WEBVTT

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Did you know that even after just one shoulder

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dislocation, a really significant number of patients

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already show signs of bone loss? That's right.

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There's a study by Griffith and colleagues. Quite

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striking, really. They found galenoid bone loss

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that's on the socket in 41 % of cases after a

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first time dislocation. 41%. Wow. And presumably,

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it gets worse if it happens again. Oh, dramatically

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worse. That same study found the rate jumped

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to 86 % in patients with recurrent dislocations.

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And other research backs this up, showing significant

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bone defects on both sides of the joint, the

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socket and the ball, becoming almost the norm

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in those chronic cases. And for younger active

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people, that risk of it happening again, it's

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incredibly high, isn't it? Disturbingly high.

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Rates up to 96 % recurrence been reported for

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young patients after a first traumatic dislocation.

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It sets the stage for a cycle of instability.

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So it begs the question, what happens when this

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common painful injury just keeps coming back?

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When it becomes this recurring nightmare causing

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complex problems that the usual straightforward

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fixes just can't seem to handle? That's the crux

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of the issue we're exploring today. Welcome to

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the deep dive. We're the show that aims to cut

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through the jargon and extract the really crucial

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insights from dense source material. Today, we

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are digging into the complexities of shoulder

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instability. And we're drawing heavily on some

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very detailed clinical perspectives, particularly

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from the book Complex and Revision Problems in

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Shoulder Instability. Exactly. Our focus isn't

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on a simple strain or first -time injury that

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gets better easily. We're navigating the much

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tougher terrain. Think significant bone damage,

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specific patient factors making things trickier,

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or situations where previous surgeries haven't

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quite worked out. These are the scenarios that

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demand more advanced thinking, more sophisticated

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techniques. We want to understand why those standard

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approaches sometimes fail and what the next level

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of solutions actually involves. And exploring

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that intricate landscape requires a clear view

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of the evidence and the practicalities. Which

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is why I'm delighted you're here to guide us.

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Your expertise in synthesizing this complex medical

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knowledge, connecting the dots between diagnosis,

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treatment, and importantly, long -term patient

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outcomes is exactly what we need. Happy to be

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here and delve into it. Right. Let's kick off

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with a quick rapid fire round just to set the

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scene for our deep dive. Three quick questions.

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Fire away. OK, first one. When a shoulder keeps,

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you know, popping out, what's the fundamental

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problem we need to consider beyond just tearing

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ligaments? Well, while the ligaments in the capsule

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are definitely injured initially, the critical

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issue, especially with repeated instability,

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is often damage to the bone. Specifically, bone

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loss. Bone loss. Yes. Either from the glenoid,

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the socket, or the humeral head, the ball. Losing

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that bone fundamentally changes the joint shape

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and its mechanics. It makes it inherently less

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stable, irrespective of the soft tissues. OK,

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so bone loss is absolutely central. Second question.

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Why might an initial soft tissue repair, something

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like a bank art repair, not be enough, especially

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for certain people? The main reason they fail,

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quite often, is that the underlying bone loss

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wasn't fully appreciated or adequately addressed.

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If you're missing a significant chunk of bone

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from either side, just stitching the labrum back

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on doesn't restore the joint's structural integrity.

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Makes sense. And we know the risk factors for

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failure pretty well, now being young, playing

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high -demand contact sports, and critically having

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pre -existing bone defects, even seemingly small

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ones sometimes. These patients are much more

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likely to fail a simple soft tissue fix. Right,

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those factors really flag who might need a more

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robust solution from the start. And final, rapid

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fire. In orthopedic terms, what makes a shoulder

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problem complex or needing revision? Okay, so

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complex generally means your standard straightforward

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treatments probably won't work. This could be

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due to major bone loss, maybe the patient has

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other conditions like epilepsy or connective

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tissue disorder, or perhaps it's just a very

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unusual injury pattern. And revision? Revision

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means exactly what it sounds like. A previous

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surgery to stabilize the shoulder has failed.

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So now you're going back in. Operating on a joint

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that's already been surgically altered likely

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still has underlying problems, perhaps scar tissue.

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It makes the second or even third attempt significantly

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more challenging. That really clarifies the scope.

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Complex and revision. It's not the simple stuff.

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Yeah. Okay, let's settle in now for our first

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proper segment. Let's really unpack the anatomy

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first. Before anything goes wrong, how does a

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healthy shoulder stay stable? It has such incredible

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movement. How does it manage it? It's a fascinating

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bit of biological engineering, actually. The

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shoulder cleverly uses different mechanisms depending

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on where the arm is. OK. So in the mid -range

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of motion, think arm by your side, maybe slightly

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out in front, but not at the extremes. Stability

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mostly comes from non -ligamentous factors. Like

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what? Two main things. One is the negative intra

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-articular pressure. Basically, a suction or

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vacuum effect within the joint capsule helps

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hold the ball centered in the socket. A vacuum

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seal, almost. Kind of, yes. And the other is

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the concavity compression effect. This is where

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the rotator cuff muscles actively pull the humeral

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head, the ball, firmly into the concave glenoid

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socket. Like pressing a ball into a perfectly

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matched cup, the muscles provide the compression

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force. Okay, so suction and muscle compression

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keep it centered during everyday movements. What

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about when you reach right up high or throw something?

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The extremes of motion. That's when the passive

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structures take over, primarily the capsule ligamentous

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structures. The joint capsule itself and the

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thickened bands within it called the glenohumeral

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ligaments become taut. They tighten up. Exactly.

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They act like check reins, physically stopping

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the humeral head from sliding too far forward,

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backward, or downward on the glenoid through

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the end -range stabilizers. It's quite elegant,

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really. Different systems for different jobs.

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Now, let's bring it back to the injury. What

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actually happens to these structures during a

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traumatic anterior dislocation? It sounds quite

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violent. Often is. A forceful anterior dislocation

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typically tears the structures at the front and

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bottom of the joint, the anteroinferior capsulutamentus

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complex. So ripping the capsule and ligaments

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there? Yes, and when this involved the labrum

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tearing off the glenoid rim, that's what we commonly

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call a bankart lesion. But, and this is a crucial

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point from our source material, this event frequently

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causes significant bone damage at the same time.

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It's not just soft tissue. And that's where those

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startling statistics you mentioned right at the

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beginning come into play. It's not a rare thing

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for the bone to be damaged. Not at all. The numbers

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really drive it home. Griffith study again. 41

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% glenoid bone loss after just a first dislocation.

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It's happening right from the start in many cases.

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Not just after years of problem. Precisely. And

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after recurrent dislocations, that figure jumps

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to 86%. Other studies, like Piasecki's, found

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similarly high rates, 49 % to 89 % with glenoid

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loss and an incredible 70 % to 100 % incidence

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of damage to the humeral head, the ball, in recurring

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cases. 100%. Almost everyone with recurrent dislocations

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has damage on the ball side. in that specific

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cohort. Yes. And with Jajan and colleagues added

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another layer. They found that damage on both

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the glenoid and the humeral head occurred simultaneously

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in 54 % of patients after just one traumatic

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anterior dislocation. So bipolar bone loss damage

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on both sides is common even after the first

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time. Yes. It forces us to think differently.

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This isn't just an occasional complication. Bone

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loss is a frequent almost expected consequence

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of shoulder dislocation, especially if it happens

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more than once. Those figures really do shift

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the perspective. It's not just about stitching

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up torn ligaments. You have to account for the

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missing bone. How does this bone loss actually

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look on the bones themselves? What forms does

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it take? Good question. On the glenoid, the socket,

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you typically see two main patterns. One is erosion

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type loss. which is more common in chronic instability,

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the bone gradually wears away over time. It gets

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ground down? Essentially, yes. The other is a

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fragment type loss, often from the initial trauma,

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where the front rim of the glenoid actually fractures

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off. We often call this a bony bankart lesion.

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OK, so wearing away or breaking off on the socket

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side, what about the humeral head, the ball?

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When the humeral head is forced forwards out

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of the socket, the relatively sharp anterior

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rim of the glenoid impacts the softer bone on

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the back outer aspect of the humeral head. This

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creates a compression fracture, basically a dent

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or divot. That's the classic Hill Sachs lesion.

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or HSL. The hill -sax lesion, right? Right. And

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when you have both the glenoid bone loss, whether

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it's erosion or a bony bankart, and the hill

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-sax lesion on the humeral head, what's that

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called? That combination is termed bipolar bone

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loss. It signifies that you have these coupled

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bony problems on both the socket and the ball.

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And that inherently makes the instability problem

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much more complex to manage because you've lost

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structural support on both articulating surfaces.

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OK. Bipolar bone loss. Socket potentially chipped

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or worn down, ball with a dent. Now there's a

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really key insight, particularly from researchers

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like DiGiacomo, that challenges how we used to

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think about the Hill Sachs lesion. It suggests

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the size of that dent alone isn't the main issue.

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Is that right? Absolutely. That was a pivotal

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shift in understanding. For years, we focused

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heavily on just measuring the depth and width

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of the Hill Sachs lesion. Bigger lesion must

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be worse, right? Seems logical. But it turns

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out it's more nuanced. The real question isn't

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just how big is the dent, but will that dent

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physically engage or lock onto the front edge

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of the remaining glenoid during movement? Ah,

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so it's about contact. Does the dent catch on

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the socket rim? Exactly. If the hill -sax lesion

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engages the rim, it levers the humeral head out

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of place, causing instability or apprehension.

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If it doesn't engage, even quite a large hillsax

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might not be the primary driver of the instability

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in that particular patient. Okay, so engagement

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is key. How do we figure out if a particular

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hillsax lesion is likely to engage? This is where

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the concept of the glenoid track comes in. It's

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a brilliant way to conceptualize and, importantly,

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quantify the contact zone between the humeral

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head and the glenoid doing functional movements,

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especially those abduction and external rotation

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movements where dislocations often happen. The

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track, like a pathway on the socket. Precisely.

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DJ Komo and his team proposed a method to calculate

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the width of this safe contact zone, this track,

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and Critically, the calculation accounts for

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any anterior glenoid bone loss. How do they calculate

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it? The formula they developed is 0 .83 times

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the intact glenoid diameter minus the amount

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of the anterior glenoid bone defect. Okay, so

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0 .83 times the socket width minus the bit that's

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missing. That gives you a number representing

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the track width. What do you do with that number?

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You then measure the Hill Sachs lesion on imaging.

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usually a CT scan, you look at where the medial

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edge, the inner edge of the hill sacs lesion

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lies relative to that calculated glenoid track

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width. Right. If the medial edge of the hill

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sacs falls medial to the glenoid track, meaning

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it's further toward the center of the joint than

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the track extends, then that lesion is considered

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off track. Off track. And that means? It means

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it will engage the anterior glenoid rim during

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end range motion. It's a definite risk factor

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for instability. If the medial edge of the hill

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sacs lies lateral to the calculated track, it's

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considered on track. And theoretically, it shouldn't

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engage. OK. Off -track equals engagement. Definite

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problem. On -track means it should stay clear.

