Dr. Lau: All right. Well, welcome to the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of Arthroscopy Association or Arthroscopy Journal, but welcome everyone. I'm Brian Lau from Duke University. Today I have the privilege of speaking with two members of the Anterior Shoulder Instability International Consensus Group to discuss their three-part series of Consensus statements on anterior shoulder instability that was published in our philosophy journal.
I have Dr. Jazrawi from NYU, who's the Chief of Division of Sports Medicine and Director of Sports Medicine Fellowship there. I also have Eoghan Hurley, who's a powerhouse researcher at shoulder instability and a leader in these Consensus statements and his current resident here along with me at Duke. So we'll go right into it. And Eoghan, you've done so much research even at such an early part of your clinical career, but in terms of your research career, you're obviously far superior than most of us, and this technique that you've had is pretty unique in terms of collecting a consensus around the country and a value of experts. Tell us a little bit how you formed that group and how that technique has done.
Dr. Hurley: Thanks, Dr. Lau. Thanks for the introduction. So it's great to be here. I think the biggest thing to first say is this idea came from some of our friends in Pittsburgh who really pioneered and pushed it on as a big group project effort in orthopedics. They looked at it in ankle cartilage surgery and did a multipart series as well. I was lucky enough to be part of that group through one of my other mentors, John Kennedy, and then we took that same concept and said, "Well, we're doing a lot of research on instability. This would be a great topic." And I was doing two years of research with Dr. Jazrawi at NYU and we talked about it a few times. We went a little bit back and forth. One of the fellows at the time, Dr. Ash was also very interested in this topic, and then we were starting to tee it all up and thought this is the perfect area.
And then Covid hit and everything changed in research and then it became the even more perfect topic to do when we couldn't do our own research. We were doing Zoom calls for research every night and talking about things back and forth. So starting this off then really became how do we do it? How do we make this work? How do we get people from all over the world so we're not just getting the NYU or North America experience on shoulder instability? How are we making sure we're represented? And so we got a core group together, which included Eiji Itoi, Ivan Wong, Ruth Delaney, Lionel Neyton, George Athwal, Leo Pauzenberger, and Hannan Mullett, and got them all together and started reaching out and saying, who else should we be including who is publishing a lot on this, who's doing a lot of research, who are the thought leaders that are giving all of these lectures at conferences?
And went through the past few years for the academy, AANA, AOSSM, ESSKA, [inaudible] and said, "Who are the ones giving all these talks and producing the papers?" And then reached out, and that was probably the most nerve wracking part where I'd put a lot out there. And if it wasn't for Jaz backing me, it was one of those, if this lands, it'll be fantastic, but you really have to hope people buy in, and people did. We talked to the group that did it for the near circle and how ours was going to be different and that they were focused on indications for operative versus non-operative. And we really wanted to kind of make guidelines from the A to Z of anterior shoulder instability, which for the general practitioner doing shoulder or even for residents, learning what are kind of the guidelines, how should we be approaching this?
And then went through the few rounds of the process. So it kind of all kicked off from a few months of work. And then once it got rolling, it kind of takes over and the answers come through. And so we had three rounds of the Consensus. We started a broad questionnaire, what are your indications for operative management? Or what are the technical factors that are critical to success for a bankart? What is the critical bone loss? How long should patients be until their range of motion following a repair? And so we went through all of those questions in three broad rounds from narrowing it down, hear what people have generally said, which do you agree with? Putting the group statement together among nine separate groups and saying, okay, what do you all agree on here? What can we put forward? And then we had 69 members in total reading these, suggesting changes, and kind of coming to a consensus and then putting it forward for a final vote.
Dr. Lau: Well, I think that's, that process in terms of narrowing things down is really important because I think if you don't, you're talking forever. And so I think having been part of these, it's nice to be able to narrowed down focus discussion. I think a really cool technique because the question we always ask is what is everyone else doing? You can read all this literature and stuff, but how people are interpreting how people actually applying it. And so I think that's really, really powerful technique. Well, that's the same technique for all three Consensus papers. So that part then we kind of go a little more to the clinical stuff. And I guess the first part, we talked about diagnosis of shoulder and disability. When a patient comes in your clinic, you're seeing them in training room. And I thought it was interesting, a pretty near unanimous consensus on the history and stuff and what things we should be considering. But Dr. Jazrawi, maybe you can mention a little bit kind of what things that you find and you consider when you're first evaluating an athlete or a patient that comes into your office.
