Speaker 1: The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Journal, the Arthroscopy Association, the American Shoulder and Elbow Surgeons, TSAOG Orthopedics, the University of Colorado, or the University of Utah.
Dr. Clay Nuelle: Welcome everyone. Today we will have a collaboration between the Arthroscopy Journal and the American Shoulder and Elbow Surgeons, with the combined podcast covering the topic of shoulder instability. In particular, the instability severity index score as it relates to the predictability of recurrence rates after arthroscopic repair.
We will review two separate publications, and then compare and contrast the results, and discuss how those results influence our clinical practice. I'm Dr. Clay Nuelle from TSAOG Orthopedics, and I'm joined by my practice partner here in San Antonio, and fellow Arthroscopy Journal podcast host, Dr. Rob Hartzler. Welcome, Rob.
Dr. Rob Hartzle...: Clay, thanks for having me. Pleasure to be here.
Dr. Clay Nuelle: We are also joined by the American Shoulder and Elbow Surgeons podcast host, Dr. Rachel Frank from the University of Colorado. Welcome, Rachel.
Dr. Rachel Fran...: Thanks so much for having me. Pleasure to be here.
Dr. Clay Nuelle: And Dr. Peter Chalmers from the University of Utah. Welcome, Peter.
Dr. Peter Chalm...: Thanks so much for agreeing to do this with us. I think this is going to be great.
Dr. Clay Nuelle: We'll start with the arthroscopy article. The arthroscopy article is entitled, Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability? The lead author was Dr. Mattia Loppini, and it was published in the February 2019 edition of the Arthroscopy Journal. So Rob, if you could start off by giving us a brief synopsis of the article and then maybe a couple of your main takeaways from the article.
Dr. Rob Hartzle...: Great. So this, again, article from the Arthroscopy Journal from 2019, a multi-center retrospective study case control. The senior author, Dr. Castagna. This study looked at 670 patients, all who had minimum five-year followup, and all of whom were treated with arthroscopic isolated Bankart repair for recurrent anterior shoulder instability. They reviewed the ISI score, as described by Boileau, and retrospectively determined if this was a significant factor in the recurrence rate.
A [inaudible] very good, and in my opinion, rate of follow-up. Only 21% were lost to follow-up, which as we all know in instability studies at this long a follow-up period, minimum five years, is very good. Their overall recurrence rate at 26%, in general is fairly in keeping with the rest of the literature for isolated arthroscopic Bankart repair at this length of followup.
In analyzing the ISI score, patients who had a score of three or less points, compared with four to six, and greater than six points, had an increasing frequency of recurrent instability as the score went up. So, compared with the low group, three or less, the middle group had a risk 2.4 times.
The group that had greater than six points had a risk 9.4 times compared with the low risk group for recurrent instability. This paper does support the findings from Boileau, and from the French Arthroscopy Study Group, that the ISI score is correlated with a recurrent risk of anterior shoulder instability for patients who have greater than a score of a three.
Dr. Clay Nuelle: That's terrific. Now we'll switch over to the [inaudible] American Shoulder and Elbow Surgery article, which was published also in 2019. The title of this article from JSES was entitled, Evaluation of the Instability Severity Index Score in Predicting Failure Following Arthroscopic Bankart Surgery in an Active Military Population. The lead author was Dr. Andrew Chan and the senior author was Dr. Brian Waterman. So Peter, could you give us a brief synopsis maybe of this article and a couple of your take home points, and then Rachel, if you could give us a couple of your thoughts and take home points as well.
Dr. Peter Chalm...: Yeah, so I think this is .... First, I think these authors should be congratulated. This is a group out of a military ... It's a military consortium study, and includes authors from a couple of different centers, but it's actually a single center military study of 131 patients with a minimum of two year follow-up. There's a couple of things to say about this [scourse 00:04:28].
