Abstract
Glenoid bone loss is a common sequela of recurrent anterior shoulder instability. When treated surgically, a bone augmentation procedure is more likely to provide a good outcome with a lower risk of recurrent instability compared with a soft-tissue repair alone. There are several bone augmentation options to address glenoid bone loss, including coracoid transfer, iliac crest autograft, and distal tibial allograft (DTA). Both open and arthroscopic DTA techniques have been described using the lateral one-third of the distal tibia oriented with the anterior aspect placed superiorly on the anterior glenoid. This graft orientation places its concavity in the superior-to-inferior direction. It may be preferred to have this concavity maximized toward the anterior direction so that it can further resist anterior displacement. The posterior one-third of the distal tibia may provide a more optimal arc of resistance. However, no previous technique has used the posterior one-third of the distal tibia to reconstruct the “half-pipe” concavity of the anterior glenoid. We describe an all-arthroscopic technique for a posterior third DTA oriented with the posterior tibial edge placed anteriorly on the glenoid, termed the “congruent-arc DTA,” to address anterior shoulder instability with bone loss.
Technique Video
Glenoid bone loss is a critical factor in recurrent shoulder instability.1, 2, 3 A glenoid bone defect of 13.5% to 20% increases the risk of recurrent instability after arthroscopic Bankart repair alone4 and is an indication for bony augmentation.5,6 Several surgical techniques exist to address glenoid bone loss, including Latarjet coracoid transfer,7 iliac crest autograft,8 distal radius allograft,9 xenograft,10 and distal tibial allograft (DTA).11, 12, 13, 14 Given the similarities in anterior-to-posterior curvature between the distal tibial articular surface and proximal-to-distal glenoid, the traditional DTA using the lateral third of the distal tibia has become a popular bony reconstruction choice.2,15
DTA has several advantages for glenoid reconstruction. It is easy to harvest and osteoarticular, and it avoids the morbidity associated with autograft harvest. However, optimization of fit between the graft and the glenoid is dependent on the incisura concavity, which varies widely.16 Furthermore, although this graft increases the surface area of the glenoid from anterior to posterior, the radius of curvature in its current orientation does not optimally restore the native glenoid concavity in the axial plane.17 The traditional DTA concavity is superior to inferior, so it may act as a “slide” for the humeral head when subjected to anterior translation forces. In contrast, the posterior one-third of the distal tibia may provide better restoration of glenoid concavity depth while creating a bony “ramp” in preventing anterior translation of the humerus.18 We describe an arthroscopic technique for congruent-arc distal tibial allograft (CA-DTA) bone augmentation with cerclage fixation to treat anterior shoulder instability with glenoid bone loss.
Surgical Technique
Preoperative Workup
The workup for glenohumeral instability includes a history and physical examination. Anterior glenoid bone loss is best assessed on computed tomography (Fig 1). Bone loss over 13.5% of the glenoid width necessitates a bone-restoring procedure, such as CA-DTA. Any Hill-Sachs lesion should prompt consideration of a concomitant remplissage procedure.19
Fig 1.
Preoperative computed tomography of left shoulder. (A) Axial image showing anterior glenoid bone loss (arrow). (B) Coronal image showing Hill-Sachs lesion (arrow). (C) Sagittal image showing en fosse view of glenoid with anterior-inferior bone loss (arrow).
DTA Preparation
The distal tibia is secured, and the allograft dimensions are marked (Video 1). Typically, the graft is 25 mm long, 10 mm wide, and 10 mm deep (Fig 2). The CA-DTA orientation places the posterior distal tibia anterior on the glenoid and places the medial distal tibia at the inferior glenoid (Fig 3). The graft is stabilized and cut with an oscillating saw (Fig 4). A depth of 5 or 7 mm is measured from the anterior articular surface. Two 1.6-mm guidewires are placed with a parallel drill guide without a flange at the predetermined depth (Fig 5). The guidewires are over-drilled with a 3-mm cannulated drill. The graft is adjusted as needed to fit through the 16-mm cannula and then soaked in platelet-rich plasma on the back table while shoulder arthroscopy is completed.
