Abstract:
Methods for arthroscopic bone graft for anterior inferior glenohumeral instability repair are disclosed. The method includes providing a bone graft not attached to soft tissue. Respective passageways are formed through the bone graft and a patient&#39;s glenoid. A first implant is further provided, where the first implant is secured to a first end of a suture. The first implant is positioned on the cortical side of the bone graft and the cancellous surface of the bone graft is urged into contact with the anterior surface of the glenoid. A second implant is provided, including an eyelet extending there through. The second end of the suture is inserted through the eyelet of the second implant. The second implant is further placed in contact with the posterior surface of the glenoid. Subsequently, the second end of the suture is secured to the second implant.

Description:
BACKGROUND 
       [0001]    The shoulder joint, also referred to as the glenohumeral joint, is the joint between the glenoid cavity (a part of the scapula) and the head of the humerus (upper arm bone). The glenoid cavity is shallow, covering only about a third of the head humeral head. As a result, the glenoid cavity provides relatively little bony constraint upon motion of the humerus and the glenohumeral joint exhibits the widest range of motion of all joints in the human body. 
         [0002]    While the glenohumeral joint is also constrained by soft tissue (e.g., cartilage attached to the rim of the glenoid cavity, tendons, etc.), in general, soft tissue cannot provide the same degree of constraint as bone. Accordingly, it is relatively easy to force the humerus from its normal anatomical position with respect to the glenoid socket (i.e., dislocate the shoulder). While not life threatening, a dislocated shoulder can cause pain and immobilization of the joint, impacting a patient&#39;s lifestyle. 
         [0003]    A variety of procedures have been developed for repair of glenohumeral stability while preserving range of motion. For example, glenohumeral stability may be impaired when a portion of the soft tissue surrounding the rim of the glenoid socket (a mix of fibrous tissue and cartilage referred to as the glenoid labrum) becomes detached from the glenoid socket. In these circumstances, a surgeon may perform a “Bankhart repair,” where the detached portion of the glenoid labrum is reattached to the rim of the glenoid cavity. 
         [0004]    However, Bankhart repairs fail to provide sufficient long term stability in circumstances of severe glenoid bone loss. Under these circumstances, stability of the glenohumeral joint is analogous to balancing a golf ball (the humeral head) on a broken tee (the glenoid socket). 
         [0005]    In the case of severe bone loss, a surgeon may instead perform a “Latarjet procedure” to repair glenohumeral instability. In a Latarjet procedure, a surgeon attempts to restore bone mass to the glenoid cavity by securing a bone graft to the surface of the glenoid suffering bone loss. When successful, the bone graft acts as a scaffold, allowing the glenoid bone to grow into the bone graft and restore the lost glenoid bone mass (bone fusion). The bone graft is taken from a portion of the patient&#39;s scapula referred to as the coracoid process or simply coracoid, with muscles still attached to the coracoid. Thus, when the coracoid graft is fused to the glenoid cavity, the muscles attached to the coracoid provide further constraint upon the glenohumeral joint. 
         [0006]    Viewed in a continuum of care, Bankhart repairs are considered a relatively non-aggressive form of treatment, as they “anatomic,” preserving the patient&#39;s anatomy in its natural position. In contrast, Latarjet procedures are considered a relatively aggressive form of treatment, as the transfer of the coracoid to the glenoid is non-anatomic. For example, in addition to repositioning a portion of the coracoid and attached muscles, Latarjet procedures also require forming a channel through the subscapularis muscle interposed between the coracoid and glenoid cavity in order to achieve positioning of the coracoid upon the glenoid. Latarjet procedures have historically provided a high success rate for repairing glenohumeral stability due to glenoid bone loss and, therefore, have become a popular course of treatment under these circumstances. 
         [0007]    Notably, however, treating glenohumeral instability due to glenoid bone loss in the first instance with a Latarjet procedure goes counter to the general preference of surgeons to follow an escalating course of treatment, beginning with less aggressive procedures before moving to more aggressive procedures. 
