Anatomic Humeral Head Reconstruction With Fresh Osteochondral Talus Allograft for Recurrent Glenohumeral Instability With Reverse Hill-Sachs Lesion  Matthew T. Provencher, M.D., George Sanchez, B.S., Katrina Schantz, P.A.-C., Marcio Ferrari, M.D., Anthony Sanchez, B.S., Salvatore Frangiamore, M.D., Sandeep Mannava, M.D., Ph.D.  Arthroscopy Techniques  Volume 6, Issue 1, Pages e255-e261 (February 2017) DOI: 10.1016/j.eats.2016.10.017 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 (A) With the patient in the beach-chair position, a standard deltopectoral approach is undertaken on the affected left shoulder with the initial incision (red arrow) extending from the coracoid process to the distal aspect of the pectoralis major and anterior deltoid insertion on the humerus for a total of 7 cm in length. (B) In a left shoulder with the patient in the beach-chair position, the upper one-third to one-half of the subscapularis tendon insertion on the lesser tuberosity is peeled from the bone. Care is taken to avoid the 3 sister vessels at the inferior aspect of the insertion site. A tagging stitch (red arrow) is helpful to aid in retraction and eventual identification for partial subscapularis repair at the end of the procedure. Arthroscopy Techniques 2017 6, e255-e261DOI: (10.1016/j.eats.2016.10.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 (A) In a left shoulder with the patient in the beach-chair position, after full exposure of the glenohumeral joint, the humeral head is finally reached. The extent of the Hill-Sachs lesion can now be seen with subsequent evaluation. The red arrows indicate the large defect before careful formation of the orange slice shape necessary for bony reconstruction. (B) In a left shoulder with the patient in the beach-chair position, the prepared defect size is measured with a ruler, including width, length, and depth, to aid in the preparation of the talus allograft. The green arrows indicate the prepared defect after use of an oscillating saw. Arthroscopy Techniques 2017 6, e255-e261DOI: (10.1016/j.eats.2016.10.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 (A) The size and shape of the graft are outlined with a surgical pen and ruler (red arrows) on the surface of the talar dome based on the width, length, and depth measurements of the prepared defect. The finalized outline should measure 1 to 2 mm larger than the actual prepared defect across all dimensions. (B) The assistant and surgeon hold the graft firmly in place while all cuts are made along the outline (red arrows), with further facilitation possible through the use of towel clamps. (C) All cuts are made along the outline through use of an oscillating saw (red arrow). It is key that the allograft is kept cool with copious saline solution irrigation to avoid thermal necrosis of the cartilage and underlying subchondral bone. Arthroscopy Techniques 2017 6, e255-e261DOI: (10.1016/j.eats.2016.10.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 (A) In a left shoulder with the patient in the beach-chair position, once the cuts are made, three 2.4-mm K-wires are drilled onto the graft to be used to transport the graft. The allograft is then positioned into the prepared defect by the K-wires. The K-wires (green arrows) are advanced to reach the humeral cortex. Once this is completed, the leveling between the allograft and native humeral head is verified to ensure optimal positioning. (B) In a left shoulder with the patient in the beach-chair position, a cannulated drill is used over the K-wires and 3 separate 3.0-mm Acutrak headless compression titanium screws (green arrow) are placed in unicortical fashion to definitively fix the graft into the defect. Care should be taken to verify that the screws are countersunk into the subcortical bone to avoid violation of the cartilage surface. (C) Reconstruction of the Hill-Sachs lesion with a fresh osteochondral talus allograft (red arrows) in the affected left shoulder is shown while the patient is in the beach-chair position. Once all the screws have been placed and definitive fixation has been reached, examination by internal and external rotation of the shoulder is performed to ensure optimal positioning of the graft as well as proper leveling between the graft and native humeral head. This is also necessary to avoid any damage to the glenoid bone. Arthroscopy Techniques 2017 6, e255-e261DOI: (10.1016/j.eats.2016.10.017) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions