Abstract
Glenoid bone loss in patients with recurrent anterior shoulder instability poses a unique challenge to treating surgeons. Various bone block procedures have been used to reconstruct the glenoid, including autologous coracoid transfer, iliac crest autograft, distal clavicle autograft, and distal tibia allograft. Distal tibia allograft has been increasingly used because of its advantages over autologous graft sources. Having started out as an open procedure, glenoid reconstruction with distal tibia allograft has now found its way to evolving into an arthroscopic procedure. Various techniques have been devised for arthroscopic distal tibia allograft fixation, including screw, suture anchor, and suture button. This technical note describes an arthroscopic distal tibia allograft fixation technique, using a transglenoid parallel drill guide and 2 cerclage tape sutures that are fastened using a tensioner. This technique provides strong graft fixation while avoiding the potential complications and technical challenges of metal screw fixation.
Technique Video
The following technique demonstrates an all arthroscopic distal tibia allograft bone block cerclage for anterior glenoid reconstruction. The patient is a 32-year-old male who suffered an initial right shoulder dislocation while snowboarding 10 years prior. Since then, he’s had 10+ dislocations with several requiring formal reductions. On physical examination, he was noted to have a positive apprehension test with relocation. On imaging, including radiograph, magnetic resonance imaging, and computed tomography scan, he was noted to have a right shoulder bony Bankart lesion, with associated Hill-Sachs lesion and close to 20% anterior bone loss. Because of his risk of redislocation and failure of conservative management, a distal tibia allograft anterior glenoid reconstruction was recommended. The procedure was performed in the lateral decubitus position. Posterior, anterior, and anterosuperior portals were created. A diagnostic arthroscopy was performed, followed by elevating and freeing up of the anterior capsulolabral and boney Bankart lesion tissue from the anterior glenoid. This provided good visualization and space for positioning and fixation of the bone block. A traction stitch was also placed to aid in this process. The length, width, and depth of the defect were measured and noted for the proper size of the bone block. A TransGlenoid drill guide was then placed from the posterior portal and hooked over the anterior glenoid. The cannulated sleeve was then placed within the guide and advanced until it was flush against the posterior cortex of the glenoid. Two 3.0-mm cannulated drills were then used to create 2 transosseous tunnels at a depth of 7 mm from the articular surface and 1 cm apart from one another through the glenoid. Nitonil wires were then passed through each of these drill bits, and subsequent looped passing sutures were shuttled with one loop being placed anteriorly and one posteriorly. The distal tibial allograft was then secured to the graft prep station on the back table and was properly measured and cut. The previous drill guide was again used to drill two 3.0-mm tunnels through the bone block at a depth of 7 mm from the articular surface and 1 cm apart. Two separate FiberTape cerclage sutures were then passed through the glenoid from posterior to anterior via one of the looped passing sutures. They were taken out of the anterior portal and were shuttled through 1 end of the bone block and back through the other end in the opposite direction. They were then shuttled from anterior to posterior through the glenoid and exiting the posterior portal via the second passing suture. The bone block was then shuttled into the joint and positioned properly up against the anterior glenoid defect. The slack was removed from the FiberTape sutures, and each suture end was placed into a knot end of the other suture creating a cerclage mechanism that allowed for tensioning of the sutures over the posterior cortex of the glenoid. A suture tensioner was used, and once the bone block’s position and tension had been confirmed under direct visualization with the arthroscopy, the sutures were tied and cut appropriately. The capsulolabral tissue was then repaired over the bone block back into the glenoid, using knotless fixation. The final fixation demonstrated good positioning of the bone block with coverage of the capsulolabral tissue and centering of the humeral head on the glenoid.
Distal tibia allograft (DTA) has been increasingly used in the setting of anterior glenoid reconstruction for instability because it can avoid the disadvantages of autologous graft procedures. It also has the advantages of being dense corticocancellous bone, having a similar curvature to the native glenoid, and the presence of the articular cartilage, which allows for a more anatomic reconstruction of the glenoid.1 Initially started out as an open procedure using a traditional screw fixation method, glenoid reconstruction using a DTA has evolved into arthroscopic procedures. Recent studies that have reported using screws,2 suture anchors,3 and suture buttons4 have been used for arthroscopic fixation of a DTA to the anterior glenoid. The purpose of this technical note is to describe an arthroscopic DTA anterior glenoid reconstruction technique using cerclage tape sutures introduced via a specially designed transglenoid parallel drill guide.
