O raspador Bankart facilita o debridamento artroscópico da borda do glenoide em espaços articulares menores quando inserido através de um portal artroscópico. O raspador Bankart tem uma pequena ponta em ângulo de 90° e superfície de 4,65 mm x 7 mm e é adequado para preparar a borda do glenoide no quadrante ântero-superior.

Shoulder

Patrick J. Denard, MD (Medford, OR), discusses his experience performing combined Bankart repair with remplissage for instability with bipolar bone loss using Knotless FiberTak® soft anchors.

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Tensionable Knotless Bankart and Remplissage Using Knotless FiberTak® Soft Anchors

Hi, I'm Patrick Denard from Medford, Oregon. And I'm going to share with you a case of Remplissage using Knotless FiberTak anchors. So in recent years, we've really grown our understanding of bipolar bone loss and particularly of the glenoid track. And as we've understood this concept, we've adapted our technique to incorporate Remplissage into many of our soft tissue label repairs. A recent systematic review out of Russia looked at this in 2019. Out of JSM 778 patients, and what they demonstrated is that the recurrence rate was actually much higher with an isolated bankart repair compared to latter or even the lowest recurrence rate was with a Remplissage, where it was 4.4%, so nearly half of that with latter J. So we've had a lot of success with Remplissage, and we've used this technique for several years, but our technique has changed over time. Originally we would do a knotted technique where we placed two suture anchors in the Hill-Sachs defect posteriorly, but then had to go into the subacromial space and tie knots. That took increased time compared to what we do now. Currently, we use a knotless technique where we use two knotless 1.8 or 2.6 millimeter FiberTak anchors. And I'll show you a technique subsequently where we can do this percutaneously without having to go into the subacromial space. This leads to increased time savings, and it's backed up biomechanically with studies that show increased pullout compared to techniques where we tie knots. So here's a case example of a young man right hand dominant. He's had a left shoulder dislocation after sliding into second base. And this is his third dislocation after the first one occurred two years previous. He's otherwise healthy, but based on his age and activity level, he's at high risk for recurrence on his exam. He has normal motion, he has good strength, but he has instability on exam, as evidenced by his positive apprehension maneuver and positive relocation maneuver. Here are his radiographs. You see an AP radiograph. Here we can look at the glenoid and see that he has minimal bone loss. If we look at the axillary view you see that he has a large Hill-Sachs lesion Posteriorly. We're going to gain a better appreciation of this with this MRI. Again, we scroll up and down this axial MRI and we can see his Hill-Sachs lesion. So we're going to proceed with an arthroscopic repair. And I'm going to show you how we use these knotless FiberTak anchors to accomplish that. So here's this diagnostic arthroscopy. We have a left shoulder viewing from a posterior viewing portal. You can see his bankart tear anteriorly. And as we pull posteriorly we can see his large Hill-Sachs lesion. I'm going to move to an ASL portal and I'm first going to calculate his glenoid width. I estimate that his glenoid width is about 12mm posteriorly. So our projected width overall should be about 24mm. And on my estimation here he has about three millimeters of bone loss anteriorly. I'm now going to take that and calculate his Hill-Sachs interval. And we can see here we're estimating it. It's difficult to estimate in some cases. But we're going to estimate this at about 15 18mm. So we have a borderline lesion. But based on his age and activity level, I think this is going to be best to do a Remplissage in this case because he's at high risk of recurrence. So I placed a Gemini cannula posteriorly. I like this cannula posteriorly, because I can usually pull the soft tissue posteriorly and really create a space. I'm first going to curette the defect. I want to create a good base for healing. Next I'm going to insert my Remplissage anchors. So the first thing I'm going to do is use a spinal needle to locate where I want to place my anchors. From here I'm then going to insert a threaded cannula, and I'll swirl this cannula around to create some space in the subacromial area beneath the deltoid. But I'm not going to go all the way through the soft tissue with that cannula. Now through that cannula, I can penetrate through the capsule and the tendon percutaneously with my knotless FiberTak anchor. We want to first place our anchor inferiorly. Then through that same cannula I'm going to place my second anchor more superiorly. In doing this my sutures from both anchors are through that same cannula. We'll drill our superior anchor. Place our FiberTak anchor. This is going to set us up for our subsequent Remplissage. I'll then go to my bankart repair and I'll skip through the steps here. But you can see we have a lesion which we've prepped. I'm going to use Knotless FiberTaks to perform my repair. Here I'm going to place three anchors. These are one eight knotless FiberTak anchors. We really like these anchors because we can get nice tension of the labrum. And especially with using those knotless anchors, we can get as low as we need to get to reestablish the labral bumper. I'm going to pull the repair stitch posteriorly after I've shuttled through, and then bring the repair stitch down into the knotless mechanism, and if desired, after I place my subsequent anchors, I can go back and retention. Here you can see that labrum pulled up nicely to the glenoid rim. I'll tension a little bit more as I hold against the anchor and then cut the tail. So here's our completed bankart repair. And now I need to simply complete my Remplissage. Since I have those sutures coming out my percutaneous cannula posteriorly, I can simply link those two anchors through that cannula to create my double mattress Knotless stitch without having to go into the subacromial space. There you see that posterior capsule nicely inset into the humerus. So here he is at two years post-op. He has excellent range of motion. He has full external rotation despite the Remplissage full forward elevation and good internal rotation behind the back. Now here he is at the collegiate level, participating in boxing. You can see that Remplissage is holding up quite well on that left side. And he's been back to full activities. So I hope you enjoyed this technique. I think if you give it a try, you'll really find you'll have good success in your patients with increased efficiency for you in the operating room. Thank you.

Arthroplasty Shoulder

Elbow

Imaging and Resection

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

J. Lee Pace, MD (Farmington, CT), reviews a case in which he used remplissage and Bankart procedures to treat recurrent glenohumeral instability in a young athlete. Dr. Pace discusses using 3.9 mm Knotless Corkscrew® and 3.0 mm Knotless SutureTak® anchors to achieve an anatomically tensioned glenohumeral labral repair and remplissage to address a Hill-Sachs lesion.