Dr. Jazrawi: Yeah, sure. So I think that was a nice intro by Eoghan discussing how this came about. And one of the interesting things when Eoghan first discussed this project with me prior to Covid, my initial thought was, "Well, we're going to get everyone at the meetings to sit down in a boardroom and we're going to discuss this." That was my thought process that we really need to get everyone in a room and just think about it, all the individuals on this, it would've been impossible to get everyone in the room. And the idea, yes, we used email communicating with other individuals either across the country or with our own department. We used email, but we used it much more. And the Zoom capabilities came into fruition during Covid and then I think Covid spurred this project on and made it get completed in a more reasonable time where it was likely that this would've continued over three years of meetings, trying to get this project through, getting specific individuals in the room.
And with these topics that can get into a lot of controversial issues, the thing is you'll get into the weeds with lots of discussion, whereas Eoghan was very good at getting these questions out, answering them and understanding, yes, there are limitations to these techniques, but that's okay. The idea is to get the information out there, fill out the information and see if there's consensus on it. And I think that was the power and Covid drove this where we did it all virtually and people chimed in. We answered the questions via this red cap format, and I think it went great. I think without Covid, this probably would've not gotten done in as efficient matter as it got completed. And getting back to the history, for me, a patient coming in, a couple of the key points that... And I think this was the easiest thing in the Consensus because I think a lot of these factors we look for in the history are critical and these are these accepted things, and it was nice to sort of get everyone's opinion on it.
And for me, certainly age of the patient, how they dislocated their shoulder I think is key. The number of dislocations, did they dislocate their shoulder in their sleep? When they dislocate their arm, is their arm at the side? Do they have a history of any type of soft tissue disorder, Ehlers-Danlos, et cetera? What's their sport that they do? Are they a contact athlete? And you look at those things, they all play... We know they have an importance in what the dislocation rate is. And I think that's the key. All your history points are there helping you to figure out, well, what's the best procedure for this patient? Ultimately, everything we do in this Consensus is to figure out can we do a soft tissue procedure and is that the right thing and what will the success be with that soft tissue procedure? Do we need to do an open procedure? What type of open procedure? Do we need to do a bone procedure?
Everything in this Consensus is trying to figure those answers out because ultimately we're clinicians, we want to give the one procedure that will solve the problem for that specific patient. And if it's a contact athlete, maybe it's going to be another procedure and it'll be predicated on some other factors that come up with imaging and other things that we look at. But that's the goal. The goal is to figure out how do we best treat our patients with one procedure that will keep their shoulder in place. And yes, it's very easy to say we can do a latarjet on everyone, and while that may have a higher success rate, that's not a uniform position, there are complications associated with that procedure. And we're beginning to realize that even a patient who gets a latarjet with no bone loss, there may be issues with those patients with graft resorption, et cetera. And I think that's where these Consensus statements become interesting, and it's just an added piece of information in the literature that helps our colleagues make an informed decision about what the best thing for their patient is.
Dr. Lau: I couldn't agree more. I think that the goal of the history exam is trying to decide on what the best treatment is, and I think the Consensus pretty much was what most of us would do. I'd just read them off: Apprehension tests, [inaudible] shift, range of motion, Beighton score, all those different things we're all agreed upon basically by everyone. What factors in the history... And you mentioned a little bit about imaging and deciding on treatments, what parts of it will decide you on non-operative care and what parts of it might decide that you need to get advanced imaging?
Dr. Jazrawi: Right. For me, I think the most important thing is looking at the age. We know that based on the historical studies about recurrent instability, that patients that come into the office that are older, let's say greater than 25, obviously have a much lower incidence of recurrent instability in their shoulder compared to someone who's under 20, for example. And compared to someone who's under 18. I think the decision to get further imaging, for me it's certainly an x-ray, you're getting an x-ray. If they dislocate their shoulder, they're certainly getting an x-ray to confirm both pre reduction and post reduction films. So that's easy. And you're going to have those films in the office when they come in. In terms of more advanced imaging, for me living in a major metropolitan area where MRIs are very possible, certainly for me, an MRI is critical.
