Clinical and Radiologic Outcomes of the Bankart Repair Using Mason-Allen (BRUMA) Technique for Small Bony Bankart Lesions: An Objective,Performance Criteria-Referenced,Single-Surgeon Case Series

Abstract

Background:

The optimal management of small bony Bankart lesions remains controversial. The Bankart repair using Mason-Allen (BRUMA) technique uses indirect fragment reduction through capsulolabral retensioning without direct fixation of the bony fragment.

Purpose:

To evaluate the clinical and radiologic outcomes of the BRUMA technique using literature-derived objective performance criteria (OPC) as external benchmarks.

Study Design:

Case series; Level of evidence, 4.

Methods:

The study included 32 consecutive patients with recurrent anterior shoulder instability and anterior glenoid bone loss <25% who underwent BRUMA repair. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] and Rowe scores) and radiologic outcomes (glenoid defect size on 3-dimensional computed tomography [3D-CT], bony union, and recurrence) were assessed at a mean follow-up of 21.5 ± 8.5 months. All patients underwent postoperative 3D-CT. OPC benchmarks were derived from previously published studies reporting outcomes of arthroscopic Bankart-type techniques for small bony Bankart lesions, excluding bone-block procedures.

Results:

The mean Rowe score improved by 70.5 ± 12.3 points, significantly exceeding the OPC benchmark of 54.1 (P < .001). Glenoid defect decreased by 8.9 ± 6.0 percentage points, which was noninferior to the OPC (–10.3%; P = .212). ASES score improved by 19.9 ± 18.2 points, with 68% of patients exceeding the minimal clinically important difference. Bony union rate was 93.8% and recurrence rate was 6.3%. Although the primary confidence interval analysis did not meet all binary OPC thresholds due to small sample size, Wilson score sensitivity analysis confirmed that the union criterion was met.

Conclusion:

The BRUMA technique demonstrated superior Rowe score improvement and comparable glenoid remodeling relative to OPC benchmarks. A high bony union rate (93.8%) and a low recurrence rate (6.3%), comparable to those reported for other Bankart-type techniques, were observed. These findings suggest that indirect reduction without direct fragment fixation is an effective surgical option for small bony Bankart lesions.

Keywords

arthroscopic Bankart repair BRUMA technique small bony Bankart lesions anterior instability bone union glenoid defect

Anterior shoulder instability is frequently associated with glenoid bone loss, and small bony Bankart lesions present a unique challenge in determining the optimal surgical strategy. The reported incidence of these lesions varies widely, ranging from 5.4% to 70% among patients with traumatic anterior shoulder dislocation.⁹ Early studies by Rowe etal²³ suggested that small anterior rim fractures might not require anatomic reduction and could be successfully treated with isolated capsulolabral repair. Similarly, Bigliani etal² reported that in patients with type 2 glenoid lesions—characterized by a malunited fragment attached to the capsule—capsular repair alone could provide adequate postoperative stability.

In contrast, other authors have advocated fragment excision or direct fixation, citing concerns regarding inadequate containment, recurrent instability, and progressive glenoid bone loss when displaced fragments are not anatomically reduced.^19,21,26 To address these concerns, secure anatomic reduction and direct fixation of bony fragments have been recommended in multiple studies.^9,20 More recent techniques, such as the bony Bankart bridge (BBB), aim to achieve fragment stabilization via compressive suture bridging constructs offering an alternative to conventional fixation strategies.⁸

Despite these advances, the optimal method for achieving anatomic reduction of small bony fragments—while minimizing technical complexity and avoiding fixation-related complications—remains controversial. The Bankart repair using Mason-Allen (BRUMA) technique was developed as an indirect reduction strategy that restores capsulolabral tension without excising or directly fixing the bony fragment. Specifically, the technique was designed to address the limitations inherent to direct fragment fixation for small lesions, including the risk of fragment comminution during drilling or anchor placement, inadequate suture purchase through fragile bone, the potential for articular step-off or medialized fixation, and increased technical complexity. By avoiding direct hardware placement on small fragments, the technique aims to reduce the risk of malreduction and promote biologically favorable healing. However, whether isolated labral repair can achieve outcomes comparable to reduction- or fixation-based methods has not been established.

