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Arthroscopic Bankart Repair With SutureAnchors: Tips for SuccessKevin D. Plancher, MD,* and Stephanie C. Petterson, PhD†

1060-1872/13/doi:http://dx.do

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Anterior instability treated by arthroscopic surgery is a viable option to return the athleteand nonathlete back to activities. The use of suture-loaded anchors has become a standardmethodwith reliable fixation. Arthroscopic Bankart repair can successfully restore range ofmotion and stability and yield successful outcomes with a low recurrence rate. This articledescribes arthroscopic Bankart repair with a modified inferior capsular shift in the lateraldecubitus position.Oper Tech Sports Med 21:192-200 C 2013 Elsevier Inc. All rights reserved.

KEYWORDS shoulder, anterior instability, arthroscopic Bankart, inferior capsular shift

Anterior instability is the most common form of shoulderinstability.1 The incidence of traumatic anterior gleno-

humeral instability in the general population is 1.7%,2 with theincidence of Bankart lesions in first-time traumatic dislocatorsas high as 97%.3 A patient account of a traumatic fall with aresultant anterior dislocation documented by radiography andpositive physical findings is a good indication of a Bankartlesion. Although changes in the capsule and the glenohumeralligaments play an important role to avoid a repeat dislocation,the labrummust be addressed to restore normal glenohumeralmechanics.4

Open repair has been the gold standard of treatment forsurgical repair of Bankart lesions; however, results of arthro-scopic repair now rival those of open intervention as a result ofadvances in surgical equipment, technique, and surgeon’sexperience. The aim of this article was to demonstrate apractical, step-by-step guide to arthroscopic repair of a Bankartlesion with a reproducible success rate to return athletes andnonathletes back to their desired activities.

Relevant AnatomyThe fibrocartilaginous labrum surrounds and attaches to theglenoid in a 3601 fashion. Although anatomical variants dooccur,5,6 the anteroinferior portion, involved in the essential orBankart lesion, normally adheres in a strict fashion (Fig. 1).

$-see front matter & 2013 Elsevier Inc. All rights reserved.i.org/10.1053/j.otsm.2013.10.002

essor, Albert Einstein College of Medicine, Departmentlancher Orthopaedics & Sports Medicine, New York,

tion for Active Lifestyles, Greenwich, CT.ts to Kevin D. Plancher, MD, Plancher Orthopaedicse, 1160 Park Ave, New York, NY 10128. E-mail:erortho.com

A Bankart lesion is the avulsion of the glenoid labrum, withor without a bony lesion, with the anterior band of the inferiorglenohumeral ligament (IGHL) from the anterior inferiorglenoid. The anterior band of the IGHL is the primary restraintto anterior translation of the humeral head, particularly whenthe shoulder is in 901 abduction and placed in an externallyrotated position.7,8 A second restraint to anterior humeraltranslation is the muscular contribution of the subscapularis.Its insertion onto the anterior shoulder joint capsule implicatesits role in shoulder stability. Although many other structuresare very important to understand shoulder anatomy and theirfunctional significance, we refer the reader to other sources.

Patient HistoryA thorough history is essential to surgical decision making.Exploring the nature of the traumatic event and determiningsubsequent dislocation or subluxation episodes after the eventprovides important information to the examiner. Descriptionof events that occur during sleep and bilateral apprehensionwithout a traumatic event are more characteristic of multi-directional instability, which is beyond the scope of this article.First-time dislocators in certain demographics are goodcandidates for early arthroscopic repair because of higherfailure rates with delayed surgical intervention.9

The most common mechanism of an anterior dislocationinjury involves a posteriorly directed force when the arm is in aposition of abduction and external rotation. Therefore, patientsare often reluctant to move their shoulder in an abducted andexternally rotated position (“apprehension” on physical exami-nation) during the critical period following an anteriordislocation for fear of recreating the provocative event or evena subluxation event. Observation of functional activities in the

Figure 1 Anteroinferior portion of the fibrocartilaginous labruminvolved in the essential Bankart lesion.

