Brian Lau: Welcome to our Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of Arthroscopy Association or Arthroscopy Journal. Welcome back, everyone. This is Brian Lau from Duke University, and today I have the privilege of doing the second part of our series here with Dr. Jazrawi and Eoghan Hurley, two members of the anterior shoulder instability international consensus group to talk about their three-part consensus statements in anterior shoulder instability that was published in the Arthroscopy Journal. Last time, we spoke a little bit about the diagnosis, history and exam and the arthroscopic band card and different techniques. And today, we're going to focus on a little more advanced procedures including remplissage, Latarjet, bone grafting, and then how are we deciding to return to play?
So we'll start off with... Last time we talked a lot about bone loss, how we measure that on advanced imaging, whether it's 3D CT scans, but what about the humeral side? Eoghan, can you talk a little bit about what your thoughts are on measuring the humeral side track and then how you're deciding on what procedure? Is there a certain percentage that you're looking for or something in the history and exam?
Eoghan Hurley: So I think this is something that we have known is important but are starting to realize more and more as the glenoid track concept has kind of become mainstream and is something we get examined now on our in-training exam as residents. But I think the big thing about it is, everyone, as I said in the last podcast, seems to kind of talk glenoid bone loss, humeral bone loss, but it's really about the two of them and how they interplay. If there's an off-track lesion, it's changed by how much bone loss there is. The more bone loss there is, the more likely glenoid bone loss that... I mean the more likely there is to be an off-track lesion by nature of how it works. And I think that interplay is important. There's a difference between 15% bone loss and no off-track lesion and 10% bone loss and an offtrack lesion.
And I think that's the next main thing in research is delineating where do those cutoffs lie when they interplay with each other, not just in isolation. And I think people are becoming more and more aggressive in doing remplissage. I mean, there's now good level one evidence showing it reduces the recurrence rate. There was that randomized control trial out of Peter McDonald's group and subsequent large meta-analyses all show the same stuff that it reduces the recurrence and it's just trying to indicate that patient. So I think it's trying to find those patients who may not need something augmented on the glenoid side, but you're still worried enough that you're going to do something. And I think it's probably now trying to find when should you not, if there's a Hill-Sachs. I mean, we know the complications with it are pretty low. It does pretty well, it reduces your recurrence and I think it's definitely changed things in what people are doing and what I've seen going from New York, Dublin, Duke, and how people are treating things over the last few years.
Brian Lau: Yeah, I think that we're finding a more and more point, like you said, it's a bipolar problem and that's kind of dictating treatments. And that Dr. Jazrawi, for you, last time we talked about arthroscopic, but how are you using the humeral bone loss side? Is that helping decide remplissage or is there a role for open bank heart? I think the consensus that was an area of most discrepancy was between arthroscopic and open Bankart, no boning procedures, but just arthroscopic or bony soft tissue procedures. How are you factoring the humeral side with that?
Dr. Jazrawi: Yeah, so I think that's very important. I think certainly, for me, I have a very low threshold when I'm doing an arthroscopic procedure, an arthroscopic Bankart, if there's any degree of Hill-Sachs lesion, adding remplissage, I think the data supports it, there's minimal downsides to doing it, and there seems to be a benefit of whether it's the actual filling in of the defect at the level of the Hill-Sachs or adding of some capsular reduction, specifically posteriorly. There is a role because you're grabbing the capsule there, you're grabbing the infraspinatus, you're translating it into the defect. For certain, there's some degree of capsular volume reduction there. So for me, it's a no-brainer to add that to the procedure. And I think the problem is the controversy of deciding, "Well, when do you do an open procedure over something like a combination arthroscopic Bankart and remplissage?
And for me, that has a lot to do with, one, is there any Hill-Sachs to begin with on the patient? And are they young and a contact athlete? And I think for me, the more I look into this group of patients that has a higher failure rate with the arthroscopic technique, I get nervous specifically in wrestlers who are younger, approaching more football players, approaching them via an open Bankart procedure or open capsular shift procedure. I don't think there's anything necessarily wrong with that and it has to do with comfort level, but that there was a discrepancy in the consensus. Where does that fit in? And for me, personally, it fits in someone who has a Bankart, has instability, who's younger, who's a contact athlete and doesn't have much of a Hill-Sachs.
