Dr. Justin Arner.:              Hello, everyone. This is Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today's episode will be a bit different. We're going to look back at the 2023 Annual Meeting, with AANA in New Orleans, and talk to a few of the presenters that we heard from. But first being Dr. Patzkowski from San Antonio in the military.

                                                Hello, everyone. I'm Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today have the pleasure of speaking with Jeanne Patzkowski. She's in San Antonio and the chair there. We just heard a great talk from her this morning about pan-labral repairs and some tips and tricks related to that. So we're going to speak a little bit about that and her practice and her role as the chairwoman in San Antonio.

                                                First of all, let's chat about your talk this morning. Great talk. One thing, early in practice, I had challenging issues with fluid extravasation with these big tears, having a systematic type of sequence. Can you just give us a little recap? You mentioned about sometimes starting up with the biceps, and a little bit about your thought process and philosophy with those types of tears?

Dr. Jeanne Patzkowski.: Sure, absolutely. They are relatively rare pathology, but for whatever reason, we do tend to see more of these combined labral lesions and the pan-labral tears in the military population. Whether that's just because of their daily occupational requirements, or I think also just a sense of pushing through things. We have a lot of folks who want to get through a mission, get through a deployment before they get their injuries taken care of, and so by the time we see them, that pathology has really just increased quite a bit.

                                                In terms of addressing them, I think just really having an organized approach to it is the most important component. The principles are the same, right? You want to get your anchors low, you want to get multiple points of fixation, you want to shift your capsule up, you want to have everything balanced, but when that tissue is so incredibly mobile and just detached circumferentially, it can be really hard to control. I've had so many times where the lasso will just hub out and you're just struggling so hard to get it right. So your percutaneous portals, really making sure your portals are perfect. My partners and I always joke around, beach chair versus lateral really doesn't send a matter.

                                                I go back and forth in my practice just based on different patients. I think it's nice for the resident education too, for them to see that, but really just making sure from the very beginning those portals are perfect, and if they're not, change them. Don't be afraid to just put that extra incision on to get to where you need to be.

                                                I think there's been so great innovations in the technology too. You can really get down lower than you used to be able to. You've got curve drill guides, straight drill guides. Really, the world is I think is your oyster, and it's just a matter of how are you the most comfortable and most fast while getting the job done. I think again, going to the top can be a nice place to start when everything is taken off. Just because you have that landmark, that biceps anchor, as long as that's still attached, I can really guide you as to where you can get one point started where you know it's anatomic, and then build the rest of your repair from there. But I think when you start in the front, you start in the back, I don't think it matters too much, and certainly the literature suggests that it doesn't.

Dr. Justin Arner.:              Right. One thing I thought was interesting in your talk is you mentioned, and I've struggled with the amount of capsule to grab and, you talked about hubbing out, did you call it the nip and tuck?

Dr. Jeanne Patzkowski.: The pinch tuck?

Dr. Justin Arner.:              The pinch and tuck. Nip and tuck is maybe a different subspecialty.

Dr. Jeanne Patzkowski.: Right, exactly.

Dr. Justin Arner.:              Tell us a little bit about that. I've never done that.

Dr. Jeanne Patzkowski.: So JT Tokish taught us that years ago at an AANA/SOMOS course, and I think it's been so valuable, not only just for the regular anterior posterior labral cases, but certainly this pan labels. So when you want that big bite of capsule, but you can't get all the way around with the length of the last or your suture passing device, just grab deep of the bite of the capsule first, and then come out with that needle tip, and then you can take a second pass entirely around the labor. That really nicely pinches all that tissue together. In a way that's just a lot easier to control when things are so robust.

Dr. Justin Arner.:              That's a good trick. Rather than trying to torque on the passer. I've broken one before, which is always a little nerve, nerve-wracking trying to find that.

Dr. Jeanne Patzkowski.: So miserable to get that out, right? Exactly.

Dr. Justin Arner.:              One other thing that other speakers were talking about, are you big fan, you mentioned the percutaneous type portals, are you doing a lot of six o'clock anchors and posterior anchors if it's more an anterior base thing? You mentioned that military is a different population. I'm sure you're seeing way more multiple dislocators than a lot of others, or post your instability too.

Dr. Jeanne Patzkowski.: Sure. I think when it's just a simple anterior Bankart, then I do like to go around and put that seven o'clock just more posterior anchor into. Just again, really balance that hammock and bring everything up inferiorly. If it's a case where I'm doing a remplissage at the same time, I'm less likely to do that because I think you get that same sort of effect from the REM massage.

Dr. Justin Arner.:              That's to be determined and continually we're learning.

Dr. Jeanne Patzkowski.: Absolutely.

Dr. Justin Arner.:              One other thing we were mentioning before we started recording was a little bit about your chairperson, chairwoman job. Can you tell us a little bit about your journey, and your current title, and what you do for the military? Because we were speaking before that. There aren't any other chairwoman in the military and certainly not many in civilian film either.

