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Arthroscopic Endobutton bone block stabilisation of shoulder with iliac crest graft (Smith and Nephew)

    Overview

    Learn the Arthroscopic Endobutton bone block stabilisation of shoulder with iliac crest graft (Smith and Nephew) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Arthroscopic Endobutton bone block stabilisation of shoulder with iliac crest graft (Smith and Nephew) surgical procedure.
    Soft tissue stabilisation of antero-inferior gleno-humeral joint instability is, in general, a reliable and reproducible procedure. Anterior instability is however associated with a degree of bone loss in approximately 90% of cases. In the face of significant bone loss (defined broadly as anything around or more than 20% of the bone stock) the rate of recurrence following soft tissue stabilisation may increase dramatically to as much as 70% if using a standard arthroscopic Bankart type repair.
    Open bone transfer procedures such as the Latarjet or Eden Hybinette have been shown to improve outcome and reduce redislocation rates in the presence of significant bone loss. Since La Fosse et al first described their arthroscopic Latarjet technique in 2007, there has been increasing interest over many years in arthroscopic bone procedures.
    Whilst the Latarjet procedure may provide some dynamic stability from the conjoint tendon sling, there is reasonable concern regarding the associated complication rate (up to 30%) and the potential long-term compromise of the Subscapularis.
    The use of an iliac crest bone block passed through the rotator interval may avoid such concerns and a number of arthroscopic iliac bone block procedures have been described and reported. The fixation for most of these techniques utilises a suture-pulley and button system.
    The following guide illustrates a technique using the Smith and Nephew Endobutton implant but is largely consistent with most of the suture-pulley and button systems available.
    The arthroscopic bone block stabilisation is my preferred surgical technique for addressing significant bone loss in those not undertaking high risk activities or contact sports, allowing the bone defect to be addressed with a lower risk profile and the avoidance of compromise to the subscapularis.
    In the high-level competitive contact athlete I prefer an open modified (congruent arc) Latarjet.
    The following technique is in line with that described by Professor Ettore Taverna.

    Indications

    INDICATIONS
    The indication for an arthroscopic bone block stabilisation with iliac crest is principally symptomatic anterior instability of the gleno-humeral joint in the presence of structural bony damage to the glenoid and humeral head that would reasonably be considered to be associated with an unacceptable risk of failure with a soft tissue stabilisation procedure. In a competitive contact athlete it would be reasonable to consider a Latarjet type procedure where there may be benefit from the dynamic conjoint sling.
    An Instability Shoulder Index Score (ISIS) may be a helpful guide to management. This is based on risk factors including; age under 20, involvement in competitive contact sports or forced overhead activities, shoulder hyperlaxity, a Hill-Sachs lesion identified on an AP radiograph in external rotation and/or loss of the sclerotic boundary of the glenoid contour. Patients with a score of 6 or more out of 10 were found to have a 70% failure rate after arthroscopic Bankart repair.

    SYMPTOMS & EXAMINATION
    The pre operative symptoms are of anterior gleno-humeral joint instability. Examination should include an assessment of general laxity (Beighton score) as well as an assessment of balance and proprioception (a single leg dip is frequently a useful gross indicator). The nature and direction of any instability should be noted with particular regard to any posterior component. Anterior apprehension and a positive relocation test should be sought in particular.
    Care should be taken to assess any neurovascular injury, particularly in regard to the brachial plexus and the axillary nerve. Consideration should be given to further investigation with neurophysiology and referral for a specialist Peripheral Nerve Injury opinion.

    IMAGING
    Pre-operative plain radiographs (including an AP, Lateral and axillary views) should be obtained. Further plain imaging such as an AP in external rotation may be helpful in assessing the ISIS score. Contrast imaging with an MRI or CT allow an assessment of the extent and nature of any soft tissue and bone defects.
    I prefer an MRI arthrogram accepting that bone assessment may be marginally compromised compared to a CT but there is much better soft tissue visualisation.

    ALTERNATIVE OPERATIVE TREATMENT
    Soft tissue stabilisation, either arthroscopic or open, is appropriate for most cases of recurrent instability where conservative management has failed and surgical stabilisation is required. However, where there is significant bone loss from the glenoid in conjuction with bone loss from the humeral head (an ‘engaging’ Hill-Sachs lesion) failure rates with soft tissue stabilisation may be unacceptable and a bony procedure should be considered. A variety of bone procedures have been described of which a Latarjet (a Coracoid transfer) and Eden-Hybinette are two.