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Arthroscopic Bankart and Remplissage Repairs in a Young Patient Using Tensionable Knotless Anchors

My name is Lee pace from Farmington, Connecticut. I'm here today to share a case of a combined Remplissage and arthroscopic Bankart repair using current Knotless tensioning technology. This is a 21 year old right hand dominant male with recurrent right shoulder instability. He sustained about 10 to 15 dislocations. He's a recreational basketball player and at this point he's interested in surgery. On exam, he has obviously a positive apprehension test, relocation test, etc.. Normal cuff and deltoid strength, normal range of motion. You can see on his imaging that he has a moderate Hill-Sachs lesion on the striker notch in the West Point views. His imaging shows the obvious labral tear, about 10% bone loss on the glenoid and a moderate Hill-Sachs lesion. Our clinical decision making revolved around these different surgical options arthroscopic bankart repair and isolation versus an open bankart repair, arthroscopic bankart repair plus Remplissage, as well as a latter J. After some discussion, we decided on a arthroscopic bankart repair and then intra op examination to determine if a Remplissage would be needed. In addition to that, however, before surgery and after his last clinic visit with me, he sustained another shoulder dislocation that required a reduction in the emergency room. So now the question is, is what is his shoulder going to look like when we get into the operating room? When we did our diagnostic arthroscopy, we found actually a rather large, engaging Hill-Sachs lesion. This really confirmed our decision to perform the Remplissage in addition to the arthroscopic bankart repair. And we proceeded with this using the interconnected knotless technique. So first we threw a standard posterior portal. We drilled and placed two knotless 3.9mm Corkscrew anchors as seen here. And then after that, we established a subacromial portal using a spinal needle to localize the portal placement. And this is usually going to be a little bit lateral to a standard posterior arthroscopic portal. From there, we use a penetrating device like this to bring the sutures through the tendon of the infraspinatus. At this point, we leave these sitting in the cannula and then proceed to our arthroscopic bankart repair. We use the percutaneous kit to get low 530 to 6:00 anchor placement, and we used a series of knotless three millimeter biocomposite suture techs for this arthroscopic bankart repair. You can see here as we proceed through the aggressive appropriate bumper using Knotless tensioner technology. So there's no not BB-Tak. This is a very low profile set of implants for the shoulder joint. After that, we then turn our attention to the Remplissage in this interconnected suture passage technique. So repair anchor number one. The stitch from that gets loaded up through repair anchor number two and vice versa, to create a broad surface area to compress the infraspinatus in a knotless technique against the Hill-Sachs lesion. And you can see here in this video, as we tighten those sutures up, how the infraspinatus becomes compressed up against the Hill-Sachs lesion and obliterates that space on that engaging Hill-Sachs lesion. So our post-op protocol for this patient was a sling for three weeks daily pendulum exercises. After about six weeks, we institute full range of motion and progressive strengthening. And we anticipate a return to basketball in about 4 to 6 months. So in conclusion, with current Knotless TensionLoc technology, we were able to deliver aggressive and appropriate surgical treatment for this patient in a minimally invasive fashion. Thank you.

Paul C. Brady, MD, (Knoxville, TN) presents a Bankart repair using 3.0 mm Knotless SutureTak® anchors. During the repair, Dr. Brady shares tips regarding instrument usage, suture management, and tissue tensioning.

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Labral Repair: Tips and Tricks

Hi, my name is Doctor Paul Brady. Today I'm going to show you some techniques and pearls that I utilize when I'm doing labral repair work. So first of all, I love the Gemini cannulas in my posterior portal as well as the Gemini and my anterior inferior cannula. I typically use a rigid cannula, like the 8.25mm cannula in my antero-superolateral portal. That's primarily going to be my visualization portal. I like to make this portal right over top of the roof of the biceps. You can see there. I'm going to leave the biceps for this case. I like to make my in or my anterior portal kind of coming up over top of the subscapularis. That way I can push the subscapularis down to try to get a good angle at my 6:00 or my 630 or 7:00 position on this left cadaver shoulder. So let's switch my scope to my Antero-superolateral portal and look down on the labrum. I've created a anterior inferior labral tear here, and so I'm going to show the utilization and some tips and tricks for the Knotless SutureTak anchor. So we'll insert our first anchor. We'll make sure that we can insert it appropriately through our anterior portal. I think we're going to be able to that's a little steep right there. I'll tap the edge on the glenoid, and then I'm going to lift my hand and really lever the humeral head out of the way. So I think that's a decent angle for this first anchor. We'll go ahead and drill that all the way to the hub of the drill. I'll leave my inserter. I'm holding that tension the whole time. And we'll go ahead and tap that anchor all the way down to. It's flush with the inserter. We'll pull the black tab and then just twist and pull. And there's our anchor. So with this anchor we have a blue and white repair suture. And we've got a shuttle suture which is black and white. Okay. So let's give it a little tug to make sure the anchor is well seated. Looks good. I'm going to use a SutureLasso first I'm going to use a tight lift. This is a left shoulder. I'm going to work from my anterior portal. And I'm going to use the tight left SutureLasso through my anterior portal again visualizing from my antero-superolateral portal. So let's insert that there. So here I'll pass that through the tissue. Take a bite. Shuttle my suture in. I'll just barely shuttle it in. Now I'll grab from the posterior portal. I'll grab the loop as well as the repair suture and pull that out my posterior portal. Then we'll double that over itself. Now I'm going to pull on the limb until I get it right to the device. And then I'm going to pull the pull the device along with the suture. What I want to show on the outside is that by pulling that nitinol right up to the tip of my SutureLasso, I can now just pull the nitinol back a little bit. I can unload it, and now my device is already ready for my next pass. I don't have to reload the nitinol or anything. So that that saves you a few seconds. Or your assistant a few seconds on the back table. So now we've got our repair suture passed through the tissue, and then we've got both limbs of our shuttle suture. Let's take a grasper. I'm going to now load the repair suture into the anchor splice. And the way I do that in this case is I'm going to take all three sutures, and I'm going to pull them right to my cannula opening. I'm going to open my jaws just barely. And then my assistant is going to pull on the non looped end. He's all he does is pull it out of my grasper. Now I've pulled the repair suture and the looped end of my shuttle suture out my posterior cannula. I like loading these from a separate cannula, because that assures that you're not going to have significant twists when you finish your construct. So we'll double the white end over, and we'll pull this until we get to where we feel some tension, which is typically about there. And now on the outside you'll see I'll give it a few tug tug tug tug tug tug tugs until I've loaded that repair suture down into the anchor splice. Next, I'll tension this until I get it right on the tissue. But I don't want to over tension because I don't want to cut myself off from the remaining repair work that I'm going to have to do. So I'm going to park the repair suture. I'm going to park it in my posterior portal. And let me show you a little trick with the Gemini. So I want to be able to work in that cannula without having to worry about twisting that suture in my grasper the next time I reach in there. So I'm going to park that suture instead of inside the crystal cannula. I'm going to park it Park it between the crystal cannula and the outer blue cannula. And to do that on the outside, I just pull the crystal cannula out and put it right back in. And you can see now that suture is parked on the outside of the crystal cannula, and we can still work in that crystal cannula. Okay. We're going to place our second anchor about a centimeter above our first. Again I'll lever the humeral head a little bit. I don't have to leave her at quite as much. Tap it on the bone. We'll insert the anchor right through the inserter all the way down to the inserter. Pull the black tab. Give it a little wiggle and a pull. You don't have to unload the sutures. Just wiggle and pull. So another thing about the Gemini is I can use those those two flanges to retract tissue. If you if you notice on the outside I'm just on the outside, if you notice, I can pull back a little bit. Pull back in that retracts the tissue. It allows me to better visualization. So another benefit of this Gemini cannula is that it can you can use it as a, as a mild Eyelid retractor. So that really opens up the space there for me to work. So let's just take another bite. You see, I haven't tightened that first one, which allows me to really manipulate this tissue a little bit. Better get underneath it without as much difficulty as I would if it was super tight. And then we'll just barely pass that shuttle suture in again. I'll grab from my post here, and then I'll grab my repair suture. Pull that right there. Load the repair suture into the nitinol loop. And then I'll pull back on the nitinol loop until it's right at the tip. And then I'll pull that back and pull my repair suture through the tissue. Okay, once we've doubled over the limb on the outside, we'll load it in until we meet some friction, which is typically right about there, right when you start to see that loop. Once I get friction, I take a good grasp of this on the on the outside and I give it a few tugs, and that loads the repair suture through the splice of the anchor. And let's do one last anchor about a centimeter above our last anchor. So again, we'll tap it down onto the bone. Perfect. Now we'll drill it. And I haven't moved my hand. As long as you keep your hand still, you'll have the same trajectory for your anchor insertion. Then we'll pull the tab and twist and pull the inserter. I'll give it a few tugs. Make sure we're in good bone. And then let's go ahead and pass those shuttle, those sutures the same way. We'll take one last bite here. Come on. Take our looped limb and our repair suture. Load the repair suture into the nitinol loop, and then we'll pull that right to the tip, and then we'll Another way, if you don't want to use the posterior portal to shuttle the repair suture back into the anchor, you can go straight from your anchor insertion site into the looped end of the shuttle suture. We'll pull on it, give it a few tugs. Now, the only thing about this is you want to make sure this has more potential to have twists in it. So we want to make sure we don't have any twists in this repair construct. So we're going to go slow on our tensioning. So now we've got all three anchors in but we haven't tensioned any of them. A big benefit of this anchor is the ability to tension. At the end of the procedure, I'm going to take my repair sutures all out my anterior portal so that I can tension each one of them individually. Now, there's there's a lot of friction here between my cannula. So we're going to take out the crystal part for just a second. And then I'm going to pull those out my anterior portal. And then we'll reestablish that crystal part inside there. So we don't get too much fluid extravasation. And then first I'm just going to give each of these a little tug. So we're going to start with my inferior one. And I'm going to give that a little tug tug tug. But I'm not going to tension it too hard until I place a tension or cutter device on it. It really allows you to securely get tension and hold on to the anchor while you're tensioning, to assure that you're not going to pull that anchor out. So here's an outside view of the tensioner cutter. It's a cannula within a sleeve. And then it's got this plunger which allows you to cut the suture. So we're going to hold on to the T handle during the tensioning t handle for tensioning. And we're going to press the plunger when we're ready to cut the suture. So we'll take the most inferior repair suture and I'll load it into the tensioner cutter. And then I'll slide the tensioner cutter down. Now if you look at the tensioner cutter from the inside it has a beveled end to it. And then on the other side it has a cutting v. Okay. So we're going to take the beveled part toward the labrum such that the tip of this cannula is going to sit right on the edge of the anchor. And then we're going to hold the t handle but not press the plunger until we're ready. We'll hold the T handle and I'll get tensioning. And you can tension as tight as you want holding that anchor. And then when we're ready to cut it we'll press the plunger. And there we have our repair. So there we have a three anchor repair of this anterior inferior labral tear utilizing the three knotless SutureTak anchors.

