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IC 308-2023: Innovative Strategies for Treatment o ...
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IC 308 - Innovative Strategies for Treatment of Bone Loss in the Unstable Shoulder (4/4)
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So, I'm fairly fresh, still in practice, and I've called these folks multiple times to talk through some cases. And I think that from my training, Dr. Provencher wrote a great opinion piece about how we're doing revision procedures is greatly dictated primarily not based off of science, but based off of your training. And I think most of us are getting exceptional arthroscopic training, but a lot of the fellows now are going to fellowships to try and see open shoulder procedures and how that works. And so, my hope with this is to try and hit on some more controversial cases. I'll be asking both of you and anybody from the audience that wants to chime in on maybe some scenarios that they see relatively frequently. For me, these three come up on a very frequent basis of when should I be considering a primary latergé? Latergé versus remplissage and off-track. We just saw some of the literature from the mid-2000s about how that was working. And then, what do you do when you have a failed bain-cart with less than subcritical bone loss? Some of the things that I think we've realized is, 23 years later from Dr. Burkhardt's paper, is that when you approach any procedure, that knowing your limitations and knowing yourself and knowing what the best operation is in your hands can often be the best procedure that you can offer the patient to give them a successful outcome. And from that, the only true wisdom from this is that we actually don't know anything. I think that putting these talks together has been greatly humbling for me, knowing that folks before us have really done that. And why are we doing this? Well, we have the Hippocratic Oath that we're doing this, first to do no harm. But we have to somewhat be critical of even ourselves as we get up on stages. Are we promoting things simply for exercise of academics? Are we trying to be on a podium and try a new thing? But the reality is that we need to make a habit of two things, of helping and, at the minimum, don't do any harm. And so I've called these two on multiple occasions asking what to do. Well, they just say, know your limits. What are you trained? What do you feel best at? And so I've got a couple cases that I'd like to go through. And, you know, I think that for those of you who know Dr. Birx, I had a very conceptual conversation with him in the lobby the other day about LATER-J. And I think that we should be utilizing this as a tool, not as a grenade for every single shoulder procedure, but it is a tool. And there's a lot of different hammers that we can use to be able to accomplish a similar mission. I asked Dr. Birx, I said, you know, what is your opinion and take on the LATER-J and shoulder instability? And he said, you know, what makes me sick now is that we have turned shoulder instability into a tertiary referral procedure alone at this time. And I said, okay, well, how many procedures should we be able to do to be an adequate shoulder instability surgeon? And he said, I think two. I think if you can do a good open LATER-J and you can do a good arthroscopic bank cart repair, plus minus a REM plissage, that you can be an excellent shoulder instability surgeon. So I was hoping to make this somewhat interactive and some of the patients that have challenged me. And so within the first two weeks of getting into practice out of fellowship, I had this patient come into my clinic. And Dr. Tokish can speak to these types of patients. But this was a combat controller. So for us in the Air Force, this was our elite of the elite. And he's 6'2". He weighed 235. He was proud to say that he could bench well over 400 pounds. And he was in the middle of his wetland training. He had dealt to the size of bowling balls. And as I came in there and found out that he fell out of the back of a truck with a 100-pound ruck kit on his back. And he had a dislocation. So for me, this reminded me of a young J.T. Tokish that could still hit 450 on that bench press. So as you approach that type of case, these are the images that were given to me. And Dr. Kelly, I know that you had gone through this. What's your take on just the radiographs that you're seeing? I do see suggestions or indications of a Hill-Sachs lesion. And on the true AP, the glenoid contour doesn't look too bad. So I think he just probably has minimal glenoid bone loss. But a huge Hill-Sachs lesion. So Dr. Tokish said, I did call you about this case. And knowing that I'm four days into practice, I asked you and said, this guy is two weeks away from graduating in Special Forces training. He is going to be jumping out of planes for the next 15 years and back lands with zero help. With these x-rays, do you alter and change your surgical decision thought process as you go? I'll give you more. I know you're going to ask for more. But just your thought process on patient risk factors and profiles and how you determine