WEBVTT 00:00:00.000 --> 00:00:02.560 Okay, let's jump straight into it. That moment, 00:00:02.660 --> 00:00:07.700 your shoulder just gives way, pops out. Awful 00:00:07.700 --> 00:00:10.779 feeling. Instant pain, major disruption. But 00:00:10.779 --> 00:00:12.779 what's really frustrating, isn't it, is how often 00:00:12.779 --> 00:00:15.119 it happens again. That's the real problem, recurrence. 00:00:15.400 --> 00:00:17.379 We've been digging into the orthopedic literature, 00:00:17.579 --> 00:00:20.280 JAAS, and others, and some numbers are pretty 00:00:20.280 --> 00:00:23.660 stark. Yeah. For certain young, active patients, 00:00:23.739 --> 00:00:26.239 you know, after that first traumatic anterior 00:00:26.239 --> 00:00:30.250 dislocation, if they don't have surgery, nearly 00:00:30.250 --> 00:00:33.149 nine out of 10 might dislocate again. That statistic 00:00:33.149 --> 00:00:35.409 really sums it up. It's the core of what we're 00:00:35.409 --> 00:00:38.289 looking at today. Shoulder instability. Mostly 00:00:38.289 --> 00:00:40.469 traumatic anterior instability, right? That's 00:00:40.469 --> 00:00:42.289 the common one. That's the most frequent presentation, 00:00:42.509 --> 00:00:46.509 yes. And it's not just about reducing the dislocation, 00:00:46.549 --> 00:00:48.689 getting the ball back in the socket. No. It's 00:00:48.689 --> 00:00:50.549 fundamentally about understanding the damage 00:00:50.549 --> 00:00:53.429 done, often over multiple events, and how that 00:00:53.429 --> 00:00:57.299 damage makes the shoulder, well, inherently unstable. 00:00:57.780 --> 00:00:59.600 Exactly. So this deep dive isn't just about a 00:00:59.600 --> 00:01:02.039 simple repair. It's about how orthopedic thinking 00:01:02.039 --> 00:01:05.959 has moved on. It has. Towards much more precise 00:01:05.959 --> 00:01:08.760 diagnosis and really tailoring the management 00:01:08.760 --> 00:01:11.719 based on exactly what injuries you find. So our 00:01:11.719 --> 00:01:13.780 mission, pulling from these sources, is to get 00:01:13.780 --> 00:01:17.180 a handle on the current evidence. Spot on. What 00:01:17.180 --> 00:01:19.719 are the key factors driving treatment? How do 00:01:19.719 --> 00:01:22.219 surgeons pinpoint the real underlying problems? 00:01:22.700 --> 00:01:24.840 And crucially, What does a successful outcome 00:01:24.840 --> 00:01:27.319 actually look like, especially in stopping those 00:01:27.319 --> 00:01:29.939 repeat dislocations? That high recurrence rate, 00:01:29.959 --> 00:01:32.760 particularly in young, active people, it really 00:01:32.760 --> 00:01:35.500 stands out. It sounds like the who matters as 00:01:35.500 --> 00:01:37.760 much as the what. Oh, absolutely. Patient selection, 00:01:38.000 --> 00:01:40.879 understanding their specific risk profile. It's 00:01:40.879 --> 00:01:42.780 crucial for predicting the outcome and hopefully 00:01:42.780 --> 00:01:44.599 getting a good one. And what are the big risk 00:01:44.599 --> 00:01:46.859 factors the literature points to? Well, there 00:01:46.859 --> 00:01:48.760 are a few key ones that come up consistently. 00:01:49.000 --> 00:01:51.299 Younger age is a big one, especially under 20, 00:01:51.379 --> 00:01:54.079 maybe 25. Right. Male sex is another factor. 00:01:55.019 --> 00:01:57.480 And perhaps, obviously, playing collision sports 00:01:57.480 --> 00:01:59.560 or just participating in high -level athletics 00:01:59.560 --> 00:02:02.439 significantly bumps up that risk. So a young 00:02:02.439 --> 00:02:05.060 male athlete, they're right in the danger zone 00:02:05.060 --> 00:02:07.060 for it happening again. That's the highest risk 00:02:07.060 --> 00:02:10.139 group, yes. And because non -operative treatment, 00:02:11.139 --> 00:02:13.939 just rehab after the first time, it has such 00:02:13.939 --> 00:02:16.979 a high failure rate in these high -risk individuals, 00:02:17.199 --> 00:02:20.849 especially the younger ones. The trend is definitely 00:02:20.849 --> 00:02:24.030 towards surgery becoming the mainstay. Even for 00:02:24.030 --> 00:02:26.870 the first dislocation sometimes. Often for the 00:02:26.870 --> 00:02:29.069 primary instability in that demographic, yes. 00:02:29.490 --> 00:02:32.810 Not just for recurrences. The thinking is to 00:02:32.810 --> 00:02:35.689 intervene early, break that cycle before more 00:02:35.689 --> 00:02:38.280 damage occurs. Okay, so... If surgery's often 00:02:38.280 --> 00:02:40.719 the answer, that initial diagnosis has got to 00:02:40.719 --> 00:02:43.099 be spot on. You need to know exactly what broke, 00:02:43.300 --> 00:02:45.139 not just that it popped out. Absolutely foundational. 