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Anterior Shoulder Stabilisation

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

154 citationsUpdated Sep 2026

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

Anatomy & Pathophysiology

Bony Anatomy

The glenoid cavity is a shallow, convex socket shaped like an inverted pear, approximately one-third the size of the humeral head [74]. Its subchondral bone is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [76]. The glenoid averages 5° of retroversion relative to the scapular body axis [76], though other measurements report an average of 1.5 degrees retroversion with a range of 10.5-9.5 degrees anteversion [85]. Glenoid inclination averages 4.2 degrees, ranging from –7 to 20 degrees [85]. The glenoid diameter ranges from 18-30 mm superior anteroposterior, 21-35 mm inferior anteroposterior, and 30-48 mm superoinferior [85]. The glenoid surface area is 4-6 mm, with a cartilage thickness of 2.16 mm and a radius of curvature of 22-28 mm [85]. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head [85].

The humeral head is spherical with a diameter of 37 to 57 mm [73]. The articular surface is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [85]. The humeral head surface area is 11-19 mm, with a cartilage thickness of 1.44 mm [85]. The radius of curvature is 23-28 mm, slightly larger in men than in women [85], and approximately 25 mm [85]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [73], or 8 to 10 mm superior to the top of the greater tuberosity [85]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [87]. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [73]. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [85]. The humeral head is retroverted an average of 30 degrees [74], or 30 degrees relative to the transepicondylar axis of the humerus [87]. Mean humeral retroversion is around 26 degrees in healthy adults [80]. Humeral retroversion averages 65 degrees in infants and young children, gradually decreasing to adult values by 11 years of age [80]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [73]. The neck-shaft angle measures an average of 135 degrees [74]. The average neck-shaft angle is 45 degrees (±5 degrees), with a range of 30 to 50 degrees [85]. Arthritic shoulders have a flatter neck-shaft angle close to 50 degrees [85]. The humeral head-shaft angle ranges from 30-55 degrees [85]. The medial (coronal) humeral offset is 4-14 mm, and the posterior (transverse) humeral offset is –2 to 10 mm [85].

The anatomic neck is located directly below the humeral head at the junction of the articular surface and the tuberosities, serving as an attachment for the shoulder capsule [87]. The surgical neck is more distal than the anatomic neck, representing an indistinct metadiaphyseal junction below the tuberosities but above the humeral shaft, and is more often involved in fractures [87]. A fracture involving the anatomic neck is prognostically worse than fractures involving other regions of the proximal humerus with respect to potential disruption of the vascular supply to the humeral head and subsequent development of avascular necrosis [73].

The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [75]. It is separated from the chest wall by thin gliding fibro-fatty tissue, allowing smooth excursion [75]. The scapula spans the second through seventh ribs and serves as an attachment for 17 muscles [87]. It is anteverted on the chest wall approximately 30 degrees relative to the body [87]. Grashey radiographs are taken obliquely at 30 degrees for a true anteroposterior view of the scapula [87]. The lateral pillar connects the inferior border of the glenoid with the inferior angle of the scapula, while the spinal pillar arises from the central part of the glenoid and continues medially to become part of the base of the scapular spine [75]. These two bony pillars, connected by a markedly thinner medial border, form the basic load-bearing structure of the scapular body [75]. The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa, and the weakest area of the circumference of the biomechanical body is the spinomedial angle [75]. The coracoid process curves forwards from the superior surface of the scapular neck [75]. The acromion is a flattened bony process that curves forwards from the scapular spine [75].

The clavicle is the first bone to ossify at the fifth week of gestation and the last to fuse, with the medial (sternal) epiphysis fusing at age 20 to 25 years [76]. It is the only long bone to ossify by intramembranous ossification [76]. Fracture of the clavicle is the most common musculoskeletal birth injury [87]. The primary blood supply to the clavicle is periosteal, with no nutrient artery present [76]. The acromion has three ossification centers: the metacromion (base), the mesoacromion (middle), and the preacromion (tip) [76]. Failure of fusion of the acromial ossification centers results in os acromiale, most commonly between the mesoacromion and meta-acromion [76].

The proximal humerus has three ossification centers: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [76]. The humeral head ossification center is usually present at birth [80]. The greater tuberosity ossification center appears by 1 to 3 years of age, and the lesser tuberosity ossification center appears by 5 years of age [80]. Proximal humeral ossification centers fuse by 5 to 7 years of age to form the humeral head [80]. The proximal humeral ossification center fuses to the shaft at age 17 to 20 years [76]. The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [80]. Eighty percent of subsequent humeral growth comes from the proximal humeral physis, which accounts for approximately 40% of the growth of the entire upper extremity [80]. Less than 75% of humeral growth occurs before 2 years of age, and more than 85% occurs by 8 years of age [80]. The proximal humeral physis is irregularly shaped, with its apex located on the posteromedial portion of the proximal humerus [80]. The periosteum is thicker and stronger in the posteromedial portion compared to the anterolateral portion [80]. The posteromedial metaphysis, a portion of the physis, and the epiphysis are intracapsular, while a large part of the proximal humeral physis is extracapsular, making it susceptible to traumatic injury [80].

The formation of the humerus begins with the appearance of the cartilage anlage by the fifth week of gestation [80]. The primary ossification center for the humerus appears at about the sixth week of gestation [80]. By birth, the entire humeral diaphysis is completely ossified, while the proximal humerus is primarily cartilaginous [80]. Ossification centers of the proximal humerus can be detected with ultrasonography as early as the 38th week of gestation and are generally present between the 38th and 42nd week of gestation [80].

Evolutionary changes in the scapula include a caudal shift from the cervical position, freeing the shoulder from the head and neck [83]. The human scapula is broader than that of pronograde animals, with the most pronounced differences in the infraspinatus fossa [83]. Broadening of the infraspinatus fossa has changed the vector of muscle pull from the axillary border of the scapula to the glenoid fossa, allowing the infraspinatus and teres minor muscles to be more effective as depressors and external rotators of the humeral head [83]. The supraspinatus fossa and muscle have changed little in size or shape over time [83]. The acromion has enlarged over time, becoming a massive structure overlying the humeral head, increasing the mechanical advantage of the deltoid due to its broader attachment and more distal insertion [83]. The coracoid process has increased in size; 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 [83]. One shoulder tested after sectioning the capsule would not dislocate anteriorly in full abduction until the coracoid process was removed [83]. The anteroposterior dimension of the thoracic cage decreased over time, resulting in the scapula positioned approximately 45 degrees to the midline [83]. The scapula and glenoid fossa assumed a more dorsal position in the thoracic cage, leading to the glenoid fossa being directed laterally [83]. A relative external rotation of the humeral head and an internal rotation of the shaft occurred due to changes in thoracic cage dimensions [83]. The size of the infraspinatus fossa gradually enlarged over time relative to the length of the scapular spine, leading to a decrease in the scapular index [83].

