Recurrent Anterior Shoulder Dislocation: Surgical Options and Indications

Background

Decision Framework: The Key Variables

1. Glenoid bone loss - the single most important determinant

• < ~13.5%: soft tissue repair usually sufficient
• 13.5-17.3%: "gray zone" - patient risk profile determines threshold

• 17-25%: bone block procedure generally indicated

1. Hill-Sachs lesion (humeral bone loss) - assessed as "on-track" vs. "off-track"
2. Patient profile - age, sex, sport (contact vs. overhead), demand level

Surgical Options

1. Arthroscopic Bankart Repair (ABR)

• Recurrent anterior instability with documented Bankart lesion (most common scenario)
• Glenoid bone loss < 13.5-17.3% (no critical bone loss)
• Hill-Sachs lesion that is "on-track" (non-engaging)
• Low-to-moderate demand patients; non-contact athletes
• First-time dislocation in high-risk patients (young, male, contact sport) with documented lesion on MRI - relative indication

• Critical glenoid bone loss (> 17-25%)
• Off-track (engaging) Hill-Sachs lesion
• Capsular deficiency / prior failed thermal capsulorrhaphy
• Collagen disorders (Ehlers-Danlos, Marfan)
• Atraumatic/voluntary instability or ligamentous laxity
• Active seizure disorder

2. Open Bankart Repair

• Recurrent instability without critical bone loss, when arthroscopic approach is not feasible
• Revision of failed arthroscopic Bankart repair without significant bone loss
• Cases requiring combined procedures or complex capsular tightening
• Surgeon preference in chronic instability with capsular laxity

From Rockwood and Green's Fractures in Adults, 10th ed. 2025: "Open Bankart repair was previously considered the gold standard for treatment of traumatic anterior shoulder instability with recurrence rates of typically less than 10%... The known disadvantages of open Bankart repair include restriction of glenohumeral motion following surgery, particularly external rotation, which may lead to secondary arthritis and muscle weakness."

3. Latarjet Procedure (Coracoid Transfer / Bristow-Latarjet)

• Bony augmentation of the glenoid rim (extends the articular arc)
• Sling effect of the conjoint tendon across the subscapularis in abduction/external rotation
• Capsular reinforcement from capsule repair to the stump

• Glenoid bone loss > 13.5-25% (especially > 20-25%)
• Engaging (off-track) Hill-Sachs lesion combined with glenoid defect
• High-risk contact athletes (even with borderline bone loss ~13.5%)
• Failed prior Bankart repair (arthroscopic or open) - especially if bone loss present
• Revision instability surgery where prior soft tissue repair has failed
• Patients with capsular insufficiency in whom soft tissue repair is unreliable

4. Remplissage (Infraspinatus Tenodesis into Hill-Sachs Defect)

• Off-track (engaging) Hill-Sachs lesion with glenoid bone loss < 25% (i.e., glenoid defect doesn't mandate Latarjet)
• Hill-Sachs lesion involving 20-30% of the humeral head
• "Near-track" Hill-Sachs lesions in contact athletes (recent evidence suggests benefit)
• Goal: convert an off-track lesion into an effectively non-engaging one

5. Eden-Hybinette (Free Bone Block Augmentation)

• Large glenoid bone loss where Latarjet is not possible or has failed
• Revision after failed Latarjet (coracoid unavailable)
• Glenoid rim deficiency from prior fractures or multiple surgeries
• Patients who need glenoid augmentation but lack coracoid bone stock

6. Humeral Head Procedures (for Large Hill-Sachs Lesions)

Decision Algorithm Summary

Recurrent anterior instability
          |
   Assess glenoid bone loss
     /              \
  < 13.5%        13.5–25%          > 25%
     |              |                |
  Assess       Patient profile     LATARJET
  Hill-Sachs   + Hill-Sachs         (or Eden-Hybinette
     |              |                if Latarjet failed)
  On-track    Off-track
     |              |
  ABR alone    Contact athlete?
               /         \
             Yes           No
              |             |
      LATARJET        ABR + Remplissage

Comparative Outcomes (Rockwood & Green Table 35-6)

Recent Evidence (PubMed, 2023-2026)

• A 2025 network meta-analysis (PMID 40939903) confirmed surgical treatment is superior to conservative options in preventing recurrence in patients under 40, supporting early surgical intervention in high-risk individuals.
• A 2024 systematic review of arthroscopic Bankart repair outcomes (PMID 39428642) showed good functional results in appropriately selected patients.
• A 2024 systematic review of options after failed Latarjet (PMID 39245259) found revision options include bone block (Eden-Hybinette), repeat Latarjet with modifications, and allograft reconstruction.

Key Takeaways

• ABR is the standard procedure for most recurrent instability without significant bone loss - but patient selection is everything
• Latarjet is increasingly used primarily (not just as revision) in contact athletes with any bone loss and in high-risk populations, given its superior redislocation rate
• Remplissage should be added to ABR whenever Hill-Sachs is off-track but glenoid deficiency < 25%
• The on-track/off-track concept (bipolar bone loss assessment) using 3D-CT is now standard pre-operative workup
• Bone block procedures (Latarjet or Eden-Hybinette) are mandatory when glenoid bone loss exceeds the critical threshold