    NON-OPERATIVE MANAGEMENT
    All patients with instability of the gleno-humeral joint should be assessed for contributory factors beyond potential structural damage, such as scapula-thoracic dysfunction, poor core control, suboptimal proprioception and poor control of the kinetic chain and cuff. Almost all patients will benefit from appropriate and specialist physiotherapy and rehabilitation even if they subsequently elect to pursue or require surgery.
    Although there is evidence to support surgical stabilisation post anterior gleno-humeral joint instability, there is no absolute indication for surgical intervention and some patients may obtain satisfactory gleno-humeral joint stability with conservative management despite extensive bone loss.

    CONTRAINDICATIONS
    Absolute contraindications for this procedure are in line with those of any shoulder procedure such as local or systemic infection.

    Balg F, Boileau P. The instability severity index score: a simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89(11):1470-1477.

    Setup

    The patient should be appropriately consented, including a discussion of the alternative management options (for example soft tissue stabilisation procedures (open or arthroscopic) and alternative bone procedures such as a Latarjet procedure either arthroscopic or open and alternative bone graft sites) as well as potential conservative management.
    Risks should be discussed including associated scars, infection, general anaesthetic risks (including Deep Vein Thrombosis, Pulmonary Embolus, Myocardial Infarction and Cerebrovascular Accident), neurovascular damage, stiffness, post operative rehabilitation and impairment, the anticipated change in symptoms including success and failure rates, the potential requirement for further surgery, the risk of subsequent arthritis and graft site complications and morbidity.
    The limb is appropriately marked.
    General anaesthesia is typically utilised with the addition of regional anaesthesia such as an inter scalene nerve block.
    Prophylactic antibiotics are administered.




    Operation – 1

    The patient is placed in a beach chair position inclined at approximately 45 degrees.
    A T-Max (Smith and Nephew), or similar device, allows secure and straightforward positioning. A padded cushion maintains the knees in a flexed position.
    The contralateral arm is placed on an appropriately padded small arm table avoiding pressure on the ulna nerve in particular.
    A sandbag is placed under the buttock on the side the iliac crest is to be taken. This lifts the iliac crest slightly to allow adequate access. It is typically recommended to take the graft from the ipsilateral side to the stabilisation.

    Examination under anaestheticAn examination under anaesthetic should be performed to assess the extent and nature of translation of the humeral head against the glenoid in all planes.

    Preparation of the iliac crest.The iliac crest and surrounding skin is prepared with appropriate skin preparation first. The prepared square of skin over the iliac crest is then shut-off using 4 small drapes.

    The operative arm and shoulder girdle are then prepared with a appropriate skin preparation.The arm is the draped as for a standard shoulder arthroscopy. Small U-drapes may be used initially to shut off the prepared shoulder girdle before a large arthroscopy drape is placed over the arm. The whole arm and shoulder girdle are exposed including the base of the neck.

    The large arthroscopy drape is carefully laid over the pre-prepared iliac crest.

    The iliac crest operative field is secured.A hole is then be carefully cut in the drape over iliac crest to expose pre-prepared shut-off square.
    An occlusive drape such a Steri-Drape (3M) or Ioban (3M) can then be used to secure the large arthroscopy drape to the iliac crest site ensure a secure operative field.

    The ipsilateral arm is then placed and secured in an arm holder.Options available include a Trimano (Arthrex) or Spider (Smith and Nephew).

    The bony landmarks are identified, in particular the coracoid (A) and postero-lateral corner of the acromion (B). The spine of the scapula (C) and Clavicle (D) should be noted also.

    Local anaesthetic field block.A local anaesthetic field block is infiltrated to the proposed portal sites anteriorly and posteriorly. Typically this is in the form of 20mls 0.25% Chirocaine with Adrenaline, although great care should be taken to ensure a safe total dose of local anaesthetic is administered, particularly where regionalblocks have also been used.

