Bankart variants in shoulder instability: Arthroscopic identification, management strategies, and functional outcomes

INTRODUCTION

Anterior shoulder instability is most commonly associated with injury to the anteroinferior capsulolabral complex, classically described as the Bankart lesion.^[1] Arthroscopic Bankart repair is widely accepted as the standard treatment for the majority of patients; however, recurrence following stabilization remains a recognized concern, particularly in young and active populations.^[2] Growing evidence indicates that failure after stabilization surgery is frequently related to missed or inadequately addressed variants of the Bankart lesion, rather than technical failure alone.^[3] There is a spectrum of capsulolabral injuries rather than a single entity, encompassing periosteal sleeve avulsions, medially displaced labro-ligamentous complex, associated chondral lesions, bony Bankart defects, and combined capsuloligamentous disruptions.^[4-7]

Many of these variants can be subtle, may be underestimated on pre-operative imaging, and require systematic arthroscopic assessment for accurate identification.^[8] Since treatment strategies and prognosis differ substantially across lesion types, a uniform surgical approach may be inappropriate. Variant-specific recognition and management are critical not only for restoration of stability but also for optimization of patient-reported outcome measures following surgery.^[9,10]

The present study was undertaken to describe key arthroscopic identifying features of commonly encountered Bankart variants and highlight variant-specific management strategies. In addition, clinical outcomes were evaluated using the Constant–Murley score assessed preoperatively and at 6 weeks, 3 months, 6 months, and 1 year after arthroscopic management, with the objective of correlating lesion morphology and surgical strategy with functional recovery and patient satisfaction.

MATERIALS AND METHODS

A prospective study was conducted at a single tertiary care center to evaluate patients undergoing arthroscopic stabilization for anterior shoulder instability from January 2024 to December 2024. Institutional ethics committee approval was obtained before study initiation, and all procedures were performed in accordance with the Declaration of Helsinki. Consent was taken from all the patients before enrolling for the study.

Inclusion criteria were (1) age 18–40 years, (2) primary surgery for instability, and (3) glenoid bone loss <15%. Exclusion criteria were (1) prior shoulder stabilization surgery, (2) glenoid bone loss >15%, (3) multidirectional instability, (4) Beighton score >4/9, and (5) presence of humeral avulsion of the glenohumeral ligament (HAGL) lesions. HAGL lesions were excluded to focus specifically on glenoid labral lesions.

All patients underwent standardized pre-operative clinical assessment including documentation of mode and date of injury, number of dislocations, history of sleep dislocations, and sports participation. Standard physical examination of the shoulder, Beighton score, and evaluation for scapular dyskinesia were performed. Imaging assessment included magnetic resonance imaging for labral and associated soft-tissue pathology. Computed tomography assessment was done when glenoid bone loss or bony Bankart lesions were suspected.

All procedures were performed arthroscopically by a single experienced shoulder surgeon. Surgery was performed under general anesthesia combined with a supraclavicular block for post-operative analgesia. Patients were positioned in lateral decubitus with the shoulder maintained in 45° abduction with 3 kg traction. A standard posterior portal was used as the primary viewing portal. Three-portal technique was used in most patients, consisting of a posterior viewing portal, mid-anterior working portal, and an anterosuperior portal used for additional viewing and suture management. In selected cases, a two-portal technique was utilized, with the mid-anterior portal serving both working and suture management functions.

The antero-inferior labrum and capsule-ligamentous complex (middle glenohumeral ligament and inferior glenohumeral ligament) were assessed systematically using a probe and grasper to evaluate labral attachment, mobility, tissue quality, and capsular tension. Bankart lesions were classified intra-operatively into arthroscopic variants^[11-22] including Perthes lesion, anterior labroligamentous periosteal sleeve avulsion (ALPSA), glenolabral articular disruption (GLAD), BONY Bankart, Bankart with Hill–Sachs defect, Bankart with posterior labral tear, and Bankart with superior labral anterior and posterior (SLAP) tears [Table 1].

Management was tailored to the arthroscopically identified variant [Figures 1-8]. In general, repair involved mobilization of the labrum till it floats, preparation of the glenoid rim for enhanced healing potential, and suture anchor fixation (knotted/knotless), with additional procedures such as bony fragment fixation and remplissage performed where indicated.