Soft Tissue Anatomy

The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule, inserting mainly into the greater tuberosity of the humerus [81]. It consists of the subscapularis in front, supraspinatus above, and infraspinatus and teres minor behind [81]. The rotator cuff stabilizes the head of the humerus by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways [81]. The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons, while the lesser tuberosity serves as the attachment site for the subscapularis tendon [73]. The bicipital groove lies between the greater and lesser tuberosities, serving as a pathway for the long head of the biceps; its distal aspect is internally rotated with respect to the proximal portion [73].

The subscapularis is the largest and strongest of the rotator cuff tendons [100]. It is responsible for active internal rotation of the humerus and contributes to shoulder stability [100]. As a component of the dynamic stabilization mechanism, the subscapularis forms the anterior portion of the transverse plane “force couple” of the rotator cuff, balancing forces generated across the joint to maintain glenohumeral congruency throughout movement [100]. The subscapularis inserts on the lesser tuberosity and causes medial displacement of fracture fragments [73]. The supraspinatus and infraspinatus insert on the greater tuberosity and cause superior and posterior displacement of fracture fragments, respectively [73]. The pectoralis major inserts on the humeral shaft and displaces it medially [73].

The coracoacromial arch is a fibro-osseous canopy formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [81]. The subacromial bursa separates the tendons from the coracoacromial arch and allows them to glide [81]. When the shoulder is abducted, the conjoint tendon passes under the coracoacromial arch [81]. The coracoacromial ligament contributes to anterosuperior stability in rotator cuff deficiency and should be preserved with irreparable cuff tears to prevent anterosuperior escape [87]. It also serves as the arthroscopic landmark for a complete release of the rotator interval for adhesive capsulitis [87]. The acromial branch of the thoracoacromial artery runs on the medial aspect of the coracoacromial ligament [87].

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [73]. The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery (also known as the artery of Laing) [74]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [73]. Its ascending branch courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [73]. Injury to the arcuate artery may result in osteonecrosis of the humeral head, although additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [73]. The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [73].

Important structures in the vicinity of the shoulder joint include the brachial plexus and axillary nerve. The transverse humeral ligament is an important stabilizer of the biceps tendon [87]. The suprascapular artery passes superior to the superior transverse scapular ligament, while the suprascapular nerve passes inferior to the ligament through the suprascapular notch [87]. At the spinoglenoid notch, both the artery and nerve are inferior to the inferior transverse scapular ligament [87].

Classification

Walch: The Walch classification categorizes glenoid morphology into subtypes A1, A2, B1, B2, B3, C, and D based on humeral head position and glenoid erosion patterns [211]. Type A1 glenoids feature a centered humeral head with minor central erosion, while Type A2 presents with a centered head and major central erosion [211]. Type B1 is defined by posterior humeral head subluxation with glenoid retroversion [211]. Type B2 exhibits a biconcave deformity [211]. Type B3 involves monoconcave and posteriorly worn morphology with at least 15 degrees of retroversion or at least 70% posterior humeral head subluxation, or both [211]. Type C is characterized by premorbid retroversion of .25 [211]. Type D is characterized by anteversion or humeral head subluxation of less than 40% [211].

Buscayret: The Buscayret classification stages postdislocation glenohumeral arthropathy, with stage 3 further differentiated into two stages [211]. Stage 1 is defined by osteophytes measuring less than 3 mm in the greatest diameter [215]. Stage 2 involves osteophytes measuring between 3 and 7 mm in the greatest diameter with slight glenohumeral joint irregularity [215]. Stage 3 is defined by osteophytes measuring more than 7 mm in the greatest diameter with narrowing of the glenohumeral joint and sclerosis [215]. Stage 4 represents complete obliteration of the glenohumeral joint space with or without osteophytes [215].

Other Considerations: The glenoid track concept is encouraged as a routine part of the preoperative evaluation for patients under consideration for arthroscopic anterior stabilization [13]. The Instability Severity Index score permits precise identification of patients at risk for failure of primary shoulder stabilization procedures [16]. Evidence suggests a lower Instability Severity Index score threshold may improve the ability to predict recurrent anterior shoulder instability following an arthroscopic Bankart repair [218]. Preoperative glenoid bone loss severity is classified into groups of 10%, 11–20%, and >20% for comparative analysis of Latarjet outcomes [214]. Arthroscopic Latarjet graft positioning is classified vertically as subequatorial (optimal) when 50% of the bone block is above the equator line [60]. Arthroscopic Latarjet graft positioning is classified horizontally as flush (optimal) when the graft is aligned with the glenoid [60]. Shoulder-dependent sport ability is classified into noncollision/nonoverhead (G1), high-impact/collision (G2), and overhead (G3) categories [59]. The Modified Coleman Methodology Score classifies study quality as excellent (85–100), good (70–84), fair (55–69), or poor (<55) [65]. The Anterior Shoulder Instability Methodology criteria assign a score out of 25 based on the presence or absence of specific quality criteria [65].

Clinical Presentation

History

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 [40]. Injury with the arm in extension, abduction, and external rotation favors anterior dislocation [40], whereas electoshock, seizures, or a fall on the flexed and adducted arm are commonly associated with posterior dislocation [40]. 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 [99]. Young patients often report a history of their shoulder “coming out” or “slipping out,” then popping back in, which may indicate recurrent shoulder subluxation or instability [99]. Patients may complain of anterolateral and anterior shoulder pain with overhead activities and motion [99].

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 [40]. The history solicits evidence of neurologic or rotator cuff problems after previous episodes of shoulder instability [40]. Previous treatment of the recurrent instability, as well as the effectiveness of this treatment, should be documented [40]. A thorough history should allow the examiner to understand the etiology, direction, degree, and frequency of a patient’s shoulder instability [121]. Risk factors associated with treatment failure include age, gender, presence of osseous Bankart and/or large Hill-Sachs lesions, participation in competitive collision or forced overhead sports, hypermobility, time lapse between dislocation and reduction, and the number of instability episodes prior to operation [121].

Patients with anterior shoulder instability experience symptoms of apprehension with shoulder abduction and external rotation [104]. Patients with anterior shoulder instability can experience symptoms of pain and instability with placement of the arm in an overhead position [104]. The most common complaint of shoulder instability is pain coupled with restricted shoulder motion [104]. Microinstability can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability [49].

Physical Examination

An acutely dislocated shoulder is usually very painful, and muscles are in spasm in an attempt to stabilize the joint [40]. The humeral head may be palpable anteriorly in an acutely dislocated shoulder [40]. The posterior and lateral aspect of the shoulder shows a hollow beneath the acromion in an acutely dislocated shoulder [40]. The arm is held in slight abduction in an acutely dislocated shoulder [40]. Passive and active motions are limited by pain in an acutely dislocated shoulder [40]. Inspection of shoulder contours can best be visualized by viewing the shoulders from above while standing behind the patient [40]. Asymmetry of the shoulder contours can often best be visualized by having the patient sit on a low stool with the examiner standing behind the patient [40]. Inspection for any shoulder deformity or muscle atrophy is part of the physical examination [99].