    Access to the glenohumeral joint from a posterior portal is established.A posterior portal is established approximately an inch (2.5cm) below and medial to the poster-lateral corner of the acromion.
    A standard large-joint arthroscope is then carefully introduced in to the glenohumeral joint in the direction of the coracoid.
    The curve of the humeral head and the rim of the glenoid may be carefully felt with the tip of the trocar. The trocar is then slid up and along this ridge, over the humeral head, and in to the joint.
    Once entry in to the joint is confirmed with direct vision, fluid is then provided under pressure using an arthroscopic pump (Arthrex Dual Wave or equivalent).
    Care should be taken not to damage the humeral head. Passage in to the joint may be complicated by the presence of a Hill Sachs lesion which may alter the typical form and feel of the posterior structures.
    The position of the neurovascular structures should be considered at all times to avoid injury or harm to these structures.

    Establish the anterior portal.An anterior portal is developed with an outside in technique.
    The position of the portal is first marked with a needle and adjusted such that it enters the Glenohumeral joint at the upper lateral corner of the rotator interval. The angle of the needle should align with the anterior glenoid. Once a satisfactory position has been obtained a 1cm portal is established and a cannula placed (8.25mm Twist-In (Arthrex) or similar).

    The extent and nature of bone loss is assessed arthroscopically.The glenohumeral joint is examined from both the posterior and anterior portals to allow full visualisation of the joint and assessment of the extent and nature of bone loss from the anterior glenoid and the Hill-Sachs lesion affecting the humeral head.
    The suitability and appropriateness of considering an arthroscopic bone block procedure should be confirmed.
    Typically glenoid bone loss in excess of 20% should be present, although the extent and engagement of the Hill-Sachs lesion should be considered.

    Plan the incision for the tri-cortical iliac crest graftThe iliac crest graft site is palpated carefully and the Anterior Superior Iliac Spine (ASIS) (A), Iliac crest (B) and Posterior Superior Iliac Spine (PSIS) (C) identified.
    The 2-3 inch (5-7.5cm) incision is marked just inferior to the iliac crest.
    It should be noted that if the graft is harvested too anteriorly there may be an increased risk of subsequent fracture of the anterior portion of the iliac crest.

    The skin is incised just inferior to the iliac crest.An incision is made just inferior to the iliac crest around the mid point between the anterior superior iliac spine and the posterior superior iliac spine.
    A self-retainer such as a West is particularly helpful during the approach.

    Dissection is undertaken through the fat towards the iliac crest.Cutting diathermy may be helpful. Care should be taken to identify and protect the lateral cutaneous nerve of the thigh if it crosses the surgical field.




    The deep fascia over the iliac crest is exposed.The fascia is identified as it attaches on the the iliac crest and the potential position of the graft again confirmed with care.

    The deep fascia is then incised and released over the iliac crest.This fascia is then incised in line with the length of the crest.
    A sub-periosteal plane can then be developed using the cutting diathermy, and extended initially inferiorly over the outer aspect of the ilium.

    The fascia is then released inferiorly from the edge of the crest and periosteal dissection used to clear over the outer/superficial aspect of the ilium. Careful use of a Bristow and a sweep with a swab may be useful in clearing the soft tissue from the ilium.
    The periosteal dissection is then extended superiorly with care over the top of the crest itself.

    The iliac crest is exposed.The soft tissue is again carefully released from the inner portion of the ilium, in a similar manner, to allow harvesting of the graft.
    Typically the soft tissue should be cleared for a distance of approximately 2cm, from the crest on both the inner and outer surfers, to allow satisfactory harvest of a graft at least 1cm in thickness.
    Two Hohmann retractors are placed carefully on the inner ilium to aid exposure of the crest.

    The initial graft cuts are made carefully with an oscillating saw.Once the iliac crest is exposed a suitable tri-cortical graft is marked.
    The size of the graft size should be 2cm Long x 1cm deep x 1cm wide, but may be tailored depending on the assessment of the bony defect noted arthroscopy and on the pre operative imaging.
    Care should be taken to obtain graft of sufficient size which may then be trimmed down.
    The anterior and posterior margins are typically divided with a small thin oscillating sagittal saw to a depth of at least 1cm.

