Greg, for the opportunity to participate here, and thank you all for attending bright and early. It's an honor for me to be up here with this incredible panel. There is a lot of experience with shoulder instability on this panel. So even if we don't have time for questions, please pick the brain of everyone up here for questions that you might have after. So we'll talk a little bit today about what happens when you don't have enough bone to reconstruct arthroscopically, you don't have necessarily an option to replace enough bone with a Latter Jay, and you want to use some sort of free graft. The distal tibia allograft is one of those options, but there are several additional auto and allograft options for free grafting the anterior glenoid, but we'll focus this on the distal tibia. I do have some disclosures, none of which are directly relevant to the content of this production, although I am a consultant for some tissue companies who do supply distal tibia allografts. So we'll start with a case. This is a case of one of my colleagues, 23-year-old male right-hand dominant contact athlete, and he came in stating he had one year of recurrent instability after undergoing a previous Latter Jay operation. Now, it's important whenever I see these patients, I want to know what happened before the Latter Jay, what led them to getting the Latter Jay, what are the risk factors in the first place? So he had said that prior to the Latter Jay, he had had his first dislocation after a football tackle, and he underwent an arthroscopic stabilization. He then apparently had 100-plus instability episodes between the arthroscopic stabilization and ultimately had his Latter Jay, and then one year after his Latter Jay, he complains of instability. Now, as our panel mentioned, this is rare. There's a lot of problems that can happen after Latter Jay, and I've experienced, I think, nearly all of them, but instability is not necessarily one of them that we see very commonly. We see more frequently hardware irritation or even infection or, heaven forbid, a neurovascular injury, but instability is just not very common, so that makes us start to think why, and he's explaining that he has instability in the mid-ranges of motion, and he states it's now easier and easier to subluxate the shoulder, so we'll skip right to the advanced imaging, and this is his Latter Jay, and we can see here that I don't really see a bone graft. Greg, do you see a bone graft when I scroll through this? I'll go back. Let me see. No, on first glance, I see the screws, which appear to be intact, and there's some bony fragmentation there. You'd wanna see other views, but the graft looks like it has resorbed, essentially. Brian, is this something you see in your practice? Your video was elegant, and clearly you have the steps down right where you're prepping both the graft side and the recipient side, getting a nice flat surface and getting your screws perpendicular, but do you see resorption in your practice even with such a good technique like that? I think you need to anticipate some resorption, and it's probably gonna be up on the superior aspect of the coracoid, so you wanna make sure that top screw has plenty of bone above it, because if it resorbs around that top screw, it can pull free, but typically, you'll see that the, what I usually see is that the top screw is sitting there in the air, and the coracoid is sitting distally, and these screws are kinda, the bottom one's either broken or loose when it doesn't work out. Now, Steve, presumably there was bone, there was a coracoid when these screws were placed. What do you think potentially leads to resorption in a case of Latter Jay? And I'll ask you two questions, two for the price of one. Say you got a CT to get one of your college athletes back to play, you just wanted to get a CT, patient's completely asymptomatic, says, doc, I'm ready to go, but you see this, does this worry you? So first question, what do you think leads to, in good surgeons' hands, good techniques, but we see this resorption, what do you think leads to that? Yeah, it's a very good question, I think. So I would tell you that we, in my practice, I don't see this routinely. It's not something that I would say I anticipate, so you're putting in a slightly larger graph, thinking that it's gonna be 70% of itself once it settles. I agree with Brian, when you see it most commonly, it is gonna be more superiorly, and that's probably based on load. I think one of the other things that I always think about when I see this occur is, technically speaking, did I place the bone graft in a spot where it's gonna see some level of load, but not overload? So if you're too lateral, you'll get fragmentation and damage to the graft. And if you're too medial, you may not see any force in the graft at all, so you may get some just attritional, you know, kind of resorption of it. But it's hard to really know why this happens. Sometimes I even worry that it's some sort of subtle, like, you know, C. acnes-based infection, or something that may be biologic in nature that you're just not really picking up. Because this is pretty significant. I mean, there's really very little bone graft left, and this patient, so you have these two screws just sticking out in the wind, basically. From the standpoint, so your second question was, basically, do you see it early? So say you see