Instructional Course 202
Arthroscopic Approach To Traumatic Anterior Shoulder
Instability
Richard K. N. Ryu, M.D.
F or decades, clinicians have been in search of the
technically simple, highly effective, reproducible
procedure for recurrent anterior shoulder instability,
complemented by a facilitated rehabilitation, minimal
motion loss, and an acceptable complication rate.
What ensued is a wide array of open procedures in
which the recurrence rates are acceptable, but in
which rotation is commonly sacrificed, late arthrosis
engendered, and the rehabilitation grueling.
With the advent of arthroscopy, and with rapid
technical advances and improved implant choices, ar-
throscopic stabilization quickly became the “panacea”
for traumatic shoulder instability. Early reports were
encouraging,1-4 citing the many virtues of the arthro-
scopic approach, including minimal surgical trauma
and a facilitated rehabilitation with much less periop-
erative morbidity. The arthroscopic approach also of-
fered the additional advantages of recognizing and
treating associated pathology, such as SLAP lesions,
sparing the subscapularis, and providing a desirable
cosmetic outcome.
However, with longer-term follow-up, the initial
success rates plummeted, with recurrence rates ap-
proaching 50%5-7 in the hands of skilled and experi-
enced arthroscopic surgeons. Numerous factors6-9
were identified as potential high-risk factors for recur-
rent instability including short postoperative immobi-
lization, bony Bankart lesions, associated generalized
ligamentous laxity, Hill-Sachs lesions, contact or col-
lision sports, younger age, “inverted pear” glenoid
Address correspondence to Richard K. N. Ryu, M.D., 533 E.
Micheltorena St, Suite 204, Santa Barbara, CA 93103, U.S.A.
E-mail: FAMRYU5@aol.com
© 2003 by the Arthroscopy Association of North America
0749-8063/03/1910-0113$30.00/0
doi:10.1016/j.arthro.2003.09.032
94 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 10 (December, Suppl 1), 2003: pp 94-101
configurations as well as poor glenohumeral ligament
quality.
Clearly a dilemma exists for those of us trying to
decide if arthroscopic stabilization for traumatic ante-
rior shoulder instability is a reasonable alternative to
the traditional open approach. This presentation pro-
vides a historical perspective of arthroscopic stabili-
zation, the pathoanatomy of instability, state-of-the-art
techniques, and the current recommendations for
treating the patient with traumatic anterior shoulder
instability.
PATHOANATOMY
When discussing shoulder instability, several perti-
nent anatomic and biomechanical issues deserve dis-
cussion. Instability is a pathologic condition of the
capsuloligamentous complex whereas laxity is a phys-
ical finding. Physiologic laxity can become symptom-
atic over time and could, at that time, be considered
“pathologic”. Furthermore, intrinsic shoulder stability
depends on an intact inferior glenohumeral-labral
complex that deepens the glenoid and also provides a
“bumper” effect to the glenoid rim. Negative intra-
articular pressure ( the so-called “suction effect”) also
contributes to joint stability. The concavity-compres-
sion effect is a criticial one and also relies on an intact
labrum and rotator cuff. Shoulder instability can arise
if any or a combination of these forces is disrupted.
Sectioning and stress testing have also shown that
although considered the “essential” lesion, a Bankart
lesion alone is not enough to permit recurrent insta-
bility.10,11 Associated plastic deformation of the gle-
nohumeral ligaments is a necessary factor in recurrent
instability and must be addressed if successful stabi-
lization is to be achieved arthroscopically. In addition
to solving the Bankart lesion in a side–to–side fashion,
preventing recurrent instability after an arthroscopic
 TRAUMATIC ANTERIOR SHOULDER INSTABILITY
Bankart repair hinges on appropriate treatment of the
vertical component of instability, namely the inferior
to superior shift that must be an integral part of any
arthroscopic Bankart intervention.
CLINICAL REVIEW
Although a number of articles focusing on the re-
sults of arthroscopic stabilization have been pub-
lished, a few merit closer attention. In 1993 Grana et
al.6 were some of the first investigators to sound the
alarm regarding the high failure rate in transglenoid
Bankart repairs. The failure rate of nearly 45% was
noteworthy for a short immobilization period identi-
fied as a definite risk factor, while age, dislocation
over subluxation, and contact sports trended toward
statistical significance. Walch et al.,7 in 1995, reported
on a failure rate of 50% in tranglenoid Bankart repairs
and noted that associated ligamentous laxity and the
presence of a bony Bankart were two statistically
significant risk factors for recurrent instability.
Conversely, in 1997, Bacilla and Savoie,12 using
suture anchors and nonabsorbable suture, reported a
failure rate of only 9% despite treating a young, high-
demand patient population. No specific risk factors
were isolated with regard to increasing the risk of