    The graft is freed with an osteotome and the extracted.The graft is freed by use of a sharp curved osteotome to the outer surface of the ilium. The osteotome is advanced with care through the outer surface along the length of the graft. The osteotome should be advanced with care and caution should be taken if the inner surface of the ilium is penetrated. The osteotome may be agitated gently and the any remaining osseous attachment released to free the bone graft.
    Care should be taken given the relative proximity of the internal pelvic structures.

    The graft is freed with an osteotome and the extracted.The graft is carefully extracted and any residual soft tissue released.
    Great care should be taken in handling the graft and as the graft is released.


    Application of bone wax to the graft donor site.Bone wax may be applied to limit the bleeding from the cancellous bone at the donor site and haemostasis obtained.

    Iliac crest closureThe fascia is then carefully closed over the donor site with a Vicryl (Ethicon) or similar absorbable suture.

    The remainder of the wound is closed in layers and the skin closed with an absorbable monofilament such as Monocryl (Ethicon).
    The wound is dressed with Steristrips (3M) and an occlusive dressing such as a padded Opsite (Smith and Nephew).
    The author prefers the addition of a dressing gauze dampened with a small amount of alcoholic Chlorhexadine over the Stristrips then covered by the padded Opsite dressing.

    Operation – 2

    The harvested iliac crest graft is prepared.Once a satisfactory graft has been obtained it is then prepared.

    Excess soft tissue is first removed

    The bone graft is trimmed to the appropriate size.The graft will typically need to be trimmed down to size (2cm x 1cm x 1cm). This should be done with great care to avoid graft loss or harm to the operating surgeon.
    The cortical surfaces should be maintained and the graft prepared such that the superior aspect of the tricortical graft as it was positioned in the ilium will become the anterior surface of the graft as it is positioned in relation to the glenoid.
    The exposed cancellous bone will lie against the anterior neck of the glenoid.
    Managing editors comment: What Iain is demonstrating here in cutting towards his finger tips with a power saw is a step performed by virtually all qualified Orthopaedic surgeons. Paul Cooke of the Nuffield Orthopaedic centre in Oxford used to suggest this should be one of the key tests for entry into a training program. Anyone who could n’t perform this without removing their finger tips was probably not suitable material to be trained.

    The graft is held in the graft clamp.The Smith and Nephew system has a Graft Preparation Tool which allows the appropriate size of the graft to be confirmed and to guide the placement of drill holes through the graft.

    The graft is then drilled.Two 2.8mm drill holes are then made through the graft 10mm apart and 5mm from either end of the graft.

    The graft is finally shapedIt is helpful if the edges and corners of the of the graft are smoothed somewhat to ease the eventual passage of the graft. Care should be taken not to reduce the size of the graft or compromise its integrity.

    The button pulleys are preparedThe Smith and Nephew system utilises two Endobutton-pulley devices to secure the graft to the anterior glenoid (single device shown). The button (B) sits against the iliac crest graft holding it against the glenoid. The white sutures (C) are part of the device itself and are tied over a button that sits against the posterior glenoid (not shown) to secure graft. The striped sutures are for handling and passage of the device (A is the trailing suture and D is the lead suture used to draw the implant sutures through the graft and the glenoid).

    Suture retriever passed through the graftA suture retriever or suture-loop is passed through the graft from the surface which is due to lie against the glenoid neck to what is to be the anterior surface of the graft.
    The striped leading suture is then retrieved through the graft.

    The white “device sutures” are then pulled through the graft.The white Endobutton device sutures are then pulled through the graft.

    The Endobutton device is pulled through the graft firmly until the graft button is positioned snuggly against the anterior cortex of the graft.

    The second button is passedThe process is then repeated with the second Endobutton device and both devices are again pulled firmly to ensure the graft buttons are seated correctly against the bone block.

    The graft is then ready for implantation once both devices have been passedBoth the buttons need to be sat securely against the graft.

    A second anterior portal is then developed through the rotator interval, again using an outside in technique.
    A needle is placed, entering the rotator interval medially and inferiorly to the first anterior portal. Once correctly marked a 1cm skin incision is then made and a further cannula placed (8.25mm Twist-In (Arthrex) or similar).

