Hi my name is Ivan Wong. We'll talk about doing bone graft augmentation, how to do this safely and effectively. So my disclosures, by the end of the session you'll be more familiar with the technique of arthroscopic anatomic lumbar reconstruction or AAGR, the safety of AAGR and how AAGR can overcome flaws of existing bone augmentation techniques, and the efficacy of clinical and radiographic outcomes of AAGR. We all know that Latter-day is the gold standard for shoulder instability with bone loss because it can address the bone loss and has long historic outcomes, but it also has problems with use in soft tissue laxity. It also has problems because it's non-anatomic, has a high reported complication rate, progresses to glenocumaral arthritis, and it does change anatomy making revision surgery more difficult. So why arthroscopic Latter-day? Well Laurent Lefosse is credited with this. He says that you get better visualization, you can deal with other pathologies, hopefully get the graft in a better more accurate position having less osteoarthritis afterwards, but you still have to split the subscap, therefore you're still going to have to visualize the nerve and you're still right by the nerve. So Latter-day really trades that decrease in recurrence rate for an increase in complication rate as well as for more difficulties with future revision surgeries. So the critical flaws we found preventing a wide uptake of arthroscopic Latter-day was a very high learning curve, doesn't address the capsule, still being inherently close to the nerves with the same risks for that, you still have to split the subscap muscle, and failure of a Latter-day or arthroscopic Latter-day still results in difficult revision surgeries. So the ideal surgical technique is something that's arthroscopic anatomic, has a low complication rate, allows you to preserve the subscap, address bone loss, and allows you to repair the Bankart. And this idea of the anatomic glenoid is not new. Matt Provencher presented his first three cases in 2009 with an open technique. And we do know now with this near award paper which is a level one study comparing Latter-day with iliac crest bone grafting for treatment of anterior instability with bone loss, showing exactly the same clinical and radiographic outcomes at two years with no dislocations in either group, showing that you do not need a sling if you can recreate the glenoid bone size. We've published our technique in this in 2015 but we can go over these in detail. Essentially this is a live broadcast that we did here in Halifax in 2021. You can see the above overhead view on the upper left and the inside view on the right. First thing we do is open the rotator interval you can see here viewing from the posterior portal. The CA ligaments, the first thing you want to look at, so you want to make sure that's crossing medial lateral, and then you want to be able to see the conjoined tendon going up the arm. So that's the rotator interval. Once you be able to open that up, you move the scope into the anterior superior portal of which you can assess the posterior portal. You want this posterior portal to be absolutely parallel with your glenoid face. Once you have that, since you're looking down that rotator interval, you want to grab a traction stitch at the three o'clock position. You can see in this patient has very little labrum or capsule left. So we grab that traction stitch and that allows us to have good control of the labral capsule complex. This allows us then to do an episiotomy of the labrum between that three o'clock position and the twelve o'clock where the biceps is. And pulling on that traction stitch, we can really get good access underneath that coracoid, exposing the anterior rim of the glenoid. So here you can see we can expose the anterior rim of glenoid all the way down past six o'clock on that glenoid, just like we would for normal bankrupt repair. We want all this tissue elevated off so you can see subscap muscle belly. Now we can measure the exact size of the glenoid. You can see here this is just over 20 millimeters anterior to posterior on this male and we're trying to get it to just over 30 millimeters. So we're prepping the graft on the back table. You can see the overhead view as well as a side view with our run-and-gun camera. We're aiming for a one by two by one and a half centimeter graft that's cut in a trapezoidal shape that you can see here. And this trapezoid, the whole point of this is this is going to fit along the anterior rim of the glenoid. You want to match this because the glenoid tends to be more narrow more medially and more broad laterally and you want to have the best contact of bone all the way through. So now we go back to recreate the Halifax portal. The switching stick that's parallel to glenoid, that's subscap, superior to subscap. Here's conjoined. Now you want to go lateral to conjoined and you can see here we're pulling the shoulder posteriorly to better see, to better have that traction on that conjoined tendon. Once we get over top of this, we actually push down on the switching stick. You can see now we're aiming down towards the axilla from the outside view and now we can open that portal up. And in this view, you can see from the outside camera view, we can really get low into the axillary area and because we know we're lateral and more superficial to the conjoined tendon, we're in a completely safe zone. You don't have to worry about neurovascular structures in this area. We do not cut subscap. So here we are, we're depressing subscap with that switching stick from the posterior portal and from the anterior portal, from the halifax portal, we now guide in that bone graft on this double barrel cannula using half pipe cannulas to be able to open up that space. And with that in place, with that switching stick in the posterior portal, we can really manipulate the graft to make sure it's perfectly parallel with that glenoid face. Now we can drill through these using cannulated drills. So the same idea using a pin cannulated drill, be able to measure how big the screw is and then percutaneously insert these screws. Again, on the outside view, you can see the angle of our approach to get that screw in there compared to where our portals are as well as our camera is. We actually get excellent compression. You don't want just two finger tight here. You actually want to make sure that all the gap is completely gone. Nice squeaky tightness. Now we pull on that traction stitch and you can see that traction stitch was at three o'clock position. As we pull on it, we're able to get an excellent inferior to superior capsular shift. And in fact, we can measure the amount of shift. So we started at the three o'clock position. Now because this person had dislocated so much and the capsule was very lax, we actually want to shift it all the way up to twelve o'clock position. So we would actually shift the tissue approximately two centimeters because on a 3d model we're able to measure it was two centimeters from a three o'clock position all the way to a twelve o'clock position. This is that last stitch where we're putting the traction stitch right back into the twelve o'clock position on that glenoid surface. And when we have it all the way there, you can see the shoulders nicely balanced at the end, humeral head over top of the glenoid. Perfectly balanced and all the soft tissue in the front of the shoulders completely tight. What we want to do is we want to be able to make sure the position of the of the portals are exactly right. And this is where the 3d model really comes in. You can see here this is an on face view. I know you can see this from a 3d template but it really helps with the 3d model. I want to be able to make sure that this is parallel with the glenoid aimed at the defect. And you can see here that portal is right up abutting that scapular spine. If we look at it from inferiorly, we're looking up to see where it's parallel to glenoid. Here, anterior, making sure it's parallel to glenoid. Anteriorly, it actually goes medial to the coracoid. So you want to make sure that portal comes to the right spot. And normally we put that portal approximately one to two centimeters medially to that posterolateral corner which is right about here. But in fact when you look at it from the top, we're actually, so instead of the posterior corner being here, we're more like three to four centimeters medially to make sure this is perfectly parallel to glenoid face. So that's why I think it's very important to have these models to figure out where you want your portals because they'll really change and make the surgery more difficult if you don't do that. This is a simulation of what the view I like doing. So this is a view looking down the glenoid, right down the glenoid face and neck. And what we want to do is make sure the anterior superior portal can have this perfect view down this glenoid defect area. And in this case, normally I make it right at the anterolateral aspect or anterolateral corner of the acromion. This case we're actually making it in between, halfway in between the anterolateral corner and the coracoid. It's actually more anterior to my normal portal which will give us the ideal viewing area. And this is the estimation of my anterior inferior portal. Allows me to reach all the way down underneath the six o'clock position to get that best graft. And again this is the view for the Halifax portal. You can see that the trajectory of this is very different from the anterior inferior portal. We're pushing the subscapularis muscle down so we can get the trajectory of the screws in the right orientation. Again hopefully you can see here the learning curve of the arthroscopic latergy on the left with Laurent Lefosse's group shows that it takes about 20 cases before you get your surgical time down. But the complication rate did not decrease like the surgical time. Whereas using the arthroscopic anatomic glenoid reconstruction only took us nine cases to get proficient to get the graft exactly where we wanted to go. But we really had no complications similar to the arthroscopic latergy. Really probably because of the approach. The learning curve really you can see the number of portals that have to be created from the outside in from the arthroscopic latergy. As opposed to the anatomic glenoid on the right here. It's really one extra portal from that Halifax portal. In fact we do virtual teaching labs. Unfortunately I'm not there with you right now. You're going to be doing this on your own. But we can actually do this virtually over zoom where we can draw on a screen to be able to show you what is going on. We do this multi camera. We can actually draw on the screen to guide you how to create the graft. What not. Never actually having to meet and you can be able to do this. So you're going to do this at the Anna OLC lab and you can be able to create the graft. Hopefully you'll be able to see this. We can present and again we're showing you videos of how to cut the graft. What angles to cut. How to drill. And even after all this. So a participant who has who we've never met being able to try this just in the lab over zoom can get the graft looking in the exact right spot on the first time they're trying. So it really shows you the learning curve is quite a bit easier than the arthroscopic latergy. It also helps to address the capsule. You can see here at the end of the arthroscopic latergy on the left the capsule is gone. You're really the humeral head actually subluxes over the graft into the subscap muscle belly. So you're really relying on that conjoined sling to make it stable. Whereas on the right the anatomic glenoid the Bankart repair on top of that graft really stabilizes it right at time zero. And hopefully we've shown you and you're comfortable that we're definitely away from the nerve by going through the rotator interval instead of doing the subscap split. That conjoined and that methylene blue here where the Halifax portal is really helps to protect you against the neurovascular bundle. If we take down the conjoined on the right side of the screen here you can see the subscap helps to prevent the inferior aspect of that neurovascular bundle. Again the Halifax portal allows you not to damage the subscap. It's parallel to glenoid. They're superior to subscap and now you look at a conjoined when you're pulling the head back and you can see we can get over the conjoined nice and safe and actually get you in the exact right position to be able to screw safely. We've published our outcomes. Hopefully you've seen those to show that it's nice and safe to go in. The resorption that everyone's worried about, you actually get the same amount of resorption with the arthroscopic latter-gay using the coracoid. So it's exactly the same for outcomes. We got our two-year outcomes showing that we got excellent results with normal size of glenoid by the end of the surgery. Even the higher grade resorptions is really because we put in bigger size grafts and that's the reason why they resort back to a normal size. So Wolff's law definitely comes into play. Hopefully then I'll show you that arthroscopic anatomic glenoid has a faster learning curve similar to a Bankart repair. Allows you to repair the capsule. It's safe away from neurovascular structures. Doesn't damage the subscap and it's anatomic. It will not make future revision surgeries more difficult. In fact sometimes it can make revising a latter-gay more simple. Thank you. Take care. you

arthroscopic anatomic lumbar reconstruction

bone graft augmentation

traditional Latter-day technique

arthroscopic Latter-day

anatomic glenoid