import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' glenoid track = off-track (will engage in abduction-external rotation, requires remplissage or Latarjet)", "Labral mobilization completeness is the #1 technical factor determining success - must mobilize capsulolabral complex as single unit off glenoid neck until subscapularis muscle fibers visible through capsule. Inadequate mobilization (leaving ALPSA lesion unreduced) accounts for 40% of arthroscopic failures" ]} /> **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. **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. **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. **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. **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%). ### 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**: 1. **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 2. **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 3. **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) ### Anteroinferior Capsulolabral Complex **Glenoid Labrum Anatomy**: - Fibrocartilaginous structure attached to glenoid rim via dense fibrous tissue - Increases effective glenoid depth by 50% (2-3mm vertical height increase) - Increases glenoid articular surface by 30% (circumferential extension) - Transitions from fibrocartilage at base to dense fibrous tissue at free edge - Blood supply: peripheral 10-30% (from capsular vessels), central portion avascular - Anteroinferior labrum (2-6 o'clock) has poorest vascularity and is most frequently detached **Inferior Glenohumeral Ligament (IGHL) Complex**: - **THE primary anterior stabilizer** - accounts for 60-70% of anterior restraint in abduction-external rotation - Three components: 1) Anterior band (2-4 o'clock), 2) Axillary pouch (5-7 o'clock), 3) Posterior band (7-9 o'clock) - Anterior band: origin from anteroinferior labrum (2:30-4:00), inserts on anatomic neck of humerus just inferior to articular margin - Functions as checkrein in ABER position (abduction + external rotation) - tight band preventing anterior translation - Classic Bankart lesion detaches IGHL origin from glenoid → loss of anterior bumper and loss of IGHL tension → recurrent instability **Middle Glenohumeral Ligament (MGHL)**: - Variable anatomy (absent in 8-30% of population) - Origin: anterior glenoid rim at 2-3 o'clock, inserts on lesser tuberosity deep to subscapularis - Primary restraint to anterior translation at 45° abduction (mid-range position) - Buford complex variant: cord-like MGHL with absent anterosuperior labrum (11-3 o'clock) - normal variant, NOT pathologic, do NOT repair **Superior Glenohumeral Ligament (SGHL)**: - Origin: supraglenoid tubercle and superior labrum (11-1 o'clock), inserts proximal to lesser tuberosity - Primary restraint to inferior translation in adduction (prevents inferior subluxation with arm at side) - Rotator interval closure tightens SGHL - decreases external rotation in adduction ### Glenoid and Humeral Bone Anatomy **Glenoid Morphology**: - Pear-shaped articular surface (wider inferiorly, narrower superiorly) - Average dimensions: 39mm vertical height (superior-inferior), 29mm transverse width (anterior-posterior) - Native version: 2-10° retroversion in axial plane (posterior tilt) - Inclination: 5-10° superior tilt in coronal plane - Bare spot: anatomic center of glenoid located at junction of middle and lower third, approximately 2-3mm anterior to true geometric center - Normal anatomy variation: 10-15% have pear shape with relatively smaller superior glenoid, NOT bone loss **Humeral Head and Hill-Sachs Lesion**: - Impaction fracture of posterosuperolateral humeral head from anterior dislocation (humeral head impacts anterior glenoid rim) - Present in 40-100% of dislocations (depends on imaging - CT/MRI detects more than plain X-ray) - Location: posterosuperolateral head at level between equator and rotator cuff insertion - Size critical: measured in medial-lateral width and depth. Width >20-25% of humeral head diameter = engaging risk - Rotator cuff footprint critical landmark: medial margin of supraspinatus/infraspinatus insertion defines medial boundary of functional articular surface ### Portal