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Arthroscopic Bankart and Remplissage procedures


INSTABILITY means that the shoulder dislocates completely (dislocation) or partially (subluxation).

When the dislocation is less forceful, the bone of the socket remains intact, but the labrum (Ligament ring around the socket) tears off. This is called BANKART’S LESION. ( See the section on shoulder instability)

A corresponding injury occurs simultaneously in the ball of the shoulder joint. This is called HILL SACH’S LESION.

torn labrumHILL-SACHS DEFECT

ARROW SHOWS THE TORN LABRUM     THE HILL-SACHS DEFECT

X-RAY :

The dislocation may usually be seen very well on an X-ray. These are also relevant to verify that the shoulder is reduced after reduction maneuver.


MAGNETIC RESONANCE IMAGING (MRI) :

MRI is not needed in every case. These scans may demonstrate the presence of a Bankart lesion as well as the rare HAGL lesion (Humeral Avulsion of the Gleno-humeral Ligaments) which is also referred to as a “reverse Bankart” lesion due to the fact that the ligaments tear off the humeral head and not off the edge of the glenoid as is usually the case.

TREATMENT :

A patient with a Bankart lesion usually needs an operation to repair the ligaments to the bone, even after the first dislocation, as the lesion usually does not heal.

Does this mean that every patient with instability needs an operation?
The answer is no. If the person is willing to live with it knowing that he/she has to avoid the position of the arm where it slips out, and does not participate in any strenuous activities which may precipitate a dislocation, they could live with the potential instability for as long as they choose to.


On the other hand, repeated dislocations should be avoided as the joint is gradually damaged more and more. Also consider the fact that certain dangerous activities e.g. sports in deep water or mountain climbing could be fatal if the shoulder dislocated under such circumstances.

Various operations are available to stabilize an unstable shoulder :

ARTHROSCOPIC BANKART PROCEDURE :


It is done with an arthroscope (“key-hole surgery”), although this repair can also be done with an open technique. In our unit we prefer the arthroscopic procedure:


Usually three holes measuring about 3-5 mm are made. The arthroscope and the instruments are passed through these holes (referred to as “portals”) The arthroscope relays a picture to a television monitor and the surgeon watches his actions on the monitor. (Refer to the section on Treatments-Shoulder surgery)


First a roughened area is made on the surface of the bone of the glenoid (socket) to allow the ligaments to heal to this area of the bone. Tiny absorbable devices (“bone anchors”), with sutures attached are drilled into the bone and the sutures used to fix the ligaments to the bone of the socket. Advance techniques are used to make knots outside the joint and then passing them down the small cannulas to the inside of the joint to tie the ligaments to the bone.

arthro caparthro cap1

ARTHROSCOPIC CAPSULAR SHIFT :

In some cases the shoulder dislocates due to the ligaments being too lax and not due to tearing (Bankart lesion). This is more common in young females.

Strengthening of the surrounding muscles may improve it, but should this fail an operation may become necessary
For the cases of ligamentous laxity with instability the ligaments are tightened using the arthroscopic technique, very similar to the Bankart procedure but with more emphasis on tightening and reducing the laxity of the ligaments.

cap shft

" Shifting the capsule to tighten the ligaments (left). A special knot (right) devised by Dr Deepak Bhatia (named Double-Barrel Knot) is used to secure the shifted capsule in the new position till it heals. "

 

ARTHROSCOPIC REMPLISSAGE :

Remplissage means “to fill in”. This procedure is performed when the bone loss on the ball (humeral head) is moderate to large. The adjacent muscles are attached into the defect with anchors and this prevents failure of the arthroscopic Bankart repair.

This procedure involves 3-4 tiny keyholes, and is done along with a Bankart’s repair or a capsular shift ( described above).

cap shft1

" The muscles at the back of the shoulder (IS) are stitched into the defect on the ball (HD) using tiny “anchors”. Dr Deepak Bhatia’s technique to perform this procedure is called “ DOUBLE-BARREL REMPLISSAGE”. ( Accepted for publication, Journal ARTHROSCOPY) "

 

AFTER THE OPERATION :

You may leave the hospital on the same or next day. Pain is usually minimal to moderate. The arm will be in a sling, simply to remind you not to move the arm upwards, backwards or outwards.
Wear the sling at night while sleeping and when going out. At home it may be taken off, but remember the following restrictions:

While facing forwards and moving the arm, the hand should be visible. As soon as you move the hand backwards, out of sight, the shoulder is in a “danger zone”, and the repair can be damaged.


