Abstract
Background:
Bony injury to the anterior glenoid occurs in the setting of anterior instability, in addition to injury of the capsulolabral complex. If left untreated, this fracture—referred to as a bony Bankart—compromises the glenoid track, increasing the risk of recurrent instability. The aim of this video technique is to describe the indications and technique for arthroscopic single- and double-row repair of a bony Bankart lesion in patients with anterior shoulder instability.
Indications:
Arthroscopic management of bony Bankart lesions should be pursued aggressively in acute cases (<3-6 months postinjury), when the fragment remains viable and more easily reducible. Lesion size plays a crucial role in determining the surgical approach: smaller lesions (<10% of the glenoid rim) may be effectively managed with a single-row repair, while medium-size (10% to 20%-25% of the glenoid rim) or larger-size (>20%-25% of the glenoid rim) lesions may benefit from a double-row technique in order to confer enhanced compressive and rotational stability.
Technique Description:
Patients are placed in a lateral decubitus position. The capsulolabral complex and bony fragment are mobilized, and the glenoid margin is lightly decorticated to encourage healing. Suture anchors are first placed at the inferior and superior margins of the bony lesion, and the capsulolabral complex is restored. Depending on the bony Bankart lesion size, fixation of the lesion can be achieved using either a single-row or a double-row technique.
Results:
In the present cases, both techniques successfully achieved adequate fracture reduction, ensuring stability and proper alignment. Both patients achieved good functional outcomes, with return to all activities postoperatively.
Discussion/Conclusion:
Arthroscopic single- and double-row repair of bony Bankart lesions has demonstrated success in the treatment of anterior shoulder. While single-row repair may provide adequate fixation for smaller bony fragments, a double-row repair may offer superior biomechanical stability and be more appropriate for the treatment of medium- to large-sized bony fragments.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
This video will demonstrate the senior author's (N.V.) indications and technique for arthroscopic single- and double-row repair of a bony Bankart lesion in the setting of anterior shoulder instability.
Author disclosures are as listed.
Background
Anterior shoulder instability is common, with an incidence of 23.9 per 100,000 person-years.1,10 An anterior shoulder dislocation typically disrupts the capsulolabral complex but is also associated with anterior glenoid rim fractures in anywhere between 8% and 50% of cases. 9 This anterior glenoid rim fracture—commonly referred to as a bony Bankart lesion—is present in up to 20% of first-time anterior shoulder dislocations. 5 Surgical management is typically recommended to restore the glenoid track and prevent recurrent instability. 6
Indications
We will utilize 2 case presentations to demonstrate the indications and technique for the use of arthroscopic single- and double-row repair for bony Bankart lesions.
The first case is a left-hand-dominant 17-year-old boy who presented with recurrent right shoulder subluxations following a traumatic shoulder dislocation 5 months prior while playing football. The patient's physical examination was notable for full range of motion and strength, with a positive apprehension-relocation sign. A 4-view radiographic series of the shoulder demonstrated subtle blunting of the anterior glenoid but no other acute osseous abnormalities. Magnetic resonance imaging (MRI) was suggestive of a small bony Bankart lesion with disruption of the anterior-inferior capsulolabral complex. Computed tomography (CT) was acquired to characterize to better quantify the bony injury. This demonstrated a small, subacute bony Bankart lesion and no significant Hill-Sachs lesion. The fragment size represented the entirety of the glenoid bone loss, calculated at 8.9%.
The second case is a 31-year-old, right-hand-dominant man who presented following a traumatic left shoulder dislocation that occurred in a ski accident. Physical examination was notable for mild limitations in range of motion and strength secondary to pain, as well as positive apprehension-and-relocation testing. A 4-view radiographic series was suggestive of a bony injury to the anterior glenoid, which was further characterized on advanced imaging as being a medium- to large-sized bony Bankart fragment, calculated as being 22.0% of the native glenoid diameter.
The senior author has a surgical algorithm for acute bony Bankart lesions that separates injuries into 3 categories based on the magnitude of the lesion. Small bony Bankart lesions (<10% of the glenoid rim) undergo arthroscopic single-row repair, while medium-sized bony Bankart lesions (10%-25% of the glenoid rim) undergo arthroscopic double-row repair. Individuals sustaining an injury where a larger fragment (>20%-25% of the glenoid rim) is involved will undergo an arthroscopic-assisted fixation with cannulated screws if the fragment is salvageable. However, if the larger fragment is not salvageable, either an arthroscopic or open repair should be conducted with an anterior bone block or Latarjet.
