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Anterior Shoulder Stabilisation

Arthroscopic Bankart repair for anterior shoulder instability — distinct from open Latarjet.

160 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Anterior shoulder stabilization addresses glenohumeral instability and associated bone loss through techniques ranging from arthroscopic labral repair to open bony augmentation. The combination of Latarjet and Remplissage procedures treats severe instability and bone loss, achieving successful subjective and objective stability [1]. Dynamic anterior stabilization augmentation produces a kinematic profile that more closely approximates native shoulder motion, characterized by more centered anterior-posterior translation and preserved physiologic superior-inferior movement [2]. The Glenoid Track concept is encouraged as a routine part of the preoperative evaluation for all patients under consideration for arthroscopic anterior stabilization [10]. Inlay dynamic anterior stabilization with the long head of the biceps tendon and Remplissage procedure aims to improve stability and outcomes in patients with subcritical glenoid bone loss and on-track Hill-Sachs lesions [11].

Headline outcomes indicate high rates of return to sport among studies reporting both rate and time to return [12]. The open Latarjet procedure reliably restores stability and leads to high patient satisfaction in patients older than 40 years [13]. While surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, or patient-reported outcomes [19, 28], athletes who undergo an objective return to play criteria-based testing protocol have lower rates of recurrent instability than those cleared by time from surgery [25]. Recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% at midterm follow-up in a statistical model analysis using anatomic risk factors [26]. Approximately one third of stabilized shoulders experienced at least one redislocation after 8 to 10 years of follow-up in a study using suture anchors [7].

Sex-based recurrence data present mixed findings; males may have higher recurrence rates than females following primary arthroscopic anterior shoulder stabilization, although heterogeneity in included studies precludes definitive conclusions [4], while female patients had a similar recurrence rate to male patients after arthroscopic anterior shoulder stabilization at 5-year follow-up [6]. Stabilization of the dominant shoulder results in residual surgery-related functional impairments on both sides, whereas stabilization of the nondominant shoulder results in impairments primarily noted in the nondominant, operative shoulder [3]. Thresholds for Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) achievement have been defined at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization [8, 34]. Standardized outcome reporting is supported as necessary after arthroscopic anterior shoulder instability surgery in adolescents due to variability in current reporting [38].

Anatomy & Pathophysiology

Bony Anatomy

The glenoid cavity is a shallow socket approximately one-third the size of the humeral head [70]. It is a convex structure of shallow depth shaped like an inverted pear [69]. The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [72]. The glenoid averages 5° of retroversion in relation to the axis of the scapular body [72]. The glenoid surface area is 4-6 mm and the humeral head surface area is 11-19 mm [81]. Glenoid cartilage thickness is 2.16 mm and humeral head cartilage thickness is 1.44 mm [81]. The glenoid radius of curvature is 22-28 mm and the humeral head radius of curvature is 23-28 mm [81]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [81].

The humeral head is spherical with a diameter of 37 to 57 mm [69]. The articular surface of the humeral head is essentially spherical with an arc of approximately 160 degrees covered by articular cartilage [81]. The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [81]. The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [69]. The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [81]. Humeral version averages 29.8 degrees with a range of 10 to 55 degrees [69]. The humeral head is retroverted an average of 30 degrees [70]. The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [72]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the method used for measurement [81]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [69]. The neck-shaft angle measures an average of 135 degrees [70]. The average neck-shaft angle is 45 degrees (±5 degrees) with a range of 30 to 50 degrees [81].

The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [81]. A significant decrease in lateral humeral offset reduces the lever arms for the deltoid and supraspinatus muscles, weakening abduction and impairing function [81]. A significant increase in lateral humeral offset causes excessive tension on the soft tissues, resulting in loss of motion and likely accelerating polyethylene wear [81]. The medial (coronal) humeral offset is 4-14 mm and the posterior (transverse) humeral offset is –2 to 10 mm [81].

The scapula is attached to the axial skeleton by the clavicle via the acromioclavicular and sternoclavicular joints [71]. The scapula is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion over the chest wall [71]. The glenoid is connected with the flat body of the scapula by the scapular neck [71]. The coracoid process curves forwards from the superior surface of the scapular neck [71]. The acromion is a flattened bony process that curves forwards from the scapular spine [71]. The highest concentration of bony mass in the scapula is found in the glenoid, the scapular neck, and the lateral border of the scapular body [71]. Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar and the spinal pillar [71]. The lateral pillar connects the inferior border of the glenoid with the inferior angle [71]. The spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [71]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [71]. The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [71].

The clavicle is the first bone to ossify at the fifth week of gestation and is the only long bone to ossify by intramembranous ossification [72]. The medial (sternal) epiphysis of the clavicle is the last ossification center to fuse, at age 20 to 25 years [72]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [72]. The scapula has only one true diarthrodial articulation, the acromioclavicular joint [72]. Normal shoulder motion is approximately two-thirds glenohumeral and one-third scapulothoracic [72]. Ossification of the scapular body begins at the eighth week of gestation [72]. The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [72]. Failure of fusion of the acromial ossification centers results in os acromiale [72].

The coracobrachialis muscle and the short head of the biceps tendon originate from the coracoid process [72]. The pectoralis minor muscle inserts onto the medial coracoid process [72]. The proximal humerus has three centers of ossification: the humeral head, greater tuberosity, and lesser tuberosity [72]. The humeral head ossification center appears at 4 to 6 months, the greater tuberosity at 1 to 3 years, and the lesser tuberosity at 3 to 5 years [72]. The proximal humeral ossification centers fuse to the shaft at age 17 to 20 years [72]. The proximal humerus is primarily cartilaginous at birth, with ossification centers detectable by ultrasonography as early as the 38th week of gestation [76]. The ossification center for the humeral head is usually present at birth [76]. The greater tuberosity ossification center appears by 1 to 3 years of age [76]. The lesser tuberosity ossification center appears by 5 years of age [76]. The proximal humeral ossification centers fuse by 5 to 7 years of age to form the humeral head [76]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [76]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to approach adult values by 11 years of age [76]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis, accounting for approximately 40% of the growth of the entire upper extremity [76]. Less than 75% of humeral growth occurs before 2 years of age and more than 85% occurs by 8 years of age [76]. The proximal humeral physis is irregularly shaped, with its apex located on the posteromedial portion of the proximal humerus [76]. The periosteum is thicker and stronger in the posteromedial portion of the proximal humerus compared to the anterolateral portion [76].

The scapula has shifted caudally from the cervical position in lower animals, freeing the shoulder from the head and neck [79]. Broadening of the infraspinatus fossa has changed the vector of muscle pull from the axillary border of the scapula to the glenoid fossa [79]. This adaptation allows the infraspinatus and teres minor muscles to be more effective in their roles as depressors and external rotators of the humeral head [79]. The acromion has enlarged over time, reflecting the increasing role of the deltoid muscle in shoulder function [79]. The broader attachment of the deltoid on the acromion and its more distal insertion on the humerus have increased its mechanical advantage in shoulder motion [79]. The coracoid process has undergone an increase in size over time [79]. With the shoulder in 90 degrees of abduction, the coracoid extension over the glenohumeral joint can mechanically limit anterior translation of the humerus relative to the glenoid [79].

Soft Tissue Anatomy

The glenoid labrum is a fibrous ring attaching to the glenoid articular cartilage through a narrow fibrocartilaginous transition zone [15]. Above the glenoid equator, the labrum is relatively more mobile [15]. Below the glenoid equator, the labrum is more tightly attached to the glenoid articular cartilage [15]. The labrum is composed of dense fibrocartilaginous tissue which increases the depth of the socket by 50% around the humeral head [82]. The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [82]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [82]. The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [72].

The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity of the humerus [77]. The subscapularis is inserted into the lesser tuberosity [77]. The rotator cuff consists of the subscapularis in front, supraspinatus above, and infraspinatus and teres minor behind [77]. The coracoacromial arch is a fibro-osseous canopy formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [77]. The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch, allowing them to glide [77].

The subscapular bursa lies between the subscapularis tendon and the neck of the scapula [73]. The subscapular bursa communicates with the joint cavity between the superior and middle glenohumeral ligaments [73]. The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [73]. The subscapular bursa is linked to the coracoid process by a suspensory ligament [73]. In 28% of specimens dissected by Colas and colleagues, the subscapular bursae merged with the subcoracoid bursae, forming a unique wide bursa [73]. The subscapular bursa often houses loose bodies in the shoulder [73]. Synovitis of the shoulder may be most intense in the subscapular bursa region, where small fringes or villi can project into the joint cavity [73].

DePalma and colleagues described six common variations or types of recesses in the anterior capsule [73]. Type 1 recesses (30.2%) have one synovial recess above the middle glenohumeral ligament [73]. Type 2 recesses (2.0%) have one synovial recess below the middle glenohumeral ligament [73]. Type 3 recesses (40.6%) have one recess above and one below the middle glenohumeral ligament [73]. Type 4 recesses (9.0%) have one large recess above the inferior ligament, with the middle glenohumeral ligament being absent [73]. Type 5 recesses (5.1%) have the middle glenohumeral ligament manifested as two small synovial folds [73]. Type 6 recesses (11.4%) have no synovial recesses, although all the ligaments are well defined [73]. DePalma believed that if the capsule arises at the labrum or glenoid border of the scapula, few, if any, recesses would be present [73]. If the capsule begins farther medially on the scapula or glenoid neck, the synovial recesses are larger and more numerous [73]. DePalma believed that the end result of such recesses was a thin, weakened anterior capsule that could predispose the shoulder to instability [73].

The rotator interval is defined as the region between the superior border of the subscapularis and the anterior border of the supraspinatus [73]. The rotator interval includes the region of the superior glenohumeral ligament and coracohumeral ligament, in addition to the middle glenohumeral ligament [73]. Plancher and colleagues found the average area of the rotator interval to be 20.96 mm [73]. Dynamic testing has shown that the subscapularis and supraspinatus dimensions as well as the total area of the rotator interval decrease significantly with internal rotation and open with external rotation [73].

