Bankart repair/ anterior stabilisation of the shoulder

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1 Patient information Bankart repair/ anterior stabilisation of the shoulder This leaflet has been designed to give you some more information about having a Bankart repair. Your surgeon believes you will benefit from this operation. The aim of the operation is to reduce your pain and so improve your function. What is a bankart injury? The shoulder is a ball and socket joint and is made up of three bones; the humerus (arm bone), scapula (shoulder blade) and clavicle (collar bone). Your shoulder is the most mobile joint in your body. It is dependant on muscles, ligaments (including the joint 'capsule') and a rim of cartilage (called the 'labrum') to stabilise it during movement. The labrum is located on the rim of the socket on the ball and socket joint. What is bankart repair? Some injuries to the shoulder can dislocate it forwards, stretching and in some cases, tearing the joint capsule, ligaments and cartilage away from the front of the joint. If the labrum is torn the shoulder can become unstable. If the tear is at the front of the shoulder (anterior), it is called a labral lesion. The operation involves tightening and/or repairing the overstretched and damaged ligaments, capsule and cartilage. The operation is done to re-attach the labrum to its normal position. It is usually done arthroscopically (keyhole) but can be an open repair if the surgeon deems it necessary. This will be discussed with you before your operation. The first stage of surgery involves the tear being identified and excess/damaged tissue is removed. Then a small hole is drilled into the bone where the labrum has torn off. An anchor is placed into this hole; attached to the anchor is a strong suture. The suture is used to tie the torn labrum snuggly Barts Health Therapies Department

2 against the bone. Additional anchors are placed as needed to secure to torn labrum. The aim is to restore stability to your shoulder and prevent further dislocations. There are other labral lesions of the shoulder which you may have been told you have in your shoulder i.e. SLAP lesion or an ALPSA lesion. The repairs of these lesions are completed in the same way as described above. About the operation The operation is usually done by keyhole surgery (arthroscopy). Most people are given a full general anaesthetic, i.e. you will be asleep. Two to four,three millimetre to 10 millimetre puncture wounds are made around the shoulder to allow entry of the arthroscopic instruments; one of these is a camera, which allows the surgeon to thoroughly inspect the inside of the shoulder joint. What are the risks of having arthroscopic bankart repair? All operations involve an element of risk, these are very small but you need to be aware of them and can discuss them with your doctor at any time. The risks are: Complications relating to the anaesthetic Infection (less than one percent) Stiffness and or pain around the shoulder Damage to nerves or blood vessels around the shoulder Need to re-do the surgery e.g. if the repair fails and the shoulder becomes unstable again -this occurs in approximately 10% but can be up to 80% in individuals with labral lesions that include bone damage as well. If you suffer a sudden increase in pain, onset of pins and needles and/ or numbness or start to feel unwell and hot you must be reviewed by your doctor at the earliest opportunity. What are the alternatives? You are having this surgery because other treatment options have been unsuccessful. You have probably tried most of the alternative solutions for your shoulder pain before considering surgery. Not all these options are appropriate for all people. The younger you are the more likely you are to require surgery. They include: Modifying activity and sport to avoid the pain.. Taking painkillers and/or anti-inflammatory tablets. Physiotherapy and other allied specialities such as acupuncture. Questions that we are often asked about the operation: You will be given a general anaesthetic. General anaesthesia is drug-induced unconsciousness: an anaesthetist, who is a doctor with specialist training, always provides it. Unfortunately, general anaesthesia can cause side effects and complications. Side effects are common, but are usually short-lived: they include nausea, confusion and pain. Complications are very, very rare, but can cause lasting injury: they can include paralysis and death. The anaesthetist/ surgeon may give you an additional nerve block for pain relief. The nerve block is an injection onto or near the nerves in the shoulder for temporary pain control during and after the operation. The injection will either be an interscalene or suprascapular nerve block. The risks of anaesthesia and surgery are lower for those who are undergoing minor surgery, and who are young, fit, active and well. You will be given an opportunity to discuss anaesthetic 2