James L. Chen, MD, (San Francisco, CA) presents a case of an acute glenoid fracture where he was able to restore the anatomy arthroscopically using the Glenoid Bone Loss Set and its 3.75 mm cannulated titanium screws and long, percutaneous nesting drill guides. Dr. Chen also shares some insights regarding fracture reduction.

Arthroscopic Management of a Bony Bankart Lesion

This is a presentation on arthroscopic management of a bony bankart lesion. I'm Doctor James Chan from San Francisco. So I have a case here. This is a 43 year old male computer programmer. He's right hand dominant. He had a fall down stairs, suffered a right shoulder dislocation that was reduced in the Ed. Presented to me seven days post-injury. And I obtained a CT scan. Here are the injury CT scan. You can see the axial view. There's a large bony bankart fragment approximately one third to one half of the area. You can see on the coronal view from superior to inferior, approximately one third of the glenoid is fractured. And then on the sagittal view this is a really nice view to see that this is a fragment that's approximately one third to one half of the area in the classic position in the anterior inferior quadrant of the glenoid. And the 3D reconstruction clearly shows that. So I discussed treatment options with the patient. Non-surgical versus surgical treatment was Discussed. We reviewed the imaging. I counseled him that greater than one third of the glenoid was involved. Given his age and activity level and his high risk of recurrent instability, he opted for surgical treatment. We discussed open versus an arthroscopic approach. I consented him for an arthroscopic procedure with a possible open and so positioning. This is a beach chair position. A standard arthroscopic posterior portal is made. A low anterior portal is made at the superior border of the subscapularis, and a hand to your portal is made at the high and lateral in the rotator interval to help with fracture reduction. Typically, if the fragment is one third of the glenoid or larger, I believe that screw fixation is going to be the best treatment, and I believe the standard should be two screws. If it's a real small, just sliver of bone that's taken with the labrum, then a standard soft tissue bankart labor repair is done. If it's between a sliver and a one third fragment, then usually I would do a bridging a sandwich technique with multiple anchors. So here are some are some intraoperative images. This is a diagnostic arthroscopy portion of the case. And you can see the large anterior inferior bony fragment. I have some video here of mobilizing the fracture. And I've placed a Liberator elevator in between the fracture site. And what you really want to do here is mobilize that fracture and make sure it's completely loose. If it's partially attached, you want to detach it so that you can get an anatomic reduction and really mobilize it. So you really want to get in there and and not be fearful that you're going to fracture it further and make sure there's good separation. Here are some images showing the mobilization. I'm looking down that high anterolateral portal right into the fracture site. I have a shaver there. I want to remove all clot and debris and any little comminution. So it's a totally free fragment. And then here's a fragment reduction. I've used a curved SutureLasso. I like using the SutureLasso because it has a sharp pointed end, and so you can kind of spear and pin the fracture fragment in place. And you can see here I have an anatomic sort of provisional reduction just with the SutureLasso. And here's the image of the fragment fixation. So I've placed one suture in the anterior inferior labrum to remove the. Labrum out of the way so I can visualize better. Then I have that SutureLasso in place, have it pinned. And then I put two K-wires. These portals and K-wires are placed percutaneously using needle localization, and the glenoid set or the glenoid bone loss set has a very long nesting guide that's perfect for this. So all these portals are placed percutaneously with needle localization using that long nesting guide. And here's some videos showing Cannulae drilling by hand. I have that free elevator in place. I'm using it to retract soft tissue, and then I'm gently drilling over the K-wires so as not to shift or disrupt the fracture. And then here's some video of actual screw placement. I've retracted that soft tissue with the free elevator. Then I'm coming in by hand and gently putting that cannulated screw in, which is a 3.75 cannulated screw. I've left the other pin in place while doing this, so as not to disrupt the fracture when putting the screw in. And here's a picture of the final fracture fixation. You can see this is an anatomic reduction. The screw heads are slightly countersunk. And then I perform a soft tissue bankart repair and a capsular shift for additional stabilization to cover the screw heads. And so you can see two racking head sutures placed here. And I'm going to cover the screw heads. And then you can see me drilling the pilot hole for the PushLock. And here's the final fracture in soft tissue bank repair. So it's an anatomic reduction. And there's no screw head prominence. And the capsule and labrum have been shifted. And for this patient I got post-surgical imaging. Here's a CT scan. And you can see on the right there's an anatomic reduction of that glenoid. And then you can see the screw trajectory. Typically the screw trajectory is going to be from lateral to medial more than anterior to posterior. And you can see that in the CT scan. So what are some technical pearls. Well you want to take care not to traumatize the soft tissue bankart while working on that bony fracture. I use the analogy of a golf ball and a golf tee. And you want to you want to make sure you reduce the fracture, but you also have to keep that labor intact so you can create a deeper socket. I use traction sutures initially in the labrum to pull it out of the way while I do the bony work, and then I use that sharp SutureLasso to pin the fracture in place while placing provisional K-wires fixation. It's important to do cannulated drilling by hand not to disrupt the fracture. And then the screws are placed more lateral to medial than anterior to posterior. And then I perform the capsule labral repair after school placement to cover the screw heads. My preference card is the bony bankart set or the glenoid bone loss set. It's got K-wires. It's got a very long nesting drill guide that can be used as a skid to place those portals. And then the 3.75 cannulated screws. The standard arthroscopic instruments I have available are that sharp SutureLasso to pin the fracture in place, as well as the 2.9 PushLock. Thank you very much.

