the inferior glenohumeral ligament ( ighl ) complex is the major passive restraint to anterior  inferior dislocation in the abduction and external rotation ( aber ) position of the shoulder joint . the bankart lesion  may cause persistent antero - inferior shoulder instability . in the past decade , arthroscopic repair of the bankart lesion has become very popular and represents the current state - of - the - art in the treatment of traumatic , unidirectional anterior failure of arthroscopic bankart repair was reported to be 4 - 18% . for revision surgery after open or arthroscopic bankart repair , extra - anatomical bone block procedures such as the bristow  latarjet or iliac crest bone graft reconstruction have shown to be successful . recently , several authors reported good and excellent results with arthroscopic revision bankart repairs as well . for chronic anterior capsular deficiency , open procedures with autologous iliotibial band or hamstring graft reconstruction the aim of our study was to explore the technical feasibility of an all - arthroscopic , anatomical reconstruction of the anterior and posterior bands ( pbs ) of the ighl using a hamstring autograft in two cadaveric shoulder specimens . the concept behind anatomical ighl reconstruction is to recreate a triangular sling with the tendon autograft that prevents anterior  inferior subluxation and dislocation of the humeral head . the sling has two footprints , one located at the anterior glenoid rim attached by two suture anchors between 4 and 3 oclock on the right shoulder ( 8 and 9 for left shoulders ) at the origin of the ab of the ighl and the other one attached posteriorly between 8 ( 4 ) and 7 ( 5 ) oclock representing the origin of the pb . the sling apex is fixed as a doubled tendon graft within the humeral head and blocked with an interference screw [ figure 1a ] . the triangular construct between the glenoid and the humeral head is slack in neutral position of the glenohumeral joint and becomes progressively more tensioned with increasing aber , forming a triangular restraint in front of the humeral head [ figure 1b ] . the two limbs of the reconstructed ighl hereby adapt to the preexisting inferior capsular pouch , creating reinforcement of the incompetent ighl complex , similar to the genuine ab and pb . ( a ) ( left ) shows the slack graft in the neutral position while ( b ) ( right ) shows the tensioned graft in the abduction external rotation ( aber ) position forming a triangular restraint in front of the humeral head to simulate shoulder arthroscopy , the cadavers were placed in a beach chair - like position . first , harvesting of the ipsilateral hamstring tendons was performed using a standard 7 mm stripper for anterior cruciate ligament ( acl ) reconstruction ( karl storz gmbh and co kg , tuttlingen , germany ) . in this study , the gracilis tendon was used instead of the semitendinosus , in order to avoid bulky graft in the shoulder joint . graft lengths vary but should be a minimum of 20 cm . for diagnostic shoulder arthroscopy , the camera was brought in through the standard posterior portal . before starting the reconstruction , an anterolateral working portal was established and the antero - inferior capsule - labral complex was detached using an arthroscopic chisel ( karl storz gmbh and co kg ) . the first step of the reconstruction was placement of four suture anchors ( bioplug karl storz gmbh and co kg ) at the anterior and posterior glenoid rim . two anchors were inserted at the anatomical origins of the anterior and posterior bands at 3 ( 9 ) oclock and 8 ( 4 ) oclock , respectively . two other anchors were inserted about 5 - 10 mm inferior at the anterior glenoid and 5 - 10 mm superior at the posterior glenoid , allowing  side - to - side  attachment of the tendon ends for better graft  bone healing [ figure 2 ] . the anterior inferior anchor represents the anatomical origin of the anterior band of the ighl while the posterior superior anchor marks the origin of the posterior band . the other two anchors should allow a better ( side - toside ) engraftment of the tendon . the inlet shows the arthroscopic view of the anterior anchors the next step was percutaneous drilling of a 6 - 8 mm hole ( depending on doubled graft diameter ) through the greater tuberosity aiming at the center of the anatomical neck just above the inferior capsule using a tibial posterior cruciate ligament ( pcl ) targeting device ( karl storz gmbh and co kg ) . for that purpose , the targeting device was inserted through the posterior portal and the bullet for the drill bit was placed approximately 1 cm lateral to the palpable lateral edge of the acromion [ figures 3 and 4 ] . positioning of the targeting device : insertion through the posterior portal , viewing portal is the anterosuperior portal transhumeral outside - in drilling with a targeting device . the intraarticular drill hole is placed just above the humeral insertion of the inferior joint capsule in the center of the humeral head . for better illustration inlet : arthoscopic view of the wire tip to attach the graft to its anterior glenoid footprint , one tendon end was prepared with a baseball - type stitch from one limb of the anterior then the graft was pulled into the joint and the first ( non - gliding ) knot was tied [ figure 5 ] . enlarging the anterior footprint ( assuming better healing potential to the bone ) , the graft tail was brought upward along the anterior rim and fixed  side - to - side  with the 3 ( 9 ) oclock anchor ( gliding knot ) . arthroscopic view of the anterior graft limb pulled into the joint using one suture limb of the antero - inferior anchor posterior graft fixation was performed similarly after changing the camera to the anterolateral portal . this time  end - to - side  fixation was performed superiorly at the 8 ( 4 ) oclock anchor and  side - to - side  fixation inferiorly at the 7 ( 5 ) oclock anchor . because of limited viewing with the entire tendon graft in the joint , careful suture management is critical before pulling the posterior graft tail into the joint . therefore , two additional suture portals were established , one anterolateral and another posterolateral in the same fashion as commonly used in rotator cuff reconstructions . figure 6 shows the anteriorly and posteriorly fixed autograft in a shoulder model . as an alternative to advancing the graft through the anterior overview of the glenoidal attachments of the anterior and posterior tendon limbs finally , the apex of the graft sling was pulled inside - out into the humeral head using an already out - of - joint pds shuttle suture [ figure 7 ] . fixation of the now double - stranded sling apex was achieved with a 7  3 mm interference screw ( megafix karl storz gmbh and co kg ) [ figure 8 ] . it was essential to fix the sling apex within the humeral head in the aber position allowing full range of motion of the glenohumeral joint [ figure 9 ] . fixation of the graft in any position other than aber will subsequently lead to significant limitation in range of motion . following this principle , normal shoulder range of motion figure 10 shows the slack graft in the axillary pouch ( ap ) during neutral rotation . anterior arthrotomy after completion of the procedure confirmed correct position of the humeral graft attachment [ figure 11 ] . pull out of the graft sling : the apex of the graft is pulled inside - out into the humeral head using a graft embracing pds shuttle fixation of the sling apex with the head using a outside - in interference screw 7  3 mm megafix karl storz gmbh and co kg , tuttlingen , germany ) to obtain full of range motion , it is mandatory to fix the interference screw in the abduction external rotation position arthroscopic view of the slack graft within the joint . there is no tension on the graft since the shoulder is in neutral position post - procedure arthrotomy of a shoulder specimen : central intraarticular position of the humeral graft attachment . the complex architecture of the ighl with its three parts , ab , ap , and pb , provides selective resistance to anterior  inferior movement of the humeral head during aber . with progression into the late cocking throwing position , the ighl complex shifts from inferiorly upward like a double reinforced sheet in front of the anterior aspect of the humeral head . with chronic insufficiency , especially of the anterior band , the humeral head can easily glide over the anterior  inferior glenoid rim causing recurrent instability . arthroscopic or open bankart repair indeed re - attaches the capsulo - labral structures to the glenoid , but does not restore the anatomical and functional properties of the ighl complex in cases of chronic insufficiency . open procedures to reconstruct or reinforce the anterior joint capsule were described , but they are not anatomical and extensive surgical exploration is mandatory . last line of defense  in treatment of chronic instability , and revision surgery after failure is difficult . with the above - described and illustrated surgical technique , we successfully demonstrated the technical feasibility of a completely arthroscopic and anatomical reconstruction of the anterior and posterior band of the ighl . the two graft limbs were shown to restore the original ighl function , moving in front of the humeral head in the aber position and limiting pathological anterior  inferior humeral translation . additional anterior capsulorraphy with double - armed suture anchors may be considered to reduce the volume of the anterior capsule and to create a soft - tissue envelope for better healing of the anterior graft tail . the critical points of the procedure were careful and simple suture management ( additional suture portals ) once the graft was inserted into the shoulder joint , and the fixation of the interference screw in the aber position . preliminary storage of the graft in the ap allowed for sufficient visualization of anterior and posterior graft attachment to the glenoid . we believe this procedure is suitable for revision surgery after failed arthroscopic bankart repair , especially in the absence of major glenoidal bone loss , or as an alternative to open and extra - anatomical bone block procedures . since arthroscopic bankart repair is a common and successful primary surgical intervention in the treatment of acute anterior  inferior shoulder instability with low failure rate , we do not think that anatomical ighl reconstruction should be considered for index repair . however , further biomechanical and clinical investigations are mandatory to prove the mechanical properties and clinical impact of this technique .
failure of primary arthroscopic bankart repair in anterior  inferior glenohumeral instability is low , but in some cases revision surgery is required . 
 revision procedures show good to excellent results but typically are done open and do not respect the anatomical functionality of the joint capsule . 
 the purpose of this cadaveric study was to explore the feasibility of a completely arthroscopic anatomical reconstruction of the inferior glenohumeral ligament using a hamstring autograft .