       SUMMARY 
       [0008]    Accordingly, there is a need for less aggressive (e.g., anatomical) surgical procedures for repairing glenohumeral stability and that also provide long-term stability of the glenohumeral joint. Embodiments of the present disclosure are directed to methods for anterior inferior glenohumeral instability repair. 
         [0009]    As discussed in greater detail below, the method may include providing a bone graft having a cortical side and a cancellous side, wherein the bone graft is not attached to soft tissue; forming at least one passageway through the bone graft; forming at least one passageway through a glenoid, from a posterior surface to an anterior surface; providing a first implant secured to a first end of a suture; positioning the first implant on the cortical side of the bone graft; drawing the suture posteriorly, through the bone graft passageway and the glenoid passageway, wherein after the suture is so drawn, a second end of the suture is positioned on the posterior side of the glenoid, the first implant contacts the cortical side of the bone graft, and the cancellous surface of the bone graft is urged into contact with the anterior surface of the glenoid; providing a second implant including an eyelet extending there-through; inserting the second end of the suture through the eyelet of the second implant;
   positioning the second implant in contact with the posterior glenoid surface; and securing the second end of the suture to the second implant.   
 
         [0011]    Further embodiments of the method may include one or more of the following, alone or in combination. The method may further comprise forming a posterior portal to allow access to the glenoid. The bone graft may be an allograft. The bone graft may not be a coracoid process. The bone graft may have a length between about 10 mm to about 20 mm, a width between about 8 mm to about 10 mm and a thickness of about 5 mm to about 11 mm. Forming least one passageway through the bone graft may comprise drilling at least one passageway through the bone graft with a drill. The at least one passageway through the bone graft may be two passageways through the bone graft. The two passageways through the bone graft may be spaced about 10 mm apart. The at least one passageway through the bone graft may have a diameter of about 3 mm. Forming at least one passageway through the glenoid may comprise drilling at least one passageway through the glenoid with a drill. The drill may be a 2.8 mm sleeved drill. The at least one passageway through the glenoid may be two passageways through the glenoid. The two passageways through the glenoid may be spaced about 10 mm apart. A distance between the at least one passageway through the bone graft and another passageway through the bone graft may be substantially equal to a distance between the at least one passageway through the glenoid and another passageway through the glenoid. The at least one passageway through the glenoid may be placed about 4 mm to about 5 mm on center below a cortical edge of the anterior surface of the glenoid. Drilling at least one passageway through the glenoid with a drill may comprise passing the drill through a billet secured to the posterior surface of the glenoid. Securing the billet to the posterior surface of the glenoid may comprise securing the billet with a glenoid guide. Drawing the suture posteriorly may comprise drawing a guide wire to which the suture has been secured posteriorly. Securing the second end of the suture to the second implant may comprise tying a knot in the suture. The knot may be a Nice Knot. The second implant may be a round endbutton. 
         [0012]    Beneficially, in contrast to Latarjet procedures, embodiments of the bone graft may be a bone taken from the patient (autograft) or a donor (allograft). Furthermore, embodiments of the bone graft are not required to be taken from the patients shoulder. Additionally embodiments of the bone graft are not required to be attached to any tissue. For example, embodiments of the bone graft may include, but are not limited to, a portion (e.g., tip) of the iliac crest, the spine of the scapula, etc. As a result, glenohumeral instability due to glenoid bone loss may be repaired in a less aggressive, anatomic manner, preserving the option to perform a more aggressive Latarjet procedure subsequently, if necessary. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0013]    The foregoing and other objects, features and advantages will be apparent from the following more particular description of the embodiments, as illustrated in the accompanying drawings in which like reference characters refer to the same parts throughout the different views. The drawings are not necessarily to scale, emphasis instead being placed upon illustrating the principles of the embodiments. 