Figure 2 Infraspinatus atrophy in a 23-year-old tennis player indicatingrotator cuff dysfunction and not probable instability.

Arthroscopic Bankart repair with suture anchors 193

clinic, such as taking off a coat, can easily help to identifyaberrant movement patterns.A common complaint after a traumatic anterior dislocation

is numbness to the limb in an ulnar distribution, ofteninvolving the little finger and medial half of the ring finger.Numbness typically resolves in the first 14 days after the event.Patients who are 40 years and older should always bequestioned and examined for any weakness in the upperextremity for fear of missing a concomitant rotator cuff lesionor in patients older than 50 years, more commonly, anondisplaced, lesser or greater tuberosity fracture. A function-ing deltoid with intact sensation in the axillary nerve distribu-tion should always be confirmed.

Figure 3 Apprehension and relocation test. The involved arm isrotation. Symptoms of anterior instability or pain or both that repositive finding for anterior shoulder instability.

Physical ExaminationA comprehensive physical examination can be conducted inless than 5 minutes and can ensure an accurate diagnosis. Theexamination should assess range of motion, neurovascularintegrity, periscapular atrophy (Fig. 2), and strength, partic-ularly of the rotator cuff. Special testing should includeapprehension, relocation, augmentation, and lag signs(Fig. 3). Comparison with the opposite side must always bemade to appreciate the presence or absence of ligamentouslaxity and normal range of motion for the individual beingexamined. An anterior dislocation or subluxation event wouldstress the anterior band of the IGHL, which can contribute toincreased shoulder laxity,10 therefore, the examiner shouldgain an appreciation of the patient’s baseline external rotation

carefully placed in a position of abduction and externalsolve with a posteriorly directed force by the examiner is a

Figure 4 (A) Axillary viewwith patient positioned. (B) Plain axillary radiograph of a normal glenohumeral joint. (C) Arthritisof the glenohumeral joint.

Figure 5 AP with internal rotation view.

K.D. Plancher and S.C. Petterson194

in the opposite upper extremity. In addition, arm dominanceand sporting activity should also be taken into account wheninspecting the shoulder because of adaptations that occur,particularly in the overhead-throwing athlete. Complaints ofinstability in midranges of motion (eg, 201-601 of abduction)are frequently reported in persons with concomitant bone lossand should be a red flag for treatment.11

Radiographic EvaluationRadiographic examination should include a true anterior-posterior (AP), scapular-Y, and axillary views. The axillaryview provides good visualization of the anterior and posterioraspects of the glenoid fossa, the glenohumeral relations, andthe acromioclavicular joint. The axillary view aids in thedetection of AP subluxation or dislocation and can detectanterior or posterior glenoid rim fractures. Very often, theaxillary view is avoided for fear of pain provocation. We haveroutinely used a technique formore than 20 years to obtain thisessential view; the patient lies supine on the x-ray table holdingan IV pole with his or her arm abducted at 451 (Fig. 4A). Ifbone loss is suspected on the humeral side (Hill-Sachs lesion),a true AP with internal rotation is recommended (Fig. 5).Special views like theWest Point viewmay aid in visualization

of the anterior and inferior glenoid to detect possible bonydefects. Computed tomography or magnetic resonance imag-ing should be used to assess for other concomitant soft tissue orbony pathologies and assist with preoperative planning toavoid unexpected findings in the operating room.

Figure 6 Computed tomography scan illustrating severe bone loss.Anterior glenoid and labrum.

Arthroscopic Bankart repair with suture anchors 195

Evaluation of Bone LossThe amount of bone loss associated with a Bankart lesion is afactor that must be considered in surgical decision making.Patients with recurrent dislocations should undergo a rigorousinvestigation to identify glenoid or humeral bone loss. In theseinstances, a 3-D computed tomography scan should bepursued to evaluate possible glenoid bone loss and possibleHill-Sachs lesion. Arthroscopic Bankart repair can be successfulfor glenoid bone loss ofo20%-25%.12 Bone loss greater than25%would require a bony procedure to avoid high recurrencerates.13 There are many ways described in the literature toquantify the amount of bone loss to ensure that the arthro-scopic Bankart repairwould yield a successful outcome (Fig. 6).