surgical operation. I'm not sure I put any stock in, almost no stock in the x-rays anymore. Because they just don't tell us anything. And people will tell you all the time, I get the version of you. And I go and I get this special West Point axillary view. And I say, just get a CT and an MRI. And I get them on every single patient because you miss stuff if you don't. But on the other hand, you could say, is it going to really alter your decision making process? Because this is the elite contact athlete that I already know his failure rate with an arthroscopic bank card is a little too high. And my choice is probably going to be something more than that. So more than that could mean an open bank card, which is an awesome procedure. Or it might be a Latter Jay. Or it might be what might be. But those things are determined later. So we end up getting the MRIs with a deep Hill Sachs. That is a deep one. And his glenoid bone stock was good. Essentially no glenoid bone loss. He still had the lip, minimal contour loss. But a large Hill Sachs lesion. So I said the prayer that you told me to say before going into any procedure. Saying, dear God, please help me just make the right decision. Mostly I said, dear God, please don't make this poor bastard pay for my inadequacies. That's my general prayer before I go to the OR in the morning. But as we had talked about, can I do a primary Latter Jay? And would that work? And after especially going through these 20 plus years of literature, my head's spinning on even thinking about, like, am I even doing the right thing for this individual? And how I approach them. Well, just kind of a brief review of literature in Latter Jay. Contact athletes and whether or not there's osteolysis and does it matter. So we found that, yes, Latter Jay does work. And it does. It works with instability. But maybe it's the risk profile. Maybe it's the type of patient. But even a Bancart alone, Bancart plus Remplissage, can get people back to sport sooner. But if there's less than 15% glenoid bone loss, maybe that entire bone block is going to resorb. And is that a concern? Primary Latter Jay, in terms of instability, is better than doing it as a salvage operation. There's lower risk of instability. So if my goal is to get this patient back and give him a stable shoulder as the primary goal, it can be an excellent operation. Then Giacomo's study looked at osteolysis at one and a half years. And does it matter? Well, it does resorb. But instability-wise, it was a successful operation. And then, well, what about Father Kelly's alternative operation? Can I do a Remplissage in this type of procedure? And when I was four days into practice, that concerned me. Just based off of my training, I was kind of resting a lot of my reputation on getting this guy started and getting him back to his team in a safe way. These are some of the updated studies that we've had looking at Remplissage versus Latter Jay. Now, Dr. Dennard is an excellent surgeon, and he's technically amazing. I think he's compared his Latter Jay to his Baincourt with Remplissage. And what he found is that with his Remplissage, they're able to get back at a higher rate of return to sport, including overhead activities, with a wide array of glenoid bone loss. And that off-track did not predict recurrence with the use of a Remplissage. And so 90% return to sport with a 2% risk of recurrence with different spans of bone loss, that's a pretty appealing operation in this guy. So this study by Dr. Sakaya looked at complications. You said it yourself, permanent complication. This guy can't come out lifting his arm. I'm hosed. He's hosed. Everybody's hosed in that situation. Remplissage, no reported complications with it. Five to eight degrees of loss of external rotation. Does that even matter clinically? Well, what did I do? I did a Latter Jay. So I gave him kind of the risk profile, and thankfully he's now three years out, and he has a stable shoulder. He had a multi-leg, which took him out of the game, but that's different. Just a comment, and I don't want to offend the colonel, but I always feel as surgeons we try to restore anatomy, and I think that in the presence of no bone loss, I would do Remplissage with a very, very good soft tissue repair, only because as Millet has shown, as J.T. alluded to, sometimes your coracoid is not big enough to cover that track. That, in Hillsacks, is very large. So sometimes you get in there, and I think you told me yesterday, Travis, 25% of the time your coracoid is not large enough to enlarge the track enough. So that's one case, and further meditation. And I have these patients, honestly. I'm not trying to preach here, but I think restoring the anatomy with Remplissage and a good soft tissue repair in this case, because you have the risk of vascular lysis, and even Peter Miller says in his article that he wrote, he says 23% subluxation, and he writes in the discussion, I believe that Hillsacks needs to be addressed. So he can maybe do a beach chair, do the Remplissage first. Colonel, I don't know if you've done that. That's a lot of surgery, but I would have done a Remplissage in this case. Yeah, I think that's