Arthroscopic Bankart Repair T he anterior labral complex is composed of the inferior gleno- humeral ligament and anterior la- brum. The complex stabilizes the glenohumeral joint by doubling the depth of the glenoid fossa. 1 Turkel et al 2 showed that this soft-tissue com- plex functions to resist anterior dis- location when the shoulder is posi- tioned at 90° of abduction. It is well appreciated and recognized that an- terior dislocation is commonly asso- ciated with a Bankart lesion, defined as a separation of the anterior inferi- or labral complex from the glenoid rim. 3 Rowe et al 4 reported that 85% of patients with traumatic anterior dislocation had an associated Ban- kart lesion. It is well accepted that open repair of the Bankart lesion re- stores anterior stability to the shoul- der joint and is associated with good functional outcomes. However, in 1987, Morgan and Bodenstab 5 report- ed on the results of arthroscopic re- pair of Bankart lesions in 25 pa- tients; the authors used transglenoid suture fixation with the goal of achieving clinical results similar to those of open repairs while avoiding the surgical dissection associated with open repair. All results were rated excellent, and all patients achieved full, painless range of mo- tion. Subsequent studies of arthroscop- ic Bankart repair showed that the use of osseous anchors leads to low- er rates of recurrent instability com- pared with transglenoid fixation. 6,7 Prospective studies with follow-up >2 years that compared open versus arthroscopic repair of Bankar t le- sions using suture anchors demon- strate no differences in recurrent dis- location rates or clinical outcome scores. 8,9 On the contrary, Fabbri- ciani et al 9 found that arthroscopic repair can lead to greater range of motion compared with open repair. Kim et al 10 recently reported the long-term outcome (mean, 44 months) of arthroscopic Bankart re- pair using suture anchors in 167 pa- tients with traumatic recurrent an- terior instability; they found that arthroscopic repair led to satisfacto- ry outcome in ter ms of recurrence rate, activity, and range of motion. Indications The technical demands of advanced arthroscopic shoulder procedures make indications for arthroscopic Bankart repair surgeon-specific. First, the surgeon must evaluate his or her comfort with arthroscopic in- strumentation and techniques. Ini- tially, the ideal patient for arthro- scopic repair is one who has had traumatic recurrent anterior insta- bility and failed to respond to phys- ical therapy. However, with im- proved understanding of pathology and anatomy, improved instrumen- tation, and improved surgical tech- nique, the indications have expand- ed to include patients with first-time dislocations, recurrent bidirectional instability, atraumatic instability, and even revision following failed previous repair attempts. 11 Arthro- scopic repair in such patients in- volved in high-level contact sports remains controversial, but Pagnani and Dome 12 reported a 90% success rate after open repair in professional football players. Contraindications Contraindications to arthroscopic repair include significant osseous de- fects on either the humeral head (large engaging Hill-Sachs lesions) or the glenoid (inverted pear glenoid), and humeral avulsion of the gleno- humeral ligaments (HAGL) lesion. Although arthroscopic repair of vol- Brian Su, MD, and William N. Levine, MD Dr. Su is Postdoctoral Residency Fellow, Center for Shoulder, Elbow and Sports Medicine, New York Orthopaedic Hospital, Columbia University Medical Center, New York, NY. Dr. Levine is Director of Sports Medicine and Associate Director, Center for Shoulder, Elbow and Sports Medicine, New York Orthopaedic Hospital, Columbia University Medical Center. None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Su and Dr. Levine. Reprint requests: Dr. Levine, 622 W 168th Street, PH-1117, New York, NY 10032. JAmAcadOrthopSurg2005;13:487- 490 Copyright 2005 by the American Academy of Orthopaedic Surgeons. The video that accompanies this article is “Arthroscopic Bankart Repair,” available on the Orthopaedic Knowledge Online website, at http://www5.aaos.org/oko/ jaaos/surgical.cfm Surgical Techniques Volume 13, Number 7, November 2005 487 untary dislocators is contraindicat- ed, patients who have recurrent dislocations or capsulolabral redun- dancy, including multidirectional instability, are becoming increasing- ly suitable candidates for arthroscop- ic repair. Finally, patients with bra- chial plexus or scapulothoracic dysfunction are not candidates for arthroscopic repair. Surgical Technique Our preoperative evaluation in- cludes a thorough history of the traumatic event, including arm posi- tion, energy level, and treatment compliance. The physical examina- tion focuses on confirming the diag- nosis with provocative tests such as apprehension, relocation, anterior release, anterior and posterior load and shift, sulcus sign, the active- compression test, and determination of ligamentous laxity. It is critical to differentiate anterior instability sec- ondary to a Bankart lesion from mul- tidirectional instability, isolated su- perior labrum anterior posterior (SLAP) lesions, and generalized liga- mentous laxity. Examination under anesthesia provides additional information re- garding the primary direction of in- stability and should correlate with the preoperative findings. Imaging includes a standard shoulder radio- graph series (true anteroposterior [AP], AP in internal rotation, AP in external