           [0014]      FIG. 1  is a photograph illustrating a patient constrained for glenohumeral repair surgery; 
           [0015]      FIGS. 2-3  are images of a glenohumeral joint under preparation for repair according to embodiments of the disclosed repair operation; 
           [0016]      FIG. 4  is an image of a glenohumeral joint illustrating insertion of a spinal needle during repair according to embodiments of the disclosed repair operation; 
           [0017]      FIGS. 5-11  are schematic illustrations of a patient&#39;s glenoid and glenoid guide illustrating positioning of a glenoid drill guide during repair according to embodiments of the disclosed repair operation; 
           [0018]      FIGS. 12-13B  are schematic illustrations of preparation of a bone graft for use in embodiments of the disclosed repair operation; 
           [0019]      FIGS. 14-22  are schematic illustrations showing passage of the graft and loading of an implant to secure the graft in position in embodiments of the disclosed repair operation; 
           [0020]      FIGS. 23A-23F  are images illustrating formation of a Nice Knot in embodiments of the disclosed repair operation; 
           [0021]      FIGS. 24-26  are schematic illustrations showing a Nice Knot being secured in embodiments of the disclosed repair operation; 
           [0022]      FIG. 27  is a schematic illustration showing the bone graft secured to the glenoid upon completion of embodiments of the disclosed repair operation. 
       
    
    
     DETAILED DESCRIPTION 
       [0023]    Embodiments of the present disclosure will now be discussed with reference to the figures. 
         [0024]    In the description that follows, like components have been given the same reference numerals, regardless of whether they are shown in different examples. To illustrate example(s) in a clear and concise manner, the drawings may not necessarily be to scale and certain features may be shown in somewhat schematic form. Features that are described and/or illustrated with respect to one example may be used in the same way or in a similar way in one or more other examples and/or in combination with or instead of the features of the other examples. 
         [0025]    Comprise, include, and/or plural forms of each are open ended and include the listed parts and can include additional parts that are not listed. And/or is open ended and includes one or more of the listed parts and combinations of the listed parts. 
         [0026]    The discussion will now turn to the figures, beginning with  FIG. 1-3 , illustrating patient positioning and preparation of the glenohumeral joint for repair according to embodiments of the disclosure.  FIG. 1  illustrates a photograph of a patient positioned prior to surgery. In certain embodiments, the patient may be positioned in the beach chair or lateral decubitus position. The scapula may be bolstered to externally rotate the glenoid. Draping may allow ready access to the posterior and anterior aspects of the shoulder girdle. 
         [0027]      FIGS. 2-3  are images of the embodiments of the glenohumeral joint. In the embodiment of  FIG. 2 , the labrum and capsule are elevated through abrasion and debridement of the anterior glenoid neck. In the embodiment of  FIG. 3 , a small area of articular cartilage along the anterior glenoid edge is debrided to allow recognition of the glenoid cortex. 
         [0028]    The discussion will now turn to  FIGS. 4-11 , illustrating embodiments of glenoid guide and drill pin placement. A posterior portal is formed in the body to allow access to the glenoid face. For example, a needle  10  ( FIG. 4 ) is inserted from posterior to anterior, along the face of the glenoid and below the midline, to form the portal. In further embodiments, a medial portal is made to provide access to the glenoid face. 
         [0029]      FIGS. 5-11  are schematic illustrations of a patient&#39;s glenoid  100  illustrating positioning of a glenoid guide  102  during repair according to embodiments of the disclosed repair operation. In the embodiment of  FIG. 5 , the glenoid guide  102  includes an arm  104  having a hook  106  formed in the distal end. The hook  106  of the glenoid guide  102  is inserted through the posterior portal (not shown). The hook  106  is passed along the glenoid  100 , with the arm  104  of the glenoid guide  102  parallel to the glenoid face  126  in order to avoid damage of the articular surface. The hook  106  is further passed over the cortical edge  124  of the glenoid  100 . With reference to the embodiment of  FIG. 6 , once the glenoid guide  102  is sufficiently advanced, the glenoid guide  102  is rotated to capture the anterior surface  108  of the glenoid  100 . In certain embodiments, the hook  106  may be placed at the position that correlates with the mid-point of a bone graft, as further described below. 