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Is it always that simple, or are on -track lesions

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completely safe? Ah, well, it's rarely that simple

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in biology. There are definitely nuances. And

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the source material highlights this. Even on

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-track lesions aren't always benign. they can

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still contribute to instability and lead to worse

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outcomes after a simple soft tissue repair if

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they are very large or very close to the edge

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of the track. So location matters, even if it's

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technically on. Yes. Yamamoto and colleagues

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introduced the idea of peripheral track lesions.

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These are on track, but they take up a large

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portion, maybe 75 % or more, of the humeral head's

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circumference where the track lies. Yang found

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a similar high occupancy ratio of predicted recurrence.

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Others talk about near -track lesions maybe within

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eight millimeters of the track edge. These are

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also considered higher risk. So the on -track

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off -track distinction is the foundation, but

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you still need to look at the size and proximity

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to the edge for those on -track ones. Exactly.

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The key takeaway is that assessing a hill -sax

00:12:26.980 --> 00:12:29.840
lesion requires more than just measuring its

00:12:29.840 --> 00:12:33.220
size. You absolutely have to consider its relationship

00:12:33.220 --> 00:12:35.840
to the glenoid, particularly any bone loss there.

00:12:36.559 --> 00:12:39.059
this glenoid tract concept and its refinements.

00:12:39.559 --> 00:12:41.779
That relationship is what truly determines the

00:12:41.779 --> 00:12:44.580
risk it poses. That makes complete sense. It's

00:12:44.580 --> 00:12:46.600
about the interaction between the two damaged

00:12:46.600 --> 00:12:49.620
surfaces. And this deeper understanding directly

00:12:49.620 --> 00:12:52.220
explains why just fixing the soft tissues, like

00:12:52.220 --> 00:12:54.960
a standard bankart repair, isn't always going

00:12:54.960 --> 00:12:57.919
to be enough. Precisely. An arthroscopic bankart

00:12:57.919 --> 00:12:59.879
repair works well when you have a simple labral

00:12:59.879 --> 00:13:03.019
tear and minimal or no significant bone loss.

00:13:03.259 --> 00:13:06.419
But if you've got, say, more than 15 -20 % glenoid

00:13:06.419 --> 00:13:09.360
bone loss or an engaging off -track Hillsax lesion,

00:13:09.840 --> 00:13:12.000
just reattaching the labrum doesn't address the

00:13:12.000 --> 00:13:13.899
fundamental bony instability. The foundation

00:13:13.899 --> 00:13:16.360
is still compromised. Correct. And that's why

00:13:16.360 --> 00:13:18.299
the reported failure rates for bank art repair

00:13:18.299 --> 00:13:20.860
alone can be quite high in some studies. Figures

00:13:20.860 --> 00:13:23.940
ranging from under 10 % up to over 35 % are cited.

00:13:24.639 --> 00:13:26.899
And significant bone loss is consistently identified

00:13:26.899 --> 00:13:29.769
as a major reason for those failures. Which naturally

00:13:29.769 --> 00:13:32.309
led people to try and figure out before surgery

00:13:32.309 --> 00:13:35.470
who is likely to fail that standard repair, right?

00:13:35.750 --> 00:13:38.389
To identify those who need something more substantial.

00:13:38.649 --> 00:13:41.409
Yes, exactly. This spurred the development of

00:13:41.409 --> 00:13:43.649
scoring systems, the most well -known probably

00:13:43.649 --> 00:13:46.409
being the Instability Severity Index Score, or

00:13:46.409 --> 00:13:49.350
ISIS score. ISIS score? What does that measure?

00:13:49.590 --> 00:13:52.090
It combines several known risk factors for failure

00:13:52.090 --> 00:13:55.039
after a bank art repair. Things like the patient's

00:13:55.039 --> 00:13:58.159
age younger is higher risk, their activity level

00:13:58.159 --> 00:14:00.679
collision sports are higher risk, whether they

00:14:00.679 --> 00:14:03.220
had generalized ligament laxity or hyper laxity,

00:14:03.720 --> 00:14:06.360
and crucially, the presence and extent of bone

00:14:06.360 --> 00:14:09.419
defects seen on imaging both glenoid and humeral

00:14:09.419 --> 00:14:12.330
head. So it quantifies the overall risk profile.

00:14:12.570 --> 00:14:14.549
Precisely. The original recommendation based

00:14:14.549 --> 00:14:16.269
on the score was that if you scored above six

00:14:16.269 --> 00:14:17.929
points, you were considered high risk for bank

00:14:17.929 --> 00:14:20.610
art failure and a bony procedure like the latar

00:14:20.610 --> 00:14:22.990
jet should be strongly considered instead. Has

00:14:22.990 --> 00:14:25.129
that threshold changed? There's been discussion

00:14:25.129 --> 00:14:27.490
and some studies suggesting that for certain

00:14:27.490 --> 00:14:30.529
very high risk groups, perhaps even a lower threshold,

00:14:30.649 --> 00:14:33.230
maybe four points or even three points, might

00:14:33.230 --> 00:14:35.450
be more appropriate for recommending a bony procedure.

00:14:35.740 --> 00:14:38.860
It reflects a growing awareness that even combinations

00:14:38.860 --> 00:14:41.519
of seemingly moderate risk factors can lead to

00:14:41.519 --> 00:14:44.820
failure. The point is, we now have tools to help

00:14:44.820 --> 00:14:48.059
stratify patients and tailor the treatment, rather

00:14:48.059 --> 00:14:50.039
than just doing a bank card on everyone with

00:14:50.039 --> 00:14:53.590
instability. So the ISIS score and the glenoid

00:14:53.590 --> 00:14:55.870
tract concept are guiding lights here, helping

00:14:55.870 --> 00:14:58.409
surgeons decide who needs more than just soft

00:14:58.409 --> 00:15:00.950
tissue work. And as you said, if you identify

00:15:00.950 --> 00:15:03.649
an off -track hill -sax lesion, a bankart repair

00:15:03.649 --> 00:15:06.110
alone is basically off the table. That's the

00:15:06.110 --> 00:15:08.590
current thinking, yes. If you know that lesion

00:15:08.590 --> 00:15:11.110
is going to engage the rim, performing only a

00:15:11.110 --> 00:15:13.309
bankart repair doesn't solve the mechanical problem.

00:15:13.889 --> 00:15:15.929
You need a procedure that either directly addresses

00:15:15.929 --> 00:15:19.009
the hill -sax defect itself or alters the glenoid

00:15:19.009 --> 00:15:21.750
geometry to prevent that engagement. A bank card

00:15:21.750 --> 00:15:24.250
doesn't do either of those things. Okay, so this

00:15:24.250 --> 00:15:27.690
sets the stage perfectly. If that simple soft

00:15:27.690 --> 00:15:30.169
tissue fix isn't appropriate, particularly with

00:15:30.169 --> 00:15:32.850
bone loss or these engaging lesions, what are

00:15:32.850 --> 00:15:35.610
the surgical options? Let's move into our next

00:15:35.610 --> 00:15:38.110
segment and really explore these more advanced

00:15:38.110 --> 00:15:40.990
procedures. Sounds good. There are several approaches

00:15:40.990 --> 00:15:43.409
depending on the specific problem. Let's start

00:15:43.409 --> 00:15:45.759
with the Hill Sachs lesion. If that's deemed

00:15:45.759 --> 00:15:48.480
the main issue needing direct attention, perhaps

00:15:48.480 --> 00:15:50.620
alongside a bank heart repair for the labrum,

00:15:51.000 --> 00:15:53.399
how can surgeons deal with that dent on the ball?

00:15:53.659 --> 00:15:56.299
A common and effective technique is called remplassage.

00:15:56.759 --> 00:15:59.139
It's a French term, roughly meaning to fill.

00:15:59.620 --> 00:16:01.600
Remplassage. Filling the defect. How does that

00:16:01.600 --> 00:16:04.039
work mechanically? It's usually done arthroscopically

00:16:04.039 --> 00:16:06.559
at the same time as the bank heart repair. The

00:16:06.559 --> 00:16:08.720
surgeon identifies the hillsack's defect on the

00:16:08.720 --> 00:16:11.500
back of the humeral head. Then they take the

00:16:11.500 --> 00:16:13.360
infraspinatus tendon, which is one of the rotator

00:16:13.360 --> 00:16:15.980
cuff tendons, and the underlying posterior capsule,

00:16:16.039 --> 00:16:19.600
and they suture, or tendities, that tissue directly

00:16:19.600 --> 00:16:22.419
into the bony defect. Stitching the tendon into

00:16:22.419 --> 00:16:24.960
the dent. Essentially, yes. The idea is that

00:16:24.960 --> 00:16:27.120
this soft tissue fills the hole. So when the

00:16:27.120 --> 00:16:29.779
arm moves into that vulnerable position of abduction

00:16:29.779 --> 00:16:32.159
and external rotation, where the hill sacs would

00:16:32.159 --> 00:16:35.460
normally engage the glenoid rim, now this plug

00:16:35.460 --> 00:16:38.279
defect with the soft tissue makes contact instead.

00:16:38.590 --> 00:16:41.470
It prevents the bony locking mechanism. It effectively

00:16:41.470 --> 00:16:44.230
makes the defect extra -articular. Ah, I see.

00:16:44.230 --> 00:16:46.190
So it acts like a soft bumper, preventing the

00:16:46.190 --> 00:16:48.850
bone -on -bone clash. What do the results look

00:16:48.850 --> 00:16:51.230
like when remplassage is added? Does it actually

00:16:51.230 --> 00:16:54.230
reduce the risk of dislocation? Yes. The data

00:16:54.230 --> 00:16:56.850
is quite compelling. Adding remplassage to a

00:16:56.850 --> 00:16:58.789
bank card repair has been shown to significantly

00:16:58.789 --> 00:17:00.590
lower recurrence rates compared to doing the

00:17:00.590 --> 00:17:02.830
bank card alone, particularly in patients selected

00:17:02.830 --> 00:17:05.289
appropriately. How much lower? Well... Overall,

00:17:05.450 --> 00:17:06.730
recurrence rates with the combined procedure

00:17:06.730 --> 00:17:09.410
are reported as low as 4 % in some series. But

00:17:09.410 --> 00:17:11.509
looking at studies that directly compared, the

00:17:11.509 --> 00:17:13.930
differences are stark. Our source material cites

00:17:13.930 --> 00:17:17.069
comparisons like 2 .1 % recurrence with remplasage

00:17:17.069 --> 00:17:21.509
versus 9 .3 % without, 1 .8 % versus 11%, 5 %

00:17:21.509 --> 00:17:25.109
versus 30%, even 13 % versus 47 % in another

00:17:25.109 --> 00:17:27.829
group. The pattern is consistent. It provides

00:17:27.829 --> 00:17:30.210
a clear protective benefit against repeat instability.

