In the view from the anterolateral superior portal, the detached labrum, especially the ALPSA lesion, can be easily recognized (Fig. 12.4a–c) and is released by an elevator through the anterior portal. It is mandatory to release scar tissue between torn labrum and scapular until the subscapularis muscle belly can be visualized (Fig. 12.5), then the labrum can be easily repositioned.

The glenoid rim is debrided with a shaver and freshened with the rasp to create a bleeding bone surface for healing.

Usually, three to four anchors are used to repair the Bankart lesion and are inserted from inferior to superior through the anterior portal. The implant choice is made based on each surgeon’s preference and familiarity with any of the available 2.8- to 3.5-mm anchors.

For the first suture anchor at the 5:30 o’clock position, some authors recommend to create the deep anteroinferior portal through the lower third of the subscapularis.

The first suture anchor is implanted at the 5:30 o’clock position of the glenoid. From the anterior portal (Fig. 12.6), a suture passer is then used to pass a shuttling suture through the capsule, anterior bundle of the inferior glenohumeral ligament, and labrum about 6–7 mm inferior to the previously placed anchor, so that the whole capsulolabral complex including the aIGHL is incorporated. The goal is to get a healthy capsular bite, grabbing inferior to the anchor in an effort to shift the tissue superiorly, reducing capsular volume (Fig. 12.7).

The sutures were shuttled and tied arthroscopically in a simple or mattress fashion. Afterward, other anchors are implanted sequentially to repair the labrum in the same manner. The capsulorrhaphy is routinely incorporated into labral repair in the recurrent cases.

The remplissage technique is used to address the engaging Hill-Sachs lesion. The goal of remplissage technique is to fix the conjoined infraspinatus tendon and posterior capsule to the Hill-Sachs lesion. The procedures of anchor implanting and suture passing must be completed before Bankart repair. Otherwise, the reduced capsular volume will compromise the visualization of Hill-Sachs lesion.

With viewing from anterolateral superior portal, the extent and location of the Hill- Sachs lesion is evaluated. The surface of the engaging Hill-Sachs lesion is gently freshened with a bur through the posterior portal (Fig. 12.8).

Usually, two anchors are employed in remplissage technique and are placed in the most distal and superior aspects of the Hill-Sachs lesion in sequence. These anchors are placed in the inferior medial and superior medial margins of the defect (Fig. 12.9)

Following the sutures of two anchors being retrieved from anterior portal, the cannula in posterior portal is withdrawn outside the posterior capsule and infraspinatus tendon into the subdeltoid space.

A penetrating grasper is used to pass through the infraspinatus tendon and posterior casule, to retrieve the sutures individually through the posterior cannula, so that finally mattress knots could be tied extraarticular, in the subdeltoid space. If the visualization of knot tying is necessary, the arthroscope can be switched to the subacromial space to view the corresponding suture threads being tied in a mattress suture (Fig. 12.10a, b)