The superior shoulder suspensory complex (SSSC) provides a stable connection between the scapula and the axial skeleton [72]. The SSSC is composed of the glenoid, the coracoid process, the coracoclavicular ligaments, the distal clavicle, the AC joint, and the acromion [72]. The superior strut of the SSSC comprises the middle clavicle [72]. The inferior strut of the SSSC comprises the lateral scapular border/spine of the scapula [72]. The SSSC is a bone–soft-tissue ring that provides a stable connection of the glenoid and scapula to the clavicle [78]. The SSSC is composed of four bony landmarks—distal clavicle, acromion, coracoid process, and glenoid neck—and the supporting ligamentous complexes of the AC joint and the CC ligaments [78]. The coracoclavicular ligaments consist of the conoid (medial) and trapezoid (lateral) ligaments [72]. The coracoclavicular ligaments are the primary stabilizers to superior (vertical) translation of the distal clavicle [72]. The superior and posterior AC ligaments are the primary stabilizers to anterior and posterior (horizontal) translation of the clavicle [72]. The posterior SC joint capsule and ligaments are the primary stabilizers to anterior and posterior translation of the medial clavicle [72]. The sternoclavicular joint is the only true diarthrodial articulation between the upper appendicular and axial skeletons [72]. The AC joint is a small diarthrodial joint with an interposed fibrocartilaginous disk [72].

The superior transverse scapular ligament arises from the medial base of the coracoid overlying the suprascapular notch [72]. The suprascapular artery runs superior to the superior transverse scapular ligament, and the nerve runs deep to the ligament [72]. Entrapment of the suprascapular nerve at the superior transverse scapular ligament causes denervation of both the supraspinatus and the infraspinatus [72]. The spinoglenoid ligament overlies the suprascapular nerve at the spinoglenoid notch [72]. Entrapment, traction, or compression of the suprascapular nerve at the spinoglenoid notch causes denervation of the infraspinatus [72].

The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps [69]. The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [69]. The greater tuberosity is located in a posterior-superior location with respect to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [69]. The lesser tuberosity is located on the anterior aspect of the proximal humerus and serves as the attachment site for the subscapularis tendon [69].

Classification

Glenohumeral Biomechanics: The glenohumeral joint relies on combined static and dynamic mechanisms for stability, necessitated by the large, spherical humeral head articulating with a relatively small and shallow glenoid [15]. Static stability is provided by capsuloligamentous structures, the rotator cuff, scapular stabilizers, and the biceps muscle [15]. In midranges of rotation, stability is primarily achieved through the dynamic action of the rotator cuff and biceps tendons via concavity compression of the humeral head within the glenoid socket [15]. Ligamentous structures function primarily at extreme positions of rotation to prevent excessive rotation and translation [15]. The fibrous labrum compensates for the relative lack of depth and surface area of the bony glenoid to maintain normal glenohumeral biomechanics [15]. The labrum is a fibrous ring attaching to the glenoid articular cartilage through a narrow fibrocartilaginous transition zone [15]. Above the glenoid equator, the labrum is relatively more mobile, whereas below the equator, it is more tightly attached to the glenoid articular cartilage [15]. The three glenohumeral ligaments constitute relatively constant elements of the anterior capsuloligamentous complex [212].

Walch Classification: The Walch classification categorizes glenoid morphology into subtypes based on three-dimensional imaging [217]. Type A involves central erosion [217]. Type B involves posterior subluxation or deformity [217]. Type C involves premorbid retroversion [217]. Type D involves anteversion or subluxation of less than 40% [217]. Type B1 glenoids are characterized by posterior humeral head subluxation with glenoid retroversion [217]. Type B2 glenoids present with a biconcave deformity [217]. Type B3 glenoids are monoconcave and posteriorly worn, defined by at least 15 degrees of retroversion or at least 70% posterior humeral head subluxation, or both [217]. Type C glenoids have a premorbid retroversion of .25 [217]. Tightening of the anterior capsule in post-dislocation arthropathy can result in posterior displacement of the head, leading to severe B2 and B3 deformities [217].

Other Considerations: The glenoid track concept is encouraged as a routine part of preoperative evaluation for all patients under consideration for arthroscopic anterior stabilization [10]. The Instability Severity Index score permits precise identification of patients at risk for failure of primary shoulder stabilization procedures [30]. Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology [30]. Bipolar bone loss and glenoid bone loss alone are both associated with failure after arthroscopic anterior shoulder stabilization [229]. A Hill-Sachs lesion is an impaction fracture of the posterolateral humeral head articular surface that may increase a patient's risk of recurrent instability [231]. Calculation of the glenoid track and Hill-Sachs interval allows surgeons to predict preoperatively engagement of the Hill-Sachs lesion with the anterior glenoid rim [231]. Male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability [31].

Clinical Presentation

History Taking

The history must define the mechanism of injury, including the position of the arm, the amount of force applied, and the point of force application [37]. Injury with the arm in extension, abduction, and external rotation favors anterior dislocation [37]. In traumatic anterior shoulder dislocation, patients report a shoulder in abduction and external rotation receiving a hit to the arm with the arm in full outstretched motion [96]. For recurrent instability, the history defines the initial injury, the position or action that results in instability, how long the shoulder stays out, whether radiographs are available with the shoulder out of joint, and what means have been necessary to reduce the shoulder [37]. The history solicits evidence of neurologic or rotator cuff problems after previous episodes of shoulder instability [37]. Previous treatment of the recurrent instability, as well as the effectiveness of this treatment, should be documented [37].

The patient history should be evaluated for age, gender, mechanism of injury, occupation, sport played and position, level of sport, whether it required reduction, and hyperlaxity [29]. For recurrent anterior shoulder instability, the history should evaluate age at first instability event and number of previous episodes [29]. The history should include details of the initial injury, activities that cause symptoms, and previous conservative or surgical treatment of the involved shoulder [40]. It is not uncommon to see patients with presumed traumatic anterior shoulder instability who in fact have posterior instability, which emphasizes the importance of the physical examination [40]. The history should include handedness, sport or recreational activity, unilateral or bilateral complaint, family history of shoulder dislocation, and initial traumatic event [117]. The history should include the number of previous episodes of dislocations or subluxations, whether the dislocation was reduced in the emergency department, and the interval of time between dislocation and reduction [117]. The history should include the degree of trauma required for recurrence, voluntary dislocation, dislocation during sleep, presence and location of pain, presence or absence of mechanical symptoms, sensory disturbance or motor weakness, and previous shoulder surgery [117]. Patients with anterior shoulder instability will experience symptoms of apprehension with shoulder abduction and external rotation [101]. Patients with anterior shoulder instability can experience symptoms of pain and instability with placement of the arm in an overhead position [101]. Microinstability can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability [154].

Physical Examination

An acutely dislocated shoulder is usually very painful, and muscles are in spasm in an attempt to stabilize the joint [37]. The humeral head may be palpable anteriorly in an acutely dislocated shoulder [37]. The posterior and lateral aspect of the shoulder shows a hollow beneath the acromion in an acutely dislocated shoulder [37]. The arm is held in slight abduction in an acutely dislocated shoulder [37]. Passive and active motions are limited by pain in an acutely dislocated shoulder [37]. Assessment of the neurovascular status of the upper extremity and charting of the findings before reduction is an essential part of the physical examination of an anteriorly dislocated shoulder [37]. A thorough neurovascular exam, including assessment of the axillary nerve, should be performed [96]. The axillary nerve is the most commonly injured nerve in up to 42% of traumatic anterior shoulder dislocations [96]. Initial examination should include a complete neurovascular examination to document any neurologic or vascular deficits [101]. Brachial plexus lesions and vascular lesions are rare but can present with high-energy traumatic events [101]. Testing of the axillary nerve is performed by assessing light touch over the lateral deltoid and by palpating the deltoid muscle for contraction while having the patient abduct the arm against resistance at the elbow [101].

Documentation of active and passive ROM of the shoulder for internal and external rotation as well as forward flexion and abduction is important [101]. Marked loss of motion is seen with persistent dislocations and rotator cuff lesions [101]. Rotator cuff testing is an essential part of the shoulder instability examination particularly in patients over the age of 40 years as the incidence of rotator cuff lesions increases [101]. The belly press or bear hug test is the most effective test to evaluate the function of the subscapularis in the acutely injured patient [101]. Testing of resisted shoulder abduction in the first 30 degrees of shoulder flexion with the arm internally rotated is effective for evaluating the supraspinatus [101]. Evaluation of the infraspinatus is performed by applying resisted external rotation with the elbow flexed to 90 degrees [101]. The physical examination should include rotator cuff strength testing, neurological exam, and anterior instability testing [29]. The physical examination should include Beighton score/hyperlaxity of the shoulder at external rotation at side >85°, Gagey test, and findings on inspection [29]. Constitutional ligamentous laxity should be assessed using the Marshall test or Beighton score [117]. Shoulder range of motion and scapular symmetry should be assessed [117]. Strength testing of shoulder girdle muscles should be performed [117]. Lift-off and belly press tests should be performed [117]. The sulcus sign should be assessed [117]. The anterior apprehension test and position of arm, including evaluation for mid-range instability, should be assessed [117]. The relocation test should be performed [117]. Load and shift testing for anterior and posterior instability should be performed [117]. The Jerk test should be performed [117]. O’Brien’s active compression test should be performed [117]. Hawkins and Neer impingement tests should be performed [117]. Cross-body adduction should be assessed [117].

