. So he came in, so COVID here, hey, listen, we got to make do. So no, no, let me give you a background on him. So he had an ACL in high school. He came in, he played a little bit as a freshman, sophomore year, beginning of the year. He was actually in line to be a starter and retors graft. And so he had a revision ACL, missed essentially that whole season, comes back the following season, played fair bit, but it took him a while just because it was revision ACL. This is the following season. So this is his fourth year. So he's a kid who wants to play ball, right? So any concerns about trying to let him see how he does, or do you guide this guy towards surgery? Who wants to step up on this? What do you think? JT, what do you think? This guy will let him play through the season. I think, you know, Dickens and our group, we published on that with collegiate players, Bust has the other big one in high school players. These kids get back. In our series, he's a full dislocator, a little slower, but it's around three to four days. So they get back and they can finish the season pretty effectively, and these guys, although you should tell him he's going to come out again, that's most likely the case. And then we'll have the discussion about what you do at the end of the season later. So how much do you tell them about progression? Are you worried about progression? You know, is that information that we have, you know, how do you talk about longer term stuff with them? Ben. Most people do it. Once again, if you try to do the best thing at the right time, you know, you want one shot, your best shot is right now. Is to fix it. To fix it. You've got the, you know, no problem going on, a little piece of bone, and that's sitting right there. That's almost a slam dunk as far as I'm concerned. With everything that JT says and the literature says, totally true. But once again, you want one shot for your best shot. I tend to go that direction. I value Champ Baker's advice on this. God bless him and rest in peace. But Champ always said, you don't have to fix them after the first one. Just fix them before the second one. That's great advice. Mike. You know, the one thing, the one question I'll throw out there, and I want to get Jake Kelsey's, what he would do here, but we've got to remember JT's got a linebacker mentality, you know, so he's going to put one of those big braces on, and he's going to be able to do stuff below shoulder level, but this is a defensive back. Does that, do you have to lay more crepe there, knowing that this guy's going to have to get his arms up in the head? Are you going to put him in a sole or some kind of brace, and is he going to be able to perform in that? Is the question with these skill type positions. Yeah. I looked after Air Force. We didn't have any past defensive or defensive back positions. So if you, I will tell you, if you rehab him, and you put him in a sully, and you take an eight-pound medicine ball and throw it in a trampoline in here, he doesn't have to really get up to here, but he's got to get to here. So part of the rehab and the criteria of return of play, depending on how good he is, you might have a lot of depth at Tulane. So it does, much as you would not think, it does play a role in how we're doing it, but you talk to the kid, you talk to the parents, and go, we can do this, but they've got to do that before we let him on the field. Because otherwise, he can't protect himself. And if he says he's shifting when I'm doing this, then you fall to the bench and you've got to do this. I feel like you can, especially with DVs or anyone who has to get up with their hands, they might start the game in the brace, but by halftime, it's on the bench. Right? I think that they'll oftentimes take it. Put it back on. Yeah. Yeah. They hate it. They tend to hate it. No question. I mean, I don't know how much it's really protecting them except for keeping them from getting up there, but I don't know. The DVs tend to hate them, I think. So it's been mixed. We try them, and everybody, other than maybe a receiver is kind of hard. Obviously, you can't do it in the throwing shoulder. But you can try a solo. You can try a harness. Obviously, you can adjust how tight you set them. It adds something. Right? It adds something. It's feedback. Yeah. We never do a static brace. It's always got to be elastic so that it brings the muscles out. We looked at this across our South Carolina population, 53 schools with Ellen Shandy, whether bracing was effective. And interestingly, in that high school population, high school, not college now, but high school population of mostly football players, bracing was completely ineffective. Yep. Ineffective based on what measurement, though? Redislocation of shoulders, time patients come to surgery at the end of the day. So no difference in redislocation rate, performance rate, anything that we measure. Yeah. Albert? Steve, I think this conversation is, you know, I think what J.T. said was right. If you say return to play is your outcome, this person is going to be able to return to play and finish the season. But if recurrence is your outcome, then what Ben was saying is also true, too, right? The best chance of having a good outcome is repairing it after the first dislocation, before it comes out again or has recurrent stability. And so I think the athlete needs to just understand what that is, right? You can finish, but you might come out again. If you come out again, you might need a bigger surgery. Yeah. And I think that's sort of, you know, I think that's kind