Given the heterogeneity of published outcomes and the lack of standardized control groups in prior studies, literature-derived objective performance criteria (OPC) provide a pragmatic benchmark for evaluating emerging techniques such as BRUMA. Although OPC benchmarking offers a structured framework for assessing single-arm data in the absence of a control group, its performance is inherently dependent on the quality and comparability of the source studies, and confidence interval (CI)–based thresholds may be overly conservative in small cohorts.^5,16,28 Therefore, the purpose of this study was to assess the clinical and radiologic outcomes of the BRUMA technique for small bony Bankart lesions and to compare its performance against literature-derived OPC benchmarks.

Methods

Study Design

This study was designed as a single-arm cohort investigation evaluating the clinical and radiologic outcomes of the BRUMA technique in patients with small bony Bankart lesions (anterior glenoid bone loss <25%). Because no concurrent control group was available, we adopted an OPC-referenced single-arm analysis, in which performance benchmarks derived from published literature were used to determine whether the BRUMA technique met minimum acceptable standards.

Patient Selection

Patients who underwent arthroscopic repair using the BRUMA technique at a single institution between July 2014 and October 2022 were retrospectively identified. Of the 168 cases reviewed, 32 consecutive patients met the eligibility criteria and were included in the final analysis (Figure 1). All patients completed a minimum postoperative follow-up of at least 12 months (mean, 21.5 ± 8.5 months; range, 12-50 months).

Figure 1.

Study diagram. BRUMA, Bankart repair using Mason-Allen.

Inclusion criteria were as follows:

Recurrent anterior shoulder instability

Anterior glenoid bone loss <25% confirmed on preoperative 3-dimensional computed tomography (3D-CT)

Presence of a clearly identifiable small bony Bankart fragment confirmed on preoperative 3D-CT

Treatment performed exclusively with capsulolabral repair without direct fragment fixation, consistent with the BRUMA technique

Exclusion criteria were these:

Absence of a clearly identifiable bony fragment on preoperative imaging

Intraoperative bone fragment excision or direct fixation

Cases in which BRUMA was not the primary stabilization procedure due to additional pathology

Preoperative glenoid defect size was measured using 3D-CT, and postoperative defect size and bony union were assessed on 3D-CT obtained at the final follow-up.Clinical outcomes, including American Shoulder and Elbow Surgeons (ASES) and Rowe scores, were recorded preoperatively and at final follow-up.Postoperative instability events, recurrence, and complications were also documented.

This study was approved by the institutional review board (approval No. 2025-03-014). Informed consent was waived due to the retrospective nature of the study.

Surgical Technique

All surgical procedures were performed arthroscopically by a single senior surgeon (J.Y.P.) using the BRUMA technique (see the online Video Supplement for this technique). Patients were positioned in the lateral decubitus position with a traction device to maintain proper shoulder alignment during the procedure. Standard posterior and anterior arthroscopic portals were established, and diagnostic arthroscopy was conducted to assess the extent of the injury and confirm the presence of a bony Bankart lesion. When an off-track Hill-Sachs lesion was identified intraoperatively, a concomitant remplissage procedure was performed during the same operation. Representative arthroscopic images of the procedure are shown in Figure 2.

Figure 2.

Intraoperative arthroscopic views demonstrating the suture technique.

Figure 3 provides a schematic illustration of the key steps of the BRUMA technique and the modified Mason-Allen suture configuration.

Figure 3.

Schematic illustration of the Bankart repair using Mason-Allen (BRUMA) technique. Left, pre-reduction state showing the displaced bony Bankart lesion and the planned suture path through the labrum. Right, post-reduction state; note that the bony fragment is not directly sutured, but instead the labrum is approximated to the glenoid rim to indirectly reduce the fragment. The red dotted line indicates the restored smooth continuity of the glenoid articular surface.

The labroligamentous complex was mobilized by carefully releasing the soft tissue around the glenoid rim using a liberator. Notably, no direct fixation or excision of the bony fragment was performed; instead, the overlying labrum was mobilized to indirectly stabilize the fragment and promote biological healing.

After adequate mobilization, 4 suture anchors (PressFT, CONMED Linvatec; or Gryphon, DePuy Synthes Mitek Sports Medicine) were placed sequentially along the anterior glenoid rim from the 5:30- to the 2-o’clock position. Sutures from these anchors were passed exclusively through the labrum using a modified Mason-Allen stitching technique, where horizontal mattress sutures and simple stitches are combined to enhance tissue-holding capability and prevent suture cut-through. This technique indirectly secured the fragment while restoring labral tension. Fragment reduction was confirmed intraoperatively by restoration of the capsulolabral bumper height along the anterior glenoid rim under arthroscopic visualization. When an engaging Hill-Sachs lesion was identified intraoperatively, a concurrent remplissage procedure was performed.

