Abstract
Background:
Despite technical advancements, recurrent glenohumeral joint instability after surgical treatment is still a major issue. Challenging conventional arthroscopic Bankart repair, the labral bridge technique provides an even labral compression to the glenoid rim, potentially enabling anatomic healing and lasting stability.
Purpose:
To evaluate clinical outcomes after arthroscopic Bankart repair using the labral bridge technique at a short-term follow-up.
Study Design:
Case series; Level of evidence, 4.
Methods:
Patients aged 18 to 50 years with traumatic first-time or recurrent shoulder dislocation treated with the arthroscopic labral bridge technique and an early motion rehabilitation protocol were consecutively included. Exclusion criteria were concomitant fractures, bony defects >10%, multidirectional shoulder instability, previous shoulder surgery, epilepsy, or chronic alcohol or drug abuse. Postoperative shoulder stability was assessed using the Rowe score. Patient-reported outcome measures, including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), and Visual Analog Scale (VAS) for pain were evaluated preoperatively and after a minimum of 2 years.
Results:
A total of 46 patients (mean age, 28.9 ± 9.0 years) were included. At the final follow-up (mean, 35.8 ± 10.3 months), 2 patients (4.3%) experienced a recurrent traumatic anterior dislocation. The Rowe score improved significantly with lasting stability compared to preoperative levels (mean, 93.0 ± 16.7 postoperatively vs 37.8 ± 15.2 preoperatively; P < .001). Except for a significant improvement in forward flexion by 10.5° (P = .013), no differences in postoperative range of motion were observed compared to preoperative levels. The ASES score, SANE, and VAS for pain improved significantly compared to preoperative levels (all P < .001). The minimal clinically important difference was reached by 92.7% of patients for the Rowe score, 92.9% for the ASES score, 83.3% for the SANE, and 73.8% for the VAS for pain. The patient acceptable symptom state was achieved by 92.9% of patients for the ASES score, 83.3% for the SANE, and 97.6% for the VAS for pain.
Conclusion:
Arthroscopic Bankart repair with the labral bridge technique for the treatment of anterior shoulder instability demonstrates a low recurrent shoulder instability rate and significant improvements in clinical and functional outcomes at a minimum follow-up of 2 years.
Keywords
The glenohumeral joint has the greatest range of motion (ROM) in the human body at the expense of its stability. Approximately 1.7% of the entire population experiences at least 1 shoulder instability event during their lifetime, of which 95% occur in an anteroinferior direction.3,28 In the United States, the incidence of anterior shoulder dislocation reaches 0.08 per 1,000 person-years within the general population.19,55 However, in high-risk populations, such as overhead or contact sports, an instability rate of up to 14.8% is reported. 33
In both athletic and nonathletic populations, achieving a quick and safe return to the preinjury level of activity after shoulder instability is challenging. Buss et al 9 conducted a study of 30 athletes treated nonoperatively after a traumatic shoulder dislocation during in-season play and reported a return-to-sport rate at the preinjury level of 87%. However, 37% experienced at least 1 subsequent shoulder instability event after the nonoperative treatment. 9 Given the higher risk of recurrent shoulder dislocations after nonoperative treatment, surgical stabilization, particularly in a younger and active population, is considered the gold standard.29,39,47,63 This includes both competitive and recreationally active patients, reflecting the mixed (athlete and nonathlete) population investigated in the present study.
Despite ongoing technical innovations in traditional Bankart repair, a persistently high recurrence of instability prevails.15,18,44,51 In a systematic review, Murphy et al 51 reported an overall recurrence rate of 31% after arthroscopic Bankart repair. A crucial factor increasing the risk of persistent glenohumeral instability may be the limitation of solely single-point fixations of simple-stitch configurations of the capsulolabral complex to the glenoid, which may be unable to ensure optimal and uniform pressure of the soft tissues to the bone. 54 The novel labral bridge technique faces this limitation by reconstructing the capsulolabral complex using a bridging technique, trying to ensure an equal and balanced pressure distribution of the labrum to the anterior glenoid rim, aiming to enhance healing of the capsulolabral complex onto the bone. 54 However, to date, available data on clinical outcomes are limited, with currently no existing study investigating the clinical outcomes of the labral bridge technique.
