Primary Distal Tibia Allograft for Restoration of Glenohumeral Stability with Anterior Glenoid Bone Loss

Fig 1. Drawing of the left shoulder (in beach chair position), viewed from anterior. When performing the subscapularis split, the split should be made in line with the fibers of the subscapularis tendon and at the 60%/40% separation (60% of the tendon above the split, 40% of the tendon below the split). It should be taken medially to the level of the conjoined tendon to avoid damage to the upper subscapular nerve.

Fig 2. Drawing of the left shoulder (in beach chair position), viewed from anterior. The capsulotomy should be made so that the horizontal limb is in line with the subscapularis split, and the vertical limb is extending inferiorly at the level of the glenoid neck. This reduces risk of damage to the underlying cartilage. A suture can be placed in the apex of the capsule to improve visualization and retraction.

Fig 3. The distal tibial allograft after preparation, (A) viewed from medial to lateral and (B) viewed from the front aspect of the graft. The completed distal tibia allograft will have two 4.0 mm drill holes through the center in an anterior to posterior direction. The graft surface that will be placed against the native glenoid will be angled, based on cutting block used. The new anterior glenoid rim will correspond to the lateral surface of the distal tibia.

Fig 4. Operative photograph of the left shoulder (in beach chair position), viewed from anterior. Once the graft is placed and secured using two 4.0 mm fully threaded, noncannulated screws, joint surface congruity and joint stability can be assessed. The suture washers and loaded sutures provide a stable fixation point for the anterior capsule and remnant labrum to be reattached.