Bankart and Latarjet: Understanding Shoulder Instability Surgeries

What is the difference between Bankart and Latarjet?

Bankart and Latarjet are distinct surgical procedures primarily used to treat chronic shoulder instability resulting from anterior glenohumeral dislocation, with Bankart addressing soft tissue (labral) damage and Latarjet addressing significant bone loss from the glenoid or humeral head.

Understanding Shoulder Instability

The shoulder joint (glenohumeral joint) is the most mobile joint in the body, a ball-and-socket articulation where the head of the humerus (upper arm bone) fits into the shallow glenoid fossa of the scapula (shoulder blade). Its stability relies heavily on surrounding soft tissues, including the joint capsule, ligaments, and the glenoid labrum – a fibrocartilaginous rim that deepens the glenoid socket. When the shoulder dislocates, these stabilizing structures can be damaged, leading to recurrent instability.

The Bankart Lesion and Repair

A Bankart lesion is the most common injury associated with anterior shoulder dislocation. It involves a tear of the anterior-inferior labrum, often accompanied by a detachment of the inferior glenohumeral ligament from the glenoid rim. This detachment effectively reduces the depth and stability of the glenoid socket, making subsequent dislocations more likely.

• What is a Bankart Lesion? It is a specific type of labral tear where the labrum and often the attached anterior capsular ligaments are pulled away from the front and bottom edge of the glenoid.
• The Bankart Repair Procedure: This surgical technique aims to reattach the torn labrum and ligaments back to the glenoid rim.
  • Approach: It is most commonly performed arthroscopically (minimally invasive, using small incisions and a camera). In some cases, an open approach may be used.
  • Technique: Surgeons use small anchors (often bioabsorbable) with sutures. These anchors are inserted into the glenoid bone, and the sutures are then passed through the torn labrum and capsule, effectively pulling and securing them back to their anatomical position on the glenoid rim.
• Indications for Bankart Repair:
  • First-time or recurrent anterior shoulder dislocations.
  • Presence of a clearly identifiable Bankart lesion.
  • Minimal to no significant bone loss (osseous defect) from the glenoid or humeral head (Hill-Sachs lesion).
  • Patients with an intact glenoid bone stock who primarily have soft tissue damage.
• Advantages and Disadvantages:
  • Advantages: Less invasive (arthroscopic), preserves native anatomy, generally good outcomes for appropriate candidates.
  • Disadvantages: Higher risk of recurrence in patients with significant glenoid bone loss, large Hill-Sachs lesions, or those participating in high-demand overhead sports.

The Latarjet Procedure

The Latarjet procedure is a bone block transfer technique designed to address shoulder instability, particularly when there is significant bone loss from the anterior glenoid or a large Hill-Sachs lesion (a compression fracture on the posterior-superior humeral head). It provides both a bone block effect and a dynamic sling effect.

• What is the Latarjet Procedure? This procedure involves transferring a piece of bone from the coracoid process (a small, hook-like projection of the scapula) along with its attached muscles (conjoint tendon, comprising the short head of biceps and coracobrachialis, and often part of the pectoralis minor) to the anterior-inferior aspect of the glenoid.
• The Latarjet Surgical Technique:
  • Approach: Traditionally performed as an open procedure, though arthroscopic Latarjet is increasingly common in specialized centers.
  • Technique: The coracoid process is osteotomized (cut) and repositioned onto the anterior glenoid rim. It is typically secured with two screws. The transferred bone effectively extends the glenoid articular surface, compensating for bone loss. Furthermore, the conjoint tendon, which remains attached to the transferred coracoid, acts as a dynamic sling, compressing the humeral head into the glenoid when the arm is abducted and externally rotated, thereby preventing dislocation.
• Indications for Latarjet:
  • Significant anterior glenoid bone loss (typically >20-25% of the glenoid width).
  • Recurrent dislocations despite a previous Bankart repair (failed soft tissue repair).
  • Large, engaging Hill-Sachs lesions.
  • Patients involved in high-risk contact or overhead sports with significant instability.
  • Generalized ligamentous laxity or hyperlaxity contributing to instability.
• Advantages and Disadvantages:
  • Advantages: Significantly lower recurrence rates, especially in cases with bone loss, addresses both bone and soft tissue deficiencies, and provides a robust mechanical block.
  • Disadvantages: More invasive than arthroscopic Bankart, potential for nerve injury (e.g., musculocutaneous nerve), non-union of the bone block, or hardware-related complications.

Key Differences and Decision Factors

The choice between a Bankart repair and a Latarjet procedure hinges on a thorough assessment of the patient's specific injury pattern, activity level, and the extent of bone loss.

• Primary Issue Addressed:
  • Bankart: Primarily addresses soft tissue detachment (labral tear and capsular avulsion) with intact or minimal bone loss.
  • Latarjet: Primarily addresses significant bone loss from the glenoid and/or humeral head, often with associated soft tissue deficiency.
• Mechanism of Stability:
  • Bankart: Restores the anatomical integrity of the labrum and capsuloligamentous complex, deepening the socket and providing static stability.
  • Latarjet: Provides both a static bone block that extends the glenoid and a dynamic sling effect from the transferred muscles, offering superior stability in complex cases.
• Surgical Complexity/Invasiveness:
  • Bankart: Most commonly arthroscopic, generally less invasive.
  • Latarjet: Historically open, though arthroscopic techniques are evolving; typically considered more involved due to bone transfer.
• Recurrence Rates:
  • Bankart: Higher recurrence rate in patients with significant bone loss or high-risk activities.
  • Latarjet: Generally lower recurrence rates, especially in cases with bone loss, making it the preferred choice for complex instability.
• Rehabilitation Considerations: Both procedures require a period of immobilization followed by progressive range of motion and strengthening. Latarjet may have an emphasis on bone healing, while Bankart focuses on soft tissue integration.

Rehabilitation Considerations

Regardless of the procedure, a structured and progressive rehabilitation program is crucial for optimal outcomes.

• Phase 1: Immobilization and Protection (0-6 weeks): Focus on protecting the repair, pain management, and gentle passive range of motion.
• Phase 2: Early Mobility and Strengthening (6-12 weeks): Gradually increase range of motion and begin isometric and light resistance exercises.
• Phase 3: Advanced Strengthening and Proprioception (12-24 weeks): Progress to more challenging resistance exercises, incorporate functional movements, and improve neuromuscular control.
• Phase 4: Return to Activity/Sport (6+ months): Sport-specific drills and gradual return to full activity, contingent on strength, stability, and surgeon clearance.

Conclusion

Both Bankart repair and Latarjet procedures are effective treatments for shoulder instability, but they are indicated for different underlying pathologies. The Bankart repair is the preferred choice for soft tissue-only lesions with minimal bone loss, aiming to restore the shoulder's native anatomy. The Latarjet procedure is reserved for more complex cases involving significant bone loss, recurrent instability after previous repairs, or high-risk athletes, providing a robust biomechanical solution. The decision for either surgery is highly individualized, made by an orthopedic surgeon based on detailed imaging, clinical examination, and patient-specific factors.