The first is there's a bunch of different papers showing the score works. There's Boileau's, obviously original study, showing that a cutoff of six in 131 patients is appropriate, but there's been a couple of subsequent studies. Loppini, the author of the other study we're talking about [inaudible] set a cut off of three, [Thomazeau] which is a ... They published a soft gut study showing that ISIS of two of less was actually the best cutoff. There's another study by [Thadnes] and AGSM.
There's three of three separate studies apart from this one that showed that it may not work. There's a study published by [IBAN] with 163 patients in KSSTA, and they actually found zero difference in the ISI score between those with or without recurrence. There's also the [inaudible] study in arthroscopy that showed the [culinary track 00:05:13] was actually outperformed the ISI score. There's also study by [Buelane] in the British Journal of Bone and Joint Surgery with 110 patients.
So upon that backdrop of constant controversy, I think this study maybe adds to our understanding a little bit. The first thing you should say is this, so the study that we're talking about here is a military study and basically all the patients get two points on the SI score just for being in the military. That's because they were all considered competitive athletes. Their recurrence rate as a result of [inaudible] studies is substantially higher than Loppini style. So they had 26% recurrence. 41% of patients had intermittent pain which I think is much higher than probably community instability, it's much more of a military population.
The most interesting thing they found here is there was no difference in the ISA score between those patients that failed at 3.4 on average, and those patients who succeeded who had 3.5 on average, but they also found that nothing was predictive of failure in their group. Age, garnered bone loss, Hill-Sachs size, sports hyperlaxity, none of these things were predictive.
Some of the strengths of this study are that this is a large patient population, it's a relatively captured homogeneous patient population, but there's some slight of hand in this paper that I think we should address. That's it that there is no listed rate of follow-up, so there's no real description here of how many patients they actually perform this procedure on, in the center during the time period, for us to know how many patients were lost to follow-up. And there's also no description of how many patients underwent open stabilization or [inaudible] Remplissage during this time period.
So we don't know what degree of selection bias there is within this cohort. That being said again, I think the author should be congratulated for this analysis, that again, calls into question the value of the ISI predictive recurrence.
Dr. Clay Nuelle: That's a true terrific synopsis. Thank you, Peter. Rachel, would you want to give us a couple of your thoughts and then I have a lead in question for you that Peter alluded to, one of which being the followup and the rate of follow-up in this military study in the JSCS paper here. The minimum two year follow-up as Peter alluded to, whereas in the arthroscopy paper, the average recurrence was at three years. And as Rob had mentioned, sometimes in instability studies, longer term follow-up, obviously you see the recurrence rates go up.
Give us maybe your kind of main thoughts and then a leading question. Do you think that that kind of follow up rate is a major factor, and how did that influence this paper's results versus the arthroscopy paper results and instability recurrence rates?
Dr. Rachel Fran...: No, I think everyone's brought up great points, and both summaries really highlighted a lot of the interesting findings of each of these studies conclusions. It's great to compare these two studies, particularly given, especially as Peter was mentioning, there several studies and literature that advocate both for and against using the ISI score, and those who are proponents for using the score really vary in their cutoffs. Whether you're using a score as low as two or up to as high as six for determining if someone should get an arthroscopic repair versus a bony reconstruction.
With these two studies we have two different patient populations, the all military or athletic patient population in the JSCS article versus a more general patient population, although still with a high percentage of competitive sport athletes in the arthroscopy paper. As mentioned while the techniques seem modern, with modern suture anchor techniques, the surgical techniques did vary. In the JFCS study they were either performed in the beach-chair or lateral decubitus position, whereas in the arthroscopy paper all in the lateral decubitus position. Just some other variables that may come into play when we look at these outcomes.
I do think, and one of the points that I noted when reviewing both of these studies, is the follow-up. I'll get into that question you were asking. I do think that follow-up is relevant as Christian Gerber pointed out in his paper a year or so ago. Five-year follow-up really does matter when it comes to shoulder instability, and probably all orthopedic procedures. I say that humbly, because a lot of the papers I've been lucky enough to be a part of have that minimum two year follow-up, but don't necessarily reach that five year follow-up, and certainly, I think all of us as researchers should strive to reach that five year follow-up, because I think that's when we start to really see some differences. And so, as Peter was mentioning, we may see different outcomes in the JFCS study if we had either more follow-up duration, with regard to the length or if we knew the complete denominator of the cohort.
