Thank you, Mark. And now we have Rachel Frank, who's going to tell us why we should be doing Latter-Gays. While the slides are coming up, how many in the audience do Latter-Gay? Raise hands. Keep them up if you can. And how many do open Latter-Gay? So anyone arthroscopic, drop your hands. And who does arthroscopic Latter-Gay? Okay. So still not much arthroscopic Latter-Gay in 2022. I'm equal parts humbled and intimidated by my co-panelists here, so thank you, Rick, for inviting me, and I'm sorry if I bring the level down, but we'll try to get the level at least moderate here. So I do have some disclosures. They're all in our program and online, none are directly relevant. So we all heard about this all day today for the last year, for the last 10 to 20 years. Despite a more evolved understanding of shoulder instability, recurrence rates remain high. Why do they remain high? There's a variety of different factors, but they really come down when you look at the literature into a variety of different factors that you see here, but namely bone loss. Bone loss is the consistent factor that leads to recurrent instability. When we talk about bone loss, we have to remember the glenoid does not take a joke, especially in small glenoids, which often can be in the female athlete, but in particular in the male athlete who happens to have a small glenoid, who's a contact athlete. Just a few millimeters of bone loss can equate to significant bone loss from a clinical perspective, and that can become a big problem in our athletes. A word of caution, we've learned about attritional bone loss. This is the patient that you've seen that's had many dislocations. Their x-ray is not that impressive. Their MRI might not be that impressive, but when you get in there, you are impressed, and then you have to make a decision, and what do we need to do with this bone loss? We've got to really worry about attritional bone loss, and subcritical bone loss has been popularized by JT, and really has evolved my practice to understanding that the glenoid really does not take a joke, and we have to understand bone loss. This is the old paradigm, but this is not necessarily what we use today. We use patient-specific factors, the sport that they play. Are they a contact athlete, male, female? What's the quality of their bone? It's old news when we look at that old paradigm, and Latter-Jay will be successful in every single instability case that you do, and that's my argument for you here. Why is Latter-Jay effective? Well, it's got a triple blocking effect. It doesn't even matter how much bone loss you have, because Latter-Jay offers more than just bone. As we all know, we move the coracoid over, but that coracoid is attached to a conjoint tendon, and that tendon provides you a sling effect. Even if you're just replacing a sliver of bone, minimal bone loss, you still get a good effect with regard to restraining anterior instability. That coracoid graft plus the conjoined tendon augments that lower subscap area, and then you can get a really nice reconstruction. And that, again, that's why the French and many in Europe do Latter-Jay for every single patient regardless of the degree of bone loss. It's not just about the bone. It's about ensuring that we have a stable joint with a reproducible and predictable procedure. What do the outcomes show us? Well, this was a paper that we did now several years ago looking at 10 different studies ranging in follow-up from six months to 14 years. The PROs that were reported were variably reported, so it's very difficult to draw substantial conclusions. But what we can say is that recurrence rates in general after Latter-Jay are low, lower than with soft tissue stabilization alone, and satisfaction is high, good to excellent results. Complications also variably reported. It depends on the honesty of the surgeon and the data collected by that group. But those typically involve neuropraxias, wound complications, et cetera. The more difficult complications include hardware failure, coracoid fracture, particularly in our high-level professional athletes, and those can be challenging, and that's where the learning curve of Latter-Jay comes into play. This is one of my favorite papers, and it's a really good paper because it highlights the importance of long-term clinical outcomes. A lot of papers that we publish have six months to two-year outcomes. We know with instability that's probably not good enough. When we look at the literature, we really need to look at five-year outcomes or longer so that we can understand what happens to these athletes. And here's a good example. High school kid that you stabilize and go to college. If you just care about his career or her career through the duration of high school, you're probably going to miss the potential injury that they have in college. And so it's important to get five or more years of outcomes on instability patients. And when you look at this paper by Christian Gerber, at an average of 10 years, minimum of six, they compared Latter-Jay to soft tissue stabilization, and they found that the recurrence rate was ridiculously low in Latter-Jay compared to arthroscopic soft tissue stabilization. And the patient satisfaction was much higher in the Latter-Jay group. So these results are important for us to be able to counsel our patient. Yes, Latter-Jay is more technically difficult than soft tissue stabilization. Yes, the complications may be a little bit more burden to bear for the patient, but the results when it's done well and the patient does well are indisputable. Latter-Jay has lower recurrence rates, and those recurrence rates go down the longer we follow patients out, at least in this study by Christian Gerber. He's not the only one. Many other authors have reported on outcomes following Latter-Jay, and again, from bone loss ranging from no bone loss, like you might see in France, to 25 to 30 percent bone loss, like you might see more often in the U.S., the results are the same. High rates of joint instability at medium to long-term follow-up. Now, some people might say, well, you can always do a Latter-Jay. Let's do the soft tissue stabilization, and if it doesn't work, we'll do the Latter-Jay. Not so fast. When we look at the work by Dickens and his group, we can see that there's no free lunch here. It's not as good if you've had a prior surgery. So don't just think that you can do the soft tissue surgery and then go do the Latter-Jay and expect those results to be equivalent to as if you had just done a Latter-Jay on your own. Take-home points. Soft tissue stabilization, open or arthroscopic, it doesn't sufficiently treat glenoid bone loss, and when we add a remplissage, we do add another restraint, but we may compromise range of motion. Latter-Jay replaces bone loss with bone. Latter-Jay is successful even with minimal bone loss, and that's been well popularized by our colleagues in France and throughout Europe. And Latter-Jay reads to lower recurrence rates and higher patient satisfaction compared to soft tissue stabilization. Thank you all very much.

Latter-Jay

shoulder instability

bone loss

triple blocking effect

long-term clinical outcomes