Looking at other things that may impact the outcome, not so much in recurrent instability, but other things like cartilage damage, the extent of the labral tearing that may not end up in frank instability in these patients later on, but more pain. And so that's important for me to know. But what I'm looking for with the imaging outside of the fact that if they're older, they're unlikely or less likely to have recurrent instability is really looking for obviously major labral pathology extending into the biceps anchor, other cartilage injuries that we know that can happen with dislocations. And then ultimately whatever imaging you look for, some 3D advanced imaging, which was discussed in the Consensus, looking at degree of bone loss both on the glenoid and the humeral head, that will help you make your decision about what's the appropriate approach to this patient combined with a good history.
Dr. Lau: Okay. I think we'll point out and I would ask you about... And maybe Eoghan can chime in too a little bit about age being a factor in terms of... And then of course adding your imaging findings as well. The thing that always confused me a lot is we're younger patients, so less than maybe preteen age, they come in [inaudible], but we know that they have a high risk of the returning back to high risk sports. But at that age, you also try to avoid surgery when someone's so young. So how do you weigh that balance in someone who's young, who's maybe at higher risk, but also trying to avoid an early surgery? What are your thought processes in those really younger athletes?
Dr. Jazrawi: Yeah, so 14, with the dislocation, they're a very hard group to manage. And my feeling is in those younger patients, certainly they're a challenging group, because for me, those patients always have some associated other factors that lend to their instability. It's not so straightforward in them. Again, the goal for them, I'm treating them after I get the imaging non-operatively, unless they have multiple dislocations prior to seeing me and one patient that I'm currently taking care of, 14-year-old female, history of dislocations, no bony loss, both on the glenoid and the humeral head. Had an anterior labral tear, fixed her big capsule plication, rotator interval closure, did well for two years, she's 16 now, she's having recurrent instability again. Those are the tough patients and it's challenging when they're very young like that, what's the next procedure on this patient who had a well done capsule label reconstruction that now has recurrent instability, still no bone loss in her shoulder? So that's a tough one. And for her, her next procedure in my hands is not a bony procedure.
She doesn't have bone loss, but is some type of open capsular labral reconstruction, meaning where I'm reducing the volume of her capsule either with a near inferior capsular shift, or an anterior capsular labral reconstruction where I'm doing an open bankart to try to reduce the capsular volume in her shoulder. And for me, that's how I'm thinking. If I have a failed procedure in a patient that doesn't have bone loss, that's what I'm doing. I'm doing an open capsular shift. What I think is critical is if they start to get any degree of bone loss that approaches a significant value. And in this case, the significant value is arguable. I think in the Consensus statement you're looking at what subcritical bone loss, but as it approaches 10%, 12%, you're getting up to those factors, then you're starting to look at the humeral head bone loss and correlating that number via the glenoid track. You start to think about a bony procedure. But for me, without any even measurable bone loss, I'm thinking some type of open procedure, open capsular shift on a young female like this that I mentioned.
Dr. Lau: Sounds like younger person, you're feeling that we should be operating on them a little bit even if they're will be younger, just to avoid them from those recurrent instabilities. Is that accurate?
Dr. Jazrawi: I still rehab them, but we know the natural history in these patients is very high in terms of recurrent instability, but it's hard. A 14-year-old kid trying to convince the parents after just a first time dislocation to proceed to a surgical procedure, especially when they start feeling fine after a couple of weeks of therapy, I think that challenge in those patients. I think they declare themselves, especially if they're contact athletes, those kids are either apprehensive, don't want to go back, and that's a lot easier to get them in.
But for me, in my practice, a lot of those younger patients don't end up seeing me. If they see me when they're 14, they'll come back when they're 16 with another dislocation. At which point for me, that's when we push the trigger. But I think if we can get them early, it could be better. But the question is what's the right procedure at that young age? And even without bone loss in those younger patients as good a job as we do arthroscopically, reducing the capsular volume, I think they're just a lot more plasticity in those patients leading to potentially a higher failure rate with some of the arthroscopic techniques. So I think that's where you look at potentially an open procedure in some of those younger patients to try to reduce their capsular volume.
Dr. Lau: Definitely makes sense. And we're definitely getting the procedures here in a little bit, but for the first part here, you mentioned a lot about bone loss and advanced imaging and how are you measuring that? I don't know. I mean maybe Eoghan, I know you've done a little bit on imaging type stuff and what's your advice based off the Consensus? It seemed like that was probably the area that had the biggest discrepancy, but your thoughts on what type of imaging, in terms of how people should measuring that?
