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Anterior Shoulder Stabilisation (Bankart Repair)

intermediate Level

Primary Indication

Recurrent anterior shoulder instability with documented Bankart lesion (anterior-inferior labral tear), first-time dislocation in young athletic patient (<25 years), or instability with significant glenoid bone loss (<20-25% requiring bony procedure)

Danger Structures

  • Axillary nerve (inferior portal placement)
  • Musculocutaneous nerve (anterior portals too medial)
  • Subscapularis tendon
  • Brachial plexus
  • Cephalic vein
  • Glenoid articular cartilage

Visual Atlas

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Step-by-Step Technique

1

Position in beach chair or lateral decubitus, establish posterior viewing portal

Surgeon's Tip
EXAM KEY: Lateral decubitus provides better inferior access for 5-6 o'clock labral work
Danger Zone
  • Axillary nerve with low portals
  • Inadequate access to inferior labrum
2

Perform diagnostic arthroscopy: assess labrum, glenoid bone loss, Hill-Sachs lesion, rotator cuff

Surgeon's Tip
EXAM KEY: Quantify glenoid bone loss using bare spot method or en-face view. ISIS score predicts recurrence.
Danger Zone
  • Missing bony Bankart
  • Underestimating bone loss
3

Assess Hill-Sachs lesion for engagement - dynamic examination with arm in abduction/external rotation

Surgeon's Tip
EXAM KEY: Engaging Hill-Sachs needs remplissage or bone augmentation - not just soft tissue repair
Danger Zone
  • Missing engaging Hill-Sachs
  • Recurrence from engaging lesion
4

Establish anterior-superior portal (rotator interval) and anterior-inferior portal

Surgeon's Tip
EXAM KEY: Anterior-inferior portal made outside-in using spinal needle to optimize angle for anchor placement
Danger Zone
  • Musculocutaneous nerve (too medial)
  • Cephalic vein
5

Mobilize labrum from glenoid neck, elevate from 3 o'clock to 6 o'clock position

Surgeon's Tip
EXAM KEY: Adequate mobilization is critical - must elevate labrum and subscapularis attachment from medialized position
Danger Zone
  • Inadequate mobilization (main cause of failure)
  • Axillary nerve with inferior dissection
6

Prepare glenoid neck with rasp or burr to create bleeding bone bed

Surgeon's Tip
EXAM KEY: Fresh bleeding surface promotes healing. Remove any fibrous tissue from glenoid face.
Danger Zone
  • Excessive bone removal
  • Glenoid fracture
7

Place first anchor at 5:30 position (6 o'clock in lateral decubitus)

Surgeon's Tip
EXAM KEY: Most inferior anchor is most important - restores inferior bumper effect. Place on glenoid face, not neck.
Danger Zone
  • Anchor too medial (on neck)
  • Axillary nerve injury
8

Pass suture through labrum using suture passer, ensure capsular shift included

Surgeon's Tip
EXAM KEY: Include capsule with labral tissue for capsular shift - this tightens redundant capsule
Danger Zone
  • Labral-only repair (no capsular shift)
  • Suture cutting through tissue
9

Tie sutures using sliding knot followed by alternating half-hitches

Surgeon's Tip
EXAM KEY: Place knot on capsular side (away from joint) to prevent articular damage
Danger Zone
  • Knot in joint surface
  • Loose repair
10

Place subsequent anchors at 30-minute intervals up to 3 o'clock position

Surgeon's Tip
EXAM KEY: Minimum 3 anchors typically needed. Restore labral height above glenoid rim (bumper effect).
Danger Zone
  • Too few anchors
  • Anchors too far apart
11

If ALPSA lesion present (labrum healed medially), mobilize and restore to glenoid rim

Surgeon's Tip
EXAM KEY: ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) needs mobilization back to rim - higher recurrence if left medialized
Danger Zone
  • Incomplete mobilization of ALPSA
  • Failure to recognize lesion pattern
12

If engaging Hill-Sachs present, perform remplissage (infraspinatus tenodesis into lesion)

Surgeon's Tip
EXAM KEY: Remplissage fills Hill-Sachs defect, converts extra-articular. Indicated for >25% humeral head involvement.
Danger Zone
  • Loss of external rotation
  • Capsule over-tightening
13

Final assessment: probe repair stability, assess engagement, check ROM

Surgeon's Tip
EXAM KEY: Repair should be stable to probing. No engagement of Hill-Sachs with arm in ABER position.
Danger Zone
  • Accepting loose repair
  • Over-tightening causing stiffness
14

Document anchor positions, number of anchors, any additional procedures

Surgeon's Tip
EXAM KEY: Photographic documentation important for future reference if revision needed
Danger Zone
  • Inadequate documentation
  • Missing pathology
15

Close portals, apply sling with abduction pillow, begin rehabilitation protocol

Surgeon's Tip
EXAM KEY: Sling for 4-6 weeks, no external rotation past neutral initially. Sport-specific return at 4-6 months.
Danger Zone
  • Early aggressive rehab causing failure
  • Stiffness from prolonged immobilization