The anterior apprehension sign is done with the patient in the supine position in which the arm is placed into 90 degrees of abducted and maximally externally rotated (ABER) position resulting in a feeling of pain, discomfort, and potential instability [101]. From the ABER position, the relocation test can be performed in which a posteriorly applied force to the proximal humerus will elicit a feeling of reduced apprehension or pain from the patient [101]. An anterior release test (surprise test) can be performed by removing the posteriorly directed force abruptly when the patient's arm is in the 90 degrees of abduction, 90 degrees of elbow flexion, and maximal external rotation position [101]. A feeling of pain or apprehension is a positive result for the anterior release test [101]. Caution should be taken not to dislocate the patient's shoulder with anterior release testing [101]. The apprehension and relocation tests assess anterior GH instability [96]. The patient should be lying in supine position on examination table with their arm abducted to 90 degrees and externally rotated for apprehension and relocation tests [96]. If the patient feels a slipping sensation or fear of a impending dislocation of their shoulder with this motion that is improved with applying a posterior force to the GH joint, it is a positive relocation test [96]. The sulcus sign is performed at 0 degrees of abduction [96]. Downward traction is applied on the humerus for the sulcus sign [96]. Dimpling or a “gap” formed in the GH joint is a positive sign, indicating laxity of the superior GH ligament [96]. The load and shift test is used to evaluate anterior and posterior GH laxity and is performed while the patient is in a seated or supine position with the humeral head centered in the glenoid fossa and translated [96].

Load and Shift Grading: * Grade 0: Normal translation [96]. * Grade 1: Translation to rim and back, less than 1 cm [96]. * Grade 2: Translation over the rim followed by spontaneous reduction, 1 to 2 cm [96]. * Grade 3: Translation over the rim without spontaneous reduction, greater than 2 cm [96].

Generalized joint laxity should be assessed using the Beighton score (0–9 point scale) [96]. The opposite shoulder is first assessed to ascertain the degree of physiologic ligamentous laxity normally present for the individual [40]. Generalized ligamentous laxity may be evaluated further by examining for elbow hyperextension and hyperextension of the metacarpophalangeal joint of the thumb in relation to the forearm [40]. The involved shoulder is assessed for inferior instability by testing for a sulcus sign followed by sequential evaluation of the glenohumeral ligaments for anteriorsuperior, anterior-middle, and anterior-inferior instability [40]. Posterior instability is assessed in the supine position with posterior displacement of the glenohumeral joint as the shoulder is internally rotated [40]. The apprehension and relocation tests may be used to augment findings of the physical exam but should not be relied upon exclusively because they are nonspecific [40]. In traumatic recurrent anterior instability, anterior-inferior instability usually will be confirmed with a careful history and physical examination [40]. Patients with severe glenoid defects typically present with midrange-of-motion instability [102]. Clinical signs for anterior instability in particular the apprehension and relocation tests are found to be positive in patients with severe glenoid defects [102].

An examination under anesthesia is critical to the success of arthroscopic stabilization and is more sensitive for determining both the degree and direction of instability [117]. The pattern of instability can be determined without getting affected by patient apprehension or guarding during examination under anesthesia [117]. The axial load test or load-and-shift test is conducted during examination under anesthesia and the translation noted in the anterior, inferior, and posterior directions [117]. Grading of load-and-shift reflects the degree of humeral head translation anterior and posterior to the glenoid rim [117].

Examination Under Anesthesia Grading: * Grade 1+: Translation of the humeral head to the edge of the glenoid [117]. * Grade 2+: Humeral head subluxated over the glenoid rim but reducing spontaneously [117]. * Grade 3+: Frank dislocation of the humeral head over the glenoid rim that does not reduce spontaneously [117].

Investigations

Plain radiography: The standard shoulder series includes a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [104]. The axillary view is necessary for evaluating glenohumeral joint instability and determining humeral head position within the glenoid fossa [104]. This view is often referred to as the “truth view” because it demonstrates glenohumeral relationships in the functional position of elevation, unlike CT scans taken with the arm adducted [36]. It enables measurement of posterior subluxation or “functional decentering” that is not evident when the arm is at the side [36]. At least two views are required: an AP in the plane of the glenoid and an axillary projection with the arm in abduction to show humeral head-glenoid relationship [86]. For proximal humerus fractures, the Neer trauma series (AP, lateral in scapular plane, and Velpeau modified axillary) evaluates the joint in three perpendicular planes [90]. Special views include the West Point view for anterior glenoid bone loss, the Stryker notch view for Hill-Sachs lesions, and the apical oblique view for glenoid rim fractures [104]. While standardized plain films are almost always sufficient and provide information unobtainable from CT [36], they are inferior to CT for assessing osseous lesions, especially at the glenoid rim [249]. Radiographs can screen for significant glenoid bone loss [248], but bone defects seen on plain films are less important than accurate imaging for determining their role in instability recurrence [245].

CT: CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in shoulder instability [104]. On occasion, CT scanning is necessary for detailing bony anatomy in proximal humerus fractures [90]. A robust imaging approach recognizes that the shoulder is a three-dimensional structure where critical relationships, such as humeral head centering, change with arm position [91]. Surgeons must adopt a judicious approach to avoid “over-imaging,” obtaining only necessary scans or reconstructions [36, 91]. Significant heterogeneity exists in imaging modalities and methods used to measure glenoid bone loss [268]. Future studies should control for relevant factors and use advanced imaging for these measurements [253]. Until a threshold is validated prospectively in multicenter cohorts with standardized advanced imaging and formal glenoid track assessment, it should be applied with considerable caution [273].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [98]. It complements physical examination and standard radiographs in managing anterior shoulder instability [94]. MRI provides high contrast and spatial resolution for soft tissue evaluation [94]. T1-weighted MRI reveals Hill-Sachs lesions and is often used with MR arthrograms for detailed joint surface imaging [98]. T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [98]. Multi-planar imaging allows detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff [94]. MRI identifies osteonecrosis of the humeral head or bone tumors [86]. It can identify labral and rotator cuff tears, though accuracy for these is enhanced by combining the scan with arthrography [86]. MR accuracy in identifying labral and rotator cuff tears ranges from 70% to 100% [94]. Evaluation of Hill-Sachs extension below the humeral equator on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss [254]. These static sagittal measures may provide a basis for future studies of treatment effect as they are identifiable on MRI in a clinical setting [259].

MR Arthrography: MR arthrography (MRA) involves MRI of a joint injected with intra-articular contrast (diluted gadolinium or saline) under strict aseptic technique via fluoroscopic or ultrasound guidance [94]. Contrast distends the joint capsule, outlining cartilage, ligaments, and labrum to increase sensitivity for detecting tears [94]. In acute dislocation, joint effusion may outline these structures, making arthrogram unnecessary [94]. MRA increases both sensitivity and specificity for detecting capsulolabral–ligamentous complex injuries compared to traditional MRI [94]. A meta-analysis of 6 studies including 4,667 shoulders found greater diagnostic accuracy for MRA over MRI for glenoid labral lesions (MRA sensitivity 88% and specificity 93% vs. MRI sensitivity 76% and specificity 87%) [94]. MRA is considered the benchmark for evaluating labral tears and is rarely indicated for rotator cuff pathology [98]. When MRI or MRA is contraindicated (e.g., pacemaker, vascular clips), CT arthrography is indicated [98]. Arthrography enhances imaging of the joint to better identify normal structures and pathology involving joint surfaces [98]. Enhancement MR imaging is a useful technique to assess the anterior capsular mechanism [257].

Positioning and Specific Findings: With standard MRI or MRA, the shoulder is routinely positioned in neutral or partial external rotation, but alternative positions can increase sensitivity for detecting labroligamentous injuries [94]. Abduction and external rotation (ABER) of the arm increases sensitivity and specificity for detecting anteroinferior labroligamentous injury [94]. Limited ROM or pain may prohibit patients from performing the ABER provocative maneuver [94]. Schreinemachers et al. found that full routine MRI or MRA examination had similar accuracy as the ABER sequence for evaluating the anteroinferior labral–ligamentous complex [94]. Conversely, Tian et al. found that MRA with the ABER position had significantly higher sensitivity for detecting anteroinferior labral lesions than MRA in neutral position and was more effective in identifying Perthes lesions [94]. MRAs can demonstrate a patulous capsule on coronal, sagittal, and axial imaging in patients with multidirectional instability [94]. They are helpful in evaluating rotator interval lesions and other associated findings that may affect surgical planning [94]. Glenoid dysplasia, increased capsular cross-sectional area, and increased glenoid retroversion are associated with increased posterior labral tears and symptomatic instability [94]. Parada et al. demonstrated that glenoid retroversion was significantly increased in patients with symptomatic posterior labral tears, but there was no significant association between instability and increased humeral head subluxation [94].

Ultrasonography: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating skeletal and soft-tissue structures [98]. It provides immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [98]. It can measure the subacromial space, detect rotator cuff muscle atrophy, and evaluate impingement in various positions and motions [98]. It is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [86]. It can guide injections or barbotage (aspirating calcific deposits) [86]. The shoulder is the most commonly performed joint examination using ultrasonography [84]. Accuracy depends on the skill of the scanner operator and awareness of pitfalls [84]. Ultrasonography is highly operator-dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [98]. Ultrasonic measurement found an average translation of 4.9 mm in unstable shoulders and 1.9 mm in stable shoulders [55].

Other Considerations: The purpose of shoulder imaging is to establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition to the patient [36]. Clinicians should keep in mind that the diagnosis of multidirectional instability is a clinical one, and the need for expensive and/or invasive imaging should be weighed against the information gained [94]. Often, patients with multidirectional instability present having already had an MRI or MRA, so these studies should be reviewed [94].

Treatment

Operative

Indications: Arthroscopic stabilization is indicated for young, active patients, where it yields significantly lower rates of recurrent instability compared with non-operative management [206]. Participation in collision and contact athletics is not a contraindication for arthroscopic anterior shoulder stabilization using suture anchors, proper suture placement, capsulorrhaphy, and occasional rotator interval plication [182]. The Instability Severity Index Score can guide decision making on whether Bankart surgery is sufficient for anterior shoulder instability [179]. Indications for the open Latarjet-Patte procedure include documented anterior dislocations with evidence for emergency reduction, with or without hyperlaxity and confirmation of a traumatic capsuloligamentous lesion [179]. Contraindications for the open Latarjet-Patte procedure include voluntary dislocations and multidirectional instability without specific criteria [179]. Large Hill-Sachs lesions may be an indication for additional remplissage in the context of the open Latarjet-Patte procedure [179].