Surgical Technique
Step 1: Patient Setup and Diagnostic Arthroscopy
An examination under anesthesia of the bilateral shoulders is performed in the supine position to evaluate bilateral shoulder stability. The patient is then positioned in the lateral decubitus position. The operative upper extremity is suspended in a lateral traction device of choice and prepped and draped in the routine sterile fashion. A posterior viewing portal is established 2 cm distal and 1 cm medial to the posterolateral corner of the acromion with emphasis placed on being parallel with the glenoid surface for later placement of a transglenoid drill guide (Table 1). Anterosuperior and anteroinferior portals are also established under direct visualization with needle localization. The anterosuperior portal is placed superiorly just behind the intra-articular part of the long head of the biceps tendon. A 7-mm cannula is inserted through each of the anterosuperior and anteroinferior portals. A diagnostic arthroscopy is performed, and any other intra-articular pathologies are addressed, as needed. The anterior glenoid is then examined to determine the extent of glenoid bone defect, capsulolabral injury, and chondral injury.
Table 1.
Pearls and Pitfalls
Pearls
|
Pitfalls
|
Step 2: Preparation of the Anterior Glenoid Defect
Viewing from the anterosuperior portal, the anterior glenoid is then prepared using an elevator, radio frequency device, oscillating shaver, and burr. The anterior capsulolabral tissue is freed from 2 to 6 o’clock and all the way medially until the subscapularis muscle fibers can be visualized. A traction stitch can be used to retract the freed capsulolabral tissue anteriorly and create more space while performing these steps (Fig 1). Special attention is taken to create a flat, fresh bone surface on the anterior glenoid neck that is free of soft tissue for distal tibia allograft incorporation. The size of the glenoid bone defect is measured in the superoinferior, anteroposterior, and mediolateral dimensions using a ruler to estimate the length, width, and thickness of the allograft bone block (Fig 2).
Fig 1.
Arthroscopic image of a right shoulder viewing from the anterosuperior portal in the lateral decubitus position, following preparation of the anterior glenoid (G) with a traction suture (red arrow) in the anterior capsulolabral tissue (CL).
Fig 2.
Arthroscopic image of a right shoulder viewing from the anterosuperior portal in the lateral decubitus position, demonstrating measurement of the length or superoinferior dimension of the anterior glenoid defect with arthroscopic measuring device. CL, anterior capsulolabral tissue; G, glenoid.
Step 3: Drilling of Glenoid Bone Tunnels
Following preparation of the anterior glenoid, two bone tunnels are drilled across the glenoid with the aid of a specialized, cannulated TransGlenoid drill guide (Arthrex, Naples, FL) (Fig 3) that allows for two parallel tunnels at offset depths of 5 mm or 7 mm and 1 cm apart. The drill guide hook is placed from the posterior portal, while viewing from the anterosuperior portal, and is centered and hooked over the anterior glenoid defect (Fig 4). The cannulated drill sleeve is then slid into the guide and inserted extra-capsularly through the posterior portal until it rests on the posterior glenoid neck. Once the guide is seated flat on the glenoid surface at a desired location, two, 3.0-mm cannulated drills are used to drill two parallel transglenoid tunnels while visualizing their exit points out the anterior glenoid neck. The guide is removed, and then nitinol wires are placed through the cannulated drills from posterior to anterior. The wires are retrieved through the anteroinferior portal, and the cannulated drills are removed. Two looped sutures (FiberLink and TigerLink; Arthrex) are then shuttled using the nitonil wires making sure that the loop of one suture is anterior, and the loop of the other suture is posterior for later shuttling of cerclage sutures (Fig 5).
Fig 3.
Photograph of the posterior aspect of the right shoulder positioning in the lateral decubitus position with a TransGlenoid parallel drill guide placed through a posterior incision in line with the level of the glenoid (courtesy of Arthrex, Naples, FL).
Fig 4.
Arthroscopic image of a right shoulder viewing from the anterosuperior portal in the lateral decubitus position with the TransGlenoid drill guide centered over the anterior defect. CL, anterior capsulolabral tissue; G, glenoid.
Fig 5.