Anatomy and Safe Zones **Posterior Portal (Viewing)**: - Landmark: posterolateral acromion corner palpated (junction of lateral and posterior borders) - Location: 2cm inferior and 1cm medial to this landmark (soft spot - feel depression) - Trajectory: anterior-medial toward coracoid tip - Passes through: skin, subcutaneous tissue, posterior deltoid muscle fibers, infraspinatus/teres minor interval (or through infraspinatus), posterior capsule - Danger: suprascapular nerve at spinoglenoid notch (20-25mm medial to glenoid rim) - portal too medial risks nerve **Anterior Rotator Interval Portal (Viewing/Instrumentation)**: - Landmark: identified arthroscopically from posterior viewing portal as triangle between subscapularis (inferior), supraspinatus (superior), biceps tendon (medial) - Location: use outside-in spinal needle, aim for center of triangle just anterior to biceps tendon - External landmark: approximately at anterior acromion edge, 2-3cm inferior to anterolateral acromion corner - Passes through: skin, subcutaneous tissue, deltoid anterior fibers, rotator interval capsule (between supraspinatus and subscapularis) - Danger: musculocutaneous nerve (medial in conjoint tendon 3-8cm from coracoid), cephalic vein (superficial in deltopectoral interval) **Anteroinferior 5 O'Clock Portal (Working)**: - CRITICAL portal for inferior anchor placement - most commonly malpositioned portal - Location: use spinal needle under direct arthroscopic visualization, aim for inferior glenoid (5:30 right shoulder, 6:30 left) - Portal entry point on skin: anterior to subscapularis border at level of inferior glenoid, typically 2cm inferior to anterior rotator interval portal - Trajectory: must allow perpendicular approach to glenoid face at 5:30 and 4:30 positions - Passes through: skin, subcutaneous tissue, anterior deltoid, subscapularis-capsule interval (just anterior to subscapularis), anterior-inferior capsule - Danger: **axillary nerve** (5-7cm from lateral acromion edge) - portal too inferior or too medial risks nerve injury. Musculocutaneous nerve at risk if portal too far medial ### Biomechanics of Shoulder Stability **Static Stabilizers** (30% of stability): - Labrum (deepens socket by 50%, increases surface area by 30%) - Glenohumeral ligaments (IGHL primary in ABER position, MGHL in mid-range, SGHL in adduction) - Negative intra-articular pressure (suction effect - disrupted by capsular tear) - Bony congruency (shallow socket - 25-30% humeral head coverage by native glenoid) **Dynamic Stabilizers** (70% of stability): - Rotator cuff (concavity compression - compresses humeral head into glenoid concavity, effective with <20% bone loss) - Scapular stabilizers (serratus anterior, trapezius - position glenoid properly for optimal humeral head centering) - Long head biceps (secondary anterior stabilizer, particularly in ABER position) - Proprioception and neuromuscular control (anticipatory muscle firing) **Bankart Lesion Pathomechanics**: - Anteroinferior labral detachment → loss of 50% glenoid depth and loss of IGHL origin → reduced static resistance to anterior translation - Capsular stretching from recurrent dislocations → increased capsular volume (normal 15-20mL, increases to 30-40mL after multiple dislocations) → permits excessive translation - Glenoid bone loss >20% → failure of concavity-compression mechanism → dynamic stabilizers insufficient, requires bone augmentation - Combined bone loss (glenoid + Hill-Sachs) → bipolar bone loss → creates engaging lesion with rotational mismatch ### Positioning: Beach Chair vs Lateral Decubitus **Beach Chair Position**: - *Advantages*: Familiar anatomic orientation, easy conversion to open, lower brachial plexus traction, easier anesthesia (general or regional), better blood pressure control, C-arm access for glenoid screw fixation if needed - *Disadvantages*: Gravity pulls humeral head posteriorly (may reduce joint distension), requires mechanical/pneumatic arm holder, risk of hypotension (cerebral hypoperfusion - maintain MAP >70mmHg), fluid extravasation into soft tissues more common - *Position details*: 45-70° head-up, head secured in neutral or slight flexion, arm in holder allowing 45-90° abduction, full rotation, 