Dr. Travis Dekker:
Welcome to the Arthroscopy Association's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal, nor are they meant to be used as treatment recommendations for patients. Welcome, everyone. I'm Dr. Travis Dekker coming from the United States Air Force Academy and this afternoon, I'm following up on part two of the Posterior Shoulder Instability Consensus Statement and get the privilege of welcoming two total rock stars, both Doctors Hurley and Dickens coming from my alma mater Duke University. They're both great friends, mentors, and amazing forward thinkers when it comes to shoulder instability, how best to evaluate and treat our patients. I think this will be a fun podcast as we can go back and forth. Eoghan's both in training under Jon and I think he's still training both John and I on how to do these types of studies, so welcome to the podcast to both of you.
Dr. Jonathan F Dickens :
Go Army. Welcome. Thank you, Travis. It's great to be here. Hope you guys didn't take last year's loss to Army too hardly, but looking forward to the discussion.
Dr. Eoghan T Hurley:
Yeah, thanks for having us on. Appreciate it.
Dr. Travis Dekker:
Well, gentlemen, we'll start today by discussing the article that was published in May of this past year entitled Posterior Shoulder Instability Part II: Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation/Return to Play - An International Expert Delphi Consensus Statement. It's great to have a follow on from our last episode where we went over diagnosis, non-operative management, and labral repair in the setting of posterior shoulder instability. So for this part two, Eoghan, Jon, can you discuss how you all came up with your questions? It's always an interest of mine, of where you guys start with this process. How do you begin with the questions and driving those?
Dr. Jonathan F Dickens :
Yeah, I think fortunately in this case, there's just so many questions already. If you just look at posterior shoulder instability and how we're recognizing it now, more frequently we're treating it or at least actively treating it more often surgically, it seems like. It's just raised so many questions and then that's going to open up the whole field of posterior bone loss and then how do we manage that. And we just have so many new questions that have come across and been developed as part of that increased recognition. And there's really been a lot of evolution specifically about posterior bone loss and how we recognize it and treat it, that it just lends itself nicely to a lot of questions that we face every day treating these patients. So I think overall it's just a really timely topic and we have so many questions that are relevant clinically that generating these questions has not been too hard.
Dr. Travis Dekker:
We talked a little bit about the methodology of how you all derived the questions. Can you kind of talk and go through that process a bit?
Dr. Eoghan T Hurley:
Yeah, so it was something where, again, there are so many questions and things to discuss on it. We wanted to be as comprehensive as possible and really take it from A to Z with the surgical procedures like what are the indications and just starting there and then going stepwise logically through it and just thinking each step of the process, what else is a question from indications and to bone loss, then to the actual technical factors alongside those and just try to say what is controversial or even a question.
Some things were just accepted standards but still just important to put in there and making it as comprehensive as possible. And so just took a bit of sitting down with Dr. Dickens and just trying to determine, "Okay, what do we need to ask here? What are we missing?" And then going back to our group and that's all the named authors on those two papers and saying, "Okay, here's what we're coming up with. What do people feel need to be asked on these topics?" And asked everyone to give us a few questions or what they thought was relevant or important or they'd want to get a consensus on too.
Dr. Travis Dekker:
I feel like asking questions in this type of study is a bit of a process and there's some nuance to it. When I go through and I was reading the questions we're so used to saying, "What is your exact percent bone loss cutoff and what is the exact amount of time that you're talking about rehab versus surgical intervention?" Tell us a little bit about that process when you're getting these questions back from the experts and then how you... It's almost like you don't narrow them down. It's almost like you broaden them out to make them more applicable to all of the experts because there are so many nuances to how every individual is doing it.
Dr. Jonathan F Dickens :
Yeah, Travis, I would say you're right, it is a iterative process and there's a lot of different opinions as you might imagine in terms of different opinions on how things should be treated coming from different experts with different practices and certainly different biases. And so, you're 100% right. A lot of it is carefully crafting the statements so that it is both specific and applicable clinically, but also that it is broad enough that we can get some degree of consensus to guide our treatment. And Eoghan, fortunately, has a lot of experience in this and has been very successful at helping us gain some consensus opinions through this process and really is an expert in this Delphi process.
