actually. So this is being recorded. It'll be transferred to the AOSSM playbook on their website. It'll be on the Learning Management System and available next week. So this week's speakers talks will be added on at the end of this week. So next week it'll be available. So again if you have any questions please submit it on the chat function and I'll ask at the end. We'll also unmute the faculty so that they can contribute to the presentation. Though everything we'll ever need to know about bony deficiency and shoulder instability will be answered today in the next half hour to 45 minutes. So we are very fortunate to have Matt Preventer who's a good friend. Matt I think we got to click on your screen to get your thing up. Matt Preventer has been all over the place most recently now he's at in Vail Colorado but he was in Massachusetts General Hospital. Before that he was at the Naval Academy and he was at Navy Balboa. He is the fellowship director at the Steadman Clinic and he's got many many titles and has done many things. So most everybody knows Matt and one of his big areas of interest in it has been about bone loss and shoulder instability and tells you why you should be putting your ankle into your shoulder. So without without further ado notice how well how quickly the weather changes in Vail Colorado. You can see how nice it is from his video of just how it was probably a couple weeks ago to how it how he how he's looking today. Without further ado Matt Preventer. Thanks Matt. Yeah no Mark thank you very much. You know thanks for setting this up and your energy behind this is you know it's infectious and contagious so I think it's really great to have you know someone like you spearheading these and I want to thank all the distinguished faculty and then all the other folks that are on this call. Thank you. This actually we actually did get about a foot of snow the other day so it's it's not over. It comes but it melts rapidly at this point thankfully. So these are some of the things I'm going to talk about today and when you look at age here you've got TV 12 maybe at the far end it's a little there's an app for that I think my kids actually showed me that or what Brady might look like down the road. Expectations whether your contact forced overhead overhead you know I grew up learning on a population that when they did halo high altitude low opening so they would jump out of the plane very high speed plane you know in 180 200 plus 225 miles an hour and the first thing you do is abduct externally rotate your arm and you just can't land dislocated where these men and women are landing in harm's way and so we cut our teeth early and you know we would get these things like I was jumping on the plane dock and dislocated it was really bad because I'm you know one of us six in a squad that needed to complete objective X and that was always hard. We talked about non-operative versus surgical repair and primary stabilization outcomes and we go back to Kirkley's work in 99 also republished again in 2005 won two awards and again the first time dislocator you know just like just like with the ACL and many of us deal with it's not a benign thing I'm going to show you that to talk about this whether you're taking boards whether you're taking your recertification or whether you're just talking to your patients this is this is super important. Surgery gives you better scores early better function and less redislocation rate but we're still not there yet in the shoulder for some reason and it completely blends into why we don't do surgery early but it also blends into what's going on in the shoulder joint and meaning bone loss. So prospect of multi-center study when you look at return to plane recurrent instability this was Dickens and through the multi-center all the service academies recurrent instability of the 33 they returned in season and so if you say you return the season well here's some great data 64% you know until I see you on the phone and when you tell your team that this is you know it's going to be 64% chance and you know maybe it's a little different military population but guess what it's still division one football except for Air Force. So there is a cost of recurrent instability and this is this is what you have the discussion with more labral tears larger heel sacks lesions more glenoid bone loss more capsule injuries more glad lesions cartilage injuries more Alps of tears which are not as benign as we think and then just more off-track lesions these are not benign things guess what the meniscus and cartilage in the knee is having the same effect as with the ACL when it tears I guess since we don't walk on our shoulders we may be getting away with it but the problem is it's not benign especially these younger patients so you have all this data and all this information will quickly go through this but you get more labral tears if you have more instability longer time of instability guess what more labral tears and they're also bigger more glenoid bone loss if you have recurrence if you have more than one time if you have other issues you have more glenoid bone loss it's a it's a fact there's no no question about that you have larger heel sacks if you have recurrence 62% of you have recurrence only 33% in primaries larger heel sacks more recurrence and heel sacks as we know confounds recurrent instability because we're not just dealing with one side of the shoulder joint it's both the glenoid and heel sacks now it interacts we do know there's more capsular injuries recurrent instability provides more capsular stretch more capsular tear more capsular injury I'll show you that in a second with this we showed more dislocations more instability events or if you had an MDI shoulder that was coming out this was not a classic MDI this was like an anterior inferior type of instability person had a long time instability you had much more capsular volume capsular stretch than you did with an anterior and there may be some chicken and egg there but the reality is when we when we did this study was pretty well controlled to have a pretty similar patient population so we felt that at least with a same standard MR arthrogram injection of 12 and a half milligrams of gadolinium or 12 and I'm sorry 12 FCC's of gadolinium we were able to see a pretty good difference in capsular volume based on you know how many times it came out and so inferentially that was about capsular issues we've also shown among others that there's more glad lesions more Alps of tears more problems and so why is Alps an issue my former partner JP Warner has shown that you have a 3x recurrence rate just if you have an Alps of tear if you see on MRI that you have an Alps of tear guess what now you have a three times potential injury for Alps um we looked at this and if you have an Alps of tear there's a good example of it see that red arrow on the left that's a classic Alps of highlighted very nicely by the MR arthrogram fluid you have twice the amount of glenoid bone loss you also had more instability events you had more problems but that labrum healing down there and if you see that well just elevate it up bring it back yeah nuts I would be careful you got to know that you have a higher recurrence rate and other issues and then lastly here's some new stuff that shows you have more off-track lesions off-track and glenoid track has not been found to be a great thing we have a lot more work to do on this but it does tell us how these things are interacting in a bipolar fashion and that's how we have to start thinking about this and so you have more off-track lesions meaning more bone loss on both sides we've also looked at this I think and it's been underestimated we have looked at these two-dimensional CT scans forever but the problem is these have not been formatted correctly and if you just look at the actual CT you can underestimate the amount of bone loss when you actually look at probably what's the gold