Dual arthroscopic approach for simultaneous Bankart lesion repair and acromioclavicular joint stabilization: A case report

Abstract

BACKGROUND

Associated shoulder injuries, such as acromioclavicular (AC) dislocation and Bankart lesions, are complex and challenging to treat, particularly when accompanied by a chronic Hill-Sachs lesion. Each injury can independently compromise shoulder function and stability, and their coexistence further increases treatment complexity. This case report describes the arthroscopic treatment of a 32-year-old military serviceman with a soft tissue Bankart lesion, Hill-Sachs lesion, and Rockwood type IIIA AC joint dislocation.

CASE SUMMARY

The patient presented with a nine-year history of recurrent anterior shoulder dislocation after a motor vehicle accident that resulted in glenohumeral instability with a Bankart tear and Hill-Sachs lesion. He subsequently sustained another injury that caused AC joint deformity and was diagnosed as a Rockwood type IIIA AC joint dislocation. Physical examination showed shoulder instability, pain, and restricted range of motion. Imaging studies, including magnetic resonance imaging and computed tomography scans, revealed a soft tissue Bankart lesion, a Hill-Sachs lesion of the posterolateral humeral head, and a type IIIA AC joint separation. A combined arthroscopic approach was selected because of the complexity of the injuries and the need to achieve optimal joint stability and rapid recovery. The patient underwent arthroscopic Bankart repair with knotless suture anchors for labral reattachment and anterior glenohumeral joint stabilization. He also underwent AC joint stabilization with an adjustable Endobutton fixation device to restore clavicular alignment.

CONCLUSION

The combined arthroscopic procedure for shoulder joint instability and AC joint dislocation was beneficial in restoring shoulder stability and function, as demonstrated by minimal postoperative pain, recovery of a full range of motion, and an uneventful course without recurrent dislocation. This case illustrates the effectiveness of a less invasive arthroscopic approach for managing complex shoulder pathologies and its potential as an alternative to open surgery in selected cases. Further research is required to assess long-term outcomes.

Key Words: Acromioclavicular joint dislocation; Bankart lesion; Hill-Sachs lesion; Shoulder arthroscopy; Adjustable Endobutton; Military injury; Shoulder instability; Case report

Core Tip: The management of chronic anterior shoulder instability accompanied by a Bankart lesion and Rockwood IIIA acromioclavicular joint dislocation is rare. In this case, the patient underwent combined arthroscopic Bankart repair and acromioclavicular joint stabilization with an adjustable Endobutton fixation system. The findings indicate that both conditions can be successfully managed in a single minimally invasive procedure.

INTRODUCTION

Shoulder disorders are among the most common musculoskeletal complaints encountered in clinical practice and are associated with substantial functional impairment and healthcare utilization. Symptoms may be persistent and disabling, limiting an individual’s ability to perform daily activities at home and at work. These disorders also impose substantial economic costs because of increased healthcare demand, impaired work performance, sickness absence, early retirement, and job loss[1]. The complexity of the shoulder joint, which includes the glenohumeral, acromioclavicular (AC), sternoclavicular, and scapulothoracic joints, provides a high degree of mobility. However, this same complexity makes the shoulder prone to instability and injury, particularly in active and athletic populations[2].

Among shoulder injuries, glenohumeral dislocation and AC joint dislocation are common but usually occur separately. They are typically treated independently because they involve different anatomical structures. Glenohumeral dislocation commonly leads to Bankart lesions, which are tears of the anteroinferior labrum. Bankart lesions are associated with anterior dislocations, which account for 96% of shoulder dislocations, and are a major cause of instability if left untreated[3]. In contrast, AC joint dislocation occurs at the junction of the distal clavicle and the acromion process of the scapula. It commonly results from direct trauma, such as falls onto the shoulder or contact sports, and accounts for 9% of shoulder injuries[4,5].

The AC joint plays an important role in shoulder biomechanics by facilitating coordinated scapular and clavicular motion during upper-limb movement[6]. AC joint dislocation can be categorized according to the severity of ligament injury using the Rockwood classification system, which ranges from type I to type VI, from mild ligament sprain to severe joint dislocation[7]. Injuries to the AC joint are common in athletes and individuals who participate in high-impact sports, in which substantial force is transmitted to the shoulder joint.

Bankart lesions are usually managed arthroscopically to restore joint stability, especially in young patients who are prone to recurrent instability[8]. Arthroscopic Bankart repair, in which the torn labrum is reattached to the glenoid rim, has been shown to reduce recurrent dislocations, particularly in patients with high functional demands. Modern techniques, such as knotless or knot-tying suture anchors, have improved outcomes and accelerated recovery[9]. For AC joint injuries, surgical options include open reduction and internal fixation with hook plates or Endobutton devices, particularly in cases of severe dislocation or in patients with high functional demands[10].

