Chris: Welcome to the Arthroscopy Associations Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. I'm Dr Chris Tucker from the Walter Reed national military medical center and founder of the podcast. Tonight's episode we're shaking things up a little and deviating from our typical format to bring you the first annual year and recap episode. I'm joined by all three of my cohosts for what should be a fun and informative discussion of the five award-winning papers from 2019. First of all, however, I wanted to briefly acknowledge the significant efforts and contributions of everyone who has supported our podcast from the initial conception of the idea two years ago. Thank you to the entire team of the Arthroscopy Journal on which our podcast is based, but especially our editor in chief Jim Lubowitz for his support and willingness to let us run with this idea and Deborah Vannoy who does way more logistical and transcription coordination than I want to know about, keeping us up and running.
Chris: Also thank you to the Arthroscopy Association of North America, our parent society and its leadership, social media team and members as well as our publisher Elsevier. This will be episode 51 for the podcast and I have to say I'm very proud of what we're doing and I hope you're enjoying listening to it. We hope to continue to expand our reach and improve our content and everyone should expect to see even more exciting ventures in 2020. Without further ado, I want to welcome our three other hosts and we're now world famous radio voices to the discussion and take a moment to say thank you to them for their many hours of work invested in this project. We have with us Dr Rob Hartzler from the San Antonio orthopedic group, a former Burkhart fellow and shoulder specialist, Dr. Clay Nelly, also from the San Antonio orthopedic group who takes a special interest in knee and cartilage surgery and Dr Andrew Sheean from the San Antonio military medical center, an active duty air force surgeon who's also very involved in resident education and works at a level one trauma center.
Chris: Guys genuinely thank you for your hard work and your partnership. Let's jump right in. This year's arthroscopy journal award for clinical research excellence is, The Presence of the Arthroscopic, "Floating Meniscus" Sign as an Indicator for Surgical Intervention in Patients with Combined Anterior Cruciate Ligament in grade II Medial Collateral Ligament Injury. By Luis, Funchal, Diego, Astur, Rafael Ortiz and Moises Cohen, Aaron Black in an accompanying editorial commentary wrote, "It is a great step forward for our knowledge to begin to infer medial stability from the status of the medial meniscus in these complex cases. In my practice this manifests at understanding that a floating meniscus indicates deep MCL injury." Clay, what do you like about this article? What are you taking away from it for your own practice?
Clay: Yeah, I think it was a well done study and a well done article. I think first and foremost just for people that maybe aren't familiar or remember what the term floating meniscus means. So the floating meniscus is, it's just as you alluded to, if there's a deep MCL or even more specifically a meniscal tibial ligament injury along with an MCL injury and with a concurrent ACL tear, the floating meniscal sign is when you float a small valgus stress on the knee and you're looking at that medial meniscus arthroscopically. And that meniscus literally just looks like it's kind of floating in between the condos and doesn't have any superior or inferior attachments. And in many cases even is a little bit redundant or in deletes onto itself just because there's no meniscal tibial attachments or no deep MCL attachments.
Clay: And so that's something I think anybody that's done a knee arthroscopy with an MCL tear has seen when that medial compartment opens up way more than it usually does. And you can see the entire posterior horn, the entire posterior root because that medial compartment opens up so wide.
Clay: So that's what the definition of floating meniscus sign is. And I think it was a well done study. So they had, 112 patients with concurrent ACL tears and grade II MCL tears that didn't have that positive floating meniscus sign upon diagnostic arthroscopy. And they did autographed ACL reconstruction and autographed MCL reconstruction in one group, which was 50, I think it was 58 patients. And then they did just isolated ACL reconstruction and did nonsurgical management in another group which was 54 almost the same amount of patients. And their results showed higher outcome scores as based on taking her outcome and La Shawn scores with the surgical management of both ACL and meniscus and, and also statistically significant lower rate of the ACL reconstruction with the patients that had both ACL and meniscus. And so, I think it changes maybe some of our dynamic with the way that we treat some of these medial sided injuries.