Now, how many of those patients do we see in the office that don't have some sort of Hill-Sachs procedure? It's low. Have some sort of Hill-Sachs lesion? It's lower. So for me, that's definitely a smaller percentage. So if they have a Hill-Sachs that's on the smaller side and certainly have a Bankart, I'm approaching with an arthroscopic repair and remplissage. For more of the contact athlete who's younger with a large Bankart, less of a Hill-Sachs, I may consider an open capsular shift on them or an open Bankart.
Brian Lau: Yeah, I think that's a good point. Most patients do have a Hill-Sachs and I had a patient, though it looked like there was going to be just a really small Hill-Sachs and when we got in there, it was actually even smaller than we anticipated. And we ended up converting to an open for that very reason because I wanted to give her extra stability because she had so much instability. So I think that's where the role is. If somebody has a lot of instability, you're concerned that just isolated arthroscopic, you could probably add an remplissage, but the Hill-Sachs for whatever reason ends up being small or has remodeled a little bit. But what's your technique for remplissage? How are you doing it? Are you putting anchors in before you start doing your labor part? Are you doing knotless or tie? How are you doing your remplissage?
Dr. Jazrawi: Yeah, so I've transitioned, I think the first one's the standard traditional anchor technique. I'll insert them first. I'll use a 70 degree scope in the front looking towards the back, insert the anchors, pass the sutures, don't tie them, switch to the... Put the scope back in the posterior portal, then address the anterior Bankart, repair that, and then back and tie the remplissage sutures at the end of the procedure.
I think if you tie them early on, you can reduce some of the capsular volume. There are others who say where they'll tie them first and they feel like it brings the head back and it gives them more anterior exposure. For me, I've not had that experience. For me, I'll just pass the sutures, go back to the front, repair the Bankart, and then do the remplissage tying at the end. I've transitioned to using more of a knotless technique where I think you can get a greater reduction and tensioning via these knotless all suture based anchors. So I think there's benefit to that, so I've transitioned to that. But the same thing, I won't tension them until the end of the procedure.
Brian Lau: Gotcha. Yeah, I think that's important. I think that it kind of closes down your space if you do it first. And then one of the really interesting questions you guys asked in the consensus, and Eoghan this was one good for you is, indications for a remplissage and isolation. I thought that was a really unique question to ask and your take on that, how [inaudible] came up with that and your takeaway from that question and the consensus.
Eoghan Hurley: Yeah, I guess we're kind of looking at that. I mean, we were thinking ahead in what the answer turned out to be as something I've seen before where going back it's a failed Latarjet or there's still current instability and doing a remplissage then without doing anything to address the front. And it's in those patients who you've done a well-placed Latarjet, there's still recurrence. How do you address it in a minimally invasive manner without going back, reopening everything up, doing an [inaudible]? And it's in those patients who either they have a new worsened Hill-Sachs or it just wasn't addressed. I know there's that saying, I've never met a Hill-Sachs lesion that wasn't on track after a Latarjet, but there certainly are those patients who have severe bone loss and I think this is targeting them specifically.
Brian Lau: Yeah, so in a scenario where you've done the procedure in the front and maybe should have done something in the back but didn't earlier? Is that what-
Eoghan Hurley: Yeah, exactly.
Brian Lau: Nice. Yeah, I thought that was an interesting question because I haven't thought about that in isolation, but I don't know. Dr. Jazrawi, do you have anything to add to that remplissage and isolation?
Dr. Jazrawi: That's a great question. That certainly didn't come from my brain. It is one where I rarely see. And my concern is, if you do have a patient like that who has a successfully healed anterior approach, the question is, "Well, they're still locking into that lesion." And it's a challenge for me how I'm going to approach that. Am I going to ignore the front? And I think a lot of it has to do based on the patient's history, their symptomatology. But if I truly feel that, for example, the anterior Latarjet has fully healed and it's strictly an isolated posterior, and in a like this, it's going to be something much larger. And for me, something like that, when they approach that size, I'm not doing a remplissage, I'm approaching it with some sort of open graft into the back to get some bone in there.
