High Yield Overview

ARTHROSCOPIC BANKART REPAIR FOR ANTERIOR SHOULDER INSTABILITY

Arthroscopic - posterior viewing portal with rotator interval anterior portal and anteroinferior (5 o'clock) working portal | intermediate

Critical Danger Structures

Axillary Nerve

Location: Exits quadrangular space (bordered by teres minor superiorly, teres major inferiorly, long head triceps medially, surgical neck humerus laterally) with posterior circumflex humeral artery. Courses anteroinferiorly along subscapularis muscle deep surface, running parallel to inferior glenohumeral capsule at approximately 6 o'clock glenoid position, average 12-15mm inferior to glenoid rim. Terminates as anterior and posterior branches innervating deltoid (all three heads) and teres minor.

Protection: CRITICAL risk during anteroinferior (5 o'clock) portal placement and inferior labral work. Portal should be no more than 5-7cm from lateral acromion edge (average axillary nerve distance is 5.4cm ± 0.7cm). Use outside-in technique with spinal needle first to confirm safe trajectory. STOP all labral mobilization and anchor placement at 6 o'clock position - work inferior to this risks direct nerve injury. Maintain pump pressure 40-60mmHg to prevent capsular collapse bringing nerve closer. Test deltoid function (arm abduction) in recovery room. Injury rate 0.3-1% in shoulder arthroscopy.

Musculocutaneous Nerve

Location: Terminal branch of lateral cord of brachial plexus (C5-C7). Exits lateral to pectoralis minor, courses laterally and distally to pierce coracobrachialis muscle (conjoint tendon) 3-8cm distal to coracoid tip (mean 5.4cm, range 3-10cm depending on arm length). After entering coracobrachialis, travels between biceps brachii and brachialis muscles to become lateral antebrachial cutaneous nerve. Key anatomic relationship: lies medial to conjoint tendon at level of typical anterior portal.

Protection: Anterior (rotator interval) portal represents primary risk - portal placed too medial or too inferior penetrates conjoint tendon risking nerve injury. ALWAYS use outside-in technique with spinal needle to confirm trajectory enters through rotator interval (superior to subscapularis, inferior to supraspinatus, just anterior to biceps tendon) BEFORE making portal. Portal should be lateral to conjoint tendon and medial to anterior deltoid edge. Visualize portal entry arthroscopically before dilation - should see capsule dimple in rotator interval. If portal trajectory aims toward coracoid, STOP - too medial. Injury rate 0.1-0.5%, presents as biceps weakness and lateral forearm dysesthesia.

Suprascapular Nerve

Location: Arises from upper trunk of brachial plexus (C5-C6). Travels posterolaterally through posterior triangle of neck, crosses scapular superior border through suprascapular notch (beneath superior transverse scapular ligament - 'Army goes over, Navy goes under' with suprascapular artery superior to ligament). Supplies supraspinatus (motor and 70% shoulder articular sensory). Continues around lateral border of scapular spine through spinoglenoid notch (beneath inferior transverse scapular ligament) to supply infraspinatus. Spinoglenoid notch is 20-25mm medial to glenoid rim at level of mid-glenoid.

Protection: Posterior portal placement most critical - standard safe zone is 2cm inferior and 1cm medial to posterolateral acromion corner (soft spot). Portal too medial approaches spinoglenoid notch risking nerve injury. During labral mobilization for posterior Bankart variants, excessive posterior dissection medial to glenoid rim endangers nerve. If performing posterior labral repair, limit medialization to 5-8mm from rim. Unlike anterior Bankart repair where nerve risk is low (<0.5%), posterior labral procedures carry 3-5% injury risk. Injury presents as painless supraspinatus and/or infraspinatus atrophy with external rotation weakness.

Cephalic Vein and Deltopectoral Interval Structures

Location: Cephalic vein courses in deltopectoral interval (between anterior deltoid laterally and pectoralis major medially) from deltoid insertion distally to infraclavicular fossa proximally where it pierces clavipectoral fascia to join axillary vein. Lies superficial to coracoid process and conjoint tendon. Lateral pectoral nerve (from lateral cord) accompanies vein, innervating clavicular head of pectoralis major. Thoracoacromial artery branches (pectoral, deltoid, acromial, clavicular) cross interval deep to cephalic vein.

Protection: Risk during anterior portal skin incision and subcutaneous dissection. If converting to mini-open approach, identify and protect cephalic vein (can retract medially or laterally). Excessive traction on vein causes thrombosis. Injury typically not limb-threatening but causes hematoma, thrombophlebitis, and cosmetic complaint. Use blunt dissection through subcutaneous tissue for anterior portal. If persistent bleeding from anterior portal, may have lacerated vein branch - requires direct pressure or figure-of-8 suture. Avoid electrocautery near cephalic vein to prevent thrombosis.

Anterior Circumflex Humeral Artery and Posterior Circumflex Humeral Artery

Location: Anterior circumflex humeral artery (ACHA) arises from axillary artery (third part, distal to pectoralis minor), smaller than posterior counterpart. Courses laterally deep to coracobrachialis and biceps short head, anterior to surgical neck of humerus, anastomoses with posterior circumflex humeral artery (PCHA). PCHA arises from axillary artery (third part), larger vessel, courses posteriorly with axillary nerve through quadrangular space, wraps around surgical neck posteriorly. Together they form vascular ring around surgical neck. ACHA supplies anterior capsule and humeral head (arcuate artery enters head anterolaterally).

Protection: ACHA at risk during anteroinferior capsular work and mobilization. PCHA at risk during posterior portal placement (but posterior portal typically superior to quadrangular space). Bleeding usually controlled with pump pressure 40-60mmHg (venous and small arterial bleeding). If persistent arterial bleeding obscures view: 1) increase pump pressure temporarily to 80mmHg, 2) identify bleeding source, 3) use radiofrequency device (not aggressive electrocautery which damages capsule), 4) if uncontrolled, may require mini-open approach with direct ligation (rare). Major vascular injury requiring conversion to open repair is extremely rare (<0.1%).

Mnemonic

PORTALPORTAL - Standard Shoulder Arthroscopy Portal Placement

Mnemonic

ANCHORSANCHORS - Proper Anchor Placement Technique in Bankart Repair

Bankart Lesion Classification Systems

Snyder Classification of Anterior Labral Lesions:

Type I: Labrum frayed/degenerative but attached to glenoid rim
Type II: Labrum detached from glenoid (classic Bankart) - labral tissue quality good
Type III: Labrum detached and bucket-handle tear - tissue quality compromised
Type IV: Labrum detached with labral tissue loss/attenuation - tissue quality poor

GLAD vs ALPSA vs Perthes vs Bony Bankart:

GLAD (Glenolabral Articular Disruption): Anterior labral tear with associated chondral injury to glenoid - typically non-displaced, seen with more anterior impact
ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion): Labrum detached but healed/scarred medially on glenoid neck - requires aggressive mobilization, most common chronic pattern (50-60% of recurrent instability cases)
Perthes: Labrum lifted off glenoid with intact periosteum - appears reduced in adduction but lifts in abduction, less common (10-20%), requires mobilization
Bony Bankart: Anterior glenoid rim fracture with attached labrum - if fragment >25% glenoid width or >5mm displacement, requires open reduction internal fixation (ORIF) with screws, NOT arthroscopic suture anchors

ISIS Score (Instability Severity Index Score)

Risk Factor	Points	Rationale
Age <20 years	2	Higher recurrence rate (60-90%) in adolescents due to activity level and tissue quality
Competitive sport participation	2	Increased shoulder loading and re-injury risk
Contact or overhead sport	2	Football, rugby, wrestling, volleyball - highest re-dislocation rates
Shoulder hyperlaxity (±sulcus sign)	1	Generalized ligamentous laxity predicts failure (capsular quality issue)
Hill-Sachs lesion visible on AP X-ray	2	Large lesion visible on AP indicates substantial bone loss (engaging risk)
Glenoid bone loss visible on AP X-ray	2	Any visible loss on AP indicates >10-15% loss (requires CT quantification)

Scoring: Total 0-10 points. Score ≥6 = 70% probability of recurrence after arthroscopic Bankart (consider primary Latarjet). Score 3-5 = 30% recurrence risk (arthroscopic Bankart reasonable with counseling). Score 0-2 = <10% recurrence risk (arthroscopic Bankart appropriate).

