Behind the scenes John Dickens is keeping things going here so let's hear it for John Dickens and Jarrett too. You guys are keeping things going great. Hey I'm very excited this is it's wonderful to see everybody here for something that's very special and it's as I said earlier it's great to combine the ASES and the American Orthopedic Society for Sports Medicine and this combined specialty day. This is a very special lecture and before I introduce our speaker I want to talk a little bit about JC or Jack Kennedy, Dr. Kennedy. So Dr. Kennedy was one of the legends in sports medicine and this lecture is provided by an endowment that's supported by the Kennedy family as well as AJSM and it does honor Dr. Kennedy who was a sports medicine physician one of the founders of AOSSM. He's on the board of directors. He was AOSSM president as well as the president of the Canadian Orthopedic Association. Like our speaker he was also the recipient of the Mr. Sports Medicine now called the Robert E. Leach Leadership Award. As you can see our past recipients are a pantheon of leaders in orthopedics and not just sports medicine but all specialties sub specialties of orthopedics and and our speaker today certainly fits in with the high quality of speakers that we've had in the past and and our Kennedy lecturer today is my good friend and mentor Bob Arciero. Bob grew up and graduated from Allegheny High School in Central New York and went on to college at St. Bonaventure University, went to medical school on a health profession scholarship at Georgetown University, did his residency at Madigan Iron Medical Center and then spent time with John Fagan and Jackson Hole with the team at West Point and at the Hospital for Special Surgery for subspecialty training in sports medicine. Bob had a distinguished military career that began as an ROTC student in at St. Bonaventure and continued with his residency training as an intern at Madigan Army Medical Center before he was a general medical officer in Germany. He returned to Madigan for his orthopedic residency under Dick Camp and Tom Parr and many other mentors that he developed there in addition to Bob Winquist in Seattle where Bob learned a lot about trauma. His first assignment after residency was it at West Point and then he went on to be the fellowship director and head team physician from 1991 to 2000 after deploying to Operation Desert Shield Desert Storm in Iraq in 1990 and 1991. Now I first met Bob when I was a fellow and these two guys were my fellowship directors and this is a picture from about that time of Bob with Jack Bryan and together they had a significant impact on my life as well as the lives of many others that have gone through the West Point Fellowship. Now at West Point there's a term called a gray hog and cadets who are gray hogs love everything about the Academy. Now Bob Arciero is grayer than any gray hog or Academy graduate. He loves everything about West Point. So Bob this is for you. A picture of the last Army-Navy game in December of Army's goal line stand on fourth down that won the Army-Navy game for Army. No apologies to Matt Preventer or any other Navy grads here. Bob and I had a lot of adventures after we met first in 1991 including adventures on the sideline here with Navy team docs John Wilkins, Eddie McDivitt, our fellow at the time Craig Battani, adventures on the golf course, adventures in the training rooms. Bob was an amazing mentor, fellowship director, partner and then in 2000 he went on to the University of Connecticut and had a continuation of a tremendous academic sports medicine career. He and his partners established the University of Connecticut sports medicine program as one of the top ones in the country here shown with two of his partners Gus Mazzocca and Kathy Coyner. Bob sometimes even went above and beyond the team physician role and I think would be accused of a coach at times. But I would say that out of everybody in this room he probably has more national championship rings than anyone because he's done such a great job taking care of the UConn women's and men's basketball teams. Now he's also been very impactful in terms of helping all of us understand sports medicine and shoulder surgery better. Not only is he a Leach Leadership Award winner but he's also in the AOSSM Hall of Fame and this is Mary Lloyd Ireland presenting him with his plaque in 2021 inducting him into the Hall of Fame. Now Bob loves a lot of things and he loves shoulder instability and we're going to hear a little bit more about that here shortly but I would be remiss if I didn't mention that that Bob is a true humanitarian and and a wonderful person who loves a lot of things outside of shoulder surgery and sports medicine. He loves his hog, he loves his guitar, and the video is not playing, and most of all he loves his family and here he is pictured with his wife Kathy and his wonderful family. So without further ado ladies and gentlemen our Kennedy Lecturer for 2024, Bob Arciero. I'm on the Mac. Thanks Dean. Way, way too kind and indeed it is a privilege and honestly the last two sessions you probably don't even need to hear this talk because I'll summarize a lot of things but I think I'll try to