Traumatic glenohumeral dislocation or chronic glenohumeral dislocation/subluxation can cause damage to or fracture the glenoid rim. The resulting bone loss leads to instability that cannot be corrected with soft-tissue/labral repair alone. 
 
Common reconstructive techniques include Latarjet or glenoid augmentation using free bone block grafts, such as iliac crest or distal tibia. The increase in bone surface area leads to a stabilized glenohumeral joint. 
 
Arthrex offers a portfolio of instruments and fixation devices to accommodate a wide range of glenoid bone loss techniques.

Shoulder

Procedure

Bone block cerclage is an innovative arthroscopic surgical technique that preserves the integrity of the subscapularis and provides a metal-free fixation of the bone graft.1 Two interconnected FiberTape® and TigerTape™ cerclage sutures provide firm compression of the graft and strong fixation that minimizes construct displacement at high loads.2,3
The FiberTape Cerclage for Glenoid Bone Loss Implant System contains all the necessary implants and disposables for the procedure (except <a href="https://www.arthrex.com/shoulder/knotless-18-fibertak-soft-anchor">capsulolabral repair anchors</a>). To help provide a reproducible surgical technique, the kit includes an arthroscopic measuring probe, two 3-mm cannulated drills of different lengths to facilitate unobstructed drilling, and the MegaLoader suture-passing loop to aid in the passage of sutures into instruments and bone grafts.
References
1. Hachem AI, Del Carmen M, Verdalet I, Rius J. Arthroscopic bone block cerclage: a fixation method for glenoid bone loss reconstruction without metal implants. Arthrosc Tech. 2019;8(12):e1591-e1597. &nbsp;doi:10.1016/j.eats.2019.08.014
2. Arthrex, Inc. LA1-000140-en-US_A. Naples, FL; 2024
3. Ritter D, Hachem AI, Scheibel M, et al. Primary stability and bone contact loading evaluation of suture and screw based coracoid graft 
fixation for anterior glenoid bone loss.&nbsp;Am J Sports Med. 2023;51(11):2858-2868. doi:10.1177/03635465231188976

This animation demonstrates the arthroscopic bone block cerclage technique for glenoid bone loss, which preserves the integrity of the subscapularis and provides a metal-free fixation of a bone graft using FiberTape® cerclage. The procedural steps show in detail the use of the TransGlenoid drill guide, as well as all the components of the procedure kit.

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Human

Bone Block Cerclage

The bone blocks are. Collage technique for glenoid bone loss is an arthroscopic surgical procedure that preserves the integrity of the subscapularis and provides a metal free fixation of a bone graft after soft tissue release and bone preparation with direct vision from an anterolateral portal. The glenoid defect is measured using an arthroscopic measuring probe through an anterior inferior portal. The middle of the defect is calculated to aid in correct placement of the drill guide. Insert the trans glenoid guide hook through a posterior portal and place the anatomic hook flush to the glenoid surface as close as possible to the center of the defect. The hook of the guide is curved to sit flush to the glenoid. Anatomy and features A ten degree safety angle incorporated in the shaft. The V laser mark projects to show the expected exit points of the drills. Select the desired offset 5 or 7mm and introduce the drill sleeve until firm contact is felt against the posterior scapula. Take note of the intraosseous distance depicted by the laser marks on the drill sleeve. Using the short cannulated drill. First drill a three millimeter bone tunnel across the glenoid with direct visualization of the defect and drill exit points. The drill tip should exit anteriorly as the corresponding laser mark on the drill. Lines up with the drill sleeve. Use the long cannulated drill in the same manner for the second bone tunnel. Remove the drill sleeve and use the slot in the handle to remove the guide hook. Leaving the drills in place. Drill two tunnels through the bone block, one centimeter apart and corresponding to the medial glenoid. Offset of the previously drilled tunnels through the glenoid. Remove the pins from the cannulated drill. Pass a SutureLasso wire through the cannulation of the drill from posterior to anterior, leaving the loop of the wire posteriorly. Retrieve the wire out of the joint through the rotator interval and then remove the drill. Pass another wire through the cancellation of the second drill and retrieve through the rotator interval, leaving the loop anteriorly. Replace the wires with FiberLink and TigerLink sutures, making sure to leave the loops as done previously. Use the loop of the FiberLink suture posteriorly. Pass both single limbs of the FiberTape and TigerTape. Cerclage sutures through the same glenoid tunnel, through the rotator interval, and out the out the interior portal. Use the Mega Loader to pass both cerclage sutures through the cancellous side of the bone block, and then back through the other drill hole. Use the remaining TigerLink suture loop to transport the cerclage sutures through the rotator interval and the other glenoid bone tunnel. Introduce the graft and maintain orientation while pulling on the sutures posteriorly. Pull on each limb to individually remove the slack. Introduce the single limb of the FiberTape cerclage suture into the knot of the TigerTape. Cerclage suture using the orange loader. Remove the loader and make sure to slide the FiberTape cerclage suture until the tape portion and slightly tighten the knot. Repeat the process for the TigerTape cerclage suture and FiberTape cerclage. Not grasp and pull the individual sutures a few centimeters at a time, alternating between the suture pairs to reduce the knots down to the bone. To make sure the knots are fully reduced to the bone. Load the FiberTape cerclage suture into the tensioner and lightly tension until resistance is felt. Repeat this step with the TigerTape cerclage suture. Cut the FiberTape cerclage suture to separate the limbs. Throw a half hitch and reduce the knot to the bone. Insert the hitching suture limb into the tensioner and tension to around 30, while having direct visualization of the anterior portion of the bone graft in the cerclage SutureBridge. Apply additional alternating half hitch knots and cut the sutures. Repeat the same steps for the TigerTape cerclage suture. Reattach the CapsuleLink labral complex to the anterior glenoid rim with knotless 1.8 FiberTak anchors to avoid damaging the construct. Use flexible non fluted drills when placed between the bone tunnels.

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Bone Block Graft Fixation for Glenoid Bone Loss: A Comparative Study of FiberTape® Cerclage vs Endobutton Constructs

Bone Block Graft Fixation for Glenoid Bone Loss: A Comparative Study of Construct Tensioning Protocols Using FiberTape® Cerclage

Child (D)

The Glenoid Bone Loss Set includes unique instrumentation and implants to make the open Latarjet technique more consistent and repeatable. The Congruent Arc Latarjet Technique involves dissecting the coracoacromial ligament and pectoralis minor from the coracoid and performing a coracoid osteotomy. A grasping coracoid drill guide is used to prepare two parallel holes in the coracoid graft, which then mate with one of the glenoid parallel drill guides. The cannulated guide allows the graft to be positioned on the glenoid, while guidewires are placed through the graft and into the glenoid. Self-drilling, self-tapping 3.75 mm titanium cannulated screws are then placed over the guidewires to secure the graft into position.