Surgical Approach / Technique: Arthroscopic Bankart repair requires at least four anchor points to obtain secure shoulder stabilization [236]. The modified capsulolabral reconstruction with suture anchors might be a successful procedure for repairing the anterior instability of the shoulder [65]. A combined procedure of Bankart repair and anterior capsular shift provides good long-term stability for shoulders with a high rate of recurrency that are not suitable for an arthroscopic procedure [60]. The described open technique for anterior shoulder stabilization using modern instrumentation can be performed in a reliable, efficient, and reproducible manner [9]. The standard open Latarjet procedure is performed via a mini deltopectoral incision, involving withdrawal of the coracoid process while preserving the attached coracoacromial ligament, release of the subscapularis muscle, decortication of the anterior edge of the glenoid, and fixation with two 4.5-mm bicortical malleolar screws [189]. The Walch technique for the open Latarjet-Patte procedure requires mastering three key maneuvers (arm positioning, retractor placement, safe conjoint tendon releases) and six surgical stages [179]. A 360° anterior scapula neck exposure is crucial to drill the inferior cornerstone hole in the open Latarjet-Patte procedure [179].

The arthroscopic Latarjet procedure enables shoulder surgeons to treat all cases of instability arthroscopically [133]. It is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting [143]. Early results suggest that arthroscopic coracoid transfer is a technically feasible procedure that is able to restore shoulder stability [147]. The arthroscopic Latarjet procedure with coracoid stabilization with 2 screws can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability [238]. Both screw and suture button fixation techniques in the arthroscopic Latarjet procedure achieve comparable graft union rates and effectively restore shoulder stability [237]. Similar results in return to sports, recurrences, and healing rates were observed between the classic and congruent-arc Latarjet for athletes with recurrent glenohumeral instability and a failed stabilization [57].

The arthroscopic Latarjet procedure with double suture-button fixation involves 5 consecutive steps: coracoid preparation and osteotomy, glenoid preparation and drilling, subscapularis splitting with axillary nerve protection, transfer and fixation, and capsulolabral repair when tissue quality permitted [58]. In this procedure, capsulolabral repair was performed in 72 patients (90%), while in the remaining 8 cases (10%), repair was not possible due to insufficient tissue quality [58]. The procedure involves typically harvesting a 15—20 mm bone graft [58]. The arthroscopic Latarjet procedure with double-button fixation involves 5 successive steps: coracoid preparation and osteotomy, glenoid preparation, subscapularis split, bone block fixation, and Bankart lesion repair [175]. The arthroscopic Latarjet procedure with double suture-button fixation involves 5 steps: preparation of the coracoid, preparation of the glenoid, split of the subscapularis, coracoid transfer and fixation, and Bankart repair [186].

Specific technical details for the arthroscopic Latarjet include using a 70° arthroscope and specific instruments through five arthroscopic portals in five successive steps [189]. The procedure uses a 70° scope and specific instruments through a standard posterior portal plus 5 anterior portals [58]. It also uses a 70° scope and specific instruments through 5 arthroscopic anterior portals [175]. Additionally, it uses a 70° scope and specific instruments through five anterior portals and two posterior portals [186]. The coracoid osteotomy is performed at approximately 1.5 cm from the tip of the coracoid [175]. An anchor is inserted at 3 o'clock during glenoid preparation [175]. Definitive fixation of the bone block is achieved with a posterior cortical button fixation with compression controlled at 100 N by a Nice knot [175]. Definitive fixation of the double-button sutures is tensioned by the suture tensioner at 120 N [186].

Preparation of the coracoid involves using a dedicated rasp to refresh the inferior side and make it flat, then drilling with a dedicated guide, and finally cutting with a dedicated saw [186]. Preparation of the glenoid involves using the same rasp to refresh the anterior and sub equatorial rim and make it flat [186]. Drilling of the glenoid is performed from posterior to anterior with a dedicated guide [186]. The procedure involves release of the pectoralis minor tendon and the coracoacromial ligament, freshening of the inferior aspect, positioning of the cortical button, and osteotomy of the coracoid [189]. It also involves abrasion and flattening of the neck of the scapula, insertion of an anchor at 3 o'clock, and positioning of a posterior-anterior pin with the glenoid drill guide [175]. The subscapularis is split with 2 spreaders, one from the posterior portal and one from the east portal [186]. Alternatively, the subscapularis is split using an intra-articular spreader transfixing the subscapularis muscle and opening a "safe window" by protecting the visible axillary nerve in front [175]. A second spreader placed from the east portal is used to extend the subscapularis split [175].

Transfer of the coracoid is performed through the subscapularis split with shuttle suture [175], or through the subscapularis against the glenoid [186]. Final positioning of the bone block is achieved in rotation to obtain a flush position [186]. Bankart lesion repair is performed with the previously positioned anchor and 1 or 2 sutures [175], or using the 2 previous anchors [186]. The procedure involves placing 2 suture anchors for the Bankart repair at 3 hours o'clock and 5 hours 30 for a right shoulder [186]. Positioning of the peg button occurs during coracoid preparation [175]. Abrasion and flattening of the under face of the coracoid is also part of the process [175]. Definitive fixation with a posterior cortical button fixation is standard [175]. Definitive fixation of the double-button sutures with a Nice knot is utilized [186].

Implant Selection: Glenoid faceplate fixation did not make the shoulder more stable compared to glenoid rim fixation, and creating a tissue 'bumper' did not increase stability [235]. The combination of arthroscopic subscapularis augmentation and bone block procedure with a xenograft was effective in the glenoid reconstruction and restoration of shoulder stability [251].

Adjuncts: The combination of arthroscopic Bankart repair with remplissage and arthroscopic subscapularis augmentation provides a viable option for managing recurrent anterior instability, particularly in cases with poor tissue quality and glenoid bone loss less than 15% [43]. The described procedure of arthroscopic Bankart repair and subscapularis augmentation is a reproducible and effective technique used to restore joint stability in patients engaged in sports who have incurred anterior recurrent shoulder dislocation associated with glenoid bone loss [44]. Overall, instability recurrence was low, indicating that both arthroscopic Bankart repair with remplissage and open Bankart repair are safe and effective techniques for treating anterior shoulder instability [46]. The stability of the shoulder has been achieved successfully both subjectively and objectively using a combination of Latarjet and Remplissage for treatment of severe glenohumeral instability and bone loss [1].

Setting of Care: A single anesthetic with proper management of analgesia is a reliable technique for major shoulder surgery in an ambulatory care unit [170].

Revision: Revision arthroscopic suture anchor repair is best indicated if the patient has recurred instability after a previous repair, has undergone reconstructive surgery only once, has a defect in the anterior glenoid less than 30% of the glenoid circumference, has no desire to modify activity, and has failed an appropriate rehabilitation regimen [192].

Other Considerations: Early arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with a 10-year recurrence rate of 35% [21]. With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years following arthroscopic shoulder stabilization using suture anchors [7]. In patients who did not undergo further surgery, good to excellent shoulder function as well as low pain and instability levels were observed at a minimum 20 years after arthroscopic Bankart repair [247]. Patient-reported outcomes decline over time following arthroscopic Bankart repair for anterior shoulder instability [250]. The presence of a posterior glenoid fracture (bony Bankart lesion) did not represent a contraindication to arthroscopic shoulder stabilization [54].

Female patients had a similar recurrence rate as that of male patients after arthroscopic anterior shoulder stabilization at 5-year follow-up [6]. Males may have higher recurrence rates than females following primary arthroscopic anterior shoulder stabilization, although the heterogeneity of included studies precludes definitive conclusions [4]. Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides, whereas stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder [3]. The overall complication rates in modern shoulder stabilization surgery are demonstrated by a large systematic review [20]. This study defines the thresholds for minimal clinically important difference and patient acceptable symptom state achievement at minimum 2 year follow-up in a cohort of patients undergoing arthroscopic anterior shoulder stabilization [8]. Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning [64]. The open Latarjet-Patte procedure is intricate and technically demanding, with heterogeneous outcomes and complications in the literature [179]. Screw removal alleviated pain in 14 shoulders (67%) and reduced pain in the remaining 7 shoulders (33%) after open Latarjet procedures [246].

Complications

Recurrent Instability and Failure Rates

Recurrent instability remains the primary mode of failure following anterior shoulder stabilization. The overall redislocation rate was 18.18% (26 shoulders) at a mean follow-up of 13.3 years after arthroscopic shoulder stabilization for anterior-inferior shoulder instability [93]. At midterm follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series [26]. Eighteen per cent of the patients had signs of instability during the 8-year follow-up period after arthroscopic intra-articular Bankart repair using absorbable tacks [68]. At a mean follow-up of 128.1 months, 25.0% of patients experienced recurrent instability and 19.6% underwent subsequent surgery after arthroscopic Bankart repair for on-track lesions [261]. All patients with poor results had postoperative re-dislocation, resulting in a recurrent rate of 15% after arthroscopic bankart repair (Caspari's technique) [262]. In a military population, a combined failure rate of 13.8% was identified at 2 to 7 years' follow-up, including surgical revision and shoulder-related military discharge [103].

Revision surgery outcomes vary by technique. In this series, 94% of shoulders were stable after arthroscopic revision anterior shoulder reconstruction [56]. Recurrent instability rates were higher in the all-arthroscopic group (19% versus 8%) following revision anterior shoulder stabilization compared to the Latarjet group [288]. Recurrent instability rates were higher in the all-arthroscopic group (19% versus 7%) following revision anterior shoulder stabilization compared to the Latarjet group [289]. Arthroscopic revision anterior stabilization is associated with a high rate of recurrent instability, and patient selection is of critical importance in order to minimize recurrence [280]. There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery [265]. The recurrence rate following open repair was 5% compared with 15% for arthroscopic stabilisation using a suture anchor [285].

Timing and patient demographics influence recurrence risk. Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events [252]. Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores [275]. The effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time, with less than half of recurrences occurring after 2 years [282]. While recurrence rates increased over time, patient satisfaction remained high, and no revision surgeries were required, demonstrating the long-term reliability of ABR for anterior shoulder instability [274]. There were high rates of recurrence with moderate rates of revision surgical stabilization in the medium term after open Bankart repair in collision athletes aged 18 years or less [283]. However, there was a moderate rate of recurrent instability and further revision surgery following arthroscopic Bankart repair in athletes [286]. The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery [22]. Patients may benefit from more aggressive stabilization strategies and techniques due to high rates of failure in the pediatric and adolescent population [269].