Fig 2.
Right congruent-arc distal tibia allograft dimensions. The graft length (L) is 25 mm and is measured in the medial (M)–to–lateral (La) direction. The graft width (W) is 10 mm and is measured in the posterior (P)–to–anterior (A) direction. The graft depth (D) is 10 mm and is measured in the proximal-to-distal direction.
Fig 3.
Orientation of right congruent-arc distal tibia allograft during harvest and after implantation into shoulder. (A) Graft orientation with respect to the distal tibia, with the anterior-most articular surface (A), posterior-most articular surface (P), medial-most surface (I), and lateral-most surface (S) identified. (B) View from the posterior portal of the graft orientation once implanted in a left shoulder, with the previously anterior-most surface (A) now articulating with the anterior glenoid (G), the previously posterior-most surface (P) now the most anterior, the previously medial-most surface (I) now inferior, and the previously lateral-most surface (S) now superior.
Fig 4.
As the graft is fashioned from the posterior third of the articular surface of a right distal tibia, a sharp towel clamp may be used to stabilize the graft from the medial aspect.
Fig 5.
Two 1.6-mm guidewires are placed with a parallel drill guide without a flange at the predetermined depth, 10 mm apart in the lengthwise direction to drill the superior and inferior tunnels of the congruent-arc distal tibial allograft, pictured on the right and left, respectively.
Surgical Positioning and Portal Placement
After a general anesthetic is administered, an examination under anesthesia is completed. The patient is placed in the lateral decubitus position, supported by a deflatable beanbag. The humeral head is translated laterally and placed in longitudinal traction using a 3-point shoulder distraction system (AR-1600M system with STaR sleeve; Arthrex, Naples, FL). A medialized posterior portal is established, and anterosuperior and midglenoid portals are placed under direct visualization in the rotator interval by an outside-in technique (Fig 6).20 A posterior capsulotomy facilitates placement of a transglenoid drill guide (Arthrex) across the glenoid face.
Fig 6.
Patient positioning: left shoulder in lateral decubitus position. (A) View from anterior, with lateral traction visualized and coracoid and anterosuperior portal adjacent to coracoid marked on skin. (B) View from posterosuperior, with posterior portal more medial and superior than normal marked on skin.
Diagnostic Arthroscopy, Glenoid Preparation, and Concurrent Procedures
Diagnostic arthroscopy is performed. If a concurrent Hill-Sachs lesion is present, remplissage anchors may be placed (Fig 7). While viewing from the anterosuperior portal, the anterior labrum and capsule are elevated subperiosteally from the anterior glenoid neck until the subscapularis is visualized (Fig 8).
Fig 7.
Hill-Sachs lesion diagnosis and treatment in left shoulder in lateral decubitus position. (A) The Hill-Sachs lesion (HS) is visualized through the anterosuperior portal during diagnostic arthroscopy as a posterosuperior impaction fracture of the humeral head (HH) deep to the rotator cuff (RC). (B) A drill guide is placed through the rotator cuff (RC) and capsule within the posterior aspect of the Hill-Sachs lesion (HS) in preparation for anchor placement and remplissage.
Fig 8.
View of left shoulder in lateral decubitus position from anterosuperior portal. The subperiosteal capsulolabral complex (L) is elevated from the anterior glenoid (G) with a radiofrequency ablator.
