Navigation‐Guided Trans‐glenoid Flexible Fixation Technique for Arthroscopic Autologous Iliac Crest Grafting Treatment of Recurrent Shoulder Dislocation

Fig 1. (A, B) Three-dimensional reconstruction images of the bilateral glenoid are reconstructed by Mimics software (Materialise). A virtual circle (red circle) is drawn on the normal glenoid as a reference. The same-sized circle (diameter ab) on the contralateral glenoid shows the extent of the bone defect (longest diameter [i.e., diameter bc]), and the percentage of the bone defect is roughly estimated as bc/ab.

Fig 2. (A-D) We designed a set of bone tunnel guide instruments with 3 components. The targeting component (red arrows) with a 7-mm offset (black arrows) is introduced into the joint from the posterior portal. The hollow guiding component (black triangles) allows a 2.0-mm K-wire and keeps aligned with the anterior targeting hook. The slide component (black stars) allows the angle to be adjusted between 10° and 30° to meet different surgical needs.

Fig 3. (A) Bony markers on left shoulder, including clavicle (a), coracoid (b), acromion (c), and scapular spine (d), as well as arthroscopic anterosuperior (e), anteroinferior (f), and posterior (g) portals. (B) Five-centimeter skin incision marker on anterior superior iliac spine. (C) The surgical procedure is performed with the patient in the “lazy” lateral decubitus position. (D) Diagnostic arthroscopic examination is performed from the posterior portal to view the glenoid bone defect (left shoulder, 30° arthroscope, lateral decubitus position). (E) Anterior portals are established using a needle in an outside-in manner. (F) The arthroscope is transferred to the anterior portal to observe the glenoid defect and Bankart lesion. (C, capsule; G, glenoid; HH, humeral head; LHBT, long head of biceps tendon; SSP, subscapularis.)

Fig 4. (A, B) A 20 × 10 × 10–mm tricortical iliac crest graft is harvested from the anterior superior iliac spine on the ipsilateral side per the preoperative plan. (C) Four 2-mm-wide holes are drilled by an electric drill, approximately 5 mm apart, through the graft (black arrow). (D, E) Method by which bone block (black star) is bridged with EndoButton (black arrow) using high-strength sutures (black triangle). If the patient has significant osteoporosis of the graft, an additional EndoButton (red arrow) may be added anterior to the bone block to reduce the cutting effect of the sutures leading to fracture. As shown, sutures 1, 2, and 3 are used to pull the graft anteriorly to posteriorly; of these sutures, sutures 1 and 2 are used to achieve a seesaw effect on the plate whereas suture 3 is used to tighten the bone posteriorly. Anterior sutures 4 and 5 are used as “guide sutures” to adjust the rotation of the bone block and to direct the anchors’ sutures passing through the upper and lower holes of the graft. Suture 6 is knotted in front to compress the graft.

Fig 5. (A) The guide (black star) is introduced through the posterior portal and kept parallel to the cartilage surface to avoid injury (left shoulder, 30° arthroscope, lateral decubitus position, view from anteroinferior portal). (B) The hook (black triangle) is positioned at about the 4-o’clock position of the glenoid. (C) A 2.0-mm K-wire (black arrow) is drilled from the posterior using an electric drill following the guide access; alignment is maintained with the anterior hook (black triangle), and drilling too deeply should be avoided to prevent damage to the vessels and nerves. (D) A 4.5-mm hollow drill (white arrow) is used to enlarge the bone tunnel along the K-wire guide, the K-wire is withdrawn, a metal traction wire (black arrow) is fed through, and a grasper (black star) is introduced from the anteroinferior portal to take the wire outside (left shoulder, 30° arthroscope, lateral decubitus position, view from anterosuperior portal). (E, F) Two anchors (black arrows) are introduced at the 3- and 5-o’clock positions of the glenoid to serve as the anti-rotation suture and to perform Bankart repair, respectively (left shoulder, 30° arthroscope, lateral decubitus position, view…

Fig 6. (A, B) The rotator cuff interval (black star) is cleaned sufficiently using arthroscopic tools, with removal of the access cannula of the anteroinferior portal and enlargement of the incision to ensure that the graft can be introduced smoothly through the guidewire (black arrow) (left shoulder, 30° arthroscope, lateral decubitus position, view from posterior portal). The bone block is introduced into the joint through the rotator cuff interval and undergoes traction posteriorly. (C) Tension is maintained on the anterior sutures (suture 6 in Fig 4E) as the EndoButton passes over the bone tunnel and a seesaw sensation occurs (left shoulder, viewed from above). The grasper is introduced from the anterior 2 portals to assist in proper placement and to ensure there is no rotation and lateralization of the graft and it fits well to the bone defect surface. (D) After the final adjustment is completed, tension is maintained on the posterior sutures (suture 3 in Fig 4E) (left shoulder, viewed from above). (E, F) The 2 anchors’ sutures (black stars) are passed through the bone holes following the guide sutures (sutures 4 and 5 in Fig 4D), and the tails of the sutures (black arrows) are…

Fig 7. Computed tomography (CT) images of right (R) shoulders in typical patients at postoperative follow-up. (A-C) CT images on first day postoperatively (PO1D) showing good positioning of bone block (white arrow) and posterior EndoButton (black arrow). (D) CT scan at 6 weeks postoperatively (PO6W) showing good bone healing (white arrow). (E, F) Complete bone healing and remodeling of glenoid (black star) at 3 months postoperatively (PO3M). PO3M-3D, post-operatively 3 months-3 dimensional reconstruction.