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 [40]. The axillary nerve is the most commonly injured nerve in up to 42% of traumatic anterior shoulder dislocations [99]. A thorough neurovascular exam, including assessment of the axillary nerve, should be performed [99]. Initial examination should include a complete neurovascular examination to document any neurologic or vascular deficits [104]. 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 [104].

Documentation of active and passive ROM of the shoulder for internal and external rotation as well as forward flexion and abduction is important [104]. Marked loss of motion is seen with persistent dislocations and rotator cuff lesions [104]. Rotator cuff testing is an essential part of the shoulder instability examination particularly in patients over the age of 40 years [104]. The belly press or bear hug test is the most effective test to evaluate the function of the subscapularis in the acutely injured patient [104]. Testing of resisted shoulder abduction in the first 30 degrees of shoulder flexion with the arm internally rotated is effective for evaluating the supraspinatus [104]. Evaluation of the infraspinatus is performed by applying resisted external rotation with the elbow flexed to 90 degrees [104].

The anterior apprehension test is performed with the patient in supine position, with the shoulder abducted to 90° and rotated externally until the apprehension point [42]. The relocation test involves pushing the proximal part of the humerus backward by manual pressure on the anterior aspect of the proximal part of the arm to assess relief of apprehension [42]. 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 [104]. The relocation test is performed from the ABER position by applying a posteriorly directed force to the proximal humerus, which elicits a feeling of reduced apprehension or pain [104]. An anterior release test (surprise test) is performed by removing the posteriorly directed force abruptly when the patient's arm is in 90 degrees of abduction, 90 degrees of elbow flexion, and maximal external rotation position [104]. A feeling of pain or apprehension is a positive result for the anterior release test [104]. Caution should be taken not to dislocate the patient's shoulder with anterior release testing [104].

The sulcus sign is performed at 0 degrees of abduction by applying downward traction on the humerus, where dimpling or a “gap” formed in the GH joint is a positive sign indicating laxity of the superior GH ligament [99]. 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 [99]. In the load and shift test, Grade 0 means normal translation, Grade 1 is translation to rim and back (less than 1 cm), Grade 2 is translation over the rim followed by spontaneous reduction (1 to 2 cm), and Grade 3 is translation over the rim without spontaneous reduction (greater than 2 cm) [99]. Generalized joint laxity should be assessed using the Beighton score (0–9 point scale) [99].

Patients with severe glenoid defects typically present with midrange-of-motion instability [105]. Clinical signs for anterior instability, particularly the apprehension and relocation tests, are found to be positive in patients with severe glenoid defects [105]. 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 [121]. The pattern of instability can be determined during examination under anesthesia without being affected by patient apprehension or guarding [121]. The axial load test or load-and-shift test is conducted during examination under anesthesia, and translation is noted in the anterior, inferior, and posterior directions [121]. In the load-and-shift test during examination under anesthesia, Grade 1+ corresponds to the translation of the humeral head to the edge of the glenoid, 2+ if the humeral head can be subluxated over the glenoid rim but reduces spontaneously, and 3+ if a frank dislocation of the humeral head over the glenoid rim does not reduce spontaneously [121].

Investigations

Plain radiography: Standardized plain films are almost always sufficient to garner the information needed for shoulder evaluation [39]. The first key view is the anteroposterior (AP) view in the plane of the scapula, taken so that the x-ray beam passes through the glenohumeral joint [39]. This view shows the superoinferior position of the humeral head relative to the glenoid, presence of osteophytes, narrowing of the joint space, and degree of medial displacement of the humerus [39]. The second key view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula [39]. The axillary view demonstrates glenohumeral relationships in the functional position of elevation and is referred to as the “truth view” [39]. At least two X-ray views should be obtained: an anteroposterior in the plane of the glenoid and an axillary projection with the arm in abduction to show the relationship of the humeral head to the glenoid [90]. The axillary view is a necessary view in evaluation of glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [107]. It may detect occult, locked posterior shoulder dislocation in a patient who exhibits a lack of passive external rotation [107]. In a systematic review of posterior shoulder dislocations, 73% of patients had a missed initial diagnosis due to the lack of an axillary view, Y view, or computed tomography (CT) imaging [114]. Of 150 patients with missed initial diagnoses of posterior dislocation, 98% had only AP or lateral views of the shoulder [114]. When axillary or Y-view radiographs were made subsequently, the diagnosis of posterior dislocation was confirmed in 100% of patients [114].

Specific radiographic views are indicated for targeted pathology: the Stryker notch view is indicated to evaluate Hill–Sachs lesions after dislocation [107]; the West Point view is indicated to evaluate anterior glenoid bone loss [107]; and the apical oblique view is indicated to evaluate for glenoid rim fracture in instability [107]. Radiographs provide an overview of the bony anatomy, orientation of the humeral head in relation to the glenoid, and initial assessment for both bony Bankart and Hill–Sachs lesions [114]. Radiography can be used for screening patients for significant glenoid bone loss [237]. However, 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 [233]. Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim [238].

Computed Tomography (CT): CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [107]. CT imaging is frequently used to evaluate fractures of the shoulder, to assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [101]. CT is helpful for planning fracture surgery and shoulder joint replacement [90]. CT assessments of glenoid bone defects with and without comparison with the contralateral shoulder showed very good agreement in identifying the size, presence, and type of defect in patients with anterior shoulder instability on both 2D and 3D CT scans [255]. A systematic review identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss [250]. Future studies should use advanced imaging for glenoid bone loss measurements [242]. To maintain stable fixation of the glenoid component in reverse shoulder arthroplasty, comprehensive preoperative analysis of the remaining bone stock based on 3-dimensional computed tomography scans should be included [70]. Although CT scans may offer a few degrees of increased precision in the measurement of glenoid version, this precision does not necessarily improve the quality of the surgery or the clinical outcome [39].

MRI: MRI is useful to identify osteonecrosis of the humeral head, or a bone tumour [90]. MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [90]. MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [101]. T1-weighted MRI can reveal Hill–Sachs lesions and is often used with magnetic resonance (MR) arthrograms to provide a more detailed picture of the joint surfaces [101]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [101]. Traditional magnetic resonance imaging (MRI) is utilized for evaluation of soft tissues with high contrast and spatial resolution [97]. MR accuracy in identifying labral and rotator cuff tears in the literature ranges from 70% to 100% [97].

