This presentation is entitled, Not Everyone Needs a Latter-Jay, Other Bony Options. This is entitled, Not Everyone Needs a Latter-Jay, Other Bony Options. I'm Matthew Preventcher out of the Steadman Clinic in Vail, Colorado. Current disclosures are listed here. You see the Academy website for the most up-to-date and complete list. So how do we identify bone loss and what is our preferred surgical approach? Well not all bone loss is the same. When you look at these patients, we have different types. It can be an acute fracture. Most of the patients that have bone loss and certainly some level of recurrent instability symptoms for some level of duration and we think this is anything more than three months, you can get partial attritional loss. So that the remaining bone does not allow you to reconstruct what's missing from the glenoid. And this is actually the vast majority of the patients. And then sometimes you get fully attritional. But again, this partial attritional loss is the one that we're dealing with and the one we have to be mindful of. What type of bone loss guides treatments when we look at recurrent instability and how we identify bone loss? You have to look at symptom duration as well. This was one of the most important things to determine glenoid bone loss was that patients with longer duration of symptoms, meaning those more than three months, were higher bone loss across the board. So now let's talk about stabilization with distal tibial graft, which is another option besides the very good Latter-J and other bone grafts. So the first case that I performed to this was approximately 2007. We had done about two years of lab work prior. And what we found was the distal tibia is well conserved across the human species. I now use this for defects around 20%, but I am considering it for lesser defects. So a failed Latter-J is a great option, and then also cartilage or other bony problems. And we also think about this for any off-track lesions. The goal is to reconstruct the glenoid. We know that it fits the humeral head quite well. We tried to get fresh glenoids and we still try to get them, but they're very difficult to obtain due to harvest concerns and contamination concerns. So I asked what you don't use, and that's the distal tibia. When we compared this first against the Latter-J for a 30% defect, which admittedly is a little bit high, but we wanted to see how the contact pressures did, you can see that the distal tibia did extremely well and matched almost perfectly the glenoid up to a certain level. And that's probably 50% bone loss of the anterior glenoid and about 25 to 28 millimeters superior to inferior. We also had much lower peak forces than the Latter-J reconstruction. And this is the Latter-J done in the traditional technique, not the congruent arc, just to keep in mind. So our indications are large bone loss, failed primary, bipolar issues, and we also think about this for the off-track lesion. It's important to do excellent bony preparation. I like the 3D CT scan so I can measure preoperatively approximately what size distal tibia I want to use. We're still trying to do a bone-preserving procedure. So although we're doing an excellent preparation, we don't want to take a lot of the bone away and I don't want to take a lot of the cartilage, except to make this a linear line that is parallel or nearly parallel to the long axis of the glenoid. You can use a commercially available workstation, but you can also just use towel clamps and towels and have an assistant hold it for you. You can do it freehand. And this is how I've always started. Pre-op 3D models can also help you size the graph. We also do allograft principles where we do pulse lavage for anywhere from 5 to 10 minutes and then we soak the distal tibia, which is a fresh allograft in PRP after. It should be noted that folks like Ivan Wong out of Halifax are also using frozen distal tibia and he's shown excellent results and his team has very little resorption as demonstrated on CT scan many years post-operatively. I usually use two K wires and then I use full thread 4mm compression screws with suture washers and this ensures a very nice flush transition between the graft and glenoid cartilage. I do not use cannulated screws. I do use solid screws and you can see we put sutures under the washers or integrate them with suture washers. So what were our initial outcomes when we published on this in the mid-2015s? 27 patients, relatively young age. The allograft lysis was overall very low and in fact, much less than what's been shown in Latter-day to be anywhere from 40 to 57% depending on who you read and we had overall about a 90% interface healing rate and I think that's the key because we can't just talk about lysis. We have to actually talk about what's going on at the glenoid graft interface and what that healing looks like. When all else fails such as scope and scope with bone loss, resorption due to non-union, hardware issues or even some level of arthritis in young patients which has been successful with distal tibial allograft. The reason is you get both a cartilage and cortical cancellous solution for reconstructing the glenoid. What about the failed Latter-day? When we revised this, we recently published on this with my co-authors, we had 31 patients. All of these patients presented with recurrent instability events after Latter-day which when you look at the literature, a Latter-day is good but it's not perfect and if you really distill down how a Latter-day does, it's anywhere from 3 to 4%, even up to 15% with recurrent subluxation and failure just due to dislocation or subluxation. So Latter-day although very good, if you really scrutinize the literature, it's not perfect. Our average resorption at the end of the day was around 80% so we do think that there's some remodeling going around, around the outer aspects and superior aspects just like it does with an autograft and Latter-day but what we did have was very good union in more than 90% of the patients. We call that complete union from top to bottom and had what we called a significant partial union in the other 10% which was more than 80-85% of that interface graft that had healed. In fact, our outcome scores also did very well with this as well. What about some other options and I've used this as a workhorse which is iliac crest bone graft for certain cases and I used to use this quite a bit before the distal tibia but now with the distal tibia, I just feel like we have a very good allograft fresh option both with corticocancellus and nice cartilage. The iliac crest does not have cartilage but it is smooth. I do use it for 30% or more defects, some failed Latter-days. The patients will have hip issues and pain for a while and that can persist for 6, 8, 12 months and sometimes longer but with some backfill of this area and this tricortical crest, you can actually do pretty well and minimize their pain. You can use commercially available guides, put this in place but it's very much like doing a free graft and these free grafts now I think are going to be done more and more arthroscopically. If you look at JP Warner's work, recurrent instability using tricortical iliac crest bone graft, this is the largest in the literature with just 11 patients, reasonably good follow-up, no recurrence and all patients demonstrated on x-ray union. They didn't look at CT scans. We don't know full resorption and full interface healing but at least had some level of healing on plain radiograph. Another study looked at autologous graft from the iliac crest. This is from Krauss, 15 patients, 6 months, no redislocations or subluxations with overall very good scores. These patients were very severe glenoid bone loss patients, it should be noted. Distal clavicle has also been postulated as a good graft. The advantages are you're right there. It's potentially got some cartilage as long as it doesn't have distal clavicle lysis or cystic changes which many of our patients, even their 20s have and we note that on MRI, most are asymptomatic. You can see that there's an opportunity to use this, craft it and shape it as a very nice free graft and I see all of these depending on no matter what graft you use as an opportunity to do this now arthroscopically or arthroscopically assisted and this actually fits well once you harvest this, craft it. You do have to be careful about some distal clavicle issues and distal clavicle insufficiency and other problems. You can't take too much because you don't want to rob Peter to pay Paul and create another issue at the AC joint where there wasn't one prior. When you look at JT Tokish's work, no cost, rarely available, they had some very good results with this in a small case series of patients. So in conclusion, identifying the bone loss guide surgical approach, making sure that most of these patients, if they have prolonged instability, they do have bone loss that is attritional in nature. I certainly consider DTA for defects greater than 20% but that number is getting lower and lower and especially if you look at JT's work and many of other work and our recent publications, we're all in agreement that that number for bone loss that's significant is going down much lower but we do have to think about it as a bipolar problem and certainly now 10% and 15% I'm considering grafting especially from an all arthroscopic standpoint especially with improved implants and guides. Iliac crest bone graft for potential revisions, potential allograft revisions or for large cases or for patients that just do not want allograft and then distal clavicle autograft should certainly be in your armamentarium for certain cases. Thank you.

Latarjet alternative

distal tibial graft

bone loss instability

glenoid reconstruction

surgical approach options