Right Shoulder Bankart Lesion & Arthroscopic Bankart Repair

1. The Bankart Lesion — Pathology

• Hill-Sachs lesion - posterolateral humeral head impaction fracture (occurs at the time of anterior dislocation)
• HAGL lesion - Humeral Avulsion of the Glenohumeral Ligament
• SLAP tear - Superior labrum anterior to posterior tear
• Rotator cuff tears (especially in older patients)

2. Preoperative Workup

Imaging

• Plain radiographs: AP, lateral, axillary views to screen for bony lesions
• MRI or MRA: MRA is more sensitive and specific than MRI for anteroinferior labral tears
• CT scan with 3D reconstruction: Mandatory to quantify glenoid bone loss before surgery

Bone Loss Assessment - the Critical Decision

"The critical bone loss that changes the indication from ABR to a bone procedure is between 13.5% and 17.3% according to the literature. In high-demand/contact sports patients, a bone-based procedure should be considered at 13.5%; in low-demand patients, 17.3% is the critical threshold." - Rockwood and Green's Fractures in Adults, 10th ed. 2025

• Glenoid bone loss <13.5%: ABR is appropriate
• 13.5-17.3%: Surgeon discretion based on patient demands (contact athlete vs. sedentary)
• >17.3%: Open bony reconstruction (Latarjet procedure) should be considered

3. Indications for Arthroscopic Bankart Repair

• Recurrent traumatic anterior shoulder instability
• First-time dislocation in young, active patients or athletes in certain scenarios
• No significant humeral or glenoid bone loss (below the critical threshold)
• No capsular deficiency

• Glenoid bone loss >13.5-17.3%
• Engaging Hill-Sachs lesion (may require remplissage procedure concurrently)
• Young male contact-sport athlete (higher recurrence risk)
• Multiple prior dislocations
• Capsular hyperlaxity / generalized ligamentous laxity

4. Surgical Technique - Arthroscopic Bankart Repair

Patient Positioning

1. Lateral decubitus (preferred by many surgeons): Patient on a beanbag; arm placed in 45-60° abduction, 20° forward flexion with 12-14 lb of traction
2. Beach chair: Head holder with patient sat at 70-80° flexion; arm in spider arm holder

Portals

• Posterior portal: ~2 cm below and 1 cm lateral to the posterolateral edge of the acromion (viewing portal)
• Anterolateral portal: ~1 cm from the anterolateral edge of the acromion (working portal)
• Anteroinferior / 5:30 portal: Just above the subscapularis tendon, slightly above the glenoid fossa (drilling and suture passing)

Step-by-Step Surgical Steps

• Place anchors 1-2 mm over the articular surface (at the glenoid rim, not medially on the neck)
• Minimum of 3 suture anchors are required; start inferiorly (6 o'clock position) and work superiorly
• Either knotted or knotless anchors can be used - no reported difference in clinical outcomes
• If knotted anchors are used, ensure knots do not cause articular impingement

• Start at the 6 o'clock position
• Take a bite of approximately 1 cm of capsule
• Needle should come out through the capsule and pass up under the labrum in correct anatomic position
• Superiorly advance the capsulolabral complex as each suture is tied - this restores physiologic tension and eliminates the "drive-through sign"

• Posterior capsular laxity: Posterior capsular plication if PIGHL injury is present
• Hill-Sachs lesion (engaging): Remplissage procedure (posterior capsulodesis) - except in throwing athletes' dominant shoulder
• SLAP tear: Repair through anterosuperior portals
• Rotator interval: Close if significant defect exists

Key Technical Points for Success (Campbell's)

1. Careful preoperative assessment of bone defects (3D CT, MRI)
2. Arthroscopic examination through anterosuperior portal to evaluate "inverted pear" glenoid defect
3. Complete mobilization of capsulolabral complex to 6 o'clock
4. Abrasion of glenoid neck for vascularized healing bed
5. Superior advancement of the glenohumeral complex to restore physiologic tension
6. Minimum 3 suture anchors with secure fixation 1-2 mm over articular surface
7. Anchor/knot placement to avoid impingement
8. Goal-oriented supervised rehabilitation

5. Postoperative Rehabilitation Protocol

Preoperative Goals

• Independent with postoperative exercise program
• Preoperative strengthening with isometrics in pain-free range

Phase I - Protection & Early Motion

• Sling at all times except PT
• No true ABD PROM
• No ER with arm abducted from body

• PROM: 150° FL, 150° scaption, 40° ER, 60° IR in 45° scaption

Phase II - Graded AROM and Strengthening

• Discontinue sling
• PROM FL to WNL, scaption to WNL, ER 70° at 90° scaption
• AROM FL and scaption to at least 90° with proper scapular mechanics
• Independent ADLs (grooming, dressing, car door)

Phase III - Return to Activity

• Progressive strength and endurance
• Sport-specific training from ~months 4-5
• Return to contact sports: typically 6-9 months

