WEBVTT 00:00:00.000 --> 00:00:02.819 Imagine for a moment you're, say, an ambitious 00:00:02.819 --> 00:00:05.179 cricketer, maybe playing at a high amateur level, 00:00:05.360 --> 00:00:08.080 or perhaps a professional rugby player. You dislocate 00:00:08.080 --> 00:00:10.099 your shoulder. It's painful, obviously, frustrating. 00:00:10.539 --> 00:00:12.140 But you do the recovery, all the physio, you 00:00:12.140 --> 00:00:13.720 build the strength back up. You think, OK, I'm 00:00:13.720 --> 00:00:17.780 clear. But then, thwack, it happens again. And 00:00:17.780 --> 00:00:20.519 maybe again after that. That's the, well, the 00:00:20.519 --> 00:00:22.879 crushing reality of recurrent shoulder instability. 00:00:23.140 --> 00:00:25.079 It's this relentless problem. It doesn't just 00:00:25.079 --> 00:00:27.359 sideline careers. It can really impact your daily 00:00:27.359 --> 00:00:30.160 life, strips away confidence, limits even the 00:00:30.160 --> 00:00:32.200 simple things, that frustration, you know, of 00:00:32.200 --> 00:00:34.179 a part of your body just refusing to stay put. 00:00:34.740 --> 00:00:37.179 It can be immense, huge career implications, 00:00:37.299 --> 00:00:38.979 not just for athletes, but other professionals, 00:00:39.200 --> 00:00:43.159 too. And the emotional toll, of course. Now... 00:00:43.000 --> 00:00:45.460 For far too long, considering how common this 00:00:45.460 --> 00:00:47.899 is, there's been a surprising lack of a clear 00:00:47.899 --> 00:00:50.140 agreed upon gold standard treatment, really quite 00:00:50.140 --> 00:00:52.539 surprising. And this has led to vastly different 00:00:52.539 --> 00:00:55.219 surgical approaches across the world, often influenced 00:00:55.219 --> 00:00:57.579 more by where a surgeon trained or the local 00:00:57.579 --> 00:00:59.460 traditions rather than perhaps what the most 00:00:59.460 --> 00:01:01.899 robust up -to -date evidence actually suggests. 00:01:02.140 --> 00:01:05.180 So today we're embarking on a really insightful 00:01:05.180 --> 00:01:07.680 journey into this critical area of orthopedic 00:01:07.680 --> 00:01:10.959 surgery, an area where, maybe surprisingly, treatment 00:01:10.959 --> 00:01:13.620 decisions have often been shaped by, let's say, 00:01:13.739 --> 00:01:16.640 inherited wisdom and regional habits, our mission, 00:01:16.819 --> 00:01:19.019 it's clear. We want you to gain a crystal clear 00:01:19.019 --> 00:01:22.140 understanding of what the very latest, most comprehensive 00:01:22.140 --> 00:01:24.439 analysis reveals about treating this recurrent 00:01:24.439 --> 00:01:26.819 shoulder instability effectively. We're aiming 00:01:26.819 --> 00:01:29.079 to cut through the noise, bring you the definitive 00:01:29.079 --> 00:01:31.739 insights, and to help us navigate this, well, 00:01:32.060 --> 00:01:34.359 intricate and often debated landscape. We are 00:01:34.359 --> 00:01:36.359 incredibly privileged to be joined today by Professor 00:01:36.359 --> 00:01:39.060 Mo Imam. His deep expertise and importantly, 00:01:39.280 --> 00:01:41.620 his recent significant contributions to synthesize 00:01:41.519 --> 00:01:44.159 the critical evidence in this field are genuinely 00:01:44.159 --> 00:01:46.420 setting new benchmarks for clinical practice. 00:01:47.140 --> 00:01:49.319 Professor, it is an absolute pleasure to have 00:01:49.319 --> 00:01:51.599 you with us for this deep dive. It's genuinely 00:01:51.599 --> 00:01:54.319 a pleasure to be here, a really vital topic to 00:01:54.319 --> 00:01:56.909 explore for patients and clinicians too. Professor, 00:01:56.930 --> 00:01:59.049 before we get into the specific treatments, could 00:01:59.049 --> 00:02:02.069 you maybe help us grasp the sheer scale of this? 00:02:02.489 --> 00:02:06.290 The profound impact of recurrent anterior shoulder 00:02:06.290 --> 00:02:08.969 instability. Who typically gets affected most? 00:02:09.930 --> 00:02:12.370 And crucially, what are the bigger long -term 00:02:12.370 --> 00:02:14.830 implications if it's not properly addressed? 00:02:15.210 --> 00:02:17.030 It sounds like it's much more than just a temporary 00:02:17.030 --> 00:02:19.569 setback. You've hit on a crucial point there. 00:02:19.870 --> 00:02:21.889 Recurrent instability of the shoulder is, well, 00:02:22.050 --> 00:02:24.129 it's far more than a minor issue. It's a truly 00:02:24.129 --> 00:02:27.069 significant, often quite debilitating complication 00:02:27.069 --> 00:02:29.550 after that first dislocation, or even sometimes 00:02:29.550 --> 00:02:32.110 after a less severe subluxation. When you look 00:02:32.110 --> 00:02:34.210 at the statistics, they are quite sobering actually. 00:02:34.370 --> 00:02:37.669 Data shows that up to 60%, six zero of patients 00:02:37.669 --> 00:02:39.729 who have an acute traumatic anterior shoulder 00:02:39.729 --> 00:02:42.710 dislocation will unfortunately go on to suffer 00:02:42.710 --> 00:02:46.180 from recurrent instability. 60%, wow. Yes, it's 00:02:46.180 --> 00:02:48.259 a massive proportion. And what's particularly 00:02:48.259 --> 00:02:50.479 striking, and frankly quite concerning from a 00:02:50.479 --> 00:02:53.620 clinical view, is this inverse relationship with 00:02:53.620 --> 00:02:56.960 age. Put simply, the younger you are when you 00:02:56.960 --> 00:02:59.120 first dislocate your shoulder, the dramatically 00:02:59.120 --> 00:03:01.340 higher your risk of it happening again. To give 00:03:01.340 --> 00:03:04.080 you a concrete example, take a 20 -year -old 00:03:04.080 --> 00:03:07.469 male patient. After their first traumatic anterior 00:03:07.469 --> 00:03:10.069 dislocation, the risk of it happening again can 00:03:10.069 --> 00:03:14.090 be astonishingly high, up to 72%. 72%. Indeed. 00:03:14.250 --> 00:03:16.650 Think about that. Almost three quarters of young 00:03:16.650 --> 00:03:18.509 men in that age group could face this problem 00:03:18.509 --> 00:03:21.330 repeatedly. This figure really highlights that 00:03:21.330 --> 00:03:23.689 this is overwhelmingly a problem affecting young, 00:03:23.830 --> 00:03:26.430 active people, often at the peak of their physical 00:03:26.430 --> 00:03:28.849 activity, whether that's sport or demanding jobs. 00:03:29.099 --> 00:03:32.300 72 % for a 20 -year -old, that's, well, nearly 00:03:32.300 --> 00:03:34.500 three out of four. That's not just a clinical 00:03:34.500 --> 00:03:37.000 statistic, is it? It sounds like a profound, 00:03:37.039 --> 00:03:40.099 almost life -altering risk for someone just starting 00:03:40.099 --> 00:03:42.539 their adult life or, say, building an athletic 00:03:42.539 --> 00:03:45.419 career. It really underscores why just treating 00:03:45.419 --> 00:03:48.080 the first injury isn't always enough. We need 00:03:48.080 --> 00:03:50.520 solutions that truly prevent it happening again. 00:03:50.900 --> 00:03:52.819 Which is exactly what your analysis looks at. 00:03:52.919 --> 00:03:55.419 Uh -huh. Are there specific risk factors, then? 00:03:55.460 --> 00:03:57.889 Things that... makes some people more susceptible 00:03:57.889 --> 00:04:01.090 than others. Absolutely. Beyond age and the, 00:04:01.090 --> 00:04:03.129 you know, traumatic nature of the initial event, 00:04:03.469 --> 00:04:06.909 we've identified several key anatomical and patient 00:04:06.909 --> 00:04:10.349 -specific risk factors. These significantly contribute 00:04:10.349 --> 00:04:12.330 to these high recurrence rates. They include 00:04:12.330 --> 00:04:14.969 specific bony lesions on the shoulder joint surfaces. 00:04:15.050 --> 00:04:18.029 For instance, a hill sex lesion. That's an indentation 00:04:18.029 --> 00:04:20.250 or compression fracture on the back of the humeral 00:04:20.250 --> 00:04:22.769 head, the ball part of the joint. It happens 00:04:22.769 --> 00:04:24.670 when it hits the front of the glenoid socket 00:04:24.670 --> 00:04:26.829 during the dislocation. Then there's the bank 00:04:26.829 --> 00:04:28.970 heart lesion. This is where the labrum, that 00:04:28.970 --> 00:04:31.110 crucial ring of cartilage that deepens the socket, 00:04:31.290 --> 00:04:33.810 gets torn away from the bone. Both of those indicate 00:04:33.810 --> 00:04:36.029 structural damage that basically compromises 00:04:36.029 --> 00:04:39.050 the shoulder's stability. Other factors include 00:04:39.050 --> 00:04:41.949 the patient's sex males often have higher recurrence 00:04:41.949 --> 00:04:45.129 rates. their age, as we just discussed, and the 00:04:45.129 --> 00:04:47.850 presence of what we call hyperlaxity. Hyperlaxity. 00:04:47.990 --> 00:04:49.850 Yes, essentially meaning someone is naturally 00:04:49.850 --> 00:04:51.889 double -jointed or has very flexible joints. 