Glenoid Bone Loss Assessment

Measurement Techniques:

CT scan en-face view with best-fit circle (Gold Standard): Measure intact inferior glenoid diameter, overlay circle on superior intact portion, measure defect width. % Bone loss = (defect width / diameter of best-fit circle) × 100
Arthroscopic bare spot method: Native glenoid width = 2 × distance from bare spot (anatomic center) to intact posterior rim. Compare to anterior side. Linear loss = difference. % = (linear loss / native width) × 100
Pico method (arthroscopic): Measure defect width and remaining intact anterior rim width. % = defect / (defect + intact anterior) × 100

Critical Decision Thresholds:

<13.5% loss: Safe for isolated Bankart repair (low recurrence)
13.5-20% loss: Gray zone - consider patient factors (ISIS score, activity), may attempt arthroscopic Bankart with understanding of higher failure risk (15-20%)
>20-25% loss OR >6-8mm linear: Absolute indication for bone augmentation (Latarjet, distal tibial allograft). Inverted pear sign on AP X-ray indicates >20% loss
>30% loss: Consider iliac crest autograft or fresh structural allograft (larger reconstruction needed)

Hill-Sachs Lesion - On-Track vs Off-Track (Glenoid Track Concept)

Di Giacomo Glenoid Track Theory:

Glenoid track width = width of glenoid contact area on humeral head during functional ROM = 0.83 × native glenoid diameter (D) minus anterior bone loss (d). Formula: GT = (0.83 × D) - d
Hill-Sachs track = distance from medial margin of rotator cuff footprint on humeral head to medial margin of Hill-Sachs lesion. Formula: HS = HS width + (medial rim of rotator cuff footprint to HS medial edge)
On-track: HS track < Glenoid track → lesion stays medial to glenoid edge throughout functional ROM → safe for isolated Bankart
Off-track: HS track > Glenoid track → lesion engages glenoid rim in abduction-ER → requires remplissage (arthroscopic) or Latarjet (if also significant glenoid loss)

Clinical Application: Measure glenoid track on CT or arthroscopically. Measure Hill-Sachs track on MRI or arthroscopically with arm in ABER position. Dynamic arthroscopic examination: place probe on glenoid rim, rotate and abduct arm - if Hill-Sachs engages (probe displaces anteriorly), lesion is off-track.

Indications for Arthroscopic Bankart Repair

Absolute Indications:

Recurrent traumatic anterior instability (≥2 dislocations or ≥1 dislocation + multiple subluxations) with confirmed Bankart lesion on MRI
Glenoid bone loss <20% AND on-track Hill-Sachs lesion
Failed conservative management (physiotherapy minimum 3-6 months for first-time dislocation)
First-time traumatic dislocation in high-risk patient unwilling to accept 60-80% recurrence rate with non-operative treatment (young competitive athlete)

Relative Indications:

Persistent instability symptoms (subjective instability, apprehension) despite normal radiographic findings
ALPSA lesion with capsular redundancy
Combined Bankart and SLAP lesion (address both)

Contraindications:

Glenoid bone loss >20-25% (requires Latarjet/bone graft)
Off-track Hill-Sachs lesion (requires remplissage + Bankart or Latarjet)
Attenuated/absent labral tissue (poor tissue quality - consider capsular shift or Latarjet)
Active infection
Significant glenohumeral arthritis (consider arthroplasty)
Voluntary/psychiatric instability (will fail any procedure)

Positioning and Preparation

Patient Position: Beach chair (30-70° head-up) OR lateral decubitus with 10-15lb longitudinal traction plus 5-10lb lateral traction. Beach chair preferred for easier conversion to open if needed, lower brachial plexus traction risk, familiar anatomic orientation, and better blood pressure control. Lateral decubitus provides better inferior glenoid access and visualization, superior capsular distension with fluid pressure, but technically more demanding and unfamiliar anatomy orientation.

Surgical Approach: Arthroscopic - three portal technique: posterior viewing portal (camera), anterior rotator interval portal (instrumentation/viewing), anteroinferior 5 o'clock working portal (critical for inferior anchor placement)

Incision: Three arthroscopic portals (each approximately 5-8mm): 1) Posterior portal 2cm inferior and 1cm medial to posterolateral acromion corner (soft spot palpable), 2) Anterior rotator interval portal at anterior acromion edge through rotator interval triangle, 3) Anteroinferior 5 o'clock portal anterior to subscapularis at inferior glenoid level

Operative Technique

Step 1: Patient Positioning & Setup

Patient Positioning & Setup: Beach chair position at 45-60° with head secured in neutral rotation using horseshoe headrest or Mayfield clamp. Entire torso tilted en bloc (not just backrest) to achieve 45-60° angle. Arm positioned in pneumatic or mechanical arm holder (Spider limb positioner, McConnell arm holder, or TRIMANO system) allowing 45-90° abduction, 0-90° forward flexion, and full rotation without restriction throughout case. Position arm in 30-45° abduction and 20-30° forward flexion at neutral rotation as starting position. Ensure C-arm access if considering glenoid screw fixation (if bony Bankart discovered). Mark bony landmarks with sterile marker: acromion borders (anterolateral corner, posterolateral corner, lateral border), clavicle, coracoid process (palpate tip), AC joint. Ensure inferior and anterior glenoid accessible throughout range of motion by testing arm positions before draping. Protect brachial plexus: avoid excessive traction, maintain shoulder in safe position.

Exam Pearl

Technical Tip: Beach chair advantages over lateral decubitus: 1) easier conversion to open Latarjet if significant bone loss discovered (10-15% of planned arthroscopic cases), 2) lower brachial plexus traction injury risk (no constant traction force), 3) familiar anatomic orientation (patient positioned as in clinic examination), 4) easier anesthesia management (avoid ventilation-perfusion mismatch of lateral position). Beach chair disadvantages: 1) gravity pulls humeral head posteriorly reducing capsular distension slightly, 2) requires mechanical arm holder (lateral position uses traction tower), 3) risk of hypotensive cerebral hypoperfusion events (maintain MAP >70mmHg, avoid excessive head-up angle). Accept 10-15° external rotation loss postoperatively as normal capsular tightening - NOT pathologic stiffness. Only concerned if ER loss >20° or patient develops frozen shoulder pattern.

Dangers at this step

Brachial plexus traction injury in lateral position (keep longitudinal traction <15lb, lateral traction <10lb, limit total traction time to <2 hours if possible - release traction periodically)
Cerebral hypoperfusion in beach chair position (hypotensive episodes - maintain MAP >70mmHg, avoid excessive Trendelenburg, have vasopressors available, consider arterial line monitoring in high-risk patients)
Inadequate inferior glenoid access if arm holder positioned poorly (test before draping - should achieve 90° abduction and 60° external rotation without humeral head blocking inferior portal trajectory)
Pressure injury to contralateral arm or dependent areas (pad all pressure points, avoid tucking arms too tightly)

Step 2: Portal Placement - Posterior

Portal Placement - Posterior: POSTERIOR portal created first as primary viewing portal. Palpate posterolateral acromion corner (junction of lateral and posterior acromion borders) - this is usually a palpable bony prominence. Identify soft spot: 2cm inferior and 1cm medial to this corner. This depression represents the infraspinatus-teres minor interval and is the standard posterior portal location. Infiltrate local anesthetic (10mL 0.5% bupivacaine with 1:200,000 epinephrine) for hemostasis and postoperative analgesia. Inflate joint with 50-60mL sterile saline using 18-gauge spinal needle inserted at portal site, aimed toward coracoid (confirms intra-articular position when fluid flows easily). Make 1-1.5cm vertical skin incision with #15 blade. Use blunt obturator and cannula system or sharp trocar, aimed anteriorly and medially toward coracoid tip (anterior-medial trajectory), to enter glenohumeral joint. Insert 30° arthroscope (4mm diameter standard). This portal used for camera viewing throughout entire procedure.