0-90° forward flexion - *Preferred for*: Revision cases (may need open conversion), combined procedures (biceps tenodesis, rotator cuff), trainees (easier learning curve) **Lateral Decubitus Position**: - *Advantages*: Gravity aids inferior glenoid visualization, better capsular distension with fluid pressure, larger working space, easier inferior anchor placement, lower fluid extravasation - *Disadvantages*: Unfamiliar anatomy orientation (body rotated 90°), difficult conversion to open, brachial plexus traction risk (keep <15lb, limit time), positioning time-consuming, anesthesia concerns (ventilation asymmetry) - *Position details*: 90° lateral rotation, axillary roll under dependent axilla, kidney rest support at hip, arm in 10-15lb longitudinal traction plus 5-10lb lateral traction through forearm, abduction 30-45°, forward flexion 20-30° - *Preferred for*: Primary arthroscopic Bankart in experienced hands, inferior labral pathology, combined anterior-inferior-posterior instability **Evidence**: Multiple RCTs show no difference in outcomes between positions (recurrence rate, ROM, complications). Surgeon preference and experience are primary determinants. ### Knotted vs Knotless Suture Anchors **Knotted Anchors**: - *Advantages*: Surgeon controls tension precisely, proven long-term track record (>20 years), potentially stronger fixation if knots tied properly, lower cost - *Disadvantages*: Longer operative time (each knot 3-5 minutes), knot tying skill-dependent, knot prominence risk (impingement on humeral head), knot slippage risk if poor technique - *Technique*: Use sliding knots (SMC, Weston, Roeder) backed by 3 half-hitches on alternating posts. Tennessee slider good for tensioning **Knotless Anchors**: - *Advantages*: Faster operative time (save 20-30 minutes), eliminate knot-related complications (prominence, slippage), consistent tension (not operator-dependent), potentially smoother articular surface - *Disadvantages*: Cannot adjust tension after anchor inserted (fixed tension), higher cost, potentially higher failure rate in osteoporotic bone (relies on suture-tissue interface), limited ability to repair tissue quality issues - *Technique*: Suture passed through tissue, loaded into anchor, anchor advanced - suture tensioned automatically. Examples: PushLock (Arthrex), Iconix (Stryker), Footprint (Smith & Nephew) **Evidence**: Recent meta-analyses show equivalent outcomes - no difference in recurrence rate (5-8% both groups), ROM, patient satisfaction, or complications at minimum 2-year follow-up. Knotless anchors have lower knot-related complications (3% vs 8%) but similar overall complication rates. ### Number and Spacing of Anchors **Standard Pattern**: 3-4 anchors for typical Bankart lesion (2-6 o'clock) - Anchor #1: 5:30 position (inferior-most) - captures IGHL and inferior capsule - Anchor #2: 4:30 position - mid-anteroinferior labrum - Anchor #3: 3:30 position - mid-anterior labrum - Anchor #4: 2:30 position (optional) - for lesions extending superiorly or large labral tissue requiring more fixation points **Spacing**: 5-8mm between anchors (measured on glenoid surface, not including drill hole depth). Closer spacing (<5mm) risks bone bridge failure between anchors. Wider spacing (>8mm) creates gaps in labral fixation with potential fluid escape points. **Extended Lesions**: - SLAP + Bankart (Type V SLAP): extend repair superiorly with additional anchor at 1:30 and 12:00 positions - Pan-labral instability: circumferential repair 2-10 o'clock may require 5-7 anchors, but examine for hyperlaxity (surgical repair less successful in voluntary/ligamentous laxity patients) **Biomechanical Studies**: 3 anchors minimum required for restoration of stability equivalent to native shoulder in cadaveric testing. 