Implantless transosseus Bankart repair: technical note

Anterior shoulder instability occurs when the humeral head repeatedly dislocates or subluxates from the glenoid cavity, most commonly due to a Bankart lesion involving detachment of the anteroinferior labrum and capsule. It predominantly affects young, active individuals and athletes engaged in overhead or contact sports.¹ Recurrent instability episodes cause pain, weakness, and progressive structural damage, including glenoid bone loss or Bankart lesions.^2,3 The extent of bone loss and the integrity of the labrum-capsuloligamentous complex are key determinants of treatment selection, whether conservative, arthroscopic, or open surgery stabilization procedures. Arthroscopic Bankart repair is one of the most common surgical approach for anterior shoulder instability due to its minimally invasive nature and ability to anatomically restore labral attachment. Several studies have reported high patient satisfaction, good functional scores, and high return-to-sport rates.^5,12,13

Conventional arthroscopic repairs employ metallic, bioabsorbable, or soft-body suture anchors for fixation. However, the use of implants can increase cost, risk of hardware failure, and bone loss due to peri-implant osteolysis which is an inflammatory response resulting from small wear of the anchor as a foreign body.^9,16 Implantless techniques utilizing trans-osseous or trans-glenoid sutures have been introduced to achieve anatomic labral reattachment while preserving glenoid bone stock.^7,14

In developing countries, several challenges limit optimal management of shoulder instability. Limited access to equipment due to high costs of suture anchors, financial barriers to imported implants, uncovered cost by medical insurance constrain treatment options. This condition may delay surgery or lead to non-operative management despite recurrent instability.¹⁵ These realities highlight the importance of developing cost-effective and reproducible surgical options that reduce reliance on expensive hardware while maintaining biomechanical strength. To overcome these constraints, the use of innovative transosseous and transosseus-equivalent arthroscopic techniques may eliminate or minimize the use of anchors.

This technical note describes an implantless arthroscopic Bankart repair using trans-osseous suture fixation without the use of anchors, emphasizing its practical steps, instrumentation, and potential advantages for surgeons practicing in developing countries, where implant cost and availability remain as significant barriers to modern arthroscopic procedures.

Surgical technique

The technique is presented in Video 1. The surgery was performed in a supine position with arthroscopic approach with the following steps:

• 1.Diagnostic arthroscopy
• 2.Capsulolabral mobilization and lesion preparation
• 3.Trans-osseous tunnel creation
• 4.Suture passage and fixation

Patient position and portal placement

The patient is positioned in supine position under general anesthesia. The arm is extended and placed on assist arm as shown in Figure 1, A. Supine position with traction offers comprehensive 360° view of the glenoid, facilitating adequate visualization of the anterior glenoid rim and capsulolabral complex. Standard high posterolateral and anterior working portal are established, with an additional anteroinferior portal at the 5-o'clock position for optimal access to the anteroinferior glenoid as shown in Figure 1, B and C. Diagnostic arthroscopy is performed to confirm the presence of a detached labrum and assess bone loss.

Figure 1.

(A) The patient was positioned in the supine position with the operative arm placed in an extended posture and secured to an assist arm device. (B and C) The right shoulder was being operated on standard portals (high posterolateral and anterosuperior) were established at 9-o'clock and 12-o'clock, respectively, with extra anteroinferior working portal at 5-o'clock.

Capsulolabral mobilization and lesion preparation

Soft tissue is released along the anteroinferior glenoid margin (from 6 to 2 o'clock) using a radiofrequency probe and shaver to expose healthy bone. Bankart rasp was also used to mobilize the labrum. The glenoid rim is lightly abraded with a burr to promote bleeding and fibrocartilaginous healing. This step is critical for subsequent fixation strength. Lesion preparation is illustrated on Figure 2, A and B.

Figure 2.

The right shoulder was being operated on, with the patient in supine position. (A) Soft tissue was being shaved using radiofrequency (RF) probe and abraded using burr to expose healthy bone in 6 to 2-o'clock direction. (B) Anterosuperior arthroscopic portal view, soft tissue was being shaved with RF probe through the anteroinferior working portals.

