Editorial Commentary: Arthroscopic Free Bone Blocks with Alternative Fixation is Likely the Wave of the Future but Further Research is Necessary Before Widespread Adoption.

Recurrent anterior instability with glenoid bone loss is a difficult problem with several surgical options. The Latarjet technique remains the gold standard for glenoid bone reconstruction in the setting of critical glenoid bone loss with excellent long-term outcomes. However, this technique has well known downsides including high rates of complications. Free bone blocks have become popular to overcome these limitations and are more flexible for restoring anatomy. Iliac crest bone autograft (ICBA) is a tried-and-true graft used world-wide, particularly in countries where allograft is cost prohibitive, and has shown great clinical results and instability recurrence rates similar to Latarjet. However, ICBA has also been associated with high rates of donor site morbidity. Alternative methods of fixation such as endobuttons and tape cerclage are gaining popularity due to reported risks of screw fixation, including hardware prominence and osteolysis with mixed results in the literature compared to screws. In many cases, I believe the issues with screws develop as a result of oversized grafts which eventually remodel to the normal shape of the glenoid leading to screw "prominence." Nonetheless, screw fixation remains the gold standard for fixation. As more is learned of the complex interplay between humeral and glenoid bone loss, simply reconstructing the glenoid may not be enough to address the Hill-Sachs, particularly if remodeling of the glenoid occurs over time. Regardless of technique, glenoid bone reconstruction should be sized to match the native glenoid and then potentially addressing a concomitant Hill Sachs lesion (HSL). In our practice, for subcritical bone loss (<20%) we utilize the Pittsburgh Instability Tool (PIT) score to determine anterior Bankart repair with or without remplissage versus bone reconstruction. For glenoid bone loss 20-30% we typically offer an open Latarjet and consider remplissage for off-track or near track HSL. For glenoid bone loss > 30%, we utilize Latarjet if glenoid native anatomy can be restored. Otherwise, we typically recommend a distal tibia allograft with screw fixation and potentially a remplissage based on track status of the Hill-Sachs lesion.