Bony Bankart lesions: epidemiology of 790 cases from the Swedish Fracture Register

doi:10.21203/rs.3.rs-2868151/v1

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Bony Bankart lesions: epidemiology of 790 cases from the Swedish Fracture Register

https://doi.org/10.21203/rs.3.rs-2868151/v1

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Background: A bony Bankart lesion is a common type of fracture associated with anterior shoulder dislocation. This type of fracture could directly affect the stability of the shoulder by reducing the glenoid joint-contact area.

The aim of this study was to report and describe epidemiological data relating to bony Bankart lesions in Sweden using the Swedish Fracture Register. The purpose is to evaluate age and sex distribution in the population with BB lesions, its impact on treatment strategy and to analyse patient-reported outcomes.

Methods: An epidemiological descriptive study based on data from the national Swedish Fracture Register. The inclusion criteria were all patients with a unilateral bony Bankart lesion registered between April 2012 and April 2019. The patients’ specific data (age, sex, type and time of injury, treatment option and patient-reported outcomes) were extracted from the Swedish Fracture Register database.

Results: A total of 790 unilateral bony Bankart fractures were identified. The majority of the patients were male (58.7%). The mean age ± SD for all patients at the time of injury was 56.3 ± 16.1 years. Females had a higher mean age, 64.3 ± 12.8, compared with males, 50.7 ± 15.7.

Most of the BB lesions, 91.8% (662), were registered as a low-energy trauma. More than two-thirds of all cases, 509 patients (70.1%), were treated non-surgically, 217 patients (29.9%) were treated surgically, while, in 17 patients (7.8% of all surgically treated patients), the treatment was changed from non-surgical to surgical. Surgical treatment was chosen for 34% (146) of males and for 23% (71) of females. Patient quality of life decreased slightly in both surgically and non-surgically treated groups one year after BB injury.

Conclusion: This national register-based study provides detailed information on the epidemiology, choice of treatment and patient-reported outcomes in a large cohort of bony Bankart lesions. Most BB lesions affected males between 40 and 75 years after low-energy falls and were treated non-surgically.

bony Bankart

glenoid rim fracture

anterior shoulder instability

The glenohumeral joint is one of the most mobile joints in the human body and is therefore one of the most unstable (1). The most common type of glenohumeral instability is anterior, accounting for more than 90% of all shoulder dislocations (2, 3). One of the most common associated injuries, following anterior shoulder dislocation, is the Bankart lesion (2, 4). This is an injury to the anterior-inferior glenoid labrum with or without a bone fragment and it is usually associated with an inferior glenohumeral ligament (IGHL) complex injury (4). A Bankart lesion, which includes a bone fragment, is usually called a bony Bankart (BB) (5). A BB occurs when the injury to the anterior glenoid labrum extends into the bony glenoid margin, creating a fracture line through the anterior-inferior part of the glenoid (6). Erosion of the anterior glenoid rim or BB is a common injury and occurs in between 30% and 41% after primary anterior dislocation (7–10). BB fragments can differ in size and form and can directly affect the stability of the shoulder by reducing the joint-contact area and congruency (11–13).

There is ample evidence of isolated soft-tissue Bankart lesions and risk factors predisposing to first-time or recurrent traumatic anterior shoulder dislocations (14). It has been reported that, in younger age groups, this type of injury is more common in males, especially between 20 and 30 years of age, whereas, after the age of 50, it is more common among women (2, 15, 16). The risk of recurrence after an anterior shoulder dislocation is high, particularly in younger patients, and can lead to osteoarthritis (OA) later in life (17). Young patients with no concurrent fracture at the time of the primary shoulder dislocation have been shown to have a high risk of recurrence (18). Moreover, the recurrence rate is highest in individuals aged ≤ 20 years, where nearly 50% will require surgical stabilisation at a later stage (19).

There is a lack of consensus and only limited data in the literature related to the treatment strategy for a BB injury. It is known that surgical treatment for large BB fragments (more than 20% of glenoid width) plays a crucial role in improving patients’ clinical outcomes (20) and it has been shown to be a successful treatment strategy for athletes (21). On the other hand, it has also been shown that even large and displaced glenoid rim fractures can be treated non-surgically (22, 23), especially when the glenohumeral joint is concentrically reduced (20), (24).