this, and it's asymptomatic. Yeah, so I think for quite a while, traditionally would get, in my kind of high-stakes cases, so, you know, the football players who are going back to play football, or like a fighter or something where you're gonna see, maybe a rodeo person, I'd get a CT to make myself feel better that it healed. I've kind of gone away from doing that, unless I have concerns based on the x-rays. Because the answer to your question is, yes, it worries me, and no, I probably wouldn't change course. You know, you're not gonna operate on them if they feel stable, they seem stable, et cetera. You'd certainly have to alert them to, hey, listen, the bone graft is resorbed, so I'm about to keep a close eye on you. But I don't know that you'd hold them, and I certainly don't think you'd reintervene unless they're having recurrent instability, so. So lesson number one for the audience, don't get images if you don't wanna see. So I would say for cases like this, if you're not gonna make clinical decisions based on your imaging, I do this for my osteochondrolografts, even ACLs, et cetera. We don't get advanced imaging for these cases unless it's for research purposes, or you have a clinical concern. I would say I like to get the CT to tell my athlete, yep, you can go back, you've totally got a bony union, but sometimes I see things I don't wanna see, and they're doing just fine. And then it gets in both the athlete's head and my head. So I've tended not to get imaging unless it's for another purpose. So I would agree with that. Can I add one last quick thing? Sometimes I still will get a CT if the timeline is such that I wanna try to return this athlete early. So let's say it's four months, the season's about to start, that kind of thing, and I wanna creep into it, that may still be a circumstance where you might wanna consider it, because it gives you some reassurance that that might be okay to do. Sure. Okay, so Laterge, we had a very elegant video. So this is a video of Dr. Tony Romeo, who's one of my mentors, who taught me about Laterge. So I'm not going to highlight any more than Dr. Wolf's talk was phenomenal, and that technique was one of the best I've ever seen. We know with Laterge reconstructions, the outcomes are good from a stability standpoint. There are high rates of joint stability at greater than 20 years. This is a time-tested and true operation. It works, it's got a learning curve, it can be done open, it can be done arthroscopic, but this is a phenomenal operation, and failure is uncommon. The laterge, there's not a lot of papers on this. Even in 2022, I looked as recently as last night, not a lot of data to tell us what to do and why these cases happen, other than technical issues. We know technical issues in Laterge surgery as well as in any surgery can lead to failure. But what we don't fully understand after Laterge surgery is what actually is a failure? Sure, recurrent instability is, but what about pain, stiffness, hardware irritation, et cetera? What are the reasons that people don't get back to sport or are not satisfied after their Laterge? And so we don't fully understand that, and that can be a topic up for debate because when we think about peer-reviewed literature, how we define failure is the headline, right? That's in the abstract, that's what most people read. But not all of us agree on what's truly a failure other than recurrent instability, including subluxation or dislocation. But anyway, in this case, the patient clearly has a failure, he's recurring, so I think we can all agree that he has failure. He has a clinical failure, he has a radiographic failure, and he's 23 and wants to play sports. So what are our options here? Well, we have all the options, right? We have therapy, interarticular injection to manage pain, biopsy to check for infection, as was mentioned here, and then revision reconstruction, and our options are either autograft or allograft. I think we can all agree there's no arthroscopic soft-tissue-only approach that would help this patient. Or would anyone on the panel try that? Would anyone consider an arthroscopic capsular plication, remplissage, seven o'clock anchor, anything here that might help this patient? No, I think if Ivan Wong were here, he would do an arthroscopic bone block, remove the screws, but I think he needs a new bony procedure. New bony procedure, okay. Now, is anyone on the panel considering a biopsy to look for something like subtle infection? Or are we going right to surgery? Any other things that would be suggestive of a subtle infection? Zero. Labs are normal, as is often the case with a C. Acnes infection. Otherwise, no concerns, he had no wound issues. Only risk factor is now he's had two surgeries on the shoulder. So I would tell you, in this patient, I mean, he's got a very troubling history with his failed arthroscopic procedure and all the dislocations and then the coracoid transfer that obviously didn't work out very well. I have in a few patients, and it hasn't been in this particular patient population, gone in, scoped the joint, removed the screws because they're causing damage, and taken some biopsies arthroscopically. I think if you're really looking for something that would be causing this, it's infectious. I think just labs or aspirations probably not gonna be high yield. So if you're convinced or you're concerned, and in this