Glenoid Tunnel Formation and Retrograde Drilling
A transglenoid drill guide (Arthrex) is placed through the posterior portal, parallel to the glenoid face, with the hook seated at the 3-o’clock position (Fig 9). The guide is secured by advancing the double barrels against the posterior glenoid. Two 1.6-mm Kirschner wires are placed through the double barrels. The Kirschner wire depth is assessed via an arthroscopic ruler (Fig 10). The guide is removed, and the wires are over-drilled. The top-hat guide for a FlipCutter (Arthrex) is placed over the inferior cannulated drill bit and tapped with a mallet into the posterior glenoid. The drill bit is replaced with a FlipCutter. As previously stated, the optimal FlipCutter size would be 16 mm; however, 13 mm is used because this is the largest size currently available.11 The goal is to remove as little anterior glenoid bone as possible while achieving a flat, flush surface for CA-DTA contact (Fig 11). A FiberStick (Arthrex) is placed through the top-hat guide. The same sequence is completed for the superior glenoid tunnel.
Fig 9.
View from anterosuperior portal of left shoulder in lateral decubitus position. The transglenoid guide (T) is placed through the posterior portal between the humeral head (HH) and glenoid (G) parallel to the glenoid face.
Fig 10.
View from anterosuperior portal of left shoulder in lateral decubitus position. The arthroscopic ruler (R) measures the depth of the cannulated drill bit (D).
Fig 11.
Flattening of anterior glenoid surface via superior and inferior 13-mm FlipCutter in left shoulder in lateral decubitus position. (A) View from anterosuperior portal of FiberStick (I) through inferior tunnel of glenoid (G). (B) View from midglenoid portal of flattened anterior glenoid surface (G) with FiberStick (I) in inferior glenoid tunnel and FlipCutter (S) in superior glenoid tunnel.
Graft Passage
The midglenoid portal is replaced with a 16-mm cannula (Arthrex) (Video 1). The passing sutures from the glenoid tunnels are retrieved through this cannula. The inferior suture is replaced with a FiberLink suture (Arthrex) with the loop posterior. Single limbs of the cerclage sutures are passed through the inferior tunnel out the 16-mm cannula using the FiberLink loop. A Hewson suture retriever (Smith & Nephew, London, England) is used to pass the cerclage sutures from posterior to anterior through the inferior hole of the CA-DTA. This step is repeated to pass the cerclage sutures from anterior to posterior through the superior hole of the graft. The cerclage sutures are then passed through the superior glenoid tunnel using the passing suture, and the graft is shuttled into the shoulder. Slack is sequentially removed from the leading cerclage sutures and the trailing limbs (Video 1).
Graft Fixation
Once the graft is seated (Fig 12), the cerclage mechanism is deployed by introducing the FiberTape cerclage suture (Arthrex) into the knot of the TigerTape cerclage suture (Arthrex) using the nitinol loop of the orange loader (Arthrex). The same step is repeated but with the sutures reversed. The knots are sequentially tightened manually while maintaining the bone block position. A tensioner (Arthrex) is used to tighten each suture to 40 N. The cerclage sutures are cut at the connected end to obtain 2 separate limbs per suture (4 in total). A half-hitch is thrown, and the hitching suture is re-tensioned to 40 N for each cerclage suture. The fixation is completed with alternate half-hitch knots. The remplissage anchors are tightened after completion of bone block fixation.
Fig 12.
View from posterior portal of left shoulder in lateral decubitus position. The correctly seated graft (distal tibial allograft [DTA]) position on the anterior surface of the glenoid (G) is shown.
Rehabilitation Protocol
A sling is worn for 6 weeks with the initiation of passive pendulum exercises immediately and progressive passive range of motion (ROM) at 3 weeks. If full ROM is restored at 8 weeks, active ROM is initiated. Strengthening is added at 16 weeks, and a full return to activity is permitted at 6 months.
Discussion
The optimal bony reconstruction for anterior glenohumeral instability remains controversial. The traditional DTA was initially described by Provencher et al.12 and used the lateral one-third of the distal tibia. Since then, this technique has been widely adopted in both open and arthroscopic settings, but several studies have found conflicting results regarding the congruency of the graft in its traditional orientation and the native glenoid.17,21,22 Decker et al.17 found a radius-of-curvature mismatch over 0.3 cm in 78% of DTA-glenoid comparisons. Restoration of the anterior glenoid concavity is important for glenohumeral stability23, 24, 25, 26 and may not be adequately re-established with a traditional DTA. The CA-DTA may maximize the anterior glenoid concavity by orienting the posterior tibia’s native concavity anteriorly to act as a ramp after fixation.
