Anatomical Glenoid Reconstruction Using Fresh Osteochondral Distal Tibia Allograft After Failed Latarjet Procedure  Anthony Sanchez, B.S., Marcio B. Ferrari, M.D., Ramesses A. Akamefula, Rachel M. Frank, M.D., George Sanchez, B.S., Matthew T. Provencher, M.D.  Arthroscopy Techniques  Volume 6, Issue 2, Pages e477-e482 (April 2017) DOI: 10.1016/j.eats.2016.11.003 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Deltopectoral incision performed in a right shoulder with the patient positioned in the beach chair position. The approach is performed between the deltoid and pectoralis major muscle, starting at the inferior aspect of the clavicle and following the deltopectoral groove distally for approximately 7 cm. The deltoid muscle is retracted laterally and the pectoralis major medially. The deltopectoral fascia is the first structure behind the subcutaneous tissue and should be incised in accordance to the skin incision. The cephalic vein is identified using blunt dissection and carefully protected and retracted either medially or laterally. Of note, because of adhesions and scar tissue formation from previous surgery, the vein position can be altered and care must be taken to avoid damage during dissection. Arthroscopy Techniques 2017 6, e477-e482DOI: (10.1016/j.eats.2016.11.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Deltopectoral approach performed in a right shoulder. After superficial dissection, deep structures are identified. A tenotomy of the subscapular tendon is performed near the tendon insertion site at the lesser tuberosity of the humeral head. The subscapular tendon is then tagged with a No. 2 high-strength suture and retracted medially. A medial-based T capsulotomy is performed to access the joint. Glenoid bone loss, humeral head bony defects, and chondral lesions are evaluated at this point. Arthroscopy Techniques 2017 6, e477-e482DOI: (10.1016/j.eats.2016.11.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 A custom distal tibia allograft cutting device (Arthrex, Naples, FL) is used to perform necessary cuts of the distal tibia allograft to arrive at the desired graft for bony augmentation (A, B). The graft is placed with the distal cartilage surface facing up and firmly secured in the device. The cuts are performed at the lateral aspect of the bone, which provides a better congruency with the humeral head. Of note, care must be taken to maintain constant saline irrigation to keep the graft cool while the cuts are performed. Arthroscopy Techniques 2017 6, e477-e482DOI: (10.1016/j.eats.2016.11.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 After preparation of the distal tibia allograft, the graft is submitted to pulsed lavage (A) for approximately 5 minutes to assure removal of all marrow elements and bone debris that may be left from previous osteotomies. After the pulsed lavage, the graft is soaked with platelet-rich plasma (B) before graft placement to improve the potential for bony union with the native glenoid. Arthroscopy Techniques 2017 6, e477-e482DOI: (10.1016/j.eats.2016.11.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 The distal tibia allograft must be correctly positioned and fixed at the glenoid bone of the affected right shoulder. The graft is provisionally fixed to the anterior glenoid rim with 2 K-wires placed in a bicortical fashion to the posterior aspect of the glenoid. The K-wires are then measured to aid in screw selection. After this, a cannulated drill is used over the K-wires, through the previously drilled 4.0-mm holes, into the near cortex of the native glenoid, which will allow for lag screw compression of the graft to the glenoid. The K-wires are then removed and two 3.75-mm noncannulated fully threaded screws with suture washers are inserted. Arthroscopy Techniques 2017 6, e477-e482DOI: (10.1016/j.eats.2016.11.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions