Preferred positioning is in the 30° semi‑lateral position so the glenoid is parallel to the floor. The patient’s arm is then placed in an arm holder and abducted to 60 degrees in balanced suspension.

The arthroscopic portals are then located (Posterior, Anterosuperior, Anteroinferior & the Medial Portal).

• Posterior
• Anteroinferior
• Anterosuperior
• Medial Portal (Halifax Portal) 

A standard diagnostic arthroscopy is performed. A biceps tenotomy is recommended in the presence of preexisting biceps pathology.

Use VAPR™ TRIPOLAR Electrode & FMS™ Shavers to release the rotator interval. The anterosuperior portions of the subscapularis are fully visualized by this release.

Through the anteroinferior portal, a labral elevator is used to mobilize the labrum. This will help to assess the bone loss.

The arthroscope is then shifted to the anterosuperior portal and a cannula is placed in the posterior portal to serve as an outflow to maintain a low intraarticular portal pressure.

A traction suture is placed around the labrum to assist with mobilization.

At this point the anterior glenoid is completely cleared of tissue using the VAPR™ TRIPOLAR Electrode.

The anterior glenoid is then rasped and decorticated using a burr to provide a bleeding surface for promoted healing.

The appropriate size of the graft is determined based on the dimensions of the glenoid.  A calibrated probe can be used as a reference.

The bare spot can be used as the reference to the center of the native glenoid to determine bone loss.

A Distal Tibial Allograft (Parametrics) is used for the reconstruction. Usually, the tibia of the same side as the shoulder is used.

Size and mark the distal tibia based on the intraoperative measurements.

Use the posterolateral corner because it best replicates the contour of the native glenoid and provides 3 cortical surfaces for better strength and screw fixation.

Use a microsagittal saw to cut the distal tibia to the appropriate dimensions.

Tip: The dimensions are generally 10 to 15 mm in anteroposterior width and 25 mm in inferior-to-superior height. The graft thickness tends to be 15 mm.

Tip: Trapezoid shape to increase medial side of the graft for better contact on the anterior glenoid 

Introduce K-wires in Alpha and Beta holes through the Inline Drill Guide (288200). Check the position of both K-wires. If they are not located correctly, replace them one by one.

The offset pin is used to stabilize graft while drilling and provide a 7 mm offset.

Drill the Alpha hole through the Distal Tibia Graft, over the K‑wire, using the Step Drill for a surgery with Top Hat.

Tip: Place a gauze under the graft when drilling

Remove the drill from the Alpha hole, which will remove the K‑wire. Drill the Beta hole over the K‑wire in the same manner.

Tap the hole with the Top Hat tap then implant Top Hats in the Alpha and Beta holes using the combo screwdriver.

The clear double‑barrel cannula is then attached to the graft inserting the two 3.5 mm screws into the Alpha and Beta holes and tightening until sufficient stability is felt.

The medial portal is then created using an inside-out technique.

The switching stick in the posterior portal is advanced parallel to the glenoid, superior to the subscapularis, and as high as possible toward the humeral head (this ensures reduced risk to the neurovascular structures).

The switching stick is then advanced through the deltoid, and a skin incision is made over the switching stick. A slotted cannula is placed through this portal, followed by a large channeler, to bluntly dilate the medial portal. This allows for easier passage of the Distal Tibial Allograft at later stages.

During insertion of the graft, retract the subscapularis inferiorly using a switching stick from the posterior cannula as opposed to performing a subscapularis split.

Two slotted cannulas (214136) can be used to help prevent soft tissue from being dragged into the shoulder when passing the graft from the outside.

By use of the doublebarrel cannula, the graft is introduced through the medial portal, lateral to the conjoined tendon, and superior to the subscapularis and directly onto the anterior glenoid rim.

Note: Care is taken to view the positioning of the graft through all the portals to ensure accuracy.

Use the switching stick in the posterior portal that was used to retract the subscapularis inferiorly to manipulate and position the graft, keeping it level with the glenoid face.

Two K-wires are inserted through the 3.5 mm screws located in the purple double cannula and penetrated through the skin posteriorly, parallel to the posterior portal.

Tip: Alternate K wires to optimize positioning of the graft

Tip: Penetration of the articular cartilage should be avoided. The graft height (lateral to medial translation) can be fine-tuned by rotating the double-barrel cannula with 1 K-wire used as fixation on the glenoid. 

The threaded 3.5 mm screws are removed from the double cannula. The calibrated Glenoid drill is used to drill and estimate screw length as it perforates the posterior glenoid cortex.

Tip: Kocher forceps are placed on the guidewires to prevent migration during drilling.

Tip: The screw length is typically 34 to 40 mm.

Load the Cortical Screw over the Glenoid K-wire and insert into the Alpha hole using the combo screwdriver. Repeat this for the Beta hole. The screws should be tightened in alternating fashion, it is during this tightening and compression phase that the tophat washers absorb the hoop stress.

Note: It is important to be collinear to prevent stripping of the screw heads. The subscapularis is then reduced back into the native position in front of the graft using a switching stick from the anteroinferior portal. 

With the arm repositioned to a 60° abducted position.

Perform a standard Bankart repair of the labrum using GRYPHON™ Anchors for additional soft tissue support and to make the graft extraarticular.

Tip:  Take inferior to superior capsular shift taking traction suture from 3 o’clock to 12 o’clock

View from all portals to ensure a glenoid positioned humeral head while taking it through range of motion and an anterior stress test.

The arthroscopic portals are closed and the arm is placed in a neutral rotation sling.