Hope you guys had a longer night's sleep than I did with our fellows in residence, but we're gonna talk a little bit about bone loss and shoulder instability. It's true, Travis and I played at the same university and once they saw him play, they said, geez, you never played like that. He's not only a better ball player than you, he's a hell of a lot smarter than you are too. We played for the same coach. It was a little rough on my ego. He is the future. So as you saw in that talk, incredibly complete and tons of tons of work that goes into that. So congratulations and thank you. When I watched Travis kind of give that talk, it's sort of eerily similar to my career because I finished my training in 2000. And so the bone loss concept of shoulder instability has been my life over the last 20 years and I've had a long military practice. And so mostly it was early failures because we didn't understand this stuff. I remember taking this to Rich Hawkins, who was my fellowship director, when the first Burkhart to beer paper came out and I said, sir, have you seen this? And he says, I don't know, it hasn't really seen me. Maybe it is. I took it to Rockwood. I said, bone loss and shoulder instability and Rockwood said, this isn't a problem. And so then we watched over and over again while those patients came back and failed. And most of this has been a humbling experience for me over the last 20 to 25 years of sort of understanding this concept and very grateful for many of our mentors that have taught us along the way. This is me in 2001. I went home after five arthroscopic bank carts on a single day and these are all cadets. I had this patient. I did what I thought was an excellent arthroscopic bank cart in 2001, went home, told my wife, I've got this figured out. We're not ever gonna see failures now. This arthroscopic bank cart thing's gonna work. And then 18 months later, I had three failures in the same day and I said, if I ever come home again and tell you I have something figured out, please kick me in the groin. She's been doing that once a week, whether I asked for it or not. So this was me, 2001. I was all good. This is me 16 months later and I had no idea what was going on here. This picture in the bottom right is a picture from Codman's original textbook back in the 30s and this is what he said. He was to give a talk at Harvard University in the bastion of medical education and he unveiled this, which was a sort of life-size poster and what he was telling all the surgeons is, your head's in the sand, you're ignoring the facts, you're not following your outcomes and I think we were and are as guilty of that today as we were a hundred years ago. Well, how much is critical? Travis was kind enough to talk about this. This was Jimmy Shehey, one of our residents at the time. What we found was we knew 20%, 25% and credit to Professor Itoi for teaching us this and Nobu Yamamoto, but we were seeing failures at much lower rates than this and so we ran the data and that's where the number came out at 13 1⁄2%. Obviously, that's a millimeter one way or the other from 10 to 15%. I think the key on it is to understand that you may look at an X-ray or you may not see massive bone loss, but I'm here to tell you, if you're gonna do an arthroscopic bank card in someone who has significant bone loss and what is significant? That's three millimeters, four millimeters of bone loss. You think, well, I can do an arthroscopic bank card here. I promise you, you can. You probably do it really well and that patient's gonna fail, but they're not gonna fail till 18 months and so you're not gonna know it and so you're gonna walk away from that thinking that you did an awesome operation and listen, don't ask me how I know this. This is an incredibly humbling sort of gig and what we found on this paper that was also impressive to us was it wasn't just the failure rate. It was their WOSI score too. See, in the past, all you had was a row score and if you look at ASDS scores, row scores, SANE scores and you ask somebody how their shoulder is doing, zero to 100, they'll say they're 90 even if they re-dislocate. So the problem is is that those scores don't really test or ask those patients how they're doing, but when you throw a WOSI at them, those patients really get to it and say, did your shoulder come out? No, it didn't come out. How's your shoulder doing? You ask them, 52%. These are in patients with subcritical bone loss. They're terrible even if they never came out and that got us thinking, gosh, it taught us a lot. One was you can't just use recurrence rate as your outcome score. If you operate on any of these folks and they have contact athletes with any bone loss, you and me, we will fail. You take a look at these things, it's an incredibly high failure rate and yet, all of us say this, we all come to national meetings, we say, well, what do you do in this situation? Everybody goes, well, I do a lateral J, I do a bone, blah, blah, blah, blah, blah, and then you go home and you do an arthroscopic bank card. You do, I do, we all do and unfortunately, the data is so clear now about the dangers of this in the young contact athlete with any bone loss at all, so we gotta get better. Bone loss cannot be tolerated. There's lots of approaches to this. We don't know yet where the exact answer is with all of these things. Adding remplissage is better, but is it enough? Well, the challenge with it is that it is a, I thought, by the way, I would have told you 10 years ago that this was a fool's errand. Why? Well, because it's easy, it's slick, and you can bill for it and anytime you have those three things together, we as orthopedic surgeons, that's catnip for us. It's irresistible and usually, it's a long rabbit hole to a bad