give you yeah the PowerPoint there we go yeah what I'm gonna try to do is give you can we put the first slide on there do I have to hit it no okay so what I like to give you is sort of a working algorithm framework that I've that I've developed over now in my 37th year of doing this and I I wanted to share science with you as well as experience experience with the treatment of traumatic anterior shoulder instability. I don't have anything to disclose for this talk and basically are you a splitter or are you a lumper and I'm what I mean by that is you just heard all of the options that we can do in tackling an unstable shoulder and it's confusing it's confusing for me to listen and to hear it because I go through this every week the literature is confusion confusing there's a lot of bias Tony Romeo brought brought up outstanding comment that we always brush over and the technique are we doing the technique completely are we doing it right is it consistent it's really hard to tell from the literature and also when we look at outcomes we're not we are hung up on recurrence but it ought to be recurrent dislocation and subluxation and it should also look at outcomes you can have a patient who has a totally stable shoulder but they're miserable with a loss of 30 degrees of external rotation or they have pain they can't get back to their sport or their work so we have to put in an outcomes measure so I'm going to talk first about initial dislocation you heard from Dean and people who know me I had the privilege of being at West Point and basically there's required obstacle courses there's required tackle football there's required rugby for the 4100 cadets there and basically gives us 12 to 15 brand-new first-time dislocators a year and so we had an opportunity to look at these because traditional put them in a sling rehab them then put them back out simply resulted in over 90% of them coming to surgery three or four months later our president Dean Taylor while he was there with me looked at 63 consecutive patients and Ivan said it very well he said we know what the lesion is and honestly for a dislocation that requires a reduction Bankart lesion is seen 97% of the time and not a lot of bone loss after that first dislocation there are exceptions but it's unusual so one of my predecessors who I learned so much from Jim Wheeler started putting the scope in the shoulders in 1987 and using this Lanny Johnson staple in a very small series and found out the they weren't re dislocating I went through a time using trans glenoid sutures and a sure attack and Brett Owens looked at a 13-year follow-up and we basically reversed the natural history of this problem at West Point but that's old stuff but if you look in the literature recently using modern suture anchor techniques now the recurrence rate after primary intervention is between 6 and 10% for the vast majority of the literature so there's a mark decrease in recurrence there's improved outcomes at five-year follow-up there's a mark decrease in subsequent surgery and Brian Feeley in a paper that I don't think it's enough mileage found that adolescence and recurrence separately independently were associated with a much higher degree of off-track lesions and we now know that off-track lesions demand something else Leonard Hovelius won the near award for this paper where he looked at primary dislocators 25-year radiographic follow-up had over 90% follow-up if you never dislocated again you had an 18% chance of having visible away on radiograph but if you had just one more dislocation it was up to 40% and this is out of his paper shoulders without recurrence had less arthropathy so it's an indirect reason to consider being aggressive I'm asked this all the time since you left arm that just applies to military people right wrong I'm so convinced that this is the right way to do it I was so glad to hear Peter McDonald say I'm a little bit more aggressive now with these it does lead to the best outcome to fix them were taught not talking about all comers we're talking that at risk 15 to 22 that's where the natural history says they're gonna have a high recurrence rate and guess what it is the best time to fix it tissues in the best shape almost no bone loss and it's a much easier thing to do what about in season Eric McCarty like I said you guys already heard a lot of this so in season collision contact overhead had athletes what do we do in that situation will most high school and collegiate athletes want to play and we know that they can so we put them through a range of motion rehab program maybe we use a brace and we can get them back and in fact are one of our course chairman's John Dickinson Dan bus independently did two studies and basically this is what I tell the parents and the athlete I kind of merge their results into one slide if you will that you have a 75% chance of going back and finishing your season at the high school and collegiate level it takes about 10 days to get back some people get back sooner some a little later but about half of you are gonna have recurrences during the season and about half of you will require surgery or will go on to have surgery at the end of the season but then out of mom's