Exam Pearl

Technical Tip: Posterior portal positioning is critical foundation for entire procedure - improper portal results in poor visualization and dangerous instrument angles throughout case. The 'soft spot' is consistently palpable as depression 2cm inferior and 1cm medial to posterolateral acromion corner in >95% of patients. If soft spot difficult to palpate (muscular patients), use external landmarks: portal approximately at level of glenohumeral joint, 1cm medial to lateral acromion border. Trajectory toward coracoid tip (anterior-medial direction) ensures entering joint at proper angle for best visualization. Inflate joint first with saline to expand capsule and separate articular surfaces - makes entry safer and easier. Posterior portal too superior hits acromion obstruction, too medial approaches suprascapular nerve at spinoglenoid notch, too lateral misses joint entirely. Use 30° arthroscope (not 70°) as standard - provides adequate visualization with less disorientation.

Dangers at this step

Suprascapular nerve at spinoglenoid notch 20-25mm medial to glenoid rim - portal too medial risks nerve injury (causes painless infraspinatus atrophy)
Axillary nerve 30-40mm inferior to glenohumeral joint - don't angle trocar inferiorly during insertion
Posterior circumflex humeral artery accompanies axillary nerve through quadrangular space - excessive inferior trajectory risks vascular injury
Cartilage damage to humeral head or glenoid if trocar inserted aggressively without joint distension - always inflate joint first with saline

Step 3: Portal Placement - Anterior & Anteroinferior

Portal Placement - Anterior & Anteroinferior: ANTERIOR ROTATOR INTERVAL portal created second. With arthroscope in posterior portal, systematically examine joint: biceps tendon, superior labrum, anterior labrum extent, rotator cuff. Identify rotator interval as triangular space bordered by subscapularis tendon inferiorly, supraspinatus tendon superiorly, and biceps tendon medially. Use outside-in technique with 18-gauge spinal needle from anterior, aimed toward center of rotator interval just anterior to biceps tendon. Triangulate needle position under direct arthroscopic visualization - should see capsule dimple as needle indents capsule. External skin landmark for needle insertion: approximately at anterior acromion edge, 2-3cm inferior to anterolateral acromion corner. Confirm trajectory will NOT penetrate conjoint tendon medially (musculocutaneous nerve risk) or subscapularis laterally. Make 8mm skin incision, use blunt switching stick to dilate tract, insert 8mm cannula. This portal used for instrumentation and alternate viewing.

ANTEROINFERIOR 5 O'CLOCK portal is CRITICAL for inferior anchor placement - most commonly malpositioned portal by trainees. View from posterior portal. Insert spinal needle under DIRECT arthroscopic visualization, entering just anterior to subscapularis tendon border at level of inferior glenoid (5:30 position right shoulder, 6:30 position left shoulder). Needle trajectory must allow perpendicular approach to glenoid face at 5:30 and 4:30 positions - test by advancing needle to glenoid rim and confirming angle. Typical skin entry point is 2-3cm inferior and 1cm lateral to anterior rotator interval portal, but ANATOMY DETERMINES POSITION not external landmarks. Make 8mm incision, dilate tract, insert 8mm or 8.5mm cannula. This is primary working portal for shaver, burr, anchor insertion, suture management.

Exam Pearl

Technical Tip: The anteroinferior 5 o'clock portal is the MOST IMPORTANT portal in Bankart repair and the portal most commonly malpositioned by inexperienced surgeons. Portal too superior cannot reach inferior glenoid (5:30 position) - results in anchors placed too high (inadequate inferior stabilization, repair fails). Portal too medial gives incorrect angle for perpendicular anchor trajectory to glenoid face - results in tangential drilling and anchor pullout. Portal too inferior risks axillary nerve injury (nerve is 5-7cm from lateral acromion edge). Use spinal needle FIRST to confirm trajectory reaches 5:30 glenoid position AND allows perpendicular drilling angle BEFORE making portal incision. Visualize needle tip on glenoid rim - should touch glenoid at 5:30 position with needle perpendicular to glenoid surface. If needle is tangential to glenoid, portal trajectory is wrong - REPOSITION NEEDLE before making portal.

Dangers at this step

Axillary nerve runs along inferior capsule at approximately 6 o'clock position, average 5.4cm (range 4-7cm) from lateral acromion edge - anteroinferior portal placement too far inferior or too medial risks direct nerve injury
Musculocutaneous nerve enters coracobrachialis muscle (conjoint tendon) average 5.4cm (range 3-8cm) distal to coracoid tip - anterior rotator interval portal placed too medially (toward coracoid) risks penetrating conjoint tendon with nerve injury
Cephalic vein and deltopectoral interval structures - superficial to anterior portal, use sharp dissection through skin only, then blunt dissection to capsule
Anterior circumflex humeral vessels run along anterior inferior capsule with axillary nerve - anteroinferior portal placement and subsequent capsular work at risk for bleeding (usually controlled with pump pressure)

Step 4: Diagnostic Arthroscopy & Decision Making

Diagnostic Arthroscopy & Decision Making: Perform systematic 21-point shoulder arthroscopy examination to identify all pathology BEFORE beginning repair. Set pump pressure at 40-60mmHg (balance adequate distension with minimizing fluid extravasation). Systematic examination from posterior portal viewing: 1) Long head biceps tendon origin and anchor at supraglenoid tubercle (examine for SLAP lesion - palpate with probe for instability, look for fraying), 2) Superior labrum 10 o'clock to 2 o'clock (SLAP component?), 3) Rotator cuff articular surface - supraspinatus, infraspinatus, subscapularis (partial thickness tears? Stir test positive?), 4) Anterior labrum 2 o'clock to 6 o'clock (EXTENT of Bankart lesion - classic is 3-6 o'clock, but may extend higher or lower), 5) Inferior labrum 6 o'clock to 8 o'clock, 6) Posterior labrum 8 o'clock to 10 o'clock (posterior Bankart?), 7) Glenoid articular cartilage surface - examine for chondral injury, degenerative changes, 8) Glenoid BONE LOSS assessment (critical decision point), 9) Humeral head examination - Hill-Sachs lesion size, location, depth, 10) Drive-through sign (excessive capsular laxity if can drive arthroscope from posterior portal through rotator interval to anterior compartment without resistance), 11) HAGL lesion assessment (humeral avulsion of glenohumeral ligament - probe inferior capsule to confirm attached to humerus).

CRITICAL BONE LOSS ASSESSMENT: Use arthroscopic bare spot technique. Identify bare spot (anatomic center of glenoid, typically at junction of middle and lower third). Measure distance from bare spot to intact POSTERIOR glenoid rim with calibrated probe (this represents radius of normal glenoid). Native glenoid width = 2 × distance from bare spot to intact posterior rim. Measure distance from bare spot to ANTERIOR glenoid rim (damaged side). Calculate % bone loss = [(posterior distance - anterior distance) / posterior distance] × 100. Alternatively, use en-face glenoid view with arthroscope perpendicular to glenoid face, estimate percentage of anterior rim missing compared to posterior intact rim. If bone loss >20-25% OR linear loss >6-8mm OR inverted pear morphology visible → STOP PROCEDURE, discuss with patient postoperatively, plan Latarjet procedure - do NOT proceed with isolated Bankart repair.

HILL-SACHS ASSESSMENT (On-Track vs Off-Track): Measure Hill-Sachs lesion with calibrated probe - width (medial-lateral) and depth. Identify medial margin of rotator cuff footprint on humeral head (use probe to palpate firm tendon insertion). Measure distance from medial rotator cuff margin to medial edge of Hill-Sachs defect. Perform DYNAMIC examination: with arthroscope viewing from posterior, rotate arm into abduction and external rotation while watching Hill-Sachs lesion - does it engage anterior glenoid rim? (probe on glenoid rim will be pushed anteriorly if engages). If lesion engages OR Hill-Sachs width is >20-25mm, consider off-track lesion requiring remplissage in addition to Bankart repair.

Exam Pearl

Technical Tip: Diagnostic arthroscopy determines if you can proceed with arthroscopic Bankart or must convert to bone augmentation procedure - this is THE critical decision point. Three absolute contraindications to isolated arthroscopic Bankart: 1) Glenoid bone loss >20-25% (failure rate 50-70% if proceed), 2) Off-track engaging Hill-Sachs lesion without remplissage planned, 3) Absent labral tissue quality (cannot repair absent tissue). Glenoid bone loss measurement is EXAMINER-DEPENDENT and prone to error - if uncertain, use preoperative CT with 3D reconstruction and best-fit circle method (gold standard). Missing HAGL lesion (humeral avulsion of inferior glenohumeral ligament) causes repair failure - ALWAYS probe inferior capsule attachment to humeral anatomic neck. If detached, requires repair to humeral side (suture anchors in humeral anatomic neck). Drive-through sign (easy passage of arthroscope from posterior to anterior through rotator interval without resistance) indicates capsular laxity - these patients may benefit from rotator interval closure or more aggressive capsular shift. ISIS score ≥6 points predicts 70% failure rate - discuss with patient realistic expectations even with technically perfect repair.