Postoperatively, the shoulder was immobilized in a brace for approximately 6 weeks. Thereafter, gradual rehabilitation was initiated with progressive passive and active range of motion exercises, followed by strengthening exercises. Return to sports was generally permitted after adequate recovery of shoulder motion and strength, typically at 6 to 12 months.

Radiologic Assessment

Anterior glenoid bone loss was calculated on 3D-CT using the best-fit circle method:

B o n e l o s s (%) = \frac{A - B}{A} \times 100,

where A is the ideal glenoid circle area and B is the remaining glenoid area. Bony union was defined as cortical bridging and restored continuity on final follow-up 3D-CT.

Outcome Measures

Recurrent Instability

Recurrent instability was defined as any postoperative episode of frank dislocation requiring manual reduction or subjective subluxation symptoms accompanied by a positive apprehension sign on physical examination during the follow-up period.

Bony Union

Bony union was radiologically defined as the presence of cortical bridging and restored continuity between the glenoid rim and the bony fragment on the final follow-up 3D-CT scans.

Change in Anterior Glenoid Defect Size

This was the quantitative reduction in bone loss, calculated as the difference between the preoperative and final follow-up glenoid defect percentages. Both measurements were performed on 3D-CT using the surface area method.

ASES Score Improvement

Functional improvement was assessed using the ASES scoring system, which evaluates patient-reported pain (50 points) and activities of daily living (50 points). Improvement was defined as the statistically significant increase in the score from preoperative baseline to the final follow-up.

Rowe Score Improvement

Stability and functional outcomes were assessed using the Rowe score, a clinician-based rating scale focusing on stability (50 points), motion (20 points), and function (30 points). Improvement refers to the change in scores reflecting restored stability and function at the final follow-up compared with preoperative values.

Other Complications

These included any intraoperative or postoperative adverse events directly related to the surgical procedure, including infection, nerve injury, anchor pull-out, implant failure, or stiff shoulder (requiring intervention), excluding recurrent instability.

Revision Surgery

This included any secondary surgical intervention performed on the ipsilateral shoulder due to failure of the primary repair (recurrence) or management of postoperative complications.

Construction of Objective Performance Criteria

OPC were constructed as external benchmarks following established methodological frameworks for single-arm clinical evaluations, wherein literature-derived performance goals are applied when randomized comparative groups are not feasible. This methodological approach aligns with prior OPC-based frameworks described in the vascular and orthopedic literature as well as regulatory guidance.^5,16,27

The literature search used for OPC construction was independently performed by 2 authors (H.S.J. and H.K.P.) using the PubMed database. The search covered January 1, 2005, to January 31, 2025, and was restricted to original research to ensure primary clinical data. Keywords included “arthroscopic,”“Bankart,”“repair,”“bony,” and “osseous.” Review and systematic review articles were excluded using the NOT operator:

"arthroscopic"[tiab] AND "Bankart"[tiab] AND "repair"[tiab] AND ("bony*"[tiab] OR "osseous*"[tiab]) NOT ("review"[pt] OR "systematic review"[pt]) AND ("2005/01/01"[PDAT]: "2025/01/31"[PDAT])*

Among 175 retrieved studies, 17 were initially shortlisted by title/abstract screening. Both reviewers independently assessed eligibility; discrepancies were resolved through consensus. Ten studies remained after exclusion of those without defect-size <25% data, incompatible baseline characteristics, or insufficient quantitative outcomes. These were used to construct the OPC (Appendix Table A1).

Extracted outcomes included recurrence rate, union rate, improvements in ASES and Rowe scores, and changes in glenoid defect size. For each outcome measure, the number of contributing studies used for OPC calculation was specified. Pooled means and 95% CI were calculated to establish the OPC thresholds as follows:

Recurrence rate: less than or equal to the upper limit of the 95% CI

Union rate: greater than or equal to the lower limit of the 95% CI

Improvement in ASES and Rowe scores: greater than or equal to the pooled mean

Reduction in glenoid defect size: greater than or equal to the pooled mean

Additionally, none of the included OPC studies reported data on the proportion of patients undergoing remplissage, which may represent a potential source of heterogeneity in outcome comparisons.

Statistical Methods

In this study, statistical analyses were conducted to evaluate both the within-cohort outcomes of the BRUMA technique and its performance relative to literature-derived OPC. Continuous variables were summarized as means and standard deviations, whereas categorical variables were expressed as counts and percentages.