standard if you look at this from a research standpoint we do we don't do this in the clinic but if you actually measure this surface area in square millimeters usually it's around 600 square millimeters for the for the glenoid that we're interested in we actually can subtract that out and look at the difference interestingly Europe there's many of my colleague and our colleagues in Europe that have put out there that we should do bilateral CT scans we just we just completed a study it's in review actually that looked at bilateral CTs and the guess what your dominant arm has a bigger glenoid so it's probably not even a valid comparison so just getting one side was what we do anyway because the radiation exposure or a good quality MRI or marathon Graham especially three Tesla can be very good you know this goes back quite a ways but the mechanics knowing about it ahead of time how much is enough and treatment strategies are all are all very important but the key is you can't predict this and know this within one minute of talking to your patient you know obviously find out what they do but if they have a high mechanism of injury if the arm was abducted and extended at the time of initial dislocation and these are the key things patient notes of progressive ease of instability or if they have a prolonged history of instability what's that mean a prolonged history of instability from what we've found and our studies as well as in the literature and that's probably not that long probably more than four months not that long three to four months that's chronic and then that the instability occurs in kind of a mid-range of motion of the arm all the way up you can have it here and have instability and so those are so there's things you can pick up easily on history for patients that have a anterior issue we also know that not all bone loss is the same there's an acute fracture on the left and here's multiple instability events in a person that had two and a half to three years of instability you can see the significant attritional loss there was no surgery in this patient the bone just sort of melted away after numerous dislocations we can pick this up on x-ray but in 2020 it's not good enough in my opinion to be able to see how what we need to do with these patients who make thoughtful decisions now if you're Christian Gerber in Switzerland you know he says we overthink this way too much you Americans you overthink it way too much there's too many problems if you have more he says if you have just more than one recurrence that's a latter day if it happens more than once it's a latter day otherwise he would think about scope or maybe an open bank card but you really have to pin them down for that you can also see the hill sacks on several different images here internal rotation striker notch view and others we look at this instability severity index score and certainly highlighted some of the factors that are probably important and things that we were not paying as much attention to and so when Pascal below first published this his score of less than four showed arthroscopic to be a significant bad outcome whereas you have a better outcome than those greater than six what I can tell you this study has been repeated many times and now the score is anything anything higher than three to three point five shows more than a ten to fifteen percent recurrence rate so this adds up very quickly the problem was you know in my population certainly military if you showed up you had more you if you showed up to my clinic your score was above four already and so that that's a problem so even as you'll wash when you pin them down we'll say I think it's time for you know and instability severity index for part two or version 2.0 this certainly helped us there's no question but I think we have to get a little better in terms of what we do we also need to think about this thoughtfully and say okay well they have this much bone loss and you may think well this middle picture I can put that bone piece back but you know what there's not much bone there that it there's all these things undergo a lot of resorption a lot of attritional loss and any of us that have operated on these know that bone can be very brittle it can be very soft but you know if you're dealing with a fracture on the left that could actually be fixed with a variety of techniques and whether it's a bridge technique with anchors or small screws and I think you do have to be careful because the problem is these things are actually they look pretty big on CT scan but you get in there and they're really only four or five six millimeters and that's what makes that's what really makes a difference here here you can see you know they're going to bone loss we look at this kind of well fit circle it's pretty easy to put this on you can easily look at it we actually look in here at the area and you can see the difference but you know you can do this pretty easily with a diameter or you know kind of looking at it or use some other rules of thumb this is a good rule of thumb but about every 1.5 millimeters of loss is 5% and so sometimes we're making decisions from 10 to 15 percent well guess what that's you know 10 to 15 percent is 1.5 millimeters and so if I'm at 12 and a half or 13 percent or you know what are we you know what are we measuring this with you know the packs can be you know quite and quite inaccurate here you can see 32 percent bone loss you know we have to we just have to be thoughtful and I think recognizing it I don't know if it's super important to say it's 12.5 versus 16.5 when you add up the other factors what do they do are they playing a contact sport are they a wrestler where their job is to dislocate the other wrestlers shoulder you're thinking about doing other things for that patient no matter what it's always good to know and be thoughtful about it but sometimes you know if it's a wrestler and I see the x-rays I've got the MRI you know I'm not necessarily getting a CT scan if I'm worried about it and a lot of this can be gleaned on MRI and just like MRI CT scan is very important this is a study we published looking at how we take most of our CT scans and what happens here is you get this these are the cuts we would like to have like that but the problem the problem is when you're in the when you're in the scanner those cuts are about 30 degrees straight up and down and so when you take your actual cuts that's why the actual CT and that's why your XLR MRI doesn't look good and so you're now an average of about 34 degrees off the long axis of the glenoid so you have to what I'm showing here is a yellow lines of how you have to reformat that and your text I'm showing the picture of the tech here your tech can we do that reformat it for you so you can actually get a reasonable two-dimensional reformat when you get it why we like 3ds is the 3d takes all of this futz factor out of it so 2d is a reformat 3d is a reconstruction and so a reformat can give you a lot of bad information and the axle frankly can give you some bad information and that's again what we've what we've shown again and again and you can get some pretty significant differences in AP width based on you know how this is formatted just in the CT scan we do know that a squanoid track is important the Hill sacks being the important issue many times we can get away with either ignoring this based on what we're doing or potentially soft tissue work such as remplissage or just bony work in the front such as latter-day and there are many surgeons out there and Jill Walsh included that would say you know we have the Hill sacks but really the Hill sacks can be treated and politely ignored if you do the latter Jane or if you do a bone graft because you're restoring the art and I don't know if that's fully the case we do have to be a little bit careful on this we do have better clinical application we do have to be a little bit careful this was all extrapolated in a