BANKART LESIONS - ANTERIOR LABRAL INSTABILITY
Anterior-Inferior Labral Tear | Gold Standard: Arthroscopic Repair | Assess Bone Loss
BANKART VARIANTS
Critical Must-Knows
- Bankart lesion is an anterior-inferior labral tear from traumatic anterior dislocation
- 90% of anterior dislocations result in a Bankart lesion (Perthes variant if periosteum intact)
- Glenoid bone loss assessment is mandatory - over 20% (inverted pear) needs Latarjet
- ISIS score predicts instability risk: higher score = greater likelihood of failure with arthroscopic repair
- Arthroscopic repair is gold standard for soft tissue Bankart with minimal bone loss
Examiner's Pearls
- "Bankart = anterior-inferior labral tear from anterior dislocation
- "ALPSA = labral tear with periosteum intact but medially displaced
- "Perthes = labral tear with intact periosteum (partial Bankart)
- "Bony Bankart = greater than 20% glenoid bone loss requires bone augmentation
Clinical Imaging
Imaging Gallery
Critical Bankart Lesion Exam Points
Bone Loss Assessment Critical
Always assess glenoid bone loss. Over 20% bone loss (inverted pear appearance) predicts arthroscopic failure and requires Latarjet or bone block. Use CT or MRI to measure. Engaging Hill-Sachs also critical.
ISIS Score Decision Tool
Instability Severity Index Score (ISIS) predicts recurrence risk after arthroscopic repair. Score over 6 = high risk (consider Latarjet). Factors: age under 20, competitive sports, contact sports, shoulder laxity, Hill-Sachs on AP X-ray, glenoid bone loss.
First Time vs Recurrent
First-time dislocators under 20 have up to 90% recurrence rate non-operatively. Consider early stabilization in high-risk patients. Recurrent instability is an absolute indication for surgical repair.
ALPSA vs Bankart
ALPSA lesion (Anterior Labroligamentous Periosteal Sleeve Avulsion) has intact periosteum but medially displaced labrum. Requires mobilization before repair. Diagnosis on MRI (labrum medial, intact scapular periosteum).
Quick Decision Guide - Bankart Management
| Lesion Type | Bone Loss | Patient Age/Activity | Treatment |
|---|---|---|---|
| Soft tissue Bankart | Under 15% | Any age, non-contact sport | Arthroscopic repair (3-4 anchors) |
| Soft tissue Bankart | 15-20% subcritical | Under 20, contact sport | Consider Latarjet (ISIS over 6) |
| Bony Bankart or critical bone loss | Over 20% inverted pear | Any age, any sport | Latarjet or bone block procedure |
| ALPSA lesion | Under 15% | Any age | Arthroscopic repair after mobilization |
| First-time dislocation | Minimal bone loss | Over 30, low demand | Trial of non-operative (3 months rehab) |
BANKART - Essential Components
Memory Hook:BANKART covers the key assessment and management principles for anterior shoulder instability
ISIS - Instability Severity Index Score
Memory Hook:ISIS score over 6 points predicts high failure rate (over 70%) with arthroscopic repair - consider Latarjet
ALPSA - Variant Lesion Pattern
Memory Hook:ALPSA has intact periosteum but medially displaced - like a sleeve rolling down - must mobilize back to glenoid rim
3 CLOCK RULE - Anchor Placement
Memory Hook:Think of a clock face on the glenoid rim - anchors at 3, 4:30, 5:30 positions restore the anterior-inferior bumper
Overview and Epidemiology
A Bankart lesion is a tear of the anterior-inferior glenoid labrum and associated inferior glenohumeral ligament (IGHL) complex. It is the essential lesion in traumatic anterior shoulder instability, occurring in over 90% of anterior dislocations.