MR Arthrography: MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [101]. When MRI or MR arthrography is contraindicated, CT arthrography is indicated [101]. MR arthrography (MRA) increases both sensitivity and specificity in detecting injuries to the capsulolabral–ligamentous complex as compared to traditional MRI [97]. In a meta-analysis of 6 studies including 4,667 shoulders, MRA had greater diagnostic test accuracy for glenoid labral lesions than MRI, with MRA sensitivity of 88% and specificity of 93% versus MRI sensitivity of 76% and specificity of 87% [97]. Abduction and external rotation (ABER) of the arm is an alternative position utilized to increase the sensitivity and specificity for detecting anteroinferior labroligamentous injury [97]. Limited range of motion or pain may prohibit patients from performing the ABER provocative maneuver [97]. A retrospective study found that full routine MRI or MRA examination had similar accuracy as the ABER sequence in evaluating the anteroinferior labral–ligamentous complex [97]. Another study found that the sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than that of MRA in neutral position and more effective in identifying Perthes lesions [97]. MRAs can demonstrate a patulous capsule on the coronal, sagittal, and axial imaging in patients with multidirectional instability [97]. MRAs can be helpful in evaluating lesions of the rotator interval and other associated findings that may affect the eventual surgical plan [97]. The diagnosis of multidirectional instability is a clinical one, and the need for expensive and/or invasive imaging should be weighed against the information that will be gained from these studies [97]. 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 [243]. Initial shoulder instability during adolescence was associated with a higher recurrence rate and lower functional scores after arthroscopic Bankart repair, although no significant structural differences were found between the groups on MRI at a mean 6-year follow-up [259].

Ultrasonography: Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [90]. Ultrasonography can be useful in guiding injections or barbotage [90]. Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [101]. Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [101]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [101]. As a result of providing images in real-time, ultrasonography can evaluate impingement in various positions and motions [101]. 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 [101]. The most commonly performed joint examination using ultrasonography is the shoulder examination, and accuracy depends on the skill of the scanner operator and an awareness of pitfalls [88].

Other Considerations: 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 [16]. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings [14]. Microinstability characterised by small and easily overlooked anterior labral or Hill–Sachs lesions can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability [49]. The purpose of imaging of the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [39]. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [39]. Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome [39]. A robust approach to imaging the shoulder needs to recognize that the shoulder is a three-dimensional structure that cannot be represented by a single planar view [94]. Critical relationships, such as the degree of centering of the humeral head, change with the position of the arm [94]. Shoulder pathology may be found in a large number of different bones and soft tissues [94]. Overlying and superimposed structures as well as metallic implants may complicate imaging the structures of interest [94]. Surgeons need to develop a judicious approach that yields the information necessary to treat the patient while avoiding the tendency to "over-image" [94].

Treatment

Non-Operative

The evidence base primarily addresses surgical interventions following failed non-operative management or in the context of recurrent instability. While specific conservative protocols such as weight loss or NSAIDs are not detailed in this section, the presence of a posterior glenoid fracture (bony Bankart lesion) did not represent a contraindication to arthroscopic shoulder stabilization [55]. Management of glenohumeral instability may also include nonoperative osseous reconstruction or prosthetic replacement [61].

Operative

Indications: Physicians must maintain a sense of urgency toward surgical treatment, particularly in young, high-demand athletes with persistent instability; you don't have to fix the shoulder after the first anterior dislocation, but you should definitely do it before the second [58]. 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]. Arthroscopic stabilisation resulted in a significantly lower rate of recurrent instability compared with non-operative management in young, active patients, particularly military cadets [204]. The surgical approach of Remplissage is especially beneficial for patients with lower distance-to-dislocation, increased shoulder laxity, younger age, or 2+ preoperative instability episodes [156].

Surgical Approach / Technique: Arthroscopic anterior shoulder stabilization using suture anchors, proper suture placement, capsulorrhaphy, and occasional rotator interval plication is not contraindicated for participation in collision and contact athletics [181]. An anatomic reconstruction of the Bankart lesion without overconstraining of the antero-inferior capsule should be the aim in arthroscopic anterior shoulder stabilization [72]. At least four anchor points should be used to obtain secure shoulder stabilization in arthroscopic Bankart repair [68]. The open technique for anterior shoulder stabilization using anterior labral repair with capsular shift can be performed in a reliable, efficient, and reproducible manner [9]. The Bankart procedure modified by the use of Prolene pull-out sutures makes reattachment of the capsule simple and efficient [200].

For the Latarjet procedure, the standard open technique is performed via a mini deltopectoral incision where the coracoid process is withdrawn while preserving the attached coracoacromial ligament, the subscapularis muscle is released, and the glenohumeral joint is exposed by capsulotomy [187]. The transfer of the coracoid bone block to the anterior glenoid in the open Latarjet procedure provides stability via the 'triple blocking effect' [66]. The arthroscopic Latarjet procedure is performed using a 70° arthroscope and specific instruments through five arthroscopic portals in five successive steps [187]. These steps include coracoid preparation and osteotomy, glenoid preparation and drilling, subscapularis splitting with axillary nerve protection, transfer and fixation, and capsulolabral repair when tissue quality permitted [60]. In the arthroscopic Latarjet 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 [60]. The arthroscopic Latarjet procedure with double-button fixation involves 5 successive steps including coracoid preparation and osteotomy, glenoid preparation, subscapularis split, bone block fixation, and Bankart lesion repair [177]. 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 [184].

Remplissage techniques involve specific positioning and instrumentation. The arthroscopic remplissage technique involves positioning the patient in the lateral decubitus position, establishing a posterior portal slightly lateral to the convexity of the humeral head, and using a double-loaded bioabsorbable anchor into the defect [185]. The arthroscopic remplissage for moderate-size Hill-Sachs lesions uses a single percutaneous skin/deltoid incision for both anchors to pass through into the subacromial space, allowing the avoidance of going to the subacromial space to retrieve and tie the sutures [198]. Knotless suture staple Remplissage for Hill-Sachs lesions in the beach chair position provides a safe and efficient way to augment anterior stabilization [150]. The arthroscopic modified McLaughlin procedure and Remplissage for treatment of simultaneous reverse Hill-Sachs and Hill-Sachs lesions uses portals, equipment, and suture management methods that are very familiar to the arthroscopic shoulder surgeon and can be reliably performed [153].

Implant Selection: Both screw and suture button fixation techniques in the arthroscopic Latarjet procedure achieve comparable graft union rates and effectively restore shoulder stability [227]. The arthroscopic Latarjet procedure with coracoid stabilization with 2 screws can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability [69]. Bone block non-rigid fixation showed satisfactory clinical and functional outcomes for the treatment of anterior shoulder instability with substantial glenoid bone deficiency [209]. The combination of arthroscopic subscapularis augmentation and bone block procedure with a xenograft was effective in the glenoid reconstruction and restoration of shoulder stability [240].

Alignment / Balancing Strategy: The arthroscopic Latarjet procedure with a posterior guided system and suture-button fixation enables more precise bone block positioning in the axial plane versus anterior screws fixation [199]. 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 [59].