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Figure 1: Arthroscopic appearance and management of a Perthes lesion. (a) Arthroscopic view of the anteroinferior labrum appearing intact and continuous with the glenoid rim. (b) Probing of the anteroinferior labrum demonstrating loss of firm attachment to the glenoid despite an intact periosteal sleeve. (c) Mobilization of the labroligamentous complex following identification of the plane between the labrum and glenoid neck. (d) Completed arthroscopic repair with anatomic reattachment of the labrum to the glenoid rim and restoration of capsulolabral tension.

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Figure 2: Arthroscopic appearance and management of anterior labroligamentous periosteal sleeve avulsion Lesion. (a) Medialization of labroligamentous complex. (b) Mobilization of the labrum allowing anatomic reduction of the labrum to rim. (c) Mobilization completed till 6 o’clock position. (d) Anatomic reduction of the labrum.

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Figure 3: Arthroscopic appearance and management of glenolabral articular disruption lesions. (a) Torn labroligamentous complex with a chondral flap and chondral loss as viewed from the anterosuperior portal. (b) Mobilization of the labroligamentous complex. (c) Incorporating the chondral flap into the repair. (d) Radial tear of the labrum. (e) Extending the repair up to the chondral defect margin. (f) Final image after repair shows the humeral head centered over the glenoid.

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Figure 4: Arthroscopic appearance of a bony Bankart lesion and its management. (a) Osseous fragment visualized after liberation of soft tissue. (b) A suture lasso is passed medial to the fragment. (c) A suture anchor is deployed at the scapular neck. (d) After retrieving the threads of the suture anchor through the lasso loop, the same threads are brought laterally and buried into the glenoid rim using a knotless anchor. (e) Final image after fixation showing a double row repair.

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Figure 5: Arthroscopic appearance and management of Hill–Sachs lesion. (a) Hill–Sachs defect as viewed from the posterior portal. (b) Double-loaded anchor deployed and bites taken from the INFRASPINATUS tendon. (c) Equidistant bites taken to fill the defect. (d) Final image after knot tying shows closure of the defect.

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Figure 6: Arthroscopic appearance and management of Kim’s lesion. (a) Concealed lesion at 7 o’clock position. (b) Final image showing suture anchor repair of the lesion.

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Figure 7: Arthroscopic appearance and management of a superior labral anterior and posterior (SLAP) lesion. (a) Peel back test, (b) preparation of glenoid rim, (c) suture lasso used to take bite of labrum, (d and e) Knotless fixation, (f) final image of a repaired type 5 SLAP lesion.

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Figure 8: Arthroscopic appearance and management of bucket-handle labral tears. (a) Bucket-handle tear of the labrum. (b) Repaired labrum.

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All patients followed a standardized rehabilitation protocol divided into progressive phases: protection (0–4 weeks), early motion (4–6 weeks), strengthening (6–12 weeks), advanced strengthening (12–20 weeks), and return to sport (20–24 weeks) [Table 2].^[23] However, external rotation and overhead activities were delayed by 2–4 weeks in patients with remplissage and in patients with poor labral tissue quality. Slower progression through phases was advocated. Patient-reported outcomes were assessed using the Constant–Murley score preoperatively and postoperatively at 6 weeks, 3 months, 6 months, and 1 year (final follow-up).

RESULTS

A total of 46 patients underwent arthroscopic stabilization for anterior shoulder instability during the study period. Demographic profile of patients is shown in Table 3. The mean injury-to-surgery duration was 8.8 ± 5.84 months (range 1–22 months), with a median interval of 7 months (IQR: 4–12.75 months).

Labral involvement most commonly extended from the 3–6 o’clock position, observed in 24 (52.17%) cases. Other commonly seen patterns included 3–5.30 o’clock in 9 (19.57%) and 3–5 o’clock in 4 (8.70%) cases. Less frequent patterns included 3–7 o’clock in 3 (6.52%), 2–6 o’clock and 4–6 o’clock in 2 (4.35%) cases each, and 2–7 o’clock and 3–9 o’clock in 1 (2.17%) case each.