Therefore, the purpose of this study was to evaluate clinical outcomes after arthroscopic Bankart repair using the novel labral bridge technique at a minimum follow-up of 2 years. We hypothesized that patients would have a low recurrent shoulder instability rate along with an improvement in patient-reported outcome measures (PROMs).
Methods
This retrospective data analysis was performed as a single-center retrospective cohort study at the Sportorthopaedie Zentrum Hietzing, Vienna. The study was conducted in line with the Helsinki Declaration and was approved and supervised by the Ethical Committee of the City of Vienna (1027/2021). Written informed consent was obtained from all patients before the final follow-up at a minimum of 2 years postoperatively. The study included patients who underwent surgical treatment for anterior shoulder instability using the novel labral bridge technique 54 between January 2018 and June 2021. Eligible patients were between 18 and 50 years of age at the time of surgery with a minimum follow-up of 2 years postoperatively; had experienced a traumatic first-time shoulder dislocation, a recurrent shoulder dislocation, or symptoms of a chronic shoulder instability lasting >3 months as evidenced by recurrent subluxations after a primary dislocation event. Patients were excluded in case of concomitant fractures of the affected shoulder, critical glenoid bone loss (GBL) >10% or engaging Hill-Sachs lesions of the affected shoulder, multidirectional instability, previous surgery of the affected shoulder, epilepsy, and chronic alcohol or drug abuse. GBL was not routinely obtained by 3-dimensional computed tomography (CT) in this relatively young cohort to avoid additional radiation exposure. GBL was assessed by means of magnetic resonance imaging. However, in case of recurrent or chronic shoulder instabilities, GBL was measured by CT according to the PICO (patient, intervention, comparison, outcome) method 4 and a critical defect was determined as >10% of the glenoid cavity. All measurements were performed by the senior author (U.L.).
Follow-up and Data Collection
As part of a standardized postoperative protocol, all patients were clinically followed up at 1 week, 6 weeks, and 3 months postoperatively. These early postoperative visits were used for wound control, complication screening, and monitoring of ROM, whereas the present analysis focuses on preoperative and final follow-up values. Subsequently, patients were prospectively invited for a final follow-up at a minimum of 2 years postoperatively. Physical examinations including ROM and an assessment of the Rowe score (100, best; 0, worst) were performed to evaluate glenohumeral instability. ROM was measured in a passive manner by a single examiner (U.L.) and determined using a goniometer. The examiner was not blinded at any timepoint. Secondary study outcomes were assessed using PROMs including the American Shoulder and Elbow Surgeons (ASES) score (100, best; 0, worst), the Single Assessment Numeric Evaluation (SANE) (0 to 100 according to preinjury level), and the Visual Analog Scale (VAS) for pain (0, no pain; 10, severe pain). Additionally, PROMs were compared with predefined minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds.48,58
Surgical Procedure
All surgical procedures were performed in beach-chair position by a single fellowship-trained shoulder surgeon (U.L.) under general anesthesia and interscalene plexus blockade. The surgical technique was previously described (Figure 1). 54
Arthroscopic capsulolabral reconstruction of a right shoulder using the labral bridge technique, view from the posterior portal. (A) After mobilization and anterior glenoid rim preparation, a 45° SutureLasso was used to arm the capsulolabral complex with a 1.3 FiberLink (blue), a 1.3 TigerLink (black/white striped), and 1.5-mm LabralTape. (B) A 2.9-mm knotless BioComposite PushLock anchor was inserted through the anteroinferior portal, while the LabralTape limbs were held under tension to initiate a superior capsular shift. (C) After the first anchor was set, the LabralTape was shuttled back through the labrum, creating a U-stitch configuration with both limbs remaining on the glenoid side of the labrum. (D) One limb of the LabralTape was shuttled out of the joint through an anterolateral portal using the TigerLink loop to prepare for the bridging step. (E) A second knotless BioComposite PushLock anchor was loaded with the LabralTape limb and inserted, creating a “bridge” of tape between the anchors, securing the soft tissues to the glenoid rim with evenly distributed pressure. (F) The completed repair showing 3 sequential knotless anchors (blue icons). The red dashed lines illustrate the bridging LabralTape, which provides greater footprint coverage compared with standard single-point fixations of simple-stitch configurations.