However, the coexistence of AC joint dislocation and Bankart lesion presents diagnostic and management challenges because each condition requires specific attention to restore complete shoulder function. The rarity of this combination makes treatment planning difficult, as these injuries are usually managed through different treatment pathways[11]. For AC joint injuries, stabilization of the clavicle and acromion is crucial to prevent malalignment and reduce pain or weakness. For Bankart lesions, labral reattachment is necessary to prevent recurrent glenohumeral dislocation.

This case report highlights the rare coexistence of AC joint dislocation and Bankart lesion, which creates the challenge of treating two distinct causes of shoulder instability during a single operation. We chose a combined arthroscopic procedure that incorporated the adjustable Endobutton technique for AC joint dislocation repair with Bankart repair to stabilize both joints. This approach preserved the integrity of the shoulder joints and supported a rapid recovery, making it a potentially viable option for similarly complex cases.

The successful outcome in this patient, who had an excellent postoperative course with no recurrent dislocation or loss of function, indicates that a combined arthroscopic procedure may be an effective method for treating complex and rare shoulder injuries. This case report is intended to inform practitioners about the management of such patients and to encourage further research toward validated treatment protocols for complex shoulder pathologies.

CASE PRESENTATION

Chief complaints

Recurrent shoulder dislocation associated with pain.

History of present illness

The patient is a 32-year-old right-handed military service member. He was in a motorcycle accident nine years ago that hurt his left shoulder badly. He was going about 80 km/hour at the time. He hurt his left shoulder the most when he fell. His shoulder hurt a lot, and his arm was swollen, so he could not move it. He had to go to the emergency room immediately. At that moment, X-rays showed that the front of the shoulder was misaligned. The success of the closed reduction can be attributed to the administration of sedatives to the patient. The patient was immobilized in a sling for 20 days following successful closed reduction. The first clinical exam showed that the neurovascular system was working fine.

The patient was managed conservatively and, after the recommended period of immobilization, returned to his regular military duties. However, over the following nine years, he experienced recurrent left shoulder dislocations in different settings. Several episodes reduced spontaneously before medical evaluation. A few months before the presentation, he sustained another injury to the left shoulder that differed from the original motorcycle accident. After this injury, he noticed deformity of the AC joint associated with pain and tenderness.

After this injury, the patient noted marked prominence of the distal clavicle with local tenderness over the AC joint. The deformity became more pronounced during physical activity.

Despite the chronic nature of his symptoms, the patient had not undergone a formal orthopedic evaluation or surgical intervention for his shoulder condition. He reported persistent instability and described the shoulder as frequently “slipping out of place”. He also experienced pain localized to the anterior and superior aspects of the shoulder, accompanied by intermittent catching and locking sensations. In addition, he reported pain and discomfort over the AC joint, which were exacerbated by cross-body movements and overhead activities. The patient denied weakness, numbness, tingling, or other neurovascular symptoms in the affected extremity. However, recurrent instability episodes progressively limited his range of motion (ROM) and functional capacity because of apprehension and fear of further dislocation.

History of past illness

The patient has no previous medical history.

Personal and family history

The patient has no personal or family history.

Physical examination

General appearance and inspection: During physical examination, the patient exhibited mild forward shoulder positioning, likely related to shoulder instability and compensatory posture. There was a marked asymmetry between the left and right shoulders. The AC joint showed a prominent step-off deformity. This deformity, together with superior displacement of the distal clavicle, was suggestive of a Rockwood type III AC joint injury, which was later confirmed by imaging as a Rockwood type IIIA injury. These findings suggested severe damage to the AC ligaments and surrounding soft tissues. The deformity became more noticeable with specific positional changes, such as cross-body adduction and palpation around the AC joint.

The AC joint and front shoulder were slightly swollen, but there was no bruising or redness. The deltoid and scapular stabilizers showed no signs of atrophy, suggesting that the muscles remained strong despite being unstable for a long period.

Palpation: Tenderness was present over the anterior and superior aspects of the left shoulder, particularly around the AC joint. Palpation of the AC joint revealed a step-off deformity, indicating an abnormal relationship between the clavicle and acromion. Tenderness was also present over the coracoid process and anterior capsule, supporting the presence of a Bankart lesion.

Tenderness was also present over the posterior aspect of the humeral head, where the patient reported deep, aching pain. This finding was suggestive of a Hill-Sachs lesion, which had developed because of recurrent anterior dislocations and impaction of the humeral head against the glenoid rim.

