I'm Steve Brockmeyer, University of Virginia. And so my task here is to talk about REM plissage. And the patients that Brian showed, I think we're gonna talk about similar patients, maybe not quite as severe bone loss. And I'll talk you through kind of where I am right now with this operation in my practice. So I hear my disclosures. So I'm gonna approach this kind of similar, Brian, with a case, although I may kind of prompt the panel a little bit just to see if they would approach it differently. So this is a 19-year-old guy. It's actually a fairly recent case. This was about a year or so ago. And just to frame it, so he's one of our linebackers. He's a guy, he was a scholarship guy, but he's maybe too deep or so like that on the roster. He plays some of the special teams. He had an injury in practice, two games into this, or it says second games, which is obviously not grammatically correct, but two games into the season. He did report kind of like a distant prior event in high school. So he had like, I think a dislocation when he was either a sophomore or junior, reduced, never had it worked out, seen, managed at all, never had a recurrence in high school, played a senior year. And so now he's with us. So here is x-rays. To me, those x-rays don't look too worrisome. I don't know if you guys see anything that stands out to you or not. And then you can see, here's his imaging. So I'll let that run through. All right. So Greg, what do you think about this guy? How would you approach this guy? So number one, you operate on him now, or do you try to let him finish out the season or what kind of criteria do you use for that? And then number two, if you are gonna operate on him at any point, what are your thoughts on that? So you said he's in preseason or fall practice? No, he's got two games into the season. He's a guy who's pretty good at his job. He's got a lot of experience. He's a guy who's battling for a spot, so to speak, but he's not a starter. He's certainly not like a senior or team leader or anything like that. Yeah, I think that this is, with any of these in-season athletes, you need to have a discussion about their goals and in terms of the season. The majority of the time, I would say that people would try to rest and wear a brace and come back in a couple of weeks and try to finish out the season if he's trying to battle for a spot. But with any further instability, I think you would be considering a season-ending operation for him. Okay. Brian, would you let him play or would you shut him down and operate? So I missed it. Did he dislocate or desubluxate? So it was kind of a very temporary. So he dislocated, the trainers put him right back in. So he was stuck out for a very short period of time. So by classification, dislocation. Yeah, I would agree. I mean, we generally try to brace these guys up and let them play. If he's a D-back, it's gonna be difficult. D-backs and linebackers have a lot of trouble. I would tell him if his shoulder dislocates again to the point that it is out and he's not a main contributor, then we would pull the trigger. If he's a young guy and he's not in the starting 11, then we're pretty quick to pull the trigger and get him ready for next year. Got it. All right, Rachel, when you're looking at this MRI, what's your quantification of bone loss on the glenoid on the MRI? I think the glenoid looks pretty good, all things considered. In these cases, you see a nice, juicy Bankart lesion there. But I've been amazed by how often I think an MRI looks pretty good and then I get in for, say, I'm taking him for an arthroscopic repair and there's some attritional loss, even with a, quote, first-time dislocator with maybe a history. And I'm always a little surprised and then I say, man, I wish I got a CT. Not that I think the CT would have changed my plan necessarily to go for the scope, but it certainly would have made me think. But I think here his glenoid looks reasonable. You can see a little blunting anterior, but I think it looks reasonable. Yeah, I didn't think it looked too bad. You can see his heel sacs on that single coronal slice right there. So, all right, so first of all, some generic slides. So shoulder instability, contact athlete, obviously something that we all see and treat commonly. Probably one of the most common things short of ankle instability that we see in our football players at our institution. And so presents with some common management strategy challenges. The military group did look prospectively in their, I think it was three of their institutions at their football athletes as to how these athletes did if you tried to let them play through the season after an instability event. And so the data there is actually very interesting. Many of them were able to continue to try to play. And I think that's been certainly our experience at UVA. And I imagine at some of your other places as well. These guys are going to want to try to continue and play through the season and delay surgery until afterwards. About 73% of these athletes were able to return for all or part of the season. And this is in the military academy teams. And then, but only 20% or 27% completed the season without a recurrence. So, you know, as Greg and Brian said, you know, these are athletes where you do worry about a recurrence, almost anticipate a recurrence, and you need to have that conversation with them. And then Brian astutely asked subluxation versus dislocation. And I think that's actually very important. Subluxations are certainly seemingly less severe and less worrisome than a dislocation or like this athlete where he had this distant prior event. And then what's the downside here? And this is a case where I'll show you that, you know, I do personally believe that there's always a price or always a