    The anterior capsulo-labral structures are carefully released off the front of the glenoid to expose the anterior glenoid.
    The technique is that used used during a standard arthrosocpic soft tissue stabilisation.
    A shoulder tissue elevator (15 degree and or 30 degree (Arthrex) or similar) is used to carefully release the soft tissues off the anterior glenoid neck.


    Clearance of the glenoid neck.The capsulo-labral structures should be released to the point where there is sufficient space to place the bone block graft against the glenoid neck and repair the labrum over the top of the graft.

    The anterior glenoid neck is preparedThe anterior glenoid neck is then prepared with a rasp (Shoulder debridement rasp (Arthrex)) or shaver (5.5mm Bonecutter (Smith and Nephew)) to ensure a smooth fresh surface against which the graft is to be secured.
    A smooth flat surface is then created against the bone block will sit flush against.

    It is helpful to pass a suture around the anterior labral remnant which can be used to retract the anterior capsulo-labral structures away from the glenoid neck to facilitate the bone graft repair.
    This suture may used at the end to repair the capsulo-labral structures to the glenoid rim over the bone block once the bone block is secured.

    The arthroscope is then swapped to the anterior portal to allow the glenoid and posterior joint capsule to be visualised. A spinal needle is then introduced posteriorly such that it lies flush with and in the plane of the glenoid below the mid line. A further posterior portal is established as indicated by the position of the spinal needle.

    A posterior glenoid aiming guide is used to direct the trans glenoid drill holes.
    This is essentially a modified double barrelled ACL Jig.
    There is a hook which rests against the anterior glenoid and targets the ‘bullet’ drill guides. The ‘bullets’ rotate with a ratchet on one side, which allows their position to advanced and then fixed.
    These images are courtesy of Smith & Nephew

    The drill guide is placed into the joint through the posterior portal with care so as not to damage the articular surfaces.The hook of the jig is passed through the posterior portal and introduced across the joint such that the hook lies parallel with the joint surface.
    The hook is carefully advanced avoiding any damage to the articular surfaces.

    The guide is then advanced such that the hook extends beyond the anterior glenoid at the site of the bone loss. Once passed the anterior edge of the glenoid the hook is rotated 90 degrees to catch the anterior glenoid rim.
    At this point the square profile of the guide should lie flush against the glenoid articular surface with the hook engaged anteriorly.

    The first drill guide ‘bullet’ is then introduced Two ‘bullets’ or drill guides are then placed against the posterior glenoid.
    Holding the hook guide carefully in place against the anterior glenoid, a further posterior skin incision is made to allow the introduction of one of the bullets. This is then advanced carefully until it rests securely against the posterior glenoid.
    The ‘bullet’ should be rotated such that ratchet on the guide holds it in position.
    The correct positioning of the hook guide should be maintained and appropriate adjustments made to correct any slippage.

    The second drill guide ‘bullet’ is then introduced through a further posterior skin incision and advanced against the posterior glenoid. The process is repeated with the second ‘bullet’. Again the ‘bullet’ is rotated to ensure the ratchet secures the position against the posterior glenoid.
    Care should be taken to ensure the hook of the guide remains engaged against the anterior glenoid rim, in the desired position for the graft, and that the guide remains flush and square with the glenoid articular surface. The guide position should be held firmly enough to maintain the position, but it a firm hold should be maintained to ensure the correct position is maintained.

    The 2.8mm sleeved or cannulated drill is carefully advanced along the bullets and across the glenoid.

    The anterior glenoid neck is observed and the drill stopped once it is visible just at the surface of the glenoid neck. The drill should exit the glenoid neck at approximately 5mm from the surface to ensure subsequent satisfactory graft placement. The drill is removed leaving the sleeve in place across the glenoid.

    Operation – 3

    The inner drill wire is removed from the bullett.A bung is placed on the drill sleeve to maintain water pressure and visualisation within the joint.

    A second sleeved or cannulated drill is carefully advanced along the bullets and across the glenoid.The anterior glenoid neck is again observed and the drill stopped just at the bone surface. The second drill should again appear 5mm from the articular surface and 10 mm from the previous drill hole.

    The second drill wire is again removed and a second bung applied to the cannulated drill.