00:02:45.300 --> 00:02:47.099 Yeah. Can't stress that enough. It starts with 00:02:47.099 --> 00:02:49.560 a really meticulous clinical evaluation. Taking 00:02:49.560 --> 00:02:52.139 a proper history. Detailed history, yes. How 00:02:52.139 --> 00:02:54.560 did it happen? The mechanism. How many times 00:02:54.560 --> 00:02:56.439 before? Crucially, how old were they the first 00:02:56.439 --> 00:02:58.520 time it happened? Age at first dislocation matters. 00:02:58.840 --> 00:03:01.219 Big time. And also, what are their goals? You 00:03:01.219 --> 00:03:03.400 know, are they hoping just for pain relief? Or 00:03:03.400 --> 00:03:05.000 are they trying to get back to playing rugby 00:03:05.000 --> 00:03:07.900 or competitive swimming? Very different demands. 00:03:08.280 --> 00:03:10.360 Makes sense. And the physical examination, what 00:03:10.360 --> 00:03:12.740 are you looking for there? The exam is key for 00:03:12.740 --> 00:03:15.759 assessing the degree of instability. How much 00:03:15.759 --> 00:03:18.780 does the humeral head, the ball, actually move 00:03:18.780 --> 00:03:21.199 relative to the socket, the glenoid? How do you 00:03:21.199 --> 00:03:23.919 test that? We assess glenohumeral translation 00:03:23.919 --> 00:03:27.680 and use provocative tests. Things like the apprehension 00:03:27.680 --> 00:03:30.740 and relocation tests, trying to mimic that feeling 00:03:30.740 --> 00:03:32.939 of instability the patient gets. See if you can 00:03:32.939 --> 00:03:35.039 make it feel like it's going to pop out. Exactly. 00:03:35.439 --> 00:03:37.960 And then see if relocating the head, sort of 00:03:37.960 --> 00:03:40.219 pushing it back gently, makes that feeling go 00:03:40.219 --> 00:03:42.800 away. We also look for general joint laxity. 00:03:43.259 --> 00:03:45.659 Like being double -jointed elsewhere. Sort of. 00:03:45.740 --> 00:03:47.340 Though the source has mentioned general scores 00:03:47.340 --> 00:03:49.939 like Baton aren't always that helpful, specifically 00:03:49.939 --> 00:03:52.580 for the shoulder. Things like excessive external 00:03:52.580 --> 00:03:55.520 rotation or a sulcus sign that little dimple 00:03:55.520 --> 00:03:57.759 under the shoulder suggesting downward laxity 00:03:57.759 --> 00:03:59.319 could be more telling for the shoulder joint 00:03:59.319 --> 00:04:02.159 itself. Okay, so history, exam, then you need 00:04:02.159 --> 00:04:04.819 to look inside presumably. Imaging. Imaging is 00:04:04.819 --> 00:04:07.340 non -negotiable, really. It confirms what you 00:04:07.340 --> 00:04:09.900 suspect clinically, but more importantly it identifies 00:04:09.900 --> 00:04:12.340 the specific structural damage. Starting with 00:04:12.340 --> 00:04:14.699 x -rays. Usually plain radiographs, yes. They're 00:04:14.699 --> 00:04:17.420 good for gross issues alignment, obvious fractures, 00:04:17.779 --> 00:04:21.540 and specific views like the grassy, axillary, 00:04:21.819 --> 00:04:24.939 burnigo, striker notch, west point, they help 00:04:24.939 --> 00:04:27.360 visualize the bone shapes better. Looking for 00:04:27.360 --> 00:04:30.740 those bony defects? Precisely. But, and this 00:04:30.740 --> 00:04:33.000 is important, the sources point out standard 00:04:33.000 --> 00:04:36.180 x -rays often miss more subtle bone loss, especially 00:04:36.180 --> 00:04:38.199 if it's not a fresh break or a really chronic 00:04:38.199 --> 00:04:41.339 problem. Right. So x -rays for the big bony picture. 00:04:41.680 --> 00:04:44.240 What about the soft bits, the ligaments, the 00:04:44.240 --> 00:04:47.500 labrum? That's where MRI comes in, or M .R. Arthrography 00:04:47.500 --> 00:04:49.800 MRA. These are essential for evaluating the soft 00:04:49.800 --> 00:04:52.819 tissues. The labrum, capsule, ligaments. Exactly. 