Arthroscopic Bankart Repair

Overview

The shoulder accounts for nearly 50% of all dislocations (2% incidence in the general population); anterior dislocations make up 90-95% of recurrent dislocations (Campbell Ch 52). Recurrence depends on age, return to contact or collision sport, hyperlaxity and bone loss: in one series recurrence occurred in 90% of patients younger than 20 years, 60% at 20-40 years and 10% over 40 years, approaching 100% in skeletally immature collision athletes. Sling immobilization longer than 1 week gives no benefit after a primary anterior dislocation (Campbell Ch 52). Arthroscopic anchor repair, plication and interval closure give recurrence rates comparable to open techniques in appropriately selected patients (Campbell Ch 57).

Pathoanatomy (Campbell Ch 52)

• The glenoid labrum deepens the glenoid by 50% and increases humeral contact to 75%. The anteroinferior glenohumeral ligament complex is the main restraint with the arm abducted 45 degrees or more.

• The Bankart lesion is the most commonly observed lesion but not the "essential" lesion; capsular laxity, posterior capsular injury ("circle concept"), Hill-Sachs lesions and glenoid rim loss all contribute.

• In patients over 40, recurrence is uncommon but rotator cuff tears are present in 30% (over 80% after 60 years); cuff tears and greater tuberosity fractures take precedence over capsular repair.

• Matsen classification: TUBS (traumatic, unidirectional, Bankart, surgery) and AMBRII (atraumatic, multidirectional, bilateral, rehabilitation, inferior capsular shift, interval closure).

Evaluation (Campbell Ch 52, Ch 57)

• History: energy of the first event, arm position, ease of reduction, dislocation during sleep or in midrange with minimal trauma (suggests bone loss), nerve symptoms, "dead arm."

• Examination under anesthesia: translation two grades greater than the opposite side gives 93% sensitivity and 100% specificity for instability.

• 3D CT is the best method to quantify glenoid and humeral bone loss. Bone loss (Provencher bare-spot method) = (B - A) / 2B x 100, where A and B are distances from the bare spot to the anterior and posterior rims.

Instability Severity Index Score (ISIS) (Campbell Ch 52)

Total 10 points; higher scores predict failure of arthroscopic Bankart repair.

Glenoid track: on-track / off-track (Campbell Ch 57)

1. Measure the inferior glenoid diameter (D) on 3D CT/MRI or arthroscopically.

2. Measure the width of anterior glenoid bone loss (d).

3. Glenoid track (GT) = 0.83 D - d.

4. Hill-Sachs interval (HSI) = width of the Hill-Sachs lesion + the bone bridge between the cuff attachment and the lesion.

5. HSI > GT: off-track (engaging). HSI < GT: on-track.

Indications and Decision-Making

• Stabilization after a primary event is indicated in high-risk patients (contact or collision athletes near season end, dominant-shoulder dislocation in overhead athletes); in-season rehabilitation returns 75% of athletes to play, but two-thirds have further instability. Recurrent instability despite conservative treatment is also an indication (Campbell Ch 57).

• Contraindications: uncooperative or medically unstable patients, poorly controlled seizures. Voluntary dislocators with secondary gain are poor candidates (Campbell Ch 52, Ch 57).

• Relative contraindications to arthroscopic soft-tissue repair: glenoid bone loss of 20-25% (about 6 mm) or humeral bone loss that cannot be addressed with remplissage (Campbell Ch 57).

Lesion-based algorithm (Campbell Box 57.2, Ch 52)

Recurrence rose from 6.5% to 89% in contact athletes with a 25% glenoid defect or engaging Hill-Sachs lesion treated arthroscopically; in active military patients, bone loss of 13.5% already reduced functional outcomes (Campbell Ch 57).

Campbell's Concepts: Technical Points for Success (Campbell Ch 57)

• Set realistic goals and timelines; identify bone defects preoperatively (MRI, 3D CT) and arthroscopically ("inverted pear" from the anterosuperior portal).

