Abstract
Bony Bankart anterior glenoid rim fractures typically result from traumatic anterior shoulder instability. Management options include nonoperative treatment, open reduction and internal fixation, and arthroscopic fixation. Treatment selection varies based on fracture size, displacement, comminution, and chronicity, as well as patient-specific factors. Arthroscopic fixation has shown similar functional outcomes with lower morbidity when compared with open techniques. The purpose of this technical note is to describe a reproducible arthroscopic technique for anterior glenoid fracture reduction and fixation using a suture cerclage construct. This method uses metal-free, robust suture cerclage fixation to capture and reduce the fracture via guided bone tunnels.
Technique Video
Bony Bankart glenoid fractures are present in as many as 22% of first-time anterior shoulder dislocations and 45% of patients with recurrent anterior instability.1 These injuries result in loss of glenoid concavity and, often, persistent shoulder instability. Failure to identify and appropriately address a bony Bankart glenoid fracture frequently leads to recurrent instability and accelerated degenerative joint disease.2 Management options include nonoperative treatment, open reduction and internal fixation, and arthroscopic fixation. The treatment algorithm involves assessment of fracture size, comminution, displacement, and chronicity, in combination with patient demographic characteristics and demand level.3 Fractures involving more than 20% of the glenoid cavity, displacement greater than 10 mm, or associated glenohumeral instability are potential candidates for surgical management.4,5 This technical note describes a reproducible arthroscopic technique for anterior glenoid fracture reduction and fixation using a FiberTape (Arthrex, Naples, FL) suture cerclage construct (Video 1).
Surgical Technique
Indications
Arthroscopic reduction and fixation using a FiberTape cerclage may be indicated by clinical and radiographic evidence of bony Bankart glenoid fractures that include the following: large, non-comminuted fragments involving more than 20% of the glenoid cavity, fracture displacement greater than 10 mm, and associated glenohumeral instability.
Preoperative Planning
Preoperative imaging is key in guiding optimal management and is essential for accurately assessing fracture size, chronicity, comminution, and displacement (Fig 1). Standard radiographic views include anteroposterior shoulder, Grashey, scapular-Y, and axillary views. Computed tomography images with sagittal reconstructions perpendicular or en face to the glenoid articular surface and 3-dimensional reconstructions of the glenoid with humeral head subtraction can be particularly helpful. Magnetic resonance imaging is a useful adjunct for evaluating the extent of associated capsulolabral injury.
Fig 1.
Preoperative imaging of a right shoulder showing a glenoid fracture (red asterisks). (A) Grashey-view radiograph showing a fracture at the mid anterior glenoid (black arrow). (B-D) Two- and three-dimensional computed tomography scans revealing a mildly comminuted, impacted fracture involving the anterior and mid to inferior glenoid, with approximately 5 mm of articular surface depression.
Preparation
Surgery is performed under general anesthesia with an interscalene nerve block. The patient is positioned in the lateral decubitus position with all bony prominences well padded. An examination under anesthesia is performed to assess the degree of anterior shoulder laxity. The arm is placed in a Shoulder Suspension System (S3) Positioner (Arthrex) under 15 lb of balanced suspension. The upper extremity is prepared and draped in standard sterile fashion.
Technique
A standard posterior arthroscopic portal is created. Via needle localization, an anterior superolateral (ASL) portal and an anterior rotator interval portal are created, and cannulas are placed. An 8.25-mm Twist-In cannula (Arthrex) is placed in the ASL portal, and a Gemini SR8 cannula (Arthrex) is placed in the rotator interval portal. Routine diagnostic arthroscopy is performed. The anterior glenoid facture is assessed to determine the size, comminution, medialization, and extent of associated capsulolabral disruption (Fig 2). The posterior humeral head is assessed for an associated Hill-Sachs lesion. The arthroscope is placed in the ASL portal to enhance visualization. An arthroscopic shaver and elevator are used to mobilize the glenoid fracture fragment (Fig 3) until it can be reduced and the subscapularis muscle fibers are visualized, and fracture hematoma is debrided. If a concomitant remplissage procedure is indicated, 2 all-suture anchors are placed in the humeral head using a previously described technique.6 The remplissage is not completed until after the bony Bankart fracture is fixated.