recurrent instability. O’Neill13 cited a recurrence rate
of only 5% after treating high-demand athletes with a
transglenoid stabilization for anterior instability. In
that study, 40 of 41 patients returned to the previous
level of competition, and the follow-up averaged more
than 4 years.
Burkhart and DeBeer9 introduced the concepts of
the glenoid “inverted pear” configuration as well as
the “engaging Hill-Sachs “lesion, both bony defects
that contributed to a failure rate approaching 70% in
their series. It is noteworthy that in their patient pop-
ulation without bony risk factors, the recurrence rate
was 3% to 4%.
Although some prospective studies have been re-
ported, none fully adhere to the randomized, blinded
format that delivers the most compelling data. Weber14
described a failure rate of 16% for arthroscopic repairs
versus 4% for the open approach. However, the over-
hand athletes in the study exhibited a much greater
likelihood of returning to the premorbid level of com-
petition. Cole et al.15 included apprehension as well as
subluxation and frank dislocation to his study criteria,
comparing open and arthroscopic techniques, and re-
ported recurrence rates of 24% in the arthroscopic
group compared with 18% in the open, a somewhat
alarming number for the proponents of open stabili-
95
zation. Kim et al.16 were the first to describe a failure
rate lower for the arthroscopic approach, 3% as com-
pared with 6% in the open technique, in a well-
matched prospective study. Sperber et al.17 in 2001
also reported on short-term results comparing open
and arthroscopic techniques, and although the arthro-
scopic technique was associated with a failure rate of
23%, the open technique was associated with a failure
rate of 12%, again considerably higher than the tradi-
tional 3% to 4% recurrence rate historically associated
with open techniques.
These recent data beg the question of whether or not
the long-term success rate of open stabilization is
actually lower than that previously perceived. Al-
though the classic article of Rowe18 from 1978 formed
the basis for the 3.5% failure rate cited with open
surgery, it is noteworthy that nearly 20% did not have
a Bankart lesion and that the activity level after sur-
gery was not well documented. In 2002, Pagnani and
Dome19 authored a compelling report on open stabi-
lization in contact athletes. The success rate of 97%
and the fact that 52 of 58 athletes were able to return
to their sport serves as the current gold standard in
comparing arthroscopic and open techniques.
However, there is very recent and compelling data
that suggest that the long-term follow-up of open
stabilization may be associated with recurrence rates
that approximate those of the arthroscopic series. De-
tailing a military academy experience in 2000, Uhor-
chak et al.20 reported a recurrent dislocation rate of 3%
and a recurrent subluxation rate of 19% for a com-
bined 22% recurrent instability rate. All patients were
collision or contact athletes, averaged 19.5 years in
age, and had a follow-up averaging 4 years. Finally,
Magnusson et al.21 evaluated 47 of 54 open Bankart
patients with a follow-up exceeding 5 years. Of these,
66% were contact or overhead athletes. The combined
recurrent dislocation or subluxation rate was 17%,
nearly a 500% increase over the results reported by
Rowe.
In the past 2 or 3 years, numerous investigators
have reported encouraging results after arthroscopic
Bankart stabilization. Gartsman et al.,22 as well as
Abrams et al.23 and Romeo and Carriera,24 reported
failures rates ranging from 0% to 7.5% after arthro-
scopic Bankart repair with suture anchors. Mishra and
Fanton25 reported a failure rate of 7% with combined
Bankart repair and thermal treatment. These improved
statistics reflect the technical lessons that arthrosco-
pists have discovered over the past decade regarding
shoulder stabilization:
96 RICHARD K. N. RYU
1. The damaged glenohumeral ligament must be
sufficiently mobilized so that an inferior to su-
perior shift can be accomplished.
2. Placement of suture anchors must be on the
glenoid face so that a labral “chock block” is
re-established versus anchor placement on the
glenoid neck .
3. At least 3 suture anchors must be used in the
repair.
4. Associated ligamentous laxity must be ad-
dressed in the form of a capsular “tuck,” possi-
ble adjunctive thermal treatment, and potential
rotator interval closure.
5. Postoperative rehabilitation should be well-su-
pervised and individualized, especially if ther-
mal energy is used concomitantly. A minimum
period of 3 to 4 weeks of restricted motion
should accompany the arthroscopic stabilization
procedure.
The data garnered from a review of the literature is
noteworthy for differing patient populations, varying
surgical techniques, and results that at best would be
considered “conflicting.” Are we witnessing the mat-
uration of a “technique in evolution,” namely arthro-
scopic Bankart repair, and are the recent reports citing
single digit recurrence rates an indication of what we
can now expect from this intervention? Furthermore,
