anatomical. So these are my disclosure and good afternoon to everybody. Thank you to the moderator. So while we are talking about another boning procedure, first of all let's talk about everybody agrees. We know that if we have bone defects in an unstable shoulder, if we don't select the patient and we do soft tissue, bunker repair, bunker plus, we have a very high recurrence rate. And this everybody agrees. Everybody agrees also on the fact that the larger is the bone defect and the less stable is going to be the shoulder. And also that a bipolar defect reduces furthermore the stability of the joint. What we don't agree is, first of all I heard for many years, we don't look, we don't see these bony lesions. We don't see the bony lesion because we don't have the proper algorithm for evaluating the patient in the office. So first of all when you have a patient coming to your office with an unstable shoulder, let's have a true AP view of the joint. If you have a loss of contour of the anterior glenoid, you know that here there is a bone loss. So this is the first step. Second, try to measure. And the PICO method still is very good and reliable, but it doesn't matter. Use the method you want, but calculate as precise as you can be this bone defect. And third, if there is a heel socks lesion, you must have also a 3D CT scan of the humeral head. Because the heel socks, if it's not lateral, if it's central, is a contraindication for a remplissage and the stability of the shoulder is definitely less. Where nobody agrees is, when to do a bony procedure instead of a soft tissue? Because we heard about many numbers of the bone defect percent where a bunker repair is no more good. And this has changed dramatically during the years. We started with 30%, 25%. We heard that. We have seen that even today. But if you look at the most recent literature, you see that between 10 and 50%, this shoulder is going to be unstable, even if you do your bunker repair. Plus, of course, you have to consider the patient. If it's young, if it's involved in contact or collision sports, or if it's in a competitive sport activities, this reduces the stability of your soft tissue construct. And if this is controversial, ISIS scores is a good guideline in order to know which procedure to do. Many years ago, we're talking about 2006-2007, I decided that to have this treatment algorithm. When I have to fix a shoulder, unstable shoulder, with more than 10% bone defect, I was doing a bony procedure. If it was not a chronic instability, I did, and still I'm doing, the bone block procedure, which is an anatomical procedure for fixing bone defect. If it's chronic, l'attaché. If it's less than that, bunker is fine. This is a classical case I face almost weekly in my office. A 24-year-old man playing soccer. We had the first dislocation 1.5 years before, and three dislocations total. You look with the PICC method, it has about 18% of bone defect. He has a heel-socks lesion. This, for me, is a perfect candidate for a bone block procedure. And actually, to my knowledge, I was the first who was showing this technique in 2005 in San Diego, which was using, at that time, an SEL guide from posterior to anterior to drill the tunnel through the glenoid. And this allowed me to introduce a clear crest tricortical autograft through a cannula, fixing temporarily with the suture, and then fixing with the Kishner wire. And then after that, I was fixing that with screws. And as you can see, I was still able to do a good positioning of the graft. But this was a challenging procedure, not reproducible. And even if the graft was good, the position and direction of the screw was not satisfactory for me, because many of the time, we are oblique to the glenoid. And so I developed this technique, the bone block technique, having a proper... How to say? Instrumentation for that. First of all, the guide that is very similar to the guide that Beth showed you for the lottage, but has two tunnels. And so in this way, we are able to create two tunnels perfectly perpendicular to the anterior glenoid neck, one centimeter apart with an offset of five millimeters. This allows my graft to be in a proper position and perfectly placed. And since the buttons are available, I'm doing that with buttons. And I have also the patent for this technique. And this, what I showed many years ago in Barcelona at an ESCA meeting. So as you can see, this is a beach chair position, but you can do a lateral position, it's the same. It's a classical shoulder arthroscopy with 30 degree scope posterior, two canals in the anterior part and through the rotator interval. And actually, you start your procedure in the usual way you do your bonk art. At that time, I was using holograft, now I'm using xenograft. But of course, the graft is the surgeon's preference. Preparing the graft with a dimension I liked for the most of the dimension