Dr. Justin Arner:

Welcome everyone. I'm Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today, I have the pleasure of speaking with Dr. Albert Lin, also at the University of Pittsburgh, associate professor and associate chair of sports medicine, as well as newly appointed residency program director in the Department of Orthopedic Surgery as I mentioned in Pittsburgh at UPMC. Dr. Lin was the senior author of the paper titled “Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes,” which is in press in the Arthroscopy Journal. Welcome, Albert, and thanks so much for joining me.

Dr. Albert Lin:

Justin, thanks so much for inviting me. I'm really honored to be here and talk a little bit more about our paper.

Dr. Justin Arner:

Yeah, this is great. I want to congratulate you and thank you for all the teaching you've done for me and for a lot of other residents that I worked under you. So I appreciate you always helping me out when I have a question and being a great mentor. So thanks for that. And again, for your paper, it's an important study that a lot of us have suspected, I remember when I was in high school, I dislocated my shoulder and some people said, "Just keep dislocating and it's fine." And others say, "Well, maybe you should fix this. We think it's not good to keep dislocating," but now we have some real data that you've provided for us. So I appreciate you doing this. It's not an easy task to undertake.

Dr. Albert Lin:

Well, to be fair, Justin, I don't feel like you needed that much help when you were a resident. It was always a real pleasure when you were on my service. I'm proud of everything that you've done and I'm glad that you're hosting this and we can have a great discussion regarding this study.

Dr. Justin Arner:

Thanks, Albert, appreciate it. So let's get right into it. Tell us a little bit about your study and the results. And I think that's kind of the most interesting is the difference in revision rate and how people did after one versus two dislocations.

Dr. Albert Lin:

Yeah, so like you were mentioning, Justin, I think the thought that we've always had as orthopedic sports surgeons and shoulder surgeons is that when we see an athlete that is dislocated that we maybe for a first time and then we maybe got them through the season and then we went to repair them afterwards that the tissue quality never looks great. The capsulolabral quality looks chronically attenuated, there might be some more bone loss that you didn't suspect the first time. And the reason we did this study was that if you look at the literature, they usually break down dislocations into primary dislocation versus recurrent dislocation. And even if you look at multi-center randomized control trials, of which there are several looking at non-op versus operative management for a first time dislocation, they always broke it down into one versus many. And while that is important, and those studies obviously have essentially demonstrated that at least all of those studies have demonstrated that first time dislocations or operating after first time dislocation has better outcomes than if you wait until it's become recurrent.

The more practical, I think, question was, does it really matter if it dislocates a second time? And I think that always entered my thought process and I think maybe yours and several of us who do this frequently, that if we just let the player play and then we just operate on them after they dislocate again, are they going to have the same outcome? And I think that's a very different question than if you're looking at a multiple dislocator who has dislocated two, three, four, five or x amount of times. And so when we granularly looked at these two cohorts, a first time dislocated versus a two-time dislocated and looked at how they did, surprisingly the two-time dislocated had a much higher failure rate and that we're looking almost at a 40% failure rate compared to in the teens failure rates percentage wise for a first time dislocation. And so I think reaffirmed a suspicion I always had that even if you wait for a second dislocation that you were going to have poor outcomes. But I was actually a little bit surprised about how dramatic that finding was.

Dr. Justin Arner:

Yeah, 40% is certainly impressive and the other listeners know here, we certainly still haven't solved this issue and one study comes to mind that I did with Dr. Millett as a fellow, we were thinking these ALPSA of tears that we're maybe getting better now that JP Warner taught us, one of your mentors, what that was and how they didn't do as well. Maybe now we elevate them better and we can repair them better with better anchors and really hasn't changed. So this recurrence and dislocation I think is really a big deal and your numbers are impressive.

One thing that I wanted to ask you about and mention is that you looked at the overall rate of recurrent dislocations and revisions, so the revisions were 19.5% versus 23%, which is on the kind of higher side of what we think, but I actually think that's really the accurate number. I think maybe it is partially selection bias, like you mentioned in your paper, that these patients are notoriously difficult to get ahold of and people that maybe have dislocated or have revisions you can get ahold of easier. But tell us what your thoughts are just in general about these high rates of revision and recurrent instability and how do you think we can improve on this issue, which we really haven't been able to over the last, say, 15 or 20 years?

