All right, so this is a 26-year-old female with right shoulder recurring anterior instability. She was a college soccer player prior, currently playing recreational soccer, no medical history. Surgical history is somewhat complex, had six total surgeries on this shoulder already when she saw me. Arthroscopic bend cart eight years ago, revision, arthroscopic bend cart, debridement, open bend cart, and lastly, ladder J, which is about a year ago that also failed. She had precision apprehension instability and also pain. This is the exam when she came to see me. She couldn't lift it more than 45 degrees. She felt the shoulder was coming out. Any time I do passive range of motion above 45, she felt instability of the shoulder. She's pretty debilitated like that for the last year. Here the imaging, you can see the screw, the graph is resorbed. The screw's a little bit more medial. And then the glenoid's right there where the humeral head is subluxated about 50% or 70% anteriorly. CT shows non-union, resorption of graft, 30% bone loss, MRI, there's a 1.5 centimeter full thickness cartilage defect on the humeral head. So here's the MRI. Here's the full thickness defect on the humeral head. And I apologize, I don't have the CT image, but it does show about 30% bone loss with complete resorption of the graft. So what are the surgical options? For me, in my practice, this is probably either iliac crest DTA or you can do distal clavicle. I haven't done much of distal clavicle, but those are two options I use, iliac crest DTA. You can do xenografts in Europe, but we don't have that option here in the U.S. In hernia, iliac crest bone graft indications, anterior bone loss, more than 30% in my practice, chronic instability, chronic glenoid rim fractures, fetal lateral joints are most common. And also do it for people who have chronic dislocations with major anterior bone loss, you can put a crest in the front and then you can reconstruct the base plate of the reverse over the iliac crest bone graft. Can be staged or you can do a single stage or you can stage it with a two-stage reconstruction. Some of the key stuff is the BTR setup. I do a diagnostic scope on everybody, take a look at the glenoid cartilage and then the labrum, examine anesthesia, prep out the harvest site shoulder, and then the approach over the original incision with a medial over the axilla. I do a subscap peel and a later repair with a suture bridge technique where we control through the tuberosity with a trans-osseous tunnel. You want to expose the prepped anterior glenoid, the iliac crest harvest, and then graft reconstruction. I'll give you some tips and pros for doing that. So this is a lady that I examined under anesthesia, you can see she's about maybe two plus posterior, but anterior she locks out in the front. Here's her scope, this is the anterior glenoid rim. This is the sacs lesion and the humeral head defects. And this is how I set up all my patients with the iliac crest bone graft, do a modified BTR. I put the drape on, just square out the iliac crest, and then I put an outband on top, do the shoulder, drape it, cut a hole in the drape, and then put an outband on top so you can harvest the crest at the same time you do it in the BTR position. This is the original incision, quite large, I think you probably need half of that incision and you'd be okay for this case, but that was the original incision that she came to me with from outside surgery. So here's the crest harvest, and then key is ID the biceps tendon, the subscap, you do a subscap peel, here's the subscap right here to the left of the biceps. Once you peel it, tag it with two number two sutures, put a retractor underneath. So I flipped this, this will kill the humeral head, you can see a large lesion, and maybe talk about around the table what you do about that in a 24, 25 year old. I can tell you I put a graft here, but that's not, I can show you later, but it's not at the same time, osteochondral transplant. But here's the glenoid defect in the front, put a retractor, this is just a standard Fukuda, a Benkai retractor and then a sharp hole underneath, you can expose it pretty well this way. You want to prep it, use a TPS bur to make sure it's nice and flat, and then I go to the iliac crest harvest. And I expose the inner and outer table, and then you put two retractors, a Cobra in the front, Cobra in the back, and then put a couple of gauze in there so you can actually get control of the bleeding. And once you do that, I take just the sagittal side a little bit for the ACL, cut the graft in the front and back, and then, really the key is a 90 degree saw, this is what I use for a latter J, you can retract down and do the 90 degree saw, you can get a perfect cut on the iliac crest underneath. And then here's the harvest, and you can see you can get a graft about 2, 2.5 centimeters in length. So I apologize for this video flip, but that's the graft. And then I pre-drill these with 2.5 or 3.0 drill bits, and I use about a 4 or 5.0 millimeter screw for this. Then I put some thrombin in the iliac crest harvest and close it, and here's the graft preparation. Put a K wire in the middle of the graft, when you put the K wire in the middle of the graft, you can control the graft exactly where you want, drive the K wire in to hold it, and then I have my resident drill the first one, either on top or bottom, and then put the screw in. And then you can rotate the graft, make sure it's completely flush, and drill the second hole underneath and then put the screw underneath for that. And then tighten down both screws sequentially so you can get the graft tightened down. So here's the final reconstruction, and sorry for this video flip as well, but you can see it's pretty flush to the glenoid. So I think in terms of graft size, 2.5 centimeter height, inter-table matches glenoid, raised curvature, 1.5 centimeter depth, and I used 4.0, 5.0 Osteopenia screws, 32 to 34 is usually a good length, and you measure the second hole so you can get a perfect length for this. Another trick I use is you can get better angles, you can take a, this is our scapula, you put it in the base of the coracoid harvest, you can externally rotate the scapula, and then you can get your hand off the chest wall so you can get a better screw position that's more parallel to the glenoid. Just a little trick so you can externally rotate the whole scapula over. So anchor is a direct repair for this particular patient, I just drilled a couple of tunnels across it, less tuberosity, repair down sutures, you can put suture breast technique, whichever one you're comfortable using, and then adding an anchor to repair down the subscap. So this is a post-op x-rays particular patient, you can see this is the glenoid, that's the hemo head centered, and if you look at the x-rays, the graph that recreates that curvature, the graph sits a little bit anterior, so you can get this curvature, and then the screw just kind of sits off just a little bit in terms of angle towards the glenoid. So this here post-op, pre-op, post-op, two weeks of pre-op, you can see it's dislocated anterior, here's the post-op, it's reduced, this patient here. So this is the post-op video. So she's about seven years out, still doing well, pain very minimal, no instability, she got almost full range of motion back, back to soccer and very mild arthritis in the joint. So just a couple of last slides to conclude, this is an autographed Iliac crest in the literature, 46 patients, 18-year follow-up, very good outcomes, normal range of motion, 77% were stable at the final follow-up, very mild arthritis, about two-third, and moderate severe at about 12%. And lastly, systemic review in the literature of 261 patients, one to four-year follow-up, you know, good to excellent in most patients, about two-third of patients are able to return to sports, re-operation is 6.1%, recurrent stability about 5%, osteolysis about 2%, heartwarren complications 4%. It's a very good operation, I think, for these tough cases. All right, thank you.

recurring anterior instability

iliac crest DTA

distal clavicle procedures

bone loss

autograft iliac crest