you've been able to see that this can be able to be done, but the trouble with it is is that Latter-J, even the arthroscopic, changes that decrease in recurrence rate for an increase in complications and for more difficulties with future revisions. So ideally we want something that has a low learning curve, preserves the capsule, can allow for a safer procedure to be able to do a Bankart repair with no bone loss. So this idea is not new. Matt Provencher has obviously talked about this, and we've seen with this randomized control trial study that we don't need a conjoined sling to make a stable shoulder if you can get the bone back to normal size. So the technique is already published in 2015 in Journal of Arthroscopy, and we now actually show this if you actually need to see it. This is actually a live viewing of one of our surgeries over Zoom, so we can actually show you both the outside view on the top left and the inside view on the right. So the first section is to open that rotator interval, and opening that rotator interval, the biggest thing that you want to be able to see is to be able to see the CA ligament there. So once you see the CA ligament after you open that rotator interval tissue, you then want to be able to see the conjoined tendon. And to see the conjoined tendon, you actually pull the head back and be able to separate that from the subscap muscle belly. Now we switch the scope in the anterior superior portal to be able to assess the positioning of our posterior portal, and want that posterior portal to be perfectly parallel to the glenoid to get in there. And once we have that, we now want to get that traction stitch. So you can see the amount of terrible anterior soft tissue there. We grab this traction stitch at the 3 o'clock position because we want to translate this back up to 12 o'clock to do an inferior to superior capsular shift by about 2 centimeters. We then do an episiotomy between that tissue from that 3 o'clock traction stitch in the biceps tendon, and by pulling on it, we can actually help to get that capsule labral complex elevated off that anterior glenoid, even though this person's dislocated so many times, you can see the tissue is very poor. So we get all the way down to 6 o'clock, actually to the 7 o'clock position, making sure we can see the subscap muscle belly just like we normally would with a normal Bankart repair. And once we can see that, we can do a measurement. And this is where we want to try to recreate the normal glenoid side. So you can see this one's just under 25 millimeters here. We did measure him to that. We did want it to get up to just over 30 millimeters to be normal. So we're going to measure the graft on the back table. And here you can see, we can show outside inside views, or sorry, 90 degree view, so we can see what type of graft we want. We want this trapezoidal graft shape to try to recreate that to get maximal glenoid contact. So this is the trapezoid shape that you want, so you get maximal anterior glenoid contact when you put it on a double barrel can that you can manipulate inside the shoulder. Once you have that, this is the Halifax portal to get the right thing. You want to see the subscap, so this is going to be superior to subscap. You want to be lateral to conjoined, just like Dr. Ciccone shows. This is going to be lateral to conjoined, and it's parallel to glenoid. So once you get it through this, now you want to push the subscap as inferior as possible, because you're going to reduce, you're going to inferiorize that subscap. And you can see the angle here. While we push the switching stick inferiorly with the arm internal rotated, we can really get to the very bottom of the glenoid. So here this is that channel dilator to dilate that off, and we can estimate where we want that graft to go. And now you can see from that very inferior portal that we created, we can actually get to the very bottom of the glenoid. With the switching stick at the posterior portal, we can actually keep that all that tissue, all that subscap and labral complex, because we preserved it inferior. And with the half pipe cannulas from your HIPAA set, we can actually get the graft inside the shoulder. And once it gets in there, now with that double barrel cannula, we can actually manipulate this to make this perfectly flush with the with the normal side of the glenoid. You can see the switching sticks in the back. We manipulate the graft to be able to lever it using that switching stick to the right position. And now we can actually watch as we over drill these cannulated holes with these top pad washers in there to be able to get excellent drilling and then fixation. So with distal tibia arthroscopically, we can actually get excellent compression. You see that washer was actually sticking out. We compress this harder than two-finger tightening. This is actually squeaky tight, so you can make sure there's absolutely no gap between the glenoid and that graft. Now that traction stitch that we had initially grabbed at the three o'clock position, we pull on that. And because we didn't actually cut anything out, we can actually pull on that tissue. And we can measure the amount of inferior to superior glenoid shift. Because that tissue, again, we grabbed at three o'clock position. Now we can get the bank out repaired on top of this. And we can move this so that this is a second suture going on here. You can see our traction suture is not there yet. This is three o'clock where we're putting the second suture in. And by tractioning it, we can actually measure to get the bank out repair back to 12 o'clock. So an inferior to superior shift from three o'clock to 12 o'clock. And on the 3D model, we measure that to be about two centimeter shift. So we can actually objectively measure how much shifting we would do from that soft tissue. So again, we mentioned that the learning curve has changed. Using this anatomic glenoid, we seem to make this even faster than doing a arthroscopic Latter Jay, probably because the number of portals. We really only have one extra portal compared to the arthroscopic bank out repair compared to the arthroscopic Latter Jay, which has four new portals that you don't really know about. In fact, it is actually easy enough that we can actually teach this to other people. This is a surgeon in Texas that I did over Zoom. I'm drawing on the screen, guiding where he wants to do the cut. So we use multiple camera views to be able to show how we do this, where we do this, overlay the drawing to be able to describe how we want to do the bone graft, showing them which the articular surface is, where to do the drills, where to do the screws. And we can guide this, in case you can't understand, we actually overlay different videos of how to best do it. And then you can try copy this in the lab while he's over there. And again, I've never met him. And this is the end of his lab procedure, the first time he's trying this technique. You can actually teach somebody to do this over Zoom, never meeting each other in one two-hour lab session to be able to do something. And that looks pretty good for his first time doing it. Again, you can address the capsule for this. So arthroscopic Latter Jay, the original technique requires you to excise the capsule. You can see on the left here, when you push the humeral head from over the coracoid, it actually subluxes over the coracoid into this muscle belly, which is why they may still have apprehension afterwards. In the anatomic glenoid, you actually recreate that bone graft and then do a bank out repair on top of this, so the shoulder is stable right at time zero. In fact, it's also away from the nerve. You can see we go through the rotate interval instead of the subscap split. And by doing that, you don't damage the subscap. So again, this is a Halifax plural. Parallel to the glenoid, superior to subscap, and lateral to conjoin, internal rotation of the arm brings the subscap very inferior, and you can get this really low grab of that bone to get inside the shoulder. We're getting excellent radiographic clinical results. We've published this in AJSM multiple times, and for multiple years rather, and hopefully we'll be able to show you that we get a nice, faster learning curve. It's very similar to bank out repair. You're able to repair the capsule. It's safe away from neurovascular structures, doesn't damage the subscap muscle, and it's anatomic, doesn't make future surgeries more difficult. Thanks.

anatomic glenoid

Bankart repairs

shoulder instability

capsule preservation

trapezoidal bone graft