Technical Note

Arthroscopic Bone Block Cerclage: A Fixation

Method for Glenoid Bone Loss Reconstruction
Without Metal Implants
Abdul-Ilah Hachem, M.D., Marcos Del Carmen, M.D., Iñigo Verdalet, M.D., and
Javier Rius, M.D.

Abstract: Large glenoid bone loss defects are associated with higher failure rates after arthroscopic Bankart repair in cases
of glenohumeral anterior instability, further necessitating bone graft reconstruction. Because most techniques use strong
initial fixation using metal devices, bone graft resorption considered to be closely related to the presence of metal com-
ponents is a potential shortcoming of these techniques. We describe an arthroscopic technique for anatomical recon-
struction of the glenoid that uses a tricortical iliac crest with a metal-free fixation method using 2 ultra-high-strength
sutures (FiberTape Cerclage System; Arthrex, Naples, FL), which provide substantial stability to the graft, and finishing
with a capsulolabral reconstruction.

G lenohumeral instability with large anteroinferior

bone loss that changes the shape of the glenoid
has been associated with failure of arthroscopic Bankart
the absence of a sufficiently stable graft fixation and
the presence of metal implants.18-20
We describe an anatomical arthroscopic reconstruc-
repair procedures.1,2 Failure is defined by the presence tion technique that uses a tricortical iliac crest bone
of defects greater than 15% to 20%,3 but ‘’subcritical’’ graft with a nonmetal fixation method using 2 ultra-
bone loss is also associated with a subjective feeling of high-strength suture tapes. The tapes are passed from
instability and poorer results.4 Although anatomical the posterior to the anterior glenoid rim, passing
and nonanatomical bone graft reconstruction have through the graft from the anterior to the posterior
been used for the treatment of these cases, most of part, compressing the cancellous face of the graft to the
these techniques use metal implants for fixation, inde- glenoid defect, increasing the stability of the structure,
pendent of the graft used.5-17 Bone resorption and and eliminating secondary metal-related problems. The
residual pain are considered to be closely related to final step involves extraarticular capsulolabral recon-
struction (Video 1). The advantages, disadvantages, and
possible complications of this technique are described
(Table 1).
From the Department of Orthopedic and Traumatology Surgery (A.-I.H.H.,
M.D.C.R., J.R.M.) and University of Barcelona Shoulder Surgery Master
Fellowship (I.V.O.), Hospital Universitari de Bellvitge (L’Hospitalet de Llo- Surgical Technique
bregat) Barcelona, Spain.
The authors report the following potential conflicts of interest or sources of Preoperative Assessment
funding: A.-I.H.H. reports nonfinancial support from Arthrex, outside the All patients with 2 or more shoulder dislocations were
submitted work, and a patent pending from Bone Block Cerclage. Full ICMJE studied using 3-dimensional computed tomography
author disclosure forms are available for this article online, as supplementary
with humeral head suppression to ensure accurate
material.
Received June 25, 2019; accepted August 16, 2019. preoperative planning. This surgical technique is indi-
Address correspondence to Abdul-Ilah Hachem Harake, C/ Feixa Llarga S/ cated for anteroinferior major defects covering at least
N Hospital de Bellvitge Pl. 10 Traumatology and Orthopedic Secretary, 15% of the glenoid surface (Table 2).
Hospital Universitari de Bellvitge (L’Hospitalet de Llobregat), Barcelona,
Spain 08907. E-mail: [email protected] Patient Position and Arthroscopic Diagnosis
Ó 2019 by the Arthroscopy Association of North America. Published by
The patient was positioned in the lateral decubitus
Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/). position with 30 of posterior obliquity to ensure that
2212-6287/19802 the glenoid was parallel to the floor. Posterior sacral and
https://doi.org/10.1016/j.eats.2019.08.014 dorsal stops were placed. The arm was put into a

Arthroscopy Techniques, Vol 8, No 12 (December), 2019: pp e1591-e1597 e1591

e1592 A-I. HACHEM ET AL.