Figure 7 Lateral decubitus position.

Operative TreatmentProceeding with surgical intervention should only occurfollowing the extensive evaluation described earlier and alengthydiscussionwith the patient. It is imperative that patientsunderstand the pros and cons, ramifications, expectations, andpossible complications of the proposed surgical intervention aswell as those associated with not having surgery.Although age does not exclude a patient as a candidate for an

arthroscopic procedure, patients younger than 25 years mustunderstand reported recurrence rates of 15%-98%, whichhave been published by various authors, especially in theathlete who plays contact sports.14 We have also found thatwrestlers have a much higher recurrence rate compared withathletes in other contact sports.Historically, outcomes of arthroscopic repairs were poor.

The technical components of arthroscopic Bankart stabilizationhave matured over the years and failure rates have decreasedranging from 8%-25% depending on patient characteristics(eg, athlete in recreational and collision sports).15-20 First-timedislocators who participate in collision activities are motivated,and the oneswho desire to participate in overhead activities arethe ideal candidates for the procedure described later.21

Preparation, Positioning, andDrapingThe patient is examined in the preoperative area and theappropriate limb is marked before proceeding. The patient isthen placed supine on the operating room table. Followingappropriate anesthesia, an intraoperative examination shouldbe conducted on both the limbs to confirm the preoperativeimpression and evaluate shoulder laxity or the ability to freelydislocate in the absence of muscle guarding by the patient.A time-out is performed and antibiotics are routinely admini-stered.Arthroscopic Bankart repair can be performed in the lateral

decubitus (Fig. 7) or beach-chair positions.We believe that ourexperience in performing the procedure in the lateral decubitusposition reproducibly provides access to the 6-o’clock positionand permits a sure way to easily return the capsulolabralcomplex to its anatomical position with a modified inferiorcapsular shift or Bankart repair as described by others.22

The lateral decubitus position aids in positioning the glenoidparallel to the floor, creating a standard reference point, andallows for excellent visualization and workspace during theoperation, whether a muscular or small patient.23 Risksassociated with the lateral decubitus position include com-pression of the common peroneal nerve and the contralateralbrachial plexus, which are minimized with appropriate posi-tioning and padding, verified by the surgeon and detailed later.A beanbag is placed in advance on the operating table and

the patient is laid in the lateral decubitus position. The beanbagis placed up, but not above, the inferior border of the scapula ofthe affected side. The patient is then moved to the head of thetable with his or her head in line with the head of the table. Thepatient is secured in place. The lower leg is padded with apillow and a foam donut or gel pad is placed with the fibularhead draped, free and protected to avoid nerve compression. Apillow is placed between both the legs and both the ankles arewrappedwith padding. Sequential pneumatic boots are placedon both legs. A warming blanket is placed below the nipplearea and not inflated until the patient is appropriately draped.

K.D. Plancher and S.C. Petterson196

Finally, understanding preoperatively the version of theglenoid, the table is tilted toward the surgeon to allow theglenoid to be parallel to the floor. The operating table is turnedso that the surgeon can work at the head of the table with2 monitors, one to the right of the surgeon and the otheropposite the surgeon, when standing behind the patient. Anarm holder is placed on the opposite side of the operatingroom table as low as possible to allow for traction to bemaximum, when needed.Following examination under anesthesia, the arm is secured

in a holder in approximately 451 of abduction and 151 offorward flexion and neutral rotation. We have not found anypostoperative stiffnesswith our patients in this position, as longas the arm is maintained in an abducted and externally rotatedposition with limited weight, no greater than 3.18-4.54 kg.Caution must be taken when applying traction in this positionto prevent damage to peripheral nerves and the brachialplexus. Tractioning in this position may assist in defininglabral tears and improving access to the labrum, subacromialspace, inferior capsule, andunderside of the rotator cuff.23 SplitU sheets are used when draping to expose the midsternal lineanteriorly and the medial border of the scapula posteriorly.Commercially available preparations are used; however, ourpatients must wash their entire body with Hibiclens (Moln-lycke Health Care Inc., Norcross, GA) or Phisohex (Sanofi-Aventis, Bridgewater, NJ) scrub for 5 days before surgery.