00:17:30.460 --> 00:17:32.940
Those are really significant reductions in recurrence.

00:17:33.279 --> 00:17:35.500
Does the stitched -in tissue actually heal well

00:17:35.500 --> 00:17:38.059
into the bone defect? Yes. Healing rates appear

00:17:38.059 --> 00:17:41.240
to be very good. Studies using MRI or second

00:17:41.240 --> 00:17:44.160
-look arthroscopy have shown integration of the

00:17:44.160 --> 00:17:46.799
Tenedes tissue into the Hill Sachs defect in

00:17:46.799 --> 00:17:50.579
the range of 85 % to 100 % at follow -up. And

00:17:50.579 --> 00:17:53.380
encouragingly, longer -term studies haven't shown

00:17:53.380 --> 00:17:55.960
major concerning changes in that tissue, suggesting

00:17:55.960 --> 00:17:58.849
it's biologically well tolerated. It sounds effective.

00:17:59.130 --> 00:18:01.009
Who is it typically recommended for now? Have

00:18:01.009 --> 00:18:03.430
the indications changed over time? They certainly

00:18:03.430 --> 00:18:06.009
have broadened. Initially, Remplisage was mainly

00:18:06.009 --> 00:18:08.269
reserved for those definite off -track hillsax

00:18:08.269 --> 00:18:10.890
lesions, the ones clearly engaging. However,

00:18:11.089 --> 00:18:13.309
its use has expanded quite a bit. In what way?

00:18:13.450 --> 00:18:15.650
It's now often considered even for on -track

00:18:15.650 --> 00:18:17.490
lesions. If other factors put the patient at

00:18:17.490 --> 00:18:20.190
high risk of recurrence, young age, collision

00:18:20.190 --> 00:18:23.230
sports, maybe borderline bone loss. And importantly,

00:18:23.349 --> 00:18:25.150
it's being used increasingly for patients with

00:18:25.150 --> 00:18:27.710
what's termed subcritical glenoid bone loss,

00:18:28.109 --> 00:18:31.210
usually defined as between maybe 15 % and 25%.

00:18:31.210 --> 00:18:33.769
Why in that group specifically? Because studies

00:18:33.769 --> 00:18:36.210
show that in this subcritical bone loss group,

00:18:36.849 --> 00:18:39.650
doing a bank heart plus rumpusage significantly

00:18:39.650 --> 00:18:41.750
reduced the failure rate compared to just doing

00:18:41.750 --> 00:18:44.480
a bank heart alone. It seems to add stability

00:18:44.480 --> 00:18:46.859
even when the primary issue isn't necessarily

00:18:46.859 --> 00:18:50.200
an engaging HSL, but rather borderline glenoid

00:18:50.200 --> 00:18:52.559
deficiency. So it's becoming a tool for managing

00:18:52.559 --> 00:18:56.079
moderate risks. To some extent, yes. Some surgeons

00:18:56.079 --> 00:18:58.220
referenced in our source material now advocate

00:18:58.220 --> 00:19:01.299
considering Bancart plus remplasage for nearly

00:19:01.299 --> 00:19:04.759
all young active patients with less than, say,

00:19:04.920 --> 00:19:07.900
15, 20 percent glenoid bone loss, almost irrespective

00:19:07.900 --> 00:19:10.150
of the glenoid tract calculation. They might

00:19:10.150 --> 00:19:12.329
reserve an isolated bank heart repair primarily

00:19:12.329 --> 00:19:15.789
for perhaps older, 25, lower demand patients

00:19:15.789 --> 00:19:17.769
experiencing their first dislocation with minimal

00:19:17.769 --> 00:19:20.369
bone loss. So the trend is definitely towards

00:19:20.369 --> 00:19:22.670
using RemplaSage more broadly in high -risk patients.

00:19:22.809 --> 00:19:24.750
That's a really interesting evolution in practice.

00:19:24.950 --> 00:19:26.930
OK, so RemplaSage deals with the humeral head

00:19:26.930 --> 00:19:29.789
side, the HSL, or helps bolster stability and

00:19:29.789 --> 00:19:32.549
borderline glenoid loss. But what if the glenoid

00:19:32.549 --> 00:19:34.569
bone loss is more substantial, say clearly over

00:19:34.569 --> 00:19:37.549
20 % or 25 %? Is filling the HSL enough then?

00:19:37.869 --> 00:19:41.220
No, probably not. Once you get into significant

00:19:41.220 --> 00:19:44.400
anterior glenoid bone deficiency, simply addressing

00:19:44.400 --> 00:19:46.819
the humeral head defect or the labrum usually

00:19:46.819 --> 00:19:49.759
isn't sufficient. The socket itself is too shallow

00:19:49.759 --> 00:19:52.799
to unstable. In these cases, you need to physically

00:19:52.799 --> 00:19:54.920
reconstruct the missing part of the glenoid using

00:19:54.920 --> 00:19:57.140
a bone graft. Right, replacing the lost bone.

00:19:57.279 --> 00:19:59.640
Has the threshold for deciding you need a bone

00:19:59.640 --> 00:20:02.769
graft changed? Yes, it has tended to decrease

00:20:02.769 --> 00:20:05.029
over time, especially for high -risk individuals.

00:20:05.710 --> 00:20:07.309
Historically, the threshold might have been cited

00:20:07.309 --> 00:20:11.829
as 20 % or 25 % glenoid bone loss. Now, many

00:20:11.829 --> 00:20:13.549
surgeons will consider a bony reconstruction

00:20:13.549 --> 00:20:16.589
for defects over 15 -20 % and sometimes even

00:20:16.589 --> 00:20:19.789
lower, perhaps around 13 .5 -15 % if the patient

00:20:19.789 --> 00:20:21.829
is very high -risk, young collision athlete,

00:20:22.109 --> 00:20:24.269
or if it's a revision surgery after a failed

00:20:24.269 --> 00:20:26.980
bank art. Subcritical bone loss itself is now

00:20:26.980 --> 00:20:29.180
recognized as a significant risk factor. Okay,

00:20:29.299 --> 00:20:31.539
so the bar for needing a bony fix is getting

00:20:31.539 --> 00:20:34.359
lower. Where does the actual bone for the graft

00:20:34.359 --> 00:20:36.880
come from? There are two main sources, autograft

00:20:36.880 --> 00:20:39.240
and allograft. Autograft means using the patient's

00:20:39.240 --> 00:20:41.440
own bone. The most common place to take it from

00:20:41.440 --> 00:20:43.559
for glenoid reconstruction is the iliac crest,

00:20:43.740 --> 00:20:45.720
the top part of the hip bone. Taking it from

00:20:45.720 --> 00:20:48.920
the hip. Are there other spots? Yes. Sometimes

00:20:48.920 --> 00:20:50.839
bone can be harvested from the distal clavicle,

00:20:50.900 --> 00:20:53.539
the end of the collarbone, or parts of the scapula

00:20:53.539 --> 00:20:56.500
itself, like the scapular spine. The alternative

00:20:56.500 --> 00:21:00.660
is allograft. Allograft meaning donor bone. Exactly.

00:21:00.900 --> 00:21:03.720
Bone from a tissue bank, which has been processed

00:21:03.720 --> 00:21:06.720
and sterilized. Common allograft sources used

00:21:06.720 --> 00:21:09.539
for the glenoid include the distal tibia, the

00:21:09.539 --> 00:21:11.900
lower end of the shin bone, parts of the femoral

00:21:11.900 --> 00:21:15.240
head, the ball of the hip joint, or even a donor

00:21:15.240 --> 00:21:18.259
humeral head. Is any particular type of graft

00:21:18.259 --> 00:21:21.019
highlighted as being especially suitable for

00:21:21.019 --> 00:21:25.009
rebuilding the glenoid? The distal tibial osteoarticular

00:21:25.009 --> 00:21:27.190
allograft gets mentioned quite positively in

00:21:27.190 --> 00:21:29.130
the source material. Why that one specifically?

00:21:29.309 --> 00:21:31.710
Several reasons. Its natural shape often matches

00:21:31.710 --> 00:21:34.049
the curvature of the glenoid quite well. It's

00:21:34.049 --> 00:21:36.450
known to be dense, strong bone, which is good

00:21:36.450 --> 00:21:39.089
for holding screws securely, but perhaps most

00:21:39.089 --> 00:21:41.450
importantly, it comes with its own layer of articular

00:21:41.450 --> 00:21:43.910
cartilage intact. Ah, so it rebuilds not just

00:21:43.910 --> 00:21:47.470
the bone but the smooth joint surface too. Precisely.

00:21:47.990 --> 00:21:50.529
That allows for a more anatomical reconstruction.

00:21:50.700 --> 00:21:53.539
which theoretically might lead to better long

00:21:53.539 --> 00:21:55.880
-term joint health and potentially less arthritis

00:21:55.880 --> 00:21:58.359
down the line compared to using a graft that's

00:21:58.359 --> 00:22:00.740
just bare bone. Clinical results reported are

00:22:00.740 --> 00:22:02.950
generally good. with high healing rates around

00:22:02.950 --> 00:22:06.190
89 % sighted and relatively low rates of the

00:22:06.190 --> 00:22:09.190
graft shrinking or resorbing over time, maybe

00:22:09.190 --> 00:22:11.509
around 3%. That cartilage surface does sound

00:22:11.509 --> 00:22:14.049
like a big advantage. What are the general pros

00:22:14.049 --> 00:22:16.569
and cons of using donor bone, the allograft,

00:22:16.730 --> 00:22:19.049
versus the patient's own bone, the autograft?

00:22:19.269 --> 00:22:21.589
The main advantage of allograft is avoiding donor

00:22:21.589 --> 00:22:23.630
site morbidity. You don't have to make a separate

00:22:23.630 --> 00:22:25.369
incision and take bone from the patient's hip

00:22:25.369 --> 00:22:27.829
or elsewhere, which avoids the pain, potential

00:22:27.829 --> 00:22:29.750
nerve issues or other complications associated

00:22:29.750 --> 00:22:32.029
with that harvest site. Makes sense. And specifically

00:22:32.029 --> 00:22:34.710
for the distal tibial allograft, you get that

00:22:34.710 --> 00:22:37.430
cartilage surface, good bone stock, and it can

00:22:37.430 --> 00:22:40.190
often be shaped to fill quite large defects.

00:22:41.250 --> 00:22:44.160
The disadvantages. Well, allografts are more

00:22:44.160 --> 00:22:46.299
expensive. There can sometimes be issues with

00:22:46.299 --> 00:22:49.140
availability. There's an extremely small theoretical

00:22:49.140 --> 00:22:51.700
risk of disease transmission, though screening

00:22:51.700 --> 00:22:53.980
and processing methods are very rigorous now.

