High-yield overview
Anterior-Inferior Labral Tear | Gold Standard: Arthroscopic Repair | Assess Bone Loss
90%Of anterior dislocations have labral tear
20%Glenoid bone loss indicates bony Bankart
85-95%Success rate arthroscopic repair
3-4Minimum anchors for repair
BANKART VARIANTS
Soft Tissue Bankart
PatternAnterior-inferior labral tear without bone
TreatmentArthroscopic suture anchor repair
Bony Bankart
PatternLabral tear with glenoid fracture fragment
TreatmentORIF vs Latarjet if critical bone loss
ALPSA
PatternAnterior labroligamentous periosteal sleeve avulsion
TreatmentArthroscopic repair with mobilization
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
Clinical 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) |
Mnemonic
BANKART - EBANKART - Essential Components
| B | Bone loss assessment Over 20% = Latarjet, not arthroscopy |
| A | Anterior-inferior labrum Classic location 3-6 o'clock position |
| N | Number of dislocations Recurrent instability increases risk |
| K | K-wires never used Suture anchors are gold standard |
| A | Age under 20 high risk 90% recurrence in young athletes |
| R | Repair early prevents arthritis Recurrent instability leads to cartilage damage |
| T | Test with apprehension Apprehension test reproduces instability sensation |
| B | Bone loss assessment Over 20% = Latarjet, not arthroscopy | K | K-wires never used Suture anchors are gold standard | T | Test with apprehension Apprehension test reproduces instability sensation |
| A | Anterior-inferior labrum Classic location 3-6 o'clock position | A | Age under 20 high risk 90% recurrence in young athletes | ||
| N | Number of dislocations Recurrent instability increases risk | R | Repair early prevents arthritis Recurrent instability leads to cartilage damage |
Hook:BANKART covers the key assessment and management principles for anterior shoulder instability
Mnemonic
ISIS - IISIS - Instability Severity Index Score
| I | In young patients (under 20) Add 2 points if age under 20 years |
| S | Sport at competitive level Add 2 points if competitive athlete |
| I | In contact/overhead sport Add 1 point if contact or overhead sport |
| S | Shoulder hyperlaxity Add 1 point if shoulder hyperlaxity present |
| Hill-Sachs | Hill-Sachs visible on AP X-ray Add 2 points if Hill-Sachs on AP radiograph |
| Loss | Loss of glenoid contour Add 2 points if anterior glenoid bone loss |
| I | In young patients (under 20) Add 2 points if age under 20 years | I | In contact/overhead sport Add 1 point if contact or overhead sport | Hill-Sachs | Hill-Sachs visible on AP X-ray Add 2 points if Hill-Sachs on AP radiograph |
| S | Sport at competitive level Add 2 points if competitive athlete | S | Shoulder hyperlaxity Add 1 point if shoulder hyperlaxity present | Loss | Loss of glenoid contour Add 2 points if anterior glenoid bone loss |
Hook:ISIS score over 6 points predicts high failure rate (over 70%) with arthroscopic repair - consider Latarjet
Mnemonic
ALPSA - VALPSA - Variant Lesion Pattern
| A | Anterior labrum Still involves anterior labrum |
| L | Labroligamentous Labrum and ligament complex |
| P | Periosteal sleeve Periosteum remains intact (key feature) |
| S | Sleeve avulsed Sleeve displaced medially on glenoid neck |
| A | Arthroscopic mobilization needed Must mobilize before repairing to glenoid rim |
| A | Anterior labrum Still involves anterior labrum | S | Sleeve avulsed Sleeve displaced medially on glenoid neck |
| L | Labroligamentous Labrum and ligament complex | A | Arthroscopic mobilization needed Must mobilize before repairing to glenoid rim |
| P | Periosteal sleeve Periosteum remains intact (key feature) |
Hook:ALPSA has intact periosteum but medially displaced - like a sleeve rolling down - must mobilize back to glenoid rim
Mnemonic
3 CLOCK RULE - A3 CLOCK RULE - Anchor Placement
| 3 | 3 o'clock position Anteroinferior anchor (right shoulder) |
| 4 | 4:30 position Inferior anchor (6 o'clock on glenoid face) |
| 5 | 5:30 position Posteroinferior anchor |
| TOTAL | 3-4 anchors minimum May add superior anchor at 2 o'clock if needed |
| 3 | 3 o'clock position Anteroinferior anchor (right shoulder) | 5 | 5:30 position Posteroinferior anchor |
| 4 | 4:30 position Inferior anchor (6 o'clock on glenoid face) | TOTAL | 3-4 anchors minimum May add superior anchor at 2 o'clock if needed |