AnesthesiaArthroscopic Bankart repair is performed with an interscaleneblock placed under ultrasound guidance and supplemental,general endotracheal anesthesia. Although some have cau-tioned against the use of the interscalene block because oftemporary or permanent neurologic complications,24 we havefound it to be a safe, reliable regional anesthetic for shouldersurgery.25-27 The use of the interscalene block is associatedwith decreased blood loss,25,28 shorter stays in the recoveryroom, decreased postoperative opioid use, and faster dischargefrom the hospital. In conjunction with intra-articular analgesicinjections following the surgical intervention, interscaleneinjection can enhance pain control and has been shown todecrease the use of morphine consumption in the first 24hours following surgery.29 Our patients more often than notrefrain from opioid use and use only NSAIDs in the post-operative period. The phrenic nerve is affected with aninterscalene block, which normally leads to an ipsilateralhemidiaphragmatic paresis, and we avoid its use in patientswith complex respiratory diseases.

Surgical TechniquePortal PlacementWe use a modified 3-portal technique similar to that ofNebelung.22 Portals are established with an outside-in techni-que using an 18-gauge spinal needle to optimize positioning.The placement of the 2 anterior portals is crucial; too close

proximity would lead to crowding of the cannulas. Swellingcan be avoided with a pump pressure as low as possible(� 40 mm Hg) and turning off all fluids when not activelyperforming a task inside the shoulder (ie, when waiting foranchors or any equipment).

Posterior PortalThe posterior portal is typically the first portal placed and is theprimary viewing portal for the diagnostic arthroscopy. Astandard posterior portal is created 3 fingerbreadths inferiorto the posterior lateral border of the acromion and 2 finger-breadths medial in the soft spot in a routine fashion forshoulder arthroscopy.

Anterosuperior PortalThe purpose of the anterosuperior portal is 3-fold, to visualizethe pathology, to prepare the glenoid rim, and to repair theBankart lesion. With the scope visualizing the rotator intervalafter inspecting the 15 points described by Snyder,30 an 18-gauge spinal needle is introduced superiorly and must touchthe 1- or 11-o’clock position (right or left shoulder). The spinalneedle is positioned 451 to the glenoid rim. The position of thespinal needle must be in line with the anterior lateral border ofthe acromion and is often 1 cm inferior. The spinal needle isreplaced by a 5.5 cannula at first and then a long switchingstick is used with a metal dilator with the placement of an 8.0-mm � 90-mm cannula.

Anteroinferior PortalA second cannula is introduced in a similar fashion with aspinal needle staying lateral to the coracoid at all times, withthe tip of the needle approaching the 5:30-6:00 position ofthe glenoid rim at a 451 angle and perpendicular to theglenoid. We have often placed our cannula through thesubscapularis or even inferior to the tendon with impunity.Placement below the subscapularis allows the portal to beplaced accurately 2.5-4 cm from the axillary nerve, which issafe.22,31 The portal provides improved access to the glenoidfor optimal anchor placement in good bone stock to thearticular margin of the medial glenoid rim. The 5:30position in a right shoulder or 6:30 in a left shoulder. Wehave never detected any weakness, pain, or clinical issueswith this low portal.Once the spinal needle is introduced in the proper

position, it is left in place. An 11-blade (single-piece blade)is introduced alongside the needle and is brought into thejoint under direct visualization to open the capsule. Theknife is withdrawn and now a long, double-ended switchingstick is introduced into the joint through the same openingin the joint. A metal dilator is placed to stretch the capsuleopening and the 8.0-mm � 90-mm cannula can now beeasily introduced without struggling when pushing throughor even below the subscapularis. It is important whendilating to ensure that the switching stick is in the sameposition that the spinal needle was placed to ensure that thecannula is directed perfectly. With the 2 anterior cannulasplaced, the operative procedure is nearly complete as therest is now a technical exercise.We have noted not to abduct

Figure 8 Cannulas in place. Facilitates passage of instruments in andout of the shoulder and facilitate suture management.

