I appreciate the opportunity to present from ANA and AOSSM. So this is my disclosures. They're available on the Academy website. So coracoid transfer, the latter is a procedure that was designed and described initially for anterior glenoid bone loss associated with poor anterior capsular tissue. It's described as an open approach that revolves a vertical incision with a delta pectoral approach with coracoid exposure and then coracoid osteotomy, placing it through a subscapular split with fixation to screws of the glenoid neck. This was recently modified by Dr. LaFoss who talked about a arthroscopic Latter Jay procedure that basically copied the open procedure, again, fixation with screws. Even more recently, a second arthroscopic technique was described with a guided technique along the glenoid with button fixation. So today's focus, we're gonna look specifically at graft positioning, graft healing, complications and the learning curve associated with the arthroscopic Latter Jay as compared to the open Latter Jay. So we know that in graft positioning in sagittal plane or vertically, 50% of the graft should be below the glenoid equator. In the axial or horizontal plane, the graft should be aligned with the subchondral bone as opposed to the articular surface. We know that two medial placement of the graft results in recurrent instability and two lateral placement of the graft can result in glenohumeral arthropathy. Also in the axillary plane, the orientation of the fixation is important with increased angulation being associated with poor screw fixation, closer proximity to the suprascapular nerve as well as humeral head abrasion on the screw heads. So poor positioning has been well described even in the open procedure. Hovelius described a 67% rate of poor block positioning in the open procedures and this is confirmed in even later studies. In the arthroscopic technique, the graft positioning is more difficult because we're constrained by the position of the portals to the trajectory of the graft. So this is a right shoulder in the beach chair position. Looking from anterior superior, you can see the defect on the glenoid. We bring a switching stick through from posterior to the central portion of the defect on the glenoid and then we'll go through the subscapularis lateral to the conjoined tendon to avoid the neurovascular structures. This is then pushed through the pectoralis major to create our medial portal using an inside out approach. We can then perform the subscapularis split which is performed then lateral to the switching stick for safety and then it was progressed medially and then one can project their trajectory to the glenoid using this channeler device that can show where your positioning will be once you try to put your graft in to make sure you have enough exposure. So the arthroscopic latergi can put the bone block in the good position. It's better in the sagittal plane than the axial plane. When you compare the three techniques that being open latergi with screws, arthroscopic latergi with screws and the arthroscopic button technique, you can look at the differences in variabilities in these techniques. So the percentage of the graft below the equator in the sagittal plane, there were no differences in variability between these three techniques. In the axial plane with position relative to the joint line, the arthroscopic screw technique was the most variable and in the angulation study looking in the axial plane, the arthroscopic scope button technique had the lowest variability probably secondary to the use of the guide that improves your accuracy. When we look at graft healing in studies that have compared open latergi with screw fixation versus those with open screw, excuse me, with double button fixation arthroscopically, the screw rates have a higher fusion at three and six months than those with the button. However, in a meta-analysis, if you look at open versus arthroscopic, there's no difference. Open latergi is not without its complications. Short-term complications is described at 4.3% to 30%. Those common complications being infection, recurrent instability, neurologic injury, and hematoma. In a recent study looking at short-term complications in North America, a multi-center perspective study was done that showed an overall complication rate of 24% with the most common complication being intraoperative fracture of the coracoid. The learning curve has been discussed throughout the literature on the arthroscopic latergi and after 30 cases, in this study, decrease in surgical time, frequency of complications, number of hardware problems, and need for revision. This has been confirmed over multiple studies. So overall, when you take a meta-analysis of open versus arthroscopic latergi in a most recent meta-analysis performed, when you look at these different outcomes, persistent apprehension was the only difference between the open and the scope, with the scope being more apprehensive than the open procedure. So overall, for graft position arthroscopically, in the sagittal plane, there's no difference in variability between the open and the arthroscopic techniques. In the axial plane, the dual-screwed technique is the most variable. The button fixation technique has the lowest variability due to the use of a guide. For graft healing, overall, probably no difference, open versus arthroscopic. However, the button fixation may require longer time to heal. And in complications, overall, no difference, open versus arthroscopic, with a decreased risk in the arthroscopic groups over the next 30 cases. Thank you.

coracoid transfer procedure

glenoid bone loss

graft positioning

complications

arthroscopic approach