As a result, there is a need to collect more data in order to produce evidence relating to the most used treatment strategy for and epidemiology of BB lesions. High-quality epidemiological data could increase our understanding of this injury. This knowledge can be used for further studies in terms of fracture types in relation to treatment options.

BB injuries are relatively rare, especially in small to medium-sized hospitals. Large registers with good quality data input need to be used in order to collect high-quality epidemiological data.

The aim of this study is to report epidemiological data relating to BB lesions in Sweden using the Swedish Fracture Register. The purpose is to evaluate age and sex distribution in the population with BB lesions and its impact on treatment strategy and to analyse patient-reported outcomes.

Data from the Swedish Fracture Register (SFR) were extracted. The SFR was developed in 2009–2010 (25). Data registration began in 2011 at Sahlgrenska University Hospital. Since 2012, more departments in Sweden have been invited to join and, in 2021, full national coverage was achieved among the 54 orthopaedic and trauma departments in the country. More than 300,000 fractures from approximately 40 of 55 Swedish departments were registered in the SFR (26) by 2018.

In the SFR, the modified Euler and Rüedi classification, edited by Habermeyer in 1996, is used to classify different types of glenoid fracture (27). Data are reported to the register by the treating physician at the emergency department or the orthopaedic department. We defined a BB injury as all patients with a registered type D1a injury according to the modified Euler and Rüedi classification (Table 1).

Tab. 1 Modified Euler and Rüedi classification of scapular fractures

Data for these patients from 1 April 2012 to 1 April 2019 in the SFR were extracted.

Epidemiological data in terms of sex, age, cause of injury and type of treatment were collected from the SFR and analysed.

Patients are classified based on trauma mechanism, as high- or low-energy trauma, based on the criteria from the ATLS guidelines (28). A low-energy trauma is usually associated with injury mechanisms such as falling from standing height or less.

The type of treatment was divided into three groups: non-surgical, primary surgical or secondary surgical (when a primary decision to perform non-surgical treatment had been revised at an early stage).

The EQ-VAS score was used to evaluate patient-related outcomes (29). This score ranges from 0 to 100, with 0 denoting the worst and 100 the best health state imaginable. The first measurement referred to as PROM0 presents patient quality of life before the injury and the second measurement, PROM1, presents it one year after the injury. The first PROM was obtained using the recall technique during the first weeks after the fracture occurred.

The study was approved by Ethical Committee confirming that all methods were carried out in accordance with relevant guidelines and regulations.

Statistics

The IBM SPSS Statistics, Version 2, statistical software (SPSS Inc., Chicago, USA) was used. Categorical variable numbers (n) are presented in per cent. For continuous variables, the mean ± standard deviation (SD)/median value (range) in numbers are presented, depending on whether or not data were normally distributed. For comparisons between groups, Fisher’s exact test (lowest one-sided p-value multiplied by 2) was used for dichotomous variables.

If no exact limits could be computed, the asymptotic Wald confidence limits with continuity correction were calculated instead. For comparisons within groups, the Wilcoxon Signed Rank test was used.

Seven hundred and ninety patients with unilateral BB injuries were identified. Only one patient with a bilateral BB injury was reported and was not included in this study.

Epidemiology

Of 790 patients, 58.7% were males (Table 2). The mean age ± SD for all patients at the time of injury was 56.3 ± 16.1 years (Fig. 1). Females had a higher mean age, 64.3 ± 12.8, compared with males, 50.7 ± 15.7.

Table 2

Mean age and sex at the time of injury
Variable	n = 790
Age¹ mean (SD) median (min-max)	56.3 (16.1) 57 (12–95)
Gender, n (%)
Female	326 (41.3)
Male	464 (58.7)
¹Age at the time of injury

In 91.2% (721) of the cases, the trauma energy level was defined. Most of the BB lesions, 91.8% (662), were registered as a low-energy trauma.

A fall from the same level was the most common cause of injury or 62.5% (494), while a fall from a height occurred in 10.5% (83) of the patients. Traffic accidents, including falls from bicycles and from motorcycles, caused 3.7% (29) and 1.5% (12) of all injuries, respectively.

