Will New Information Remove Our Guilt for Being Unable to Perfectly Match Graft and Glenoid Heights?

Commentary Since the coracoid process transfer procedure was first described by Latarjet, a French physician, in 1954, the procedure has been indicated as a unique option for patients with recurrent shoulder instability with substantial glenoid bone deficiency1. In performing this procedure, every surgeon tries to adjust the position of the graft relative to that of the glenoid and make them both congruent to prevent glenohumeral osteoarthritis. No matter how carefully the surgeon does this, a mismatch between the height of the glenoid and of the graft will inevitably occur to a certain extent, and the surgeon cannot help but think about whether this will unintentionally harm the patient. Despite the strong effects of this technique, many surgeons may have hesitation in performing this technique because of concerns about the occurrence of potential complications. Based on the results of this study by Do et al., we surgeons can become more forgiving of ourselves even when we do not attain a perfectly congruent position of the graft. Even without perfect congruency between the glenoid and the graft, the findings of this study provide support for the patient's own healing potential and the remodeling process, as observed through computed tomographic arthrography, which showed a smooth articular surface in all patients in whom the graft was initially poorly positioned. Even 2 of the 4 grafts with medial step-offs converted to the flush position, presumably because of appropriate loading on the flush portion of the graft and subsequent remodeling of the non-flush portion toward a congruent position or actual osseous outgrowth or gap filling. Despite these surprising findings of the study, the things that are regrettable when considering its clinical applications are no correlation between the restoration of congruity and long-term clinical outcomes related to arthritis progression and the impact on the development of glenohumeral osteoarthritis. A systematic review and pooled analysis including 280 patients who underwent the Latarjet procedure with a minimum follow-up of 5 years showed that radiographic signs of the development or progression of glenohumeral osteoarthritis were observed in 25.8% of the patients, of whom 88.6% exhibited grade-1 osteoarthritis according to the Samilson and Prieto classification. The overhanging position of the bone graft was the only significant factor for onset or worsening of osteoarthritis2. It is expected that follow-up studies will lead to clarity regarding how the findings of this study by Do et al. relate to the clinical outcomes and the occurrence of glenohumeral osteoarthritis.