All right, thanks Greg, that was a great introduction, and I was tasked with talking about what's gotten a lot more common over the 20 years I've been in practice, Latter-day. It's interesting, when I was doing my fellowship in 2002, I never saw a Latter-day in fellowship, and now it's a big part of our practice and how I'm dealing with this problem. Here's conflicts. So just throwing a case out here to begin with, 18-year-old male. He's had three and a half years of shoulder instability. He's never needed a reduction, he's never been to the ER, he's had frequent subluxation events. He's going to go play D3 college basketball. He's got a little bit of laxity, 5 over 9, Bayton score, he's got full range of motion, he's grossly apprehensive. Here's his plane radiographs. I'd argue on his axillary view there, you're starting to get a little hint that he probably has a little bit of glenoid involvement. Here's his MRI axial views, and as we get inferior, we're starting to see a little chipping and a little erosion off his anterior glenoid, and when we look at this series of cuts here, you'll see some injury to his anterior glenoid. So when we get suspicious on our MRI, I have a very low threshold to get CT scans or 3D reconstructions. We do a lot of this now with MRI measurements and so forth. Brett Owens put out a very nice algorithm of evaluating bone loss on MRI, but I still find the CT scan very visually appealing to just look at, and we can do our measurements of how to deal with this. So in this kid, we have an 18-year-old who's never had surgery before, options, you could do a scope Bankart, try to incorporate a bony fragment. You could argue that fragment may be a little atrophic or not exactly what it was like, maybe three years ago when it first happened. Do an open Bankart, incorporate things, or do some kind of bony procedure. This study was brought up by Greg. We put this out there a couple of years ago, looking at bone and cartilage lesions in the Moon's shoulder group, 500 and some odd patients, very active young cohort, and we found that almost 20% of our primary cases had some degree of bone loss that we considered to be significant. So what are the indications for doing a Latter-J? We probably have a bit of variance even up here on the panel, but I think the indications in terms of bone loss purely on the glenoid, 15 years ago it was 25%. It went down to 20, it went down to 15, and then with some of the work by J.T. Tokish and others on PROs and just how patients do, it started to even drift down towards 10%, probably in that 13% range. Especially for off-track lesions, when you have big hill-sax lesions, you can consider that. Or in cases like this where you have a bony Bankart, but that piece just doesn't look like a real piece that might restore normal bony anatomy. The PICO method is probably our most precise method, the most packed systems these days. You can draw that circle on the lower 75% to 80% of the glenoid, match up with your posterior and inferior cortex of your glenoid. Get that nice on-foss view, measure the area that's missing over the rest of it and get a percentage. That's probably the most commonly used, and again, most packed systems will allow you to do this. A little bit about Latter-J. It started back in 1954. It was first described as a coracoid bone block procedure, suggesting that that coracoid could be fixed in the anterior glenoid, as we have all seen with screws. It became very common in Europe. I would say even in 2010 when I did the traveling fellowship through Switzerland, that's what they were doing for everybody, first-time dislocators and so forth, Switzerland, Northern Italy, Germany. Big outcomes series from Gilles Walsh and others of thousands of procedures with relatively good results. So a traditional Latter-J as described by Walsh, coracoid osteotomy, you like to have a 20 to 25 millimeter fragment if you can, doing a subscapular split somewhere in the 50 to lower two-thirds aspect of the subscap, and then fixed to the anterior aspect of the glenoid, saving a stump of the CA ligament to help repair your capsule. Latter-J was slowly adopted in the United States. I would say one of the early proponents was Steve Burkhardt, who published his series of large failures with bone loss. So a modified Latter-J, an Americanized Latter-J, if you will, coracoid osteotomy in a similar way, doing a subscapularis tenotomy as opposed to a split. Again, a lot of Americans were trained on open bankart 20 years ago, and doing a tenotomy was a very common way to address an open bankart. And then there was the option of doing a congruent arc where that coracoid is flipped 90 degrees and actually creating a wider surface of the glenoid where the capsule could then be repaired right to the native glenoid, making the bone block extra-articular. Latter-J is not benign. If anybody's done a lot of Latter-J or seen a lot of Latter-J patients in follow-up, you can get pulled off conjoined tendons. There can be a miserable scar if you're trying to revise it. The bone block will resorb a bit, so you have to anticipate that, especially on the superior aspect. There's concerns about arthrosis if the bone block's not placed appropriately, but you can maximize your outcomes and minimize complications by just trying to get things right the first time. This was an Ohio State study about ten years ago now, 1,900 patients. They've reported a 30% complication rate with 9% recurrent instability, non-unions, neurovascular complications, and some external rotation loss. So how do we do a Latter-J? A few different varieties, like everything else in orthopedics. Everybody likes to adopt their own slightly different version