I think that does have some potential serious implications into the final calculations with regard to recurrence rates, and then their association with the instability security index score. One question I had for everyone here is, I know at least in my practice, and where I trained, and all of the mentors that I worked under; while the score is great to talk about from a research perspective and analyzing papers. Most of us, if not all of us use advanced imaging as part of our diagnostic toolbox for evaluating these patients and determining what procedure they should get.
Certainly in the instability security index score, it's all based on the different categories, but the imaging component is radiographs as opposed to CT or MRI. So, do you guys use this score in your practice, in terms of stratifying patients for getting an arthroscopic repair versus a bony procedure? Or do you rely more on other factors that are not identified in the score?
Dr. Rob Hartzle...: Yeah, that's a great question, Rachel. In my practice, I don't think that I calculate the ISI score, and then rely on it for the decision for arthroscopy versus open surgery, particularly Latarjet because I think there's a little bit of a false dichotomy in terms of; if you have a higher ISI score, saying that the only option that we have besides isolated arthroscopic Bankart repairs, Latarjet, because we actually have Remplissage that we can add to an arthroscopic procedure for these patients with recurrent instability.
So, I haven't calculated what I do based on ISI. I have to go back and do that, but I actually might follow it, because I lean heavily on Remplissage to save the [inaudible] in these patients that are at high risk for occurrence. Thoughts on that everybody else?
Dr. Clay Nuelle: Peter, do you use ISI regularly in your practice, or do you rely more on advanced imaging?
Dr. Peter Chalm...: I personally use advanced imaging. We get a lot of CT scans, or if you can get a good MRI, sometimes that can be helpful to tell you grossly where you are, but it's not useful [inaudible] we publish for fine delineation. I definitely rely on Glenoid bone loss, and I often calculate the Glenoid tract as [DeJakima] mentions in his article.
I will tell you what the Glenoid track, one of the issues I've had with it. This is coming out in some research that we're doing right now, is your measurement of the Glenoid tract is not very reliable. One of the bigger issues of Glenoid tract is that your measurement in 2D, is probably completely different from what we measure in 3D as it was originally described, and measuring it in 3D is not trivial. And it's not probably easily accomplishable with any current software, at least that I've encountered commercially. I think that's probably going to be something that's going to change the way we look about this in the future, and that we're going to be able to maybe more accurately calculate what was on or off track.
That may change our use of Remplissage. I definitely use Remplissage as well, but I think that Glenoid bone loss can be more accurately reliably calculated, that's for me been a fine [alineator] of what to do. That being said, I definitely use the factors that are considered within this instability severity index score to bias you one way or another. So if a patient has 19% bone loss, but they're 35 and not competitive or contact athlete, I think Latarjet does not enter the conversation as much as if someone has 14% bone loss, but they are 15 years old and trying to get back to football the next year. So again, I think that probably everyone does that subconsciously. I think the score is a really nice way to codify it, and I think that Boileau should be congratulated for helping us to do that more formally.
Dr. Clay Nuelle: Those are terrific points. I think my practice mirrors everything that you guys just said. We just actually had a recent podcast with Justin [Honore] and Matt Provencher. And Peter and Rachel, both of you have done a lot of great work with this particular arena, and he alluded to the exact same thing. That a lot of us use the advanced imaging and do some of those types of calculations, [inaudible] but as the advanced imaging has gotten better, we're able to really assess the Glenoid much better, and assess the overall track much better. And a lot of us probably have gone more to that versus specifically kind of calculating the ISI.