Arthroscopic Bankart repair with suture anchors 197

the arm more than 451 at any time, to avoid bringing theaxillary nerve close to our portals (Fig. 8).

Diagnostic ArthroscopyAlthough complete examination of the joint is required for allshoulder procedures, this article only discusses our techniquefor treatment of traumatic anterior shoulder instability. Visual-ization from the posterior portal is begunwith evaluation of thesubscapularis recess. An attempt is made to visualize possiblemedial displacement of the capsulolabral complex, whichmore often than not requires visualization from the anterosu-perior portal. It is important to use the switching sticks tomaintain the portals. Turning the inflow off whenever waitingfor an instrument minimizes swelling of the shoulder andallows this procedure to be completed safely and with ease. Inaddition, the usage of a larger cannula 8.0 mm � 90 mmallows passage of instrumentation in a facile manner.

Glenoid Neck PreparationThe glenoid preparation requires complete mobilization ofthe Bankart lesion (soft tissue or bony fragment). The

Figure 9 (A) Burr in place. Anterior glenoid rim is debrided to crebe removed for suture placement. The labrum would not heal

capsulolabral complex must be completely freed up with anelevator from the glenoid neck, and the subscapularis musclebelly must be visualized before bringing the burr onto theglenoid surface while viewing with the camera from theanterosuperior portal. After confirming the glenoid has nomore than 20% bone loss, a round, 3.5-mm burr is used toprepare the glenoid neck. Placement of the anchors on theglenoid face allows for the best bone purchase and recreatesan anatomical position to reestablish a labral bumper (Fig. 9).

Anchor PlacementWe have always agreed with recent studies that encourage theusage of a minimum of 3 anchors for stabilization.32 Theseanchors are placed below the 3-o’clock position, 451 relative tothe glenoid rim, and at least 3-mm inside the edge of theglenoid surface. We have found that in the lateral position, thetension on the capsulolabral structures is maintained in a goodposition with slight external rotation. If the portals have beenplaced correctly as instructed earlier, separation of the3 anchors is easily attained. Once the anchor is implanted,the suture limbs are retrieved. One limb is retrieved throughthe anterosuperior portal and the other limb is ready to be usedfor soft tissue tensioning. Use of double-loaded or triple-loadedanchors is based on surgeon preference (Fig. 10).

Capsular ImbricationCapsular stretch owing to repeated dislocations shouldernever be forgotten, as failure to address this issue can resultin an arthroscopic failure. Adequate tissue must be sewnwith a soft tissue grasper placed from the anteroinferiorportal, at a position several millimeters inferior to the alreadyplaced anchor (Fig. 11). This would allow for not onlyanterior stabilization but also an inferior capsular shift. Thistask is easily accomplished with many lasso passers, nowcommercially available. Before knot tying, the limb isretrieved from the anterosuperior portal and brought backinto the anteroinferior portal. A knot pusher is passed downboth the limbs to ensure that no crossing of sutures has

ate a bleeding bony bed. (B) Spatula in place. Cartilagemayto cartilage.

Figure 10 (A) An arthroscopic guide placed on glenoid bumper for accurate placement. (B) Anchor in place with sutureready for lasso passer.

K.D. Plancher and S.C. Petterson198

occurred with either limb. Simple knots are tied (we use amodifiedWeston knot) by tying the knot on the nonarticularside of the repair, holding the soft tissue in place (Figs. 12and 13). On completion of the inferior-most knot, theprocedure is repeated moving in a superior direction. Whentying each knot, a small amount of the weight is releasedfrom the traction device. Closure of the surgical incisions isroutine, using Vicryl and Monocryl sutures. The joint isinfiltrated under direct visualization with 10-mL 0.25%Marcaine without epinephrine. To date, we have not seenchondrolysis in our patients up to 10 years postoperatively.