00:04:53.279 --> 00:04:56.139 And importantly, in patients over 40, the rotator 00:04:56.139 --> 00:04:58.100 cuff tendons as well. They can tear during a 00:04:58.100 --> 00:05:00.759 dislocation too. MRA involves injecting dye. 00:05:01.019 --> 00:05:03.899 Yes. Contrast dye into the joint. It's generally 00:05:03.899 --> 00:05:05.800 considered more sensitive for picking up more 00:05:05.800 --> 00:05:08.300 complex or subtle tears, things like pan -laboral 00:05:08.300 --> 00:05:10.879 tears going all the way around, or SLAP lesions 00:05:10.879 --> 00:05:13.100 up top where the biceps attaches. And standard 00:05:13.100 --> 00:05:16.240 MRI. Standard MRI is noted as being particularly 00:05:16.240 --> 00:05:19.240 good for those anterior labrum tears, the classic 00:05:19.240 --> 00:05:21.839 bankart lesion. And checking the rotator cuff 00:05:21.839 --> 00:05:24.480 in older patients is vital. Finding a tear there 00:05:24.480 --> 00:05:26.819 can definitely change the surgical plan. Okay, 00:05:27.000 --> 00:05:30.449 MRMRA for soft tissue. What if you suspect significant 00:05:30.449 --> 00:05:32.829 bone damage that the x -ray didn't really show 00:05:32.829 --> 00:05:35.610 clearly? That's when CT scans become crucial, 00:05:36.069 --> 00:05:39.870 particularly 3D CT reconstructions. Why 3D? The 00:05:39.870 --> 00:05:42.550 sources are very clear on this. The anphase sagittal 00:05:42.550 --> 00:05:45.750 view you get from a 3D CT reconstruction is the 00:05:45.750 --> 00:05:49.579 best way to accurately measure to quantify the 00:05:49.579 --> 00:05:51.839 amount of glenoid bone loss. And getting that 00:05:51.839 --> 00:05:54.259 measurement right is critical. Absolutely vital, 00:05:54.319 --> 00:05:56.180 because that number, that percentage of bone 00:05:56.180 --> 00:05:58.800 loss, heavily influences the treatment decision. 00:05:58.920 --> 00:06:01.019 And the sources really drive home how important 00:06:01.019 --> 00:06:02.939 these bony injuries are, don't they? They're 00:06:02.939 --> 00:06:04.800 not just side effects, they dictate the whole 00:06:04.800 --> 00:06:07.860 strategy. They really do. The two main bony problems 00:06:07.860 --> 00:06:10.240 in recurrent instability are glenoid bone loss, 00:06:10.519 --> 00:06:14.060 GBL, and hill -sax lesions, HSLs. GBL is damage 00:06:14.060 --> 00:06:16.779 to the socket rim. Yes, wear or a fracture off 00:06:16.779 --> 00:06:19.089 the front edge of the glenoid socket, the shallow 00:06:19.089 --> 00:06:21.589 dish the ball sits in. And the hill sex is on 00:06:21.589 --> 00:06:23.930 the ball part. Correct. It's an indentation, 00:06:23.990 --> 00:06:26.250 a defect usually on the back, upper part of the 00:06:26.250 --> 00:06:29.370 humeral head caused when the ball impacts the 00:06:29.370 --> 00:06:31.790 sharp glenoid rim during the dislocation. It's 00:06:31.790 --> 00:06:34.050 like the ball hitting the edge of a damaged cup. 00:06:34.509 --> 00:06:37.490 It dents the ball and chips the cup rim further. 00:06:37.949 --> 00:06:40.550 That's a good analogy. It's often a cycle of 00:06:40.550 --> 00:06:42.970 progressive damage. Each dislocation can make 00:06:42.970 --> 00:06:45.620 both defects worse. And the sources talk about 00:06:45.620 --> 00:06:48.139 a newer way of thinking about Hillsac's lesions, 00:06:48.500 --> 00:06:51.439 on -track versus off -track. Yes, that's a really 00:06:51.439 --> 00:06:53.579 important concept now. It seems to be a more 00:06:53.579 --> 00:06:56.379 reliable way to predict recurrence and surgical 00:06:56.379 --> 00:06:59.759 outcomes compared to the older idea of just engaging 00:06:59.759 --> 00:07:02.420 versus non -engaging lesions. What's the actual 00:07:02.420 --> 00:07:04.879 difference, on -track versus off -track? It's 00:07:04.879 --> 00:07:07.620 about biomechanics. Think about the glenoid track, 00:07:07.699 --> 00:07:10.060 the contact area on the socket. An on -track 00:07:10.060 --> 00:07:12.579 Hillsac stays within that contact zone during 00:07:12.579 --> 00:07:14.930 normal shoulder movements. It's there, but it 00:07:14.930 --> 00:07:17.550 doesn't slide off the edge. An off -track lesion, 00:07:17.670 --> 00:07:20.410 however, is big enough or positioned so that 00:07:20.410 --> 00:07:22.550 when the arm moves into an unstable position, 00:07:22.649 --> 00:07:25.550 like abduction and external rotation, that defect 00:07:25.550 --> 00:07:28.750 on the humeral head actually translates medial 00:07:28.750 --> 00:07:30.449 to the front edge of the glenoid. It essentially 00:07:30.449 --> 00:07:32.569 falls off the track. It loses the bony stability 00:07:32.569 --> 00:07:35.110 of the saccharin. So off -track means it can 00:07:35.110 --> 00:07:38.189 basically slip past the point of no return much 00:07:38.189 --> 00:07:41.189 more easily, leading to another dislocation. 