Even though we, as you alluded to Peter, probably all indirectly do that to some degree. So another big question I have for each of you and you can each take it individually. One of the big things that we all talk about in the instability literature is defining instability, and in particular subluxations versus dislocations. And how do we really define recurrence rate and define true recurrence rate when it comes to subluxations and dislocations? So how do each of you evaluate each of these individual papers, and then compare and contrast them in lieu of that thought, and that thought of how we best evaluate and define recurrence rate. Rob, we can start with you.
Dr. Rob Hartzle...: Great question. I think that in almost all of these articles, it's failure defined by recurrent instability is pretty liberal where even subluxations are counted as a failure. That's been suggested as a reason why the failure rates are high. I don't know what everybody else thinks about it, but when I survey the literature of isolated arthroscopic Bankart repair, if you have the longterm follow-ups that is particularly minimum seven, or minimum 10 year follow-up, it's quite high defined in that way. It's around 20%. So I sympathize with the [fringe] surgeons in particular who say that we should be doing better than 20%, but I don't know, maybe not. That's probably a great question for discussion. Is that failure rate for a safe operation too high?
Dr. Rachel Fran...: Yeah, I totally agree, and it's a great question, and I think it warrants a lot of discussion. Not just with regard to these two articles, but how we all define our outcomes. It's funny, when you talk to some patients after shoulder instability, a lot of them, especially a year or two years after, feel great. But then if you ask them, "Do you ever feel like your shoulders loose or slipping?", even when those athletes feel great, they've gotten back to sport, whether it's contact sport, or overhead sport, or whatever it might be. Some of them may report. Yeah, I've had a sense here and there. Never anything that they'd ever bring up unless you specifically ask them, and that sometimes is not captured in patient reported outcome surveys or scores, and we might be missing more subtle subluxations or sense of apprehension, than we actually see reported. Or even we collect ourselves depending on the type of survey that we give our patients.
In the military study, they really defined in their methods, how they defined failure either by gross re-dislocation or subluxation. And in the Italian study it was a little bit more vague and they just said they defined it by either submit a subluxation, or dislocation, or any feeling of instability, but still very subjective on the part of the patient to report that. And yeah, I think the question remains is a 20% or so failure rate for an operation that's relatively safe and comfortable for the vast majority of us acceptable. And I think a lot of the papers that we see maybe report failure rates under 10%, even for arthroscopic stabilization. But if you really talk to the patients, it's probably higher, but maybe less relevant because they're still playing, and satisfied, and happy with their outcome.
Dr. Peter Chalm...: This is such an interesting topic, and the military is to be congratulated for their careful use of the [Hosey score 00:17:43]. The Hosey score's really challenging to use for research because you can't really collect it over the phone. We'd been in our own research asking three questions. Have you had a recurrent dislocation? Have you had a recurrent subluxation or feeling the shoulder is slipped? And do you feel apprehensive about the shoulder? In addition to asking of course about reoperation is that our standard PRO's.
One of the things you mentioned, Rob, that I think is super important for us to understand, and such a challenge with clinical research is that oftentimes by the time we get longterm follow-up our techniques have changed. Now, that happens in these two studies. If you look at the time periods for these two studies, they're nearly non-overlapping. So Loppini had 2002 -2009, where's Chan had 2007 - 2014. Certainly things changed in our technique between 2002 and 2014. Hard to know if those make a difference, but things did change. And those are reflected in these papers. For instance, there's a minimum of three anchors in the Chan paper and Loppini has a minimum of two anchors. They're double loaded so there's four sutures, but still only two anchors. Certainly when I saw this paper presented, Loppini presented at SESAC. Immediately, someone got up to the microphone and said, "This work is not valid because he didn't use enough anchors.". I don't know if that matters or not, but it makes it hard to interpret our literature, and it's going to be a continuing problem from forward.
Dr. Clay Nuelle: Yeah, I think those are great points. The other thing with the Loppini paper, inherent just in the study design, but you wonder somewhat about recall bias. And then again, the recall ability of subluxation versus dislocation versus apprehension can be somewhat difficult to quantify, after the fact in that regard. So when it comes to these types of evaluations, when you guys see, say a patient with just a 20 year old standard Bankart tear, but without significant bone loss, what's the conversation that you have with that patient? And then if they have a recurrent instability episode of recurrent apprehension, how do you kind of progress down that pathway? Peter, you want to start off with that one?