Those are the ones that I've seen. When I've had a Latarjet and it's extremely rare where they still have some sort of apprehension, the Hill-Sachs tends to be very large and I'm approaching it with filling it in and with bone. For me, bipolar lesions and, for example, seizure patients who have both a significant anterior glenoid bone loss and a large Hill-Sachs, someone like that, I'm approaching with a DTA from the front because their bone loss tends to be well closer to 30% on the glenoid. But when they have a large, large Hill-Sachs, if I'm going through the front, I'm going to try to address that back lesion, especially on a seizure patient who will stress whatever I do in the front. So again, large Hill-Sachs lesion is usually going to be in the case that Eoghan's talking about. And for me, it's more of a bony procedure than a soft tissue procedure.
Brian Lau: Yeah, I think that's... Revision surgeries and those posterior dislocations from seizure patients, those are very challenging cases. Going back to more of the traditional remplissage arthroscopic, when you decide to do remplissage, are you counseling patients about loss of motion? I mean, there's some data to say that maybe that's not much of a concern, but how do you counsel patients in terms of if you're going to do the remplissage and their motion?
Dr. Jazrawi: Yeah, great question. For me, it doesn't come up. It's part of the capsular label reduction in volume. So to me, that's part of that procedure. In terms of addressing their instability, I don't even bring it up in the sense that I tell them that, "You may have some minor motion loss reductions, but it's minor and you won't even be affected by it." And I have that same discussion, whether it's just the labor repair plus or minus a remplissage. So that comes up very little in isolation as the remplissage procedure reducing motion. I've not seen that in my practice, so it's not an issue.
Brian Lau: Good. I think that's more of a recent data showing that that should be... It's less and less concern, if anything, maybe only one or two degrees, which I think, as you mentioned, most people won't even notice that. And then moving on from the remplissage, more bone loss. So when are you thinking about a Latarjet? Now, we've talked about in the last podcast a couple of different points in terms of not just using the numbers but the history and exam, but what's your traditional classic indication for a Latarjet, Dr. Jazrawi?
Dr. Jazrawi: Yeah, so greater than 15% bone loss on the glenoid plus or minus some humeral head involvement or Hill-Sachs involvement. Contact athlete, younger. So once they start getting to that 20% mark, I'm considering a Latarjet, especially mid-range instability, Latarjet. As it approaches 25, 30%, I start to get concerned about the ability of the Latarjet to control the bone thickness to control all the instability, and I start considering a DTA, distal tibial allograft procedure where I can get a bigger piece of bone there. But I use measurements and I look at the thickness to the coracoid and I calculate all those in association with the bony thickness of the glenoid. And for the most part, even in certain patients approaching 25 to 30% bone loss, sometimes their coracoid is thick enough that I'm okay and they don't have much of a Hill-Sachs that I'll do a Latarjet those patients. But traditionally, as you get much higher bone loss on the glenoid, I want to reconstitute that with a distal tibia allograft, also restoring some of the cartilage. For lower degrees, approaching more 20%, less than 25, I'm considering a Latarjet.
Brian Lau: Yeah, I think that makes a lot of sense and I use a lot of similar logic in my own decision making in terms of when it gets higher up and whether or not that bone block from the coracoid can restore it, I'm not certain of. That brings up another point that came up in the consensus. Eoghan, this one's kind for you. It's like, we talked about the area that the least amount of consensus was the classic versus congruent arc technique for the Latarjet probably because of deciding how much bone loss you need. What's your take on that in terms of that with the consensus?
Eoghan Hurley: Yeah, I mean, I think what people said in the consensus was the classic technique may be better, but I think it kind of lacks maybe some of the nuance in individual patients. I think the thought behind the classic technique being better is you get more bone to bone fixation, there's more likely to get a bony union. You may not restore as much glenoid face with that as the congruent arc. And there's also some element of its curvature is more natural. I mean, I know you can burn it down a little bit after when you do the classic to match the natural curvature of the bone itself. I think the main thing is, how much bone loss does the patient have? The congruent arc can restore much more, but do you need that in every patient? Probably not.