Anthony A. Romeo, MD, (Chicago, IL) uses the glenoid bone loss and open shoulder retractor sets to perform a Latarjet procedure through a subscapularis splitting approach. Dr. Romeo thoroughly describes relevant anatomy and demonstrates techniques for obtaining excellent glenoid exposure, both with and without the coracoid in place. He highlights the options of using an iliac crest autograft, distal tibia allograft, or traditional Latarjet technique to correct a glenoid bone-loss defect through a subscapularis split.

Congruent Arc Latarjet Through Subscapularis Split

I'm going to demonstrate a technique for performing anterior glenoid bone reconstruction. The most common technique is the latter procedure, but other bone grafts can be used in that area. The Arthrex shoulder retractor set will allow us to accomplish that very effectively. Whether we take down the subscapularis, which is the traditional technique, or the technique that I'll be showing you, which is a split through the subscapularis, which is less morbidity for our patients. And hopefully we'll result in a better long term function. This is a right shoulder. I've marked out the landmarks on the skin the acromion, the clavicle, the CA ligament, the coracoid process, and then an axillary incision, which is the traditional open incision for anterior stabilization of the shoulder. As you know, for reconstructions that include the humerus, such as a total shoulder, we typically do a diagonal incision. And we're specifically looking for the deltopectoral interval, which should be marked by a plane of fat, because that's where the cephalic vein is located. Now if we look here, we can see the soft tissue fibers going in this direction. And then to the more medial aspect we see that there's this fat plane here and that represents the fat over the cephalic vein. So we're taking the vein more laterally. You can see the vein is here underneath. And we will proceed down so that we have good exposure down to where the pectoralis major tendon inserts on the humerus. And we keep widening our boundaries to ensure that we have adequate exposure of where we're trying to work. So as we're looking at the boundaries of our surgical site, our pectoralis major tendon is here. Our deltoid is being retracted by our pointed homan at the top of the incision coracoid process. Here coracobrachialis short head of the biceps and then the muscular portion of the biceps in this direction here. So again, here's our coracoid here. Here is the fascial layer with the coracobrachialis and short head of the biceps. And then you see the muscular portion of the short head of the biceps further lateral. And that identifies the plane that we want to establish our further surgical dissection coming underneath the coracoid process safely as we know our, our structures that we're going to run into that we have to be careful about is going to be the musculocutaneous nerve, which is typically 3 to 5cm below the tip of the coracoid, but has been reported as close as one centimeter below the coracoid. So we just have to be safe in that direction. And then the next structure that we're going to run into, as far as the nerve is going to be our axillary nerve, which is going to be behind these blood vessels right here known as the three sisters or the anterior circumflex vessels. These mark the inferior border of the subscapularis. We typically during this procedure do not have to sacrifice those blood vessels, and the majority of our cases, we can take the arm and place it into a little bit of abduction using our TRIMANO arm holder, and then we can lift up on our deltoid, and we can free up the subacromial space of any adhesions that might be restricting our motion between the deltoid and the rotator cuff. We take the arm and put it down into a deduction or adduction. And now we work on the undersurface of the coracoid very safely here. Now we're ready for our next self-retaining retractor, which is known as the Cobell retractor, also found on the open shoulder retractor set. This retractor can be placed either in the direction where the bend is towards the shoulder or away from the shoulder. It's been my experience that I find that if you put the bend towards the shoulder, that it seems to stay in position a little bit more effectively. Once the blades are connected, we can then open up this tissue and get further exposure. Now, to hold this clamp in a good position, we can use Coban to wrap around the arm. You can also use a towel clip to Coban that has been used on the patient's arm to help hold that in a nice position, so it stays where you would like it to. So as we proceed down to the layer of the subscapularis, we can widen our exposure a little bit as necessary. You can release a little bit of the pectoralis if this is starting to take some of your exposure, particularly the falciform ligament coming up at the top to get a little bit better exposure inferiorly. But now that we know the boundaries of our subscapularis, here is our inferior border marked by the three sisters, our superior border is marked by our biceps tendon and the rotator interval, and our lateral border again is the biceps tendon. We can then go in between the upper half and the lower half, and proceed towards the glenoid to perform our subscapularis split. We can mark this so that we do not get too distracted by the soft tissues. We want to go along the line of the subscapularis. As we see here, we'll make our incision through the subscapularis. You can see now this is capsule of the shoulder, and then the muscle is separated from that. Right through this layer here. Once we get to the front of the scapula, we can actually put a retractor. If it's not well visualized, you can place your finger across this area to feel for the scapula to ensure that you're in the correct position. We can take an elevator more medially and help to separate out these muscular tissues off of the capsule. As you see here. Then we'll take our small anterior glenoid retractor, and we'll place this through the muscular portion of the subscapularis all the way over to the anterior neck of the glenoid. We're going to perform a capsulotomy that will allow us to us to expose the glenohumeral joint at this time. This is the inferior half of the subscapularis with the capsule which has been split. Here we see the labrum on the front of the glenoid and the superior aspect of the subscapularis. So we are now into the glenohumeral joint, as you see here. What we can do to further expose this area as we take our Fukuda or ring retractor, and we can slide this in between our split and our capsule and glenohumeral joint. And this is we have to wiggle this in safely to catch the posterior glenoid and then open up this tissue here. So now what we can see is the anterior neck of the glenoid. Now notice we do not have great exposure to the articular surface of the glenoid. But in fact, that's not what we want to see. What we want to see is the anterior face of the glenoid. And we're starting to get excellent exposure. Once we get down to this layer, oftentimes these self-retaining retractors will in fact impede our view. And so at this time we can actually remove the Self-retaining retractor. So once we have our ring retractor across the glenohumeral joint and our anterior glenoid retractor, we've started the tea in our capsule and our labrum. And now we need to continue that further, medially, all the way over the top of the glenoid to allow exposure of our glenoid bone that we are then going to reconstruct. Again, this certainly is a tight space, but the important thing to recognize is that we have not released the subscapularis at all, and we have exposure of the entire anterior neck of the glenoid for our bone reconstruction. So in an effort to get better exposure superiorly, the easiest way to do that is to prepare the bone at the top part of the exposure, and then to place a Steinmann pin into the scapula. We'll go up to the top of the scapula. We have to aim in and we'll get this started into the glenoid bone just at the base of the coracoid. And this pin can then be bent in a superior direction. And we'll stay as a self-retaining retractor throughout the remainder of this part of the case. Again, this exposure, without taking down the sub GAP, gives us all the access that we need to solve the problem that we're dealing with here with respect to anterior glenohumeral instability, with glenoid bone loss. And this was done without taking down the coracoid process. We've prepared our bone bed from our bone defects so that we have a bleeding bony surface. And this should be prepared close to the inferior aspect of the glenoid to approximately two centimeters proximal and at least one centimeter medial, to create enough of a bone bed to have our fixation of our graft. At this time, the graft choice can either be a coracoid? It could be an iliac crest or an allograft. So for the purposes of this demonstration, we're going to proceed at this time with a exposure of our coracoid and a takedown of our coracoid process. So we will remove our retractors at this time. And now we're going back to our initial retractor. So we'll take the retractor. But at this stage we're going to want to see our coracoid process. So we're going to move that retractor a little bit more superiorly, so that we can see the structures that attach to the coracoid here, the short head of the biceps and the coracobrachialis. We'll take a pointed Homan retractor which comes from the open shoulder retractor set. And we'll slide over the top of the coracoid process and elevate up our tissues. There