Greetings everyone, I'm here to talk to you about the Open Latter-Jay Procedure, Bony Augmentation. I'm Matt Provencher from Bale, Colorado. Thank you very much for attending this course and it's a pleasure to speak with you today. These are my disclosures, they're also on the AAOS website. So when do we consider Latter-Jay? Certainly critical size matters. We used to think this was about 20, 25, maybe 30%, but recent literature by Tokish, ourself, Giuseppe Milano, Giovanni Di Giacomo, have shown us this number is really around 10, 12, 15% of bone loss, but it also depends on the humeral interaction as shown here. When you have a four millimeter osseous defect with a reasonable or just middle of the road hill sacks, you're risking a high chance of re-dislocation if you don't do a bony procedure and do arthroscopic only. So what are these subcritical sizes? Well, if you look at area four, that's about 20 to 25% and you can see that the WOSI score even in three as JT and others have shown us goes down dramatically even if you have 12 to 13% of bone loss. If you fix these arthroscopically and we know we can do better with a bony augmentation. Burkhart and DeBeer showed us very clearly that the inverted paraglenoid and more bone loss is a higher risk of recurrence and that you can have a significant amount of recurrence if you have more than 20 to 25% bone loss when this is treated arthroscopically. However, treatment decisions start in the clinic and examination room. History and physical examination are absolutely the most important and you can determine if they have bone loss and if they have issues with potentially bipolar lesions or even an off-track lesion very easily in the clinic without even getting imaging and you can predict this from history if they've had multiple dislocations, bilateral shoulder dislocations, failed stabilization procedures, as well as instability in mid-range of motion as demonstrated here the arms abducted 30 degrees and you can see this patient has significant instability findings and apprehension just with 30 degrees of abduction and a little bit of external rotation. This is highly suggestive of bone loss as we published and tested on. However, not all bone loss is the same. You can have an acute fracture. This is a large group of more than 200 patients, which we had CT scans on and instability anteriorly. Acute fracture in the minority, about 5% of patients. Partial attritional bone loss resorption, almost 80%. This was the number one and then complete resorption or fully attritional at about 10%. This is a general breakdown. Also depends on the demographics of patients you see, but a lot of times that number two or partial attritional fragment is just not enough to reconstruct the glenoid and if you go in there thinking that you'll be able to reconstruct it with that, bring the glenoid back to its native self. I think what we found is this is just a little bit disappointing. You're not able to reconstruct everything and that's when we're starting to really consider bone block augmentation and in this picture, the latter shade. So when we looked at this, guess what? Total time of instability and number of instability events are highly correlated with this attritional bone loss, total bone loss, et cetera. The more time you have instability and this is really now just more than three months. So three months of instability symptoms are three months from your initial instability event. Maybe they lived with it. Maybe they hit it. Maybe they dealt with it. They were a coper on some level, but you're going to know that they have bone loss and issues. So when do I use latter shade history of multiple recurrences? As Gerber would say, he uses it. If there's more than one recurrence, he doesn't even really get imaging. He just does it. If there's more than one recurrence and does the latter shade, I don't know if I'm quite there yet, but certainly history of multiple recurrences or a prolonged duration of instability, more than three to six months with imaging findings, such as an off-track lesion, certainly lead me to the latter shade. A contact athlete increases that instability and history findings in mid abduction. And again, that length of instability time and the number of instability events are critical because the capsule in labrum just can't hold it. And we have bone loss. Well, how do these do? We looked at this at 26 years. It was one of the longest studies in the literature for the Bristol latter shade. Jay Cox, who was there as an orthopedic surgeon at the Naval Academy in the 1970s had 52 shoulders and followed up. 91% of these were followed at 26 years. We did have a 15% recurrence, but I think if you look really closely at the latter shade literature and even Pascal Below's stuff, you'll see anywhere from an 8% to 15% chance of recurrent subluxation type of symptoms in these patients. The latter shade is not perfect, but it's pretty