As Dr. Jazrawi mentioned earlier, they tend to really model back to whatever normal is over time. So I think in most patients, if it doesn't exceed what can be restored physiologically by using a classic arc, that's kind of where you may think congruent arc may be better, but there's really not a huge amount of evidence comparing the two. Most of it's out of the group in Bueno Aires and they've said similar outcomes both do about the same. Both are pretty good, no major difference. But I think that's just getting into kind of the weeds of when you might think one or the other.
Brian Lau: Yeah, and I think you bring up good points in terms of that. And for Dr. Jazrawi, we had talked a little bit about screws versus buttons, and I think one of the challenges of the congruent arc is you have a lot less surface area to put screws in. Are you experimenting with any buttons? And it came up that was the area of discrepancy on the consensus as well, screws versus buttons and what the optimal was. What's your take on that and also between classic and congruent arc, if that factors in?
Dr. Jazrawi: Yeah, I think overall, especially for the younger residents and younger attendings listening to this, the key thing is whatever you decide to do, the first thing is that you want to be comfortable doing it and skilled at it, and whether that takes practice to do it and test the technique. Sometimes if you can do the traditional technique as opposed to the congruent arc and you're more comfortable with that, that's what you should do for the most part, I think, especially with the data supporting both. The congruent arc, I think personally that thinner bone and we know some of these coracoids can be quite thin and then you're shooting a screw through that. I think that's where you lead to the risk of fracture. I like the congruent arc technique in the sense that you can try on the inner aspect of it to restore the capsule label and make the graft almost extra articular.
There is some work where you can do that also with the traditional European Latarjet. But just like Eoghan said, I believe you can get better compression on a larger surface area for potential healing. And for me, that's what it's all about. It's about getting healing of this graft and I think there's just more surface area where you have the traditional European technique to basically reconstitute that anterior glenoid. But whatever you're comfortable with, I think, is the key too. And in the case of doing the congruent arc, I think there's a little more skill that's required in terms of getting that proper centering point on that thinner piece of coracoid. In terms of buttons versus screws, I think the controversy comes in, can you get solid fixation with buttons and what's the lever arm? We know that the lever arm for the button technique where you're fixated with buttons on both sides, the lever arm is the suture and that moment arm and that micro motion is going to be a lot greater with that technique.
I think as we improve the technology in those where the buttons and the motion between that and the biomechanics come close to screw fixation at time zero, I think that's the key to figure out that technique. For me, the button technique, I'm utilizing it when I do an arthroscopic DTA technique. I think, for me, it makes the technique easier for me. I've not had any issues with healing yet, but it always concerns me. But because I can do it better with the button technique and it's easier, that's why I've sort of transitioned to that. But I think it's something that we need to look at and I'm not quite ready to do on an open procedure, a button technique. If it's open and I'm looking straight at it, I'm putting a screw and getting solid fixation to make sure I don't have issues with healing afterwards.
Brian Lau: Yeah, I think well good points there in terms of doing what you're comfortable with. I still like doing screws, but I think the consensus still lean more towards screws, but buttons are starting to get some interest. And then you mentioned a little bit about the DTAs and that kind of segues nicely into the next topic is bone grafting DTAs and how are you deciding that? Does the sling effect factor in for the Latarjet and how are you deciding when to bone graft? You mentioned a little bit about size. And also, which bone graft? Is it DTA? Should we be doing autographed? And it seemed in the consensus that the main consensus was that it should be up to the surgeon because there was no real consensus [inaudible] for that, but what's your take on that, Dr. Jazrawi?
Dr. Jazrawi: Yeah, so that's a great question. And for me, I'm fortunate to be at a major academic institution with access to distal tibial allograft. I think that's an ideal graft both in terms of bony reconstitution, the ability to get cartilage in there as you... The size of these lesions where they're involving a significant portion of the glenoid, you're losing cartilage there and I think when you put in a fresh piece of cartilage in there, you're reconstituting that and I think that's critical. So for me, that is an excellent graft option. Now, the utilization of iliac crest bone graft and things like that, I think they're acceptable. But for me, when you get to those larger bone defects, that's where I want to put an intraarticular graft with cartilage on that.