Dr. Jeanne Patzkowski.: Sure. It's absolutely been an interesting journey, not the sort of path that I thought I was going to take when I first started getting into residency, and certainly even just completing fellowship. I think that I owe a lot of time to the militaries. So under those circumstances, eventually you're either going to be at the table helping to make some of those decisions, or you're just not going to have a voice. And watching in some of our institutions what can happen there when physicians just relinquish that leadership responsibility, I think just can really have some devastating consequences. I'm a problem solver at heart, and so the chair path I thought was a little bit more intriguing to me than say the GME path. But I think they're just both incredibly valuable and important physicians inside the hospitals. So it's been a huge learning experience. I've been in this job now about 18 months, and there's a lot to learn.

                                                I think every day. There's days where I feel like, "Man, I have really just messed everything up today," and the stone is just rolled all the way right back down the mountain. And then you have days where you feel maybe it's slow and steady progress, but you realize that, "Yes, there's gains that are being made." I think just so much of it has been communication, and we were just talking about with the diversity panel, really trying to figure out what is it that drives people? What is it that motivates them? What is it that's going to help them get to that next stage in their development?

                                                Recognizing that not everybody wants the same path. Not everybody has the same interests and the same passions. I think one of my friends said it best, "You love all your children by treating them differently." So recognizing those differences and how you can apply them to that person's situation. And if all you're doing is just removing the hurdles from the really motivated person, then that's great. But if you're also just trying to sit down with that other person that doesn't know what they want to do and who they want to be in life. So I think those can be the parts of it that are really satisfying, and make up for those days that just feel incredibly frustrating.

Dr. Justin Arner.:              Very well said. Certainly in my own little world, certainly not like yours, but trying to just manage a few people on your personal team with different personalities.

Dr. Jeanne Patzkowski.: Absolutely.

Dr. Justin Arner.:              And just something that we don't really have training for any other people in business. Tell us a little bit about how you've leaned on mentors, or how you've learned this leadership path, because your military training is certainly different than ours. Tell us a little bit about that.

Dr. Jeanne Patzkowski.: Absolutely. I've had great mentors, both civilian and military as well. I think just those people, again, that recognizing and just really seeing, wanting to invest that time to develop people, right? Because that's, I think the important part of a person like a chair or program director is to say, "I have this platform, and I can use it to help you. I'm going to look down and in to bring you up because you're that next generation."

                                                So I really benefited from people that wanted to do that level of mentorship and sponsorship, and then just trying to figure out how can I then turn that and pay that forward. I think on the civilian side, AANA has been just such an important organization for me. Because for me there's always been this sense of I come to an AANA meeting, I can talk to a world expert, and I don't feel put out that like, "Who's this person who's so junior coming and asking these questions?" People are really excited here to share what they've learned, and it's not this sense of hoarding knowledge, and I have to keep it to myself to be on top. That's what I really love about AANA. I think that from a leadership perspective, a clinical research, every kind of perspective, this is a meeting where I come, and I enjoy the interactions with people. I learn an incredible amount, and I walk away feeling I've just made true connections. I just think that's so incredibly valuable and why I love coming here.

Dr. Justin Arner.:              Certainly AANA. I have the same experience with being unique as in inclusive of residents and junior residents and mentorship. They really have been front of us, so I feel the same. You're welcomed as a junior resident coming here trying to learn, saying, "What are they doing?" Just trying to gather some knowledge, and it's very inclusive.

                                                We're back after that discussion we had in the Exhibit Hall with Dr. Patzkowski. We're going to stay on the same topic of anterior shoulder instability, and talk a little bit more about bony type work with Dr. Galvin, who presented some of Dr Boileau's   research at the annual meeting in New Orleans.

Dr. Joe Galvin:                   So I'm Joe Galvin from Madigan Army Medical Center. I'm a orthopedic surgeon, mainly doing shoulder and elbow surgery.

Dr. Justin Arner.:              Joseph Galvin, we're thankful to have him here today. We were just speaking a little bit about his unique training and give Pascal Boileau's talk today and opinion versus screws and buttons. So could you first talk a little bit about your training, and seeing your extensive experience spending time in Europe, their philosophy versus your training in the United States, and your unique military population, what you've gathered from both sides of the ocean?

Dr. Joe Galvin:                   Sure. Yeah, so I did fellowship with JP Warner in Boston. As part of that, spent three months in Europe, first with Christian Gerber, then a month with Pascal Boileau, and a month with Laurent Lafosse. So they all manage things a little bit differently. Christian Gerber, I asked him, "What's your indication for Bankart repair? How much bone loss?" He said, "I don't have an indication for Bankart repair." So you have that side of the spectrum there. But they pretty much in Switzerland, we're doing primarily open Latarjet, and fairly aggressive with it.

                                                A lot of that is based on the evidence in the classic Zimmerman Gerber paper in JBJS 2016 that had 30 to 40% failure of arthroscopic Bankart versus there's a 3% red dislocation rate with their Latarjet. So they're very evidence-based. Then after that experience went to Nice, France with Pascal Boileau, who's also very aggressive with arthroscopic Latarjet. And so got to see his experience with his cortical button system. He's obviously a very skilled and masterful surgeon who's probably done a 1000 arthroscopic Latarjets. And as you saw in the presentation, has gotten very good healing rates and outcomes from that.