a question, right? This guy falls into the tweener group. He's not a quote-unquote contact athlete, but he acts like it, and he's a little older. He's not under 20, so the risk factors, I think, matter, and I think a Remplissage would have been a very reasonable choice for this guy. I mean, we have the leading guy in the world on Remplissage level 1 data with us in Pete McDonald and showed us that the outcomes with Remplissage versus Bankart alone are clearly better with that, and you start to wonder if there's a situation where you would ever do an isolated arthroscopic Bankart. People say, do you do a Remplissage every time? I say, yeah, I kind of do, and they say, well, do you? What happens if you don't have a Hillsacks? And I say, well, I make one. I mean, I don't make one, but I kind of make one. You kind of roughen up the bone up there, and then I'll stick it down to it, and I think we're just starting to sort of figure that out, but I think a Remplissage in that case would have been reasonable, but DeLatter-Jay is an excellent operation, but when you're looking at a guy who's got cannons like you got and you're in there and you're trying to get that thing flat to the glenoid, I mean, I'm watching your screw because I'm thinking this guy is a beast, and you're trying to get that thing flat. If you've ever been in there and you've done this operation, you know that is no easy task, and so good on you. It looks great. Peter. Yeah, there we go. thanks for the reference to our paper, a randomized clinical study, and we had less than 15 percent bone loss as an occlusion criteria on the glenoid for our study. So the patients in the Bankart alone group had a recurrence rate of almost 30 percent four years, and with Rompelsage it went to about 10 percent, so big difference, and it does work in that subcritical bone loss situation. Question about the Hill-Sax lesion, the location and the depth of the Hill-Sax lesion, do we place any stock in that? What do you guys think? Male Speaker 2 I'll get my Irish up here, they all engage, that's how they happen, and clearly we heard a paper I guess on Thursday, the lower, below the equator really mattered in terms of whether it affected the recurrence rate, so more is bigger and I think you have to address it, and I'd be in complete humility, I don't know, there is a critical mass that's too big, I don't know what that number is, but I relentlessly, because of lack of consent for letter Js, I end up doing it when they get in the OR, and I've had some huge ones you say, hey Kel, why don't you put an allograft, well I didn't consent for an allograft, and it's hard to get an allograft in Philadelphia, it's hard to get braces paid for in Philadelphia, so I end up doing Remplisagin, and I really don't know, I'm in complete humility Peter, but I do think they all engage, and like the colonel said, it's like a fasciotomy, I think about doing it, I just do it. Male Speaker 3 Yeah, I think you guys know, Giacomo published on this as well, but there's kind of two types of Hill-Sax, one's the abduction type, one's the adduction type, so we all think that patients dislocate here, but actually the majority of them are a little lower down, you've got a rugby player or whatever, and they're playing and they get knocked out here, there are many, I think, Hill-Sax lesions that are not amenable to a Remplisagin, so if you go in and that's the only tool you have in your toolbox, then be careful, because sometimes that thing, when the arm is just here and you're in the arthroscopy position, to be able to advance the infraspinatus tendon, whatever that you want to put into that defect, that thing is so far down, it's not happening. So I do think that there are a number of Remplisages that are not, we haven't figured out exactly where that is yet, but it is not a catch-all operation, because there are places that you cannot put it. The other thing I'll tell you is we think that it's a filler, or that it excludes the Hill-Sax lesion, and there may be some truth in that, but honestly, for those of you that have done it, you know this, or the next time you do it, consider this, once you put your anchors in, pull on your anchors, and what you find is, as you tighten that Remplisage down, it's not so much of a filling or an exclusion, it's actually, it just takes the head and it puts it back. So instead of doing this, when the head rolls through its range of motion, it stays back and does this more, right? And all of us, I think, are figuring that out. So maybe you don't need to fill the entire Hill-Sax defect, but if you can just put that tether back there and shift that head back, that might do the same. I guess an extension of that is, I remember Tony Mignacci's article on humeral head allografts, you know it had great results, no, zero instability with humeral head allografts, and subcritical bone loss on the glenoid, is there a role for that operation still in our algorithm today? A hundred percent. You know, Peter, you've watched Tony's videos, without even repairing the capsule, it just eliminates dislocation. So absolutely, I just have a difficult time getting it procured and approved, but