Paul C. Brady, MD, (Knoxville, TN) demonstrates the versatility of tensionable, knotless anchor technology for a Bankart and remplissage repair using Knotless SutureTak® and Knotless Corkscrew® anchors.

Bankart and Remplissage Repair

Hi, my name is Doctor Paul Brady. I'm from Knoxville, Tennessee, and today I want to demonstrate a bank cart Remplissage combination utilizing the latest and knotless technology, including the three Knotless SutureTak for my Bankart repair and the three nine Knotless Corkscrew for my Remplissage repair. Now I'll I'll hold position while my assistant taps seats it, and then go ahead and drill all the way to the hub for our three Knotless SutureTak. And again, I'm holding the position. I'm not moving my hand. My assistant puts in the anchor, taps it down flush, and all you have to do is remove the tab and then twist and pull the inserter. And there you have it. And now we'll have to pass the repair suture. So you see here we have a have a repair suture. We have a repair suture. And which is blue and white? And we have a FiberLink, which is blue. Okay. So we'll take a good inferior bite of our tissue. Give it a just rotate the hand. Looks like a good bite. And then we'll load in some monofilament. And then when we load in the monofilament I'll reach in through my antero-superolateral portal. And I'll grab both my repair suture and the monofilament. And I'll pull that out my antero-superolateral portal. So here we just load a, make a loop on our monofilament and place our repair suture in the loop. Tighten that up, and then we'll be able to load this or shuttle this through the tissue. Our repair suture is not a sliding suture. So you can go ahead and get it nice and tight. And the last step is to load the repair suture into the looped end of the splice. So I'm going to go ahead and take them out another portal so I know I have the right one. So I'll go ahead and load the repair suture into the looped end of the FiberLink. And then I'll pull on the other end of the FiberLink. And this is going to load my suture here. My suture is coming down right here. Now once it gets to that point where you get a little tension, you want to give it several tugs. So I'm going to give it a little tug and that loads it into the splice. I'll go ahead and finish my tensioning. And I'm going to I'm going to tension it just with a few tugs. And then I'm going to finish my tensioning with a new instrument called the tensioner cutter device. This is nice because it's got a tip which allows you to seat the device right on top of the anchor that you just placed. And if you see there's the tensioner cutter is beveled. You want the hole where the suture is coming out toward the glenoid. Okay. So we're going to pull tension there. I'm going to insert the that side onto the glenoid right onto the anchor. And once it's onto the anchor I'm going to hold the T handle pull tension. Pull tension on my suture. But I'm not going to push the plunger until I'm ready to cut the suture. So let's go ahead and tension it holding the suture. That feels good. And then at the final step, we'll pull the plunger and pull our suture out. Now let's turn to our Remplissage. I'm going to do most of this procedure while visualizing through the Antero-superolateral portal. So there we see our bankart repair. Now let's turn to our Remplissage. Now, the safest way to insert the anchors on this Hill-Sachs defect is through the posterior portal. We're going to utilize three nine Knotless Corkscrew anchors for our Remplissage. So we're going to go ahead and put this right here. That's I'm going to look at the humeral head. That looks like a like a very safe. I'm not going to penetrate the humeral head with that anchor. You know, you can either drill or tap this. If it's really hard bone, you probably want to drill it. We're going to go ahead and try a tap first and see if the tap is adequate. Looks like the tap is going to be perfect for this cadaver situation. Right to the line. I'm going to hold my inserter there and then we'll take the anchor. It's a 3.9 knotless Corkscrew peak anchor. We'll seat that. That's perfect. And again we just pull the tab and then twist the inserter while we're pulling. And we'll give that a little tensioning. And that's nice. That anchors in there. So so let's insert the second anchor also through our posterior portal. Now this one I think is going to we're going to get a better approach to this if we give it some external rotation. Perfect. Okay. So? So I'll seat this. I'll use my hand to lever that exactly where I want it. I think that's a safe spot right there. Just insert the anchor anchor right over top of the right through the inserter. And then we'll give that a few tugs just to make sure that's that's in there. And both those anchors are, are nicely seated through our posterior portal. Next we want to go ahead and and place our sutures. I'm going to use a spinal needle to get the appropriate angle here. So I want one coming essentially just inferior to that posterior cannula which on the outside view you can see is is a pretty good angle there. Okay. So I like that angle. Let's make a small nick in the skin. I'm going to use a spinal needle where I've already placed a sheath from a FiberStick over top of the spinal needle, and that sheath is going to act as a protector for my sutures when I load those sutures through here. So. So I know my trajectory. I'm going to go through that small hole with my suture retriever. I'm going to grab all the sutures from my inferior anchor, along with the loop of the nitinol, and I'm going to pass those out my posterior portal. I took the spinal needle out. I'm going to load those sutures through the sheath of the FiberStick, the FiberStick sheath. We're going to hold that FiberStick sheath in place. I'm going to pull those sutures in. You can see that red catheter protecting all those sutures. This is important because when I go into the subacromial space, I'm going to be able to utilize my shaver into the subacromial space without having to worry about capturing those sutures. So we're going to place a hemostat right on those sutures. That's going to keep that red cannula, red catheter in place and protect those sutures. So now we're in the subacromial space. I need to make a lateral portal for my working portal in the subacromial space. We'll place a passport cannula in that lateral portal. So we'll go ahead. And now that we've got remember we have those red catheters that are protecting our sutures. So essentially I'll just take the shaver and I'll keep working my way toward my camera. And there we see one of them right there. Now we have our two catheters here. So to complete our Remplissage, we're going to load the repair suture from one of these anchors into the splice of the second and vice versa. So I'll go ahead and get my suture retriever. Let's go ahead and get the inferior repair suture. So let's take the catheter off the inferior sutures. We'll get just the repair suture. And then now let's take the catheter off the superior. And I'm going to get just the, the looped end. So I'm going to push I'm going to actually push everything away from me. Get some slack. And then if you'll pull on the looped in real gently, there's the looped in right there. So so we'll pull out those two from our posterior portal, and we'll go ahead and load the repair suture into the looped end of the FiberLink, and then we'll pull tension on the other end of the FiberLink that's going to load the inferior repair suture into the superior anchor. Now I'm going to tension it right till it's touching the tissue, but not I don't want it. I don't want it compressing the tissue. Okay, so let's go just a tad further. There you go. Now I want to I want to note which one of these I just took because I don't want to take that one again. So hold that one for me. Now we'll grab the other repair suture, which I believe is this one. Give that one a tug that we did. Yep. So that's I've got the right one and then I'll take the looped end of the other FiberLink. There we go. So we got the looped end and we got the repair the second repair suture. We'll pull that out our posterior portal, load our splice and then load that back into the splice. Again we'll tension it until the till. The suture is just touching the tissue. But I don't want to. I want to equally tension these, and I don't want to do the final tensioning until. Until we've got an intra-articular view. So there. We're there. We're barely on the tissue, but we're not compressing the tissue. Now we're going to go into the subacromial space. This is my favorite part to watch this come down here. So there we see our our Hill-Sachs defect. Now I'm going to take these repair sutures one in each hand. And I'm going to alternatively tension them. Number one, number two, number one, number two. So let's go ahead and do that. And you can see how that seats the the cuff the infraspinatus down into the Hill-Sachs defect nicely. Let's externally rotate this now makes this a non engaging lesion. And this has been very successful with these patients with significant bankart even some bone loss.

