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. 2025 May 30;14(8):103658. doi: 10.1016/j.eats.2025.103658

Arthroscopic Fixation of Large Glenoid Bony Bankart Fracture Using Halifax Portal With Dual Screw Fixation and Labral Repair

Lindsey V Ruderman a,∗, Nicole L Levine b, Zoe W Hinton b, Tom R Doyle b, Eoghan T Hurley b, Oke A Anakwenze b
PMCID: PMC12420508  PMID: 40936545

Abstract

Bony Bankart fractures occurring after traumatic dislocations are challenging to manage. Large fractures may render the shoulder at high risk of recurrent instability and/or arthritis. The purpose of this Technical Note is to present the arthroscopic fixation of a large glenoid bony Bankart fracture using the Halifax portal with dual screw fixation and labral repair.

Technique Video

Download video file (41.6MB, mp4)

Bony Bankart fractures occurring after traumatic dislocations are challenging to manage. While nonoperative treatment of smaller fractures may be sufficient,1 larger fractures may render the shoulder at high risk of recurrent instability and/or arthritis.2 In the setting of attritional bone loss greater than 20%,2 surgical management typically consists of glenoid bony augmentation with Latarjet or bone block reconstruction.3,4 However, nonattritional bone loss may be managed with fracture fixation, preserving the existing bony fragment. This may be accomplished via open5 or arthroscopic techniques6 utilizing anchor or screw fixation. Open fixation techniques are technically challenging to expose due to local soft tissues, including the subscapularis, with the risk of injury to the tendon. Similarly, arthroscopic fixation presents unique challenges, including the ability to adequately reduce the fracture and place screws in an adequate position and angle. In this Technical Note, we describe our technique for a large glenoid fracture after traumatic dislocation managed with dual screw fixation, utilizing the Halifax portal with a dual fixation guide to fix with 2 screws, followed by labral repair to provide additional fixation.

Surgical Technique

Preoperative Assessment and Patient Positioning

Physical examination of the shoulder should be performed. Guarding, tenderness to palpation in the anterolateral and posterior shoulder, and positive apprehension and relocation tests may be present. Neurovascular intactness should be checked. Radiographs of the shoulder can reveal the Bankart fracture and Hill-Sachs lesion (Fig 1). Computed tomography scan of the shoulder (Fig 2) can reveal stigmata of prior anteroinferior glenoid dislocation, including large bony Bankart fracture deformities.

Fig 1.

Fig 1

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Pre-operative Grashey view radiograph of the right shoulder shows Bankart fracture and Hill-Sachs lesion.

Fig 2.

Fig 2

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Pre-operative computed tomography scan of the right shoulder revealing stigmata of prior anteroinferior glenoid dislocation, including large bony Bankart fracture deformities. (A) Coronal view. (B) Sagittal view showing significant glenoid bone loss measuring approximately 30%.

The patient is placed in a lateral decubitus position and regional interscalene block is administered. Examination under anesthesia can confirm anteroinferior instability.

Diagnostic Arthroscopy

The procedure is commenced by the establishment of the posterior viewing portal and anterior working portals.7 A diagnostic arthroscopy is then performed to evaluate the intactness of the superior labrum, biceps and biceps pulley, supraspinatus, subscapularis, infraspinatus, teres minor, and cartilage. Additionally, the presence of loose bodies or synovitis of the axillary pouch is evaluated. Significant damage to the glenoid cartilage and the large anterior glenoid fracture is observed (Fig 3). An osteochondral defect noted along the anterior defect is subsequently debrided. A nonengaging Hill-Sachs lesion is present on the humeral cartilage. The anterior labral defect with a large anteroinferior glenoid bone fracture is observed. The fracture is then evaluated to be of sufficient size and integrity to be rigidly fixed with screws. The fracture is mobilized (Fig 4) and debrided (Fig 5), and traction reduction sutures are placed exiting the superior portal (Fig 6).

Fig 3.

Fig 3

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Arthroscopic image of the right shoulder glenoid from the posterior portal showing Bankart fracture visualization.

Fig 4.

Fig 4

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Arthroscopic image of the right shoulder from the anterior portal showing elevation of the glenoid Bankart fracture.

Fig 5.

Fig 5

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Arthroscopic image of the right shoulder showing scar tissue debridement and release.

Fig 6.

Fig 6

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Arthroscopic image of the right shoulder showing fracture reduction with traction sutures that exit through the posterior portal.

Halifax Portal Establishment

Looking from anterior to superior, the Halifax portal is established.8 A switching stick is placed in the posterior portal and advanced anteriorly through the rotator interval to be superior to the subscapularis tendon, staying lateral to the conjoint tendon under direct visualization (Fig 7). The switching stick is then advanced anteriorly through the deltoid, and the skin is then incised over the switching stick to the appropriate size using a scalpel.