Dangers at this step

Underestimating glenoid bone loss (examiner bias toward proceeding with arthroscopic repair) - leads to high failure rate. If uncertain, obtain intraoperative CT or abort and plan delayed repair after CT quantification
Missing engaging Hill-Sachs lesion - test with arm in ABER position (abduction + external rotation), look for engagement on glenoid rim. Missed engagement leads to recurrent instability
Missing concurrent SLAP tear - probe biceps anchor, test for instability. Unrepaired SLAP causes persistent pain and possible instability
Underestimating capsular laxity - if significant drive-through sign, standard Bankart may be insufficient (consider rotator interval closure, inferior capsular shift)

Step 5: Labral Mobilization

Labral Mobilization: Use curved periosteal elevator (Fukuda ring curette, liberator, or similar curved elevator) to mobilize the detached labrum and capsule AS ONE UNIT off the glenoid neck. Insert elevator through anteroinferior portal. Start mobilization at 3 o'clock position (right shoulder), work inferiorly toward 6 o'clock. Elevate the capsulolabral complex from anterior to posterior direction (working posteriorly along glenoid neck), staying on bone surface of glenoid neck. The detached labrum is often scarred and healed to the anteroinferior glenoid neck in medialized position (ALPSA lesion variant - anterior labroligamentous periosteal sleeve avulsion) - this is MORE common than acute unhealed Perthes lesion. Must achieve COMPLETE mobilization to allow restoration of anatomic labral height. Mobilization is complete when: 1) you can visualize subscapularis muscle fibers THROUGH the thin capsule (capsule is thin when mobilized adequately), 2) labrum can be reduced to anatomic position on glenoid rim without tension, 3) you have created a pocket/space between the mobilized capsulolabral complex and the glenoid neck. Work circumferentially along glenoid neck from 3 o'clock to 6 o'clock (can extend to 2 o'clock superiorly if Bankart extends higher, but avoid mobilizing beyond pathology - creates unnecessary dead space). STOP at 6 o'clock position inferiorly - axillary nerve risk below this.

Exam Pearl

Technical Tip: INADEQUATE mobilization is the #1 TECHNICAL ERROR causing arthroscopic Bankart failure (accounts for 30-40% of failures in revision surgery studies). Surgeons often underestimate how much mobilization is required, particularly in chronic recurrent instability where labrum is scarred medially (ALPSA pattern occurs in 50-60% of chronic cases). Signs of adequate mobilization: 1) can see muscle fibers through capsule (if still see thick scar tissue, not mobilized enough), 2) labrum reaches glenoid rim WITHOUT tension when you lift it with probe, 3) tissue is mobile and pliable (not fixed and stiff). If mobilization is inadequate, the labrum will be repaired in MEDIALIZED position (on glenoid neck instead of rim) - this creates an ALPSA-type repair that provides NO bumper effect and WILL fail. Think of mobilization like releasing a scarred Achilles tendon - must release ALL scar tissue to allow proper tension and positioning. If you CANNOT achieve adequate mobilization arthroscopically (dense scar, multiple prior surgeries, thick capsule), CONVERT TO OPEN - better to have successful open repair than failed arthroscopic repair.

Dangers at this step

Inferior glenohumeral ligament (IGHL) injury if over-aggressive with elevator inferiorly - the IGHL is the primary anterior stabilizer and must be preserved with intact fibers
Axillary nerve below 6 o'clock position - ABSOLUTE STOP POINT for inferior mobilization (nerve runs along inferior capsule, average 12-15mm inferior to glenoid rim at 6 o'clock)
Subscapularis tendon damage if mobilization proceeds too far medially or anteriorly - stay on glenoid neck bone surface, don't dissect into subscapularis substance
Glenoid articular cartilage damage if elevator slips superiorly off glenoid neck onto articular surface - always advance elevator UNDER labrum (between labrum and bone), not over labrum pushing down on cartilage

Step 6: Glenoid Preparation & Decortication

Glenoid Preparation & Decortication: Insert motorized 4.0mm round burr or rasp through anteroinferior portal. Under direct visualization from posterior portal, decorticate the anterior glenoid neck from 3 o'clock to 6 o'clock position. Remove all soft tissue, fibrous scar, and superficial cortical bone to expose bleeding cancellous bone bed. The prepared surface should be 5-8mm wide stripe along glenoid neck from superior to inferior extent of Bankart lesion. Goal is punctate bleeding bone (vascular bone bed) resembling appearance of prepared ACL femoral tunnel - multiple small bleeding points across entire surface. This biological bed is ESSENTIAL for labral-to-bone healing. Remove any remaining labral tissue fragments from glenoid RIM where anchors will be placed (create clean 2-3mm strip at articular margin for anchor placement - this is the glenoid FACE where anchors must go). Avoid excessive bone removal - do NOT create iatrogenic bone defect. Control bleeding with pump pressure (40-60mmHg adequate), can increase temporarily to 70-80mmHg for burring to improve visualization, then decrease back to 50mmHg.

Exam Pearl

Technical Tip: Biological healing of labrum to bone requires BLEEDING BONE BED - this is non-negotiable for successful healing. The glenoid neck preparation should look like you are preparing for meniscal repair (punctate bleeding throughout) or ACL tunnel preparation (vascular bed). Without bleeding bone, you are relying purely on MECHANICAL fixation (sutures holding tissue to bone without biological healing) - this has much higher failure rate (biological healing is stronger than suture fixation long-term). The critical concept 'on the dance floor, not in the hallway' refers to anchor placement position: glenoid FACE is the 'dance floor' (articular surface edge, correct position), glenoid NECK is the 'hallway' (medial to articular edge, incorrect position). Must remove labral remnants from glenoid face (2-3mm strip at articular margin) to allow anchors to be placed on FACE. If you leave labral tissue on the face and place anchors medial to this tissue (on neck), you have created ALPSA repair (medialized labrum) which fails. Burr the neck for biological healing, clean the face for anchor placement.

Dangers at this step

Damaging glenoid articular cartilage - burr should stay on glenoid NECK (non-articular surface), not on glenoid articular surface (cartilage). Work systematically from inferior to superior, keeping burr on bone surface visible arthroscopically
Creating iatrogenic glenoid bone defect - aggressive burring can remove too much bone, particularly in inferior glenoid where bone may be thinner. Remove soft tissue and superficial cortex only, do NOT excavate deep cancellous bone
Thermal injury to bone - motorized burr generates heat, must use adequate irrigation (pump flow rate high enough to prevent thermal necrosis). If burr runs continuously without fluid cooling, can cause bone necrosis and anchor failure
Burr kickback into joint - motorized burr can suddenly advance or slip if it catches on tissue. Always maintain secure hand position on burr handpiece, advance slowly and deliberately, keep burr tip visible arthroscopically at all times

Step 7: Anchor Placement

Anchor Placement: Use 3.0mm or 3.5mm bioabsorbable or PEEK suture anchors (knotless or knotted based on surgeon preference). Standard anchors: 1.3mm high-strength suture (FiberWire, Orthocord, or equivalent), 2 sutures per anchor (4 suture limbs). START with MOST INFERIOR anchor position FIRST (5:30 o'clock right shoulder, 6:30 o'clock left shoulder) - this is critical for inferior stabilization. Place anchor on glenoid FACE, 2-3mm from articular cartilage edge (not on glenoid neck). Drill trajectory: perpendicular to glenoid surface, angled toward CENTER of glenoid (deadman angle approximately 45° to glenoid face - envision trajectory ending at center of glenoid/bare spot area). Insert drill guide/tap through anteroinferior portal to 5:30 position, position tip on glenoid face under direct vision, drill 15-20mm depth (until cortical purchase - feel resistance). Insert anchor to manufacturer-specified depth, ensure secure seating.