mouth is but everything's gonna be alright if Johnny goes back and plays in his high school football game this Saturday but there are consequences of continued instability just gonna give you a case example one of our captains from a number of years ago first-time dislocation you know no way he's coming out it was in preseason he wanted we wanted to be rehabbed and certainly we did his initial MRI kind of a bland you know ten to six o'clock MRI little bony edema no bone loss at all so we let him play and to our knowledge over the next five games he had like three subluxation events and then we had a game where he had a major instability event in the first half and shame on me I should have yanked him out then I let him talk me into it but I had control over the situation in the second half yet another when I said you're done that's it so we get an MRI now what do we got what we got almost a 300 degree labral tear now we have a six-anchor double-loaded repair fortunately we had very little bone loss but there's no question that just letting your player play even though we do it there's issues and it's but if they're having recurrence so we get asked this a lot and Eric brought this up as well should I get this fixed at the end of the season doc well John Dickens did another study looking at 39 athletes in which 10 chose non-operative treatment at the end of the season season but the 29 who had who had surgery at the end there was only there was only a 10% recurrence whereas for the 10 that didn't were there they were the only ones to complete the following season without having instability so I would say at the end of the season if the patient is totally asymptomatic no apprehension I mean looks great I probably wouldn't operate on them but if they have any signs that there's residual instability I would fix them at the end of the season so let's talk about recurrent anterior instability now this is this is the bugaboo right I mean this is the problem that we all face in this country with what is the optimum treatment it all boils down to like so many things that we do how we pick our patient and how we do the surgery and how we do the surgery is really really important okay and we just brush over we say arthroscopic bank card you know or you know ACL reconstruction or lateral meniscal repair the devil is always in the details so I think the work by Pascal just illuminated how we need to look at demographics I'm not this has been validated I won't say that I pull the score out and estimate a score when I see it but I think about the patient okay how old is this kid just like what Eric talked about what activity they do they want to get back to is it a collision or contact sport do they have any bone loss on imaging and in the original study if you got two points for every one of these parameters if you hit six points he had a 70% failure rate but that study has been repeated several times I think we're down to two points if you're a male and you're 20 years old and you have you you're gonna have a higher than predictable or acceptable degree of instability with an arthroscopic bank card alone this has been documented this is just a few studies there are many more that show what I think is an unacceptable recurrence rate for recurrent anterior instability in a certain group with a soft tissue procedure by itself and who's at risk is this group adolescent young male collision athlete those are the ones that we got to be really really stringent about what we're doing now I'm going to share with you our study at UConn that we presented in September at Issacoss Matt Schumann one of our residents and John Stelzer did the lion's work these are all my cases 150 of them minimum 10-year follow-up so the average follow-up is 15 years on this now the problem is we only have like 55% follow-up but it's not insignificant and we did them all lateral position they're all double loaded anchors we did poster placation and many of them we close the rotator interval read them and weep so at an average follow-up of 15 years we had a 23% recurrence rate we had a 14% that needed additional surgery and guess what the recurrence rate and the need for revision were much higher in those under the age of 23 but one of the real startling things I think about this study is that in my group anyway they didn't have recurrence till almost four years out. So I think, honestly, I've said this before, but I really believe it now, that a minimum two-year follow-up is not satisfactory when you're talking about shoulder instability, really isn't, because these are very young patients. It may not be satisfactory for ACL, for that matter. Now, you gotta exclude bone loss, this is no mystery, but things like apprehension at low levels or low angles of abduction, external rotation, certainly somebody who pops their shoulder out in their seizure, revision, you know, you can almost implicate bone loss in every single one of these. Now, we have redefined this, we haven't, but the group at Tripler with Batani, Saha, and Tokish found that, really, it might be down as low as 13% because they had a number of outcome failures even though they didn't have recurrence in their group, and recurrent