Historical context:
- First described by Arthur Sidney Blundell Bankart in 1923
- He recognized the labral tear as the "essential lesion" causing recurrent anterior instability
- Initially treated with open repair (Bankart repair remains the eponym)
- Modern era dominated by arthroscopic techniques with equivalent outcomes
Mechanism of injury:
- Traumatic anterior dislocation is the typical mechanism
- Shoulder is forced into abduction, extension, and external rotation (ABER position)
- Anterior capsulolabral structures exceed their tensile strength
- Labrum avulses from anterior-inferior glenoid rim (typically 3-6 o'clock position)
Essential Lesion Concept
Bankart called this the "essential lesion" because it is the pathoanatomic basis for recurrent anterior instability. Restoring the labral bumper and tensioning the anterior capsule is the goal of surgical repair.
Epidemiology:
- Incidence: 17 per 100,000 person-years for shoulder dislocation
- Age: Peak incidence in second and third decades
- Gender: Male predominance (3:1 ratio)
- Sports: Contact sports, rugby, Australian football, overhead sports
- Recurrence risk: Inversely related to age (up to 90% in patients under 20 years)
Natural history:
- First-time dislocation in young athlete: up to 90% recurrence without surgery
- First-time dislocation over age 40: approximately 20% recurrence
- Each recurrent dislocation increases risk of bone loss and cartilage damage
- Chronic instability leads to early glenohumeral arthritis
Pathophysiology and Mechanisms
Glenoid labrum anatomy:
The glenoid labrum is a fibrocartilaginous rim that:
- Deepens the glenoid socket by 50% in depth
- Increases articular surface area by up to 75%
- Serves as attachment for glenohumeral ligaments
- Acts as a "bumper" or chock-block against translation
Anterior-inferior labral complex:
- The anterior band of IGHL is the primary restraint to anterior translation in abduction and external rotation
- Inserts into the anterior-inferior labrum (3-6 o'clock position on right shoulder)
- Forms a hammock beneath the humeral head when arm is abducted
- The labrum and IGHL function as a unit - disruption of either causes instability
IGHL and Labrum Unity
The inferior glenohumeral ligament (IGHL) complex and labrum function as a single unit. The IGHL inserts into the labrum, so a Bankart lesion represents both a labral tear AND a ligamentous avulsion. Repairing the labrum restores both structures.
Glenoid anatomy:
- Pear-shaped in normal state
- Anteroinferior quadrant is the critical zone for stability
- Glenoid version (normally 5-10 degrees retroversion)
- Bare area is central non-articular zone (normal finding, not pathologic)
Bankart lesion variants:
Bankart Variants
Understanding the variants is critical for surgical planning and exam discussions:
- Classic Bankart: Labral tear with avulsion from glenoid rim
- Bony Bankart: Labral tear with glenoid bone fragment (fracture)
- Perthes lesion: Labral tear but periosteum remains attached (partial Bankart)
- ALPSA: Labral avulsion with intact periosteum, medially displaced sleeve
- GLAD: Glenoid articular disruption with anterior labral tear (cartilage injury)
Pathophysiology of instability:
When the labrum is torn from the glenoid:
- Loss of the bumper effect - humeral head can translate anteriorly without resistance
- Loss of concavity-compression - labral rim normally deepens the socket
- Capsular laxity - capsule stretches with recurrent instability
- Bone loss - recurrent dislocations cause progressive glenoid erosion and Hill-Sachs lesions
- Proprioceptive deficit - loss of mechanoreceptors in labrum and capsule
Glenoid bone loss:
Critical concept for surgical decision-making:
- Under 15% - subcritical, arthroscopic repair successful
- 15-20% - borderline, consider patient factors (ISIS score)
- Over 20% - critical bone loss, "inverted pear" glenoid, high failure rate with arthroscopy alone
- Over 25% - bone augmentation (Latarjet) mandatory
Classification Systems
Classic Bankart vs Variants
| Lesion | Description | MRI Appearance | Treatment Implication |
|---|---|---|---|
| Classic Bankart | Labral tear from glenoid rim | Labrum detached, fluid in gap | Standard arthroscopic repair |
| Bony Bankart | Labral tear with bone fragment | Bone fragment visible | ORIF if large, or Latarjet if over 20% |
| Perthes | Labral tear, periosteum intact | Labrum appears attached | May be subtle, can repair arthroscopically |
| ALPSA | Labrum displaced medially | Labrum on glenoid neck, intact periosteum | Mobilize before repair |
| GLAD | Glenoid cartilage and labral tear | Cartilage defect visible | Address cartilage, may affect prognosis |
ALPSA Recognition
ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) can be missed on MRI if you're not looking for it. The labrum appears to be in place but is actually displaced medially on the glenoid neck. Must mobilize before repairing to the rim.
