Arthroscopic Anterior Labrum and Bankart Repair

As noted, repair is sometimes recommended in young patients who dislocate the shoulder for the first time.  Prior to the advent of modern advanced (minimally invasive) surgical technique, surgery was almost never offered for first time dislocation, and instead the procedure was reserved until disabling pain and recurrent dislocations were observed.  More recently, technology and technique for noninvasive outpatient repair is better which does not significantly change recovery time compared with sling immobilization.  These observations, coupled with emerging evidence that early surgery results in better outcomes, have resulted in changes to recommendations in some younger at-risk patients.  Specifically, it has been shown that athletes younger than the age of 25 who are at-risk of re-dislocating the shoulder, primary repair performs better than nonsurgical treatment at 2 year follow up(2).

The most common indication for Bankart repair is in the setting of recurrent dislocation.  When the shoulder has dislocated twice or more, the shoulder becomes increasingly susceptible to further dislocation and the force or load required to dislocate the shoulder becomes lower.  The reason the shoulder is more susceptible to recurrent dislocation when it has become recurrent is because the labrum “bumper” is deficient, and the ligaments that connect the ball to the socket are left in a loosened position.  In other words, there is an easier pathway for the ball to keep coming out the front of the socket.

If recurrent dislocations continue, there may be a gradual erosion of the bone of the socket, which may require advanced bone reconstruction, oftentimes with a procedure known as a Latarjet reconstruction.  Because the structural damage worsens with each and every dislocation of the joint, sometimes earlier surgery is more beneficial in the long run(2).

Least commonly, some patients with labrum tears that are older or have more recreational athletic demands may be candidates for labrum repair.  This is performed to improve symptoms of apprehension with the arm overhead and pain with certain activities.  It is important this population be screened for other sources of shoulder pain (including tendon tears and arthritis), because sometimes over-tightening the shoulder with repair when alternative pain sources are present can lead to stiffness.

Surgical repair is not recommended for patients at low-risk of recurrent instability including older, recreational athletes.  These individuals are often treated with sling immobilization and exercise treatments to strengthen the shoulder in preparation for full return to activity.  Additionally, arthroscopic repair is not recommended in patients with a significant dent in the ball, called a Hill-Sachs Lesion, or in those with significant bone loss in the front of the socket.  These patients are sometimes best treated with other procedures called remplissage and Latarjet, respectively.

Arthroscopic Bankart repair is performed as a minimally invasive, outpatient procedure, that generally takes less than one hour to complete.  The procedure has a goal restoring anatomy, or repairing the injured tissue back to the glenoid bone donor site.  Modern arthroscopic technique takes advantage of “knotless” suture anchors which are low-profile, not irritating to the shoulder, and reliably and reproducibly result in excellent long-term healing outcomes.

Arthroscopic anterior labrum repair is performed under a light general anesthetic and a regional shoulder block that allows the patient to awaken immediately after surgery and leave the facility.  A sling is generally maintained for six weeks and return to full activity is permitted generally between 3 and 6 months.

As noted, labrum tears are very common in young athletic patients, particularly those participating in contact sports such as ice hockey and football. These patients often required specialized counseling to help them decide when or if to repair the shoulder, depending on the year in school, demands for return to competitive athletics, and what part of the season the patient injures the shoulder.  As an example, a college-bound high school senior football lineman that injures the shoulder in the middle of the senior season may elect to postpone surgical repair until the season is complete, even if returning to play sooner means additional risk of reinjury.