Stephen S. Burkhart, MD, (San Antonio, TX) describes a case with a patient who has experienced several anterior dislocations, has some glenoid bone loss and an off-track Hill-Sachs lesion. He was able to restore function, range of motion and strength using a combined arthroscopic Bankart and Remplissage using biocomposite Knotless SutureTak® anchors.

Knotless Remplissage with Interlinked Knotless SutureTak® Anchors

I'm Steve Burkhart from San Antonio, Texas. And I want to introduce you to a concept that has dramatically improved my ability to do Remplissage in an efficient, rapid manner that's quite secure. This Knotless Remplissage is currently done with two Knotless SutureTak. You can also use Knotless corkscrews if you'd like. In the Hill-Sachs lesion, we pass the sutures trans tendon into the subacromial space, and then we do a reciprocal threading of the splice, where you take the suture from one anchor through the splice of the second anchor, and then you take the working suture of the second anchor through the splice of the first anchor. This is a cadaver demonstration that shows a combined bankart repair and Remplissage. And we're using these knotless biocomposite suture tax for the repairs. This is a right shoulder. You see, we're placing the anchors into the glenoid, and we're then going to pass them but not tighten them. I think the order of steps here is important, because you want to place the anchors for Remplissage prior to tightening the sutures for your bankart lesion repair, because you could actually loosen or disrupt your bankart repair when you insert the the anchors posteriorly in the humeral head, by virtue of that anteriorly directed force that you have from the anchor insertion. So we're threading the splice on these anchors for the bankart repair. But we're not going to cinch them down yet. So we leave a kind of a loose loop. And we'll come back later to cinch these down. So now we've passed the sutures. We've cinched them to a loose loop, and we'll come back later to tighten those. The next step then in this case, we're making our Hill-Sachs lesion. This is a cadaver. Of course we're going to make that just anterior to the bare spot in the posterior part of the humerus. We'll place two anchors, one at the top of the Hill-Sachs, one at the bottom of the Hill-Sachs. In this case, they're not less SutureTak anchors. We're placing those through a posterior portal. Then we're going to want to pass these out through the tendinous portion of the infraspinatus. So we need to come in at about a 45 degree angle to the angle of anchor insertion. And we're coming through a more lateral point in the infraspinatus tendon. So we place a spinal needle to to get that angle of approach. Then we go in the subacromial space. We clear the bursts out around the needle so that we can see the musculotendinous junction. We're just lateral to that. We'll place a subacromial portal with the subacromial cannula, and we're going to then put a Penetrator suture passer through there and pass those sutures out from intra-articular into the subacromial space and out through that subacromial cannula. So we pass the first set out and then we sweep the cannula over about a centimeter and a half and go through a different point in the infraspinatus and pull those sutures out, and we keep those separate. So there are two separate bundles there. Then we'll thread the working suture of anchor number one through the shuttling suture of anchor number two. So it threads the splice of anchor number two. And we'll pull that down so that it's not quite tight. It's just down in the subacromial space. And then we'll do the opposite. We'll thread the working suture of anchor number two through the splice of anchor number one using that shuttling suture. So then we can reciprocally tighten those by pulling on those sutures to tighten that splice. And that pulls the soft tissue down into the Hill-Sachs lesion. Here's our clinical case. This is a 30 year old athletic male. He has had three anterior dislocations. We calculated a 12% glenoid bone loss with an off track Hill-Sachs lesion. This is his left shoulder. So we looked through an antero-superolateral viewing portal, and he's got this lesion where his capsule is healed in a medial position. He also has a Slap lesion that we're going to repair. And then he has this off track Hill-Sachs lesion we're preparing right now with a curette preparing the bone bed. We place these two knotless SutureTak anchors back into the Hill-Sachs. We repaired. His lesion in this case was not at anchor so that we could get two sutures per anchor. And then we came back to the Hill-Sachs and passed those sutures at that 45 degree angle through the tendon. In blind fashion, we sweep that cannula from one point to another 15mm. So we have two separate penetration points where those sets of sutures come through. Then we reciprocally tighten. So we get that double pulley to come down basically through the interconnected knotless mechanisms. And here's our final result. When I go back up in the subacromial space and locate this double mattress knotless configuration here in the Subacromial space, here's the patient at two year follow up. He's stable. He has full range of motion. You see in his clinical video here. He it's his left shoulder. He has full overhead motion. People get concerned about whether it restricts internal rotation or external rotation. You see in this young man that it's not restricted his rotation at all. He can do horizontal abduction back behind the plane of the body without getting any apprehension. He was quite happy with his result, and I asked him if he had resumed his full athletic function. And here's what he had to say. So do you feel like the shoulder is normal now? Yes, sir. Are there any things athletically that you're not able to do or where you feel apprehensive? No, sir. Back to 100%. 100%. And you told me you just played basketball yesterday, right? Yes, sir. Okay.

Peter J. Millett, MD, MSc, (Vail, CO) demonstrates the advantages of using knotless SutureTak® anchors for Bankart repair.

Bankart Repair with Knotless SutureTak® Anchor

I'm going to demonstrate a case here of a knotless bankart repair using the Knotless SutureTak. This is a 28 year old male. He's otherwise healthy. He works as a physical therapist. He's had progressive right shoulder pain and instability over the last nine years. His first dislocation was suffered while playing soccer and he's had numerous dislocations since, including while sleeping. He had an extensive physical therapy and anti-inflammatories, but had persistent instability of his shoulder. His physical exam demonstrated no obvious deformity or tenderness. He had full range of motion and normal strength. He did have a positive anterior apprehension sign and a positive anterior relocation sign, and he had no hyper laxity in his examination. Here you see the x rays of his shoulder on the right. You see the axillary view demonstrating that the joint is centered on the left. You see the normal glenoid contour. You don't see any evidence of significant bone loss. Here you see his preoperative MRI I imaging, which demonstrates a small amount of capsule labral disruption anteriorly. No large Hill-Sachs defect is noted, so our assessment was that the patient had anterior shoulder instability with out any evidence of hyper laxity, and he had an anterior capsule labral disruption, also known as a bankart lesion, due to the failure of his non-operative management. He elected to proceed with surgical treatment. The operative setup that I prefer for anterior instability is the beach chair position with an arm holder. The TRIMANO arm holder from Arthrex works very well. I perform an examination under anesthesia followed by a diagnostic arthroscopy. Typically I use one posterior portal and then two anterior portals, through which I'll place a five millimeter cannula, anterior superior and an 8.25mm cannula at the anterior inferior portal. I'll use 30 and 70 degree arthroscope. I'll use the 30 degree scope initially, and then we'll switch to the 70 degree scope to visualize anterior inferiorly. Then we'll use an elevator to elevate the bankart lesion until we can see this underlying subscapularis. And then we'll use the three millimeter knotless SutureTak, usually four anchors, sometimes five in the front. And we'll use a 25 degree tight right SutureLasso to do the passing of the sutures and then secure it in a knotless construct. So here's the case example. This is a right shoulder. You can see we're doing our diagnostic arthroscopy. We look at the rotator cuff. You can see there's some scuffing of the posterior humeral head cartilage with the Hill-Sachs but no bony defect. You can see the capsule labral disruption anteriorly here as we distend the arm and pull the humerus out of the way, you can see the capsule labral disruption consistent with a bankart repair. It extends down to about the 6:00 position. We checked the axillary pouch. There's no haggle lesion. We always look from the front of the shoulder. You can see that there's no significant glenoid bone loss, which would be a contraindication for an arthroscopic repair. Following this, will establish our anterior inferior portal with an 8.25mm cannula, and then carefully mobilize the bankart lesion. This is the first anchor going in. You can see how the knotless SutureTak can be inserted through a guide. Retrieve the suture, retrieve the tissue with a grasper, and then use a SutureLasso to pass the sutures around the anterior band of the inferior glenohumeral ligament. We pass the braided suture around this, and then we shuttle that suture back through the eyelet of the anchor, and then we can tension this, the tissue with our grasper, and then cut the cut the free suture, creating a knotless construct. This is the second anchor going in again through through a guide. Retrieve the marked suture. Use our lasso to pass around the labrum. We also grab some of the capsule so we're not just getting a labor repair, but getting a capsular shift. Shifting the capsule from inferior to superior and from lateral to medial. Again, we'll grab the tissue prior to securing it down, and now we can tension it after the anchor has been inserted, which is a big advantage of the knotless SutureTak. And then we use this flush cutting suture cutter to cut the remaining suture. We carry this up the front of the glenoid. Usually I use at least three, preferably four anchors for a typical instability. And in some cases up to five anchors anteriorly. And here we're again retrieving our sutures out through separate cannulas coming through with a 25 degree tight SutureLasso. Retrieve the wire, shuttle the suture through the tissue, and then we'll pass the suture through the loop on the outside of the of the cannula. And then tension and repair the And then cut it flush. So here you can see the completed repair. Excellent stability. We can perform an arthroscopic draw test. And now the shoulder stability has been restored with this capsule label repair using the Knotless SutureTak anchors. Following surgery, the post-operative rehabilitation. The patients placed in a sling for immobilization for a period of four weeks. They usually start passive range of motion. We limit their external rotation to less than 30 degrees for the first four weeks, at around four weeks, to let them go to full passive motion. Active range of motion has started at 4 to 6 weeks. Postoperatively and return to full activities for a typical Bankart repair in my practice is about four months post-operatively. So in summary, anterior instability can be treated effectively. Arthroscopically the knotless SutureTak anchors are ideal for a bankart repair. It's fast, versatile, and reliable, and it allows an excellent capsule labral repair. Thank you very much.

Stephen S. Burkhart, MD, (San Antonio, TX) describes a case with a patient who had a bony Bankart, large Hill-Sachs lesion and massive supraspinatus tear. He was able to restore function and strength using a combined arthroscopic Bankart, Remplissage and Superior Capsular Reconstruction (SCR). Dr. Burkhart also shares the one-year postoperative results.

Superior Capsular Reconstruction (SCR): A Unique Solution for an Irreparable Cuff Tear in an Unstable Shoulder

I'm Steve Burkhart from San Antonio, Texas. And I just want to show you a case where superior capsular reconstruction provided a very unique solution for an unusual problem in a patient that had an irreparable cuff tear, but also a very unstable shoulder. This was a 41 year old physical therapist, a very active person whose hobbies are golf, scuba diving and downhill skiing. In fact, six months earlier, he dislocated his left shoulder while downhill skiing. Since that time, he had a pseudo paralysis, and he said that his shoulder would sublux dozens of times per day. He was able to return to his job as a physical therapist, but he had to work one handed and was concerned about the future of his job, which obviously was very physically demanding. His local surgeon had referred him to me for a possible latter day reconstruction because his instability was so bad, but he also had this very massive cuff tear with a true pseudo paralysis. He had active elevation of only 20 degrees, whereas he had passive elevation of 160 degrees. He had very weak resisted external rotation, and he had a positive apprehension sign at a very low angle of just 45 degrees, indicating that he had an extremely unstable shoulder. You see his x rays here on the AP. You can actually see his bony bankart lesion. You can see it better on the axillary view, where he has a bony bankart that has healed as as a bony Alps in a medial position. The 3D CT scan shows this perhaps a little bit better. You see, it seems to be a rather large fragment, but it's idealized. Looking at his MRI scan, you can see that he has a massive rotator cuff tear. His muscles look reasonably good in terms of their integrity, and it looks like if we could get some sort of a partial repair, that would help. But he obviously may not have a completely repairable tear. So here are choices whether to do an open ladder J plus open partial repair, an open superior capsular reconstruction. And my concern there is that's a lot of open surgery. And I'm not so sure how well he would do with that. The arthroscopic option that I had in mind was an arthroscopic bankart repair There, combined with arthroscopic Remplissage to aid in the stability and then to do an arthroscopic superior capsular reconstruction if we weren't able to obtain a complete repair. So here is the surgery on his findings. You see that he's got a big Hill-Sachs lesion. He's got this big bony bankart that had to be mobilized. It had healed in a medial position. Now we've mobilized that bony bankart just prior to fixation here. Looking from a posterolateral portal you see, in this left shoulder, we're doing a posterior rotator cuff repair using a Remplissage type of technique in setting the posterior cuff into the Hill-Sachs lesion. But as you can see superiorly, his supraspinatus is not repairable at all. So we had to use a supra capsular reconstruction with dermal allograft to cover over the top. Here he is at one year post-op. You can see no instability problems now, no pseudo paralysis. He has excellent strength with resisted external rotation, as you can see. The internal rotation is good. No instability problems. He has no apprehension and abduction. External rotation. He has regained all of his external rotation strength. Looking from the front, you can see how he raises the arms. Once again. No apprehension. He can do everything he wants to do. In fact, he's already made his reservations for his next downhill ski trip next winter. So you see what we've accomplished. Arthroscopically in this patient. We've restored his stability. We've restored overhead motion, and we've restored his strength with this arthroscopic procedure that includes a superior capsular reconstruction. So I would urge you to keep this in your armamentarium, because it can be very helpful in some of these combined types of problems that don't have a very easy solution otherwise. Thank you.