Clinical Presentation and Assessment
History:
- Mechanism: Traumatic anterior dislocation (ABER position)
- Number of dislocations: First-time vs recurrent
- Ease of reduction: Self-reduction suggests severe instability
- Sports and activity level: Contact sports, overhead sports
- Dominant arm: High-demand considerations
- Occupation: Overhead work, manual labor
- Psychological impact: Fear of dislocation (apprehension)
Symptoms:
- Instability sensation (feeling of shoulder "coming out")
- Apprehension with certain positions (abduction-external rotation)
- Pain (especially early after dislocation)
- Weakness (secondary to pain or rotator cuff tear)
- Clicking or catching (labral tear, loose body)
Dead Arm Sensation
Patients may describe a "dead arm" sensation during throwing or overhead activity. This represents a transient subluxation - the shoulder partially dislocates and immediately reduces, causing brief paralysis-like sensation and inability to complete the throwing motion.
Physical examination:
Physical Examination Findings
| Test | Technique | Positive Finding |
|---|---|---|
| Apprehension test | 90deg abduction, external rotation applied | Patient feels shoulder will dislocate, guarding |
| Relocation test | Posterior force applied during apprehension | Relief of apprehension, increased ER range |
| Anterior release test | Release posterior force from relocation | Return of apprehension sensation |
| Load and shift | Translate humeral head anteriorly with load | Excessive anterior translation (grade 2-3) |
| Sulcus sign | Inferior traction on arm | Inferior translation, sulcus below acromion |
| Beighton score | Generalized laxity assessment | Score over 4 indicates hyperlaxity |
Apprehension test is the gold standard:
- Sensitivity: 50-72%
- Specificity: 96-98%
- Most reliable test for anterior instability
Associated injuries to assess:
- Rotator cuff tear (especially in patients over 40 years)
- Greater tuberosity fracture (on initial X-rays)
- Nerve injury (axillary nerve most common, check sensation over deltoid)
- Vascular injury (rare, check pulses)
Investigations
Radiographic assessment:
Plain X-rays (essential first-line):
- AP view in scapular plane: Assess glenoid bone loss, Hill-Sachs
- Axillary lateral: Essential to confirm concentric reduction
- West Point axillary: Profiles anterior-inferior glenoid rim
- Stryker notch view: Profiles Hill-Sachs lesion
Axillary Lateral Mandatory
Never accept AP view alone. The axillary lateral is mandatory to confirm concentric reduction after dislocation and to assess posterior shoulder pathology. A missed posterior dislocation is a medicolegal disaster.
X-ray findings:
- Hill-Sachs lesion visible on AP (if large) or Stryker notch view
- Glenoid bone loss - loss of pear shape on AP, "inverted pear" if critical
- Bony Bankart fragment - small anterior-inferior glenoid fragment
- Greater tuberosity fracture - more common in older patients
MRI with intra-articular gadolinium (MR arthrogram):
Gold standard for soft tissue assessment:
- Labral tear (Bankart lesion): High signal fluid between labrum and glenoid
- ALPSA lesion: Labrum displaced medially on glenoid neck, intact periosteum
- Perthes lesion: Subtle partial detachment with periosteum intact
- Capsular stretching: Increased capsular volume
- Rotator cuff tear: Assess for concomitant injury (especially over 40 years)
- Hill-Sachs lesion: Size, depth, orientation
- Glenoid bone loss: Can measure, but CT is superior
MRA vs Non-Contrast MRI
MR arthrogram (intra-articular gadolinium) is superior to non-contrast MRI for labral tear detection. Sensitivity improves from 82% (non-contrast) to 96% (arthrogram). Always request MRA for suspected Bankart lesion.
