<p>The flat, angled Glenoid Rasp is designed specifically for debriding the glenoid rim during Bankart repair procedures. The Glenoid Rasp has a 15° tip angle, which provides the appropriate arthroscopic angle to safely and easily debride the glenoid rim.</p>

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

<p>Matthew T. Provencher, MD (Vail, CO), demonstrates using the distal tibia allograft for anterior glenoid reconstruction when dealing with significant bone loss. He uses the distal tibia allograft workstation to accurately template and prepare the desired bone block.</p>

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Distal Tibia Allograft for the Treatment of Glenoid Bone Loss

Hi, my name is Matthew Provencher and I'm an orthopedic surgeon. I'm here to talk to you about the new Arthrex distal tibia allograft workstation. This was developed by Arthrex to supplement the current large bone graft set for cases of glenoid bone loss, in which you might think a fresh distal tibial allograft can be utilized to reconstruct the anterior glenoid. This is a new system that will be utilized to prepare a fresh distal tibia allograft for implantation to the glenoid. I like using this with the open shoulder retractor set. So we start with our deltopectoral incision, almost an open bankart type of incision. We go through the skin and we're going to identify the deltopectoral interval. So here's some deltoid fibers I'm going to come down through the deltopectoral, incise this and then bring our vein laterally. But sometimes it does go medially depending on the type of patient and where the branches are. So right here is our vein. And we're going to keep that laterally as this sort of seems where it wants to go. And here's our coracoid right here which signals the deltopectoral interval. So we put in a Cobell retractor, which is what I generally use for all of my open shoulders. This comes in the shoulder arthroplasty or open shoulder retractor set. So now we've got just the deltopectoral interval identified. And so what you see here is tip of the coracoid. Here's the conjoint tendon which is the white stripe. You're then going to see a small red stripe right here. That red stripe represents the short head of the biceps. Then there's a layer of fat right here. And that's the interval to get under the conjoint tendon and to get in the joint. So you come right in that area where that fat interval is just come lateral white stripe. Red stripe. Short head biceps fat. And then now you're into underneath the conjoint tendon. We put a pointed Hohmann retractor right at the top just to exploit that subacromial space. It goes right on top of the rotator cuff. You can then just gently resect some of the Bursa here. And then what we'll do is replace the Cobell retractor underneath the conjoint tendon. So now what we're defining is the top rolled edge of the subscapularis, which is right here down to the three sisters, which are right here. So what I generally like to do is to split this almost in half, maybe a little bit more towards the bottom. So we're just going to stay and protect this away from the biceps tendon. Take our knife and incise this in line. And with your assistant just does a little bit of external rotation as you're going through this. You'll then be able to incise these fibers in line. You don't want to come too far medially because the nerve to subscapularis penetrates about 1.5cm medial to the coracoid medial border. And you want to be careful to avoid injuring that structure. The posterior side of SpeedScap is a relatively safe area, as long as you're not going too medial. But it's relatively safe from being back here and doing blunt dissection, because there's no nerves that penetrate the posterior aspect of the subscapular in this area. So this is the Subscapular retractor. And generally I put the retractor handle medially. And then I'm able to put this deep in the shoulder, which then allows us a really nice exposure of. Now the now the capsule. Here's the glenohumeral joint right here. And so now what we're going to do is peel off the capsule in an L shaped fashion. And so the L is going to be like this all the way down like this. So we're going to go about a centimeter medial on the glenoid. You have to be careful here. And I usually start down at the joint so that the knife goes in without injuring any of the cartilage. So now we're going to peel this off. Once we get through, I switch the knife around so that the sharp part is toward the capsule. Here's the capsule layer, and here's the capsule as we head out to the lesser tuberosity. I'm just going to incise that. Now we're down to the down to the glenoid. And basically we want to do at this point is then excise the capsule off of the off of the glenoid. This capsule will be used for repair at the end to suture washers in the anterior aspect of the glenoid tibial bone graft. We're going to put this in the front corner, basically the apex of the L of the Capsulotomy for eventual repair. At the end of the case, we'll put a Fukuda retractor in, and this will expose the anterior aspect of the glenoid. We'll then use a forked anterior glenoid retractor. So this is the sizing guide which we put on a handle. This is a seven millimeter anterior to posterior by ten degree angle. And you can see that ten degree angle relative to the block which will be perpendicular to the face of the glenoid. So it's important to prepare your glenoid perpendicular to the cartilage so that you get these angles correct, which you can see is the congruent fit as we put it. We want to make sure that this is perpendicular to the glenoid surface. So what we have first is the important center post. And the center post is what the shaft of the tibia is going to go down. And you can see this is going to go down like this and engage. And I'm going to show you how to do this just to make sure that you can get this properly positioned, because there's still a little bit of play and you want to get this exactly right before making your cuts. And so we're going to put in this one, slide it in. This is going to be near center point. And then this is going to accommodate pins that will put across the tibia to hold it in place. And so we'll just put just put this in loosely like that. And then we're going to take the distal tibia. The first thing I'm going to do on the distal tibia is mark the edges of the cartilage. And so I'm just going to put a dot right on the edge of the cartilage here. And then another dot here. This is the area that we're interested in for the graft. This is the perineal tubercle. So this is the lateral sulcus and lateral side of the distal tibia. And then here's our arc that will match the concavity of the glenoid. So once we make these two marks I think it's important to make a center mark. So we're going to make a center mark which will be the center point which is usually the deepest portion of the concavity of the tibia which you can see right here. So now once I've done that I'm going to put this into the guide. I keep the lateral side towards me, which is where all the action will be, and put the medial malleolus away from me. So we're going to make sure that this line is centered up with this track here. And then what we're going to look at look at is how the graft sits. If we bring this right down the shaft, what you may end up with is a graph that's slightly tipped and we don't want that. Once I have that center post, I'm going to check again my alignment on the top. Tighten down both of these. So as a final check to make sure that the graft is positioned correctly