No tenderness or masses were detected over the neurovascular bundles, and the radial and ulnar pulses were intact.

ROM: (1) Active ROM: The patient had significant difficulty moving the shoulder joint actively, especially during abduction, external rotation, and flexion. The active abduction could only go up to 90 degrees, and the external rotation could only go up to 45 degrees. At the end of the range, there was pain and fear. Because of pain and instability, flexion was limited to 120 degrees; and (2) Passive ROM: The patient could move their arms and legs almost normally, but they felt pain at the ends of their range, especially when rotating their arms and legs outward. This was consistent with the Bankart lesion, which caused AC joint dysfunction and shoulder instability.

Strength testing: The patient had full strength (5/5) in the major rotator cuff muscles (supraspinatus, infraspinatus, subscapularis, and teres minor), as well as in the deltoid and biceps muscles. These findings excluded significant muscle weakness despite the recurrent and chronic nature of the injury.

The supraspinatus and infraspinatus muscles retained their muscle mass, further supporting the conclusion that the patient’s functional impairment did not stem from a neurologic problem.

Tests for stability: The apprehension test was positive when the patient was lying down because the patient felt pain and apprehension when they moved their shoulder away from their body and turned it outward. This indicates that the front of the shoulder is unstable.

Relocation test: With the patient in the supine position, posterior pressure applied to the humeral head reduced apprehension and pain, supporting the presence of anterior instability.

The cross-body adduction test: This test caused pain in the AC joint, strongly indicating underlying AC joint pathology. The test result, together with the patient’s history of deformity and pain, supported the diagnosis of AC joint separation.

Neurovascular assessment: The neurovascular structures were intact, with normal sensation in the C5, C6, C7, and C8 dermatomes. There were no signs of nerve impingement or compression, and the patient denied paresthesia or paralysis in the upper limb.

The radial, ulnar, and brachial pulses were strong and symmetrical, with no signs of vascular injury.

Laboratory examinations

Pre-operative blood work/laboratory done and was unremarkable.

Imaging examinations

An X-ray of the left shoulder demonstrated superior displacement of the distal clavicle, consistent with a Rockwood type IIIA AC joint dislocation (Figure 1A). Magnetic resonance imaging (MRI) of the left shoulder provided additional information regarding the injury. The MRI scan showed a Hill-Sachs lesion on the posterolateral aspect of the humeral head, measuring 21 mm × 17 mm, which was typical of recurrent anterior dislocation (Figure 1B). A soft tissue Bankart lesion was also identified, characterized by detachment of the labrum from the glenoid rim. This finding indicated anterior shoulder instability.

Figure 1 Diagnostic imaging. A: X-ray showing acromioclavicular joint dislocation; B: Magnetic resonance imaging image showing the soft tissue Bankart lesion of the anterior glenoid and the Hill-Sachs lesion of the posterior humeral head; C: X-ray showing the acromioclavicular joint postoperatively.

Closer evaluation of the supraspinatus tendon on MRI showed bursal-sided fraying, consistent with a low-grade partial-thickness tear, despite the absence of joint effusion. The long head of the biceps tendon was correctly positioned and intact (Figure 1B). Taken together, these imaging findings supported the diagnosis of combined AC dislocation, Hill-Sachs lesion, and anterior labral tear. They also provided a comprehensive assessment of the complex shoulder injury.

FINAL DIAGNOSIS

Chronic recurrent shoulder instability with a Bankart tear, Hill Sachs lesion and a Rockwood type IIIA AC joint dislocation.

TREATMENT

Surgical technique

The coexistence of a chronic Bankart lesion and Rockwood type III AC joint dislocation in this patient required a two-fold strategy to restore stability to the shoulder complex. An arthroscopic-assisted procedure was selected because of its minimally invasive advantages, which allowed precise repair of both the glenohumeral and AC joints. The procedure was performed as follows.

Positioning and preparation

The patient was placed in the beach-chair position under general anesthesia to allow optimal visualization and access to both the glenohumeral and AC joints. An interscalene nerve block was performed to ensure adequate postoperative analgesia.

After positioning, the entire left upper extremity, including the shoulder region, was prepared and draped in sterile fashion. The acromion, clavicle, coracoid process, and scapular spine were identified as bony landmarks to ensure correct positioning and portal placement throughout the procedure. The beach-chair position with shoulder rotation was used to facilitate gravitational control of arthroscopy fluid and access to the anterior shoulder region.