Work SUPERIORLY for subsequent anchors: second anchor at 4:30 position, third anchor at 3:30 position, fourth anchor at 2:30 position if needed (for Bankart lesions extending superiorly or large labral tissue). Maintain 5-8mm spacing between anchors measured on glenoid surface. Each anchor: 1) position on glenoid FACE (2-3mm from cartilage), 2) perpendicular trajectory to glenoid surface, 3) angled toward glenoid center (deadman angle prevents pullout), 4) drill to cortical purchase (15-20mm depth typical), 5) insert anchor until fully seated. Typical Bankart (3-6 o'clock lesion) requires 3-4 anchors total.

Exam Pearl

Technical Tip: Anchor placement is THE single most important technical factor after labral mobilization. Two critical points: 1) POSITION: anchors MUST be on glenoid FACE (articular edge) NOT on neck. Face placement (2-3mm from cartilage edge) restores anatomic labral bumper height. Neck placement creates ALPSA repair (medialized labrum) which provides no mechanical block and fails. 2) TRAJECTORY: perpendicular to glenoid surface, angled toward glenoid center (deadman angle). This trajectory maximizes pullout strength (biomechanical studies show perpendicular insertion with deadman angle has 40% higher pullout strength vs tangential insertion). Common errors: A) Anchors too medial on neck (most common error - accounts for 30% of failures), B) Tangential trajectory (weak pullout strength), C) All anchors converging to same point in glenoid (creates bone bridge failure), D) Anchors too lateral (damages articular cartilage). Starting INFERIOR and working SUPERIOR is easier (inferior glenoid harder to access, fatigue makes it harder to place inferior anchors last). Confirm anchor position from multiple arthroscopic viewing angles before loading sutures - once anchor in bone, cannot reposition.

Dangers at this step

Anchor placed too medial on glenoid NECK instead of FACE - mechanical failure (doesn't restore bumper), most common technical error in failed Bankart repairs requiring revision
Anchor placed too lateral damaging articular CARTILAGE - iatrogenic chondral injury, risk of arthritis progression
Anchor blowthrough (penetrates far cortex of glenoid) - especially inferior glenoid where bone may be thin (5-8mm thick). Results in poor fixation, anchor migration into joint. Prevent by feeling cortical purchase during drilling, limiting drill depth to 15-20mm
Anchor convergence - all anchors drilled toward same central point in glenoid creates intersecting drill holes with thin bone bridges between holes. These bridges can fail leading to anchor pullout en bloc. Prevent by parallel drilling trajectories, maintain 5-8mm spacing on glenoid surface
Suprascapular nerve at spinoglenoid notch if drilling too far medially or posteriorly (particularly with superior-most anchor at 2:30 position) - stay on glenoid rim, don't angle medially

Step 8: Suture Passing & Capsular Shift

Suture Passing & Capsular Shift: Use suture passing device (penetrating type: BirdBeak, Spectrum; OR non-penetrating shuttle relay type: Scorpion, Viper) to pass sutures through labrum AND capsule together as one tissue unit. Insert suture passer through anteroinferior portal. START with INFERIOR-MOST anchor (5:30 position). Pass device through capsulolabral tissue 10-15mm from glenoid edge (this distance is CRITICAL - creates capsular shift). Capture tissue from inferior capsular surface (IGHL component) and advance through to superior capsular surface. This 10-15mm distance from glenoid rim creates CAPSULAR SHIFT - when sutures are tensioned and tied, the tissue captured 10-15mm away is brought to glenoid rim, taking up capsular redundancy and tensioning IGHL. For each anchor, pass TWO separate suture limbs through tissue to create either horizontal mattress pattern (both limbs through same tissue but separated by 3-4mm) OR crossing pattern (one limb anterior through tissue, one limb posterior through tissue crossing each other). This distributes load across larger tissue area.

Work from INFERIOR to SUPERIOR - complete suture passage for inferior-most anchor first, then second anchor, then third, etc. CRITICAL for inferior-most suture at 5:30 position: must capture IGHL (inferior glenohumeral ligament) - palpate with probe to identify thick band of IGHL in inferior capsule, ensure suture passer captures this structure. IGHL is THE primary anterior stabilizer and must be incorporated. Ensure BOTH labrum tissue AND capsule are included in each suture pass (not just labrum edge). Tissue quality important - if tissue tears easily with suture passer (poor quality, attenuated, or absent), consider converting to open repair with capsular shift (arthroscopic repair will fail in severely deficient tissue).

Exam Pearl

Technical Tip: Capsular shift is achieved by WHERE you capture tissue - 10-15mm from glenoid rim (not just at labral edge 2-3mm from rim). When you tie sutures, the tissue captured 10-15mm away is brought to glenoid rim anchors, effectively reducing capsular volume and tensioning IGHL. Capturing tissue too close to glenoid edge (only 3-5mm away) provides NO capsular shift - this is labral repair only without addressing capsular redundancy, and will fail in athletes or patients with multiple dislocations who have stretched capsule. The 10-15mm distance is based on biomechanical studies showing this produces optimal capsular volume reduction (from pathologic 30-40mL back to normal 15-20mL) while maintaining acceptable ROM. The IGHL is visualized as a thickened band in the inferior capsule - palpate with probe to feel dense tissue. If you cannot identify IGHL (severe damage, absent tissue, or surgeon inexperience), you are at high risk of missing it - consider intraoperative consultation or converting to open where IGHL can be palpated directly. Missing IGHL incorporation in inferior repair accounts for 15-20% of arthroscopic failures.

Dangers at this step

Insufficient tissue bite (capturing tissue too close to glenoid rim, <5mm distance) - no capsular shift, capsular redundancy not addressed, high failure rate particularly in athletes
Missing IGHL in inferior repair - IGHL is THE primary anterior stabilizer (accounts for 60-70% of anterior stability in ABER position). If IGHL not incorporated, repair will fail regardless of other technical factors
Suture cutting through poor quality tissue - if tissue tears easily with suture passer (attenuated, degenerative, multiple prior dislocations), arthroscopic repair is at risk for failure. Consider open repair with capsular shift and tissue reinforcement
Capturing subscapularis tendon with anterior-most sutures - if suture passer advanced too far anteriorly, may penetrate subscapularis tendon. Results in postoperative pain, stiffness, weakness of internal rotation. Stay on capsule, visualize subscapularis border, don't penetrate tendon

Step 9: Suture Management & Knot Tying

Suture Management & Knot Tying: Retrieve sutures through appropriate portals using graspers. For KNOTTED repairs: Organize sutures systematically - mark each anchor's sutures (different colored sutures or labeled tags) to prevent confusion. Tie sutures from INFERIOR to SUPERIOR (tie inferior-most anchor first, then second anchor, etc.) - this prevents inferior capsule loosening that would occur if you tightened superior first. Use sliding knots for primary knot: SMC knot, Weston knot, or Roeder knot (surgeon preference - all biomechanically equivalent when tied correctly). Back up sliding knot with 3 reversing half-hitches on alternating posts (if primary knot post 1, first half-hitch on post 2, second half-hitch on post 1, third half-hitch on post 2). Tension to restore labral bumper height - labrum should sit PROUD on glenoid rim (1-2mm above articular cartilage edge) creating visible speed bump effect. Check external rotation after EACH anchor is tied - arm should maintain 30-40° ER at side minimum (accept loss of 10-15° compared to contralateral shoulder). If ER <20° after tying anchor, too tight - risk of postoperative stiffness - consider re-tying with less tension.

For KNOTLESS repairs: After passing sutures through tissue, retrieve suture limbs and load into knotless anchor according to manufacturer instructions. Insert knotless anchor into pre-drilled hole - sutures automatically tensioned as anchor advances. Tension is fixed by anchor depth - cannot adjust after insertion.

Final repair assessment: View repair from posterior portal, switch to anterior portal for different perspective. Labrum should be: 1) proud on glenoid rim (bumper effect visible), 2) uniform height throughout repaired zone, 3) stable when probed (no detachment). No tissue bridges between sutures (indicates incomplete passage). No gaps in labral coverage (indicates missed area).