I think it's, as Major Decker said, you know, we're bone surgeons, and I think it's a wonderful place for that. I think it's hugely important, but the reason we don't do it is because, number one, it's hard, and number two, you've got to take down the subscap. We haven't figured out a good arthroscopic way. That's probably what you guys are going to help us do, the young people in the audience. But if we could replace that Hill-Sax, if you go back to the 76 paper from Carter Rowe, the original Bankart end results idea paper, he didn't have many failures, and I think it was four failures that he had in his entire series. Way back in the day with an open Bankart, the four all had large Hill-Sax lesions. That's the one I fear. Buccolinoid bone loss. I can fix that now. But the large Hill-Sax lesion can be really, really tricky, so I think Peter's point's exactly right. But it's hard to do. You can't do it really arthroscopically, and do you really want to take a subscap down in the 24-year-old, and otherwise you're, you know, figuring something else out. I think that once that gets figured out, an arthroscopic way to deliver a bone graft in that place, we'll see a lot more of those filling up, and I think we'll be better for it. And quickly on that, Bob Arciero had taught me a little technique where he actually splits the infraspinatus posture, and I had an ego attack about 15 years ago. I did a couple of oats plugs in Hill-Sax, and I published it, and the guy failed after it got published. But I do think that J.T.'s, as usual, is right. I think that, you know, there's not, once you get through the infraspinatus, there's no real major nerves there, so I think we're going to develop a, someone in this room smarter than me is going to develop a way of delivering allograft. All right. We'll head to this next case, 24-year-old, another, an EOD guy. So he, I already know from the beginning he's going to ignore every post-op precaution I give him. He dislocated in jujitsu training, and all he wants to do is become an MMA professional fighter as he's part of the junior circuit right now. And so he has a history of a failed bank cart. He's had greater than 10 dislocations. And so, once again, I go back to Dickens' paper. He had a failed arthroscopic bank cart. Am I going to be doing something more right away? So here's the x-rays. Maybe a small hill sac lesion present. Getting the CT scan and the MRI and going through, you can see where his prior repair was done. When we look at the CT, the anterior lip is gone. And so I think more for academic's sake, I measured it at exactly 10% with a perfect distance to dislocation of eight millimeters with the shallow hill sacs. He's considered on track. Dr. Kelly? I know this sounds very egocentric, but when I see a patient like this, I always ask, like, who did it? If I know that surgeon, that very good surgeon, and most of them are in Philadelphia, then I have a lot more reverence, and I'm more quicker to go to a bone procedure. But given the clown, I bone lost 10%. I know I'm the outlier here, but I think I would, I'm a big believer in a horizontal mattress, sutures, restore the bumper. I do an interval, a CHL closure at times. Sometimes I implicate the posterior inferior IGHL, and I would do the remplisage in this guy. So I'm the outlier here, but that's what I would do. Your take on Dr. McCabe's paper about failure rate in primary versus revision remplisage? That's not been my experience. In fact, we just, I was going to talk about this. We've just looked at my results versus the latter J, and David Glazer is a very talented surgeon at Penn. It's funny, the people that had over 20% bone loss had only 11% recurrence, but people had 13.5 to 20 kernel, had 17%. So there's something we don't know. It's not all about just pure bone loss, and I'm here in complete humility. I don't know what that is, but when I have a 20, 25% bone loss, and they're only coming in at 11% recurrence, like, that's not bad, you know, when you don't have those nerve injuries that, you know, the kernel mentioned. So I just, you know, I can't give you a cogent argument except for my experiential, you know, take on it is that it doesn't bother me. I guess the question of a revision procedure, Dr. Dixon, when I asked him about his paper, he feels that it's a soft tissue problem, the quality of the soft tissue changes in a revision procedure, even with an addition of a remplisage. I'm getting my eyes shut, because I think the biggest thing that Buddy taught me, and you know, you get like an ALPS-like lesion is you got to spend the time in mobilizing the tissue. That's one of the reasons why the ALPS lesion fails so much, because the tissue is poor, but if you take your time. I think we fall into a trap here, though. We say, well, we just got to do it better. So, you know, we'll say, well, I just, I really pay attention to the technique. Well, so do you, and so does everybody, and the arthroscopic Vanguard is not a difficult operation anymore. I mean, our residents learn it very well by the time they're done. Our fellows certainly do. It's going to fail. This guy's already failed that operation, and he's an MMA