Anatomic pathology and bone loss are critical determinants of failure. Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology, and the instability severity index score permits precise identification of patients at risk [30]. In group B (≥17.3% bone loss), the redislocation rate was 28.6% compared to 2.2% in group A (<17.3% bone loss) after arthroscopic Bankart repair [88]. In group B (≥17.3% bone loss), the subjective instability rate was 14.3% compared to 1.5% in group A (<17.3% bone loss) after arthroscopic Bankart repair [88]. The number of episodes of dislocation before surgery and the delayed surgical intervention did not increase the recurrent anterior shoulder instability rates postoperatively after an open Latarjet-Bristow procedure [267]. Recurrence rates of instability are acceptable and reoperation rates were low after open Latarjet procedure for failed arthroscopic Bankart repair [281]. No further episodes of instability have been reported by any of our patients to date after achieving the optimum bone block position in the Latarjet procedure [266]. The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years is associated with good functional outcome and stability [51]. Despite a higher complication rate than in the younger population, shoulder stabilization using the Latarjet procedure is effective in patients over 50 without associated cuff damage [276]. The Latarjet procedure effectively prevented chronic anterior shoulder instability and was associated with high patient satisfaction as both a primary and a revision procedure [59].

Alternative techniques and specific populations show varied outcomes. The method aims to improve stability and outcomes in patients with complex shoulder instability issues using inlay dynamic anterior stabilization with the long head of the biceps tendon and remplissage procedure [11]. The index procedure effectively improved shoulder stability and function, achieving a relatively high rate of coracoid graft union with no requirement for revision surgeries at a mean followup of 26.7 months after arthroscopically assisted conjoined tendon-coracoid tip complex transfer combined with Bankart repair [210]. This combined procedure provides good long term stability for shoulders with high rate of recurrency and which seem to be not a successful case for an arthroscopic procedure [60]. Surgical stabilization decreases the chances of a second instability event and affords a player a greater interval between the initial injury and a recurrent event in National Football League athletes [263]. Early arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with a low 10-year recurrence rate of 35% compared to non-operative management [21]. The outcome of immediate arthroscopic repair of primary anterior shoulder dislocation is superior and encouraging with significant reduction in failure and revision rates compared to conservative treatment [287].

General Complication Rates

This large systematic review demonstrates the overall complication rates in modern shoulder stabilization surgery [20]. The overall complication rate was 0.67% following arthroscopic Bankart repair, with frozen shoulder being the most common complication occurring in 0.32% [203]. Reported complications were lower overall in the arthroscopic stabilization group when compared with open surgeries [290]. Meta-analysis of available randomized controlled trials and case–control studies demonstrated that arthroscopic repair and open Bankart repair were similar in safety [113]. There were no significant differences when comparing open and arthroscopic stabilization with regard to infection, hardware failure, motion loss requiring surgery, or nerve injury [218]. The overall clinical complication rate was 21% and the overall reoperation rate was 9% after the open Latarjet procedure in patients aged 40 years or older [202]. When performed by an experienced shoulder surgeon, the open Latarjet procedure shows good safety with low risk of major complications in treating anterior shoulder instability in a primary and revision surgical setting [271]. The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist [284]. Overall complication rates were similar between screw fixation and suture button fixation for arthroscopic Latarjet, with 15.4% of the SF and 14.9% of the SB groups experiencing a postoperative complication [191]. The overall complication rate was 1.9% after modified arthroscopic Latarjet procedure with suture-button fixation [208]. There were 13 patients (18%) who had a recurrence of any type after surgery in a prospective evaluation of arthroscopic Bankart repairs for anterior instability [134]. Two patients (3%) subsequently underwent revision surgery for instability and two patients had revision surgery for postoperative shoulder stiffness in a prospective evaluation of arthroscopic Bankart repairs [134]. There were no infections, neuropathies, or implant failures in a prospective evaluation of arthroscopic Bankart repairs for anterior instability [134]. There were no neurovascular complications, postoperative infections, or cases of postoperative shoulder stiffness that needed surgical intervention within the patient population of 66 patients undergoing arthroscopic Bankart repair for chronic glenohumeral instability [188]. Wound infection or iatrogenic nerve injury were not reported in all patients in a study comparing arthroscopic remplissage combined with Bankart repair versus Bankart repair alone [141]. No postoperative infection, axillary nerve injury, or vascular injury occurred in any patient in a study of modified arthroscopic Latarjet procedure with suture-button fixation [208]. Resident participation does not affect outcomes or complications after arthroscopic Bankart repair surgery [183].

Specific Complications: Nerve Injury

Nerve complications occurred in 0.07% following arthroscopic Bankart repair, with the musculocutaneous (0.01%) and axillary (0.01%) nerves being the most commonly affected [203]. Transient nerve injury to the musculocutaneous or axillary nerve occurred in 3% of patients after the open Latarjet procedure in patients aged 40 years or older, with all recovering within 1 year [202]. One patient in the SF group and 2 patients in the SB group experienced transient musculocutaneous nerve injury, with all patients recovering fully without reoperation after arthroscopic Latarjet [191]. The neurological injuries reported in open coracoid transfer procedures included temporary palsies of the ulnar, median, radial and suprascapular nerve with permanent palsies noted with the musculocutaneous and axillary nerves as well as the brachial plexus at the trunk level [219]. A permanent axillary nerve palsy treated with a sural nerve graft was documented in 1 case among 1658 open coracoid transfer procedures [211].

Specific Complications: Infection and Wound

Wound complications occurred in 0.03% following arthroscopic Bankart repair, with no deep wound infections reported [203]. Superficial infection occurred in 1% of patients after the open Latarjet procedure in patients aged 40 years or older [202]. Deep infection occurred once in the SF group after arthroscopic Latarjet with screw fixation [191]. Two additional patients in the SF group underwent reoperations for deep infection and graft fracture after arthroscopic Latarjet with screw fixation [191]. The reported rate of infection for open coracoid transfer procedures is low, whilst one author reported an infection rate of 6%, most authors have shown an infection rate of <1% [219]. Infection was documented in 5 cases among 1658 open coracoid transfer procedures [211].

Specific Complications: Stiffness and Pain

Frozen shoulder occurred in 0.32% following arthroscopic Bankart repair, making it the most common complication [203]. Persistent pain occurred in 0.15% following arthroscopic Bankart repair [203]. Musculoskeletal complications occurred in 0.30% following arthroscopic Bankart repair, with the most common being frozen shoulder (0.21%) and biceps tendonitis (0.04%) [203]. Frozen shoulder occurred in 2% of patients after the open Latarjet procedure in patients aged 40 years or older [202]. One patient underwent capsular release at 2 years because of persistent frozen shoulder after the open Latarjet procedure in patients aged 40 years or older [202]. Twenty percent of patients complained of some degree of pain and/or stiffness postoperatively after the open Latarjet procedure in patients aged 40 years or older [202]. One patient experienced stiffness of the shoulder joint, and forward flexion and abduction were less than 120° and 90°, respectively, after modified arthroscopic Latarjet procedure with suture-button fixation [208]. Two patients in the SF group reported stiffness compared with 1 in the SB group after arthroscopic Latarjet [191].

Specific Complications: Hardware and Graft

Hardware complications occurred in 0.05% following arthroscopic Bankart repair, with the majority being symptomatic hardware (0.04%) [203]. Repeat surgery was documented in 81 cases (4.9%) among 1658 open coracoid transfer procedures, including for hardware problems in 50 and recurrent instability in 20 [211]. Coracoid graft fracture is reported to occur in 1.5% of cases with evidence of lysis in 3.2% of patients after open coracoid transfer procedures [219]. Graft migration into the joint was documented in 1 case among 1658 open coracoid transfer procedures [211]. Aseptic graft necrosis with a cutaneous fistula was documented in 1 case among 1658 open coracoid transfer procedures [211]. One patient in the SF group experienced a hardware complication, which was pain attributed to the screwhead position causing impingement with the humeral head due to the angle of screw insertion after arthroscopic Latarjet [191]. One patient in the SF group experienced a graft fracture after arthroscopic Latarjet [191]. Two nonunion incidents occurred in the SB group and 1 in the SF group after arthroscopic Latarjet, defined as failure of graft union after 6 months [191]. One patient required another surgical procedure to remove symptomatic screws 2 years after the revision operation following the open Latarjet procedure in patients aged 40 years or older [202]. Large drill holes are still present in the long term after arthroscopic Bankart repair with absorbable tacks, as demonstrated in an 18-year randomized prospective study [121].

Specific Complications: Vascular and Thromboembolic

Postoperative deep venous thrombosis and pulmonary embolism are unusual but serious and potentially fatal consequences of arthroscopic shoulder surgery with a low incidence of 0.24% [215]. Vascular injuries that have been reported after open coracoid transfer procedures include axillary artery pseudoaneurysms, presenting from 6 months to 15 years after the primary procedure, and one intraoperative laceration to the axillary artery requiring vascular surgical intervention [219]. Increased risk of short-term complications and venous thromboembolism in Latarjet-Bristow procedures compared with Bankart repairs has been noted [204].

Specific Complications: Hematoma

Hematoma occurred in 0.03% following arthroscopic Bankart repair [203]. Hematoma occurred in 2% of patients after the open Latarjet procedure in patients aged 40 years or older [202]. One patient underwent hematoma evacuation after the open Latarjet procedure in patients aged 40 years or older [202]. Hematoma occurred in 3 cases among 1658 open coracoid transfer procedures [211]. One patient in the SF group experienced a postoperative hematoma after arthroscopic Latarjet [191].