cadaveric situation and I'm going to show this a little bit Giovanni and Steve Burkhardt have obviously helped us understand this a little bit better from e toy and Yamamoto's initial work that was all cadaver based but now we're in this on track off track the off track being bad meaning you put this best fit circle down you then measure the glenoid width and then once you do that you take 83% of that and that's where you are for the run of width so you have to subtract a little bit more here because you're 83% of where the glenoid is so that's a little bit longer and then you have the amount of bone loss and you take 83% of that subtract D from the glenoid width and then you contact the news you can see that you basically are taking 83% of the glenoid width and subtracting the bone loss and then you apply the on and off track and you can see the medial border of the rotator cuff versus where the most medial aspect of the injury is now the problem is what if you have a calculation of 18 millimeters on the glenoid which is what this one was and you have 18 millimeters or 18.5 millimeters here then you have a near track lesion and now what do you do with that well that again is can be confusing it can be an issue and so we're looking closely at the near track lesion in terms of how we how we deal with that but this can this can at least help you with helping estimate those lesions that are bigger those lesions that are estimated to engage easily let's let's be honest you know to get this it has to engage at some point either I'm not pushing hard enough or the anesthesiologist hasn't given them enough muscle relaxation which is usually the case but if you have this lesion by definition it's already engaged when you have glenoid bone loss it reduces this requirement for the on off track lesion because you don't have as much of the lever in the front to be able to prevent this from happening we looked at revising the instability score and looking at minimal differences in latter J and basically we had better outcomes in our bank our patients when we extrapolated CT scan you can see what we did here is we took a CT scan basically did on and off track and just substituted out the plain radiographs which is what Pascal and his colleagues did initially and we found this to be actually much more accurate so here's the same points the same other prognostic factors but we look at the bone loss on CT or actually to get much more accurate in terms of how these how these folks did and so this is what Giovanni and Steve Burkhardt and others would recommend and you know if you have glenoid bone loss less than thirteen point five percent again it gets back to our measurements what's ten versus thirteen point five percent you know honestly that's about point seven to point nine millimeters that's small so we have to be you have to this is the art of where we still need to figure out what's going on obviously it's easy if they're big differences but if you have this off track you know you can start putting other things on the arthroscopic vanguard repair but I would also start thinking about ramp massage because you might have this issue that will give you a lesser outcome if you're around this 13% or you can start thinking about other options and certainly greater than 25% you're talking about bone block procedures whether they're on or off track because they're just a challenge so Michelle Latourjet was certainly a pioneer in all of this and you can see this is a classic Bristow so it was really called the Bristow Latourjet when you really do that I see Jim Bradley there who loves the Bristow and gets great results Jim how you doing and there's a lot to be said about that because this has been done since the 50s and done very well by and it's really affectionately known as the Bristow Latourjet and you get this triple effect you get the bumper of the bone you also get the bone block but you get the bumper of the bone and the capsule sorry you do get the bone block on top of it and then you get this sling effect which actually for about 50 years was theorized certainly by the French to work but not tested until about 2000 2007-2008 by Yamamoto which found a pretty significant improvement in stability by keeping the sling effect intact I will tell you this when you do this and you start dissecting this down and many times we don't see this we really don't want to see this in the operating room but this stuff is right here and you're designing defining a surgical safe zone with the Latourjet you have to be really careful because all of this is very close and once you take that conjoined tendon down it's quite naked and so we have all these numbers worked out now this is I think very helpful especially if you're doing vision work after a Latourjet it's a very challenging case but you need to know where these structures are and they can sometimes be scarred even closer or pulled up even closer especially the axillary and musculocutaneous these things are very close to where we're working and also big red the axillary artery is also very close so when we're deciding about this Latourjet and you're doing a bone block procedure we generally take this in the two-thirds one-third area and we split the we split the subscap I tended to do a split all the time I'll show you that in a reason if unless I really really have to take down part of it then I'll do a very diligent meticulous repair because outcomes of the Latourjet have also been associated with the integrity of the subscapularis as well as muscle volume so once you get through that subscapularis split you have to be careful as you go medially and I use either blunt dissection but I usually you can also start more medial and what I'm showing here with the met scissors I'm coming underneath the subscap and identifying the capsule if you look at some of this if you did a tenotomy but and then also repaired it just by doing a tenotomy you had 28% loss of strength reduction with significant significant post-operative difference both in constant scores tenotomy versus split so really one of the cool study that's actually shown us really clinically that even a tautomy and repair is much more than a split. So I really try to do a split if we can. There's a lot of different ways to do it. If you look at this study as well, you can see more fatty atrophy. Excellent. The other thing to look at is when you're harvesting, we wanna stay out of the trapezoid ligaments. Now, honestly, I think we probably get a few millimeters of the fibers, but when we look at this, Jorge, Chalo, myself, and other colleagues did this study looking at the actual length of the bone graft we get and then how many angles we can get and sizes and et cetera. What's pretty cool here, and I go back to that, that's the oscillating saw right there. If you look to the hub of the oscillating saw right to the edge of the bed, that's our typical 90 degree one, that's 25 millimeters. So I use that to score it, and I score it on the top, I score it medially, and then I score it laterally. And then we're taking great care to preserve, you know, to protect this medially. I put my finger, you can see here, I have a small, gentle retractor. I usually use just a cob or some blunt retractor, but you can see, I do not want to put anything medial, but you can see how you roll over the top, and you're able to at least score it, and then you can complete it with osteotome, or you can do it with all osteotome. I like doing this because it helps me get the correct size, which I want to be about 24 or 25 millimeters. I generally use a curved half-inch osteotome, and we gently keep testing it, we're gently levering it. When you get that curved half-inch, you can see it's mostly off, and then you know that this is, I feel good about this, because I know it's levered deep, because it's down into the elbow area. So then we got this piece, we put a clamp on it, that's on the CA ligament, and then right there, you