First, a standardized diagnostic arthroscopy was performed in all patients. After identification of the extent of injury, the capsulolabral complex was adequately mobilized to ensure a proper reduction and anatomic reconstruction. Any adhesions or scar tissue formations were debrided, and the glenoid was abraded to improve biological healing. Through an anterosuperior portal passing within the rotator interval, the capsulolabral complex was reconstructed, ensuring a cranial soft tissue shift. Using a 45° SutureLasso (Arthrex), the capsulolabral complex was armed with a 1.3 FiberLink suture (Arthrex) as well as a 1.5-mm LabralTape (Arthrex). Then, through the anteroinferior portal, the SutureLasso was passed approximately 5 mm superior to the first stitch through the capsulolabral complex. In the same manner, a nitinol wire loop was advanced into the joint and shuttled through an anterolateral portal. Outside the shoulder, the loop of a 1.3 TigerLink (Arthrex) was passed through the loop of the nitinol wire and then shuttled back through the anterolateral portal, leaving the loop of the TigerLink on the capsular side of the labrum. This loop and the capsular sided limb of the LabralTape were then shuttled through the anterolateral portal using a suture grasper to avoid soft tissue bridges between these 2 sutures. Then the limb of the LabralTape was passed through the loop of the TigerLink outside the shoulder and the LabralTape was shuttled back through the labrum, leaving both limbs of the LabralTape on the glenoid side of the labrum with a U-stitch configuration through the capsulolabral complex. For placement of a first knotless 2.9-mm BioComposite PushLock anchor (Arthrex) through the anteroinferior portal, a superior capsular shift was performed by pulling the 2 LabralTape limbs cranially. The anchor was then loaded with both ends of the LabralTape crossing in the eyelet of the anchor. This left the 2 ends of the LabralTape and the loop of the 1.3 FiberLink suture on the glenoid side of the labrum. Similarly, both ends of the LabralTape were shuttled on the capsular side of the labrum using another 1.3 FiberLink suture. Then the capsulolabral complex was again grasped through the anteroinferior portal using the SutureLasso, anticipating the placement of the second anchor. The nitinol wire was again advanced into the joint and shuttled out of the anterolateral portal. Then, the actual SutureLasso device was removed, leaving both ends of the wire outside the anteroinferior and anterolateral portals. The LabralTape was passed through the loop of the nitinol wire and shuttled to the anterolateral portal, allowing the LabralTape to pass through the capsulolabral complex. A second knotless 2.9-mm BioComposite PushLock anchor was loaded with the limb of the LabralTape in the anteroinferior portal. Hereby, the soft tissues between both anchors were secured to the glenoid rim. The LabralTape was then cut as close as possible to the anchor and the second end of the LabralTape was used in the same manner for a third knotless 2.9-mm BioComposite PushLock anchor.
Postoperative Rehabilitation Protocol
All patients followed postoperative rehabilitation according to the early motion rehabilitation protocol established by Gibson et al. 21 To protect the surgically treated shoulder, patients were instructed to wear a removable Gilchrist sling during sleep and outdoor activities for the initial 4 weeks after surgery. Immediate postoperative active ROM was allowed with individualized restrictions determined by an intraoperative dynamic assessment. This assessment, conducted under an intra-articular arthroscopic view, documented the angle at which stress occurred on the capsulolabral repair due to capsular stretch and/or translation of the humeral head in forward flexion, abduction, and external rotation. Postoperative active ROM allowance and intraoperative stress assessment impacted each other in a 1:1 manner, leading to a lesser allowance when stress occurred at an earlier range. Two days after surgery, closed kinetic chain exercises and isometric exercises were initiated. While kinetic chain exercises focused on symmetric movements, isometric exercises allowed for early strengthening of the rotator cuff. Following the return-to-activity algorithm by Keller and Kurz, 34 different levels of exercises were introduced on completion of specific tests, ranging from level 1 (return to activity) to level 4 (return to competition). On return to competition, no specific testing was conducted. However, endurance and some contact sports (eg, soccer and skiing) were allowed between weeks 11 and 14 postoperative, overhead sports and major contact sports (eg, American football, basketball, and tennis) were allowed between 6 and 9 months postoperative. This protocol was enforced under supervision of the patient's physical therapist, who was given an information sheet on this postoperative rehabilitation protocol. Patients met with their therapists for 10 to 15 sessions of 45 minutes each. Frequency and compliance were not documented.