00:22:54.480 --> 00:22:56.460
And the surgical technique for implanting an

00:22:56.460 --> 00:22:58.539
allograft, especially an osteoarticular one,

00:22:58.859 --> 00:23:01.299
can be technically quite demanding. Right. Technical

00:23:01.299 --> 00:23:04.240
complexity is a factor. Okay, moving on from

00:23:04.240 --> 00:23:06.960
free bone grafts, perhaps the most famous bony

00:23:06.960 --> 00:23:09.599
procedure for shoulder instability is the latarget.

00:23:09.819 --> 00:23:12.000
It seems like a real workhorse for these complex

00:23:12.000 --> 00:23:14.599
cases. Can you break down what the latarget procedure

00:23:14.599 --> 00:23:18.079
actually involves? Certainly. The latarget procedure

00:23:18.079 --> 00:23:20.660
is named after Michel Latourge. the French surgeon

00:23:20.660 --> 00:23:23.259
who described it. It involves taking a specific

00:23:23.259 --> 00:23:25.440
piece of bone from the patient's own shoulder

00:23:25.440 --> 00:23:27.759
blade, the scapula called the coracoid process,

00:23:28.220 --> 00:23:30.440
along with the tendons that attach to it, and

00:23:30.440 --> 00:23:32.680
transferring this whole unit to the front lower

00:23:32.680 --> 00:23:35.660
edge of the glenoid socket. So moving a piece

00:23:35.660 --> 00:23:38.119
of bone from one part of the shoulder blade to

00:23:38.119 --> 00:23:41.839
the rim of the socket. Why that specific piece?

00:23:42.240 --> 00:23:45.079
How does it stabilize the shoulder? It provides

00:23:45.079 --> 00:23:47.319
stability through what's famously known as the

00:23:47.319 --> 00:23:49.559
triple blocking effect. It's quite clever. Triple

00:23:49.559 --> 00:23:51.559
effect. What are the three parts? Okay, first,

00:23:51.980 --> 00:23:55.039
the bone block itself. Transferring the coracoid

00:23:55.039 --> 00:23:57.819
bone physically extends the glenoid surface area,

00:23:58.079 --> 00:24:00.319
replacing the missing bone and deepening the

00:24:00.319 --> 00:24:02.500
socket at the front. That's the direct bony block.

00:24:02.599 --> 00:24:04.640
Right, just making the socket bigger. Second,

00:24:04.920 --> 00:24:07.299
the tendons attached to the coracoid, the conjoint

00:24:07.299 --> 00:24:09.140
tendon, which is formed by the short head of

00:24:09.140 --> 00:24:12.299
the biceps and the coracobrachialis muscle, are

00:24:12.299 --> 00:24:14.579
transferred along with the bone. they end up

00:24:14.579 --> 00:24:16.279
lying across the front of the shoulder joint.

00:24:16.920 --> 00:24:19.059
When the arm is moved into vulnerable positions

00:24:19.059 --> 00:24:21.980
like abduction and external rotation, these muscles

00:24:21.980 --> 00:24:24.759
contract, and the tendon acts like a dynamic

00:24:24.759 --> 00:24:27.519
sling, actively resisting the humeral head from

00:24:27.519 --> 00:24:30.599
sliding forward. A dynamic sling. Active muscle

00:24:30.599 --> 00:24:33.700
support. That's clever. It is. And third, the

00:24:33.700 --> 00:24:36.900
procedure also has a tenodesis effect. Transferring

00:24:36.900 --> 00:24:40.019
the coracoid and its tendon effectively reinforces

00:24:40.019 --> 00:24:43.079
the often stretched out or damaged antero -inferior

00:24:43.079 --> 00:24:45.559
joint capsule. So you get bony augmentation,

00:24:46.079 --> 00:24:48.920
a dynamic muscular sling, and capsule reinforcement

00:24:48.920 --> 00:24:51.500
all in one. It's a powerful combination. That

00:24:51.500 --> 00:24:53.660
triple effect makes sense why it's so effective.

00:24:54.119 --> 00:24:56.980
When is Letarge at the go -to procedure, and

00:24:56.980 --> 00:25:00.140
when might it not be suitable? The primary indication

00:25:00.140 --> 00:25:03.220
is significant anterior glenoid bone loss, typically

00:25:03.220 --> 00:25:05.720
over that 15 -20 percent threshold we discussed,

00:25:06.099 --> 00:25:08.279
depending on the patient. It's also very commonly

00:25:08.279 --> 00:25:10.720
used for revision surgery after a failed bankart

00:25:10.720 --> 00:25:13.279
repair, especially if bone loss was the reason

00:25:13.279 --> 00:25:16.420
for failure or has developed since. And contraindications?

00:25:16.680 --> 00:25:18.680
Well, if the bone loss is absolutely massive,

00:25:18.779 --> 00:25:21.369
perhaps beyond what the coracoid can reasonably

00:25:21.369 --> 00:25:24.250
reconstruct, although there are technical modifications

00:25:24.250 --> 00:25:26.710
like the congruent arc technique for larger defects,

00:25:27.029 --> 00:25:30.069
these might carry slightly higher risks. Significant

00:25:30.069 --> 00:25:32.349
instability in other directions, like posterior

00:25:32.349 --> 00:25:35.130
instability, might also be a relative contraindication

00:25:35.130 --> 00:25:37.369
or require additional procedures. You mentioned

00:25:37.369 --> 00:25:40.349
techniques. Can this be done arthroscopically,

00:25:40.910 --> 00:25:43.569
minimally, invasively, or is it typically an

00:25:43.569 --> 00:25:46.390
open operation? It can be done both ways. Traditionally,

00:25:46.470 --> 00:25:48.950
it was an open procedure requiring a larger incision.

00:25:49.049 --> 00:25:51.390
But over the last couple of decades, techniques

00:25:51.390 --> 00:25:54.109
for performing the latarjet arthroscopically

00:25:54.109 --> 00:25:57.069
through keyhole surgery have become well established.

00:26:00.529 --> 00:26:03.269
Both approaches have demonstrated excellent results

00:26:03.269 --> 00:26:05.349
in terms of restoring stability and function,

00:26:05.869 --> 00:26:08.230
with low rates of recurrent dislocation when

00:26:08.230 --> 00:26:10.940
performed well. The reported recurrence rates

00:26:10.940 --> 00:26:13.420
after Latorgiat are generally low figures like

00:26:13.420 --> 00:26:16.279
4 % at 5 years, maybe up to 11 % at 10 years

00:26:16.279 --> 00:26:19.160
are cited. One large series even reported just

00:26:19.160 --> 00:26:22.119
1 % recurrence. That's impressively stable. It

00:26:22.119 --> 00:26:24.980
is. And while overall complication rates reported

00:26:24.980 --> 00:26:27.359
in the literature can seem broad, ranging from

00:26:27.359 --> 00:26:30.559
6 % up to nearly 24%, in the hands of surgeons

00:26:30.559 --> 00:26:32.680
who do a lot of these procedures, the rates tend

00:26:32.680 --> 00:26:35.880
to be much lower, often in the 4 -7 % range.

00:26:36.140 --> 00:26:38.309
It's technically demanding either way. You mentioned

00:26:38.309 --> 00:26:40.569
recurrence is low, but when it does happen after

00:26:40.569 --> 00:26:43.210
a latarjet, is there a typical time frame? Yes.

00:26:43.529 --> 00:26:47.109
Interestingly, most recurrences following a latarjet

00:26:47.109 --> 00:26:50.589
procedure tend to happen relatively early, usually

00:26:50.589 --> 00:26:53.730
within the first year or two after surgery. Compared

00:26:53.730 --> 00:26:56.569
to bank heart repair, though, latarjet generally

00:26:56.569 --> 00:26:59.529
provides superior long -term stability, especially

00:26:59.529 --> 00:27:02.069
in those high -risk patients. And for athletes,

00:27:02.069 --> 00:27:04.730
that's often the key group needing this. What

00:27:04.730 --> 00:27:07.029
about getting back to sport after a latarjet?

00:27:07.160 --> 00:27:09.440
Return to sport rates are consistently high,

00:27:09.519 --> 00:27:11.720
which is a major advantage and why it's often

00:27:11.720 --> 00:27:14.480
favored for athletes, particularly those in contact

00:27:14.480 --> 00:27:17.380
or collision sports. The source material suggests

00:27:17.380 --> 00:27:21.200
overall return rates up to 88%, with around 72

00:27:21.200 --> 00:27:23.500
% managing to get back to their pre -injury level

00:27:23.500 --> 00:27:26.079
of competition. That's very encouraging for athletes

00:27:26.079 --> 00:27:28.619
facing this. Absolutely. That combination of

00:27:28.619 --> 00:27:30.759
high stability and high return to sport rates

00:27:30.759 --> 00:27:33.440
makes it a very appealing option for that population,

00:27:33.680 --> 00:27:35.740
even though it's a more complex operation than

00:27:35.740 --> 00:27:38.589
a simple bank car. Okay, so excellent stability,

00:27:39.009 --> 00:27:41.710
good return to sport, but it is more complex.

00:27:42.250 --> 00:27:44.589
What are the potential downsides or complications

00:27:44.589 --> 00:27:47.769
specific to the Letarjet procedure? Well, the

00:27:47.769 --> 00:27:49.990
main conceptual disadvantage is that it's inherently

00:27:49.990 --> 00:27:52.730
non -anatomical. You're changing the shoulder's

00:27:52.730 --> 00:27:55.210
natural structure by adding bone and moving tendons.

00:27:55.869 --> 00:27:58.210
This can potentially make any future surgery,

00:27:58.589 --> 00:28:00.549
should it be needed, more difficult. Right, operating

00:28:00.549 --> 00:28:04.660
on altered anatomy. Exactly. Also, The bone graft

00:28:04.660 --> 00:28:07.599
itself, the coracoid, doesn't have articular

00:28:07.599 --> 00:28:09.880
cartilage on the surface that faces the humeral

00:28:09.880 --> 00:28:13.039
head. There's a theoretical concern, though it's

00:28:13.039 --> 00:28:16.420
debated, that this bone -on -cartilage articulation

00:28:16.420 --> 00:28:18.759
could potentially increase the risk of developing

00:28:18.759 --> 00:28:21.519
osteoarthritis over the very long term. And other

00:28:21.519 --> 00:28:24.160
complications. Specific complications can include

00:28:24.160 --> 00:28:26.539
problems with the graft itself, putting it in

00:28:26.539 --> 00:28:29.180
the wrong position, it not healing to the glenoid,

00:28:29.200 --> 00:28:32.200
non -union, or shrinking over time, resorption.