Dr. Travis Dekker:
That was definitely something I came to appreciate after learning. I think that first podcast that we had, Eoghan was almost less of a highlight of the paper and more of an understanding and a teaching to the audience and those who listened about the process of this Delphi statement, this whole Delphi process. So truly appreciate you going through that last time. And one thing I noticed compared to last time was that management versus the diagnostics and non-operative care seemed to be a little bit more controversial. So can you discuss the overall results of this study in general compared to part one in terms of levels and degrees of consensus?
Dr. Jonathan F Dickens :
Well, thanks, Travis. I think you're 100% right. There's less consensus in the treatment overall compared to the diagnostics or part one paper. And I think that really just speaks to the fact that we're looking at a lot of things that we're still trying to figure out with the treatment and there's a lot more controversy as we're still learning here. I think no one would argue that there is a lot to learn as it pertains to bone loss in the posterior aspect of the shoulder and what the different treatment options are and what's really optimal. And so, I don't think either of us were surprised to see less consensus, although it's not to say there wasn't consensus because there definitely was strong consensus among many of our questions. And I know Eoghan can go into some of the specifics there.
Dr. Eoghan T Hurley:
Yeah, exactly what Dr. Dickens said there, and I don't think it was too surprising that some of the groups in the second paper had less consensus. There were just naturally the ones that are going to be more controversial. I mean diagnosis, non-operative management, and arthroscopic labral repair, much more straightforward relatively speaking. Still a lot to learn on those, but compared to when to do a bone block or when to do osteotomies, hardly surprising to see differences there. I think the biggest thing with bone grafting and osteotomies, even when they did have consensus, they just had a lower agreement or even a few that didn't reach it.
I think when people are disagreeing over when is an osteotomy even really indicated, and it depends probably largely on where you're from and we didn't break down because it was all anonymous where people voted depending on their demographics or geographics, but I think it would definitely play a role in what people certainly thought. Although the last part of it, rehab/return to play, again, I think there's so much even with anterior shoulder and disability that we don't know, which is still so much better studied.
I think there were certainly things where people had a much more clear point on, "This is how they at least get them back or this is how they rehab them," especially indications for revision, like when is time to go back. I thought that was probably not overly surprising that people general consensus there, but yeah, I think it shows one of the highlights of this is where there is no consensus, that's probably where we need to do more research rather than adding level one on level one where we already have some great evidence.
Dr. Travis Dekker:
Yeah. When you started to get into that, I think the ones that had moderate consensus or just consensus alone, those are the more generalized ones, but how about... I think it's easy to highlight the extremes, the ones that were absolutely unanimous and then those that didn't reach consensus. In looking at those specifics, since there was only a few that reached that threshold for both of those, can you take us through those results and maybe some of the trends that you found and that we discovered from these?
Dr. Eoghan T Hurley:
Yeah, absolutely. In the second paper really there is with no consensus for how should we be fixing bone blocks, is it going to be screws or suture buttons? There was no consensus there, which I don't think is overly surprising after we watched the debate at AOSSM this year that you were so good in the corner for. And again, that's anterior where there's a lot more evidence than even with osteotomies. When are they indicated? I think that's the biggest thing is, "All right, we generally agree this is roughly how they can be done if they are to be done," but for a lot of people they just say, "This is something I'm never going to do."
And that's the same with a lot of things, but where is that exact role even if it's not something I do? Who do I refer to and when? And then I think the rehab/return to play part of it, again, I don't think this is based on great evidence. I think this is just based on what we know about other pathologies and a lot of return-to-play evidence is based on an idea from an ACL that we've just extrapolated to another joint, especially the return-to-play criteria, which was unanimous. But again, there's no evidence behind that. That's really just the ACL criterion expanded.
And then I think lastly, routine imaging, everyone who gets a boning procedure, they agree that this should be done at all time points in the formal radiographs and then also revision surgery if someone is having pain further instability events, that's the kind of decision where we say, "Hey, maybe this is something where going back and doing another surgery is right at this time." Because I know that's indicating people is always... Seems like it's going to be an easier thing on these, but everyone has just nuances that they don't quite agree on.
Dr. Travis Dekker:
And even in that response, talking about glenoid osteotomy, John and I have both seen in our practices that we see these extreme cases with severe glenoid retroversion and recurrent posterior instability in it with dysplastic glenoid and then they're also retroverted when we're doing osteotomies and bone blocks and all these controversial questions. And then like you said at the end of the day, well, I'm still not going to do it. So how that impacts the study, this result is pretty interesting. John, do you have indications for glenoid osteotomy at this point?