of like the dichotomy. I think it's also important when we look at the literature that we tease out what exactly is the outcome we're looking at, return to play or recurrence, because they're not the same thing. I think that's a great summary of it, right? So you've got to tell them it is highly likely you'll have events or an event or multiple events. But more than likely, in football, these guys find a way. It's also amazing. These guys come in. I mean, he gets his MRI. He comes and sees me, and his shoulder looks essentially normal when you examine him. I mean, these guys, they're different. They're much different than some of these overhead athletes we've looked at before. Mike, do we have until 8.15 or 8.30 for this? Is 8.30 right? Yeah, good. All right, so just some data, right? The NCAA injury surveillance system, pretty common. Shoulder instability, highest it's going to be in the sports you would suspect. Lots of judgments that you have to make. This is a great study if you're not familiar with it. Military academies where they really followed over a season prospective study, and basically 73% were able to return for all or part of the season, so most were able to get back and play. But only 27% completed the season without a recurrence. So, again, just goes to what Albert was saying there. Oh, and the other thing that's key here, too, subluxations versus dislocations. And we didn't touch on this, but they're a different animal. So, you know, this guy was a complete dislocation on the field, was out, and so that's typically going to be a more significant structural injury for these patients. And then if you look at the kind of the discussion point, and I think we still don't have enough data to tell us this, the long-term outcomes, the consequences associated with a second event or a third event or more than that, we just don't know what that is, but I'm sure all of us suspect that it's probably not necessarily a good thing. So you've got to think about who the patient is, what do they have pathology-wise to help you figure out what to do. Again, some of the bone stuff, and we can kind of get into this if need be. And then, again, a nod to the military because they've really helped us to define in this bone loss patient, because you saw that little fleck of bone, you know, kind of how you approach these. All right, so let's walk through this case and kind of get to some discussion on what you do with him as you navigate down the path. So I'm sorry, it was game two that this happened. He returned to play. He missed one game, came back game four, and frankly probably could have played game three, but we kind of took it slow with him because it was earlier in the season, and we really wanted to try to get him, you know, a little bit of time to kind of rehab and get the shoulder to normalize. He did play in a harness, and he actually did pretty well with the harness. Didn't really complain about it much. He was able to finish the season. He did not have any subsequent dislocation events, but he had a few kind of, you know, my shoulder got tweaked a little bit in practice or in a game type of thing. His shoulder doesn't feel back to normal. He's still a little apprehensive on exam. All right, so now what are you going to do with him? So, Jake, what do you think? I mean, so this guy, now he's finished the season. He got some time. You know, he's a guy, actually, he's got one more year. He's actually planning on coming back and playing because of the COVID year, et cetera. So he doesn't have, like, draft concerns and that kind of thing. You know, it's January. You know, he made it through the season. Are you going to operate on him? And if so, what's your surgery in this setting? Yeah, I mean, I think, you know, we kind of know what his pathology is, right? We have the MRI kind of showed it really nicely for us, and we know that his risk of recurrence is high. You know, and he's already kind of, you know, unstable, right? He's subluxing. He's had some mini recurrences throughout the season. If he's still apprehensive, I think you have a discussion with him, you know, to fix it. I think, in this case, it can be, you know, a soft tissue, you know, repair, and you don't have to, you know, before you get to something a little bit bigger. So I think now is a good time to do it, let him rehab over the summer and be ready to play the following season. So would anybody in this room treat this conservatively? Everybody's got to operate on this guy at this point. Ben? Yeah, I think you might want to re-imaging him. So I was going to ask that question. This thing's gone around posterior now at least, and so you need to know that. With all that stuff that's been going on, he's got either an anterior capsular tear or more posterior extension. Now, you may not need the imaging of that. You just need to make sure that you look at all that area because that's the problem he's going to face right now. So what type of gap would lead you towards re-imaging him? Because he's got another event, because it was game two and he played ten more games, is there a criteria you guys use? I wouldn't necessarily, but when you scope him, you need to make sure you rule that stuff out because that's the problem. So whether you need an MRI, more power to you, resources, whatever you want to do, but you need to make sure that you look for it. All right. Do we have time to go to the tables to discuss how you'd operate on this guy? Maybe give it five minutes to have the discussion and then come back? Yeah, do five minutes. All right. So I