Rotator Interval ClosureIn the multiple dislocated shoulder of patients reportingsubluxation or dislocation symptoms in their sleep, thearthroscopic rotator interval is closed (Fig. 14). When doingso, the arm is abducted to 451, with 451 of external rotation inthe lateral decubitus position. We are aware as reported byothers that interval closure is associated with reduced APtranslation and decreased motion.33 To minimize this risk ofpostoperative stiffness or loss of external rotation, we ensurecorrect positioning of the arm.

Figure 11 Arthroscopic suture lasso placed under the labrum to recon-struct for stability.

Postoperative Care andRehabilitation ProtocolAll postoperative medicines, braces, and slings are given to thepatient preoperatively. The patient is then seen on post-operative day 1 for a dressing change and to review instructionsand postoperative rehabilitation. The patient is instructed tocome out of the sling and abduction pillow 3 times a day toallow the arm to hang at the patient’s side for 5minutes. Bicepsisometrics are also initiated. This protocol is followed for3.5 weeks after surgery. At 2 weeks, sutures are removed andpassive supine forward flexion is checked. If the patient is stiff(ie, they cannot maintain 901), passive flexion range of motionis started. External rotation beyond 101 is prohibited and notbegun until 4 weeks postoperatively. External rotation isalways limited to half the range of motion of the contralateralside for 12 weeks. The abduction pillow (Fig. 15) is discon-tinued at 4 weeks, and a soft sling is used while sleeping andwhen out in public for an additional 2 weeks. Supine, active-assisted forward flexion to 1201 progressing to 1601 is initiatedat 4weeks. Scapular-stabilization exercises are initiated 6weekspostoperatively. Strengthening is initiated at 8 weeks when

Figure 12 Second suture placed inferior to the right to secure theanterior labrum.

Figure 13 Bumper recreated for the unstable shoulder.

Figure 15 Abduction pillow.

Arthroscopic Bankart repair with suture anchors 199

motion has been attained in a supine and upright position.Patients involved in noncontact sports are allowed to return tomost sports after 3 months. Athletes who play contact sports(ie, basketball, wrestling, football, and hockey) are not allowed

Figure 14 (A) Rotator interval closure. Spinal needles placed throughupper border of the subscapularis. (B) Piercing instrument to close therotator interval through the superior glenohumeral ligament.(C) Rotator interval closed arthroscopically.

to return to sport until 4-5months. The last exception, baseballpitchers,mustwait 9months before throwing on themound atfull speed, although a true dislocation in this type of athleteis rare.

ComplicationsMany patients have discussed the various problems associatedwith failure of arthroscopic Bankart repair. The followingsection describes some of the pitfalls that should be avoided.

Significant Bone LossOsseous glenoid lesions affect the success of arthroscopicmanagement for anterior shoulder instability, therefore carefulconsideration and preoperative planning are key to successfuloutcomes. Bone loss greater than 25% should be addressed byother procedures. The capsulolabral defect with such a greatloss of bone would not suffice to yield stability.34 Potentialoptions include the Latarjet-Bristow, remplissage, humeralhead osteotomy, and osteochondral allograft transplantation.All of these procedures are discussed elsewhere in this journal.

Poor Mobilization of the Bankart LesionPoor mobilization of the Bankart lesion can lead to inferioroutcomes. The goal in mobilizing the labrum is to be able toshift the capsule superiorly and laterally to attain adequatestability and fixation. Failure to mobilize the labrum willlead to recurrence. As outlined earlier, visualization of thesubscapularis muscle must be evident. On completion of themobilization, we often place the arthroscope in the superiorportal to inspect if we have performed an adequate job.

Insufficient Anchors and Incorrect PlacementRecent studies have substantiated the need for an adequatenumber of anchors (4 minimum)32 with placement on the

K.D. Plancher and S.C. Petterson200

glenoid rim. Many surgeons may also use knotless anchors;adequate tissue must be imbricated to avoid failure.