Dr. Albert Lin:

Yeah, I mean, that's a great question, Justin. I think if you look at what we call as a failure, I think it's important to look in even in our own studies or when we look at other studies, what are we actually looking at? Are we looking at recurrent dislocation? Are we looking at just a subjective feeling of instability or subluxations? I really think if you pull all of those together, your failure rate probably is going to be higher than what we typically see in the literature. And I think being all-inclusive looking at that is important. The other thing is we're starting to see more data and I think Bob Arcerio is actually going to be presenting this at AOSSM of how failure rates following arthroscopic repair, may not show up within two years. He's actually, I think, going to present a study where they have 10-year follow-up and it looks like right around the seven-year threshold is when you start seeing increased bail rates.

And so I think that if we're going to be really honest about how successful we are with these surgeries, we also have to follow these out long term enough to capture all of them and make our definition relatively broad. What do I think is going on? I think there's a lot of things. I think even though our surgical techniques have improved, I think a lot we don't probably truly understand about the nature of the, in particular, soft tissue injury patterns. We've done some work as adjusted in our orthopedic robotics lab modeling dislocations, and we see capsular injury everywhere in the capsule. Non-traditional places like the posterior capsule, other areas. There's a lot of plastic deformation that I don't think you can maybe address with arthroscopic approaches or it's very difficult to do so. So there's certainly a ... there's capsular or soft tissue component we may not be addressing.

And then there's a lot of talk about bone loss and what that means, and certainly all of these patients, not all of them had no bone loss. Many of them had Hill-Sachs lesions, some subcritical bone loss. There's a complex interplay between the glenoid track, new concepts like near track lesions. This is a very dynamic phenomenon. And I also think that there's a lot that we are scratching the surface on regarding our understanding of instability. And what I mean by that is, you and I were both brought up under Freddie and everything is sort of about anatomy and there's probably a complex interplay too with the shape of the humeral head, the cavity of the glenoid actually these things have been shown in the literature. How we put all that together is very difficult. And so when we're looking just at a pure soft tissue procedure to address one component of injury, there is a lot I think that we're not probably addressing or even thinking about, which is probably the reason why we still see high failure rates.

Dr. Justin Arner:

I totally agree and I'd like to discuss this, how it's defined in the literature. If people say only the shoulder, if it came out the whole way and had to be reduced, but I think the subluxations and subjective feelings of instability maybe are just as important and sometimes that's really hard to define with patients. One thing that you brought up is the near track and different concepts and certainly on and off track as it was a great start and we've learned a lot more about that. I know it's a little off topic, but can you give the listeners just a little bit of a background about your distance to dislocation work? And you've had a few really good papers come out lately related to that.

Dr. Albert Lin:

Well, yeah, and so the reason we got into the whole concept about distance to dislocation was that the way we understand, or we had understood the treatment algorithm for on and off track was very binary and we're all familiar with the paper with Burkhart. That essentially concludes that if you are off track, you don't have bone loss in the glenoid, you add a remplissage and if you're on track and you don't have bone loss, then you can just do a Bankart alone. But my suspicions for that kind of just a practicality standpoint was I would have a 17-year-old football player who dislocated who was by measurement on track, but he might be one or two millimeters to being off-track. And I felt the case where he can just do a Bankart alone and be okay. And so that's really what stimulated the thought process behind, okay, there's a gradation between on track lesions.

Some of them are probably well on track and some of them are very close to being off track. And so how do you calculate that? Well, then we basically looked at a whole quarter of patients who are only on track lesions and only had an arthroscopic Bankart alone because that's what the algorithm had dictated that time. And then just started looking at the diminishing distances in which you would become an off track lesion. And not surprisingly, the closer you got the higher failure rates, we know we were observing. And there's a particular threshold for that. And depending on which studies you're looking at, our initial study was based on receiver operator curves and that value was around eight millimeters.

And so we kind of termed that a near track lesion, so a distance deification eight millimeters or less. And then our prior fellow from last year looked at that a little bit more granularly just looking at true failure rates as you went from X on track to zero. And as you got incrementally closer to zero at two millimeter diminishing intervals, that became exponentially more at high risk for failure and that threshold was 10. And so that's maybe a longwinded answer sort of what the newer track concept is, but we're trying to think of this more in a continuum in terms of the glenoid tract concept rather than a binary concept.