Illustration demonstrating two looped passing sutures (FiberLink and TigerLink, Arthrex, Naples, FL) that are shuttled through the posterior portal, the two transglenoid tunnels, and the anteroinferior portal. Noted that the loop of one suture is anterior, and the loop of the other suture is posterior for later shuttling of cerclage sutures (courtesy of Arthrex) (reprinted after modification).
Step 4: Preparation of Fresh Distal Tibia Allograft
A fresh distal tibia allograft that matches the patient's glenoid dimension is precured and prepared on the back table. The graft is secured to the graft station and the lateral part of the distal tibia is cut using a cutting guide or free-hand technique to create a bone block with the proper length, width and thickness using an oscillating saw and copious irrigation. The size of a bone block depends on the size of the glenoid bone defect, but it is generally around 20 mm × 8 mm × 12 mm (length × width × thickness, respectively). The medial cancellous cut side of the bone block is used to match the contour of the anterior glenoid neck, and the lateral side of the bone block is oriented anteriorly later in the joint. The articular cartilage side of the graft is marked to identify the proper position and orientation once it is passed into the joint. The previously used TransGlenoid drill guide is then centered over the bone block, and two parallel holes are drilled with the 3.0 cannulated drills at the same depth and spacing as the glenoid (Fig 6).
Fig 6.
Photograph of two 3.0-mm cannulated drills through the transglenoid drill guide into the DTA bone block.
Step 5: Shuttling in the Distal Tibial Allograft
After the distal tibial allograft bone block has been prepared, it is ready to be shuttled into the joint. The anteroinferior portal cannula is removed, and the portal incision is extended along with removal of the rotator interval tissue via the radio frequency device to allow for enough space to easily pass an index finger. Two separate cerclage tape sutures (FiberTape and TigerTape cerclage suture; Arthrex) are shuttled together from posterior to anterior using one of the previously placed looped shuttle sutures through the posterior portal, through one of the glenoid bone tunnels, and out through the anteroinferior portal. The tape cerclage suture ends are then shuttled through one of the distal tibia bone block holes from the cancellous graft side and then back through the other hole in the opposite direction. It is important to ensure that the tape sutures are placed, so that the graft will be properly oriented when shuttled into the joint (Fig 7). The tape sutures are then shuttled via the second looped suture through the anteroinferior portal and the other transglenoid hole from an anterior to posterior direction (Fig 8), exiting out the posterior portal. Each of the tape suture ends are carefully and gradually pulled, while shuttling in the graft through the anteroinferior portal until it is properly positioned along the anterior glenoid neck Once all of the slack from the tape sutures has been removed, the graft position is finally adjusted using a probe, so that it sits flush along the anterior glenoid (Fig 9).
Fig 7.
Illustration demonstrating two tape sutures (FiberTape and TigerTape, Arthrex, Naples, FL) shuttled together from posterior to anterior using one of the previously placed looped shuttle sutures through the posterior portal, through one of the glenoid bone tunnels and out through the anteroinferior portal. The tape cerclage suture ends are then shuttled through one of the distal tibia bone block holes from the cancellous graft side and then back through the other hole in the opposite direction (courtesy of Arthrex) (reprinted after modification).
Fig 8.
Photograph from the anterior shoulder with the two tape suture (FiberTape and TigerTape) strands shuttled through the distal tibial allograft bone block drill holes prior to being shuttled back through the joint.
Fig 9.
Arthroscopic image of a right shoulder viewing from the anterosuperior portals in the lateral decubitus position visualizing an anatomic positioning of the DTA bone block at the anterior glenoid. CL, anterior capsulolabral tissue; DTA, distal tibia allograft; G, glenoid.
Step 6: Tensioning the Distal Tibial Allograft
One cerclage tape suture end is then introduced into the knot of the other cerclage tape suture, establishing an interconnecting cerclage of the two tape sutures (Fig 10). Each knot is slid down to the posterior glenoid, and each limb is tensioned individually until proper tensioning is visualized under direct visualization with the arthroscope. Each tape suture limb is then loaded into a tensioner and is lightly tensioned to ensure the slack has been removed from the system and the knots are fully reduced to the posterior cortex of the glenoid. The swaged portion of one of the tape sutures are cut to separate their 2 limbs. A half-hitch knot is thrown and pushed to the posterior glenoid bone. The half-hitch limb is loaded into the tensioner and tensioned up to 30 on the tension scale. A few additional alternating half hitches are thrown, and the tape sutures are cut just above the knot stacks. The same steps are repeated on the other tape suture.