instability wasn't observed until they got up to about 20%. So I think that's a redefinition, and Al has done phenomenal work that I wanna talk about as well in a minute, redefining that concept. So for me, for arthroscopic stabilization, I am definitely a splitter. Buddy Savoie said you need to fit the procedure to the patient, you shouldn't just have one hammer. So first time dislocator, I'm gonna do an arthroscopic soft tissue procedure. Overhead athlete, less than 10% bone loss, especially if they're on-track lesions, I still would be cautious in that 15 to 19-year-old hockey player, lacrosse defenseman, linebacker, we're still gonna have some problems. Pan-labral injuries, and they are suitable for this. But what is the key thing technically? You have to do more. I personally, I don't know if you can do this operation well enough until you're in a lateral position, and you can get this, a right shoulder, get way down to the bottom, you gotta mobilize the capsulin labrum, and you've gotta be able to placate and repair the labrum. I like to use this technique, an inferior anchor, but then we're passing our placation labral sutures even more inferiorly, and what I do with one of the limbs is I pass it as a mattress, and then the other limb goes over the top through the goal post of the two limbs, so I have a mattress with a simple suture for each anchor. And what that does is it really gives you a bolstering of the concavity, a portion of your repair, and at the same time, can really tighten that inferior glenohumeral ligament. And you can see here, just this one suture, how much we've pulled up that lower pouch and re-tensioned that ligament. This would be a case where I did a remplissage. This would be what I would want it to look good. You know what, if it looks good, it's good. If it doesn't look good, it's shitty, honest to God. So, and we all know that when we leave the operating room. You're shaking your head, that wasn't my best effort. But you wanna not have that feeling. And I do think remplissage is a game changer. I'm not sure to call it a, it is soft tissue, but it's, you're addressing a bone defect. So, lots of studies, Peter elaborated extensively, and you know, I chose, I think, an image from his article. But it's pulled down the recurrence rate considerably. The outcomes have been good for most of the time. The motion loss has not been an issue. We actually looked at this, a former fellow, Justin Yang, who's out here at Kaiser, and Mike Pearl, we coupled his patients with mine and Gus's for off-track heel sacks, with subcritical glenoid bone loss. That's a mouthful. Where we compared remplissage versus a Laterge. And WOSI scores, recurrence rates, all that were the same. And the complication rate, as you would predict, was a little higher with the Laterge. However, in a revision setting, and if the glenoid bone loss was greater than 10%, or contact collision athlete, Laterge was a better operation. Now we're gonna get to the 800-pound gorilla in the room, as far as I'm concerned, the open Bankart. And people would say it's an obsolete operation. I don't think so, not yet. It will probably become it, but not yet. And I'm talking about not just an open Bankart, but a Bankart with a capsular shift. And here's where I use it. Intermediate bone loss, collision male, multiple dislocations, and a revision of an arthroscopic repair that I think was well done. And I do a lot of Laterges, but it's not an innocent operation. There is a price to pay if you have some of these complications. Nerve injury, devastating, coracoid nonunion fracture, hardware migration, and oh, by the way, follow your patients, you'd be surprised. I think graft resorption is totally underreported, in my opinion. So here's the Bankart, quick and dirty, right shoulder. So we're gonna do a T-capsulotomy, just like Charlie Near described to us. And we're gonna open that up, and you'll see that this is what we can do. We can double breast the capsule. We can do a double row repair. And what's different is we don't do a spot weld. We put the sutures all the way through the labrum and the capsule, and all these sutures are tied in a mattress configuration outside, totally obliterating the pouch. Then the inferior leaf can be brought up, almost covering the entire joint. Superior leaf brought inferiorly and laterally, and you get a double-breasted repair. This is a different operation than an arthroscopic Bankart. And it's been reliable, depends on who you read. Some people might debate it, but there've been some recent studies that study by Batar looking at 90 collision athletes, open Bankart shift with Latter-Jay, no bone loss greater than 20%, and they were equal. And I would say they're equal without the risk of those inherent with a Latter-Jay. This is a paper that doesn't get quoted enough by Maroter, JBJS, minimum 20-year follow-up. Now, you might look at it and say, oh, recurrence rate is 17%. That is at 20 years. But the real kicker here is this, only two revisions and 95% were satisfied with the procedure. So I do not think that open Bankart is obsolete. It may have a narrow indication, but I think it's still there. And we know that bone defects occur with recurrent