All right, so I'm going to present, try to move through this arthroscopic bone block technique with distal tibial allograft for posterior instability. These are my disclosures. I want to thank my authors. So our patient here is a 17-year-old football player, sustained a posterior subluxation episode and had played throughout the season, kept on having posterior subluxation episodes. He came in after the season, complaints of pain and instability with any type of lifting, particularly bench pressing. You can see here his plane radiographs, axillary view, you see some blending of the posterior glenoid there. So we got an MRI scan, shows his reverse bony Bankart lesion. And because of that, we also got a CT scan with 3D reconstructions to fully evaluate the bony defect. You can see here the malunited posterior reverse bony Bankart lesion with posterior glenoid bone loss. So for this, we elected to do the arthroscopic distal tibial allografts. I want to present our surgical technique here. We do the lateral position for a couple of reasons. One, that allows nice distraction to the joint. And also, if you do have to abort and do an open procedure for posterior instability, this is much easier in this position. We do a diagnostic arthroscopy looking from posterior here. You can see our glenoid defect and our posterior labral tear. We then fully evaluate the defect. And often these kids have, or these patients have, articular cartilage damage as well. After doing this, we release the capsule coming from anterior to posterior. You really want to get good release of that labrum and capsule so we have great visualization of that posterior inferior glenoid when we pass our graft and to make sure it's flush. We also put a traction suture in that capsule to kind of pull that back. So again, we have direct visualization of that posterior inferior glenoid there. After doing this, we use a burr to kind of really smooth off that site there so the graft sits nicely on it. Also, that stimulates bleeding. We then measure our defect and the depth of defect as well as the superior inferior dimensions of it. And this is our posterior inferior portal that we'll use to deliver the graft. And you always want to put a finger in there and really sweep all that soft tissue out of the way because that graft can get caught up on soft tissue even though you think it's nice and clear. So you really want to do that. So then we fashion our graft based on the dimensions that we measured earlier. And then we place these top hats in the graft that will secure the graft to the insertion device. And that's what we're drilling for our top hats, and that's the construct that we're going to introduce into the joint. So we go through there and we fix. This is outside visualization. We fix the graft provisionally with K-wires, and then we overdrill and place screws in here. And this is what you see arthroscopically. So we're positioning the graft where we want it. Once we get it into a good position here, we secure it with the K-wires, which we then overdrill and place our screws in. And as you place your screws, you put both screws in and you go back and forth between superior and inferior so the graft doesn't toggle and make sure you get a nice flush approximation of the graft to the native glenoid here. And this is kind of our construct after we compressed it down here. So you see a nice flush, nicely flush. This is before the compression and then after we compress the screws down here. After doing this, we want to make sure that our screw heads are approximated well to the allograft. And so we look at them, assess those, and then we take the K-wires out and then look at the construct again, make sure it's secured nicely and it's nice and flush. We then repair our capsule labrum back over the top of this. We do inferior first percutaneously. As you can see here, we tie the knots inferiorly and then we go superiorly and we'll pull that whole capsule labral construct over the top of the distal tibial allograft. This is our final construct here with the labrum, nice posterior labral bumper. And then a video of our final construct here, looking posteriorly. So good position of the graft in the capsule and labrum. So postoperatively, we place these patients in an external rotation brace for six weeks. We then start some physical therapy, some active motion, about four weeks, and progress strengthening and range of motion from six to 12 weeks. In the 12 weeks, we build endurance and strengthen power. And the return to sport is anywhere between four to six months, provided the graft heals nicely and the patient has full range of motion and strength. And this is a postoperative x-ray of our construct here. See the axillary view next, which will show a nice approximation of the graft and good position of the screws. This is our patient now nine months post-op. He's back to sport, no instability, no pain, bench pressing without any issues. You can see he's restored his motion. In particular, next year, you can see his internal rotation at 90 degrees looks good here. So I want to present a final case here. This is another gentleman that we did about four years prior. He had a revision. It was a revision for posterior instability. We did a distal tibial allograft. We did this open. So he had a re-injury and he had a rotator cuff tear, so we were able to visualize, able to get imaging and arthroscopic pictures. These are x-rays of his graft here, which is nicely healed in. You can see through the CT scan, we'll slow it up here, so you can see the graft nicely healed in there. And you can see on the sagittal view, the graft nicely approximated. And the CT scan, again, showing nice bony union. So these distal tibial allografts can actually heal in very nicely. Sorry about the visualization here as you blow the picture up, but that's the graft underneath the probe and that's the native glenoid there, so a nice transition. The labrum's kind of healed over the top of that graft. Just another final picture here. So really kind of incorporated nicely with the native articular cartilage. So thank you and I'm sorry about the delay.

surgical technique

arthroscopic bone block

posterior instability

diagnostic arthroscopy

allograft