• Release the capsuloligamentous complex to about the 6 o'clock position until the subscapularis muscle is visible, to allow superior advancement.

• Abrade the glenoid neck to a bleeding bed.

• Advance the complex superiorly to restore tension and eliminate the drive-through sign; repair associated posteroinferior IGHL injury.

• Place a minimum of three anchors, 1-2 mm onto the articular surface, with secure knots or knotless fixation that avoids impingement.

• Repair significant rotator interval, labral and cuff defects; supervised rehabilitation.

Technique 57.10: Arthroscopic Bankart Repair (Campbell)

1. Lateral decubitus on a beanbag with a kidney rest, pad prominences and the axilla, heating blanket and compression devices. Drape widely; arm in 45-60 degrees of abduction and 20 degrees of forward flexion with 12-14 lb traction.

2. Mark landmarks and portals.

3. Make the posterior portal 2 cm inferior and just medial to the posterolateral acromion.

4. Perform a complete 360-degree examination of labrum, capsule and humeral ligament attachments and assess bone loss; repair significant Hill-Sachs lesions with remplissage (Technique 57.14) and restore glenoid loss over 6 mm with a Latarjet.

5. Plan portals by the quadrant(s) involved using spinal needles.

6. Anterosuperior portal: just behind the biceps and in front of the supraspinatus; best view of capsular damage and bone loss.

7. Anterior central portal: 8.25-mm clear cannula just above the subscapularis at about 45 degrees to the glenoid for anchors and suture passers.

8. If the lesion extends posterior to 6 o'clock, add a 7 o'clock portal for inferior anchors or suture shuttling.

9. Viewing from anterosuperior, elevate the capsulolabral complex until the subscapularis is visible and abrade the glenoid neck.

10. Perform posterior capsular plication if needed along the posterior band of the IGHL (rasp the tissue first).

11. Starting at about 6 o'clock, take an approximately 1-cm capsular bite passing under the labrum; knotted or knotless anchors give similar outcomes, but knot stacks must be kept away from cartilage.

12. Free the anterior capsulolabral complex for superior advancement; plan at least three anchors below 3 o'clock.

13. Place the inferior anchor through a percutaneous 5 o'clock portal (needle at 45 degrees), at about 5:30 and 1-2 mm onto the articular surface; tap in and test. Anchors posterior to 6 o'clock are best placed percutaneously through the 7 o'clock portal; curved guides for all-suture anchors are an alternative.

14. Shuttle sutures through capsule and labrum distal to each anchor and tie (or use knotless anchors), directing knots away from the joint, to recreate the soft-tissue bumper.

15. Place three or four anchors 5-7 mm apart; simple or mattress configurations as dictated by tissue; tie posterior plication sutures.

16. With hyperlaxity and a sulcus, close the rotator interval (middle to superior glenohumeral ligament, usually two sutures tied extracapsularly), accepting slight loss of external rotation.

17. Close portals subcuticularly; dressing and abduction sling.

Postoperative Care (Campbell Ch 57)

• Sling for 4-6 weeks; physical therapy from 2-3 weeks.

• Active-assisted motion weeks 2-8 (e.g., external rotation limited to 30 degrees at 3 weeks and 40 degrees at 4 weeks); isometric strengthening weeks 8-12.

• Return to conditioning and weight training at 12 weeks; contact sports at about 6 months when motion and strength match the opposite shoulder.

Complications (Campbell Ch 57)

• Recurrent instability is the most common failure, largely avoidable by recognizing bone loss and hyperlaxity preoperatively; insecure knots cause loosening.

• Overconstraint from excessive plication or interval closure.

• Axillary and suprascapular nerve injury from portals or traction; the subclavian vein lies within 1 cm of the 5 o'clock portal.

• Chondrolysis (avoid intra-articular anesthetic infusion), infection, thromboembolism.

References

1. Brolin TJ, Lamplot JD. Arthroscopy of the upper extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 57, Technique 57.10.

2. Lamplot JD, Brolin TJ. Recurrent dislocations. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 52.