of the procedure. At being a self-trained Latter-J surgeon over the last 20 years, this is how I do it. So take that with a grain of salt, and there'll be some controversial points that we can debate a little bit as we want. Forty-five degree beach chair position, it is helpful to bump the scapula to try to externally rotate your scapula. It's going to make it a lot easier to get your screws in to fix your corcoid if that scapula is extended and externally rotated, because you're going to fight the chest otherwise. You want to make a four to six centimeter incision. You can make it very small. Quite honestly, the bigger the patient, the bigger the incision needs to be. The bigger their pec, the bigger their deltoid, the bigger the incision needs to be. I don't think I've ever had anybody come back after a Latter-J and ask why their incision was six centimeters instead of four. So do what you need to do to see. You're going to identify your delto-pector interval. I won't walk you through this, because most of us know how to get through here. You want to expose your corcoid. Place a Hohmann retractor right over the corcoid, or I actually like to use the two-pronged Bankart retractor. You put it right at the base of the CC ligaments, and you can actually, it's a little bit easier for my assistant to hold that. We want to free up the lateral side of our conjoined tendon. We're going to find the CA ligament. You have to make a decision at this point in time, are you going to do a traditional Latter-J where you're going to sew the capsule into your CA ligament, or are you going to use anchors? I use anchors, so I sacrifice the CA ligament. It allows me to just free that whole lateral border of the corcoid up. Again, this is a debatable point. A lot of people like to save that soft tissue. We're going to identify our pec minor. We release the pec minor off the superior aspect of the medial base of the conjoined, and then probably a little bit of the dicey part of the case is freeing up that interval between your conjoined tendon and your pec minor distally, because your musculocutaneous nerve is going to be sitting right deep underneath that. We'd like to have a stump that's, or a piece of bone that's 20 to 25 millimeters long. You are going to be a little bit limited based on patient size. You obviously don't want to compromise your CC ligaments, but getting a 20 to 25 millimeter fragment is usually very easy. You want to use a 90 degree saw. You're going to fight your retractor up there, whether it's a Hohmann or a Bankart retractor, sawing inferiorly, trying not to go medial. You want to protect those neurovascular structures that are medial to the base, and then you complete your osteotomy. You can get a bit of a feel of what the depth of that fragment can be. Quite honestly, you're going to be running into the front of your glenoid. You can't take too much without compromising getting into the bone of your anterior glenoid, so you want to make sure you have a nice deep fragment that you can then place on your glenoid. So once we get our fragment, we're going to remove the periosteum from the inferior surface. If we're going to do a traditional Latergé, we're going to flatten this. You can use your 90 degree saw. You can use like a medium average saw and just kind of flatten it down, but you want to have a nice flat surface. I think the biggest problem that I see with Latergé is non-union. When you have bad problems, this is a non-union surgery. So you're trying to stick a piece of bone onto the glenoid that wasn't meant to be there. So you have to treat it like a tibial non-union or anything. You have to have a nice bleeding surface on both sides. So really take your time with corcoid prep. Take your time with the glenoid prep. You can blame screws. You can blame all kinds of things, but a lot of it is biology, and just making sure you have a nice bleeding surface that's flat is appropriate. There's different systems out there. This is one of the systems that's available, allows you to pre-drill your corcoid. It's helpful for me. It's not helpful for everybody, but it does allow you to kind of preset where your screws will be. And you're going to want to probably think about doing these in compression mode, so slightly bigger holes on your corcoid so you can really squeeze that piece. Now we get into the subscapularis, so you make a decision about doing a split versus a tenotomy. I've done it both ways. I do a tenotomy now preferentially. I think it allows me to see better. I think it allows my assistant to see better. We've done some follow-up studies with the MOON cohort, and at six months we didn't find any difference because we have a fair number of people in our group that do splits. So in terms of range of motion and strength at six months, we didn't find a difference. The downsides of doing a tenotomy is it takes longer to put it back together. You have to do it well. It's a longer closure, and if you have a subscap failure, it's a disaster. But I do think some of the benefits are it's probably an easier exposure to be able to see everything you want to see on the anterior glenoid. So here we've done a split on the upper two-thirds, or tenotomy, I should say. Now you have to manage your capsule. The benefits of doing a tenotomy is I have complete view of the capsule, so I can see this big patchless capsule. We're going to open our rotator interval that's already opened laterally, get the loose piece out. We free up our glenoid, put in our furcuda retractor, put in our bankart retractor, get all the pieces out. But at the end of the day, we want to have a nice, clear view here of the anterior glenoid. In this case, we had kind of