can see the elbow. So we just took just enough of that bone right down the elbow, which is the max for this person, but you can plan this out preoperatively, and then release all the tissue, and then actually dissect out the, just down to the level of the musculocutaneous nerve, so we remove all the pec minor fibers. I do keep, I have that retractor on the CA ligament, and what I'm measuring here is, we're actually putting our bone tunnels. You can use proprietary retractors, and also proprietary drill guides and sleeves, but I also just mark it, just to give myself a gut check. You can pre-drill this, or you can drill it after you put it in place. You can put just small K wires into it, to hold it in place when you get there, but the reality is, you just wanna tuck this in. What I have there is a CA ligament latally, about a centimeter, and all the pec minor peeled off, and then everything posteriorly is meticulously dissected with tenotomies. We then get to the glenoid, and this is gonna be the same for all, and this is through a subscap split. I like using a power rasp, and other types of rasp. I do like flat rasp, because it just causes less gouging. I also can use a K wire. I mean, I am using a round one here, but you can see I do get a power rasp, which is a flat, there you go, you can see that right there, that's a flat rasp. You really wanna create this perpendicular environment. Both ourselves, and Peter Miller, and myself, we looked at all the difference, in terms of classic and congruent arc techniques, and how the latter's A, and how the orientation is, and you can see that the failure load is actually a little bit better with the congruent arc, but you have to cut a little bit of the bone out. So when you're taking a congruent arc, you usually take about 30%, that's when you rotate it 90 degrees, so that the inferior surface of the coracoid becomes the glenoid face. This is, I generally use solid screws, that are generally 4.0, or 4.5 millimeters. I've seen a lot of issues with cannulated screws that are under 4.0, or maybe 3.75 size, so I'd be very careful about cannulated screws, but I use a, usually an overdrill type of situation, so either a 4.0 lag technique, with a 2.5 in the back cortex, or a 4.5 with a 2.5 in the back cortex. Also, I also put this suture washer on the end, to be able to help manage capsule, and top of the CA ligaments, so you have a little bit of backup if you need to, and that's a tension slide, a suture that goes through that washer. So generally, we're in the 23 to 25, 26 millimeter range. Jill Walsh does not do this, his Later-Jay takes about 30 minutes, but he does a subscap split, goes through the capsule, goes down to the glenoid, puts on the coracoid, and then closes the subscap. I have traditionally done a little bit of the capsule separation, repaired that to the front, you can also use suture anchors, but you have to be careful about posteriorizing too much your repair, and then you tie the subscap, just lateral, to the subscapularis, usually with some type of number two non-absorbable suture, usually that's about three or four, and you wanna stay out of the biceps, so with all the split, you make sure you wanna stay out of the biceps area, and I've seen a couple of those with Popeye deformities after Later-Jay, so you have to be careful. So there are a lot of long-term outcomes, the least of which is this study, Mullet, who had 822 patients, 10 years of follow-up, returned to play 85%, 76% to the same level, which actually, when you look at instability, is not too bad. The instability recurrence rate, 8.5%, so people that talk about a two, three, four, 5% recurrence rate in Later-Jay, it's not true. It's in really scrutinized literature, and we just did a systematic review on this, it's anywhere from six to 12, 13%, depending on how you classify instability. Certainly, dislocation is a little bit harder, but a recurrent subluxation in the shoulder not feeling right is a challenge. Now, to be fair, some of that might be due to subscapularis issues or subscapularis atrophy, if you've done a tonotomy, or there's issues after even the split, so you have to be careful about that. And then the sobering thing is arthritic changes in 38%, so this is not benign. We looked at the Later-Jays at the Combine, we had pretty significant, and my theory on this, and certainly I'd love to get Jim Bradley's thoughts, as well as others, is there were hardware complications in six out of 13, graft resorption was significant in eight out of 13, and these folks dropped very low, and their numbers are all in the draft, and probably much lower than they should have gone, even if they were drafted. So you have to be really careful. My theory on this is, I mean, number one, there's obviously a technique aspect to it, and some other things, and certainly in between a rock and a hard place, so this is the option, but contact football, and when you're tracking them, and when you're using next-gen stats, or using the catapult system, you guys are going 20, 21, 22 miles an hour on kickoffs, especially the gunner, and if you are hit by that player at 20, 21, 22 miles an hour, this ain't rugby, that's different. It's a very different sport, and so you got this significant load, the arm out to the side, and I think that conjoint actually can be an issue, in terms of how you, how it behaves, and is actually centrically loading, and pulling through the Latergé more than we'd like. Not all athletes are equal, obviously, but we have, here, a higher return to sport after arthroscopic, a shorter time to return to sport, though, after Latergé, and here's a study looked at primary Latergé with better outcomes for us, but it's not perfect. These are all things easier to my patients, or patients that have been sent in to me, but these are all issues that exist. Pull-out, arthritis, heart issues, coracoid resorption. I asked the graft companies, and had fresh glenoids on order, back, going back to about 2004, 2005, and I just couldn't get them. They had an issue, the graft companies, they're all by federal government, will have to be non-profit, but they are still accountable to respect the donor, and respect the process that the donors go through, and on average, every donor amounts to about 120 to 170 separate lots of allograft tissue. It's pretty amazing, and that's bone, that's chips, that's spine stuff, that's skin, so 110 to 160 lots that can be put back to use. If you have a grade three contamination, clostridium is one of them, among others, and that contamination increases as you go more central to the body, all of those grafts can't be used, so on some of that, it's a big decision about respect of the donor, and others, so it's very hard to get central grafts, and certainly, a four-quarter amputation and getting a glenoid was hard, so I said, well, what don't you use, and this was in 2006. Well, we throw away a lot of distal tibias, our foot and ankle guys are using a lot of the talus, but the foot and ankle surgeons, we process these, because it's part of the joint, but we don't use any, and said, well, send it to me. We did a lot of testing on it, and basically, here's some unmatched working that we found, unmatched work, we found some really good, really good match, and so, what are my indications at this point? Large, very large bone loss, and especially young patients, certainly a failed open bank card if you have bone loss, certainly a failed laterge is a great indication for this, or if you have significant bipolar lesions, and a lot of times, we're thinking about doing not just a distal tibia, but also a fresh graft to the humerus, which, guess what? Since a tibia fits, I don't want to offend any foot and ankle surgeons here, but I have been using quite a few talus now to be able to nicely fit the heel sacs, especially reverse heel sacs, which is all cartilage. We looked at these. I stopped for about two years after doing my first one in 2007. We