result. So I said, well, I don't think this is gonna work, but there's been a number of studies, many of them led by Dr. Kelly himself, who showed that remplissage has actually stood the test of time. This is a very, very good operation, even for a guy like me who was a naysayer, but there are some challenges. Getting those patients back to sport, tricky, right? Verlakis, Boileau, even John Kelly himself shows that many of those patients don't get back to high-level sports after some of these cases with remplissage. If you have bone loss, if you're a contact athlete, if you're a vision, those are three areas where you oughta see if, I don't know about remplissage, but it's so easy. The technique we described, these guys, you know, you can do this, you guys know this, you can do this in 10 minutes, it's simple, and you're right there. But the question is, is do you have the courage to say, I can do it, it's gonna look awesome, kid's gonna feel great for 18 months, and he's gonna fail. So if you take a look at head-to-head and the athlete, and this is something that I think is important, I think I give a lot of credit to Bob Arcieros, who can do this operation open, he can do bone loss, he does a beautiful Laterge, he does a beautiful open Bankart, and he also taught us all about arthroscopic Bankarts. But what he found was, when we take a look at recurrence rates alone, if you look at contact athletes with remplissage, 30% failure rates, doesn't help you very much in the contact athlete. And if you look at bone loss greater than 15%, you're looking at recurrence of 29 versus six, et cetera. Revision surgery, recurrence was 34 versus 10, so that's been borne out. So then you say, well, let's just go Euro on you, full Euro, no stop, let's just do a Laterge every time. You say, well, that makes sense, and there are many places around the world where that's exactly what they do, just do a Laterge. I remember I was giving a talk in Columbia with Gilles Walsh himself, and I gave a talk on posterior instability. And he said, can we have coffee afterwards? I said, well, Gilles Walsh, I'll mow your lawn. So we go and have coffee, and he goes, I don't understand this posterior instability. I said, well, what do you do when a guy has posterior, you know, he push pulls out, the guy's got this posterior labral tasis, I do Laterge. I thought, wow, that is amazing. But why not Laterge every time? Well, you guys know this, the problem is is that the European literature, if you've done 5,000 of them as he has, maybe you get pretty good at it. But for those of us that are mere mortals, you're looking at a 30% complication rate. And if you neurotest these cats, they all have alerts. Many of them wake up with a deficit post-op. And you can argue, but some of those are permanent. Now you say, well, it's only 5%. And actually, that study's been redone because the French came back and said, you guys aren't doing it right. You're not practicing the right techniques. You've got arm holders and everything else. So they repeated that 5.3% study, and they found that it's true. Your permanent neurologic deficit rate will go down, but it goes down to 2.5%. Travis does 100 Bankarts a year. If he does a Laterge on everybody, that means two of those kids are gonna come back with permanent neurological injuries. Those are not recoverable. You know this. And it's why it hasn't been widely adopted in this country. And it won't be. We've gotta have a better solution. Why? Because there are certain things, listen, it's terrible to have a kid fail a Bankart, but that's an entirely different thing than a kid who can't bend his elbow or he can't lift his arm. It's not, you can't do it. So this is not a, I mean, listen, I do a lot of Laterges. I love the operation. There's places for it, but we have to be able to do better. So in excellent hands, you get this, but be careful. The recurrence rates, if you take a look, are still 15 to 17%. Listen, we're not talking about recurrence rates. Did it come out again? We're talking about apprehension, right? Those kinds of things. When you look at it at what we in the U.S. would say is an evaluation system for outcomes, those failure rates are still 15, 17%. And that's in our CRO's hands. Well, what about the sling effect? That's what usually gets knocked on it. Well, you know, and biomechanically, for sure that sling effect matters. But if you take a look at the clinical work that's been done, those effects go away. If you replace the bone loss. So what about laterges that fail, and they do fail, unfortunately? This is work out of Peter Millett. Peter and I were fellows together many, many years ago. What he found was is that you could put the laterge on, but sometimes if your bone loss is big enough, you're still off track, even if you put the bone block down. And if you do that, and you're still off track, you're gonna fail, four times higher rate than if you have an on-track lesion. If you do laterges in everyone with 0% bone loss, this is not a factor, and that's what's happening in Europe, but if you're doing it on somebody with 30%, 33% bone loss, you're still off track when it comes, depending on how you shave that thing down. The other thing, there have been several papers now that have looked at this, showing that if you're persistently off track, it's a problem. Okay, so what do you do? Well, we've had a lot of discussions over the years about which graft. Maddy did a distal tibia, I took a distal clavicle, because it was autograft. There's the old Eden-Hibonet, where you take the iliac crest. And what I'm here to tell you is I don't think it matters. But I think you gotta put bone. But the thing is, is I don't think the graft is as important, it's the technique that matters. Why? Well, because