BB lesions occurred in the right shoulder in 51.1% cases (404) and in the left shoulder in 48.9% (386).

For the distribution of injuries over the year, see Table 3. Thirty-five per cent of the injuries occurred during the first quarter of the year.

Table 3 Distribution of BB lesions per month.

Treatment strategy

More than two-thirds of all cases with registered treatment data (missing value in 56 cases), 509 patients (70.1%), were treated non-surgically, 217 patients (29.9%) were treated surgically, while, in 17 patients (7.8% of all surgically treated patients), the treatment was changed from non-surgical to surgical, mostly due to recurrent instability of the shoulder (Fig. 2). The mean age of the patients in the surgical group was similar to that of the non-surgical group (57.1 versus 53.8) (Table 4).

Table 4

Mean age of the patients for different treatment options
Variable	Non-surgical treatment n = 509	Primary surgical treatment n = 200	Secondary surgical treatment n = 17
Age¹ mean (SD) median (min;max)	57.1 (16.3) 58 (15; 95)	53.8 (15.1) 55 (19;83)	56.9 (15.2) 56(21;79)
¹Age at the time of injury

Surgical treatment was chosen for 34% (146) of males and 23% (71) of females (Table 5).

Table 5

Treatment type distribution in relation to sex.
Variable	Men (n = 464)	Women (n = 326)
Treatment type
Non-surgical treatment	279 (65.2%)	230 (75.2%)
Primary surgical treatment	137 (32.0%)	63 (20.6%)
Secondary surgical treatment	9 (2.1%)	8 (2.6%)
Missing	36	20

BB lesions induced by high-energy trauma were more often treated surgically (Table 6, Fig. 3) and 48% (26) of the patients in the high-energy trauma group were treated surgically, compared with 29% (175) in the low-energy trauma group.

Table 6

Choice of treatment for high- and low-energy-induced BB lesions
Variable	Non-surgical treatment (n = 459)	Surgical treatment (n = 201)	p-value	Difference between groups Mean (95% CI)
Type of injury
High energy	28 (6.1%)	26 (12.9%)		-6.8 (-12.3; -1.3)
Low energy	431 (93.9%)	175 (87.1%)	0.0067	6.8 (1.3; 12.3)

Patient quality of life decreased slightly in both surgically and non-surgically treated groups one year after BB injury (Table 7).

Table 7

Quality of life changes in the non-surgically and surgically treated groups
	Non-surgically treated group (n = 509)
Variable	Mean (SD) Median (min; max) n=	p-value within group
EQVAS (prom0)	83.9 (18.6) 90.0 (0.0; 100.0) n = 185
EQVAS (prom1)	79.1 (18.7) 80.0 (0.0; 100.0) n = 100
EQVAS difference between pro0 and pro1	-4.70 (20.86) -5.00 (-80.00; 80.00) n = 88	< .0001

	Surgically treated group (n = 217)
Variable	Mean (SD) Median (min; max) n=	p-value within group
EQVAS (prom0)	86.2 (18.3) 90.0 (1.0; 100.0) n = 84
EQVAS (prom1)	83.6 (13.5) 85.0 (40.0; 100.0) n = 47
EQ-VAS difference between prom0 and prom1	-4.07 (18.62) -5.00 (-50.00; 57.00) n = 44	0.031

The most important benefit of this study is the reporting of many epidemiological variables of an uncommon injury. This was made possible by the large data sample in the SFR.

The present study shows that BB lesions are more common in the population over 50 years of age. This is contrary to the soft-tissue Bankart lesion which usually occurs in the young population (30). One reason why a BB lesion is more typical in older patients could be biomechanical and biological changes leading to reduced elasticity in the joint capsule (31, 32).

There was a predominance of BB lesions in males (58.7%), which is much lower when compared with the soft-tissue Bankart lesions (75%) in the same group (30). A simple, low-energy fall was one of the most common causes of this injury. This study further reveals a seasonal variation in the distribution of BB lesions. This type of injury is more common during the winter period, possibly related to slippery conditions.