did quite well. We looked at the interface healing. It did have resorption, just like we do with a laterge, but if you look at Giovanni Di Giacomo's work with a laterge, 57% of the bone resorbs after a laterge. Guess what? The outcomes are still fine, but we didn't find as much resorption here. I think probably, I did it first because I was making the grass probably too big because I was worried I needed a big platform. I didn't want to dislocate. I didn't want to have a problem with it, but actually, I think matching it or maybe matching it plus a millimeter or two is actually important. These are the new concept I mentioned about the near track, and so now we're segmenting zone one, two, three, and four. This is now getting really into the weeds, but Yamamoto found, I pushed him on a meeting a couple of years ago. I said, we need to look at the near track here, and so he was able to start work on this and see that here's how he defined some of the zones. There's some work out there. I still think it's going to need a lot of work to finally get us to where we need to do. I consider a talus fresh allograft. First of all, it's readily available, and many of you may have done fresh humeral head allografts or frozen humeral head allografts or maybe frozen femur, but I can tell you up to about 40 to 42, 44 millimeters, especially if you're using a male talus to a male patient, you can get this to fit very well. It's very dense bone in the talus, obviously, and you can see very nice, good fit. This was a case with severe bipolar bone loss, just to show you some of the issues of a 38-year-old. You can see he had very significant loss in the back, some loss in the front, and a pretty extensive reverse heel sacs, and so we're doing sort of a combination approach here and a double allograft approach where we ordered both a talus and a distal tibia. Just FYI, that cost overall is about the same as a fresh hemicondyle for the knee, so it's about half the price as a hemicondyle for the knee, but if you do both, then it ends up being hemicondyle for the knee. So you can see this very significant heel sacs, reversal, missing about 30-degree arc, and that's the problem with the reversal sacs. I actually think it's a bad term because it's all cartilage, and you can see how it's all humpty-dumpty, cracked in eggshells there. We then are able to take down the top three centimeters of the subscap, which we've already done here, and then prepare this. We do some measurements and then employ Woodshop Class 401. I actually do some 3D printing on all of these, so I 3D print. I actually sterilize the model on the back table, and so it's a closed 3D model that we can sterilize and then actually put on the back table and do a reverse mold. You can use bone cement or something else and do kind of a reverse mold. You can also use bone wax, which I've used, and then that makes it much easier, but when I first started these, I wasn't doing that. I wasn't doing 3D printing ahead of time. So you can see I was starting with this. It's a little too big, and we just keep Woodshop 401 going back and forth. I put one K wire in so I don't inadvertently drop this thing, obviously employing the allograft principles, and we machine it down to the final pulse lavage. I do use PRP in this, or sometimes bead mag, and I do a soak, and you can see we put this in and we're able to keep our lesser tuberosity intact, repair to that. I use a headless titanium compression screw. It's just been my workhorse for these for a long time, and it's done very well. And you can see, make sure we recess those well below the cortex. These things fit very well, and you can see an unmatched talus that fits here really nice, and I can tell you the same thing in the back is if it gets into the cartilage and gets big, it's a really nice option for you guys to have out there, and here's what you can see. This was the front and back graft. You can see the reconstructed glenoid and then the reconstructed hillsacks. So this is obviously a huge topic. I just wanted to show you on some of the things that we've been thinking about and how we sort of approach the patient and their indications. We do try to use this glenoid tract instability management score. We just had that published last year. DTA is a great option for large glenoid bone loss, revision latter J, latter J for bone loss if you're concerned or higher risk, but certainly less than 10, 12, 15% and not a huge hillsacks. Again, let's not throw out the good scope bank or if it's done very well, it pays good attention to inferior, posterior inferior and addresses all the pathology. Thank you all very much. Matt, that was great. I appreciate it. I've started to unmute some of the folks. First up, of course, the U.S. Air Force Academy physicians. We're gonna start off with asking some questions. But in all seriousness, that was fantastic. Great overview. The boning deficiency. I'll tell you, when I was doing more shoulder stuff back at Kaiser and I was doing open shoulder instability operations and we used to take down the subscap, about 40% would actually still have, 30 to 40% would have a positive liftoff sign even though they had evidence of it being impact on MRI. So I think you're thinking about splitting subscap. I would agree with you 100% on that. That's amazing you had that mark. I feel my knots get in the stomach every time I do a takedown on some level of subscap. And obviously, arthroplasty and totals are different, but I still get knots in my stomach. And more and more, we're doing these free bone grafts now arthroscopically. I started doing some arthroscopic latinergies and did quite a few, but at the end of the day, I've been much happier with a free bone graft. Now pick your bone graft. It doesn't have to be a distal tibia. You could do an iliac crest, you could do others. Distal clavicle, as JT has shown us. I mean, there's a lot of options out there, but for me, it's mostly been the distal tibia or iliac crest, depending on the situation. I think that ability to do it arthroscopically really takes down a massive issue that we were having in the shoulder, which is that subscap. Yeah, yeah, I mean, I always worry with the graft, and you talked about it, is the graft resorption issue. So Dr. Manova said, Dr. Preventer, great talk. Can you give me a sense of how patient age factors into your treatment algorithm? Do you change, do things change when your patient's 30, 50, 70? When does reverse total become your primary procedure choice? Yeah, no, I mean, great question. I mean, age is one of our primary predictors still in instability, so whether or not, I think that's an indication question first, and then from, say, a bone graft side, so now you're dealing with an issue. I don't hesitate that, I look at my age, and I'm in one of those categories now that's getting older, is I look at it, I'm like, you know what, if I had a significant bone issue and had multiple recurrences and tried to treat it, but I do, it's amazing, I do see some of these late 30s, early 40-year-olds are like, okay, yeah, you're in the demographic, you're gonna be able to live with it, it's gonna heal. You know what, it depends on what you do, and those are the ones that you're gonna get bone loss. Why, because they keep coming out, they keep having some subluxations, they keep having nutritional, you know, on top of the ones that are in the younger age group. So I treat the pathology, but also keep in mind their age. I will tell you, I have done some of these in anticipation of arthroplasty. If they have significant loss, a 72-year-old with a shoulder dislocation, massive cuff tear, massive bone loss, I have used the Coracoid before doing Reverse to reconstruct the glenoid. I have also used Iliac Crest, I've also used distal tibia, and I've actually reamed into all three of those bones after they've healed, and it's been a very good option. I've also done them primarily all at the same time, so, you