Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Shoulder Instability

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Shoulder Instability · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  Okay, let's jump straight into it. That moment,
• 0:02
  your shoulder just gives way, pops out. Awful
• 0:07
  feeling. Instant pain, major disruption. But
• 0:10
  what's really frustrating, isn't it, is how often
• 0:12
  it happens again. That's the real problem, recurrence.
• 0:15
  We've been digging into the orthopedic literature,
• 0:17
  JAAS, and others, and some numbers are pretty
• 0:20
  stark. Yeah. For certain young, active patients,
• 0:23
  you know, after that first traumatic anterior
• 0:26
  dislocation, if they don't have surgery, nearly
• 0:30
  nine out of 10 might dislocate again. That statistic
• 0:33
  really sums it up. It's the core of what we're
• 0:35
  looking at today. Shoulder instability. Mostly
• 0:38
  traumatic anterior instability, right? That's
• 0:40
  the common one. That's the most frequent presentation,
• 0:42
  yes. And it's not just about reducing the dislocation,
• 0:46
  getting the ball back in the socket. No. It's
• 0:48
  fundamentally about understanding the damage
• 0:50
  done, often over multiple events, and how that
• 0:53
  damage makes the shoulder, well, inherently unstable.
• 0:57
  Exactly. So this deep dive isn't just about a
• 0:59
  simple repair. It's about how orthopedic thinking
• 1:02
  has moved on. It has. Towards much more precise
• 1:05
  diagnosis and really tailoring the management
• 1:08
  based on exactly what injuries you find. So our
• 1:11
  mission, pulling from these sources, is to get
• 1:13
  a handle on the current evidence. Spot on. What
• 1:17
  are the key factors driving treatment? How do
• 1:19
  surgeons pinpoint the real underlying problems?
• 1:22
  And crucially, What does a successful outcome
• 1:24
  actually look like, especially in stopping those
• 1:27
  repeat dislocations? That high recurrence rate,
• 1:29
  particularly in young, active people, it really
• 1:32
  stands out. It sounds like the who matters as
• 1:35
  much as the what. Oh, absolutely. Patient selection,
• 1:38
  understanding their specific risk profile. It's
• 1:40
  crucial for predicting the outcome and hopefully
• 1:42
  getting a good one. And what are the big risk
• 1:44
  factors the literature points to? Well, there
• 1:46
  are a few key ones that come up consistently.
• 1:49
  Younger age is a big one, especially under 20,
• 1:51
  maybe 25. Right. Male sex is another factor.
• 1:55
  And perhaps, obviously, playing collision sports
• 1:57
  or just participating in high -level athletics
• 1:59
  significantly bumps up that risk. So a young
• 2:02
  male athlete, they're right in the danger zone
• 2:05
  for it happening again. That's the highest risk
• 2:07
  group, yes. And because non -operative treatment,
• 2:11
  just rehab after the first time, it has such
• 2:13
  a high failure rate in these high -risk individuals,
• 2:17
  especially the younger ones. The trend is definitely
• 2:20
  towards surgery becoming the mainstay. Even for
• 2:24
  the first dislocation sometimes. Often for the
• 2:26
  primary instability in that demographic, yes.
• 2:29
  Not just for recurrences. The thinking is to
• 2:32
  intervene early, break that cycle before more
• 2:35
  damage occurs. Okay, so... If surgery's often
• 2:38
  the answer, that initial diagnosis has got to
• 2:40
  be spot on. You need to know exactly what broke,
• 2:43
  not just that it popped out. Absolutely foundational.
• 2:45
  Yeah. Can't stress that enough. It starts with
• 2:47
  a really meticulous clinical evaluation. Taking
• 2:49
  a proper history. Detailed history, yes. How
• 2:52
  did it happen? The mechanism. How many times
• 2:54
  before? Crucially, how old were they the first
• 2:56
  time it happened? Age at first dislocation matters.
• 2:58
  Big time. And also, what are their goals? You
• 3:01
  know, are they hoping just for pain relief? Or
• 3:03
  are they trying to get back to playing rugby
• 3:05
  or competitive swimming? Very different demands.