CT scan (critical for bone loss assessment):
CT with 3D reconstruction is the gold standard for bone loss quantification:
- Glenoid bone loss percentage (best-fit circle method)
- Hill-Sachs size and location (en face view)
- On-track vs off-track calculation
- Surgical planning for Latarjet or bone grafting
When to order CT:
- All recurrent dislocators (assess bone loss before surgery)
- Any suggestion of bony Bankart on X-ray
- ISIS score calculation (need accurate bone loss measurement)
- Preoperative planning for Latarjet procedure
Ultrasound:
- Dynamic assessment of labrum (operator-dependent)
- Limited role compared to MRI
- May detect labral tear in experienced hands
Management Algorithm
Emergency department management:
Acute dislocation:
- Neurovascular examination (axillary nerve most at risk)
- X-rays (AP and axillary lateral)
- Closed reduction (multiple techniques available)
- Post-reduction X-rays (confirm concentric reduction)
- Immobilization in sling (traditionally internal rotation, but see below)
- Orthopaedic follow-up within 1-2 weeks
Reduction techniques:
- Stimson technique: Prone, arm hanging with weight
- Cunningham technique: Gentle massage of shoulder girdle muscles
- Milch technique: Arm overhead abduction with gentle traction
- Traction-countertraction: Assistant holds sheet around chest
Immobilization Position Debate
Traditional immobilization in internal rotation (sling) vs external rotation (ER brace) has been debated. The ESTIR trial showed no difference in recurrence rates. Most surgeons use standard sling for comfort, as surgery is definitive treatment for high-risk patients anyway.
The key is not immobilization position but rather identifying which patients need surgery.
Surgical Technique
Arthroscopic suture anchor repair - Gold standard for soft tissue Bankart
Positioning:
- Beach chair or lateral decubitus (surgeon preference)
- Beach chair: Better anatomic orientation, easier conversion to open
- Lateral: Better distraction, visualization of inferior glenoid
Portal placement:
- Posterior portal: Viewing portal (standard, 2cm inferior and 2cm medial to posterolateral acromion)
- Anterior superior portal: Working portal (rotator interval)
- Mid-glenoid portal: Anchor placement portal (at anterior glenoid rim, 5 o'clock position for right shoulder)
Key steps:
- Diagnostic arthroscopy: Confirm Bankart lesion, assess for ALPSA, GLAD, Hill-Sachs
- Preparation of glenoid rim: Use shaver or rasp to create bleeding bone surface
- Mobilization (if ALPSA): Release medially displaced labrum from glenoid neck
- Anchor placement: 3-4 suture anchors at anterior-inferior glenoid rim
- 5:30 position (posteroinferior)
- 4:30-5:00 position (inferior)
- 3:00-3:30 position (anteroinferior)
- Optional 2:00 position (anterosuperior)
- Suture passing: Pass sutures through labrum and capsule
- Knot tying: Secure labrum back to glenoid rim
- Capsular shift (if needed): Plication of stretched capsule
- Closure: Close portals
Anchor Position Critical
Anchors must be placed on the articular margin of the glenoid (not medial on the neck). Think "bumper" restoration. If anchors are medial, the labral bumper effect is lost. Place at the 2, 3, 4:30, and 5:30 o'clock positions (right shoulder).
Number of anchors:
- Minimum 3 anchors required
- Most surgeons use 4 anchors for better coverage
- Studies show failure rate increases with fewer than 3 anchors
The systematic placement of anchors from inferior to superior ensures complete anterior-inferior stabilization.