know, being a good bone grafter of the glenoid can also get you out of jail, like the 70-year-old doctor that you mentioned, to be able, you know, if you do have a significant glenoid bone loss. We're not talking about burial loss, we're talking about anterior bone loss, usually from a dislocation, or dislocation arthropathy, or something else. Dr. Bradley, Dr. Provencher called you out to comment earlier, you wanna comment? I've unmuted you. Yeah. That's very dangerous. You're unmuted, Bradley. Now you're in trouble. But he's talking tomorrow, so, you know, we have to, you know, bring him out. Yeah, I changed my topic because I didn't wanna steal his thunder. Can you hear me? Yes. Very well. So, here's an issue that we have. They come into the combine with the latter J. They're resorbed, there's resorption, they've got the screws in the wrong place, and now we got a problem. So I just wanna put this out there before we go do that. You know, Mike Pagnani has showed great results with an open bank card, disregarding the bone completely in American football players. And his results were pretty, pretty good. Matt, you would agree? I agree. Okay, so my point is, why not do that first? You know, if you're in between, if you're a tweener, and then you can always go to a bone block procedure. Now, I'm not gonna grade you poorly. So in other words, your grade, if you walk in with a ladder J, is right away, you've got significant risk. Because if you fail, I've gotta go to a distal allograft, tibial allograft, right? And there's no research on the NFL with that. So now I'm screwed, right? So my coach goes, can you fix this? I'm going, well, I don't know. But if he comes in with a good bank card that fails, I know I can go to, in my hands, a Bristow, because I trained with Frank Jobe, in your hands, a ladder J. So now I've got a little wiggle room. So why don't you talk to me about when open bank card is appropriate? Yeah, you know, Bradley, you always have good questions. Very practical, you know, for being a Steelers guy, it's pretty fitting. Yeah, well, that picture with your boy there is just too much. It's caused you a lot of torture over the years. I know, I know. It gets your stomach in knots. I get it. So here's the deal. Arciero talks about this all the time. He's like, how do we go from A to C and, you know, forget, you know, the arthroscopic, all the way to the coracoid, and he calls it the B. How do we not do the bank card, meaning the open bank card? And he left out the B. And Pagnani, others have shown us very well that the open bank card works wonderfully. It is honestly my go-to in a trainer patient. If I've got a five, 12, 15, 20, 28%, maybe even more, and certainly in a sport like the NFL, I would lean to doing an open bank card. There's no question. And it's exactly what I talked about. I think that conjoint tendon is pull and that eccentric contraction on that that's attached to a number. It's not just one muscle it's attached to. I think that extreme contraction is an issue at 20, 21, 22 miles an hour for some of these folks down the sideline. Now, if you're in New Zealand or you're in Australia or you're in South Africa and a rugby player gets a dislocation, guess what they say? They want, doc, just give me the bone graft. All I want is the bone. Because they know it works well. And why is that? They don't have pads. So they're not doing the same thing, but it works great in them. And they get it back in play very reliably. Now you probably could get away with an open bank card as well, but here's where I think we really have to titrate down what that athlete's gonna do, what that person's going back to, because these procedures are not all created equal. And I fully agree with you. Once you get down that Latter-day path, it's a very tough, it's a very nerve wracking revision. And I've revised hundreds of Latter-day's now. And the number keeps increasing. I just have two more points and I'll get off. My first point is this. The fellows come into our programs, they have never seen an open bank card. Now I was trained by Frank Jobe, who probably did the best one you've ever seen in your life. My point is, we have to teach them that, and they have to have that in their armamentarium, because when they're in there arthroscopically, and they get in trouble, or they're not doing it, they need to go to that before they go to a bone block procedure. Would you agree with that? I agree. Maybe the OSSM president can make a part of his presidential decree this year. My second point, just my second point. But I love it. I'm 100% on board with you. I send our fellows to the lab all the time, talk to Arnor, talk to him about it. And not only when we're doing the open arthroplasty, every time I take them through an open arthroplasty, I'm saying, okay, let's look at it. I mean, it's arthritic. Let's look at a capsule, let's separate it out. Let's take a few extra minutes here. This is how we're gonna do the Vanguard. I mean, you're still taking down the subscap, or ignoring it anyway, in a reverse. So you can get away with that. Get creative in our teaching, guys, to be able to show this. I think we absolutely have to show it. I would have loved to have learned from Job. I mean, it was a very, very elegant, you know, I've learned from Jill and others on how to do an open. But there are about 20 different variations on the open Vanguard, and it's the real deal. Just one more thing. So Neil Elitrage, you know Neil. He does bristos the same way I do them. And he put his bristos up against his partner's lat herzes. And you know what happened, didn't you? Neil's resolve was actually- How much bias was in the study? Of course, maybe there was. But my point is, they're surely equal in someone that was trained at Curl and Job. Yeah, and there's, you know, there's no, so when I, our article that went back and looked at Jay Cox's bristos at the Naval Academy from 1970 to 1975, it's actually the longest long-term study in literature. They're all Naval Academy. I found them all through the Naval Academy network, called them all, brought them all in, got their X-rays. The recurrence rate was 14% at 25 years. They did have arthritis on about 40%, just like the rest of literature. But they were very stable and they got through their careers. The bristo by Jay Cox at the Naval Academy in the 70s was unbelievably good. So you're right, I don't think so. But I do think we're heading down a pathway where if we can do this well arthroscopically, if we can do it safe, if we can do it reproducibly and restore that bone arthroscopically, we're gonna take, we're gonna be able to, I think, complete the Holy Grail. We're gonna be able to do the bone, not morbidly, have an anatomy issue, have a very non-anatomic solution to this. And I do think that the bristo, a Lander and a Latter Jay, is a good solution in the right patients. Thank you. Let me ask the faculty, since you've got Steve Cohen, Winston, Guathame, Seth Latul on as well. And Jim, obviously, you've made your point, I think, but just curious, I mean, do you guys also do open Bankarts for your patients? In my mind, I used to do it when I was up at UC because I realized that the fellows weren't learning how to do open shoulder anymore. And so just so that we make a point of doing some so that they got used to the open approach or bailout procedure, if you will. But are you guys doing open Bankarts or is it arthroscopic onto Latter Jay or bristo? So in the revision setting, I'll do an open Bankart or a capsular shift if some were open, but typically arthroscopic and then onto Latter Jay normally. But sometimes in revision, I'll do it. Steve? Yeah, I think Jim's point is great, is that the ability to do an open Bankart needs to be there. I mean, you have to have that in your armamentarium and it doesn't matter at what phase you are. Again, there are roles for arthroscopic, there's roles for open, and then there's roles for Latter Jay. I mean, we've