Function of the Shoulder and the Labrum

• Joint stability: the shoulder is a ball-and-socket joint. Because the socket (glenoid) is shallow, most of the stability is provided by the labrum and the capsuloligamentous complex.
• Deepening the socket: the labrum increases the depth of the glenoid by approximately 50%, helping to keep the humeral head in place.
• Ligament attachment: the glenohumeral ligaments (particularly the inferior glenohumeral ligament) attach to the labrum, so a labral tear also impairs the function of the ligament complex.
• Proprioception: receptors in the labrum and capsule provide a sense of shoulder position; after a tear this sense is disturbed and a feeling that "my shoulder is going to come out" develops.
• Healing potential: the labrum is only partially vascularised; the success of repair depends on the location and pattern of the tear and on any associated bone loss.

Classification by Bone Loss

• Classic (soft-tissue) Bankart: no bone loss; high repair success rate
• Bony Bankart: a bone fragment at the glenoid rim; repair is appropriate when bone loss is under 20%
• Extensive bone loss (>20%): Bankart repair alone may be insufficient; a bone block procedure (Latarjet) may be required

Soft-tissue Bankart or Tears with Limited Bone Loss

These lesions can heal by reattaching the labrum to the glenoid rim with anchors and sutures, preserving healthy tissue.

Types of Tear

• Classic Bankart: a soft-tissue tear; the most common pattern, seen in young patients after an acute dislocation
• Posterior Bankart: usually seen in patients who have had a seizure (for example following electrocution or epilepsy) and in professional athletes
• Bony Bankart: a tear including a bone fragment at the glenoid rim; seen with recurrent dislocations
• ALPSA (anterior labroligamentous periosteal sleeve avulsion): the labrum slips inferiorly together with the periosteum and heals in a medialised position
• Perthes lesion: the labrum is detached but the periosteum remains intact; easily missed on MRI
• HAGL (humeral avulsion of the glenohumeral ligaments): the ligament avulses from the humeral side; rare, and requires separate repair

Symptoms and How the Diagnosis is Made

• A sensation that the shoulder is about to come out: particularly when the arm is raised overhead and externally rotated
• Recurrent dislocation or subluxation: the shoulder comes out of joint and relocates either spontaneously or with assistance
• Pain: during sleep or when lying on the affected shoulder, and with overhead activity
• Loss of strength: particularly in external rotation and abduction
• Clicking or popping: a mechanical sensation and sound during movement
• Apprehension: a feeling of the shoulder "giving way" when throwing, serving or reaching overhead

Diagnosis

Examination includes the apprehension, relocation and sulcus tests. Previous dislocations, the mechanism of dislocation and the sense of instability are assessed in detail. Plain radiographs are obtained to evaluate bone loss, a Hill–Sachs lesion and joint architecture. MRI demonstrates the labrum and ligaments; where required, MR arthrography with intra-articular contrast is the gold standard for detecting a labral tear. CT is requested to quantify glenoid bone loss in recurrent dislocation. The definitive decision and treatment plan are made at arthroscopy, with the tear seen directly.

Advantages

The most important advantage is prevention of the glenoid bone loss and shoulder arthritis that can develop from recurrent dislocation over the long term. Without surgery the shoulder dislocates repeatedly and at increasing frequency, additional structures tear and joint damage accumulates.

• Operative time: on average 60–90 minutes; general anaesthesia (which may be combined with an interscalene block)
• Discharge the following day
• Small incisions (1 cm), less pain, lower infection risk and better range of motion

Disadvantages

• You will need to wear a sling for 4–6 weeks. Moving the shoulder excessively during this period may cause the repair to fail in the early phase.
• External rotation (turning the arm outwards) is restricted completely at first and then to a set angle; shoulder stiffness may therefore develop in the first 2–3 months, although this resolves completely with physiotherapy.
• In patients with significant bone loss, Bankart repair alone may be insufficient; additional procedures such as Latarjet or remplissage may be required.

Why Bankart Repair?

The labrum and the glenohumeral ligament complex have critical roles in shoulder stability, proprioception and retention of the humeral head within the socket. Preserving as much healthy labral tissue as possible is therefore of great importance in preventing recurrent dislocation, glenoid bone loss and shoulder arthritis in later years. Studies show that the risk of recurrent dislocation reaches 70–90% in young, active patients who do not undergo surgical repair after a first shoulder dislocation.

Who is a Candidate?

Arthroscopic Bankart repair is performed for tears of the anteroinferior labrum with glenoid bone loss under 20%, in which the labrum can be reattached with anchors and healing can be expected.

• Active athletes who have sustained a first traumatic shoulder dislocation
• Patients with recurrent shoulder dislocation or subluxation
• Those participating in contact or overhead sport (football, basketball, volleyball, wrestling, gymnastics)
• Young patients under 35
• Individuals in whom MRI shows a classic Bankart, ALPSA or Perthes lesion
• Patients whose general health is suitable for general anaesthesia and surgery

Common (Under 5%)

• Superficial wound infection (usually treated with antibiotics)
• Postoperative pain and swelling (settles within a few days)
• Temporary joint stiffness — resolves with regular physiotherapy
• Mild loss of strength — regained with rehabilitation
• Slight permanent restriction of external rotation

Less Common

• Recurrent shoulder dislocation / failure of the repair (5–15%; particularly where there is bone loss or in contact athletes)
• Loosening or migration of a suture anchor
• Frozen shoulder (adhesive capsulitis) — prolonged stiffness
• Axillary nerve or surrounding vascular injury (very rare, <1%)
• Deep vein thrombosis (very rare)
• Chondrolysis — dissolution of the joint cartilage (very rare)

Contact Your Doctor Immediately If You Have

• Sudden increase in pain or swelling
• Fever above 38 °C
• Numbness, tingling or loss of strength in the arm or hand
• Discharge or malodour from the wound
• A feeling that the shoulder has come out again, or sudden deformity
• Shortness of breath or chest pain