00:07:41.550 --> 00:07:44.470 Precisely. Identifying an off -track lesion is 00:07:44.470 --> 00:07:47.470 critical information. It changes the whole stability 00:07:47.470 --> 00:07:49.529 equation and really pushes you towards surgery 00:07:49.529 --> 00:07:52.050 that addresses that humeral head defect too, 00:07:52.389 --> 00:07:54.589 not just the glenoid side. And the amount of 00:07:54.589 --> 00:07:56.910 glenoid bone loss is just as critical. Are there 00:07:56.910 --> 00:07:59.470 specific percentages that trigger different treatments? 00:07:59.670 --> 00:08:01.790 Yes. The literature talks about definite thresholds. 00:08:01.790 --> 00:08:04.370 There's a bit of variation. But common figures 00:08:04.370 --> 00:08:08.329 are, say, less than 10 % or 13 .5 % GBO. OK, 00:08:08.410 --> 00:08:10.310 minimal loss. And in intermediate zone, maybe 00:08:10.310 --> 00:08:14.250 13 .5 % up to 20 % or 25 % loss. And then significant 00:08:14.250 --> 00:08:17.430 loss. than 20 -25%. Crossing these thresholds 00:08:17.430 --> 00:08:19.250 usually means you need a different surgical approach 00:08:19.250 --> 00:08:21.750 to get stable. It sounds like knowing these numbers, 00:08:22.189 --> 00:08:23.870 understanding the bone damage, it almost creates 00:08:23.870 --> 00:08:26.189 a flow chart for treatment. That's absolutely 00:08:26.189 --> 00:08:28.629 the direction things are going. An algorithmic 00:08:28.629 --> 00:08:31.420 approach. The type and amount of bony damage, 00:08:31.620 --> 00:08:34.340 the GBL percentage, the on -drack -off -track 00:08:34.340 --> 00:08:37.580 HSL, combined with pager factors like age and 00:08:37.580 --> 00:08:40.440 activity level, that dictates the best strategy. 00:08:40.779 --> 00:08:43.100 So arthroscopic surgery isn't always the answer. 00:08:43.519 --> 00:08:45.720 Arthroscopic stabilization is often the first 00:08:45.720 --> 00:08:47.879 thought, and it works well for many, but the 00:08:47.879 --> 00:08:50.799 sources are clear. It's not one size fits all. 00:08:50.889 --> 00:08:52.789 Especially not when you've got significant bone 00:08:52.789 --> 00:08:55.250 loss or other high risk factors. Right. So let's 00:08:55.250 --> 00:08:57.029 walk through the surgical options then. Starting 00:08:57.029 --> 00:08:59.129 arthroscopically, what's the standard go -to? 00:08:59.470 --> 00:09:01.750 The foundational arthroscopic procedure is the 00:09:01.750 --> 00:09:04.950 bank cart repair. Using keyhole surgery scope 00:09:04.950 --> 00:09:07.789 and small instruments to reattach the torn anterior 00:09:07.789 --> 00:09:10.190 labrum back to the bone of the glenoid rim. Using 00:09:10.190 --> 00:09:12.769 little anchors? Using suture anchors, yes. The 00:09:12.769 --> 00:09:15.049 aim is to restore that bumper effect of the labrum 00:09:15.049 --> 00:09:16.950 and tighten up the capsule a bit. And when is 00:09:16.950 --> 00:09:19.340 that the recommended route? Primarily for patients 00:09:19.340 --> 00:09:23.019 with minimal or no significant glenoid bone loss. 00:09:23.620 --> 00:09:26.940 Generally cited as, you know, 0 -10 % GPL. Some 00:09:26.940 --> 00:09:29.740 even suggest considering it for young, high -risk 00:09:29.740 --> 00:09:32.580 athletes with less than 5 % loss, just because 00:09:32.580 --> 00:09:34.799 their recurrence risk without surgery is so high. 00:09:35.019 --> 00:09:37.440 How well does a standard bank card work on its 00:09:37.440 --> 00:09:39.879 own? Well, the results vary quite a bit in the 00:09:39.879 --> 00:09:41.620 literature. Recurrence rates reported anywhere 00:09:41.620 --> 00:09:45.700 from, say, 6 % up to over 35%. That's quite a 00:09:45.700 --> 00:09:48.529 range. It is. But here's the crucial bit. tying 00:09:48.529 --> 00:09:51.210 back to bone loss. Studies show a dramatically 00:09:51.210 --> 00:09:53.590 higher recurrence rate, sum up to 67 percent, 00:09:53.769 --> 00:09:55.649 if you do a standard bankart repair in someone 00:09:55.649 --> 00:09:57.529 who does have significant bony defects. Like 00:09:57.529 --> 00:10:00.629 that inverted pair glenoid shape from bone loss 00:10:00.629 --> 00:10:03.129 or an engaging hillsack. Exactly. Compare that 00:10:03.129 --> 00:10:05.450 to patients with no bone loss beforehand, where 00:10:05.450 --> 00:10:07.470 recurrence after a bankart can be as low as four 00:10:07.470 --> 00:10:10.549 percent. Wow. That difference is massive. It 00:10:10.549 --> 00:10:12.490 totally underlines why you need that precise 00:10:12.490 --> 00:10:15.240 imaging first. Absolutely. and the risk factors 00:10:15.240 --> 00:10:17.620 for a bank art repair failing echo the general 00:10:17.620 --> 00:10:20.639 recurrence risks, but add surgical points. Younger 00:10:20.639 --> 00:10:23.960 age? male, more prior dislocations, high -level 00:10:23.960 --> 00:10:26.759 sport, using fewer anchors, more glenoid bone 00:10:26.759 --> 00:10:30.639 loss, and having a significant HSL or an ALPSA 00:10:30.639 --> 00:10:33.379 lesion. What's an ALPSA lesion again? It's where 00:10:33.379 --> 00:10:35.799 the torn labrum heals, but it heals in the wrong 00:10:35.799 --> 00:10:38.559 place, peeled off, and shifted medially. It doesn't 00:10:38.559 --> 00:10:41.039 function as a bumper anymore. OK. So if there 00:10:41.039 --> 00:10:43.100 is some bone loss, say, in that intermediate 00:10:43.100 --> 00:10:46.720 10 -20 % zone, or a tricky hillsax, but maybe 00:10:46.720 --> 00:10:50.159 not bad enough for open surgery, Can you boost 00:10:50.159 --> 00:10:53.360 the arthroscopic approach? Yes, definitely. The 00:10:53.360 --> 00:10:55.820 literature talks about arthroscopic plus procedures 00:10:55.820 --> 00:10:58.059 for these sorts of situations. Two common ones 00:10:58.059 --> 00:11:00.159 are combining the bankart repair with a rimplissage 00:11:00.159 --> 00:11:02.919 or doing a double -row capsule labral repair. 00:11:03.500 --> 00:11:05.019 Rimplissage? Interesting name. What does that 00:11:05.019 --> 00:11:07.500 involve? Rimplissage means filling in in French. 00:11:07.759 --> 00:11:10.159 It's a technique used for those engaging or critically 00:11:10.159 --> 00:11:12.919 off -track hill -sax lesions, usually when the 00:11:12.919 --> 00:11:14.879 glenoid bone loss isn't too severe, maybe under 00:11:14.879 --> 00:11:17.399 25%. And the goal is to stop that hill -sax catching. 00:11:17.600 --> 00:11:21.019 Exactly. You arthroscopically stitch the posterior 00:11:21.019 --> 00:11:23.820 capsule and often part of the infraspinatus tendon 00:11:23.820 --> 00:11:26.620 from the rotator cuff right into that hill sacks 00:11:26.620 --> 00:11:29.039 defect on the back of the humeral head. So you're 00:11:29.039 --> 00:11:31.919 literally filling the dent? Pretty much, yes. 00:11:32.220 --> 00:11:34.240 Filling it with soft tissue to stop it dropping 00:11:34.240 --> 00:11:36.840 off the glenoid edge when the arm's in that vulnerable 00:11:36.840 --> 00:11:39.919 position. Does it work? Studies show good results 00:11:39.919 --> 00:11:41.779 in preventing recurrence in the right patients. 00:11:42.350 --> 00:11:45.350 The main potential drawback mentioned is that 00:11:45.350 --> 00:11:47.549 tethering the tendon there can sometimes limit 00:11:47.549 --> 00:11:49.990 external rotation slightly. Might be an issue 00:11:49.990 --> 00:11:52.629 for throwing athletes, for example. Okay. And 00:11:52.629 --> 00:11:55.570 the double row capsule labral repair? That's 00:11:55.570 --> 00:11:58.149 suggested for moderate glenoid bone loss. Maybe 00:11:58.149 --> 00:12:00.830 10 -20 % when the soft tissues are still good 00:12:00.830 --> 00:12:03.029 quality and there isn't a major hill -sax issue. 00:12:03.149 --> 00:12:04.950 How's it different from a standard bain -carte? 00:12:05.129 --> 00:12:07.370 Instead of just one row of anchors on the glenoid 00:12:07.370 --> 00:12:10.350 rim, you use two rows, one on the rim, and another 00:12:10.350 --> 00:12:12.570 set further medially on the neck of the glenoid. 