WEBVTT 00:00:00.000 --> 00:00:02.140 Imagine you're a surgeon, you're looking at the 00:00:02.140 --> 00:00:05.139 scan, patient's shoulder keeps copping out anteriorly. 00:00:05.339 --> 00:00:07.299 You know you've got options, right? The Bankart, 00:00:07.820 --> 00:00:10.720 LaTarjet, maybe others. But choosing the right 00:00:10.720 --> 00:00:13.160 one for this patient, their specific anatomy, 00:00:13.400 --> 00:00:17.140 the exact injury, well, it feels less like picking 00:00:17.140 --> 00:00:20.339 a tool, more like a really tricky puzzle, high 00:00:20.339 --> 00:00:23.039 stakes. It absolutely is. It's a challenge orthopedic 00:00:23.039 --> 00:00:26.839 surgeons face all the time with traumatic anterior 00:00:26.839 --> 00:00:29.640 recurrent. shoulder instability. You know, the 00:00:29.640 --> 00:00:32.100 usual soft tissue fixes might not cut it if there's 00:00:32.100 --> 00:00:34.500 significant bone damage, but then bone procedures, 00:00:34.500 --> 00:00:36.939 they have their own set of issues. The big question 00:00:36.939 --> 00:00:38.960 has always been how do we map that out? How do 00:00:38.960 --> 00:00:41.719 we get a reliable guide to the best treatment 00:00:41.719 --> 00:00:44.210 for each person? And that is exactly what we're 00:00:44.210 --> 00:00:46.549 digging into today. We're looking at a systematic 00:00:46.549 --> 00:00:48.689 review from the Archives of Bone and Joint Surgery. 00:00:49.049 --> 00:00:51.409 You co -authored it, and it doesn't just summarize 00:00:51.409 --> 00:00:53.229 the evidence, it actually proposes a whole new 00:00:53.229 --> 00:00:56.289 classification system. The idea is to cut through 00:00:56.289 --> 00:00:58.990 that complexity, yeah, simplify those decisions 00:00:58.990 --> 00:01:01.850 for this specific type of instability. Yes, it's 00:01:01.850 --> 00:01:03.490 great to be able to talk about this. The goal 00:01:03.490 --> 00:01:05.549 really was to bring together the current evidence 00:01:05.549 --> 00:01:08.969 and offer a more structured evidence -based way 00:01:08.969 --> 00:01:10.730 forward for both surgeons and their patients. 00:01:10.930 --> 00:01:12.890 Okay, so before we jump into the nuts and bolts 00:01:12.890 --> 00:01:15.310 of this new system, let's just stay with that 00:01:15.310 --> 00:01:17.989 complexity for a second. Why weren't the old 00:01:17.989 --> 00:01:21.109 ways quite working? You know, just relying on 00:01:21.109 --> 00:01:23.230 surgeon preference or existing classifications, 00:01:23.489 --> 00:01:25.650 what crucial things weren't really being looked 00:01:25.650 --> 00:01:29.170 at together? Well, the core problem is that success 00:01:29.390 --> 00:01:31.650 Preventing it from happening again. It hinges 00:01:31.650 --> 00:01:34.049 on several things all working together not just 00:01:34.049 --> 00:01:36.310 one or two factors You can fix the torn tissue 00:01:36.310 --> 00:01:39.489 sure, but if there's say Quite a bit of bone 00:01:39.489 --> 00:01:42.909 loss on the socket the glenoid Or if that dent 00:01:42.909 --> 00:01:45.549 on the ball part of the arm bone the hill sacks 00:01:45.549 --> 00:01:48.590 lesion catches when they move The shoulder can 00:01:48.590 --> 00:01:51.890 still pop out right and equally if the patient's 00:01:51.890 --> 00:01:54.370 soft tissues are just well poor quality from 00:01:54.370 --> 00:01:56.790 repeated dislocations Even a technically good 00:01:56.790 --> 00:01:59.640 repair might not hold Older systems tended to 00:01:59.640 --> 00:02:02.079 focus on maybe just the bone loss or just the 00:02:02.079 --> 00:02:04.680 tissue or maybe the hill sacks. They didn't really 00:02:04.680 --> 00:02:07.700 combine the assessment of all three effectively. 