before we put the cross pins. And the cross pins are going to go from here left to right, which is from the arm that has the post to the arm that does not have the post. And this will lock the graft in. But we just want to make sure one last check is to make sure that the height is correct. And so what we do is we take cut number three which looks at the graph thickness. We're going to tighten this down to the front arm here. And then we're going to drop it all the way down. Take our sizing block put our sizing block on and know that we have enough room to make the cut. We'll have plenty of room here. So I always hold the graph. Make sure we're still oriented here. So once we get this set, it's really going to hold the graft in really nicely. And so we just check to make sure that the guide pins have engaged all the way through this outer arm. They stop there based on how the guide pin is designed. We're going to start with the first cutting block, which has cut one and cut two incorporated into it. This is what we sized Preoperatively and also intraoperatively with a sizing guide to be seven millimeters anterior to posterior by ten degree angle. So now with the allograft workstation we're going to size this and make sure that this is once we have this position we can move this around and make sure that this is on center point. So we marked our center point where our center point just to be right in line with the center aspect. So we'll tighten that down. And then we'll put a cutting block number one and number two on the end of this. Now we're going to drop this down to the tibial surface. So we loosen up this I'm going to hold this up here so that we're able to drop this down carefully down to the cartilage surface. Once that's done we're going to tighten this in position. So now that we have our height set you can see that this slides in right at the level of the concavity and center point on the distal tibial allograft. So we now need the finger which then sets the depth of the cut. This is how the finger engages the center point on the tibia. And so again this is center center. We just want it to engage. We don't want to over engage it so that it's tilted. As soon as it hits then we're going to tighten our screw right here because we're also cutting into a fresh osteochondral allograft. We're going to do irrigation while we make these cuts. So so cut one. Will generally just take off some of the perineal tubercle in the back of this graft. And then cut two will be at the ten degree angle that we templated. And so you can see this comes in at the ten degree angle. Again we're going to use irrigation to cool this. I always start the saw inside of the cutting guide. First score the cartilage score the cortex and then start slowly coming through. We take this off and you can see here is our cut. That's our seven millimeter depth. Now we use the free graft guide which we're going to put wires in. And we put this right at center point. Also from the side here we want to make sure that this is completely flush. And the finger is completely flush with the tibia cartilage surface. This point we're going to put in the guide pin holding this flush. And then a second pin. And if you can see from the side you have the two pinholes in place. Then we're going to verify the depth using this finger. And this is what we use to help put the graft in place. Now we're going to finish up with cut three and cut number four. First I tighten on the black knob and then we'll adjust the height. Right here you can see we can come up and down. And I think I like that right there. And so on. Cut number three. You can come all the way across here. The here. The graft will not come free because it hasn't been freed fully on the edges yet. And making sure that the saw blade has passed this cut number two, which sets the seven millimeter depth. Now we're going to put on cut number four. This is actually two cuts to set the total length from superior to inferior of the graft. First I put this on the end post. And then I'm going to bring it in and tighten it fully into position. I tighten all of the knobs. And then I'm going to put this basically right up against our cut number one. Now you have this down on center point you have three options for graft length superior to inferior. You can have 18mm if you just do two cuts right here. You could have 20.5mm if you go from here to here or here to here. If you're going to use some of this offset cutting, you're going to have to loosen the knobs to make sure that you do the second cut under a center radius of curvature. In this case this patient size to size to 23mm. So we're going to cut using these two outer slots for the saw. We're going to make our last two cuts again using copious irrigation. Since this is fresh cartilage at this point the graft is now free. We can put in our block and there's our fresh distal tibia. We also note that the fit is very good. The finger is flush with the center point. And also you have the very nice dense cortico cancellous bone graft, the fresh cartilage of approximately 2.5mm thickness. And if we put this next to the sizing block, you can see that we have 23 millimeter block that also respects the ten degree angle that we cut into the tibia. This is simulating our pulse lavage. After I pulse lavage this for ten minutes to remove the marrow elements, I will then soak it in ACP for approximately ten minutes while I finish making my approach and get the anterior glenoid ready for implantation. So now we have the graft. Now sometimes when we when we put it in, I have to take out the anterior retractor just to help position this. And so once I get this in, the finger here sort of acts as the retractor. So now we're going to position the graft, hold it in place. And we're going to fix it provisionally with some K-wires. We're then going to push the graft down. Hold it in place with an elevator. We drill across the cortex. So now we're going to use our 36 millimeter screw. This is a fully threaded screw 3.75 Cannulated. It also has the suture washer. You can see how the suture comes around that washer to be able to slide, and will allow you to repair the capsule down to the front of this screw. So we're going to load this up. And you put this over the cannulated pin. And generally I start inferiorly I'm going to hold this in place here. We want the sutures like this. Because that's how you're going to tie down the anterior capsule to the front of the graft. So we're gonna put a second screw in. Again, a 36 with the suture washer. There's our reconstructed glenoid. There's the bottom of the glenoid right here. So we've reconstructed that whole anterior aspect. 23mm, top to bottom of the anterior glenoid. The last thing we're going to check here is how the humeral head nicely articulates. With the front of the glenoid. The anterior capsule of the shoulder will be closed over the anterior aspect of the graft, making this an intra-articular graft. Using standard techniques with the suture washer number two FiberWire, the capsular closure is performed with a figure of eight high strength suture, keeping the knots outside of the joint using standard techniques. The final closure is the subscapularis split closure, which is done with figure of eight. Number two. Fiberwire suture.

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SutureTak® Bankart & SLAP Repair

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Distal Tibia Allograft for the Treatment of Glenoid Bone Loss

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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