are a number of different ways to take the coracoid tip. So if you take just one centimeter of the coracoid tip, as was described by Doctor Helfert when he was describing the Bristow procedure, here's the tip of the coracoid. We take approximately one centimeter. You'd make your saw cut in this in this area. What has become the standard for treating anterior glenoid bone loss has been the latter procedure described by Michel Latarjet, and the latter procedure. Typically, we have a minimum of two centimeters of bone, and preferably a little bit more, so that we can safely get two screws to fix our coracoid process. Our most superior boundary is going to be the attachment of our CC ligaments, which are further back here. So we should be able, if we mark this point here and we mark this point up here, we should be able to safely get at least two centimeters or more of bone. Now, in terms of the other structures that we have to be very careful about, we know that on the medial aspect of the coracoid process is the attachment of this tendon here, which is our pectoralis minor tendon. And this needs to be released off of the coracoid process and can be done very safely, either with scissors or with a knife. We'll continue to free this up over the top. And we want to be careful because once we release the pectoralis, we're right next to the brachial plexus which is underneath the pectoralis minor tendon that is attached to this edge, so the pectoralis minor is released medially. Laterally. We have the coracoid acromial ligament in the technique as described by George. The coracoid ligament can be used as part of your repair of your capsule, and if you choose to use that technique, you can leave five millimeters or more of the coracoacromial ligament. So this tissue can be used as part of your soft tissue repair. What we're going to demonstrate is a congruent arc technique as described by Burkhart. And in that situation, we have to turn our graft and the ligament no longer comes into play in terms of our soft tissue reconstruction. So we're going to release our ligament. The coracoid can be cut either with an osteotomy or a saw. And then again one centimeter is to here two centimeters back to here. And we can start with our saw cut. We have an osteotomy which then has a safety sleeve that goes over the top of it so that when you put your osteotomy down, it has a limited excursion. We have to separate the coracoid and the short head and long head from the surrounding structures so that we get mobility of the coracoid process. So this just takes some separation of the soft tissues, and we have to be careful as we proceed distally to avoid any injury to the musculocutaneous nerve. That nerve will start to come in right here as we see the fatty plane developing. We have a couple of different ways to prepare our bone graft. The typical method, as described by ladder J, would be to take this graph and place this directly on the neck of the glenoid, and our screws would go through this position. The alternative technique is described by Burkhart, is to take the graft and rotate it 90 degrees, so that the inferior portion of the graft is the actual articulating surface, and the screws go in from the lateral aspect of the coracoid process. Since this is going to be the articulating surface which matches up very nicely to the glenoid curvature, we're going to take off a small amount of bone, which can be done either with a bur or with a small saw. So that should give us a nice surface to heal down to the glenoid. All right. So our graft is prepared. Now we can go ahead and take our clamp. So once we have our clamp in place holding our graft, we'll then drill our holes for our 3.75 cannulated screws that we're going to be using to fix the graft. And we'll also test to see what size inserter would work best. We usually start out with the six to see if that fits nicely with our preparation. The six is pretty good, but I think we can go to the four on this one. And that's how that graft is going to sit down and hold that hold that into place and be secure on the anterior glenoid. So we're good with the four. That looks very nice. And we're good with the freeing up of our soft tissues. And now we have to go back to our subscapularis exposure that we had before. So now we'll take our four millimeter guide. We'll set this in the proper position in our graft. And it should be you know, you could use either a iliac crest or you could use an allograft exactly the same way. Preparing the bone and making this preparation available. So this is what we have here. You can see how that graft sits nicely. And what we can do is here's our coracoid process. There's the sling. We come over the top and we'll slide right on down to the neck of the glenoid. And we can feel the neck of the glenoid in a good position here. We'll then advance through our guide system to guide pins, which we would like to go through both cortices to hold this pin in a good position. And we'll take our take our second pin. We're now going to take a cannulated drill. So we'll go down and we'll drill to the opposite cortex right over our guide pin. And then we'll back this out. And we'll put this across the pin and we'll start to insert this in place. The surgeon can feel that front rim and see how this is feeling. But the guide pin should hold this in a pretty nice spot there where we want to be. And these are self-tapping screws. So they should go down fairly effectively. And you can hear that squeaking. We typically would use a measurement preoperatively to check on this. And then intraoperatively. We do have a depth gauge that allows us to have a better understanding of that if we put our pins in a good spot. So we can slide this across. We know that this goes a little bit past where we're at. And so you can oftentimes see that usually it's beyond a 30. It's almost never up to a 40 or 42. So I typically use between a 32 and a 34, and the vast majority of my cases to secure this down into position. So we're going to drill our second screw. And you can see our coracoid soft tissue has come up close to where we're working. So we can take a soft tissue retractor and hold that into position. And we'll go through our graft and then just drill. You really only need to drill that first cortices because these are self-tapping screws. When we initially drilled our graft with our clamp in place, we used a 4.0 drill to create a hole larger than our 3.75 screws. So these screws are not getting any purchase into the bone on the graft side until the head engages. In other words, it's lagging that down to the glenoid. So we have a 4.0 drill to prepare the actual graft. And then the appropriate size drill for the 3.75 cannulated screws so that it fixes nicely on the glenoid side, and we get very secure fixation of our graft. And we can take that out. And again, we can check this anterior edge to ensure that we're in a good position. This is where it gets particularly valuable in terms of having the subscapularis split, because essentially at this time, all that needs to be done is a side to side repair. And the initial description by latarjet, no capsule or labral repair was performed in the modified technique by Burkhart and Deburr. They do place anchors at times along the native rim of the glenoid, and they show their capsule down to that layer. In this setting here we have capsule superiorly. We have some capsule inferiorly, so we can't get a closure of the capsule right over our graft in this area. But we can take the capsule here medially, and this can be done as a single layer and then a second layer for the muscle. Or it can be all done as one layer. But we take the arm in external rotation so we don't over tension the shoulder. And we're closing down the capsule as you see here. And these are just side to side sutures, which makes our rehabilitation protocol much easier for our patients. We do not have to worry about trying to let the rotator cuff tear that we created by cutting the subscapularis off of its insertion point, probably trying to protect that. We can just go ahead and start with an early range of motion program. So again, we'll take another capsular stitch here to the inferior capsular stitch, which is we separated this out in the beginning. And then we can secondarily close our subscapularis muscle itself. And we'll just free up this edge here. We see our muscles here and our lower muscle is here. And we'll take the two muscular layers and we approximate these tissues. So you can see that the closure here and here is our sling effect. And then with rotation our subscapularis stays together nicely with no tension. Now we put the arm in abduction external rotation, and look and see what happens to the short head of the biceps and the coracobrachialis. It comes across the anterior aspect of the glenohumeral joint. And so as we rotate, you get this secondary stabilizer of this tissue that goes down to the actual glenoid neck. Now this may be very important in some patients and others the glenoid bone defect is all that needs to be replaced. And again a graft from another source may be very valuable. But all of this can be done through a subscapularis split without taking down the coracoid, or after you've taken down the coracoid for a latter day procedure. After we've closed the subscapularis, we have the deltoid and the pectoralis muscle that are just closed side to side. So what you can see from this operation is that the only area that needs to be protected is that anterior glenoid bone graft, and that is going to be under stress only in abduction and external rotation.

