Bankart repair for unstable dislocating shoulders: Surgery to anatomically and securely repair the torn anterior glenoid labrum and capsule without arthroscopy can lessen pain and improve function for active individuals.

Figure 5 - Axillary incision leaves a small scar

Figure 6 - Anatomical repair for ligaments and labrum

Figure 7 - Open repair

Considering surgery

Goal of surgery

Surgery to repair instability can help restore the function and comfort of unstable and dislocating shoulders. The goal of surgery for traumatic anterior instability is to repair the ligaments and the labrum that are torn from the lower front part of the glenoid socket. The opportunity for a secure and anatomic repair is best when the repair is done through open (not arthroscopic) surgery. As shown in the figure, the incision is made in the normal skin creases around the shoulder, leaving a minimal surgical scar.

Surgery for traumatic vs. atraumatic instability

Figure 6 shows how ligaments and the labrum can be anatomically repaired so that their function is restored. If there is a substantial loss of the bone of the anterior glenoid lip, this can be restored by fixing a bone graft from the iliac crest (hip bone at the belt line) outside the shoulder joint capsule.

When performed by an experienced shoulder surgeon, surgery for traumatic anterior instability has an excellent chance of restoring stability to the shoulder.

For traumatic posterior instability, a similar repair can be carried out through an incision over the back of the shoulder.

For atraumatic instability, exercises are the first choice in treatment. When these are not successful, the surgical approach needs to be tailored to the specific circumstances. If the primary direction of atraumatic instability is posterior, a posterior glenoid osteoplasty provides a robust reconfiguration of the shape of the glenoid so that it provides additional stability. For multidirectional instability, a procedure to build up the glenoid labrum may increase the effective concavity of the glenoid socket. For patients with ligamentous hyperlaxity (excessive range of motion of the shoulder) a ligament and capsule tightening procedure is considered. This has been done with open surgery (known as a capsular shift) and by arthroscopic surgery (for example by burning and scarring the capsule).

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.

What happens without surgery?

Surgical options

For traumatic anterior shoulder instability, the most dependable results have been obtained with an open (not arthroscopic) repair that securely restores the attachment of the labrum and the ligaments to the edge of the glenoid socket, as shown in the figure.

While arthroscopic approaches to surgical repair have been developed, the chance of persistent instability is less when the repair is carried out by open surgery. This may be due to the increased difficulty in restoring the normal anatomy and in achieving a secure repair using arthroscopic surgery. The return to activities after open surgery is at least as fast as with arthroscopic repair. The cosmetic appearance of the shoulder after open surgery done through the natural skin creases is at least as good as that after arthroscopic repair.

For shoulders in which the bone of the anterior (front) lip of the glenoid socket is lacking, bone grafting can be used to restore the configuration of the socket.

For shoulders in which the back of the socket is too flat, a reshaping of the socket (posterior glenoid osteoplasty) can be used.

For shoulders in which the soft tissues provide insufficient stability to the shoulder, procedures can be considered to tighten the ligaments and capsule and to thicken the glenoid labrum (the "O" ring that surrounds the surface of the socket).

Effectiveness

In the hands of an experienced surgeon, repair for recurrent traumatic 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.

The results of surgery for the more unusual types of instability depend on the specifics of the shoulder problem and the type of surgery performed. Patients should discuss the details of the problem and the proposed procedure with the surgeon.

Urgency

Surgery for instability is not an emergency. Such a repair is an elective procedure that can be scheduled when circumstances are optimal. The patient has time to become informed and to select an experienced surgeon.

Before surgery is undertaken, the patient needs to:

1. be in optimal health,
2. understand and accept the risks and alternatives of surgery, and
3. understand the post operative rehabilitation program.

Surgery for shoulder instability should be performed when conditions are optimal. Particularly in the case of atraumatic instability, an extended effort at non-operative management is suggested. This is because there is not a specific surgical repair for a specific injury. On the other hand, in the case of recurrent instability or apprehension after an injury, surgery can be performed whenever it becomes evident that exercises are not effective in restoring the shoulder's ability to function. Usually a 6- to 12-week try at strengthening exercises is sufficient to determine whether exercises are likely to be effective.

Risks

The risks of surgery for shoulder instability include but are not limited to the following:

• infection
• injury to nerves and blood vessels
• inability to carry out the planned repair
• stiffness of the joint
• tear of the rotator cuff
• pain
• persistent instability
• the need for additional surgeries

There are also risks associated with anesthesia, including death. An experienced shoulder surgery team will use special techniques to minimize these risks, but cannot totally eliminate them.

Managing risk

Many of the risks of surgery for instability can be effectively managed if they are promptly identified and treated. Infections may require a wash out in the operating room and subsequent antibiotic treatment. Blood vessel or nerve injury may require repair. Stiffness may require exercises or additional surgery. Persistent instability may require the consideration of additional surgery.

If the patient has questions or concerns about the course after surgery, the surgeon should be informed as soon as possible.

10 surgery questions for your surgeon before having surgery

Surgery for shoulder dislocations at the University of Washington, Department of Orthopaedics and Sports Medicine, Seattle, Washington

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