00:04:52.470 --> 00:04:55.550 This predisposes them to instability. These elements 00:04:55.550 --> 00:04:58.699 act as, well, predictors for who might struggle 00:04:58.699 --> 00:05:01.180 with recurrent dislocations. So it's not just 00:05:01.180 --> 00:05:03.800 about the initial pop out of jank. It's about 00:05:03.800 --> 00:05:06.000 underlying structural issues, maybe bone damage, 00:05:06.139 --> 00:05:08.600 maybe torn tissue, and even a person's natural 00:05:08.600 --> 00:05:11.259 joint flexibility. That paints a much clearer 00:05:11.259 --> 00:05:13.660 picture of the vulnerability. And you mentioned 00:05:13.660 --> 00:05:15.720 the impact on patients' lives earlier. Could 00:05:15.720 --> 00:05:17.939 you expand on what disabling affliction really 00:05:17.939 --> 00:05:20.000 means for these young, active people? What's 00:05:20.000 --> 00:05:23.439 the real world consequence? Yes, the term disabling 00:05:23.439 --> 00:05:26.839 affliction is chosen quite deliberately. because 00:05:26.839 --> 00:05:30.120 that's precisely what it can be. For young, active 00:05:30.120 --> 00:05:33.000 patients, athletes especially, this isn't just 00:05:33.000 --> 00:05:35.439 an inconvenience, it can be genuinely career 00:05:35.439 --> 00:05:37.779 -ending. Think about a professional athlete, 00:05:38.279 --> 00:05:40.600 a rugby player needing to make powerful tackles, 00:05:40.860 --> 00:05:43.379 maybe a tennis player serving with force, or 00:05:43.379 --> 00:05:46.540 even just an avid recreational climber who absolutely 00:05:46.540 --> 00:05:49.699 relies on full shoulder stability. If their shoulder 00:05:49.699 --> 00:05:52.120 consistently gives way, they're suddenly unable 00:05:52.120 --> 00:05:54.600 to participate in their sport, their pre -injury 00:05:54.600 --> 00:05:57.660 activities. It fundamentally limits their participation, 00:05:57.980 --> 00:06:00.399 their performance, and often their professional 00:06:00.399 --> 00:06:02.839 livelihood. We often see patients who just can't 00:06:02.839 --> 00:06:04.879 return to their prior level of activity, where 00:06:04.879 --> 00:06:07.019 they live with this constant apprehension, this 00:06:07.019 --> 00:06:09.500 fear of it happening again. That affects their 00:06:09.500 --> 00:06:11.300 mental well -being just as much as their physical 00:06:11.300 --> 00:06:14.139 capacity. It's profoundly limiting. And for our 00:06:14.139 --> 00:06:15.980 discussion today, it's important just to clarify. 00:06:16.579 --> 00:06:19.319 When we use the term instability, we're encompassing 00:06:19.319 --> 00:06:21.920 both subluxation, where the joint partially comes 00:06:21.920 --> 00:06:24.259 out and then goes back in spontaneously, and 00:06:24.259 --> 00:06:26.660 frank dislocation, where it completely separates 00:06:26.660 --> 00:06:29.639 and needs someone to put it back in. We treat 00:06:29.639 --> 00:06:32.060 them as a single clinical entity here, because 00:06:32.060 --> 00:06:34.240 both represent a failure of the shoulder to stay 00:06:34.240 --> 00:06:37.100 stable and can have similar underlying issues 00:06:37.100 --> 00:06:40.430 and long -term consequences. Beyond that immediate 00:06:40.430 --> 00:06:42.750 impact on activity and function, there's a really 00:06:42.750 --> 00:06:45.110 critical long -term consequence, one that often 00:06:45.110 --> 00:06:47.790 gets overlooked, perhaps, but is maybe one of 00:06:47.790 --> 00:06:50.069 the most compelling reasons for definitive treatment. 00:06:50.709 --> 00:06:52.910 Recurrent instability has been positively correlated 00:06:52.910 --> 00:06:55.449 with a significantly increased risk of subsequent 00:06:55.449 --> 00:06:58.310 degenerative joint arthritis, decades later. 00:06:58.529 --> 00:07:02.189 Potentially, yes. What this means is, if these 00:07:02.189 --> 00:07:04.430 recurring dislocations or subluxations aren't 00:07:04.430 --> 00:07:07.050 definitively treated, the cumulative trauma to 00:07:07.050 --> 00:07:10.060 the joint The repeated impact, the wear and tear, 00:07:10.339 --> 00:07:12.199 can lead to premature degeneration of the joint 00:07:12.199 --> 00:07:15.040 surfaces. This can cause debilitating arthritis 00:07:15.040 --> 00:07:17.519 decades down the line, long after their athletic 00:07:17.519 --> 00:07:20.300 careers might have ended. So treating this effectively 00:07:20.300 --> 00:07:22.019 isn't just about getting someone back to sport 00:07:22.019 --> 00:07:24.540 quickly. It's profoundly about protecting their 00:07:24.540 --> 00:07:26.620 long -term joint health and our overall well 00:07:26.620 --> 00:07:29.220 -being. This really underscores why finding the 00:07:29.220 --> 00:07:31.379 optimal evidence -based solution, one that offers 00:07:31.379 --> 00:07:34.279 true long -term stability, is so absolutely crucial, 00:07:34.620 --> 00:07:36.899 both for immediate relief and for sustained quality 00:07:36.899 --> 00:07:39.529 of life. That truly highlights the gravity, doesn't 00:07:39.529 --> 00:07:41.589 it? It sounds like a problem that doesn't just 00:07:41.589 --> 00:07:44.250 impact immediate function, quality of life, but 00:07:44.250 --> 00:07:46.490 casts this long shadow over a patient's joint 00:07:46.490 --> 00:07:49.389 health for decades. It really brings home the 00:07:49.389 --> 00:07:52.610 urgent need for effective, evidence -based solutions, 00:07:52.750 --> 00:07:55.649 not just quick fixes. Given this pressing need, 00:07:55.750 --> 00:07:58.709 Professor, two surgical procedures seem to, well, 00:07:59.009 --> 00:08:00.569 dominate the conversation for definitive treatment, 00:08:00.769 --> 00:08:02.990 the Bancard procedure and the Latarjet procedure. 00:08:03.470 --> 00:08:04.949 Could you walk us through what each of these 00:08:04.949 --> 00:08:07.600 involves? shed some light on why there's such 00:08:07.600 --> 00:08:09.939 a noticeable divide globally in preference for 00:08:09.939 --> 00:08:12.740 one over the other. Certainly. These two are 00:08:12.740 --> 00:08:15.259 indeed the primary surgical options for recurrent 00:08:15.259 --> 00:08:17.740 anterior shoulder instability, and they approach 00:08:17.740 --> 00:08:20.019 the problem from, well, fundamentally different 00:08:20.019 --> 00:08:23.480 anatomical and biomechanical angles. Understanding 00:08:23.480 --> 00:08:25.500 their differences is really key to appreciating 00:08:25.500 --> 00:08:27.720 the debate around them. Let's start with the 00:08:27.720 --> 00:08:30.860 Banker procedure. At its core, this procedure 00:08:30.860 --> 00:08:33.019 is about repairing the damaged soft tissues, 00:08:33.500 --> 00:08:35.539 the bits that were torn during the dislocation. 00:08:36.159 --> 00:08:38.240 Specifically, it involves re -tensioning the 00:08:38.240 --> 00:08:40.580 anterior capsule that's the main ligament structure 00:08:40.580 --> 00:08:42.840 at the front of the shoulder, which can get stretched 00:08:42.840 --> 00:08:45.700 or torn, and crucially the direct repair of the 00:08:45.700 --> 00:08:49.080 ovals labrum. As we discussed, the labrum is 00:08:49.080 --> 00:08:51.500 that vital ring of cartilage around the shoulder 00:08:51.500 --> 00:08:54.340 socket, the glenoid. It deepens it, helps stabilize 00:08:54.340 --> 00:08:56.940 the joint. When the shoulder dislocates, this 00:08:56.940 --> 00:08:58.940 labrum can be torn away from the bone that's 00:08:58.940 --> 00:09:01.019 the specific bankart lesion. Right, the torn 00:09:01.019 --> 00:09:03.950 cartilage ring. Exactly. The procedure typically 00:09:03.950 --> 00:09:07.190 uses strong sutures, or sometimes small absorbable 00:09:07.190 --> 00:09:10.029 suture anchors put into the bone, to reattach 00:09:10.029 --> 00:09:12.230 this torn labrum and tighten up the stretched 00:09:12.230 --> 00:09:15.389 capsule. The aim is basically to restore the 00:09:15.389 --> 00:09:18.190 natural anatomy of the joint. Now the Bankart 00:09:18.190 --> 00:09:20.789 procedure was initially described way back, actually, 00:09:20.950 --> 00:09:22.990 but gained wider recognition and refinement much 00:09:22.990 --> 00:09:25.710 later. It has since evolved so it can be done 00:09:25.710 --> 00:09:28.509 through open surgery, a larger incision, or, 00:09:28.669 --> 00:09:31.330 much more commonly today, arthroscopically. Keyhole 00:09:31.330 --> 00:09:34.720 surgery. Precisely. Using small incisions, a 00:09:34.720 --> 00:09:37.480 tiny camera to see inside the joint, and specialized 00:09:37.480 --> 00:09:40.360 instruments. Its widespread adduction is quite 00:09:40.360 --> 00:09:43.080 remarkable. Historically, something like 90 % 00:09:43.080 --> 00:09:44.740 of surgeons internationally, particularly in 00:09:44.740 --> 00:09:46.720 North America and parts of Europe, have favored 00:09:46.720 --> 00:09:48.799 arthroscopic bankart repair as the first line 00:09:48.799 --> 00:09:51.320 treatment, mainly due to its minimally invasive 00:09:51.320 --> 00:09:53.279 nature and the perception of restoring the anatomy. 00:09:53.620 --> 00:09:56.399 So the bankart is essentially patching up the 00:09:56.399 --> 00:09:59.090 soft tissue damage, like... sewing up a tear, 00:09:59.309 --> 00:10:01.850 really. And it's been the go -to for a long time, 00:10:01.950 --> 00:10:04.730 especially the keyhole version. That makes sense. 00:10:04.830 --> 00:10:07.230 The appeal of less invasive surgery is obvious. 00:10:07.629 --> 00:10:09.610 But what about the Letarjet procedure, then? 00:10:09.669 --> 00:10:11.870 How does that differ? And why is there such a 00:10:11.870 --> 00:10:14.169 strong alternative preference in some places? 00:10:14.669 --> 00:10:17.870 That's a perfect segue. Because in stark contrast, 00:10:17.990 --> 00:10:20.899 we have the Letarjet procedure. Sometimes it's 00:10:20.899 --> 00:10:23.899 more descriptively called the coracoid bone block 00:10:23.899 --> 00:10:27.200 procedure. This is a more involved surgical technique. 00:10:27.759 --> 00:10:30.139 It addresses not just the soft tissue damage, 00:10:30.659 --> 00:10:33.360 but also, and this is critical, potential bone 00:10:33.360 --> 00:10:36.539 loss or significant structural deficiencies around 00:10:36.539 --> 00:10:39.460 the glenoid socket itself. It involves transferring 00:10:39.460 --> 00:10:42.019 a specific piece of the coracoid process that's 00:10:42.019 --> 00:10:44.000 a small, hooked bit of bone that normally sits 00:10:44.000 --> 00:10:46.080 off the shoulder blade along with its attached 00:10:46.080 --> 00:10:48.460 conjoined tendon, which includes parts of the 00:10:48.460 --> 00:10:50.700 biceps and corcabrachialis muscles. Okay, so 00:10:50.700 --> 00:10:52.899 you're actually moving a piece of bone. Exactly. 