Arthroscopic Autologous Iliac Crest Bone Grafting for Reconstruction of the Glenoid: A Nonrigid Fixation Technique

Fig 1. Preoperative 3-dimensional computed tomography scans of left shoulder (normal) (A) and right shoulder (glenoid defect side)(B). Significant anterior glenoid bone loss is shown in the right shoulder (white arrow). Preoperative circles of the same size can be drawn to roughly estimate the size of the bone defect.

Fig 2. Two 2-mm-wide holes placed approximately 5 mm apart are made through the graft (white arrow) and the third hole is drilled in 1.5mm away from the edge of the bone by an electric drill (white star). Then a high-strength suture (black arrow)penetrate the hole.

Fig 3. Skin markings for standard shoulder arthroscopy portals (right shoulder): posterior (A), anterosuperior (B), and anteroinferior (C) portals.

Fig 4. A 20 × 10 × 10–mm tricortical iliac crest graft is harvested from the ipsilateral side. (A) A 25-mm-long bone graft, including 3 cortices, is taken 3 cm behind the anterior superior iliac spine with an osteotome. (B) Two 2-mm-wide holes placed approximately 5 mm apart are made through the graft (white arrow) and the third hole is drilled in 1.5mm away from the edge of the bone by an electric drill (white star).Then a high-strength suture (black arrow)penetrate the hole. (C) An EndoButton (white triangle) is used as a fixture for our nonrigid technique. The 2 ends of 3-strand high-strength sutures (black arrow) are respectively passed through the hole in the EndoButton by a looped guidewire. (D) The 2 ends of the sutures (black arrow) are inserted into 2 holes in the iliac bone graft (white arrow) through the looped guidewire, and then the suture is tightened. (E) The most commonly used graft is 10 mm in width, 20 mm in length, and 10 mm in height, although the size can be customized depending on the case.

Fig 5. Surgical portal and arthroscopic inspection. (A) A standard posterior portal is created for the insertion of the arthroscope (white star) (Smith & Nephew). (B) The arthroscope is introduced through the anterosuperior portal, the anterior glenoid rim is further decorticated, and the glenoid neck is prepared with a motorized burr (white triangle) (Arthrex) to create a flat and bleeding bony surface. (G, glenoid; H, humerus.)

Fig 6. Two sets of grafting instruments were developed by the senior author, including glenoid bone graft guides and a bone graft introducer. (A) The glenoid bone graft guides are 7 mm (yellow triangle), 8 mm (black triangle), and 9 mm (white triangle) wide. (B) There is only 1 size of bone graft introducer (white star).

Fig 7. Transglenoid tunnel placement. (A) The glenoid bone graft guide (white star) is placed through the posterior portal (right shoulder, viewed from above). The arthroscope (white triangle) is placed through the anteroinferior portal. (B) The core bar (white arrow) of the bone graft guide (black arrow) is placed into the joint along the guide, which closes to the anterior glenoid margin at the 4- to 5-o'clock position (right shoulder, lateral decubitus position, 30° arthroscope through anterosuperior portal). (C) One hole is drilled from the posterior glenoid to the anterior glenoid with a 2.0-mm drill (black triangle) (right shoulder, viewed from above). (D) The 2.0-mm drill (white arrow) cannot penetrate the joint surface (right shoulder, lateral decubitus position, 30° arthroscope through anterosuperior portal). (G, glenoid.) (E) Drilling is performed with a 2.4-mm hollow drill (white triangle). (F) Arthroscopic view showing 2.4-mm hollow drill (white triangle) (right shoulder, lateral decubitus position, 30° arthroscope through anterosuperior portal). (G) A 2-mm monofilament wire (white arrow) is passed posteriorly through the hollow drill (white triangle) (right shoulder, viewed…

Fig 8. Graft passage and fixation. (A) The bone graft introducer (white star) is then inserted from the anteroinferior portal to allow introduction of the switching stick (white triangle) (Smith & Nephew) (right shoulder, viewed from above). (B) The monofilaments (black arrow) (Smith & Nephew) are retrieved through the anteroinferior portal and taken out through the bone graft introducer (white star) to prepare for graft passage (right shoulder, viewed from above). (C) Suture tails from the EndoButton in the graft (black arrow) are placed through the monofilaments, which are pulled out from the bone graft introducer (white star); the monofilaments (white arrow) are then used to pass the sutures through the transglenoid tunnels and retrieved through the posterior portal (right shoulder, viewed from above). (D) With use of the introducer, the graft (white triangle) is pushed into the joint (right shoulder, lateral decubitus position, 30° arthroscope through anterosuperior portal). (E) A grasper (white arrow) placed through the anteroinferior portal is used as a stick to assist in proper placement and to ensure there is no lateralization of the graft (right shoulder, viewed from above).…

Fig 9. Bankart repair. (A) The capsule-labrum structure (white star) is pulled over the bone graft and attached to the glenoid bone strap using the remaining suture (white triangle) on the 2 anchors (right shoulder, lateral decubitus position, 30° arthroscope through anterosuperior portal). (B) The Bankart repair is completed; the bone graft is kept outside the joint, forming a backup to the repaired capsule-labrum structure (right shoulder, lateral decubitus position, 30° arthroscope through anterosuperior portal). (G, glenoid; H, humerus.)

Fig 10. Three-dimensional computed tomography images showing en face views of glenoid. (A) Image obtained preoperatively. (B) Image obtained after operation. (C) Image obtained at 6 months, showing complete bone healing and remodeling.