Hello, my name is Grant Gergues. I'm from Rush University Medical Center. I'm excited to be here to talk to you about my experience with the arthroscopic LaPrage procedure. My disclosures are here. The relevant one is to Pew Mitech, a company which makes a procedure kit for this exact operation. We know bone loss is important when talking about instability surgery. We used to think you needed that inverted pair with 20 or 25% glenoid bone loss. We know that smaller degrees of bone loss can still impart a significant negative prognostic factor. We talked about this with regard to on-track versus off-track lesions, and we know that soft tissue procedures are doomed to fail with off-tack procedures and possibly even smaller lesions. We know that the Ladder J procedure has a much lower recurrence rate than arthroscopic Benkart. This is all quite clear. Why does the arthroscopic procedure have such a high recurrence rate? Well, it's not clear. Some of it has to do certainly with patients that return to sport, but it can be 15% or more in some patient populations, so this is not a benign scenario. How do we decide who is going to need a bony procedure and who can get by with an arthroscopic Benkart? Well, the EC score, ISIS, or instability index score, popularized by Pascal Boileau, has shown us that patients with a score greater than 3 have a significantly increased redislocation rate with arthroscopic Benkart. What does it take to get an EC score greater than 3? Well, not much. So here's the original figure from the Boileau article. If your age is less than or equal to 20 and you are involved in a competitive sport, presumably that's anything from bowling to lawn darts, you have an EC score of 4, and you're already somebody who they're going to recommend for a bony procedure. So enter the Latter-Jay. What is the Latter-Jay procedure? Well, it's when we take the coracoid, we put it through a subscapular split onto the anterior glenoid. The picture on the lower left shows a Bristow modification where the piece of the coracoid is a little bit smaller, and there's typically one point of fixation, but it's the same concept. This has the bony effect that increases the arc length of the glenoid, so that's certainly relevant with regard to your on-track versus off-track discussion. But the second effect is really important. So if you look at the middle picture there, you can imagine that if the arm is in the position of abduction and external rotation, the only thing keeping the humeral head from dislocating anteriorly and inferiorly is that capsule, which may be deficient, stretched out, ruptured off the labrum and the glenoid neck, etc. The Latter-Jay uses both the inferior third of the subscapularis as it's held down by the orientation of the conjoint and the conjoint itself as a double buttress or sling effect that acts as a check rein, augmenting that deficient anterior and inferior capsule in that position of instability. Well I've shown you that Latter-Jay has a lower recurrence rate than Benkert, but why would we mess around with this arthroscopic procedure? Well the bottom line is that it works. Laurent Lafosse has showed us with 100 arthroscopic Latter-Jay procedures from this article in a patient population with a very high involvement in sports, many with bone loss and even bipolar bone loss, very low complication rate and excellent results. In fact, 91% excellent results and 9% good results. So conclusion, he showed it was reliable. There is a difficult learning curve. He was a brachial plexus surgeon before he became a shoulder surgeon and thus is very comfortable with the neurovascular anatomy. And I believe as he does as well, you really can get excellent graph position with this procedure. You can see exactly what you're doing. It's very analogous to doing arthroscopic rotator cuff repair in this way. What does it last? Absolutely it lasts. So Laurent has showed us 62 patients with minimum five-year follow-up and only one patient report of a subluxation event. This is unbelievably good. I would put this up against any long-term instability or medium-term instability paper out there. Again, these are patients involved in sports, a lot of bipolar bone loss and have only one subluxation event and 62 patients for five years is phenomenal. Is it safe? Absolutely. This is a description from Pascal Boulleau of his modification of the procedure. He uses a Bristow type procedure done arthroscopically as you can see there. He had 121 patients and no neurologic complications whatsoever. This has been confirmed by the French multi-center arthroscopy study. It works, it lasts, it's safe, and it's reproducible. So they took over 1,500 patients with arthroscopic Latter-day and showed really a very low incidence of complication, excellent graft position, and low recurrence rate of instability. So as the French would say, c'est bon. What about versus open Latter-day? Are there any advantages to the arthroscopic procedure? I mentioned graft position earlier, but there's actually also decreased pain. So in this study with 184 patients, decreased pain scales, not surprising given the more minimally invasive nature of the procedure. So same complication rate, same recurrence rate as I've shown. Here's a head-to-head study where they did a systematic review and meta-analysis doing the same thing. The bottom line is it's not a surprise. The nerves are there either way. So some people are daunted by the arthroscopic nerve dissection, but the bottom line is the nerves are there either way whether you choose to dissect them or not as my friend Charlie Getz says. As I would say a little less eloquently, you can screw it up royally with or without a scope. So this is an example of an open Latter-day procedure where the graft was put directly on the glenoid face. This is not good. Here you can see on the coronal view, this is going to certainly help with the stability of the patient is essentially auto-fused, but it causes severe and rapid arthritis in this young active patient. So the bottom line is you have to know your anatomy, you have to know what you're doing with