think at this point we're thinking surgery. I don't have new imaging to show you. Let me just say that we scoped him. We had plans going into surgery, plan A, plan B, et cetera, but really not really any notable bone loss. And his EUA, he was about a two to the front, so not like a kind of sitting out when he's under anesthesia and the muscles aren't holding the shoulder and the joints, so nothing that's too tricky in that regard. So what are you going to do with this guy? You've got to operate on how you're going to fix it. You can do it with scope, you can do it open, do a boning procedure, anything along those lines. All right. So we'll come back in about five minutes and kind of discuss it further. Do you take him out of the harness? First of all, if he likes it, do you let him just continue to play in the harness? If he likes it, it's fine. If not, no, I would. I would force him to play in the harness. But I've seen some guys, I've had some guys, and even after I've fixed it, they like to harness him and play in the harness. And, again, he's playing safety. He's not playing defensive back. He's coming down on you guys. He's going to exercise. He's not going to be inferior. That's the issue. My son went back to Kansas State. He's a big, he ain't, you know, safety's coming down on guys, but a lot of those guys don't have to cover as much. He's a bigger guy. Actually, how do you fix, so like, what's your fix that you need to do in the time, you know, how do you make sure that you're doing it the right way? I don't want to say I've done it both ways, but I, you know, I'm more anonymous. I think the key when you're doing this is, you know, you have to see, you have to see everybody. It definitely wraps around around 6 o'clock. Right. You've got to get the 7 o'clock to go at all and put, you know, probably an hour back there. Right. You have to re-tension everything. You have to make sure that it's fast. You told me you don't want to slide five times or something like that. Do you suture and then re-tension them all, or do you cut them as you go? I cut them, I cut them. Yeah, if I have too many in there, then it's just like, yeah, it's just a back and forth. That's why these guys are so flat. We'll see how many you can do as you go. I do everything. Yeah, so we went in with a plan B. I can't. I can't. I just did my training. Yeah. I tried, did something around. I mean, my partner is pretty good. There's four of us. We're split, 50-50. But in the tight shoulder, the lateral guy's got it. Well, that's a different game. Right. Yeah, this guy's like first time in season type of thing. All right, cool. We'll catch up. I don't think there's any, like, difference in outcomes or anything. No, there isn't. Okay, cool. I'll mention it. That way. That's what you're comfortable with. So you're making this on the ZX, like an arthroscopic make, are you? Yeah. Probably. He's the one who runs this thing. All right. Why don't we go ahead and bring it on back? Yeah. All right. So why don't we start at the back of the room. So, Mike, what are you guys doing with this? Well, you know, we're going to do an arthroscopic make, percapsillography. We had a lot of discussion about, you know, making sure you do at least three acres. We used double-loaded acres and the 7 o'clock portal getting down to 6 o'clock, 6.30. The question is, do you add a room massage or not? Okay. And we were kind of arguing, not arguing, but different sentiments on that. I actually would add a room massage. Even though it doesn't look very deep, that's not what's important. It's the width. Okay. And I reckon this contact guide, to me, it's a little bit more predictable. Just don't get too close to the articular edge. All right. Albert? I think the group here decided they wanted to do an arthroscopic approach, try to incorporate the bone piece, look for any labral tear extensions, and then fix that. I did bring up the point, would you just put a room massage into this for a high-risk person, even if they're not going for off-draft? I think the discussion is less reminded regarding that, but I think that's where the approach is, assuming that there isn't more bone loss that's occurred through the season. Sounds good. J.T.? Our group also voted for arthroscopic Vanguard room massage. One of the groups thought maybe an open Vanguard, which I was so proud to hear and happy to hear about. I think the data on arthroscopic Vanguard and the contact athlete alone should give us all pause, especially in recurrence. That being said, that was the decision our group made. Would you do an open Vanguard on this guy? Yeah. I would not do an arthroscopic Vanguard on a contact athlete that's 19 that's going to be returned. Yeah. I just hear failure rates. The literature just shows it over and over again. Now, we all have cases that we've gotten away with, right? So I wouldn't judge anybody for doing it. I would just say that in my hands, I've seen this song over and over again where you think it's perfect. You can make it perfect. All of you can. You can make it perfect. And they leave the operating room, and 18 months later or 12 months later, they're out. Yep. Ben, what would you guess? We spend more time talking about fixing a right than doing a rehabilitation, of course. I would vote with JT. Open Vanguard? Open. Yeah, open capsule. I'm pretty sure if you do an open, you don't need a rehabilitation because you've stabilized it well enough. JT, you ever do a rehabilitation with an open? With bone grafts. With an open Vanguard, I haven't done a rehabilitation in China. But at