Trans-osseous tunnel creation

Because no suture anchor is used (implantless), fixation relies on trans-osseous tunnels created across the anterior glenoid rim. A zone-specific glenoid guide is used and introduced through the anterior-inferior portal to determine the entry points for each tunnel. To begin the creation of the tunnels, first a 2.3-mm drill bit (Q-Fix or Y-Knot Flex system) was used to create a clearance hole which enables the next drill bit to do gliding motion to determine the appropriate angle for the transosseus tunnel. Then, the 1.8-mm drill bit (Q-Fix or Y-Knot Flex system) was used to create pilot hole to establish the transousseus tunnel as shown in Figure 3, A–C. Three holes are sequentially created at the following positions: first hole at 5:30 o'clock (corresponding to soft tissue at 6 o'clock) (Fig. 4, A and B), second hole at 4:30 o'clock (soft tissue at 5:00 and 5:30 o'clock) (Fig. 4, C and D), and third hole at 3:30 o'clock (soft tissue at 4 o'clock) (Fig. 4, E–G). Note that the pilot hole entry point is placed approximately 5 mm medial to the glenoid articular margin in approximately a 30° angle manner relative to the glenoid surface (Fig. 4,H). Each hole is drilled from the articular margin of the glenoid toward the medial cortex, maintaining a bone bridge between tunnels for secure suture passage. If available, a cannulated sleeve or slotted sheath (zone-specific guide system) is used to prevent cortical blowout and ensure parallel trajectory. The procedural steps are illustrated in Figure 4.

Figure 3.

Anterosuperior arthroscopic portal view of the right shoulder was being operated on, with the patient in supine position. (A) Creating clearance hole using 2.3-mm drill bit through anteroinferior working portal. (B and C) Creating pilot hole penetrating through the glenoid cortex to establish tunnel using 1.8-mm drill bit through the high posterolateral portal.

Figure 4.

(A and B) Illustration of the creation of the first transsosseus tunnel. (C and D) Illustration of the creation of the second transsosseus tunnel. (E and F) Illustration of the creation of the third transsosseus tunnel. (G) Tunnels were created at 5:30, 4:30, and 3:30 position using 2.8 mm drill bit from articular margin of glenoid penetrating to medial cortex to establish trans-osseus tunnel. (H) Pilot hole angle and entry point.

Suture passage and fixation

Once the bone tunnels are prepared, a monofilament shuttle suture (polydioxanone no. 2) is passed immediately after the establishment of each individual tunnel to maintain tunnel patency and facilitate controlled suture management. The shuttle suture is introduced through the tunnel using a suture passer or spinal needle from the anterior side toward the posterior glenoid surface. A high-strength non-absorbable suture (No. 2 ultra-high molecular weight polyethylene or equivalent) is then loaded into the shuttle and drawn posteriorly, as shown in Figure 5, A–C.

Figure 5.

Anterosuperior arthroscopic portal view of the right shoulder was being operated on, with the patient in supine position. (A) Monofilament suture is passed through the high posterolateral portal to the anteroinferior portal. (B) A high-strength non-absorbable (UHMWPE no. 2) loaded and shuttled through transosseus tunnel with the monofilament suture. (C) All 3 tunnels were utilized to fixate the labrum to the glenoid. UHMWPE, ultra-high molecular weight polyethylene.

The anterior limb of each suture is subsequently passed through the adjacent capsulolabral tissue corresponding to the respective bone tunnel using a suture-passing device (Y-Knot Flex or Scorpion passer). After all sutures have been sequentially passed, the labrum is anatomically reduced onto the prepared glenoid rim. Each pair of suture limbs is then tied over the anterior glenoid cortex, creating a stable implantless trans-osseous fixation construct. Note that the labrum reduced must be anatomically precise by inserting the suture limbs to the labrum approximately 5-7 mm from the border of the Bankart lesion. This process ensures no excess soft tissue protruding to the joint space to avoid glenohumeral joint impingement. The procedural steps are illustrated in Figure 6, A–D.