Fig 2.
Intraoperative posterior (A) and anterior superolateral (B) portal view of the right shoulder, with the patient in the lateral decubitus position, showing a large, medially displaced fracture of the glenoid (red asterisks), encompassing approximately 30% to 40% of the total glenoid area. The black asterisks indicate the intact glenoid.
Fig 3.
(A, B) Intraoperative posterior portal view of the right shoulder, with the patient in the lateral decubitus position. An elevator and motorized shaver (black arrows) are introduced into the joint by the posterior portal and are used to complete debridement of the fracture site, removing hemorrhagic material, loose chondral fragments, and smaller irreparable portions of the glenoid labrum. The red asterisks indicate the displaced fracture of the glenoid.
A drill guide is used to place a 1.8-mm knotless FiberTak all-suture anchor (Arthrex) at the inferior margin of the fracture, typically near the 6-o’clock position (Fig 4 A and B). A 25° SutureLasso (Arthrex) is used to shuttle the repair suture from the anchor around the inferior capsulolabral tissue (Fig 4C). The repair suture is converted through the anchor using the shuttling suture. Slack is removed in the repair suture, but it is not fully tensioned until later in the procedure (Fig 4D).
Fig 4.
Intraoperative anterior superolateral portal view of the right shoulder, with the patient in the lateral decubitus position. (A, B) A 1.8-mm knotless FiberTak anchor is placed at the 5:30 clock-face position (black arrows) distal to the fracture site. (C) A lasso (white arrows) passes the suture around the capsulolabral junction near the fragment. (D) Tensioning the knotless anchor (black arrow) helps aid fracture reduction to the native glenoid. The red asterisks indicate the displaced fracture of the glenoid. The black asterisks indicate the intact glenoid.
A transglenoid drill guide (Arthrex) is then introduced via the posterior portal. The hook is placed over the anterior rim of the fracture fragment to act as a reduction clamp and adjusted until the fracture fragment is reduced to the intact glenoid (Fig 5A). Electrocautery is used to make a small split in the anterior capsulolabral junction (Fig 5B). The posterior portal is slightly enlarged to accommodate the attached drill sleeve, which is placed flush against the posterior glenoid. Two parallel drill pins are advanced deep to the articular surface through the glenoid and across the fracture site, exiting through the anterior surface of the fracture fragment (Fig 6A). Two guidewires are fed through the drill pins and are retrieved out the anterior portal (Fig 6B). The drill pins and drill guide are then removed. The passing wires are exchanged for 2 looped passing sutures that are used to shuttle the FiberTape cerclage suture, creating a circumferential construct with the preset knot positioned posteriorly (Fig 6C). The cerclage suture tail is loaded into the preset knot and hand tensioned. A mechanical tensioner device is then used to tension the knot to 60 N. Several half-hitches are placed to back up the knot (Fig 6D). A second 1.8-mm knotless FiberTak all-suture anchor is placed just superior to the fracture in a similar fashion to the first (Fig 7A). Both labral anchors are tensioned, and the repair suture is cut flush (Fig 7B). This completes repair of the bony Bankart lesion (Fig 8). A probe is used to confirm anatomic reduction and fracture stability. Repeated examination under anesthesia is performed to assess stability of the shoulder.
Fig 5.
Intraoperative anterior superolateral portal view of the right shoulder, with the patient in the lateral decubitus position. (A) The glenoid guide (black arrow) engages and reduces the fracture fragment (red asterisk) to the intact glenoid (black asterisk). (B) Radiofrequency ablation (white arrow) is used to create a small split at the anterior capsulolabral junction, anterior to both the Bankart fracture fragment (red asterisk) and glenoid guide (black arrow), allowing visualization of the guide pins exiting the fragment.
Fig 6.