Fig 7.

Fig 7

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Arthroscopic image of the right shoulder showing Halifax portal establishment superior to the subscapularis and lateral to the conjoint tendon.

Arthroscopic Fracture Fixation

A dual screw guide (Mitek, DePuy Synthes) (Fig 8) is introduced through the Halifax portal. The fracture is then reduced under direct visualization (Fig 9) and provisionally stabilized using 2 pins through the guide (Fig 10). Two cannulated screws are then inserted over the guidewires and used for definitive fixation (Fig 11, Fig 12, Fig 13). The reduction is assessed (Fig 14). Finally, 3 anchors are inserted, above and below the fracture fragment, to repair the torn capsulolabral complex and increase stability of the bony fixation (Fig 15, Fig 16). Portal sites are then closed with nylon. The patient is transferred to the postanesthesia care unit in stable condition. Postoperative radiographs reveal satisfactory fixation of the glenoid fracture (Fig 17, Fig 18). A demonstration of the technique is presented in Video 1. Pearls and pitfalls of the technique are presented in Table 1.

Fig 8.

Fig 8

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An offset dual K-wire drill guide is used to drill through the fracture fragment parallel to the glenoid.

Fig 9.

Fig 9

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Arthroscopic image of the right shoulder showing superior and inferior tunnels drilled with cannulated drills while holding the fracture reduced, drilling parallel to the glenoid.

Fig 10.

Fig 10

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Arthroscopic image of the right shoulder showing K-wires placed into tunnels.

Fig 11.

Fig 11

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Arthroscopic image of the right shoulder showing the use of a switching stick to hold the fracture in place while placing screws.

Fig 12.

Fig 12

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Arthroscopic image of the right shoulder showing placement of the superior screw.

Fig 13.

Fig 13

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Arthroscopic image of the right shoulder showing placement of the inferior screw.

Fig 14.

Fig 14

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Arthroscopic image of the right shoulder showing assessment of the fracture reduction.

Fig 15.

Fig 15

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Arthroscopic image of the right shoulder showing labral repair anchors placed superior and inferior to the fragment.

Fig 16.

Fig 16

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Arthroscopic image of the right shoulder showing the capsulolabral complex superior and inferior to the fracture bed for more stability.

Fig 17.

Fig 17

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Postoperative radiographs of the right shoulder showing satisfactory fixation of the glenoid fracture with 2 cannulated screws. (A) Anteroposterior view. (B) Axial view.

Fig 18.

Fig 18

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One-year postoperative Grashey view radiograph of the right shoulder showing satisfactory, unchanged appearance of the 2 cannulated screws.

Table 1.

Pearls and Pitfalls of This Technique Utilizing the Arthroscopic Halifax Portal for Fixation of a Large Glenoid Bony Bankart Fracture With Dual Screw Fixation and Labral Repair

Pearls Pitfalls
Appropriate patient selection with indication of significant nonattritional glenoid bone loss is crucial. If it is significantly attritional without a solid noncomminuted fragment, screw fixation will not work.
Establish provisional reduction with traction sutures, probes, switching sticks, and so on. Avoid fixation without confirming the ability to reduce the fracture. Ensure the fracture is well released.
Ensure that fracture is large enough for two 4.5-mm screws. Ensure both screws are well in the bone and parallel.
If the piece cannot contain 2 screws, place 1 screw in the center of the fragment. Avoid placing the screw too inferior to avoid axillary nerve injury.
Always consider labral repair superior and inferior to the fragment. Rotational instability is more likely if the labrum is left unrepaired.
When establishing the Halifax portal, stay lateral to the conjoint tendon and superior to the subscapularis. Avoid placing screws too lateral. Use a guide to place screws medial and parallel.
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Postoperative Care

Postoperatively, the patient is in a sling full-time except for grooming and physical therapy for the first 2 weeks; the sling is weaned over the next few weeks and is discontinued completely at week 6. Formal physical therapy is attended every week from 2 weeks to 3 months postoperatively and on a biweekly basis thereafter. The patient is seen for routine postoperative appointments in the clinic at 2 weeks, 4 weeks, 3 months, 6 months, and 1 year postoperatively.

Discussion

This Technical Note presents a way to manage large bony Bankart fractures arthroscopically using the Halifax portal to adequately reduce and fix the fracture with 2 screws in an appropriate position and angle.