Dr. Peter Chalm...: It's a 20 year old, entering for a labral tear, no glenoid bone loss. Is the person an athlete?
Dr. Clay Nuelle: The person is a, we'll say contact athlete. They've had a recurrent subluxation or recurrent apprehensive type of episode.
Dr. Peter Chalm...: So, I still think that the Arthroscopic Labral Repair is a reasonable first option for that patient. Certainly, as Rob said earlier, I would be aggressive with the Remplissage in that case. I would definitely be aggressive with extending around the back. I think you could also seriously consider an open Bankart in that situation, for no bone loss, but with a contact athlete. I get nervous about that because you have to take down the subscap. That's what I would do. I don't know if it's the right answer. What about you guys? What would you do in that situation?
Dr. Rachel Fran...: Well, for me, I'd go and having that discussion with the patient. I like these patients, especially if they've not had prior surgery and they have minimal to no bone loss. I think when you get above 12 or with [JT jokesters 00:20:51] 13.5% subcritical bone loss number. When you start getting into a single digit percent and how that might change your decision making, I think that's a more difficult conversation, but still fun to have with the patients. But I tell them these are the outcomes with a soft tissue procedure that can be done arthroscopically. These are the outcomes of the bony procedure, these are the complication rates, and these are the risks in my hands for the patients that you just described.
I think in arthroscopic stabilization, I'm aggressively placing a seven o'clock anchor, really getting and restoring that bumper up, and using, in this case, with the labral tear you described, probably from three to six o'clock I'm probably using a minimum of four suture anchors and being aggressive with Remplissage, but not always. Again, depending on Hill-Sachs involvement and whatnot. I think it'd be aggressive, at least in my practice, to go with a boney reconstructive procedure as a first time option.
But I'll tell you when I was spending time training, after my first fellowship or after my regular fellowship, when I was in Europe and in particular in France and Italy, Latarjet was a primary procedure of choice for the vast majority of surgeons that I followed. And that was irrespective of bone loss. That's just the nature of bias, and in training in certain regions of the country and world versus others. So I wouldn't fault anyone for choosing a bony reconstructive procedure, but in my practice for that type of patient that you described, I would proceed with an arthroscopic stabilization.
Dr. Rob Hartzle...: I think the same for me, that I would lean heavily towards arthroscopy for that patient, but just the risk factors for recurrence would push me towards doing Remplissage, assuming they have the Hill-Sachs lesion, even if they were to have an offtrack Hill-Sachs lesion. And that decision, Clay mentioned before [Preventer's] podcasts that we just had. And he made the point that you can get the most sophisticated algorithm and decision making system in place that you can, but there's always going to be a little bit of art of medicine, and maybe a bit of intraoperative decision-making with these patients or really any way that we make medical decisions. Because there's borderline cases, and there's other extenuating factors, and things like that.
So I think for me given this clinical scenario. We know it's a high risk for occurrence, so I would go for arthroscopy, but lean towards doing Remplissage if that was available for that patient to try to lower the recurrence risk.
Unknown: [What about you, Clay? What'd you do? 00:00:23:35]
Dr. Clay Nuelle: I think I'm in agreement with all of you. Definitely in the contact athlete, it's a conversation be had about the recurrence risk as you alluded to. I think I've definitely become much more aggressive in the last few years, or I shouldn't say maybe aggressive, but I'm much more lenient towards doing a Remplissage in an index procedure, especially if there's a decent sized Hill-Sachs deformity as Rob mentioned. And so I agree with all of you in that I would do an arthroscopic stabilization, but it certainly would have a conversation with that patient about the recurrence rates, and depending on the Hill-Sachs and the overall deformity, I would certainly have a low index for Remplissage. Do you think that each of you have increased your frequency of either Remplissage and/or Latarjet within the last few years? Or do you think that's been stable for each of you?