of the coracoid is one centimeter by one by two. I was placing the guide centered on the glenoid bone defect from posterior to anterior and drilling two tunnels. Then placing a canal at 10 centimeter diameter in the rotator interval allowed me to take off from the rotator interval. So no strange portals, no difficult or challenging portals, classical portals. Outside that, the shuttle suture coming from posterior. I was loading the graft with the suture and pulling and releasing with two hands the graft in the cannula. I was able and I'm able to place the graft almost exactly in the place it should be without funny portals, without spreading the SIPS cap, just being very anatomical, very conservative. And having two couples of rounded buttons allows you to drive the graft more easily than one rounded bottles. If you have only one, it starts to rotate on itself and you have to grasp with a grasper in order to place that properly in position. And then, of course, I fix that in the usual way with the tensioner. On top of that, I reconstruct the capsule with a bunker repair. So how it works? It works placing a bone where there is the bone missing, perfectly flush with the glenite rim, as you can see here. And on top of that, I reconstruct the capsule. The graft remain extra articular and this for me is the really bunker plus. It's a bunker plus the bone is missing and so this is an anatomical reconstruction of an unstable shoulder. And I publish my data. This is five years follow up. I have following my algorithm 1.38% of recurrence rate, which is equal, if no better than Lataget. And the position in the graph studied with a CT scan is perfect, thanks to the guide. And this is not only my publication, we had other publication in literature. These are two review articles of 2021 showing that the bone block is good for bone defect. But compared to soft tissue, we have definitely a lower recurrence rate and it's an anatomical reconstruction of both soft tissue and bone. Compared to Lataget has other advantages. Lataget still indicated yes in chronic cases because of the thing that showed you Nuno. When we have a deformation of the capsule, even if we are able to reconstruct this one, hold the bone in position. And so in this case, we had to do the Lataget. But when we have the same patient with not a chronic dislocation, I prefer the bone block because it's anatomical, there is no tendinous transfer, there is no subscap split, the perfect position of the graft is very easily reproducible thanks to the guide. And there are no complication due to the guide. And this is a publication of this year, just released by me, where I checked and controlled my Lataget, my bone block. I compared the allograft, the autograft, and the xenograft, and the buttons and the screw. And this is what we've seen. We compared 45 Lataget and 78 bone block. And we compare also the differences in a CT scan study of the buttons and the screw. What we have seen is that osteointegration, the best results are for the bone block, especially if we use the xenograft instead of allograft. The worst results with this are the coracoid with screws. Same thing with osteolysis. Best results in bone block with a quine bone, worst results, Lataget with screws. So buttons gives a little better osteointegration and less osteolysis than screws, even in Lataget. But the most important thing is that we found statistically significant difference in complication, just regarding placement of the graft and the screws, and the nonunion of our Lataget, the osteolysis, and comparing this with the bone block. Bone block has no all these complications. So this study showed a significant lower rate of complication after bone block instead of Lataget. Other non-statistically significant findings suggest better results in terms of osteolysis, graft integration, with the bone block compared to Lataget, and the double and the button fixation compared to the screw fixation. So whenever possible, my philosophy, we are talking about this, is when I can, I'd prefer anatomical procedure, even in case of bone defects. Bone block is an anatomical procedure because we restore the bone stock and we repair the labrum and the capsule in the usual fashion the way we do Lataget. And the very conclusion is that when it's feasible and when there is indication, bone block is a safe procedure because there are not strange or funny or portals. So safer than Lataget, open or arthroscopic, equal to bunker because there are no different portals. It's reproducible because thanks to the guide, everybody who is facing this technique is able to place the graft very easily in the proper position, and is effective because we have the same results of Lataget in case of bone defects, and better than bunker. Thank you very much for your attention.

bone defects

unstable shoulders

treatment

bone block procedure

evaluation techniques