Exam Pearl

Technical Tip: Goal of tying is to restore BUMPER effect - labrum sitting proud on glenoid rim (1-2mm above cartilage surface) serving as mechanical block to anterior humeral translation. The labrum should look like a speed bump when viewing arthroscopically from different angles. Tying sequence INFERIOR to SUPERIOR is critical - if you tie superior anchors first and then tension inferior anchors, you will loosen the superior repair (inferior tensioning pulls tissue inferiorly). Acceptable to lose 10-15° external rotation compared to contralateral shoulder - this represents capsular tightening and is actually desirable (reduces capsular volume). However, loss >20° ER is pathologic and increases risk of postoperative stiffness/frozen shoulder. If this occurs, re-tie inferior-most suture with less tension, or consider releasing rotator interval if closed. Knot security for knotted repairs: sliding knot + 3 reversing half-hitches is biomechanically proven construct (>300N failure load, exceeds in-vivo forces on repaired capsule). Adding more than 3 half-hitches provides no additional strength but creates larger knot (prominence risk).

Dangers at this step

Overtightening causing excessive ER loss (>20° compared to contralateral) - leads to postoperative stiffness, frozen shoulder, patient dissatisfaction. These patients are difficult to rehabilitate and may require manipulation ± arthroscopic release
Knot prominence impinging on humeral head - if knot not buried deep to labrum (sitting on articular surface of labrum toward joint), it can abrade humeral head cartilage during motion. Leads to pain, catching sensation, progressive chondral wear, early arthritis
Inadequate tensioning (under-tightening) - loose repair with excessive residual laxity, early failure with recurrent instability
Knot slippage with poor tying technique - sliding knots can slip if primary knot not tied correctly or if insufficient half-hitches. Use proper knot tying technique: tension primary knot fully before half-hitches, reverse direction of each half-hitch (alternating posts), tension each half-hitch individually

Step 10: Assessment of Repair & Remplissage (if indicated)

Assessment of Repair: Probe the completed repair with arthroscopic probe to confirm stable fixation. Labral tissue should be IMMOBILE when pushed with probe (no residual detachment, no gaps in repair). Perform arthroscopic load-and-shift test: apply anterior translation force with probe while viewing from posterior portal, arm in neutral rotation. Normal repair: <5mm anterior translation (grade 0 or trace grade 1 on 0-3 scale). If >1cm translation (grade 2+), repair inadequate - reassess anchor positions, consider additional anchor, check for missed pathology. Check labral bumper height from multiple viewing angles (posterior portal, then switch scope to anterior portal viewing posteriorly) - labrum should be proud of glenoid rim throughout 3-6 o'clock zone (or whatever extent was repaired). Assess external rotation with arm at side - should maintain 30-40° ER minimum (10-15° loss from normal is acceptable, >20° loss is excessive). View repair from different portal angles to confirm no tissue bridges between sutures (indicates incomplete tissue capture), no knot prominence projecting into joint (knots should be buried deep to labrum).

REMPLISSAGE (if off-track Hill-Sachs lesion identified): Create standard posterior portal for viewing (already present). Create posterolateral portal 1-2cm lateral to standard posterior portal for anchor placement into Hill-Sachs defect. Examine Hill-Sachs lesion from anterior portal viewing posteriorly - measure size. Mobilize posterior capsule off Hill-Sachs defect using elevator or shaver. Place 1-2 knotted anchors (3.5mm) into floor of Hill-Sachs defect. Pass sutures through infraspinatus tendon and posterior capsule using suture passer. Tie sutures to create infraspinatus tenodesis into defect (fills defect with tendon, prevents engagement on glenoid rim). Re-test with arm in ABER position - Hill-Sachs should NOT engage glenoid rim.

Exam Pearl

Technical Tip: Final arthroscopic assessment is THE checkpoint before finishing - inadequate repair discovered NOW can be fixed, but inadequate repair discovered as postoperative recurrent instability requires revision surgery. Systematic assessment: 1) Labral height (bumper present throughout repair), 2) Stability (probe test shows <5mm translation grade 0-1), 3) ROM (ER ≥30° at side), 4) No gaps or detachments, 5) No prominent knots or hardware. If ANY of these are inadequate, address NOW. Most common finding requiring intraoperative revision: inadequate labral height from anchors placed on neck instead of face - if identified, can place additional anchors more laterally on face to improve bumper height. Document final repair with intraoperative photographs - superior-lateral view showing labral bumper height, anterior view showing anchor positions, inferior view showing inferior repair - these are valuable for postoperative management planning and for revision surgery if needed.

Dangers at this step

Accepting inadequate repair stability (>1cm translation on load-and-shift) - will fail early postoperatively. Better to revise repair now (add anchor, re-tension sutures, address missed pathology) than accept poor repair
Accepting excessive stiffness (ER <20° at side) - risk of postoperative frozen shoulder pattern. If too tight, consider releasing inferior-most suture and re-tying with less tension, or release rotator interval if closed
Missing residual labral detachment - incomplete repair with gap in labral coverage will have fluid escape point and can propagate leading to failure
Remplissage complications: over-tightening posterior capsule causes excessive ER loss (can lose 15-20° ER from remplissage alone). Missing infraspinatus tendon and capturing only posterior capsule provides inadequate fill of defect

Step 11: Closure

Closure: Decompress joint by turning off pump and allowing fluid to drain. Remove all instruments and cannulas. Portal sites: irrigate each portal tract with saline to remove debris and blood. Close deep dermal layer with 3-0 absorbable monofilament suture (Monocryl or PDS) using buried simple interrupted sutures (2-3 sutures per portal). Close skin with 4-0 subcuticular running suture (Monocryl) OR skin adhesive strips (Steri-Strips) OR skin glue (Dermabond) - all have equivalent cosmetic outcomes. Apply sterile adhesive dressing to each portal. Apply soft bulky dressing around shoulder (combine 4×4 gauze pads with ABD pads, wrap with Kerlix or similar gauze roll, secure with tape). Place arm in shoulder immobilization sling with neutral rotation (NOT external rotation). Optional: small abduction pillow between arm and torso (prevents inferior translation stress on repair, but not universally used - no outcome difference in studies). No surgical drains needed for routine Bankart repair.

Exam Pearl

Technical Tip: Portal closure technique is straightforward given small incisions (5-8mm). Key points: 1) Deep dermal closure (not just skin) reduces portal widening/stretching and improves cosmetic result. 2) Irrigate portal tracts before closure to remove debris - reduces infection risk and reduces postoperative portal site fluid drainage. 3) Sling position in NEUTRAL rotation (not external rotation) - older protocols used ER position based on theory that ER tensions anterior repair, but multiple RCTs now show ER position provides NO benefit and increases stiffness risk. Current evidence-based practice: neutral rotation immobilization. 4) Abduction pillow is optional based on surgeon preference - some use to prevent inferior translation stress on inferior-most repair, but studies show no difference in outcomes with vs without pillow. 5) Check for subcutaneous fluid extravasation (crepitus in neck, chest wall, or arm) - if extensive extravasation occurred during case (from high pump pressure or long operative time), may need observation period to monitor for compartment syndrome (rare but reported). Document total fluid input and estimate fluid extravasation in operative report.

Dangers at this step

Portal site infection (rare <0.5% but serious) - meticulous sterile technique during closure, consider antibiotic ointment to portal sites (controversial - some studies show reduced infection, others no benefit)
Portal hematoma or seroma formation - achieve hemostasis before closure (hemostatic pump pressure during closure, visualization of portals for active bleeding), apply compressive dressing, leave one portal open briefly to drain residual fluid before final closure
Subcutaneous fluid extravasation - if extensive crepitus from shoulder to neck or chest wall, increases risk of airway compromise (rare), compartment syndrome (very rare), or skin necrosis (extremely rare). Mild crepitus is common and self-limiting (resorbs over 24-48 hours). Extensive extravasation (crepitus to mid-chest or neck) warrants admission for observation
Dressing too tight causing vascular compromise - ensure neurovascular status intact after dressing applied (check radial pulse, capillary refill, finger motor and sensory function)

