Arthroscopic Bankart Repair for Unstable Dislocating Shoulders

What it is

The normal shoulder is a marvel of mobility and stability. It provides more motion than any other joint in the human body yet the humeral head (ball of the shoulder joint) remains precisely centered in the glenoid (the socket of the joint) throughout the wide range of shoulder activities. One of the main stabilizing mechanisms is concavity compression in which the head of the humerus is held into the glenoid concavity by the action of the rotator cuff (much like a golf ball is held into the concavity of a golf tee).

The glenoid labrum and the ligaments can be torn when the arm is forced backwards allowing the humeral head to dislocate from the glenoid. If the labrum and the ligaments do not heal the shoulder may continue to be unstable allowing the ball to slip from the center of the glenoid even with minimal force.

When recurrent shoulder dislocations or feeling of instability interfere with the comfort and security of the shoulder a repair of the ligaments and labrum by an experienced shoulder surgeon can usually restore the stability of the joint.

The most common form of ligament injury is the Bankart lesion in which the ligaments are torn from the front of the socket. A solid surgical repair requires that the torn tissue be sewn back to the rim of the socket. Failure to secure this lesion solidly can result in failure of the repair.

If the glenoid bone is deficient the shoulder may benefit from a surgery to restore the lost bony anatomy.

Cause

A Bankart lesion is very common when an individual sustains a shoulder dislocation. As the shoulder pops out of joint, it often tears the labrum. The tear is to the inferior glenohumeral ligament which is part of the labrum. When the inferior glenohumeral ligament is torn, this is called a Bankart lesion.

Symptoms

• A feeling of the joint being instable
• Dislocations occurring repeatedly
• Catching sensations
• Aching of the shoulder
• A feeling that the shoulder may dislocate again

Surgical Procedure

This arthroscopic procedure is used to repair a detached labrum. The labrum is a thick band of cartilage attached to the glenoid bone. It lines the shoulder socket and helps keep the ball of the humerus in place. In this procedure, the surgeon will reattach the labrum to the glenoid.

Length of surgical repair for shoulder dislocations

The procedure usually takes approximately one hour but the preoperative preparation and the postoperative recovery may add a few more hours to this time. Patients often spend two hours in the recovery room and about two days in the hospital after surgery.

Who should consider surgical repair for shoulder dislocations?

Surgery is considered for patients with:

• recurrent instability or feelings of unsteadiness or apprehension after a traumatic shoulder dislocation or
• atraumatic instability that has not responded to a well-conducted rehabilitation program.

Effectiveness

In the hands of an experienced surgeon repair for recurrent instability has an excellent chance of restoring much of the lost comfort and function to the unstable shoulder. With a good rehabilitation effort and with the avoidance of additional injuries the result of the surgery should last for a long time.

Anesthetic

Shoulder instability surgery may be performed under a general anesthetic or a brachial plexus nerve block. A brachial plexus block can provide anesthesia for several hours after the surgery. The patient may wish to discuss their preferences with the anesthesiologist before surgery.

Preparation

Surgery for instability is considered for healthy and motivated individuals in whom shoulder dislocations or apprehension interfere with shoulder function. Successful surgery for instability depends on a partnership between the patient and the experienced shoulder surgeon. The patient’s motivation and dedication are important elements of the partnership. Patients should optimize their health so that they will be in the best possible condition for this procedure. Smoking should be stopped a month before surgery and not resumed for at least three months afterwards–ideally never. This is because smoking interferes with healing of the repair. All heart lung kidney bladder tooth or gum problems should be managed before surgery. Any infection may be a reason to delay the operation.

The patient’s shoulder surgeon needs to be aware of all health issues including allergies and non-prescription and prescription medications being taken. Some of these may need to be modified or stopped. For instance aspirin and anti-inflammatory medication may affect the way the blood clots. The skin around the shoulder must be clean and free from sores and scratches.

Before surgery patients should consider the limitations alternatives and risks of surgery. Patients should also recognize that the result of surgery depends in large part on their efforts in rehabilitation after surgery.

