Posterior Bony Bankart Bridge and Reverse Remplissage in an Elite Contact Athlete

Posterior or multidirectional shoulder instability are common among athletes subjected to repetitive posterior loading. Posterior glenohumeral dislocation can result in a posterior bony Bankart lesion, which presents a unique challenge in arthroscopic repair.

Surgical repair is considered for patients with high physical demands and for those with instability refractory to nonoperative treatment, as observed in this 21-year-old professional hockey player. In select cases of elite contact athletes, even a modest reverse Hill-Sachs lesion (rHSL) and posterior bone loss may justify augmentation with a posterior bony Bankart bridge and reverse remplissage, as these techniques aim to minimize the risk of recurrence and optimize return to play.

The patient is positioned in the beach-chair position. The rHSL is gently debrided. A straight crescent suture lasso is used to pierce the lateral subscapularis from anterior to posterior, and a 1.3-mm SutureTape is shuttled. Both suture limbs are retrieved and loaded into a 4.75-mm SwiveLock anchor. The anchor is placed in the rHSL, securing the tendon into the defect under individual limb tensioning. To repair the posterior bony Bankart lesion, a posteroinferior portal is created. The bony lesion is debrided and elevated. Two 1.8-mm knotless FiberTak anchors are placed to repair the posterior labrum inferiorly and superiorly to stabilize the bony fragment to the glenoid and aid in repair. A 2.4-mm SutureTak anchor is then placed at the glenoid neck medial to the lesion, and its sutures are inserted into a 2.9-mm PushLock anchor at the glenoid margin between 2 previously placed anchors, creating a "bony Bankart bridge" for compression. Capsular closure is performed with a polydioxanone suture, which is passed through the posterior capsule using a lasso from the posterior portal and tied down with Weston knots to close the deep capsule and maintain tension. When the anchor trajectory is challenging, curved guides may be substituted for straight guides. The posterior bony Bankart fragment is carefully exposed and debrided before fixation to ensure optimal healing.

Published outcomes of the posterior bony Bankart bridge demonstrate excellent stability with high return-to-sport rates. Similarly, while most literature focuses on anterior remplissage, the principles and outcomes of reverse remplissage are consistent with low recurrence rates in patients with rHSLs. Even small rHSLs and modest posterior bone loss may warrant augmentation in elite collision athletes, as recurrent instability can have career-threatening consequences. Further research should focus on long-term durability and comparative effectiveness of this combined strategy.

Appropriate portal placement and meticulous technique execution are integral to avoiding possible complications, including recurrent instability, loss of motion, and/or subscapularis weakness. Additionally, deep closure of the posterior capsule is critical to maintain capsular tension. While standard posterior labral and bony Bankart repairs generally achieve excellent outcomes, they are less reliable in elite collision athletes, where even modest posterior bone loss or an rHSL can predispose to failure. In this case, reverse remplissage neutralized the humeral defect and reinforced subscapularis restraint, while the bony Bankart bridge provided compression and anatomical restoration of the fragment. This combined approach offered superior protection against recurrence and progression of bone loss compared with soft-tissue repair alone.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.