2025 ISAKOS Biennial Congress Paper
J-Graft Updated Experience and Preparation for Automation
Gregory A. Hoy, FRACS, FAOrthA, FACSP, FASMF, Melbourne, VIC AUSTRALIA
Lukas Ernstbrunner, MD, PhD, Parkville AUSTRALIA
Melbourne Orthopaedic Group[, Melbourne, Victoria, AUSTRALIA
FDA Status Cleared
Summary
Posterior instability with bone loss corrected by opening wedge osteotomy and use of an iliac crest J-Graft can dramatically improve outcomes
Abstract
Introduction
J-Grafts were initially inserted anteriorly by Resch, but recent use of the J-Graft posteriorly for posterior instability has been suggested and published (Ernstbrunner et al). We did our first J-Graft in 2021, and have now completed 11 of these operations for the retroverted glenoid with bone loss situation.
Methods
The surgery is done in lateral decubitus, with the J-Graft taken from the widest point of the iliac crest. The angles of the wedge are pre-measured off a CT and the bone wedge is fashioned on the back table to open the glenoid osteotomy the appropriate amount.
A vertical incision from acromion is made and the deltoid split rather than lifting it up in abduction, as the bulk of the muscle in athletes prevents access to the joint. The capsular T-flap from the glenoid margin is opened and the anchor and sutures passed BEFORE graft insertion which covers the view of the repair at the completion. The osteotomy is made with a micro-saw with distance markings showing the depth, and is not completed.
The graft is inserted and checked for stability. I have inserted a K-wire in one as it felt likely to back out and so was fixed. Closure is performed with drainage if the bone is still oozy. An abduction pillow with external rotation to neutral is used.
Post-operatively, the sling is kept on for 6 weeks and then removed.
Since 2021 we have done 11 of these operations with 8 operations in 7 patients able to be assessed post-operatively. We used a pre-op Sane Score and a post-op Sane score as well as asking if they would have the operation if offered now.
Results
All patients said they would have the operation again. The average pre-op Sane score was 29/100. The average post-operative Sane Score was 85/100. The correction of the retroversion was complete in 7 and incomplete in 1. Two professional AFL Football Players returned to their highest level of sport. No patient was worse off and all patients described their shoulders as stable. One patient with pre-operative early osteoarthritis (after 4 soft tissue operations) had some ongoing pain from the osteoarthritis.
Discussion
We feel the J-graft offers distinct advantages to the recalcitrant posteriorly unstable shoulder. The technical difficulty of the surgery has made us look at the use of CT based guides for both the harvesting of the J-Graft from the iliac crest, and guiding the position, angle, and depth of the glenoid osteotomy. We are also exploring the use of these guides to control the opening wedge whilst the graft is inserted.
Further use of other osteotomies such as the Scapinelli procedure can be examined for applicability to these unusually challenging patients.