Statistical Analysis
Descriptive statistics were used for the presentation of patient and clinical data. Data distribution was assessed by visual inspection of histograms and Kolmogorov-Smirnov tests. Normally distributed continuous data are presented as mean and standard deviation.
For the comparison of preoperative and postoperative ROM and PROMs, Student t tests were used for statistical analysis. All tests were 2-sided, and P values <.05 were considered statistically significant. All statistical analyses were conducted using SPSS Statistics Version 28 (IBM).
Results
Between January 2018 and June 2021, 118 patients were surgically treated for anterior shoulder instability. After application of the exclusion criteria, 48 patients were eligible for study recruitment. Two patients (4.2%) were lost to follow-up, with one patient declining participation and the other due to missing contact information, resulting in 46 patients available for data analysis (Figure 2). The mean age at surgery was 28.9 ± 9.0 years (range, 18-48 years). The mean final follow-up was 35.8 ± 10.3 months (range, 24-56 months). Concomitant surgical procedures included superior labrum anterior-posterior type 2 repair (n = 7; 15.2%), partial articular supraspinatus tendon avulsion repair (n = 4; 8.7%), humeral avulsion of glenohumeral ligaments repair (n = 2; 4.3%), humeral microfracturing (n = 2; 4.3%), and tenodesis of the long head of the biceps tendon (n = 1; 2.2%). Demographic data of the patients are presented in Table 1.
Flowchart of study.
Demographic Data of the Study Population a
Data are presented as n (%).
With the exception of a significant postoperative improvement by 10.5° in forward flexion (P = .013), ROM at the final follow-up showed no difference compared with preoperative assessment (Table 2). All PROMs showed significant improvements at the final follow-up (all P < .001) (Table 3). The predefined MCID was reached by 38 of 41 (92.7%) patients for the Rowe score, 58 39 of 42 (92.9%) for the ASES score, 48 35 of 42 (83.3%) for the SANE, 48 and 31 of 42 (73.8%) for the VAS for pain. 48 The predefined PASS was achieved by 39 of 42 (92.9%) patients for the ASES score, 48 35 of 42 (83.3%) for the SANE, 48 and 41 of 42 (97.6%) for the VAS for pain. 48 For the Rowe score, no predefined PASS was available.
Pre- and Postoperative Range of Motion a
Data are presented as mean ± standard deviation. Boldface type indicates statistical significance.
Pre- and Postoperative Patient-Reported Outcome Measures a
Data are presented as mean ± standard deviation. Boldface type indicates statistical significance. ASES, American Shoulder and Elbow Surgeons; SANE, Single Assessment Numeric Evaluation; VAS, Visual Analog Scale.
Recurrent Shoulder Instability and Complications
Two patients (4.3%) experienced a recurrent traumatic anterior shoulder dislocation 16 and 32 months after surgery. While one event occurred after a tackle during American football practice, the other one resulted after a fall during sleep walking. In both patients, the dominant shoulder was affected. After the recurrent dislocations, one patient underwent an arthroscopic Latarjet procedure, while the other was treated nonoperatively with immobilization for 2 weeks and physical therapy. Additionally, 2 patients had a positive anterior apprehension test at the final follow-up without any persisting glenohumeral instability. These patients were not classified as having recurrent instability because they did not report dislocation or subluxation events. The findings were recorded as clinical signs at the final follow-up. One patient required an intra-articular corticoid steroid injection due to a postoperative frozen shoulder. Beyond the events described above, no anchor-, hardware-, or nerve-related complications, infections, or thromboembolic events were documented.