cost. And in this case, I think there is some risk of progression. This was earlier in the season and this young man wanted to continue to play. And so we don't know what the downsides are and we don't have a really good quantification of what we're exposing them to. So going back to this guy. So, you know, we use typically in linebackers, linemen, fullbacks, if we have a fullback in our offensive scheme, tight ends, we use this type of harness. You can see here on this particular player. It's a pretty good way of controlling entrance stability. It is certainly by no means, you know, perfect. In fact, a lot of times they will still have some events, even if they're wearing something like this, but it can be protective. There are some studies out there looking at this and the studies aren't as encouraging as you'd like them to be as far as how well this protects the athlete, but it's certainly worth using and trying. So anyways, this is a 19 year old college football linebacker shoulder dislocation second event. We talked about, you know, kind of what do we do in this circumstance? I had an extensive conversation with this young man. We gave it a couple of weeks, let his shoulder kind of calm down. His exam very much normalized and he opted to delay surgery. He was not a starter. He did play sparingly. So it's kind of helpful if these guys actually don't play very much because the exposure is less and maybe it's a little bit more protective. This guy practiced. He did play a little bit in special teams. He did not have any recurrent events during the season that he noted or reported to us. His shoulder actually felt okay, but you know, just not quite normal and he was still a bit apprehensive. So we did end up operating on him at the end of the season. So here's what the inside of his shoulder looks like. So this is viewing from back to front. I do my scope instability surgery in the beach chair position. So you can see pretty good looking labral tissue here. And then this is a video of his actual case. So his Hillside lesion did look pretty legit. And so going into this, this is one where actually I did have a plan of doing a room plissage. And that's not a common operation I've used in my contact athletes, my football players. And I'm gonna press some of the panel on that. Now in that video, and I wonder if I can back it up a little bit. Let's see if I can. In the video, you can see here that the glenoid looks a little bit more worrisome than I thought the MRI suggested, right? Would you guys agree with that? And so I guess the question becomes, was that present or was that acquired during the season? And so that's what I was kind of referencing there. From a step standpoint, when I'm doing an arthroscopy and a Bankart with a room plissage, you wanna be thoughtful about the cadence of your steps. So you do your diagnostic scope and EUA, you assess your damage. His labral tear really extended only to about six o'clock, but sometimes these will extend around more posteriorly so you can address that component first. I will typically prepare the labrum and get it mobilized. I'll prepare the Hill Sachs defect and get ready for the room plissage. I'll then take the scope out of the joint, go up into the subacromial space. You can see here we've kind of cleaned some bursa off and gotten a view up there. I'll typically place a portal up in this space that I'm gonna use for suture management in this space. I'm not a big fan of kind of just passing and tying blindly because I do think you may tether the glenoid in the back. And while that may be beneficial from the standpoint of helping the thing become stable, maybe part of the reason why sometimes some of these studies have demonstrated some range of motion loss in these patients. And so I'll get everything set up in the subacromial space. I'll then go back into the joint. I will typically place my anchors, you can see in this video, I've placed anchors. Hold on, let me go back further right here into the defect. I've actually gone to using this technique probably over the past year and a half to two years where with these particular anchors, these are all suture anchors, so-called soft anchors. They actually hold great because this bone's basically compacted down bone. It's fairly hard and it's a very kind of robust bony surface. It's not like putting anchors in for a rotator cuff repair. This bone holds much better. And so these are 1.8 millimeter, all suture anchors. You can use a curve targeter to basically put these in and you have your sutures through two small holes in the capsule and the kind of the very far lateral infraspinatus. And so you can see where I have these anchors positioned towards the medial margin of the HillSax defect. So your tissue will go down and really cover up that defect well. You wanna flatten out the HillSax lesion as well. So you have a good surface for this to heal to. And then you can see, I'll go ahead and advance the video now. So you can see, we're just pulling on the sutures to show how this tissue is gonna reduce down. And it looks like it's gonna lay pretty flush to me. So I'm happy with that position. So next we'll fix the glenoid in the front. And then the last step is then to go ahead and close down the remplissage because that's gonna close down your joint space. You can link one anchor to the other and create what we like to call a suture staple. So basically you end up having one limb going to one anchor from the other anchor and vice versa. And you can really tension this down nicely. And here you can see the Bankart repair anteriorly. He did have a little bit of extension superiorly. So I put one anchor up to kind of close down that superior labrum. And then I think the video will show you in the back here as well. So here's our