Clay: I think historically if patients had a grade I or grade II even, or even kind of borderline grade II-ish, grade III if you want to call it that, MCL injury with a concurrent ACL injury, historically the thinking would be you delay your ACL surgery, you let your MCL heal for a few weeks and then you come back hopefully after the MCL is "tightened up." And then you just do an isolated ACL reconstruction or anything else that might be necessary intra-articularly.
Clay: And so, but this study shows that may be is not the best idea. Maybe you should go ahead and do the ACL but also do something on the medial side, and in this case a reconstruction. And so I think that may be changing some of our way that we treated medial instability in the past. And certainly this is a level one randomized control trial that was a well done study. And so I think it was very well done. It was a great study to kind of look at a problem that we see frequently, would maybe change the dynamic or change the way that we treat it on a regular basis.
Chris: I think that's a fantastic summary. It's clear why this was the award winner in clinical research, which is a fairly competitive category every year. And if you look through the list of the finalists for this category, they were all great papers and I think they all contributed something significant. This was improved my understanding of the medial side of the knee for sure. Anybody else have any other thoughts on this paper?
Clay: Oh I thought, I think it's interesting because that floating meniscus is something that, like I said before, I think we've all seen and we all say, "Oh yeah, obviously they've got an MCL injury here, but maybe after we do the ACL reconstruction it'll tighten up and that medial compartment won't widen as much." And that maybe happens to some degree certainly. But I think this study was something that kind of said, okay, maybe it's more than just doing the ACL and that if there's a meniscal tibial injury a deep MCL injury and truly a higher grade MCL injury that you should go ahead and formally address that medial instability as well as some sort of a concurrent procedure. Whether that be a full blown reconstruction or something similar.
Chris: Sure, I think it furthers our understanding of evidence based medicine. It takes out a little bit of the Kentucky windage for these kinds of injury treatments. Moving along to the resident fellow research. Excellent award winner. The 2019 winner was the paper titled, Predicting Severe Cartilage Damage in the Hip: A Model Using Patient Specific Data from 2,396 Hip Arthroscopies. By doctors Utsunomiya, Briggs, Dornan, Bolia, Locks and Philippon. Ryan Degen editorial board member noted in his commentary that using a large registry to create a predictive nomogram could allow more accurate identification of patients with advanced cartilage damage at the time of hip arthroscopy than using MRI. The nomogram establishes negative prognostic factors that may lead to inferior surgical outcomes. Andy, I asked you to take a look at the paper and talk to us about it. What are your thoughts?
Andy: Yeah, thanks Chris. So I think that, first of all, anytime that we can draw on the experience of a single senior surgeon like Dr Philippon and I think we should be paying close attention to what it is that he's been able to observe over the years. And these were essentially almost 2,400 hip arthroscopy that he did over a 10 year period. And I was struck by a couple of things. One, 41% of all hips that were scoped had severe cartilage damage in nerves ta glum, and 11% had severe cartilage damage in the femoral head. The 41% proportion I thought was particularly striking. I was not surprised by the fact that the older the patients were, the more likely they were to have significant cartilage lesions outer bridge grade III and four legions.
Andy: And I think overall the interesting thing about this paper and the utility of this paper is underscored by the limited diagnostic strengths of MR, and I think that that's something that hip arthroscopist continued to lament is the fact that the MR does not really tell you the whole story until you get in there. And so from the standpoint of using this information and using this nuanced statistical analysis, I think this paper really gives us a lot of powerful information in terms of being able to counsel patients preoperatively and to develop appropriate surgical tactic such that if and when you do encounter these lesions you're expecting it.
Andy: You've already talked to the patient, manage their expectations and you've got a good plan about how to deal with it. The other thing that I think is worth mentioning too is something that our hip preservation specialist continue to belabor, which is that the contribution of hip dysplasia based upon the lower center of jangle and the tone of singles are harbingers for more advanced disease as well.
Chris: Yeah. I think it was another clear, clear winner for the resident category. Anybody else who does hip scopes have anything to say about that one?
Clay: Yeah, I just think that it just kind of goes to the points of the fact that, certainly I think recently in the last few years our indications for hip arthroscopy have certainly expanded as people become more facile with hip arthroscopy and that sort of thing. And so I think people probably have maybe started to push the envelope some in terms of, doing hip scope on patients that are older. Certainly there's been some studies that show the patients that are even over the age of 40 and even a couple of studies that in age 50 that hip scopes patients can still do well in the appropriate setting and with the appropriate indications. And certainly I think this study showed that older age is a risk for worst cartilage damage, which everybody knows is kind of a standard thing.