our table, one of our members brought up a really good point in that the concept about bringing those 7 o'clock anchors or posterior anchors, the old circle concept, if you will, also may give you the same benefit as a rim plissage. I thought that was a really astute comment. That's our experience. Tightening it up as well. If you get that posterior right, a rim plissage is much less needed. So I've thought that. There's one biomechanical study out there that kind of supports that. But, I mean, basically you're tensioning the back, kind of a belt and suspenders type thing. So in this athlete, if you're doing an arthroscopic, I typically will do that. Jake, what did you guys decide? Yeah, I mean, same. We were pretty unanimous arthroscopic on this one. I think that the key, if you are going to do arthroscopic, is you have to restore the inferior sling, right? You have to sort of get around well past 6 o'clock because it likely goes past 6 o'clock and get that last anchor probably in through the 7 o'clock portal. And for all football players, I always put that 7 o'clock portal and get that so I can get a good anchor past 6 o'clock because I think it's really important. Well, that's what the pathology is, right? Yeah, if that's what the pathology is. All right, and Buddy? We had two tables. Arthroscopic, bank guard repair. Very similar to Jake. We also thought maybe get a new MRI because we're not convinced about the hillsides. And just make sure that you know the contour of that and that. But very aggressive all the way down around the bottom. Low anchors, posterior-inferior, then anterior-inferior, and then doing the shift. If you have to add a rumple size or a classic flication posteriorly, we would add that. And then if you need to flicate some of the capsule on the front, because he's a football player, we would add that in as well. It sort of gets around Jake's current trait. Contact athletes would start adding these things just like you would with bank guards. All right. So let's see what we got here. So this is inside the joint. Good labral tissue. Kind of did extend around to the bottom but not past it. So we did, basically, there's that posterior anchor. Kind of just tensioned up that capsule so kind of put that in and parked it. Did a nice bumper repair in the front. Arthroscopic bank guard repair for this guy. A couple comments on that. So number one, I think JT actually said it very well. We've all done this and we've all gotten away with it. I've had a few of these guys where we did this when they were freshmen or sophomores. They did great. And a couple years down the road, you know, they healed up and then they re-dislocated because football's football. I've done some open capsule orifice, open bank guard, and I think in this patient that may be a really good option. I found that they tend to be stiffer for longer as they come back and that's maybe a good thing and that may be why they don't have the recurrence rate. I don't have as much of a track record with remplissage in these athletes. I've started doing them in these kind of tweener cases over the past few years and this is a guy where that might be a good option. He did not really end up having much of a hill sack so there really wasn't, you can only remplissage if there's something to remplissage into and he didn't really have that. You ever create a remplissage? I've never done that. Have you? We're putting it as part of the Oasis trial. We thought, you know, we're randomizing this to try to figure this out and so the option comes up. What if they don't have a hill sack lesion at all? And the idea is, well, maybe make one. Not make a big defect but just kind of shave it up there and tie it down in advance. That's going to be one of the grooves in that study. So if the thought is, though, if you're doing it on the glenoid side with the capsule... So put your anchor in the bare spot and then you can go through almost dead even with it. Right, and you get about six, eight millimeters of vacation in the back and you still go through. So then when they come back over, you don't have to make a hill sack. You just kind of clean up the bare spot with an anchor. Soften the bare spot as opposed to a hill sack which is hard but it's basically almost like you're doing a posterior capsule shift on the pneumo side like you used to do when you just used a bare spot with an anchor. That actually works pretty well. So if you're thinking that it's tensioning the posterior capsule, I've always thought go to the glenoid side if there's not a hill sack but it's an interesting concept. Michael? I would just mention for those who haven't seen the literature that Albert Lin's done that to not get so black and white with on track or off track people realize that that's near track. Yeah. You know, and I think Albert's worked with eight millimeters or less. Isn't that right, Albert? I mean, just be cognizant of that, the failure rates. I would recommend everyone read that. Our fellow's actually going to present this on Saturday and we look at the increments for how far the track is from being off track. It doesn't seem to matter in contact athletes. You can be 25 millimeters on track from being like that distance from being on track to off track. You can be 25 millimeters and your recurrence rate is still way higher. I don't think it's rocket science because I think we kind of all know that that contact athlete's a problem but I think it argues for maybe augmenting these people with something. So if you're going to do an arthroscopic approach and you have a hill