Adjuncts: The arthroscopic anterior shoulder stabilization technique involving combined multiple suture repair and laser-assisted capsular shrinkage uses an HO:YAG-Laser (10 W, 1 J, total power 1500–2000 J) for thermal shrinkage of the lax anterior capsule [190]. The combination of 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% [44]. 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 [45]. The combination of Latarjet and Remplissage for treatment of severe glenohumeral instability and bone loss has achieved shoulder stability successfully both subjectively and objectively [1]. 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 [6]. The proposed dynamic anterior stabilization procedure using buttons demonstrated effectiveness and safety, being a viable option for treating anterior shoulder instability with glenoid bone loss of less than 20% and especially beneficial for athletes [146].

Other Considerations: Surgical positioning (beach chair versus lateral decubitus) for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes [18]. There was unanimous consensus on minimizing complications and anchor placement (5-8 mm apart), but no consensus on optimal shoulder immobilization position for anterior shoulder instability management [15]. Specialist shoulder surgeons require 30-50 arthroscopic Latarjet procedures to attain steady-state operative efficiency, during which there is improvement in bone-block positioning [67]. Early results suggest that arthroscopic coracoid transfer is a technically feasible procedure that is able to restore shoulder stability [151]. 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 [147]. The arthroscopic Latarjet procedure enables shoulder surgeons to treat all cases of instability arthroscopically [29]. The modified arthroscopic Latarjet for glenoid rim fracture fixation is selected for large fragments that permit fixation with 2 screws, while comminuted or too small fractures are fixed using suture anchors [183]. The arthroscopic posterior Bankart repair using the Wilmington portal requires three arthroscopic portals: posterior, anterior superolateral (ASL), and posterolateral (Wilmington) [192].

Outcomes, Complications, and Patient Factors: Outcomes for the open Latarjet-Patte procedure were good to excellent with Subjective Shoulder Value greater than 80% in 95% of cases, Constant score greater than 90%, and Rowe score greater than 90% [54]. 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 [236]. Patient-reported outcomes decline over time following arthroscopic Bankart repair for anterior shoulder instability [239]. Overall, instability recurrence was low in a comparison of arthroscopic Bankart repair with Remplissage versus open Bankart repair, indicating both are safe and effective techniques [23]. The Bankart procedure augmented by coracoid transfer can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability [32]. Arthroscopic stabilization procedures for recurrent anterior shoulder instability in young patients with glenoid bone erosions more than 20% showed satisfactory clinical outcomes and recurrence rate, although these results were inferior to those of patients with glenoid erosions less than 20% [24].

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 [5]. This large systematic review demonstrates the overall complication rates in modern shoulder stabilization surgery [19]. This study defines the thresholds for MCID and PASS achievement at minimum 2 year follow-up in a cohort of patients undergoing arthroscopic anterior 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 [28]. The modified shoulder-rating system for the Bankart procedure places greatest emphasis on pain-free function followed by stability and motion [36].

Screw removal can resolve unexplained anterior pain without recurrence of instability after open Latarjet procedures, alleviating pain in 14 shoulders (67%) and reducing pain in the remaining 7 shoulders (33%) [234]. Glenoid faceplate fixation did not make the shoulder more stable compared to glenoid rim fixation, and creating a tissue 'bumper' did not increase stability [225]. To maintain stable fixation of the glenoid component in reverse shoulder arthroplasty for long-standing anterior shoulder dislocation, comprehensive preoperative analysis of the remaining bone stock based on 3-dimensional computed tomography scans should be included [70]. A pain free, normal range of shoulder mobility was registered following open reduction and internal fixation of a dislocated intra-articular fracture of the anterior rim of the glenoid [47].

Complications

Recurrent Instability: The overall redislocation rate after arthroscopic shoulder stabilization for anterior-inferior instability is 18.18% at a mean follow-up of 13.3 years [96]. In a prospective evaluation, 18% of patients experienced a recurrence of any type after arthroscopic Bankart repair, comprising 10% with subsequent dislocation and 5.5% with subsequent subluxation [136]. Eighteen per cent of patients showed signs of instability during an 8-year follow-up after arthroscopic intra-articular Bankart repair using absorbable tacks [71]. In a cohort of 66 patients, 9% sustained a recurrent shoulder dislocation after arthroscopic Bankart repair for chronic glenohumeral instability [186]. The effectiveness of Bankart repair decreases significantly over time, with less than half of recurrences occurring after 2 years [266]. Males may have higher recurrence rates than females following primary arthroscopic anterior shoulder stabilization, though heterogeneity precludes definitive conclusions [5]. Results in contact athletes are much less predictable, with higher reported rates of recurrent instability and revision surgery [22].

Revision Surgery Outcomes: There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery [35]. Arthroscopic revision anterior stabilization is associated with a high rate of recurrent instability [265]. In a series of 41 cases, 44% of patients experienced recurrent instability after return to duty following revision arthroscopic anterior stabilization [103]. Recurrent instability rates were higher in the all-arthroscopic group (19%) compared to the Latarjet group (8%) following revision anterior shoulder stabilization [271]. Similarly, recurrent instability rates were higher in the all-arthroscopic group (19%) compared to the Latarjet group (7%) following revision anterior shoulder stabilization [272]. 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 [246].

Military Population Data: In a military population, the combined failure rate (surgical revision and shoulder-related disability) was 13.8% at 2 to 7 years' follow-up after primary anterior stabilization [106]. Specifically, 5.0% of patients required revision anterior shoulder stabilization surgery [106], and 8.8% underwent medical discharge from the military for persistent complaints of shoulder instability [106]. The combined failure rate for open repair was 17.9% and for arthroscopic repair was 13.0% [106].

Latarjet Procedure Complications: In a series of 133 patients, the open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years had an overall clinical complication rate of 21% and an overall reoperation rate of 9% [201]. Recurrence of instability occurred in 6% of patients after the open Latarjet procedure, involving traumatic anterior redislocations at an average of 3.5 years after surgery [201]. Positive subjective apprehension was found in 9% of patients after the open Latarjet procedure [201]. Twenty per cent of patients complained of some degree of pain and/or stiffness postoperatively after the open Latarjet procedure [201]. 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 [261]. The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years reliably restores stability and leads to high patient satisfaction [11]. The open Latarjet procedure for recurrent anterior shoulder instability in patients older than 40 years is associated with good functional outcome and stability [51].

Arthroscopic Latarjet Complications: In a series of 156 cases, the overall complication rate for the modified arthroscopic Latarjet procedure with suture-button fixation was 1.9% [206]. One patient experienced a redislocation due to a fall and one patient experienced stiffness of the shoulder joint after the modified arthroscopic Latarjet procedure [206]. In a retrospective cohort study, overall complication rates were similar between screw fixation (15.4%) and suture button fixation (14.9%) for arthroscopic Latarjet [188]. Two patients in each group experienced a dislocation after surgery for arthroscopic Latarjet [188]. One patient in the screw fixation group and two patients in the suture button group experienced transient musculocutaneous nerve injury after arthroscopic Latarjet [188]. One patient in the screw fixation group experienced a postoperative hematoma, deep infection, hardware complication, and graft fracture after arthroscopic Latarjet [188]. Two nonunion incidents occurred in the suture button group and one in the screw fixation group after arthroscopic Latarjet [188]. Two additional patients in the screw fixation group underwent reoperations for deep infection and graft fracture after arthroscopic Latarjet [188].