The patient needs to plan on being less functional than usual for up to twelve weeks after the shoulder repair. Lifting pushing pulling and some activities of daily living can place stresses on the repair. Performing usual work or chores may be difficult during this time. Plans for necessary assistance need to be made before surgery. For people who live alone or those without readily available help arrangements for home help should be made well in advance.

Hospital stay

After surgery the patient spends about an hour in the recovery room. A drainage tube is sometimes used to remove excess fluid from the surgical area. The drain is usually removed on the second day after surgery. Bandages cover the incision. They are usually changed the second day after surgery.

Hospital discharge

Patients are discharged as soon as:

• the incision is dry
• the shoulder is comfortable with oral pain medications
• the patient can perform the range of motion exercises
• the patient feels comfortable with the plans for managing the shoulder and
• the home support systems for the patient are in place.

Discharge is usually on the second day after surgery.

Physical therapy

A progressive rehabilitation program after instability surgery is critical for achieving optimal shoulder function.

Instable shoulders may become stiff after surgery so early protected motion is often suggested. However the repair needs to be protected from re-injury especially during the healing period. Thus the surgeon will often prescribe limited early motion for three to six weeks and then strengthening exercises for a second six-week period.

Rehabilitation options

It is often most effective for patients to carry out their own exercises so that they are done frequently effectively and comfortably. Usually a physical therapist or the surgeon instructs the patient in the exercise program and advances it at a rate that is comfortable for the patient.

For the first six weeks after surgery emphasis is placed on protected motion. For the second six weeks emphasis is placed on strengthening exercises to so that strong muscles will protect the shoulder as it returns to normal activities.

The exercises that may be used to develop strength and flexibility after the first six weeks following surgery; however the surgeon must be consulted for the specifics on each case.

Once the range of motion and strength goals are achieved the exercise program can be cut back to a minimal level. However gentle stretching is recommended on an ongoing basis.

Examples of shoulder exercises

Patients are almost always satisfied with the increases in range of motion comfort and function that they achieve with the exercise program. If the exercises are uncomfortable difficult or painful the patient should contact the surgeon promptly.

Stressful activities and activities with the arm in extreme positions must be avoided until healing is almost complete–often for three months after the surgery.

In general the exercises are best performed by the patient at home. Occasional visits to the surgeon or therapist may be useful to check the progress and to review the program.

The surgeon and therapist should be able to provide the information on the usual cost of the rehabilitation program. The program is quite cost-effective because it is heavily based on home exercises.

This is a safe rehabilitation program with little risk.

Returning to ordinary daily activities

In general patients are able to perform gentle activities of daily living with the operated arm at the side starting two to three weeks after surgery. Walking with the arm protected is strongly encouraged. Driving should wait until the patient can perform the necessary functions comfortably and confidently. This may take up to one month if the surgery has been performed on the right shoulder because of the increased demands on the right shoulder for shifting gears.

With the consent of their surgeon patients can often return to activities such as swimming golf and tennis at six weeks after their surgery.

Patients should avoid activities that involve major impact (chopping wood contact sports sports with major risk of falls) or heavy loads (lifting of heavy weights heavy resistance exercises) until three months after surgery. and until the shoulder has excellent strength and range of motion–essentially equivalent to the opposite side. In this way the risk of re-injury is minimized.

Summary of surgical repair for shoulder dislocations for shoulder dislocations

Shoulder instability surgery can help restore comfort and function to shoulders with dislocations instability or apprehension. In the hands of an experienced surgeon shoulder instability surgery can be a most effective method for restoring comfort and function to a shoulder with recurrent instability dislocations or apprehension in a healthy and motivated patient. The best results are obtained when the surgery repairs a shoulder injury which resulted a tear of the labrum and ligaments from the glenoid socket. In this situation the surgeon has a good opportunity to restore the normal anatomy of the shoulder. Pre-planning and persistent rehabilitation efforts will help assure an optimal result for the patient.