Treatment of shoulder instability, Bankart injury

Shoulder instability caused by traumatic injury to the labrum is one of the most common causes of shoulder pain, especially in young people.

The labrum is almost always damaged in shoulder dislocations (Bankart injury). In addition, similar injuries occur when playing various sports: falls, injuries, throwing movements, power loads, uncoordinated movements.

With a significant defect in the labrum, repeated shoulder dislocations (habitual shoulder dislocation) may occur; with less significant damage, a feeling of instability of the joint occurs during certain movements and loads, and clicking in the joint. The so-called symptom of “premonition of pain” is noted when the patient knows that if the abduction or rotation of the arm continues beyond a certain degree, pain will occur.

Normally, the humeral head is kept in contact with the glenoid cavity of the scapula due to several factors: the stabilizing action of the labrum, joint capsule, ligaments, as well as due to the pressing action of the surrounding muscles.

When Bankart is damaged, the stabilizing effect of the articular labrum, joint capsule, and the centering of the head in the joint are disrupted. The humeral head is able to slide off the glenoid articular surface.

Often such damage is combined with the formation of a cartilaginous or osteochondral defect in the posterior part of the head of the humerus (Hill-Sachs injury). When the arm is abducted and rotated, the head slips into the area of ​​the defect, which is accompanied by pain and a clicking sound in the joint.

Figure 1: Anatomy of the shoulder joint.

Figure 2: Normal labrum structure.

Most often, damage to the labrum occurs in the anterior, anterior-inferior part of the joint (Bankarta injury). There are several options for damage to the articular labrum, depending on the location of the damage and concomitant damage to the periosteum, ligaments, cartilage, and bone tissue. It is possible to tear off the articular labrum with a portion of the glenoid bone fragment - bone Bankart, damage to the articular labrum with the periosteum and joint capsule - GLAD, ALPSA, damage to the articular labrum at the site of attachment of the tendon of the long head of the biceps - SLAP injuries. separation of the joint capsule from the humeral head - HAGL, etc.

Figure 5: Anatomical specimen demonstrating the structure of the labrum.

Figure 6: Variants of labral injury.

BANK CARD OPERATION

To restore the anatomy and stability of the joint, lip refixation surgery (Bankart procedure) is used. Currently, these operations are predominantly performed arthroscopically - “Arthroscopic labral plastic surgery”. For injuries with a bone defect in the edge of the glenoid cavity (more than 20%), operations are used that include bone grafting - the Laterger operation (Bristow-Latarget operation). In case of significant Hill-Sachs damage, additional fixation of the joint capsule to the defect area (remplissage) can be performed.

What is a Hill-Sachs lesion?

Damage or subchondral Hill-Sachs fracture - a defect of the head of the humerus, which is a consequence of a dislocated shoulder.

Reference. Translated from Greek, subchondral means “under the cartilage.”

Actually, under the cartilage tissue there is subchondral bone, which provides support for the cartilage. It is this bone and cartilage that is affected.

During injury, a limited depressed (impression) fracture of the head of the humerus occurs. The mechanism of damage is as follows: due to the traumatic impact, the head of the bone rolls over the sharp edge of the glenoid cavity of the scapula.

If the defect is extensive, then it can further contribute to recurrent instability of the shoulder in the position of abduction and rotation of the arm.

Reference . This phenomenon was first described by American doctors Hill and Sachs in 1940.

As a result of anatomical studies of the shoulder during dislocations, doctors came to the following conclusions:

1. With this injury, an impression fracture of the head of the bone often occurs.
2. Keeping the bone in an unnatural position for a long time contributes to an increase in the defect.
3. With repeated dislocations, an increase in the defect is observed.

The Hill-Sachs impression fracture is the most common defect in posterior dislocation. According to statistics, it occurs in 86% of cases.

The severity of the pathological condition depends on the severity of the traumatic impact, as well as the time that has passed since the injury.

MAIN STAGES OF BANK CARD OPERATIONS.

Using standard arthroscopic ports, the shoulder joint is examined, the location and nature of the damage to the labrum, and associated injuries are clarified. An important stage is the complete mobilization of the articular labrum, which in case of old injuries is often fixed below the edge of the articular surface of the glenoid.

Figure 7: Arthroscopic appearance of a Bankart lesion.

The next step is to clean the bony surface of the glenoid to create the possibility of fusion of the labrum to the site of fixation.

Then, several holes are formed in the edge of the glenoid cavity of the scapula, into which special anchor clamps are inserted (Y-KNOT 1.3 mm anchor clamp is used in the pictures). The labrum is sutured, tightened and fixed to the bone edge using threads connected to anchors. A kind of “roller” is formed in the area of ​​the glenoid edge. This creates conditions for the fusion of the articular labrum to the site of separation and restoration of joint stability.

Currently, there are quite a large number of different anchors, differing in diameter (1.3 - 3.5 mm), absorbable (polylactic acid), or non-absorbable material (titanium), number and type of threads, as well as knotted or knotless thread fixation method.