The idea of using an [inaudible] where you're attempting to putting the graft extraarticular I think is certainly an option. And some people don't have access to distal tibial allograft, but I think if you have access to it, distal tibial allograft is an easy graft to work with. It's contoured almost perfectly when you work with it, it's easy to contour it and shape it towards the anterior glenoid. And it almost looks like God put it there perfectly for us to utilize it as a graft source. So for me, that's my go-to.
Brian Lau: Yeah, I think you brought up a good point about cost. Are you using fresh or frozen? I think some of Dr. Ivan Wong's work said that frozen may be useful and may help bring down that cost a little bit, but which one are you using?
Dr. Jazrawi: I mean, I have access to fresh, so I'm going with that. There have been cases from my partners who have used frozen. And I think when you look at it from that standpoint, you're reconstituting the bone in those cases. And I think we know that any way we reconstitute the bone at the anterior aspect of the shoulder is good in the sense of that plays a critical role in recurrent instability. So one of my partners does it with frozen and he fashions it such that he'll try to make it extraarticular, which again, if you, again, believe that that adds to less of a degree of arthrosis later on by making those bone grafts extraarticular, I think that's debatable. But if I have access to fresh cartilage, I'm putting in fresh cartilage in the shoulder because using DTA for much larger lesions that are 25, probably closer to 30% and above, where I think that's you're really getting glenoid cartilage involved.
Brian Lau: Right. So you're keeping it intraarticular because you're doing on these much bigger lesions that you feel like needs to restore some cartilage.
Dr. Jazrawi: Yes.
Brian Lau: Well, good points. And then one thing that always comes up and segue a little bit into the next topic, which is return to play is, when you do a bone block procedure, whether that's Latarjet or DTA or any other bone graft, are you gaining Cts? Are you checking reabsorption? Are you using that to help you [inaudible]? Or do you feel like you're always going to have some gap in there?
Dr. Jazrawi: Yeah, so that's a great question. So for the athlete that needs to get back within that four to six month mark, absolutely. So I'm approaching it, getting a CT to confirm that it's healed to allow them to go back to work, to contact sport. For the traditional patient that we see in the office that is not in a rush to necessarily get back to anything, I'll use traditional imaging, x-rays, and decide on... For them, they've gone through a lot with their shoulder, they're not itching to get back to any type of contact sport for more closer to eight months to a year. So I typically don't have issues with them and will track them with x-rays at the six to eight month mark to confirm certainly healing before saying, "Hey, you're good to go back." But it's really for those athletes who need to get back, desire to get back, the younger patient who has a sport that's coming up that I'll just double check that we've got significant healing on the bone before letting them go back to play.
Brian Lau: And does that mean you want to see 100% bony healing? Or is there a degree that you're looking for? Or just make sure there's some bridging gap callus there?
Dr. Jazrawi: Yeah, for me, it's bridging callus significant over... Whether you quantify it or not, for me, it's about 80% and I'm not worried about the other 20%. I'll let them... Especially at the four to six month mark, if I see that much healing, I'm confident, especially with screw fixation, to let them go back.
Brian Lau: That's good. And then a little bit more into return to play, I'm going to ask you about that because I think one of the things that was really unique to this consensus that was different than other talks about return to play was that you tried to define what failure actually was, and I don't know if there's ever been a site that had made people trying to define what failure was. What's your takeaway from it? And how should we be defining failure as a group and from the consensus?
Eoghan Hurley: Yeah, I think it's the interesting thing in this, and one of the backgrounds why this came up is sometimes patients, when we looked at our five-year Bankart outcomes, the biggest predictor of athletes being happy was, were they able to get back to sports? So we often talk about failure just in terms of is a recurrence, but I mean, these patients can be apprehensive, painful, and it's trying to set what factors actually go into that. What should we be considering to say a successful procedure? Or even other complications, if they have a Latarjet, there's a subscap failure going back to do something there maybe considered a failure of the treatment. So it was trying to define that more closely. I mean, even with return to play saying they return to play, it's like, that's great, but did they return to play without re-injuring? And it's just saying, trying to define better are we getting the patients back to everything they wanted out of the surgery?
