Thank you very much. Good afternoon all. My name is Rakesh John. I'm doing my arthroscopy and sports medicine fellowship with Dr. Ivan Wong and Dr. Cathy Cody at the Dalhousie University Halifax in Canada. Today I'll be presenting the clinical and radiological outcomes of arthroscopic anatomic glenoid reconstruction using the distal tibial allograft with a minimum of two-year follow-up. It's well established that glenoid bone loss is associated with high rates of failure or recurrence after Bankart repairs. Many techniques have been developed to address glenoid bone loss. One such technique is the arthroscopic anatomic glenoid reconstruction using the distal tibial allograft without splitting the subscapularis in the lateral decubitus position. This was described by Dr. Wong and Urquhart in 2015. It requires one additional portal compared to a Bankart repair. This is the Halifax portal, which is a far medial portal created by an inside-out technique by inserting a Weisinger rod through the posterior portal, parallel to the glenoid surface through the rotatory interval, above the subscapularis, and lateral to the conjoined tendon to protect the neurovascular structures. The safety of this portal was established in a cadaveric study by Moga et al. In this image you can see the location of the Halifax portal, denoted by the arrow, and its distance from the neurologic structures, which is measured to be around four centimeters, and you can compare this with the subscapular split indicated by the blue and its association to the neurological structures. The graft is fixed with two canalated screws, the subscapularis is repositioned, and we do an additional Bankart repair, keeping the bone block extra-articular. The advantage of this technique is it is anatomic, not only in the sense that it recreates the glenoid surface, but also because it preserves the subscapularis, the coracoid process, the conjoined tendon, and hence the risk of injury to neurovascular structures is low. The purpose was to see the clinical radiological outcomes with a minimum of two-year follow-up. This was a retrospective study. All cases were operated by Dr. Ivan Wong. All consecutive AAGR procedures with a minimum of two-year follow-up were included. Posterior multidirectional instability and associated cuff pathologies were excluded from the study. We measured our clinical outcomes using the Wurzi, DASH, and Mark scores at regular intervals. We recorded the intraoperative and postoperative complications. Clinical outcomes were assessed on plane radiographs and CT scans by two independent blinded observers, and we went on to measure four parameters, the first being graft union assessed in sequential CT images and classified either into union or non-union. We classified graft resorption into four grades, grade zero being no resorption, grade one being 25% resorption where the top hat washer is exposed, grade two is less than 50% resorption where 50% of the screw shaft length within the graft is exposed, and grade three being more than 50% resorption where more than 50% of the screw length within the graft is exposed. We measured the alpha angle, which is defined as the angle between the screw shaft axis and the native glenoid in the axial view with a normal value between 15 to 25 degrees. Graft positioning accuracy was measured both in medial lateral as well as in vertical position. Overall, we had 66 patients with a mean age of 29.7 years. 24 of the 66 were revisions of previous failed stabilization surgery. The mean follow-up was 2.4 years, post-op CT was available in 56. Complications, we did not have any re-dislocations or instability, but we did have one subjective subluxation or a positive apprehension. There were no cases of nerve injury. Five hardware complications required a screw removal procedure. There was a significant improvement in all three clinical outcome scores measured. The WOSI score went down from a mean value of 72.7 pre-operatively to a value of 28 post-operatively. In this video, you can see this young athlete, two previous failed bank card repairs, eight months post AAGR with excellent active range of motion and function. The graft union rate was 100%. Close to 84% patients had less than 50% graft resorption. Nine out of 56 patients had more than 50% graft resorption. However, none of these patients in grade three resorption had instability. And you can see in this table that even in those who had grade three resorption, the AP dimension of the glenoid was maintained at a value of 30 mm, which is the normal value, and the diameter of the graft remaining was still 7 mm, and this can be probably explained by physiological bone desorption as the bone graft size is larger than the glenoid defect. The alpha angle was between 18.1. Scab positioning was flush with the glenoid in 91% cases. There was no lateral step-off in any cases. Vertical positioning was excellent in 54 of the 56 cases. Open LATA-J continues to be the gold standard in the management of instability with glenoid bone loss. However, it has several disadvantages. It's an open technique. It's non-anatomic. Subscap strength is reduced post-operatively. Complication rates are high with significant risk of injury to neurovascular structures, and revision may be difficult in cases of recurrence or arthritis. Arthroscopic LATA-J is technically very challenging, not very widely popular. Here the AAGR procedure can be an alternative to LATA-J as it is safer, the technique is easier, and it's surgically similar to an arthroscopic Bankart repair. To summarize, AAGR has excellent clinical and radiological outcomes at the two-year follow-up mark. It addresses both bone loss as well as soft tissue instability. It's an anatomic technique. It's safe. Importantly, it does not burn bridges if revision is needed as the anatomy is not distorted. However, we do need long-term follow-up for better assessment of outcomes and to see the effects of graft disruption. Thank you.

arthroscopic anatomic glenoid reconstruction

distal tibial allograft

Halifax portal

Bankart repair

clinical and radiological outcomes