Fig 10.
Illustration demonstrating that one cerclage tape suture end is introduced into the knot of the other cerclage tape suture establishing an interconnecting cerclage of the 2 tape sutures that can then be used for tensioning of the bone block (courtesy of Arthrex) (reprinted after modification).
Step 7: Repairing the Capsulolabral Tissue
Following fixation of the graft, the anterior capsulolabral tissue can then be repaired back to the anterior glenoid rim using standard fixation techniques per the surgeon’s preference, making the graft extra-articular (Fig 11). Generally, using one suture anchor at both the superior and inferior ends of the graft is sufficient. Care should be taken to not inadvertently cut the tape sutures placed in the glenoid during drilling and anchor insertion. The incisions are then closed, and dressings are placed in a standard fashion. The shoulder is immobilized in an abduction arm sling. The above-mentioned technique is demonstrated in Video 1.
Fig 11.
The final arthroscopic image viewing from the anterosuperior portals visualizing final images of the anterior glenoid reconstruction after capsulolabral repair over the DTA bone block. CL, anterior capsulolabral tissue; G, glenoid.
Postoperative Protocol and Rehabilitation
Postoperatively, the arm sling is maintained for 6 weeks. The patient returns to clinic in 2 weeks with postoperative radiographs and begins formal therapy shortly thereafter. Gentle passive and active assisted range of motion exercises are started at 2 weeks. Active motion exercises are started at 6 weeks, and strengthening exercises are started at 12 weeks.
Discussion
Anterior shoulder instability can be a challenging problem especially when there is anterior glenoid bone loss. A recent study by Hettrich et al., showed that over 20% of anterior shoulder instability patients had anterior glenoid bone loss and over 50% had a Hill-Sachs lesion.4 On the basis of age of the patient, activity level, amount of glenoid and humeral bone defects, and other factors, a number of surgical techniques have been described, including open versus arthroscopic procedures or all soft tissue repair versus glenoid bone reconstruction procedures. In the setting of recurrent anterior shoulder instability with or without critical bone loss, arthroscopic glenoid reconstructions are becoming more popular. A recent study by Tucker et al. showed that arthroscopic anatomic glenoid reconstruction has similar complications rates in regard to subluxation, infection, graft fracture/failure, chondrolysis, neurovascular deficits, and stiffness, as arthroscopic Bankart repairs, but has a significant lower rate of postoperative dislocation.5 Commonly used options to reconstruct the anterior glenoid include the Latarjet procedure,6 iliac crest autograft,7 distal clavicle autograft,8 and distal tibia allograft.2, 3, 4, 9,10 Options for graft fixation include metal screw,2 suture anchor,3 and suture button.9 Metal screws have been traditionally used for bone fixation and have advantages of achieving direct and effective compression across the bone interface. However, issues related to metal screw fixation have been reported, including fixation loss, screw loosening and migration, and neurovascular injuries.11, 12, 13 Using screws for fixation of a bone block graft to the anteroinferior glenoid poses technical challenges such as obtaining a perpendicular screw trajectory to the graft and glenoid bone requires an inferomedial portal and is technically demanding. Drilling and insertion of screws through an inferomedial portal to the anteroinferior quadrant of the glenoid carry the risk of injury to the adjacent axillary nerve and vessels and the musculocutaneous nerve. There has been increasing interest in employing “screwless” techniques. A recently published technique article by Tokish et al.3 reported an arthroscopic glenoid reconstruction technique using 2 soft suture anchors for DTA fixation. They used a drill guide developed for an arthroscopic Latarjet procedure, which provided similar transglenoid osseous tunnels to our technique. Another recently published technique article by Lukenchuk et al.9 described an arthroscopic DTA fixation technique using 2 independent suture button fixation.
The technique described in this article uses an all-arthroscopic approach with DTA bone block suture tape cerclage fixation. This technique not only maintains the advantages related to an all-arthroscopic approach but also eliminates the risks of other fixation methods seen with metal screws, suture button, or suture anchor fixation (Table 2). Future studies should focus on both biomechanical and clinical outcomes related to this technique with comparison to other techniques currently being performed.
