Arthroscopic Stabilisation

Labral Repair

Arthroscopic Shoulder Stabilisation



1.  EUA


Compare both shoulders


- anterior and posterior draw

- load and shift

- sulcus sign


2.  Labral Assessment


A.  Above equator


Labral detachments here not uncommon 

- degenerative tear in throwing athlete

- likely a SLAP constributes to instability


Beware normal variations in this area


Rao JBJS Am 2003

- variations in the antero-superior labrum

- found in 13% of patients

- 3 main types


1.  Sublabral foramen


Arthroscopy Anterior Sublabral ForamenShoulder Sublabral foramen


2.  Sublabral foramen with cord like MGHL


Buford Complex


3.  Absence of AS labrum with cord like MGHL

- Buford complex


Buford Complex


B.  Below equator 


Labral detachments / Bankart

- cause of instability

- 3 to 6 o'clock

- tear of anterior IGHL with labrum

- can be variants (ALPSA, GLAD, Perthes)


Anterior Bankart LesionShoulder Anterior Bankart


C.  Exclude HAGL


Assess anterior IGHL attachment to humeral neck


Normal IGHL Humeral Attachment


D.  Posterior Labrum


Always assess

- place camera through anterior portal


Arthroscopy Posterior Labral Tear


3.  Bony Assessment


A.  Anterior Glenoid

- measure bone anterior to bare area in centre of glenoid

- compare to bone posterior to bare area

- beware > 4 mm difference

- look for pear shaped glenoid

- is there sufficent bone for ST surgery alone?


Shoulder Anterior Glenoid DeficiencyGlenoid Bone Loss


Glenoid Bone Loss Measurement 1Glenoid Bone Loss Measurement 2



- anterior bony procedure


B.  Hill Sachs

- posterolateral with anterior dislocation

- assess ER

- only a problem if engages with head centred and ER < 30 - 40o


Hill Sachs ArthroscopyHill Sachs Lesion SuperiorShoulder Engaging Hill Sachs




1.  Latarjet / Bristow

- ensures no engagement on anterior glenoid


2.  Wolf Remplissage

- mobilisation of capsule and infraspinatous into Hill sach's

- renders defect extra-capsular


3.  Humeral head allograft


4.  Humeral head osteotomy


Technique Anterior Bankart Repair


Labral Repair


Set up


Beachchair / lateral (surgeon preference)

Pressure pump

- usually less pressure required than subacromial work

- 40 mmHg




Shoulder Portals Labral Repair


A.  Standard posterior portal

- 2 cm below and 2 cm medial to PL acromion

- in soft spot

- good angle for GHJ work


B.  Anteroinferior Portal (AI)

- for anchor placement

- rotator interval just above SSC
- 1 cm lateral to glenoid

- establish with spinal needle

- need to access 3 - 6 o'clock

- 8 mm portal


Shoulder Scope Anteroinferior Portal


Anterosuperior Portal (AS)

- for suture management

- 1 cm superior and 5 mm lateral

- spinal needle

- enters rotator interval at angle between biceps and glenoid

- 8 mm cannula


Shoulder Arthroscopy Anterosuperior PortalShoulder Stabilisation 2 Anterior PortalsRotator Interval 2 cannulas



- can make rotator interval very crowded

- repair can be done through single portal


Mobilise labrum


Shoulder Scope Bankart RaspShoulder Stabilisation Labral Mobilisation


Labral mobiliser / rasp / scissors

- labral tear can be obvious, but may have partially healed or healed medially

- mobilise until can see SSC muscle underneath

- change camera to ASL portal for better view


Shoulder Arthoscopy Bankart MobilisationShoulder Scope Bankart Mobilisation


Bony Fragments

- important to recognise




1.  Incorporate in repair

- pass sutures medially to bony fragments


2.  Remove / debride


Shoulder Arthroscopy Bony Bankart


Debride bone to bleeding base

- tear is from 3 to 6 o'clock

- use shavers / burrs


Shoulder Stabilisation Anterior Labral MobilisationShoulder Stabilisation Anterior Labral Mobilisation 2


Labral Repair



- 2.3 or 3.2 mm bioabsorbably anchors


Insert inferior anchor

- most difficult and most important

- via anteriorinferior portal or via stab incision in SSC

- on anterior edge of glenoid cartilage

- want to recreate bumper effect

- inferior anchor first at 5.30

- insert drill guide, pass drill, insert anchor

- usefull to have assistant distract head laterally at this point


Arthroscopy Bankart Anchor Drill GuideInferior Glenoid Anchor


Suture passer

- again, assistant distracts shoulder

- right angled for right shoulder, left angled for left

- via the AI portal

- decide whether to take labrum only or capsule then labrum

- want to pull tissue superiorly and laterally

- suture passer with loop / single nylon in anterior to posterior direction

- retrieve through portal

- retrieve suture posterior to anterior through portal


Shoulder Bankart Repair Suture PasserShoulder Instability inferior Suture passage


Tie knot

- simple knot / Duncan Ely / Modified Roeder

- ensure post / subsequent knot is anterior to labrum

- recreate bumper effect


Arthroscopy Anterior Bankart Repair


Remaining anchors

- 5 mm apart

- beware lysis and risk of anterior glenoid / postage stamp fracture

- up to glenoid equator

- usually three in total


Shoulder Bankart RepairShoulder Scope Bankart Repair 2


Additional Issues / Continued Instability


Capsular Shift

- take bite of capsule with suture passer, then labrum


Shoulder Instability Capsular Plication



- contributes to inferior instability

- requires repair


Rotator Interval

- can tighten with continued instability

- close capsule in this area with suture

- must do with arm at 30o ER

- do away from glenoid on humeral side or will make patient very stiff


- must do last




Primary Arthroscopic Stabilisation


Altchek et al Am J Sports Med 2010

- Hospital for Special Surgery New York

- prospective follow up 88 patients 2 years

- 18% recurrent instability episode / 3% revision

- identified patients < 25 / ligamentous laxity / Hill Sachs > 250mm3 high risk


Carreira et al Am J Sports Med 2006

- prospective follow up 87 patients followed for 2 years

- 10% recurrent instability


Arthroscopic v Open Bankart Repair


Bottoni et al Am J Sports Med 2006

- RCT open v arthroscopic, 2 - 3 year follow up

- 2 failures in open group v 1 failure in arthroscopic group

- open took significantly longer and was associated with decreased ER


Revision of Failed Arthroscopic Stabilisation


Cho et al Am J Sports Med 2009

- revision of 26 failed arthroscopic stabilisation with open bankart

- redislocation in 3 shoulders all with engaging Hill Sachs and ligamentous laxity


Francheschi et al Am J Sports Med 2008

- 10 patients with failure of arthroscopic stabilisation

- managed with repeat arthroscopic stabilisation

- 1 recurrence