case, it's not unreasonable to be, then I would take that approach. I'd scope it, I'd remove the screws, I'd take some tissue biopsies, probably five of them, and kind of see if anything comes back. So this patient got C. C is always the answer on a multiple choice test. That's why I put biopsy as C. But this patient got a biopsy with open, he actually opened a Breedman, open removal of screws. This is one of those cases you go in through the scope, at least I go in through the scope and I say, I'm a hero, I'm gonna get the screws out. This is gonna be awesome. And then you can't get them out, even though they're staring at you because there's no coracoid bone left. And so this ultimately becomes an open to Breedman where you can get phenomenal tissue. So you can get your five tissues. So small open to Breedman, hardware removal, tissue cultures, negative for infections. So now, what are our options here? So autograft option, we have distal clavicle GT tokish has popularized that as have others. We have Iliac crest, certainly a very viable option for a structural graft, patient's autologous tissue, cost effective, maybe advantageous, particularly overseas where allografts may not be as readily viable. Or we have allograft options, also Iliac crest, fresh or frozen distal tibia and a variety of other grafts, even fresh glenoid, which is almost impossible to get for a variety of reasons. So I'd like to go down the panel, Greg, in your hands, what's the, you're reconstructing the glenoid, what graft are you using? I would do a open distal tibia allograft, getting some cartilage back, the curvature is great, the bone, I've had good luck with the bone healing, so that's what would be my go-to. Brian, how about for you? Yeah, fresh distal tibia. Steve? Same. Same, so fresh distal tibia, and that's what, that's the topic of this panel, so, or this particular case, so that's what was done here, but all of these options should be tools in our toolbox, and certainly we can have the debate on arthroscopic versus open approaches, but in my hands, this is an open approach. So let's talk about distal tibia allograft, and I wanna credit many people, but two in particular, Matt Preventer and Tony Romeo, for not only teaching me, but so many of us, the basic science of this graft, the biomechanics, the anatomy, and certainly clinical outcomes early, and then many others have now started to publish their clinical outcomes, but this is something where I was in, or doing my research fellowship, and then in residency and fellowship, this was in diapers, this was, distal tibia was barely thought of, and now it's got five to 10 years worth of data, and this is where novel, having a novel technique, and then following your patients, reporting on early outcomes, good, bad, or ugly, and then continuing to publish is so helpful for the rest of us. So distal tibia has been published back since 2007, 2008, 2009, again, led by Matt Preventer and Tony Romeo, and we've learned that the anatomy of the distal tibia really does match the anatomy of the anterior glenoid, and it's quite interesting that no matter whether it's male, female, or right or left, 70 plus percent of distal tibia allografts match the various glenoids, and so it's quite a readily available graft from a tissue bank and cadaveric perspective, and the radius of curvature of that distal tibia is quite nice when you think about it on top of the humeral head, and so many others over the last couple years have started to look really into the morphology of the distal tibia and anatomic differences in the distal tibia, and I wanna highlight this bottom study published in AJSM. They looked at 85 ankle MRIs to look at the morphology of the distal tibia. They found that deep concavity made a graft unacceptable, which makes intuitive sense. Think about the ball and socket joint. If you have a super deep distal plafond, you're not going to really get a nice radius of curvature fit on the humeral head. They found that of these 85 ankle MRIs, 14.1% were unacceptable. I'm only highlighting the specifics of this study because 100% of the female ankles were acceptable, so female donors were more acceptable, 100% in this case compared to male donors, and this is very interesting, and when we think about using grafts in general, this is an area of the literature that's devoid of good research talking about male versus female tissue donors when it comes to all types of grafts, whether it's cartilage, osteochondral, ligament, tendon, skin, et cetera, so something we have to pay more attention to in terms of sex and gender characteristics with regard to grafts, but anyway, female grafts were more acceptable in this particular study. When we think about the biomechanics, this was a study first done by one of my, one of my and Greg's co-residents at Rush, Sanjeev Bhatia, back when Matt Preventer was finishing his fellowship, and they looked at comparison of glenohumeral contact pressures and contact areas, reconstructing the glenoid with both the latter J and distal tibia, and found very favorable biomechanical profiles with the distal tibia, and this is likely due to two factors. Number one, the distal tibia has articular cartilage, and so that articular cartilage can marry nicely along the glenoid articular cartilage, whereas a latter J or a coracoid transfer or even an iliac crest does not have that