6. Outcomes

• Overall recurrence of shoulder instability: ~10.7-13.1% at follow-up

• Young age
• Higher number of preoperative dislocations
• Significant bone loss (humeral head or glenoid)
• Inferior capsule hyperlaxity
• Male sex / contact sport athlete

• VAS pain: 0.0 ± 1.7 (minimal)
• Rowe score: 90.0 ± 20.5
• ASES score: 92.0 ± 17.0
• Patient satisfaction: 92.3%

• Loss of external rotation at side: 3-9°
• Loss of ER at 90° abduction: 3.5-6°
• Loss of forward flexion: 1-3° (minimal)
• ROM after arthroscopic repair is superior to open repair - an important consideration for overhead throwing athletes

7. Special Considerations

• Posterior capsulodesis + infraspinatus tenodesis into the Hill-Sachs defect
• Performed alongside ABR for engaging lesions
• Avoid in the dominant shoulder of overhead throwing athletes

• Transfers the coracoid process to the anterior glenoid rim
• Provides both a bony augment and a sling effect via the conjoint tendon
• Preferred for glenoid bone loss >13.5-17.3%, contact athletes, and revision cases

Complications of Arthroscopic Bankart Repair

Complications Summary

1. Recurrent Anterior Instability (Most Common)

• Young age (especially males <25 years)
• Contact sport athlete (collision sport, overhead throwing)
• Higher number of preoperative dislocations before surgery
• Significant glenoid bone loss (>13.5-17.3%)
• Engaging Hill-Sachs lesion not addressed at primary surgery
• Inferior capsule hyperlaxity / generalized ligamentous laxity
• Failure to mobilize capsulolabral complex sufficiently to 6 o'clock
• Placement of anchors medially on the glenoid neck rather than at the rim

• For recurrence without critical bone loss: revision open or arthroscopic Bankart can still be successful. Neviaser et al. reported on 30 patients who failed prior ABR and underwent open repair - at 10.2 years, no patient had apprehension, pain, or instability; ASES 89.44, Rowe scores excellent.
• For recurrence with bone loss: Latarjet coracoid transfer or allograft bone block reconstruction.

2. Loss of Range of Motion / Stiffness

• External rotation at side: 3-9° loss
• External rotation at 90° abduction: 3.5-6° loss
• Forward flexion: 1-3° loss (minimal)

• Incidence requiring secondary surgical release is very low at 0.5%
• Managed first with physiotherapy and glenohumeral corticosteroid injections
• If refractory: arthroscopic lysis of adhesions

3. Neurologic Injury

• Careful suture passage with awareness of axillary nerve location (passes along inferior capsule at 5-6 o'clock)
• Limited traction weight (12-14 lb) in lateral decubitus position
• Proper padding and positioning

4. Anchor-Related Complications

• Anchor pullout: Usually due to osteoporotic bone, anchor placed medially on glenoid neck (not at rim), or inadequate number of anchors (<3)
• Knot impingement / chondral damage: Knotted anchors placed too laterally can abrade the humeral articular cartilage; knotless anchors avoid this
• Anchor migration: Loose anchors can become intra-articular loose bodies
• Suture failure: Suture breakage or cut-through if tissue is thin or repair is overtightened

• Minimum 3 anchors placed 1-2 mm over the articular surface
• Use knotless anchors or carefully bury knots to avoid impingement
• Adequate capsulolabral tissue bite (~1 cm)

5. Infection

• Superficial wound infection: managed with oral antibiotics
• Deep septic arthritis: requires arthroscopic washout, IV antibiotics, possible hardware removal
• Risk factors: diabetes, immunosuppression, prolonged operative time, steroid injections within 3 months

6. Overtightening / Iatrogenic Stiffness

• Capsular plication is too aggressive
• Rotator interval is closed excessively
• Capsular tissue is advanced too superiorly

7. Glenohumeral Arthrosis (Late)

• Recurrent dislocations before or after surgery
• Intraoperative chondral damage (anchor placement, aggressive glenoid abrasion)
• Prior metallic hardware (historical - less relevant with modern bioabsorbable/all-suture anchors)
• Missed or undertreated bone loss leading to recurrent instability and progressive joint damage

8. Positioning-Related Complications

9. Fluid Extravasation

• Anterior chest/mediastinum: rare but potentially serious
• Soft tissue swelling: common, self-resolving
• Risk increases with prolonged operative time and high pump pressures

Key Takeaways

1. Recurrence (~10-13%) is the dominant concern, not perioperative complications
2. Recurrence risk is heavily driven by patient factors (age, sport, bone loss) more than surgical technique
3. Nerve injury is rare (0.3%) but the axillary nerve is the most at-risk structure during inferior capsular mobilization
4. Stiffness requiring reoperation is very rare (0.5%) - ABR preserves ROM better than open repair
5. Anchor complications are minimized by correct placement at the glenoid rim (not neck) with ≥3 anchors
6. For high-risk patients (young male contact athlete, bone loss), primary Latarjet may be preferable to ABR despite its higher complication rate, given far lower recurrence