Associated arthroscopic variants or additional pathology were absent in 24 (52.17%) cases. Among those with additional findings, Hill–Sachs lesions were the most common, identified in 11 (23.91%) patients. Bony Bankart lesions were noted in 4 (8.69%) cases. Other findings, each present in 1 (2.17%) case, included 270° labral tear, Perthes lesion, Perthes with Hill–Sachs lesion, bucket-handle tear of the anterosuperior labrum, GLAD lesion, Bankart with SLAP LESION, and Hill–Sachs with SLAP lesion [Figures 1-8].

The most frequently performed procedure was isolated arthroscopic Bankart repair, conducted in 26 (56.52%) patients. Bankart repair with remplissage was performed in 10 (21.74%) cases. Knotless Bankart repair was used in 2 (4.35%) cases. Additional procedures, each performed in 1 (2.17%) patient, included Bankart repair with biceps tenodesis, Bankart repair with capsulorrhaphy, Bankart repair with capsulorrhaphy and remplissage, Bankart repair with remplissage and biceps tenodesis, Bankart repair with extension till chondral defect, double-row repair, labral repair, and osseous Bankart double-row repair [Figures 1-8].

Three anchors were used in the majority of cases (28/46; 60.87%), followed by four anchors in 14 (30.43%) cases. Five anchors were used in 3 (6.52%) cases and six anchors in 1 (2.17%) case. The mean number of anchors used was 3.5 ± 0.72 (range 3–6), with a median of 3 (IQR: 3–4).

The most common anchor configuration was three 3^rd-generation all-suture anchors, used in 19 (41.30%) cases. This was followed by three knotless anchors in 8 (17.39%) and three 3^rd-generation all-suture anchors with one Hydroxyapatite (HA) anchor in 7 (15.22%) patients. Other configurations (including mixed all-suture, HA anchors, and knotless combinations) were less frequent, occurring in 1–4 cases each.

A three-portal technique was utilized in 38 (82.61%) cases, whereas two portals were used in 8 (17.39%). The mean number of portals was 2.83 ± 0.38 with a median of 3 (IQR: 3–3).

The mean pre-operative Constant score was 59.78 ± 5.21. At 6 weeks postoperatively, the score decreased to 48.57 ± 4.09, representing a statistically significant reduction compared to baseline (p < 0.0001). Subsequently, a significant improvement was observed at 3 months (68.57 ± 4.09; p < 0.0001), with further gains at 6 months (82.98 ± 4.12; p < 0.0001) and 1 year (90.98 ± 2.93; p < 0.0001), demonstrating sustained functional recovery [Table 4].

The mean change in Constant score compared to baseline showed an expected early postoperative decline, followed by progressive improvement. The mean change at 6 weeks was −11.22 ± 1.28, improving to +8.78 ± 1.28 at 3 months, +23.2 ± 1.39 at 6 months, and reaching a maximum improvement of +31.2 ± 2.35 at 1 year. All patients (46/46; 100%) successfully returned to sports or work by the final follow-up [Figure 9].

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Figure 9: Trend of Constant score at different time intervals.

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DISCUSSION

Traumatic anterior glenohumeral instability represents a spectrum of capsulolabral injuries rather than a single pathological entity, and successful stabilization depends on accurate identification of variant lesions and associated pathology. In the present study of forty-six patients, the most common tear pattern involved the three to 6 o’clock region, and associated lesions were identified in a substantial proportion of cases, most frequently Hill–Sachs defects. These findings emphasize the importance of systematic arthroscopic evaluation to detect both primary and associated lesions that may influence surgical planning and outcomes.

Functional outcomes improved significantly over time, with Constant–Murley scores increasing from pre-operative values to near-normal levels at 1 year. These results are consistent with contemporary literature demonstrating favorable patient-reported outcomes following arthroscopic Bankart stabilization in appropriately selected patients without critical bone loss. Our 1-year Constant score is comparable to pooled postoperative values reported after combined Bankart and superior labral anterior and posterior repair, supporting the effectiveness of a lesion-specific surgical approach.^[24] Importantly, failure after arthroscopic stabilization is more commonly associated with missed pathology or inadequate lesion management rather than technical error alone.^[2]