Table 1. Advantages and Disadvantages of the Technique head of the biceps and rotator cuff lesions were
Advantages discarded.
 Can be used for auto- or allografts
 Requires small drill tunnels (2.4 mm) Glenoid Preparation
 Preserves joint capsule with reconstruction An anterior portal was realized above the rotator in-
 Involves strong and broad compression of the graft with greater
stability
terval and an 8.25-mm cannula was placed (Arthrex).
 Does not use metal implants Camera vision was switched to a superior portal behind
 Reproducible technique and easy revision the biceps tendon and an accessory portal, and the
Disadvantages trans-subscapular deep axillary at 5 o’clock was
 Demanding technique in comparison with other arthroscopic gle- established.
noid augmentations
 Requires preparation of the graft
Capsulolabral lesions were elevated from 1 to 6
 Possibility of wrong graft positioning o’clock, allowing visualization of subscapular muscle
 Presents minimal vascular-nervous risk; however, using the pos- fibers. From an axillary approach, we placed a Sutur-
terior guide assures safety during procedure eLasso (Arthrex) to place a polydioxanone suture (PDS)
 Compression depends of the bone graft quality through the capsulolabral complex, which facilitated
suture manipulation (Fig 1) and defect visualization.
Table 2. Initial Evaluation of Shoulder Instability The anterior glenoid defect was debrided and abraded
First dislocation mechanism to improve the biological integration of the graft.
Number of episodes In situ sizing of the defect is very important to achieve
External aid for reduction a perfect fit of the allograft. We used an arthroscopic
Ligament hyperlaxity
probe or a specific measuring probe (Arthroscopic
Test of apprehension e repositioning e release
Functional scales: Western Ontario Shoulder Instability index; Quick- Measurement Probe, 220 mm, 60 ; Arthrex) from the
Disabilities of the Arm, Shoulder, and Hand; American Shoulder posterior portal to measure the anteroposterior defect
and Elbow Surgeons and from the interval portal to measure from proximal-
Radiology: anteroposterior radiograph and Bernadeau projection to-distal and anteroposterior width according to the
3-dimensional computed tomography scan with humeral suppression
bare area when possible (Fig 2).
Best fit circle for calculating glenoid bone defect by area and diameter
Measurement of humeral defect (Hill-Sachs lesion) for studying the To calculate where the drill guide would be placed,
‘’on-track/off-track’’ method. we made a mark at a minimum distance of 10 mm from
the lower edge of the longitudinal-sized defect.

traction foam sleeve (3-Point Shoulder Distraction Allograft Preparation

System; Arthrex, Naples, FL) to use 2 points of traction. Cuts with an oscillating saw were made according to
The bony structures and arthroscopic portals were the measurements previously obtained from the gle-
drawn. noid defect (Fig 3). The iliac crest graft determines the
Although capsulolabral and bony injuries can be depth, which is usually 10 to 12 mm. The curved edge
confirmed in a posterior view, the glenoid defect cannot that best resembles the glenoid rim was selected. Graft
be measured in this view. The Hill-Sachs injury was sizes were usually 28 to 30  10  10 mm. The graft
visualized and its vertical or horizontal direction and was marked on the articular face. The tricortical allo-
size were described. Other pathologies such as the long graft tunnels were made with a 2.4-mm drill from the

Fig 1. Right shoulder. Arthro-

scopic view, anterosuperior por-
tal. (A) Debridement and lifting of
the glenoid labrum and place-
ment of PDS sutures for labrum
manipulation and visualization
improvement. (B) Subscapular
muscle fibers must be seen. (C,
capsule; G, glenoid; PDS, poly-
dioxanone suture; SSC,
subscapularis.)
 GLENOID DEFECT MESASUREMENT e1593

Fig 2. Right shoulder. Arthro-

scopic view, anterosuperior por-
tal. (A) Intraoperative
measurement of the ante-
roposterior defect, (B) long-side
proximal-distal defect, and (C)
middle-lateral wide defect. (D)
Distance from the bare area to the
distal end defect is also measured.
Measurement probe in anterior
portal.

cancellous to the cortical side. The lower tunnel was Posterior Glenoid Drilling
made first 10 mm from the proposed lower rim, after An arthroscopic posterior guide (Arthrex) was intro-
which the higher tunnel was made 10 mm superior to duced. The hook component was placed parallel to the
the first, imitating the dimensions of the glenoid drill glenoid, just above our previous mark and 5 mm deep,
guide (Fig 4).

Fig 3. Prepped iliac crest allograft. Photographic markings Fig 4. Prepped iliac crest allograft. Allograft tunnel drilling
according to the joint position. (A, anterior; I, inferior, P, separated 10 mm similar to the drill guide with a 2.4- mm drill
posterior; S, superior) and measurement for tunnel position. (IT, inferior tunnel; ST, superior tunnel.).
e1594 A-I. HACHEM ET AL.

Fig 5. Right shoulder. Arthroscopic view, anterosuperior Fig 6. Right shoulder. Arthroscopic view, anterosuperior
portal view of the posterior drill guide with a hook position portal. Intraoperative view of the nitinol pass. Leaving 1 loop
5 mm deep of the anterior glenoid surface and parallel to it for posterior and the other 1 anterior is important. (A, anterior
correct placement of drill tunnels, both separated by 10 mm. glenoid defect; C, capsule; IT, inferior tunnel; NL, nitinol with
(A, anterior glenoid defect; C, capsule; IT, inferior tunnel; ST, loop; ST, superior tunnel; SSC, subscapularis.)
superior tunnel.)