Dr. Rob Hartzle...: Yeah, that's a great question. The question that's begged by these articles is: Should isolated arthroscopic Bankart repair be a lot more rare than we probably do on a whole in the US, or maybe in the non-French world. Because a lot of these patients have ISI scores that are greater than two or greater than three. So that seems to be what a lot of the literature says, is that we shouldn't do an isolated arthroscopic Bankart repair. That we should either go for Latarjet or that we should add Remplissage I don't know. I think that's the big conundrum for me.
Dr. Rachel Fran...: I think it's hard to say because we probably need some additional studies looking at this score in the setting of arthroscopic stabilization with a Bankart repair plus Remplissage. I think we need some longer term studies with that. And like anything else the techniques for Remplissage have changed dramatically over the last several years, as industry and implants help improve our ability to do that type of surgery. So that's going to be difficult study because techniques for that portion of the arthroscopic procedure have evolved over the last several years.
I still think there's a role for a lonely Bankart repair for the right patient, without adding a Remplissage, and without proceeding directly to a bony procedure. But I think we have to give caution to when we're deciding just to do that, and make sure we're not doing that out of ease or getting the surgery done quicker, and making sure we know our risk factors for our patients. Particularly for the hyperlax patient without bone loss. I think that Remplissage can play a huge role, but you do risk potentially over tightening a patient that's used to being pretty loose if they're hyperlax. But yeah, I still think there's a role for an isolated Bankart repair. I just think we have to know our risk factors, and the higher those factors as noted by the ISI score, the more we have to consider augmenting our procedures.
Dr. Rob Hartzle...: Right? So should it be less than two or three? That's my whole question is, do we really need more information to know? Because there's many, many studies that have the longterm followup that show a 20% failure rate for isolated arthroscopic Bankart repair. And the French literature supports rare use of it. That's my whole question is: What should we say about all of that literature? That the surgeries weren't well done? It was old technology? Are we going to be having this discussion in another five to 10 years and find out that it was still that high?
Dr. Rachel Fran...: That's a good question. What do you guys think?
Dr. Peter Chalm...: I am. Look, to answer your initial question Clay, I definitely think I'm doing more Latarjets then I was doing when I first started. I think the main thing that's changed for me, that I think is probably for a lot of people. In response to the careful work the military has done, that we're redefining critical bone loss. Definitely in patients in the 13.5% To 20% range. Those patients I did not do Latarjet on when I first started, and I've gotten a lot more aggressive with the Latarjet in that group. Especially when you have an ISI that's higher. When you have a contact collision, hyperlax, that kind of patient.
One of the things that I think is super interesting here is, we all talk about the Remplissage as though it's something you get for free. Which, I think that's what everyone thinks is that, Oh, you got a Remplissage? it's another 15 minutes of the OR, it cost you maybe one or two more anchors. And I think that's probably not going to be true in the long term. And I don't know in what way it's not going to be true, but it's just generally true that you never get anything for free. So there's going to be a cost to Remplissage, and I don't know if it will be cuff tears later on. I don't know if it will be ... I feel the range of motion thing has not played out. Definitely those patients have a harder recovery. But I think that we need to watch that closely in the longterm, because generally, in medicine, you never get anything for free.
Dr. Rob Hartzle...: Yeah. That's a great point, Peter. It's, it's more anchors, everything you said, it's harder to rehab. I rehab them slower with Remplissage, but to me it looks like the clinical outcomes are better. What's your sense about that, for the whole group?
Dr. Peter Chalm...: I would agree with you that there's literature would suggest that that's been my personal experience, that the recurrence rate is slower. I definitely think that they have a hard rehab. I don't [crosstalk] have themselves slower.
Dr. Rob Hartzle...: Yeah. I mean, what do you guys think about? It's an old idea that the Hill-Sachs lesion might be the "primary factor of why patients have symptoms". I mean-
Dr. Clay Nuelle: The instigator.