Figure 6.

(A) Monofilament suture (polydioxanone no. 2) loaded with high-strength non-absorbable suture (UHMWPE no. 2) was passed via high posterolateral portal through the anterior side of the tunnel then drawn to the posterior side of the tunnel. (B) Suture passer loaded with monofilament shuttle suture is introduced via high posterolateral portal and passed through labrum adjacent to the hole established, shuttle suture then drawn to the anteroinferior portal and tied over the posterior limb of UHMWPE no. 2 suture. The anterior limb of the shuttle suture then pulled over through the high posterolateral portal. (C) Position of suture after the shuttle suture was pulled over. (D) Final construct after tying the sutures over the anterior glenoid cortex, demonstrating anatomical reduction and stable fixation of the labrum without the use of anchors. UHMWPE, ultra-high molecular weight polyethylene.

Notably, the second trans-osseous tunnel (4:30 o'clock position) is utilized to secure the capsulolabral complex with 2 independent suture limbs, providing enhanced fixation at the anteroinferior region where the labral detachment and capsular redundancy are typically most pronounced. This double-suture configuration increases contact pressure between the labrum and the glenoid rim and promotes more evenly distribution of stability across the repair site (Fig. 6, D).

Intraoperative assessment

After completing all 3 fixation points (5:30, 4:30, and 3:30) (Fig. 6, D), the repair is inspected arthroscopically. The labrum should appear elevated and flush against the glenoid rim, restoring the anteroinferior concavity. Shoulder motion is then checked to ensure that the capsule is adequately tensioned without over-restriction of external rotation.

Closure and post-operative protocol

All instruments are removed, and portals are closed with absorbable sutures. A sterile dressing and an arm sling are applied. Post-operatively, the arm is immobilized for 3 to 4 weeks, followed by gradual passive and assisted motion avoiding external rotation beyond neutral during the early phase. Strengthening begins at 6–8 weeks, and return to overhead activity is allowed after 4–6 months depending on patient recovery.

Discussion

The success of Bankart repair has been well established over the past 3 decades, with both open and arthroscopic techniques demonstrating significant improvement in shoulder stability and patient function. Arthroscopic Bankart repair using suture anchors has become the gold standard due to its minimally invasive nature, preservation of soft tissue, and ability to restore the anatomic capsulolabral complex.¹⁰ Number and size of anchors significantly influence construct stability and clinical outcomes. Sufficient number of anchors is needed to create multiple points of fixation and the strongest repair possible.⁶ A typical arthroscopic Bankart repair requires 3 to 4 anchors, some suggest to use a minimum of 4 to 6 anchors, depending on the size of the patient.¹¹ Furthermore, the use of smaller-diameter suture anchors helps preserve the structural integrity of the glenoid rim. Despite the ability of the solid suture anchors to handle physiological load, they may present challenges such as chondral damage due to anchor size and imperfect angulation, as well as anchor breakage.¹⁰

Reliance on anchors poses logistical and economic challenges in resource-limited settings, where the cost and availability of multiple implants can hinder standardized arthroscopic stabilization.¹ Beyond the number of implants required, the cumulative cost of suture anchors which each of the implants may cost hundreds of dollars may exceeds the financial capacity of public hospitals and uninsured patients.¹⁶ Furthermore, the availability of small-diameter anchors (1.8–2.8 mm) is often limited, and the use of larger anchors increases the risk of glenoid bone loss and complicates future revision procedures.

These challenges highlight the clinical value of implantless trans-osseous techniques. Early arthroscopic techniques described trans-glenoid sutures using posterior knots for fixation but then replaced by anchor due to convenience and improved instrumentation. Nowadays with modern suture materials, smaller cannulas, and zone-specific drill guides, implantless techniques have regained interest. Benefits of anchorless suture fixation includes smaller drill holes, a reduction in native bone removal, and the elimination of the risk of losing rigid material in the joint.