This report describes the rationale, technique, and limitations of CA-DTA in the treatment of anterior glenohumeral instability (Table 1). Benefits of the reported technique include restoration of the anterior glenoid concavity with articular cartilage and cerclage fixation to avoid the complications associated with screws.27 Limitations include the potential for an increased learning curve, a lack of long-term clinical outcomes, and necessity for allograft availability (Table 2). Long-term studies are needed to analyze the clinical outcomes and adverse events of the reported technique.
Table 1.
Pearls and Pitfalls of Congruent-Arc Distal Tibial Allograft for Anterior Shoulder Instability With Bone Loss
| Pearls | Pitfalls |
|---|---|
| The slope of the vertical saw cut during graft harvest should be oriented parallel to the anatomic axis of the tibia, rather than perpendicular to the cartilage surface. | An imperfectly oriented cut at the glenoid-graft interface may result in gapping between the 2 cartilage surfaces. |
| Cerclage sutures should be passed in the superior one-third of the graft to close the gap between the graft and glenoid cartilage surfaces. | Failure to insert a 16-mm cannula fully into the capsule through the midglenoid portal may result in the graft becoming caught in the anterior soft tissues. |
| The surgeon should maneuver the graft into the desired position and tighten the cerclage sutures slowly to allow for small adjustments prior to tightening. | Failure to recognize a large Hill-Sachs lesion may result in postoperative failure even in the context of satisfactory glenoid bone augmentation. |
Table 2.
Advantages and Disadvantages of Different Sources of Glenoid Augmentation in Anterior Shoulder Instability
| Advantages | Disadvantages | |
|---|---|---|
| Coracoid transfer (Latarjet) | Autograft may have improved healing rate, “triple effect” of conjoined tendon and coracoacromial ligament, and reliable long-term outcomes | Morbidity associated with autograft harvest, nonanatomic, nonarticular graft, high complication rate associated with most common fixation strategy (screws), and maximum graft size is limited by coracoid size |
| Iliac crest autograft | Autograft may have improved healing rate, large graft is possible, and reliable long-term outcomes as revision after failed Latarjet procedure | High morbidity associated with autograft harvest, non-articular graft, and does not re-create anterior glenoid concavity |
| Distal radius allograft | May have similar radius of curvature compared with glenoid, osteoarticular graft, and no morbidity of harvest | New graft with limited availability, no long-term outcomes, and unknown size limitations of graft |
| Traditional distal tibial allograft harvest origin and orientation | Osteoarticular graft, no morbidity of harvest, and reliable long-term outcomes | Graft location from distal tibia and orientation may not re-create anterior glenoid concavity, cost, and necessity for allograft availability |
| Congruent-arc distal tibial allograft harvest origin and orientation | Potential for greater anterior glenoid concavity restoration, opportunity for 2 grafts (posterior one-third and anterior one-third of distal tibia), osteoarticular graft, and no morbidity of harvest | No long-term outcomes, cost, and necessity for allograft availability |
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: J.M.T. reports a consulting or advisory relationship with Arthrex and DePuy Synthes Mitek Sports Medicine and reports board membership with Arthroscopy Association of North America. A.J.H. has received hospitality payments from Arthrex, Smith & Nephew, and ImpactOrtho. C.H.L. has received hospitality payments from Stryker, ImpactOrtho, and SI-BONE. S.V.T. has received education and hospitality payments from ImpactOrtho and Stryker. The other author (C.