Clay: And so certainly when you expand those indications and are kind of pushing the envelope into older age patients or patients with some of those other factors that were mentioned in the paper, you're going to find more aging or more cartilage damage. And so I don't think any of that was surprising, but certainly being able to look at a busy arthroscopy, and like Andy said, 2,400 hip scopes for a single surgeon is pretty impressive. And so being able to look at what factors predispose potentially a patient to having more evidence of cartilage damages is helpful to certainly every other surgeon that's nearly as probably not nearly that busy of a hip arthroscopist. When they do get that one patient that's kind of on the edge or kind of on the borderline of the indications for hip arthroscopy and being able to counsel them appropriately accordingly based on those factors.
Chris: Let's get Rob involved and talk about the systematic review, meta-analysis research. Excellent award, inaugural winner of this award is the article, The Therapeutic Benefits of Saline Solution Injection for Lateral Epicondylitis: A Meta-analysis of Randomized Controlled Trials Comparing Saline Injections With Nonsurgical Injection Therapies. By Burke Gao, Shashank Dwivedi, Steven DeFroda, Steven Bokshan, Lauren Ready, Brian Cole and Brett Owens. Lateral epicondylitis represents an under investigated condition relative to its clinical occurrence. Inclusion of the control group with the sham intervention was particularly persuasive because the effect of the injection independent of the therapeutic agent isn't always considered. And this paper concluded, no statistically significant difference in patient reported outcome measures was found between the salient solution or non saline solution injections. So Rob, you do a lot of upper extremity surgery almost exclusively. What are your thoughts?
Rob: It's a provocative study because what the authors did was they looked at what is the clinical effect of saline, which in a number of studies is used as the control. And so if you think about that, if the control has a clinical effect, what's going on there and how big is that? And is it statistically significant, is it clinically meaningful? And looking at these 10 studies, the authors found that it virtually all time points a salient solution does have a clinically meaningful improvement in pain scores and gash scores for patients with tennis elbow. So essentially what this study does is it quantifies the placebo effect for a saline injection for tennis elbow. This has been looked at in the knee for what is the effect of a saline injection for osteoarthritis. And I think that there's some thought that that might have a biological way of being clinically efficacious.
Rob: I have a hard time understanding how that could be true for tennis elbow. For saline I think this is likely the placebo effect. And it's just interesting to think about that and to sort of ponder how much of what we do and a lot of things is the placebo effect. And if we knew that, would it change our behavior in clinic? And so I thought it was a really interesting article. It one, in this meta analysis category, the statistics were really good in the paper, very sound. But I think it's even more interesting from sort of an ethical and philosophical standpoint as we ponder what is the placebo effect for different things that we do in medicine.
Chris: Here's a question for all of you guys, for how do you guys treat epicondylitis and if you give injections, what injections do you give and how many?
Rob: So I mean for me the vast majority of my treatment is counseling and I do, I think the usual things with counterforce bracing and physical therapy and a bit of injections. But typically it's a lot of explaining the natural history and reassuring patients that they can do their activities and exercise and things like that. When I do injections, I've tried to go away from corticosteroid injections just because they haven't seem to be clinically beneficial versus saline and there is some concern for deleterious effects on the tendon. So I've gone, if patients have really failed physical therapy and other non procedural interventions, I've gone more for PRP. This last year, I think there's some evidence that can be efficacious for patients and I think probably better for their tissues and corticosteroid. But it sort of makes you wonder whether maybe we should just give them saline injections. It would be cheap and safe and do as well as it's something that it's expensive. Other thoughts?
Chris: I recently read something where they described lateral epicondylitis as actually a misnomer and I kind of buy into that where it's not really inflammation of the epicondyle. It's lateral elbow pain with proximal extensor tendinitis. And so I mean I think that kind of conceptually helps me understand how I want to treat it, which is very similar to what Rob just described. I think I take the lead from some of my hand surgery partners who basically utilize the occupational therapists until the patients either stop coming back or come back begging for something else. And I'll utilize biologics like PRP. I never do steroid injections. I haven't ventured into the saline or pelotherapy realm myself, so I'm a fairly straightforward brace and occupational therapy and activity modification and non-open to death. I haven't done a surgery on this in probably 10 years.
