Recurrent Shoulder Dislocation: Bankart Repair, Latarjet Procedure, and Recovery

Understanding Surgical Interventions for Recurrent Shoulder Dislocation

For individuals experiencing recurrent shoulder dislocations, surgical intervention is often recommended to restore stability and prevent future episodes. The primary surgical procedures are the Bankart Repair (for soft tissue damage) and the Latarjet Procedure (for significant bone loss).

Introduction to Recurrent Shoulder Dislocation

The shoulder joint (glenohumeral joint) is the most mobile joint in the human body, a characteristic that also makes it highly susceptible to dislocation. A dislocation occurs when the head of the humerus (upper arm bone) completely separates from the glenoid fossa (shallow socket of the shoulder blade). While an initial dislocation can result from significant trauma, recurrent dislocations often indicate underlying structural damage that compromises the joint's stability. This instability can severely impact daily activities, athletic performance, and overall quality of life.

Recurrent dislocations typically stem from damage to the key stabilizing structures of the shoulder, including:

• Labrum: A ring of cartilage that deepens the glenoid socket. A tear in the labrum (e.g., a Bankart lesion) is common.
• Joint Capsule and Ligaments: The connective tissues that surround and reinforce the joint.
• Bones: Specifically, bone loss from the glenoid rim or a compression fracture on the humeral head (Hill-Sachs lesion) can significantly contribute to instability.

When conservative treatments like physical therapy and activity modification fail to prevent further dislocations, or when significant structural damage is present, surgical intervention becomes the most effective long-term solution.

Primary Surgical Procedures for Recurrent Shoulder Dislocation

The choice of surgical procedure depends heavily on the specific type and extent of damage to the shoulder's stabilizing structures.

Bankart Repair

The Bankart Repair is the most common surgical procedure for recurrent anterior shoulder instability, particularly when the primary issue is a soft tissue injury.

• Indications: This procedure is indicated when there is a Bankart lesion, which is a tear of the anterior (front) inferior labrum where it detaches from the glenoid bone. It often occurs after an anterior shoulder dislocation.
• Procedure:
  • Traditionally performed as an open procedure (larger incision), it is now most commonly performed arthroscopically (minimally invasive, keyhole surgery).
  • During the surgery, the detached labrum and associated ligaments (inferior glenohumeral ligaments) are reattached to the anterior rim of the glenoid using small anchors (sutures or bio-absorbable materials).
  • This effectively re-tensions the joint capsule and ligaments, restoring the anatomical integrity and stability of the shoulder.
• Outcome: Highly successful for isolated labral tears without significant bone loss, with good return-to-activity rates.

Latarjet Procedure (Coracoid Transfer)

The Latarjet Procedure, also known as the Coracoid Transfer, is a reconstructive bone block procedure that addresses recurrent shoulder instability, especially when there is significant bone loss from the glenoid socket or a large Hill-Sachs lesion.

• Indications: This procedure is typically reserved for cases where:
  • There is significant glenoid bone loss (often greater than 20-25% of the glenoid width).
  • There is a large, engaging Hill-Sachs lesion (a compression fracture on the posterior-superior aspect of the humeral head caused by impact against the glenoid rim during dislocation).
  • Previous Bankart repair has failed.
  • Patients are involved in high-demand overhead or contact sports.
• Procedure:
  • This is typically an open surgical procedure.
  • A section of the coracoid process (a small, hook-like projection from the scapula) is osteotomized (cut), along with its attached muscles (short head of biceps and coracobrachialis).
  • This bone block is then transferred and fixed with screws to the anterior-inferior aspect of the glenoid.
  • The transferred coracoid provides a bony buttress, effectively extending the glenoid articular surface and preventing the humeral head from dislocating anteriorly. The attached muscles also provide a dynamic sling effect, further enhancing stability, especially when the arm is abducted and externally rotated.
• Outcome: Offers excellent stability, particularly in complex cases with bone loss, with lower rates of re-dislocation compared to Bankart repair in these specific situations.