darn good. So how do we do this? I've gone through this whole thing here. I think it's very important to break this down into steps because as Rich Hawkins says, this is a very challenging procedure, especially as you get down to the capsular management. So it starts with patient positioning and setup. And we put towels here on the medial border of the scapula. This helps bring the glenoid out so you can easily get access to that front face of the glenoid. We don't bring the beach chair up as high. You can use a commercial holder, or usually I use a padded mayo stand. You have to watch the perineal nerve in the buttocks. And right here, those legs are externally rotating. We actually pad those as you can see with foam and just gently hold the legs in place. This is key, getting this set up first for success. We all know the delta pectoral approach, but the coracoid prep is very important. After we get through that delta pectoral approach, I put a homin right in back of the trapezoid ligament to be able to expose the coracoid. And we did a good study, I think, looking at the anatomy of the CAL, the coracochromial ligament, and then also the pec minor attachments. And you can see that the vast majority of that is an anterior coracochromial ligament. There's a small portion of posterior coracochromial ligament. But what we do is cut this about one centimeter lateral to the coracoids so that we have something to tie into at the end. If we want to have it, it gives us some options. What about neurolysis? We looked at this, what happens after the Laterge and even before. So here's the pec minor attachment. You can see the CAL and this we published on AJSM. But we look at how far this is away from the musculocutaneous nerve. And every time I'm taking on the coracoid, I just gently do a neurolysis down to the level of musculocutaneous nerve, but not going too close to it because the musculocutaneous nerve does not take a joke. It is two to eight centimeter closest to the pec minor. And it does help with conjoined tendon mobilization and prevent nerve issues down the road. So we have to be really careful with our structures posteriorly. And as you take that coracoid off, it does reveal quite a few vessels. And so you have to be careful because that coracoid and conjoined tendon protects a lot of the neurovascular structures just posterior to it. So with the coracoid, the bony harvest is very important. Here's what we looked at for the pec minor. If you go to the trapezoid and conoid ligaments, the trapezoid and conoid are about 28 millimeters in a male and about 25 millimeters in a female. So I usually take anywhere from 22 to 25 millimeters depending on a male or female. I use a 90 degree saw and you can see we do this kind of just roll the hand over. I start medially and then roll my hand laterally. We use a sagittal at 90 degree blade. Now this saw works okay, but we do complete it either with a straight saw depending on the angle or a curved osteotomy shown here. And usually you just need a few taps and it is able to come off very easily. And there it is there, freeing it up and we're able to extract it. And then remove the rest of the soft tissue after we've taken off the pec minor subperiosteally. And then also one centimeter of the coracoid acromial ligament. Next step, coracoid in preparation for implantation. Very important, we have to decide if we're going to use the lateral, traditional latergé as a glenoid surface or we're going to do the congruent arc. Congruent arc is where the inferior surface of the coracoid becomes the glenoid. We have to decide on this. I usually decide ahead of time based on how much bone loss there is. We can get much more with the inferior surface, anywhere from 11 to 14 millimeters of bony reconstruction. But it's thinner and you have to get those screws in correct. The trajectory has to be spot on for those screws. The lateral surface is a much broader surface and that's anywhere from about eight to nine millimeters of bony reconstruction that you're able to get. I do lateral or the traditional latergé probably about three quarters or 75% of the time. We have to get the cancellous bone exposed. And you can see that we're trying to match this up better. You can see these are not the best fits and we want to get better fits and better approximation of these. You can see the inferior surfaces DeBeer and Burkhart have taught us is a really nice concavity for the glenoid. Here you can see us. I'm using the sagittal saw to remove the tissue. I'm doing the traditional latergé. Here's that inferior surface. We're working the sagittal saw on and you can see that we're removing that cancellous bone. We can use commercially holders to do the drill ahead of time or you can just use K wires down the road. Critical, the subscapularis split. This is really important. The subscapularis is five centimeters top to bottom. In general, we want to preserve this. We want to do a split. It's one of the three things that allows the latergé to work, including the bony block, the capsule, and then the sling effect. So what we do is two-third to one-third split in general. Now, Jill Walsh and Pascal Below will tell you, we move this up a little bit higher in patients with hyperlaxity, especially a significant sulcus component. Now, the latergé is not a great procedure for multidirectional instability. Keep that in mind. But if they have anterior instability in the setting of multidirectional laxity, you might want to move that up just a little bit. But usually we do about three centimeters at the top, from the top of the rolled edge. And that's where I make my split, taking care to stay away from that biceps tendon. And why do we do a split instead of takedown? Well, takedown has been shown again by Ray Sachs, Laderman, and others to result in less outcomes and fatty atrophy, the subscap. So we try to preserve this. If the patient's really big, though, you can take down the top portion and the top two-thirds of that and then repair it very meticulously. Thunoid capsule management. This is very important and what Hawk would say is one of the most challenging aspects of this case. Once we get through that subscap split, what I usually do is an L-shaped capsulotomy. You can use a knife, you can use a needle tip, but you have to be careful and protect the axillary nerve inferiorly. It's right there and you have to be really close. And what I'm doing is taking that capsule all the way off the glenoid neck. I put a suture limb in the capsule right at the apex of this L, and then we take that capsule off and manage it later. How about next, glenoid bone preparation? This is important. We want to make sure we get a flat surface, 90 degrees. Now, glenoid bone defects usually happen 90 degrees relative to the face of the glenoid. And so what we use is a high-speed burr, a high-speed rasp, and we're able to get really nice cancellous bone exposure. A lot of times this is well corticated bone and we have to be able to make sure we have good bleeding bone exposed. We really want that 90 degree angle so we can fit the bone graft on really well. What about coracoid fixation? In general, I use two screws, one centimeter apart. You can do these in a commercial guide. This is a long 2.5 millimeter drill. We like to make sure that that drill is less than 10 degrees to the glen surface, as LaFosse has shown us. The outcomes are better if the screws are less than 15 degrees off the glenoid face, as you can see there in the bottom right radiographic image. We do an overdrill lag technique. I use solid 4.0 millimeter screws and also use a suture washer type of device where the suture is integrated into the washer so that I can repair the capsule down in a tension slide technique. Which helps with some options for our capsular closure. Speaking of capsular closure, here's our second to last step. We have that anterior coracoacromial ligament that we have one centimeter of. You can tie it into the stump. I not only tie the capsule into the stump with the arm in 45 degrees of external rotation, but I use number two sutures and the number two high strength suture from the suture washer to tie down the capsule of the arm in about 40 to 45 degrees of external rotation. The subscap in the bottom there is shown to be closed with high strength number two suture, just lateral to the conjoined tendon only. Post-operative plan. These patients do quite well and they recover pretty quickly. I do acrylic skin glue for all my shoulder open incisions. You have to keep the arm bit dry using ABD pad. Then we start passive and gentle active assist right away, as well as scapular contraction and rows right away. We start active and passive right away with this actually. And especially if you have good bony fixation with the screws, I don't mind that, especially in the scapular plane. We avoid resist double flexion for about four to five weeks to help protect that conjoined tendon in the sling and return to full activity at maybe three to four months, just depending on their full contact sport type of activities, four months for more contact or higher level sports. Maybe a little bit longer, just depending on how they do in terms of shoulder testing and isokinetic testing. So treatment decisions start in the clinic exam room. You can pick up bone loss with a good history and examination. When do I do more than arthroscopic and believe me, I love an arthroscopic case plus or minus the remplisage, but these are the ones multiple recurrences, especially more than several recurrences, instability in mid abduction, bone loss and off-track lesion on radiographs. And then contact Roverhead athletes. I want to wish you luck in your bone loss journey. Thank you for the opportunity and have a great course.

Open Latarjet Procedure

Bony Augmentation

Bone Loss

Shoulder

Latarjet Procedure