an atrophic piece that we want to get out. We're going to get all these old pieces out. Then this is the second half of the equation for the biology. We have to have a nice, flat, bleeding surface on our anterior glenoid. You want that piece to have a perfectly flat area to sit with some nice, bleeding bone so that when we screw it down, it has a really good biologic setting to do what it needs to do. And fix it in place. You'll hear debate about screws and titanium washers versus stainless steel and malleolar screws. Again, I think the biology is more important. I use cannulated, fully threaded screws and compression with washers. That's just what I do. It has not been a problem for me. I think if you get a non-union, whether it's a solid screw or a cannulated screw or stainless steel or titanium, it's going to break no matter what it is. So getting everything flat, getting things compressed the appropriate way with screws that you have available, I think is the most important thing. You don't want to place your graft too low. If your graft is too low, you potentially have axillary nerve problems or your humeral head can dislocate over the top of your coracoid. You don't want to put it too high because then you really place a lot of stress on your conjoined tendon and you're probably not addressing the bone loss as well if your coracoid is too high. Now you have to deal with your capsule. So if you've saved your CA ligament, if your CA ligament is still attached there to your coracoid, you can just sew that vertical limb of your capsule into your CA ligament. I've sacrificed the CA ligament, so I use anchors. If you're going to use anchors, you have to really be very careful about that vertical limb of your capsule to lengthen your capsule, otherwise you might have a bit of tightness with your shoulder. But when you use anchors, you're basically doing an open bank art repair with a coracoid process transfer. So you're doing a bit of a shift in bank art repair in addition to a bony procedure. So here we are kind of doing our medial bank art repair, capsule repair, makes our bone block extra articular. Again we tried to make sure that we lengthened our capsule, really peeling it medially off the glenoid so it's not too tight. If you think you want to close your rotator you can, occasionally we'll close it lateral. Just make sure you don't over tighten that shoulder because they will lose motion no matter what you do in this procedure. And then if you've done a subscapularis tenotomy, we want to make sure that we have a brilliant super tight repair that's going to be stable and heal nicely. So our rehab, very similar to what we would be used to with arthroscopic or open, I'm actually a little quicker to get them out of their sling, a little quicker to get them moving because I do tend to think they get a little tighter than my arthroscopic repairs. So what about that case? This kid had a grade 3 instability, we did a ladder J, we did the procedure we just demonstrated in the videos. You know at 5 months he was back to basketball, he had lost about 10 to 15 degrees of abduction external rotation. I did not get a CT scan before sending him back, it's probably something we could talk about here today. If their x-rays look good I don't get a CT scan, a lot of people will want to get a CT scan, but in my book if they're doing alright I don't want to not let them play based on a fibrous union or something else that a CT scan might show and I don't like to radiate my young people if I don't have to. Just another case, 21 year old, college power 5 defensive back, a few subluxations over the years, never brought it up, nothing reported. He finally gets an MRI and a CT, he's got this, again he's never had surgery, he's never been to the emergency room, but his imaging is quite concerning. Another case that's treated with a ladder J as a first time procedure. So indications as noted here, if you have a nice bony fragment there, that's certainly something that you can fix. I would argue that the CT scan here on the bottom, this is one that I would probably fix that piece whether arthroscopic or open. I can't make that glenoid more normal than that if I can get that piece to heal. So certainly a role for bony bank art repair if you can catch these early and the fragments are still viable. Lots of different outcomes out there, so some of these were already reported. Young people, recurrence rates of 50%, 24% with arthroscopic bank art in young active contact athletes. You look at different papers and it's not so bad, 10% safer at all, I think which is Jimmy Andrews group, Dickens group when they excluded bone loss, 6%. So really important to analyze the bony anatomy of the shoulder because you can have good outcomes with an arthroscopic bank art, but they have to be appropriately indicated. How about scope bank art versus ladder J? Recurrence of instability is always higher in the arthroscopic bank art group. Dissatisfaction is usually related to recurrent instability, so this was Gerber's group. When you look at some of the other studies that are out there, Blani et al. here matched 30 patients. They had no difference in their outcome scores, they had no recurrences with ladder Js, but they actually found that more patients went back to sport after the scope bank art, they had better range of motion in their throwing positions, they had better perception of their shoulder with the arthroscopic bank art, but they had higher recurrence rates. There's probably a little bit of give and take here that has to always be considered. Bessier et al., 93 scope bank arts matched with 93 ladder Js. Recurrence rates you can see there, 10% versus 22%. Reoperations