Intraoperative anterior superolateral portal view of the right shoulder, with the patient in the lateral decubitus position. (A) Two parallel guide pins (black arrows) are inserted through the posterior glenoid, exiting anteriorly through the fracture fragment. (B) Passing wires (white arrows) are placed through the cannulated guide pins. (C) The passing wires are exchanged for passing sutures, which shuttle 2 FiberTape cerclage sutures (blue arrow) in a circumferential path through the posterior glenoid, around the fracture fragment, and back out posteriorly. (D) The cerclage sutures are linked, tensioned sequentially, and secured with half-hitches, completing fragment fixation. The red asterisk indicates the displaced fracture of the glenoid, now fixed to the intact glenoid (black asterisks).
Fig 7.
Intraoperative anterior superolateral portal view of the right shoulder, with the patient in the lateral decubitus position. (A) A second 1.8-mm FiberTak anchor (black arrow) is placed superior to the fracture fragment, and a lasso passes the suture around the capsulolabral junction. (B) Tensioning the anchor (black arrow) reduces the capsule (white asterisks) over the fracture fragment (red asterisk).
Fig 8.
Intraoperative anterior superolateral (A, B) and posterior (C, D) portal view of the right shoulder, with the patient in the lateral decubitus position, comparing intra-articular situation at the beginning of the procedure (A, C) and at the end (B, D). The red asterisks indicate the displaced fracture of the glenoid. The black asterisks indicate the intact glenoid. Anatomic reduction is noted, with a relatively flush articular surface and the humeral head (white asterisks) well centered on the glenoid.
Rehabilitation
The patient is placed in an immobilizer sling for 6 weeks. Physical therapy is initiated within 1 week of the procedure, focusing initially on passive range of motion, limiting forward flexion to 90° and external rotation to 20°. The sling is then discontinued, and the patient progresses to active range of motion. Strengthening is initiated at 10 to 12 weeks. Full return to activity is anticipated at 5 to 6 months. Serial radiographs are used to monitor fracture healing (Fig 9).
Fig 9.
Six-month postoperative radiographs of the right shoulder showing interval progressive healing with mild cortical irregularity at the anterior inferior glenoid fracture site (black arrow): Grashey view (A), lateral/scapular-Y view (B), and axillary view (C).
Discussion
This technical note describes a reproducible arthroscopic technique for the reduction and fixation of bony Bankart glenoid fractures using a metal-free, tensionable suture cerclage construct. This construct provides high-strength, circumferential compression around both the fracture fragment and the intact glenoid. The technique offers several advantages (Table 1), namely anatomic reduction with a strong, stable, compressive fixation; the absence of temporary or permanent hardware; avoidance of suture material on the chondral surface; and the use of standard arthroscopic portals—avoiding complications associated with open reduction and internal fixation.
Table 1.
Advantages and Disadvantages
| Advantages |
| Anatomic reduction |
| Effective for non-uniform fragments |
| Strong circumferential compression with high stability |
| Avoids screw- and metal-related complications |
| Avoids suture material on chondral surface |
| Standard arthroscopic setting, avoiding open approach |
| Allows simultaneous repair of other injuries related to shoulder joint, including addition of remplissage |
| Disadvantages |
| Potential lower primary stability vs screw constructs |
| Requires precise suture passage and tensioning to avoid displacement |
| Requires advanced arthroscopic skills |
If not appropriately treated, bony Bankart glenoid fractures can result in considerable morbidity.2,4 Surgical management options for anterior glenoid fractures include open or arthroscopic reduction and internal fixation. Historically, surgical anterior glenoid fractures were managed through an open approach.5 Improvements in arthroscopic techniques and instrumentation have enabled the minimally invasive fixation of these fractures, showing similar functional outcomes with lower complication and reoperation rates compared with open procedures, which often require larger incisions; greater soft-tissue violation, including that of the subscapularis tendon; and an increased risk of serious complications such as infection and neurovascular injury.7,8 Additionally, arthroscopic fixation offers better visualization of the articular surface, reduced blood loss, improved cosmesis, and faster recovery and allows simultaneous repair of intra-articular soft-tissue injuries.9