seen it all, but you have to have the ability to do that. And I think, you know, Jim's point is he takes care of contact athletes and so does Matt. But, you know, the open Bankart and the elite level football player, I mean, it should be, it should really be considered. Steve, I like that your hair is almost as long as mine now. The- Thanks for noticing, Matt. We do this, so shortstop, second base, open Bankart, no problem. Throwing shoulder, shortstop, second baseman, whipping it, no problem. No, no, but we're talking about- How about a pitcher? How about a pitcher? No, again, you're talking about a different patient population, right? I mean, you're talking about the contact or collision athlete. And, you know, the thrower that has instability is a totally different, and Jim's gonna talk about this, you know, I know in post here, but it still applies anteriorly as well. You remember a guy named Oro Hirshhiser? He had an open Bankart by joke, because I did it with him. I think he was a fairly good pitcher after that. I'm just saying. Bradley, you're old, man. Latone? Yeah, you know, yeah, we do some opens, mainly a revision, but this is hard, because, you know, when I trained as a resident, that's all we did was open Bankart. It's a very elegant procedure. And I'm not sure we are churning out enough open cases from a capsular shift or Bankart standpoint for our fellows, even though they may see a few. I'm not sure they're gonna leave and be proficient at doing it, because they weren't doing it in residency. So it's tough, but yeah, I'll do some in some revision situations for sure. Seth? Well, it's hard for me, because I'm a lot younger than Latone. So in my training, you know, I did not get the exposure or the learning curve to open Bankart. Although HSS Heritage, we talk about it, and, you know, they certainly do there. At Rush, we didn't do as many, and I don't do as many in practice, but I agree with all points made. I would just add, not every arthroscopic Bankart's the same. So going around, you know, taking care of the inferior hammock, getting around posteriorly as well on an anterior, doing not one to three anchors, but, you know, four, five, six, or more on these big guys, adding remplissage, you know, I think those are all things I think about, you know, before jumping. No, you know, to that point is, I think I've seen two or three high caliber wrestlers in the last several months, all of them for failed arthroscopic. For me, a wrestler is, I don't even need to get studies. I can do x-rays and do an open Bankart, because they're just in such extreme positions. I do think there's probably some other sports we should consider this, but we have to, you know, we have forced contact, we have forced overhead, we have some of these other things, but we've kind of, we've been, we're very lumpered, you know, contact or not contact. It's much grayer than that. We have to be better. Contact in rugby is different than contact in NFL, just like we talked about. We have to be better about this for this particular condition. Can you explain, Matt, what exactly do you think is better about the open Bankart than a really well done expert arthroscopic, like, you know, for the young guys and for me? Yeah, you know, probably at the end of the day, it's just all about scar tissue and healing. And it's, you know, you can talk about all the differences. You know, even all, that's number one. Number two is, you know, if you're doing a classic capsular, you know, Job shift, then you'd get the capsular shift with that. And, you know, some level of pants over vest. You know, if you believe all the way down to the T-plasty, that's what I'm telling you, there's about 15 to 20 different ways that have been described to do the open Bankart. Depends how you do it. Medially based shift, laterally based shift. You take, how do you handle the labrum? How do you, you know, put your anchors in? But most of them are generally anchors on the glenoid. Some level of capsular leaflets that you're able to fold over and imbricate or do something with that. So you're getting a much different operation. Now we threw in arthroscopic rotator interval. Why do we do that? Because we felt we needed to do more than we were doing for the open Bankart. That's why that was all thrown in, but that didn't work. It doesn't work. It doesn't help you. Jim, you wanted to say something? Yeah, man, I want you to, I'm going to put your foot to the fire, okay? So what bone loss are you talking? Are you going to go 13.5? Are you going to go 20? So these are the scenarios, okay? So there is amount of bone loss and it's on track and you're going to probably do some kind of arthroscopic. Is there some kind of bone loss and it's off track and I would bet you're going to do arthroscopic REM plissage and then there's going to be amount of bone loss and then that amount of bone loss, you're going to say, nope, we're going immediately to a bony procedure. What is the bone loss number? Is it 13.5? Is it 20, 25? What's that number? Yeah, I mean, to be fair, you know, every 5% is 1.5 millimeters. So we have to keep that in mind. That being said, I think with that, there's a range. And again, it gets back to who you are and what you do, how long you've had it. So things I look at are what type of sports you play? What are you going back to? Number two is your age. If you're under 25, you're in a bad category. Number three, if you're in that 10 to 20% bone loss, you're in a bad category. Number four, if you've had more than four months of instability symptoms. So if you let someone, Jim, go back and play high school, you let them go back and play college, you let them go back and play pro and they got three or four months left in the season, guess what? That's not an arthroscopic repair. Just from that one variable alone for me, that's open or potentially bony procedure. And then the prolonged history of instability and then history of progressive ease of dislocation. So those are my main factors I'm looking up. So guess what? The history is super important here and what they do and who they are. We always talk about all these imaging because it's cool and easy to look at, but it's so much more. The image is just one part of it, Jim. But I think you're in that 10 to 20% range with some of those other variables ticking off as, yes, that's an easy open bank cart or a bony procedure for me. So Tim Wang asks to continue in the tweener discussion, where does rump massage fall in the algorithm, especially versus open bank cart? Yeah, so rump massage has enjoyed certainly some success in the literature, but it's also produced some other issues that we haven't been fond of. If you look at Pascal Below's work, posterior superior shoulder pain, what anterior instability patient has posterior superior shoulder pain before they come in? None. If you don't have posterior superior shoulder pain, it's a problem. That's a big issue. And now you're dealing with all kinds of other problems. So that's about 30%. I think that's becoming less and less. You do lose some motion with it, but let's be honest, we lose motion with all of these procedures to a certain extent. I think rump massage can be important if you have a heel sax that is not too medial, meaning if you can put it in the footprint where it's still pretty far lateral, if your heel sax shows up in the first one or two axial cuts on the MRI or CT, and it's not medial, and it's not into the cartilage area posteriorly, then I'll add in rump massage. Certainly more than 10% bone loss. And then again, if they have aggressive ease of instability, some of these other things, and then probably over the age of 25. Again, if I'm under the age of 25, usually these other factors are playing in. So I actually looked at my rump massages. I don't have a lot of rump massage under the age of 25. I'm doing other things. So you had opened the door also about baseball. I know though Jim's gonna be talking more about