00:02:08.520 --> 00:02:10.960 The bone loss, the quality of the soft tissue 00:02:10.960 --> 00:02:13.740 that's left, and the specific nature of that 00:02:13.740 --> 00:02:17.240 hill sacks lesion is engaging or not. That wasn't 00:02:17.240 --> 00:02:19.699 really integrated into one single pathway. So 00:02:19.699 --> 00:02:21.599 surgeons were sort of... mentally juggling these 00:02:21.599 --> 00:02:23.780 variables. Leading to less consistency, I imagine. 00:02:23.860 --> 00:02:25.919 It sounds like those key puzzle pieces weren't 00:02:25.919 --> 00:02:28.159 being fitted together properly. Exactly. And 00:02:28.159 --> 00:02:31.240 that's precisely the gap this new both classification 00:02:31.240 --> 00:02:34.500 system aims to fill. It gives a structured method 00:02:34.500 --> 00:02:36.900 to assess these three really critical injury 00:02:36.900 --> 00:02:40.180 features and then map them to the surgical strategies 00:02:40.180 --> 00:02:43.180 that the evidence supports most strongly. Both. 00:02:43.759 --> 00:02:46.080 OK, let's break that down. B -O -T -H. What's 00:02:46.080 --> 00:02:47.939 it stand for and how does it bring order to this? 00:02:48.180 --> 00:02:51.009 So both stands for bone loss, tissue quality, 00:02:51.229 --> 00:02:53.349 and hill sacs lesion. The whole idea is that 00:02:53.349 --> 00:02:55.629 by accurately classifying the severity and the 00:02:55.629 --> 00:02:57.909 type of damage in these three areas, you can 00:02:57.909 --> 00:03:00.289 seriously narrow down the surgical choices. You 00:03:00.289 --> 00:03:02.930 can pinpoint the procedure, or maybe combination 00:03:02.930 --> 00:03:05.189 of procedures, that's most likely to give that 00:03:05.189 --> 00:03:07.189 patient long -term stability. Right, getting 00:03:07.189 --> 00:03:09.229 really specific about the injury pattern. Okay. 00:03:09.409 --> 00:03:12.189 Okay, let's start with MO bone loss. How do you 00:03:12.189 --> 00:03:13.889 look at that? What are the key differences the 00:03:13.889 --> 00:03:18.009 system makes? Bone loss refers to how much bone 00:03:18.009 --> 00:03:20.610 has been chipped away or worn down from the front 00:03:20.610 --> 00:03:22.789 of the glen or at the socket. We usually measure 00:03:22.789 --> 00:03:25.969 it from CT scans, look at it as a percentage 00:03:25.969 --> 00:03:29.310 of the socket surface. And the research, which 00:03:29.310 --> 00:03:31.770 lines up with what's already known, points to 00:03:31.770 --> 00:03:34.849 a key threshold often around 15 to 20 percent 00:03:34.849 --> 00:03:37.800 damage below that level. We call that subcritical 00:03:37.800 --> 00:03:40.719 bone loss. More than that is critical bone loss. 00:03:40.939 --> 00:03:43.300 And that distinction is really fundamental because 00:03:43.300 --> 00:03:44.780 critical bone loss usually means you have to 00:03:44.780 --> 00:03:47.419 add bone back to make the socket stable again. 00:03:47.800 --> 00:03:50.280 Subcritical loss. Well, you might manage with 00:03:50.280 --> 00:03:51.979 just soft tissue work, but it depends on the 00:03:51.979 --> 00:03:54.419 other factors. OK, so bow is subcritical or critical 00:03:54.419 --> 00:03:57.000 around that 15, 20 percent mark. Got it. Yeah. 00:03:57.300 --> 00:03:59.340 Next up to tissue quality. What's being assessed 00:03:59.340 --> 00:04:01.580 there? Peace looks at the quality of the labrum 00:04:01.580 --> 00:04:03.240 and the capsule at the front of the shoulder. 