Based on the senior author's algorithm for management of bony Bankart lesions, the patient in the first case was indicated for an arthroscopic single-row repair, whereas the patient in the second case was indicated for an arthroscopic double-row repair.
Technique Description
The procedures were performed in a modified lateral decubitus position under general anesthesia and interscalene nerve block. A surgeon-controlled arm holder (Smith & Nephew Tenet Spider2 Limb Positioner; 7210576 [Lateral Shoulder Connection Bar] and 7210577 [Tenet Traction Accessory]) is utilized to apply balanced axial traction and maintain 15° of forward flexion and 30° of abduction throughout the procedure, while a lateral jack (Smith & Nephew Tenet Lateral Jack; 72201428 [Lateral Jack]) is utilized to provide further axillary distraction. Additional axillary distraction may be obtained utilizing a roll of Coban-wrapped surgical towels, if needed.
A posterior portal is first established. After a standard diagnostic arthroscopy to confirm the radiographic findings, a mid-glenoid portal is established in the rotator interval, followed by the placement of a cannula. Spinal needle localization is utilized to confirm adequate portal placement and trajectory for instrumentation. An accessory anterosuperior viewing portal is then created just off the anterolateral acromion, superior to the biceps within the joint. This portal is used for viewing throughout the remainder of the procedure.
An arthroscopic Bankart elevator (Arthrex modular tissue elevator) is then utilized to mobilize the torn glenoid labrum. An arthroscopic grasper may be utilized to verify the ease of fragment and capsulolabral complex reduction. An arthroscopic shaver is then utilized to lightly decorticate the glenoid rim to promote healing before anchor placement. Utilizing a 7:00 portal, a 1.8-mm, knotless, all-suture anchor (Knotless 1.8 FiberTak Soft Anchor; Arthrex) is placed at the 6:30 position. A curved suture passer (Spectrum II; ConMed Linvatec) is then utilized to pass a No. 1 polydioxanone suture (Ethicon) passing suture through the capsulolabral complex. After the repair suture from the anchor is passed through the tissue, it is subsequently shuttled through the knotless mechanism of the anchor and provisionally tensioned. Anchors are subsequently placed just inferior and superior to the border of the bony Bankart lesion, through a 5:00 portal and the mid-glenoid portal, respectively. Notably, the repair sutures from these anchors are not fully tensioned in order to facilitate anchor placement and suture passage around the bony Bankart fragment. Finally, through the 5:00 portal, 2 additional suture anchors are placed just medial to the glenoid margin within the base of the bony Bankart fragment, with sutures passed around the fragment and shuttled through the knotless mechanism of the anchor in a standard fashion. The repair sutures from the first 3 anchors are fully tensioned to restore the capsulolabral complex before tensioning the 2 repair sutures around the bony Bankart lesion to achieve an appropriate reduction of the bony fragment.
For the second case, a double-row repair of the bony Bankart lesion is performed. After establishing portals in a similar fashion, an arthroscopic shaver is used to clear hemarthrosis, granulation tissue, and inflammatory debris, followed by a bone-cutting shaver to lightly decorticate the glenoid rim. After similar mobilization of the capsulolabral complex using an elevator, the fragment is mobilized to ensure adequate reduction. An accessory 5-o’clock portal is created using a spinal needle. A suture anchor (Knotless 1.8 FiberTak Soft Anchor; Arthrex) is placed at the 5:30 position, securing the inferior margin of the labral tear. Sutures are passed through the capsulolabral complex and provisionally tensioned via an accessory 7-o’clock portal. Another suture anchor (Knotless 1.8 FiberTak Soft Anchor; Arthrex) is then placed at the superior margin of the labral injury, near the 2:30 position, with sutures again passed through the capsulolabral complex and provisionally tensioned. To establish the medial row, an accessory 4-o’clock portal is created in line with the glenoid under spinal needle localization. A double-loaded all-suture anchor with tape (Knotless 1.8 FiberTak Soft Anchor; Arthrex) is placed along the glenoid neck, medial to the fragment. The fragment is then reduced, and the previously tensioned repair sutures from the anchors at the superior and inferior margins of the fragment are tightened to achieve this provisional reduction and fixation. Two of the 4 tape sutures from the medial, double-loaded anchor are then passed through the capsulolabral complex and secured into a pilot hole at the superior fragment margin using a knotless suture anchor (Knotless 2.9 PushLock Anchor; Arthrex). The process is repeated for the remaining 2 tape sutures from the medial row anchor, securing them into the glenoid at the inferior fragment margin with another knotless suture anchor (Knotless 2.9 PushLock Anchor; Arthrex), thereby achieving a double-row repair construct.
