This article is more than 5 years old. Information may no longer be current.
Arthroscopic bony Bankart bridge technique provides secure fixation
Click Here to Manage Email Alerts
An acute shoulder instability event has several pathologic etiologies including soft tissue capsulolabral avulsion, humeral-sided ligament detachment or a bony Bankart fracture. A bony Bankart lesion involves avulsion of the inferior glenohumeral ligament complex in association with an anterior or posterior glenoid rim fracture. This injury occurs more commonly in men and is easily missed on radiographs. Early surgery for this injury is often recommended.
Surgical options to address bony Bankart lesions include arthroscopic labral fixation with or without capturing the bony fragment, excision of the fragment and standard labral repair, open screw fixation or open Latarjet/bone grafting procedure. Excising the bony fragment is not ideal because it can lead to glenoid bone loss, which can result in higher failure rates with soft tissue repair. The bony fragment is often not large enough to accommodate screw fixation. The arthroscopic bony Bankart bridge technique was described by Millett and colleagues in 2009 and has several advantages. Secure two-point fixation and fragment compression can be achieved arthroscopically without sacrificing the bony fragment.
This technique was our choice of treatment for a 25-year-old female patient who tripped and fell directly on her outstretched arm. She reported that her shoulder “popped out” daily, especially with her arm out in front of her body. She had significant posterior shoulder apprehension, even with low forward flexion angles. Radiographs and MRI revealed a large posterior bony Bankart lesion (Figures 1 and 2).
Figure 1. This axillary radiograph shows a posterior bony Bankart fragment.
Figure 2. An axial MRI demonstrates a large posterior bony Bankart fragment and posterior shoulder subluxation.
Figure 3. The reverse Hill-Sachs lesion is visualized and a posterior bony Bankart lesion is encountered.
Figure 4. An elevator is used through the posterior portal to free the posterior bony Bankart fragment from the glenoid.
Images: Bollier M
A lateral arthroscopy set-up is used for instability procedures. We entered the glenohumeral joint through an anterosuperior portal so that the posterior portal could be created under direct visualization. Cannulas were placed posteriorly and anterior-inferiorly. A reverse Hill-Sachs lesion and posterior bony Bankart lesion were encountered (Figure 3). An elevator and burr were used to create a healing response between the glenoid and posterior bony Bankart fragment (Figure 4). A single-loaded 3-mm suture tak anchor (Arthrex; Naples, Fla.) was placed 8 mm to 10 mm below the cartilage surface on the posterior glenoid neck (Figure 5). Both limbs from the anchor were retrieved out the anterior cannula. A suture lasso was used to pass a nitonel wire around the posterior bony Bankart fragment (Figure 6) and both limbs from the medial row anchor were shuttled around the fragment (Figure 7). Both suture limbs were placed in the eyelet of a 2.9-mm pushlock anchor (Arthrex; Naples Fla.) and the anchor was secured at the glenoid rim to compress the fragment with two-point fixation (Figure 8). Two additional suture tak anchors (Arthrex; Naples, Fla.) were placed above and below the fragment and a simple stitch through the capsule and labrum was placed (Figure 9). An arthroscopic knot was tied. Finally, the posterior portal was closed with an arthroscopic knot tied extra-capsularly (Figure 10).
Figure 5. An anchor is placed 8 mm to 10 mm below the glenoid rim on the posterior glenoid neck.
Figure 6. A suture lasso is used to shuttle both limbs from the medial anchor around the bony Bankart fragment.
Figure 7. Both limbs are shuttled around the posterior bony Bankart fragment.
Figure 8. Both limbs are placed through the eyelet of a second anchor, which is placed at the glenoid rim. This secures the two-point fixation and fragment compression.
Postoperatively, the patient was placed in a 30° external rotation shoulder immobilizer for 6 weeks. Physical therapy and shoulder range of motion was started at 4 weeks, but strengthening was delayed until 3 months.
Figure 9. Two additional anchors are placed above and below the fragment. Simple stitches are passed through the capsule and labrum and the knot is tied arthroscopically.
Figure 10. The posterior portal is closed with the knot tied extra-capsularly.
For more information:
Disclosure: Bollier is a consultant for Arthrex.