Dr. Hurley: Yeah, obviously that's something we're working on together as well. So of interest to both of us. I mean, what we kind of agreed upon with this, and I think one of the interesting things just to say with agreement in these statements is these are agreements kind of all around the world. It's not just this is the American approach or the French approach to just do a latarjet or just do this. This is, when you kind of get down to what do people actually agree with and with kind where we are now, the evidence and what we're looking at was CT probably better if there's bone loss, newer MRI sequences, getting there, similar, comparable, especially 3D MRI reconstructions. And that also gives you the soft tissue evaluation that you don't otherwise get with an MRI.
And then in terms of how do we actually look at it, it's really the circle method using an on face view of a 3D reconstruction and we said CT in our Consensus, but obviously there's a lot to suggest 3D MRI on face just as accurate. And I know that's something we're both working on together. And then when it comes to the Hill-Sachs, it's really the glenoid track and how does that correlate? And there's some other interesting research coming out of me, especially the guys in Pittsburgh as well, where they're looking at whether it's on-track, off-track, near on-track, where it is? Is it peripheral? And trying to say how much that interplays, but I think we kind of know that if it's an offtrack lesion that's increasing our risk. And everyone talks about it, glenoid bone loss, humeral bone loss, but it really should be looked at in that kind of 3D. It's how they interplay with each other.
Dr. Lau: Yeah, I agree with that. I mean, we're working on a lot of those things together, but [inaudible] method and then you mentioned a few different numbers and I think in the Consensus was 15, 20%, but what numbers are you using to decide on surgery or not surgery or advanced procedure versus an arthroscopic bankart?
Dr. Jazrawi: Yeah, I think in addition to the degree of bone loss, getting back, Brian, that you brought up about the history, sometimes you get a patient who's in their late twenties, maybe they're not a contact athlete, they're having some instability. A patient with a 15 degree bone loss for that specific patient that's not a contact athlete may benefit from a capsular labral reconstruction. Whereas someone who's a contact athlete that has 15% glenoid bone loss or this subcritical bone loss, that's a contact athlete that may have, as Eoghan brought up some humeral head, a smaller Hill-Sachs, you have to consider the glenoid track. I think that's critical. And for someone, even if they're older, but a contact athlete who's approaching those higher degrees of bone loss, that's when I start thinking about restoring the bone either via latarjet, distal tibial allograft. For a younger patient, my threshold as they get younger and have a higher chance for recurrent instability and they're a contact athlete, that drives me even with those subcritical bone losses to consider a bony reconstruction procedure on them like a latarjet.
And for example, a wrestler who we know is going to have a higher rate of instability with subcritical bone loss because of their fact that they're a contact athlete and added a Hill-Sachs there with a glenoid tracts affected, that makes me lean more towards some type of bony reconstruction procedure. So all these factors, and whether you look at the instability severity score or the modified version that Preventure put out, I think those all play a role in your decision-making process. And certainly as we get more sophisticated in looking at this, I think that's the approach. It's not just looking at the bone loss per se, it's looking at the age, whether they're a contact athlete. All these things come into play and that's essentially what the instability severity score is trying to point us to. And the newer version with prevention is a little more sophisticated and I think... But that's sort of the gestalt that you get from that. When can you get away without doing a bony procedure? And if it's borderline, maybe you should proceed with that bony procedure on that patient to guarantee more of the success.
Dr. Lau: Yeah, I think that you make some... And then that's the key point there. I think for history and exam and imaging, you can't just pinpoint on a single number. And I think that a lot of the literature and a lot of people are like, "Oh, it's 20%, I got to do this or whatever." And I think you're right. You can't just do it that way. It depends on the patient, their age, counseling them and what their goals are, because sometimes I had soccer athletes who have 18% bone loss and there's no way I'm doing anything other than just an arthroscopic procedure because they don't want anything bigger. So I think you got to factor all that stuff in and I think it's really important points that you're making there.
Dr. Jazrawi: The one thing that I think also plays a role is you have a patient that comes in that their shoulders falling out when they're sleeping. I think that's a concern when they have bone loss or they have mid-range instability. Someone who's only comes out up here versus someone who's coming out much lower. Obviously for me, that plays a role in my decision-making process because I know when you're down here, the bone is playing a major role in that instability and in mid-range instability. So that's another factor that kind of drives me towards a potential bony procedure.
