Let's talk about some instability cases. Instability is obviously something we all see in our practices, and I wanted to discuss some of the more complicated aspects of it because I think we've all heard a lot about, you know, the patient who has a Latter-Jay, or the patient who needs a Latter-Jay, the patient who needs an arthroscopic vanguard. So this is something I think we've all seen occasionally and can be a challenging concept. So this patient's 38. She comes to me having had a Latter-Jay outside that was done about two years ago, and she says my shoulder dock still dislocates. She's had multiple dislocations that she can reduce herself, and she's got good range of motion. She's got good strength. She doesn't have any pain in the mid-ranges. Her main complaint is recurrent instability. So what are your thoughts, Brandon? When you look at these x-rays, what do you think? So a couple things. One is she hasn't developed arthritis, which is good, so they didn't over-lateralize her. Maybe on that axial slice, it's a little bit more lateral, so that may cause a problem in some time, but it has not yet. Those screws are a little bit higher than where I would aim to shoot on the glenoid, so I think they restored kind of mid and upper bony anatomy, but I think they may have missed maybe that 5 o'clock position where you're trying to get it sometimes. I think the screws may be positioned just a little bit high, so maybe not on that sagittal, but I probably would have gone a little bit lower personally. So I think if she's still unstable after this, the bone block looks like it's healed. Is she tissue deficient? Is there anything going on with her cuff? Is her capsule, was her capsule not repaired? Does it look like it's thin on the MRI that she got? Yes, you can see I got a CT arthrogram. I can tell you her cuff is intact, and her capsule looks like any post-open Latter-day capsule would look. Sure. So yeah, I think the graph looks like it's healed there. It doesn't look like the graph is resorbed too much. It's maybe a little bit lateral. What was your exam like in her? Was she unstable? Yeah, I mean, she would, as soon as I come up even to here, she's starting to do this kind of like... Okay. So it wasn't her feeling that the head was just riding on that little bit lateralized bump there? No, and in abduction, she was perfectly stable. Got it. It was only up in the abduction that she had problems. So tell us, so you look at this and you see the graph looks a little high. What's your ideal graph position when you do your Latter-days? Somewhere around 5 to 530 to 230-ish. So maybe you want the bottom of the graph to be like one or two millimeters above the bottom of the glenoid? Yeah. You don't want to be right at the bottom, but I think you want to be just up a little bit. Obviously, you have to accommodate for the curve a little bit, so you have to be careful there to make sure you don't put the graph too lateral. But I think if you stick it way too high, and that superior scrutiny I think is probably a little bit high, I think you don't get the same benefit you do as if you put it a little bit lower, because obviously instability is an inferior problem, not a straight anterior problem. What do you think, Greg? Yeah, so I would try to really understand the instability, and you can fill us in. You should, even with a high graph that's healed, you should still have a sling effect from the conjoined tendon that's helping you here. And luckily, the cuff is intact, which would be a much bigger problem. The arthrogram shows that pretty nicely. The bone is healed. In terms of graph placement, again, more five to three position, not overhanging the inferior glenoid. And honestly, if you get to the patient with 13%, 15%, 20% bone loss, that CT, you get a 3D, that portion is flat. And you put the graph at that flat portion, that's where the bone loss is, and you're basically replacing it. It's kind of teed up and ready for you. But this graph is high. Fixing that is challenging, certainly. All right, so I mean, and I think one of the things- Also, I would like to see more views of the hill sacs to see how large that is. Yeah, so definitely, that's one thing I don't have in here. I don't have the same videos, but you can see from her AP that she's got a substantial hill sac. She's got a big shark bite out of the back of her head. One of the things I think is interesting about this slice over on the far right is you can definitely see subscapularis below your graft, and there is no subscapularis above the graft. So I'm not sure if they put the graft above the subscapularis, or if they split the subscapularis so high that the top of the subscapularis gave up the ghost. Tell us, when you do your subscapularis split, when you do latter days, are you a two-thirds, one-third? Are you a 50-50? Where do you guys make your split? I find the 50-50, and I go a little bit below that. So I don't know what that is, 60-40 maybe. What's your- It's not that precise. 60-40, perfect. Yeah. Greg's got the ruler out. I've got the ruler. I've got the ruler. So tell me, when you do your latter days, what's your inferior retractor? Like how are you seeing the bottom of the, like what are your retractors when you're trying to place your graft? So I have a Facuda in the joint, retracting the head, and the, what I call the Batman, the Bankart retractor in the front, down the glenoid neck. And then inferiorly, depending how my view is, I'll be able to do that with just the anterior retractor, or sometimes put a small Holman retractor down there. What about you, Brandon? So same exact thing. I split it basically at the 50-yard line. I think it helps, but sure, if you're going to err, just slightly inferior. I use the same retractors, the Facuda, the Batman. If they're really, really small, sometimes you can use Robin. But generally, if you put that retractor low enough on the glenoid, you can see right down below, and you should be able to, I usually repair the capsule afterwards, so I usually put an anchor below the graft when I put it in. So I think you can still get that with those retractors. But the pointed Holman is a great option there if you can't see it. Oftentimes, it's harder to see above, so you oftentimes wind up with a pointed Holman above. Some people put a Steinman pin in to help retract above. I generally don't do that. All right. So this is all the imaging information you're going to get. Are you going to go in, take the hardware out, osteotomize the graft, move it down? Are you going to go in, put a distal tibia below the graft? If you do that, what are you doing with the subscapularis? What do you guys do in this case? Well, I'd like to really analyze the hillsacks. I might consider a scope just to figure out what the heck's going on, maybe do a remplisage at that time. I think redoing the graft in the front is possible, but pretty tricky, and it'd be nice to know what's going on with the subscap. So I might have all of the options on the table, but I would certainly start with a scope to figure out is this graft above the subscap, is there, what's going on? Okay, so this brings me to, I think, an area where we still have some controversy. What are the indications for doing a bone block and also doing a remplisage at the same time? So when is the hillsacks big enough that you're still going to be off-tracked after your bone block? So tell me guys, are there situations in which, as a primary surgery, you're doing either a combined latergi in remplisage or a combined distal tibia in remplisage? When are you doing that? Are you making certain calculations to figure out how thick the graft is going to be? How do you do that? I usually don't do a concomitant latergi with a remplisage. For me, if I don't think that I'm going to get enough bony fixation with the coracoid, then I'll just go straight to a distal tibia holograft at the start. So if there's more than 25% bone loss in the glenoid, or if you calculate out and you're adding in roughly 10, 8 to 10 millimeters and you're not going to be back to being an on-track lesion, it's still going to be off, then I would consider just going straight to a distal tibia holograft and using that. I generally don't do a remplisage with a latergi. What about you? Yeah, so for me, I will measure the glenoid track. If it's off track, I'll add the typical size of a bone block that would restore a fairly normal glenoid width. I don't think supersizing the glenoid bone block helps you that much because it will resorb and remodel back to normal size. So I will measure that and then I'll recalculate if it's still off track, which is almost always a seizure patient for me with very poorly controlled seizures. I will do an arthroscopic distal tibia with a remplisage for those patients to avoid taking down their whole subscap to do bipolar bone grafting. Totally agree with Greg about that situation. Such a difficult situation, the recurrent seizure patient, absolutely the arthroscopic distal tibia with the remplisage is the best option because you don't have, if there is a seizure, the pull on the subscap, you don't have the pull on the straps. So that even if there's a seizure in PACU, everything will still look the same. All right, so I'll show you what I did and you can tell me if you think this is wrong. So we did exactly what you suggested, Greg. I did a scope. And when I went in arthroscopically, this is at the bottom of the bone block. So the bone block you can see is actually covered very nicely with kind of pseudocartilage capsular tissue, but right below it, you can see there's actually a labral tear. So right below it, there's this tear. So she has a tear in her labrum below her prior latergie. So what we did is I actually took that down and we did a labor repair. And then at the same time, you can see she's got a substantial health sac. So we took that down, did a remplisage. She's got a labor repair remplisage. This is kind of like what I would have done normally primarily, but in the presence of a prior high latergie. She's I think at this point four years out and has remained stable. But I think this is, if you want to pay attention to one situation, I think it's that situation. When do you add the remplisage with the latergie? And then obviously with the latergie, as everyone in the room knows, graft positioning is everything. That's the whole case. You got to get the graft in the right position, not just medial laterally, which everyone has talked about, but also superior inferiorly, or you can have recurrent stability. Are you doing any remplisage with the primary latergie? I do have the occasional patient I'm doing it in. I like you, I think have switched largely to the arthroscopic distal tibia where it's a little bit easier to do the remplisage at the same time. And it's a little bit easier to judge when you need it, because you can more easily look. So that's one of the issues with our primary open latergie is you get no view at all of the back. You would have to do a scope at the same time and then do the scope remplisage in the feature position. Yeah, I think fortunately, that's a pretty rare indication, but you do not want to completely ignore the Hill Sachs. If it's substantial, the latergie won't necessarily solve everything. But for 99% of cases, that's going to be successful. What's your, so occasionally if it's a really, really big Hill Sachs, I'll allograft the Hill Sachs at the same time as doing the latergie. So what's your kind of threshold guys for doing an art? So if you're going to do the latergie for doing a remplisage versus adding bone to that Hill Sachs. So where's your cutoff in your head? It's just like, this looks terrible, so I'm adding bone? Or you have a calculation? I wish I could tell you I had a number. I don't have a number. Exactly. I have the same. I look at the x-ray and I say, this looks terrible. Yeah, of course. Yeah. What about you, Greg? Do you have a number or do you have just the terrible sensation? For grafting the Hill Sachs? Yeah. Yeah, it's the terrible, but if it's that terrible, sometimes it's a humeral hemiarthroplasty if they have 50% humeral bone loss or something like that. I don't know. I think for the most part, I've moved away from grafting both because of the surgical morbidity that I can deal with the bone loss on the glenoid and the Hill Sachs, both arthroscopically. And theoretically, I could still come back and regraft everything with a revision procedure with pristine anatomy in the front there. But it's not, if it was, I don't know, if it was big enough, I would certainly go do it. Any questions from the audience about that before we move on? So this is a slightly different case, another largely soft tissue case. So this is M.W., she's a 35-year-old female. She had a labral repair 14 years ago. You can still see that single anchor at the two o'clock position. She did well for many years and then she had recurrent instability for the past three months. So her main complaint is both pain, but she's also, I'm sorry, her main complaint is instability, but she also is complaining of some pain in her shoulder. She's got full range of motion, full strength. What are your thoughts, Brandon? When you look at these x-rays, what do you see? Your MRI. So a couple things. One is the glenoid bone itself on your sagittal looks okay. I don't see her starting to erode away significantly. The humeral head, to me, is what we're looking at here. Certainly kind of funky looking. She's definitely been coming out the front? Yep. Okay. Yep. Based on the history of the front. Okay. Because that just looks different to me. Maybe that's just her anatomy, but that just doesn't look normal to me. Capsule doesn't look too, too patchy-less, subscaps intact still. So actually not a bad-looking shoulder, all things considered. And considering she did well for 13 and a half years from a one-anchor labral repair within basically recess, I would probably consider redoing it. We'll see if you have more images. Was she ligamentously lax? Is she an MDI? Okay. Was this traumatic recurrent instability? She had a traumatic recurrence, so she was kiteboarding. Kiteboarding fell ER reduction or no? She got it back herself in the water. Is there a hill sax? There is no hill sax. Okay. It's diminutive, I guess I would say. So I don't see any glenoid bone loss. CT is certainly better than an MRI, but nothing obvious. The anchor is super high. Maybe some early glenoid degenerative changes, but not bad. The inferior capsule looks stretched out, but sometimes the arthrogram shows that. There could be sort of a chronic haggle, so I would be trying the hyperabduction test to see if there seems to be inferior laxity there. Certainly no harm to a trial of PT, but this has been going on three months. That's kind of my thoughts. So hyperabduction, so by that you mean the gage maneuver. So show us, when you do that, how are you doing that in clinic? Show us how you do that. So you stabilize the scapula and you look at the abduction of the glenohumeral joint relative to the other side. So I did that in clinic and she says she has pain and subjective feelings of apprehension and with that maneuver. Does that change things for you in how you approach this patient? Do you think that's usually positive with patients with labral tears or no? I don't find that to be positive with labral tears, because you're not putting them into that true apprehension position where they're externally rotated, and I think that's much more suggestive of a capsule or injury here. So I thought the same thing, and when I look at her coronal views I worried about the capsule here I feel like I can see it here and then it's a little bit unclear what's happening down here so what tell us guys what how frequently you're seeing the haggle are you ignoring the haggle what do you do with the haggle I honestly don't see it all that frequently I mean sometimes you can get it traumatic instability