Dr. Justin Arner:

Yeah, it's a great explanation and thanks for that. One thing, I think we lost our connection just for a second. Could you just go back and describe the one portion how you calculated? I think we just missed kind of like a one sentence you discussed about that.

Dr. Albert Lin:

Yeah, yeah. So we calculated distance to dislocation in a very simple way, which was essentially taking the glenoid tract, subtracting the Hill-Sachs interval and then coming up with the distance to dislocation. And so if that value is negative, that's obviously an off-track lesion. If it's positive, that's considered an on-track lesion. And then there's a gradation with your on-track lesions where a worrisome on-track lesion or return a near track lesion is either eight millimeters or less or 10 millimeters or less depending on which paper you're looking at.

Dr. Justin Arner:

Yeah, perfect. Thank you so much for explaining that. Now getting back to your paper, I thought one thing that was interesting of the numbers that met MCID, which is more and more in the literature, which is I think a great addition, the people that had two dislocations before surgery, only 57% of them met MCID, and I feel like ASCS isn't the most stringent tool either, I think would you say that just speaks again for the first time dislocated, we really get aggressive and are you talking in clinic with these patients about this data and those kinds of outcomes like the ASCS score on MCID?

Dr. Albert Lin:

Yeah, I mean, I think in a yes and no, I mean, obviously the patients aren't going to really understand the concepts of MCID, but what I will tell them is this is very similar to the data that JT Tokish and team have reported on their famous 13.5% paper. In their paper, recurrent dislocation is just one primary outcome. And their patients, even though they did not have increased risk of recurrent dislocation at that 13 and half percent threshold, they had much lower outcomes scores, which I think is a much more stringent tool. And so I think what this speaks to is that even if you don't have the primary outcome of a recurrent dislocation or current instability, there is something going on that the outcomes from a subjective standpoint are not as robust or as good as if you had fixed these early.

And again, I think intuitively, and I might be wrong, but intuitively, I think ... I always joke with the residents or fellows, or not joke with them, but we always say in the operating room when we see these patients and these athletes after the season and repair them, how unpredictable the tissue quality looks at that time. And I think there is no question that if you leave these alone and these patients have an acute injury that the tissue just is, it's going to look chronic, it's going to look chronic after several weeks or several months have passed.

Dr. Justin Arner:

All very good points. And the one thing you mentioned earlier, tell me what you do personally and where do you think we're going with these in seasons, say, particularly football players that are first time dislocated? Are you bracing them? We know braces haven't been shown to really prevent recurrence, but are you bracing them and letting them play, giving them a discussion about higher failure rates, telling them they can't play? Or what conversation do you have with those kind of patients and their parents?

Dr. Albert Lin:

Yeah, it's always so interesting, because there's the medical side of things and there's sort of the practicality side of things. And I have always, I even think before any of this data, this paper, there was a lot of evidence already over the last 10 years that fixing these early just has better outcomes. And so I've always been more aggressive suggesting it or recommending it. I certainly think the clinical scenario matters. I think if this is a freshman in high school has several years of playing, I'm probably going to be a lot more aggressive recommending early fixation for a first time dislocated. If this is a collegiate athlete who has aspirations of going pro and they're in their senior year, I'm probably going to let them play this out and I'm going to explain what the risks are.

I don't think it's a wrong thing to let an athlete play through it, but they just have to understand that, one, the surgery to address it may not be as successful if you're definitely considering arthroscopic approach or that they're going to have a more aggressive surgery if they have further injuries after having other episodes. So I think these are always difficult conversations with the patient and the family and the parents. And if it becomes really difficult, I often just give them the two options about the risk and benefits are and then they choose. But in general, my overall bias is that I'm a little bit ... I feel that it is my duty to recommend early surgery for these and then have them decide.

Dr. Justin Arner:

Yeah, certainly educating them is the most important, like you mentioned. One thing that I've talked about before in our conferences with the fellows and something you mentioned before is remplissage and Dr. Bradley's a big proponent of open Bankarts. And tell us a little bit about, let's say this contact athlete. Are you doing remplissage in a lot of those patients that are, say the younger 16-year-old kid with a Bankart repair in a sizable Hill-Sachs who's still on track and just doing that on more risky scenarios? Do you have a role for an open Bankart in your practice? Are you ever doing primary Latarjet for patients that are at high risk that maybe don't have bone loss? Tell us kind of your thought process about those high risk patients.