Several reports have demonstrated comparable functional outcomes and recurrence rates between anchorless and anchor-based arthroscopic Bankart repairs, with the additional advantages of cost reduction and bone preservation.^4,8 This technique allows surgeons to perform reliable anatomic repairs using standard arthroscopic instruments and high-strength sutures, making it particularly suitable for resource-limited environments.

The implantless bone-bridge technique presented in this technical note combines the biological advantages of direct bone healing with the economic feasibility needed in low-resource environments. By creating 3 trans-osseous tunnels between 5:30 and 3:30 o'clock, surgeon may achieve an evenly distributed fixation that replicates the capsulolabral contour without introducing foreign material. Anterior knot tying ensures secure tensioning while avoiding intra-articular prominence or cartilage abrasion.

Despite its advantages, certain limitations should be acknowledged. The trans-osseous technique is technically demanding and requires precise orientation of drill tunnels to avoid cortical blowout or injury to the suprascapular nerve. Operative time may increase due to the demands of suture passage and knot tying, the use of unfamiliar instruments, and the associated learning curve, all of which require a higher level of arthroscopic proficiency. Moreover, in cases of poor bone quality or significant glenoid bone loss, the mechanical strength of suture fixation may be inferior to anchor-based systems or bone-block procedures such as Latarjet. Nevertheless, in appropriately selected patients with soft-tissue–predominant lesions, implantless Bankart repair represents a safe, cost-effective, and reproducible alternative to traditional anchor-based techniques.⁷ Pearls and pitfalls are mentioned in Table I. Advantages and disadvantages are mentioned in Table II.

Table I.

Pearls and pitfalls.

Pearls	Pitfalls
The patient is positioned supine, with the operative arm placed in assist arm device in extended, facilitating optimal access for arthroscopic portals	Anesthesia-related issues
Establish access to shoulder joint by creating 3 arthroscopic portals (anterior, posterior, and anteroinferior)
Perform lesion preparation by abrading the glenoid using radiofrequency probe and burr to promote healing	Poor visualization is inevitable due to bleeding
Creating Trans-osseus tunnel using 2.3-mm and 1.8-mm drill bit to facilitate suture passing and replace the use of anchors	Inaccurate drill angulation or applying excessive force may lead to unintended penetration of the medial cortex. compromising bone bridge resulting in decrease the overall mechanical stability of the construct.
Passing each suture through each one of the tunnels to fixate the labrum with the glenoid, forming an implantless transousseus fixation	Failure to tension sutures evenly or difficulty handling multiple suture limbs may result in a non-anatomic repair or persistent capsular laxity.

Table II.

Advantages and disadvantages.

Advantages	Disadvantages
Minimal invasive approach to repair Bankart lesion	Technically demanding procedure requiring advanced arthroscopic surgical skills
Improved visualization of glenoid by creating 3 portals
Eliminating the use of anchors, reducing implant dependence and contributes to lowering overall operative expenditure.	Limited long-term outcome data, compared to the current gold standard
Provides correction of Bankart lesions	Relatively difficult suture passage and management
Minimalize the risk of complication compared to open Bankart repair surgery	Technically more challenging in complex tear configurations. Possible cut-through of sutures in osteoporotic bone.

Conclusion

Implantless Bankart repair presents an effective alternative that circumvents the issue of variable global access to advanced implant technologies. It offers a comprehensive surgical option that balances high clinical and biomechanical value with economic viability, making it a valuable option for surgeons practicing in developing countries or in cases where implant use is limited. To fully assess its efficacy, long-term clinical data on the durability, recurrence rates, and functional outcomes of this technique relative to traditional anchor-based repairs are required. Future observational study of the patient undergo implantless Bankart repair is guaranteed.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: The author, their immediate family, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Supplementary Data

Video 1

Supplementary Video of Surgical Technique.