         [0030]    With regards to the embodiment of  FIG. 7 , the glenoid guide  102  is secured in place. For example, in an embodiment, the glenoid guide  102  is secured in place by two bullets  110  placed percutaneously. A small skin incision is made and a bullet  110  may be advanced until it firmly contacts the posterior surface  112  of the glenoid  100 . In certain embodiments, ratcheted teeth  116  of the bullets  110  are aligned with the screws  118  adjacent to a handle of the glenoid guide  102 . This process may be repeated for the second bullet  110 . In further embodiments, each bullet  110  may be approximately parallel to one another. In additional embodiments, the bullets  110  may be separated by a selected distance (e.g., 10 mm). 
         [0031]    With regards to the embodiment of  FIG. 8 , a drill is placed in the glenoid guide  102  (not shown). For example, in an embodiment, a sleeved drill (e.g., a 2.8 mm sleeved drill)  122  is placed in each bullet  110  and advanced until exiting from the anterior surface  108  of the glenoid  100 . Each drill  122  may be placed a selected distance (e.g., about 4 to about 5 mm) on center below the cortical edge  124  of the anterior surface  108 . 
         [0032]    With regards to the embodiment of  FIG. 9 , the drill is removed. For example, the sleeved drill  122  is removed, leaving the cannulated outer sleeve  128 . The presence of arthroscopic fluid exiting posteriorly from the outer sleeve  128  may be employed as confirmation of safe positioning. 
         [0033]    With regards to the embodiment of  FIG. 10 , the bullets  110  and glenoid guide  102  (not shown) are removed once drilling is complete. For example, in an embodiment, the bullets  110  may be removed by rotating each bullet  110  to disengage the ratcheted teeth  116  of the bullets  110  and extracting the bullets  110  posteriorly. In a further embodiment, the hook  106  (not shown)of the glenoid guide  102  may be disengaged from the glenoid  100 . For example, the glenoid guide  102  may be rotated such that the hook  106  is flat against the glenoid surface  126 . Should the hook  106  become caught on the posterior labrum, the handle of the glenoid guide  102  may be dropped (or raised, depending on the orientation of the hook) while retrieving. During removal of the bullets  110  and glenoid guide  102 , the outer sleeves  128  are left in place, firmly positioned within the glenoid  100 . 
         [0034]    With regards to the embodiment of  FIG. 11 , a cannula  130  is introduced through the rotator interval region of the patient&#39;s shoulder  132 . For example, in an embodiment, a 10 mm cannula  130  is introduced through the rotator interval  132 . Flexible looped guide wires  134  enter the outer sleeves  128  by passing one guide wire  134  through each outer sleeve  128 , posterior to anterior. Each guide wire  134  is subsequently retrieved using a loop grasper  136  passed through the cannula  130 . The guide wires  134  are separated and stored (i.e., set apart). After completing storage of the guide wires  134 , the outer sleeves  128  may be removed from the glenoid  100 . 
         [0035]      FIGS. 12-13B  are schematic illustrations of preparation of a bone graft  140  for use in embodiments of the disclosed repair operation. In an embodiment, the dimensions of the bone graft  140  and the type of bone are selected. For example, in an embodiment, the dimensions of the bone graft  140  may be about 20 mm long by about 8 mm wide by about 8 mm thick. In a further embodiment, a bone graft  140  having the selected dimensions may be prepared from the patient&#39;s tricortical iliac crest (autograft) or donor (allograft) material. However, it may be understood that, in alternative embodiments, the bone graft  140  may be taken from other bones. In further embodiments, the prepared bone graft  140  is not attached to soft tissue (e.g., tendon, etc.), in contrast to Latarjet procedures or other bone-tissue-bone type grafts. 
