And we'll try to make this somewhat interactive, so please interrupt when there's a question, especially between talks or as we get to the cases. Our disclosures are in the program. So glenohumeral instability is a complex topic, and we know that bone and cartilage lesions at the time of surgery are very significant. These are also very common in the Moon Shoulder Study. We see that of the 500-plus patients at the time of this article, there was over 20% had lesions to the bone and cartilage. And this is a little less common, but still almost 20% in the primary setting and almost half of revision settings. And so this has to be on your radar even for the primary instability, but definitely in the revision. This is predominantly bony bankart or Hill Sachs lesions, which will be the main focus of the topic of discussion today. In the military, nice study looking at the progression of glenoid bone loss from first time and recurrent instability. And this bone loss can happen quickly. And so after the first dislocation, there was about two millimeters of bone loss in this cohort. And nonetheless, there was some patients with over five or over the 13.5, even from one dislocation. Patients with prior instability, this increased faster and it hit the 20% mark pretty quickly. There's many, many studies on the success of arthroscopic bankart repair. Some studies give you a lot of pause with the recurrence rate in contact and collision athletes. There was just one from AJSM a few years ago showing a 50% rate of recurrence in adolescents undergoing arthroscopic bankart repair. And if they were under 16, the recurrence rate was 90%. So this is a complex topic and we don't like surgery with a 50% failure rate. And so we have to think about why this surgery may not have worked. Was this due to patient factors, age, contact sports, hyperlaxity, technical factors? Are we not doing a good enough repair, enough shift or anchors or so forth? Or was there pathology that wasn't well recognized and addressed such as bone loss? We know from Burkhart many years ago in a cohort that recurrent instability was very high from an arthroscopic stabilization with bone loss present. And he recommended if there was over 25% bone loss to do a Laterge in order to prevent engagement of the Hill Sachs lesion because he had a two-thirds recurrence rate. Boyleau similarly alerted us to this almost 20 years ago, 90 patients, 75% recurrence if there was 20, 25% bone loss. And so that was our first inclination that an arthroscopic procedure was not successful in these higher degrees of bone loss. Laterge was far more successful down closer to a 5% recurrence. So it's important to evaluate this bone loss. And here we see it evaluated arthroscopically, measurement with a probe, but really you want to evaluate this preoperatively, CTs, MRIs, depending on your institution and your protocol can give you a great sense of this and consider patient factors so that you can choose the right surgery going into it and not go into a scope and see 25% bone loss and be having a difficult repair and a high chance it's not going to be successful. More modern indications for a bony procedure may be bone loss closer to 10 to 15% instead of 25, an off-track Hill Sachs, or failed prior scope, or perhaps even just a high-risk patient that doesn't quite meet these criteria, and that's what we'll be discussing today. There is this concept of glenoid tract that we'll get into, and this is a nice diagram showing as the amount of bone loss in the glenoid changes and the location of the Hill Sachs changes, that Hill Sachs can be more prone to engage. So at the bottom, you see a Hill Sachs bottom left, the Hill Sachs is well within the glenoid. The Hill Sachs that's more medial or larger will engage that glenoid, and bottom right you see with some glenoid and some humeral bone loss that engagement becomes easier even for a smaller Hill Sachs. And so J.T. Tokish and others have showed us that bone loss, even to a lesser extent, is very important for success after surgery and recurrence even. And so this is where the thresholds closer to 10 to 15%, or in this study 13.4%, led to a clinically significant decrease in the WOSI score from an arthroscopic Vanguard. Matt Preventure provided a nice study looking at the instability severity index score showing different factors were more predictive than the ISIS score. So arthroscopic Vanguard, he had 11% recurrent instability, and here were the factors which are starting to coalesce with some of the other literature, including glenoid bone loss 14%, again, that lower threshold, longer duration of instability, larger Hill Sachs, contact sport and young age. So these are really a good summary of the factors that are going to make your arthroscopic Vanguard more likely to fail. Garciero and others showed a nice retrospective comparative study of REMPLASAGE versus LATERGÉ, two of your main options to address these lesions. And complications were higher in LATERGÉ, 12 versus 1%. Recurrence was higher for REMPLASAGE, but not quite significant, 13 versus 5%. And the specific groups with a significantly lower recurrence for LATERGÉ were prior surgery, glenoid bone loss over 15%, and contact athletes, which was 30% versus 0%. So this is something where prospective comparative studies of these techniques that we'll discuss today will be very important, because they are two of the major options for addressing that off-track Hill Sachs. So with that brief introduction, let me introduce our course faculty. We have Rachel Frank here from University of Colorado, local, relatively local at least. Brian Wolfe from University of Iowa, and Steve Brockmeyer, University of Virginia. Julie Bishop unfortunately couldn't make it, so I'll be covering her stuff. So please enjoy the course and let us know if there's questions. Thanks.

glenohumeral instability

bone and cartilage lesions

arthroscopic bankart repair

glenoid bone loss

bony procedures