Table 2.
Advantages and Disadvantages of the Technique
Advantages
|
Disadvantages
|
DTA, distal tibia allograft.
Footnotes
The authors report no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
The following technique demonstrates an all arthroscopic distal tibia allograft bone block cerclage for anterior glenoid reconstruction. The patient is a 32-year-old male who suffered an initial right shoulder dislocation while snowboarding 10 years prior. Since then, he’s had 10+ dislocations with several requiring formal reductions. On physical examination, he was noted to have a positive apprehension test with relocation. On imaging, including radiograph, magnetic resonance imaging, and computed tomography scan, he was noted to have a right shoulder bony Bankart lesion, with associated Hill-Sachs lesion and close to 20% anterior bone loss. Because of his risk of redislocation and failure of conservative management, a distal tibia allograft anterior glenoid reconstruction was recommended. The procedure was performed in the lateral decubitus position. Posterior, anterior, and anterosuperior portals were created. A diagnostic arthroscopy was performed, followed by elevating and freeing up of the anterior capsulolabral and boney Bankart lesion tissue from the anterior glenoid. This provided good visualization and space for positioning and fixation of the bone block. A traction stitch was also placed to aid in this process. The length, width, and depth of the defect were measured and noted for the proper size of the bone block. A TransGlenoid drill guide was then placed from the posterior portal and hooked over the anterior glenoid. The cannulated sleeve was then placed within the guide and advanced until it was flush against the posterior cortex of the glenoid. Two 3.0-mm cannulated drills were then used to create 2 transosseous tunnels at a depth of 7 mm from the articular surface and 1 cm apart from one another through the glenoid. Nitonil wires were then passed through each of these drill bits, and subsequent looped passing sutures were shuttled with one loop being placed anteriorly and one posteriorly. The distal tibial allograft was then secured to the graft prep station on the back table and was properly measured and cut. The previous drill guide was again used to drill two 3.0-mm tunnels through the bone block at a depth of 7 mm from the articular surface and 1 cm apart. Two separate FiberTape cerclage sutures were then passed through the glenoid from posterior to anterior via one of the looped passing sutures. They were taken out of the anterior portal and were shuttled through 1 end of the bone block and back through the other end in the opposite direction. They were then shuttled from anterior to posterior through the glenoid and exiting the posterior portal via the second passing suture. The bone block was then shuttled into the joint and positioned properly up against the anterior glenoid defect. The slack was removed from the FiberTape sutures, and each suture end was placed into a knot end of the other suture creating a cerclage mechanism that allowed for tensioning of the sutures over the posterior cortex of the glenoid. A suture tensioner was used, and once the bone block’s position and tension had been confirmed under direct visualization with the arthroscopy, the sutures were tied and cut appropriately. The capsulolabral tissue was then repaired over the bone block back into the glenoid, using knotless fixation. The final fixation demonstrated good positioning of the bone block with coverage of the capsulolabral tissue and centering of the humeral head on the glenoid.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The following technique demonstrates an all arthroscopic distal tibia allograft bone block cerclage for anterior glenoid reconstruction. The patient is a 32-year-old male who suffered an initial right shoulder dislocation while snowboarding 10 years prior. Since then, he’s had 10+ dislocations with several requiring formal reductions. On physical examination, he was noted to have a positive apprehension test with relocation. On imaging, including radiograph, magnetic resonance imaging, and computed tomography scan, he was noted to have a right shoulder bony Bankart lesion, with associated Hill-Sachs lesion and close to 20% anterior bone loss. Because of his risk of redislocation and failure of conservative management, a distal tibia allograft anterior glenoid reconstruction was recommended. The procedure was performed in the lateral decubitus position. Posterior, anterior, and anterosuperior portals were created. A diagnostic arthroscopy was performed, followed by elevating and freeing up of the anterior capsulolabral and boney Bankart lesion tissue from the anterior glenoid. This provided good visualization and space for positioning and fixation of the bone block. A traction stitch was also placed to aid in this process. The length, width, and depth of the defect were measured and noted for the proper size of the bone block. A TransGlenoid drill guide was then placed from the posterior portal and hooked over the anterior glenoid. The cannulated sleeve was then placed within the guide and advanced until it was flush against the posterior cortex of the glenoid. Two 3.0-mm