3 options and risks with your anaesthetist before your surgery. If you are worried about any of these risks, please speak to your consultant or a member of their team. Getting ready for your operation The staff will ask routine questions about your health, the medicine you take at the moment and any allergies you may have. You will be given instructions on eating and drinking. You will be able to discuss the operation with a doctor. You will be asked to sign a consent form to say that you understand the procedure, and what the operation involves. What happens on the day of your operation? You will come into hospital on the day of your operation. Please make sure you contact the ward before you leave home to check bed availability. Please leave all cash and valuables at home. The Trust does not accept responsibility for items not handed in for safekeeping. There is a very small lockable cupboard by your bedside which will be used to store your medication and small amounts of petty cash. It cannot accommodate large items. You will be asked to remove jewellery - plain bands can be worn but they will be taped. Please leave body piercings at home. Acrylic nails and nail polish will also need to be removed. If you are on regular medication, you will be told to take this if necessary. A bracelet with your personal details will be attached to your wrist. You may be prescribed some medication to take before your operation by the anaesthetist. A member of the nursing staff will give this to you. You will be given a gown to wear for your operation. A nurse and porter will accompany you to the operating theatre. Your dentures, glasses or hearing aid can stay with you on your journey to the operating theatre. When you arrive in the waiting area, a theatre nurse will check your details with you. The ward nurse will then leave you and you will then be taken to the anaesthetic room What should I expect after the operation? After your operation you will be kept in the theatre recovery room before being transferred to the ward. A nurse will check your pulse, blood pressure, and breathing rate regularly. It is important that if you feel any pain you must tell the nursing staff, who can give you painkillers to help. The first time you get out of bed, please make sure you ask a nurse to be with you. This is in case you feel dizzy. If you have had a regional block, you are likely to feel little pain post operatively. Sometimes the block can be very dense and also lead to weakness in the muscles of the arm and hand and well as numbness. Do not worry, the function does return when the anaesthetic wears off. It is important for you to be particularly careful with your arm and protect it in the sling initially as during this period it will be numb. It is also very important you start taking your pain-killers regularly straight away, despite having little of no pain. When will I go home? You will usually be discharged home the same day as your operation. Occasionally you may be kept in hospital overnight. Remember that you have just had an operation. It is normal to feel more tired than usual for a few days after having an operation. Your shoulder is likely to be uncomfortable in the first few days post-surgery. This is normal. You may not feel there is a significant improvement in your pre-operative pain until a few weeks after surgery. 3

4 Discharge information Will I be in pain? It is normal to feel some pain following your operation. You will be given some painkillers and/or anti-inflammatory medication to take in the days following the operation. It is vital to begin the tablets prescribed by the surgeon immediately after the operation even if you are pain free because of a very effective nerve block. It is important that you have adequate pain relief for when the block eventually wears off. Using ice on your shoulder can be helpful in reducing pain. Wrap a bag of crushed ice, or frozen peas in a damp towel. Protect your dressings from getting wet with a layer of cling film, or a plastic bag, before applying the ice pack for minutes at a time. Posture can make a big difference to your pain after surgery. Avoid hitching your shoulder or holding it in an elevated position. Also try to avoid slumping or standing/sitting with round shoulders as this puts more stress onto your shoulder. What do I do about the wound? You will not have any stitches, only small sticking plaster strips over two or four small wounds. Keep the wounds dry until they are healed, which is normally within five to seven days. You must keep them covered when showering or bathing for the first week. Your shoulder is filled with water during the operation and this often will make your shoulder look very swollen initially. The wounds sometimes allow some of this fluid to escape which will be blood stained. Do not be alarmed. If your dressings become soaked following discharge, either attend your GP practice to change them or attend our fracture clinic. Are there things that I should avoid? Yes, it is very important to protect the repair. You will be advised to wear a sling for six weeks. Do not lift your operated arm without assistance until it is allowed out of the sling. Do not use the unoperated arm for any heavy manual work whilst the operated arm is in the sling How long do I need to wear the sling? Your arm is supported in a sling straight after your operation to protect the repair. It is essential that you wear the sling day and night for six weeks (your physiotherapist will advise you). This will be explained to you after your surgery. You can remove the sling to carry out your exercises and for washing and dressing only. Do I need to do exercises? Yes (see at the end of this leaflet) you will be shown exercises by the physiotherapist and you will need to continue with the exercises once you go home. They aim to stop your shoulder, elbow and wrist getting stiff. How long will it take me to recover? Rehabilitation varies depending on factors such as the strength of the repair, and the preference of the surgeon. Most often, a period x 4