Complications
Complications of Bankart Surgery
| Complication | Incidence | Prevention/Management |
|---|---|---|
| Recurrent instability | 5-10% arthroscopic, 2-5% Latarjet | Adequate anchor number, assess bone loss preoperatively |
| Stiffness/loss of motion | 10-20% | Early motion protocol, avoid over-tensioning |
| Nerve injury (axillary, musculocutaneous) | 1-2% | Careful retraction, identify anatomy |
| Anchor-related complications | 2-5% | Proper anchor placement on articular margin |
| Subscapularis dysfunction (open repair) | 10-20% | Careful repair, preserve tendon quality |
| Infection | Under 1% arthroscopic, 2-3% open | Sterile technique, antibiotic prophylaxis |
| Chondrolysis (thermal injury) | Rare with modern devices | Avoid excessive thermal devices |
Recurrent instability:
- Most common cause of failure
- Risk factors: Young age, contact sports, inadequate bone loss recognition
- Prevention: Proper patient selection, adequate anchors, bone augmentation if needed
- Treatment: Revision surgery, consider Latarjet if failed arthroscopic repair
Stiffness:
- More common with open repair than arthroscopic
- Risk increased with over-tensioning of capsule
- Prevention: Early motion protocol (within first week)
- Treatment: Aggressive physiotherapy, possible manipulation under anesthesia, capsular release
Anchor Pullout
Suture anchor pullout is rare (under 2%) with modern all-suture or PEEK anchors. Risk factors include poor bone quality, anchor placed in glenoid neck (not rim), and inadequate number of anchors. Place anchors on the articular margin with good bone purchase.
Nerve injuries:
- Axillary nerve: At risk during anterior inferior portal creation and inferior capsular dissection
- Musculocutaneous nerve: At risk during Latarjet (in conjoint tendon)
- Prevention: Know anatomy, gentle retraction, identify nerves intraoperatively
- Most are neurapraxia and recover within 6 months
Postoperative Care and Rehabilitation
Arthroscopic Bankart repair protocol:
- Sling immobilization for 4-6 weeks (sleep in sling)
- Remove for hygiene and gentle pendulum exercises only
- No active ROM of shoulder
- Elbow, wrist, hand motion encouraged
- Pain and inflammation control
- Anchor healing phase critical
- Wean from sling at 6 weeks
- Begin passive ROM exercises with physiotherapist
- Avoid combined abduction-external rotation (ABER) position
- Progress to active-assisted ROM by week 10
- No strengthening yet
- Goal: 140 degrees forward elevation, 40 degrees ER by week 12
- Active ROM exercises
- Begin rotator cuff strengthening
- Scapular stabilization exercises
- Progressive resistance band exercises
- Avoid heavy lifting or contact sports
- Full ROM expected by week 16
- Progressive strengthening program
- Sport-specific rehabilitation
- Non-contact sports at 4 months
- Contact sports at 6 months
- Throwing athletes may need 9-12 months
- Full unrestricted activity by 6 months
Latarjet postoperative protocol:
- Sling immobilization for 6 weeks
- Passive ROM allowed after 2-3 weeks (earlier than arthroscopic)
- Bone healing phase
- No active ROM or strengthening
- Active ROM exercises
- Bone healing confirmed on X-ray
- Gentle strengthening begins week 8
- Avoid ABER position
- Progressive strengthening
- Return to non-contact sports at 3-4 months
- Return to contact sports at 6 months
- Full activities by 6 months
Key rehabilitation principles:
- Avoid ABER position for 3 months (position of injury)
- Early passive motion to prevent stiffness
- Delayed active strengthening to protect repair (wait 6 weeks)
- Gradual return to sport to prevent re-injury
- Patient compliance is critical for success
Outcomes and Prognosis
Outcomes of arthroscopic Bankart repair:
Recurrence rates:
- Overall: 5-10% (modern series)
- Subcritical bone loss (under 15%): 5-8%
- Borderline bone loss (15-20%): 10-15%
- High ISIS score (over 6): 15-30%
Functional outcomes:
- Return to same level of sport: 80-90%
- Patient satisfaction: 85-95%
- Improved ROM compared to open repair
- Lower complication rate than open
Outcomes of Latarjet procedure:
Recurrence rates:
- Overall: 2-5% (excellent for high-risk population)
- Critical bone loss: 2-4%
- Revision cases: 5-10%
Functional outcomes:
- Return to sport: 80-90%
- Patient satisfaction: over 90%
- Minimal loss of motion (5-10 degrees external rotation)
- Higher complication rate than arthroscopic (10-15%)
Latarjet for High Risk
Latarjet has lower recurrence than arthroscopic repair in high-risk patients (young, contact sports, bone loss). For ISIS score over 6 or bone loss over 20%, Latarjet is superior. Accept the higher complication risk for better stability outcome.