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: 23.9 per 100,000 person-years for shoulder dislocation (US emergency-department data, Zacchilli & Owens)
- Age: Peak incidence in the 20-29 year decade (highest rate 47.8 per 100,000); 46.8% of dislocations occur between ages 15-29
- Gender: Male predominance (incidence rate ratio 2.64; 71.8% of dislocations in males)
- Sports: Almost half (48.3%) occur during sport/recreation; 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)
Differential diagnosis of the unstable or painful shoulder:
Differential Diagnosis - Anterior Bankart vs Mimics
| Diagnosis | Distinguishing features | Key test / imaging |
|---|---|---|
| Anterior (Bankart) instability | Traumatic ABER mechanism, anterior apprehension, dead-arm in throwers | Apprehension/relocation positive; MR arthrogram anteroinferior labral tear |
| Posterior instability / reverse Bankart | Seizure, electrocution, axial load on adducted arm; pain in flexion-adduction | Jerk/Kim test positive; axillary view confirms posterior subluxation |
| SLAP / superior labral tear | Overhead athlete, deep-seated pain, clicking; no frank dislocation | O'Brien and biceps load tests; superior labral signal on MRA |
| Multidirectional instability (MDI) | Atraumatic, bilateral, generalised laxity, voluntary component | Positive sulcus sign, Beighton over 4; instability in 2 or more directions |
| Rotator cuff tear (over 40) | Weakness and night pain rather than apprehension after dislocation | Drop-arm/Jobe; ultrasound or MRI for cuff integrity |
| First-time bony injury (GT fracture / fracture-dislocation) | Older patient, marked pain, limited movement post-reduction | AP and axillary radiographs; CT for fracture pattern |
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
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. Although early studies suggested an external-rotation brace might reduce recurrence, larger randomised trials and meta-analyses have not confirmed a clinically meaningful difference. Most surgeons use a standard sling for comfort, since definitive stabilisation is the key decision for high-risk patients.
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:
Weeks 0-6: Protection Phase
- 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
Weeks 6-12: Passive ROM
- 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
Weeks 12-16: Active ROM and Strengthening
- 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
Months 4-6: Return to Sport
- 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:
Weeks 0-6: Protection
- Sling immobilization for 6 weeks
- Passive ROM allowed after 2-3 weeks (earlier than arthroscopic)
- Bone healing phase
- No active ROM or strengthening
Weeks 6-12: Progressive ROM
- Active ROM exercises
- Bone healing confirmed on X-ray
- Gentle strengthening begins week 8
- Avoid ABER position
Months 3-6: Return to Activity
- 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
Level III
Balg & Boileau - Instability Severity Index Score (ISIS)
Key Findings:
- Prospective case-control study of 131 patients undergoing arthroscopic Bankart repair with suture anchors; 14.5% recurrent instability at mean 31 months. Identified 6 pre-operative risk factors (age under 20, competitive/contact/overhead sport, hyperlaxity, Hill-Sachs on AP radiograph, loss of glenoid contour) compiled into a 10-point score. A score over 6 carried a 70% recurrence risk.
Clinical Implication: ISIS over 6 is a relative contraindication to arthroscopic Bankart repair - the original authors recommend a Bristow-Latarjet procedure instead. Use the score to triage borderline (15-20% bone loss) cases.
Source: J Bone Joint Surg Br 2007
Level IV
Burkhart & De Beer - Inverted-Pear Glenoid & Engaging Hill-Sachs
Key Findings:
- Case series of 194 arthroscopic Bankart repairs. With no significant bone defect the recurrence rate was 4%; with an inverted-pear glenoid or engaging Hill-Sachs it rose to 67%. In contact athletes the contrast was 6.5% versus 89%. Defined the inverted-pear glenoid and the engaging Hill-Sachs as the key bony reasons for arthroscopic failure.
Clinical Implication: Assess glenoid and humeral bone loss before offering arthroscopic repair. Significant bone defects mandate a bony procedure (Latarjet with coracoid graft) rather than isolated soft-tissue repair.