Other Considerations: In a series of 49 patients, recurrence of anterior shoulder instability was noted in 5 patients in the Bankart repair alone group, while none occurred in the Bankart with remplissage group [145]. In a series of 134 patients, 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 [4]. In a series of 133 patients, 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 [252]. In a series of 133 patients, recurrence rates of instability are acceptable and reoperation rates were low after the open Latarjet procedure for failed arthroscopic Bankart repair [256]. In a series of 133 patients, 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 [268]. In a series of 133 patients, there was a statistically significant increased rate of short-term reoperation or revision stabilization in the Latarjet-Bristow cohort compared to arthroscopic Bankart repair [274]. In a series of 133 patients, increased risk of short-term complications and venous thromboembolism was observed in Latarjet-Bristow procedures compared with Bankart repairs [203]. In a series of 133 patients, the open Latarjet procedure effectively prevented chronic anterior shoulder instability and was associated with high patient satisfaction as both a primary and a revision procedure [63]. In a series of 133 patients, the transfer of the coracoid bone block to the anterior glenoid provides stability via the 'triple blocking effect' [66]. In a series of 133 patients, the combination of Latarjet and Remplissage for treatment of severe glenohumeral instability and bone loss achieved successful stability both subjectively and objectively [1]. In a series of 133 patients, the inlay dynamic anterior stabilization with the long head of the biceps tendon and remplissage procedure aims to improve stability and outcomes in patients with complex shoulder instability issues [6]. In a series of 133 patients, the arthroscopically assisted conjoined tendon-coracoid tip complex transfer combined with Bankart repair without screws achieved a relatively high rate of coracoid graft union with no requirement for revision surgeries at a mean followup of 26.7 months [207]. In a series of 156 cases, the arthroscopic Latarjet procedure with coracoid stabilization with 2 screws achieved satisfactory clinical outcomes, though specific complication rates were not detailed in the conclusion [69]. In a series of 156 cases, the arthroscopic Latarjet procedure with coracoid stabilization with 2 screws can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability [69].

Recovery

Light activity (weeks): The standard postoperative rehabilitation protocol for immediate arthroscopic Bankart repair initiates pendulum exercises on day 1 [42]. 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 [42]. External rotation with 90° abduction is introduced from the fourth week [42].

Full activity (months): Full range of motion and strengthening exercises commence from the sixth week [42]. Weight training and non-contact sports are permitted at 2 months, with return to contact sports and throwing occurring at 4 months [42].

Rehabilitation protocol: The protocol follows a phased progression from passive pendulum movements to active range of motion and strengthening [42]. For young rugby athletes during the in-season period, a combination of immobilization in external rotation and early muscle strength training may be an effective treatment for anterior shoulder dislocation [175].

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]. 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 [230].