                                                And then moved on from there to watch Laurent Lafosse do an arthroscopic Latarjet in 59 minutes, but he uses screws. So when I came back, transitioned out of fellowship, and came back to Madigan trying to synthesize all of that data in addition to what I'd learned in the military during residency, I had to come up with my own practice algorithm. I think the most important thing that as I started practicing, and working amongst other sports partners and surgeons in the community, was understanding what the standard of care is in the US because we're not in Europe anymore.

                                                So in Europe it was very aggressive obviously for Latarjet. They do a lot of these things based on the evidence, but in the US it's a different ballgame I think. So I tried to be very strict on the indications for open Latarjet. I've probably done maybe 30 to 35 over the past three to four years, and as you know in the military, it's just high volume instability through actually the AANA SOMOS initiative. I had the opportunity to go down and spend three weeks with JT Tokish down in Mayo Clinic, Arizona. That was a transformative experience. Not just from the life lessons and leadership and mentorship that he provided, but also learning his arthroscopic remplissage technique with the double pulley single incision. So after I went down there coming back, having that as another tool in the tip bag, it's not just Bankart versus Latarjet. It's now you have this technique in the middle that you can do quickly and well, and potentially decrease complication rate for that subcritical bipolar off track lesion.

                                                That's been a huge help. So I think as you saw from the presentation, the last couple slides. The other thing that I've learned from Pascal Boileau was his arthroscopic Eden-Hybinette technique. So I haven't adopted his arthroscopic Latarjet technique with buttons, but I've had three cases now where I've used the cortical button fixation with iliac crest, and you're drilling from back to front, you pass the graph through the rotator interval, you're lateral to the conjoin, you take all of the neurovascular structure risk off the table, and you can do a Bankart repair to make it extra articular. In two of the cases, I added a REM massage using Tokish's technique because the patients had very deep off-track Hill-Sachs lesion. So that's been the evolution for me. It's basically learning from expert surgeons. I've had the opportunity to do that, which has been nice.

Dr. Justin Arner.:              It's a unique perspective being able to see all these different master surgeons from different avenues, and different parts of the world, and being able to synthesize what works in your community is certainly a skillset set. So for the people that weren't able to be at the meeting, tell us a little bit about your thought process, the data, the overall decision making with cortical buttons versus screws. If you could give a summary, and your opinion as well.

Dr. Joe Galvin:                   I think the first thing I think is the debate over screws or buttons. I think screws have stood the test of time. You achieve excellent fixation. We've all seen the complications of screws backing out or breaking. I think the majority, in my experience, the majority of complications with screws, I think it's almost this bimodal. So you have within a year complications, which are typically screws backing out. And from what I've seen from cases that have been referred to me are; they're typically screws that have a high divergence, so they're not placed at a good almost perpendicular angle to the glenoid. So those a lot of times those graphs go on to non-union, and the screws will back out, or they become symptomatic because the graft resorbs. So that's one population of screw related complications. And then the second is the longer term follow up where the superior half, the superior portion of the graft will resorb, and then it's irritating the subscap or the plexus.

                                                So I think that that's a real problem, as you saw in the presentation. I think that's an area where potentially cortical buttons can obviate the need for a secondary surgery later on to take out hardware. So I quoted one of the papers by Greaser et al, and it was published in JSCS 2013, where 35% of reoperations were due to screw, needing to take screws out. So if you don't have to undergo another operation because you use cortical buttons, that's a win. The cortical button from listening to Ivan Wong's data, I think that's a great study. I would not use cortical buttons with a distal tibial allograft. I think to me that seems pretty clear. The experience that from extrapolating from Pascal Boileau's, when you tension it to a 100 Newton's three times, you can achieve good healing at that interface.

                                                I actually, before I started doing, before I did the first case with portable buttons, I actually had heard from one of the implant company reps that Albert Gee up in University of Washington was using a similar system and having good results. So I actually called him. He does doesn't know me, but I called him up and I wanted to get his opinion. He said, "Yeah, I've been using this, and my partner and I have been using this, and we've been achieving good healing rates." So that along with Pascal Boileau's experience emboldened me to do it. The three cases that I've done it in, have achieved union and good outcomes. So I think you could achieve good outcomes, but clearly more study is needed. Obviously, good studies with CT scan follow-ups before. I think you can say definitively that it's safe.

Dr. Justin Arner.:              Great talk today, and thanks for sharing your opinions and experience. Such a unique training opportunity, which is huge that we've been following.

Dr. Joe Galvin:                   Thanks for having me. Appreciate it. Thanks a lot.

Dr. Justin Arner.:              That'll wrap up our discussion with Dr. Patzkowski and Dr. Galvin at the 2023 AANA annual meeting in New Orleans. I'd like to thank them for their time, and excellent discussions both on the podium, and in the Exhibit Hall.

Speaker 5:                           This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.

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