Discussion
The arthroscopic Bankart repair using the labral bridge technique showed excellent outcomes with low recurrent shoulder instability (4.3%) and significant improvements of PROMs together with a significant reduction of pain. Furthermore, the labral bridge technique did not result in any loss in ROM after a minimum of 2 years after surgery.
In our study, all outcome measurements, including the ASES score, SANE, and VAS for pain, significantly improved after 2 years compared to the preoperative assessment. Previously described MCID and PASS values were reached in most cases, indicating a full return to daily and sport activities. Also, excellent results were noted for the Rowe score 2 years after surgery. After arthroscopic Bankart repair, a loss of ROM is commonly observed in forward flexion and external rotation. 15 However, using the labral bridge technique, patients regained a full ROM and even significantly improved forward flexion postoperatively, most likely due to the early motion rehabilitation protocol and the anatomic repair of the capsulolabral complex to the glenoid.
While nonoperative treatment with physical therapy and immobilization has little to no effect on the risk of recurrent glenohumeral instability after traumatic anterior shoulder dislocation,9,26,39,66,67 surgical treatment achieves significant improvements in long-term stability and function.8,38,42,49,53,60,61 Since its first introduction in 1923, the traditional Bankart repair 2 has evolved into an arthroscopic approach with numerous technical modifications allowing for improved stabilization while maintaining only little tissue damage. However, modern arthroscopic Bankart repairs still face a notably high rate of recurrent shoulder instability.10,15,18,43,44,51,56 DeFroda et al 15 reported of a lifetime recurrence rate after arthroscopic Bankart repair ranging from 4% to 33%, with a mean rate of 13%. A recent systematic review included 9 studies with 822 shoulders analyzing long-term outcomes after arthroscopic Bankart repair. 51 The authors reported an overall postoperative recurrent instability rate of 31.2% with an overall revision rate of 17% due to recurrent instability. 51 Studies included in this systematic review followed the concept of simple-stitch configurations, which are known to solely provide a punctual fixation of the capsulolabral complex to the glenoid. 54 While biomechanical studies showed similar results in terms of ultimate failure load and stiffness between commonly performed simple-stitch configurations and mattress-stitch configurations,12,32,36,40,52 Lacheta et al 40 reported that knotless mattress-stitch configurations decreased the capsular strain similar to the native state. Furthermore, mattress-stitch configurations allow improved blood flow in soft tissues and therefore might enhance biological healing after surgical repair.13,25,54 The novel labral bridge technique is a mattress-stitch configuration-like technique, using a U-stitch configuration that does not constrict the labrum, which may allow keeping its blood supply intact. Thereby, the labral bridge technique might improve biological healing. Through the concept of anchor load sharing, a lasting anatomic repair may be further achieved.
In contrast to simple- and mattress-stitch configurations, double-row repairs utilize 2 rows of suture anchors—a medial row close to the articular surface and a lateral row placed along the glenoid rim. In this configuration, sutures are most commonly passed in a mattress-stitch fashion. 32 Biomechanical studies demonstrated that double-row repair techniques provide superior coverage of the native labral footprint on the glenoid rim. Although cadaveric studies showed no significant difference in load-to-failure compared with single-row techniques, double-row repairs may lead to improved biological healing and enhanced long-term clinical stability.32,36 The labral bridge technique incorporates the concept of anchor load sharing by creating a bridge using a LabralTape between 2 anchors. Consequently, this technique aims to achieve greater footprint coverage and more evenly distributed pressure across the labrum compared with conventional single-row techniques. 54
GBL is frequently observed after glenohumeral instability events, ranging from 6.8% after a single dislocation to >20% in case of recurrent dislocations, 16 subsequently leading to a higher failure rate after arthroscopic Bankart repair.16,27,44 Bone block procedures allow great reproducible stabilization in cases of higher GBL1,5,6,44,68 and are associated with improved outcomes when applied as first-line treatment compared with a revision surgery after failed arthroscopic Bankart repair regardless of the extent of GBL.62,68,70 However, bone block procedures have a higher complication rate17,22,24,30,44 and still result in recurrent instability of up to 8.5% in the long term. 31 In a recent meta-analysis, Masud et al 44 reported no significant differences across all outcome parameters between arthroscopic Bankart repair and bone block procedures in cases of GBL <10%. The low recurrence rate in our study stands in line with these previous findings, as all patients included in this study had a GBL <10%.