00:12:12.649 --> 00:12:15.309 What's the idea behind that? The idea is to create 00:12:15.309 --> 00:12:18.610 a much broader, more robust footprint for reattaching 00:12:18.610 --> 00:12:21.169 the labrum and capsule. Trying to build a stronger 00:12:21.169 --> 00:12:23.769 buttress, essentially. The sources mention it, 00:12:23.789 --> 00:12:25.889 but also note there's still limited comparative 00:12:25.889 --> 00:12:29.419 data. more research needed to really prove its 00:12:29.419 --> 00:12:32.059 long -term value against other options for that 00:12:32.059 --> 00:12:34.580 level of bone loss. Right. So arthroscopic options 00:12:34.580 --> 00:12:37.659 cover minimal loss or can be augmented for moderate 00:12:37.659 --> 00:12:40.840 loss or specific HSLs. What happens when the 00:12:40.840 --> 00:12:43.659 glenoid bone loss is really significant over 00:12:43.659 --> 00:12:47.200 that 20 -25 % mark? When you cross that threshold 00:12:47.200 --> 00:12:50.059 or sometimes with specific off -track HSLs where 00:12:50.059 --> 00:12:52.519 other methods won't cut it, the literature generally 00:12:52.519 --> 00:12:55.620 points towards open surgery. Arthroscopic fixes 00:12:55.620 --> 00:12:57.840 alone often aren't enough to restore stability 00:12:57.840 --> 00:13:00.259 then. And what are the main open procedures discussed? 00:13:00.740 --> 00:13:02.879 Well, one is specifically for when there's a 00:13:02.879 --> 00:13:04.919 displaced glenoid fracture fragment that represents 00:13:04.919 --> 00:13:07.899 significant bone loss, say over 20%, that's glenoid 00:13:07.899 --> 00:13:10.460 open reduction and internal fixation or IF. Fixing 00:13:10.460 --> 00:13:12.799 the broken teeth back on. Exactly. Open up, put 00:13:12.799 --> 00:13:14.659 the bone fragment back where it belongs, and 00:13:14.659 --> 00:13:16.460 fix it with screws or maybe a small plate. How 00:13:16.460 --> 00:13:18.840 does that fare? The evidence base is a bit smaller 00:13:18.840 --> 00:13:21.279 compared to other procedures. One study showed 00:13:21.279 --> 00:13:23.799 no redislocations if you get good fixation in 00:13:23.799 --> 00:13:26.539 the right fracture types. But it also noted some 00:13:26.539 --> 00:13:28.460 patients had hardware issues or maybe didn't 00:13:28.460 --> 00:13:30.759 get full function back. It's really reserved 00:13:30.759 --> 00:13:33.299 for those acute displaced fractures where fixing 00:13:33.299 --> 00:13:36.299 the original bone makes most sense. Okay. And 00:13:36.299 --> 00:13:39.039 the other big open procedure, the one often mentioned 00:13:39.039 --> 00:13:42.399 for significant bone loss. The Latarjet. Ah, 00:13:42.399 --> 00:13:45.159 yes, the Latarjet. Definitely a key procedure 00:13:45.159 --> 00:13:48.580 when glenoid bone loss is substantial over that 00:13:48.580 --> 00:13:52.500 20 -25 % mark, usually, or for certain off -track, 00:13:52.720 --> 00:13:54.860 hill -sax lesions where other options aren't 00:13:54.860 --> 00:13:57.159 suitable. It's really designed for significant 00:13:57.159 --> 00:13:59.679 bony deficiency. Remind us what the Latarjet 00:13:59.679 --> 00:14:02.019 actually does. It involves taking a piece of 00:14:02.019 --> 00:14:04.419 bone called the coracoid process. It's part of 00:14:04.419 --> 00:14:06.759 the shoulder blade along with its attached tendons. 00:14:06.919 --> 00:14:09.059 The biceps and corcabrachialis. That's right, 00:14:09.080 --> 00:14:11.710 the conjoined tendon. transferring that whole 00:14:11.710 --> 00:14:14.029 unit, the bone block and tendons, to the front 00:14:14.029 --> 00:14:16.009 of the glenoid socket, fixing the bone block 00:14:16.009 --> 00:14:17.950 there with screws. And that creates stability 00:14:17.950 --> 00:14:19.909 how? It gives you what's called a triple blocking 00:14:19.909 --> 00:14:23.149 effect. First, the bone block itself extends 00:14:23.149 --> 00:14:25.909 the glenoid surface, acting as a physical buttress. 