         [0036]    In further embodiments, the size of the bone graft  140  may be varied. For example, the bone graft  140  may be approximately 10 mm long by 10 mm wide or larger. The thickness of the bone graft may be about 5 mm to about 11 mm. In another embodiment, the cross-sectional area of the bone graft  140  may be dimensioned smaller than the cross-sectional area of a cannula through which the bone graft  140  is passed. In additional embodiments, the bone graft  140  may be passed into the patient&#39;s anatomy using a half cannula so as to not limit the size of the bone graft  140  to a constraining dimension. The bone graft  140  may be fashioned utilizing a graft master preparation board (not shown). 
         [0037]    With further regards to the embodiments of  FIGS. 12-13B , a drill guide  142  is employed to drill a plurality of holes or passageways  144  at selected locations within the bone graft  140 . For example, in an embodiment, two holes  144  having a diameter of about 3 mm may be formed using a drill guide (e.g., Kirschner wire or “K-wire”) that are about 10 mm apart and about 5 mm from each edge of the bone graft  140 . The drill guide  142  enters through the cortical side  146  and exits the cancellous side  148  of the bone graft  142 . The created holes  144  may correspond to the outer drill sleeves  128  previously placed on the glenoid  100  ( FIG. 11 ). With a marking member (e.g., an ink marker), the cortical side  146  of the bone graft  140  is marked ( FIG. 13B ). The cancellous side  148  of the bone graft  140  will be secured against the anterior surface  108  of the glenoid  100 . 
         [0038]    With further regards to the embodiments of  FIGS. 14-22 , passage of the bone graft  140  and loading of an anterior implant  150 , which may be a button, to secure the bone graft  140  in position in embodiments of the disclosed repair operation is illustrated. In the embodiment of  FIG. 14 , prior to loading the anterior implant  150  ( FIG. 15 ) onto the guide wires  134 , care is taken to insure that the looped guide wires  134  are not tangled within the joint. Each looped guide wire  134  is inserted into the passageways  144  of the prepared bone graft  140  on the cancellous side  148  and exits on the cortical side  146 . As shown in  FIG. 14 , the guide wires  134  may have different shapes depending on how much they are pushed into the joint. In the embodiments of  FIGS. 15A-15B , the anterior implant  150  is secured to the end of the loop guide wire  134  (e.g., with a classic slip knot). This operation may be achieved by passing the loop of the lead suture  152  through the looped guide wire  134  and feeding the anterior implant  150  through the lead suture loop  152 . 
         [0039]    In the embodiment of  FIGS. 16-17 , the guide wires  134  (not shown) are retracted and the bone graft  140  is inserted within the cannula  130 . For example, in an embodiment ( FIG. 16 ), the bone graft  140  is inserted into the cannula  130  within the rotator interval and the guide wires  134  are withdrawn posteriorly to engage the anterior implant  150  and remove slack. This operation allows for smooth movement of the bone graft  140  down the cannula  130 . In a further embodiment ( FIG. 17 ), the bone graft  140  is tipped for insertion into the cannula  130  (e.g., a 10 mm cannula). Care may be taken to ensure that the superior end  154  of the bone graft  140  enters the cannula  130  first. 
         [0040]    In the embodiment of  FIGS. 18A-B , the bone graft  140  is advanced through the cannula  130 . For example, in the embodiment of  FIG. 18A , the bone graft  140  is advanced through the cannula  130  by pushing it down using a prosthetic device, such as an obterator (not shown). In the embodiment of  FIG. 18B , the bone graft  140  is set into position by pulling the guide wires  134  (not shown) posteriorly. The bone graft  140  may be oriented so that the cancellous side  148  is approximately perpendicular to the anterior surface  108  of the glenoid  100 . In further embodiments, slight tension may be maintained on the guide wires  134  during advancement of the bone graft  140  through the cannula  130 . 