Recurrent Dislocation Specifics

Two patients in each group experienced a dislocation after surgery—a total of 4 patients with dislocation—after arthroscopic Latarjet, with 2 occurring during sports and 2 as a result of falls [191]. Of those with recurrent dislocation after arthroscopic Latarjet, both patients in the SB and 1 in the SF groups underwent additional surgical stabilization procedures due to recurrent instability [191]. The cases of recurrent instability after the open Latarjet procedure in patients aged 40 years or older involved traumatic anterior redislocations at an average of 3.5 years (range, 0.5-5.5 years) after surgery [202]. In most patients with recurrent instability after the open Latarjet procedure in patients aged 40 years or older, there was a single episode of instability associated with persistent pain, apprehension, and loss of function, but 2 patients did complain of recurrent dislocations [202]. Only 1 patient required open reduction as the initial treatment for recurrent instability after the open Latarjet procedure in patients aged 40 years or older [202]. Four patients underwent an Eden-Hybinette procedure for recurrent instability after the open Latarjet procedure in patients aged 40 years or older [202]. In another patient with hyperlaxity, secondary posterior instability developed and an arthroscopic labral repair was performed 7 years after the initial Latarjet procedure with poor final clinical outcomes [202]. One 42-year-old female patient experienced a redislocation due to a fall that was manually reduced after modified arthroscopic Latarjet procedure with

Recovery

Light activity (weeks): Postoperative rehabilitation for arthroscopic Bankart repair initiates with pendulum exercises on day 1 [39]. Internal rotation and forward elevation are permitted as pain tolerated from day 3, while external rotation is allowed as pain tolerated from the first week [39]. External rotation with 90° abduction is introduced from the fourth week [39]. Shoulder immobilization for at least 3 weeks is a critical factor for achieving good functional results after arthroscopic glenoid labrum repair [171].

Full activity (months): Full range of motion with strengthening exercises commences from the sixth week postoperatively [39]. Weight training and non-contact sports are permitted at 2 months postoperatively in a standard arthroscopic Bankart repair rehabilitation protocol [39]. Return to contact sports and throwing is permitted at 4 months postoperatively in a standard arthroscopic Bankart repair rehabilitation protocol [39].

Rehabilitation protocol: Early start of physiotherapy is essential for good functional outcomes following arthroscopic glenoid labrum repair [171]. A shorter rehabilitation regimen does not prejudice the ultimate stability of the shoulder after Bankart repair [172]. Shorter rehabilitation regimens are generally more successful in patients with an intense desire to return to top-level sport [172]. For young rugby athletes during the in-season period, the combination of immobilization in external rotation and early muscle strength training may be an effective treatment for anterior shoulder dislocation [173].

Functional milestones: This study defines the thresholds for MCID and PASS achievement at minimum 2 year follow-up in a cohort of patients undergoing arthroscopic anterior shoulder stabilization [8]. This study defines thresholds for MCID and PASS achievement at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization [34]. When assessed 4.5 months postoperatively, the balance of function between dominant and nondominant shoulders in reference to those of healthy athletes would be better predictors of returning to preinjury sport at the preinjury level [242].

Other Considerations: Patients with anterior shoulder instability who undergo an arthroscopic or open Latarjet procedure can expect high rates of return to work and sport [177]. Over 89% of patients return to work after undergoing an arthroscopic or open Latarjet procedure for anterior shoulder instability [177]. The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years leads to high patient satisfaction [13]. The Latarjet procedure for anterior shoulder instability results in a high rate of return to sport among athletes at long-term follow-up [213]. The open Bankart procedure for recurrent shoulder instability allows patients to reliably return to high-level sports activities at long-term follow-up [244]. Arthroscopic anterior shoulder stabilization significantly improved functional scores in a cohort of martial arts athletes [62]. Contact athletes demonstrate similar rates of return to sport compared with noncontact athletes after primary arthroscopic anterior Bankart repair [240]. Contact athletes demonstrate similar rates of return to preinjury level of play compared with noncontact athletes after primary arthroscopic anterior Bankart repair [240]. The open Latarjet procedure can be considered for primary shoulder stabilization in competitive athletes who have high functional demands and great risks of redislocation [197]. The open Latarjet procedure produces better outcomes in competitive athletes compared with recreational athletes [197]. The Bankart procedure augmented by coracoid transfer can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability [45]. Despite high scores on shoulder outcome measures, the athlete's rate of return to their sport was only moderate following arthroscopic anterior shoulder stabilization [243]. One-third of athletes practicing high-risk sports are unable to return at their pre-instability level following Hill-Sachs remplissage, despite having a stable shoulder [207]. The results of anterior shoulder stabilisation in contact athletes are much less predictable, with higher reported rates of recurrent instability and revision surgery [22]. Open Latarjet procedures result in lower rates of return to play in athletes following failed prior instability surgery [277]. The open Latarjet procedure results in excellent clinical outcomes and low recurrence rates for those undergoing the procedure for failed prior instability surgery [277]. There exists minimal variability in recommendations between North American and European shoulder surgeons regarding return to play criteria despite the absence of evidence-based guidelines [198]. Evaluating readiness after shoulder instability is extremely difficult, and a validated, normalized return to play objective metric is still being searched for [239]. With additional dynamic anterior stabilization augmentation, the kinematic profile more closely approximated native shoulder motion, characterized by more centered anterior-posterior translation and preserved physiologic superior-inferior movement [2]. The stability of the shoulder has been achieved successfully both subjectively and objectively following a combination of Latarjet and Remplissage [1]. The method of inlay dynamic anterior stabilization with the long head of the biceps tendon and remplissage aims to improve stability and outcomes in patients with complex shoulder instability issues [11]. The Latarjet procedure is effective for treating primary chronic anterior instability and for stabilizing a shoulder after a failed Bankart repair [278]. Prior Bankart repair is associated with significantly lower functional scores and higher pain compared to primary Latarjet cases [278]. None of the patients had subsequent dislocations, and all returned to full working capacity following an anatomic open procedure for traumatic recurrent anterior dislocation [205].