tissue. And as we tension it down, you can really see this tissue kind of cranked down. And it's kind of a really nice way of fixing it. So once I have the things positioned, then you can actually tension and kind of monkey down your anchors there and really compress that tissue down nicely. And so you can see it sits really nicely in the joint. You could also see actually nicely how that humeral head kind of gets pulled posteriorly. I think there's probably some element of that with a REM plissage as far as its benefit. And so I've become more and more enamored with this operation. It's a nice kind of middle ground operation. And again, not a huge experience in our contact athletes. In fact, this is our first college football player that I've used a REM plissage. I've always skewed towards doing a bony procedure because these are such high risk athletes. So we'll see, hopefully I won't be burned. This was last season. So this guy hasn't really played any game yet. So I think algorithmically, and Brian addressed some of this, so I'll try to kind of add some commentary. So I think the keys, when I look at these patients, who's the patient and what do they have? And I think you need to have kind of in your mind an algorithm. I think we're still trying to figure out these kind of mid-range patients, the so-called subcritical bone loss patients. Do you do in that patient just a standard arthroscopic Bankart and kind of roll the dice? Do you combine that with a REM plissage, which I think is actually a pretty good middle ground operation? Do you do an open Bankart, which I think classically probably has the best track record with those patients, or do you need to do more like a Latter-Jay? And people with kind of advanced bone loss beyond about that 13.5% range, I typically do a glenoid-based procedure, a Latter-Jay, or in larger bone loss cases, I'll do a distal tibial osteochondral allograft. This is a three-dimensional issue. I think Brian referenced this to some degree, but the Hilsack's lesion, I think sometimes, in particular traditionally, has been underestimated as far as its contribution. You need to think about where that lesion is, how medially it extends. You know, sometimes you have these skip lesions where the Hilsack's lesion sits off of, so you have kind of almost like this island of cartilage, and then you have a Hilsack's lesion. Those are particularly tricky, and I'll be curious, I may ask the panel how they address those if they're thinking about doing a REM plissage. But really, the idea is to determine is this on or off track? Brian addressed this. A number of papers now out there looking at subcritical bone loss. So my post-op management for patients with arthroscopy and a labral repair and a Latter-Jay, I typically mobilize in a sling for six weeks. I agree with Brian. I think you can and should be a little bit more aggressive in getting them out of the sling in Latter-Jay patients because it's a more stable repair, frankly, and it's bone-to-bone healing versus soft tissue healing with rigid screw fixation. With these, I do tend to be protective. I want to make sure that they heal and they stay stable. I do kind of set targets for range of motion progression. We want to get external rotation back, both at the side and up at 90 degrees. And so you set targets so that they kind of get to that target and you don't necessarily stretch them out and impact healing of your repair, but they also don't end up too stiff. Strength progression. Typically for me, they start PT-based strength progression around week seven or week eight, but it's very, very gradual. And they can get back in the weight room at about three months post-op. Full range of motion, your target is at around four months with these. And then cleared for return to play. For me, this soft tissue operation is a six-monther. And typically in a contact athlete, I don't like to necessarily cheat that up. For a bony procedure like a Laterge, I've gone to letting them go back at like four and a half months, because again, it's bone-to-bone healing. And so we can talk about that as a panel if you guys like as well. And then I do like to put them back in the harness as they're getting back into practice, just again as a protective mechanism. I think they very commonly don't mind that as an intervention. So outcomes. And I did do a quick literature review to kind of see what's new. And all of these papers have been within the past few years. So I think this operation has really started to kind of take foothold, both in our armamentarium, but also kind of people looking at outcomes of these. And what the papers are really showing is that this is definitely a more predictable operation from the standpoint of recurrence when compared to an arthroscopic bancart alone. So I do think the rempassage component adds. It's not as predictable with the recurrence rate as a bony procedure. I think in my practice, coracoid transfer, there's obviously, as Brian showed you, a lot of concerns and risks. But recurrence in my practice has really not been something that I've seen after a coracoid transfer, knock on wood. But with this, this is something where you do, I think, have to be cautious in picking the right patient to do it in. So when do I do rempassage? When do I consider it my practice? And I'll tell you that it has been. I would think each year I'm doing more and more of this. But really, this is kind of where I'm really thinking about it for the most part. So in the at-risk or, quote, subcritical bone loss patient, typically I'm looking at older patients. And I know I showed you an example of a 19-year-old. But I do think that the wheelhouse patient for this is going to be both males and females, 22 and above, maybe slightly less risky for recurrence. Has not traditionally