00:10:53.460 --> 00:10:55.940 This bone block, with the tendon still attached, 00:10:56.320 --> 00:10:58.559 is then precisely positioned and secured with 00:10:58.559 --> 00:11:01.159 screws onto the front rim of the glenoid socket. 00:11:01.399 --> 00:11:04.379 It essentially extends and reinforces the socket 00:11:04.379 --> 00:11:07.220 forwards. The mechanism here is ingenious, really. 00:11:07.360 --> 00:11:10.159 It's twofold. Firstly, it creates a physical 00:11:10.159 --> 00:11:13.080 bony block, a buttress if you like. It physically 00:11:13.080 --> 00:11:15.100 stops the humeral head from slipping forward 00:11:15.100 --> 00:11:17.799 out of the joint. Secondly, those transferred 00:11:17.799 --> 00:11:19.919 muscles, which stay attached to the moved bone, 00:11:20.519 --> 00:11:22.960 provide a dynamic stabilizing effect. So when 00:11:22.960 --> 00:11:25.039 the arm moves into positions where it might normally 00:11:25.039 --> 00:11:27.700 dislocate, these muscles contract, pulling the 00:11:27.700 --> 00:11:30.059 humeral head back into the socket, an extra layer 00:11:30.059 --> 00:11:32.909 of stability. This procedure was initially described 00:11:32.909 --> 00:11:35.970 by Dr. Michel Letargette back in 1954, and he 00:11:35.970 --> 00:11:39.309 later modified it in 1980. Now what's truly fascinating 00:11:39.309 --> 00:11:41.929 about the Letargette is its very distinct geographical 00:11:41.929 --> 00:11:44.710 preference. While Benkart dominates in many regions, 00:11:44.990 --> 00:11:47.450 you see this stark contrast in places like France. 00:11:47.950 --> 00:11:49.990 For example, our research indicates that an astonishing 00:11:49.990 --> 00:11:53.330 72 % of French shoulder surgeons prefer the Letargette 00:11:53.330 --> 00:11:55.570 procedure as their first -line treatment. 72 00:11:55.570 --> 00:11:58.789 % compared to 90 % internationally favoring Benkart. 00:11:58.990 --> 00:12:02.000 Precisely. It truly illustrates the powerful 00:12:02.000 --> 00:12:04.779 influence of tradition, surgical training environments, 00:12:05.299 --> 00:12:07.419 local schools of thought on established surgical 00:12:07.419 --> 00:12:10.549 practice. often more so than global consensus 00:12:10.549 --> 00:12:13.629 based purely on evidence. That is a staggering 00:12:13.629 --> 00:12:15.590 regional difference. It's almost like different 00:12:15.590 --> 00:12:18.029 medical dialects have evolved over time, and 00:12:18.029 --> 00:12:19.929 this brings us perfectly to what you've termed 00:12:19.929 --> 00:12:22.929 the consensus gap. Could you elaborate on this 00:12:22.929 --> 00:12:25.629 core problem? How has it impacted treatment decisions, 00:12:25.830 --> 00:12:28.110 especially given the historical limitations in 00:12:28.110 --> 00:12:30.330 the available research you mentioned? Exactly. 00:12:31.230 --> 00:12:33.409 This geographical divergence really brings us 00:12:33.409 --> 00:12:36.639 to the heart of this consensus gap. A situation 00:12:36.639 --> 00:12:39.159 where there's no universally agreed upon gold 00:12:39.159 --> 00:12:42.100 standard treatment. The core problem has been 00:12:42.100 --> 00:12:44.580 that the choice of which surgery to perform has 00:12:44.580 --> 00:12:47.259 largely been based on a surgeon's training background, 00:12:47.759 --> 00:12:50.080 their personal experience, maybe the prevailing 00:12:50.080 --> 00:12:52.899 traditions within their region or hospital, rather 00:12:52.899 --> 00:12:55.399 than on robust, high -level comparative evidence. 00:12:56.019 --> 00:12:58.379 This has led to significant variation in care. 00:12:58.539 --> 00:13:01.539 And frankly, it's left many patients, and indeed 00:13:01.539 --> 00:13:04.019 clinicians, without a definitive answer on what 00:13:04.019 --> 00:13:06.899 the optimal approach truly is. For a long time, 00:13:07.019 --> 00:13:09.179 the academic challenge was made worse by inherent 00:13:09.179 --> 00:13:11.679 limitations in the published literature. Many 00:13:11.679 --> 00:13:14.340 prior studies were restricted to older retrospective 00:13:14.340 --> 00:13:16.740 reviews looking back at patient data, or perhaps 00:13:16.740 --> 00:13:19.200 single surgeon series, where one surgeon reports 00:13:19.200 --> 00:13:21.669 on their own patients. Now, while these studies 00:13:21.669 --> 00:13:24.049 can give valuable initial insights, they inherently 00:13:24.049 --> 00:13:26.870 carry significant risks of confounders, other 00:13:26.870 --> 00:13:28.850 factors that might skew the outcomes and bias. 00:13:29.210 --> 00:13:31.289 Right, like maybe surgeons choosing LaTarget 00:13:31.289 --> 00:13:33.769 only for the really bad cases. Exactly, that 00:13:33.769 --> 00:13:36.350 sort of thing. A surgeon might unconsciously 00:13:36.350 --> 00:13:39.090 select Bancart for less severe cases and LaTarget 00:13:39.090 --> 00:13:41.750 for more complex ones, which makes a direct comparison 00:13:41.750 --> 00:13:45.700 unreliable. Such studies, while useful, couldn't 00:13:45.700 --> 00:13:48.019 definitively or systematically compare the efficacy 00:13:48.019 --> 00:13:50.840 of these two very different procedures in a truly 00:13:50.840 --> 00:13:54.440 unbiased way. This situation starkly underscored 00:13:54.440 --> 00:13:56.759 the critical need for a more comprehensive and 00:13:56.759 --> 00:13:59.740 systematic analysis. One that looks at all the 00:13:59.740 --> 00:14:02.240 existing evidence, carefully pooling the data 00:14:02.240 --> 00:14:04.539 to really understand which procedure offered 00:14:04.539 --> 00:14:06.700 the best, most durable outcomes for patients 00:14:06.700 --> 00:14:09.120 across the board. That's the gap our work aimed 00:14:09.120 --> 00:14:11.789 to fill. That deeply entrenched preference, almost 00:14:11.789 --> 00:14:14.490 like an inherited surgical philosophy, is really 00:14:14.490 --> 00:14:16.889 eye -opening, especially when science could potentially 00:14:16.889 --> 00:14:19.590 offer a clearer path. It makes the kind of rigorous 00:14:19.590 --> 00:14:22.049 analysis you've conducted even more vital for 00:14:22.049 --> 00:14:24.350 orthopedic professionals, for anyone trying to 00:14:24.350 --> 00:14:26.389 make the absolute best decisions for patients. 00:14:26.850 --> 00:14:28.870 So let's talk about that path. How exactly did 00:14:28.870 --> 00:14:31.309 you and your team go about rigorously comparing 00:14:31.309 --> 00:14:33.590 these two procedures? How did you try to cut 00:14:33.590 --> 00:14:35.490 through that traditional bias and give us more 00:14:35.490 --> 00:14:37.830 definitive answers? What was the methodology 00:14:37.830 --> 00:14:40.379 behind this deep dive? That's a critical question 00:14:40.379 --> 00:14:43.700 because the strength and reliability of our conclusions 00:14:43.700 --> 00:14:47.100 fundamentally hinge on the meticulousness, the 00:14:47.100 --> 00:14:50.269 rigor of our methodology. Our study was designed 00:14:50.269 --> 00:14:53.210 as a systematic review and meta -analysis. For 00:14:53.210 --> 00:14:54.850 those unfamiliar, this is generally considered 00:14:54.850 --> 00:14:57.250 the highest level of evidence when you're synthesizing 00:14:57.250 --> 00:14:59.870 existing research. It involves a structured, 00:15:00.269 --> 00:15:02.149 comprehensive search for all relevant studies 00:15:02.149 --> 00:15:04.830 on a topic, followed by a statistical pooling 00:15:04.830 --> 00:15:07.789 of their results. It represents, to date, the 00:15:07.789 --> 00:15:09.929 largest and most up -to -date comparison of these 00:15:09.929 --> 00:15:13.090 two specific procedures, Bankert versus Letarget 00:15:13.090 --> 00:15:15.549 in the published literature. To give you a sense 00:15:15.549 --> 00:15:17.690 of the sheer volume, the statistical power of 00:15:17.690 --> 00:15:20.230 the data we examined, our analysis pooled information 00:15:20.230 --> 00:15:23.090 from seven distinct cohort studies. These are 00:15:23.090 --> 00:15:25.230 studies that follow groups of patients over time. 00:15:25.590 --> 00:15:27.490 Collectively, these studies involved a substantial 00:15:27.490 --> 00:15:32.129 total of 300 -275 patients. Over 3 ,000 patients. 00:15:32.149 --> 00:15:34.809 That's significant. It is. To break that down 00:15:34.809 --> 00:15:38.409 further, 2 ,791 individuals had undergone the 00:15:38.409 --> 00:15:42.309 Bancart repair, while 484 had the Laddarjet procedure. 00:15:42.639 --> 00:15:46.259 This extensive patient population allowed us 00:15:46.259 --> 00:15:49.000 to conduct a truly robust, powerful examination 00:15:49.000 --> 00:15:52.019 of the comparative outcomes. It gives our findings 00:15:52.019 --> 00:15:55.259 significant statistical weight. Our search strategy 00:15:55.259 --> 00:15:58.299 was incredibly comprehensive, designed to capture 00:15:58.299 --> 00:16:00.259 virtually all relevant studies published up to 00:16:00.259 --> 00:16:03.620 January 2018. We systematically searched across 00:16:03.620 --> 00:16:05.639 all the major medical and scientific databases. 00:16:06.220 --> 00:16:08.220 PubMed, Cochrane Central Register -controlled 00:16:08.220 --> 00:16:12.179 trials, Scopus, Ovid, web of science, this broad 00:16:12.179 --> 00:16:14.259 systematic approach was absolutely essential 00:16:14.259 --> 00:16:16.700 to ensure we didn't miss any pertinent research 00:16:16.700 --> 00:16:18.940 and thus reduce the risk of what's called publication 00:16:18.940 --> 00:16:20.799 bias, where studies with certain results might 00:16:20.799 --> 00:16:22.320 be more likely to get published than others. 