Dr. Jonathan F Dickens :
Yeah, I think it's such an uncommon procedure in my practice and I think just in general that I still think it's hard to have a clear indication, a clear absolute indication for glenoid osteotomy. So that really leads us to a case-by-case and patient-by-patient decision-making. Actually, the statement that received consensus in our study was that there is no amount of glenohumeral retroversion that should be performed or should be indicated for, but it may be considered if it's in this case. In the case of this Delphi process greater than 15 degrees of retroversion, I'll tell you that 15 degrees of retroversion in my practice is not an absolute indication by any means.
And certainly, these patients have combined retroversion as well as significant glenoid bone loss. I think clinically the hard part, and I would prefer a posterior allograft bone block as my primary procedure, but I think the clinical concern that I do have in those cases with severe retroversion and bone loss is, "Are they going to still preferentially wear on that posterior graft?" We're going to have a decreased contact area, increased contact forces on the graft, and is that as well going to lead to increased wear or worse outcomes in those patients? So I guess that's a long-winded answer for what should be a relatively short answer, and that is I don't have any absolute indications currently for those patients. Because it is so uncommon in such a difficult problem.
Dr. Travis Dekker:
Well, and then in a similar vein, I've tried to learn from you technical pearls for posterior in arthroscopic-based bone blocks and we talk about grafting and fixation hot topics with Dr. Ivan Wong, talks about types of fixation of grafts for anterior instability. So can you talk to us a little bit about what your cutoffs are for bone grafting for these posterior bone loss cases? And then also because of those controversies for anterior instability, what are your fixation methods?
Dr. Jonathan F Dickens :
Yeah, yeah, I think this is still something that is evolving and I would say that where I am right now is cautiously optimistic in a select group of patients. There's been some systematic reviews, actually one that was done relatively recently in arthroscopy that looked at this and for distal tibia allografts, posterior distal tibia allografts, or bone blocks I should say. And really, the conclusion was that there weren't good outcomes. Now that included a whole host of patient populations and indications. And so I think it's hard to draw generalizable conclusions, but I think in the revision setting, so that's folks that have failed in my hands prior arthroscopic stabilization, have had repetitive or traumatic posterior subluxation or dislocation and bone loss, that's at least 15%.
Those are the patients that I would consider it on, though I still give caution to those that are highly competitive athletes or going back to or required to go back to contact collision-type sports because I do think that the long-term durability of this, while it's good for I think a recreational athlete, I think we do worry about long-term durability. In terms of the fixation, there's a lot of debate, especially in the interior free bone block literature for different types of fixation screws versus suspensory versus suture-based and maybe even hybrid fixations. And some of that depends on or is technically driven because it requires either Halifax portal for screws or whatnot, and it can be more difficult. Posteriorly actually, a screw-based fixation is simpler, it's easier, it's faster, and it also offers better time zero stability, especially for larger-width bone blocks. So I prefer and find that it's easier to do screw-based fixation for posterior free bone blocks.
Dr. Travis Dekker:
Regardless the size of graft, are you doing these arthroscopically?
Dr. Jonathan F Dickens :
I am. I think, for me, as I've started to develop the process of arthroscopic posterior bone blocks, I can see the posterior articular surface with the bone block. You can actually bring the graft in just deep to or medial to the posterior capsule and labrum. And it allows me to not only see my bone graft, it allows me... I can still see my screw fixation. For me, I do think that it is an overall easier procedure to visualize especially someone who has a large deltoid trying to do open posterior exposure and looking down a darker hole that's deep and trying to get visibility. But I think certainly in this case it's been beneficial to do this arthroscopically, for me.
Dr. Travis Dekker:
Well, I know and I'll have you lead in with this last question that I have is that I think all of us have discussed today just there's so much that we're learning about posterior shoulder instability in terms of management specifically, and we're going to continue to develop thresholds in terms of version, whether it's glenoid or combined dysplastic, posterior instability, recurrent instability versus a first-time unstable patient. I think we're going to continue to ask these questions.