Most BB lesions were treated non-surgically, particularly in females. This could be related to fracture size, the position of the fracture related to differences in ligament laxity, bone quality or other factors (32, 33). The age of the patients did not affect the treatment strategy.

A higher prevalence of non-surgical treatment could be related to the relatively low degree of dislocation of the BB fragment, a low complication rate and good bone-to-bone healing potential (23, 34, 35). Olds et al. reported a low risk of recurrent instability in the presence of a BB lesion (14). Robinson et al. reported an increased risk of recurrence in the presence of a glenoid rim fracture during the first six weeks following a first-time traumatic anterior shoulder dislocation in only 3.2% of patients(36).

One-third of BB patients (27.5%, n = 217/790) were treated surgically, which is similar to previously published data on the treatment of soft-tissue Bankart lesions (37, 38). In the present study, we found that the majority of the BB lesions were due to low-energy trauma and were mostly treated non-surgically (71% of all patients), compared with high-energy BB lesions, which were treated surgically to a greater extent. Almost half the patients (48%) with BB lesions induced by high-energy trauma were treated surgically, which could be related to more dislocated and larger BB fragments due to high-energy forces.

It is difficult to draw any definitive conclusion in terms of patient quality of life one year after injury due to the low response rate. However, quality of life appears to decrease slightly in both groups, especially in the non-surgically treated group. These results were statistically significant, albeit not clinically relevant, since the minimal clinically important change on the EQ-VAS has been shown to supersede the attained values (39).

Further, we compared the data with previously published epidemiological studies based on the SFR analysing other types of fracture (40–42). Some differences and common features were found. Most fractures had a similar seasonal variation with an increased number of injuries during the winter months and a higher incidence after the age of 40 years. The main difference between studies was the distribution of gender. The majority of BB lesions occurred in males and decreased dramatically after the age of 75 years compared with other fractures (40–42).

These results may suggest that BB injuries are probably not related to fragility or reduced bone mineral density.

There are several limitations to the present study. One of them was the low response rate in PROMS, especially at the one-year follow-up. Another limitation is that the modified Euler and Rüedi classification could lead to misclassification, causing difficulties for surgeons to classify the fracture in some non-standard cases. The simplicity of this classification that has been used to classify different types of glenoid fracture in the SFR is an advantage, compared with the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification of scapular fractures from 2013. However, it is incomplete and can make it difficult to distinguish isolated anterior glenoid fractures with a large anterior fragment from BB lesions in several patients (43).

One of the main strengths of this study is the large amount of data from the Swedish Fracture Register, including non-surgically treated fractures. Our register-based study provides reliable data on BB occurrence in Sweden.

This national register-based study provides detailed information on the epidemiology, choice of treatment and patient-reported outcomes in a large cohort of bony Bankart lesions. Most BB lesions affected males between 40 and 75 years of age after low-energy falls and were treated non-surgically.

Bony Bankart (BB)

inferior glenohumeral ligament (IGHL)

osteoarthritis (OA)

Swedish Fracture Register (SFR)

Ethic approval:

In Sweden, informed consent is not required in order to be part of a national registry such as the one we have used in the present study. This is clearly stated in Swedish law. The following paragraphs underline this fact. (Chapter 7 of the Swedish Patient Data Act (2008:355)

This is also part of the ethical approval for the present study which has been approved by the Swedish ethical review authority so thereby the waiving of the consent is also approved by the Swedish ethical review authority. The present study was approved by Gothenburg Ethical Committee on 28 November 2018 (Dnr: 825-18).

All patients who are registered in the SFR receive according to Swedish legislation information about their registration and are given the option of withdrawing (opt-out). Written consent is not needed for registering patients in national quality registers in Sweden. The data from SFR were fully anonymized before data analysis begun.

The study was approved by Ethical Committee confirming that all methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication: not applicable

Availability of data: The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interest

Funding: No

Authors’ contributions: All authors contributed to design, planning, data collection and writing of manuscript.

Acknowledgement: not relevant

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No competing interests reported.

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Bony Bankart lesions: epidemiology of 790 cases from the Swedish Fracture Register

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Abstract

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Background

Materials and methods

Statistics

Results

Epidemiology

Treatment strategy

Discussion

Conclusion

Abbreviations

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