Other Less Common or Ancillary Procedures

While Bankart and Latarjet are the primary procedures, other techniques may be used in specific circumstances:

• Capsular Shift/Plication: Involves tightening the stretched or redundant joint capsule to reduce overall joint volume and improve stability. Often performed in conjunction with a Bankart repair or for multi-directional instability.
• Remplissage Procedure: This technique is often performed alongside a Bankart repair when a significant Hill-Sachs lesion is present. It involves tenodesing (attaching) the posterior capsule and infraspinatus tendon into the Hill-Sachs defect, effectively filling the defect and preventing it from "engaging" with the glenoid rim during specific movements.

When is Surgery Indicated?

The decision for surgery is made collaboratively between the patient and an orthopedic surgeon, considering several factors:

• Number of Dislocations: Multiple dislocations significantly increase the likelihood of requiring surgery.
• Age and Activity Level: Younger, more active individuals, especially athletes in contact or overhead sports, are more likely to opt for surgery to prevent future episodes and facilitate return to sport.
• Extent of Structural Damage: Significant labral tears, capsular laxity, or glenoid bone loss are strong indications for surgical repair.
• Failure of Conservative Treatment: If physical therapy and activity modification do not successfully stabilize the shoulder.
• Patient Preference: Understanding the risks, benefits, and rehabilitation commitment is crucial.

The Surgical Process: What to Expect

Regardless of the specific procedure, the surgical journey typically involves:

• Pre-operative Assessment: Comprehensive evaluation, including physical examination, imaging (X-rays, MRI, sometimes CT scan), and discussion of surgical risks and benefits.
• Anesthesia: General anesthesia is typically used, often combined with a regional nerve block for post-operative pain control.
• Procedure: The surgeon performs the chosen repair, which can take 1-2 hours depending on complexity.
• Post-operative Care: Immediate post-op care involves pain management and often immobilization in a sling. Most procedures are outpatient or require a single overnight stay.

Post-Operative Rehabilitation

Rehabilitation is a critical component of successful surgical outcomes and is often as important as the surgery itself. It typically progresses through several phases:

1. Immobilization Phase (0-4/6 weeks): The arm is kept in a sling to protect the healing tissues. Passive range of motion (PROM) exercises may begin under therapist guidance to prevent stiffness.
2. Early Motion Phase (4-12 weeks): Gradual increase in active range of motion (AROM) exercises. Focus on restoring mobility without stressing the repair. Light strengthening may begin.
3. Strengthening Phase (3-6 months): Progressive strengthening of the rotator cuff, scapular stabilizers, and deltoid muscles. Proprioceptive training to improve joint awareness.
4. Return to Activity/Sport Phase (6-12+ months): Sport-specific drills, progressive loading, and agility training. Full return to competitive sports or demanding activities is typically gradual and depends on individual progress and the sport's requirements.

Adherence to the rehabilitation protocol is paramount to ensure proper healing, regain full function, and minimize the risk of re-dislocation.

Potential Risks and Complications

While generally safe and effective, shoulder stabilization surgeries carry potential risks, including:

• Infection: Risk is low but present with any surgery.
• Stiffness (Arthrofibrosis): Can occur if rehabilitation is not followed diligently.
• Nerve or Blood Vessel Damage: Rare, but possible.
• Re-dislocation: While surgery significantly reduces the risk, it does not eliminate it entirely.
• Hardware Complications: Screws or anchors can sometimes cause irritation or require removal (rarely).
• Pain: Persistent pain, though typically improved after surgery.

Long-Term Outlook and Return to Activity

The long-term outlook after shoulder stabilization surgery is generally very positive, with high rates of success in preventing recurrent dislocations and restoring function. Most patients can return to their pre-injury activity levels, including sports. However, the exact timeline and level of return depend on the individual, the extent of the initial injury, the specific surgical procedure, and adherence to the rehabilitation program. Athletes in high-impact or overhead sports may require a longer and more structured return-to-sport protocol.

Conclusion

Recurrent shoulder dislocation is a debilitating condition that often necessitates surgical intervention to restore stability and function. The Bankart Repair effectively addresses soft tissue damage, while the Latarjet Procedure provides a robust solution for cases involving significant bone loss. Understanding the specific nature of the injury and the appropriate surgical approach, combined with dedicated post-operative rehabilitation, is key to achieving optimal outcomes and enabling individuals to return to their desired activities with confidence and stability. Consulting with an orthopedic surgeon specializing in shoulder injuries is essential for accurate diagnosis and personalized treatment planning.