Laurence Higgins, MD, (Boston, MA)&nbsp;uses the Glenoid Bone Loss Set to perform a Latarjet procedure through a subscapularis splitting approach.&nbsp; He demonstrates a classic European technique orienting the inferior surface of the coracoid against the anterior glenoid rim and using the stump of the coracoacromial ligament for capsular reconstruction. &nbsp;He shows the sling effect provided by the conjoined tendon passing through the subscapularis split as the arm is abducted and externally rotated. &nbsp;He also discusses his expanding indications for the Latarjet procedure in his practice.

Open European Latarjet through Subscapularis Split Cadaveric Demo

Hi, I'm Larry Higgins. Today we're going to do a cadaveric demo using the Arthrex ladder system using a European technique. So here we're looking at a left shoulder. And the incisions for a ladder vary significantly. What I found to be the most effective is not to make a traditional deltopectoral incision along this line. I find a kind of ancillary axillary based incision is ideal. Here's the tip of the coracoid. You can typically do this with about a 5 or 6 centimeter incision from the tip of the coracoid down, ending somewhere about here. That being said, for the purpose of demonstration, we're going to make a larger incision for ease of visualization. Typically, I'll use helps here to open this up and then we'll find the deltopectoral interval. See we're coming right on to the deltopectoral interval right there. The vein is probably right here. And I'll take the vein and I'll slide it laterally. The key to this is getting a good coracoid exposure. And I'm going to put a Hohmann retractor just above the coracoid like that. And that really exposes the coracoid. It's very, very straightforward to do that now. Arm position helps your exposure. The first thing that we want to do is bring the arm into slightly externally rotated position. And that will facilitate us seeing the CRx ligament. And in the European technique, we want to leave a part of the CRx ligament attached to the coracoid for capsular reconstruction. So what we've done is I've cut the CA ligament about a centimeter from the coracoid. It's right down here. Then we bring the arm into internal rotation, and we'll find this little raphe right here. And this is the RAF between the pec minor and our conjoint tendon. And this is best done with an electrocautery because there are bleeders here. But we want to take the pec minor directly off the coracoid. We're going to stay right on bone here. And we'll do this with a knife here. But you want to make sure the entire pec minor is released. The coracohumeral ligament Underneath the coracoid can be somewhat adherent, particularly in someone who has had multiple dislocations, so I tend to make sure that area is open. You can use a Kelly or any clamp to make sure that you've actually opened up underneath the coracoid, and the coracoid ligament is going to be running out over on this side. So I like making sure that I can come underneath the coracoid and I can see that. Kelly. So I've kind of freed this area up a little bit. That will help when we mobilize the coracoid for our later repair. At this stage, we're going to use a right angle saw blade. And I think this is a critical component to actually having a good outcome. For me, I like using this from a medial to lateral direction. And you want to have at least 20mm of coracoid. There we go. So now we'll spin the graft and we'll look at the graft upside down. And we get a nice view of the CRx ligament. You can see where our osteotomy is here. A little bit of bone wax put in there is actually helpful. And there's our graft length. We can measure our graft length. And we'll see our graft is a little over 20mm long. So long, so that's going to look good. Now we have to clean the back surface of the graft off. This graft is a little bit narrow from the anterior posterior direction. And from the standpoint of putting screws in using the congruent arc technique you can put screws in here. You may have a slightly narrower graft. This gives you a broader graph to get screw purchase in. What's important to do, though, is to make sure the back of the graft is flush, because we're going to want to have a flat graft on the back surface. [00:03:29] There we go. Okay. So now we'll just make sure we have a back. Part of the graph will be flat and we'll cut this off. And then we'll just stick our graph medially and kind of get it out of the way. But we have a nice nice sized graft here. Really robust graft. Okay. And now this is perfectly flat. And this is going to be our mating surface for our for our ladder. This surface here on this side is going to be our articular margin. And I will sometimes just take a look at this side to make sure that it's relatively straight. But that's going to fit in very nicely. And we'll have a nice graft right there. Now I'm going to tuck our graft away, and I'm going to push our graph medially to take tension off the musculocutaneous nerve. And I'll put in our Cobell retractor so we can take a look at the subscapular. Okay. So here we are looking at the subscapularis. And with the coracoid osteotomy you can see there's the base of our coracoid right here. We really have a great view of the subscapular okay. And you want to do your split kind of in the mid portion of the subscapularis with a little external rotation of the arm. You can see how that really opens up the subscapularis. And we're going to take a feel from top to bottom. And we're going to work on splitting the subscapularis somewhere in this plane here it's very helpful to take a latex sponge. We just have a regular sponge here, but a latex sponge, and I'll put a suture in it just to mark the end of it. And this is actually going to do a lot of our dissection. So we'll take a curved mayo and we're going to keep the arm in a little bit of external rotation. And we're going to feel for the midpoint of the subscapularis, which is right about here. And I'm going to push in into the subscapularis. So I'm going to start to spread. Okay. And if you notice right away I start seeing capsule. So I've split our subscapularis just like that. And in a native shoulder. It literally is that easy. Then I'll take a pair of pickups and I'll take this sponge and I'll use the sponge to do the dissection for me. So I'm sticking it through that split. And that really, really helps. The reason I attach