Prognostic factors:
- Age: Younger patients higher recurrence
- Bone loss: Critical bone loss (over 20%) needs Latarjet
- Sport level: Competitive contact sports higher risk
- Number of anchors: 3 or more reduces recurrence
- Capsular quality: Stretched capsule increases risk
- Compliance: Rehabilitation adherence critical
Long-term considerations:
- Recurrent instability leads to progressive arthritis
- Early surgical stabilization may prevent arthritis
- Late repair (years after injury) has worse outcomes
- Latarjet long-term arthritis risk unclear (non-anatomic bone block)
Evidence Base
- Large prospective cohort of over 1,000 anterior instability patients. Identified key risk factors for recurrence after arthroscopic Bankart: age under 20, contact sports, bone loss over 15%, hyperlaxity. Led to development of ISIS score.
- Developed Instability Severity Index Score (ISIS) based on 6 risk factors. Scores 0-2: under 10% recurrence. Scores 3-6: 10-30% recurrence. Scores over 6: over 70% recurrence. Validated in multiple subsequent studies.
- Introduced concept that critical glenoid bone loss is 20-25% (inverted pear). Below this threshold, arthroscopic repair successful. Above this threshold, high failure rate. Changed surgical decision-making.
- Introduced glenoid track concept. Off-track Hill-Sachs lesions engage anterior glenoid and cause recurrent instability. On-track lesions remain on glenoid articular surface and do not require treatment. Mathematical formula to calculate track width.
- Long-term follow-up of Latarjet procedure showed 3% recurrence rate, 85% return to sport, 90% satisfaction. Higher complication rate (15%) including nerve injury, hardware issues. Excellent outcomes in high-risk patients with bone loss.
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Young Athlete with Recurrent Instability
"An 18-year-old rugby player presents with his third anterior shoulder dislocation. He is a competitive athlete hoping to play at university level. X-rays show a small Hill-Sachs lesion but no obvious glenoid bone loss. He wants surgery. How would you assess and manage this patient?"
Scenario 2: First-Time Dislocator - Surgical Decision
"A 25-year-old recreational surfer has his first anterior shoulder dislocation. It was reduced in the ED, post-reduction X-rays show concentric reduction and a small Hill-Sachs lesion. He asks whether he needs surgery. How do you counsel him?"
Scenario 3: Failed Arthroscopic Repair - Revision Strategy
"A 22-year-old patient had an arthroscopic Bankart repair 18 months ago after recurrent instability. He has now had 2 more dislocations. You obtain a CT scan showing 22% glenoid bone loss and a large engaging Hill-Sachs lesion. How do you approach this complex problem?"
MCQ Practice Points
Definition Question
Q: What is a Bankart lesion? A: A Bankart lesion is a tear of the anterior-inferior glenoid labrum and associated inferior glenohumeral ligament (IGHL) complex, typically occurring at the 3-6 o'clock position (right shoulder). It is the "essential lesion" in traumatic anterior shoulder instability.
Bone Loss Question
Q: What percentage of glenoid bone loss is considered critical and requires bone augmentation rather than isolated arthroscopic repair? A: Over 20% glenoid bone loss is considered critical. This creates an "inverted pear" glenoid shape and predicts high failure rates (over 60%) with isolated arthroscopic Bankart repair. Latarjet or bone block procedures are indicated.
ISIS Score Question
Q: What is the ISIS score and when does it predict high failure with arthroscopic Bankart repair? A: The Instability Severity Index Score (ISIS) predicts recurrence after arthroscopic Bankart based on 6 risk factors: age under 20 (2 points), competitive sports (2 points), contact/overhead sports (1 point), hyperlaxity (1 point), Hill-Sachs on AP (2 points), glenoid bone loss (2 points). Score over 6 predicts over 70% recurrence and suggests Latarjet should be considered.
ALPSA Question
Q: What is an ALPSA lesion and how does it differ from a classic Bankart? A: ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion) is a variant where the labrum is torn but the periosteum remains intact, allowing the labrum to displace medially onto the glenoid neck. Unlike Bankart where labrum is completely avulsed, ALPSA requires mobilization of the medially displaced sleeve before repair to the glenoid rim.