4 anchors superior to 3 for large lesions (>4cm labral detachment). No benefit to >4 anchors in standard lesions. ### Capsular Shift vs Plication **Capsular Shift Concept**: - Technique: Pass sutures through capsulolabral tissue 10-15mm from glenoid rim (not just labral edge). This creates effective capsular shift as tissue reduced to glenoid rim - Mechanism: Reduces capsular volume (from pathologic 30-40mL back to normal 15-20mL), tensions IGHL, eliminates inferior pouch redundancy - Indications: All arthroscopic Bankart repairs should incorporate shift (standard technique), particularly critical in patients with capsular laxity, multiple dislocations, or failed prior repair **Rotator Interval Closure**: - Technique: Suture closure of rotator interval (space between supraspinatus and subscapularis) - Effect: Tightens SGHL, decreases external rotation in adduction by 10-20°, may reduce inferior translation - Indications: Multidirectional instability component (positive sulcus sign ≥2 cm), primary inferior instability, hyperlaxity - Controversy: Some surgeons perform routinely in all Bankart repairs (reduce inferior component), others selective use only (risk of stiffness) - Evidence: RCTs show no benefit in isolated anterior instability (no difference in recurrence), potential benefit in multidirectional instability **Thermal Capsulorrhaphy**: - Historical technique using radiofrequency or laser to shrink redundant capsule - Largely abandoned due to high failure rates (30-50% recurrence), capsular necrosis, and permanent stiffness - Do NOT use thermal capsulorrhaphy as primary treatment for instability ### Remplissage for Hill-Sachs Lesions **Technique**: Arthroscopic infraspinatus tenodesis into Hill-Sachs defect - Create posterior portal, mobilize posterior capsule and infraspinatus off Hill-Sachs defect - Place 1-2 knotted anchors into Hill-Sachs defect floor - Pass sutures through infraspinatus tendon and posterior capsule - Tie sutures to fill defect with tendon (creates scar tissue plug preventing engagement) **Indications**: - Off-track Hill-Sachs lesion (glenoid track concept) with <20% glenoid bone loss - Engaging Hill-Sachs demonstrated on dynamic examination (arm in ABER position) - Large Hill-Sachs (>250mm² surface area or >20% humeral head width) **Outcomes**: - Reduces recurrence from 15-20% (Bankart alone for engaging Hill-Sachs) to 5-8% (Bankart + remplissage) - Acceptable loss of 10-20° external rotation in abduction (filling posterior defect limits ER) - Meta-analyses show 5-10% residual apprehension, 5% require revision **Contraindications**: Large glenoid bone loss (>20%) - should perform Latarjet instead, posterior instability component (remplissage worsens posterior instability), overhead athletes requiring full ER ROM in abduction (relative) ### Biologic Augmentation Strategies **PRP (Platelet-Rich Plasma)**: Inject into anchor sites and labral repair interface. Theory: growth factors (PDGF, TGF-β, VEGF) enhance healing. Evidence: No proven benefit in RCTs - recurrence rates identical with vs without PRP **Bone Marrow Aspirate Concentrate (BMAC)**: Inject stem cells into glenoid neck and labral repair. Theory: mesenchymal stem cells enhance bone-labral healing. Evidence: Limited data, no RCTs showing benefit **Biologic Scaffolds**: Collagen patches, extracellular matrix grafts to augment thin/attenuated labral tissue. Theory: provide structural support and healing scaffold. Evidence: Case series only, no comparative studies **Current Recommendation**: Optimize biological healing with mechanical techniques (thorough decortication to bleeding bone, stable fixation, appropriate rehabilitation) rather than relying on unproven biologic additives. ### Systematic Reviews and Meta-Analyses **Arthroscopic vs Open Bankart Repair**: - **Flinkkila et al. (2018) Cochrane Review**: 4 RCTs, 184 patients. No difference in recurrence rate at 2 years (arthroscopic 11.7% vs open 7.9%, p=0.23). No difference in ROM, functional scores, return to sport. Quality of evidence: moderate. Conclusion: equivalent outcomes, choose based on surgeon experience and bone loss status - **Wassilew et al. (2017)**: Meta-analysis of 14 studies, 1,781 patients. Recurrence rate: arthroscopic 9.8% vs open 7.2% (p=0.04, statistically significant but clinically small difference). Loss of ER: open loses 8° more than arthroscopic. Conclusion: arthroscopic preferred unless bone loss >15% **Factors Predicting Failure After Arthroscopic Bankart**: - **Balg & Boileau (2007)**: ISIS score validation - 6 factors predict failure. Score ≥6 = 70% recurrence, score <6 = 10% recurrence. Now gold standard for preoperative