    With the drill sleeves still in situ across the glenoid, it is helpful to prepare the anchor holeA drill hole is placed in the in the anterior glenoid rim in preparation for the capsulo-labral repair at the end of the procedure.
    Drilling at this stage with the drill sleeves still in place avoids the risk of damaging the fixation sutures, if the glenoid is drilled with the Endobutton devices in place at the end of the procedure.
    At this stage a large 15mm diameter cannula may be used to replace the second anterior viewing cannula.
    Alternatively the second cannula can be removed and the portal extended slightly to accommodate passage of the graft without a cannula.

    A flexible looped wire is then passed from posterior through the inferior cannulated drillA flexible looped wire is then passed from posterior through the inferior cannulated drill and retrieved with an arthroscopic suture retriever through a second anterior portal.

    This loop is then used to draw the lead suture of the inferior graft device through the anterior portal and out to the back of the shoulder. It may be necessary to withdraw the cannulated drill at the same time to aid passage of the lead suture.

    A second wire or suture shuttle is then placed A second wire is then passed through the inferior cannulated drill guide and retrieved from the same anterior portal.

    Avoid a tissue bridge when passing the second wire.Great care should be taken to avoid a tissue bridge between the wires or the Endobutton devices at this point.
    This can be avoided by sliding the suture retriever over the first first lead suture as it enters the joint to retrieve the second wire.

    The superior lead suture is then shuttled into the joint, through the glenoid and out posteriorly.

    At this point the graft is held anteriorly with the the two device sutures entering the joint through the same portal (either without a cannula or with a large diameter cannula). Here the cannula has been removed.
    By continuing to view the anterior glenoid from the posterior portal, the sutures can be visualised entering the drill holes through the glenoid and exiting the shoulder posteriorly through their respective posterior portals.

    The graft is then pulled in to the joint though the anterior portal.The operative technique recommends the graft is drawn in to the joint leading with the superior end.

    Alternatively the graft may be introduced in to the joint, inferior pole first using a Kocher to aid passage of the graft as tension is applied on the device sutures posteriorly.
    Visualisation of the graft entering the joint should be maintained through the posterior portal.

    Maintenance of some tension on the device sutures such that they remain taut minimises the risks of knots or tangles developing during passage of the graft into the joint.

    The graft position can be adjusted once it lies against the anterior glenoid in relation to the glenoid articular surface.

    Initial graft position adjustment – external view

    All implant loops through the glenoidThere should now be a continuous loop out of the two posterior incisions with a traction suture on each.
    The traction suture is then divided and removed to separate the two ends of the loop suture.
    There should then be 2 loops of suture out of each of the posterior incisions.

    Sutures passed through first buttonThe posterior Endobutton Fixation implant is then placed on a straight suture retriever.

    Sutures passed through second buttonThe suture is then pulled through the eyelet of the button.
    The procedure is repeated for the second suture.
    The button is then advanced on the sutures with a knot pusher until the button rests against the posterior aspect of the glenoid.

    A sliding Nice knot is then is then produced.
    One loop is passed over and then under the post-suture loop coming up through the inside as shown. (Image courtesy of Smith and Nephew).


    The post suture is then passed through the loop as shown. (Image courtesy of Smith and Nephew).

    The Nice knot is then slid down the post until it holds the posterior button against the posterior glenoid.

    The process is repeated for the second button.

    Both buttons should then lie against the posterior aspect of the glenoid.
    (Image courtesy of Smith and Nephew).

    The tensioner is then applied to the posterior sutures The device sutures are passed one at a time through the suture tensioner. A suture retriever may be used to facilitate this. The suture tensioner is advanced such that it lies against the posterior glenoid and the posterior button knot. The handle is then twisted to apply increasing tension, as measured on the tensioners gauge. Tension is applied to 50 Newtons and the process repeated with the second device suture.

    Whilst tension is being applied the position of the block may be adjusted with a probe. As the sutures are tensioned, the graft should be visualised through the posterior portal, so that the graft position can be confirmed to be flush with the boney glenoid.
    The graft position may again be adjusted with a probe through the anterior portal, to ensure an optimal bone block position.

    Operation – 4

    The device sutures are again sequentially passed through the tensioner in turn and then tensioned to 100 Newtons (A).
    The graft position should again be visualised through the posterior portal (B) to ensure correct graft placement.
    Once the sutures have been tensioned and the correct graft position confirmed the device sutures are then both tied-off with 3 square knots.