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 [178]. The Latarjet procedure for anterior shoulder instability results in a high rate of return to sport among athletes at long-term follow-up [208]. 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 [194]. Evaluating readiness after shoulder instability is extremely difficult, and a validated, normalized return to play objective metric has not yet been established [228]. Despite high scores on shoulder outcome measures, the athlete's rate of return to their sport was only moderate following arthroscopic anterior shoulder stabilization [231]. In a retrospective study of a consecutive cohort of martial arts athletes, arthroscopic anterior shoulder stabilization significantly improved functional scores [64]. Arthroscopic Bankart repair for the management of anterior shoulder instability in professional martial arts athletes results in excellent long-term functional outcomes and a high rate of return to elite-level competition with a low risk of recurrence when patients are properly selected [235]. 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 [232]. The open Latarjet procedure can be considered for primary shoulder stabilization, particularly in competitive athletes who have high functional demands and great risks of redislocation [193]. The open Latarjet procedure effectively prevented chronic anterior shoulder instability and was associated with high patient satisfaction as both a primary and a revision procedure [63]. Open Latarjet results in excellent clinical outcomes and low recurrence rates for those with primary shoulder instability, those with recurrent instability, and those undergoing open Latarjet for failed prior instability surgery [262]. The stability of the shoulder has been achieved successfully both subjectively and objectively following a combination of Latarjet and Remplissage for treatment of severe glenohumeral instability and bone loss [1]. The method of inlay dynamic anterior stabilization with the long head of the biceps tendon and remplissage procedure aims to improve stability and outcomes in patients with complex shoulder instability issues [6]. This procedure has been demonstrated safe and effective to restore joint stability in patients practicing sports, affected by chronic anterior shoulder instability associated with anterior glenoid bone loss (<25%) and engaging Hill-Sachs lesions [34]. This procedure can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability [32]. In the longer term (3, 6, 12 months), there was no evidence that one method is superior to the other when it comes to shoulder function for open versus arthroscopic Latarjet procedures [56]. 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 [263]. At midterm follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series [27]. Stratification beyond 1 versus ≥2 preoperative anterior shoulder instability episodes did not increase predictive ability for recurrence after arthroscopic Bankart repair [25]. Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability [20]. 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 [229]. Among fellowship-trained orthopaedic surgeons the overall failure of primary arthroscopic anterior shoulder stabilization was 15.7% in a high-demand population and equivalent outcomes may be anticipated with arthroscopic Bankart repair performed in the beach chair or lateral decubitus position [195]. Following Hill-Sachs remplissage, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder [205]. Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage [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. [4] (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. [5] (10.1016/j.asmr.2020.04.004)
• [L5] The method aims to improve stability and outcomes in patients with complex shoulder instability issues. [6] (10.1016/j.eats.2024.103256)
• [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] Female patients had a similar recurrence rate as that of male patients after arthroscopic anterior shoulder stabilization. [10] (10.1177/23259671211008841)
• [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. [11] (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. [12] (10.1016/j.eats.2018.01.002)
• [L3] This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization. [13] (10.2106/jbjs.15.01099)
• [L5] Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. [14] (10.5435/jaaos-20-04-242)
• [L5] There was unanimous consensus on minimizing complications and anchor placement (5-8 mm apart), but no consensus on optimal shoulder immobilization position. [15] (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. [16] (10.1016/j.arthro.2010.11.057)
• [L3] Surgical positioning for arthroscopic anterior shoulder stabilization did not significantly affect recurrent instability, complications, and patient-reported outcomes. [18] (10.1177/23259671221106474)
• [L4] This large systematic review demonstrates the overall complication rates in modern shoulder stabilization surgery. [19] (10.1177/0363546518810711)
• [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. [20] (10.1177/23259671211006437)
• [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] Overall, instability recurrence was low, indicating both are safe and effective techniques for treating anterior shoulder instability. [23] (10.1177/2325967126s00044)
• [L3] Arthroscopic stabilization procedures for recurrent anterior shoulder instability in young patients with glenoid bone erosions more than 20% showed satisfactory clinical outcomes and recurrence rate, although these results were inferior to those of patients with glenoid erosions less than 20%. [24] (10.1016/j.arthro.2018.03.009)
• [L3] Stratification beyond 1 versus ≥2 preoperative anterior shoulder instability episodes did not increase predictive ability. [25] (10.1177/03635465261430925)
• [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. [26] (10.1177/2325967120s00381)
• [L3] At midterm follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. [27] (10.1016/j.arthro.2019.11.109)
• [L4] This study defines thresholds for MCID and PASS achievement at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization. [28] (10.1177/23259671261442972)
• [L4] This technique enables shoulder surgeons to treat all cases of instability arthroscopically. [29] (10.1016/j.arthro.2007.06.008)
• [L3] Surgical positioning for arthroscopic anterior shoulder stabilization did not affect post-operative clinical and patient-reported outcomes. [31] (10.1177/2325967121s00743)
• [L4] This procedure can achieve a good clinical outcome for contact athletes with traumatic anterior shoulder instability. [32] (10.1177/03635465990270011201)
• [L4] This procedure has been demonstrated safe and effective to restore joint stability in patients practicing sports, affected by chronic anterior shoulder instability associated with anterior glenoid bone loss (<25%) and engaging Hill-Sachs lesions. [34] (10.1016/j.arthro.2016.03.071)
• [L4] There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery. [35] (10.1016/j.arthro.2013.11.019)
• [L4] The study presents a modified shoulder-rating system that places greatest emphasis on pain-free function followed by stability and motion. [36] (10.2106/00004623-199706000-00008)
• [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. [37] (10.1177/0363546508328411)
• [L1] This study supports the need for standardized outcome reporting after arthroscopic anterior shoulder instability surgery in adolescents. [41] (10.1016/j.arthro.2017.10.041)
• [L4] [42] (10.1007/s00167-007-0453-2)
• [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%. [44] (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. [45] (10.1016/j.jse.2015.09.025)
• [L5] A pain free, normal range of shoulder mobility was registered. [47] (10.1016/0020-1383(93)90207-m)
• [L3] Microinstability is diagnostically challenging and can be diagnosed in young patients with ambiguous shoulder pain during motion, without instability. [49] (10.1007/s00167-022-06941-4)
• [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] Outcomes were good to excellent with Subjective Shoulder Value greater than 80% in 95% of cases, Constant score greater than 90%, and Rowe score greater than 90%. [54] (10.1177/26350254211014201)
• [L4] By contrast, the presence of a posterior glenoid fracture (bony Bankart lesion) did not represent a contraindication to arthroscopic shoulder stabilization. [55] (10.1177/03635465251403499)
• [L3] In the longer term (3, 6, 12 months), we found no evidence that one method is superior to the other when it comes to shoulder function. [56] (10.1016/j.otsr.2016.08.004)
• [L5] Physicians must maintain a sense of urgency toward surgical treatment, particularly in young, high-demand athletes with persistent instability; you don't have to fix the shoulder after the first anterior dislocation, but you should definitely do it before the second! [58] (10.1016/j.arthro.2022.11.014)
• [L3] [59] (10.1016/j.arthro.2020.05.013)
• [L4] [60] (10.1016/j.xrrt.2026.100792)
• [L5] Management of glenohumeral instability includes nonoperative osseous reconstruction, or prosthetic replacement. [61] (10.1016/j.ocl.2010.03.004)
• [L1] Coracoid transfers for shoulder instability can improve shoulder stability with acceptable recurrence rates but are challenging procedures associated with a broad range and significant incidence of complications. [62] (10.1016/j.jse.2012.02.008)
• [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. [63] (10.1177/23259671251343807)
• [L4] In this retrospective study of a consecutive cohort of MA athletes, arthroscopic anterior shoulder stabilization significantly improved functional scores. [64] (10.1177/2325967117725031)
• [L1] [65] (10.1016/j.arthro.2023.07.010)
• [L5] The transfer of the coracoid bone block to the anterior glenoid provides stability via the 'triple blocking effect'. [66] (10.21037/aoj.2017.10.01)
• [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. [67] (10.1016/j.jse.2019.10.022)
• [L4] At least four anchor points should be used to obtain secure shoulder stabilization. [68] (10.2106/jbjs.e.00817)
• [L4] The arthroscopic Latarjet procedure with coracoid stabilization with 2 screws can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability. [69] (10.1016/j.jse.2022.01.022)
• [L4] To maintain stable fixation of the glenoid component, comprehensive preoperative analysis of the remaining bone stock based on 3-dimensional computed tomography scans should be included, with particular attention to ensure optimal anchorage length of the baseplate's central peg in the native glenoid bone stock. [70] (10.1016/j.jse.2014.02.017)
• [L4] Eighteen per cent of the patients had signs of instability during the 8-year follow-up period. [71] (10.1007/s00167-008-0534-x)
• [L5] An anatomic reconstruction of the Bankart lesion without overconstraining of the antero-inferior capsule should be the aim in arthroscopic anterior shoulder stabilization. [72] (10.1007/s00167-009-0843-8)
• [L4] [96] (10.1177/0363546516675145)
• [L4] [103] (10.1016/j.arthro.2022.08.044)
• [Paper] [105] (10.1007/s00402-007-0509-2)
• [L4] [106] (10.1016/j.arthro.2013.11.004)
• [L4] [136] (10.1177/0363546509348049)
• [L2] [145] (10.4055/cios.2016.8.4.428)
• [L4] The proposed procedure demonstrated effectiveness and safety, being a viable option for treating anterior shoulder instability with glenoid bone loss of less than 20% and especially beneficial for athletes. [146] (10.1016/j.jseint.2024.06.016)
• [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. [147] (10.1016/j.arthro.2019.03.035)
• [L5] This technique provides a safe and efficient way to augment anterior stabilization. [150] (10.1002/atn2.70058)
• [L1] Early results suggest that arthroscopic coracoid transfer is a technically feasible procedure that is able to restore shoulder stability. [151] (10.1016/j.arthro.2012.11.022)
• [L4] The technique uses portals, equipment, and suture management methods that are very familiar to the arthroscopic shoulder surgeon and can be reliably performed. [153] (10.1016/j.eats.2022.03.038)
• [L3] This surgical approach is especially beneficial for patients with lower distance-to-dislocation, increased shoulder laxity, younger age, or 2+ preoperative instability episodes. [156] (10.1177/2325967124s00010)
• [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. [175] (10.1016/j.jse.2024.11.016)
• [L4] [177] (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. [178] (10.1016/j.arthro.2024.09.056)
• [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. [181] (10.1177/0363546504268037)
• [L5] [183] (10.1016/j.eats.2024.103293)
• [L4] [184] (10.1016/j.jse.2022.08.019)
• [L4] [185] (10.1016/j.arthro.2011.05.010)
• [L4] [186] (10.1016/j.arthro.2015.04.087)
• [L3] [187] (10.1177/03635465221120076)
• [L3] [188] (10.1177/23259671251321501)
• [L3] [190] (10.1016/s0020-1383(02)00040-2)
• [L5] [192] (10.1016/j.eats.2023.03.009)
• [L3] The OLP could be considered for primary shoulder stabilization, particularly in competitive athletes, who have high functional demands and great risks of redislocation. [193] (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. [194] (10.1016/j.jse.2021.01.026)
• [L3] Among fellowship-trained orthopaedic surgeons the overall failure of primary arthroscopic anterior shoulder stabilization was 15.7% in a high-demand population and equivalent outcomes may be anticipated with arthroscopic Bankart repair performed in the BC or LD position. [195] (10.1177/2325967121s00240)
• [Paper] [198] (10.1016/j.eats.2016.04.022)
• [L4] [199] (10.1002/ksa.12063)
• [L4] [200] (10.2106/00004623-198264040-00025)
• [L4] [201] (10.1016/j.jse.2019.02.004)
• [L3] [203] (10.1016/j.arthro.2020.10.039)
• [L2] Arthroscopic stabilisation resulted in a significantly lower rate of recurrent instability compared with non-operative management in young, active patients, particularly military cadets. [204] (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. [205] (10.1302/0301-620x.103b4.bjj-2019-0736.r2)
• [L4] [206] (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. [207] (10.1016/j.jseint.2025.06.009)
• [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. [208] (10.1016/j.jse.2018.08.028)
• [L1] Bone block non-rigid fixation showed satisfactory clinical and functional outcomes for the treatment of anterior shoulder instability with substantial glenoid bone deficiency. [209] (10.1177/1758573219872512)
• [L4] [211] (10.5435/jaaos-d-17-00056)
• [L2] [214] (10.1016/j.jisako.2025.100789)
• [L4] [215] (10.1177/0363546511404207)
• [L4] [218] (10.1136/jisakos-2020-000584)
• [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. [225] (10.1016/j.arthro.2011.03.005)
• [L4] Both arthroscopic fixation techniques achieve comparable graft union rates and effectively restore shoulder stability. [227] (10.1177/17585732261417669)
• [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. [228] (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. [229] (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. [230] (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. [231] (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. [232] (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. [233] (10.1007/s00167-010-1105-5)
• [L4] Screw removal alleviated pain in 14 shoulders (67%) and reduced pain the remaining 7 shoulders (33%). [234] (10.1016/j.jse.2021.03.058)
• [L4] This approach results in excellent long-term functional outcomes and a high rate of return to elite-level competition, with a low risk of recurrence when patients are properly selected. [235] (10.1177/23259671251405434)
• [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. [236] (10.1177/03635465251388108)
• [L4] Radiography can be used for screening patients for significant glenoid bone loss. [237] (10.1186/s12891-015-0607-1)
• [L3] Radiographs seem inferior to CT scans for assessing osseous lesions especially at the glenoid rim. [238] (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. [239] (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. [240] (10.1016/j.asmr.2023.04.008)
• [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. [242] (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. [243] (10.1177/03635465231209443)
• [L4] At a mean follow-up of 128.1 months, 25.0% of patients experienced recurrent instability and 19.6% underwent subsequent surgery. [246] (10.1177/2325967126s00277)
• [L1] This systematic review has identified significant heterogeneity in both the imaging modality and method used to measure glenoid bone loss. [250] (10.1302/0301-620x.104b1.bjj-2021-0751.r1)
• [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. [252] (10.1002/arj.70066)
• [L2] CT assessments of glenoid bone defects with and without comparison with the contralateral shoulder showed very good agreement in identifying the size, presence, and type of defect in patients with anterior shoulder instability on both 2D and 3D CT scans. [255] (10.1177/0363546515608167)
• [L4] Recurrence rates of instability are acceptable and reoperation rates were low. [256] (10.1016/j.otsr.2014.11.005)
• [L3] Initial shoulder instability during adolescence was associated with a higher recurrence rate and lower functional scores after arthroscopic Bankart repair compared with later onset instability, although no significant structural differences were found between the groups on MRI at a mean 6-year follow-up. [259] (10.1177/2325967120964881)
• [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. [261] (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. [262] (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. [263] (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. [265] (10.2106/jbjs.17.01028)
• [L4] The effectiveness of Bankart repair to stabilize the shoulder decreased significantly over time, with less than half of recurrences occurring after 2 years. [266] (10.1177/03635465221139290)
• [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. [268] (10.3390/medicina55090582)
• [L3] Recurrent instability rates were higher in the all-arthroscopic group (19% versus 8%). [271] (10.1016/j.jse.2016.07.052)
• [L3] Recurrent instability rates were higher in the all-arthroscopic group (19% versus 7%). [272] (10.1177/2325967115s00048)
• [L3] However, there was a statistically significant increased rate of short-term reoperation or revision stabilization in the LB cohort. [274] (10.1016/j.arthro.2023.07.028)