fighter, for God's sakes. Do you think that arthroscopic Vanguard, and you can add a remplisage all you want, but you think that guy's going to go out and not fail that operation? I'm sorry, man, but he's coming back. Well, I would add the Father Kelly seed grafting, too. We'll talk about that. All right. I can't argue with that, JT. That's wonderful. Right? I mean, who wants to operate on a wrestler? My God. I mean, those guys, those guys, they'll kill everything you do, man. They'll kill everything you love. They are just soul killers because of what they go after, and this guy's already failed an operation, and the bone loss is always more because that MRI, with all due respect, it's great, but man, I mean, those things are gone, man. There's bone loss there, and I'm just telling you, this is one of those things, please, God, learn it from me and not with me. Those guys are going to fail if you do something short of a bone-replacing procedure, which is good. Wow. As I kind of gave up. This is what we want. Yeah. Controversy. I ended up doing a Latter-day. He's a year and a half out, and he's now out of the military, but he's still in Florida trying to hurt people. All right. So this will be the last case that goes- You're starting to look European here, Travis. Everything ends up in a Latter-day, man. We're trying to- We're giving the Latter-day talk, so yeah. There's plenty of arthroscopic there, too. All right. So this is an Army Ranger. He's older, but he, once again, he's going to be a non-compliant guy because at 30, he's got about six years left on- Do you notice, Travis, that a 30-year-old is older? Well, you said 28 or was older a second ago, so- That's rough. He's got a three in front of his name. I had to say he was older. So a 30-year-old, he's had recurrent instability, a failed procedure once again. And so MRI, we go through, and I think that we've already, just based off of the last case for illustration cases, I had already gone through my thought process on why. John Dickens is a good friend. He's had a significant impact on me. And so the controversy for me wasn't this case and this time, of what was I going to do? Because he was another big dude, just like that first guy. But really, the question then becomes, and this is where I wanted to get, this is his right shoulder, which he subsequently dislocated, and now he has primary instability with just a labral tear on his right side. So on his left side, he came in two weeks later, lifting his arm over his head, saying, thanks, doc. I'm riding my motorcycle now. I'm very happy with this. And the first time I had my bank card repair done, my shoulder was tight, stiff, and I hated it. And now I'm happy with this. Can you just do a lateral J to my right side, please? I've got to get back to my team. Please do a lateral J. And I had this talk with him two weeks ago. So Dr. Kelly, we briefly talked about this case. What are you doing in this guy when he's begging for a lateral J on his right side with primary instability and no glenoid bone loss, even though that's what he wants? I try to be a holistic provider, and as we say, a doctor. I hate that word provider, doctor. And Jed Kuhn taught me through the Moon Group that belief is so powerful. So if he doesn't believe a bank card's going to work and he wants a lateral J, then sometimes I will definitely use that in my thinking. And with Jed Kuhn showing the rehab predictors for belief in the therapy, because the patient comes into your office, and I don't think rehab's going to work. It's not going to work. So if he believes he needs lateral J, then I would probably bend my criteria a little bit. And that is certainly reasonable. Dr. Tokish? Yeah, I agree. I think he'd be a great candidate for an arthroscopic one on the other side, but it's hard to be perfect. So he gets matching sets for me. I'd convince him to do an arthroscopic bank card repair. Ah, you silver-tongued devil, you. That's good. And he's doing well, I assume? 61245. If he's jumping out of planes, he's dislocating because he's too big for the parachute, man.
Video Summary
In this video, a surgeon discusses different approaches to shoulder instability procedures. The surgeon emphasizes the importance of knowing one's limitations and choosing the best operation based on their skills and training. They discuss controversial cases related to primary laterjet, laterjet versus remplissage, and failed bank art repairs. The surgeon shares their experience with these cases and the decisions they made, highlighting the importance of individual patient factors and surgeon expertise. The surgeon also discusses the benefits and limitations of different procedures, such as laterjet, arthroscopic bank art repair, and remplissage. They emphasize the need for ongoing research and development in shoulder instability procedures. The video includes discussions and input from other surgeons, providing different perspectives and insights.
Asset Caption
Travis Dekker, MD
Keywords
shoulder instability procedures
limitations
primary laterjet
remplissage
failed bank art repairs
research and development
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