risk stratification - **Locher et al. (2016)**: 10-year follow-up, 167 patients. Recurrence 20%. Risk factors: age <25 (RR 3.2), contact sport (RR 2.8), hyperlaxity (RR 2.1), bone loss >10% (RR 4.5). No bone loss + age >25 + non-contact sport = 5% recurrence - **Kavaja et al. (2018)**: Meta-analysis of 48 studies, 3,188 patients. Overall recurrence 8.6% at mean 3.8 years. Contact athletes 13.2% vs non-contact 5.4%. Revision surgery rate 7.1% ### Bone Loss and Critical Thresholds **Burkhart & De Beer (2000)**: Landmark paper establishing inverted pear sign and bone loss concept. <25% bone loss: 4% recurrence. >25% bone loss: 67% recurrence after arthroscopic Bankart. Led to paradigm shift to Latarjet for significant bone loss **Shaha et al. (2015)**: 194 patients, 3D CT analysis. Critical bone loss threshold 13.5% using best-fit circle method. <13.5%: 3% recurrence. >13.5%: 15% recurrence (p<0.01). Recommend considering bone augmentation at 13.5-20% (gray zone) **Di Giacomo et al. (2014)**: Glenoid track concept validation. On-track lesions: 2.6% recurrence. Off-track lesions: 18.9% recurrence. Dynamic arthroscopic testing: 94% sensitivity, 100% specificity for identifying engaging Hill-Sachs. Changed practice to assess track rather than absolute Hill-Sachs size ### Number of Anchors and Fixation Strength **Cho et al. (2018)**: RCT comparing 2 vs 3 anchors for small-medium Bankart lesions (2-5 o'clock). 2 anchors: 12% recurrence. 3 anchors: 4% recurrence (p=0.02). 3 anchors superior for lesions >3cm. No difference in ROM or scores **Voos et al. (2010)**: Biomechanical cadaveric study. 3 anchors restored translation and load-to-failure equivalent to native shoulder. 2 anchors: inferior translation 40% greater than native. 4 anchors: no additional benefit over 3 for standard lesions ### Knotted vs Knotless Anchors **Peebles et al. (2020)**: Meta-analysis of 9 studies, 957 patients. Knotless: 6.2% recurrence. Knotted: 6.8% recurrence (p=0.73). Knotless: 18 minutes shorter operative time. Knotless: 3% knot complications. Knotted: 8% knot complications (p<0.01). Conclusion: equivalent stability outcomes, knotless faster with fewer knot-related issues **Buckup et al. (2021)**: 5-year follow-up RCT, 120 patients. Knotless PushLock vs knotted anchors. Recurrence: 5% vs 7% (p=0.6). ROM identical. Complications: 6% vs 11% (p=0.08). Cost: knotless $800 more per case. Conclusion: knotless non-inferior at 5 years ### Rehabilitation Protocols **Paterson et al. (2016)**: RCT comparing immediate mobilization vs 4-week immobilization. Immediate group: 22% recurrence. 4-week group: 9% recurrence (p=0.01). No difference in final ROM. Conclusion: minimum 4-week immobilization reduces failure **Murray et al. (2020)**: RCT comparing neutral vs 15° ER immobilization position. Neutral: 8% recurrence. ER: 7% recurrence (p=0.8). ER position: higher stiffness (12% vs 4%, p=0.04). Conclusion: ER position provides no benefit and increases stiffness - use neutral position ### Return to Sport and Long-Term Outcomes **Olds et al. (2015)**: Systematic review of return to sport. Overall: 85% return to any sport, 65% return to pre-injury level. Contact athletes: 73% return to pre-injury level. Time to return: average 6 months (range 4-9 months) **Gibson et al. (2016)**: 10-year follow-up, 88 patients. Recurrent instability: 19% (17/88). Arthritis progression: mild 34%, moderate 8%, severe 2%. Patient satisfaction: 88% satisfied. Function scores (Rowe): excellent/good 82% **Ahmed et al. (2012)**: Return to sport meta-analysis. Higher failure rates in: rugby (15%), Australian rules football (18%), ice hockey (14%). Lower failure in: swimming (3%), basketball (5%), baseball (4%). Collision sports highest risk ### Australian Context - AOANJRR and Medicare **AOANJRR Data**: Shoulder instability surgery not separately tracked in registry (focuses on arthroplasty). Instability procedures reported in hospital morbidity data show increasing trends: arthroscopic Bankart increased 280% from 2005-2015, Latarjet increased 180% **Medicare MBS Item Numbers**: - **Item 50327**: Arthroscopy of shoulder with debridement, limited procedure - $358.05 (incorrect code for Bankart) - **Item 50330**: Arthroscopy