Dr. Rob Hartzle...: Yeah. And I just wonder if some of these patients who don't really have frank recurrent instability, but as Rachel was saying before, feel like there's something not quite right. And they guard their shoulder and say, "if I don't use it in a certain way it wants to come out.". I mean, is that their Hill-Sachs lesion just being symptomatic?
Dr. Rachel Fran...: It's so tough- [crosstalk 00:00:29:46].
Dr. Peter Chalm...: -Bone loss, or is it both?
Dr. Rob Hartzle...: Yeah, right?
Dr. Rachel Fran...: Or is it some component of hyperlaxity? We have the Beighton score. We have the general distalt of, are they flexible loosey-goosey person or are they not? But I don't think we fully understand the ramifications of generalized ligament hyperlaxity, just by using a Beighton score. It's the best we have, but that can all come into play too. And so, it's hard to know. It's really hard to know. Remplissage has become really popular in the last five years or so, because literature has expanded. I think it's been more popularized in conferences and the technique journals, et cetera. And again, it's relatively easy to do, relatively quick to do, but I agree with what Peter was saying. There's definitely no free lunch. It just hasn't been around long enough for us to know what the potential downstream ramifications are.
Dr. Rob Hartzle...: Have you all had a Remplissage complication yourself, or one referred? Because I've had a couple referred to me.
Dr. Peter Chalm...: What were the complications? Tell us.
Dr. Rob Hartzle...: [inaudible] [coughed hair 00:00:30:51], as you said. And that's, If you have a musculotendinous infraspinatus tear and you're 30, that's a bad problem. And I had another patient who had their deltoid Remplissaged into their rotator cuff.
Dr. Peter Chalm...: I haven't seen either of those. That's nasty.
Dr. Clay Nuelle: I was just going to say, the point you make is a good one though, for the longterm follow-up. Each of these things we do, that we're talking about here outside of a basic primary Bankart stabilization, is non-anatomic, right? Or we're creating these different non-anatomic structures in an effort just create a stable shoulder. And so I think each of these things definitely has to be critically evaluated longterm, as you alluded to and as you pointed to.
Dr. Peter Chalm...: So one of the things that I think is super interesting about that point is, it's true that the Remplissage is non anatomic and puts the rotator cuff attachment a place where it is not normally. People say the same about the Latarjet. What I think is interesting is that the baseline anatomy of the scapula, in patients with instabilities, not the same as the baseline anatomy patients without. We've shown that in a careful [Cisco] shape modeling study we did that showed that the Glenoid is taller and narrower. There's another military study that showed that previously, in addition to the coracoid is farther back, as is the scapular spine. The whole thing is rotated around to provide less support.
The other two things that are interesting is there's a study that [Moroder] did that show that the glenoid is less curved in patients with instability. And then there's also old data showing that the subscapularis is not normal in patients with instability. The subscapularis is more lax. So these things about the Latarjet that addresses all of those things. It moves the coracoid down, it builds the anterior inferior glenoid, and it tensions the subscapularis. So we refer to it as a non--anatomic operation, but in a lot of ways it may be making what was at baseline abnormal anatomy closer to normal anatomy.
Dr. Rob Hartzle...: [crosstalk] Peter, you just blew my mind with that. I think we have to just close now.
Dr. Rachel Fran...: I was going to say, it's comments like these that made me, in residency, refer to Dr. Peter Chalmers as the professor who is the smartest human alive.
Dr. Peter Chalm...: You guys got to stop. I just think there's a lot we don't understand about this, that we're going to understand more of. The thing that I think is nice about the Latarjet is you can point to longterm follow-up studies. There's longterm follow-ups from [inaudible 00:33:20], that's been done in Sweden and elsewhere. And in France to show that the study, this procedure does work in the long term. Obviously [Grouper's] study as well.
Speaker 1: It's a terrific discussion everyone, on shoulder instability. That concludes this special combined edition of the Arthroscopy Journal and American Shoulder and Elbow Surgeons podcast. Thank you everyone for listening. Please join each of us next time.