instability. In fact, we should take the attitude that there is gonna be a bone defect if somebody's had more than two instability events. And we know that the critical numbers of glenoid bone loss of at least 20 and on the humeral head will really sacrifice your soft tissue repair. Itoi, Yamamoto, Tajakamo, Burkhart, et cetera, introduced the glenoid track, which really enlightened us to look at the effect in that given patient of bilateral, bipolar bone lesions. Now we can compute and look at how they interplay in that given patient, which I think is an enormous contribution. So we have the concept of being off track or on track. I'm not gonna go over this in detail, but I'm sure everybody in this room is familiar with this. But Al Lin in the group at Pittsburgh, I love this distance to dislocation because it's refining on track, off track, even further. Now I poke fun of him because he calls it near track. I think it's near to being off track. That's why it makes more sense to me to look at it that way. But it's his term, so we'll stick with it. But you take your glenoid track, you subtract the Hill-Sachs index, and so you want the glenoid track to be positive. But he found that it had to be positive by at least eight before, if it was less than that, there was an exponential increase with arthroscopic Bankart repair only. You heard his wonderful paper today. So what can you do in these cases? So I do think remplisage is a game changer. I think it helps. I haven't taken the attitude, I'm doing it on everybody, and I certainly don't scuff up the back of the head to do a damn remplisage. I'm not doing that, not yet. Okay, I'm just not going that far. But you should have some concerns about loss of motion. And in overhead athletes, you should have some concern. And John Kelly, who's a huge proponent, this is from his paper, only 50% of baseball and football throwers got back to the same level. Now, maybe you can modify the Hill-Sachs and not make them so tight. Which leads me to bigger bone loss issues. For definitely over 15%, over 20%, definitely over 20%. I think this operation is a fantastic operation. But huge learning curve. So same exposure. We're gonna take down the CA ligament. You stay lateral to the muscle belly of the short head, and you can get a nice piece of CA ligament and it won't bleed. Then you take the pec down. Positioning is critical too, so that you can rotate and have the coracoid staring you, coming up out of the wound and not being tilted medially. I think this 90 degree saw, that's another game changer for me doing this operation. But this is a kind of exposure that I like to get that I demand that when we do it. And so then you can prepare this. And I do think you need to flatten it. Ivan says, I saw how meticulous he is with preparing the DTA and the scapular neck. That was the musculocutaneous nerve, by the way. Which I like to see, sort of. I like to know where it is. And I like to have enough play in the conjoint tendon that I can pull it out of the wound so that when I go to transfer, it's going to an inferior location. So when that patient puts their arm up, there's going to be more tension on the musculocutaneous. This is not my idea. I borrowed this operation from Gilles Walsh, to be quite honest. Split the subscap between two thirds, one third. I like to make a very medial capsulotomy with the arm in maximum external rotation. In fact, when I do this, it's actually hard to get in there because I want to make sure I have a lot of capsule medially. Because I like to do a bank card on top of this. So I don't use any guides. I just use a ruler and I use 3.5 non-cannulated synthese screws. And if you have good exposure, you can place these screws parallel to the joint. You want to fight like crazy to get these screws parallel because if they're not, they can impinge. And certainly if they dislocate, they'll impinge. Fortunately, dislocation after this operation is pretty low. I don't use washers anymore. There's the CA ligament. And you can use the upper screw hole as a guide for your second drill and screw application. So, and then we'll check it. You can look inside and if you have any overhang, you can take a burr and make it perfectly symmetrical and congruent, I should say. I thought there was a little excess bone there. So we'll just take a little of it down. And then I put a couple double loaded anchors right at the interface between the bone and the, I mean the coracoid and the glenoid fossa. And then you can take the Fukuda out, which we'll do in a half second. And you can then bring the capsule inside the joint without restricting motion. And I put the capsule in with the arm in at least 60 degrees of external rotation. So I'm not, I haven't had any issues with, to be honest, with loss of motion doing it this way. So anyway, let me go on. So I think that's a workhorse. For me, this is an ideal x-ray, which means, you know, when you get an x-ray at six months, it looks this good. In three months, you're coming in with a recurrent dislocation. You know how that is. So, but I want to be parallel. I want that bone block flush. And I think it works very, very well. But it's got a steep learning curve. Now, you've heard