00:28:32.509 --> 00:28:34.970
The screws used for fixation can cause issues

00:28:34.970 --> 00:28:37.250
if they're too long, too short, break, or irritate

00:28:37.250 --> 00:28:39.630
tissues. Persistent instability can still occur

00:28:39.630 --> 00:28:41.650
if the underlying issues weren't fully addressed.

00:28:42.289 --> 00:28:45.329
Infection is a risk, as with any surgery. And

00:28:45.329 --> 00:28:47.910
nerve injuries, while uncommon, are a known potential

00:28:47.910 --> 00:28:50.549
complication due to the location of the dissection.

00:28:50.950 --> 00:28:52.829
Let's pause on those specific challenges for

00:28:52.829 --> 00:28:55.430
a moment. Our source material delves into certain

00:28:55.430 --> 00:28:58.490
patient groups where instability is particularly

00:28:58.490 --> 00:29:00.829
complex. You mentioned patients with seizure

00:29:00.829 --> 00:29:03.740
disorders earlier. How do seizures complicate

00:29:03.740 --> 00:29:05.480
shorter instability? It seems like a difficult

00:29:05.480 --> 00:29:07.599
combination. It really is, and it's a crucial

00:29:07.599 --> 00:29:10.839
group to consider. Patients with epilepsy, or

00:29:10.839 --> 00:29:14.819
PWE, can have incredibly forceful, uncontrolled

00:29:14.819 --> 00:29:17.859
muscle contractions during seizures. These contractions

00:29:17.859 --> 00:29:19.839
can be strong enough to actually dislocate the

00:29:19.839 --> 00:29:22.319
shoulder or even cause fractures around the joint.

00:29:22.680 --> 00:29:25.259
So the seizure itself causes the dislocation.

00:29:25.420 --> 00:29:27.599
Yes, it can be the primary mechanism of injury

00:29:27.599 --> 00:29:31.069
or re -injury. Historically, posterior dislocations

00:29:31.069 --> 00:29:33.549
were often associated with seizures, perhaps

00:29:33.549 --> 00:29:36.190
due to typical arm positioning, but actually

00:29:36.190 --> 00:29:38.470
both anterior and posterior dislocations are

00:29:38.470 --> 00:29:41.390
well documented. The forces are just overwhelming.

00:29:41.789 --> 00:29:44.130
Furthermore, repeated seizures, especially if

00:29:44.130 --> 00:29:46.190
poorly controlled and perhaps in younger patients

00:29:46.190 --> 00:29:48.490
whose bones are still developing, might lead

00:29:48.490 --> 00:29:51.170
to gradual bony changes over time, like increased

00:29:51.170 --> 00:29:54.309
retroversion, backward tilt, of the glenoid socket,

00:29:54.589 --> 00:29:57.619
further predisposing to instability. Wow. So

00:29:57.619 --> 00:29:59.980
the underlying condition directly impacts the

00:29:59.980 --> 00:30:02.539
gaint mechanics and risk. How does this change

00:30:02.539 --> 00:30:05.660
the treatment approach? It adds significant complexity.

00:30:06.420 --> 00:30:08.500
Trying non -operative management is often less

00:30:08.500 --> 00:30:10.759
successful if seizure control isn't optimal.

00:30:11.460 --> 00:30:13.819
When considering surgery, achieving good control

00:30:13.819 --> 00:30:16.380
of the seizure disorder first is absolutely paramount.

00:30:16.400 --> 00:30:19.500
That's so critical. Because having a major seizure

00:30:19.500 --> 00:30:22.259
soon after surgery could easily disrupt the repair

00:30:22.259 --> 00:30:24.759
or reconstruction. Many recommend aiming for

00:30:24.759 --> 00:30:26.400
a seizure -free period, perhaps at least six

00:30:26.400 --> 00:30:29.099
months, before undertaking elective stabilization

00:30:29.099 --> 00:30:31.579
surgery to minimize this risk. And the type of

00:30:31.579 --> 00:30:34.359
surgery. Does it influence that, too? Yes, strongly.

00:30:35.099 --> 00:30:37.480
Given the potential for massive uncontrolled

00:30:37.480 --> 00:30:40.119
forces during a seizure, relying solely on a

00:30:40.119 --> 00:30:42.500
soft tissue repair is often considered too risky.

00:30:43.119 --> 00:30:45.700
Bony stabilization procedures, like the Laffer

00:30:45.700 --> 00:30:48.819
jet for anterior instability, or perhaps bone

00:30:48.819 --> 00:30:51.480
grafting for posterior defects, are frequently

00:30:51.480 --> 00:30:54.230
favored. They provide more robust structural

00:30:54.230 --> 00:30:56.529
stability that's less likely to be overcome by

00:30:56.529 --> 00:30:59.509
muscle contraction. The absolute key, though,

00:30:59.829 --> 00:31:02.809
is multidisciplinary care. Close collaboration

00:31:02.809 --> 00:31:05.410
between the orthopedic surgeon and the neurologist

00:31:05.410 --> 00:31:08.190
managing the epilepsy is essential. That integrated

00:31:08.190 --> 00:31:10.549
approach sounds vital. What about the other challenging

00:31:10.549 --> 00:31:12.650
group mentioned patients with hyperlaxity, maybe

00:31:12.650 --> 00:31:14.690
conditions like Ehlers -Danlos syndrome where

00:31:14.690 --> 00:31:17.450
ligaments are naturally loose? Yes. Managing

00:31:17.450 --> 00:31:19.630
instability and generalized hyperlaxity is a

00:31:19.630 --> 00:31:22.309
different kind of challenge. Here, the core problem

00:31:22.309 --> 00:31:25.569
isn't usually a single traumatic tear, but rather

00:31:25.569 --> 00:31:27.789
the inherent stretchiness of all the connective

00:31:27.789 --> 00:31:30.369
tissues. So surgery might not be the first step.

00:31:30.509 --> 00:31:33.609
Absolutely not. The initial approach, and often

00:31:33.609 --> 00:31:37.029
the mainstay of treatment, is intensive non -operative

00:31:37.029 --> 00:31:39.890
management. This means a prolonged course of

00:31:39.890 --> 00:31:42.349
dedicated physical therapy, often lasting three

00:31:42.349 --> 00:31:45.309
to six months or even longer. What's the focus

00:31:45.309 --> 00:31:47.970
of the physio? It's all about building dynamic

00:31:47.970 --> 00:31:50.490
stability, strengthening the muscles around the

00:31:50.490 --> 00:31:52.910
shoulder, the rotator cuff, the muscles that

00:31:52.910 --> 00:31:55.750
control the scapula, and improving proprioception,

00:31:56.150 --> 00:31:58.630
which is the joint sense of its position in space.

00:31:59.240 --> 00:32:02.380
The aim is to use active muscle control to compensate

00:32:02.380 --> 00:32:04.640
for the loose passive ligaments and capsule.

00:32:05.240 --> 00:32:07.319
Trying to make the muscles do the stabilizing

00:32:07.319 --> 00:32:10.180
work the ligaments can't. Exactly. And if that

00:32:10.180 --> 00:32:12.779
extensive physio still isn't enough, what are

00:32:12.779 --> 00:32:14.839
the surgical options then? If surgery becomes

00:32:14.839 --> 00:32:16.819
necessary, it's usually focused on tightening

00:32:16.819 --> 00:32:19.640
the overly loose joint capsule. For patients

00:32:19.640 --> 00:32:22.000
with true multi -directional instability, where

00:32:22.000 --> 00:32:24.519
the shoulder feels loose in all directions, the

00:32:24.519 --> 00:32:26.920
typical procedure is an arthroscopic pen capsule

00:32:26.920 --> 00:32:30.180
application. Pen capsule application. Tightening

00:32:30.180 --> 00:32:32.900
the whole capsule. Yes, essentially gathering

00:32:32.900 --> 00:32:35.259
up and suturing the redundant capsule from all

00:32:35.259 --> 00:32:37.700
sides to reduce the joint volume and improve

00:32:37.700 --> 00:32:41.700
stability. If the hyperlaxity is present, but

00:32:41.700 --> 00:32:44.400
the main problem is still primarily anterior

00:32:44.400 --> 00:32:47.140
instability, sometimes surgeons might perform

00:32:47.140 --> 00:32:49.619
a bank heart repair, combined with a procedure

00:32:49.619 --> 00:32:52.900
to augment or tighten the subscapularis tendon

00:32:52.900 --> 00:32:55.559
at the front. What's the big challenge when operating

00:32:55.559 --> 00:32:58.539
on hyperlax patients? The challenge is finding

00:32:58.539 --> 00:33:00.960
the sweet spot. You need to tighten things enough

00:33:00.960 --> 00:33:03.279
to provide stability, but because their tissues

00:33:03.279 --> 00:33:06.180
are inherently stretchy, it's easy to over tighten

00:33:06.180 --> 00:33:08.380
and leave them with significant functionally

00:33:08.380 --> 00:33:11.259
limiting stiffness. It's a very delicate balancing

00:33:11.259 --> 00:33:13.519
act. Right, so we've journeyed from the basic

00:33:13.519 --> 00:33:15.960
mechanics through to advanced procedures like

00:33:15.960 --> 00:33:19.180
remplasage and letarget, tackled bone loss, and

00:33:19.180 --> 00:33:21.079
considered these specific patient complexities.

00:33:21.359 --> 00:33:23.599
But as we know, surgery isn't always the final

00:33:23.599 --> 00:33:26.259
chapter and things can go wrong. Let's pivot

00:33:26.259 --> 00:33:28.420
now to look at complications, the challenges

00:33:28.420 --> 00:33:30.960
of revision surgery, and the longer term outlook

00:33:30.960 --> 00:33:33.619
for these shoulders. Indeed, understanding potential

00:33:33.619 --> 00:33:35.940
failures and complications is crucial. You mentioned

00:33:35.940 --> 00:33:38.660
earlier that failure after a standard bankart

00:33:38.660 --> 00:33:42.140
repair often links back to unaddressed bone loss.

00:33:42.759 --> 00:33:44.859
Is there a characteristic way the glenoid bone

00:33:44.859 --> 00:33:47.559
fails after that kind of repair, especially with

00:33:47.559 --> 00:33:50.420
modern anchor techniques? Yes. There's a specific

00:33:50.420 --> 00:33:52.500
pattern that's been described, particularly following

00:33:52.500 --> 00:33:55.900
arthroscopic bankart repairs using suture anchors

00:33:55.900 --> 00:33:58.220
drilled into the bone. It's sometimes called

00:33:58.220 --> 00:34:01.359
the postage stamp fracture. Postage stamp fracture.