Brad Parsons, MD, (New York, NY) discusses his treatment paradigm for dealing with instability and glenoid bone loss including: arthroscopic bony Bankart repair, Remplissage, Latarjet and the use of allografts for glenoid bone reconstruction.

Managing Glenoid Bone Loss

We know that bone loss is common. It happens even with a first time dislocation. You can have Hill-Sachs deformity occur. You can even have some glenoid rim insufficiency occur. And so you have to look for it. And we know it's a source of failure. Thanks to Doctor Burkhart and others, we know that when you perform a stabilization procedure, even open procedures, historically in the face of bone loss, they have a higher rate of failure in soft tissue situation repairs alone. When you think about the glenoid, I think there are two aspects you have to think about. One is the fracture where the glenoid rim has been damaged, but the bone is still there, versus the sort of attritional lesion where the bone has been whittled or dissolved away. And I think you can handle those two things differently. When you see your patient, you need to think about the potential of bone loss. And some of the things I think about that come from the history. The physical exam is if they have had multiple episodes of instability, we know with recurrent instability, four, five, six occurrences. They're more likely to have sort of that Alps lesion where the capsule label complex is scarred immediately. It's been repeatedly stretched. But you have to think about the bone as well. And each time that shoulder comes out again, that whittling effect of the glenoid can occur. Also, when the patient says, well, it just comes out of my sleep, it comes out when I reach for anything in the mid arc. That ease of instability is also a concerning sign, and should raise your hairs in the back of your neck that you may be dealing with bone loss. If you're getting plain imaging, which I routinely do in these patients, you know, you can look at the anterior rim of the glenoid and see on an AP image that it can be sort of missing in that sclerotic line. You see, superiorly is gone. And this patient actually has a fracture. And there the piece is there. And so take time to look at your standard X-rays because they'll give you some clues. And in those situations, you're probably going to want to go ahead and get more advanced imaging. And I started with using MRI fairly routinely for these. But for some of these cases where the bone loss is a little bit more severe, I've gone to using a Cat scan and I'll add an arthrogram to it to help look at the cuff, see if there's posterior or superior labral issues. Because if you're going to do an open procedure and you've got to post your labral tear, that needs to be dealt with as well, that can be a little bit difficult or a labral tear superiorly at a slap tear. And so I looked at these Cat scans and MRIs. And I find the most helpful view is that on face view, shown here in the top right with a three dimensional image, as well as the top left, that on face view from the sagittal image, and that the reason I find that helpful is it's really how I try to quantify or gauge how much bone is missing. One of the challenges we have is how much bone is too much to be missing. And when do we have to resort to an open procedure or coracoid transfer or something like that? And so I'm not much of a mathematician and so I can't follow Steve's on track off track thing. It's very hard. I've heard his talk probably a half a dozen times, and I'm not smart enough to fully get it. Even though he talks in very simple language and makes it easy to understand. I think it's just me. And so I have to try to do simple math. And so Christian Gerber came up with the idea of sort of this rise over run, where you measure the tangential line of deficiency. We know the inferior glenoid is supposed to be a perfect circle, and then you compare that to the radius or really the diameter of what the bone should be. And if x is greater than two r, you know, you know, you're missing around 20 or 25% of your anteroinferior glenoid. And that from many cadaver studies by Baliani and others is sort of the critical volume we think is is really concerning where a soft tissue procedure may not work. So like everything in orthopedics, we tend to develop algorithms as we move along in practice. And so I've developed one for myself with patients with instability. And so if I see a patient with bony insufficiency even mild, I again talk to them potentially about a coracoid transfer or other procedures. But if it's less than 15% of the glenoid rim is deficient, if they have relatively small Hill-Sachs, less than 10% or so, then I'll usually indicate that patient for an arthroscopic stabilization, and I'll talk to them potentially about the potential of a Remplissage. And we'll talk about Remplissage a little bit later in the talk. Patients who have had prior instability surgery that I feel was done well, so they've had an appropriate number of anchors, as Mark just showed, appropriate placement, appropriate techniques, and they failed. They've either had a recurrent trauma or they've just developed recurrent instability a traumatically well, that often even in the face of less bone loss in 15 or 20%, is an indication for coracoid transfer in my hands. But, you know, sometimes you have higher demand. Patients who come in never having had surgery and they're missing 15, 20, 25% of their glenoid rim, or they have a larger Hill-Sachs. I'll talk to them about a latter day as well, because I think, at least in my hands, that's probably a more predictable option in the young active patient in that scenario. You have situations sometimes where the bone loss is really big, so you're missing half the glenoid or 40% if you're using a classic sort of traditional French style latarjet, which I'll talk about in a second, that may be may be actually too big for the coracoid to fill that defect and keep the shoulder stable. So Steve Burkhart has talked about the the congruent arc technique, where you turn the coracoid on the side, and that actually gives you a little bit more of a diameter to help stabilize the shoulder. And so that's an option in some of these more severe bone loss patients or Matt prevention has talked about the distal tibia allograft. And that's really what I've gone to doing in these more severe patients. And then if you have that bony bankart where it's not dissolved but still there, I think that's amenable to repair. And so here's a case of a situation where you might see that. So a patient you could see the anterior inferior rim fragment. You can see that it's displaced on the MRI and the Cat scan. And so the technique I tend to use is the one Peter Millet designed and described with an arthroscopic double row technique, where you have SutureTak medially along the medial aspect of the fracture bed, and then cerclage sutures, and a knotless fashion to, to push locks up on the face. And so here's sort of just quickly piece of time before an intraoperative picture and then after where you're collaging that piece. And that's really robust fixation that allows that piece to get sort of stuck in and heal reliably. But really, I think what my task today is to talk about is what do we do in the situation where the bone is missing? And as I said, many of these patients will be indicated for a coracoid transfer in ladder J. And this is the schematic of the classic technique, where the lateral surface of the coracoid faces the lateral aspect, and the inferior surface goes flush to the glenoid neck. That allows you to use the coracoacromial ligament stump as a soft tissue reinforcement that you can repair to the lateral capsule lateral to your arthrotomy. This is what the congruent arc looks like, and Steve and others have done research showing that the radius of curvature of that arc is pretty close to the native glenoid. So again, it may be advantageous in these situations. For me, sometimes the coracoid can be very thin, especially in women. And so you have to be a little careful in those thin patients that you're not going to be in a situation where it may fracture. And so that's some of the of the challenges, but it's