cannulated drills were then used to create 2 transosseous tunnels at a depth of 7 mm from the articular surface and 1 cm apart from one another through the glenoid. Nitonil wires were then passed through each of these drill bits, and subsequent looped passing sutures were shuttled with one loop being placed anteriorly and one posteriorly. The distal tibial allograft was then secured to the graft prep station on the back table and was properly measured and cut. The previous drill guide was again used to drill two 3.0-mm tunnels through the bone block at a depth of 7 mm from the articular surface and 1 cm apart. Two separate FiberTape cerclage sutures were then passed through the glenoid from posterior to anterior via one of the looped passing sutures. They were taken out of the anterior portal and were shuttled through 1 end of the bone block and back through the other end in the opposite direction. They were then shuttled from anterior to posterior through the glenoid and exiting the posterior portal via the second passing suture. The bone block was then shuttled into the joint and positioned properly up against the anterior glenoid defect. The slack was removed from the FiberTape sutures, and each suture end was placed into a knot end of the other suture creating a cerclage mechanism that allowed for tensioning of the sutures over the posterior cortex of the glenoid. A suture tensioner was used, and once the bone block’s position and tension had been confirmed under direct visualization with the arthroscopy, the sutures were tied and cut appropriately. The capsulolabral tissue was then repaired over the bone block back into the glenoid, using knotless fixation. The final fixation demonstrated good positioning of the bone block with coverage of the capsulolabral tissue and centering of the humeral head on the glenoid.
The following technique demonstrates an all arthroscopic distal tibia allograft bone block cerclage for anterior glenoid reconstruction. The patient is a 32-year-old male who suffered an initial right shoulder dislocation while snowboarding 10 years prior. Since then, he’s had 10+ dislocations with several requiring formal reductions. On physical examination, he was noted to have a positive apprehension test with relocation. On imaging, including radiograph, magnetic resonance imaging, and computed tomography scan, he was noted to have a right shoulder bony Bankart lesion, with associated Hill-Sachs lesion and close to 20% anterior bone loss. Because of his risk of redislocation and failure of conservative management, a distal tibia allograft anterior glenoid reconstruction was recommended. The procedure was performed in the lateral decubitus position. Posterior, anterior, and anterosuperior portals were created. A diagnostic arthroscopy was performed, followed by elevating and freeing up of the anterior capsulolabral and boney Bankart lesion tissue from the anterior glenoid. This provided good visualization and space for positioning and fixation of the bone block. A traction stitch was also placed to aid in this process. The length, width, and depth of the defect were measured and noted for the proper size of the bone block. A TransGlenoid drill guide was then placed from the posterior portal and hooked over the anterior glenoid. The cannulated sleeve was then placed within the guide and advanced until it was flush against the posterior cortex of the glenoid. Two 3.0-mm cannulated drills were then used to create 2 transosseous tunnels at a depth of 7 mm from the articular surface and 1 cm apart from one another through the glenoid. Nitonil wires were then passed through each of these drill bits, and subsequent looped passing sutures were shuttled with one loop being placed anteriorly and one posteriorly. The distal tibial allograft was then secured to the graft prep station on the back table and was properly measured and cut. The previous drill guide was again used to drill two 3.0-mm tunnels through the bone block at a depth of 7 mm from the articular surface and 1 cm apart. Two separate FiberTape cerclage sutures were then passed through the glenoid from posterior to anterior via one of the looped passing sutures. They were taken out of the anterior portal and were shuttled through 1 end of the bone block and back through the other end in the opposite direction. They were then shuttled from anterior to posterior through the glenoid and exiting the posterior portal via the second passing suture. The bone block was then shuttled into the joint and positioned properly up against the anterior glenoid defect. The slack was removed from the FiberTape sutures, and each suture end was placed into a knot end of the other suture creating a cerclage mechanism that allowed for tensioning of the sutures over the posterior cortex of the glenoid. A suture tensioner was used, and once the bone block’s position and tension had been confirmed under direct visualization with the arthroscopy, the sutures were tied and cut appropriately. The capsulolabral tissue was then repaired over the bone block back into the glenoid, using knotless fixation. The final fixation demonstrated good positioning of the bone block with coverage of the capsulolabral tissue and centering of the humeral head on the glenoid.