00:16:22.600 --> 00:16:24.740 So you cast a really wide net, gathered all the 00:16:24.740 --> 00:16:26.360 relevant data. Once you had all these studies, 00:16:26.580 --> 00:16:28.759 how did you then go about aggregating and analyzing 00:16:28.759 --> 00:16:30.720 such different types of data? You mentioned things 00:16:30.720 --> 00:16:32.620 like operative time versus whether someone got 00:16:32.620 --> 00:16:34.840 an infection. How do you compare those statistically? 00:16:35.159 --> 00:16:37.480 That's a great question. It's all about matching 00:16:37.480 --> 00:16:40.000 the right statistical tool to the nature of the 00:16:40.000 --> 00:16:43.139 data we were analyzing. For what we call continuous 00:16:43.139 --> 00:16:45.519 data, things like operative time, measured in 00:16:45.519 --> 00:16:48.340 minutes, or patient -reported outcome scores, 00:16:48.659 --> 00:16:50.960 like the Rose score, which are numerical scales, 00:16:51.519 --> 00:16:54.559 we pool these as mean differences. This simply 00:16:54.559 --> 00:16:56.460 allowed us to calculate the average difference 00:16:56.460 --> 00:16:58.539 in these measures between the two groups, the 00:16:58.539 --> 00:17:01.220 Bankart group and the Letarjet group. So for 00:17:01.220 --> 00:17:03.659 example, we could see if one procedure on average 00:17:03.659 --> 00:17:06.079 took significantly longer or resulted in a higher 00:17:06.079 --> 00:17:08.940 average score. But for dichotomous data, that 00:17:08.940 --> 00:17:11.000 is, outcomes that either happened or didn't, 00:17:11.079 --> 00:17:13.240 a yes or no event, things like whether the shoulder 00:17:13.240 --> 00:17:15.500 experienced another recurrence, if a revision 00:17:15.500 --> 00:17:18.180 surgery was needed, if there was a full redislocation, 00:17:18.359 --> 00:17:20.740 the development of arthropathy, or complications 00:17:20.740 --> 00:17:23.460 like infection or hematoma. The binary outcome. 00:17:23.700 --> 00:17:26.259 Exactly. For those, we pooled the results as 00:17:26.259 --> 00:17:30.200 risk ratios, often abbreviated RR, with 95 % 00:17:30.200 --> 00:17:33.190 confidence intervals. Our risk ratio is a very 00:17:33.190 --> 00:17:35.190 powerful measure. It tells us how many times 00:17:35.190 --> 00:17:37.190 more likely an event was in one group compared 00:17:37.190 --> 00:17:39.809 to the other. For instance, if the risk ratio 00:17:39.809 --> 00:17:42.329 for recurrence was, say, 2 .5, it would mean 00:17:42.329 --> 00:17:44.170 that recurrence was two and a half times more 00:17:44.170 --> 00:17:46.069 probable in one surgical group compared to the 00:17:46.069 --> 00:17:49.009 other. The 95 % confidence interval just gives 00:17:49.009 --> 00:17:50.750 us a range of certainty around that estimate. 00:17:51.349 --> 00:17:54.049 Now, to ensure the utmost methodological rigor 00:17:54.049 --> 00:17:56.329 and to minimize any potential bias throughout 00:17:56.329 --> 00:17:58.970 this complex process, we adhered strictly to 00:17:58.970 --> 00:18:01.519 the PRISMA guidelines. These are the internationally 00:18:01.519 --> 00:18:03.940 recognized standards, a checklist really, for 00:18:03.940 --> 00:18:06.420 histomatic reviews and meta -analyses. They ensure 00:18:06.420 --> 00:18:09.240 transparency and reproducibility. Our eligibility 00:18:09.240 --> 00:18:11.240 screening process, deciding which studies to 00:18:11.240 --> 00:18:13.660 actually include, involved two meticulous steps. 00:18:14.140 --> 00:18:16.279 Each step was conducted independently by three 00:18:16.279 --> 00:18:20.779 experienced reviewers. Yes, that redundancy helps 00:18:20.779 --> 00:18:23.440 ensure that studies are included or excluded 00:18:23.440 --> 00:18:26.079 consistently and objectively. It prevents any 00:18:26.079 --> 00:18:28.559 single reviewer's potential bias from influencing 00:18:28.559 --> 00:18:31.980 the selection. Similarly, the crucial task of 00:18:31.980 --> 00:18:34.119 data extraction, pulling out all the relevant 00:18:34.119 --> 00:18:36.380 numbers and facts from the selected studies, 00:18:36.779 --> 00:18:38.660 was performed independently by three different 00:18:38.660 --> 00:18:41.980 authors. Any disagreements at either stage, screening, 00:18:42.180 --> 00:18:44.819 or extraction were thoroughly discussed and resolved 00:18:44.819 --> 00:18:47.680 by consensus among the reviewers. This multi 00:18:47.680 --> 00:18:49.819 -reviewer approach is vital for building confidence 00:18:49.819 --> 00:18:53.000 in the dataset. Furthermore, we rigorously assess 00:18:53.000 --> 00:18:55.160 the quality of each included study using the 00:18:55.160 --> 00:18:58.130 Newcastle -Ottawa scale. This is a widely respected 00:18:58.130 --> 00:19:00.109 tool that evaluates studies based on three key 00:19:00.109 --> 00:19:02.410 things. How carefully the study participants 00:19:02.410 --> 00:19:04.690 were selected, how comparable the groups were 00:19:04.690 --> 00:19:06.549 for important factors that could influence outcomes, 00:19:06.710 --> 00:19:08.950 and how robustly the outcomes themselves were 00:19:08.950 --> 00:19:11.349 measured. The included cohort studies in our 00:19:11.349 --> 00:19:13.630 meta -analysis achieved a high mean score of 00:19:13.630 --> 00:19:15.970 8 out of 9 possible points on this scale. That 00:19:15.970 --> 00:19:18.490 sounds very good. It is, yes. It's an excellent 00:19:18.490 --> 00:19:20.630 indicator. It means they were generally of good 00:19:20.630 --> 00:19:22.910 methodological quality, which further strengthens 00:19:22.910 --> 00:19:25.029 the credibility and reliability of our pooled 00:19:25.029 --> 00:19:28.680 results. Finally, and this is where our analysis 00:19:28.680 --> 00:19:30.920 perhaps made a particularly vital contribution, 00:19:31.420 --> 00:19:33.680 we placed a crucial focus on follow -up time. 00:19:33.920 --> 00:19:36.940 This was critical because previous analyses hadn't 00:19:36.940 --> 00:19:38.759 systematically looked at how the differences 00:19:38.759 --> 00:19:41.319 in outcomes between the two procedures might 00:19:41.319 --> 00:19:44.200 evolve, might change over time. There was a growing 00:19:44.200 --> 00:19:46.519 body of newer evidence suggesting that the true 00:19:46.519 --> 00:19:48.880 long -term advantage of one procedure over the 00:19:48.880 --> 00:19:51.400 other might only become really clear with longer 00:19:51.400 --> 00:19:53.920 observation periods, not just looking at immediate 00:19:53.920 --> 00:19:56.200 post -op results. Right. Things might look similar 00:19:56.200 --> 00:20:00.000 early on, but diverge later. Precisely. Our included 00:20:00.000 --> 00:20:02.019 studies had follow -up periods ranging from as 00:20:02.019 --> 00:20:03.980 short as just 30 days right up to as long as 00:20:03.980 --> 00:20:07.700 10 years. This broad range allowed for a truly 00:20:07.700 --> 00:20:10.279 comprehensive long -term analysis, especially 00:20:10.279 --> 00:20:12.759 using what we call subgroup analysis based on 00:20:12.759 --> 00:20:15.140 different follow -up durations. This temporal 00:20:15.140 --> 00:20:16.839 dimension allowed us to see if, for example, 00:20:16.960 --> 00:20:19.000 a procedure that seemed comparable in the short 00:20:19.000 --> 00:20:21.599 term might actually be significantly less effective, 00:20:21.640 --> 00:20:24.460 or even fail more often, in the long run. It 00:20:24.460 --> 00:20:26.380 paints a much more complete picture of durability. 00:20:26.650 --> 00:20:28.910 That's a truly impressive level of methodical 00:20:28.910 --> 00:20:31.670 investigation, Professor. It really underscores 00:20:31.670 --> 00:20:33.849 why your findings carry so much weight moving 00:20:33.849 --> 00:20:36.690 beyond maybe anecdotal experience or single studies 00:20:36.690 --> 00:20:39.069 to what the collective evidence truly shows. 00:20:39.809 --> 00:20:41.809 Now, let's get to those critically important 00:20:41.809 --> 00:20:44.720 results. For patients, and indeed for clinicians, 00:20:45.000 --> 00:20:47.519 the ultimate measure of success in shoulder stabilization 00:20:47.519 --> 00:20:50.279 surgery often boils down to one thing, preventing 00:20:50.279 --> 00:20:52.599 the shoulder from dislocating again. What did 00:20:52.599 --> 00:20:54.940 your rigorous analysis reveal regarding recurrence 00:20:54.940 --> 00:20:57.380 and redislocation rates for bankart versus latarjet? 00:20:57.640 --> 00:20:59.920 Were there any surprises? This is indeed the 00:20:59.920 --> 00:21:01.920 most critical finding for everyone involved, 00:21:02.339 --> 00:21:05.180 and our analysis revealed a very clear, I would 00:21:05.180 --> 00:21:08.220 say quite stark difference. When we looked at 00:21:08.220 --> 00:21:10.720 overall recurrence rates, and by recurrence, 00:21:11.059 --> 00:21:13.299 remember, we mean any instance of the shoulder 00:21:13.299 --> 00:21:16.279 feeling unstable, whether it was a minor subluxation 00:21:16.279 --> 00:21:18.880 or a full dislocation after the surgery, the 00:21:18.880 --> 00:21:21.240 findings were absolutely compelling. The arthroscopic 00:21:21.240 --> 00:21:23.779 bankart procedure was consistently associated 00:21:23.779 --> 00:21:26.119 with a significantly higher risk of recurrence 00:21:26.119 --> 00:21:28.980 compared to the Letarjet procedure. Specifically, 00:21:29.279 --> 00:21:33.380 the risk ratio, the RR, was 2 .87, and the P 00:21:33.380 --> 00:21:37.720 value was very low. less than 0 .0001 indicating 00:21:37.720 --> 00:21:41.740 high statistical significance. 2 .87. So what 00:21:41.740 --> 00:21:43.819 does that mean in practical terms? In practical 00:21:43.819 --> 00:21:45.720 terms, it means the patients undergoing a bank 00:21:45.720 --> 00:21:48.279 cart repair were nearly three times more likely 00:21:48.279 --> 00:21:50.720 to experience some form of recurrent instability 00:21:50.720 --> 00:21:53.000 compared to those who had the latarjet procedure. 