Clay: Yeah. I think your point about the misnomer is a good one. In many cases it is chronic and anybody that has done the surgery and has looked at that kind of abnormal tendon and that area knows that it really should be more of a call... If it's going to be called anything. It would be a tendinosis, not a tendonitis as you alluded to Chris, because it is really more of a chronic state and chronic changes of the tendon with fibrosis and that sort of thing. Does anybody have anyone in their practice or does anyone recommend ever the Tenex procedure?
Chris: At Walter Reed we have a clinic that does the Tenex. It's the sports medicine primary care clinic. To be honest, I haven't had much communication with them about the results because it's a fairly new procedure that they're starting to do and I haven't sent anybody to them specifically for it. But I know it is something available to the beneficiaries in our area.
Rob: It's kind of weird to think about the placebo effect, because I mean if you think about what we do as doctors, a lot of patient improvement in their conditions has to do with their expectations and the ritual of laying on of hands and visiting with them in the office and counseling them. And I don't know, it's just one of those things that it's like you start to think about it too much. You almost don't want to, how much of what we do as surgeons. I mean we always think as surgeons that we're going in there and 'fixing something' and, are we?
Chris: I think it's conceptually a provocative paper and I enjoyed it for that reason.
Chris: Okay, three of five down. Let's move on to the next one. The basic science research excellence award winner was an article titled, Objectively Assessing Intraoperative Arthroscopic Skills Performance and the Transfer of Simulation Training in Knee Arthroscopy: A Randomized Controlled Trial. By Patrick Roberts, Abtin, Alvard, Marco Gallieri, Caroline Hargrove and Jonathan Rees. In a commentary, Michael Feldman, associate editor and former AANA Snyder teaching award recipient, poetically highlighted Garfield Robert's finding that both speed and economy of motion distinguish a Maestro arthroscopy list from a novice, but you're more on the Maestro end of the spectrum than novice. What were your thoughts on this article
Clay: I don't know about Maestro but yeah, I think it was an interesting article. I mean there's been a number of kind of a simulation articles that have been published to varying degrees that showed different things. I think it was interesting the way they set it up where in a wireless elbow, motion sensors was the way they set up this study and they use second and third year residents. So kind of mid-level residents, not necessarily right at the beginning or right at the end when you would hope that there'd be a little bit more experience arthroscopy. So I think it was a good group that they utilized to see if there was an improvement in their ability levels or in their efficiency of the use of the arthroscope with the knee arthroscopy. And so they were randomized to two groups, either the group that got some simulation training and then did a knee arthroscopy or just the control group, which was, they just went through their standard residency education training and that sort of thing.
Clay: And so it was interesting that they found that the group that did the simulation training was more efficient in the OR with less frequent hand movements, more smoothness and less time taken to perform the partial meniscectomy or the simple knee arthroscopy at the end of the study.
Clay: Another interesting finding that I found was that they also compared them to the supervisor. The attending surgeon that was supervising each of them. And the people that the residents that went through the simulation study did better than the control group. The residents that didn't, but they also still performed less well and were less efficient than the supervisor, which you would expect. But I think that just basically points to the fact that, I think with things that we do in most things, experience trumps a lot of things, particularly when it comes to efficiency or things such as efficiency of using the arthroscope.
Clay: I think experience is big and whether you can get that experience hands on, in the actual operating room frequently that's great and probably ideal. But if you can supplement it maybe with the simulation training to get some degree of experience and that may be helpful in an education program too, but at the end of the day nothing trumps experience. And certainly those that have done 10,000 arthroscopes are probably going to be a little bit more efficient and have a lot less hand movements than somebody who's done 100 arthroscopes. And so I think that's kind of the overreaching cinnamon. Not only of the article but just in training programs in general. But I would definitely be interested to hear Andy's take on it as he works with residents on a daily basis of all different levels and teaching in that regard.