00:34:01.480 --> 00:34:04.480
Why that name? Because if the shoulder redislocates

00:34:04.480 --> 00:34:06.640
after such a repair, especially if there was

00:34:06.640 --> 00:34:09.639
already some bone loss, the anterior rim of the

00:34:09.639 --> 00:34:11.579
glenoid can fracture right through the holes

00:34:11.579 --> 00:34:13.920
where the anchors were placed. It creates this

00:34:13.920 --> 00:34:16.280
fragmented, almost perforated look along the

00:34:16.280 --> 00:34:18.719
rim, like the edge of a sheet of postage stamps.

00:34:19.039 --> 00:34:21.900
Ah, I see. The ankle holes become weak points.

00:34:22.239 --> 00:34:24.780
Exactly. It suggests the bone quality wasn't

00:34:24.780 --> 00:34:27.320
sufficient to withstand the forces. Potentially

00:34:27.320 --> 00:34:30.039
exacerbated by the underlying bone loss, and

00:34:30.039 --> 00:34:32.039
maybe even related to the stress concentration

00:34:32.039 --> 00:34:34.639
caused by the anchors themselves, their placement,

00:34:34.840 --> 00:34:37.300
size, or material might play a role. That sounds

00:34:37.300 --> 00:34:39.360
like it would make going back in for revision

00:34:39.360 --> 00:34:42.949
surgery even trickier. When a bankart does fail,

00:34:43.210 --> 00:34:45.949
how do surgeons decide what to do next? Try another

00:34:45.949 --> 00:34:48.829
bankart or switch to something like a latarjet?

00:34:49.409 --> 00:34:52.210
That's a really critical decision. If the primary

00:34:52.210 --> 00:34:55.050
bankart failed clearly because of significant

00:34:55.050 --> 00:34:57.710
bone loss that wasn't addressed initially, or

00:34:57.710 --> 00:34:59.849
if the patient has multiple high -risk factors

00:34:59.849 --> 00:35:02.769
like being a young collision athlete, then simply

00:35:02.769 --> 00:35:05.630
repeating the bankart repair is very unlikely

00:35:05.630 --> 00:35:08.510
to succeed. It's often considered contraindicated

00:35:08.510 --> 00:35:10.510
in those situations. So, letarget becomes the

00:35:10.510 --> 00:35:12.570
main option? In most cases of failed bankart

00:35:12.570 --> 00:35:14.789
repair, yes, especially if there's documented

00:35:14.789 --> 00:35:17.510
bone loss either initially missed or developed

00:35:17.510 --> 00:35:19.690
over time or the patient falls into that high

00:35:19.690 --> 00:35:22.630
-risk category. A bony procedure like the letarget

00:35:22.630 --> 00:35:25.469
or sometimes a bone grafting technique is generally

00:35:25.469 --> 00:35:27.929
the preferred revision strategy. How do the outcomes

00:35:27.929 --> 00:35:30.190
compare revising with another bankart versus

00:35:30.190 --> 00:35:32.949
revising with a letarget? The source material

00:35:32.949 --> 00:35:36.269
suggests that Generally, revising a failed bank

00:35:36.269 --> 00:35:39.150
card with a Letarget leads to better functional

00:35:39.150 --> 00:35:41.849
scores, better stability, and higher rates of

00:35:41.849 --> 00:35:44.230
return to sport compared to attempting a revision

00:35:44.230 --> 00:35:47.210
bank card. However... There's always a however.

00:35:47.469 --> 00:35:51.010
There is. Revisional latargette doing a latargette

00:35:51.010 --> 00:35:53.809
after a previous failed surgery can be technically

00:35:53.809 --> 00:35:55.750
more demanding than doing a latargette as the

00:35:55.750 --> 00:35:57.989
first operation. It might be associated with

00:35:57.989 --> 00:36:00.429
slightly higher complication rates, potentially

00:36:00.429 --> 00:36:02.750
more post -operative pain, and sometimes greater

00:36:02.750 --> 00:36:05.510
loss of external rotation compared to a primary

00:36:05.510 --> 00:36:08.349
latargette. So while it's often the better option

00:36:08.349 --> 00:36:10.829
for stability, it's not without its own challenges.

00:36:11.159 --> 00:36:13.719
Revision surgery is just inherently more complex.

00:36:14.079 --> 00:36:16.480
What about failures of the bony procedures themselves?

00:36:16.559 --> 00:36:19.280
Can letarget or bone grafts fail too? Oh, absolutely.

00:36:19.320 --> 00:36:21.699
They can fail for various reasons. Yeah. Technical

00:36:21.699 --> 00:36:24.099
issues during the initial surgery are one cause.

00:36:24.400 --> 00:36:26.900
Maybe the graft wasn't sized correctly, or it

00:36:26.900 --> 00:36:29.139
was put in the wrong position, or the screws

00:36:29.139 --> 00:36:31.679
used for fixation weren't quite right, leading

00:36:31.679 --> 00:36:34.440
to instability or non -healing. So surgical technique

00:36:34.440 --> 00:36:37.119
is paramount. Hugely important. Other causes

00:36:37.119 --> 00:36:39.500
can include failing to address other problems

00:36:39.500 --> 00:36:42.139
at the same time. like significant soft tissue

00:36:42.139 --> 00:36:45.440
damage elsewhere, or a large hillsax lesion that

00:36:45.440 --> 00:36:48.139
also needed attention. Infection is always a

00:36:48.139 --> 00:36:51.480
risk. Hardware can fail or break. And specific

00:36:51.480 --> 00:36:54.059
to bone grafts, they can sometimes fail to heal

00:36:54.059 --> 00:36:57.099
to the patient's bone, non -union, or they can

00:36:57.099 --> 00:37:01.119
gradually resorb or shrink over time. The bone

00:37:01.119 --> 00:37:03.139
graft actually disappearing. That sounds like

00:37:03.139 --> 00:37:05.599
a major problem for long -term stability. How

00:37:05.599 --> 00:37:08.099
often does that happen? It is a concern, particularly

00:37:08.099 --> 00:37:10.559
perhaps more with allografts than autografts,

00:37:10.559 --> 00:37:12.659
although it can occur with both. The reported

00:37:12.659 --> 00:37:14.820
rates vary quite a bit in the literature, but

00:37:14.820 --> 00:37:17.280
significant resorptions say losing more than

00:37:17.280 --> 00:37:19.960
25 % of the graft volumes definitely described.

00:37:20.480 --> 00:37:22.420
It seems less common now with modern techniques

00:37:22.420 --> 00:37:25.039
and fixation, but it's a known potential long

00:37:25.039 --> 00:37:27.199
-term complication. What causes the graft to

00:37:27.199 --> 00:37:29.460
resorb? It's often thought to be related to mechanical

00:37:29.460 --> 00:37:32.139
factors. If the graft isn't positioned perfectly

00:37:32.139 --> 00:37:34.920
flush or isn't held absolutely rigidly with a

00:37:34.920 --> 00:37:38.820
fixation, any tiny movement or micromotion at

00:37:38.820 --> 00:37:41.219
the graft -host interface can hinder proper bone

00:37:41.219 --> 00:37:43.960
healing and potentially trigger resorption. The

00:37:43.960 --> 00:37:45.860
biological properties of the graft type might

00:37:45.860 --> 00:37:48.119
also play a role, with some suggesting living

00:37:48.119 --> 00:37:51.019
autograft cells might make it less prone to resorption

00:37:51.019 --> 00:37:54.630
than processed allograft. Really meticulous surgical

00:37:54.630 --> 00:37:57.530
technique and achieving solid fixation are key

00:37:57.530 --> 00:38:00.090
to minimizing the risk. Beyond the surgery just

00:38:00.090 --> 00:38:02.630
not working to stabilize the shoulder, what other

00:38:02.630 --> 00:38:05.190
common complications can pop up after these complex

00:38:05.190 --> 00:38:07.650
instability procedures? Well, nerve injury is

00:38:07.650 --> 00:38:09.710
one that always needs careful consideration.

00:38:10.329 --> 00:38:12.150
Fortunately, permanent nerve damage is rare,

00:38:12.730 --> 00:38:14.909
but transient injuries or irritation can happen.

00:38:15.130 --> 00:38:17.789
Which nerves are most at risk? It depends a bit

00:38:17.789 --> 00:38:21.059
on the procedure. With the latar jet, because

00:38:21.059 --> 00:38:23.320
the dissection is near the coracoid process,

00:38:23.719 --> 00:38:25.880
the muscular cutaneous nerve is most commonly

00:38:25.880 --> 00:38:28.639
cited as being at risk. Some reports mention

00:38:28.639 --> 00:38:31.760
it in up to 30 % of nerve complications, though

00:38:31.760 --> 00:38:34.380
actual lasting weakness is much less frequent.

00:38:35.420 --> 00:38:37.440
The axillary nerve, which runs around the back

00:38:37.440 --> 00:38:39.719
and side of the shoulder, is also vulnerable,

00:38:40.039 --> 00:38:42.679
especially during screw placement, or if extensive

00:38:42.679 --> 00:38:45.579
dissection is needed, maybe around 13 % of nerve

00:38:45.579 --> 00:38:48.739
issues involve the axillary nerve. The superscapular

00:38:48.739 --> 00:38:51.280
nerve can also be at risk during certain arthroscopic

00:38:51.280 --> 00:38:54.099
approaches. So careful nerve monitoring is needed.

00:38:54.360 --> 00:38:56.420
Careful technique during surgery and a thorough

00:38:56.420 --> 00:38:58.559
neurological exam after surgery are crucial.

00:38:59.099 --> 00:39:01.539
If a nerve deficit is found, especially if there's

00:39:01.539 --> 00:39:03.539
suspicion it might be due to misplaced hardware

00:39:03.539 --> 00:39:06.300
compressing the nerve, then urgent further investigation

00:39:06.300 --> 00:39:09.119
like a CT scan and potentially revision surgery

00:39:09.119 --> 00:39:11.460
to reposition or remove the hardware might be

00:39:11.460 --> 00:39:13.539
necessary. Okay, nerves are one thing. What about

00:39:13.539 --> 00:39:15.780
stiffness? We touched on it with hyperlaxity,

00:39:15.780 --> 00:39:19.400
but is it a general risk? Yes, stiffness, particularly

00:39:19.400 --> 00:39:22.380
loss of external rotation, is a well -recognized

00:39:22.380 --> 00:39:25.300
potential downside. It's that constant trade

00:39:25.300 --> 00:39:27.539
-off. Surgeons are trying to make the shoulder

00:39:27.539 --> 00:39:29.840
stable, which often involves tightening structures,

00:39:30.199 --> 00:39:33.300
but overdo it, and you sacrifice motion. Which

00:39:33.300 --> 00:39:35.639
procedures are most likely to cause stiffness?