Perthes lesions are particularly challenging due to their subtle presentation, as the labrum may appear intact despite detachment from the glenoid. Failure to identify and adequately mobilize these lesions can result in non-anatomical repair and persistent instability. Systematic probing of a seemingly normal labrum is therefore essential. When properly recognized and treated, outcomes of arthroscopic repair are comparable to classic Bankart lesions, with low recurrence rates and high return-to-sport rates.^[25,26]

ALPSA lesions are characterized by medial displacement of the capsulolabral complex along the scapular neck, leading to loss of capsular tension and instability. These lesions have been associated with higher recurrence rates if not adequately mobilized. Complete liberation of the medialized labrum until it can be anatomically reduced to the glenoid rim is the key determinant of successful repair. Ozbaydar et al. demonstrated that ALPSA lesions differ from classic Bankart lesions in behavior and require meticulous mobilization to prevent recurrence.^[21] Our findings support that careful arthroscopic identification and restoration of capsular tension can achieve excellent outcomes even in these higher-risk lesions.

GLAD lesions involve combined labral injury and glenoid chondral damage and may contribute to persistent postoperative pain. Recent studies suggest that the presence of these lesions does not adversely affect outcomes when appropriately managed. Vieider et al. reported favorable outcomes and low recurrence rates following arthroscopic repair irrespective of the presence of GLAD lesions,^[27] and similar findings have been reported in comparative analyses.^[28] These observations support an individualized approach, ranging from debridement to incorporation of reparable chondral flaps into the repair construct. Although uncommon in our cohort, their identification underscores the need for careful cartilage evaluation during arthroscopy.

Bony Bankart lesions compromise stability by reducing the anterior glenoid arc and increasing the risk of engagement. Restoration of glenoid anatomy is therefore critical. Arthroscopic fixation techniques, including double-row constructs, have demonstrated favorable functional outcomes in selected cases.^[29,30] More recent studies have shown that suture-bridge fixation techniques can provide stable fixation with good clinical outcomes.^[31] In our study, anatomical restoration of the osseous fragment contributed to satisfactory functional recovery, supporting current evidence favoring anatomical reconstruction when feasible.

Hill–Sachs lesions were the most common associated pathology in our study. Management has evolved from the traditional engaging versus non-engaging paradigm to a bipolar assessment using the glenoid track concept. Di Giacomo et al. introduced the on-track and off-track concept, which improves surgical decision-making by predicting the risk of engagement and failure after isolated soft-tissue repair.^[22] In our cohort, remplissage was performed in selected cases based on this risk assessment. Systematic reviews have demonstrated that Bankart repair with remplissage significantly reduces recurrence rates without compromising range of motion,^[32] and comparable outcomes have been reported when compared with open Latarjet in subcritical bone loss scenarios.^[33] Our findings support the role of remplissage as an effective augmentation procedure in appropriately selected patients.

Kim’s lesion represents a concealed posteroinferior labral injury that may coexist with anterior instability and is frequently missed without careful probing.^[34,35] Failure to identify this lesion can result in persistent instability despite adequate anterior repair. Arthroscopic management involves conversion to a complete tear followed by repair and capsular plication, which has been shown to yield favorable outcomes with improved stability and function.^[25,26,36] Routine posterior labral assessment is therefore recommended, particularly in patients with extensive labral involvement.

Combined Bankart and superior labral anterior and posterior lesions represent complex injury patterns, particularly in young and active individuals. The primary surgical challenge is to restore stability while avoiding overtensioning and post-operative stiffness. A systematic review by Feng et al. demonstrated significant functional improvement with a pooled recurrence rate of approximately 6.47% following combined repair,^[24] and similar favorable outcomes have been reported by Cho et al.^[37] Our results are consistent with these findings, suggesting that combined repair, when indicated and appropriately balanced, can achieve outcomes comparable to isolated stabilization.

CONCLUSION

Arthroscopic stabilization tailored to Bankart variants and associated lesions produced excellent functional improvement at 1 year in this cohort, with Constant–Murley scores improving to near-normal values and all patients returning to sport/work. Our findings support a structured arthroscopic strategy that emphasizes lesion recognition, anatomic restoration, and selective augmentation (such as remplissage) in patients with clinically significant Hill–Sachs defects. Longer-term prospective studies incorporating recurrence endpoints and lesion- specific risk stratification are required to confirm durability and refine decision-making algorithms.