are we also witnessing a burgeoning recurrence rate of
open procedures as a result of longer-term follow-up?
Could these procedures, both open and arthroscopic,
have recurrence rates that are converging as a result of
technical advances and pragmatic considerations, such
as the desire to improve external rotation in the throw-
ing athlete while performing an open procedure? As
an increase in external rotation becomes one of the
primary surgical goals, the recurrence rate will surely
increase, both for the arthroscopic and the open tech-
niques.
The most important question to be answered by
individual clinicians is “ What is an acceptable recur-
rence rate in my practice?”. The answer will be dif-
ferent for us all and will reflect the patient population
we treat. The orthopaedist striving to maintain the
highest level of skill and control in a professional
pitcher may have very different goals when treating
instability in a classroom teacher.
PERSONAL CLINICAL EXPERIENCE
From 1991-1998, fifty-seven patients who had un-
dergone an arthroscopic Bankart procedure were
available for review. The average age was 25, ranging
from 15 to 46 years old. The average follow-up was
33 months and the majority (46 of 57) were men. The
technique changed over the course of several years
and included metallic staple (1), Sure-Tac (2),
transglenoid (14), and eventually suture anchors (40).
Of the 57 patients, 9 developed recurrent instability
with 5 patients requiring revision stabilization sur-
gery. The overall recurrence rate was discouraging,
approaching 17% with 4 of the 9 sustaining recurrent
dislocations and 5 describing subluxation symptoms.
A second cohort of patients from 1998-2000 were
also treated for shoulder instability with a revised
technique in which all of the principles listed above
were implemented in a meticulous fashion. In partic-
ular, a much greater emphasis was placed on treating
associated capsular redundancy. The technique in de-
tail is as follows:
1. Lateral decubitus positioning with dual traction;
axial traction of 8 to 10 lb; distraction force
separating the glenohumeral joint also 8 to 10
lb. Examination under anesthesia should con-
firm the preoperative diagnosis. Comparison
with the contralateral side is recommended if the
diagnosis is in doubt.
2. Dual anterior portal technique is recommended.
Low anterior portal just above the intra-articular
slip of the subscapularis is created as well as a
high anterior portal, directly behind the biceps
tendon, for anterior visualization (Fig 1). The
posterior portal is converted to a working portal
to facilitate suture handling.
3. After the joint is entered, all pathology is care-
fully evaluated. Associated rotator cuff or SLAP
injuries may require concomitant treatment. The
Bankart lesion should be easily identified from
the anterior portal or as an alternative, from the
posterior portal with a 70° arthroscope. The
condition of the Bankart lesion (Fig 2) should be
assessed, including tissue integrity, presence of
a bony component, and suspected capsular re-
dundancy.
4. This step is the most critical one. The Bankart
lesion must be completely freed from the neck
of the glenoid. For the ALPSA (anterior liga-
mentous periosteal sleeve avulsion) lesion, this
dissection can be tedious. Every attempt should
be made to avoid thinning or harming the gle-
nohumeral ligament during the dissection. At
the completion of this step, the subscapularis
muscle should be clearly visible through the tear
 TRAUMATIC ANTERIOR SHOULDER INSTABILITY
FIGURE 1. The orientation is that of the lateral decubitus position.
The small arrow points to the anterosuperior viewing cannula,
entering directly behind the biceps. The larger arrow indicates the
low anterior working portal just superior to the intra-articular slip
of the subscapularis tendon.
site (Fig 3). Grasping tools can be used to eval-
uate how far the tissue can be shifted superiorly.
5. The anterior glenoid rim and neck are prepared
with a ring curette and a shaver. Use of a mo-
torized burr is rarely necessary.
6. Through the low anterior portal, instrumentation
for anchor placement is placed at the lowest
FIGURE 2. In a left shoulder, viewing from the anterosuperior
portal, the Bankart lesion remains scarred to the anterior glenoid
(arrows). A thorough dissection is needed in order to shift tissue
superiorly.
97
FIGURE 3. After the inferior glenohumeral ligament (IGHL) has
been released, the subscapularis tendon is easily visualized.
anchor site first, approximately the 7-o’clock
position in a left shoulder. The drill hole is made
with the guide on the glenoid face by 2 or 3 mm
(Fig 4). This is essential for recreating the labral
bumper but also ensures that the most inferior
anchor will achieve adequate bony purchase.
7. The suture anchor is inserted, and the sutures
separated. One strand is brought through the
FIGURE 4. The initial anchor placement is the most inferior one
and should remain 2 or 3 mm on the glenoid face (arrows). This
permits adequate bony purchase and also allows recreation of a
labral “bumper”.
98 RICHARD K. N. RYU