00:39:36.280 --> 00:39:38.840
Some older open techniques that involved splitting

00:39:38.840 --> 00:39:41.300
or significantly tightening the subscapularis

00:39:41.300 --> 00:39:43.780
muscle were known for causing external rotation

00:39:43.780 --> 00:39:47.000
loss. Modern arthroscopic capsule replication

00:39:47.000 --> 00:39:49.739
used for laxity intentionally tightens the capsule

00:39:49.739 --> 00:39:52.340
and can limit motion if not done judiciously.

00:39:53.019 --> 00:39:55.039
And the literature jet procedure, due to the

00:39:55.039 --> 00:39:57.539
anterior bone block and potential scarring, can

00:39:57.539 --> 00:39:59.599
also lead to some loss of external rotation.

00:40:00.380 --> 00:40:02.340
While small loss might be acceptable for improved

00:40:02.340 --> 00:40:04.639
stability, significant stiffness can be very

00:40:04.639 --> 00:40:07.019
disabling, so rehabilitation is key to manage

00:40:07.019 --> 00:40:10.440
this. And infection. How common and serious is

00:40:10.440 --> 00:40:12.889
that? Thankfully, deep infection after shoulder

00:40:12.889 --> 00:40:15.730
instability surgery is rare, probably less than

00:40:15.730 --> 00:40:18.829
1 % in most series, but when it happens, it's

00:40:18.829 --> 00:40:21.869
serious. Superficial wound infections might just

00:40:21.869 --> 00:40:24.590
need antibiotics, but a deep joint infection

00:40:24.590 --> 00:40:27.449
requires urgent surgical washout and debridement,

00:40:27.889 --> 00:40:30.849
plus a long course of antibiotics. Does the hardware,

00:40:31.090 --> 00:40:33.969
like screws or anchors, complicate infection

00:40:33.969 --> 00:40:37.239
treatment? It certainly can. If the infection

00:40:37.239 --> 00:40:39.400
involves the implants, particularly those holding

00:40:39.400 --> 00:40:42.159
a critical bone graft in place, you face a real

00:40:42.159 --> 00:40:44.760
dilemma. Removing the hardware might be necessary

00:40:44.760 --> 00:40:47.079
to clear the infection, but doing so could compromise

00:40:47.079 --> 00:40:50.260
the stability the surgery aimed to achieve. It

00:40:50.260 --> 00:40:52.719
requires very careful management. Thinking even

00:40:52.719 --> 00:40:55.280
longer term now, we've mentioned osteoarthritis.

00:40:55.500 --> 00:40:57.619
Is there a specific link between having shoulder

00:40:57.619 --> 00:40:59.880
instability and developing arthritis later in

00:40:59.880 --> 00:41:02.699
life? Yes, absolutely. The term used is dislocation

00:41:02.699 --> 00:41:05.389
arthropathy. This describes the osteoarthritis,

00:41:05.889 --> 00:41:08.349
the cartilage wear, joint space narrowing, bone

00:41:08.349 --> 00:41:10.329
spur formation that develops as a consequence

00:41:10.329 --> 00:41:13.250
of having had chronic or recurrent shoulder instability.

00:41:13.969 --> 00:41:15.489
And importantly, this can happen whether or not

00:41:15.489 --> 00:41:17.809
the shoulder was surgically stabilized. So the

00:41:17.809 --> 00:41:20.250
instability itself damages the joint over time.

00:41:20.449 --> 00:41:22.789
Precisely. The repeated episodes of the joint

00:41:22.789 --> 00:41:25.869
sliding partially or fully out of place, the

00:41:25.869 --> 00:41:28.329
abnormal forces across the cartilage, the damage

00:41:28.329 --> 00:41:30.230
from the initial injury and subsequent events,

00:41:30.949 --> 00:41:33.210
potentially subtle joint incongruity from bone

00:41:33.210 --> 00:41:36.090
loss. All these factors contribute to wearing

00:41:36.090 --> 00:41:39.190
down the joint surfaces over years. even if surgery

00:41:39.190 --> 00:41:41.829
successfully stops the dislocations. Even then,

00:41:41.929 --> 00:41:44.130
the joint has already suffered insults. The surgery

00:41:44.130 --> 00:41:46.409
itself, while necessary, might also slightly

00:41:46.409 --> 00:41:49.090
alter joint mechanics. So while stabilization

00:41:49.090 --> 00:41:51.210
surgery is crucial to prevent further damage

00:41:51.210 --> 00:41:54.050
and improve function, it doesn't necessarily

00:41:54.050 --> 00:41:56.929
erase the increased long -term risk of developing

00:41:56.929 --> 00:41:59.269
arthropathy that comes with having had significant

00:41:59.269 --> 00:42:01.829
instability in the first place. What does dislocation

00:42:01.829 --> 00:42:04.429
arthropathy mean for the patient? Over time,

00:42:04.530 --> 00:42:07.090
it typically leads to increasing pain and stiffness.

00:42:07.630 --> 00:42:10.050
Ironically, the joint often becomes more stable

00:42:10.050 --> 00:42:12.750
as the arthritis progresses, but it's a stiff,

00:42:12.889 --> 00:42:15.690
painful stability. It can significantly limit

00:42:15.690 --> 00:42:17.929
function. And the data shows this isn't just

00:42:17.929 --> 00:42:19.869
theoretical studies looking at patients years

00:42:19.869 --> 00:42:22.590
after bankart repairs, for example, show a clear

00:42:22.590 --> 00:42:25.130
increase in osteoarthritis rates compared to

00:42:25.130 --> 00:42:27.630
their preoperative state. Figures cited show

00:42:27.630 --> 00:42:30.869
rises from maybe 9 % pre -op to nearly 20 % at

00:42:30.869 --> 00:42:34.460
6 .5 years, or from 10 % pre -op up to 60 % in

00:42:34.460 --> 00:42:37.019
one study looking out over 13 years. It's a real

00:42:37.019 --> 00:42:39.719
long -term consequence. That really hammers home

00:42:39.719 --> 00:42:42.079
the importance of managing instability effectively,

00:42:42.199 --> 00:42:44.639
and perhaps early, to protect the joint long

00:42:44.639 --> 00:42:47.019
term. Are there specific strategies recommended

00:42:47.019 --> 00:42:49.400
to try and prevent or at least minimize this

00:42:49.400 --> 00:42:52.000
risk of dislocation arthropathy? Yes, the International

00:42:52.000 --> 00:42:54.599
Society of Arthroscopy, Knee Surgery, and Orthopedic

00:42:54.599 --> 00:42:57.500
Sports Medicine, ISACOS, has put forward recommendations.

00:42:57.960 --> 00:43:00.559
A key one is trying to reduce the number of dislocations

00:43:00.559 --> 00:43:02.980
the patient experiences before surgery. This

00:43:02.980 --> 00:43:05.139
implies that earlier surgical intervention, rather

00:43:05.139 --> 00:43:07.019
than letting someone have multiple dislocations

00:43:07.019 --> 00:43:09.440
over years, might be protective for long -term

00:43:09.440 --> 00:43:12.360
joint health. So don't wait too long if dislocations

00:43:12.360 --> 00:43:14.880
keep happening. That's the suggestion. Other

00:43:14.880 --> 00:43:17.079
recommendations include meticulously assessing

00:43:17.079 --> 00:43:19.900
all the existing damage, bone loss, cartilage

00:43:19.900 --> 00:43:22.960
damage, pre -existing arthritis, before deciding

00:43:22.960 --> 00:43:25.539
on and performing the surgery, as this informs

00:43:25.539 --> 00:43:28.360
the best procedure and prognosis. And for soft

00:43:28.360 --> 00:43:31.340
tissue repairs, ensuring really accurate anchor

00:43:31.340 --> 00:43:34.039
placement right on the glenoid rim and secure

00:43:34.039 --> 00:43:36.800
fixation is emphasized to minimize the chance

00:43:36.800 --> 00:43:39.920
of early failure, recurrence, and the subsequent

00:43:39.920 --> 00:43:42.260
joint damage that follows. The underlying theme

00:43:42.260 --> 00:43:44.619
is controlling the instability effectively and

00:43:44.619 --> 00:43:46.940
managing the bony architecture properly. Makes

00:43:46.940 --> 00:43:49.719
sense. Okay, one last area before we wrap up

00:43:49.719 --> 00:43:51.639
getting back to activity, especially for athletes.

00:43:52.320 --> 00:43:54.639
What's the typical journey after these surgeries?

00:43:55.179 --> 00:43:57.739
The rehabilitation and return to sport discussion

00:43:57.739 --> 00:43:59.739
is often complex, particularly for athletes.

00:44:00.019 --> 00:44:01.679
There's that fundamental trade -off we touched

00:44:01.679 --> 00:44:03.719
on earlier. Non -operative versus operative.

00:44:04.000 --> 00:44:06.239
Yes. Trying non -operative management, mainly

00:44:06.239 --> 00:44:09.300
physio, might allow a quicker return to play,

00:44:09.659 --> 00:44:11.500
possibly even within the same season for some.

00:44:12.519 --> 00:44:15.320
But it comes with a significantly higher risk

00:44:15.320 --> 00:44:17.739
of the shoulder dislocating again. Where is surgery?

00:44:17.880 --> 00:44:20.480
Surgery almost always means the athlete is out

00:44:20.480 --> 00:44:23.420
for the remainder of that season. Recovery typically

00:44:23.420 --> 00:44:26.000
takes a minimum of five, six months, sometimes

00:44:26.000 --> 00:44:27.760
longer depending on the procedure in the sport.

00:44:28.659 --> 00:44:31.300
However, the major benefit is a much, much lower

00:44:31.300 --> 00:44:33.500
rate of recurrence in the long run and therefore

00:44:33.500 --> 00:44:35.519
a higher chance of a durable return to sport.

00:44:35.940 --> 00:44:38.480
That must be an incredibly difficult conversation

00:44:38.480 --> 00:44:40.780
and decision for a young athlete focused on their

00:44:40.780 --> 00:44:43.559
current season or scholarship prospects. It is

00:44:43.559 --> 00:44:45.539
one of the toughest decisions in sports medicine.

00:44:45.880 --> 00:44:47.820
The discussion has to be very comprehensive.

00:44:48.320 --> 00:44:50.739
You need to consider the athlete's specific history.