Brian Lau: And so when we think about failure, obviously, the main thing is, can they get back to sport, as you mentioned, their activities? Dr. Jazwari, what are you guys doing at NYU in terms of return to play testing? And one of the things that came up with the consensus was psychological factors. Is that part of any kind of battery you're doing there at NYU? How are you guys doing it?
Dr. Jazrawi: Yeah, I think that's a great question. And certainly for lower extremity, I think we're well tapped into this with return to play for ACL reconstructions and things like that. For upper extremity shoulder and return to play, I think we have for our parameters, unfortunately, even at a major institution, are pretty archaic in the sense that they've gone through their physical therapy, they're at least six to eight months out, they don't feel any anterior apprehension. And if they've had a bony procedure, they've had some imaging that confirms some significant healing. I'm not sure that that's good enough.
We don't do any type of muscle testing or anything like that. And I'm not sure whether in the shoulder that's going to play as major a role as we know as it does in the knee. Probably makes sense that it does. And I think this is certainly an area that's ripe for more research into it that there are other factors other than the healing of the tissue, i.e. ACL when it heals. That's not the only factor. We know that muscular control and achieving a certain muscular strength compared to the contralateral extremity is important. So unfortunately, Brian, we don't have as sophisticated a testing scheme other than what I just described to get patients back after upper extremity surgery. I don't know. Do you have anything at Duke that you're doing that adds a little to this?
Brian Lau: Yeah, we are. We're building a battery that we have that we're looking at strength, we're looking at endurance, fatigability, we're looking at performance testing on force plates, looking at the rate of firing their muscles as well as the total amount of strength. We're still kind of in the first eight months of getting the pilot data on that. And on top of that, we're also looking at psychological factors, so shoulder instability, return support at OARSI, and as well as we'll see scores and everything that comes with that battery. And so data to come, I was going to ask Eoghan too because I know he's done a systematic review recently on return to play return shoulder instability and your take from that systematic review adding into itself from the consensus here, what do you find are things that we should be incorporating and considering?
Eoghan Hurley: I mean, I think mainly patient factors. I think the big thing is moving beyond just time-based points of return and saying that an athlete can go back at four months and this is when they're cleared. I think it really is individual, it's looking at how they do compared to that contralateral side. And there really isn't that same level of evidence that we have in the ACL, which has really been well borne out. But I mean, the good thing about studying shoulder instability is, you can just take an ACL concept and try and look at it because an unstable joint seems to have similar concepts. And I think that's kind of the next area and what we're looking at in Duke.
But I really think the big thing is just saying beyond time-based return, what patient factors. There is a big difference between someone who has a soft tissue procedure, a bony procedure, how long they need to be immobilized and getting their strength back. And I think making sure they're confident enough to go back. Because I mean, again, we know from the ACL that if they're more apprehensive they might stop suddenly or even kind of just second guess themselves before doing actions. And people with lower OARSI scores in the knee have higher failure rates. And I think that there may be something there, but it's something we really need to look at more closely.
Brian Lau: Yeah, I agree. There's a lot to be taken over and we know that with the knee and as well as some early studies with the shoulder, the Pittsburgh group, that just the fact of doing testing decreases the rate, just having some objectives to look at. So definitely an area to grow and I think there'll be more to come with that. But I wanted to thank both Dr. Jazrawi and Dr. Hurley for their time for this series of podcasts and sharing your experience with this consensus and your thoughts on shoulder instability and hitting basically the full gamut of history, physical, imaging, arthroscopic procedures, bony procedures and all that and return to play. I appreciate you guys taking the time, and thanks to the audience. These articles can be found in Arthroscopy Journal online at www.arthroscopyjournal.org. Thanks for joining us and thanks again, Dr. Jazrari and Dr. Hurley, for your time.
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