Imagine you're a surgeon, you're looking at the
scan, patient's shoulder keeps copping out anteriorly.
You know you've got options, right? The Bankart,
LaTarjet, maybe others. But choosing the right
one for this patient, their specific anatomy,
the exact injury, well, it feels less like picking
a tool, more like a really tricky puzzle, high
stakes. It absolutely is. It's a challenge orthopedic
surgeons face all the time with traumatic anterior
recurrent. shoulder instability. You know, the
usual soft tissue fixes might not cut it if there's
significant bone damage, but then bone procedures,
they have their own set of issues. The big question
has always been how do we map that out? How do
we get a reliable guide to the best treatment
for each person? And that is exactly what we're
digging into today. We're looking at a systematic
review from the Archives of Bone and Joint Surgery.
You co -authored it, and it doesn't just summarize
the evidence, it actually proposes a whole new
classification system. The idea is to cut through
that complexity, yeah, simplify those decisions
for this specific type of instability. Yes, it's
great to be able to talk about this. The goal
really was to bring together the current evidence
and offer a more structured evidence -based way
forward for both surgeons and their patients.
Okay, so before we jump into the nuts and bolts
of this new system, let's just stay with that
complexity for a second. Why weren't the old
ways quite working? You know, just relying on
surgeon preference or existing classifications,
what crucial things weren't really being looked
at together? Well, the core problem is that success
Preventing it from happening again. It hinges
on several things all working together not just
one or two factors You can fix the torn tissue
sure, but if there's say Quite a bit of bone
loss on the socket the glenoid Or if that dent
on the ball part of the arm bone the hill sacks
lesion catches when they move The shoulder can
still pop out right and equally if the patient's
soft tissues are just well poor quality from
repeated dislocations Even a technically good
repair might not hold Older systems tended to
focus on maybe just the bone loss or just the
tissue or maybe the hill sacks. They didn't really
combine the assessment of all three effectively.
The bone loss, the quality of the soft tissue
that's left, and the specific nature of that
hill sacks lesion is engaging or not. That wasn't
really integrated into one single pathway. So
surgeons were sort of... mentally juggling these
variables. Leading to less consistency, I imagine.
It sounds like those key puzzle pieces weren't
being fitted together properly. Exactly. And
that's precisely the gap this new both classification
system aims to fill. It gives a structured method
to assess these three really critical injury
features and then map them to the surgical strategies
that the evidence supports most strongly. Both.
OK, let's break that down. B -O -T -H. What's
it stand for and how does it bring order to this?
So both stands for bone loss, tissue quality,
and hill sacs lesion. The whole idea is that
by accurately classifying the severity and the
type of damage in these three areas, you can
seriously narrow down the surgical choices. You
can pinpoint the procedure, or maybe combination
of procedures, that's most likely to give that
patient long -term stability. Right, getting
really specific about the injury pattern. Okay.
Okay, let's start with MO bone loss. How do you
look at that? What are the key differences the
system makes? Bone loss refers to how much bone
has been chipped away or worn down from the front
of the glen or at the socket. We usually measure
it from CT scans, look at it as a percentage
of the socket surface. And the research, which
lines up with what's already known, points to
a key threshold often around 15 to 20 percent
damage below that level. We call that subcritical
bone loss. More than that is critical bone loss.
And that distinction is really fundamental because
critical bone loss usually means you have to
add bone back to make the socket stable again.
Subcritical loss. Well, you might manage with
just soft tissue work, but it depends on the
other factors. OK, so bow is subcritical or critical
around that 15, 20 percent mark. Got it. Yeah.
Next up to tissue quality. What's being assessed
there? Peace looks at the quality of the labrum
and the capsule at the front of the shoulder.
They're the main soft tissue stabilizers. like
a bumper and a strong hammock holding the ball.
If they've been torn repeatedly or they're stretched
out or maybe just naturally a bit lax, well,
they can't stabilize things properly. So we classify
this quite simply as good or poor. Good or poor,
okay. Good quality you typically see after maybe
a first or second dislocation, someone without
that underlying looseness. Poor quality is more
common after lots of dislocations. The tissue
is just degraded, worn out, can't really do its
job as a primary stabilizer anymore. So tease
about how resilient those soft tissues are still
up to the job, or basically worn out. Makes sense.
And finally, H. hilsax lesion. You mentioned
it's a dent, but the classification isn't just
if it's there. It's about this. on track versus
off track thing. Precisely. A hill -sax lesion,
that's a dent on the back of the humeral head,
the ball. It happens when it hits the glenoid
rim during a dislocation. Right. But the really
critical thing, and this builds on some very
important work in the field, is whether that
dent engages or catches on the front edge of
the socket when you move your arm into certain
positions like reaching up and out. Ah, I see.
If it doesn't catch, doesn't lever the joint
out, we call it noontrack. But if it does engage,
acts like a sort of cam forcing the joint out,
then it's off -track. And an off -track hillsax
is a major driver of instability. It needs specific
treatment, really regardless of the other factors.
So the both system puts these three things together.