00:21:53.579 --> 00:21:55.880 Wow. Nearly three times more likely. Exactly. 00:21:56.000 --> 00:21:58.660 That is a substantial and crucially a statistically 00:21:58.660 --> 00:22:01.160 highly significant difference. It's not a marginal 00:22:01.160 --> 00:22:03.579 variation. It's a profound distinction in the 00:22:03.579 --> 00:22:06.180 stability offered. Okay, that's dramatic for 00:22:06.180 --> 00:22:08.259 overall recurrence. And how did that play out 00:22:08.259 --> 00:22:10.279 for actual full -blown dislocations? Was the 00:22:10.279 --> 00:22:13.000 pattern similar there? Precisely. The pattern 00:22:13.000 --> 00:22:15.799 was strikingly similar, reinforcing that initial 00:22:15.799 --> 00:22:18.859 finding. When we focused specifically on overall 00:22:18.859 --> 00:22:21.359 redislocation rates, which refers to the shoulder 00:22:21.359 --> 00:22:23.740 fully coming out of the socket again, the picture 00:22:23.740 --> 00:22:26.630 was equally clear. Arthroscopic bank art was 00:22:26.630 --> 00:22:29.250 also strongly linked to a higher risk of actual 00:22:29.250 --> 00:22:32.730 redislocation with a risk ratio of 2 .74 and 00:22:32.730 --> 00:22:35.950 a p -value of 0 .03. Again, this indicates a 00:22:35.950 --> 00:22:37.789 substantial and clinically meaningful difference 00:22:37.789 --> 00:22:39.890 in the long -term stability offered by the two 00:22:39.890 --> 00:22:42.349 procedures. Now, here's where our study makes 00:22:42.349 --> 00:22:45.509 perhaps its most significant contribution. Understanding 00:22:45.509 --> 00:22:48.329 the long -term perspective. We specifically focused 00:22:48.329 --> 00:22:51.089 on how these outcomes changed over time, because 00:22:51.089 --> 00:22:52.869 as you said, short -term success isn't always 00:22:52.869 --> 00:22:55.079 the whole story. What we discovered was that 00:22:55.079 --> 00:22:57.279 the pronounced advantage for the Letarge procedure 00:22:57.279 --> 00:22:59.660 in preventing recurrence became most evident 00:22:59.660 --> 00:23:02.200 with longer follow -up periods. This difference 00:23:02.200 --> 00:23:04.579 became particularly clear and statistically robust 00:23:04.579 --> 00:23:07.180 between six and ten years post -operatively. 00:23:07.460 --> 00:23:10.579 Six to ten years later. Yes. In that extended 00:23:10.579 --> 00:23:13.319 window, the risk ratio for recurrence with Bankart 00:23:13.319 --> 00:23:16.140 actually escalated to 3 .00. Just three times 00:23:16.140 --> 00:23:18.400 the risk again in the long run? It's exactly. 00:23:19.339 --> 00:23:21.630 After six to ten years, Patients who underwent 00:23:21.630 --> 00:23:24.329 a Bancart repair were truly three times more 00:23:24.329 --> 00:23:26.190 likely to experience their shoulder coming out 00:23:26.190 --> 00:23:29.250 again compared to those who had a Latarjet. This 00:23:29.250 --> 00:23:32.009 isn't a small, fleeting difference. It's a sustained, 00:23:32.390 --> 00:23:34.890 powerful, and durable long -term benefit seen 00:23:34.890 --> 00:23:37.509 with the Latarjet procedure. And we observed 00:23:37.509 --> 00:23:40.670 an identical, concerning trend for full redislocation 00:23:40.670 --> 00:23:44.029 as well. The higher redislocation rate for arthroscopic 00:23:44.029 --> 00:23:46.490 Bancart also became particularly evident in that 00:23:46.490 --> 00:23:49.259 six - to ten -year postoperative window. with 00:23:49.259 --> 00:23:53.119 a risk ratio of 2 .85. This consistent pattern, 00:23:53.619 --> 00:23:56.619 across both recurrence and redislocation, especially 00:23:56.619 --> 00:23:59.420 when observed over a longer time horizon, strongly 00:23:59.420 --> 00:24:01.480 suggests something important. It suggests that 00:24:01.480 --> 00:24:03.380 while a bankrupt repair might hold up reasonably 00:24:03.380 --> 00:24:05.680 well in the very short term, its effectiveness 00:24:05.680 --> 00:24:08.019 in maintaining definitive stability significantly 00:24:08.019 --> 00:24:10.200 diminishes over the medium to long term, when 00:24:10.200 --> 00:24:12.119 you directly compare it to the lethargic procedure. 00:24:12.539 --> 00:24:14.980 It's important mention, just for full transparency, 00:24:15.440 --> 00:24:17.519 that one single study within our analysis did 00:24:17.519 --> 00:24:19.700 show no significant difference between the procedures 00:24:19.700 --> 00:24:21.819 at the one to five year mark. Okay, an outlier. 00:24:22.220 --> 00:24:24.400 Yes, but it's crucial to understand that this 00:24:24.400 --> 00:24:28.049 single outlier doesn't diminish the robust overall, 00:24:28.130 --> 00:24:30.809 and particularly the long -term trends we observed 00:24:30.809 --> 00:24:33.210 from the pooled data across all the included 00:24:33.210 --> 00:24:35.549 studies. The overwhelming evidence, especially 00:24:35.549 --> 00:24:37.789 looking at that broader time horizon in the large 00:24:37.789 --> 00:24:40.450 patient population, clearly points to the Latarjet 00:24:40.450 --> 00:24:42.869 procedure offering superior sustained long -term 00:24:42.869 --> 00:24:45.150 stability. This is a critical insight. So the 00:24:45.150 --> 00:24:47.490 long -term data really paints a very clear, quite 00:24:47.490 --> 00:24:49.890 compelling picture then. While both procedures 00:24:49.890 --> 00:24:52.450 are aiming to stabilize the shoulder, The Latarjet 00:24:52.450 --> 00:24:54.950 appears to offer this distinct, lasting advantage 00:24:54.950 --> 00:24:57.049 in keeping the shoulder definitively in place, 00:24:57.089 --> 00:24:59.670 particularly years down the line. That's a powerful 00:24:59.670 --> 00:25:01.650 and practical insight for anyone considering 00:25:01.650 --> 00:25:04.130 these options, especially those young, active 00:25:04.130 --> 00:25:05.970 individuals wanting to get back to high -level 00:25:05.970 --> 00:25:08.349 activity without that constant fear of it happening 00:25:08.349 --> 00:25:11.269 again. Now, while stability is paramount, patients 00:25:11.269 --> 00:25:14.170 obviously worry about the trade -offs, particularly 00:25:14.170 --> 00:25:16.710 complications and overall functional recovery. 00:25:17.430 --> 00:25:19.390 There's a common perception, I think, that perhaps 00:25:19.390 --> 00:25:21.839 more invasive procedures like lethargia might 00:25:21.839 --> 00:25:24.859 carry inherently higher risks. What did your 00:25:24.859 --> 00:25:27.220 meta -analysis truly reveal about complications? 00:25:27.500 --> 00:25:30.160 Things like infection, hematoma, maybe issues 00:25:30.160 --> 00:25:32.519 with the screws or anchors, and perhaps even 00:25:32.519 --> 00:25:34.559 more importantly, how do the two procedures compare 00:25:34.559 --> 00:25:36.839 in terms of patient -reported functional outcomes, 00:25:37.259 --> 00:25:39.359 those scores that often reflect quality of life 00:25:39.359 --> 00:25:41.359 after surgery? That's an excellent point and 00:25:41.359 --> 00:25:44.710 a very common concern. Our findings on complications 00:25:44.710 --> 00:25:47.250 really do challenge some long -held perceptions, 00:25:47.730 --> 00:25:50.009 which is, in itself, a significant takeaway from 00:25:50.009 --> 00:25:52.950 our work. When we meticulously looked at various 00:25:52.950 --> 00:25:55.329 surgical complications, the picture was, as you 00:25:55.329 --> 00:25:58.309 hinted, quite nuanced and often surprising. For 00:25:58.309 --> 00:26:00.769 instance, regarding infection. Our analysis presented 00:26:00.769 --> 00:26:03.509 a genuinely surprising finding. The Bancart procedure 00:26:03.509 --> 00:26:05.490 was actually associated with a lower risk of 00:26:05.490 --> 00:26:08.089 infection compared to Letarget. The risk ratio 00:26:08.089 --> 00:26:11.210 was 0 .16, with a statistically significant p 00:26:11.210 --> 00:26:14.710 -value of 0 .0002. Lower risk with Bancart? That 00:26:14.710 --> 00:26:17.789 is surprising. It is. It means Bancart patients 00:26:17.789 --> 00:26:20.410 were considerably less likely to develop a post 00:26:20.410 --> 00:26:23.130 -operative infection based on this data. Now, 00:26:23.210 --> 00:26:25.029 it's vital to acknowledge a limitation here. 00:26:25.130 --> 00:26:27.309 The number of studies reporting specifically 00:26:27.309 --> 00:26:30.069 on infection was relatively small, only three, 00:26:30.450 --> 00:26:32.670 and the definitions of infection weren't entirely 00:26:32.670 --> 00:26:35.769 standardized across them. However, based on the 00:26:35.769 --> 00:26:37.869 available evidence, it does suggest this is a 00:26:37.869 --> 00:26:41.150 real, albeit potentially small in absolute terms, 00:26:41.650 --> 00:26:44.109 difference. It's certainly a point for surgeons 00:26:44.109 --> 00:26:46.130 to be particularly mindful of with the Lodgett. 00:26:46.319 --> 00:26:49.559 However, when we examined other anticipated complications, 00:26:50.160 --> 00:26:52.799 that common perception about latarjet being inherently 00:26:52.799 --> 00:26:55.180 riskier simply didn't hold up in the aggregated 00:26:55.180 --> 00:26:57.380 data. For hematoma formation, that's a collection 00:26:57.380 --> 00:26:59.599 of blood near the surgical site, we detected 00:26:59.599 --> 00:27:01.720 no significant difference between the two procedures. 00:27:02.319 --> 00:27:06.039 The risk ratio was 0 .20. Similarly, a specific 00:27:06.039 --> 00:27:08.500 concern often raised about latarjet relates to 00:27:08.500 --> 00:27:10.839 screw -related complications, given it involves 00:27:10.839 --> 00:27:13.079 fixing a bone block with screws. Right. You'd 00:27:13.079 --> 00:27:14.960 think that might cause more issues. You might. 