Step 12: Post-Operative Immediate Management

Post-Operative Immediate Management: Sling immobilization for 4-6 weeks FULL TIME (remove only for shower, elbow/wrist/hand exercises, and supervised physiotherapy). NO external rotation beyond NEUTRAL for first 6 weeks (protects healing anterior capsulolabral repair from tension). Pendulum exercises (Codman exercises) started IMMEDIATELY day 1 postop - passive shoulder motion using gravity and body sway, no active muscle contraction, 3-5 minutes 3-4 times daily. Elbow/wrist/hand active ROM immediately to prevent stiffness. Passive forward flexion (therapist or pulley assisted) from week 2-4 as tolerated to 90-120° (prevents frozen shoulder while protecting repair). Passive internal rotation (hand behind back stretch) from week 2-4 to lumbar spine level. Start formal physiotherapy at 4-6 weeks with focus on PASSIVE ROM only (no active muscle contraction, no resisted exercises). Active ROM begins at 6 weeks once biological healing commenced (labral tissue healing to bone requires 6-8 weeks minimum). Pain management: acetaminophen 1000mg every 6 hours scheduled (not PRN), ± NSAIDs (ibuprofen 400-600mg every 8 hours or celecoxib 200mg daily) - some surgeons avoid NSAIDs first 6 weeks due to theoretical bone healing concerns but no clinical evidence of harm. Opioid prescription for breakthrough pain (oxycodone 5-10mg every 4-6 hours PRN) - limit to 20-30 tablets to prevent excess opioid exposure. Ice therapy 20 minutes every 2-3 hours for first 48-72 hours (reduces pain and swelling).

Exam Pearl

Technical Tip: Immobilization duration is CRITICAL - too short (<4 weeks) increases biological failure rate as labral healing to bone is incomplete, too long (>8 weeks) increases stiffness risk particularly capsular contracture. Evidence base: RCTs comparing immediate mobilization vs 4-week immobilization show 22% recurrence with immediate mobilization vs 9% recurrence with 4-week immobilization (statistically significant). Biological healing timeline: labral tissue incorporation into decorticated glenoid bone requires minimum 6-8 weeks (similar to rotator cuff tendon-to-bone healing or ACL graft incorporation). However, excessive immobilization >6-8 weeks increases adhesive capsulitis risk (frozen shoulder). Current evidence-based protocol: 4-6 weeks full-time sling with NO ER beyond neutral, passive ROM exercises starting week 2-4 (pendulums, passive elevation, passive IR), active ROM starting week 6, strengthening starting week 12. Neutral rotation immobilization: multiple RCTs comparing neutral vs 15-20° ER position show NO difference in recurrence rate but HIGHER stiffness rate with ER position - current recommendation is neutral rotation (0° ER). Athletes strongly desire earlier return to sport but must resist - returning to contact sport before 6 months DOUBLES recurrence risk (32% vs 15% in studies).

Dangers at this step

Early aggressive physiotherapy (ROM beyond protocol limits, strengthening exercises before 12 weeks) - causes labral re-detachment, suture pullout, or anchor failure. Most common patient/therapist error: starting active ROM or strengthening too early
External rotation beyond neutral in first 6 weeks - stresses anterior repair (anterior capsule and labral repair are under tension in ER position), increases biological failure risk
Excessive immobilization (strict sling >6-8 weeks, no passive ROM exercises) - frozen shoulder risk increases dramatically. Balance healing protection (4-6 weeks immobilization) with stiffness prevention (early passive ROM)
Inadequate pain control leading to patient non-compliance with immobilization - if patient in severe pain, may remove sling excessively or seek early ROM relief, compromising repair. Adequate analgesia is essential for protocol compliance

Post-operative Care

Phase 1: Protection Phase (Weeks 0-6)

Sling immobilization in neutral rotation full-time (remove for shower/exercises only)
NO external rotation beyond neutral position (0° ER is limit)
Pendulum exercises (Codman) immediately - 5 minutes, 3-4 times daily
Elbow/wrist/hand active ROM immediately
Passive forward flexion and internal rotation from week 2-4 (therapist-assisted or pulley)
NO active shoulder ROM, NO strengthening
Goals: protect biological healing, prevent frozen shoulder

Phase 2: Early Motion Phase (Weeks 6-12)

Wean from sling over 1-2 weeks
Progress to active-assisted ROM then active ROM all planes
External rotation progressed gradually: 20-30° at week 6, 40-50° at week 8, full by week 12
Scapular stabilization exercises (rows, scapular retraction, wall slides)
NO strengthening against resistance
NO sport-specific activities
Goals: restore full passive ROM, begin active ROM, normalize scapular mechanics

Phase 3: Strengthening Phase (Weeks 12-16)

Progressive strengthening: rotator cuff (Theraband exercises, light weights), periscapular muscles (rows, lat pull-downs), deltoid (progressive resistance)
Initiate sport-specific drills (non-contact): throwing program for overhead athletes, swimming drills, golf swing, tennis groundstrokes
Advance ROM to full active and passive in all planes
Proprioception training (body blade, unstable surface exercises, ball toss drills)
Goals: restore strength to 80-90% of contralateral, prepare for return to sport

Phase 4: Return to Sport Phase (Weeks 16-24)

Advanced strengthening: plyometric exercises (medicine ball throws, push-up variations), sport-specific resistance training
Progressive return to sport: non-contact practice at 4 months, contact practice at 5 months, full competition at 6 months minimum
Criteria for return to full sport: full painless ROM (ER should match contralateral ± 10°), strength ≥90% of contralateral on isokinetic testing, negative apprehension test, patient confidence restored, sport-specific functional testing passed
Goals: safe return to pre-injury sport level

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 22-year-old elite rugby player presents with recurrent right shoulder instability - 3 documented dislocations in the past 12 months, all requiring emergency department reduction. He is right-hand dominant and this is his dominant shoulder. MRI arthrogram shows anteroinferior labral detachment from 3-6 o'clock. You obtain a CT scan which shows 15% glenoid bone loss by best-fit circle method. On examination, he has positive apprehension and relocation tests, but no generalized ligamentous laxity (Beighton score 1/9). He is motivated for surgery. Walk me through your decision-making process - would you offer arthroscopic Bankart repair or Latarjet procedure, and justify your answer with the relevant evidence."

EXCEPTIONAL ANSWER

This is a complex decision requiring systematic evaluation of multiple risk factors and shared decision-making with the patient. I would calculate his ISIS score as my primary decision tool: Age <20 years = 0 points (he's 22), Competitive sport = 2 points (elite rugby), Contact/overhead sport = 2 points (rugby is high-risk contact sport), Shoulder hyperlaxity = 0 points (Beighton 1/9 is normal), Hill-Sachs visible on AP = unknown without reviewing films, Glenoid bone loss visible on AP = likely 2 points given 15% loss on CT. His ISIS score is therefore 6 points minimum, possibly 8 points if Hill-Sachs visible on plain films. With ISIS score ≥6, the literature shows 70% probability of recurrent instability after arthroscopic Bankart repair. His 15% glenoid bone loss is in the controversial 'gray zone' - Burkhart's critical threshold is 20-25%, but Shaha's data suggests increased failure rates above 13.5%. For a 22-year-old elite rugby player who cannot afford mid-season re-injury, I would counsel him that he has two evidence-based options: First option - arthroscopic Bankart repair with acceptance of 20-30% recurrence risk given his high-risk profile, but potentially faster recovery and return to sport at 4-6 months. Second option - primary Latarjet procedure which reduces recurrence risk to 5-10% in his demographic, but requires longer recovery (6-9 months to contact sport) and has different complication profile including hardware complications, nerve injury risk, and arthritis concerns long-term. I would present the data and engage in shared decision-making. My recommendation would lean toward Latarjet given his elite level, contact sport, and inability to accept re-injury mid-career, but would respect informed patient preference for arthroscopic approach if he prioritizes faster return over lower recurrence risk. If arthroscopic Bankart chosen, I would ensure meticulous technique with adequate labral mobilization, anchors on glenoid face not neck, capsular shift, assessment for Hill-Sachs and remplissage if off-track, and strict 6-month return to contact sport timeline.

VIVA SCENARIOStandard

EXAMINER

"You are performing an arthroscopic Bankart repair on a 25-year-old female recreational netball player with recurrent anterior instability. Intraoperatively after completing your labral mobilization and anchor placement, you assess the repair and note that while the superior anchors (3:30 and 2:30 positions) look excellent with good labral height, the inferior-most anchor at 5:30 has labrum sitting low - not proud on the glenoid rim but rather sitting slightly medial on the glenoid neck. When you probe this inferior repair, it feels stable without detachment, but the bumper height is clearly inadequate compared to the superior repair. What is the most likely technical error that led to this appearance, and how would you manage this intraoperatively?"

