Bankart Repair: Procedure, Recovery, and Risks

How is Bankart repair done?

A Bankart repair is a surgical procedure primarily performed to stabilize the shoulder joint after recurrent anterior dislocations by reattaching the torn labrum to the glenoid bone, typically using arthroscopic or open techniques.

Understanding the Bankart Lesion

The shoulder is a ball-and-socket joint, with the head of the humerus (ball) articulating with the glenoid fossa (socket) of the scapula. Surrounding the glenoid is a ring of fibrous cartilage called the labrum, which deepens the socket and provides stability. A Bankart lesion occurs when the anterior-inferior (front-bottom) portion of this labrum tears away from the glenoid bone, often along with the anterior capsule and ligaments. This injury is most commonly caused by an anterior shoulder dislocation, especially in younger, active individuals, and it significantly compromises the shoulder's stability, making it prone to recurrent dislocations.

Indications for Bankart Repair

Surgical Bankart repair is typically recommended for individuals experiencing recurrent anterior shoulder instability following a traumatic dislocation where a Bankart lesion has been identified. While initial dislocations may be managed non-surgically, persistent instability, pain, or functional limitations despite conservative treatment (e.g., physical therapy) are strong indicators for surgical intervention. The goal of the surgery is to restore the normal anatomy and stability of the shoulder joint, preventing future dislocations.

Pre-Operative Preparation

Before a Bankart repair, patients undergo a thorough evaluation. This typically includes:

• Clinical Examination: A physical assessment by an orthopedic surgeon to evaluate shoulder stability, range of motion, and pain.
• Imaging Studies: Magnetic Resonance Imaging (MRI), often with contrast (arthrogram), is crucial for visualizing the labral tear and assessing the extent of damage to surrounding structures, including potential bone loss (e.g., Hill-Sachs lesion on the humeral head or bony Bankart lesion on the glenoid). CT scans may also be used to assess bone loss.
• Patient Education: Detailed discussions about the procedure, potential risks, expected recovery timeline, and post-operative rehabilitation protocol.
• Pre-habilitation: In some cases, a short course of physical therapy may be recommended to optimize shoulder mobility and strength before surgery.

The Surgical Procedure: How It's Done

Bankart repair can be performed using either an arthroscopic (minimally invasive) or open surgical technique. The choice depends on the surgeon's preference, the complexity of the lesion, and the presence of associated injuries (e.g., significant bone loss).

• Anesthesia: The procedure is typically performed under general anesthesia, often supplemented with a regional nerve block (e.g., interscalene block) to provide pain relief post-operatively.
• Patient Positioning: The patient is usually positioned in either a beach chair position (semi-seated) or a lateral decubitus position (lying on their side), allowing optimal access to the shoulder joint.

Arthroscopic Bankart Repair (Minimally Invasive)

This is the most common approach due to its smaller incisions, reduced pain, and faster initial recovery.

• Incision Points (Portals): Several small incisions (typically 0.5-1 cm) are made around the shoulder. These are called portals.
• Arthroscope Insertion: An arthroscope, a small camera on a thin tube, is inserted through one portal to visualize the inside of the joint on a monitor.
• Fluid Infusion: Sterile saline solution is continuously pumped into the joint to expand it and provide a clear view.
• Instrument Insertion: Specialized surgical instruments are inserted through other portals to perform the repair.
• Debridement and Preparation: The torn edges of the labrum and glenoid bone are carefully debrided (cleaned) to create a bleeding surface, promoting healing.
• Labral Reattachment: Small, bioabsorbable or titanium suture anchors are drilled into the anterior rim of the glenoid bone. Strong sutures attached to these anchors are then passed through the torn labrum.
• Tensioning and Knot Tying: The sutures are carefully tensioned and tied, pulling the labrum back into its anatomical position and securely reattaching it to the glenoid. This effectively restores the bumper function of the labrum.
• Capsular Plication (if needed): If the joint capsule is stretched or redundant, the surgeon may also perform a capsular plication (tightening) to further enhance stability.
• Final Inspection: The surgeon thoroughly inspects the repair and the overall stability of the joint.

Open Bankart Repair (Traditional)

This approach involves a larger incision and direct visualization of the joint. It may be chosen for complex cases, revision surgeries, or when significant bone loss on the glenoid requires a bone graft procedure (e.g., Latarjet procedure combined with Bankart repair).

• Incision: A single, larger incision (typically 5-10 cm) is made on the front of the shoulder, usually along the deltopectoral groove.

• Muscle Dissection: Muscles, such as the deltoid and pectoralis major, are carefully separated or retracted to gain access to the shoulder joint capsule.

• Direct Visualization: The surgeon has a direct view of the glenoid and labrum.

• Repair: Similar to the arthroscopic technique, the torn labrum is prepared, and suture anchors are used to reattach it to the glenoid bone.

• Capsular Closure: The joint capsule is meticulously repaired and tightened if necessary.

• Layered Closure: The muscles are reapproximated, and the incision is closed in layers.

• Closure: Regardless of the technique, once the repair is complete, the instruments are removed, and the small arthroscopic portals or the larger open incision are closed with sutures or surgical tape, followed by a sterile dressing.

Post-Operative Care and Rehabilitation

Post-operative care is critical for the success of a Bankart repair.

• Immobilization: The arm is typically immobilized in a sling for a period of 4-6 weeks to protect the healing repair.
• Pain Management: Pain medication will be prescribed.
• Physical Therapy: A structured and progressive physical therapy program is essential. It typically progresses through several phases:
  • Phase 1 (Protection): Focus on protecting the repair, pain control, and gentle passive range of motion.
  • Phase 2 (Early Motion): Gradual introduction of active-assisted and active range of motion exercises.
  • Phase 3 (Strengthening): Progressive strengthening of the rotator cuff and scapular stabilizers.
  • Phase 4 (Advanced Strengthening & Return to Activity): Sport-specific drills, plyometrics, and functional training, leading to a gradual return to full activity.
• Adherence: Strict adherence to the surgeon's and physical therapist's instructions is paramount to prevent re-injury and optimize recovery.

Potential Risks and Complications

While Bankart repair is generally safe and effective, like any surgical procedure, it carries potential risks, including:

• General Surgical Risks: Infection, bleeding, adverse reaction to anesthesia, blood clots.
• Specific Complications:
  • Stiffness (Adhesive Capsulitis): Restricted shoulder movement.
  • Nerve Damage: Injury to nerves around the shoulder, leading to weakness or numbness.
  • Recurrent Instability/Re-dislocation: Though the goal is to prevent this, failure of the repair or re-injury can occur.
  • Hardware Complications: Irritation or breakage of suture anchors (rare).
  • Chronic Pain: Persistent pain despite successful repair.

Prognosis and Recovery Timeline

The prognosis after a Bankart repair is generally excellent, especially for preventing recurrent dislocations. Full recovery can be a lengthy process, typically taking 6 to 12 months or even longer for athletes returning to overhead or contact sports. Factors influencing recovery include the patient's age, the extent of the initial injury, the presence of associated injuries, adherence to rehabilitation, and overall health. A successful Bankart repair, coupled with diligent rehabilitation, allows most individuals to regain full shoulder function and stability, enabling them to return to their desired activities safely.