Preoperative and postoperative values and changes in continuous variables, including ASES score, Rowe score, and glenoid defect size, were analyzed using paired t tests after confirmation of normality with the Shapiro-Wilk test. Both preoperative and postoperative mean scores were reported to provide absolute outcome values, and mean differences with 95% CIs were reported. Recurrent instability, bony union, and complication rates were calculated as proportions with exact 95% CIs using the Clopper-Pearson method.

To determine whether the BRUMA cohort met the predefined OPC benchmarks, 1-sample inferential analyses were performed. For binary endpoints, OPC fulfillment was assessed exclusively using 95% CI comparisons.

Recurrence: the upper bound of the BRUMA 95% CI was required to be less than or equal to the upper CI limit of the OPC benchmark.

Union: the lower bound of the BRUMA 95% CI was required to be greater than or equal to the lower CI limit of the OPC benchmark.

Failure to satisfy these CI-based criteria was interpreted as not meeting the OPC standard.

For continuous outcomes (ASES improvement, Rowe improvement, and glenoid defect reduction), 1-sample t tests were conducted by comparing the BRUMA cohort’s mean values with the pooled means derived from the literature. Based on the magnitude and statistical significance of these differences, performance relative to OPC benchmarks was classified according to predefined interpretation criteria:

Superior: BRUMA mean greater than the OPC mean with P < .05

Noninferior: BRUMA mean greater than or equal to the OPC mean, or slightly lower without statistical significance (P≥ .05)

Not meeting (inferior): BRUMA mean lower than the OPC mean with P < .05

All statistical tests were 2-sided, and statistical significance was defined as P < .05. Analyses were conducted using R software (version 4.5.2).

Results

A total of 32 individuals were enrolled in the BRUMA cohort (Table 1). Their mean age was 25.4 ± 8.3 years, with a strong male predominance (31/32; 96.9%). In 19 cases (59.4%), the dominant shoulder was affected. The mean size of the anterior glenoid defect before surgery was 13.2% ± 6.0%. Baseline functional assessments showed significant limitation, as reflected by a mean ASES score of 65.7 ± 16.4 and a Rowe score of 28.8 ± 12.2. A concomitant remplissage procedure was carried out in 15 patients (46.9%). ASES scores were unavailable at baseline for 2 patients.

Table 1

Baseline Characteristics of the BRUMA Cohort ^a

Variable	Value
Patients	32 (100)
Age, y	25.4 ± 8.3
Sex
Male	31 (96.9)
Female	1 (3.1)
Side involvement
Dominant side	19 (59.4)
Nondominant side	13 (40.6)
Preoperative glenoid defect, %	13.2 ± 6.01
Preoperative ASES score ^b	65.7 ± 16.4
Preoperative Rowe score	28.8 ± 12.2
Remplissage performed	15 (46.9)
No. of dislocation episodes, median (range)	5 (1-120)
Origin of injury
Traumatic	28 (87.5)
Nontraumatic	4 (12.5)
Preoperative fragment size, %	5.1 ± 3.6
Time from initial instability to surgery, mo	53.0 ± 62.0
Competitive athletes	6 (18.8)

Values are expressed as n (%) or mean ± SD unless otherwise noted. ASES, American Shoulder and Elbow Surgeons; BRUMA, Bankart repair using Mason-Allen.

Two patients had missing ASES values at baseline.

Significant postoperative improvements were observed across all functional outcomes (Table 2). The mean ASES score increased by 19.9 ± 18.2 points (P < .001), and the mean Rowe score improved by 70.5 ± 12.3 points (P < .001). The anterior glenoid defect decreased by 8.9 ± 6.0 percentage points (P < .001).

Table 2

Clinical and Radiologic Outcomes of the BRUMA Cohort ^a

Clinical Outcome	Preoperative	Postoperative	Change	P
ASES score	65.9 ± 17.2	85.8 ± 11.3	+19.9 ± 18.2	<.001
Rowe score	28.8 ± 12.2	99.2 ± 1.8	+70.5 ± 12.3	<.001
Glenoid defect, %	13.2 ± 6.01	4.3 ± 4.5	−8.93 ± 5.97	<.001
Radiological Outcome	n (%)	95% CI of %
Recurrent instability	2 (6.3)	0.8%-20.8%
Bony union	30 (93.8)	79.2%-99.2%
Complications	2 (6.3)	0.8%-20.8%

Values are expressed as n (%) or mean ± SD unless otherwise noted. ASES, American Shoulder and Elbow Surgeons; BRUMA, Bankart repair using Mason-Allen.