Andy: And before I answer your question, I'm curious to, nope, talk to you guys about this as it pertains to the methods of this paper, and what else has been written on simulations. I mean the way that they went about characterizing or I guess quantifying efficiency and smooth, are these things that have been written about before? Do you guys know or is this, are these novel metrics that have been unveiled here in this paper?
Clay: It's a little bit novel and that they use the motion analysis technology. I haven't seen that done, at least in an orthopedic simulation training. Most of the simulation training papers, they'll make them do a task, right? And they make them do some sort of a task where they have to put something on something arthroscopically and they test how long it takes them to do it. And then they go through a simulation training program for how many weeks. And then they make them do the exact same task again and they see if they can do it faster or they see if they can put more blocks on top of each other. Then they in a certain set period of time than they could the first time they did it.
Clay: And so that's usually the way that people, it's an actual kind of task oriented training. Whereas this one was more, they use the motion analytics. So I think that was novel at least that I've seen within the orthopedic literature. Now, whether or not you think that that is a viable test of proficiency, I think you know that you could argue or you could discuss that because what's one man's or woman's hand movements compared to another's? Maybe someone's takes a few less, than someone takes a few more, but they're equally as efficient.
Andy: Getting back to your question, we've actually integrated simulator training on a routine basis into the syllabus when the residents rotate in the sports medicine and arthroscopy rotation. And I think it's this far it's been an indispensable part of especially junior resident training. The haptic component of it. But I think that it's reflected in their confidence in the operating room and I think that they'd get more, there's more educational yield. It comes out of each case, the more time they're spending on the simulators. So I think in many ways, this is, the results of this study are not surprising to me at all. And I think it should be in many ways a Clarion call for us that teach arthroscopy to continue to think of creative ways or to get more aggressive or lean farther forward in terms of integrating these types of technologies into curriculum for our residents.
Rob: Yeah, it makes total sense that we would do this. I mean, there's a cost obviously to it and time and resources, but I think that if it improves the trainees and even if you take it once a step further out to surgeons in practice are going to be faced in their career with learning new operations and techniques and if you can mitigate the learning curve for those to some extent, then you're obviously helping patients. So I look forward to seeing some of this stuff being tested and practicing surgeons too.
Andy: I think one of the greatest benefits of simulators and simulation training and even, as we go in the forward, in the future, probably virtual reality or virtual surgery or whatever you envision in the future is that those things can all be done on the resident or the trainees time potentially. So if they may be on a later lighter rotation or something like that, then potentially they can get in the simulator or whatever it may be and practice and do those things as opposed to just otherwise their training being subject to how busy the attending surgeon that they're working with happens to be on that month or that rotation, dictating how much experience they get in the actual operating room. There's no substitute, no question for actual operative experience in the operating room doing those things, but if they don't have a busy rotation or whatever else and they can get in the simulator on their own time and still be active doing those things, I think there's bound to be a benefit to that.
Chris: To piggyback on a couple of you guys' comments, Rob, you brought up the issue of cost of stimulation. I think there's been a lot of studies out there and a lot of work published about the actual cost benefit of doing simulation training. Not only from a financial standpoint where the cost of training residences, fairly expensive, but the cost of training them with repetitions of a manual task on a simulator is cheaper than doing it on a live patient in the operating room based when you factor in the time of increased surgical time, cost of our time and all those other factors. So I think that's interesting. I think, I mean I love simulation training as a concept and as it's being worked into residency programs and I remember when I was a resident having the plastic shoulder model with a saw bones and now the stuff that I'm seeing in our program with live cadaver surgeries and senior residents monitoring junior residents taking them through fracture fixation on actual tissue and virtual reality computer simulators.
Chris: It's all pretty inspiring. I think in medicine we're lagging behind other industries, especially like the aviation industry. If you look at simulation training and looking at the cost benefit of doing that versus live flying time. I think the parallel is pretty obvious for medicine, especially surgery.
Chris: Clay, your comment about experience I think is extremely spot on. I don't think there's anything that can replace experience when it comes to certain surgical skills. But I mean I think there's a lot to be learned from simulation training to make the most of that experience, especially as a resident. Like you guys said, there's always limited numbers of cases, limited time in the day if you're trying to get to the OR, the more you can prepare for that single case, you can squeeze the most out of it. But the flip side of that is I think there's been some published sealing effect of simulation training, and the most effect is on the least experienced individuals.