a very nice technique and it gives you opportunities, as I said, in a more severe bone loss situation. Arthrex has really done a nice job putting together a one stop shop kit that allows you to very easily and seamlessly do this procedure. It's got dedicated osteotomies and guides to allow you to seat your coracoid flush. The biggest challenge for many surgeons is, is when they get in there through a small window, trying to make sure that coracoid is sitting flat and perfect on the glenoid. And so the guides and and sort of seating apparatus really makes this an easy aspect of the surgery. My preference for technique is to do the classic French style technique. As I said, I do an anterior deltopectoral incision in a beach chair position. I use a horizontal slit split between the upper two thirds and inferior one third. There's usually a little raphe there where you can see that, and I'll split horizontally. I'll do a vertical arthrotomy or capsulotomy right at the medial aspect of the glenoid labrum. I want to have a nice long lateral flap of capsular tissue to imbricate at the end. I'll retain about a centimeter stump of the coracoacromial ligament on the medial border of the coracoid. And when you harvest the coracoid, you're going to release the pectoralis minor. I don't repair that. I'm worried about it trapping on the plexus or causing scarring there. So I don't routinely repair the pec minor. Once I've seated my coracoid with my two screws, I'll repair that capsular able complex to the lateral stump of the CRx ligament with the arm at about 30 degrees of external rotation. So I don't over tighten the shoulder. And it's a relatively straightforward procedure. The critical points, which we've learned thanks to Steve and others, is you've got to seat this flush. If you're going to air on coracoid position, you're going to want to air a little bit to medial. Not too lateral. Lateral is bad. It causes arthritis and stiffness and pain. It can risk the coracoid fracturing which I've had happen in the patient. That's no fun. You want to make sure you decorticate the surface of the coracoid. That's going to go to the glenoid. Often the glenoid is flat from the recurrent instability and attritional loss. And you want to make sure that bone is flush up against the medial border and you don't have any concavity where there's a gap, because that can lead to nonunion or hardware failure. I have had patients get a nonunion. It's probably more common than the French would suggest, and I think meticulous technique helps prevent that. I've also found that in older patients over the age of 35 or 40, at least in my hands, the coracoid transfer has not been quite as reliable a procedure. So I may on doing a soft tissue stabilization, even in some situations of bone loss with a Remplissage in the older patient, rather than resorting right to a ladder, J. And as J.P. Warner and others have taught us, we have to be thinking about the nerves, the musculocutaneous and axillary nerve of both the risk I've had both get injured in patients and both were practices that were recovered. But you have to think about it. And some people even advocate nerve monitoring. The success rate of a ladder J is pretty well proven now, and it gives us great success in terms of recurrent instability and and excellent opportunities to stabilize our patient's shoulders. And even long term results are pretty good in terms of not a terrible rate of arthrosis. If we do the meticulous technique. Well, what about the Hill-Sachs? And often it's something we ignore. But you can't, and you have to think about it. And so really the question is when is it too big? I think everybody would agree. That's a pretty big Hill-Sachs and probably should need something. And you know, many of these patients, if they have bone loss in front of the glenoid, you can treat that with a latarjet and it will cover both bases for you. And you don't necessarily have to do anything to the Hill-Sachs. But really the question is when do you need to use a Remplissage? And thankfully, coming to meetings like this, I've learned over the last few years to to how to do it, when to do it, and get a better sense of where it sort of lies in my armamentarium of treatment. So my indications for Remplissage is, again, Hill-Sachs greater than about 15%, and it's not so much the depth but the length of it and how easy that can engage the glenoid rim. And that really goes to Steve's on track and off track idea. If the glenoid is pretty good, I'll tend to do arthroscopic surgery with a Remplissage rather than a latarjet. Certainly if they've had a failed prior scope and don't want open coracoid surgery, then we'll consider that the big negative of Remplissage has been that it causes stiffness, especially in external rotation and abduction like in a thrower. And the reality is, is that may not be true. A nice systematic review by Bill Levine at Columbia showed that the shoulder motion in the series they reviewed was really no different between standard anterior bankart repair versus bankart plus Remplissage and a very low rate of recurrence even in situations with a fairly large Hill-Sachs. One of the tricks to try to image the Hill-Sachs is not just resort to the MRI or CT, but look at your x ray and if you see an in an AP internally rotated view this sort of wedge wedge spike out of the humeral head. That's been shown to be more likely to be an engaging lesion. So you have to think about being a little bit more meticulous or careful with that. The pearls I've learned about Remplissage from Steve and others has been pass your sutures first. You know, when the view is good, you're sort of shoulder joint is open. Once you repair your bankart, it's really hard. And so I'll pass my sutures first right through the posterior standard portal. What I've learned also is to make an accessory portal more like a standard posterior portal. And I'll put a cannula in and I'll go right up to the deep sort of surface of the superficial aspect of the infraspinatus tendon and fascia. So I go through the deltoid, superficial fascia, through the muscle, through the deltoid deep fascia. And I sweep that cannula. It's still extra articular, but that allows me to pass my sutures very easily through that. And then if I'm going to go Thai, I don't struggle trying to find the the sutures in the posterior aspect of the shoulder and the infraspinatus muscle. That can be pretty tough. I do my cuffs, beach chair. So when I go up lateral to cubitus to the rotator cuff, I'm like in lost territory. So trying to find sutures there is really tough. So having that extra cannula there that screws in and stays right there makes that very easy. I do my bankart repair and then I'll tie the sutures. Last, thanks to Paul and his technique for pasta, there's actually the ability to do this all knotless now with the double pulley technique, like Steve described with tying sutures, where you take one limb from the SutureTak, bring it to the other SutureTak, and vice versa, and you can do that all inside the the Intra-articular view. So again you can use that extra candle. You pass the suture so you know you're not going to tether it in the deltoid. But you can watch as those sutures sink down and tighten your, your Remplissage right into the right place. And so it's a nice extra trick. And when the 3.9 SutureTak comes out, it's really going to make this even more robust and strong with excellent fixation. So in conclusion, bone loss is common. I think you have to take the time to take your patient's history. Multiple episodes, ease of instability concerning for bone loss. You have to look at your imaging carefully so you're not fooled. And an MRI may underscore the severity of bone loss. So if there's any question I would get a Cat scan. I think if it's less than 15% of glenoid rim insufficiency, you can probably still do a arthroscopic surgery in those patients and add a Remplissage if you think it's indicated greater than 15 or 20%. I'm thinking laterally and I'm talking to the patient about that. And then again, Remplissage, I think gives us a little extra twist or help for some of these challenging situations.

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