Bony Bankart injuries after traumatic dislocations are challenging to manage and are associated with increased risk of recurrent instability with or without surgery.9 A systematic review by Hurley et al.10 on conservative treatment versus arthroscopic Bankart repair for first-time traumatic anterior shoulder dislocation showed that arthroscopic repair was associated with a significantly lower rate of total recurrent instability. However, for bony Bankart fractures with medium-sized (5%-20%) or large-sized (>25%) glenoid defects, conservative management is generally not an option, and surgical management is preferred11 due to the unacceptably high risk of instability with large glenoid defects and the potential to preserve the bone stock in the acute setting. Bankart fractures have increasingly been surgically managed arthroscopically rather than with open procedures12,13 due to the more invasive nature of open repair, including greater dissection of soft tissues and increased incidence of complications,14 including postoperative instability and nerve injury.13 A common, accepted technique for arthroscopic Bankart repair includes using portals within the area of the deltopectoral interval (low anteroinferior portal) and distal to the anterosuperior border of the acromion (anterosuperior portal) after diagnostic arthroscopy through a posterior portal.12 Various fixation techniques exist for the repair of bony Bankart fractures, including screw, button, and suture fixation. Nonattritional injuries may be managed with fracture fixation via nonrigid fixation with anchors for bony Bankart imbrication or double-row fixation using suture anchors.12 Smaller injuries may be managed with soft tissue labral repair, but as defects approach 13.5%, defined as subcritical bone loss, soft tissue repair may be inadequate with unacceptable risk of recurrent instability.15 Alternatively, especially with larger fracture fragments, rigid fixation with screw fixation may be preferred. Screw fixation for arthroscopic Bankart repair can be technically challenging due to the need to go through the subscapularis muscle and the risk of nerve injury.16,17

For large Bankart fractures with >25% of glenoid bone loss, existing literature generally supports open repair with glenoid bone-grafting procedures.18 In such cases of attritional bone loss, management of such injuries may necessitate glenoid bone-grafting procedures with Latarjet or bone block reconstruction with either iliac crest or distal tibial auto- or allografts.11,19 Although Latarjet and bone block reconstruction have good success rates in terms of low postprocedure instability in large glenoid defects with anterior shoulder instability,20 there are concerns regarding the complication rate with both procedures. The Latarjet procedure carries a 7% risk of complications, including graft nonunion, nerve injury, graft resorption, and hematoma.21, 22, 23, 24 Bone grafting of glenoid defects with iliac crest autograft or distal tibial allograft is also a viable option for anterior shoulder instability, which carries similar risk profiles to Latarjet, including nonunion, osteolysis, hematoma, and neurovascular injuries.14

In a systematic review by Manfredi et al.25 comparing the biomechanical outcomes of fixation methods for the treatment of anterior shoulder instability with glenoid bone loss, screw fixation was of comparable strength to suture buttons for fixation of glenoid augmentation constructs. Additionally, this systematic review found that double-screw fixation was superior to single-screw fixation. Rossi et al.26 evaluated the clinical outcomes of those undergoing a Latarjet procedure with screw fixation or suture-button fixation and found a significantly lower rate of recurrent instability in those with screw fixation compared to suture-button fixation (1.5% vs 5%, P = .001). Additionally, there were no significant differences between the groups regarding total complications (screw: 7.5% vs suture-button: 3.6%; P = .12), graft fracture (screw: 0.8% vs suture-button: 0.5%; P = .62), and symptomatic hardware (screw: 2.7% vs suture-button: 0%; P = .12). These biomechanical outcomes provide supportive evidence for the fixation technique employed in this Technical Note, which utilizes 2 cannulated screws.

In a cadaveric study,8 the Halifax portal has been shown to provide ample distance from nerves and arteries, minimizing neurovascular complications while allowing adequate access to the glenoid for reconstruction in cases of anterior shoulder instability with significant bone loss. In this Technical Note, the Halifax portal is utilized to insert 2 cannulated screws for fixation of the fracture, and 3 anchors are inserted to repair the capsulolabral complex and increase stability of the bony fixation. The utilization of the Halifax portal in this technique avoids dissection of the subscapularis muscle when reducing the fracture fragment and inserting the cannulated screws. This avoids potential nerve injury and, with decreased soft tissue dissection, is less invasive compared to open procedures. This also has the potential to accelerate healing and rehabilitation timelines postoperatively.

The long-term consequences of anterior shoulder instability are important to consider when deciding what procedure to choose for management of this condition. Bony Bankart fractures increase the risk of postinstability arthritis of the glenohumeral joint.27 At long-term follow-up following arthroscopic Bankart repair, the incidence of glenohumeral arthrosis is >60%, which is largely attributed to the incidence of postoperative recurrence. However, the severity is typically mild.28 Arthroscopic Bankart repair for anterior shoulder instability in patients over 40 years of age has been shown to be comparable to the open Latarjet procedure in terms of the development of arthropathy, likely due to the lower rate of recurrence following the Latarjet procedure.29 The long-term development of arthropathy following arthroscopic repair of large bony Bankart lesions is unclear, and while anatomic restoration of the joint may help over a bone-graft procedure, it appears that the most important aspect is a stable joint.