these sutures is that I'm going to push this all the way in till I can't see it anymore, and I have the sutures to retrieve it later. Then I'll take a knife or an electrocautery, and I'll just extend that capsulotomy right out to the lesser tuberosity, but not cut anywhere into the tendon itself. I've left the capsule completely intact. And now we have this beautiful split. And now we can really see the capsule. Well, to give you a sense of how good our visualization is. This is glenoid margin right here. This is humeral head. We have wonderful visualization as a product of taking down the conjoint tendon. So what I'll do now is I want to use a retractor to hold my subscapularis up. And I'm going to feel the body of the glenoid, and I'm going to pull the subscapularis up. And I'm going to put this into the body of the scapula, and I'm going to use this as our superior retractor. There we go. We can use a Dara or a blunt. Holman. And you're going to slide this in underneath the body of the glenoid right here. There's our visualization. Now we're ready to do our capsulotomy with a little bit of external rotation. I can feel the glenoid margin. And I'm going to do a capsulotomy. I'm going to cut directly into the joint. Okay. We'll take our Fukuda retractor now. And we're going to slide our Fukuda in. And we'll take this cowbell out. This will actually hurt us now. There we go. Okay, so there's our exposure right here. That's our defect. And you can see we've got a very, very flat meeting surface now for our graft. So we have a guide here which actually really will facilitate drilling the holes for you. And this guide here is made for the European technique. So it will capture our graft. Okay. We can come in here and we want to put this kind of right at the edge of the graft right like that. And I want to make sure our graft is kind of just showing at the very edge of this here. So I may have to just fine tune that a little bit. That looks very good right there. Okay. We're going to drill a four millimeter drill bit. Through the graft. And then the second one. Okay. And now we have a guide that's going to facilitate graph placement. You can see our screws are in bone. They're in good position. And this guide here is meant to capture the graft and allow us to position it optimally. So now we have the ability to kind of slide our graft and put it where it belongs. And so I can slide our graph superiorly, inferiorly, medially, laterally. And I can put our graft right at the articular margin so that we are perfectly congruent. Now what we'll do is we're going to pass a guidewire. And we're going to put this in here now. And I can optimize our graft position. Now we can slide this out by holding our graft. And we can check our graph position. And that really is exactly where we want it to be. I can pull the graph back and you can see as it's sitting there. Now we've over drilled our coracoid fragment. So we're going to drill our distal part so we can use a fully threaded screw which is my preference. We've measured in this specimen 40mm. And that's a pretty typical screw length. We'll get a little purchase in this bottom screw right here. Protect the soft tissue. And I won't push this all the way down I'll get to we're relatively close. Check our graph position which feels very very good. Confirm that our superior position is good. And then I'll drill the top one. Okay. We'll slide this on. And slide this on. So these screws are to be snug but not overly tight. You want to have two finger tightness. That's all you want to have on these screws. Because what you do not want to do is over tighten this and potentially crack your graph. So we'll go back and forth and tighten these sequentially. More purchase here. And we have a great interface right here. We'll slide that sideways. But we're really absolutely perfectly flush with the face of the glenoid. Now we have our CA ligament. And the real pearl of this technique also is that we're going to let our graft be intra-articular, and we're going to use this to actually lengthen our capsule. If there's any parts of the graph that at this point feel like they're lateral to the joint line, you can simply burr them or use a ranger. And it's important at this point to take this out and pull that out. So what we'll do is we'll take a bite of our capsule, our good healthy capsule right there. And then we can come through our CA ligament. And I typically do a figure of eight stitch here. And I can come down a little bit lower, a little bit higher depending on what I see. Pass through here. And now our capsule has been reconstructed. And then that last little split that we made in the subscapularis, I'll simply re approximate with a FiberWire suture here. One last stitch like this. And that is the closing part of this procedure. And you can see our graph position. So we can really get a great view of the sling effect. We see our conjoint tendon right here our coracoid graft which is reconstructed our bony defect. And as we bring the arm up into external rotation as I come into abduction, we can see how that we developed the sling effect of the conjoint tendon and our latter done in a European fashion. The indications for latter in my practice are expanding. Typically we'll do these in revision settings, and we'll do these for patients who have had failed arthroscopic or even open instability procedures. But even in the indications where patients have had revision procedures without bone loss, this is my go to procedure, because the workhorse of this procedure really is the bony reconstruction and the sling effect. As such, we're able to rehab these patients faster than we would, for example, an arthroscopic based or a capsular based procedure, because we're relying on bone to bone healing. One of the things that facilitates this procedure is the right approach and the right exposure. And also the Arthrex set has become instrumental in me getting a reproducible outcome.

Stephen A. Parada, MD (Augusta, GA), discusses the importance of understanding glenoid bone loss, which can determine the optimal surgical treatment for anterior shoulder instability. Dr. Parada presents a failed Latarjet case with a traditional linear-measurement percentage technique and introduces a novel “circle-line” method that is simple, accurate, and more reliable for real-time determination of glenoid bone loss without requiring specialized software or imaging protocols.