00:14:26.029 --> 00:14:28.639 Stops the ball sliding forward. Yes. Second, 00:14:28.840 --> 00:14:30.899 the transferred conjoined tendon acts like a 00:14:30.899 --> 00:14:33.279 dynamic sling, tightening up when the arm goes 00:14:33.279 --> 00:14:36.220 into abduction and external rotation, that unstable 00:14:36.220 --> 00:14:38.440 position. Right, a check screen effect. And third, 00:14:38.639 --> 00:14:40.720 you usually repair the capsule over the transfer 00:14:40.720 --> 00:14:42.879 as well, adding more stability. So it's bone, 00:14:43.379 --> 00:14:46.340 dynamic tendon sling, and capsule repair. A combined 00:14:46.340 --> 00:14:49.659 approach. Very much so. And the sources report 00:14:49.659 --> 00:14:52.779 good success rates in terms of restoring stability, 00:14:53.419 --> 00:14:56.899 preventing recurrence, often 0 % to maybe 9 % 00:14:56.899 --> 00:14:59.659 recurrence in those difficult cases with significant 00:14:59.659 --> 00:15:02.519 bone loss. It's very effective for stability 00:15:02.519 --> 00:15:04.820 when the bone structure is compromised. So why 00:15:04.820 --> 00:15:07.379 isn't it the first choice for everyone with bone 00:15:07.379 --> 00:15:09.740 loss, given how stable it makes things? Well, 00:15:09.919 --> 00:15:12.299 it's a bigger operation. It's open surgery more 00:15:12.299 --> 00:15:14.710 involved in arthroscopy. And it does carry a 00:15:14.710 --> 00:15:16.850 higher risk of complications. Like what? Things 00:15:16.850 --> 00:15:18.649 like nerve injury, there are important nerves 00:15:18.649 --> 00:15:21.110 nearby infection, or problems with the bone graft 00:15:21.110 --> 00:15:23.669 healing or the screws. Reported complication 00:15:23.669 --> 00:15:26.289 rates can be up to 25 % in some series. So it's 00:15:26.289 --> 00:15:28.850 a trade -off, stability versus risk. Exactly. 00:15:29.389 --> 00:15:32.149 That higher risk profile is why it's generally 00:15:32.149 --> 00:15:34.570 reserved for cases where the indication is really 00:15:34.570 --> 00:15:37.529 strong, that significant bone loss, or maybe 00:15:37.529 --> 00:15:40.870 a failed previous surgery, or an off -track HSL 00:15:40.870 --> 00:15:43.490 that can't be managed arthroscopically. It's 00:15:43.490 --> 00:15:45.330 usually not the first line treatment for all 00:15:45.330 --> 00:15:47.490 instability. Are there other ways to add bone 00:15:47.490 --> 00:15:50.110 to the glenoid apart from letarget? Yes. The 00:15:50.110 --> 00:15:52.009 source has mentioned free bone block procedures. 00:15:52.909 --> 00:15:54.919 Using bone graft, either from the patient themselves, 00:15:55.120 --> 00:15:57.720 often the iliac crest, the hip bone, or using 00:15:57.720 --> 00:16:00.460 donor bone, allograft, and fixing that to the 00:16:00.460 --> 00:16:02.759 anterior glenoid. These are sometimes suggested 00:16:02.759 --> 00:16:04.899 as potentially having a lower nerve risk than 00:16:04.899 --> 00:16:07.120 letarget, theoretically, and they're also good 00:16:07.120 --> 00:16:09.419 options if a previous letarget or other bone 00:16:09.419 --> 00:16:12.120 block has failed. We focused a lot on traumatic 00:16:12.120 --> 00:16:15.039 anterior instability. What about other types, 00:16:15.240 --> 00:16:18.100 like being unstable in multiple directions, or 00:16:18.100 --> 00:16:20.179 dealing with kids whose bones are still growing? 00:16:20.519 --> 00:16:23.850 Good point. The sources do touch on these. Multidirectional 00:16:23.850 --> 00:16:27.230 instability, MDI, is a different beast altogether. 00:16:27.409 --> 00:16:29.830 How so? It's usually instability in two or more 00:16:29.830 --> 00:16:32.990 directions, front, back, or down. Often linked 00:16:32.990 --> 00:16:35.129 more to general ligament looseness, you know, 00:16:35.309 --> 00:16:38.009 being naturally hypermobile rather than one big 00:16:38.009 --> 00:16:40.710 traumatic tear. So the cause is different? Often, 00:16:40.889 --> 00:16:44.710 yes. And distinguishing MDI from traumatic unidirectional 00:16:44.710 --> 00:16:47.669 instability is vital because the treatment starts 00:16:47.669 --> 00:16:50.129 differently. How do you manage MDI initially? 00:16:50.440 --> 00:16:52.820 Almost always starts with non -operative treatment, 00:16:53.179 --> 00:16:56.320 a really intensive, focused physiotherapy program, 00:16:56.799 --> 00:16:58.879 strengthening the rotator cuff, the muscles around 00:16:58.879 --> 00:17:01.220 the shoulder blade to improve dynamic control. 