or without the arthroscope. Here's a case to tie it all together. This is a 19-year-old collegiate soccer player with multiple instability events. A prior Bankart procedure with failed. You could see bipolar bone loss here with the Hill-Sachs lesion posteriorly and then the bony Bankart anteriorly. This is an off-track lesion and thus he is in a young active male. He's indicated for a bony procedure. In my hands, that is the arthroscopic Latter-day. Hello, my name is Grant Giergues. I'm from Rush University Medical Center. I'm excited to be here to talk to you about my experience with the arthroscopic Latter-day procedure. My disclosures are here. The relevant one is to Pew Mitech, a company which makes... So first step of the procedure is to remove all that suture material and all the stuff from his failed bony Bankart. Then we release all of the capsule around the rotator interval so you can see the conjoined tendon here in the background. You can see the CA ligament and you can see the arch of the coracoid coming up over the border of the subscapularis. Then we're going to triangulate and come from an anterior superior portal. You're going to see this view of the coracoid from laterally. So you can see here when we release the CA ligament, you really see some great anatomy. Coracoid there. We've released the clavipectoral fascia. We're releasing the tissue anterior to the conjoined. This is anatomy we see all the time, just not frequently in arthroscopic setting. Hello, my name is Grant Giergues. I'm from Rush University Medical Center. I'm excited to be here to talk to you about my experience with the arthroscopic Latter-day Procedure. So when we're done with that, next thing we're going to do is go behind the conjoint, find those three sisters vessels, follow them immediately until you see at the tip of my shaver there, the axillary nerve between the three sisters and the subscapularis. That's a key landmark for how far we can go immediately with our split. Then we have this really nice view from the anterior superior shoulder looking back at the glenoid here. You can see our cannula there posteriorly, upper border of the subscap, and really everything's kind of laid out. Hello, my name is Grant Giergues. I'm from Rush University Medical Center. I'm excited to be here to talk to you about my experience with the arthroscopic Latter-day Procedure. My disclosures are here. The relevant one is DePue MyTech, a company which makes a procedure kit for this exact operation. We know bone loss is important when talking about it as you need to see it. This is now looking from a separate portal. You're going to release the pec minor tendon here immediately as I'm doing right now. When you do that, obviously you want to be careful about the neurovascular structures that are underneath. There's a plexus that's often right under there that you need to cauterize to make sure you don't have bleeding. Then right behind that, this yellow structure right here is going to be the muscutaneous nerve. Hello, my name is Grant Giergues. So continuing on, now we've got our muscutaneous nerve freed up. You can see it right there, conjoined tendon, subscap, glenoid. Three sisters vessels are going to be our landmark for where we make our subscap split. Then in the lower left, there's that yellow x-ray nerve peeking in as well. So everything's dissected out, now we're ready to go. Next thing, we prepare our coracoid with this system. You're going to drill and then tap and then autotomize. Once the coracoid is free, we basically place this through the subscapular split. The nice thing about this is we can put it directly right where we want it, see exactly, get it low, get it in the right position, medial to lateral. If it's a little too lateral, certainly we can burn it down. I like to put it in line with the subchondral bone, we can actually have that level of precision. I don't like it in line with the cartilage, I like it with the subchondral bone exactly as you see here. Then we get our screws, the system has two very strong lag screws. We screw it in place, then we can go back and look. So there's our nerve there, I want to make sure there's no bands that are in tethering, it's free. There's our upper part of the subscap, you can see the coracoid beneath, there's the glenoid. You can see how the chondroid really drapes over that lower aspect of the subscapular. Hello, my name is Grant Giergues, I'm from Rush University Medical Center, I'm excited to be here to talk to you about my experience with the arthroscopic latitude procedure. My disclosures are here, the relevant one is to Pew Mitech, a company which makes subcapularis. So this is our result here, excellent graft position, I'll run these videos so you can see the graft really does line up quite well. I think the graft position is one of the key advantages of doing this in the arthroscopic situation. Hello, my name is Grant Giergues, I'm from Rush University Medical Center, I'm excited to be here to talk to you about my experience with the arthroscopic latitude procedure. My disclosures are here, the relevant one is to Pew Mitech, a company which makes a procedure kit for this exact operation. We know bone loss is important when talking about instability, and just to wrap it up here, here's our clinical result, again the patient was able to return to sport, excellent range of motion, no pain, and no recurrence rates, back to full sport. So in summary, there's a difficult learning curve, you have to be familiar with complex arthroscopic procedures, dissection of the neurovascular structures is imperative to do this in a safe manner, but you can really get excellent graft position with a similar complication rate. I theoretically switch from a Bankart to a Latter-Jay intraoperatively, but with our pre-op planning we really don't need to do that. The bottom line is it works, it lasts, it's safe, and it's reproducible. The arthroscopic Latter-Jay is here today to stay. Thank you for your attention, please follow me on Twitter.

arthroscopic Latter-Jay procedure

instability surgery

bone loss

EC score

coracoid