Chris: Though you can certainly make the most improvement when you know the least especially on these virtual reality trainers. But eventually there's a ceiling effect to how much better you can get practicing on a trainer versus practicing in the real world. So I think those are all really interesting topics. And I enjoy seeing more published on the topic. Whenever I read an article like this, it always reminds me of probably one of my favorite sayings when it comes to surgery, which I'm sure everybody's heard it before, but when people describe surgery, they say slow is smooth and smooth is fast. And so I think becoming efficient should be at the top of every residence kind of list, not becoming fast, because if you try to become fast and you rush, you're actually slow. But if you try to be smooth, then you'll become faster, so.
Chris: All right. So the final article of the night, we're going to talk about, which is additionally two new categories that came out this year, the most downloaded article and the most cited article. And this year, the Arthroscopy Journal evaluated articles published five years ago to allow for a true gauge of their citations. So this year, 2019, it was articles published in the year 2014, not surprisingly, the most downloaded article from 2014 was the work of Giovanni Di Giacomo, Eiji Itoi and Stephen Burkhart titled, “Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion: From Engaging/Non Engaging Lesion to "OnTrack/Offtrack" Lesion.” Since its publication, the concepts developed inn this acclaimed article have revolutionized both the academic discussion and the surgical treatment of shoulder instability. Not surprisingly, the most downloaded article was also the most cited article. Blown on humeral bone loss in patients with an unstable shoulder seems to be both a hot topic and supremely impactful. Rob, you were a Burkhart fellow, you're a practice partner of his along with Clay. I would love to hear your thoughts on this topic.
Rob: Yeah, so this article was published in 2014, the year that I was a fellow with Dr Burkhart and it's not surprising that it won in these categories. It is very useful article. It's very practical. It's also based on a lot of, very sound scientific principles and good basic science and clinical research. It's been substantiated, in subsequent studies, both biomechanical and clinical to be very solid. And I think it's one of those articles that's going to be considered a landmark article as we go forward in the future. It might be in the future that we don't quite follow exactly. The paradigm that's set forth in the article for treating bone long shoulder instability. So what this article did was it gave us the ability to quantify bone loss and by doing some simple arithmetic, predict whether a Hill-Sachs lesion is going to be an engaging lesion and therefore need to be treated.
Rob: And in this article it's proposed that that method, Hill-Sachs remplissage. So I think that it's an interesting topic because it does get into a little bit of complexity, if you use this, if you use the proposed paradigm that's in the article, you have to do some arthroscopic, or you can do the measurements radiographically, but Dr Burkhart always relied on his arthroscopic measurements as the gold standard. So you have to take some measurements and do a little bit of math. And some people are intimidated by doing that math, but it gives you at least something to sort of hang your hat on, making these treatment decisions, particularly when to perform remplissage because that does add some time and complexity to shoulder instability cases. So it's nice to at least know somewhat where we stand or you might test for instability and then would engage without doing any repairs. But if you did the Bankart repair then, would the lesion still engage? You don't really want to be testing that routinely in surgery.
Chris: So one of my questions for you, Rob, is from a practical standpoint, when Burkhart's seeing patients in the clinic, is he making these calculations every patient? Is it more of a subjective judgment call? I mean obviously it's a very scientific paper and conceptually it helps us all think about the concept, where the rubber meets the road. What are you guys doing at the clinic, evaluating these patients? Is it strictly algorithmic or is there more of a starting point?
Rob: So great question. There is the math done both radiographically and inter operatively based on arthroscopic measurements for every patient. Dr Burkhart did that up through his retirement from practicing and surgery and I continued to do that same method. In reality, we've documented how much you varied from the paradigm in another article that was published in the Arthroscopy Journal where we compared the arthroscopic and CT measurements and it was surprisingly high. It was almost half the time he would vary from the paradigm because it was either a borderline case or there was some clinical factor that came in that you would say, well it's an on track lesion, but it's really close and it's a contact athlete so we're going to go ahead and do the remplissage anyway.