00:04:03.379 --> 00:04:06.009 They're the main soft tissue stabilizers. like 00:04:06.009 --> 00:04:07.770 a bumper and a strong hammock holding the ball. 00:04:08.169 --> 00:04:10.569 If they've been torn repeatedly or they're stretched 00:04:10.569 --> 00:04:13.430 out or maybe just naturally a bit lax, well, 00:04:13.969 --> 00:04:16.269 they can't stabilize things properly. So we classify 00:04:16.269 --> 00:04:20.129 this quite simply as good or poor. Good or poor, 00:04:20.389 --> 00:04:23.170 okay. Good quality you typically see after maybe 00:04:23.170 --> 00:04:25.589 a first or second dislocation, someone without 00:04:25.589 --> 00:04:28.519 that underlying looseness. Poor quality is more 00:04:28.519 --> 00:04:30.899 common after lots of dislocations. The tissue 00:04:30.899 --> 00:04:34.300 is just degraded, worn out, can't really do its 00:04:34.300 --> 00:04:36.680 job as a primary stabilizer anymore. So tease 00:04:36.680 --> 00:04:39.319 about how resilient those soft tissues are still 00:04:39.319 --> 00:04:42.240 up to the job, or basically worn out. Makes sense. 00:04:42.699 --> 00:04:44.939 And finally, H. hilsax lesion. You mentioned 00:04:44.939 --> 00:04:47.160 it's a dent, but the classification isn't just 00:04:47.160 --> 00:04:49.600 if it's there. It's about this. on track versus 00:04:49.600 --> 00:04:52.079 off track thing. Precisely. A hill -sax lesion, 00:04:52.220 --> 00:04:53.939 that's a dent on the back of the humeral head, 00:04:53.959 --> 00:04:56.259 the ball. It happens when it hits the glenoid 00:04:56.259 --> 00:04:58.500 rim during a dislocation. Right. But the really 00:04:58.500 --> 00:05:00.459 critical thing, and this builds on some very 00:05:00.459 --> 00:05:02.660 important work in the field, is whether that 00:05:02.660 --> 00:05:05.040 dent engages or catches on the front edge of 00:05:05.040 --> 00:05:07.019 the socket when you move your arm into certain 00:05:07.019 --> 00:05:09.160 positions like reaching up and out. Ah, I see. 00:05:09.269 --> 00:05:11.649 If it doesn't catch, doesn't lever the joint 00:05:11.649 --> 00:05:14.089 out, we call it noontrack. But if it does engage, 00:05:14.470 --> 00:05:17.129 acts like a sort of cam forcing the joint out, 00:05:17.509 --> 00:05:19.509 then it's off -track. And an off -track hillsax 00:05:19.509 --> 00:05:22.149 is a major driver of instability. It needs specific 00:05:22.149 --> 00:05:24.610 treatment, really regardless of the other factors. 00:05:24.870 --> 00:05:27.350 So the both system puts these three things together. 00:05:27.569 --> 00:05:30.910 Bone loss, subcritical, tissue quality, good 00:05:30.910 --> 00:05:34.420 poor. and Hill Sachs, Noontrac off -track. That 00:05:34.420 --> 00:05:36.899 defines the specific injury patterns. And this 00:05:36.899 --> 00:05:38.620 is the map you were talking about guiding the 00:05:38.620 --> 00:05:40.480 treatment. Let's piece it together. What does 00:05:40.480 --> 00:05:44.000 both type 1 look like? Type 1 is probably the 00:05:44.000 --> 00:05:46.220 most straightforward scenario. You've got subcritical 00:05:46.220 --> 00:05:49.180 bone loss less than that 15 -20%. You've got 00:05:49.180 --> 00:05:51.500 good tissue quality. And the Hill Sachs lesion 00:05:51.500 --> 00:05:54.540 is Noontrac. So the main issue here is the initial 00:05:54.540 --> 00:05:57.220 soft tissue tear from the dislocation. But