00:44:51.119 --> 00:44:53.420
How many times has it dislocated? What level

00:44:53.420 --> 00:44:55.739
do they play at? Then the physical exam findings,

00:44:56.300 --> 00:44:58.860
detailed imaging like CT and MRI to see the extent

00:44:58.860 --> 00:45:01.139
of the damage, especially bone loss, and then

00:45:01.139 --> 00:45:03.159
layer on the timing factors. Where are they in

00:45:03.159 --> 00:45:05.400
their season? Are championships coming up? Are

00:45:05.400 --> 00:45:07.639
they trying to get recruited? Attempting to push

00:45:07.639 --> 00:45:10.500
through a season non -operatively is often seen

00:45:10.500 --> 00:45:13.530
as a very high -risk gamble. Once the decision

00:45:13.530 --> 00:45:16.030
for surgery is made, what does the rehab process

00:45:16.030 --> 00:45:18.230
generally involve? Is it similar for different

00:45:18.230 --> 00:45:20.869
procedures? The underlying principles of rehab

00:45:20.869 --> 00:45:23.010
are similar, whether it was non -operative or

00:45:23.010 --> 00:45:25.389
post -operative treatment you need to restore

00:45:25.389 --> 00:45:28.889
range of motion, rebuild strength, improve neuromuscular

00:45:28.889 --> 00:45:31.510
control and proprioception, and then gradually

00:45:31.510 --> 00:45:34.690
reintroduce sport -specific movements. However,

00:45:34.929 --> 00:45:37.690
the timeline and specific restrictions vary hugely

00:45:37.690 --> 00:45:41.309
depending on the surgery performed. How so? Bony

00:45:41.309 --> 00:45:44.170
procedures like latarjet or significant bone

00:45:44.170 --> 00:45:47.409
grafting usually require longer periods of protection,

00:45:47.949 --> 00:45:50.210
perhaps limited weight bearing or stricter range

00:45:50.210 --> 00:45:52.429
of motion restrictions initially to allow the

00:45:52.429 --> 00:45:54.690
bone to heal properly compared to a standard

00:45:54.690 --> 00:45:57.869
soft tissue bank heart repair. Adhering to the

00:45:57.869 --> 00:46:00.230
specific protocol for the procedure done is critical.

00:46:00.429 --> 00:46:02.409
And deciding when someone is actually ready to

00:46:02.409 --> 00:46:04.909
go back to playing their sport, is it just based

00:46:04.909 --> 00:46:07.389
on time? Time -based criteria, like saying, okay,

00:46:07.409 --> 00:46:09.349
it's been six months, are still commonly used

00:46:09.349 --> 00:46:11.650
as a general guideline. But there's a strong

00:46:11.650 --> 00:46:14.070
shift towards incorporating more objective functional

00:46:14.070 --> 00:46:16.869
testing alongside clinical assessment. Objective

00:46:16.869 --> 00:46:19.710
tests, like what? Things like measuring strength

00:46:19.710 --> 00:46:22.469
using isokinetic machines, assessing upper body

00:46:22.469 --> 00:46:25.110
endurance and stability with tests like the closed

00:46:25.110 --> 00:46:28.289
kinetic chain, upper extremity stability, CKC

00:46:28.289 --> 00:46:31.619
-UES test, or evaluating balance and proprioception

00:46:31.619 --> 00:46:34.639
using something like the Y balance test. These

00:46:34.639 --> 00:46:37.320
provide measurable data points. So moving beyond

00:46:37.320 --> 00:46:40.440
just how does it feel to what can it actually

00:46:40.440 --> 00:46:44.239
do? Exactly. These objective tests help the medical

00:46:44.239 --> 00:46:46.719
team, the athlete, and the coach make a more

00:46:46.719 --> 00:46:49.340
informed, evidence -based decision about whether

00:46:49.340 --> 00:46:51.260
the shoulder is truly ready to withstand the

00:46:51.260 --> 00:46:53.699
demands of their sport without an unacceptably

00:46:53.699 --> 00:46:56.119
high risk of re -injury. It helps take some of

00:46:56.119 --> 00:46:58.119
the guesswork out of that crucial return to play

00:46:58.119 --> 00:47:00.989
decision. That makes so much sense. Right, wow,

00:47:01.050 --> 00:47:03.030
we have covered an enormous amount of detail

00:47:03.030 --> 00:47:05.449
there. We started with basic stability, explored

00:47:05.449 --> 00:47:08.250
the huge impact of bone loss, dived into advanced

00:47:08.250 --> 00:47:11.289
surgeries like rimplassage, grafting, latarjet,

00:47:11.710 --> 00:47:14.130
looked at tricky patient groups, faced complications

00:47:14.130 --> 00:47:16.469
and revision surgery, and considered the long

00:47:16.469 --> 00:47:18.630
-term health of the joint right through to recovery.

00:47:19.230 --> 00:47:20.809
Let's try and crystallize some of that with a

00:47:20.809 --> 00:47:22.929
quick lightning round. Ready? Let's do it. OK,

00:47:23.130 --> 00:47:26.320
question one. In a healthy shoulder, what are

00:47:26.320 --> 00:47:28.539
the two main ways it stays stable in the mid

00:47:28.539 --> 00:47:32.219
-range of motion? Negative intra -articular pressure

00:47:32.219 --> 00:47:34.440
and the concavity compression effect from the

00:47:34.440 --> 00:47:38.219
muscles. Spot on. Question two. What concept

00:47:38.219 --> 00:47:40.940
is key to understanding if a hill -sax lesion

00:47:40.940 --> 00:47:43.659
is problematic, looking beyond just its physical

00:47:43.659 --> 00:47:46.760
size? The glenoid tract concept, whether the

00:47:46.760 --> 00:47:49.360
lesion engages the glenoid rim. Perfect. Question

00:47:49.360 --> 00:47:52.030
three. If there is significant bone loss from

00:47:52.030 --> 00:47:54.889
the glenoid socket, what are the two main surgical

00:47:54.889 --> 00:47:57.130
strategies used to replace that missing bone?

00:47:57.349 --> 00:47:59.949
Bone grafting using either autograft or allograft

00:47:59.949 --> 00:48:02.829
and the latarjet procedure. Excellent. And final

00:48:02.829 --> 00:48:05.090
lightning question, what's the potential long

00:48:05.090 --> 00:48:07.690
-term consequence for the joint surfaces resulting

00:48:07.690 --> 00:48:10.090
from recurrent shoulder instability, even if

00:48:10.090 --> 00:48:12.210
it's treated? That would be dislocation or arthropathy,

00:48:12.349 --> 00:48:14.269
which is essentially progressive osteoarthritis.

00:48:14.510 --> 00:48:17.070
Fantastic. Great summary points. So let's try

00:48:17.070 --> 00:48:20.090
and pull together maybe five key actionable takeaways

00:48:20.090 --> 00:48:22.769
from this really in -depth discussion on complex

00:48:22.769 --> 00:48:25.880
shoulder instability. One. Remember that recurrent

00:48:25.880 --> 00:48:27.599
shoulder instability is very often more than

00:48:27.599 --> 00:48:31.159
just a ligament tear. Bone loss on both the socket

00:48:31.159 --> 00:48:34.460
and the ball is incredibly common and absolutely

00:48:34.460 --> 00:48:37.099
critical to assess properly. Couldn't agree more.

00:48:37.239 --> 00:48:40.079
Assessment is key. Two. When looking at a hill

00:48:40.079 --> 00:48:42.840
-sax lesion, don't just measure its size. Use

00:48:42.840 --> 00:48:45.139
the glenoid tract concept to determine if it's

00:48:45.139 --> 00:48:48.079
likely to engage the glenoid rim. That's what

00:48:48.079 --> 00:48:50.360
really drives instability risk from the HSL.

00:48:50.619 --> 00:48:54.230
Engagement is the crucial factor. Three. If significant

00:48:54.230 --> 00:48:57.550
bone loss or specific patient risk factors mean

00:48:57.550 --> 00:49:00.110
a simple soft tissue repair isn't enough or is

00:49:00.110 --> 00:49:02.550
likely to fail, then advanced techniques like

00:49:02.550 --> 00:49:05.590
remplasage, bone grafting, or the Letarjet procedure

00:49:05.590 --> 00:49:08.730
become necessary. Each has specific indications,

00:49:09.110 --> 00:49:11.230
benefits, and potential drawbacks. Matching the

00:49:11.230 --> 00:49:13.210
procedure to the specific pathology and patient

00:49:13.210 --> 00:49:16.449
is vital. 4. Patient -specific factors matter

00:49:16.449 --> 00:49:19.610
hugely. age, activity level, especially collision

00:49:19.610 --> 00:49:21.849
sports, the number of previous dislocations,

00:49:21.989 --> 00:49:24.070
and any underlying conditions like epilepsy or

00:49:24.070 --> 00:49:26.510
hyperlaxity significantly influence the risk

00:49:26.510 --> 00:49:28.489
and the boost treatment plan. It cannot be a

00:49:28.489 --> 00:49:31.130
one -size -fits -all approach. Absolutely. Personalized

00:49:31.130 --> 00:49:33.730
medicine is essential here. And five, while modern

00:49:33.730 --> 00:49:36.670
surgery can do a fantastic job of improving stability

00:49:36.670 --> 00:49:39.449
and getting people back to activity, it's not

00:49:39.449 --> 00:49:42.329
without risks like stiffness, nerve issues, or

00:49:42.329 --> 00:49:45.320
infection. And critically, the history of instability

00:49:45.320 --> 00:49:48.920
itself carries a long -term risk of joint degeneration

00:49:48.920 --> 00:49:52.559
dislocation arthropathy. This really underscores

00:49:52.559 --> 00:49:55.519
the importance of timely, effective treatment

00:49:55.519 --> 00:49:59.840
and thorough rehabilitation. The goal is stability

00:49:59.840 --> 00:50:02.360
now, but also preserving joint health for the

00:50:02.360 --> 00:50:04.900
future. Precisely. Now, if you listening found

00:50:04.900 --> 00:50:07.300
these insights as valuable as I did, perhaps

00:50:07.300 --> 00:50:09.300
consider rating and sharing this deep dive on

00:50:09.300 --> 00:50:11.340
your professional networks, maybe LinkedIn or

00:50:11.340 --> 00:50:14.000
X. It genuinely helps others find and benefit

00:50:14.000 --> 00:50:16.139
from these important conversations. Hearing different

00:50:16.139 --> 00:50:19.250
perspectives is always useful. Absolutely. And

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that leaves us with a final thought to mull over.

00:50:22.090 --> 00:50:24.769
Given the potential for serious long -term joint

00:50:24.769 --> 00:50:27.590
damage and the complex trade -offs involved in

00:50:27.590 --> 00:50:29.610
treatment, especially for young, very active

00:50:29.610 --> 00:50:32.409
people, how do we truly strike the right balance?

00:50:32.710 --> 00:50:35.469
How do we best weigh that immediate, often intense

00:50:35.469 --> 00:50:38.070
desire for a rapid return to sport against the

00:50:38.070 --> 00:50:40.030
arguably more important goal of preserving the

00:50:40.030 --> 00:50:41.369
long -term health and function of the shoulder

00:50:41.369 --> 00:50:44.170
joint? How can surgeons, patients, families,

00:50:44.250 --> 00:50:46.489
coaches all collaborate effectively to navigate

00:50:46.489 --> 00:50:48.949
those potential competing priorities. That is

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the million dollar question, isn't it? A challenge

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we face every day.