Recurrent instability occurred in 2 patients (6.3%; 95% CI, 0.8%-20.8%). One case was attributed to early postoperative motion, whereas the other occurred due to traumatic reinjury during sports activity. No revision surgery was performed in either case. Apart from these events, no other complications (infection, nerve injury, anchor pullout, or stiff shoulder requiring intervention) were observed. Bony union was confirmed in 30 patients (93.8%; 95% CI, 79.2%-99.2%). Radiographic healing patterns demonstrated restoration of the glenoid contour on postoperative 3D-CT (Figure 4). At final follow-up, 30 patients (93.8%; 95% CI, 79.2%-99.2%) demonstrated a residual defect <10%, whereas only 2 patients (6.3%; 95% CI, 0.8%-20.8%) showed a residual defect ≥10%. Notably, all 30 patients who achieved bony union had a residual defect <10%, whereas the 2 patients without union had a residual defect ≥10%, indicating complete concordance between union status and residual defect size in this cohort.

Figure 4.

Radiologic progression demonstrating indirect anatomic reduction and bony union after Bankart repair using Mason-Allen (BRUMA) repair.

When compared with literature-derived OPC benchmarks (Table 3), the BRUMA cohort exhibited heterogeneous performance across endpoints. For binary outcomes, the upper 95% CI of the recurrence rate (20.8%) exceeded the OPC threshold (10.7%), indicating that the recurrence criterion was not met. The lower 95% CI of the union rate using the Clopper-Pearson method (79.2%) was marginally below the OPC lower limit (79.7%) by only 0.5 percentage points, representing borderline nonfulfillment. A sensitivity analysis using Wilson score confidence intervals yielded a lower bound of 79.9%, which exceeded the OPC threshold, suggesting that union OPC fulfillment is sensitive to the CI estimation method in small samples.

Table 3

Comparison of BRUMA Outcomes With Literature-Derived OPC Benchmarks ^a

Endpoint	BRUMA Estimate (95% CI)	OPC Benchmark	Met OPC	P
Recurrent instability, %	6.3 (0.8-20.8)	≤10.7%	Not meeting	—
Bony union, %	93.8 (79.2-99.2)	≥79.7%	Not meeting	—
ASES improvement	19.9 ± 18.2	≥34.24	Not meeting	<.001
Rowe improvement	70.5 ± 12.3	≥54.14	Superior	<.001
Defect reduction, %	−8.9 ± 6.0	≥−10.27	Noninferior	.212

Values are expressed as mean ± SD unless otherwise noted. ASES, American Shoulder and Elbow Surgeons; BRUMA, Bankart repair using Mason-Allen; OPC, objective performance criteria.

Continuous outcomes showed variable alignment with OPC standards. The mean ASES improvement (19.9 ± 18.2) was significantly lower than the OPC benchmark of 34.2 points (P < .001), indicating statistical nonfulfillment. However, the final postoperative ASES score remained high (85.8 ± 11.3), indicating good overall shoulder function at final follow-up.However, 68.0% of patients (17/25 with available paired data) exceeded the minimal clinically important difference (MCID) of 6.4 points, and 64.0% (16/25) exceeded the 12-point threshold, indicating that the majority achieved clinically meaningful functional improvement. The relatively lower ASES improvement compared with OPC benchmarks may partly reflect the higher baseline ASES score in our cohort (65.7), which limits the potential magnitude of improvement compared with studies with lower preoperative scores. In contrast, the final postoperative Rowe score was excellent (99.2 ± 1.8), indicating near-complete restoration of shoulder stability and function. This corresponded to a mean improvement of 70.5 ± 12.3 points, which significantly exceeded the OPC benchmark of 54.1 points (P < .001). Reduction in anterior glenoid defect (−8.9 ± 6.0%) was slightly smaller than the OPC benchmark (−10.3%), but the difference was not statistically significant (P = .212), supporting noninferiority for this radiologic endpoint.

A subgroup comparison between patients who underwent concomitant remplissage (n = 15) and those who did not (n = 17) revealed no significant differences in ASES improvement (20.5 vs 19.3; P = .865) or glenoid defect reduction (−10.5% vs −7.6%; P = .169). Rowe score improvement was modestly greater in the remplissage group (75.0 vs 66.5), reaching statistical significance (P = .042). Recurrence rates were identical between groups. However, given the small subgroup sizes and the lack of adjustment for multiple comparisons, this finding should be considered exploratory and hypothesis-generating rather than definitive.