number one, if you're doing an arthroscopic laterge, you gotta split the subscap, and that nerve is right there. I mean, it is right there. And if you don't see it, I promise you, it's staring you in the face. And if you didn't get into it, it's because you got lucky. It's a hard, it's not a, it's a hard operation to learn, but it is always in play, so be careful. So what do we need to do? Well, we as surgeons need to do a few things. Number one, with the nerve always in play, there's gotta be a better way. We have to develop techniques that will allow us to use standard portals that you and I use right now, okay? We have to deliver the graft through the rotator interval. You can't do that with a laterge, because you split the subscap. But if you can deliver a graft through the interval, then you take the nerve out of play completely, and it becomes completely safe. Takes it off the table, and you should use fixation that does not cause complications. The most common thing I do with laterges is take them back to remove screws, and to take them back for recurrent instability. It's a problem, you guys know this too in your practices, so we have to find a better way to fix it. So this is what we got started with. I found a simple syndesmosis button, and we started taking different grafts, and we started pounding these things out. And so by 2019, we had this graft. You can see here, it doesn't quite fit, but then we can suck it down with one of those tenodesis buttons like you might use for a syndesmosis, exactly the same implant that you might use for this, and you can replace this bone as you go. The free graft comes through the interval, it's simple. You're never medial to the coracoid, so it's safe, and you have these flexible fixations. But originally, these were metal, and then trying to get post-op MRIs and everything, we didn't love that, so we were hoping to get to a knotless place. But it did give us a chance to say, hey, there's no neurovascular risk and no subscap split. It's easy, it's easy. It's reproducible, and it's more anatomic. It's also osteochondral. I believe that this evolution to arthroscopic bone grafts is inevitable. Everybody's gonna do this. And I'm not sure exactly which technique is gonna win out and all those things, but it's inevitable because it's safe, and it's simple, and it's secure. You can do this, and it's graft agnostic. You can see in this case, there's a DTA, and the CT's below. You can see I put 11.3 millimeters back on that bone. That was 33% bone loss in this patient. You can make massive repairs to these patients. So John asked me to talk a little bit about our technique. So I think we've made several improvements since we've gone. So I'm gonna take you through this one. We prepped the glenoid for a seamless grasp. We used no metal. It's an anatomic reconstruction with bone and cartilage. So this is what it looks like on a saw bones, and then I'll show you in a real patient. You drill these two things, two K wires from the back. We have a guide that does this. And so now you've gotta cross it. Doesn't matter how big your bone loss is. It's as easy to do in 20% as it is in 50%. For those of you that do ACLs, where you use the flip cutter, I love this concept because I think one of the reasons that we're in trouble here is we don't do good carpentry on the front side. So you can see if I use a flip cutter, a circular router that will pull back gives you a circle. And if you do two of those that overlap, you've got an oval, which is exactly what you need to have. So these are two K wires, and then you can see, here's my second flip cutter coming in. This is what we do in surgery. And when you take this down, what you can see is you can get a completely flat structure. That's the carpentry that we need because we've gotta get these things to meld between native bone donor and recipient. Once you've done that, the case becomes as easy as anything else that you and I do in the shoulder all the time. It's just simply passing a few sutures out of an anterior portal, and then we shuttle the graft in place. Here comes the graft down as you go. And so this becomes nothing more than an exercise in the mid-glenoid portal. You're all used to making that portal. It's the same one you use for an arthroscopic bank heart. You just have to put a bigger portal in because we're putting a big piece of bone in there. So this is us as we kind of come down. This is what it looks like conceptually. And now we have these two loops at the end, and then you can tension these guys on the back, and you can see we can get incredible tension on the backside that's good enough for bone healing in that regard. So I'll fast forward from there. Now what we do is we leave a little suture in each of those loops up front. We do what's called cargo netting, and we send the loops down on one side and the other, and it helps us kind of move along. These are our three-month CT scans, and you can see that we're able to press and reconstruct pretty significant amounts of bone in this regard. Doesn't leave a mark, no metal. It allows us to CT these scans, these CATs as we go forward in follow-up, if you will. So let's see if we can get those to kind of scooch through. And I think what I'll do is I'll stop there from that standpoint. There are a couple of techniques out there. Pascal Boileau has an excellent technique. There's a number of folks that are kind of working on this. Many of us are. I think I've got cases as well, but I think what I'll do is I'll stop there and turn it over to John, and maybe we can discuss the practical applications of this. But thanks very much for your attention.

bone loss

shoulder instability

arthroscopic bankart repairs

recurrence rates

arthroscopic bone grafting