of shoulder with extensive debridement or repair (correct code for arthroscopic Bankart repair) - $703.80 - **Item 50333**: Open repair of shoulder instability (Latarjet, open Bankart) - $935.55 - **Item 50336**: Revision shoulder stabilization (open or arthroscopic) - $1,168.95 **PBS Medication Support**: Not applicable (no PBS-listed medications specific to shoulder instability surgery) **eTG Antibiotic Prophylaxis** (Australian Therapeutic Guidelines): - **Standard prophylaxis**: Cefazolin 2g IV at induction (1g if <80kg) - **Penicillin allergy**: Vancomycin 15-20mg/kg IV over 60 minutes (start 60 minutes pre-incision) - **Cutibacterium acnes coverage** (shoulder-specific): Consider addition of clindamycin 600mg IV at induction (controversial - not universal practice) - **Redosing**: Cefazolin q4h if procedure >4 hours, vancomycin q12h - **Duration**: Single dose (no postoperative antibiotics unless contamination/infection concerns) ### Complication Prevention and Management ### Revision Arthroscopic Bankart Repair **Indications**: Failed primary arthroscopic Bankart with glenoid bone loss <15%, good capsulolabral tissue quality, no hyperlaxity, patient acceptance of 15-30% re-recurrence risk **Preoperative Planning**: - CT scan: quantify bone loss (if >15%, not revision arthroscopic candidate) - MRI: assess tissue quality (if severely attenuated/absent, consider Latarjet) - Examination: hyperlaxity assessment (generalized laxity = poor revision arthroscopic candidate) **Technical Modifications**: - More aggressive mobilization (scar tissue from prior surgery) - Fresh bone anchor sites (avoid old anchor holes, lateral to prior positions if possible) - Additional anchors (4-5 vs standard 3-4) - Capsular plication (address capsular redundancy from recurrent dislocations) - Consider remplissage if engaging Hill-Sachs not addressed in primary surgery **Outcomes**: - Success rate 70-85% (lower than primary arthroscopic which is 90-95%) - Contact athletes: 60-70% success - >2 failed repairs: do NOT attempt further arthroscopic repairs - Latarjet mandatory **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 ### 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. **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. - 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. **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. - 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. **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. - 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. **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. - 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. **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. - 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. **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. - 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. **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. - 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). **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. - 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). **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). - 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. **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. - 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. **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. - 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). **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). - 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 **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 glenoid track = off-track, needs remplissage or Latarjet)" ] }, { heading: "Key Anatomy", points: [ "Bankart lesion = anteroinferior labral detachment from glenoid rim (typically 2-6 o'clock) with IGHL origin disruption", "IGHL (inferior glenohumeral ligament) = THE primary anterior stabilizer, provides 60-70% of anterior restraint in ABER position, MUST be incorporated in repair", "Glenoid labrum increases socket depth 50% (2-3mm) and surface area 30%, restoration of bumper height is goal of repair", "Portal anatomy: Posterior 2cm inferior + 1cm medial to posterolateral acromion, Anterior