Multidirectional InstabilityPatientswithout a history of a traumatic event and thosewhosephysical examination demonstrates hyperligamentous laxitywith a large sulcus sign should not be considered candidatesfor arthroscopic Bankart repair as described in this article.

SummaryTraumatic anterior shoulder instability and avulsion of theanterior inferior labrum occurs quite often in sports. Thearthroscopic technique presented here provides the opportu-nity to repair the capsulolabral complex in a successful mannerand return our athletes to competition.

References1. O’Brien SJ, Neves MC, Arnoczky SP, et al: The anatomy and histology of

the inferior glenohumeral ligament complex of the shoulder. Am J SportsMed 18(5):449-456, 1990

2. Hovelius L, ErikssonK, FredinH, et al: Recurrences after initial dislocationof the shoulder. Results of a prospective study of treatment. J Bone JointSurg Am 65(3):343-349, Mar 1983

3. Taylor DC, Arciero RA: Pathologic changes associatedwith shoulder dis-locations. Arthroscopic and physical examination findings in first-time,traumatic anterior dislocations. Am J Sports Med 25(3):306-311, 1997

4. Tauber M, Resch H, Forstner R, et al: Reasons for failure after surgicalrepair of anterior shoulder instability. J Shoulder Elbow Surg 13(3):279-285, 2004

5. Rao AG, Kim TK, Chronopoulos E, et al: Anatomical variantsin the anterosuperior aspect of the glenoid labrum: A statisticalanalysis of seventy-three cases. J Bone Joint Surg Am 85-A(4):653-659, 2003

6. Cooper DE, Arnoczky SP, O’Brien SJ, et al: Anatomy, histology, andvascularity of the glenoid labrum. An anatomical study. J Bone Joint SurgAm 74(1):46-52, 1992

7. Turkel SJ, Panio MW, Marshall JL, et al: Stabilizing mechanismspreventing anterior dislocation of the glenohumeral joint. J Bone JointSurg Am 63(8):1208-1217, 1981

8. O’Brien SJ, Schwartz RS,Warren RF, et al: Capsular restraints to anterior-posterior motion of the abducted shoulder: A biomechanical study.J Shoulder Elbow Surg 4(4):298-308, 1995

9. Jones KJ, Wiesel B, Ganley TJ, et al: Functional outcomes of earlyarthroscopic Bankart repair in adolescents aged 11 to 18 years. J PediatrOrthop 27(2):209-213, 2007

10. Mihata T, Lee Y, McGarry MH, et al: Excessive humeral external rotationresults in increased shoulder laxity. Am J Sports Med 32(5):1278-1285,2004

11. Warner JJ, Gill TJ, O’Hollerhan JD, et al: Anatomical glenoid reconstruc-tion for recurrent anterior glenohumeral instability with glenoid defi-ciency using an autogenous tricortical iliac crest bone graft. Am J SportsMed 34(2):205-212, 2006

12. Burkhart SS, De Beer J: Traumatic glenohumeral bone defects and theirrelationship to failure of arthroscopic Bankart repairs: Significance of theinverted-pear glenoid and the humeral engaging Hill-Sachs lesion.Arthroscopy 16(7):677-694, 2000

13. Kropf EJ, Tjoumakaris FP, Sekiya JK: Arthroscopic shoulder stabilization:Is there ever a need to open? Arthroscopy 23(7):779-784, 2007

14. Porcellini G, Campi F, Pegreffi F, et al: Predisposing factors for recurrentshoulder dislocation after arthroscopic treatment. J Bone Joint SurgAm91(11):2537-2542, 2009

15. Kirkley A, Griffin S, Richards C, et al: Prospective randomized clinical trialcomparing the effectiveness of immediate arthroscopic stabilization versusimmobilization and rehabilitation infirst traumatic anterior dislocations ofthe shoulder. Arthroscopy 15(5):507-514, 1999