Bone loss, subcritical, tissue quality, good
poor. and Hill Sachs, Noontrac off -track. That
defines the specific injury patterns. And this
is the map you were talking about guiding the
treatment. Let's piece it together. What does
both type 1 look like? Type 1 is probably the
most straightforward scenario. You've got subcritical
bone loss less than that 15 -20%. You've got
good tissue quality. And the Hill Sachs lesion
is Noontrac. So the main issue here is the initial
soft tissue tear from the dislocation. But the
basic structure and tissue strengths are still
pretty sound. And based on your review, what's
the recommended path for Type 1? For Type 1,
the evidence strongly supports a standard bankart
repair. This procedure just anatomically fixes
that torn labrum, tightens up the capsule, essentially
restores the soft tissue bumper. Since the bone's
okay, tissues are good, HillSex isn't causing
trouble, just fixing the soft tissue damage is
often enough to get stability back. Okay, that
makes sense. Fix the main problem if the foundations
are solid. Now, Type 1 plus seri... That little
plus suggests something extra is going on. Exactly
right. Type 1 Plus still has that subcritical
bone loss and the good tissue quality, just like
Type 1. But the key difference is an off -track
hill -sax lesion. So you still have good tissues,
not much bone loss on the socket, but that dent
on the humerus is actively making it unstable
because it's catching on the glenoid edge. So
you need to fix the tissue and deal with that
engaging hill -sax. What does the system suggest
then? For type 1 plus Harry, the recommendation
is a bankart repair plus a remplasage. Remplasage
is a technique where we take the infraspinatus
tendon from the back of the shoulder and stitch
it into that hillsack's dent. It effectively
fills the hole, stops it from catching or engaging
on the glenoid when the arm moves, so it gets
rid of that specific way it was re -dislocating.
Fascinating. So remplasage deals specifically
with that off -track hillsacks when bone loss
and tissues are otherwise alright. OK, let's
move to type 2. How does the picture change now?
With type 2, we're still looking at subcritical
bone loss and still in noon -track hill sacks.
But, and this is the crucial difference, we now
have poor tissue quality. The soft tissues, the
labrum and capsule, they just aren't reliable
stabilizers anymore. Maybe stretched, frayed
from previous dislocations. So even if the bone's
mostly fine and the hill sacks isn't catching,
if the tissue itself is compromised, a standard
bank heart probably won't hold up. That's exactly
it. Trying to repair poor quality tissue with
a standard bankard? Well, the results are less
predictable. So for type two, the research points
towards dynamic interior stabilization or DAS.
Yes. This technique uses the long head of the
biceps tendon. It's redirected to the front of
the glenoid and it acts like a dynamic sling
or a hammock. The biomechanical evidence really
supports DAS in this specific situation. It gives
that vital dynamic support that the degraded
native tissues just can't provide anymore. It
compensates for the poor tissue even when bone
loss isn't critical. That makes a lot of sense,
bringing in a reinforcement, a dynamic one, when
the original tissues are unreliable. And following
the pattern, type 2 plus must be subcritical
bone loss, poor tissue, and the off -track hill
sacks. You've got it perfectly. Type 2 plus brings
together subcritical bone loss, poor tissue quality,
and an off -track hill sacks lesion. Which would
logically need the DAS for the poor tissue and
the remposage for the hill sacks. Precisely the
recommendation, DAS plus remposage. You need
both parts to tackle that specific combination
of problems. Okay, right, so that covers all
the situations where bone loss is subcritical.
You layer in DAS for poor tissue, or remplassage
for an off -track hillsax, or both if needed.
Now, things get more complex when we cross that
15 -20 % line into critical bone loss. What about
both type 3? Well, once you have critical bone
loss, just fixing soft tissue onto a deficient
socket isn't really enough. You've got to rebuild
the bony structure. So type 3 is defined as critical
bone loss over 15 -20%, but importantly good
tissue quality. and a Noontrag Hillsax. The bone
needs sorting, but the soft tissues are still
okay. And the suggested procedure for type 3.
For type 3, the evidence points towards free
glenoid bone grafting, or FGBG. This involves
taking a piece of bone from somewhere else, often
the patient's hip bone, the iliac crest, or sometimes
another bit of the shoulder, like the end of
the collarbone, and grafting it onto the front
of the glenoid, rebuilding the socket to its
proper shape. FGBG. So basically creating a new
anatomical bony stop. The research mentioned
this might be preferred over Letarjet sometimes.
Yes. The review notes that FGBG gives you an
anatomical reconstruction, which can be an advantage.
For type 3, where the tissue quality is still
good and you don't necessarily need that dynamic
sling effect you get with Letarjet, FGBG is presented
as a really good anatomical option. It restores
the bone and potentially has a different risk
profile compared to Letarjet in just this specific
context. Interesting. So FGBG for critical bone
loss if the tissues are good. Following the pattern,
type 3 plus must be critical bone loss, good
tissue, and the off -track hill sacs. Exactly.
