Arthroscopic Parallel Double-Pulley Iliac Crest Bone Graft Fixation for Anterior Glenoid Reconstruction

Abstract

Glenoid bone defect is one major contributor to anterior shoulder instability. Numerous procedures have been developed for anterior glenoid reconstruction, such as the Eden-Hybinette procedure and the Latarjet-Bristow procedure, as well as various techniques for graft fixation, including screw, endobutton, and anchor fixation. However, these methods can be instrumentally and technically complex. This Technical Note introduces a arthroscopic technique using double-row suture anchors and parallel double-pulley to fix iliac crest bone grafts for anterior glenoid reconstruction, which enables convenient and quick fixation of the bone graft without requirement of any specialized instruments or consumables.

The shoulder is the most flexible joint in human body. The joint capsule, labrum, and rotator cuff surround humeral head to maintain joint stability.¹ Anterior shoulder instability, with an incidence rate of approximately 23.9 per 100,000 person-years, can result from various factors, including weak anterior tissues, specific movement patterns, and glenoid bone defects.2, 3, 4

Among them, glenoid bone defect is one major contributor, accounting for about 41% of cases with initial dislocations and 50% to 86% of cases with recurrent instability.5, 6, 7 Therefore, bony reconstruction is crucial for treating primary or revision anterior shoulder instability with large glenoid defect. Numerous procedures have been developed for anterior glenoid reconstruction, such as the Eden-Hybinette procedure and the Latarjet-Bristow procedure.8, 9, 10 Autologous iliac crest bone graft (ICBG), coracoid transfers, scapular spine grafts, and tibial grafts are commonly used for glenoid reconstruction.^11,12 Various techniques for graft fixation under arthroscopy have been developed, including screw, endobutton, and anchor fixation.13, 14, 15 However, these methods can be instrumentally and technically complex. In this Technical Note, we introduce an arthroscopic technique using double-row suture anchors and parallel double-pulley method to fix the ICBG for anterior glenoid reconstruction.

Surgical Technique

Position

Under general anesthesia, the patient is placed in a lateral decubitus position. The surgical arm is abducted at 20° to 30° and flexed at 20° with a lateral arm traction force of 15 pounds. Additional vertical traction is applied to the proximal upper limb, perpendicular to its long axis.

Portals and Glenoid Preparation

An arthroscopic examination of the glenohumeral joint is initially performed through the standard posterior portal. Subsequently, anterolateral and anterior portals are established through the rotator cuff interval. Additionally, a 5-o'clock portal is created through the subscapularis tendon. The arthroscope is placed in the anterolateral portal for visualization. Through the anterior portal, the labrum-capsular complex adherent to the glenoid neck is thoroughly released, and the glenoid defect and neck are freshened with a burr (Fig 1 A and B). Through the 5-o'clock portal, 2 absorbable suture anchors (2.3 mm with 1 suture; Smith & Nephew, Andover, MA) are implanted as internal-row anchors. The anchors are positioned 5 mm medial to the articular surface of the glenoid, 5 mm and 15 mm superior to the inferior pole of the glenoid, respectively (Fig 1C).

Fig 1.

(A) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position showing the release of labrum-capsular complex (LCC) adherent to the glenoid (G) neck. (B) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position demonstrating the freshness at the glenoid defect with a burr. (C) Arthroscopic image of a right shoulder viewing from the 5-o'clock portal in the lateral decubitus position showing 2 absorbable suture anchors (red arrows) implanted as internal row anchors.

Harvest and Preparation of the Bone Graft

The bone graft is harvested from ipsilateral iliac crest, with care taken to preserve the lateral and superior cortical surfaces. The length of the bone graft corresponds to the size of the glenoid defect (usually 20-25 mm), with 10 mm in width, and 10 mm in height. Two holes are drilled into the bone graft using a 2.0-mm Kirschner wire. The distance between holes corresponds to the distance between the internal-row anchors. The lower hole is positioned 0.5 cm from the inferior pole of the bone graft, corresponding to the distance between the lower internal-row anchor and the inferior pole of the glenoid (Fig 2).

Fig 2.

Image showing the iliac bone graft (IBG) harvested from ipsilateral iliac crest with 2 holes drilled.

Introduction of the Bone Graft Into the Joint Cavity

The tail sutures of the 2 internal-row anchors are passed through the upper and lowers holes of the bone graft, respectively. An additional Ethibond polyester suture is threaded through the lower hole, then introduced into the joint cavity through the anterior portal, and out through the posterior portal, serving as a traction cable. The bone graft is introduced into the joint cavity under pulling of the traction cable and pushing of a hemostat (Fig 3A). The position of the bone graft can be adjusted along the threaded tail sutures. When properly positioned, the bone graft can be temporarily fixed to the glenoid defect by tightening the tail sutures via the posterior portal (Fig 3B).

Fig 3.

(A) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position displaying the iliac bone graft (IBG) introduced into the joint cavity under pulling of the traction cable (red arrow) and pushing of a hemostat (H). (B) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position visualizing the fixation of the IBG to the glenoid (G).

