The Procedure
The Arthroscopic Bankart Repair (ABR) is a keyhole procedure to improve anterior shoulder stability in patients with a Bankart lesion. A Bankart lesion is where the labrum, the ring of cartilage around the shoulder socket, is torn or detached from the glenoid, frequently occurring during anterior shoulder dislocations.
The ABR involves bone anchors being drilled into the glenoid. Sutures are attached to the anchors to tie the torn labrum back in its original position. The shoulder joint capsule is also sutured to the anchors to tighten the capsule and hence increase the stability of the shoulder joint. The anchors I use are typically ll suture anchors or bio-composite anchors which are ceramic in nature and which will eventually be replaced by bone.
The procedure can be performed arthroscopically (keyhole) or as an open procedure. I perform the surgery arthroscopically and I will typically book two hours of theatre time for your surgery.
Pre Op
Whilst you wait for your surgery date, there are a few things to do:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to my office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners, ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications, ring your anaesthetist and confirm whether you need to stop taking them before the operation
- Confirm your admission details with my office one to two business days prior to surgery.
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Complications
General risks of surgery include:
- Bruising & haematoma: this will vary for each patient. Bruising is a normal side effect of surgery and usually resolves in a short time.
- Infection: infection is a rare but possible risk and is usually treated with antibiotics.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. . More information can be found here (hyperlink to UC Health Blood Clot pamphlet)
- Anaesthetic risks: general anaesthetic (GA) carries a number of risks, which will be discussed in detail with your anaesthetist prior to surgery. Fortunately, Australia is one of the safest places to undergo a GA. In Australia, the risk of mortality from GA is around 1 in 100,000. For context, the risk of death in a car accident in Queensland is around 1 in 10,000 per year.
- Wound issues: some superficial issues can develop in surgical wounds postoperatively, however most will require a small intervention to resolve the problem.
Risks and complications specific to the ABR procedure include:
- Shoulder joint stiffness: this is uncommon but does occur in about 2% of patients. The shoulder stiffness normally resolves over the first 12 months after surgery. If it doesn’t, I can perform an arthroscopic release of the shoulder to regain the range of motion.
- Frozen shoulder: around 3% of patients can develop frozen shoulder. It resolves with time. The frozen shoulder usually helps the surgery heal and stabilise the shoulder so you will still get a good result from the surgery once the frozen shoulder has resolved, however it can make the rehab prolonged and miserable if the frozen shoulder is severe.
- Hardware problems: the sutures used during the repair can sometimes cause issues and require a return to theatre for removal.
- Recurrent instability can occur in 5% or more of patients during long term follow-up
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be one night. You will be discharged usually around 10am. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
Recovery following the ABR is straightforward. Physiotherapy will commence immediately after surgery and the postoperative review normally occur 6 weeks post-operatively.
A sling will be required for up to 6 weeks after surgery, during which time no driving will be possible. Most people take about 6 weeks to recover following the surgery although symptoms may persist until 12 weeks post-operative.
It’s important to give your body adequate time and energy to heal after surgery, so getting plenty of rest is essential.
Rehabilitation
Rehabilitation after ABR is primarily aimed towards restoring shoulder stability and function.
In the first four to six weeks after surgery, you will need to wear a sling to immobilise the shoulder to allow the cartilage repair to heal. If you have a posterior labral repair for posterior shoulder instability, I will normally want you to wear an external rotation (ER) brace rather than a sling after the surgery. The ER brace will be fitted for you either before the surgery or the day after in the ward. Gentle, passive physiotherapy exercises will also be performed to help avoid joint stiffness.
From 6 weeks postoperatively, exercises will be focused on improving range of motion and strength.
Usually at around 6 to 9 months after surgery, normal physical activities including high intensity exercises and sports can be resumed.
Physiotherapy Guidelines
Day 1 Physiotherapy Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
Goals:
- Protect the healing labral and capsular repair – patient educated to avoid ER/Abd/Ext (external rotation/abduction/extension) combination movements
- Assist in the management of pain and inflammation
- Maintain limited GHJ PROM (glenohumeral joint passive range of motion) to avoid excessive stiffness, maintain AROM (active range of motion) of adjacent joints
- To ensure that by week 6 that the shoulder is appropriately tight: Flexion to 90, ER (external rotation) (0) 0-10
- Maintain ROM (range of motion) in adjacent joints, ensure good scapula posturing
Sling:
- Sling is to be worn full time for 6 weeks except for showering and exercises
- Patient to come out of sling 2-3x/day to perform prescribed exercises only
- Precautions:
- No active use of GHJ (glenohumeral joint)
- Avoid stressing the healing repair by avoiding Abd + ER (abduction + external rotation) or movements into elevation
Therapy:
- Ensure appropriate sling fit, pt taught to don/doff sling independently, hand to align to body midline
- Appropriate use of ice
- ADL (activities of daily living) advice – light use of hand only within sling
- Patient instructed in:
- passive ROM (range of motion) exercises for GHJ (glenohumeral joint): passive pendulum to 80 degrees flexion, stick ER (external rotation) in neutral to 0- 10 degrees
- AROM (active range of motion) for adjacent joints
- scapula awareness, ensure appropriate recruitment of upper and mid trapezius
Follow up:
- With your local physio at 2 weeks to ensure pain managed, appropriate HEP (home exercise program) and precautions being followed, more formal physiotherapy to commence after week 6 visit with me and the shoulder physio.
Results After Surgery
The ABR surgery typically provides good long-term results, with a low rate of recurrent instability. Many patients return to their pre-injury level of activity with no issue. Nevertheless, individual results will be influenced by a variety of factors, and outcomes may differ. Keep in mind, all shoulder rehab is much slower than most people would like it to be. Rehab often takes at least 6 to 9 months following surgery. It’s not uncommon for the shoulder to ache for some time after the surgery.