From what you've experienced, both that you experienced at Duke and when you're in Ireland, what do you think is on the horizon when we're looking at posterior shoulder instability patient specifically? Then John, I'll back that up with you asking kind of the same question. This is something that we're both extremely passionate about. We see it a bunch in the military cohort. We do a ton of these and we're trying to make sure that we're doing the right thing, but we're also learning while we're doing it. So I'll start out with you, Eoghan, what do you see that's coming up next in the posterior world?
Dr. Eoghan T Hurley:
I think the biggest thing is that we're just seeing it more, looking for it more. It's a case of we're seeing it as opposed to it seeing us, which was much more the case a few years ago. I certainly think seeing all the rugby players at home, the incidence of combined or posterior instability as being the dominant driver there was probably much higher than everyone talked about before and something kind of appreciate more now. But I think the biggest thing in terms of this is trying to break it down and not just talk about the one-size-fits-all posterior instability, but really breaking down how Moroder has the ABC classification for posterior shoulder instability and trying to break down the patients to be more individual on how it occurs because it's not only anterior instability where it's all traumatic dislocation, it can be much more subtle in these kind of patients. And I think breaking it down to that and trying to individualize treatment based on what they have, I think is probably the next big driver in terms of recognizing and treating these patients.
Dr. Jonathan F Dickens :
Yeah, Travis and I think Eoghan's right all in on that. I think in terms of posterior bone blocks, I really see this as evolving a lot and probably in a similar fashion to how our interior bone block procedures develop maybe at a slightly slower pace as the technology, the technique is developed and I think becomes easier and more user-friendly. I'm interested to see the indications for this and when we might be doing this expand if we're seeing better outcomes. I think there's still a lot of room to go before we're doing this and lesser amounts of bone loss or less severe posterior instability cases. But I do think that there's been some optimism here, especially with some of the recent technological and technique developments that we could see more to come and maybe more indications for this procedure moving forward.
Dr. Travis Dekker:
Yeah. John, much of what I've learned about posterior shoulder instability has been from the likes of you, Kelly Kilcoyne, Dr. Preventza, Dr. Kouyoumdjian. They've been military folks that have really helped lead the way along these lines. Dr. Brett Owens. I mean, the whole crew has just really looked at this. I think there'll be just an explosion of literature as we recognize it more. And Eoghan you hit on that nicely is that we're finally looking for it and we're not ignoring it. We're not just simply debriding it.
Well, John, you've been a thought leader in terms of acromial morphology. I think we're going to replicate studies that look at anterior-type problems in terms of bony resorption with graft fixation and types of fixation. I think there's so much to learn and then the types of posterior instability, traumatic versus these atraumatic and older patients that maybe it's just arthritis stage one and how we're treating them and can we change their pathogenesis of the progression of their symptoms over time, I think is going to be something that's fun to explore and looking forward to folks like yourself continuing to ask those questions and explore it.
I really appreciate both of you being on the call today. I know both of you're busy, Dr. Hurley's writing Dr. Dickens notes and we appreciate it. As the Air Force will come back this year strong against Army. Army can never win two games in a row. So hopefully, we can make that happen this year. But I appreciate-
Dr. Jonathan F Dickens :
I will say.
Dr. Travis Dekker:
... you both very much for being on. I know, I know. Just cursed us maybe a little bit, but that's okay. So I appreciate both of you. And this was the article done by both of you in published in May of this year. It was entitled Posterior Shoulder and Stability: Glenoid Bone Grafting, Glenoid Osteotomy, and Rehabilitation /Return to Play - An International Expert Delphi Consensus Statement. And it can be accessed at ArthroscopyJournal.org.
Once again, the views expressed in this podcast, they do not necessarily represent the views of the Arthroscopy Association nor the Arthroscopy Journal, and they're not meant to be used as treatment recommendations for patients. This is a fun podcast. It's great to be on with you all as friends and thank you all to the listeners for supporting the podcast throughout these past few years.
Dr. Jonathan F Dickens :
Thanks, Travis. And maybe we can't agree on Army or Air Force, but I think we can agree on Go Duke. So it's been great to reconnect and lots of fun coming up this season. Best of luck to Air Force Academy and we'll be rooting for you in all your games except for one.
Dr. Travis Dekker:
There you go. I appreciate it.
Dr. Eoghan T Hurley:
Thanks so much for having us.
Dr. Travis Dekker:
The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal, nor are they meant to be used as treatment recommendations for patients.
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