Results
Following surgery, patients are discharged with a sling for 4 to 6 weeks. Pain is managed with the use of oral medications, and aspirin 81 mg is prescribed twice daily for the first 2 weeks to reduce the risk of venous thromboembolic disease. Formal physical therapy begins on postoperative days 10 to 14, with patients advised to attend 2 to 3 sessions per week after their initial follow-up. During this phase, forward flexion and external rotation are restricted to 90° and 30°, respectively. Upon sling discontinuation, active-assisted and active range of motion exercises commence, with forward flexion and external rotation at the side limited to 140° and 40°, respectively. Patients are expected to achieve a full, painless range of motion by 8 to 12 weeks, at which point, strengthening exercises are introduced. Return to sports or full activities is permitted by 6 months postoperatively, provided sufficient strength and mobility have been regained and the patient has completed a graduated, sport-specific, return-to-play progression.
Relevant potential complications of the procedure include bleeding, infection, neurovascular injury, arthrofibrosis, and recurrent instability.
Discussion/Conclusion
Arthroscopic repair of bony Bankart lesions has been demonstrated by several previous series with relatively small sample sizes.1,2 Sugaya et al 8 reported their outcomes of single-row bony Bankart repair performed on 42 shoulders in 41 patients with traumatic glenohumeral instability in the setting of a bony Bankart lesion. In this series, the mean fragment size measured 9.2% of the glenoid width, and the mean glenoid bone loss measured 24.8% of the glenoid width. 2 At a mean 34-month postoperative follow-up, patients demonstrated significant improvement in mean Rowe and UCLA scores. 2 Patients demonstrated a 4.8% rate of recurrent instability and a 94.6% rate of return to sport. 2
While there is a paucity of clinical outcomes literature comparing the results of arthroscopic single-row and double-row repair of bony Bankart lesions, double-row repair has been demonstrated to confer improved biomechanical stability.3,4 In the study by Spiegl et al, 7 double-row repair led to significantly greater forces being needed to achieve 1- and 2-mm displacement of the fragment in comparison to single-row repair. Likewise, in the study by Greenstein et al, 4 single-row repair demonstrated significantly greater step-off and ultimate displacement of the fragment after cyclic loading.
Finally, Chen et al. 3 performed a systematic review of 21 studies and 769 patients who underwent arthroscopic bony Bankart repair. The authors reported a mean improvement in Rowe score from 41.9 points preoperatively to 90.8 points postoperatively. 1 At the mean final follow-up of 42.7 months, there was an 11.9% rate of recurrent instability and a 91.0% rate of return to sports. 1
The senior author's surgical algorithm for the treatment of acute bony Bankart lesions is presented here. While smaller bony Bankart lesions may be adequately treated with a single-row repair, the senior author favors a double-row repair with medium-sized lesions, measuring approximately 10% to 20% of the width of the glenoid rim, due to the increased biomechanical stability conferred by the repair construct. With larger fragments, cannulated screws can be used for the fixation of salvageable fragments, while anterior bone block procedures or the Latarjet procedure are favored when the fragment is no longer salvageable. Notably, for more chronic bony Bankart lesions, attritional damage to the bony fragment and the status of glenoid bone loss should be critically assessed to determine the ability to perform an arthroscopic soft tissue–type repair versus requiring a bony reconstruction procedure.
From Midwest Orthopaedics at Rush, we thank you for watching this video.
Footnotes
Submitted April 12, 2025; accepted July 28, 2025.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
