Arthroscopic Bankart repair results have traditionally been deemed as inferior to the results obtained through open repair. The first arthroscopic Bankart repairs were performed with transglenoid labral suturing, in which the labrum was often repaired in a medialized, nonanatomic position.^1,2,3,4,5 The development and the use of suture anchors in arthroscopic Bankart repair, along with the greater recognition of the need to repair the labrum to the glenoid rim or face, have allowed surgeons to achieve results that are comparable to open Bankart repair.^{6,7,8,9,10,11,12,13,14,15}

The senior author (SSB) has previously reviewed his results of arthroscopic Bankart repair.¹⁶ The redislocation rate in this series was 10.8%. However, the redislocation rate was only 4% for patients without significant bone defects. In patients with an engaging Hill-Sachs lesion or significant glenoid bone loss, the redislocation rate was 67%. In light of these results, it is our opinion that the failure of Bankart repairs, whether done arthroscopically or open, is not usually a failure of technique, but rather a failure to recognize and treat significant glenohumeral bone deficiency. Accordingly, we treat patients who have greater than 25% loss of the anterior glenoid or an engaging Hill-Sachs lesion with an open Latarjet procedure to restore the normal articular arc between the glenoid and the humerus.

In the contact or overhead athlete who dislocates his or her shoulder traumatically for the first time and has a documented Bankart lesion on magnetic resonance imaging (MRI) without significant bone loss, we recommend an arthroscopic Bankart repair since, in our clinical experience, the rate of redislocation without surgery in this group of athletes is quite high. For the older recreational athlete who dislocates his or her shoulder traumatically for the first time, we recommend nonoperative treatment. In all patients who have traumatically dislocated their shoulders more than once, we recommend an arthroscopic Bankart repair. Patients who have atraumatic shoulder instability and have evidence of ligamentous laxity on physical examination are initially treated nonoperatively with physical therapy.

In patients who have dislocated their shoulder multiple times and in patients who appear to have a bony Bankart lesion or a large Hill-Sachs lesion on radiographs, we obtain preoperative computed tomography (CT) scans with three-dimensional reconstructed images of the glenoid and humerus in order to assess the degree of glenohumeral bone loss. Typically, in patients who have a high degree of glenohumeral bone loss, we will perform an initial diagnostic shoulder arthroscopy in order to diagnose and arthroscopically repair any superior labral anterior to posterior (SLAP) lesion. We will also assess arthroscopically if there is an engaging Hill-Sachs lesion or quantify the degree of glenoid bone loss. If there is an engaging Hill-Sachs lesion and/or loss of greater than 25% of the anterior glenoid, we will reposition and reprep the patient and proceed to an open Latarjet procedure.

After induction of general anesthesia, the patient is placed into the lateral decubitus position. Five to 10 pounds of balanced suspension are used with the arm in 20 to 30 degrees of abduction and 20 degrees of forward flexion (Star Sleeve Traction System; Arthrex, Inc, Naples, Fla). Glenohumeral
arthroscopy is performed through the standard posterior portal with an arthroscopic pump maintaining a pressure of 60 mm Hg.

For anterior instability cases we use a standard anterior portal for suture placement and anchor placement. Often a lower anterior portal is needed for suture anchor placement in the 5 o’clock position of the glenoid.¹⁷ While a posterior viewing portal is initially used, the anterosuperior portal gives the surgeon a better view of the anterior aspect of the glenoid. An unobstructed view is essential for glenoid bone preparation and correct suture anchor placement.

Anterior instability cases are often associated with SLAP lesions or posterior labral tears. It is, therefore, important to systematically examine both the superior labrum and posterior labrum to ensure that there are no concomitant injuries to these labral structures. While viewing through the posterior viewing portal, we take the arm out of traction and place it in external rotation and abduction to see if there is a peel-back lesion. As the arm is placed in abduction and external rotation, the superior labrum, if not well anchored, will shift medially over the corner of the glenoid onto the posterosuperior scapular neck.¹⁸ A positive peel-back test confirms a posterosuperior SLAP lesion. It is also necessary to thoroughly probe the biceps root attachment since an isolated anterosuperior SLAP tear will have a negative peel-back test but will have a displaceable biceps root. Since swelling can obliterate the superior sulcus above the superior labrum, and an anterior capsulolabral repair can be a lengthy procedure, we initially prepare the bone of the superior glenoid neck, place anchors, and pass the sutures through the superior labrum. We do not, however, tie the sutures of the SLAP repair until the end of the procedure. The SLAP lesion produces some “pseudolaxity” within the glenohumeral joint, which improves the visualization and working space for anterior capsulolabral repair. Tying the sutures of the SLAP repair obliterates this laxity and makes anterior capsulolabral repair more difficult.