rotation, axillary, and later- al scapular Y) that will demonstrate Hill-Sachs lesions and glenoid defi- ciency. In some cases, to better char- acterize the labral lesion, a magnet- ic resonance arthrogram is obtained when the history and physical exam- ination are suggestive of a SLAP le- sion or when magnetic resonance imaging is equivocal. For all arthroscopic procedures, anesthesia is provided by an inter- scalene block. In most cases of rou- tine anterior instability, the patient is placed in the beach chair position, with use of a pneumatic arm holder. The surgeon may use the lateral de- cubitus position, which offers the advantage of joint distraction; how- ever, caution should be exercised be- cause traction injuries to the arm a re a known complication. If the lateral decubitus position is used, a com- mercially available arm positioner also is used, and 10 lb of traction is applied to the affected extremity. We typically use the lateral decubitus position in cases of concurrent SLAP tears or posterior labral tears, or in patients with multidirectional insta- bility. Diagnostic arthroscopy begins with a posterior portal 2 cm inferior and 1 cm medial to the posterolater- al acromion. An anterosuperior por- tal is then created under arthroscop- ic guidance just lateral and superior to the coracoid so that it pierces the rotator interval and enters the joint level at the insertion of the biceps tendon onto the superior labrum. The cannula should be able to be manipulated above and below the bi- ceps tendon ( video steps 1-3). A second anterior portal at the superi- or aspect of the subscapularis is then created (anteroinferior) so that su- ture anchors can be placed in the in- ferior glenoid. It is impor tant to leave a 3-cm interval between the two anterior portals to allow for ad- equate working space (Figure 1). Of note, threaded cannulas may be use- ful to prevent backout of the cannu- lae during manipulation and knot ty- ing. Diagnostic arthroscopy is per- formed, including evaluation of the glenohumeral ligaments, biceps ten- don, and suspected labral detach- ment. The drive-through sign 13 is performed by passing the arthro- scope between t he humeral head and glenoid at the level of the anterior band of the inferior glenohumeral ligament. The first critical technical step is to mobilize the labral-ligamentous complex from the anterior glenoid neck with a rasp, electric shaver, or elevator. Release of the labrum at the inferior aspect of the glenoid at the 6 o’clock position ( video steps 4-6), and in some cases beyond the 6 o’clock position, is mandatory to allow for proper retensioning of the labral-ligamentous complex (Fig- ure 2). The glenoid is then prepared by decortication with a shaver or burr to a bleeding surface. This is done without creating a trough to promote healing of the soft tissue to Figure 1 External view demonstrating position of anterosuperior and anteroinferior cannulae. Arthroscopic Bankart Repair 488 Journal of the American Academy of Orthopaedic Surgeons the bone (Figure 3). The number of suture anchors used varies with the degree of labral separation; we typi- cally use three uniformly spaced an- chors (on a right shoulder at the 3 o’clock, 4 o’clock, and 5:30 posi- tions) to repair most lesions. The first anchor, located at the 5:30 position, is placed as low as pos- sible by using the anteroinferior por- tal ( video step 7). The anchor must be placed directly on the edge of the articular surface 14 (Figure 4). When a nondisposable single-step device is used (ie, BirdBeak; Arthrex, Naples, FL), then both suture limbs are retrieved through the anterosu- perior cannula. Conversely, when a shuttle-type device is preferred (ie, Suture Lasso; Arthrex), then one su- ture limb is left in the anteroinferi- or cannula and one is taken out via the anterosuperior cannula to avoid suture entanglement ( video step 8). The capsulolabral tissue is then captured with the suture-passing in- strument through the anteroinferior cannula; our preferred technique uses a preloaded suture lasso. One suture limb is then secured; using the niti- nol loop as a lasso, the other limb is delivered out of the anteroinferior cannula ( video step 9). The su- ture tying is done through the antero- inferior portal. The suture anchor must be visible at all times when withdrawing the suture limb from the anterosuperior to the anteroinfe- rior portal to ensure that the suture does not unload from the anchor. This suture, which is the limb that passes through the tissue, acts as the post when the final knot is tied through the anteroinferior cannula. This places the arthroscopic knot fur- ther on the tissue side, creating an anterior buttress, rather than inter- posing the knot between the anchor and soft tissue 14 (Figure 5). Any one of many sliding arthro- scopic knots is then placed; our pre- ferred configuration is the Tennessee slider. One of the most important as- pects of using any sliding knot is maintaining loop security before placing any half-hitches. If there is any slack in the loop, the knot will tighten around itself rather than around the loop of suture around the soft tissue. Three alternating half- hitches are then placed, and the final half hitch is “flipped” to prevent the knot from slipping (knot security). Following placement of the first anchor, the 4 o’clock and 3 o’clock anchors are placed. After adequate repair of the labrum, the drive- through sign should no longer be present (Figure 6). Capsular laxity is then assessed