Discussion

This study evaluated the clinical and radiologic performance of the BRUMA technique for small bony Bankart lesions using literature-derived OPC as external benchmarks. The principal findings demonstrated that BRUMA achieved substantial functional improvement and reliable fragment healing. The final postoperative Rowe score was excellent (99.2 ± 1.8), exceeding the OPC benchmark and indicating superior postoperative shoulder stability. In contrast, the reduction in anterior glenoid defect was statistically comparable to OPC expectations, supporting noninferior radiologic performance. Although recurrence and union outcomes did not fully meet their respective CI-based OPC thresholds, the observed recurrence rate (6.3%; 95% CI, 0.8%-20.8%) falls within the 0 to 15% range reported in the literature for arthroscopic Bankart repair with subcritical bone loss, and the 93.8% union rate is consistent with reported ranges of 83% to 100% in similar cohorts. Importantly, these CI-based OPC thresholds become increasingly difficult to satisfy as sample size decreases, and the “nonfulfillment” designation should not be interpreted as clinical inferiority but rather as reflecting statistical uncertainty inherent to small-sample evaluation. Notably, a sensitivity analysis using Wilson score confidence intervals demonstrated that the union OPC threshold was met. Together, these results suggest that indirect fragment stabilization through capsulolabral retensioning can restore meaningful stability and function without the need for direct fragment fixation.

Management of small bony Bankart lesions has historically ranged from fragment excision to direct anatomic fixation. Early studies by Rowe etal²³ and Bigliani etal² supported capsulolabral repair for small rim fractures, whereas later work emphasized precise fragment reduction to prevent recurrent instability or progressive bone loss.^9,21,26 Techniques such as the BBB have achieved favorable outcomes but often require additional anchors and greater technical complexity.^13,14 In contrast, the BRUMA technique restores capsulolabral tension without manipulating or drilling the fragment. The functional and radiologic outcomes observed in this study—particularly the superior improvement in Rowe scores—are comparable to or exceed those reported for these more fixation-oriented approaches,^8-10 suggesting that indirect reduction may be a suitable alternative for selected lesions. Based on our experience and findings, the BRUMA technique may be particularly applicable when the following conditions are met: anterior glenoid bone loss <20%, a fragment that remains attached to the capsulolabral complex (ie, not free-floating), on-track Hill-Sachs lesion (or off-track with concurrent remplissage), and fragment size too small or fragile for direct instrumentation. Conversely, larger or displaced fragments amenable to anatomic reduction and fixation, chronic bone loss without an identifiable fragment, or off-track lesions without remplissage capability may represent relative contraindications. These preliminary selection criteria require validation in larger prospective series.

The technical rationale underlying the BRUMA technique provides further context for its clinical performance. By avoiding direct manipulation or drilling of small and fragile bony fragments, BRUMA minimizes the risk of fragment malreduction (Figure 5), overcompression, or suture cut-through—complications that have been reported with direct fixation methods.^7,9,24 The extensive mobilization of the capsulolabral complex and the use of a modified Mason-Allen configuration create a broad rip-stop effect that enhances soft-tissue purchase and reduces the likelihood of suture failure.^4,12 This indirect reduction may promote more uniform tensioning along the anterior glenoid rim, allowing the fragment to heal in an anatomically favorable position, as reflected by the high union rate and near-normal postoperative glenoid contour in our cohort.^10,15 Furthermore, the relatively high rate of concomitant remplissage likely contributed to the marked improvement in stability-related functional scores, given the well-established role of remplissage in mitigating engagement of off-track Hill-Sachs lesions.^3,22,26

Figure 5.

Schematic illustration showing the potential mechanism of malreduction with direct fixation. Left, the suture is passed directly through the bony fragment for direct fixation. Right, the suture tension on the bony fragment causes tilting and articular step-off (red dotted line), illustrating the malreduction that may result from direct fixation.

A notable observation is the divergence between OPC-based statistical classification and clinical interpretation for recurrence. Although the BRUMA recurrence rate did not formally meet the OPC threshold due to the wide 95% CI, the observed rate of 6.3% is numerically lower than the OPC benchmark of 10.7%. This discrepancy likely reflects the limitations of CI-based OPC thresholds in small samples rather than true clinical inferiority. Conversely, the magnitude of Rowe score improvement significantly exceeded the OPC benchmark, demonstrating robust postoperative stability among patients who achieved union. These findings emphasize the importance of interpreting OPC outcomes within the clinical context rather than relying solely on binary statistical thresholds.