The technique presented in this Technical Note, using the Halifax portal to arthroscopically reduce and fix a large bony Bankart fracture with 2 screws, shows an alternative to open procedures for cases with significant glenoid bone loss (Table 2).

Table 2.

Advantages and Disadvantages of This Technique Utilizing the Arthroscopic Halifax Portal for Fixation of a Large Glenoid Bony Bankart Fracture With Dual Screw Fixation and Labral Repair

Advantages Disadvantages
The Halifax portal has been shown to be a neurovascularly safe approach. Arthroscopic glenoid fixation can be challenging if there is inadequate access to the glenoid.
This technique avoids dissection of the subscapularis, which is necessary in open techniques. Long-term outcomes of this procedure in large studies have yet to be established.
Arthroscopic fixation may have lower rates of recurrent instability compared to open techniques. Comparison of outcomes of this technique to Latarjet or bone block procedures have yet to be established.
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Disclosures

All authors (L.V.R., N.L.L., Z.W.H., T.R.D., E.T.H., O.A.A.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

This video describes the technique for arthroscopic fixation of a large glenoid bony Bankart fracture using the Halifax portal with dual screw fixation and labral repair. The procedure is demonstrated on the right shoulder with the patient in the lateral decubitus position. Patient presentation following injury and imaging showing a large bony Bankart lesion with a Hill-Sachs defect is presented. Diagnostic arthroscopy is begun through a posterior portal, and the fracture is debrided while viewing from the anterosuperior portal. A traction suture is placed through a posterior portal exit to aid in reduction. Cartilage defect and minor bone loss are noted in the fracture bed as a result of the comminution. The viewing portal is then transitioned back to posterior in order to localize the Halifax far medial portal, which is established superior to the subscapularis and lateral to the conjoint tendon. The inside-out technique is used to ensure parallel positioning to the glenoid. An arthroscopic cannulated parallel drill guide is used to oppose the fracture fragment and reduce the fragment. Two K-wires are passed and overdrilled in a standard fashion. The measuring lengths on the drill are used to measure appropriate screw length. While maintaining fragment position with a switching stick, the cannulated superior screw is placed. The inferior screw is then placed in a similar fashion. Both screws show good purchase, and the fracture is then formally reduced. Following bony fixation, the fracture is further stabilized with imbrication. Capsulolabral repairs are made superior and inferior to the fracture bed. Postoperative radiographs show satisfactory glenoid fracture reduction using 2 cannulated screws by way of the Halifax portal. (ER, emergency room; Non OP, nonoperative; NVI, neurovascularly intact; RHD, right-hand dominant.)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Download video file (41.6MB, mp4)
Video 1

This video describes the technique for arthroscopic fixation of a large glenoid bony Bankart fracture using the Halifax portal with dual screw fixation and labral repair. The procedure is demonstrated on the right shoulder with the patient in the lateral decubitus position. Patient presentation following injury and imaging showing a large bony Bankart lesion with a Hill-Sachs defect is presented. Diagnostic arthroscopy is begun through a posterior portal, and the fracture is debrided while viewing from the anterosuperior portal. A traction suture is placed through a posterior portal exit to aid in reduction. Cartilage defect and minor bone loss are noted in the fracture bed as a result of the comminution. The viewing portal is then transitioned back to posterior in order to localize the Halifax far medial portal, which is established superior to the subscapularis and lateral to the conjoint tendon. The inside-out technique is used to ensure parallel positioning to the glenoid. An arthroscopic cannulated parallel drill guide is used to oppose the fracture fragment and reduce the fragment. Two K-wires are passed and overdrilled in a standard fashion. The measuring lengths on the drill are used to measure appropriate screw length. While maintaining fragment position with a switching stick, the cannulated superior screw is placed. The inferior screw is then placed in a similar fashion. Both screws show good purchase, and the fracture is then formally reduced. Following bony fixation, the fracture is further stabilized with imbrication. Capsulolabral repairs are made superior and inferior to the fracture bed. Postoperative radiographs show satisfactory glenoid fracture reduction using 2 cannulated screws by way of the Halifax portal. (ER, emergency room; Non OP, nonoperative; NVI, neurovascularly intact; RHD, right-hand dominant.)

Download video file (41.6MB, mp4)

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