Dr. Albert Lin:

Yeah, it's a great question. So one of the findings that Aaron Barrow study in AJSM where we looked at the on-track lesions and the higher failure rates, one of the secondary findings of that study was that contact athletes in general didn't even seem to abide by the track, the glenoid track concept. And what I mean by that was a contact athlete could be very on-track, they could have a deep distance to dislocation of 20 millimeters, and their recurrence rate universally was about three times higher than those that were not contact athletes. And so I think in that type of scenario, even when a contact athlete has an on-track lesion, I'm at this juncture being pretty aggressive adding a remplissage to it. And we actually are about to publish another paper on this concept of how much risk reduction there is an on-track lesion to put a remplissage and presenting the paper at AANA in May that if you add a remplissage in a high risk patient and high risk, meaning a near track lesion patient or a contact athlete, your risk reduction for recurrence is about 98% and it's dramatic.

So what it means long-term biomechanically, I think, we will have to find out, but remplissage for a first time dislocated in a contact athlete, I think makes the surgery much more robust in terms of recurrent instability. My role for open Bankart, I know Dr. Bradley loves the open Bankart in the contact athlete. I think it is an excellent procedure as well. If you look at literature looking at open Bankart repair in this type of scenario, in a contact athlete or even in general, I would argue that, and these are long term follow up studies, 15, 20 years, I would argue that the recurrence rates following open Bankart if well done, is still lower than arthroscopic Bankart. Now that's just looking at the literature, single digit recurrence rates. For me, the ideal person for an open Bankart is a contact athlete who has a small bony Bankart fracture or a bony Bankart.

I love doing an open Bankart in that scenario where I can incorporate the bony Bankart into it and then do a open capsular shift. In addition, that's my primary favorite indication. I also think that the zero to 10% bone loss and contact athlete is also probably a great indication for an open Bankart. The open Latarjet I would say with no bone loss, I have not Europeanized myself, I guess. I know the Europeans love to do an open Latarjet for primary instability even without bone loss. I just think it's not been adopted here in America because of the complication rates.

And it's a challenging surgery. I was just talking to a colleague of mine recently that every open Latarjet that I do always feels a little different in some ways, even though we're doing the same steps, we're trying to get our bone graft in place in the right place and we're putting the screws, there's something about it that I always, when I get the post-op X-rays, I always wonder where the screws are going to look like. It's just not, doesn't feel that reproducible. And I really wonder whether an open Latarjet is ever going to become a mainstay, primary stabilization surgery for lack of bone loss ever in America.

Dr. Justin Arner:

All great points and great review of the literature. It's something we look forward to at AANA. That's a great study. These studies are very clinically applicable and well done, and it's a hard population to really contact. So look forward to that. And like you mentioned with Latarjet arthroscopy journal paper kind of saying the same thing that people aren't reporting things as accurately regarding motion. So we really don't have great literature. And I saw a high level athlete that had an arthroscopic Latarjet done on the West Coast and there's a screw that looks like it's in the joint and the patient has terrible arthritis. It's a hard problem, which it's easy to happen. Certainly, I've never performed an arthroscopic Latarjet, it's certainly ... the surgeon did a good job, but it's, like you said, can be some devastating complications.

Dr. Albert Lin:

You know, Justin ... Are you more aggressive with remplissage as well? When I go to these meetings, the overall feeling I have had over the last maybe three years I would say or so is that there's this feeling that an arthroscopic Bankart alone at this juncture is really just not enough, that as a primary procedure, probably something else needs to be done. I know remplissage is popular currently, but people talk about the seven o'clock posterior anchor reefing up the whole posterior capsule. There's this just general sentiment that more needs to be done than an arthroscopic Bankart and the population of patients who are indicated for just an arthroscopic Bankart alone is probably kind of diminishing.