These precautions must be followed for 3weeks, after which you will receive further instructions.

The shoulder is usually stiff for a few weeks following the operation but this is common and should not raise any concern


After 3weeks
With guidance, progressive mobilization and strengthening will now be allowed. Weight training, swimming (breast stroke), etc. will be gradually introduced from 6 weeks onwards.

Return to sport
Can be allowed soon after this 6-week period, but for contact sports like rugby, and throwing sports like baseball, 3 months and more of rehab may be required.

It is important to avoid injury during the recovery period to prevent pulling out of the screws

Success Rate
The procedures mentioned above are usually successful to stabilize the shoulder and result in the patient regaining normal function, provided that the operation is tailored to the specific type of instability and is performed with the necessary expertise.


READ DR DEEPAK BHATIA’S SCIENTIFIC PUBLICATIONS ON THIS TOPIC :

1. The “Double-Barrel” Remplissage: An arthroscopic all-intraarticular technique using the double-barrel knot for anterior shoulder instability. Accepted, Arthroscopy Techniques. 2014.

2. Bhatia DN. Arthroscopic Latarjet and Capsular shift procedure. Tech Hand Up Extrem Surg. 2014.

3. Bhatia DN, De Beer JF. Management of anterior shoulder instability without bone loss: Arthroscopic and mini-open techniques. Shoulder & Elbow 2011;3:1-7.

4. Bhatia DN, DasGupta B. Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability. Knee Surg Sports Traumatol Arthrosc. 2013 Jul;21(7):1603-9

5. DeBeer JF and Bhatia DN. Shoulder instability in the middle aged and elderly patients: Pathology and surgical implications. International Journal of Shoulder Surgery, 2010;4.

6. Page RS, Bhatia DN. 2010. Arthroscopic repair of a chondrolabral lesion associated with anterior shoulder dislocation. Knee Surgery Sports Traumatology Arthroscopy. 2010 Dec;18(12):1748-51

7. Bhatia DN. 2012. Arthroscopic "Cuff sparing” percutaneous (CUSP) Technique for posterior instability repair in the beach-chair position. Tech Hand Up Extrem Surg. 2012 Sep;16(3):173-9

8. Bhatia DN. 2012. Dual-window subscapularis-sparing approach: A new surgical modification of the Latarjet procedure. Tech Hand Up Extrem Surg. 2012 Mar;16(1):30-6

9. DeBeer JF and Bhatia DN. 2009. Shoulder injuries in Rugby players. Int J Shoulder Surg, 2009; 3:1-2.

10. Bhatia DN, De Beer JF, van Rooyen KS. 2009. The Subscapularis - sparing approach: A new mini-open technique for repair of the HAGL lesion. Arthroscopy 2009;25(6): 686-690

11. Page RS, Bhatia DN. 2009. Arthroscopic HAGL repair: Anterior and posterior techniques. Techniques in Hand and Upper Extremity Surgery 2009;13(2), 98-103

12. Bhatia DN, deBeer JF, vanRooyen KS, duToit DF. 2007. The “Reverse Terrible Triad” of the shoulder: Circumferential glenohumeral musculo-ligamentous disruption and neurological injury associated with posterior shoulder dislocation. Journal of Shoulder and Elbow Surgery. 2007; 16(3): e13-17.

13. DN Bhatia, JF DeBeer. 2012. The Cape Town Approach for Latarjet Procedure: Is There a Benefit to Flip the Bone Block? In: Shoulder Concepts 2012 Ed. P Boileau. Sauramps Medical Publisher. Pg 71-74

14. DN Bhatia, JF DeBeer, DF Dutoit. 2008. Coracoid process anatomy: Implications in Latarjet procedure. In: Shoulder Concepts 2008, Arthroscopy and Arthroplasty. Ed. P Boileau. Sauramps Medical Publisher. Pg 63-78.

15. DeBeer JF and Bhatia DN. 2009. Shoulder injuries in Rugby players. Int J Shoulder Surg, 2009; 3:1-2.