One notable finding in the present study was the divergence between the Rowe and ASES outcomes when compared with OPC benchmarks. Although the improvement in Rowe scores significantly exceeded the OPC benchmark, the improvement in ASES scores did not meet the predefined OPC threshold. This discrepancy may reflect the fundamental differences between the 2 scoring systems. The Rowe score is heavily weighted toward shoulder stability, allocating up to 50 points for stability assessment, whereas the ASES score primarily reflects patient-reported pain and functional limitations in daily activities.¹⁸ This is because the ASES score incorporates patient-perceived pain and functional performance, which may be influenced by factors beyond structural stability, such as postoperative soft-tissue irritation, residual inflammation, or rehabilitation status.¹

Therefore, the divergence between Rowe and ASES outcomes may suggest that the BRUMA technique is highly effective in restoring mechanical shoulder stability, whereas some patients may continue to experience mild pain or functional limitations during the recovery process. Importantly, despite not meeting the OPC benchmark for improvement, the final postoperative ASES score remained high (85.8 ± 11.3), indicating overall good functional outcomes in most patients.

Nearly half of the cohort underwent concomitant remplissage, and this subgroup exhibited slightly greater stability-related functional gains. This is consistent with prior literature showing that remplissage enhances containment in off-track Hill-Sachs lesions. Although not the focus of the study, these findings suggest that remplissage may complement the indirect reduction achieved by BRUMA, contributing to the superior functional outcomes. However, the studies used to construct the OPC benchmarks did not report remplissage rates, which limits direct comparability between our cohort and the OPC-derived thresholds.

Our findings are consistent with previous reports emphasizing that achieving an anatomically favorable reduction is critical in the management of bony Bankart lesions. Jiang etal⁹ noted that direct fixation of small and fragile fragments may increase the risk of malreduction due to uneven compression or excessive tension at the fragment interface, potentially resulting in malunion or nonunion. In contrast, the BRUMA technique avoids direct manipulation of the fragment and restores capsulolabral tension to facilitate indirect but anatomically aligned reduction. This mechanism was supported by postoperative 3D-CT imaging, which demonstrated consistent restoration of the glenoid contour and stable fragment healing in the majority of patients (Figure 4).

Radiological outcomes in our cohort further support the efficacy of this indirect reduction strategy. A qualitative observation on postoperative imaging suggested possible glenoid surface area remodeling after fragment union in some cases (Figure 4); however, this was not quantitatively assessed in this study and requires formal quantitative evaluation in future investigations. Such remodeling, if confirmed, could reflect biological consolidation of the fragment.¹⁹ These findings reinforce the concept that indirect reduction may create a favorable environment for progressive anatomic restoration.

A notable observation in our OPC comparison was the divergence between the statistical classification of recurrence and the functional interpretation of postoperative stability. Although the recurrence rate was categorized as not meeting the OPC benchmark, this designation was driven primarily by the wide upper confidence interval—which reflects the modest sample size—rather than true clinical inferiority. The observed recurrence rate of 6.3% remained numerically below the literature-derived OPC threshold of 10.7%. In contrast, the improvement in Rowe scores significantly exceeded the OPC benchmark (70.5 vs 54.1), demonstrating robust postoperative stability among the 93.8% of patients who achieved union.

Several factors may account for this superior functional outcome. Nearly half of the cohort underwent concomitant remplissage, which likely contributed to enhanced containment of off-track Hill-Sachs lesions^6,22 and may explain the slightly higher stability-related gains observed in this subgroup.In addition, by avoiding direct fixation of the fragment, the BRUMA technique minimizes the risk of iatrogenic malreduction⁹ and permits biologically favorable indirect healing. The modified Mason-Allen configuration further reinforces capsulolabral tension through a rip-stop effect,^4,12 which may improve soft-tissue purchase and restore joint stability without compromising motion.

The present study has several noteworthy strengths. First, all procedures were performed by a single experienced surgeon using a standardized technique, minimizing procedural variability and allowing the outcomes to more accurately reflect the intrinsic performance of the BRUMA construct. Second, radiologic evaluation was performed using high-resolution 3D-CT, which provides superior accuracy for quantifying glenoid bone loss and assessing fragment morphology compared with traditional 2-dimensional imaging. This enabled reliable confirmation of fragment healing and restoration of the glenoid contour. Third, the use of an OPC-referenced analytic framework allowed objective performance assessment in the absence of a control group and facilitated comparison with established standards from the existing literature. This method is particularly advantageous for evaluating emerging surgical techniques for which randomized comparative trials may be impractical.