FIGURE 5. As seen from the anterosuperior portal, the “pinch-
tuck” technique allows additional capsular shifting, thereby reduc-
ing capsular volume. Arrows point to the “folding” of the “pinch-
tuck” technique, and the larger arrow depicts the sulcus created by
“folding” a portion of the capsule into the anchor stitch.
FIGURE 6. Curved arrow points to anchor placed on the glenoid
face. Straight arrow depicts “poor man’s shuttle” in which O PDS
suture is used to retrograde a suture limb through the inferior
glenohumeral ligament (IGHL).

curity should match the quality of knots tied in

posterior cannula. A suture hook device is then an open setting.
loaded with 0 PDS, and with the arm internally 10. Steps 6 thought 9 are repeated for the remaining
rotated while in dual traction, the inferior gle- anchors, carefully shifting tissue in a superior
nohumeral ligament is penetrated approximately direction with each additional anchor. When
1 to 2 cm inferior and lateral to the suture completed, tension within the glenohumeral lig-
anchor. This allows for adequate tissue shifting
both lateral to medial and inferior to superior. A
pinch-tuck maneuver (Fig 5), can also be imple-
mented at this time for individuals with severe
capsular redundancy. This allows for an even
greater degree of tissue shifting.
8. The 0 PDS suture is grasped through the poste-
rior portal, and the suture strand from the anchor
is brought through a simple loop in the PDS and
then retrograded through the labrum and re-
trieved from the low anterior portal (Fig 6).
Separating sutures before this maneuver pre-
vents twisting of the sutures as they exit the
same cannula.
9. When tying knots, the suture limb retrograded
through the labrum must remain as the post.
Whether tying sliding knots or alternating half-
hitches, this sequence will push the labrum onto
the glenoid face (Fig 7) recreating the labral
“bumper.” If reversed, the knot pushes the la-
brum off the glenoid face. Knot-tying skills FIGURE 7. Arrow points to knot-tying instrument pushing knot
down suture limb retrograded through the inferior glenohumeral
should be mastered before attempting this tech- ligament (IGHL). Pushing knot down this limb “rolls” labrum onto
nique. Furthermore, knot security and loop se- the glenoid face, helping to restore the “bumper” effect.
 TRAUMATIC ANTERIOR SHOULDER INSTABILITY 99

penetrating device that has been introduced

through the low anterior cannula and has already
pierced a portion of the middle glenohumeral
ligament (Fig 9). The 2 superior sutures are
captured with a crochet hook and brought
through the low anterior portal, where the su-
tures are tied in an extracapsular fashion. My
concern for overconstraining the interval and
limiting rotation is reflected in the use of ab-
sorbable suture.
Thirty-one patients treated with this revised tech-
nique were available for follow-up. This group con-
sisted of 26 men and 5 women with an average age of
24, ranging from 17 to 44 years. Early in the series,
adjunctive thermal energy was used to “tighten” re-
dundant tissue and then discontinued in favor of cap-
sular tucks and plication techniques in combination
with rotator interval closures if a patulous interval was
suspected. Seven patients had a “pinch-tuck” tech-
nique performed, in which tissue was plicated at the
time of anchor insertion. Three underwent capsular
plication after the anchors were inserted and the Ban-
kart repaired. Eleven patients had concomitant rotator
interval closures. Postoperative care consisted of im-
mobilization for a minimum of 3 to 4 weeks, with the
abducted-externally rotated position avoided for at
least 2 months. The goal was to achieve 90% of
motion at 3 months, and a return to vigorous sports
was not permitted until 5 months postoperatively.
With a shorter follow-up, averaging 23 months, the