Anchor Number Question
Q: What is the minimum number of suture anchors recommended for arthroscopic Bankart repair? A: Minimum 3 anchors, with most surgeons using 4 anchors for better coverage of the anterior-inferior labrum. Anchors are typically placed at the 2 o'clock, 3 o'clock, 4:30, and 5:30 positions (right shoulder) to restore the labral bumper effect.
Australian Context
Epidemiology:
- High incidence in Australian Football (AFL), rugby union, rugby league
- Surfing and water sports common mechanisms in coastal areas
- Motor vehicle accidents and industrial injuries
- Age distribution: Peak in second and third decades
Management pathways:
- Sports medicine physicians often involved in initial management
- Subspecialty shoulder surgeons for surgical cases
- Public hospital access: May have waiting lists for arthroscopic surgery
- Private practice: Faster access but out-of-pocket costs
Healthcare Access:
- Surgical procedures covered under Medicare with rebates
- Gap payments common in private sector
- Public hospitals: No out-of-pocket but longer wait times
Imaging access:
- MRI widely available (Medicare rebate for shoulder MRI after dislocation)
- MR arthrogram: May require private radiology for timely access
- CT with 3D reconstruction: Available at major centers
Return to sport:
- Professional athletes (AFL, NRL): Early surgical stabilization common
- Recreational athletes: Shared decision-making based on activity level
- Workers' compensation: May require early surgery to facilitate return to work
Australian Sports Context
In the Orthopaedic exam, be prepared to discuss management of the AFL player with recurrent instability. Emphasize early bone loss assessment, ISIS score calculation, and lower threshold for Latarjet in high-level contact athletes. Career longevity depends on definitive stabilization.
BANKART LESIONS
High-Yield Exam Summary
DEFINITION AND KEY FACTS
- •Bankart = anterior-inferior labral tear (3-6 o'clock position)
- •Essential lesion in traumatic anterior instability (90% of dislocations)
- •ALPSA = labrum displaced medially with intact periosteum
- •Perthes = labral tear with intact periosteum (partial Bankart)
- •Bony Bankart = labral tear with glenoid fracture fragment
BONE LOSS ASSESSMENT (CRITICAL)
- •Under 15%: Subcritical - arthroscopic Bankart successful
- •15-20%: Borderline - use ISIS score to guide decision
- •Over 20%: Critical inverted pear - Latarjet mandatory
- •Over 25%: Severe bone loss - may need bulk bone graft
- •CT with 3D reconstruction is gold standard for measurement
ISIS SCORE (PREDICTS RECURRENCE)
- •Age under 20 years = 2 points
- •Competitive sport = 2 points, contact/overhead = 1 point
- •Shoulder hyperlaxity = 1 point
- •Hill-Sachs on AP radiograph = 2 points
- •Anterior glenoid bone loss = 2 points
- •Score over 6 = over 70% recurrence with arthroscopy (consider Latarjet)
ARTHROSCOPIC BANKART REPAIR
- •Gold standard for soft tissue Bankart with minimal bone loss
- •3-4 suture anchors at 2, 3, 4:30, 5:30 o'clock positions
- •Anchors on articular margin (not medial on neck)
- •Success rate: 85-95% in low-risk patients
- •Recurrence: 5-10% overall, higher in young contact athletes
LATARJET PROCEDURE
- •Indications: over 20% bone loss, ISIS over 6, failed Bankart
- •Triple effect: bone block, sling effect, capsular repair
- •Coracoid positioned flush with glenoid rim at equator
- •Screws perpendicular to glenoid face (not parallel)
- •Success: 95-98%, complications: 10-15% (nerve, hardware)
TRAPS AND PEARLS
- •Always assess bone loss with CT before surgery
- •ISIS score guides surgical decision in borderline cases
- •ALPSA requires mobilization before repair
- •Engaging Hill-Sachs needs remplissage or Latarjet
- •First-time under 20 = 90% recurrence without surgery
- •Apprehension test: 96-98% specificity for instability