Source: Arthroscopy 2000
Level V (cadaveric)
Yamamoto & Itoi - Glenoid Track Concept
Key Findings:
- Cadaveric study (9 shoulders) mapping glenoid-humeral contact in abduction and external rotation. The zone of contact (glenoid track) had a medial margin 18.4 mm from the rotator-cuff footprint, equivalent to 84% of the glenoid width. A Hill-Sachs lesion that extends medial to this margin risks engagement and dislocation (off-track).
Clinical Implication: Calculate the glenoid track (approximately 0.83 x glenoid diameter minus glenoid bone loss). Off-track Hill-Sachs lesions need remplissage or Latarjet in addition to Bankart repair.
Source: J Shoulder Elbow Surg 2007
Level III
Hettrich et al. (MOON Shoulder Instability) - Predictors of Bone Loss
Key Findings:
- Prospective multicentre MOON cohort of 892 anterior-instability patients. Anterior glenoid bone loss was present in 20.7% and Hill-Sachs lesions in 52.7%. An increasing number of dislocations was the factor most strongly associated with glenoid bone loss, Hill-Sachs lesions and combined lesions - each additional dislocation raised the odds of a combined lesion by 95%.
Clinical Implication: Recurrent dislocation drives progressive bone loss. Early stabilisation before repeated events may prevent clinically significant osseous defects, particularly in high-risk athletes.
Source: Am J Sports Med 2023
Level I (RCT)
Bottoni, Arciero et al. - Arthroscopic Stabilisation vs Non-operative (first-time)
Key Findings:
- Prospective randomised trial in young athletes with a first-time traumatic anterior dislocation. Recurrent instability occurred in 75% (9/12) of non-operatively treated patients versus 11.1% (1/9) after early arthroscopic Bankart repair at mean 36-month follow-up.
Clinical Implication: Early arthroscopic stabilisation markedly lowers recurrence in young, active first-time dislocators and supports a lower surgical threshold in this group.
Source: Am J Sports Med 2002
Level I
Belk et al. - Stabilisation vs Immobilisation (meta-analysis of RCTs)
Key Findings:
- Meta-analysis of 5 Level-1 RCTs (259 patients) for first-time anterior dislocation. Recurrent instability was 6.3% after surgical stabilisation versus 46.6% with immobilisation; subsequent instability surgery was needed in 4.0% versus 30.8% (both p under 0.00001), at mean 60-month follow-up.
Clinical Implication: High-level evidence confirms that surgical stabilisation of a first-time dislocation substantially reduces recurrence and the need for later surgery versus a sling alone.
Source: Am J Sports Med 2022
Level IV
Ali, Hurley et al. - Revision Open Latarjet (systematic review)
Key Findings:
- Systematic review of 16 studies (713 shoulders) of the open Latarjet performed as a revision after failed prior stabilisation. Recurrence was 8.4% (redislocation only 0.9%), return to play 95.1%, mean Rowe score 92.7, with an 11% non-recurrence complication rate (nerve injury and infection each 2.1%).
Clinical Implication: Latarjet is a reliable salvage for failed Bankart repair, giving low recurrence and high return to sport, at the cost of a meaningful complication rate that must be discussed at consent.
Source: Knee Surg Sports Traumatol Arthrosc 2021
Clinical Decision Scenarios
Use these scenarios to practise clinical reasoning and management decisions
CLINICAL SCENARIOStandard
Scenario 1: Young Athlete with Recurrent Instability
CLINICAL PROMPT
"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?"