Key Evidence

• [L5] The stability of the shoulder has been achieved successfully both subjectively and objectively. [1] (10.1016/j.jor.2013.01.007)
• [L4] With additional dynamic anterior stabilization augmentation, the kinematic profile more closely approximated native shoulder motion, characterized by more centered anterior-posterior translation and preserved physiologic superior-inferior movement. [2] (10.1002/arj.70401)
• [L3] Stabilization of the dominant shoulder resulted in residual surgery-related functional impairments on both sides, whereas stabilization of the nondominant shoulder resulted in impairments primarily noted in the nondominant, operative shoulder. [3] (10.1177/03635465231156181)
• [L4] Males may have higher recurrence rates than females following primary arthroscopic anterior shoulder stabilization; however, the heterogeneity of the included studies precludes any definitive conclusions. [4] (10.1016/j.asmr.2020.04.004)
• [L3] Female patients had a similar recurrence rate as that of male patients after arthroscopic anterior shoulder stabilization. [6] (10.1177/23259671211008841)
• [L4] With a follow-up of 97%, about one third of the stabilized shoulders experienced at least one redislocation after 8 to 10 years. [7] (10.1177/0363546511415657)
• [L3] This study defines the thresholds for MCID and PASS achievement at minimum 2 year follow-up in a cohort of patients undergoing arthroscopic anterior shoulder stabilization. [8] (10.1177/2325967125s00147)
• [Paper] The described open technique for anterior shoulder stabilization using modern instrumentation can be performed in a reliable, efficient, and reproducible manner. [9] (10.1016/j.eats.2019.03.011)
• [L3] This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization. [10] (10.2106/jbjs.15.01099)
• [L5] The method aims to improve stability and outcomes in patients with complex shoulder instability issues. [11] (10.1016/j.eats.2024.103256)
• [L1] The authors maintain that their systematic review clearly stated a high return to sport (RTS) rate after anterior shoulder stabilization procedures among studies that reported both rate of RTS and time to RTS. [12] (10.1177/0363546519825642)
• [L4] The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction. [13] (10.1177/0363546519872501)
• [Paper] The authors describe the single anterior portal Bankart repair technique as a simple, reliable, and reproducible method for anterior shoulder stabilization, noting theoretical advantages of decreased invasiveness, postoperative pain, and operative time. [14] (10.1016/j.eats.2018.01.002)
• [Paper] [15] (10.1016/s0278-5919(05)70294-5)
• [L4] Arthroscopic shoulder stabilization using a bioabsorbable tac is a labral repair procedure with little capability of shifting the anterior capsule superiorly greater than 1 cm. [16] (10.1016/s1058-2746(95)80032-8)
• [L3] Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. [19] (10.1177/23259671221106474)
• [L4] This large systematic review demonstrates the overall complication rates in modern shoulder stabilization surgery. [20] (10.1177/0363546518810711)
• [L2] Early arthroscopic stabilization by anterior capsule-labrum reinsertion after initial anterior shoulder dislocation is associated with a low 10-year recurrence rate of 35% compared to non-operative management. [21] (10.1016/j.otsr.2015.09.029)
• [L4] The results of anterior shoulder stabilisation in contact athletes is much less predictable, with higher reported rates of recurrent instability and revision surgery. [22] (10.1136/jisakos-2018-000224)
• [L3] Athletes who undergo an objective return to play criteria based testing protocol have lower rates of recurrent instability following arthroscopic shoulder stabilization surgery than those cleared by time from surgery. [25] (10.1177/2325967120s00381)
• [L3] At midterm follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. [26] (10.1016/j.arthro.2019.11.109)
• [L3] Surgical positioning for arthroscopic anterior shoulder stabilization did not affect post-operative clinical and patient-reported outcomes. [28] (10.1177/2325967121s00743)
• [L5] [29] (10.1016/j.arthro.2021.07.022)
• [L5] Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology, and the instability severity index score permits precise identification of patients at risk. [30] (10.1016/j.arthro.2010.11.057)
• [L4] Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability. [31] (10.1177/23259671211006437)
• [L4] This study defines thresholds for MCID and PASS achievement at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization. [34] (10.1177/23259671261442972)
• [L1] This study supports the need for standardized outcome reporting after arthroscopic anterior shoulder instability surgery in adolescents. [38] (10.1016/j.arthro.2017.10.041)
• [L4] [39] (10.1007/s00167-007-0453-2)
• [L3] [40] (10.1097/00132589-200001040-00009)
• [L3] The combination of these techniques provides a viable option for managing recurrent anterior instability, particularly in cases with poor tissue quality and glenoid bone loss less than 15%. [43] (10.1177/23259671261418677)
• [L4] The described procedure is a reproducible and effective technique used to restore joint stability in patients engaged in sports who have incurred anterior recurrent shoulder dislocation associated with glenoid bone loss. [44] (10.1016/j.jse.2015.09.025)
• [L4] This procedure can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability. [45] (10.1177/03635465990270011201)
• [L3] Overall, instability recurrence was low, indicating both are safe and effective techniques for treating anterior shoulder instability. [46] (10.1177/2325967126s00044)
• [L3] The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years is associated with good functional outcome and stability. [51] (10.1016/j.jse.2018.11.003)
• [L4] By contrast, the presence of a posterior glenoid fracture (bony Bankart lesion) did not represent a contraindication to arthroscopic shoulder stabilization. [54] (10.1177/03635465251403499)
• [L4] We found an average translation of 4.9 mm in unstable shoulders and 1.9 mm in stable shoulders. [55] (10.1016/s1058-2746(99)90006-x)
• [L4] In this series, 94% of shoulders were stable after arthroscopic revision anterior shoulder reconstruction, and there were a high number of good and excellent outcomes. [56] (10.1177/0363546508328411)
• [L3] [57] (10.1016/j.arthro.2020.05.013)
• [L4] [58] (10.1016/j.xrrt.2026.100792)
• [L3] The Latarjet procedure effectively prevented chronic anterior shoulder instability and was associated with high patient satisfaction as both a primary and a revision procedure. [59] (10.1177/23259671251343807)
• [L4] This combined procedure provides good long term stability for shoulders with high rate of recurrency and which seem to be not a successful case for an arthroscopic procedure. [60] (10.1016/s1058-2746(95)80098-0)
• [L4] In this retrospective study of a consecutive cohort of MA athletes, arthroscopic anterior shoulder stabilization significantly improved functional scores. [62] (10.1177/2325967117725031)
• [L3] Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning. [64] (10.1016/j.jse.2019.10.022)
• [L4] The modified capsulolabral reconstruction with suture anchors might be successful procedure for repairing the anterior instability of the shoulder. [65] (10.1016/s1058-2746(96)80392-2)
• [L4] Eighteen per cent of the patients had signs of instability during the 8-year follow-up period. [68] (10.1007/s00167-008-0534-x)
• [L3] [88] (10.1177/0363546517697963)
• [L4] [93] (10.1177/0363546516675145)
• [Paper] [102] (10.1007/s00402-007-0509-2)
• [L4] [103] (10.1016/j.arthro.2013.11.004)
• [L1] Meta-analysis of available randomized controlled trials and case–control studies demonstrated that arthroscopic repair and open Bankart repair were similar in safety. [113] (10.1007/s00402-015-2175-0)
• [L2] [121] (10.1177/0363546520922191)
• [L4] This technique enables shoulder surgeons to treat all cases of instability arthroscopically. [133] (10.1016/j.arthro.2007.06.008)
• [L4] [134] (10.1177/0363546509348049)
• [L2] [141] (10.4055/cios.2016.8.4.428)
• [L4] The arthroscopic Latarjet is a challenging yet viable technique to treat anterior shoulder instability, achieving results equal to the open technique with advantages of the arthroscopic setting. [143] (10.1016/j.arthro.2019.03.035)
• [L1] Early results suggest that arthroscopic coracoid transfer is a technically feasible procedure that is able to restore shoulder stability. [147] (10.1016/j.arthro.2012.11.022)
• [L3] Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability. [154] (10.1007/s00167-022-06941-4)
• [L3] It indicates that a single anesthesic with proper management of analgesia is a reliable technique for major shoulder surgery in an ambulatory care unit. [170] (10.1016/j.jse.2005.07.011)
• [L4] Shoulder immobilisation for at least 3 weeks on the one hand, and an early start of physiotherapy on the other are important factors for good functional results. [171] (10.1016/s1058-2746(96)80380-6)
• [L4] The shorter rehabilitation regimen does not prejudice outcome in terms of the ultimate stability of the shoulder but is generally more successful in patients who have an intense desire to return to top-level sport. [172] (10.1016/s1058-2746(99)90008-3)
• [L3] The combination of immobilization in external rotation and early muscle strength training may be an effective treatment for anterior shoulder dislocation during the in-season period. [173] (10.1016/j.jse.2024.11.016)
• [L4] [175] (10.1016/j.jse.2017.12.007)
• [L4] Patients with anterior shoulder instability who undergo an arthroscopic or open Latarjet procedure can expect high rates of return to work and sport. [177] (10.1016/j.arthro.2024.09.056)
• [L4] [179] (10.1177/26350254211014201)
• [L4] Participation in collision and contact athletics is not a contraindication for arthroscopic anterior shoulder stabilization using suture anchors, proper suture placement, capsulorrhaphy, and occasional rotator interval plication. [182] (10.1177/0363546504268037)
• [L3] [183] (10.1002/ksa.12782)
• [L4] [186] (10.1016/j.jse.2022.08.019)
• [L4] [188] (10.1016/j.arthro.2015.04.087)
• [L3] [189] (10.1177/03635465221120076)
• [L3] [191] (10.1177/23259671251321501)
• [L4] [192] (10.1097/00132589-200212000-00008)
• [L3] The OLP could be considered for primary shoulder stabilization, particularly in competitive athletes, who have high functional demands and great risks of redislocation. [197] (10.1177/0363546518759730)
• [L4] Despite the absence of evidence-based guidelines, there exists minimal variability in recommendations between North American and European shoulder surgeons regarding return to play criteria. [198] (10.1016/j.jse.2021.01.026)
• [L4] [202] (10.1016/j.jse.2019.02.004)
• [L4] [203] (10.1016/j.jse.2023.08.013)
• [L3] [204] (10.1016/j.arthro.2020.10.039)
• [L3] None of the patients had subsequent dislocations, and all returned to full working capacity. [205] (10.1016/j.jse.2003.09.006)
• [L2] Arthroscopic stabilisation resulted in a significantly lower rate of recurrent instability compared with non-operative management in young, active patients, particularly military cadets. [206] (10.1136/jisakos-2016-000091)
• [L3] Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. [207] (10.1302/0301-620x.103b4.bjj-2019-0736.r2)
• [L4] [208] (10.1177/0363546519887959)
• [L4] The index procedure effectively improved shoulder stability and function, achieving a relatively high rate of coracoid graft union with no requirement for revision surgeries at a mean followup of 26.7 months. [210] (10.1016/j.jseint.2025.06.009)
• [L1] [211] (10.1016/j.jse.2012.02.008)
• [L5] The three glenohumeral ligaments constitute relatively constant elements of the anterior capsuloligamentous complex. [212] (10.1016/s1058-2746(98)90221-x)
• [L4] The Latarjet procedure for anterior shoulder instability results in excellent functional outcomes at long-term and a high rate of return to sport among athletes. [213] (10.1016/j.jse.2018.08.028)
• [L4] Postoperative deep venous thrombosis and pulmonary embolism are unusual but serious and potentially fatal consequences of arthroscopic shoulder surgery with a low incidence of 0.24%. [215] (10.1016/j.arthro.2007.03.048)
• [L4] [217] (10.5435/jaaos-d-17-00056)
• [L1] [218] (10.1177/0363546504265188)
• [L5] [219] (10.21037/aoj.2017.10.01)
• [L3] [229] (10.1177/2325967119s00316)
• [L5] [231] (10.1016/j.ocl.2022.02.005)
• [L5] Glenoid faceplate fixation did not make the shoulder more stable compared to glenoid rim fixation, and creating a tissue 'bumper' did not increase stability. [235] (10.1016/j.arthro.2011.03.005)
• [L4] At least four anchor points should be used to obtain secure shoulder stabilization. [236] (10.2106/jbjs.e.00817)
• [L4] Both arthroscopic fixation techniques achieve comparable graft union rates and effectively restore shoulder stability. [237] (10.1177/17585732261417669)
• [L4] The arthroscopic Latarjet procedure with coracoid stabilization with 2 screws can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability. [238] (10.1016/j.jse.2022.01.022)
• [L5] Evaluating readiness after shoulder instability is extremely difficult, and the study demonstrates that we are still searching for a validated, normalized return to play objective metric. [239] (10.1016/j.arthro.2025.02.035)
• [L4] Compared with noncontact athletes, contact athletes demonstrate similar rates of return to sport, return to preinjury level of play, and need for revision surgery but a higher rate of recurrent instability after primary arthroscopic anterior Bankart repair for anterior shoulder instability. [240] (10.1177/03635465251328974)
• [L2] They suggest that when assessed 4.5 months postoperatively, the balance of function between dominant and nondominant shoulders in reference to those of healthy athletes would be better predictors of returning to preinjury sport at the preinjury level. [242] (10.1016/j.jse.2024.12.046)
• [L4] Despite high scores on the shoulder outcome measures, the athlete's rate of return to their sport was only moderate. [243] (10.1177/2325967113s00098)
• [L3] At long-term follow-up, patients undergoing an open Bankart procedure for recurrent shoulder instability obtained a high percentage of shoulder stability and reliably returned to high-level sports activities. [244] (10.1016/j.jse.2009.06.010)
• [L3] Bone defects seen in preoperative plain radiographs are less important and more accurate imaging is needed to reveal their true role for recurrence of instability. [245] (10.1007/s00167-010-1105-5)
• [L4] Screw removal alleviated pain in 14 shoulders (67%) and reduced pain the remaining 7 shoulders (33%). [246] (10.1016/j.jse.2021.03.058)
• [L4] In patients who did not undergo further surgery, good to excellent shoulder function as well as low pain and instability levels were observed at a minimum 20 years after ABR. [247] (10.1177/03635465251388108)
• [L4] Radiography can be used for screening patients for significant glenoid bone loss. [248] (10.1186/s12891-015-0607-1)
• [L3] Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. [249] (10.1016/j.jse.2013.04.020)
• [L3] Patients should be counseled pre-operatively on the expected outcomes over time following ABR of anterior shoulder instability. [250] (10.1177/2325967126s00552)
• [L4] The combination of ASA and bone block procedure with a xenograft was effective in the glenoid reconstruction and restoration of shoulder stability. [251] (10.1016/j.asmr.2023.04.008)
• [L3] Immediate surgical stabilization following a 1st time dislocation significantly diminishes the risk of recurrent dislocation in comparison to those who undergo surgery following two dislocation events. [252] (10.1177/2325967121s00713)
• [L4] Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score. [253] (10.1177/03635465211038712)
• [L3] Evaluation of Hill-Sachs extension below the humeral equator (inferior equatorial extension) on sagittal MRI is a clinically facile screening tool for higher-risk lesions with subcritical glenoid bone loss. [254] (10.1177/03635465231209443)
• [L4] Enhancement MR imaging was useful technique to assess the anterior capsular mechanism. [257] (10.1016/s1058-2746(95)80305-x)
• [L3] These static measures may provide a basis for future studies of treatment effect as the sagittal measures have the advantage of being identifiable on MRI in a clinical setting. [259] (10.1177/1758573217744170)
• [L4] At a mean follow-up of 128.1 months, 25.0% of patients experienced recurrent instability and 19.6% underwent subsequent surgery. [261] (10.1177/2325967126s00277)
• [L4] All patients with poor results had postoperative re-dislocation, resulting in a recurrent rate of 15%. [262] (10.1016/s1058-2746(95)80225-8)
• [L3] Surgical stabilization decreases the chances of a second instability event and affords a player a greater interval between the initial injury and a recurrent event. [263] (10.1016/j.jse.2017.07.027)
• [L4] There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery. [265] (10.1016/j.arthro.2013.11.019)
• [L4] No further episodes of instability have been reported by any of our patients to date. [266] (10.1097/bte.0000000000000127)
• [L4] The number of episodes of dislocation before surgery and the delayed surgical intervention did not increase the recurrent anterior shoulder instability rates postoperatively. [267] (10.1016/j.jseint.2022.12.003)
• [L1] This systematic review has identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss. [268] (10.1302/0301-620x.104b1.bjj-2021-0751.r1)
• [L3] Patients may benefit from more aggressive stabilization strategies and techniques. [269] (10.1177/2325967119s00179)
• [L4] When performed by an experienced shoulder surgeon, the open Latarjet procedure shows good safety with low risk of major complications in treating anterior shoulder instability in a primary and revision surgical setting. [271] (10.1002/arj.70066)
• [L5] Until this threshold is validated prospectively in multicenter cohorts with standardized advanced imaging and formal glenoid track assessment, it should be applied with considerable caution. [273] (10.1177/03635465261464187)
• [L4] While recurrence rates increased over time, patient satisfaction remained high, and no revision surgeries were required, demonstrating the long-term reliability of ABR for anterior shoulder instability. [274] (10.1016/j.jseint.2025.07.004)
• [L3] Immediate arthroscopic surgical stabilization after a first-time anterior shoulder dislocation significantly decreases the risk of recurrent dislocation in comparison to those who undergo surgery after 2 dislocation events, with comparable clinical outcome scores. [275] (10.1016/j.arthro.2022.10.012)
• [L4] Despite a higher complication rate than in the younger population, shoulder stabilization using the Latarjet procedure is effective in patients over 50 without associated cuff damage. [276] (10.1016/j.jseint.2025.101518)
• [L3] Open Latarjet results in excellent clinical outcomes and low recurrence rates for those with primary shoulder instability, those with recurrent instability and those undergoing OL for failed prior instability surgery. [277] (10.1016/j.arthro.2021.03.062)
• [L3] The Latarjet procedure is effective for treating primary chronic anterior instability and for stabilizing a shoulder after a failed Bankart repair, but prior Bankart repair is associated with significantly lower functional scores and higher pain compared to primary Latarjet cases. [278] (10.1177/2325967119s00204)
• [L4] Arthroscopic revision anterior stabilization is associated with a high rate of recurrent instability, and patient selection is of critical importance in order to minimize recurrence. [280] (10.2106/jbjs.17.01028)
• [L4] Recurrence rates of instability are acceptable and reoperation rates were low. [281] (10.1016/j.otsr.2014.11.005)
• [L4] The effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time, with less than half of recurrences occurring after 2 years. [282] (10.1177/03635465221139290)
• [L4] However, there were high rates of recurrence with moderate rates of revision surgical stabilization in the medium term. [283] (10.1016/j.jse.2021.11.001)
• [L4] The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist. [284] (10.3390/medicina55090582)
• [L3] The recurrence rate following open repair was 5% compared with 15% for arthroscopic stabilisation. [285] (10.1016/s1058-2746(96)80394-6)
• [L3] However, there was a moderate rate of recurrent instability and further revision surgery. [286] (10.1007/s00167-021-06803-5)
• [L1] The outcome of immediate arthroscopic repair of primary anterior shoulder dislocation is superior and encouraging with significant reduction in failure and revision rates compared to conservative treatment. [287] (10.1007/s00264-018-4046-0)
• [L3] Recurrent instability rates were higher in the all-arthroscopic group (19% versus 8%). [288] (10.1016/j.jse.2016.07.052)
• [L3] Recurrent instability rates were higher in the all-arthroscopic group (19% versus 7%). [289] (10.1177/2325967115s00048)
• [L4] Reported complications were lower overall in the arthroscopic stabilization group when compared with open surgeries. [290] (10.1177/0363546511406869)