00:27:15.119 --> 00:27:17.440 But our analysis found no significant difference 00:27:17.440 --> 00:27:20.220 in screw or anchor -related complications between 00:27:20.220 --> 00:27:23.460 the two procedures. The risk ratio was 0 .17. 00:27:24.400 --> 00:27:26.259 This suggests that the presence of screws for 00:27:26.259 --> 00:27:29.220 Letarjet does not, on the whole, lead to a higher 00:27:29.220 --> 00:27:31.000 rate of implant issues compared to the anchors 00:27:31.000 --> 00:27:34.140 used in Bankart. So when we synthesize the overall 00:27:34.140 --> 00:27:36.359 complication profile, it becomes quite clear. 00:27:37.049 --> 00:27:39.490 Contrary to perhaps popular belief or historical 00:27:39.490 --> 00:27:42.309 apprehension, our comprehensive review demonstrated 00:27:42.309 --> 00:27:45.210 no significant difference in most major treatment 00:27:45.210 --> 00:27:47.990 -related complications. Beyond that specific, 00:27:48.170 --> 00:27:50.630 albeit small, observed difference in infection 00:27:50.630 --> 00:27:54.089 rates. This is a crucial finding. It can profoundly 00:27:54.089 --> 00:27:56.529 inform patient counseling. It suggests that the 00:27:56.529 --> 00:27:58.950 superior long -term stability offered by Letarget 00:27:58.950 --> 00:28:00.869 does not generally come with a higher burden 00:28:00.869 --> 00:28:03.349 of overall complications. That's a very powerful 00:28:03.349 --> 00:28:05.690 message for patients and surgeons. That's a huge 00:28:05.690 --> 00:28:08.259 finding, honestly. Challenging what many might 00:28:08.259 --> 00:28:10.700 instinctively believe about more complex procedures 00:28:10.700 --> 00:28:13.380 versus simpler ones. It implies the benefits 00:28:13.380 --> 00:28:16.180 of liturgy and stability aren't necessarily offset 00:28:16.180 --> 00:28:19.160 by a higher risk of adverse events overall. What 00:28:19.160 --> 00:28:21.079 about the long -term health of the joint itself? 00:28:21.500 --> 00:28:23.559 The development of arthritis? That's a major 00:28:23.559 --> 00:28:26.079 concern for patients looking decades ahead. You're 00:28:26.079 --> 00:28:28.019 right. Long -term joint health is absolutely 00:28:28.019 --> 00:28:31.240 paramount. Moving to long -term arthropathy or 00:28:31.240 --> 00:28:33.160 the development of degenerative joint arthritis, 00:28:33.839 --> 00:28:36.359 this was another rather unexpected outcome based 00:28:36.359 --> 00:28:39.319 on the available data. Primarily reported in 00:28:39.319 --> 00:28:42.000 one key study within our analysis, we found no 00:28:42.000 --> 00:28:44.259 significant statistical difference between Bankart 00:28:44.259 --> 00:28:46.700 and Letarget procedures in the likelihood of 00:28:46.700 --> 00:28:49.039 developing progressive arthropathy. The risk 00:28:49.039 --> 00:28:51.980 ratio was 0 .34. No difference in arthritis risk. 00:28:51.980 --> 00:28:53.740 Right. Despite the difference in instability. 00:28:54.259 --> 00:28:57.410 Exactly. And this is perhaps surprising, especially 00:28:57.410 --> 00:28:59.130 when you recall our earlier discussion about 00:28:59.130 --> 00:29:02.049 the known strong positive correlation between 00:29:02.049 --> 00:29:04.529 recurrent instability and the risk of subsequent 00:29:04.529 --> 00:29:07.829 arthritis. Logically, given bankart repair was 00:29:07.829 --> 00:29:10.390 linked to significantly higher ongoing instability, 00:29:10.849 --> 00:29:13.269 one might intuitively expect it to lead to more 00:29:13.269 --> 00:29:16.509 arthropathy over time due to that continued microtrauma. 00:29:17.210 --> 00:29:20.230 Makes sense. So why wasn't that seen? Well, one 00:29:20.230 --> 00:29:22.569 potential explanation might relate to the maximal 00:29:22.569 --> 00:29:25.089 follow -up periods of the studies included. While 00:29:25.089 --> 00:29:27.529 up to 10 years is substantial, the onset of clinically 00:29:27.529 --> 00:29:30.369 significant symptomatic arthropathy might often 00:29:30.369 --> 00:29:33.269 occur beyond that 10 -year mark, meaning we might 00:29:33.269 --> 00:29:35.109 not have captured its full progression within 00:29:35.109 --> 00:29:37.490 this dataset. It could also be influenced by 00:29:37.490 --> 00:29:39.890 other patient factors not consistently captured 00:29:39.890 --> 00:29:42.869 across all studies. Or perhaps the early signs 00:29:42.869 --> 00:29:45.869 of arthropathy are simply too subtle to be universally 00:29:45.869 --> 00:29:48.150 detected and reported within these study designs. 00:29:48.630 --> 00:29:50.789 It's an area that clearly warrants longer -term, 00:29:51.049 --> 00:29:53.420 dedicated follow -up studies. That's a fascinating 00:29:53.420 --> 00:29:56.640 paradox, then. More instability, but not necessarily 00:29:56.640 --> 00:29:59.700 more measured arthritis within the study's time 00:29:59.700 --> 00:30:02.160 frame. It really forces us to think about how 00:30:02.160 --> 00:30:05.720 long long -term truly needs to be when evaluating 00:30:05.720 --> 00:30:08.119 these outcomes. And speaking of outcomes, let's 00:30:08.119 --> 00:30:10.220 turn to the patient reported outcomes, specifically 00:30:10.220 --> 00:30:13.180 using the Rho score. This is often seen as the 00:30:13.180 --> 00:30:15.599 patient's voice in research. What did you find 00:30:15.599 --> 00:30:18.420 there, especially given the clear stability differences 00:30:18.420 --> 00:30:20.500 you've already presented? This is where things 00:30:20.500 --> 00:30:22.619 get particularly interesting and frankly quite 00:30:22.619 --> 00:30:25.059 nuanced. It reveals a critical point about how 00:30:25.059 --> 00:30:28.339 we actually measure success in these cases. Our 00:30:28.339 --> 00:30:30.480 analysis found no significant difference in patient 00:30:30.480 --> 00:30:33.240 -reported outcomes as measured by the Rho score 00:30:33.240 --> 00:30:35.980 between the two procedures. This is despite the 00:30:35.980 --> 00:30:38.599 glaring significant difference in objective and 00:30:38.599 --> 00:30:40.619 stability rates we just discussed. No difference 00:30:40.619 --> 00:30:43.119 in the Rho score. How can that be? Exactly. The 00:30:43.119 --> 00:30:46.440 mean difference was a mere 0 .22. with a p -value 00:30:46.440 --> 00:30:49.779 of 0 .94, indicating virtually no statistical 00:30:49.779 --> 00:30:52.299 difference at all. This apparent paradox demands 00:30:52.299 --> 00:30:54.960 a deeper look. To understand this, we need to 00:30:54.960 --> 00:30:57.740 delve into the row score itself. The row score, 00:30:57.779 --> 00:31:00.539 first published back in 1978, is a physician 00:31:00.539 --> 00:31:03.240 -led tool. It's designed to assess a patient's 00:31:03.240 --> 00:31:06.440 shoulder across three key areas. Its stability, 00:31:06.960 --> 00:31:09.849 its range of motion, and overall function. While 00:31:09.849 --> 00:31:11.990 it aims to give a picture of patient satisfaction 00:31:11.990 --> 00:31:14.650 and outcome, it has certain nuances, critical 00:31:14.650 --> 00:31:16.670 limitations, that can obscure the true picture. 00:31:17.269 --> 00:31:19.130 Critically, the Rho score is heavily weighted 00:31:19.130 --> 00:31:21.150 towards the stability variable. Heavily weighted 00:31:21.150 --> 00:31:23.549 towards stability. Yes. This means if a patient 00:31:23.549 --> 00:31:26.250 experiences even occasional residual subluxation, 00:31:26.490 --> 00:31:28.269 maybe a clunking sensation, even if they have 00:31:28.269 --> 00:31:30.109 excellent range of motion and feel functionally 00:31:30.109 --> 00:31:32.970 quite good in their daily activities, that instability 00:31:32.970 --> 00:31:35.029 component will significantly drag their overall 00:31:35.029 --> 00:31:36.769 Rho score down. It can make the score appear 00:31:36.769 --> 00:31:39.289 poor or fair, even if other aspects are good. 00:31:40.190 --> 00:31:43.130 It's almost like a pass fail on stability that 00:31:43.130 --> 00:31:45.809 can inadvertently overshadow other functional 00:31:45.809 --> 00:31:48.390 improvements. If a shoulder has any instability, 00:31:48.690 --> 00:31:50.690 even if it feels quite good to the patient in 00:31:50.690 --> 00:31:53.250 terms of movement, the score gets penalized heavily. 00:31:53.569 --> 00:31:55.289 And you mentioned earlier there are different 00:31:55.289 --> 00:31:57.109 versions of this score floating around. That 00:31:57.109 --> 00:31:58.990 sounds like it could muddy the waters even further. 00:31:59.309 --> 00:32:00.930 Exactly right. You've captured the essence of 00:32:00.930 --> 00:32:03.509 the paradox. It can be quite unforgiving on that 00:32:03.509 --> 00:32:06.329 stability component. And that single aspect can 00:32:06.329 --> 00:32:09.329 indeed overshadow other functional gains. And 00:32:09.329 --> 00:32:12.619 yes, a major persistent problem in the orthopedic 00:32:12.619 --> 00:32:15.099 literature is that there are actually four different 00:32:15.099 --> 00:32:17.539 versions of the Rowe score, published over the 00:32:17.539 --> 00:32:19.839 years with subtle but sometimes significant changes 00:32:19.839 --> 00:32:25.440 made in 1978, 1981, 1982, and 1988. Unfortunately, 00:32:25.940 --> 00:32:28.420 studies often don't specify which specific version 00:32:28.420 --> 00:32:31.160 they use when reporting their results. This inherent 00:32:31.160 --> 00:32:33.059 lack of standardization in the reporting tool 00:32:33.059 --> 00:32:35.660 itself makes direct comparisons of row scores 00:32:35.660 --> 00:32:38.200 across different studies incredibly problematic. 