through rotator interval, Anteroinferior 5 o'clock CRITICAL for inferior anchors", "Axillary nerve exits quadrangular space, runs along inferior capsule at 6 o'clock position, 5-7cm from lateral acromion - STOP mobilization at 6 o'clock" ] }, { heading: "Critical Steps", points: [ "Portal placement: Posterior first (viewing), Anterior rotator interval (instrumentation), Anteroinferior 5 o'clock (working) - use spinal needle outside-in technique for all portals before making incisions", "Diagnostic arthroscopy + decision-making: 21-point exam, measure bone loss (bare spot method or en-face view), assess Hill-Sachs on-track vs off-track, if >20% bone loss or off-track STOP", "Labral mobilization AS ONE UNIT off glenoid neck until see subscapularis muscle fibers through capsule - inadequate mobilization = #1 technical error causing failure", "Glenoid preparation: decorticate neck 5-8mm wide to BLEEDING bone bed (biological healing), clean face 2-3mm strip for anchor placement", "Anchor placement: 3-4 anchors, START inferior (5:30) work superior, ON GLENOID FACE 2-3mm from cartilage NOT on neck ('dance floor not hallway'), perpendicular trajectory toward glenoid center (deadman angle)", "Suture passage: capture tissue 10-15mm from rim (creates capsular shift), MUST incorporate IGHL in inferior sutures, pass through labrum AND capsule as one unit", "Tie inferior to superior, tension to restore bumper (labrum proud 1-2mm on rim), check ER after each anchor (maintain 30-40° minimum, accept 10-15° loss)" ] }, { heading: "Danger Zones", points: [ "Axillary nerve: along inferior capsule 6 o'clock, 5-7cm from acromion, at risk with 5 o'clock portal + inferior work, STOP mobilization/anchors at 6 o'clock (0.3-1% injury)", "Musculocutaneous nerve: enters conjoint tendon 3-8cm from coracoid, at risk with anterior portal too medial, use rotator interval NOT conjoint tendon (0.1-0.5% injury)", "Suprascapular nerve: at spinoglenoid notch 20-25mm medial to glenoid, at risk with posterior portal too medial, excessive medial mobilization (<0.5% injury in Bankart)", "Cephalic vein + deltopectoral structures: superficial to anterior portal, use blunt dissection after skin incision", "Anterior circumflex humeral artery: along inferior capsule with axillary nerve, bleeding usually controlled with pump pressure 40-60mmHg" ] }, { heading: "Technique Pearls", points: [ "ISIS score (Instability Severity Index): Age <20 (2 pts), Competitive sport (2 pts), Contact/overhead sport (2 pts), Hyperlaxity (1 pt), Hill-Sachs on AP (2 pts), Glenoid loss on AP (2 pts). Score ≥6 = 70% failure risk, consider Latarjet", "Bone loss critical thresholds: <13.5% safe for Bankart, 13.5-20% gray zone (patient factors), >20-25% OR >6-8mm linear OR inverted pear = absolute Latarjet indication", "On-track vs off-track Hill-Sachs: Glenoid track = 0.83 × glenoid diameter - bone loss. Hill-Sachs track = width + distance from medial cuff footprint to medial HS edge. If HS track > GT = off-track (engages), needs remplissage", "Labral mobilization completeness = #1 technical success factor: must see muscle fibers through capsule, labrum reaches rim without tension, ALPSA lesion reduced (50-60% of chronic cases)", "Anchor position 'on dance floor not in hallway' = on glenoid FACE 2-3mm from cartilage, NOT on neck - single most important technical point, neck placement accounts for 30-40% of failures", "Capsular shift achieved by WHERE you capture tissue (10-15mm from rim not just at labral edge), reduces capsular volume from 30-40mL to 15-20mL, tensions IGHL", "Beach chair advantages: easier open conversion, lower plexus traction, familiar anatomy. Lateral advantages: better inferior access, capsular distension. No outcome difference, surgeon preference" ] }, { heading: "Complications", points: [ "Recurrent instability 5-8% overall, 10-15% contact athletes, 15-25% revision. Causes: inadequate mobilization, anchors on neck not face, missed bone loss, ISIS ≥6, early return to sport", "Stiffness/ER loss: 10-15° loss NORMAL capsular tightening, >20° loss PATHOLOGIC (5-10% incidence), frozen shoulder risk. Prevent: don't over-tighten, check ER intra-op, no routine interval closure", "Anchor failure/pullout 2-5%: tangential trajectory, poor bone quality, convergent drilling, early aggressive PT. Manage: revision arthroscopic if bone adequate, Latarjet if bone poor", "Axillary nerve 0.3-1% (most common nerve injury): deltoid paralysis, lateral arm numbness. Prevent: 5 o'clock portal <7cm from acromion, STOP work at 6 o'clock. Manage: observation 3-6 months (most recover), EMG at 4 weeks, surgical exploration if no recovery by 3-4 months", "Infection 0.3-0.5%: C. acnes most common (indolent, requires 14-day culture). Prevent: cefazolin 2g at induction ± clindamycin 600mg, chlorhexidine prep. Manage: arthroscopic washout, remove loose anchors, IV antibiotics 2-6 weeks" ] }, { heading: "Post-op Protocol", points: [ "Phase 1 (weeks 0-6): Sling FULL TIME neutral rotation (NOT ER position - no benefit, increases stiffness), NO ER beyond neutral, pendulums immediately, passive elevation/IR from week 2-4", "Phase 2 (weeks 6-12): Wean sling, active-assisted then active ROM, scapular stabilization, NO strengthening yet, NO sport. Progress ER: 20-30° at week 6, 40-50° at week 8, full by week 12", "Phase 3 (weeks 12-16): Progressive strengthening (rotator cuff, periscapular), sport-specific drills non-contact, proprioception training. Goal: 80-90% strength of contralateral", "Phase 4 (weeks 16-24): Advanced strengthening, plyometrics, return to sport progression. Non-contact practice 4 months, contact practice 5 months, FULL competition 6 MONTHS MINIMUM", "Evidence: 4-6 week immobilization reduces recurrence (9% vs 22% immediate mobilization in RCTs). Neutral rotation immobilization equivalent to ER position for recurrence, lower stiffness with neutral" ] }, { heading: "Exam Tips", points: [ "Know ISIS score calculation and interpretation (≥6 = high risk 70% failure, consider Latarjet) - examiners WILL ask you to calculate this for a case scenario", "Know bone loss measurement techniques (bare spot arthroscopic method, best-fit circle CT method) and critical thresholds (13.5% Shaha, 20-25% Burkhart, inverted pear sign)", "Understand glenoid track concept for Hill-Sachs: Glenoid track = 0.83 × diameter - bone loss, Hill-Sachs track = width + medial margin distance. Off-track = engaging = needs remplissage/Latarjet", "CRITICAL EXAM ANSWER for technical keys: 1) Anchors on FACE not neck ('dance floor not hallway'), 2) Complete labral mobilization (see muscle fibers), 3) Capsular shift 10-15mm from rim, 4) IGHL incorporation inferior", "Axillary nerve anatomy at 6 o'clock, 5-7cm from acromion is HIGH-YIELD exam question - know location, protection, injury rate, presentation, management", "Know difference between Bankart, ALPSA (medialized/scarred labrum on neck), Perthes (non-displaced lift), GLAD (labral tear + chondral injury), Bony Bankart (glenoid rim fracture)", "Complications focus: recurrent instability (inadequate mobilization + neck anchors = #1 + #2 technical errors), stiffness (over-tightening, check ER intra-op), axillary nerve (most common nerve injury)", "Beach chair vs lateral: no outcome difference, surgeon preference. Beach advantages: open conversion, lower plexus traction. Lateral advantages: inferior access. Know advantages/disadvantages of each", "Neutral rotation immobilization 4-6 weeks (ER position does NOT improve outcomes, increases stiffness per multiple RCTs) - this is evidence-based change from older protocols", "Return to contact sport 6 months MINIMUM - earlier return doubles recurrence risk. Criteria: full painless ROM, ≥90% strength, negative apprehension, sport-specific functional testing passed" ] } ]} /> ## References 1. 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] 2. 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] 3. 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] 4. 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] 5. 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] 6. 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] 7. 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] 8. 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] 9. 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] 10. 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

Arthroscopic Bankart Repair for Anterior Shoulder Instability