the worst case is when you get it in a thrower that winds up with the haggle lesion because that's a real big problem I see them very infrequently maybe I'm missing them sometimes but I don't see them that often but if you do see it in somebody who's got recurrent instability like she does chances are you're probably gonna have to fix that and depending on if it feels like it's more anterior posterior you may be able to get to it arthroscopically you may have to open it to fix it adequately and do a shift what are your thoughts Greg I mean the literature would suggest it's one in 30 it's not common but that it's out there yeah for me I would say it's only a few percent of instability and and like you mentioned the pain is sometimes a more predominant complaint than true instability for these patients I I don't have any problem trialing some PT especially at an older older age but I think that I would not ignore it and certainly I would not go do a revision labral repair because I don't see a labral tear you would have to certainly assess arthroscopically if there is one but I don't think you're fixing the problem and if you're tightening just the glenoid side there I think primarily you're missing the pathology here and she's not gonna do much better unless she just gets post-operative scarring and that does the trick yes I think this one's a real challenge for me I mean it's always a challenge to interpret what's going on with the labor when there's been a prior surgery I don't know what your guys experience has been but when I get an MRI and there's been a prior surgery looking at the labrum is so challenging to understand is it torn is that normal post-operative change certainly when I look at this MRI I feel like the inter-inferior labrum doesn't look normal but I don't know if it's torn the question is was it ever you know is it just scarred down to the glenoid there on that side and it was is that what we're seeing on those two slices there like is that the labrum that's just been scarred down it was never clearly fixed in the first place so I I don't know I agree with you so what what would you approach would you would you approach this arthroscopically would you say this patient needs a CT scan what would you do now well no harm in getting the CT for me I I don't think there's gonna be anything you're I'd scroll through the rest of the I don't think you're gonna find enough bone loss to need a bony procedure here so for me I would be thinking of an arthroscopy to evaluate everything see what's going on with that labrum that's really the only way you can tell for sure see what's going on with the capsule and then possibly an open repair depending what the what the situation is when you get in there same I would start arthroscopic but have a very low threshold and tell her beforehand that there's a chance you get an incision in the front of your shoulder so how would you guys position this patient which this patient lateral or beach chair so I would put them beach chair for this I do my instability lateral but if I think that there's a high likelihood that I'm going to open I put the beach chair because I feel I can get an okay label repair in the beach chair not as good as lateral but if I'm gonna wind up opening them and tighten them up enough I think what I'll get arthroscopic will be enough plus what I do open what do you think Greg same thing okay so I would position this patient lateral I feel like a fool now but all right so so so if that's the thing is if you see a haggle you have to dress open you have to reposition and then you've just added at least 30 minutes to your day yeah that's definitely that if you're used to instability lateral that's definitely the safe play here but for me I would probably beach chair but yeah there's no harm in having to reposition and it just adds a lot of time so you have to budget that time all right so this is the this is a picture from surgery this is the posterior in for aspect of her capsule so she can see she's got some suture not there that's migrated into this this hole what do you guys think of this do you say oh this is nothing would you say that's the haggle keep looking all right so this is her labrum what do you think of her labrum do you love the labrum okay and then this is this is another picture that hole so it looks like it was probably a tear that has sort of healed and formed a pseudo capsule thing like a little veil there but really no substantial capsule or tissue the labrum looks you know you probably would do some repair there it's not clear if that's the it's not clear what the primary problem is there but so okay so so you guys at this point you would you would repair the labrum what would you do what would you do with this hole would you leave this alone would you open would you what is the right answer for this I asked you because I'm not sure I know yeah that's posterior I think I would either leave it alone or try to do an arthroscopic repair of it but if I were in the beach chair I probably wouldn't even really be able to see this very well so I would probably just be I would be fixing whatever else I could so maybe lateral was the right way to go just hands up in the audience if you see this how many people are leaving it alone and doing nothing how many people are repairing this arthroscopically