FIGURE 8. (A) Recreated labral “bumper” viewed from the an-

terosuperior portal. Tension has been restored to the glenohumeral
ligaments. (B) Labral “bumper” viewing from the posterior portal.

aments should be restored and a labral “bumper”

created (Fig 8).
11. After the Bankart lesion has been repaired, ad-
ditional capsular plication stitches can be placed
if deemed necessary for capsular redundancy.
12. If a patulous interval is noted at the time of the
diagnostic portion of the arthroscopic proce-
dure, on completion of the Bankart repair, a
rotator interval closure is completed. My tech-
nique is one of placing 2 No. 1 PDS sutures FIGURE 9. Spinal needle loaded with No. 1 PDS passed behind
the biceps (B). Grasper placed through low cannula, penetrating the
through the most superior portion of the rotator middle glenohumeral ligament (MGHL). The knot is tied in an
interval and then retrieving each with an angled extracapsular fashion.
100 RICHARD K. N. RYU
recurrent instability rate, including apprehension (0),
subluxation (1), and dislocation ( 2), was approxi-
mately 9.5%, a significant improvement over the 17%
recurrence rate noted in my initial experience. Two of
the 3 recurrent instability patients have subsequently
undergone a revision stabilization procedure.
The data listed above are preliminary and represent
a somewhat different patient population from the first
group. Included in this latter group were 5 first-time
dislocators who underwent stabilization within a 3 to
4 week period after initial injury. There were no
recurrences within this subgroup, while all other pa-
tients were categorized as recurrent, multiple disloca-
tion-subluxation patients. Additionally, contact ath-
letes were largely avoided during this time period and
would clearly represent the highest risk group for
recurrence after an arthroscopic stabilization proce-
dure.
CONCLUSIONS
The prime question to ask at this point is whether or
not current arthroscopic techniques reliably overcome
the risk factors identified. These factors consist pri-
marily of bone loss, contact or collision sports and
associated ligamentous laxity. From 1998 through
2000, the literature did not support the use of arthro-
scopic stabilization for the general orthopedist. Since
2001, with the advent of improved techniques and
equipment, one must conclude that arthroscopic sta-
bilization is the technique of choice when confronted
with the patient exhibiting unilateral anterior shoulder
instability. Current clinical data supports the lower
failure rate associated with the arthroscopic technique.
The obvious caveats involve bony integrity and post-
operative activity level; however, with meticulous sur-
gical technique almost all but the most glaring exam-
ples of bony deficiency can be managed with an
arthroscopic approach.
Currently, I advise my patient population that the
recurrence rate with an open technique approaches 5%
to 10%, while that of the arthroscopic technique
ranges from 10% to 15%. The latter number will
undoubtedly change as techniques and concepts are
further refined, but single-digit recurrence rates are, in
my opinion, acceptable in my patient population as we
continue to strive for maximum motion without insta-
bility.
Each clinician must determine the risk factors fac-
ing each patient with shoulder instability and then
should discuss these factors with the patient. After all
of the risk factors have been identified and discussed,
both surgeon and patient are committed to the final
surgical solution whether it be open or arthroscopic.
At the time of surgery, the goals achieved in open
surgery must be duplicated during the arthroscopic
approach, namely restoration of the appropriate rest-
ing length of the glenohumeral ligaments, closure of
the Bankart lesion, and recreation of the labral
“bumper,” all of which can be accomplished by fol-
lowing meticulous arthroscopic technique.
As a final note, I strongly encourage the immediate
stabilization of the first-time dislocator in the high-risk
population.26-28 As espoused in a recent article,29 the
considerations are much like the acute anterior cruci-
ate ligament injury. Rarely do we advise our patients
to go out and experience a severe pivot shift episode,
risking further damage to articular cartilage and me-
nisci, before deciding to forge ahead with stabiliza-
tion. In the high-risk shoulder instability group, the
risk for further damage is present,30-35 and the results
after late reconstruction further jeopardized. The sur-
gical circumstances for healing are ideal after the
initial dislocation, and further capsular damage can be
avoided, not to mention progressive bone loss either
from the glenoid or humeral head. Finally, quality of
life issues including emotional health and activity
level28 are clearly enhanced by early intervention in
this high-risk population.
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