nice, juicy, hyaline-type articular cartilage that fits so nicely along with the rest of the glenoid, and number two, it's a nice tricortical structure, so there's good cortical and, or excuse me, it's a cortical cancellous graft, not tricortical like a iliac crest, but it's got cortical and cancellous bone, so it provides nice resistance to stress and load. Early outcomes were published again by Matt and Tony, and I was lucky enough to be part of some of these studies, and the early cohort studies showed us that patients do quite well, and when we look at that, that's this study right here. This was a group of consecutive patients with recurrent anterior instability with a minimum of 15% anteroglenoid bone loss and a minimum clinical followup of two years duration with exclusions for hypolaxity and neurologic injury. We collected all the usual outcomes that people collect. This was a multicenter study, four surgeons across two institutions with 38 patients. As is classic for shoulder instability, 95% of the cohort was male at an average age of 29 years with an average followup, again, minimum two years, but just about four years followup on average, and of these 38 patients, four had had a prior Latter-Jay, so four of these cases were revision bone block patients, and what we found in this study is that there were significant improvements in all patient-reported clinical outcomes, most importantly the WOSI score. One infection that resulted in graft removal and a revision allograft and no cases of recurrence as we might expect. So the principal findings of this study, this is a proof-of-concept study. Let's follow our outcomes with a novel procedure that procedure works. So then the next logical question becomes, how does it compare to Latter-Jay? Because Latter-Jay is the gold standard, and so this was a project that I asked our team to help me complete when I was back a resident and fellow, and we compared the outcomes of Latter-Jay to distal tibia in a matched cohort analysis. So not a prospective trial. Indications for these procedures do tend to be a little bit different, but a retrospective review of prospectively collected data matching patients undergoing Latter-Jay through a variety of fractures to patients undergoing distal tibia. And so the inclusion criteria were consistent patients with recurrent instability with a minimum of 15% bone loss and a minimum two-year follow-up. Same exclusion criteria. And then what we did was we took our list of patients and we matched them. So I went through all the patients one by one and matched them based on age, plus or minus a couple years, sex, male to male, female to female, BMI within a couple points, history of contact sports, yes or no, and then number of prior surgeries, which was the hardest one to match because usually they had between one and three prior surgeries, and it was really hard to get one to one and two to two, et cetera. But we wanted to try to compare for all of the variables that we think lead to failure or lead to recurrent instability. And so we got this nice cohort. The average age was 26 years. Average follow-up just under four years. Prior surgery in two-thirds of the cohort. And you can see here when we compare our DTA to Latter-day patients, the cohorts are pretty evenly matched. 48 males and two females in each group. BMI within a point of each other. Number of prior surgeries, 32 and 32 in each group. History of contact sports was 16 in the distal tibia, 20 in the Latter-day. The only thing we didn't match specifically and ended up being statistically different between the groups was the percent of glenoid bone loss leading to the indication for surgery. So in this case, the distal tibia group had just under 30% average glenoid bone loss and the Latter-day group had about 22 and a half percent. And that was statistically and certainly clinically relevant. With larger degrees of bone loss, we think Latter-day may not be enough to get you everything you need and you might need that free graft. Otherwise, no difference in any of the other factors. Okay, what did we find? Well, we found that both groups had significant improvements in all of their patient reported outcome scores. And there was one case, so 1% recurrence rate in the DTA group, 1% for the cohort overall, of traumatic recurrence, athlete went back to sport. When we look at complications and reoperations, we found five total complications per group, so a 10% complication rate for the 100 patients. And three of those complications in each group required reoperation. Again, the one for recurrence in the distal tibia group. And we had the six total reoperations. Some were for subscap repair, one had that trauma, so revision, IMD, scope, et cetera. And then one, in fact, in the Latter-day group did have a musculocontinuous nerve injury that required decompression. Principal findings of this study, the outcomes are pretty good in both groups and no different between both groups. So now this gave us some evidence to say, okay, Latter-day is good and we know it, but distal tibia, at least at four years, is good and now we know that too. And when we look at the outcomes, when you go into 2020, 2021, 2022, more groups have started to utilize the techniques that have been described over a decade ago and publish on their results, doing this technique now arthroscopically, doing this not just with screws but with buttons, doing this now in a surcloged fashion with anchors, doing this with frozen grafts versus fresh grafts, and the outcomes all seem to be reproducible. So I'm not gonna use the time that we have left because we have some great cases that Greg's going to show us to highlight all of these, but we can see that patients are doing well with the use of distal tibia allograft. Now what about after a failed Latter-day? We all know that prior surgery tends to make future surgery a little bit worse for the wearer. Well, this was a paper published by Matt Preventer, Giovanni Giacomo, and others in AJSM 2019. 