the 00:05:57.220 --> 00:05:59.240 basic structure and tissue strengths are still 00:05:59.240 --> 00:06:01.589 pretty sound. And based on your review, what's 00:06:01.589 --> 00:06:04.029 the recommended path for Type 1? For Type 1, 00:06:04.149 --> 00:06:06.589 the evidence strongly supports a standard bankart 00:06:06.589 --> 00:06:09.769 repair. This procedure just anatomically fixes 00:06:09.769 --> 00:06:12.750 that torn labrum, tightens up the capsule, essentially 00:06:12.750 --> 00:06:15.389 restores the soft tissue bumper. Since the bone's 00:06:15.389 --> 00:06:17.689 okay, tissues are good, HillSex isn't causing 00:06:17.689 --> 00:06:20.209 trouble, just fixing the soft tissue damage is 00:06:20.209 --> 00:06:22.589 often enough to get stability back. Okay, that 00:06:22.589 --> 00:06:24.930 makes sense. Fix the main problem if the foundations 00:06:24.930 --> 00:06:28.439 are solid. Now, Type 1 plus seri... That little 00:06:28.439 --> 00:06:31.139 plus suggests something extra is going on. Exactly 00:06:31.139 --> 00:06:33.079 right. Type 1 Plus still has that subcritical 00:06:33.079 --> 00:06:35.459 bone loss and the good tissue quality, just like 00:06:35.459 --> 00:06:38.040 Type 1. But the key difference is an off -track 00:06:38.040 --> 00:06:41.180 hill -sax lesion. So you still have good tissues, 00:06:41.540 --> 00:06:44.240 not much bone loss on the socket, but that dent 00:06:44.240 --> 00:06:46.980 on the humerus is actively making it unstable 00:06:46.980 --> 00:06:49.420 because it's catching on the glenoid edge. So 00:06:49.420 --> 00:06:51.040 you need to fix the tissue and deal with that 00:06:51.040 --> 00:06:53.339 engaging hill -sax. What does the system suggest 00:06:53.339 --> 00:06:56.329 then? For type 1 plus Harry, the recommendation 00:06:56.329 --> 00:07:00.189 is a bankart repair plus a remplasage. Remplasage 00:07:00.189 --> 00:07:02.170 is a technique where we take the infraspinatus 00:07:02.170 --> 00:07:04.709 tendon from the back of the shoulder and stitch 00:07:04.709 --> 00:07:07.750 it into that hillsack's dent. It effectively 00:07:07.750 --> 00:07:10.769 fills the hole, stops it from catching or engaging 00:07:10.769 --> 00:07:13.089 on the glenoid when the arm moves, so it gets 00:07:13.089 --> 00:07:15.189 rid of that specific way it was re -dislocating. 00:07:15.329 --> 00:07:17.829 Fascinating. So remplasage deals specifically 00:07:17.829 --> 00:07:20.990 with that off -track hillsacks when bone loss 00:07:20.990 --> 00:07:24.100 and tissues are otherwise alright. OK, let's 00:07:24.100 --> 00:07:26.720 move to type 2. How does the picture change now? 00:07:27.100 --> 00:07:28.920 With type 2, we're still looking at subcritical 00:07:28.920 --> 00:07:31.540 bone loss and still in noon -track hill sacks. 00:07:31.860 --> 00:07:34.480 But, and this is the crucial difference, we now 00:07:34.480 --> 00:07:36.939 have poor tissue quality. The soft tissues, the 00:07:36.939 --> 00:07:39.139 labrum and capsule, they just aren't reliable 00:07:39.139 --> 00:07:42.019 stabilizers anymore. Maybe stretched, frayed 00:07:42.019 --> 00:07:44.600 from previous dislocations. So even if the bone's 00:07:44.600 --> 00:07:46.519 mostly fine and the hill sacks isn't catching, 00:07:46.860 --> 00:07:50.019 if the tissue itself is compromised, a standard 00:07:50.019 --> 00:07:52.620 bank heart probably won't hold up. That's exactly 00:07:52.620 --> 00:07:54.879 it. Trying to repair poor quality tissue with 00:07:54.879 --> 00:07:57.199 a standard