Despite these strengths, several limitations should be acknowledged. The retrospective design carries inherent susceptibility to selection bias, information bias, and uncontrolled confounding. The sample size was relatively small, which contributed to wider confidence intervals for binary outcomes such as recurrence and union, thereby making OPC threshold fulfillment more difficult to satisfy statistically. Additionally, although OPC benchmarks were derived through systematic extraction of representative studies, the inherent heterogeneity among published reports—including variation in patient demographics, lesion size, fixation techniques, and follow-up durations—may influence the comparability of pooled performance thresholds. Another limitation is the limited spectrum of patient-reported outcomes included in this study; although ASES and Rowe scores provide valuable insights into pain, function, and stability, metrics such as quality of life, return to sport, and patient satisfaction were not captured. Furthermore, the mean follow-up duration was 21.5 months (range, 12-50 months), which represents relatively short-term follow-up for shoulder instability; long-term remodeling, late fragment resorption, or recurrent instability beyond this period remain unknown. Additionally, the recurrence definition used in this study (including both frank dislocation and subjective subluxation with a positive apprehension sign) may be broader than definitions used in some of the OPC source studies, which could affect the comparability of this endpoint. Detailed information on the number of prior dislocation episodes, mechanism of injury, and sports participation level was recorded (Table 1); however, the retrospective nature of the study limited the ability to capture standardized activity-level classifications. Last, nearly half of the cohort underwent concomitant remplissage, which may have substantially influenced stability-related outcomes and limits the ability to attribute postoperative improvements solely to the BRUMA technique. Comparison of remplissage rates between our cohort and the OPC source studies is presented in Appendix Table A1 to contextualize this confounding factor.

Despite these limitations, the present study provides important insights into the clinical utility of an indirect reduction strategy for small bony Bankart lesions. By combining high-resolution radiologic assessment with OPC-referenced performance benchmarking, this investigation offers a structured and objective appraisal of the BRUMA technique within the broader context of existing surgical approaches. These findings contribute to an evolving understanding of how fragment viability, capsulolabral tensioning, and selective adjunctive procedures such as remplissage collectively influence postoperative stability and functional recovery.

The findings of this study provide several important directions for future research. Given the promising functional and radiologic outcomes observed with the BRUMA technique, larger prospective cohort studies are warranted to validate these results and refine OPC benchmarks for different patterns of bony Bankart lesions. Comparative investigations against established fixation-based methods—such as the BBB or direct fragment fixation—may offer clearer insights into the relative advantages of indirect reduction, particularly in terms of fragment viability, union quality, and long-term glenoid morphology. Biomechanical evaluations using cadaveric models or computational simulations could further elucidate the mechanisms by which capsulolabral retensioning influences joint stability and load distribution.

Because many patients with anterior instability are young and physically active, future studies should incorporate high-demand functional metrics, including return-to-sport rates, overhead activity tolerance, and validated performance measures. An extended follow-up will also be necessary to determine the durability of fragment union, assess late remodeling behavior, and identify any delayed recurrence. Finally, cost-effectiveness analyses may help determine whether avoiding direct hardware fixation on the bony fragment in the BRUMA technique has any procedural or economic implications without compromising clinical outcomes. Collectively, these efforts will help define the optimal role of BRUMA within the expanding treatment landscape for small bony Bankart lesions.

Conclusion

Supplemental Material

sj-docx-1-ojs-10.1177_23259671261442219 – Supplemental material for Clinical and Radiologic Outcomes of the Bankart Repair Using Mason-Allen (BRUMA) Technique for Small Bony Bankart Lesions: An Objective, Performance Criteria-Referenced, Single-Surgeon Case Series

Supplemental material, sj-docx-1-ojs-10.1177_23259671261442219 for Clinical and Radiologic Outcomes of the Bankart Repair Using Mason-Allen (BRUMA) Technique for Small Bony Bankart Lesions: An Objective, Performance Criteria-Referenced, Single-Surgeon Case Series by Hyung Seo Jung, Hong-Keun Park, Kyung-Soo Oh and Jin-Young Park in Orthopaedic Journal of Sports Medicine

Footnotes

Appendix

Final revision submitted March 18, 2026; accepted March 24, 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 Institutional Review Board of Konkuk University Medical Center (Approval No. KUMC IRB 2025-03-014).

ORCID iDs

Hyung Seo Jung

Jin-Young Park

A Video Supplement for this article is available is available at

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