31 patients who all had prior Latter-day, their bone loss at this point now 30%, you know, one third of the glenoid, and they found that even in these most challenging cases, and for any of you who have revised a Latter-day with broken screws and capsular issues and lots of neurovascular potential problems, these are not easy cases. All of these outcomes improved in these patients, and there were no cases of recurrence with a 92% union rate as demonstrated by CT of this distal tibia allograft. So incredible outcomes in a very challenging patient population. So back to our case, this patient got an open distal tibia allograft. I'll highlight through some of these videos. This is his examination under anesthesia. The setup in the modified beach chair position is critical with that bump under the scapula as mentioned by Dr. Wolf. This is a delto-pectoral approach. This is a big-time surgery, so this patient gets a big incision. In this case, you can do it through a revision subscap split, but many surgeons will elect to take down the subscap. There's even been a paper published on using a lesser tuberosity osteotomy for exposure with 100% healing rate, and patients do quite well. And then you prepare your anterior glenoid rim. This is now fracture surgery, removing old hardware. In this case, it was removed at the time of the biopsy, but this is now fracture surgery, and then there's a variety of proprietary systems that you can use to measure the size of the defect and then prep your allograft on the back table. When you're prepping your allograft, the key is to make sure that you will be able to get your graft flush to the glenoid and not angled, because again, it's fracture surgery, so your fixation, in this case screws, need to go perpendicular to the graft. You also need to take care, especially with allografts, not to make your graft too big. If that graft doesn't get loaded, even though it looks nice and you might think bigger is better, you're actually going to see more resorption. And then you end up placing your graft along that anterior glenoid rim, and in this case, fixing with two screws with washers. There's also mini washer-type plates that you can use for a more biomechanically rigid construct, and so a lot of different options, and then certainly using anchors or sutures or both to fix your capsule. In this case, rehab is slow. Usually we get a CT on these cases, especially in revision scenarios, especially with his lysis that he had before to determine the ability to return to sport and make sure that that graft has really healed, and these are the final x-rays in this case. Patient does well, is happy, and we're all thinking we're heroes. But at the end of the day, distal tibiafter-fouled latergé is a great option. It's an evolving option. There's now, to date, the one paper with over 30 patients, and we need more literature to see if we can support this option for the vast majority of our patients if we need to use this graft. Contraindications, even if they have hardware that doesn't look so good or a latergé graft that's been resorbed, don't need to do it. Probably if it's under 10% bone loss, I don't know that we need to use the precious resource of a fresh osteochondral allograft to reconstruct that glenoid, but I think that's debatable. Certainly if there's active infection, that would be a contraindication. Pearls, I would say rule out infection. Make sure you get exposure. So no one likes to take down the subscap, but if you need to take it down or you need to get that exposure, just do a nice repair and the patient should be just fine, and Brian showed us a great video on that. Pitfalls, you need to be careful with the scar tissue. These are often three, four, five time patients who've had surgeries in the past and your neurovascular dissection can be a little dicey, and even a little bit of traction on the nerve can cause problems down the road, so you've gotta be very, very careful. Techniques have been updated, as I mentioned before, over the last couple years, doing this all arthroscopic using novel fixation constructs such as buttons or even just pure anchors and nothing going across the glenoid, so lots of different ways to skin this cap. I would say take-home points for distal tibia. We need to understand that recurrent instability in general, especially after a Latter-day is uncommon, but fresh distal tibia is certainly a viable option and we now have data to really show that. I would make sure in any revision scenario to rule out infection. Doesn't always look like an infection, but it may be there, and take care not to make the graft too big. Thank you all very much.

distal tibia allograft

shoulder instability

recurrent instability

lattergé operation

graft resorption

bone support