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Arthroscopic congruent-arc distal tibial allograft with cerclage fixation for anterior left shoulder instability with glenoid bone loss in lateral decubitus position. The distal tibia is secured, and the dimensions are marked on the posterior one-third of the articular surface. The graft orientation places the posterior aspect of the distal tibia at the anterior edge of the glenoid and the medial aspect of the distal tibia at the inferior edge of the glenoid. An oscillating saw is used to cut the graft, and two 1.6-mm guidewires are placed using a parallel guide without a flange 5 mm deep to the articular surface that will make up the posterior aspect of the graft once oriented on the glenoid. The guidewires are over-drilled with a 3-mm drill. The patient is placed in the lateral decubitus position. Posterior, anterosuperior, and midglenoid portals are used. If a Hill-Sachs lesion needs to be addressed, anchors can be placed. The anterior glenoid is prepared by elevating the capsulolabral complex subperiosteally. A transglenoid drill guide (Arthrex) is placed parallel to the glenoid face from the posterior portal and hooked over the anterior glenoid at the 3-o’clock position. Two 1.6-mm Kirschner wires are placed through the double barrels of the guide. After confirmation of Kirschner wire depth, they are over-drilled with a 3.0-mm cannulated drill. The top-hat guide for a FlipCutter is tapped with a mallet into the posterior glenoid over the inferior cannulated drill. The FlipCutter replaces the drill and flattens the anterior glenoid surface after being flipped to a 13-mm radius. The same sequence is completed for the superior glenoid tunnel. FiberSticks are used to pass sutures from posterior to anterior through the glenoid tunnels and out the midglenoid portal after it has been replaced with a 16-mm cannula. The inferior tunnel suture is replaced with a FiberLink with the loop posterior. The cerclage suture leading limbs are passed through the inferior tunnel, out the midglenoid cannula, through the graft, and back through the superior glenoid tunnel out the back of the shoulder. After the graft is seated appropriately on the anterior glenoid, the cerclage mechanism is deployed, tightened using a tensioner (Arthrex), and reinforced with half-hitch knots. The remplissage suture anchors may be tightened at the end of the procedure.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Arthroscopic congruent-arc distal tibial allograft with cerclage fixation for anterior left shoulder instability with glenoid bone loss in lateral decubitus position. The distal tibia is secured, and the dimensions are marked on the posterior one-third of the articular surface. The graft orientation places the posterior aspect of the distal tibia at the anterior edge of the glenoid and the medial aspect of the distal tibia at the inferior edge of the glenoid. An oscillating saw is used to cut the graft, and two 1.6-mm guidewires are placed using a parallel guide without a flange 5 mm deep to the articular surface that will make up the posterior aspect of the graft once oriented on the glenoid. The guidewires are over-drilled with a 3-mm drill. The patient is placed in the lateral decubitus position. Posterior, anterosuperior, and midglenoid portals are used. If a Hill-Sachs lesion needs to be addressed, anchors can be placed. The anterior glenoid is prepared by elevating the capsulolabral complex subperiosteally. A transglenoid drill guide (Arthrex) is placed parallel to the glenoid face from the posterior portal and hooked over the anterior glenoid at the 3-o’clock position. Two 1.6-mm Kirschner wires are placed through the double barrels of the guide. After confirmation of Kirschner wire depth, they are over-drilled with a 3.0-mm cannulated drill. The top-hat guide for a FlipCutter is tapped with a mallet into the posterior glenoid over the inferior cannulated drill. The FlipCutter replaces the drill and flattens the anterior glenoid surface after being flipped to a 13-mm radius. The same sequence is completed for the superior glenoid tunnel. FiberSticks are used to pass sutures from posterior to anterior through the glenoid tunnels and out the midglenoid portal after it has been replaced with a 16-mm cannula. The inferior tunnel suture is replaced with a FiberLink with the loop posterior. The cerclage suture leading limbs are passed through the inferior tunnel, out the midglenoid cannula, through the graft, and back through the superior glenoid tunnel out the back of the shoulder. After the graft is seated appropriately on the anterior glenoid, the cerclage mechanism is deployed, tightened using a tensioner (Arthrex), and reinforced with half-hitch knots. The remplissage suture anchors may be tightened at the end of the procedure.