rates were exactly the same, and their row scores were higher in the ladder Js group, but the return to sport was no different. How about REMPLISAGE? We'll talk about that a little bit here with Steve, one of the later cases here, so I won't get into the REMPLISAGE too much. Return to sport, when you look at the systematic reviews, they're pretty similar, but they might be slightly higher in the scope bank art when you look at all the literature all together. Ladder Js are a big procedure, the return to sport time is about the same, but it's just a bigger operation for these shoulders. So in summary, patient selection, really important considerations for indications that you need to really scrutinize this. There's an extreme variance in our young contact athletes, so looking at bone loss is really important in that group, and return to sport is high, no matter how you treat them. The recurrence rate I think we can modify depending on what procedure ultimately is done in that particular setting. Lots of pitfalls, I think technique is super important. Thank you very much. Thanks, thanks Brian. One question, so you mentioned in Europe when you were there that many of the primary first time dislocators were treated with the Ladder J. Have you moved in that direction for your high end athletes or others, especially without the presence of bone loss, and are there any pitfalls there? Great question, I do more Ladder J in a primary setting now than I did 20 years ago for sure now. I don't do it if the glenoid looks normal, but I would also say I do a fair amount of open bank guard. So in my contact athletes, if I worry about laxity, if I'm worried about this is a kid that looks like they're high risk, I have a quicker trigger to move to an open banker where I think I can address, personally I can address the caps a little bit better. They would get a bank guard repair and a capsular shift. So in my hands, I have a lower threshold to do that. A little bit of what I struggle with is in that 18 year old that has a normal glenoid and not much of a hill sax is if I'm going to do a Ladder J, I have to create bone loss on his glenoid to make it flat to then put a coracoid on it. So I struggle with that a little bit just intuitively because I have to shave away part of their normal anatomy to actually make that coracoid sit nicely. And that's the way they do it in Europe, but just for me, it's a little bit of a struggle to make that leap at this point in time. Hey Brian, can I ask a question real quick? So what you said just there at the end led into exactly what I was going to ask or what I was thinking as I was watching. So first of all, that was an awesome video and I think those two cases you showed, it's hard to debate. Certainly there's going to be a bony procedure to treat both of those patients. Those are significant bone loss patients. But in both of them, the bone loss, the kind of the margin of bone loss was beveled, right? So I mean, if you remember how both those CT scans looked, you had that kind of attritional looking piece of kind of useless bone and then like a beveled surface. How do you try to position your piece? Do you try to put it right at the surface? Do you have it a little lateral, a little medial? You know, you have a great view in the joint because you're doing a tenotomy. So are you trying to be right in line? And how do you actually do that? Because if you're just going to go with where you are with that bone loss, it's going to want to put it essentially lateral. It's going to want to be almost with the curvature of the glenoid, if I'm making sense. No, and I think both those cases were probably extreme examples of that. And in those cases, it's a better operation, I think, to use anchors and repair soft tissue and then try to extend your glenoid in a way that you're not going to create a prominent corcoid that's going to set them up for problems. It's much, I mean, I think it's very straightforward for a latter-day, if they have vertical bone loss that's very much almost 90 degrees or 60 degree angle, if you look at articular surface versus the anterior surface of the glenoid, those are easier, straightforward. You already have a flat surface there. When you have these ones that are beveled, I think you have to be very careful because otherwise you do have to, I mean, you would probably have to remove 20 to 30% of the glenoid just to make it that normal angle. And in my hands, I don't think that's helping things. So I would almost have a little bit of a gap between your bone block and your remaining cartilage and fill that in with what you can do with your soft tissue repair. Yeah. In that setting, just a quick follow-up question. Do you ever consider an osteocondrograft or graft with cartilage when you see the involvement of the cartilage being more central than the involvement of the bone, again, if I'm making sense there? Right. Yeah, another great point. I think you have to, again, then analyze your CT scan of what that angle is. So if it's a very shallow, you've lost cartilage, you've lost bone, but it's more of a slight slope versus a deep slope. I still think you run into the same issues. But it's another consideration. I think that's another way you could approach it. You can either try to rebuild the bone with your LatterJ, repair your soft tissue if there's a little gap there where the cartilage is missing versus being more aggressive with the distal tibia or something similar where you can just resurface it. As long as you can create the plane that you're going to get a stable environment to fix a graft like that.

LatterJ procedure

shoulder instability

bone loss

MRI

surgical technique

rehabilitation