    The sutures are then cut with a closed knot cutter. It is crucial not to cut or damage the knots securing the buttons at this stage.
    A closed knot cutter can be carefully slid down the suture until the end is felt to just touch the knot. It can then be withdrawn 5mm and cut.

    If there is any prominence of the bone block relative to the bony surface of the glenoid then the graft may be very carefully shaved back.
    With optimal placement of the trans-glenoid and trans-bone block drill holes this should not be necessary.

    Finally, the position and fixation of the bone block should be confirmed arthroscopically.
    The anterior capsulo-labral structures can then be closed using the predrilled tunnel in the anterior glenoid.
    The anterior traction suture applied earlier in the case may be secured with a knotless anchor such as the 2.9 Bio-PushLock (Arthrex).
    In this case an all-suture anchor was used (Suture Fix, Smith and Nephew).

    The anterior capsulo-labral structures are repaired over the bone block.
    Care should be taken to secure any knots away from the joint.

    Wound closureThe wounds are then closed with absorbable monofilament sutures, with the knot buried and tied deep to the skin.

    Dressings are appliedThe wounds are then covered with Steri-strips and covered with padded Opsites .
    A padded bandage may then temporarily placed over the shoulder to absorb any excess fluid overnight or until discharge.
    A Polysling is applied with a waist band and the elbow at approximately 90 degrees.

    Post operative radiographs confirm the correct graft and button placement on the AP X-ray.

    Post operative radiographs confirm the correct graft and button placement on the axial radiograph.

    Post operative radiographs confirm the correct graft and button placement on the lateral X-ray.

    Post Operative

    Rehabilitation is in line with the standard post-stabilisation protocol.
    A Polysling is maintained for 3 weeks day and night and for a further 3 weeks at night.
    Exercises including hand,wrist and pendular movements are commenced from day one.
    External rotation is typically limited for 6 weeks.
    The dressings are taken down and the wounds are checked at 2 weeks post surgery.
    The shoulder is typically stiff when the sling is removed at 3-6 weeks post surgery and supervised range of movement exercises are commenced at 6 weeks with the addition of strength work, particularly at end of range, at approximately 12 weeks post surgery.
    Plain radiographs (AP LAT and modified axillary views) are taken at 2 weeks, 6-8 weeks, 4 months and 12 months post surgery.
    Rehabilitation should include early core stability, balance and proprioception exercises looking at the patient as a whole rather than just the shoulder.
    I typically restrict a return to contact sports and high risk activities until 6 months post surgery although more accelerated rehab programs may be reasonable.

    Recommended Reading

    Whilst outcome data remains somewhat limited, the early results for arthroscopic bone block procedures support a reliable and effective surgical technique to address anterior instability in the presence of bone loss.
    Taverna et al reported a union rate of 92.3% and no recurrent dislocations at a minimum of 2 years post stabilisation.
    An arthroscopic bone block procedure is effective in restoring stability, allowing return to sports in cases of glenohumeral instability with glenoid bone deficiency. Taverna E, Garavaglia G, Perfetti C, Ufenast H, Sconfienza LM, Guarrella V. Knee Surg Sports Traumatol Arthrosc. 2018 Dec;26(12):3780-3787.
    Bockmann et al reported a reported good functional outcomes and pain scores with a redislocation of 9% at an average of 42 months following an arthroscopic iliac crest reconstruction (3 of 32 patients).
    Mid-term clinical results of an arthroscopic glenoid rim reconstruction technique for recurrent anterior shoulder instability. Bockmann B, Venjakob AJ, Reichwein F, Hagenacker M, Nibelung W. Arch Orthop Surg. 2018 Nov;138(11):1557-1562.
    Bockmann et al assessed 9 patients with bilateral MRI scans and presented the restoration of glenoid configuration and the native contour. Cartilage like tissue was seen on the articular surface of the graft and suggested that the procedure not only limited recurrence but restored native glenoid anatomy.
    Beckmann B, Venjakob AJ, Gebing R, Reichwein F, Hagenacker M, Nibelung W. Knee Surg Sports Traumatol Arthrosc 2018 Jan;26(1):299-305.

    Reference

    • orthoracle.com

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