today, and the literature is getting robust with arthroscopic bone blocks. Latter Jay, iliac crest, distal tibia, distal clavicle. And, you know, I, about eight or nine years ago, I went into the lab for about three weeks straight. And I was toying with the idea of going to arthroscopic Latter Jay. But honestly, I do my Latter Jays in under an hour. And I just said, why should I change? And now I'm just an old man. I'm not gonna change. So, but I'll let you young guys do all the changing. But I do think, unlike Ivan, Ivan is minimizing his tremendous talent. It's his steep learning curve, very steep learning curve. And when you're doing it arthroscopically, and you have to go very medial, there's been some horrific complications. So you gotta learn from somebody. You gotta spend time in a lab. And I would suggest, if you're ever gonna do this, you start out doing parts of the operation arthroscopically, then go open until you get it right. And I think the complications are significant, but I think it is the future. In the future, this is what we're gonna be doing to handle bone loss. And we won't be quibbling about it, to be honest. Now, patients with greater than 30% bone loss, and it was great to see Buddy's seizure case, because I get tons of seizure patients, and they have the worst bone loss that there is. And the neurologist always tells you they're stable. And of course, then they seize in the recovery room. So it's just, you can't even believe them. But on that particular case that he had, you could, I would do the same thing. You could do distal tibia iliac crest, and then spin the head around and do an actual direct bone block to the humeral head. Gus and I have done a ton of those. We've also done about 10 arthrodesis. Now, these are people who've had 60, 100 dislocations, have very little bone, poorly controlled. And we've actually, we get rid of their dislocation, but that's a miserable operation. They're happy their shoulder doesn't come out, but they definitely have major functional problems. But I think you, in this day and age, this is what you've gotta be, you gotta be able to do this. If you're gonna say you're an instability surgeon, I think you have to be more of a splitter than a lumper. You could take this very, make it very easy and just do laterges on everybody. But I'm not sure that that's the right answer, to be honest. So here's my sort of closing, if you will. This is my algorithm. I do still do arthroscopic Bankarts, with or without a REM plasage. Definitely first timer. Recurrent instability, less than 10% glenoid bone loss. I do still think there's a place for the open Bankart. Admittedly, we don't teach it enough, and we know that people are shy away from it. It's not an easy operation. But once you do learn how to do it, it's pretty powerful also. I do embrace open laterge. And unfortunately, I've had to revise a lot of failed laterges, which are tough operations, and I've usually used distal tibial fresh graft or iliac crest, and been able to salvage a number of cases. They're not normal, but you can save a failed laterge, and that's when I would use a free bone block. But that's kind of my approach. I think the future is young collision athletes still gonna have high recurrence rates. I think we've kind of maxed out arthroscopic soft tissue repair. I'm not sure how much more we could do manipulating soft tissue only. I'm saying not with REM plasage, just arthroscopic Bankart. I'm not sure we can make it much better than what it is at this point. Maybe, I don't know. Maybe additional placation sutures, I'm not sure. But I think we've maxed out, and as I said, I think bone loss will be addressed with the scope, but it's definitely not a transportable technique right now. And I think we need minimum five-year follow-up, and we're throwing all these bone blocks in. We're doing laterges. We definitely need long follow-up with this issue of resorption, because it's there, and I've seen it in every circumstance, whether it's a fresh allograft, frozen allograft, laterge, we see it. And so we need longer-term follow-up, and the holy grail is to see what they look like in 20 or 25 years, because we're operating on kids who are 18, and they get to 20 years, they're only 38. So I think it's really paramount that we get some more long-term studies. Anyway, thank you for the privilege, Dean and John, for letting me spew on. Maybe it was just a recapitulation of everything that was talked about this morning in the sessions, but I really appreciate the opportunity. Thank you. I hope everybody appreciates that. That was amazing. Actually, I have something here. Is it a sip of sunshine? It's hidden. Unfortunately, it's not drinkable. Bob, that was phenomenal. That was like a PhD defense on shoulder instability, and I can't thank you enough for coming to be our Kennedy Lecturer this year. As a small token of appreciation from the AOSSM, I want to give you this crystal memento to thank you. Thank you. Much appreciated. Thanks, everyone. Thank you. Thank you. Thank you. Great young man, brother.

sports medicine

shoulder surgery

shoulder instability

bone loss

arthroscopic Bankart repair

capsular shift

long-term follow-up studies