Understanding Glenoid Bone Loss

I'm Steve Perotta. I'm the director of shoulder surgery at the Medical College of Georgia at Augusta University. And today, we're going to be talking about the importance of understanding glenoid bone loss. Glenoid bone loss measurement about the anterior glenoid is what can help us determine what the correct surgery to do for each patient. And we're going to go through a case that really highlights this, and how perhaps the incorrect surgery was chosen due to a misunderstanding of glenoid bone loss. The patient is a 23 year old active duty military male. He sustained his first dislocation on his non-dominant arm about four years ago, and then went on to have five subsequent dislocations and multiple more subluxation events. He was treated with physical therapy with no improvement on physical examination. He had a positive apprehension and relocation, and we were able to translate his humeral head to the glenoid rim with a load and shift test. He did not have any findings of ligamentous laxity and was neurovascular intact. His radiographs, taken preoperatively are an AP radiograph of the shoulder and not the not the glenohumeral joint, so it can be difficult to really ascertain any specifics about the anterior glenoid. Even on the axillary radiograph. You can see this is a little over rotated, making it difficult to appreciate the fine details about the anterior glenoid. On MRI cuts, we can see the axial cut on the left with the corresponding sagittal cut on the right. And as we go through the sagittal cuts we can see that there is a bankart lesion. But again hard to determine the amount of bone loss with the 3D CT scan and reconstructions. We can see that there is bone loss with a bony bankart fragment anteriorly. And so this leads us to the question of what is the estimation of this patient's bone loss. And there's a lot of different ways to look at this. And we know that ultimately our understanding of his glenoid bone loss and how much bone loss he has is how we're going to determine what surgery is going to be best for this patient. So again, on the sagittal image of his MRI, we're trying to look at the cut right at the articular surface. And it's hard to appreciate if there's glenoid bone loss here. When we try to place our best fit circle, it's really difficult to say whether or not there's any glenoid bone loss on this cut. When we go to a 3D CT scan and look at the reconstruction at the outside hospital. Seeing this, this was determined that he had greater than 20% bone loss. And so they decided he was indicated for a bone block procedure or a ladder. He had a ladder performed. And this is the X-rays from his first post-op visit at the time of surgery. The coracoid graft was fragmented, and they were only able to get a single screw in for fixation. These are his six months x rays. At this point he is having recurrent instability, and you can see here that the bone graft is pulled off of the screw, leading us now to having a patient with recurrent instability in the setting of a failed ladder. Ultimately, if we feel that the patient has greater than 20% bone loss, then that's going to put him into the category for most of us of performing a bony augmentation procedure. But perhaps in this patient it wasn't indicated ways to look at bone loss about the glenoid. We have lots of different ways to do that. Bilateral CT scans has been the gold standard, but looking at bilateral CT scans can be very difficult unless your hospital is set up to do that. You can see the CT scans that I sometimes obtain. We've looked at a lot of bilateral scapulas in the cadaver setting, and found that even paired scapulas in a cadaver can have significant variation from the right and the left glenoid that we feel is probably due to hand dominance. Doctor Provenza's group looked at specialized software where they can actually trace and then measure anterior glenoid bone loss. So this software does exist. It's not readily available on all imaging systems. And really this isn't always feasible to perform in clinic. It requires downloading the patient's data on their x ray and then uploading it into specialized software. And so for me, I can't really obtain this real time. During the patient encounter, Doctor Togashi's group provided this article trying to really redefine what critical bone loss was. And in their study, they used a linear measurement percentage technique, which is the most often cited technique in the literature. And they did this on the sagittal MRI. Their study, of course, found that glenoid bone loss of greater than even 13.5% was associated with worsening Z scores, even if the surgery hadn't failed. Again, what we know about the linear measurement percentage technique, though, is that this typically can overestimate bone loss. And so it's interesting to think that this critical bone loss may even be less than 13.5%. The Rus group looked at this mathematically and found that the linear measurement percentage technique is really only accurate if you're looking at a square and not a circle like the glenoid is, unless we have very large amounts of bone loss. Otherwise, again, this overestimates bone loss. And so to us this highlighted the fact that we needed a better solution. We came up with our solution that we termed the circle line method. This was a very simple Reproducible and accurate way to get real time information. This can be performed quickly in the clinic. It involves selecting the on face view of the 3D reconstruction, creating our best fit circle, and then measuring a line of bone loss termed the chord, and then also just measuring the diameter. With just those two measurements, we can plug those into a formula and get a calculation. So here in image A we have the gold standard. We took this glenoid. We traced the amount of bone loss and measured it at 15% bone loss. We performed the linear measurement percentage technique and find that that records it as 20% bone loss. Performing our circle line method again, we come up with the answer of 15% bone loss. And so you can ask yourself whether or not the difference of 15 to 20% would change your operative plan. But at least now we have the most accurate information to base our plan on which we feel is very important. And so scrolling through axial cuts of an MRI can lead us still wondering how much glenoid bone loss is in place. But again, getting the 3D reconstruction, selecting the on force view, measuring the line of bone loss, and measuring the diameter. We can plug this into our formula and get a very accurate estimation of bone loss. And in this case it was 16%. And so there are times, however, that you can get the correct study, which is the 3D reconstruction. You can get the on Foss view, but if you make your best fit circle too large, it can significantly overestimate bone loss. And so you can see here this patient, it's very easy to draw the circle too large and come up with an estimate of greater than 20% of bone loss. And again if we perform this correctly with an accurate inferior glenoid circle, we can see that the true amount of glenoid bone loss in this case is less than 10%. We've looked at a lot of normal glenoid to see where the best fit circle fits in a normal glenoid, and what we find that really, that circle is only about the About the inferior two thirds of the glenoid. If you draw a straight line from the superior glenoid tubercle to the inferior glenoid tubercle, again the height of that circle should only be about two thirds. We've looked at a lot of glenoid, and this is found to be true in almost all of them. This provides us with a very reliable landmark for trying to place our best fit circle in the setting of missing anterior glenoid bone. And so back to our patient. So now we have a young patient who has failed a ladder and continues to have recurrent anterior instability in my hands. I treat that with a distal tibia allograft. There's a lot of different graft choices. But again for me, utilizing the workstation that lets me create that graft to the exact dimensions that I want. We can put that in place and get a great reconstruction of the anterior glenoid. You can see here I've got a washer inferiorly that has an embedded FiberWire suture that helps me reconstruct the anterior capsule. And this was done through a subscapularis split. And here are post-op X-rays showing excellent placement of the graft up against the anterior glenoid. And so, in conclusion, I think ultimately we're still clinicians. The measurement of glenoid bone loss is only one piece of information that's going to kind of fit into our algorithm of how to treat glenohumeral instability in each individual patient. We know the best fit circle of approximately two thirds of the glenoid height is a great guideline to make sure that we don't mess up our estimation by making that circle too big. And again, we've come up with what we feel is a very accurate and quick measurement of anterior glenoid bone loss, and one that's feasible to do in clinic to get that real time information during the patient encounter. We know that there are many complications with latarjet surgeries and even the most experienced hands. And so it's important to make sure that we're not doing this surgery on patients when it's not indicated.