things, but you threw out second baseman and all that. So Will Workman's on the call from the Oakland A's, and I think he also has a question for you. So Will, you're unmuted, man. Oh, thanks, Matt. Thanks for a great talk. I actually- Hey, Will, thanks. I was at Mass General before you became an attending there, and I did a lot of open bank arts with Dr. Zarens, who learned from Dr. Rowe, and he was a very slick, elegant surgeon. I happened to be a little bit of a rebel, and I straightened a practice and started doing arthroscopic, and I pretty much did that. Dr. Zarens let you do that? Well, yeah, I don't know if I've ever told him, but I had a chance to spend some time with JP too, so he was wonderful. That's great. But in my mind, and I don't know the answer, but my biggest concern when I go in is what the capsule looks like. I'm fairly aggressive when I do my shift arthroscopically. I think I can get a good shift in any situation as long as the capsule's good. And so the times where I go in, sometimes on a primary if there are multiple dislocate, or sometimes a revision, and the capsule doesn't look very good, that's when I get concerned. But I still do the procedure, and then I say a little prayer, and hopefully I don't have something else happen. And then just as far as overhead athletes versus contact, again, I think having a lot of experience in arthroscopic Bankart repairs, I feel like I, yeah, it's a little bit of art to it, but I feel like I can dial in the shift a little bit with a capsule. I always take down the labrum, and I always use anchors, and shift the capsule and labrum together and make kind of a super labrum with the capsule. And then I wait till they fail again before I do a bony procedure. I agree with Dr. Bradley. Looking at hardware when you're trying to draft guys, and the resorption is a problem. And I wanna end with a question to you. You mentioned about hardware before. Obviously, solid screws versus cannulated screws make sense when it comes to screw breakage. Do you think it has any influence on healing and resorption of the graft, having a more solid fixation? Yeah, and first of all, your points are all exceptional, especially for someone who's had as much experience you've had to be able to have such a great open experience, and then come into the arthroscopic Bankart. I think you know what it needs to look like at the end, arthroscopically, because you've done it open so many times. And that's, I think, a very important point that just seeing arthroscopic, you don't know what that open looks like. So, I think your results are gonna be better because you know what it has to open look like. And then, I don't know if I can honestly answer your question. I don't know. What does everyone else on the panel think? I don't know if I can honestly answer it. I don't have the information. I don't know that I have any data on that. Does anybody else have any with the cannulated versus solid? No. Well, you're leaving us perplexed, man. Well, yeah, I don't have a better answer. I mean, obviously you want to have the best fixation. And, you know, I think we, Mark, we had a case the other day in a talk where the screws broke and the guy did fine. And they often do. I just, and again, you know, when it comes time for the combine or recruiting guys to the next level, and you see, you know, the CTs and the x-rays can look a bit concerning, and it may not disturb the treaters so much, but certainly the front office gets a little scared with that kind of thing. Well, I can tell you about one of mine. I did a linebacker, middle linebacker from out West. He came in because he needed a bony procedure. And we did him. He went to the combine and his screw, his top screw was bent. And sure enough, the guy was drafted in the second round and played for multiple years. And then when I saw him back again, his top screw was broken. He has no symptoms. He's perfectly fine. So the top screw tends to resorb in everybody I see, because it doesn't see enough stress. At least for me, the top part of the laterge goes away. So Matt, do you see that? I mean, because it doesn't see any stress. I mean, there's people out there like JT will tell you, look, we need an anatomic glenoid, right? So to make sure the whole thing sees stress. So what do you think about that? Yeah, no, I like the anatomic glenoid part. The problem with the coracoid is, many of the times, historically we've made it extra capsular at the bone graft, or at least it's partially extra capsular. If you look where the CA ligament is, and if you hook it into the CA, you're only getting about a half to a third, maybe two thirds, depending on where that CA hooks in. The CA doesn't hook at the top where you put it. It's a confluent, it's confluent in the center. And so, you're sort of making this partially extra articular on some level. There's no question it absorbs. I think we need to be on our nomenclature, though. And what we're looking very closely at is interface healing. And we want the interface healing, because we know we're gonna get some probably Wolf's Law, Wolf's Law remodeling, look at Giovanni's stuff, 57% of the bone goes away, but they still do very well. I do think that top screw is probably under more conjoined tendon issues. I think that conjoined tendon is, depending on where you put your split, even a five millimeter difference in the split can add a lot of stress and a lot of pull to that healing. And I think that's where we're going to the more anatomic and free bone graft, because I personally think we need to take the conjoined tendon stress out of there. And I don't think it's as much of a blocking effect as we've made it out to be, having that triple blocking with the sling. I don't think we need it as much in some athletes. And I think free bone blocks can help us much more, especially arthroscopically. All right, a question here is from a fellow Navy kind of guy for you here, Matt, from Mike Pullen. Dr. Preventer, great talk. Can you comment on the role in your practice, if any, of revision arthroscopy for failed arthroscopic stabilization, especially in the setting of minimal bone loss? Hey Mike, how you doing? Great question. So I would say, there never is a usual word we don't use in orthopedics, but it's pretty rare for me to have a revision arthroscopic. That being said, again, it gets back to some of those factors. And if you really scrutinize what the bone's looking like, you know, what the capsule's probably looking like, if you had an MR arthrogram and looked at failures, your capsule, you know, back to Bill's point, your capsule's probably way more attritional than you think. The labrum's way more attritional than you think. So every time I go, I've gone in to revise my own or others in arthroscopic Bankart, I've been underwhelmed. That being said, I do think there's certainly some areas where you can think about that. And the age group that I'm thinking of is 30, 35, maybe 40 or over. Those that have rotator cuff issues with a dislocation, plus a Bankart, you know, say the Bankart doesn't do well, their cuff heals, pretty rare situation. But for me, it's usually some type of an open or something else, depending on who they are, especially if they're younger. All right, well, we're over time. I want to thank Matt for awesome, awesome talk as always. I always learn from you, Matt. So it's awesome, it's great. Looking forward to Bradley tomorrow, taking the front seat on the arthroscopic management for the posterior instability, actually in the throwing athlete. And thank all the faculty for their contributions and the questions. So y'all have a good evening and thanks, and we'll see y'all tomorrow. Thank you all, great pleasure. Take care, thanks, bye-bye. Thanks guys. Thank you, bye-bye guys. See ya.

bone loss

shoulder instability

ankle placement

Latarjet procedure

long-term outcomes

distal tibia

talus bone

surgical techniques

personalized treatment plans

research