Good afternoon. It's great to be here in person. Thanks to Gus and Pat for moderating this. I've been asked to speak about intraoperative complications related to coracoid transfer, namely a fractured graft. What's the secret with the mouse? Just closer to the tip. There we go. These are my disclosures, which are available on the Academy website. Coracoid transfer is one of the options available in the menu of operations we use to manage bipolar defects, glenoid defects, as it relates to bone augmentation. The nomenclature does provide the potential for some confusion related to eponyms. Latter-Jay, obviously, Michel Latter-Jay in 1954. Prior to him, Albert Triod actually described an osteoclasis of the coracoid, going back to a paper in Dresden in 1924. Then we have all these others. You'll see these in the literature used interchangeably, Latter-Jay, Pate, Classic, Traditional Latter-Jay, Bristow, Bristow-Helfed, Bristow-Helfed-May, Congruent-Arc, Modified, and Bristow-Latter-Jay. We know that all coracoid transfers are not equivalent. The three basic types we touched on a little bit this morning in the symposia, the Original or Traditional Latter-Jay, the Congruent-Arc as described by Burkhardt in 2007, and the Bristow published by Helfed in 1958. And so when we look at these, the type of coracoid transfer selected may have procedure-specific factors resulting in a fractured graft. So we'll start with the Traditional Latter-Jay. This, as you know, is on the inferior surface of the coracoid, which is opposed to the glenoid, the so-called lying position. And that provides a larger surface area for bone-to-bone healing compared to the other transfers. The Congruent-Arc is the medial surface on the glenoid or side position, and this allows for greater restoration of the glenoid defect compared to the other transfers. These illustrations are courtesy of Luciano Rossi. And then the Bristow is the osteotomized surface of the coracoid as opposed to the glenoid, the so-called standing position. And this is a bit different because you're using the intramedullary canal for a single screw. This paper from Dumont and colleagues compared the Traditional versus the Congruent-Arc Latter-Jays. On the Traditional side, the average surface area was 5.65 centimeters squared. The mean width of bone on each side of a 3.5 millimeter screw was 7.1 millimeters, compared to the Congruent-Arc, which had much less surface area applied to bone, under four centimeters squared. And the mean width of bone on each side of a 3.5 screw was only 4.1 millimeters. So again, it provides the potential for a higher fracture risk. This paper we heard this morning, this is Joe Lamplot, one of our former fellows and my colleagues at HSS. They reviewed 117 CT scans. You can see there was considerable variability among length, width, and thickness. But most patients had a harvestable coracoid length of more than 20 millimeters. Importantly, nearly 75% of the females had a coracoid thickness less than 10 millimeters, which once again may increase the risk of graft fracture when using the Congruent-Arc. So this is essentially a technique-related complication, which is why it's important to really focus on several steps, one being the coracoid graft harvest. You saw a wonderful cadaver surgery from Matt Preventer this morning, and you really want to emphasize adequate exposure so that you don't develop a shortened graft or a missed The row retractor, which is a three-prong retractor, is very good, so is a Hohmann. As one of my former bosses when I framed houses during summers in college told me, measure twice, cut once. So be sure you're comfortable with what you've got in terms of the graft itself. Avoid a graft that is too short, and if it is, you might be able to get away with one screw as a salvage. The coracoid preparation is also important. No less than one centimeter between drill holes, and overdrill the coracoid so that you can obtain interfragmentary fixation. If you don't, you might distract the graft or you might fracture it as you're fixing it. And then with respect to fixation, whether you drill freehand or with a guide, you want to use a two-finger technique for tightening. You do not want to crush the graft because that can certainly fracture it. You want to obtain posterior glenoid purchase as well. And we discussed washers a bit this morning. You heard the discussion. We typically don't use washers, but for soft bone, you might want to distribute the surface area forces by using a washer. And there are these washers which have sutures attached, as you saw in Matt's description this morning. So what about bailouts? As I said, if you have a large enough fragment and it's attached to the conjoined tendon, you can use one screw. If the graft is comminuted, you can use suture anchor fixation with sutures passing through the tendon to bone junction, incorporating the bone. The choice of anchor is surgeon's choice. Buttress plates have been described, and they're commercially available. And you can move to transosseous button fixation if that's appropriate based upon interoperative findings. If the bone is not salvageable, certainly you can use suture anchor fixation of the conjoined tendon only. You can move to a local autograft, i.e. distal clavicle autograft, and secure the conjoined tendon again to washers. And if you're really in trouble, you can move to a complete allograft, which, depending upon your bone bank, may not be available, but you can move to a DTA or a distal clavicle allograft and, again, fix the conjoined tendon to the washers. Thanks for your attention.

intraoperative complications

coracoid transfer

fractured graft

Traditional Latter-Jay

Congruent-Arc