Arthroscopic Bankart repair

Diagnostic glenohumeral arthroscopy and initial assessment: A standard posterior portal was created approximately 2 cm medial and inferior to the posterolateral corner of the acromion. An arthroscope was inserted, and diagnostic arthroscopy was performed to verify the presence of the Bankart lesion, the extent of labral detachment, and any other intra-articular injuries. This assessment showed a Bankart lesion with anteroinferior labral detachment and a non-engaging Hill-Sachs lesion measuring 21 mm × 17 mm on the posterolateral humeral head. There was no superior labrum anterior to posterior tear or cartilage damage. The biceps anchor and rotator interval were intact.

Anterior portal placement and labral mobilization: An anterior portal was created under direct visualization using an outside-in technique to avoid injury to the rotator interval. A second anterolateral portal was created to improve the working angle on the glenoid and facilitate preparation of the anchor site.

The labrum was mobilized from capsulolabral scarring and adhesions using an arthroscopic elevator to increase its mobility for reattachment. The glenoid rim was then prepared using a shaver and burr to create a raw surface, thereby promoting healing by providing a biologically active surface for anchor placement.

Suture anchor placement and labral repair: Three high-strength nonabsorbable ULTRABRAID sutures were selected. The sutures were secured using 2.9-mm PushLock knotless anchors (Arthrex) at the 6-, 5-, and 3-o’clock positions on the left glenoid rim, with emphasis on the anteroinferior quadrant, where the Bankart lesion was most evident.

Each anchor was carefully positioned using an arthroscopic drill guide to ensure optimal fixation in the glenoid bone while avoiding subcortical penetration. The sutures were then tightened sequentially to reattach the labrum to the glenoid rim and restore the bumper effect. Finally, the Bankart repair was verified with a probe and by placing the shoulder in abduction and external rotation.

AC joint stabilization using an adjustable Endobutton device

After the stability of the Bankart repair was confirmed, the next phase focused on anatomical reduction and stabilization of the AC joint.

Exposure of the coracoid process and AC joint preparation: Arthroscopic visualization was extended to the rotator interval, which was debrided to improve exposure of the coracoid process. Soft tissue debridement was performed around the base of the coracoid to ensure a clear view and accurate device placement.

Incision and drill guide placement for AC joint stabilization: A 1.5-cm incision was made over the distal clavicle, approximately 3 cm medial to the AC joint. The AC drill guide was placed over the superior aspect of the clavicle. A 4.5-mm drill bit was used to create a bicortical tunnel through the clavicle and into the coracoid process. The tunnel was oriented vertically to avoid angulation or displacement. Fluoroscopy was essential to confirm that the tunnel trajectory would not compromise neurovascular structures, such as the subclavian vessels.

Placement and deployment of the adjustable Endobutton device: An adjustable TwinBridge Endobutton system (Smith and Nephew) was selected for its ability to provide firm fixation with adjustable tensioning. A suture passer was used to pass the Endobutton through the coracoid-to-clavicle tunnel, positioning the button firmly against the undersurface of the coracoid process.

The adjustable loop was gradually tightened to align the clavicle properly in a stable and anatomical position relative to the acromion. The Endobutton loop allowed precise tensioning to ensure that the clavicle was neither over-tightened nor loose, either of which could have compromised the repair. Final positioning was confirmed by dynamic fluoroscopy to ensure correct alignment and reduction of the AC joint. Joint stability was also tested by assessing shoulder motion during abduction and simulated overhead activity.

Closure and postoperative protocol

After AC joint stabilization, all arthroscopic portals and the clavicular incision were irrigated with sterile saline solution to reduce the risk of infection. Nonabsorbable interrupted sutures were used to close each portal, and the clavicular incision was closed in layers. Absorbable sutures were used in the subcutaneous layer, and nonabsorbable sutures were placed in the skin to achieve a secure and cosmetically acceptable closure.

Postoperative treatment

The patient was placed in a shoulder immobilizer to protect the repairs and reduce stress on the AC and glenohumeral joints during the early healing phase. A postoperative X-ray was also obtained (Figure 1C). The immobilizer was recommended for continuous use during the first four weeks, with only restricted passive range-of-motion exercises allowed under the guidance of a physical therapist.

A gradual rehabilitation program began 4 weeks after surgery, starting with pain-free passive exercises to improve the shoulder ROM without compromising the integrity of the repair. At six weeks, exercises to improve the ROM with active assistance were added. At ten to twelve weeks, exercises to progressively strengthen actively were introduced. Stabilization exercises for the scapula and strengthening of the rotator cuff muscles were advised to help the body regain functional stability. It was anticipated that individuals would be able to resume all their usual activities again six to nine months after surgery, provided their ROM, strength, and joint stability were restored without fear, pain, or dysfunction.

OUTCOME AND FOLLOW-UP

At the postoperative evaluation, marked improvement was noted in the patient’s pain and shoulder stability. Clinical evaluation showed that he had regained functional ROM, with no recurrence of either glenohumeral dislocation or AC joint instability. He was able to perform the prescribed rehabilitation exercises and resume normal activities of daily living with minimal difficulty. No postoperative complications were encountered. Validated functional outcome measures and long-term follow-up data were not available.

DISCUSSION

The coexistence of chronic anterior glenohumeral instability with a Bankart lesion and Rockwood type IIIA AC joint injury is uncommon and creates a challenging treatment problem because these injuries contribute to shoulder disability through distinct biomechanical mechanisms. In this patient, chronic recurrent anterior shoulder instability developed after a motorcycle accident, resulting in a Bankart lesion and Hill-Sachs lesion. A subsequent traumatic episode led to instability involving the AC joint[12].

The surgical approach was guided by the specific pattern of instability. Arthroscopy showed an anteroinferior Bankart lesion associated with a non-engaging Hill-Sachs lesion measuring 21 mm × 17 mm without glenoid bone loss, cartilage damage, or superior labrum anterior to posterior injury. Because this case involved soft tissue insufficiency rather than critical osseous deficiency, arthroscopic Bankart repair was an appropriate surgical approach. Remplissage and the Latarjet procedure were not considered viable alternatives because the Hill-Sachs lesion was non-engaging, and augmentative surgery was unnecessary. The literature has shown that arthroscopic Bankart repair is an appropriate surgical treatment method for selected cases of recurrent anterior shoulder instability. This procedure produces excellent outcomes with minimal risk of complications and recurrence while preserving normal shoulder function[13-15].

The treatment of the accompanying AC joint injury involved restoring coracoclavicular ligament stability and correcting the position of the distal clavicle. An adjustable Endobutton system placed arthroscopically in situ was selected because it can provide secure fixation without the need for large hardware devices or subsequent hardware removal, unlike some traditional fixation methods. The arthroscopic technique enabled both types of instability to be managed in a single operation while minimizing tissue damage. Previous studies have shown that button-suture systems can provide reliable AC joint stability and satisfactory outcomes[16-18].

Moreover, the fully arthroscopic approach provided additional benefits in this case. Arthroscopy allowed thorough evaluation of intra-articular pathology, repair of the Bankart lesion, and stabilization of the AC joint with minimal exposure. This approach minimized tissue damage and facilitated postoperative rehabilitation in a single operation. These advantages were particularly important for a soldier whose treatment goal was to regain shoulder function.

Although cases of associated AC joint dislocation and Bankart lesion have been described previously, the current literature remains limited and consists mainly of isolated case reports and case series[11,19]. Published studies usually address either glenohumeral joint instability or AC joint instability and therefore do not provide unified recommendations for the surgical management of patients with both conditions.

Our findings are consistent with previously published literature suggesting that dual shoulder instability can be effectively managed when both the glenohumeral and AC joints are identified and addressed surgically during the same procedure[11,19].

The favorable recovery in this patient supports the feasibility of a one-stage arthroscopic approach in such cases.

The limitations of this study are the same as those of all case reports. Firstly, the results of such an analysis may not be applicable to other patients, as this is based on only one patient. The second limitation concerns the follow-up period and functional assessments. There was no data about the follow-up period and functional assessments, which could have been used to evaluate the sustainability of the procedure and patient outcomes.

This report adds to the limited literature on combined arthroscopic management of glenohumeral and AC joint instability. Because the patient regained shoulder stability and function without recurrence, combined arthroscopic Bankart repair and Endobutton stabilization of the AC joint may be considered a potential treatment strategy for such complex conditions. However, further research is needed.

Patients and ethics

Before publication of this case report, the patient provided informed consent, including consent for the use of images and intraoperative photographs. The patient was fully informed about the potential benefits, risks, and expected outcomes of the surgeries. The management of this case adhered to all ethical principles. This study adhered to the principles of the Declaration of Helsinki and was approved by the institutional ethics review board.

CONCLUSION

This case report highlights the successful treatment of a rare association of shoulder injuries, namely a soft tissue Bankart lesion and AC joint dislocation, using a combined arthroscopic procedure. The adjustable Endobutton technique, combined with Bankart repair, was an effective treatment modality for restoring shoulder stability and function. The patient’s excellent postoperative course and absence of recurrent dislocation indicate that this treatment modality may be beneficial in selected cases. Further studies are recommended to confirm these findings and potentially refine treatment protocols for associated shoulder pathologies.