EXCEPTIONAL ANSWER

This scenario describes inadequate labral bumper height at the inferior-most repair, which is THE most critical area for anterior stability because the IGHL (inferior glenohumeral ligament) originates here and provides 60-70% of anterior restraint in the functional ABER position. The most likely technical error is anchor placement on the glenoid NECK rather than glenoid FACE at the 5:30 position. This is the single most common technical error in arthroscopic Bankart repair, accounting for 30-40% of failures requiring revision surgery. The concept is 'on the dance floor, not in the hallway' - anchors must be on the glenoid face (articular edge, 2-3mm from cartilage) to restore anatomic labral bumper height. When anchors are placed on the glenoid neck (medially, 5-10mm from articular edge), they create an ALPSA-type repair where the labrum sits medially and provides no mechanical block to anterior translation. This is particularly problematic at the inferior position where bone anatomy makes it technically challenging to access the glenoid face with the drill guide from the anteroinferior portal. My intraoperative management would be as follows: First, confirm the diagnosis by viewing from multiple angles - switch arthroscope to anterior portal and view glenoid from lateral perspective to clearly see anchor position relative to articular margin. Second, given that this is the critical inferior stabilizer region and inadequate repair will fail, I would revise the repair NOW rather than accepting suboptimal fixation. The revision technique: place an additional anchor at 5:30 position more LATERAL on the glenoid face (2-3mm from articular cartilage edge), ensuring proper trajectory perpendicular to glenoid surface angled toward glenoid center. Leave the medial anchor in place (provides some capsular support) but recognize it won't provide bumper effect. Pass new sutures through the mobilized labral tissue closer to the labral edge (5-8mm from rim rather than 10-15mm, since we're placing a more lateral anchor). Tie the new lateral anchor to lift the labrum to proper height on the glenoid rim. Re-assess with probe - should now have proper bumper height with labrum proud on glenoid rim throughout the repair including inferiorly. This revision adds 15-20 minutes to operative time but is essential for successful outcome.

VIVA SCENARIOStandard

EXAMINER

"You've completed an arthroscopic Bankart repair with 4 anchors (5:30, 4:30, 3:30, 2:30 positions), knotted suture anchors with capsular shift technique. The repair looks excellent on arthroscopic inspection - good labral bumper height throughout, stable when probed. However, when you check external rotation with the arm at the patient's side, you can only achieve 15 degrees of external rotation (compared to 45 degrees on the contralateral shoulder preoperatively documented in your clinic notes). The patient is a 28-year-old competitive tennis player. What is the differential diagnosis for this restricted external rotation, what are the implications if you accept this and proceed to closure, and what would you do intraoperatively to address this?"

EXCEPTIONAL ANSWER

This scenario describes excessive loss of external rotation (30-degree loss compared to contralateral side), which is above the acceptable threshold and represents pathologic tightness that will lead to postoperative stiffness and patient dissatisfaction. The differential diagnosis includes: First, over-tightening of the capsular repair - most likely if capsular shift was too aggressive (tissue captured too far from glenoid rim >15mm, or excessive tension when tying knots). Second, inadvertent rotator interval closure - if sutures passed too superiorly at the 2:30 anchor position may have captured and closed the rotator interval between supraspinatus and subscapularis, which tightens the SGHL and restricts ER. Third, superior capsular over-plication - extending the repair too far superiorly beyond the pathologic zone (beyond 2 o'clock) creates excessive superior capsular tightness. Fourth, subscapularis capture - if sutures at the 3:30 or 2:30 positions inadvertently passed through subscapularis tendon rather than capsule only, this tethers ER. The implications of accepting this restricted ER and proceeding to closure are serious: high risk of postoperative frozen shoulder (adhesive capsulitis) - studies show ER loss >20° increases frozen shoulder risk 5-fold. Poor functional outcome for overhead athlete (tennis player needs full ER for serving and groundstrokes). Patient dissatisfaction and likely need for manipulation under anesthesia ± arthroscopic capsular release at 4-6 months postop. Potential recurrent instability paradoxically - excessively tight repairs have higher failure rates due to patient non-compliance with rehabilitation and altered biomechanics. My intraoperative management would be systematic assessment and selective release: First, identify which anchor is causing excessive tightness by sequential release test - use arthroscopic scissors to cut one limb of the superior-most anchor (2:30 position) sutures and re-check ER. If ER improves significantly, the 2:30 anchor was over-tight. If no improvement, progressively test the 3:30 anchor. Second, once I identify the problematic anchor(s), I would release and re-tie with LESS tension - capture tissue closer to glenoid rim (8-10mm instead of 15mm reduces capsular shift slightly), or tie with less tension on the knot (looser). Third, if rotator interval was closed inadvertently, release this with arthroscopic scissors. Fourth, target ER goal of 30-40 degrees minimum at arm-in-side position (acceptable loss of 10-15 degrees from contralateral is normal capsular tightening). Re-assess after each modification until adequate ER achieved. For this tennis player, I would actually target closer to 35-40 degrees ER (minimal loss from contralateral) given overhead sport demands, accepting slightly higher recurrence risk in exchange for better functional outcome.

Arthroscopic Bankart Repair - Exam Day Summary

High-Yield Exam Summary

References

Balg F, Boileau P. The instability severity index score: A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007;89(11):1470-1477. [Landmark paper establishing ISIS score as primary risk stratification tool, validated in 131 patients showing score ≥6 predicts 70% failure rate after arthroscopic Bankart]
Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the engaging Hill-Sachs lesion. Arthroscopy. 2000;16(7):677-694. [Landmark study establishing critical bone loss threshold of 25% and inverted pear sign, changed paradigm to Latarjet for significant bone loss]
Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging" lesion to "on-track/off-track" lesion. Arthroscopy. 2014;30(1):90-98. [Established glenoid track concept for Hill-Sachs assessment, mathematical model predicting engagement based on glenoid track width and Hill-Sachs track width]
Shaha JS, Cook JB, Song DJ, et al. Redefining "critical" bone loss in shoulder instability: functional outcomes worsen with "subcritical" bone loss. Am J Sports Med. 2015;43(7):1719-1725. [3D CT analysis of 194 patients identifying 13.5% as critical threshold where recurrence increases significantly, challenged traditional 25% threshold]
Flinkkila T, Hyvonen P, Ohtonen P, Leppilahti J. Arthroscopic Bankart repair: results and risk factors of recurrence of instability. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1752-1758. [Long-term outcomes study showing 20% recurrence at 10 years, identified contact sport and age <25 as primary risk factors]
Kavaja L, Pajarinen J, Sinisaari I, et al. Arthrascopic Bankart repair: 2- to 10-year results. Arthroscopy. 2018;34(7):2084-2091. [Meta-analysis of 48 studies with 3,188 patients, overall recurrence 8.6%, contact athletes 13.2%, established current benchmark outcomes]
Peebles LA, Kuczmarski AS, Higgins JD, et al. Knotless versus knotted soft anchor constructs for Bankart repair: a biomechanical analysis in a human cadaveric model. Am J Sports Med. 2020;48(5):1260-1264. [Biomechanical comparison showing equivalent failure loads and gap formation, knotless 18 minutes faster operative time]
Paterson WH, Throckmorton TW, Koester M, et al. Position and duration of immobilization after primary anterior shoulder dislocation: a systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2010;92(18):2924-2933. [Meta-analysis establishing 4-week minimum immobilization reduces recurrence from 22% to 9% compared to immediate mobilization]
Murray IR, Ahmed I, White NJ, Robinson CM. Traumatic anterior shoulder instability in the athlete. Scand J Med Sci Sports. 2013;23(4):387-405. [Comprehensive review of return to sport outcomes, 85% return to any sport, 65% return to pre-injury level, contact athletes 73% return to same level, average 6 months]
Harris JD, Gupta AK, Mall NA, et al. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013;29(5):920-933. [Systematic review of long-term outcomes (>10 years), recurrence 19%, arthritis progression in 34% (mild), patient satisfaction 88%, established natural history after Bankart repair]

Arthroscopic Bankart Repair for Anterior Shoulder Instability