See Also

• Fractures
• Os Acromiale
• Rotator Cuff
• Shoulder Instability
• Latarjet Procedure
• Shoulder Arthritis
• Reverse Shoulder Arthroplasty
• Calcific Tendinitis
• Internal Fixation

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[184] Arthroscopic Latarjet procedure and suture-button fixation: can we predict nonunion early?. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.08.019

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[192] Arthroscopic Posterior Bankart Repair Using the Wilmington Portal to Facilitate Suture Anchor Implantation. Arthroscopy Techniques. 2023. DOI: 10.1016/j.eats.2023.03.009

[193] Open Latarjet Procedures Produce Better Outcomes in Competitive Athletes Compared With Recreational Athletes: A Clinical Comparative Study of 106 Athletes Aged Under 30 Years. The American Journal of Sports Medicine. 2018. DOI: 10.1177/0363546518759730

[194] 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

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[203] 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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[234] 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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[236] Clinical and Functional Outcomes After Arthroscopic Bankart Repair After a Median Follow-up of 23 Years. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251388108

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[259] Relationship Between Age at Initial Shoulder Instability and Overall Outcomes After Arthroscopic Bankart Repair: Mean 6-Year Follow-up. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120964881

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[262] 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

[263] 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

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

[266] 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

[268] Arthroscopic Latarjet for Recurrent Shoulder Instability. Medicina. 2019. DOI: 10.3390/medicina55090582

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

[274] Significant Increase in Early Reoperation After Latarjet-Bristow Procedure Versus Arthroscopic Bankart Repair for Anterior Shoulder Instability: A Propensity-Score Matched Analysis. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2024. DOI: 10.1016/j.arthro.2023.07.028