• 3:08
  Makes sense. And the physical examination, what
• 3:10
  are you looking for there? The exam is key for
• 3:12
  assessing the degree of instability. How much
• 3:15
  does the humeral head, the ball, actually move
• 3:18
  relative to the socket, the glenoid? How do you
• 3:21
  test that? We assess glenohumeral translation
• 3:23
  and use provocative tests. Things like the apprehension
• 3:27
  and relocation tests, trying to mimic that feeling
• 3:30
  of instability the patient gets. See if you can
• 3:32
  make it feel like it's going to pop out. Exactly.
• 3:35
  And then see if relocating the head, sort of
• 3:37
  pushing it back gently, makes that feeling go
• 3:40
  away. We also look for general joint laxity.
• 3:43
  Like being double -jointed elsewhere. Sort of.
• 3:45
  Though the source has mentioned general scores
• 3:47
  like Baton aren't always that helpful, specifically
• 3:49
  for the shoulder. Things like excessive external
• 3:52
  rotation or a sulcus sign that little dimple
• 3:55
  under the shoulder suggesting downward laxity
• 3:57
  could be more telling for the shoulder joint
• 3:59
  itself. Okay, so history, exam, then you need
• 4:02
  to look inside presumably. Imaging. Imaging is
• 4:04
  non -negotiable, really. It confirms what you
• 4:07
  suspect clinically, but more importantly it identifies
• 4:09
  the specific structural damage. Starting with
• 4:12
  x -rays. Usually plain radiographs, yes. They're
• 4:14
  good for gross issues alignment, obvious fractures,
• 4:17
  and specific views like the grassy, axillary,
• 4:21
  burnigo, striker notch, west point, they help
• 4:24
  visualize the bone shapes better. Looking for
• 4:27
  those bony defects? Precisely. But, and this
• 4:30
  is important, the sources point out standard
• 4:33
  x -rays often miss more subtle bone loss, especially
• 4:36
  if it's not a fresh break or a really chronic
• 4:38
  problem. Right. So x -rays for the big bony picture.
• 4:41
  What about the soft bits, the ligaments, the
• 4:44
  labrum? That's where MRI comes in, or M .R. Arthrography
• 4:47
  MRA. These are essential for evaluating the soft
• 4:49
  tissues. The labrum, capsule, ligaments. Exactly.
• 4:53
  And importantly, in patients over 40, the rotator
• 4:56
  cuff tendons as well. They can tear during a
• 4:58
  dislocation too. MRA involves injecting dye.
• 5:01
  Yes. Contrast dye into the joint. It's generally
• 5:03
  considered more sensitive for picking up more
• 5:05
  complex or subtle tears, things like pan -laboral
• 5:08
  tears going all the way around, or SLAP lesions
• 5:10
  up top where the biceps attaches. And standard
• 5:13
  MRI. Standard MRI is noted as being particularly
• 5:16
  good for those anterior labrum tears, the classic
• 5:19
  bankart lesion. And checking the rotator cuff
• 5:21
  in older patients is vital. Finding a tear there
• 5:24
  can definitely change the surgical plan. Okay,
• 5:27
  MRMRA for soft tissue. What if you suspect significant
• 5:30
  bone damage that the x -ray didn't really show
• 5:32
  clearly? That's when CT scans become crucial,
• 5:36
  particularly 3D CT reconstructions. Why 3D? The
• 5:39
  sources are very clear on this. The anphase sagittal
• 5:42
  view you get from a 3D CT reconstruction is the
• 5:45
  best way to accurately measure to quantify the
• 5:49
  amount of glenoid bone loss. And getting that
• 5:51
  measurement right is critical. Absolutely vital,
• 5:54
  because that number, that percentage of bone
• 5:56
  loss, heavily influences the treatment decision.
• 5:58
  And the sources really drive home how important
• 6:01
  these bony injuries are, don't they? They're
• 6:02
  not just side effects, they dictate the whole
• 6:04
  strategy. They really do. The two main bony problems
• 6:07
  in recurrent instability are glenoid bone loss,
• 6:10
  GBL, and hill -sax lesions, HSLs. GBL is damage
• 6:14
  to the socket rim. Yes, wear or a fracture off
• 6:16
  the front edge of the glenoid socket, the shallow
• 6:19
  dish the ball sits in. And the hill sex is on
• 6:21
  the ball part. Correct. It's an indentation,
• 6:23
  a defect usually on the back, upper part of the
• 6:26
  humeral head caused when the ball impacts the
• 6:29
  sharp glenoid rim during the dislocation. It's
• 6:31
  like the ball hitting the edge of a damaged cup.