5 of time of restricted motion is maintained for about six weeks following a labral repair. During this first phase of rehabilitation, some passive motion is allowed to prevent shoulder stiffness. In the first phase, the torn labrum is healing into its proper position. Once healed, patients enter the second phase of rehabilitation and can begin more motion at about six weeks. Physiotherapy continues to help maintain motion and regain strength of the shoulder. The final phase of rehabilitation involves more active strengthening of the muscles that surround the shoulder joint, and full recovery is expected between three to four months. Getting back to normal how you can help yourself to recover These techniques have two benefits. 1. Protects the repair. 2. Reduces pain. What is the long-term prognosis? Sleeping can be uncomfortable if you try and lie on your operated arm. We would recommend that initially you lie on your back or on the opposite side. If you lie on your back support the operated arm with a folded pillow under your lower arm. Make sure that your elbow is parallel to your body and avoid it falling backwards (see picture on right). In the first few weeks after surgery you will find it helps to support your arm when you sit as well. Put pillows behind you shoulder and elbow to prevent the arm from falling behind your trunk (see picture on left). You will continue to improve up to two years following the operation, but from six months these improvements are usually much slower. Everybody is individual and makes progress at slightly different rates, but overall more than 85% of patients get a satisfactory result in the first six months. Returning to activities When can I drive? You should not drive until you have discussed your progress with your consultant/ physiotherapist which will not be until at least six weeks following your operation. You must be able to comfortably control your vehicle and perform emergency manoeuvres. When can I return to work? The amount of time you have off work depends on your job. If you have a manual job, or one that involves lifting or overhead activities, you will not be able to do this for eight to 12 weeks. Please discuss this with your consultant or physiotherapist. When can I return to sports and leisure activities? The timescale for which you can go back to any previous sport or activity will depend on your movement and strength and the particular activity you have in mind. Please discuss returning to any activity or sport with your consultant or physiotherapist. 5

6 Physiotherapy appointments - how often will I have to attend? You will be referred for outpatient physiotherapy and until you have that appointment you are expected to start the exercises on this sheet as soon as possible after the surgery. You have an important part to play in your own recovery and are expected to follow your home exercise programme as instructed. Further appointments when will you back to see the doctor? You will be seen in outpatient clinic approximately two weeks after your surgery. This appointment will be made and given to you before you are discharged from hospital. Further clinic appointments are made after this as necessary. Important things to remember following your labral repair 1. Continue to wear your sling day and night as requested by your Consultant 2. Do NOT let your arm end up in the overarm throwing position as this will stress the surgical repair too much. 3. Do not use the un-operated arm for any heavy manual work whilst the operated are is in the sling. These are important to allow for effective healing after your operation. Notes 6

7 Exercises Day one after the operation: Use painkillers and/or ice packs to reduce the pain before you exercise, if necessary. Do short, frequent sessions (e.g minutes, 4 times a day) rather than one long session. It is normal for you to feel aching, discomfort or stretching sensations when doing these exercises. However, intense and lasting pain (e.g. for more than 30 minutes) is an indication to change the exercise by doing it less forcefully or often. When you are not doing your exercises ensure your shoulder is supported by pillows or your sling as described earlier in this leaflet, to assist with pain relief. Ensure you keep your neck, elbow, wrist and hand moving after the operation. These exercises can be started straight after the operation: 1. It is important to set the shoulder blades in a good position before commencing with these exercises. In order to do this you need to sit up straight with elbows by your sides, gently lift the tips of your shoulders very slowly upwards about two centimetres. The base of your shoulder blades will lift up and outwards very slightly. Hold for five seconds Repeat 10 times 2. Lying or sitting. Slowly take your operated arm up towards the line of your shoulder (90 degrees) using your unoperated arm. Take it no higher than shown in the picture (right). Repeat 10 times 3. Lying on your back. Hold your elbow bent at a right angle close to your body while it rests on your stomach. Hold onto you wrist with the unoperated hand. Try to move your hand outwards to in line with your shoulder. Do not go past the movement shown in the picture. Repeat 10 times 4. Take your arm out of the sling and straighten your elbow. Movement should only occur at the elbow not the shoulder (pictured right). Hold for 10 seconds Repeat 10 times Day 14 + You will begin a course of physiotherapy to check your recovery after surgery and your exercise regime will start to include strengthening exercises. 7

8 Where can I get more information? The telephone numbers and contacts below are available for you to contact a physiotherapist. You will have the opportunity to ask your orthopaedic surgeon questions about the operation during your consultation or you can also contact them via their secretary through the Barts Health switchboard. - this is a very good site that has a lot of information written by orthopaedic surgeons specialising in the upper limb. Patient Advice and Liaison Service (PALS) If you need general information or advice about Trust services, please contact the Patient Advice and Liaison Service (PALS) on or visit Alternatively please contact staff who are providing your care if you require clinical advice. Your health records To enable us to improve the quality of the care that we provide, your health records are kept by the Trust and may be used for teaching, training, audit and research. Further information on how the Trust uses your information can be found on our website at Contact information Barts Health Therapies Department The Royal London Hospital Telephone No: Mile End Hospital Telephone No: Authors: Jenny Harper, extended scope physiotherapist, Mr Ali Noorani and Mr Livio Di Masco, consultant trauma and orthopaedic surgeons. Large print and other languages For this leaflet in large print, please ring or For help interpreting this leaflet in other languages, please ring Reference: BH/PIN/189 Publication date: January 2014 All our patient information leaflets are reviewed every three years. Barts Health NHS Trust Switchboard:

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