bankard? Well, the results are less 00:07:57.199 --> 00:07:59.980 predictable. So for type two, the research points 00:07:59.980 --> 00:08:02.779 towards dynamic interior stabilization or DAS. 00:08:03.079 --> 00:08:06.540 Yes. This technique uses the long head of the 00:08:06.540 --> 00:08:09.240 biceps tendon. It's redirected to the front of 00:08:09.240 --> 00:08:11.959 the glenoid and it acts like a dynamic sling 00:08:11.959 --> 00:08:15.319 or a hammock. The biomechanical evidence really 00:08:15.319 --> 00:08:18.560 supports DAS in this specific situation. It gives 00:08:18.560 --> 00:08:21.620 that vital dynamic support that the degraded 00:08:21.620 --> 00:08:24.500 native tissues just can't provide anymore. It 00:08:24.500 --> 00:08:26.879 compensates for the poor tissue even when bone 00:08:26.879 --> 00:08:29.519 loss isn't critical. That makes a lot of sense, 00:08:29.540 --> 00:08:32.139 bringing in a reinforcement, a dynamic one, when 00:08:32.139 --> 00:08:34.779 the original tissues are unreliable. And following 00:08:34.779 --> 00:08:37.340 the pattern, type 2 plus must be subcritical 00:08:37.340 --> 00:08:39.960 bone loss, poor tissue, and the off -track hill 00:08:39.960 --> 00:08:42.500 sacks. You've got it perfectly. Type 2 plus brings 00:08:42.500 --> 00:08:45.139 together subcritical bone loss, poor tissue quality, 00:08:45.299 --> 00:08:47.320 and an off -track hill sacks lesion. Which would 00:08:47.320 --> 00:08:49.340 logically need the DAS for the poor tissue and 00:08:49.340 --> 00:08:51.480 the remposage for the hill sacks. Precisely the 00:08:51.480 --> 00:08:54.279 recommendation, DAS plus remposage. You need 00:08:54.279 --> 00:08:56.440 both parts to tackle that specific combination 00:08:56.440 --> 00:08:59.049 of problems. Okay, right, so that covers all 00:08:59.049 --> 00:09:01.169 the situations where bone loss is subcritical. 00:09:01.809 --> 00:09:05.029 You layer in DAS for poor tissue, or remplassage 00:09:05.029 --> 00:09:07.629 for an off -track hillsax, or both if needed. 00:09:07.909 --> 00:09:11.110 Now, things get more complex when we cross that 00:09:11.110 --> 00:09:14.450 15 -20 % line into critical bone loss. What about 00:09:14.450 --> 00:09:16.830 both type 3? Well, once you have critical bone 00:09:16.830 --> 00:09:19.269 loss, just fixing soft tissue onto a deficient 00:09:19.269 --> 00:09:21.269 socket isn't really enough. You've got to rebuild 00:09:21.269 --> 00:09:24.250 the bony structure. So type 3 is defined as critical 00:09:24.250 --> 00:09:27.389 bone loss over 15 -20%, but importantly good 00:09:27.389 --> 00:09:30.559 tissue quality. and a Noontrag Hillsax. The bone 00:09:30.559 --> 00:09:32.559 needs sorting, but the soft tissues are still 00:09:32.559 --> 00:09:35.360 okay. And the suggested procedure for type 3. 00:09:35.480 --> 00:09:37.659 For type 3, the evidence points towards free 00:09:37.659 --> 00:09:40.940 glenoid bone grafting, or FGBG. This involves 00:09:40.940 --> 00:09:42.720 taking a piece of bone from somewhere else, often 00:09:42.720 --> 00:09:45.480 the patient's hip bone, the iliac crest, or sometimes 00:09:45.480 --> 00:09:46.980 another bit of the shoulder, like the end of 00:09:46.980 --> 00:09:48.539 the collarbone, and grafting it onto the front 00:09:48.539 --> 00:09:50.940 of the glenoid, rebuilding the socket to its 00:09:50.940 --> 00:09:54.019 proper shape. FGBG. So basically creating a new 00:09:54.019 --> 00:09:56.539 anatomical bony stop. The research mentioned 00:09:56.539 --> 00:09:58.899 this might be preferred over Letarjet sometimes. 