through the posterior portal and the anterosuperior portals to determine the need for an antero- Figure 3 Anterior viewing portal demonstrating glenoid preparation with a burr to optimize labral-ligamentous healing. The arrow indicates the glenoid/ scapula bone preparation. Figure 4 Posterior viewing portal demonstrating suture anchor placement with sutures directly in the articular cartilage margin. Figure 5 Posterior viewing portal demonstrating the post limb (arrows) through the labral-ligamentous complex. Figure 6 Final posterior view of arthroscopic Bankart repair. Figure 2 Arthroscopic view demonstrating labral-ligamentous preparation for arthroscopic repair. The large arrows indicate the labral-ligamentous complex; the small arrows indicate the glenoid rim. Brian Su, MD, and William N. Levine, MD Volume 13, Number 7, November 2005 489 inferior capsular plication procedure. Our preferred technique for plication uses multiple nonabsorbable su- tures. Pearls • The anteroinferior and antero- superior cannulae need to be placed far apart at the skin lev- el (at least 3 cm) for ease of soft- tissue manipulation and suture management. • The labrum must be mobilized to the level of the inferior gle- noid to exclude the possibility of an anterior labral-periosteal sleeve avulsion (ALPSA) le- sion. Pitfalls • When retrieving any suture for use in arthroscopic procedures, always keep the anchor in view to avoid “unloading” the suture from the anchor. • Practice these techniques in a laboratory—the Orthopaedic Learning Center (OLC), local laboratory, or industr y labora- tory—to avoid potential intra- operative complications. Summary and Conclusions Arthroscopic Bankart repair has evolved over the past few decades from a procedure fraught with com- plications to one with decreased pain and improved functional out- come, with little recur rence of insta- bility. With appropriate patient se- lection and knowledge of technical considerations, such as anchor placement and suture management, the results of arthroscopic Bankart repair are approaching those of the traditional gold standard, open re- pair. In addition, cost analysis of ar- throscopic versus open Bankart re- pair shows that the arthroscopic repair is a more time-efficient oper- ation and results in lower overall to- tal costs. 15 Our prefer red technique for Ban- kart repair includes using two work- ing anterior portals separated by at least 3 cm for ease of suture manage- ment. Our technique also includes the use of suture anchors because they have shown superior clinical re- sults compared with transglenoid or tack repairs. Although the use of any one of many multiple suture-passing devices and sliding knot configura- tions is acceptable, it is impor tant to adhere to principles such as ade- quate mobilization of the labrum, glenoid preparation, and appropriate loop security before locking the knot. Finally, arthroscopic labral re- pair has the distinct advantage of ad- dressing concomitant lesions identi- fied at the time of surgery, such as SLAP tears, posterior labral tears, ro- tator cuff t ears, rotator interval tears, and capsular laxity. References 1. Galinat BJ, Howell SM: Abstract: The containment mechanism: The prima- ry stabilizer of the glenohumeral joint. Orthop Trans 1987;11:458. 2. Turkel SJ, Panio MW, Marshall JL, Girgis FG: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63:1208-1217. 3. Bankart A: The pathology and treat- ment of recurrent dislocation of the shoulder joint. Br J Surg 1938;26:23- 29. 4. Rowe CR, Patel D, Southmayd WW: The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 1978;60:1-16. 5. Morgan CD, Bodenstab AB: Arthro- scopic Bankart suture repair: Tech- nique and early results. Arthroscopy 1987;3:111-122. 6. Kandziora F, Jager A, Bischof F, Her- resthal J, Starker M, Mittlmeier T: Arthroscopic labrum refixation for post-traumatic anterior shoulder in- stability: Suture anchor versus trans- glenoid fixation technique. Arthros- copy 2000;16:359-366. 7. TauroJC: Arthroscopic inferior capsu- lar split and advancement for anterior and inferior shoulder instability: Technique and results at 2- to 5-year follow-up. Arthroscopy 2000;16:451- 456. 8. Cole BJ: Comparison of arthroscopic and open anterior shoulder stabiliza- tion: A two- to six-year follow-up study. J Bone Joint Surg Am 2000;82: 1108-1114. 9. Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas PD: Arthro- scopic versus open treatment of Ban- kart lesion of the shoulder: A prospec- tive randomized study. Arthroscopy 2004;20:456-462. 10. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I: Arthroscopic anterior stabilization of the shoulder: Two- to six-year follow-up. J Bone Joint Surg Am 2003; 85:1511-1518. 11. Kim SH, Ha KI, Kim YM: Arthroscop- ic revision Bankart repair: A prospec- tive outcome study. Arthroscopy 2002;18:469-482. 12. Pagnani MJ, Dome DC: Surgical treat- ment of traumatic anterior shoulder instability in American football play- ers. J Bone Joint Surg Am 2002;84:711- 715. 13. McFarland EG, Neira CA, Gutierrez MI, Cosgarea AJ, Magee M: Clinical significance of the arthroscopic drive- through sign in shoulder surgery. Ar- throscopy 2001;17:38-43. 14. De Beer JF: Arthroscopic Bankart re- pair: Some aspects of suture and knot management. Arthroscopy 1999;15: 660-662. 15. Barber FA, Click SD, Weideman CA: Arthroscopic or open Bankart proce- dures: What are the costs? Ar thros- copy 1998;14:671-674. Arthroscopic Bankart Repair 490 Journal of the American Academy of Orthopaedic Surgeons