Stephen S. Burkhart, MD, (San Antonio, TX) shares his thoughts on glenoid bone loss and describes his preferred technique for open Latarjet procedure.

Latarjet Procedure: How I Do It

Okay. So I'm going to talk to you about how I do a ladder procedure. And as we talked about earlier, it typically is if there's greater than 25% glenoid bone loss, that's when I'll do a ladder J. If you look at the differences in how these are done worldwide, the French technique, as Doctor Walsh does, it is a little bit different from this congruent arc technique that Joe Debeer and I described a number of years ago, and I'll just show you the difference. The French technique. If you look at that blue shaded undersurface of the coracoid, that's the part that goes into contact and the French technique with the anterior glenoid. And the problem I thought with that is that you can get that sort of incongruity between your graft and your glenoid articular arc, whereas the way we do it with our congruent arc technique is we rotate the coracoid graft 90 degrees around its long axis. So we line up that concavity of the inferior coracoid with the concavity of the glenoid. And it's a much smoother surface when you do it that way. So just to compare the two, the French technique on the left where you have that potential incongruity, and then the congruent arc technique on the right, which is the way that we do it. Another difference that Joe Deburr and I described was to attach the capsule to the native glenoid, which makes your your graft extra articular. So it basically avoids the abrasion that you have with the French technique of your humeral articular surface against that graft. So this is the way that I do it step by step. I'll show you on a cadaver. So this is a left shoulder. And we're going to have kind of an expanded incision just for better visualization here. There's our coracoid. We come down and the deltopectoral interval. We find our coracoid. We find our conjoint tendon. There's our CA ligament. And we're worrying that we're basically going to skeletonize the coracoid with the exception of the conjoint tendon. So we take down the c ligament laterally. There's our pec minor. We take that down medially and we leave the conjoint tendon attached distally on the coracoid. Then we use an elevator. And we get this fibrofatty tissue off the undersurface of the coracoid. I like to be able to put my index finger underneath the coracoid arch, as sort of an endpoint of when I'm ready to take the graft. You can harvest your coracoid either with an osteotomy or with an angled saw blade. I typically use an angled saw blade, particularly in a muscular patient, because it can be difficult to get that straight shot with your thumb if they have a lot of muscle muscle. So we use the angled saw blade. We go just in front of the CC ligaments and you'll cut down. And you see, typically when you've gotten the whole coracoid, there's this little spike of bone on the end of it where you make your cut. Now we're going to take a little wafer of bone off the medial side where the pec minor had been, and just cut that with a straight saw blade. Take that off. That's the part of the graph that's going to go up against your anterior glenoid. You want a flat surface. Flat against flat is the way we like to do it. And so now we'll retract that out of the way. Now I still like to to take down the upper half of the subscapular. Some people do a split, but you can more predictably put your graft in the right place if you take down the upper SpeedScap. So take that down as a flap, and then I'll develop the plain between the inferior subscapular and the capsule. So we still have the capsule deep there. So we're developing that plain. Then I want to leave about A1A one centimeter tag of, I want to take down a down a one centimeter tag off of the glenoid. So on the capsule. So I'm feeling the glenoid rim, and I want to take about a centimeter medial to that so that we'll have plenty of capsule on reattachment. So we take that down as an L-shaped flap. Just go right at the through the rotator interval. Then we come over on the bone, dissect it off the bone for a distance of about a centimeter. And then we'll come on down to about the 6:00 position. In this case we actually then use a saw to make a defect there. So now we're going to use this guide for making the holes through the coracoid to make two parallel holes. We'll take that spike of bone off with a saw or with a bronzer. So just have something to protect on the other side when you drill it. And then you have this guide that has a fin that goes out beyond the graph. So you can use it to sort of feel where the articular surface of the glenoid is. And you want to doing it this way, you want to have an angle of approach of about five degrees from lateral to medial, so that you don't penetrate through the glenoid surface. Use two screws. So here's our fin going over that over that graft. You see how nicely that'll line up. And then you're going to put your guide pins in first. The longer guide God pin above the shorter God pin below, you can measure your depth. You drill over those guide pins. Then you can measure the depth that just drill unit cortical in the glenoid. Because the screws that we use are self-tapping screws. Basically self cutting self-tapping screws. And I'll use a 36 millimeter length at the top and 34 at the bottom routinely. And that ends up being just about right in almost everyone. You can measure it, but then the guide pins often will come out if you if you're drilling bicortical. And so I get them both close to being down and then tighten them at the end here. And so you see how you have that nice smooth arc at the end. And then I'll see if I can actually dislocate. Now I'll bring the arm it abduction external rotation. You see that sling effect. There's your conjoint tendon coming up over the top of your lower Subscapular. And as you come into abduction external rotation, it pushes the shoulder back. And so typically you're not able to dislocate the shoulder at all at this point. So I'm going to try to dislocate the shoulder as hard as I can. Just can't do it. And so then the last thing we do will soft tissue reattachment we'll use suture anchors into the native glenoid. You see, we're not putting them in the graft, but in the native glenoid. And then we'll reattach our capsule with those anchors. And then we'll bring the sub, the upper sub scap back to its anatomic position and fix it either just with soft tissue sutures or with anchors. Now, I think to optimize your chance of union of your bone graft, I like to make flat saw cuts on both the glenoid and the coracoid. I showed you how I cut the coracoid and I get it perfectly flat. But I like to now use an angled saw blade to make my glenoid flat too. And I think you have a much lower incidence of nonunion. If you do that instead of just using a bird or roughing it up. So here I'm looking in a right shoulder and I've got that angle saw blade cutting down on the kind of irregular anterior rim of the glenoid. And I make it just perfectly flat. So it makes a good recipient site then for our graft. And we've seen a much higher union rate. Nonunions have become virtually non-existent since we started doing that. So SpeedScap split you can do if you want, or taking on the upper half of the sub scap. Theoretical advantage of the split is less muscle damage. The drawback is less room for error in placing your graft. So I still like to take down the upper half of the sub scap you always want to scope prior to doing the open ladder, because you may want to, you may find something else to repair. Here's an Here's an example. This is, you know, the same sitting, but it's just before. And I'm looking in here. This is a right shoulder. There's the posterior capsule and there's a reverse haggle lesion. So I'll fix that. Arthroscopically before I go on to my open ladders I'll reposition and then do the open ladder. What about arthroscopic ladders? Well there are some reasons I don't do that. It's the only operation I don't do arthroscopically. And if you look at the European experience where very accomplished surgeons are still having devastating complications, I think you basically have an unending learning curve. You never get to the point. You're not having major complications. And I think you have an unacceptable rate of not just minor complications, but devastating complications and neurovascular injury. So I still prefer the open ladders. I'm not saying we'll never do arthroscopic in the future. I think the techniques just aren't there yet. Thank you.