Critical bone loss, good tissue quality, and
an off -track hill sacs. The treatment logically
follows. FGBG plus room placage. Rebuild the
socket anatomically with the graft and neutralize
that engaging hill sacs lesion. All right. Nearly
there. Two types left. Type 4. Critical bone
loss again. What about the tissue and hill sacks
here? Type 4 is where you have the double whammy.
Yeah. Critical bone loss and poor tissue quality,
but the hill sacks lesion is noontrack. So both
the bone structure and the soft tissue restraints
are significantly compromised. Ugh. Critical
bone loss and poor tissue. This sounds like classic
territory for the Letarjet procedure, doesn't
it? Precisely. Letarjet is the recommended treatment
for type 4. This procedure, as you know, transfers
the coracoid process, that bony outcrop, from
the shoulder blade along with its attached muscles,
the conjoined tendon, to the front of the glenoid.
The bone bit addresses the critical bone loss,
rebuilds the socket depth, but crucially, that
transferred tendon acts as a powerful dynamic
stabilizer, provides that vital sling effect.
And that's particularly helpful when the patient's
own soft tissues are poor quality and can't provide
enough stability on their own. So Letarjet tackles
both issues, the missing bone and the poor tissue,
even though it's not strictly anatomical. The
research did mention its risks, though. It did.
The systematic review acknowledges Letarjet.
while highly effective, is definitely more complex
than a straightforward bank card. It has a known
learning curve, and, as the evidence we reviewed
showed, it can have complications like infection
or nerve issues, potentially at higher rates
than, say, FGBG or bank card, when used in the
right situations. Which, again, just highlights
why matching the procedure to the specific injury
pattern, like both aims to do, is so important.
Understanding the trade -offs. Okay, and finally,
type 4 plus 0. The most complex picture. Type
4 plus is critical bone loss, poor tissue quality,
and an off -track hill -sax lesion. You've got
significant bone loss, unreliable soft tissues,
and that engaging dent on the humeral head. The
full house, if you like. Lethargia, again, I
assume, because of the bone loss and poor tissue.
What about the hill -sax in this case? It's lethargia,
yes, often. Even though the Tarjet provides significant
stability, especially with that sling effect,
if you have a really large off -track hill sacks
or very severe glenoid bone loss, adding Remplasage
can give that extra bit of security. It neutralizes
that specific engaging mechanism, even on top
of the lethargic, kind of a belt and braces approach
for the toughest cases. Wow. Okay, walking through
those types really clarifies the logic behind
each treatment choice when you look at all three
factors together. Just to quickly recap the roles
of those, let's call them advanced techniques,
remplasage seems to be the go -to for that engaging
the off -track hill sex, no matter the bone or
tissue situation. Generally, yes, it addresses
that specific mechanical issue. And DAS comes
in to give that crucial dynamic support when
bone loss is subcritical but the soft tissues
are poor. Correct. It compensates for the poor
native tissue. And FGBG is presented as the anatomical
bone block choice for critical bone loss, especially
if the native soft tissues are still good and
you want that anatomical restoration. That's
an excellent summary of their specific roles
in this framework. The real strength of both
is precisely that guiding the surgeon to pick
which tool or combination of tools fix the exact
mix of bone damage, tissue integrity, and humeral
head issues. It feels like it takes something
that was maybe a bit subjective and gives it
an objective evidence -based structure, a roadmap
really. It aims to simplify things for surgeons
and hopefully lead to a more personalized approach
for patients matching the fix directly to their
injury, which surely has to mean better outcomes,
fewer redislocations down the line. That's certainly
the intention. By standardizing how we assess
these injuries and linking that assessment directly
to procedures backed by the best available evidence,
the hope is definitely to improve consistency
and optimize outcomes for patients. Our systematic
review supported these distinctions, too, noting
things like, yes, letharget might have lower
recurrence for some complex injuries compared
to bankart, but also carries a higher infection
risk. It reinforces that need for careful patient
selection based on the specific injury pattern.
And biomechanical studies also back up the reasoning.
for using techniques like DAS and those specific
poor tissue scenarios. So the core message seems
clear. Treating traumatic anterior recurrent
shoulder instability isn't one size fits all.
But this both classification offers a really
powerful framework. By carefully looking at the
bone loss, the tissue quality, and the hill sacs
lesion, surgeons can navigate the options bank
heart, DAS, FGBG, Letarjet, often adding RIMP
-Lassage to hopefully deliver a surgical solution
tailored precisely to your unique injury pattern.
It provides that clear path through the puzzle.
It helps turn a complex clinical judgment into
a more structured, evidence -informed process.
And that leaves us with a final thought to ponder.
How does creating this kind of detailed classification
system, one that meticulously breaks down a complex
problem into its key parts to guide action mirror
the way we perhaps need to tackle complex decisions
in other professional fields, especially when
dealing with lots of variables and significant
potential risks. It's a very relevant question,
well beyond the operating theater. Indeed. If
you found this deep dive useful, please do think
about rating and sharing it. It really helps
other people find these discussions. Thank you
for the opportunity to explore this research
today.