Arthroscopic Bony Bankart Repair

Bony Bankart fractures can occur with or without injuries to surrounding tissues in the shoulder. In large part, bony Bankart lesions occur in young contact athletes where a large collision or fall causes the ball to dislocate and therefore traumatically crack the front socket bone of the shoulder. These injuries can also occur in individuals slightly older, and when they do, they commonly occur in conjunction with tears of the tendons (known as the rotator cuff).  When the ball traumatically dislodges from the socket as it breaks the socket bone, the rotator cuff is susceptible to being traumatically pulled off the humerus ball portion of the shoulder, resulting in a traumatic rotator cuff tear.

The treatment focus of bony Bankart lesions in younger patients and in older patients (who also have concomitant injuries to the rotator cuff tendons) is slightly different.  In the younger age category, repairing the bone securely in the acute setting (when the fracture is still freshly broken) is strongly recommended.  Unlike with soft tissue Bankart lesions, an untreated bony Bankart lesion leads to attritional bone loss, where the bony piece dissolves with time.  This leads to a much more destabilizing effect on the shoulder versus a simple soft tissue Bankart lesion.  In the hands of an experienced arthroscopic surgeon, excellent outcomes can be achieved when the bony piece is incorporated into the repair construct using a technique called the “bridge” technique, where there are extra anchors applied to the inner (medial) fracture bed and the bone fragment is “pinned” into the correct anatomical position with well-tolerated sutures(1).

In the older population of patients that dislocate the shoulder resulting in a bony Bankart lesion as well as a rotator cuff tear, the treatment generally is focused more on the rotator cuff tendon tear as opposed to the bony Bankart fracture.  The reason for this different focus is that older patients are less at risk of re-dislocating the shoulder, even with nonsurgical management, but the traumatic tear in the rotator cuff can be a problem with long term follow-up.  In this case, even if the bone fragment heals in a sub-optimal position, the shoulder may function but become painful and weak with nonsurgical management.  Therefore, in older active patients, arthroscopic repair affords the benefit of repairing the bone fragment as well as repairing the rotator cuff anatomically.  Excellent outcomes are expected in these cases.

If surgery is avoided for these injuries, the long-term consequences are different in the different age categories and depending on what the concomitant damage is.  In the younger active contact athlete population, glenoid (socket) bone loss is expected, which leads to recurrent dislocations and limitations in function in the athlete.  Studies have shown that even small amounts of bone loss in the socket can lead to substantial increases in the rates of recurrent shoulder instability(2).

In the older population, the long-term consequences of avoidance of surgery relate more to the rotator cuff tear, instead of the glenoid (socket) fracture.  Rotator cuff tears that occur when the shoulder forcefully dislocates are at a relatively substantial risk of continued weakness and progression, largely because the tendon was traumatically pulled (ripped) off the bone when the ball came out.  In patients that have chronically untreated traumatic tears in the rotator cuff, the tear can enlarge, the muscles can atrophy, and sometimes the tear can become so large it is irreparable.

The surgery for a bony Bankart fracture is performed arthroscopically as an outpatient, where you leave the facility the same day.  A sling is worn for six weeks to let the tissues heal, during which time gentle exercises are initiated.  Once the sling is off, you may resume full use of the arm with the exception of heavy overhead lifting.  Full functional recovery is expected between 5 and 7 months with subtle improvements expected up to one year following surgery.