Open Latarjet Instrumentation

Congruent-Arc Latarjet Using the Glenoid Bone Loss Set with 3.75 mm Cannulated Screws

Congruent Arc Latarjet

Treatment of shoulder instability due to glenoid bone loss can be challenging. Common reconstructive techniques include the Latarjet procedure (coracoid transfer) or glenoid augmentation using autograft iliac crest or allograft distal tibia allograft (DTA).1 The lateral portion of the distal tibia is a great match to the patient’s glenoid because it has similar curvature, dense bone, and cartilage.
The Distal Tibia Allograft Workstation allows the surgeon to use trials to determine the desired size and shape of the bone block for use with Bone Block Cerclage or the Glenoid Bone Loss Set. A set of simple cutting guides are then used to precisely machine the DTA to match the trial for the procedure.
Reference
1. Provencher MT, Ghodadra N, LeClere L, Solomon DJ, Romeo AA. Anatomic osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid deficiency using a distal tibia allograft.&nbsp;Arthroscopy. 2009;25(4):446-452. doi:10.1016/j.arthro.2008.10.01

Matthew Provencher, MD, (Vail, CO) discusses his rationale for using a distal tibia allograft to treat glenoid bone loss. He shares his years of research and clinical results, and discusses how the Arthrex Distal Tibia Allograft Workstation has made the technique easier and more reproducible.

Anterior Instability: Distal Tibia Allograft

Hi, I'm Matt Provencher, and I'm here to discuss why I use distal tibial allograft for glenoid bone deficiency. So when do I consider fresh distal tubule allograft? Certainly in cases of significant glenoid bone loss, more than 20 to 25%. And in cases of the failed latarjet procedure, although the latter has been around for more than 50 years, it's not perfect. There are cases when the conjoint tendon can pull off the bone block. Resorption of the bone block exists. We do know that even a well performed and perfect latarjet there is resorption of the coracoid, bone block, screw prominence, screw bending, hardware failure, arthrosis concerns. But it's really hard to argue the test of time. So when we were thinking about this problem to reconstruct the glenoid, a natural fit obviously would be a fresh glenoid. However, there are donor concerns and it's very challenging to get a fresh glenoid. What we did find was that the distal tibia fit the humeral head beautifully. We found that it didn't matter for side right to left, left to right. And the overall size was really not a big issue because it fit the humeral head very well. In addition, the distal tibia provided very dense cortical cancellous bone, as well as the added advantage with which the other graphs did not have, which is fresh cartilage. We have also found that the fresh cartilage is basically the same thickness and composition as that of the glenoid, approximately 2.2 to 2.7 millimeters. When we looked at the contact pressure of this, we found out that the distal tibia fits very well. It basically reconstructs the concavity of the glenoid and actually fits better than the traditional ladder. We also showed that the contact pressures are nearly identical to the native glenoid. When you reconstruct it with a distal tibia, much improved over the latter when we tested this against iliac crest. We found out that the distal tibia did as good or better than the inner table of the iliac crest, and it had the added advantage of having fresh cartilage. So this is actually a video of the first case I did in 2008. You can see a patient here has recurrent instability. He basically dislocates on the table as soon as we get him asleep. This was for approximately 25 to 30% glenoid bone loss. You can see here we're preparing the anterior aspect of the glenoid. And in 2008 this was a freehand technique. Obviously we had some challenges trying to get the distal tibia to fit correctly, to make the right cuts and to approximate not only the cartilage surface, but the concavity as perfect as possible. You can see how well the graft fits the anterior aspect of the glenoid. We used screws with washers and actually sutures that I tied underneath the washers with half hitches, and then close the capsule at the end of the case. Now, we've published on this in Arthroscopy Journal, where we had our first 27 patients, where the average age was 31 years. We had almost four years of follow up on all of these patients where we tracked their outcome scores, but also CT scan analysis. What we found overall, when we looked and scrutinized the CT scans was an 89% allograft healing rate and only a 3% average allograft lysis. We also looked at the allograft angle or the angle with the graft made with the native glenoid, and that was approximately 14 degrees, which actually reconstructed the concavity of the glenoid quite well. When you look at the normal anatomy, our clinical results also reflected the radiographic results being very good outcome scores and saying, whoa, see, we had no cases of recurrent instability, but we did have one superficial infection. And just to be safe, I removed that graft and actually revised it to another distal tubule graft after appropriate antibiotic treatment. We now have more data. And this is a recent presentation we made in 2017, where we now have compared latarjet in a match group to distal tibial allograft. The patients were nearly matched to glenoid bone loss. There was 20% average. This is a challenging patient population. We had three year follow up, all with CT scans, and you can see that all the clinical outcomes were nearly identical for both groups. So since 2008, we have made a lot of progress in developing this technique to make it more reproducible and a little bit easier from not only allograft preparation, but also insertion and fixation. We have developed the ability to size the defect with an open approach. We have developed ways to cut the graft in a very reproducible manner. After we have determined the size not only from CT scan, but also from intra-articular measurement. We then also use existing technology, such as the large bone grafting set to be able to fix the graft. Again, I like this technique and is my preferred technique for fixing the failed large glenoid bone defects that are greater than 20 to 25%. When you have not only the bone defect issue, but also a cartilage problem, and you want to reconstruct both.

Glenoid Bone Loss

Bone Block Cerclage

Congruent Arc Latarjet

Distal Tibia Allograft Workstation for Glenoid Bone Loss