See Also

• Latarjet Procedure
• Shoulder Instability
• Os Acromiale
• Rotator Cuff
• Fractures
• Calcific Tendinitis
• Frozen Shoulder
• Capsular Release for Frozen Shoulder

References

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[2] Dynamic Anterior Stabilization Shows Glenohumeral Kinematics Closer to Native Motion to Isolated Bankart Repair: A Dual Fluoroscopic Imaging Study. Arthroscopy. 2026. DOI: 10.1002/arj.70401

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[36] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Radiographic Evaluation.

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[154] Microinstability characterised by small and easily overlooked anterior labral or Hill–Sachs lesions can be managed with arthroscopic anterior labral repair. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-06941-4

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[173] Early muscular training and immobilization in external rotation could reduce the recurrence rate in first-time shoulder dislocators among young rugby athletes. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.11.016

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[177] Over 89% of Patients Return to Work After Undergoing Arthroscopic or Open Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2024.09.056

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[183] Resident participation does not affect outcomes or complications after arthroscopic Bankart repair surgery. Knee Surgery, Sports Traumatology, Arthroscopy. 2025. DOI: 10.1002/ksa.12782

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[189] Arthroscopic Latarjet With Cortical Buttons Versus Open Latarjet With Screws: A Short-Term Comparative Study. The American Journal of Sports Medicine. 2022. DOI: 10.1177/03635465221120076

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[198] Return to play criteria among shoulder surgeons following shoulder stabilization. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.01.026

[202] Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.02.004

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[204] Increased Risk of Short-Term Complications and Venous Thromboembolism in Latarjet-Bristow Procedures Compared With Bankart Repairs. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2020.10.039

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[239] Editorial Commentary : Upper‐Extremity Limb Asymmetry May Complicate Objective Evaluation of Criteria on the Basis of Return to Sport Evaluation After Arthroscopic Bankart Repair. Arthroscopy. 2025. DOI: 10.1016/j.arthro.2025.02.035

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[242] Are the dominant-nondominant functional differences at 4.5 months after open Latarjet procedure better predictors for successful return to sport at 1 year postoperatively than the operated-nonoperated differences?. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.046

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[246] Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Instability After Open Latarjet Procedures. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.03.058

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[269] OUTCOMES OF ARTHROSCOPIC BANKART REPAIR IN THE PEDIATRIC AND ADOLESCENT POPULATION: HIGH RATES OF FAILURE. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00179

[271] Open Latarjet Yields a Low 90‐Day Complication Rate in Primary and Revision Shoulder Stabilization. Arthroscopy. 2026. DOI: 10.1002/arj.70066

[273] Episode Count Should Not Substitute for Anatomy in Arthroscopic Bankart Repair: Letter to the Editor. The American Journal of Sports Medicine. 2026. DOI: 10.1177/03635465261464187

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[275] Increased Failure Rates After Arthroscopic Bankart Repair After Second Dislocation Compared to Primary Dislocation With Comparable Clinical Outcomes. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.10.012

[276] Long-Term Outcomes of the Open Latarjet Procedure for Recurrent Anterior Shoulder Instability in Patients Over 50 Years Old. JSES International. 2026. DOI: 10.1016/j.jseint.2025.101518

[277] Open Latarjet Procedure in Athletes Following Failed Prior Instability Surgery Results in Lower Rates of Return to Play. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021. DOI: 10.1016/j.arthro.2021.03.062

[278] Outcomes of the Latarjet procedure for the treatment of chronic anterior shoulder instability: patients with prior arthroscopic Bankart repair versus primary cases. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00204

[280] Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.17.01028

[281] Open Latarjet procedure for failed arthroscopic Bankart repair. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2014.11.005

[282] A 2-Year Follow-up May Not be Enough to Accurately Evaluate Recurrences After Arthroscopic Bankart Repair: A Long-term Assessment of 272 Patients With a Mean Follow-up of 10.5 Years. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465221139290

[283] Return to play following open Bankart repair in collision athletes aged 18 years or less. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.11.001

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[286] Evaluation of factors associated with successful 5‐year outcomes following arthroscopic Bankart repair in athletes. Knee Surgery, Sports Traumatology, Arthroscopy. 2021. DOI: 10.1007/s00167-021-06803-5

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[288] Clinical outcomes following revision anterior shoulder stabilization: arthroscopic revision stabilization vs. latarjet. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.07.052

[289] Clinical Outcomes Following Revision Anterior Shoulder Stabilization. Orthopaedic Journal of Sports Medicine. 2015. DOI: 10.1177/2325967115s00048

[290] Surgical Trends in Bankart Repair. The American Journal of Sports Medicine. 2011. DOI: 10.1177/0363546511406869