00:32:38.740 --> 00:32:41.579 It can quite literally obscure genuine underlying 00:32:41.579 --> 00:32:44.019 differences in stability when only the combined 00:32:44.019 --> 00:32:46.789 overall score is reported. Secondly, another 00:32:46.789 --> 00:32:49.329 reason for the similar row scores, despite objective 00:32:49.329 --> 00:32:51.390 stability differences, could simply be if the 00:32:51.390 --> 00:32:53.069 function and mobility components of the score 00:32:53.069 --> 00:32:55.470 were significantly similar between the two groups. 00:32:55.849 --> 00:32:58.450 If patients in both the Bancard and Letarget 00:32:58.450 --> 00:33:01.230 groups regain excellent range of motion and were 00:33:01.230 --> 00:33:03.609 able to perform daily tasks with similar ease, 00:33:04.130 --> 00:33:06.509 these components, even if stability differed, 00:33:06.650 --> 00:33:08.990 might influence the overall score sufficiently 00:33:08.990 --> 00:33:11.569 to mask that underlying difference in stability 00:33:11.569 --> 00:33:14.569 when you just look at that single combined row 00:33:14.569 --> 00:33:17.579 number. This truly highlights that functional 00:33:17.579 --> 00:33:21.119 outcome is a complex, multifaceted measure. A 00:33:21.119 --> 00:33:23.319 similar composite score doesn't necessarily mean 00:33:23.319 --> 00:33:25.559 the underlying stability problem has been addressed 00:33:25.559 --> 00:33:28.619 with equal effectiveness. It's a key lesson in 00:33:28.619 --> 00:33:30.240 interpreting these outcome measures carefully. 00:33:31.059 --> 00:33:32.920 Finally, just briefly regarding operative time. 00:33:33.339 --> 00:33:35.420 One study within our review did report on this. 00:33:35.799 --> 00:33:38.019 It found that arthroscopic bankart was associated 00:33:38.019 --> 00:33:41.240 with a shorter operative time by about 225 minutes. 00:33:41.599 --> 00:33:44.529 Shorter time for bankart. Yes, but this finding 00:33:44.529 --> 00:33:46.930 was based on limited data from just that one 00:33:46.930 --> 00:33:49.569 study. So while we noted it, it doesn't carry 00:33:49.569 --> 00:33:52.069 the same statistical weight or generalizability 00:33:52.069 --> 00:33:55.549 as our more broadly pooled data for recurrence 00:33:55.549 --> 00:33:58.750 and complications. An interesting point, but 00:33:58.750 --> 00:34:01.460 needs more robust evidence, really. That's a 00:34:01.460 --> 00:34:03.720 vital distinction, Professor. It really underscores 00:34:03.720 --> 00:34:06.400 that functional outcome is complex. We can't 00:34:06.400 --> 00:34:08.500 just rely on a single composite score number. 00:34:09.079 --> 00:34:11.139 While a patient's reported satisfaction or perceived 00:34:11.139 --> 00:34:13.900 function might seem similar, the underlying stability 00:34:13.900 --> 00:34:16.619 can differ profoundly, with potential implications 00:34:16.619 --> 00:34:19.239 over a very long timeline that a single score 00:34:19.239 --> 00:34:21.760 might not fully capture. It certainly makes you 00:34:21.760 --> 00:34:24.019 think critically about how we define and measure 00:34:24.019 --> 00:34:27.219 true surgical success. Now, while this comprehensive 00:34:27.219 --> 00:34:29.420 analysis is incredibly insightful, providing 00:34:29.420 --> 00:34:32.400 very clear trends, as you've mentioned, no single 00:34:32.400 --> 00:34:34.960 study tells the entire story. What were some 00:34:34.960 --> 00:34:36.940 of the limitations or nuances you encountered 00:34:36.940 --> 00:34:39.000 in the available evidence? Things that prevented 00:34:39.000 --> 00:34:41.599 an even clearer, more definitive picture? And 00:34:41.599 --> 00:34:43.780 crucially, what important questions still remain 00:34:43.780 --> 00:34:45.960 for future research in this field? That's an 00:34:45.960 --> 00:34:48.480 absolutely crucial point to address. No study, 00:34:48.820 --> 00:34:51.119 no matter how rigorous, is entirely without its 00:34:51.119 --> 00:34:54.769 limitations. Understanding these nuances is key 00:34:54.769 --> 00:34:57.570 to interpreting the findings correctly and, perhaps 00:34:57.570 --> 00:35:00.030 even more importantly, guiding future research 00:35:00.030 --> 00:35:02.670 efforts. The primary limitation we encountered 00:35:02.670 --> 00:35:04.769 was the inherent level of evidence in the existing 00:35:04.769 --> 00:35:07.670 literature. While we meticulously selected only 00:35:07.670 --> 00:35:10.170 well -conducted studies, the included literature 00:35:10.170 --> 00:35:12.489 largely consists of Level 3 quality evidence, 00:35:12.769 --> 00:35:15.619 primarily cohort studies. Ideally, for truly 00:35:15.619 --> 00:35:17.980 definitive, unassailable conclusions, especially 00:35:17.980 --> 00:35:19.719 when comparing two different surgical procedures 00:35:19.719 --> 00:35:21.920 like this, we would prefer randomized controlled 00:35:21.920 --> 00:35:24.860 trials, RCTs, level 1 evidence. The gold standard 00:35:24.860 --> 00:35:27.800 for comparison. Exactly. RCTs are specifically 00:35:27.800 --> 00:35:30.179 designed to minimize bias by randomly assigning 00:35:30.179 --> 00:35:32.820 patients to different treatment groups. This 00:35:32.820 --> 00:35:35.239 ensures any differences observed are truly due 00:35:35.239 --> 00:35:37.960 to the intervention itself, not other confounding 00:35:37.960 --> 00:35:41.440 factors. With cohort studies, there are inherent 00:35:41.440 --> 00:35:44.139 weaknesses and risks of bias that, despite our 00:35:44.139 --> 00:35:46.579 best efforts in the meta -analysis, cannot be 00:35:46.579 --> 00:35:49.880 entirely eliminated. Our systematic review synthesizes 00:35:49.880 --> 00:35:52.139 the best available evidence, but it can only 00:35:52.139 --> 00:35:54.539 ever be as strong as the underlying studies it 00:35:54.539 --> 00:35:57.440 incorporates. Ideally, we'd want more level 1 00:35:57.440 --> 00:36:00.659 evidence from well -designed RCTs. Another significant 00:36:00.659 --> 00:36:03.199 nuance that introduced complacity was the variability 00:36:03.199 --> 00:36:06.269 in the surgical techniques themselves. Even within 00:36:06.269 --> 00:36:08.909 the broadly defined bankard and letterjet procedures, 00:36:09.369 --> 00:36:11.329 there was a surprising lack of standardization 00:36:11.329 --> 00:36:13.849 in the exact operative techniques used across 00:36:13.849 --> 00:36:16.250 the various studies. For instance, with latarjet, 00:36:16.369 --> 00:36:18.409 this could involve subtle but potentially impactful 00:36:18.409 --> 00:36:21.070 variations, like the precise position of the 00:36:21.070 --> 00:36:23.489 coracoid bone block, or the number and type of 00:36:23.489 --> 00:36:25.960 screws used to fix it. Similarly, for bank card 00:36:25.960 --> 00:36:28.539 repairs, we saw variations in the number or type 00:36:28.539 --> 00:36:31.119 of suture anchors used, or exactly how the capsule 00:36:31.119 --> 00:36:33.820 was handled during the repair. Furthermore, some 00:36:33.820 --> 00:36:36.039 studies even included patients who underwent 00:36:36.039 --> 00:36:39.000 additional or combined procedures. Ah, mixing 00:36:39.000 --> 00:36:41.880 things up even more. Precisely. For example, 00:36:42.179 --> 00:36:44.440 some bank card patients might have also had additional 00:36:44.440 --> 00:36:46.719 capsular imprecation, a tightening of the capsule. 00:36:47.260 --> 00:36:49.840 Or some latar jet groups included patients who 00:36:49.840 --> 00:36:52.960 had concomitant capsular shifts. or even a few 00:36:52.960 --> 00:36:55.639 patients who underwent both letarget and bankart 00:36:55.639 --> 00:36:59.239 repairs simultaneously. This makes direct, truly 00:36:59.239 --> 00:37:01.300 apples -to -apples comparisons more challenging. 00:37:01.920 --> 00:37:04.219 The specific surgical intervention wasn't always 00:37:04.219 --> 00:37:07.099 uniformly applied, introducing some heterogeneity 00:37:07.099 --> 00:37:09.210 that's difficult to fully account for. That's 00:37:09.210 --> 00:37:11.309 a fascinating point about the subtle variations 00:37:11.309 --> 00:37:13.789 in technique. It's almost like different chefs 00:37:13.789 --> 00:37:15.590 using slightly different ingredients or methods 00:37:15.590 --> 00:37:18.030 for the same basic recipe. And you also mentioned 00:37:18.030 --> 00:37:20.530 patient heterogeneity and unreported data. That 00:37:20.530 --> 00:37:22.650 sounds like a major challenge for robust comparison. 00:37:22.989 --> 00:37:25.329 How did that impact your ability to draw even 00:37:25.329 --> 00:37:29.030 more precise conclusions? Indeed, patient heterogeneity 00:37:29.030 --> 00:37:31.769 and the sheer amount of unreported data proved 00:37:31.769 --> 00:37:35.000 to be a crucial and complex limitation. This 00:37:35.000 --> 00:37:37.360 is where selection bias becomes a significant 00:37:37.360 --> 00:37:40.030 concern that we couldn't fully mitigate. Many 00:37:40.030 --> 00:37:42.190 of the included studies simply did not provide 00:37:42.190 --> 00:37:44.530 detailed information regarding the severity of 00:37:44.530 --> 00:37:47.690 the instability. For example, precisely how many 00:37:47.690 --> 00:37:49.789 dislocations a patient had experienced before 00:37:49.789 --> 00:37:52.630 surgery, or, critically, the presence and extent 00:37:52.630 --> 00:37:54.949 of associated pathology. This includes vital 00:37:54.949 --> 00:37:57.030 anatomical factors like the presence and size 00:37:57.030 --> 00:37:59.610 of hill -sax lesions on the humeral head, or 00:37:59.610 --> 00:38:01.710 the presence and magnitude of bony bank cart 00:38:01.710 --> 00:38:03.809 lesions where there's actual bone loss from the 00:38:03.809 --> 00:38:05.869 glandoid rim itself. And that missing data is 00:38:05.869 --> 00:38:08.420 really important. absolutely vital because it 00:38:08.420 --> 00:38:10.920 raises the strong possibility that the LATR -JET 00:38:10.920 --> 00:38:12.900 procedure might have been preferentially performed 00:38:12.900 --> 00:38:16.139 for patients with more severe instability or 00:38:16.139 --> 00:38:18.440 for those with significant co -existent bone 00:38:18.440 --> 00:38:21.690 pathology. In clinical practice, Latarget is 00:38:21.690 --> 00:38:24.150 often reserved for these more complex scenarios 00:38:24.150 --> 00:38:27.469 where a soft tissue repair alone, like Bankart, 00:38:27.789 --> 00:38:30.610 might not be sufficient. Now, if Latarget was 00:38:30.610 --> 00:38:33.070 indeed consistently applied to these more challenging 00:38:33.070 --> 00:38:35.670 cases, then the superior outcomes we observe 00:38:35.670 --> 00:38:38.070 for Latarget in preventing recurrence might actually 00:38:38.070 --> 00:38:40.590 be an underestimation of its true advantage for 00:38:40.590 --> 00:38:42.730 these particularly difficult presentations. Right. 