00:09:59.259 --> 00:10:01.919 Yes. The review notes that FGBG gives you an 00:10:01.919 --> 00:10:04.320 anatomical reconstruction, which can be an advantage. 00:10:04.679 --> 00:10:06.840 For type 3, where the tissue quality is still 00:10:06.840 --> 00:10:09.200 good and you don't necessarily need that dynamic 00:10:09.200 --> 00:10:12.179 sling effect you get with Letarjet, FGBG is presented 00:10:12.179 --> 00:10:15.139 as a really good anatomical option. It restores 00:10:15.139 --> 00:10:17.580 the bone and potentially has a different risk 00:10:17.580 --> 00:10:20.580 profile compared to Letarjet in just this specific 00:10:20.580 --> 00:10:23.779 context. Interesting. So FGBG for critical bone 00:10:23.779 --> 00:10:26.500 loss if the tissues are good. Following the pattern, 00:10:26.659 --> 00:10:29.539 type 3 plus must be critical bone loss, good 00:10:29.539 --> 00:10:31.679 tissue, and the off -track hill sacs. Exactly. 00:10:31.759 --> 00:10:33.759 Critical bone loss, good tissue quality, and 00:10:33.759 --> 00:10:35.820 an off -track hill sacs. The treatment logically 00:10:35.820 --> 00:10:39.200 follows. FGBG plus room placage. Rebuild the 00:10:39.200 --> 00:10:41.779 socket anatomically with the graft and neutralize 00:10:41.779 --> 00:10:44.100 that engaging hill sacs lesion. All right. Nearly 00:10:44.100 --> 00:10:46.740 there. Two types left. Type 4. Critical bone 00:10:46.740 --> 00:10:48.860 loss again. What about the tissue and hill sacks 00:10:48.860 --> 00:10:50.799 here? Type 4 is where you have the double whammy. 00:10:51.139 --> 00:10:53.120 Yeah. Critical bone loss and poor tissue quality, 00:10:53.419 --> 00:10:56.100 but the hill sacks lesion is noontrack. So both 00:10:56.100 --> 00:10:58.139 the bone structure and the soft tissue restraints 00:10:58.139 --> 00:11:01.139 are significantly compromised. Ugh. Critical 00:11:01.139 --> 00:11:04.000 bone loss and poor tissue. This sounds like classic 00:11:04.000 --> 00:11:06.179 territory for the Letarjet procedure, doesn't 00:11:06.179 --> 00:11:08.840 it? Precisely. Letarjet is the recommended treatment 00:11:08.840 --> 00:11:12.149 for type 4. This procedure, as you know, transfers 00:11:12.149 --> 00:11:14.830 the coracoid process, that bony outcrop, from 00:11:14.830 --> 00:11:17.049 the shoulder blade along with its attached muscles, 00:11:17.450 --> 00:11:19.750 the conjoined tendon, to the front of the glenoid. 00:11:19.919 --> 00:11:22.779 The bone bit addresses the critical bone loss, 00:11:23.039 --> 00:11:25.899 rebuilds the socket depth, but crucially, that 00:11:25.899 --> 00:11:28.200 transferred tendon acts as a powerful dynamic 00:11:28.200 --> 00:11:30.639 stabilizer, provides that vital sling effect. 00:11:30.740 --> 00:11:32.899 And that's particularly helpful when the patient's 00:11:32.899 --> 00:11:35.639 own soft tissues are poor quality and can't provide 00:11:35.639 --> 00:11:38.259 enough stability on their own. So Letarjet tackles 00:11:38.259 --> 00:11:40.620 both issues, the missing bone and the poor tissue, 00:11:40.620 --> 00:11:43.659 even though it's not strictly anatomical. The 00:11:43.659 --> 00:11:46.100 research did mention its risks, though. It did. 00:11:46.539 --> 00:11:48.980 The systematic review acknowledges Letarjet. 