Cameron10 reported the first successful case of all-arthroscopic reduction and fixation of a glenoid fracture using a partially threaded cancellous screw. Other reported arthroscopic techniques for glenoid fracture fixation include single or multiple screws,8,11 suture fixation either around or through the osseous fragment,12, 13, 14 suture bridge constructs using anchors,15 pulled sutures,16 suture button fixation,17 suture double-anchor compression,18 and combined screw and suture anchor fixation.19 These methods have shown favorable outcomes, each exhibiting several advantages to achieving anatomic reduction with stable fixation while avoiding the morbidity associated with open procedures. However, many techniques fail to avoid the use of implantable hardware, disruption of the chondral surface, and metal screw–related complications such as neurovascular injury, impingement, mechanical failure, and damage to surrounding structures from screw heads.20
A similar technique to that described in this technical note has been used in arthroscopic glenoid bone block procedures to eliminate metal-related complications associated with screw fixation.21, 22, 23 Although similar principles are used in these arthroscopic glenoid bone block procedures, our technique is distinguished by the ability to achieve complete arthroscopic reduction and stable fixation of the native glenoid without the need for graft augmentation. Biomechanical studies on the suture cerclage technique—when applied in glenoid bone block procedures—have shown greater fixation strength, higher load to failure, and reduced cyclic displacement compared with suture button constructs. Compared with screw fixation, the technique shows lower primary fixation strength and greater cyclic displacement, despite a similar ultimate maximal load to failure.24 Clinical and radiographic outcomes are favorable when the fixation method is applied to glenoid bone block procedures, with all patients showing radiographic consolidation at 3-month follow-up and no reported major complications.25 These biomechanical and clinical findings support the application of metal-free suture cerclage fixation in the setting of an acute glenoid fracture.
The presented technique is a viable alternative for achieving anatomic reduction with stable fixation of glenoid fractures. Pearls and pitfalls are described in Table 2.
Table 2.
Surgical Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
| Debride the fracture until the subscapularis muscle fibers can be visualized to aid in fragment mobilization and reduction. | Poor placement of the posterior portal can make accurate transglenoid-guide placement difficult. |
| Place the inferior labral anchor prior to fracture reduction for ease of placement. | Inadequate fracture mobilization can result in malreduction. |
| Ensure that the transglenoid guide is flush with the native glenoid to ensure proper guide pin placement. | Failure to create a capsular split will make visualization of the guide pins exiting the fracture fragment very difficult. |
| Intraoperative fluoroscopy may be used for fracture reduction and pin placement but is not routinely necessary. |
Disclosures
All authors (T.J.K., D.J.L., D.J.S., K.H.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
The authors thank Mitch Klapper, Arthrex, Green Bay, Wisconsin, for arthroscopic surgery video editing.
Supplementary Data
Arthroscopic fixation of an acute right-sided Bony Bankart fracture utilizing a circumferential suture cerclage construct. The patient is positioned in the lateral decubitus position under balanced suspension. Viewing is performed through the anterior superior lateral (ASL) portal, with working instruments introduced through the anterior rotator interval and posterior portals. Key steps demonstrated include: diagnostic evaluation of the glenoid fracture, mobilization and preparation of the fracture fragment, placement of an inferior knotless all-suture anchor, fragment reduction using the transglenoid guide, transglenoid tunnel creation for cerclage passage, and final circumferential fixation with tensioning and supplemental superior anchor placement. This video emphasizes a technique for anatomic reduction, stable fixation, and restoration of glenoid concavity in acute bony Bankart injuries.
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Associated Data
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Supplementary Materials
Arthroscopic fixation of an acute right-sided Bony Bankart fracture utilizing a circumferential suture cerclage construct. The patient is positioned in the lateral decubitus position under balanced suspension. Viewing is performed through the anterior superior lateral (ASL) portal, with working instruments introduced through the anterior rotator interval and posterior portals. Key steps demonstrated include: diagnostic evaluation of the glenoid fracture, mobilization and preparation of the fracture fragment, placement of an inferior knotless all-suture anchor, fragment reduction using the transglenoid guide, transglenoid tunnel creation for cerclage passage, and final circumferential fixation with tensioning and supplemental superior anchor placement. This video emphasizes a technique for anatomic reduction, stable fixation, and restoration of glenoid concavity in acute bony Bankart injuries.