• 6:34
  It dents the ball and chips the cup rim further.
• 6:37
  That's a good analogy. It's often a cycle of
• 6:40
  progressive damage. Each dislocation can make
• 6:42
  both defects worse. And the sources talk about
• 6:45
  a newer way of thinking about Hillsac's lesions,
• 6:48
  on -track versus off -track. Yes, that's a really
• 6:51
  important concept now. It seems to be a more
• 6:53
  reliable way to predict recurrence and surgical
• 6:56
  outcomes compared to the older idea of just engaging
• 6:59
  versus non -engaging lesions. What's the actual
• 7:02
  difference, on -track versus off -track? It's
• 7:04
  about biomechanics. Think about the glenoid track,
• 7:07
  the contact area on the socket. An on -track
• 7:10
  Hillsac stays within that contact zone during
• 7:12
  normal shoulder movements. It's there, but it
• 7:14
  doesn't slide off the edge. An off -track lesion,
• 7:17
  however, is big enough or positioned so that
• 7:20
  when the arm moves into an unstable position,
• 7:22
  like abduction and external rotation, that defect
• 7:25
  on the humeral head actually translates medial
• 7:28
  to the front edge of the glenoid. It essentially
• 7:30
  falls off the track. It loses the bony stability
• 7:32
  of the saccharin. So off -track means it can
• 7:35
  basically slip past the point of no return much
• 7:38
  more easily, leading to another dislocation.
• 7:41
  Precisely. Identifying an off -track lesion is
• 7:44
  critical information. It changes the whole stability
• 7:47
  equation and really pushes you towards surgery
• 7:49
  that addresses that humeral head defect too,
• 7:52
  not just the glenoid side. And the amount of
• 7:54
  glenoid bone loss is just as critical. Are there
• 7:56
  specific percentages that trigger different treatments?
• 7:59
  Yes. The literature talks about definite thresholds.
• 8:01
  There's a bit of variation. But common figures
• 8:04
  are, say, less than 10 % or 13 .5 % GBO. OK,
• 8:08
  minimal loss. And in intermediate zone, maybe
• 8:10
  13 .5 % up to 20 % or 25 % loss. And then significant
• 8:14
  loss. than 20 -25%. Crossing these thresholds
• 8:17
  usually means you need a different surgical approach
• 8:19
  to get stable. It sounds like knowing these numbers,
• 8:22
  understanding the bone damage, it almost creates
• 8:23
  a flow chart for treatment. That's absolutely
• 8:26
  the direction things are going. An algorithmic
• 8:28
  approach. The type and amount of bony damage,
• 8:31
  the GBL percentage, the on -drack -off -track
• 8:34
  HSL, combined with pager factors like age and
• 8:37
  activity level, that dictates the best strategy.
• 8:40
  So arthroscopic surgery isn't always the answer.
• 8:43
  Arthroscopic stabilization is often the first
• 8:45
  thought, and it works well for many, but the
• 8:47
  sources are clear. It's not one size fits all.
• 8:50
  Especially not when you've got significant bone
• 8:52
  loss or other high risk factors. Right. So let's
• 8:55
  walk through the surgical options then. Starting
• 8:57
  arthroscopically, what's the standard go -to?
• 8:59
  The foundational arthroscopic procedure is the
• 9:01
  bank cart repair. Using keyhole surgery scope
• 9:04
  and small instruments to reattach the torn anterior
• 9:07
  labrum back to the bone of the glenoid rim. Using
• 9:10
  little anchors? Using suture anchors, yes. The
• 9:12
  aim is to restore that bumper effect of the labrum
• 9:15
  and tighten up the capsule a bit. And when is
• 9:16
  that the recommended route? Primarily for patients
• 9:19
  with minimal or no significant glenoid bone loss.
• 9:23
  Generally cited as, you know, 0 -10 % GPL. Some
• 9:26
  even suggest considering it for young, high -risk
• 9:29
  athletes with less than 5 % loss, just because
• 9:32
  their recurrence risk without surgery is so high.