okay good so I picked a good case there's no agreement I want to do with this good so I'll show you what I did I don't know if it's the right answer she obviously I'm presenting the patient because the patient did well but so we took we took this down and repaired this you know with one anchor and brought that capsule back up and I think you can see once you bring the capsule back up this looks way more normal and it looks way different than what we started with and then obviously we did our labor repair in the front so she's you know she's three years out now and send her current disability and says her shoulders like 99 out of 100 so I mean obviously that's why I present this meeting but so let's talk a little bit about the technique for labor repair so you guys are sounds like positioning lateral primarily tell us what tell us what your portals look like so I think part of how you're gonna look and where your portals are depends on who's helping you so if you have a little bit less reliable help like sometimes I do I'll start posterior and I'll stay posterior for most of the case just because it's easier for me so every labor repair right off the bat post your incision anterior portal goes in and then a seven o'clock portal goes in and they both get seven to five cannulas in them and I generally work through those and then I have no qualms about making percutaneous incisions as I need to to put anchors in to get the right trajectory you just want to make sure that when you're putting in your trajectory for your cannulas that you're not come you oftentimes are coming in a little flattened so sometimes it can be hard to lever up to get the right angle down now some of the curve drill guides have helped with that a little bit so if you're using I use knotless fixation so they have a curve drill guide that you can use that if you're coming in a little flat you can pretty easily lever off the head with that drill guide and the anchor goes in through the drill guide so sometimes with the old push locks and things you had you could drill and lever off the head when you put the anchor and you can't get the same trajectory because you're gonna snap the anchor when you're doing it with the knotless ones now you can lever pretty significantly off the head and then you can leave the drill guide and put the anchor in through the drill guide and you can actually get a really good trajectory so I found that that's actually pretty helpful for me because I can I really lever the heck out of this thing when I'm when I'm doing it but for me it's those portals so I stay posterior of you posterior unless I need to switch to an anterior superior but I generally don't even make an anterior superior portal I make a make portal basically right above the subscap but enough where I can have good mobility of my of my instruments when I'm coming in so not too tight to the subscap otherwise you lose some mobility but the seven o'clock in I'll go trans subscap if I have to but that's my general I think I set it up fairly similar to what you showed in your video post you're viewing portal to start with I'll cheat it lateral if I think I need to get any anchors posterior superior or straight posterior because it can be a good angle there for pure anterior instability maybe not as much of a need to be lateral and then I primarily view from the interest of your lateral portal like you are here which gives a great view straight down the anterior glenoid face and that's if that's your main pathology it's very helpful to be able to see that medialized Alps or the medial heel Bankart lesion and really mobilize that to the subscap you can also do it with a 70 degree scope from the back and see down around the corner but for me that ASL viewing is the primary portion of the procedure another rotator interval portal just over the subscap as low as I can used for anchor placement suture passage and then depending how far the tear extends around the back I will also add a seven o'clock portal which is a few centimeters down and way lateral which gets you nice six o'clock seven o'clock anchor placement although you can get down to about six with an anterior with a curved drill guide in my experience you can't get up the back unless you add that and that's that's a percutaneous portal for me and then what is your guys so so excellent tips there I as you can tell view from anterior superior I don't I think if you could do you can get an excellent repair viewing from either either place that you can actually pair with knotless or knotted anchors with solid or with all suture anchors I think that's a detail that the real critical thing to me is how you tension the capsule when you do it and getting a good fixation on the capsular side because I think when this fails it doesn't fail on the gun it said it tells in the capsular side tell us Greg now if you were to repair the capsular tear arthroscopically how you doing that so for that posterior capsular tear the open approach really doesn't get you any benefit so arthroscopic is the way to go and you will generally need something along the lines of that seven o'clock posterior portal accessory portal in the defect to place your anchor to pass a suture through that a lot of times like in this one it's kind of pseudo healed over so you have to kind of develop