00:17:01.259 --> 00:17:03.940 And surgery? Surgery, usually tightening the 00:17:03.940 --> 00:17:06.960 capsule arthroscopically, a cascular placation 00:17:06.960 --> 00:17:09.880 or shift, is really only for cases where a prolonged, 00:17:09.880 --> 00:17:13.210 dedicated rehab program hasn't worked. And even 00:17:13.210 --> 00:17:15.509 then, the literature suggests surgical outcomes 00:17:15.509 --> 00:17:18.609 for MDI can be less predictable, maybe not quite 00:17:18.609 --> 00:17:20.950 as good as for traumatic instability. And what 00:17:20.950 --> 00:17:23.690 about the youngsters? Skeletally immature patients 00:17:23.690 --> 00:17:25.789 with open growth plates. That must be tricky. 00:17:26.109 --> 00:17:29.009 It absolutely adds complexity. You've got to 00:17:29.009 --> 00:17:31.950 protect those growth plates, the physis. Prompt 00:17:31.950 --> 00:17:34.470 reduction of the dislocation and some immobilization 00:17:34.470 --> 00:17:36.910 is standard first aid. But what about surgery? 00:17:37.609 --> 00:17:40.890 Well, for athletic teenagers, say 14 or older, 00:17:41.109 --> 00:17:43.349 who have a traumatic dislocation and a clear 00:17:43.349 --> 00:17:46.910 bankart tear is found. The sources suggest early 00:17:46.910 --> 00:17:48.910 surgery might be warranted. Even though they're 00:17:48.910 --> 00:17:51.710 still growing. Yes, because their risk of recurrence 00:17:51.710 --> 00:17:55.049 without it is just so high. For younger children, 00:17:55.230 --> 00:17:57.829 it's less clear cut after a first dislocation. 00:17:57.950 --> 00:18:00.650 But if they start having recurrent instability, 00:18:01.269 --> 00:18:03.650 surgery is generally considered, though the techniques 00:18:03.650 --> 00:18:06.329 have to be adapted very carefully to avoid injuring 00:18:06.329 --> 00:18:08.549 the growth plate. Okay. So pulling all this together, 00:18:08.730 --> 00:18:10.769 then, if you had to summarize the main message 00:18:10.769 --> 00:18:12.970 from this deep dive into how we manage shoulder 00:18:12.970 --> 00:18:15.009 instability now. I think the core message is 00:18:15.009 --> 00:18:17.750 that the whole field has evolved. It's way beyond 00:18:17.750 --> 00:18:21.089 just fix the labrum. While arthroscopic repair 00:18:21.089 --> 00:18:23.609 is still common, the absolute game changer, the 00:18:23.609 --> 00:18:25.710 critical factor driving strategy and outcome. 00:18:25.829 --> 00:18:28.609 is identifying and accurately measuring the bony 00:18:28.609 --> 00:18:31.109 damage. Specifically the glenoid bone loss and 00:18:31.109 --> 00:18:34.470 the hill -sax lesion. Exactly. Especially quantifying 00:18:34.470 --> 00:18:37.289 that GBL and understanding if the hill -sax is 00:18:37.289 --> 00:18:40.910 on track or off track. That information is paramount. 00:18:41.089 --> 00:18:43.049 And that bony picture dictates the treatment 00:18:43.049 --> 00:18:46.170 algorithm. Precisely. The amount of GBL, primarily, 00:18:46.710 --> 00:18:49.049 tells you whether a simple arthroscopic repair 00:18:49.049 --> 00:18:52.069 is likely enough, or if you need an arthroscopic 00:18:52.069 --> 00:18:54.549 pluses procedure like remplussage, or if you 00:18:54.549 --> 00:18:56.589 really need to go to an open reconstruction like 00:18:56.589 --> 00:18:59.490 a latarjet or free bone block to restore proper 00:18:59.490 --> 00:19:02.160 bony stability. It's incredible, really, how 00:19:02.160 --> 00:19:04.980 understanding the bone in such detail changes 00:19:04.980 --> 00:19:07.279 everything for what seems like a common injury. 00:19:07.460 --> 00:19:09.339 It really underscores the complexity, doesn't 00:19:09.339 --> 00:19:11.279 it? And, you know, the sources remind us it's 00:19:11.279 --> 00:19:13.539 still evolving. We need more research to validate 00:19:13.539 --> 00:19:15.960 some techniques like the double row repair and 00:19:15.960 --> 00:19:17.940 always looking for ways to improve outcomes and 00:19:17.940 --> 00:19:19.779 reduce complications for the bigger procedures 00:19:19.779 --> 00:19:22.279 like Le Tarjet. It makes you think, doesn't it? 00:19:22.480 --> 00:19:25.539 Considering how much this precise, lesion -specific 00:19:25.539 --> 00:19:28.079 understanding of bone changes the game for shoulder 00:19:28.079 --> 00:19:31.289 instability, how could Applying that kind of 00:19:31.289 --> 00:19:34.009 detailed algorithmic thinking based on the specific 00:19:34.009 --> 00:19:36.329 damage help us tackle other complex problems. 00:19:36.450 --> 00:19:38.329 Maybe not just in medicine, but in other fields 00:19:38.329 --> 00:19:38.710 too.