Parallel Double-Pulley Fixation of the Bone Graft

One external-row suture anchor (2.9 mm with 2 sutures; Smith & Nephew) is implanted below the anterior cartilage edge of the glenoid, aligning with the lower internal-row suture anchor. One of the 2 tail sutures is tied with the tail suture of the lower internal-row anchor, which passes through the lower hole in the bone graft, forming a double pulley (Fig 4A). The same process is repeated for the other pair of external and internal row anchors. Ultimately, the bone graft is firmly fixed to the glenoid by 2 parallel double-pulley structures (Fig 4B).

Fig 4.

(A) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position showing a double pulley tied by one tail suture of the external anchor and the tail suture of the internal anchor. (B) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position showing 2 parallel double-pulley structures (red arrows).

Repair of the Labrum-Capsular Complex

The remaining sutures of the 2 external-row anchors are used to further repair the labrum-capsular complex, tightening and lifting the inferior glenohumeral ligament (Fig 5A). Depending on the condition of the repair, additional suture anchors may be needed. For this case, one additional 2.3-mm suture anchor was placed at 2 o’clock to repair the labrum (Fig 5B). The pearls and pitfalls of this technique are summarized in Table 1. The entire processes of the technique are demonstrated in Video 1.

Fig 5.

(A) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position showing the remaining tail sutures of the 2 external-row anchors used to repair the labrum-capsular complex (LCC) and tighten the inferior glenohumeral ligament (IGL). (B) Arthroscopic image of a right shoulder viewing from the anterolateral portal in the lateral decubitus position with additional suture anchor needed to further repair the labrum-capsular complex.

Table 1.

Pearls and Pitfalls of the Technique

Pearls

Pitfalls

•The iliac bone graft should be sufficiently long (generally 20-25 mm) to allow for the creation of 2 fixation holes with a diameter of 2 mm. •When introducing the bone graft, the portal should be appropriately enlarged on both the skin and joint capsule sides to facilitate the passage of the graft. •When introducing the bone graft into the joint cavity, it is important to use a traction cable, which is threaded through the lower hole to maintain a correct orientation of the bone graft. •During double-pulley fixation, the correct position of the bone graft should be confirmed before tightening the sutures. To avoid insufficient fixation strength, the sutures should be tightened as much as possible.

•It is important to avoid placing the internal-row anchors too medially, as it may lead to incorrect position of the bone graft or fixation failure.

Discussion

Biomechanical studies have shown a strong relationship between glenoid bone loss and shoulder stability.^16,17 Arthroscopic glenoid reconstruction has been shown to result in a significantly lower rate of postoperative shoulder dislocation compared with isolated Bankart repair.¹⁸ Achieving a feasible and reliable fixation of the bone graft to the glenoid defect under arthroscopy is a vital step of glenoid repair. Several techniques have been developed to address this challenge.13, 14, 15

Initially, a metallic screw was used to fix bone graft. Although screw fixation can provide solid compression of the bone graft against the glenoid, obtaining good screw insertion and drilling trajectory are always difficult. Repeated intraoperative fluoroscopic examinations typically are needed. In addition, screw technique leads to greater risk of axillary nerve and vessel injury.⁸ Screwless techniques have been developed to facilitate arthroscopic operation, such as posterior button fixation, cerclage suture fixation, anterior suture anchor fixation, and transglenoid fixation using all-suture anchors.^12,14,19,20 However, these techniques require some specialized transglenoid instruments, suture tapes, or anchors, which may not be accessible in all medical facilities.

In this Technical Note, we described an all-arthroscopic parallel double-pulley technique to conduct anterior glenoid reconstruction with ICBG. Besides maintaining the advantages of other arthroscopic screwless techniques, this technique enables convenient positioning and fixation of the bone graft without the requirement of any specialized transglenoid instruments. The predrilled openings on the bone graft can serve as traction, guide, and fixation holes. The bone graft can be easily introduced into the joint cavity and moved to the desired position. Double-row anchors and parallel double-pulley provide sufficient fixation strength to hold the bone graft in position. However, it should be noted that the positioning of double-row anchors, the size of the bone graft, and the locations of predrilled holes must be carefully planned and executed. Errors in size and position can result in bad positioning and fixation of the bone graft (Table 2). Generally, this technique provides a promising surgical option for anterior glenoid reconstruction.

Table 2.

Advantages and Disadvantages of the Technique

Advantages	Disadvantages
•Minimally invasive, fewer surgical portals, and less trauma. •Avoiding exposure of the coracoid process. •Ability to simplify the surgical procedure and reduce the risk of vascular and nerve injuries. •Avoiding drilling through the glenoid cavity, no need for additional instruments or consumables •No metallic implants are left in the body for long-term retention.	•To fixed the bone graft on the intended position, the positioning of double-row anchors, the size of the bone graft, and the locations of predrilled holes must be meticulously calculated and executed, Which may be challengeable to an inexperienced surgeons.

Disclosures

All authors (Y.X., L.Y., D.L., S.Y., W.Y., X.Z., B.D.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding

This study is supported by the Health Commission of Sichuan Province, China (Grant No.: 24SYJS06).

Supplementary Data

Video 1

Arthroscopic video of a right shoulder in the lateral decubitus position showing The entire arthroscopic processes of the parallel double-pulley iliac crest bone grafts fixation.