Dr. Justin Arner:

Yeah, I agree with you. I hadn't seen or done a lot of remplissage in my training and I initially started in practice doing it on patients that were maybe in their thirties that weren't as active in sports that just had very large Hill-Sachs lesions. And for my athletes that were football players, I was doing the posterior seven o'clock portal and a six o'clock anchor and putting one posteriorly trying to tighten the capsule up in the back. But I've become more aggressive like you have, discussing this in the contact athletes and I think I'll continue to become more aggressive. The thing that you mentioned, it makes me a little bit uneasy about what's going to happen with the infraspinatus long term. And you do hear stories of people having rotator cuff tears, which, knock wood, thankfully I haven't seen, but that can be a pretty devastating scenario.

I think very rare, but I think if we do it the right way, that's pretty unlikely. But you're right. I mean, having a 20, 30% failure rate from a surgery is just really unacceptable. So one last question I wanted to ask you was about revision arthroscopic repair, which unfortunately is fairly common. What's been your approach? Are you looking at patients if they have no bone loss saying, "Well, I think I can do a remplissage here." They have a fairly large Hill-Sachs lesion or an open Bankart, or do you think usually the answer is a Latarjet?

Dr. Albert Lin:

Yeah, I mean, I would say the short answer that is no. I think there are some individuals who are indicated for a revision Bankart. A number of years ago, we looked at a large cohort of our own patients at UPMC, a multi surgeon had a good number of patients, I believe it was around 90 to a hundred that had revision Bankart repairs. And this was before the days of where remplissage was popular. And what we found was that if you were highly critical of the or highly selective of the patients, that you could have a failure rate that was similar around 19%. And those risk factors, if you eliminate them, were age less than 22 years old that they had an off-track lesion. If you were critical with your patient selection and indicated those patients for revision Bankart, you could have a pretty reasonable outcome of the revision Bankart.

I think a lot of this also comes down to what the activity level of the patient is, right? And so a 25-year-old recreational athlete who has a recurrent dislocation is probably going to be a lot more likely to have a successful revision Bankart with or without remplissage or some augmentation rather than a 19-year-old that had a Bankart repair a year prior, two years prior and then relocated in player or football player. And so I think as with many things, I think your indications patient selection is really critical for this type of decision making. I think once you start veering on bone loss, particularly with attritional bone loss, I think that your approach probably has to be likely more aggressive than an arthroscopic approach and revision open Bankart and open Bankart as a revision for a failed primary arthroscopic stabilization, I think has a role.

Again, I think it's probably a great procedure in a zero to 10% bone loss category, particularly if patient has hyperlaxity and do all the things with an open Bankart that you can't do with an arthroscopic Bankart or doing some kind of a bone block procedure is certainly ... no one would argue doing that as well. So I think once you start veering on bone loss, I think that's when my thresholds for doing a revision arthroscopic Bankart starts to increase significantly. I would veer towards doing an open type procedure by that time.

Dr. Justin Arner:

Yeah, I think these are a great discussion. Certainly we could talk and people have weeks and days of conferences and discussions about this, but I think we better wrap up here and really appreciate your time. I know you're in Las Vegas at the academy. Appreciate you sneaking away and look forward to seeing all your great studies at AANA upcoming and appreciate your time.

Dr. Albert Lin:

Justin, thanks so much. I mean, as you can tell, I love talking about this subject. As you mentioned, their whole day symposiums that regarding this subject. And I think what makes this subject to me so fascinating and so interesting is that I really think we're just scratching the surface of it. I think the optimal surgery we haven't really discovered yet, I think are true understanding of bone loss, the complex interplay, the dynamic nature of it. I mean, the glenoid tract is something we measure on a 2D CT or a 2D MRI, and there's a lot of dynamic components to it. We don't take into account the soft tissues and how the patient moves. I just think it is such a field that has so much possibilities. And so I appreciate you having me on this podcast so that we can talk about it and you can allow me to drone on about the things that I'm passionate about, that I'm interested in. So I really thank you for the opportunity.

Dr. Justin Arner:

Yeah, thanks again for your time. Certainly, the case, we're just scratching the surface and it'll be interesting in 10, 15, 20 years what the procedures will be done and if we'll be looking back like people did with lateral release saying, "What were we thinking?" So hopefully we improve our techniques and make some excellent progress and we'll do that. Thanks to all your great work. So thanks again.

Dr. Albert Lin:

Thanks, Justin.

Dr. Justin Arner:

Dr. Lin's article entitled “Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation Comparable Clinical Outcomes” is in Press in the Arthroscopy Journal and is available online on arthroscopyjournal.org. Thanks so much for joining us. Views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.