Dr. Lau: Yeah, I think that that's a great physical exam finding that we should highlight because I'm not sure it was mentioned in the Consensus, but the mid-range instability, really important factor I think in terms of deciding on what your treatment plan. And so kind of extending from this first paper, you guys talked a little bit about the bankart, so now you've decided that you're going to do bankart based on your history and exam. What's your take on, what's the ideal number? I think the Consensuses has a couple points that they make, but what's the number of bankarts we should doing? What should be placed? Are you a lateral guy or a beach-chair guy?
Dr. Jazrawi: So that's a great question, and I think at our institution we have over about 15 sports individuals within the institution, and I've been there about 25 years. So for me, it's been enlightening to see how things have transitioned over the years in terms of how people do things. And I think there's nothing greater than having a diverse group of people who do things all differently, may have gone to train at different fellowships. And we have the core group of residents and fellows who work with all the attendings to see over the years how the transition has been from beach-chair, in a lot of these individuals who only did beach-chair and have transitioned to lateral decubitus strictly because two things.
One, it was easier to get a lot of the things done that we need to get done arthroscopically to repair a labrum. Also, two, to reduce that capsular volume. And I think there's nothing wrong with doing the beach-chair position. There are tricks in the beach-chair position that you can utilize to help you with your reduction of capsular volume and getting a nice shift. But it's pretty clear from objectively and looking at different people at our institution, where all of them have transitioned now to do lateral decubitus for their instability work. So to me, that was enlightening, but it also proved a point that these individuals who were beach-chair trained finally make the transition to lateral because they realized it was a lot easier.
Dr. Lau: Yeah, I do think we have partners here who do beach-chair and lateral. I'm a lateral guy, and I find the same things too. I find it a little bit easier to get more inferior and stuff, but obviously you can do it in beach-chair with the right techniques. Now, where are you putting your anchors and how many are you putting in?
Dr. Jazrawi: So I think for me, whether you look at Bradley's work who spoke about a minimum of three anchors and whether that's focused on posterior instability, the idea is getting these multiple fixation points. And while the Consensus I believe talked about minimum of two to three anchors, a lot of these newer anchors... And I think this is where sometimes reading the papers closely is important. Some of these anchors have now three fixation points. A lot of them, there's also the idea of doing mattress sutures where you get a different type of bumper.
So I think you have to be careful in just reading number of anchors now because these anchors are obviously different than the anchors we used in the past where we were strictly tying knots or they were just simple suture fixation. So I think that you have to really consider, but the classic teaching was a minimum of two, preferably three anchors, getting multiple points of fixation, getting as low as you can into the 5:30 or even six o'clock position, and even the possibility of doing a posterior anchor to reduce capsular volume. I think these all came out in the Consensus, and these are things that are all related to reducing the capsular volume and maximizing your ability to reduce that capsular volume. And that seemed to be uniform in the Consensus when we look back at the data.
Dr. Lau: I think that it kind of shows and matches with literature, and I think your points are well taken, the technology has changed. Are you doing simple or mattress or are you using a three fixation point anchor or what's your current technique?
Dr. Jazrawi: Yeah, so I am not tying knots. I'm using these all suture based anchors and essentially passing a mattress now through. Certainly for the inferior ones and as I come up more superiorly, I'll transition to a traditional simple base suture. But I think getting that bumper inferiorly, and I think it could be better replicated with a mattress suture, though there's some biomechanical data to support that. I think for me, the look of it and recreating that bumper effect, which recreates that capsule labral seal that we wanted, that suction effect that also contributes to instability prevention, for me is critical.
So I try to get that one inferior and as I work up, I transition to these more simple based sutures, but I'm using these tensionable knotless fixation that I'll keep the first one in and I'll transition to the second one and secure that, and then I'll go back and retention the more inferior based one and work my way up. And I think whatever company you use, I think it's just another way to allow us to accomplish what we want to accomplish with better technology. And I think it makes the average surgeon better with this newer technology. And ultimately that will translate to more uniform, better results across the country, ranging from the average maybe non-sports trained orthopedic surgeon to someone who does shoulder all the time to try to have similar results for all shoulder surgeons.
Dr. Lau: I think those really good points and interesting technique and how things are advancing. Thanks so much for talking about the history exam and then the arthroscopic bankart techniques. So we'll move on the next session you'll joining us be on latarjets, [inaudible], glenoid bone grafting, and [inaudible].
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