Editorial Commentary: Arthroscopic Free Bone Blocks With Alternative Fixation Are 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 is a tried-and-true graft used worldwide, particularly in countries where allograft is cost prohibitive, and has shown great clinical results and instability recurrence rates similar to the Latarjet procedure. However, iliac crest bone autograft has also been associated with high rates of donor site morbidity. Alternative methods of fixation such as cortical buttons and tape cerclage are gaining popularity owing to reported risks of screw fixation, including hardware prominence and osteolysis, with mixed results in the literature compared with screws. In many cases, we believe the issues with screws develop as a result of oversized grafts that 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 lesion (HSL), particularly if remodeling of the glenoid occurs over time. Regardless of technique, glenoid bone reconstruction should be sized to match the native glenoid, potentially followed by treatment of a concomitant HSL. In our practice, for subcritical bone loss (<20%), we use the Pittsburgh Instability Tool score to determine whether to perform anterior Bankart repair with or without remplissage or bone reconstruction. For glenoid bone loss of 20% to 30%, we typically offer an open Latarjet procedure and consider remplissage for off-track or near-track HSLs. For glenoid bone loss of more than 30%, we use the Latarjet procedure if the glenoid native anatomy can be restored. Otherwise, we typically recommend a distal tibial allograft with screw fixation and potentially a remplissage based on the track status of the HSL.