The number of anchors used for arthroscopic Bankart repair is still an ongoing debate. Some studies suggested no difference between the use of 2 or 3 anchors concerning the risk of recurrent shoulder instability.45,57,71 On the other hand, Trasolini et al 69 identified the use of <3 anchors as a significant factor in 67% of recurrent instabilities, and the use of at least 3 anchors results in greater glenohumeral stability. Other studies even suggested that a minimum of 4 anchors is necessary to maintain a high shoulder stability in the long term.7,65 Pearce et al 59 recently published satisfying results after a newly described simple-stitch technique using 5 anchors. The rationale of using an increased number of suture anchors in arthroscopic Bankart repair with simple-stitch configurations is to achieve an improved and balanced pressure of the capsulolabral complex with the glenoid, thus imitating the possible effect of the labral bridge technique, which aims to achieve a more robust anatomic repair through improved load sharing. In our study, all patients underwent reconstruction using 3 anchors connected with a bridging technique, leading to a low recurrence rate at the final follow-up.
After surgical treatment, a fast return to the preinjury level is still a major challenge. Even though studies reported that early postoperative mobilization has no influence on recurrent shoulder instability,37,41,64 immobilization is still routinely used after arthroscopic Bankart repair.11,20,23,37,46,50 Furthermore, there is no clear consensus on accelerated rehabilitation after surgical shoulder stabilization, with many proposed accelerated rehabilitation programs reporting different immobilization intervals. 14 In the present study, all patients were treated according to the accelerated rehabilitation protocol proposed by Gibson et al, 21 allowing immediate postoperative active ROM based on personalized limitations according to an intraoperative assessment. As overhead and contact sports are high-risk factors for recurrent glenohumeral instability, 69 patients were assessed according to the return-to-activity algorithm of Keller and Kurz, 34 allowing a return to competition for high-risk sports after 6 to 9 months and for endurance as well as some body-contact sports after only 11 weeks. This rehabilitation approach in combination with the labral bridge technique showed excellent results, with only 2 recurrent postoperative shoulder dislocations and only 1 patient engaging in overhead and/or contact sports. This aligns with the findings of Kelley et al, 35 who reported a 6.5% recurrence rate following a postoperative functional rehabilitation protocol in a group of 62 overhead athletes. Overall, the postoperative rehabilitation approach of our study displayed a low rate of recurrent shoulder instability.
Limitations
Our study has several limitations. First, as this study provides a short-term follow-up of a minimum of 2 years, mid- and long-term data of the labral bridge technique are still missing. Furthermore, this study was conducted as a single-center retrospective cohort study without a control group. Consequently, causal inference was not possible and a clear superiority over simple-stitch configurations, commonly performed for arthroscopic Bankart repair, could not be drawn. Nevertheless, even if the study design is of a retrospective nature, all patients were prospectively included and followed for a final follow-up at a minimum of 2 years. Third, ROM assessments as well as preoperative radiographic evaluation were performed by a single examiner, who was not blinded at the timepoint; thus, no formal inter- or intrarater reliability analysis was possible, introducing potential measurement bias. Furthermore, our cohort is heterogeneous with respect to concomitant pathology and additional procedures, which may confound pain and function. In addition, the study population consisted of a relatively older, mixed athlete and nonathlete population, limiting generalizability to younger high-risk collision athletes and potentially confounding PROMs and stability outcomes. However, it may be argued that high-risk populations should nevertheless primarily be treated with a bone block procedure over an arthroscopic Bankart repair. Lastly, rehabilitation exposure and adherence as well as return to sport were not documented.
Conclusion
Arthroscopic Bankart repair with the labral bridge technique for the treatment of anterior shoulder instability demonstrates a low recurrent shoulder instability rate and significant improvements in clinical and functional outcomes at a minimum follow-up of 2 years.
Footnotes
Final revision submitted February 23, 2026; accepted February 26, 2026.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
Ethical approval for this study was obtained from the Ethical Committee of the City of Vienna (1027/2021).