sax maybe it might be useful to put a remplisagin. Alright, I'm going to show you a quick second case. So this is an 18 year old. This guy's a linebacker. It happened in Spring Ball. Here's his MRI. It's kind of an uglier looking lesion. And so as contrast we got a CT on this guy. You can see that fleck and certainly this is either off track or as Mike alluded to, near track. And so you got a bunch of these options we discussed. Here's what this looked like in this athlete when we scoped his shoulder looking from that kind of anterior superior portal on down and you can just see that area where their glenoid is deficient. And so in my experience, and he's got a little bit of a hill sax, but when it's primary glenoid bone loss this is one where I'm going to do an anterior bony procedure. So this is a guy where we did a Latter Jay and I will tell you my experience with football guys I think what Albert was saying in the end absolutely resonates. It may not be all the stuff that we think about in instability it may just be that they're football players. And so the recurrence risk is high so I have gone to being more aggressive in these athletes, in particular when they have any type of bone loss, if they have laxity or positions at risk. So just keep in mind that you want to be really, really smart about trying to get them to not re-dislocate. I know we're out of time, but I was wondering, JT, do you think this is the, you presented on this this is the type of person that would be perfect for an outback bone blocking procedure? I do. I think the screw problems in these guys, 18 years old is non-anatomic. I think this is one where you can get either a distal clavicle or a distal tibial allograft and you can make it perfect and plush you can then incorporate the vanguard you can do a REM plissage you can do a REM plissage if you start out with the scope but nobody does. It's a pain in the butt especially if you're in the lateral position. So I think Latter Jay is on solid footing. I think everybody should know how to do that operation if you're looking after that contact athlete population, but you've got a chance especially if you've got significant cartilage loss I think there are a lot of advantages and the other thing is, even my Latter Jays now are soft tissue fixation, so we use knotless anchors and multiple cargo netting over the top, because I hate screws because all of us have seen those terrible things and bony erosion, even in a well done Latter Jay like that one superior erosion is going to happen 60% of the time and that patient will oftentimes rub against that bone a little bit So yeah, I think that's where we're going Real quickly, so you're saying for Latter Jays like in this guy, a college athlete you would use anchors and a cargo net versus screws at this point? Yes It holds pretty well? Yeah The newer stuff, if you take a look at the Boileau's single anchor works very well we've got some data that we've looked at as well that stiffness, etc. are good Remember it's a race between healing and displacement right? And so the biomechanics studies if you compare them to screws are not quite as strong but that's where you've got a pestle pushing down on it biomechanically in Gus' lab where he can break anything and in these patients you're not doing that these patients are soft tissue, they're sort of passive motion only for a little while, etc. and they're protected. Now I will say one thing about it is that Ivan Wong who's a genius, you guys know Ivan Ivan just presented at ANA this year a comparison of his distal tibial allografts one group was, he does prosims exactly the same way between the two techniques one group he used screws on one group he used soft tissue anchors on one particular company it's a button if you will if I may, it's the Smith and Nephew button that they use that Boileau sort of described there are other companies with this so he compared the soft tissue that was the only variable and he found an alarmingly high failure rate at 18 months with the patients that he used that soft tissue button fixation on which gives us all positive it's not as rigid a fixation we went to the cargo netting so I agree, I think two or one doesn't give you that same one so we augment these knotless constructs now, you can take it and plant it into other areas of the glenoid so it does give you a very good sense of how strong that is, but the data's still out, honestly I think an open procedure here is very good, I think an open Bankart is an excellent choice and even that patient, Pagnani, has taught us that and others as well I think the jury's still out, doing a good Latter Jay, golly, I think that's such an important thing, but I think that we can improve upon the Latter Jay, as you may know LaFosse himself changed and went to a bioabsorbable screw because he had problems with it, I guarantee he knows how to do the procedure correctly, but then he had to go back because the bioabsorbable screws aren't working so there's a lot of discussion about this and I think we've got to see data as we go along, but I think stay tuned it's a really exciting time to be a shoulder surgeon alright great insight, no that's great thanks to everyone for coming, when you get the reviews if you don't mind, just please give the course a review, that allows us to continue to move forward and if the faculty could just come up, we need a quick picture and thank you, have a good meeting

orthopedic surgeons

anterior shoulder dislocation

arthroscopic Bankart repair

Hill-Sachs lesion

remplissage

shoulder instability