         [0041]    In the embodiment of  FIG. 19 , the bone graft  140  is positioned on the glenoid  100 . For example, in an embodiment, the guide wires  134  (no shown) are drawn posteriorly until the bone graft  140  sits approximately flush on the anterior surface  108  of the glenoid  100 . A suture (e.g., a size 00 suture) attached to the suture loop  152  is pulled posteriorly, through the skin. In certain embodiments, the suture  152  may be a continuous loop of suture. Subsequently, the continuous loop of suture  152  is cut to separate the two ends of the continuous loop. 
         [0042]    In the embodiment of  FIGS. 20-21 , the posterior implant  150  is loaded. In an embodiment, the posterior implant  150  is a round endobutton having a plurality of eyelets  162 . Non-limiting examples of the round endobutton may be found in U.S. patent application Ser. No. 13/213,966, the entirety of which is hereby incorporated by reference. For example, in an embodiment ( FIG. 20 ), the posterior implant  150  is loaded by advancing an instrument  160  (e.g. a transporter) through an eyelet  164  of the posterior implant  150 . In a further embodiment ( FIG. 21 ), the suture  152  is passed through the instrument  160 . The instrument  160  is retracted to allow the suture  152  to pass through the eyelet  164  of the posterior implant  150 . The operations of  FIGS. 20-21  are repeated for the second eyelet  164  with the other side of the suture  152 . 
         [0043]    In the embodiment of  FIGS. 22A-B , the posterior implant  150  is advanced into contact with the glenoid  100 . For example, in an embodiment, the posterior implant  150  is advanced to sit approximately flush against the posterior surface  112  of the glenoid  100  using a knot pusher (not shown). Beneficially, the knot pusher may provide tactile feedback when the posterior implant  150  is properly seated. 
         [0044]      FIGS. 23A-23F  are images illustrating formation of a “Nice Knot”  166  ( FIG. 23F ) in embodiments of the disclosed repair operation. In the embodiment of  FIG. 23A , the side of the continuous suture loop  152  with the attached size 00 suture  162  will function as a post  162 ′. In the embodiment of  FIG. 23B , with the post  162 ′ in the surgeon&#39;s dominant hand, a figure four is created by placing the suture loop  152  over the post  162 ′. In the embodiments of  FIG. 23C-23E , the suture loop  152  is brought underneath the post  162 ′ and through the figure four. The suture loop  152  is subsequently opened at its end. The post  162 ′ is then placed through the suture loop  152 . In the embodiment of  FIG. 23F , care is taken to ensure that the Nice Knot  166  is fully taut prior to pulling the post  162 ′ and advancing the posterior implant  150 . 
         [0045]      FIGS. 24-26  are schematic illustrations showing a Nice Knot  166  being secured in embodiments of the disclosed repair operation. In the embodiment of  FIG. 24 , the Nice Knot  166  is advanced to the face of the posterior implant  150  by pulling on the post  162 ′ (not shown). In the embodiment of  FIG. 25 , a tensioner  168  may be employed to better secure the posterior implant  150 . After the posterior implant  150  has been tensioned, it may be secured with further knots (e.g., half-hitch knots). Once the posterior implant  150  has been secured, the remaining suture  152  may be cut. In the embodiment of  FIG. 26 , the operations illustrated in  FIGS. 23A-25  may be repeated for other posterior implants  150 . In another embodiment, the Nice Knot  166  may be a sliding, locking knot. 
         [0046]      FIG. 27  is a schematic illustration showing the bone graft  140  secured to the glenoid  100  upon completion of embodiments of the disclosed repair operation. 
         [0047]    One skilled in the art will realize the invention may be embodied in other specific forms without departing from the spirit or essential characteristics thereof. The foregoing embodiments are therefore to be considered in all respects illustrative rather than limiting of the invention described herein. Scope of the invention is thus indicated by the appended claims, rather than by the foregoing description, and all changes that come within the meaning and range of equivalency of the claims are therefore intended to be embraced therein.