PRACTICAL APPROACH
This young rugby player has **recurrent anterior shoulder instability** - a clear indication for surgical stabilization. As a young competitive contact athlete, he is at extremely high risk for continued recurrence without surgery. **Assessment:** I would take a comprehensive history including number and ease of dislocations, any subluxations, impact on sport, and his goals. On examination, I would perform **apprehension testing** (expects to be positive), assess shoulder laxity with sulcus sign and Beighton score, and check for any rotator cuff weakness. **Imaging:** Essential investigations are: - **MR arthrogram** to confirm Bankart lesion and assess for variants (ALPSA, GLAD) - **CT scan with 3D reconstruction** to accurately measure glenoid bone loss (critical decision-making) - **Calculate ISIS score** to stratify his recurrence risk **ISIS Score Calculation:** This patient likely has high score: age under 20 (2 points), competitive sport (2 points), contact sport (1 point). That is already 5 points before assessing hyperlaxity, Hill-Sachs on AP, or bone loss. If any of those factors present, he would score over 6, which predicts over 70% recurrence with arthroscopic Bankart alone. **Treatment Options:** If bone loss is **under 15%** and ISIS score under 6: **Arthroscopic Bankart repair** with 3-4 suture anchors If bone loss is **15-20%** or ISIS score over 6: Strongly consider **Latarjet procedure** If bone loss **over 20%**: **Latarjet is mandatory** **Counseling:** I would discuss that this is a career-threatening injury if not addressed. Arthroscopic repair has 85-90% success in low-risk patients but potentially only 60-70% in high-risk patients like him. Latarjet has 95-98% success but higher complication rate (nerve injury, hardware issues). Given his career aspirations, I would likely recommend Latarjet if ISIS over 6 or bone loss in borderline range. **Timing:** Surgery within 6-12 weeks after adequate rehabilitation to restore motion. Return to rugby at 6 months.
KEY CLINICAL POINTS
Recurrent instability in young athlete = surgical indication
Must obtain MR arthrogram AND CT scan for complete assessment
Calculate ISIS score to predict recurrence risk
CT measures glenoid bone loss accurately (critical for decision)
Age under 20, competitive sport, contact sport = already 5 ISIS points
Over 20% bone loss = Latarjet mandatory
15-20% bone loss with ISIS over 6 = consider Latarjet
Arthroscopic Bankart: 3-4 anchors at 2, 3, 4:30, 5:30 o'clock
Latarjet: Better stability (2-5% recurrence) but higher complications
Return to contact sports at 6 months post-surgery
COMMON PITFALLS
Not ordering CT scan (bone loss assessment mandatory)
Relying on MRI alone for bone loss quantification
Not calculating ISIS score
Offering arthroscopic repair to high-risk patient without discussion
Not counseling about Latarjet option
Underestimating recurrence risk in this population
FURTHER QUESTIONS
"His CT shows 18% glenoid bone loss and his ISIS score is 7. What would you recommend?"
"Explain the Latarjet procedure and its triple effect."
CLINICAL SCENARIOChallenging
Scenario 2: First-Time Dislocator - Surgical Decision
CLINICAL PROMPT
"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?"
PRACTICAL APPROACH
This is a common scenario requiring **shared decision-making** based on evidence and patient factors. A first-time dislocation in a 25-year-old has intermediate recurrence risk - not as high as a teenager but not as low as someone over 40. **Risk Stratification:** I would explain that recurrence risk depends on several factors: - **Age**: At 25, approximately 40-50% recurrence without surgery - **Activity level**: Recreational surfing is overhead but not contact - moderate risk - **Bone loss**: Need to assess (order MRI and possibly CT) **Initial Management:** I would recommend **3 months of non-operative management** initially: - Sling for 2-3 weeks for comfort - Structured physiotherapy focusing on rotator cuff and scapular strengthening - Gradual return to surfing with activity modification - Close monitoring for any instability episodes **Imaging:** - **MR arthrogram** to confirm Bankart lesion and assess labral tear pattern - **CT scan if considering surgery** to measure bone loss **Discussion of Surgery:** I would explain the pros and cons: **Arguments FOR early surgery:** - Prevents recurrent dislocations (which increase bone loss and cartilage damage) - Each dislocation makes the problem worse - Earlier surgery has better tissue quality - 85-95% success rate with arthroscopic repair - If he is going to need surgery eventually, better to do it sooner **Arguments AGAINST early surgery:** - 40-50% recurrence means 50-60% will **not** have another dislocation - Surgery has risks (infection, stiffness, recurrence despite surgery) - Can always operate later if recurrent instability develops - 3-month rehab trial is reasonable **My Recommendation:** For a 25-year-old recreational athlete, I would suggest a **3-month trial of rehabilitation** with the understanding that if he has **any further instability episodes** (dislocation or subluxation), we proceed to **arthroscopic Bankart repair**. However, if his MRI shows significant bone loss (over 15%) or ALPSA lesion, I would lower threshold for surgery. If he is a **professional surfer** or **competitive athlete**, I would recommend **early surgical stabilization** given the career impact and high functional demands.