been my go-to in the contact athlete. But I'm curious. And I may continue to use it a little bit more commonly in the right circumstance. I don't think it's a great operation in the overhead athlete. So be conscious of that. Because you are altering anatomy a little bit in the posterior cuff, which can be risky, as we know. Primary humoral bone loss is going to be your wheelhouse for this. I would say unanticipated glenoid bone loss would be a good option, too. So I showed you in this case, I got in there and the glenoid looked a little bit trickier than I thought it would look. And I, you know, as much as we all want to be very, very astute in our workup preoperatively, sometimes you get in there, you're like, gosh, this is a little bit worse than I thought. So having this in your back pocket is probably not a bad thing. And so that's sometimes when I'll consider using it. Again, the off-track patient, combined bone loss, subcritical glenoid bone loss, you can consider this as an option. Poor soft tissue in the front, if you want to kind of do a belt and suspenders is a good option as well. And then in revision circumstances. So anyways, that's kind of what I'm thinking as far as remplissage. I'd welcome any questions or comments from either our panel or from the audience. Thank you. I was fearful that Dr. Warren would ask me a question. You mentioned the patient, the linebacker that doesn't have a lot of bone loss, right? In which you might do a level J. There's a couple of papers out there, which they didn't put the bone in, they just put the joint in. One paper actually demonstrated a significant reduction in the translation. So it might be an option where you say, gee, I don't have bone loss, but I do want to hedge the bet. So you can hedge it and do the remplissage. So I can tell you, so I'm curious if you've ever done that, Dr. Warren, because you've done pretty much everything. So I'll tell you, I think it's a great question. It's entered my mind. Yeah, let me repeat the question. So what Dr. Warren from HSS is asking us, so there's some papers and people have talked about considering, instead of taking the coracoid with the conjoined tendon and transferring it over for extension of your glenoid bone in the setting of bone loss, just taking the conjoined tendon off of the coracoid and transferring it in and creating a sling effect. I think that's what you're asking essentially, Dr. Warren, right? The other question I had was, you know, Peter Millat had a paper just recently about the Alps, and he had a 33% failure rate with his scope repairs. And I was kind of curious how you handle it, because if you look at that and say, maybe I should always do a remplissage with it, or maybe I should do it over with a 33% recurrence rate. Do you do anything different with your options? I absolutely do. So first of all, for the first question, you know, Brian showed his technique, really, really cool technique. When I do laterges, I typically or traditionally done more of the European technique where you do it through a split, you place the bone graft in the split. And I actually think that the conjoined tendon does act as a tether. And I feel like that perhaps there is some additional stabilization provided by that sling effect. I've not done just an isolated conjoined transfer, I've considered it. I think it's a really good idea in that setting where maybe it's a higher risk patient, but you don't really have glenoid bone loss, you don't really have a Hill Sachs lesion to remplissage into, which is really, you know, do you create a defect to make the thing heal in? I've not done that either. But that came up in an ICL that I did yesterday as potentially something you do. So it's a good idea. And I'm not sure if anybody else has tried that. With the other question that you asked, ALPSs, I think are really, really tricky. And I think that's almost been my most common indication for remplissage, because most of the time, they do have a nutritional Hill Sachs lesion to repair into. And so if I see kind of pretty crappy, recessed, medialized tissue in the glenoid side, I'll try to mobilize it as best as I can. And then I'll add a remplissage in the back. And as you as you point out, the the alternative to that is an open Vanguard in that particular patient. So I'll be curious if you guys have any comments there. Yeah, great questions. I have not tried the conjoined tendon transfer. I do think in that setting that the open Vanguard is a reasonable option when there's not much to remplissage in the back, you have a very high risk patient contact sports. The track record of that operation is great, even though it's fallen by the wayside in many modern fellowship training. I think there still is an important role for that. And that's a good option there. And then in terms of the opposite, as mentioned, the tissue deficiency, I think that adding that remplissage, adding something else to try to augment your repair is a good option in that setting. I think Steve very nicely outlined the steps, very important to get the steps right, because you can get yourself very lost putting anchors into the humerus and the glenoid and tightening the wrong thing first, losing your space and your visualization. I think it's very important to follow the steps to be able to get that procedure done well and efficiently. Yeah, I haven't done it either. But I've thought about it. And there's there's another technique out there taking the long head of the biceps and swinging that over. That's another sling technique that's that's been described that has an arthroscopic option, which might might be helpful. But I think that's a I'm waiting for the right patient to try that on. I know that Chris Wall up in Seattle has talked about it. And he and I have debated