Most important is to evaluate the degree and direction of the instability to reflect and interpret the imaging findings. This will direct the surgical strategy and help balance the shoulder stability. All patients should be examined regarding their range of motion, strength, and sensibility before evaluating their instability. A variety of tests can be used to address the instability components and directions like anterior-inferior or posterior load shift, apprehension, relocation, posterior jerk, and Kim test.

The load and shift test evaluates the translation of the humerus in relation to the glenoid and is graded in four stages from 0 to 3. The patient is placed supine on the edge of a bench and the arm is positioned in 90° of abduction. An axial load to the humerus is applied with one hand, while the other hand is used to translate the anterior and posterior humerus.

For the jerk test, patients are sitting or standing with the surgeon behind them. Patient’s scapula is fixed with one hand; the affected arm is positioned at 90° abduction and internally rotated. Pushing the elbow posteriorly provides an axial load to center the humerus, and a horizontal motion of the arm across the body is performed. A positive test is indicated by a sudden click as the humeral head slides off the back of the glenoid. When the arm is returned to the original position, a second click may be observed, as the humeral head is returning to the glenoid.

For the Kim test, patients are in a sitting position and the arm in 90° of abduction. The surgeon stands behind the patient holding on to the elbow with one hand, and the other hand is holding on to lateral aspect of the proximal humerus. Simultaneously, an axial loading force to the elbow and upward elevation is applied over the elbow, while the other hand pushes the proximal humerus posteroinferiorly. Posterior shoulder pain is considered as a positive test result, and an additional click can occur but is not mandatory for a positive result.

All directions should be evaluated with appropriate tests as extended labral tears result in bidirectional instability. A general impression for mobility and laxity should also be evaluated in order to include findings into preoperative planning for possible capsule shifts. The sulcus sign is helpful for this evaluation. Therefore, the arm is pulled caudally in neutral rotation and the lateral aspect underneath the acromion is inspected for any dimpling which can be measured and graded. The test is repeated in external rotation to evaluate the rotator interval and in internal rotation to address the posterior capsule more specifically. Lastly, examination under anesthesia should be performed to confirm clinical findings. We prefer to divide this into two separate steps, first after the still-awake patient received the nerve block where the position of patient and arm can be changed freely and a second look with the patient asleep to fully understand the direction and extension of the instability.

Patient should have a history of traumatic dislocation that resulted in symptomatic anterior- inferior or bidirectional instability. Appropriate physical examination findings included 2+ or greater anterior-inferior or posterior-inferior load shift, symptomatic apprehension test with positive relocation, symptomatic posterior jerk test, and a positive Kim test, and this is confirmed by MRI imaging showing extended anterior, inferior, and posterior labral tears while ruling out significant bone loss. Surgeons should expect a more extended injury with the combination of abovementioned clinical and imaging findings. This may influence surgery setup to favor lateral decubitus position to perform a posterior stabilization, and surgery time may be planed for an extended case.

The procedure starts with the performance of an examination under anesthesia. Therefore, the patient is positioned supine, and all previously performed clinical tests are repeated, and the contralateral shoulder is examined for comparison. Afterward, the patient is positioned in the lateral decubitus and secured with a bean/sand bag or vacuum mattress. The involved arm is prepared and draped utilizing an overhead traction device with 5 lbs of longitudinal traction and 7 lbs of abduction/distraction (Fig. 19.2). The surface anatomy is marked with a sterile marker, and initial anterosuperior viewing portal is established. The posterior portal can then be created under arthroscopic visualization with a spinal needle and switching stick to determine the optimal entrance trajectory and location of the posterior anchor. This way the posterior portal can be placed more laterally to achieve the optimal angle for anchor placement. We recommend the use of cannulas in both portals for suture management purposes to avoid soft tissue bridges and prevent fluid extravasation. An additional anteroinferior portal can be created directly above the subscapularis midway between the humeral head and the glenoid for better triangulation. As for every Bankart lesion, the labrum first has to be mobilized precisely using a sharp elevator along the lesion’s entirety. The labral footprint is then to be prepared using a hand rasp and motorized burr, decorticating the glenoid neck to improve the healing capacity. We typically repair the labrum in a posterior to anterior fashion wherein the number of suture anchors is determined by the extent of the tear. In accordance with what is performed for simple anteroinferior instability cases, the anchors can be placed every 10–12 mm along the glenoid rim. For a standard Bankart repair in a right shoulder, this would represent three or four anchors placed at the 5-o’clock, 4-o’clock, 3-o’clock, and 2-o’clock positions anteriorly and two or three anchors placed at the 7-o’clock, 8-o’clock, and sometimes 9-o’clock positions posteriorly. The posteroinferior anchor can be placed through a percutaneous insertion to provide a perpendicular angle to the glenoid. A suture passing instrument helps grasping tissue inferiorly and passing the suture underneath the capsulolabral complex to shift tissue from inferior to superior for each individual anchor. We prefer to put a shuttle suture prior to the anchor in place because we believe accurate placement of suture is necessary for adequate capsular retensioning which we believe is the most important part of the procedure, especially inferiorly (Fig. 19.3). This ensures that the shuttle suture is placed caudal to the planed anchor position so that subsequent shuttling of the permanent suture housed within the anchor knot tying will cause an inferior to superior shift of the capsulolabral complex. The same suture-first technique is applied to a second anchor and so forth. In traumatic injuries such as these, the extended labral detachment is also composed of a capsular laxity component. In such cases, we perform a capsulorrhaphy approximately 10 mm away from the labrum. There is a balance between retensioning of the posterior band of the inferior glenohumeral ligament complex, without extensive plication to avoid overtightening and subsequent loss of internal rotation. Postoperatively, while the patient is still on the operating room table, we examine internal rotation to make sure there is no restriction. Once the posterior labrum is repaired, the scope is switched to the posterior portal, and the anterior and inferior labrum can be addressed. Anchors are placed percutaneously through the subscapularis starting inferior and moving superior similar to the posterior repair (Fig. 19.4). With consideration of tissue quality, laxity, and previous clinical findings, a capsule shift or plication can be integrated into the either anterior or posterior repair. The same applies for a rotator interval closure. The closure is performed by passing a suture through the middle glenohumeral ligament and the superior glenohumeral ligament and tying them at the end of the procedure (Fig. 19.5).