00:11:49.080 --> 00:11:52.299 while highly effective, is definitely more complex 00:11:52.299 --> 00:11:54.799 than a straightforward bank card. It has a known 00:11:54.799 --> 00:11:57.779 learning curve, and, as the evidence we reviewed 00:11:57.779 --> 00:12:00.120 showed, it can have complications like infection 00:12:00.120 --> 00:12:02.039 or nerve issues, potentially at higher rates 00:12:02.039 --> 00:12:05.460 than, say, FGBG or bank card, when used in the 00:12:05.460 --> 00:12:07.960 right situations. Which, again, just highlights 00:12:07.960 --> 00:12:10.200 why matching the procedure to the specific injury 00:12:10.200 --> 00:12:13.039 pattern, like both aims to do, is so important. 00:12:13.399 --> 00:12:15.720 Understanding the trade -offs. Okay, and finally, 00:12:15.960 --> 00:12:18.600 type 4 plus 0. The most complex picture. Type 00:12:18.600 --> 00:12:21.159 4 plus is critical bone loss, poor tissue quality, 00:12:21.620 --> 00:12:23.639 and an off -track hill -sax lesion. You've got 00:12:23.639 --> 00:12:26.059 significant bone loss, unreliable soft tissues, 00:12:26.220 --> 00:12:28.480 and that engaging dent on the humeral head. The 00:12:28.480 --> 00:12:30.259 full house, if you like. Lethargia, again, I 00:12:30.259 --> 00:12:31.899 assume, because of the bone loss and poor tissue. 00:12:31.960 --> 00:12:34.320 What about the hill -sax in this case? It's lethargia, 00:12:34.539 --> 00:12:38.889 yes, often. Even though the Tarjet provides significant 00:12:38.889 --> 00:12:41.230 stability, especially with that sling effect, 00:12:41.809 --> 00:12:44.169 if you have a really large off -track hill sacks 00:12:44.169 --> 00:12:48.250 or very severe glenoid bone loss, adding Remplasage 00:12:48.250 --> 00:12:51.720 can give that extra bit of security. It neutralizes 00:12:51.720 --> 00:12:54.759 that specific engaging mechanism, even on top 00:12:54.759 --> 00:12:57.279 of the lethargic, kind of a belt and braces approach 00:12:57.279 --> 00:13:00.399 for the toughest cases. Wow. Okay, walking through 00:13:00.399 --> 00:13:03.139 those types really clarifies the logic behind 00:13:03.139 --> 00:13:05.220 each treatment choice when you look at all three 00:13:05.220 --> 00:13:07.460 factors together. Just to quickly recap the roles 00:13:07.460 --> 00:13:09.700 of those, let's call them advanced techniques, 00:13:10.200 --> 00:13:12.840 remplasage seems to be the go -to for that engaging 00:13:12.840 --> 00:13:15.240 the off -track hill sex, no matter the bone or 00:13:15.240 --> 00:13:17.620 tissue situation. Generally, yes, it addresses 00:13:17.620 --> 00:13:20.309 that specific mechanical issue. And DAS comes 00:13:20.309 --> 00:13:22.429 in to give that crucial dynamic support when 00:13:22.429 --> 00:13:24.509 bone loss is subcritical but the soft tissues 00:13:24.509 --> 00:13:26.830 are poor. Correct. It compensates for the poor 00:13:26.830 --> 00:13:30.269 native tissue. And FGBG is presented as the anatomical 00:13:30.269 --> 00:13:33.330 bone block choice for critical bone loss, especially 00:13:33.330 --> 00:13:35.330 if the native soft tissues are still good and 00:13:35.330 --> 00:13:37.870 you want that anatomical restoration. That's 00:13:37.870 --> 00:13:39.529 an excellent summary of their specific roles 00:13:39.529 --> 00:13:42.049 in this framework. The real strength of both 00:13:42.240 --> 00:13:44.720 is precisely that guiding the surgeon to pick 00:13:44.720 --> 00:13:48.220 which tool or combination of tools fix the exact 00:13:48.220 --> 00:13:51.539 mix of bone damage, tissue integrity, and humeral 00:13:51.539 --> 00:13:53.759 head issues. It feels like it takes something 00:13:53.759 --> 00:13:55.779 that was maybe a bit subjective and gives it 00:13:55.779 --> 00:13:58.620 an objective evidence -based structure, a roadmap 00:13:58.620 --> 00:14:01.659 really. It aims to simplify things for surgeons 00:14:01.659 --> 00:14:04.360 and hopefully lead to a more personalized approach 00:14:04.360 --> 00:14:06.559 for patients matching the fix directly to their 00:14:06.559 --> 00:14:09.809 injury, which surely has to mean better outcomes, 00:14:10.289 --> 00:14:12.889 fewer redislocations down the line. That's certainly 00:14:12.889 --> 00:14:15.870 the intention. By standardizing how we assess 00:14:15.870 --> 00:14:17.990 these injuries and linking that assessment directly 00:14:17.990 --> 00:14:20.669 to procedures backed by the best available evidence, 00:14:21.110 --> 00:14:23.090 the hope is definitely to improve consistency 00:14:23.090 --> 00:14:26.679 and optimize outcomes for patients. Our systematic 00:14:26.679 --> 00:14:28.940 review supported these distinctions, too, noting 00:14:28.940 --> 00:14:31.559 things like, yes, letharget might have lower 00:14:31.559 --> 00:14:33.399 recurrence for some complex injuries compared 00:14:33.399 --> 00:14:35.879 to bankart, but also carries a higher infection 00:14:35.879 --> 00:14:38.620 risk. It reinforces that need for careful patient 00:14:38.620 --> 00:14:40.940 selection based on the specific injury pattern. 00:14:41.539 --> 00:14:44.159 And biomechanical studies also back up the reasoning. 00:14:44.330 --> 00:14:47.289 for using techniques like DAS and those specific 00:14:47.289 --> 00:14:50.269 poor tissue scenarios. So the core message seems 00:14:50.269 --> 00:14:52.990 clear. Treating traumatic anterior recurrent 00:14:52.990 --> 00:14:55.629 shoulder instability isn't one size fits all. 00:14:56.009 --> 00:14:58.450 But this both classification offers a really 00:14:58.450 --> 00:15:01.070 powerful framework. By carefully looking at the 00:15:01.070 --> 00:15:04.029 bone loss, the tissue quality, and the hill sacs 00:15:04.029 --> 00:15:06.789 lesion, surgeons can navigate the options bank 00:15:06.789 --> 00:15:11.039 heart, DAS, FGBG, Letarjet, often adding RIMP 00:15:11.039 --> 00:15:14.059 -Lassage to hopefully deliver a surgical solution 00:15:14.059 --> 00:15:17.039 tailored precisely to your unique injury pattern. 00:15:17.379 --> 00:15:19.460 It provides that clear path through the puzzle. 00:15:19.720 --> 00:15:21.960 It helps turn a complex clinical judgment into 00:15:21.960 --> 00:15:25.399 a more structured, evidence -informed process. 00:15:25.519 --> 00:15:27.580 And that leaves us with a final thought to ponder. 00:15:27.639 --> 00:15:30.379 How does creating this kind of detailed classification 00:15:30.379 --> 00:15:33.399 system, one that meticulously breaks down a complex 00:15:33.399 --> 00:15:36.139 problem into its key parts to guide action mirror 00:15:36.139 --> 00:15:38.460 the way we perhaps need to tackle complex decisions 00:15:38.460 --> 00:15:40.940 in other professional fields, especially when 00:15:40.940 --> 00:15:42.919 dealing with lots of variables and significant 00:15:42.919 --> 00:15:45.120 potential risks. It's a very relevant question, 00:15:45.399 --> 00:15:48.139 well beyond the operating theater. Indeed. If 00:15:48.139 --> 00:15:50.759 you found this deep dive useful, please do think 00:15:50.759 --> 00:15:53.620 about rating and sharing it. It really helps 00:15:53.620 --> 00:15:56.139 other people find these discussions. Thank you 00:15:56.139 --> 00:15:58.120 for the opportunity to explore this research 00:15:58.120 --> 00:15:58.419 today.