KEY CLINICAL POINTS
First-time dislocation at age 25 = 40-50% recurrence risk
Shared decision-making based on age, activity, bone loss
Reasonable to trial 3 months non-operative management
Structured rehab: rotator cuff, scapular stabilization
Order MR arthrogram to assess labral pathology
Consider CT if bone loss suspected or surgery planned
Surgery indicated if: recurrent instability, high bone loss, ALPSA lesion
Competitive athletes: lower threshold for surgery
Arthroscopic Bankart has 85-95% success in low-risk patients
Counsel that recurrent dislocations worsen bone loss and cartilage damage
COMMON PITFALLS
Absolute recommendation for or against surgery without discussing factors
Not ordering appropriate imaging (MRA)
Not explaining recurrence risk based on age
Not offering rehabilitation trial
Not discussing that repeat dislocations worsen prognosis
Treating all first-time dislocators the same regardless of age/activity
FURTHER QUESTIONS
"He has another dislocation 6 weeks later during surfing. What now?"
"His MRI shows an ALPSA lesion. Does this change your management?"
CLINICAL SCENARIOCritical
Scenario 3: Failed Arthroscopic Repair - Revision Strategy
CLINICAL PROMPT
"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?"
PRACTICAL APPROACH
This is a **failed arthroscopic Bankart repair** with **critical glenoid bone loss** - a challenging revision scenario. The patient needs revision surgery, but the standard arthroscopic approach is **not appropriate** given the bone loss. **Analysis of Failure:** I would review the operative report from the initial surgery to understand: - Was bone loss recognized preoperatively? (Suggests patient selection error) - How many anchors were used? (Fewer than 3 increases failure) - Was capsular shift performed? (Under-tensioning causes failure) - Likely this patient had **subcritical bone loss initially** that has now progressed to **critical bone loss** (22%) from recurrent dislocations **Current Assessment:** - **22% glenoid bone loss** = Critical (over 20% threshold) = Inverted pear glenoid - **Engaging Hill-Sachs** = Off-track lesion that catches on anterior rim - **Bipolar bone loss** (glenoid + humeral) = High-risk scenario - This patient absolutely needs **bone augmentation**, not repeat soft tissue repair **Treatment: Latarjet Procedure** This patient requires a **Latarjet procedure** for the following reasons: 1. **Addresses critical glenoid bone loss** - coracoid restores glenoid arc 2. **Sling effect** of conjoint tendon provides dynamic stability 3. **Only 2-5% recurrence** in this high-risk scenario 4. **Engaging Hill-Sachs** is often controlled by bone block preventing engagement **Latarjet Technique:** - Open deltopectoral approach - Protect musculocutaneous nerve (in conjoint, 5-8cm from tip) - Osteotomize coracoid at the knee - Subscapularis split (horizontal preferred in revision) - Position coracoid **flush** with glenoid rim at equator - Fix with 2 screws **perpendicular** to glenoid face - May need to address subscapularis from prior surgery **Alternative Consideration - Remplissage:** The engaging Hill-Sachs could theoretically be addressed with **remplissage** (infraspinatus tenodesis), but given the critical glenoid bone loss, **Latarjet alone** is likely sufficient as the bone block prevents Hill-Sachs engagement. **Counseling:** I would explain to the patient: - This is a **revision scenario** with worse prognosis than primary surgery - Latarjet has 90-95% success in this setting (much better than repeat arthroscopy) - Higher complication risk: nerve injury (1-2%), hardware issues, infection (3-5%) - May lose 5-10 degrees of external rotation - Long-term arthritis risk uncertain - Return to sport at 6 months - This is likely his **last chance** for stability - must protect the shoulder long-term The key message is that **bone loss must be recognized and addressed**. Repeat soft tissue repair in the setting of critical bone loss will fail.