00:38:42.750 --> 00:38:44.849 It might be even better than the numbers show 00:38:44.849 --> 00:38:48.769 for those specific cases. Potentially. Or, conversely, 00:38:48.869 --> 00:38:51.170 it might simply suggest that Letterjet is inherently 00:38:51.170 --> 00:38:53.869 better suited for those more severe anatomical 00:38:53.869 --> 00:38:56.809 presentations, which would be a valuable insight 00:38:56.809 --> 00:38:59.449 in itself, but one that the current aggregated 00:38:59.449 --> 00:39:02.050 data doesn't fully allow us to unpack with absolute 00:39:02.050 --> 00:39:05.130 certainty. To highlight this further, it's particularly 00:39:05.130 --> 00:39:07.190 frustrating that numerous included studies did 00:39:07.190 --> 00:39:09.289 not report the magnitude of glenoid bone loss. 00:39:09.690 --> 00:39:11.989 This is a critical piece of information. Glenoid 00:39:11.989 --> 00:39:14.090 bone loss is a strong discriminator in clinical 00:39:14.090 --> 00:39:15.989 practice when deciding the appropriate surgical 00:39:15.989 --> 00:39:19.230 strategy. Without this detail, our ability to 00:39:19.230 --> 00:39:21.489 fully contextualize the results and draw definitive 00:39:21.489 --> 00:39:23.570 conclusions about patient -specific suitability 00:39:23.570 --> 00:39:25.630 for each procedure is significantly limited. 00:39:25.889 --> 00:39:28.070 So in essence, the Latarject group might have 00:39:28.070 --> 00:39:30.250 comprised patients with more challenging conditions 00:39:30.250 --> 00:39:33.050 to begin with. which makes its superior stability 00:39:33.050 --> 00:39:35.889 finding perhaps even more compelling. Or maybe 00:39:35.889 --> 00:39:38.210 it just highlights its specific utility for those 00:39:38.210 --> 00:39:40.670 very cases. That adds really important layers 00:39:40.670 --> 00:39:43.150 of nuance to the findings. It shows that while 00:39:43.150 --> 00:39:45.710 the trends seem clear, the complexities of individual 00:39:45.710 --> 00:39:48.130 patient factors, subtle surgical variations, 00:39:48.670 --> 00:39:50.969 always need to be meticulously considered when 00:39:50.969 --> 00:39:53.349 translating research into actual clinical practice 00:39:53.349 --> 00:39:55.889 for an individual. And it certainly sets the 00:39:55.889 --> 00:39:58.050 stage for where future deep dives might take 00:39:58.050 --> 00:40:01.179 us. Are there any other major unanswered questions 00:40:01.179 --> 00:40:03.820 that weren't covered in your current scope. Absolutely. 00:40:04.460 --> 00:40:06.719 Finally, an important unanswered question, though 00:40:06.719 --> 00:40:08.780 it is beyond the specific scope of this meta 00:40:08.780 --> 00:40:11.500 -analysis, is the critical aspect of return to 00:40:11.500 --> 00:40:14.659 sport. For young, active patients affected by 00:40:14.659 --> 00:40:17.000 shoulder instability, particularly professional 00:40:17.000 --> 00:40:19.639 athletes or those with high -demand occupations, 00:40:20.219 --> 00:40:22.340 a primary concern isn't just overall stability 00:40:22.340 --> 00:40:25.079 or general function, but crucially, the ability 00:40:25.079 --> 00:40:27.400 to return to their specific sporting activities. 00:40:27.639 --> 00:40:30.380 And perhaps even more importantly, to return 00:40:30.380 --> 00:40:32.599 to their pre -injury level of competition and 00:40:32.599 --> 00:40:35.199 performance without fear of re -injury. A huge 00:40:35.199 --> 00:40:38.449 factor for them. Immense. While our review focused 00:40:38.449 --> 00:40:40.889 on objective stability and broad functional scores, 00:40:41.449 --> 00:40:43.909 this specific area of return to sport, particularly 00:40:43.909 --> 00:40:46.130 at a high level, and the comparative outcomes 00:40:46.130 --> 00:40:48.309 between Bancart and LaTargeette in that regard, 00:40:48.610 --> 00:40:50.750 is a vital consideration. It requires further 00:40:50.750 --> 00:40:53.429 dedicated systematic review, the very practical, 00:40:53.829 --> 00:40:56.050 patient -centric question that we don't yet have 00:40:56.050 --> 00:40:58.389 definitive answers for in a truly comparative 00:40:58.389 --> 00:41:00.750 sense. This really does add important layers 00:41:00.750 --> 00:41:03.670 of nuance. It shows that while the trends are 00:41:03.670 --> 00:41:06.369 clear, Those complexities, individual patient 00:41:06.369 --> 00:41:09.769 factors, surgical variations, specific functional 00:41:09.769 --> 00:41:12.889 goals like sport, always need careful consideration 00:41:12.889 --> 00:41:15.010 when translating broad research into precise 00:41:15.010 --> 00:41:17.929 individualized clinical practice. And it certainly 00:41:17.929 --> 00:41:20.010 sets the stage for where future deep dives might 00:41:20.010 --> 00:41:22.570 take us perhaps into that fascinating area of 00:41:22.570 --> 00:41:25.949 return to sport. So to tie it all together then, 00:41:26.150 --> 00:41:28.409 what we've unpacked today through this extensive 00:41:28.409 --> 00:41:30.909 and meticulous analysis is that while both the 00:41:30.909 --> 00:41:32.949 Bankhart and Letarjet procedures are certainly 00:41:32.949 --> 00:41:35.010 effective at preventing recurrence and optimizing 00:41:35.010 --> 00:41:38.349 shoulder function, the Letarjet procedure consistently 00:41:38.349 --> 00:41:41.030 demonstrates a distinct and really quite significant 00:41:41.030 --> 00:41:43.570 advantage in maintaining robust shoulder stability, 00:41:44.110 --> 00:41:46.289 particularly over the longer term, specifically 00:41:46.289 --> 00:41:48.610 between that six and 10 year mark post surgery. 00:41:49.030 --> 00:41:51.190 Importantly, the superior stability does not, 00:41:51.190 --> 00:41:53.050 for the most part, seem to come with a significantly 00:41:53.050 --> 00:41:55.420 higher burden of most post -operative complications, 00:41:55.800 --> 00:41:57.559 although we did note that slightly higher risk 00:41:57.559 --> 00:42:00.079 of infection, specifically with La Tarjet. This 00:42:00.079 --> 00:42:03.260 deep dive, we hope, offers you a direct shortcut 00:42:03.260 --> 00:42:06.019 to understanding the latest, most comprehensive 00:42:06.019 --> 00:42:08.199 evidence in this critically important field. 00:42:08.539 --> 00:42:11.199 It should empower you, hopefully, to confidently 00:42:11.199 --> 00:42:13.800 engage with discussions around shoulder instability 00:42:13.800 --> 00:42:16.000 treatment. Whether you're a healthcare professional 00:42:16.000 --> 00:42:18.079 striving for optimal patient outcomes, maybe 00:42:18.079 --> 00:42:20.320 an athlete navigating these challenging decisions, 00:42:20.639 --> 00:42:23.269 or simply someone looking to stay exceptionally 00:42:23.269 --> 00:42:25.469 well -informed about leading medical advances. 00:42:25.949 --> 00:42:28.269 If you found this deep dive valuable, we'd be 00:42:28.269 --> 00:42:30.170 incredibly grateful if you'd consider rating 00:42:30.170 --> 00:42:32.130 and sharing it with someone who might also benefit 00:42:32.130 --> 00:42:34.170 from these vital insights. Given the nuances 00:42:34.170 --> 00:42:36.530 we've discussed today, those fascinating historical 00:42:36.530 --> 00:42:39.150 preferences shaping practice, the compelling 00:42:39.150 --> 00:42:41.750 new data on long -term stability, and indeed 00:42:41.750 --> 00:42:44.250 the remaining gaps in understanding exactly how 00:42:44.250 --> 00:42:47.030 patient -specific factors, anatomy, lifestyle 00:42:47.030 --> 00:42:49.670 demands, truly influence individual outcomes. 00:42:50.079 --> 00:42:52.579 The ongoing challenge for clinicians isn't just 00:42:52.579 --> 00:42:54.719 knowing which procedure is generally more effective 00:42:54.719 --> 00:42:57.659 overall. It's about truly discerning for whom 00:42:57.659 --> 00:43:00.579 each procedure offers the most profound and lasting 00:43:00.579 --> 00:43:03.559 benefit. This comprehensive evidence serves as 00:43:03.559 --> 00:43:06.320 a crucial compass guiding us towards better practice. 00:43:07.000 --> 00:43:08.900 But the art of medicine, as always, continues 00:43:08.900 --> 00:43:11.699 to demand a thoughtful, individualized interpretation 00:43:11.699 --> 00:43:14.340 of unique patient needs against the backdrop 00:43:14.340 --> 00:43:16.800 of the most robust scientific findings available. 00:43:17.320 --> 00:43:19.400 It's a continuous journey, really, of learning 00:43:19.400 --> 00:43:22.300 and refinement. A truly thought -provoking conclusion, 00:43:22.400 --> 00:43:24.800 Professor, and a perfect reminder that that journey 00:43:24.800 --> 00:43:27.300 of learning, of applying the best evidence, never 00:43:27.300 --> 00:43:29.699 truly ends. Thank you so much for joining us 00:43:29.699 --> 00:43:31.340 for this deep dive today. We look forward to 00:43:31.340 --> 00:43:32.619 our next exploration with you.