Rob: So that was actually a lot. And I think that that speaks to your point that you can have these rules of thumb, you can have treatment algorithms, but it probably should not eliminate clinical judgment and clinical decision making in these situations, which are complex. And they have more factors than just how big are the bone lesions?
Andy: I mean, Rob, I don't know if it's just because I've been listen to too many talks by Paul Brady or John Kelly, but am I wrong for doing routinely, now doing remplissage and in my military patients with 10% anterior inferior bone loss and in a small Hill-Sachs lesion, I may, I think if I went back and scrutinized what I was doing, I think I may be today doing more remplissage on track lesions certainly than in this paper would compel us to think about, I mean, am I wrong?
Rob: Yeah, it's complicated question because you might say, why not just go the French way and just do Latarjet because that then you really won't have any recurrent instability. So I think there is a point to be made for not over-treating patients because there's a cost for doing remplissage. I think that it's more painful and typically at least we rehab them a little bit differently. You're using more implants and so even though it's not significant, patients think a little bit stiffer and might lose emotion. So you do have to be careful about... Be careful and make sure that you're not over-treating patients.
Rob: But I think that for borderline cases probably the trend is to do more in surgery. And I think adding remplissage is one of those things to do more to try to prevent recurrent instability because it's probably a lot higher than we would all like to think for arthroscopic treatment. Chris, what about you? What are you doing? Are you doing the math? I mean, we're measuring and doing multiplication on a card and in surgery.
Chris: Yeah, I mean to be honest, I do do the math. I enjoy the academic exercise. I don't hamstring or tie myself to the results and automatically decide what's going to drive my final surgical plan. But I do go through the exercise. I think being at an academic institution with residents, and exercise that helps explain the concept of shoulder instability to them. But it also reinforces my decision making. And I do it with my partners as well, who, we see clinic together and often on the same day in the same work room. And so we work through complicated cases and we do the math, we calculate the bipolar bone loss and also take into consideration the location and the width of the Hill-Sachs because we've seen a fair number of fairly dramatic, large, broad Hill-Sachs that extend all the way from the cuff insertion to the articular surface.
Chris: And they're really broad and some of them are shallow and some of them are huge shark bites. And I think, though some of them are obvious and then some of them are subtle. And when you do the combined bone loss, we don't routinely get 3D CTs, but I know reading preventers, most recent study on, comparing MRI studies of calculating bone loss that Red Owens was doing at West point and now looking at 3D CTs and getting better estimation of bone loss. We're not doing CTs on everybody. We're still calculating off of either 2D CTs or MRI. But I think going through the exercise just helps us teach the concept to residents, reinforce it for ourselves, come up with a surgical plan that at least has several options, but we're kind of thinking about which direction we're probably going and helps us get ready for the big cases that we may need to order a graft for and such like that for surgical planning. So yeah, I mean I am scientific about it. Clay, how about you, you're practice partners with Rob and Burkhart for a while. What are you doing in your practice? Anything different?
Clay: Yeah, I certainly, I take my credence from them. I do the math as well. It's been interesting, just anecdotally, I've found kind of similar findings to those guys and that sometimes the preoperative measurements don't always exactly match up with the arthroscopic findings. And so I think it's important to kind of do a full evaluation as we always should do anyway. But I've found that, they've done more remplissage and even those borderline lesions that may be are mathematically preoperatively kind of on track and borderline, I still have kind of a low index of suspicion or a low threshold for, I'm still doing something, particularly if we get in there arthroscopically. And it seems to be pretty close mathematically and just visually.
Clay: And so, yeah, I think this is obviously a landmark paper too, and all the followup papers after it had been equally substantial and confirmatory. And so I think it's something that's really helpful. Bipolar bone loss is a difficult thing and continues to be a difficult thing for everyone that treat shoulder instability. So anything we can do to be scientific with that and help us with our evaluation, I think just helps us and helps our patients longterm.
Chris: All right, Rob, Clay, Andy, thanks again for joining me. This has been a fantastic episode to round out a really great first year for the podcast. All of the articles discussed can be found in the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org. This concludes this edition of the Arthroscopy Journal Podcast. Thank you for listening. Please join us again next time.