things a little bit. And but I think that sling technique with the conjoined tendon without bone loss would be a really nice way you could do an open Bankart with that. And you kind of get the benefits of both. Hey, Steve. I think we have a question in the audience. Oh, sorry. From one of our traveling fellows. Yeah, exactly. Good morning, everybody. My name is Maricela Sakomano. I'm from Italy. I'm one of the traveling fellows, as Rachel said. So my question is the following. When you are in the context of subcritical glenoid bone loss or non bone loss and the small ill sucks, rather than consider it Bankart and remplissage or an open Bankart, why don't consider a labral augmentation technique, whatever you like, a graft, a biceps, a membrane just to reconstruct the labrum. And that's kind of give you a kind of bump effect and kind of normal labrum. Why not? And it's more anatomic than the conjoined tendon transfer. Okay. Did you guys so the question I think are you asking, like, when would you consider doing a soft tissue reconstruction of the labrum when you have bad tissue in the front? Yes, rather than an open Bankart or soft tissue transfer, which are not anatomic. Yeah, that's not something that I've used in my practice. It's a novel concept. You know, I think when you start to have bone loss, then you also have the bony components of things. So, you know, I think there's probably going to be some threshold there, but I don't have experience with that myself. I'm curious if anybody else has, or maybe you can share some experience you have. Yeah, I think it's been discussed and described. For me, I've mostly seen that degree of capsular and soft tissue deficiency in a revision setting, prior failed repairs. And I think it's a good option to do the latter J because you get the conjoined tendon sling for those settings, but I have not tried the capsular reconstruction as an isolated procedure. Yeah, even in primary cases, he said when I have an ulcer or poor soft tissue quality, basically. Yeah, I think we're going to start seeing a lot more about this. I think that we're learning a lot, and I hate to say this, but from our hip colleagues, a lot of our hip colleagues are doing labral reconstruction, whether it's for primary or secondary or recurrent FAIS, and they're having good success. Now, it's clear it's a ball and socket joint, so similar biomechanics, but a different loading, of course, and in a contact athlete versus the hip joint as a lower extremity joint. So I don't know that the outcomes will be as replicatable in the shoulder, particularly for a contact athlete, but I think it's very attractive, especially for surgeons who may not be as comfortable with latter J or with the potential complication rate, despite the recurrence being so low. And I think we're going to see as technology and anchors and delivery systems become more user-friendly from an arthroscopic approach, outcomes following glenoid reconstruction with a soft tissue cable. Using biceps autograft is a very attractive option in this scenario, as well as using free soft tissue allograft. I think the biggest question is, because the hip teams have had so much success, it's almost expected that in the shoulder we'll have the same success, and the joints are different when we talk about function. And so I think that will be, it'll be interesting to follow the data. I personally have not had any experience with that, but I think about it every single time I'm doing a primary instability where the labrum is worse than I thought, and there's minimal to no bone loss, and I'm just thinking, wow, would it be better if I put brand new tissue in here, and I don't know the answer. Yeah, actually I'm using this technique. At the moment I'm just using a membrane, a rolled up membrane, to reconstruct the labrum, but I also tried allografts and stuff like that, so, and I use it when I, in primary repair, when I have poor soft tissue, or even in revision arthroscopic bankers, so it seems it works, that's why. Thank you. That's great, thanks for introducing that topic. All right, any other audience questions? Feel free to come to the mic if you have any. Steve, question for you. So when is, when is the hillsacks too big for a remplisage, and when do you need to do something like a graft, or something like that, through a Kerbal? That's a very good question. I would, I would preface by saying that, thinking back, it's been a number of years since I've done a glenoid bone graft, so it's, you know, in my practice, I'm sorry, a humeral bone graft, thank you, so maybe the answer is right now, in my practice, not that commonly. I do think that certain glenoid defects may be more amenable to bone reconstruction, kind of the wedge-shaped one that goes way into the humeral head, that you see commonly in like seizure patients, or you know, kind of polytrauma, or what have you. I might consider a humeral bone graft in that setting. You know, as far as extension medially, you do worry about kind of, you know, non-anatomically over-tethering the joint, and so in that setting, if it's going too far medially, most of the time you'll also have some glenoid-based bone loss, so I might just address that on the glenoid side with a bone grafting procedure, or I might combine that with a remplisage, and just pick a spot that seems appropriate, maybe a centimeter or so into the defect, and just remplisage into that, but I don't think you want to go too far into the head with soft tissue, so really it's going to be the kind of the width of the defect, or the depth is probably going to be my primary indication for a grafting procedure. All right, I think we'll move on to the next presentation.

shoulder instability

remplissage

treatment options

surgery criteria

patient selection

outcomes