the interval find where the actual capsule is and you're just very careful because you're fairly close closer than normal to neurovascular bundles they're working down with the capsule it's a higher rate of neurovascular injury for that than any other arthroscopic stabilization and so I have a high posterior portal and then a accessory portal through the defect essentially for anchor placement suture passage and then it's a it's a blind tie or a knotless anchor and I I struggle to do more than one anchor so I typically will do a one anchor try to get a couple passes through the tissue because suture management you don't have a lot of room to work down there totally agreed the one the one thing I would add is that getting the right trajectory for placement of your humoral anchor there can be very very difficult so I typically use what I call a haggle portal which is kind of if you were to use your traditional seven o'clock and post your portal it's kind of like if you were to create a right right angle triangle with those two obviously suture management is a real challenge down here you don't have a lot of room to work you have to develop that interval first and then I do think you need to be really conscious of the axillary nerve which is close by to all your work here so I like to make sure I know where I'm working and then I usually will close my portals on the way out because this is a capsular issue that's about all the time we have I want to make sure I leave is there any questions from the audience about any of that okay any other tips tricks anything else that you guys would add no I think recognition of the injury there it's something that's not always on your radar because it's only that one in 30 or it's a it's a less common pathology but I think that addressing that probably was helpful for success here I see one question and what one of the cases that dr. I'm is gonna present so we could just run through it real quick just get your guys thoughts so 25 year old minor league baseball player slap tear right had a slap tear for a while rehabbed it appropriately a couple years back came back again tried to rehab it again not doing so hot from it position player so not a pitcher okay so better right so symptomatic slap tear partial thickness cuff but nothing you would take down a repair when you're managing forget the non-operative treatment stuff but if you're managing a slap tear and a thrower let's say he had he does have some bicep symptoms type to slap maybe it goes around the back a little bit so maybe more like an eight ish what's your thought are you just fixing this lap are you doing just a bicep tenodesis are you doing both a slap repair and a bicep tenodesis what are you guys doing yeah I mean for me that patient would probably get a all-time guided bicep sheath injection many of them describe substantial relief with that and if they do then I would do both of those concomitantly when you do those procedures concomitantly my position in the beach chair position you know and the the difficulty there and I think this is really critical is you know you you want to get a repair of the portions of the posterior cerebral labrum that provides stability typically for me that's with with mattresses typically for me that's right at the the capsule labral junction to make sure you don't involve any of that posterior superior capsule because you don't want to tighten that person and have them lose some of the range of motion you're fixing that with a lasso using a spinal needle percutaneously to get those sutures passed so I would probably place a posterior portal and enter superior and enter inferior portal and then I would place on my anchor in through Wilmington okay what would you guys do yeah so I agree with Peter's approach in terms of placement you can get the superior labral anchors through inter-superlateral portal pretty successfully but with the posterior extension likely you would need Wilmington type portal to get more posterior and I think that really trying to sort out biceps slap and what's causing the issues here is is critical but occasionally you do need to do both concurrent procedure the other thing I think I would say is that if you're going to do the biceps for for sure in this patient my preferred approach is a sub pectoral technique in which you drilled the smallest possible hole in the humerus this is not a good patient for you to drill like for an interference screw that's ten millimeters across because there have been described cases of spiral fractures now I'm going to pretend like I'm dr. Romy who's gonna tell you that's a load of crap and that there's only been one of those reported and stop telling people that because it's I get to say those things cuz Robbie was not here yeah so that's yeah if he was here Peter wouldn't be saying that but I but I agree so are using an S and like an old suture anchor like a 1-8 suture anchor or using I use the unicortical button which is a 2-4 hole yeah okay same 2-4 yeah okay any sorry any questions that you guys have I just wanted to get a just a quick talk on the slab stuff but anything else okay great thank you so much guys hope that was useful to you

shoulder instability

screws positioning

MRI evaluation

hillsacs examination

arthroscopic procedure

posterior capsular tear

labral repair