Arthroscopic bankart repair
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Arthroscopic Bankart Repair (ABR)
Source: Rockwood and Green's Fractures in Adults, 10th ed. 2025
Background & Rationale
The Bankart lesion — detachment of the anteroinferior capsulolabral complex from the glenoid rim — is the pathological hallmark of traumatic anterior shoulder instability. Open Bankart repair was historically the gold standard, with recurrence rates <10%, but carries risks including subscapularis injury, arthrofibrosis, and restricted external rotation.
ABR has now supplanted open repair as the treatment of choice for most anterior instability injuries. In a MarketScan database review (2008–2012), ABR accounted for 90.5% of shoulder stabilization surgeries vs. 9.5% open procedures. Modern suture anchor techniques achieve recurrence rates comparable to open repair with superior ROM preservation.
Indications
| Category | Details |
|---|---|
| Primary | ≥2 subluxations/dislocations with anterior labral detachment |
| Primary | Recurrent anterior instability despite adequate PT |
| Relative | First-time dislocation in high-risk athlete (contact/overhead sport) with documented Bankart on MRI |
Relative Contraindications
- Uncooperative patient or active seizure disorder
- Capsular deficiency or prior thermal capsulorrhaphy
- Primary collagen disorders (Ehlers-Danlos, Marfan syndrome)
- Atraumatic instability with ligamentous laxity
- Critical glenoid bone loss >17.3% (consider Latarjet/bone block instead; lower threshold of 13.5% in high-demand athletes)
- Engaging Hill-Sachs lesion (may require remplissage or Latarjet)
- Multidirectional instability
Preoperative Planning
- Radiographs + MRA: MRA is more sensitive/specific than MRI for anteroinferior labral tears
- Glenoid bone loss quantification: Critical bone loss threshold between 13.5% and 17.3% determines shift from ABR to bony procedure
- Hill-Sachs lesion assessment
- Identify capsular redundancy, ALPSA vs. classic Bankart, HAGL lesions
Patient Positioning
Two options — surgeon preference:
- Lateral decubitus (authors' preference): Bean bag, pillow under leg (protect peroneal nerve), arm holder with Coban, 5–10 lb balanced traction with lateral distraction
- Beach chair: 70–80° flexion, head holder, spider arm holder
A small axillary bump improves glenohumeral joint distraction in both positions.
Key Surgical Steps
Portal Placement
| Portal | Location | Purpose |
|---|---|---|
| Posterior (viewing) | ~2 cm distal, 1 cm medial to posterolateral acromion | 30° scope; diagnostic arthroscopy |
| Anterolateral | ~1 cm distal to anterolateral acromion | Working portal; viewing (6 mm threaded cannula) |
| Anteroinferior | Just above subscapularis, slightly above glenoid fossa surface | Suture passing and anchor drilling (8 mm cannula) |
A 70° scope can be used in the posterior portal if visualization is difficult; alternatively the 30° scope can be placed in the anterolateral portal.
Technique
- Diagnostic arthroscopy: Evaluate labrum, rotator cuff, biceps, cartilage, glenoid bone loss, Hill-Sachs lesion
- Labral mobilization: A labral elevator (CoVator) via anterolateral portal mobilizes the anteroinferior capsulolabral complex off the glenoid rim → subscapularis muscle belly must be visible below (confirms adequate mobilization)
- Suture passing: Curved suture passer (right curve for right shoulder) penetrates capsule ~1 cm distal and 1 cm from glenoid rim via anteroinferior cannula — allows adequate superior shift and capsular volume reduction
- Anchor fixation (knotless or knotted):
- Authors prefer knotless fixation (Labral Tape + Arthrex 2.9 mm PushLock anchors)
- Critical: first anchor placed at 5:30 position (right) or 6:30 position (left) on the anterior glenoid face — must be inferiorly placed
- Sequentially up to 4:30, 3:30, 2:30 (right) / 7:30, 8:30, 9:30 (left)
- Minimum 3 anchors recommended
- Endpoint: Soft tissue bumper at the chondrolabral junction confirms excellent shift of the capsulolabral complex
Outcomes
Recurrence
- Recurrence risk after ABR: ~10.7–13.1% (recent systematic reviews)
- Risk factors for failure: young age, high number of preoperative dislocations, significant bone loss (glenoid or humeral head), inferior capsule hyperlaxity
ROM
- Loss of external rotation expected: 3–9° at side, 3.5–6° at 90° abduction
- Forward flexion loss minimal (1–3°)
- ROM is superior to open repair — important for overhead-throwing athletes
Functional Scores (Long-term)
- 13-year retrospective study (n=180): VAS pain 0.0 ± 1.7, Rowe 90.0 ± 20.5, ASES 92.0 ± 17.0; patient satisfaction 92.3%
- ABR vs. open: comparable functional scores, but open Bankart has lower recurrence and ABR has better ROM
vs. Latarjet
| Parameter | ABR | Latarjet |
|---|---|---|
| Recurrence | 10.7–13.1% | ~5–10% |
| ROM | Better preserved | More restricted |
| Return to sport | ~71% | ~73% |
| Complication rate | Low (0.2–0.3%) | 10.6–15% |
Complications
| Complication | Notes |
|---|---|
| Recurrent instability | Most common adverse outcome; revise with open repair if no bone loss; Latarjet/bone block if significant glenoid deficiency |
| Postoperative stiffness | Less than open repair; main concern is ER loss |
| Neurologic injury | Musculocutaneous or axillary nerve; rate 0.3% |
| Infection | Rate 0.2% |
| Glenohumeral arthrosis | Long-term concern, less likely than after open repair |
Overall ABR complication rate is significantly lower than open Bankart (4.3%), Latarjet (10.6–15%), or bone block (17.6%).
Special Considerations
- Remplissage: Adjunct to ABR for engaging Hill-Sachs lesions — infraspinatus tenodesis into the Hill-Sachs defect; alternative is Latarjet
- Bipolar bone loss ("Glenoid track" concept): On-track vs. off-track Hill-Sachs guides whether ABR alone suffices
- Skeletally immature patients: Conservative management may be appropriate after primary dislocation without significant bone defect; surgery indicated with recurrence
- Knotless vs. knotted anchors: A 2025 meta-analysis (PMID 40483425) compares these approaches — both achieve comparable stability
Recent Evidence: A 2024 systematic review (PMID 39428642) confirms favorable outcomes for ABR in anterior shoulder instability. A 2025 meta-analysis (PMID 40483425) evaluates knotless vs. knotted techniques.
Rockwood and Green's Fractures in Adults, 10th ed. 2025 — Chapter 35, pp. 1276–1283
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