16. Arciero RA,Wheeler JH, Ryan JB, et al: Arthroscopic Bankart repair versusnonoperative treatment for acute, initial anterior shoulder dislocations.Am J Sports Med 22(5):589-594, 1994

17. Wheeler JH, Ryan JB, Arciero RA, et al: Arthroscopic versus nonoperativetreatment of acute shoulder dislocations in young athletes. Arthroscopy 5(3):213-217, 1989

18. Privitera DM, Bisson LJ, Marzo JM: Minimum 10-year follow-up ofarthroscopic intra-articular Bankart repair using bioabsorbable tacks. Am JSports Med 40(1):100-107, 2012

19. Chechik O, Maman E, Dolkart O, et al: Arthroscopic rotator intervalclosure in shoulder instability repair: A retrospective study. J ShoulderElbow Surg 19(7):1056-1062, 2010

20. Mazzocca AD, Brown FM Jr., Carreira DS, et al: Arthroscopic anteriorshoulder stabilization of collision and contact athletes. Am J Sports Med33(1):52-60, 2005

21. Bottoni CR, Wilckens JH, DeBerardino TM, et al: A prospective,randomized evaluation of arthroscopic stabilization versus nonoperativetreatment in patients with acute, traumatic, first-time shoulder disloca-tions. Am J Sports Med 30(4):576-580, 2002

22. JohnM,NebelungW,RopkeM, et al: Arthroscopic labrum reconstructionwith capsular shift in anterior shoulder instability: Improved midtermresults by using a standardized suprabicipital camera position. Arthro-scopy 23(7):688-695, 2007

23. Peruto CM, Ciccotti MG, Cohen SB: Shoulder arthroscopy positioning:Lateral decubitus versus beach chair. Arthroscopy 25(8):891-896, 2009

24. Lenters TR, Davies J, Matsen FA III: The types and severity of compli-cations associated with interscalene brachial plexus block anesthesia:Local and national evidence. J Shoulder Elbow Surg 16(4):379-387, 2007

25. Brull R, McCartney CJ, Chan VW: A novel approach to infraclavicularbrachial plexus block: The ultrasound experience. Anesth Analg 99(3):950-951, 2004; [950; author reply]

26. Hickey R, Candido KD, Ramamurthy S, et al: Brachial plexus block with anew local anaesthetic: 0.5 percent ropivacaine. Can J Anaesth 37(7):732-738, 1990

27. Borgeat A, Ekatodramis G, Kalberer F, et al: Acute and nonacutecomplications associated with interscalene block and shoulder surgery:A prospective study. Anesthesiology 95(4):875-880, 2001

28. Long TR, Wass CT, Burkle CM: Perioperative interscalene blockade: Anoverview of its history and current clinical use. J Clin Anesth 14(7):546-556, 2002

29. Tetzlaff JE, Brems J, Dilger J: Intraarticular morphine and bupivacainereduces postoperative pain after rotator cuff repair. Reg Anesth Pain Med25(6):611-614, 2000

30. Snyder S: Diagnostic arthroscopy of the shoulder: Normal anatomy andvariations, ShoulderArthroscopy, 2nded:Philadelphia: LippincottWilliamsand Wilkins, 2003

31. Burkhart SS, Nassar J, Schenck RC Jr., et al: Clinical and anatomicconsiderations in the use of a new anterior inferior subaxillary nervearthroscopy portal. Arthroscopy 12(5):634-637, 1996

32. Boileau P, VillalbaM, Hery JY, et al: Risk factors for recurrence of shoulderinstability after arthroscopic Bankart repair. J Bone Joint Surg 88(8):1755-1763, 2006

33. Plausinis D, Bravman JT, Heywood C, et al: Arthroscopic rotator intervalclosure: Effect of sutures on glenohumeral motion and anterior-posteriortranslation. Am J Sports Med 34(10):1656-1661, 2006

34. Bigliani LU, Newton PM, Steinmann SP, et al: Glenoid rim lesionsassociated with recurrent anterior dislocation of the shoulder. Am J SportsMed 26(1):41-45, 1998