Allograft Accommodation and Fixation

as close as possible to the center of the defect. The drill To facilitate suture passage through the bones, the
guide component was placed posterior to the glenoid nitinol wires were replaced with 2 loop sutures
surface. The guide allowed drilling of 2 holes with 2.4- (FiberLink/TigerLink sutures, Arthrex), as recom-
mm cannulated drills through the glenoid 10 mm apart mended, 1 with the loop anterior and the other with
(Fig 5), keeping in mind the distance from the lower the loop posterior (Fig 7). Both sutures were also passed
edge of the defect. through the graft tunnels.
The central pins of the cannulated drills were Using the FiberLink posterior loop, 2 ultra-high-
extracted, and 2 nitinol wires with loops, 1 for each strength suture tapes (FiberTape Cerclage System,
tunnel, were passed and retrieved through the ante- Arthrex) were passed from the posterior to anterior side
rosuperior interval portal (Fig 6). The drills, drill guide, and retrieved through the anterosuperior portal. They
and hook were then removed. were then passed through the allograft tunnel from the

Fig 7. Right shoulder. Arthro-

scopic view, anterosuperior por-
tal. (A) Exchange of nitinol wires
to ensure more resistant
FiberLink-TigerLink sutures and
easier and safer (B) FiberTape-
TigerTape passage through gle-
noid and graft tunnels. (FL,
FiberLink; ID, inferior tunnel; SD,
superior tunnel; TL, TigerLink.)
 GLENOID DEFECT MESASUREMENT e1595

Fig 8. Right shoulder. Patient in

lateral decubitus. (A) Shirt button
allograft image before insertion
through the interval portal
without a cannula. Right shoul-
der. (B) Anterosuperior portal.
Intraoperative view of allograft
positioning. (BB, bone block graft;
C, capsule; FTC, FiberTape Cerc-
lage; G, glenoid; H, humeral head;
TTC, TigerTape Cerclage.)

Fig 9. Right shoulder. Patient in

lateral decubitus. FiberTape and
TigerTape Cerclage System and
reduction of sutures with alter-
nating traction movement. (FTC,
FiberTape Cerclage; P, accessory
medial posterior portal; TTC:
TigerTape Cerclage.)

cancellous bone side to the cortical side. Both FiberTape Capsulolabral Repair
Cerclage sutures were then loaded in the TigerLink Finally, 3 or 4 “all suture” FiberTak suture anchors
anterior loop to pass them from the allograft cortical (Arthrex) were placed at the native glenoid rim, start-
side to the cancellous side (looking like a shirt button) ing from the middle at 3 to 4 o’clock, and introduced
and from the anterior to posterior side through the through an axillary portal after retrieving the PDS su-
glenoid. The allograft was introduced through the in- tures used at the beginning of the technique. The next
terval portal by pulling all FiberTape Cerclage sutures anchor was placed inferiorly and 1 or 2 more anchors
and held with a Kocher clamp (Fig 8). were placed superiorly, reattaching the capsulolabral
Once the allograft was inserted and well-positioned,
the sutures were interconnected to create a contin-
uous loop. The tail of the FiberTape suture was loaded
through the pretied racking hitch knot of the TigerTape
and vice versa. This allowed the application of alter-
nating traction on each suture limb to reduce the knots
to the posterior glenoid side and achieve symmetrical
tensioning of the construct (Fig 9).
Once the stability of the graft was fixed and checked,
the 2 knots were tensioned and locked, 1 after the
other, applying a mechanical force equal to 80 N with a
tensioner (FiberTape Cerclage Tensioner, Arthrex) (Fig Fig 10. Right shoulder. Patient in lateral decubitus. Applying
10) and with at least 3 alternating knots. Graft fixation tension to sutures by using a cerclage tensioner set to 80 N.
was checked. Finally, stable fixation was obtained for Sutures must be knotted and blocked after this step.
graft integration. (P, accessory medial posterior portal.)
e1596 A-I. HACHEM ET AL.

Fig 11. Right shoulder. Arthro-

scopic view, anterosuperior por-
tal. Intraoperative view of (A) first
implant insertion for capsule-
labral reparation and (B) the
final result. (BA, bare area; C,
capsule; G, glenoid; H, humeral
head.)

complex and leaving the graft extraarticular (Fig 11). The presence of metal devices and their roles in graft
Some tips and pitfalls of the technique are described resorption, humeral osteoarthritis, neurovascular
(Table 3). injury, and anterior chronic pain remain points of
debate. Zhu et al.25 reported 90.5% graft resorption at
Discussion 1 year after the Latarjet procedure in a computed to-
Glenoid bone defects reduce the surface area available mography scan study, similar to the results reported by
for humeral head contact, restricting articular congruity Di Giacomo et al.,26 but they reported no correlation
leading to shoulder instability. It is now accepted that with functional outcomes. Complications related to the
patients with defects greater than 15% to 20% should Latarjet procedure have been reported in 25% of pa-
be treated with reconstruction techniques. Many sur- tients, in contrast to anatomical arthroscopic techniques
gical techniques have been described to treat these that report low rates of complications. The process of
patients, but most of them involve metal devices. Two covering the allograft during capsulolabral reconstruc-
techniques used nonmetal hardware with good re- tion may have resulted in a lower progression rate to
sults,21 but only a few arthroscopic techniques have osteoarthritis in comparison with the Latarjet proced-
been described.9,16,22 Anatomical arthroscopic glenoid ure.19,23,27-29
reconstruction techniques offer advantages such as a
low recurrence rate, good functional results, mainte- References
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