• 9:35
  How well does a standard bank card work on its
• 9:37
  own? Well, the results vary quite a bit in the
• 9:39
  literature. Recurrence rates reported anywhere
• 9:41
  from, say, 6 % up to over 35%. That's quite a
• 9:45
  range. It is. But here's the crucial bit. tying
• 9:48
  back to bone loss. Studies show a dramatically
• 9:51
  higher recurrence rate, sum up to 67 percent,
• 9:53
  if you do a standard bankart repair in someone
• 9:55
  who does have significant bony defects. Like
• 9:57
  that inverted pair glenoid shape from bone loss
• 10:00
  or an engaging hillsack. Exactly. Compare that
• 10:03
  to patients with no bone loss beforehand, where
• 10:05
  recurrence after a bankart can be as low as four
• 10:07
  percent. Wow. That difference is massive. It
• 10:10
  totally underlines why you need that precise
• 10:12
  imaging first. Absolutely. and the risk factors
• 10:15
  for a bank art repair failing echo the general
• 10:17
  recurrence risks, but add surgical points. Younger
• 10:20
  age? male, more prior dislocations, high -level
• 10:23
  sport, using fewer anchors, more glenoid bone
• 10:26
  loss, and having a significant HSL or an ALPSA
• 10:30
  lesion. What's an ALPSA lesion again? It's where
• 10:33
  the torn labrum heals, but it heals in the wrong
• 10:35
  place, peeled off, and shifted medially. It doesn't
• 10:38
  function as a bumper anymore. OK. So if there
• 10:41
  is some bone loss, say, in that intermediate
• 10:43
  10 -20 % zone, or a tricky hillsax, but maybe
• 10:46
  not bad enough for open surgery, Can you boost
• 10:50
  the arthroscopic approach? Yes, definitely. The
• 10:53
  literature talks about arthroscopic plus procedures
• 10:55
  for these sorts of situations. Two common ones
• 10:58
  are combining the bankart repair with a rimplissage
• 11:00
  or doing a double -row capsule labral repair.
• 11:03
  Rimplissage? Interesting name. What does that
• 11:05
  involve? Rimplissage means filling in in French.
• 11:07
  It's a technique used for those engaging or critically
• 11:10
  off -track hill -sax lesions, usually when the
• 11:12
  glenoid bone loss isn't too severe, maybe under
• 11:14
  25%. And the goal is to stop that hill -sax catching.
• 11:17
  Exactly. You arthroscopically stitch the posterior
• 11:21
  capsule and often part of the infraspinatus tendon
• 11:23
  from the rotator cuff right into that hill sacks
• 11:26
  defect on the back of the humeral head. So you're
• 11:29
  literally filling the dent? Pretty much, yes.
• 11:32
  Filling it with soft tissue to stop it dropping
• 11:34
  off the glenoid edge when the arm's in that vulnerable
• 11:36
  position. Does it work? Studies show good results
• 11:39
  in preventing recurrence in the right patients.
• 11:42
  The main potential drawback mentioned is that
• 11:45
  tethering the tendon there can sometimes limit
• 11:47
  external rotation slightly. Might be an issue
• 11:49
  for throwing athletes, for example. Okay. And
• 11:52
  the double row capsule labral repair? That's
• 11:55
  suggested for moderate glenoid bone loss. Maybe
• 11:58
  10 -20 % when the soft tissues are still good
• 12:00
  quality and there isn't a major hill -sax issue.
• 12:03
  How's it different from a standard bain -carte?
• 12:05
  Instead of just one row of anchors on the glenoid
• 12:07
  rim, you use two rows, one on the rim, and another
• 12:10
  set further medially on the neck of the glenoid.
• 12:12
  What's the idea behind that? The idea is to create
• 12:15
  a much broader, more robust footprint for reattaching
• 12:18
  the labrum and capsule. Trying to build a stronger
• 12:21
  buttress, essentially. The sources mention it,
• 12:23
  but also note there's still limited comparative
• 12:25
  data. more research needed to really prove its
• 12:29
  long -term value against other options for that
• 12:32
  level of bone loss. Right. So arthroscopic options
• 12:34
  cover minimal loss or can be augmented for moderate
• 12:37
  loss or specific HSLs. What happens when the
• 12:40
  glenoid bone loss is really significant over
• 12:43
  that 20 -25 % mark? When you cross that threshold
• 12:47
  or sometimes with specific off -track HSLs where
• 12:50
  other methods won't cut it, the literature generally
• 12:52
  points towards open surgery. Arthroscopic fixes
• 12:55
  alone often aren't enough to restore stability
• 12:57
  then. And what are the main open procedures discussed?
• 13:00
  Well, one is specifically for when there's a
• 13:02
  displaced glenoid fracture fragment that represents
• 13:04
  significant bone loss, say over 20%, that's glenoid
• 13:07
  open reduction and internal fixation or IF. Fixing
• 13:10
  the broken teeth back on. Exactly. Open up, put
• 13:12
  the bone fragment back where it belongs, and
• 13:14
  fix it with screws or maybe a small plate. How
• 13:16
  does that fare? The evidence base is a bit smaller
• 13:18
  compared to other procedures. One study showed
• 13:21
  no redislocations if you get good fixation in
• 13:23
  the right fracture types. But it also noted some
• 13:26
  patients had hardware issues or maybe didn't
• 13:28
  get full function back. It's really reserved
• 13:30
  for those acute displaced fractures where fixing
• 13:33
  the original bone makes most sense. Okay. And
• 13:36
  the other big open procedure, the one often mentioned
• 13:39
  for significant bone loss. The Latarjet. Ah,
• 13:42
  yes, the Latarjet. Definitely a key procedure
• 13:45
  when glenoid bone loss is substantial over that
• 13:48
  20 -25 % mark, usually, or for certain off -track,
• 13:52
  hill -sax lesions where other options aren't
• 13:54
  suitable. It's really designed for significant
• 13:57
  bony deficiency. Remind us what the Latarjet
• 13:59
  actually does. It involves taking a piece of
• 14:02
  bone called the coracoid process. It's part of
• 14:04
  the shoulder blade along with its attached tendons.
• 14:06
  The biceps and corcabrachialis. That's right,
• 14:09
  the conjoined tendon. transferring that whole
• 14:11
  unit, the bone block and tendons, to the front
• 14:14
  of the glenoid socket, fixing the bone block
• 14:16
  there with screws. And that creates stability
• 14:17
  how? It gives you what's called a triple blocking
• 14:19
  effect. First, the bone block itself extends
• 14:23
  the glenoid surface, acting as a physical buttress.
• 14:26
  Stops the ball sliding forward. Yes. Second,
• 14:28
  the transferred conjoined tendon acts like a
• 14:30
  dynamic sling, tightening up when the arm goes
• 14:33
  into abduction and external rotation, that unstable
• 14:36
  position. Right, a check screen effect. And third,
• 14:38
  you usually repair the capsule over the transfer
• 14:40
  as well, adding more stability. So it's bone,
• 14:43
  dynamic tendon sling, and capsule repair. A combined
• 14:46
  approach. Very much so. And the sources report
• 14:49
  good success rates in terms of restoring stability,
• 14:53
  preventing recurrence, often 0 % to maybe 9 %
• 14:56
  recurrence in those difficult cases with significant
• 14:59
  bone loss. It's very effective for stability
• 15:02
  when the bone structure is compromised. So why
• 15:04
  isn't it the first choice for everyone with bone
• 15:07
  loss, given how stable it makes things? Well,
• 15:09
  it's a bigger operation. It's open surgery more
• 15:12
  involved in arthroscopy. And it does carry a
• 15:14
  higher risk of complications. Like what? Things
• 15:16
  like nerve injury, there are important nerves
• 15:18
  nearby infection, or problems with the bone graft
• 15:21
  healing or the screws. Reported complication
• 15:23
  rates can be up to 25 % in some series. So it's
• 15:26
  a trade -off, stability versus risk. Exactly.
• 15:29
  That higher risk profile is why it's generally
• 15:32
  reserved for cases where the indication is really
• 15:34
  strong, that significant bone loss, or maybe
• 15:37
  a failed previous surgery, or an off -track HSL
• 15:40
  that can't be managed arthroscopically. It's
• 15:43
  usually not the first line treatment for all
• 15:45
  instability. Are there other ways to add bone
• 15:47
  to the glenoid apart from letarget? Yes. The
• 15:50
  source has mentioned free bone block procedures.
• 15:52
  Using bone graft, either from the patient themselves,
• 15:55
  often the iliac crest, the hip bone, or using
• 15:57
  donor bone, allograft, and fixing that to the
• 16:00
  anterior glenoid. These are sometimes suggested
• 16:02
  as potentially having a lower nerve risk than
• 16:04
  letarget, theoretically, and they're also good
• 16:07
  options if a previous letarget or other bone
• 16:09
  block has failed. We focused a lot on traumatic
• 16:12
  anterior instability. What about other types,
• 16:15
  like being unstable in multiple directions, or
• 16:18
  dealing with kids whose bones are still growing?
• 16:20
  Good point. The sources do touch on these. Multidirectional
• 16:23
  instability, MDI, is a different beast altogether.
• 16:27
  How so? It's usually instability in two or more
• 16:29
  directions, front, back, or down. Often linked
• 16:32
  more to general ligament looseness, you know,
• 16:35
  being naturally hypermobile rather than one big
• 16:38
  traumatic tear. So the cause is different? Often,
• 16:40
  yes. And distinguishing MDI from traumatic unidirectional
• 16:44
  instability is vital because the treatment starts
• 16:47
  differently. How do you manage MDI initially?
• 16:50
  Almost always starts with non -operative treatment,
• 16:53
  a really intensive, focused physiotherapy program,
• 16:56
  strengthening the rotator cuff, the muscles around
• 16:58
  the shoulder blade to improve dynamic control.
• 17:01
  And surgery? Surgery, usually tightening the
• 17:03
  capsule arthroscopically, a cascular placation
• 17:06
  or shift, is really only for cases where a prolonged,
• 17:09
  dedicated rehab program hasn't worked. And even
• 17:13
  then, the literature suggests surgical outcomes
• 17:15
  for MDI can be less predictable, maybe not quite
• 17:18
  as good as for traumatic instability. And what
• 17:20
  about the youngsters? Skeletally immature patients
• 17:23
  with open growth plates. That must be tricky.
• 17:26
  It absolutely adds complexity. You've got to
• 17:29
  protect those growth plates, the physis. Prompt
• 17:31
  reduction of the dislocation and some immobilization
• 17:34
  is standard first aid. But what about surgery?
• 17:37
  Well, for athletic teenagers, say 14 or older,
• 17:41
  who have a traumatic dislocation and a clear
• 17:43
  bankart tear is found. The sources suggest early
• 17:46
  surgery might be warranted. Even though they're
• 17:48
  still growing. Yes, because their risk of recurrence
• 17:51
  without it is just so high. For younger children,
• 17:55
  it's less clear cut after a first dislocation.
• 17:57
  But if they start having recurrent instability,
• 18:01
  surgery is generally considered, though the techniques
• 18:03
  have to be adapted very carefully to avoid injuring
• 18:06
  the growth plate. Okay. So pulling all this together,
• 18:08
  then, if you had to summarize the main message
• 18:10
  from this deep dive into how we manage shoulder
• 18:12
  instability now. I think the core message is
• 18:15
  that the whole field has evolved. It's way beyond
• 18:17
  just fix the labrum. While arthroscopic repair
• 18:21
  is still common, the absolute game changer, the
• 18:23
  critical factor driving strategy and outcome.
• 18:25
  is identifying and accurately measuring the bony
• 18:28
  damage. Specifically the glenoid bone loss and
• 18:31
  the hill -sax lesion. Exactly. Especially quantifying
• 18:34
  that GBL and understanding if the hill -sax is
• 18:37
  on track or off track. That information is paramount.
• 18:41
  And that bony picture dictates the treatment
• 18:43
  algorithm. Precisely. The amount of GBL, primarily,
• 18:46
  tells you whether a simple arthroscopic repair
• 18:49
  is likely enough, or if you need an arthroscopic
• 18:52
  pluses procedure like remplussage, or if you
• 18:54
  really need to go to an open reconstruction like
• 18:56
  a latarjet or free bone block to restore proper
• 18:59
  bony stability. It's incredible, really, how
• 19:02
  understanding the bone in such detail changes
• 19:04
  everything for what seems like a common injury.
• 19:07
  It really underscores the complexity, doesn't
• 19:09
  it? And, you know, the sources remind us it's
• 19:11
  still evolving. We need more research to validate
• 19:13
  some techniques like the double row repair and
• 19:15
  always looking for ways to improve outcomes and
• 19:17
  reduce complications for the bigger procedures
• 19:19
  like Le Tarjet. It makes you think, doesn't it?
• 19:22
  Considering how much this precise, lesion -specific
• 19:25
  understanding of bone changes the game for shoulder
• 19:28
  instability, how could Applying that kind of
• 19:31
  detailed algorithmic thinking based on the specific
• 19:34
  damage help us tackle other complex problems.
• 19:36
  Maybe not just in medicine, but in other fields
• 19:38
  too.