In my practice, I primarily use anchors manufactured by ConMed Linvatec (USA), including the POPLOK® 3.5 MM (KNOTLESS) SUTURE ANCHORS knotless anchors, and the new “soft” anchor Y-KNOT™ 1.3MM ALL-SUTURE ANCHOR

An example of using a knotless POPLOK fixator when restoring a SLAP injury

In the postoperative period, when the labrum is refixed, the arm is immobilized with an orthotic bandage for up to 3 weeks. Physiotherapy exercises are carried out, followed by gradual rehabilitation treatment, periodically. Lymphatic drainage, static muscle tension, painless movements of the hand and elbow joint (from the first days after surgery), passive development of movements in the joint (from 3 weeks), then active movements in the joint, gradual restoration of the full range of motion and muscle strength, coordination work . Return to full activity and sports is possible within 4-6 months after surgery.

Symptoms

The pathological phenomenon has a characteristic clinical picture, which is characterized by the following symptoms:

• pain syndrome due to rupture of soft tissues, ligaments, capsular damage or separation of fragments of the cartilaginous ridge,
• deformity in the shoulder joint,
• impaired sensitivity of the hand, forearm, shoulder due to compression of nerve fibers by displaced bone,
• swelling, tissue inflammation,
• stiffness because the displaced bone reduces the natural range of motion.

Such manifestations are serious and require immediate visit to a specialist.

Benefits of Shoulder Arthroscopy

Here are the main advantages of arthroscopy over traditional “open” surgery that patients usually pay attention to:

• the patient is in the inpatient department of a medical institution for a short period of time: a maximum of 3 days, but most often the period is limited to 24 hours;
• During the operation, soft tissues are minimally injured, since incisions only 5-7 mm long are used;
• The cost of arthroscopy is quite adequate and affordable for absolutely all patients.

A more accurate diagnostic examination of the joint simply does not exist in medicine today! Arthroscopy does not allow errors, and at the same time it is possible to immediately carry out the necessary medical manipulations.

How to identify a shoulder dislocation or sprain. How to determine?

If a shoulder injury occurs during sports training or in a fall at home, the first thing to suspect is a dislocation. There are a number of symptoms that allow you to independently determine the presence of a ruptured joint ligament. You need to understand that this diagnostic method is not accurate, but approximate. You cannot do without contacting a medical institution:

1. Absence of visual signs - occurs when one fiber is partially ruptured. Unlike a dislocation or fracture, there is no deformation of the limb, especially the forearm area.
2. Pain occurs or intensifies, becoming unbearable if you palpate the shoulder while abducting the limb to the side.
3. Painful manifestations are not constant. The first day after the injury, any unpleasant sensations may be either completely absent or mild in nature. Sharp, sometimes unbearable pain tends to occur when the shoulder moves carelessly. For example, when putting on clothes, a careless, sharp turn.
4. Inability to completely abduct the upper limb to the side. This movement cannot be performed due to the limited functioning of the shoulder joint and due to the occurrence of severe pain at the moment.

Immediately at the moment of falling on the hand, when the fibers rupture, many patients hear a sound characteristic of this injury, similar to a crunching or crackling sound. Rarely, but not excluded, the formation of a hematoma. After some time, a slight swelling or swelling may appear in its place.

How is shoulder arthroscopy performed?

We perform each intervention on the shoulder joint only according to a specific scheme, which is considered the best option for the patient not only in terms of efficiency, but also comfort. But before the patient receives an appointment for such an intervention, we must study all the examination results available to him and collect the necessary preoperative set of tests.

Arthroscopy is performed under general endotracheal anesthesia.

The following positions are possible for the patient on the operating table:

1. Side position. The arm is fixed to the shoulder axis through a special block at an angle with a load of 3-4 kg. The patient himself at this moment is located, lying on his healthy side.
2. Beach chair position. The patient is positioned on the operating table in a “semi-sitting” position, while the arm is fixed with a special device that allows the limb to be fixed in any given position.

Once the shoulder joint is fixed in the desired position, the operation begins:

• the skin is treated with a disinfectant;
• Through an incision 5-7 mm long, an arthroscope with a video camera with a diameter of 4.2 mm is inserted into the joint cavity. The joint cavity is filled with saline solution supplied by a pump (for better visualization);
• a second incision is made, and a cannula for a surgical instrument is inserted into it if medical procedures are necessary. If necessary, 1-2 additional arthroscopic ports are installed.

And then everything depends on what results will be obtained during the examination of the joint. Thanks to modern equipment, the surgeon can see the image of the joint on the monitor, assess the condition of tissues, tendons, cartilage and bones and immediately carry out the necessary treatment.

Classification

According to the degree of change in cartilage tissue:

1st degree: no defect (softening of cartilage).

Grade 2: defect less than 50% of cartilage thickness

Grade 3: defect more than 50% of cartilage thickness

Grade 4: defect of the entire thickness of the cartilage with changes in the adjacent bone tissue.

Stages of osteochondral damage:

Stage 1: limited to cartilaginous tissue, subchondral trabecular edema is possible;

Stage 2: cartilage damage with an associated subchondral fracture without fragment formation;

Subtype A: small cysts on CT and/or trabecular edema on MRI

Subtype B: similar to subtype A, without trabecular edema on MRI.

Stage 3: demarcated but not displaced fragment;

Stage 4: displaced osteochondral fragment;

Stage 5: formation of subchondral cysts and secondary degenerative changes against the background of a displaced fragment.