KEY CLINICAL POINTS
Failed Bankart + 22% bone loss = critical glenoid deficiency
Over 20% bone loss is absolute indication for bone augmentation
Repeat arthroscopic repair will fail in this scenario
Latarjet procedure is treatment of choice
Triple effect: bone block, sling effect, capsular repair
Coracoid positioned flush with glenoid rim at equator
Screws perpendicular to glenoid face (not parallel)
Engaging Hill-Sachs usually controlled by bone block
Remplissage is alternative but Latarjet alone likely sufficient
Counsel about higher complication risk but excellent stability outcome
COMMON PITFALLS
Offering repeat arthroscopic Bankart repair
Not recognizing critical bone loss as contraindication to arthroscopy
Not ordering CT scan to quantify bone loss
Not counseling about Latarjet being definitive procedure
Underestimating complexity of revision surgery
Not discussing nerve injury risk with Latarjet
FURTHER QUESTIONS
"Walk me through the Latarjet technique step by step."
"What are the specific risks of the Latarjet procedure?"
"What if the patient has 30% bone loss - is Latarjet still adequate?"
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.
Guidelines, Registries & Global Practice
Global epidemiology (PubMed-verified):
| Metric | Figure | Source |
|---|---|---|
| Shoulder dislocation incidence | 23.9 per 100,000 person-years (US ED data) | Zacchilli & Owens, JBJS Am 2010 |
| Peak age decade | 20-29 years (47.8 per 100,000); 46.8% aged 15-29 | Zacchilli & Owens 2010 |
| Sex | Male IRR 2.64; 71.8% of dislocations in males | Zacchilli & Owens 2010 |
| Sport/recreation as cause | 48.3% of all dislocations | Zacchilli & Owens 2010 |
| Glenoid bone loss prevalence | 20.7% of instability patients (Hill-Sachs 52.7%) | MOON cohort, AJSM 2023 |
Anterior instability is concentrated in young active men worldwide. Contact and collision codes (rugby union/league, American/Australian football, ice hockey) and overhead/throwing sports dominate, with combat sports and falls contributing in older groups.
Guidance and decision frameworks, side by side:
| Body / framework | Position on first-time dislocation | Position on bone loss / recurrence | Evidence basis |
|---|---|---|---|
| AAOS (US) | Stratify by age/activity; young athletes counselled on high recurrence and early surgical option | Quantify glenoid and humeral bone loss before surgery; bony procedure for critical loss | RCT + cohort (Bottoni/Belk) |
| NICE / BOA (UK) | Reduce, confirm with axillary view, early physiotherapy; refer recurrent or high-demand for stabilisation | Specialist imaging (CT/MR) and surgeon-led choice of soft-tissue vs bony repair | Guideline + Level I evidence |
| AO Foundation / EFORT | Emphasise glenoid track and ISIS-type risk stratification | Off-track Hill-Sachs and critical glenoid loss favour Latarjet/bone block over isolated repair | Yamamoto track; Burkhart |
| ISAKOS / ISIS (Balg-Boileau) | Validated pre-op risk score | ISIS over 6 contraindicates arthroscopic repair, recommend Latarjet | JBJS Br 2007 (Level III) |
There is broad international agreement on the principles (assess bone loss, risk-stratify, repair the labrum or augment bone) even where named guidelines differ in emphasis.
Registry and large-cohort evidence:
- The MOON Shoulder Instability prospective multicentre cohort (892 patients) shows recurrent dislocations drive progressive glenoid and humeral bone loss - each additional event raises combined-lesion odds by 95% (AJSM 2023).
- National joint registries (NJR, AOANJRR, AJRR) capture arthroplasty rather than soft-tissue stabilisation, so instability outcome data come chiefly from cohort studies and society registries rather than implant registries.
Global practice variation:
- High-resource settings: routine CT/MR arthrography, glenoid-track calculation, arthroscopic Bankart +/- remplissage, Latarjet for critical loss.
- Limited-resource settings: open Bankart and open Latarjet remain workhorse procedures where arthroscopy and 3D CT are less available; plain radiographs (AP, axillary, Stryker notch, West Point) carry more diagnostic weight.
- Collision-sport regions (Australasia, South Africa, Europe): lower threshold for early bony stabilisation in elite contact athletes given career impact and high recurrence.
Examiner Framing - Global Standard
Whatever board you sit, examiners reward the same reasoning chain: confirm reduction on an axillary view, quantify glenoid and humeral bone loss, apply a risk score (ISIS) and the glenoid-track concept, then choose soft-tissue repair vs bony augmentation. Name the evidence (Balg-Boileau, Burkhart, Yamamoto, Bottoni/Belk), not a single country's pathway.
BANKART LESIONS
Clinical 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