Anterior Shoulder Stabilisation Info Evidence Consent

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Inlay dynamic anterior stabilization using the long head of the biceps tendon combined with a remplissage procedure aims to improve stability and outcomes in patients with subcritical glenoid bone loss and on-track Hill-Sachs lesions [1].
• Arthroscopic autologous iliac crest bone grafting for augmentation of glenoid bone loss using suture anchor fixation combined with the remplissage procedure shows excellent clinical outcomes for glenoid reconstruction in recurrent anterior shoulder dislocation with significant bone loss [2].
• Concomitant arthroscopic rotator cuff repair and anterior shoulder stabilization is associated with low rates of recurrent instability [3].
• Concomitant arthroscopic rotator cuff repair and anterior shoulder stabilization is associated with a meaningful risk of structural rotator cuff failure [3].
• Thresholds for the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) have been defined at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization [4].
• The open Latarjet procedure is effective for shoulder stabilization in patients over 50 years old without associated cuff damage [5].
• The open Latarjet procedure has a higher complication rate in patients over 50 years old than in the younger population [5].
• A simplified arthroscopic Latarjet technique using a 3 anterior portal approach is safe and reproducible in the treatment of recurrent anterior shoulder dislocations [6].
• Patient-reported outcomes decline over time following arthroscopic Bankart repair for anterior shoulder instability [7].
• Patients should be counseled pre-operatively on the expected outcomes over time following arthroscopic Bankart repair of anterior shoulder instability [7].
• Arthroscopic Latarjet combined with Hill-Sachs remplissage is an efficient solution for patients with significant bipolar glenohumeral bone loss [9].
• The combined procedure of arthroscopic Latarjet and Hill-Sachs remplissage deserves consideration in a high-risk population including combined bone loss, recurrent anterior instability after failed previous stabilization procedures, and/or seizure [9].
• Knotless suture staple remplissage for Hill-Sachs lesions in the beach chair position provides a safe and efficient way to augment anterior stabilization [10].
• A standardized arthroscopic Bankart repair using a minimum of three suture anchors has been evaluated for long-term clinical outcomes in patients with traumatic anterior instability [12].
• Risk factors for recurrent instability have been assessed in patients undergoing standardized arthroscopic Bankart repair with a minimum of three suture anchors [12].

Anatomy & Pathophysiology

Bony Anatomy

• The glenoid cavity is a shallow socket approximately one-third the size of the humeral head [41].
• The glenoid is a convex structure of shallow depth shaped like an inverted pear [40].
• The subchondral bone of the glenoid is relatively flat, with articular concavity augmented by cartilage and a circumferential labrum [43].
• The glenoid averages 5° of retroversion in relation to the axis of the scapular body [43].
• The humeral head is spherical with a diameter of 37 to 57 mm [40].
• The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [43].
• The humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [40].
• The head is inclined approximately 130 degrees with respect to the humeral shaft [40].
• The neck-shaft angle measures an average of 135 degrees [41].
• The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [40].
• The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps [40].
• The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [40].
• The greater tuberosity is located in a posterior-superior location with respect to the humeral shaft and serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [40].
• The lesser tuberosity is located on the anterior aspect of the proximal humerus and serves as the attachment site for the subscapularis tendon [40].
• The anatomic neck of the proximal humerus is located at the junction of the articular surface and the tuberosities [40].
• The surgical neck represents an indistinct region (metadiaphyseal junction) below the tuberosities but above the humeral shaft [40].
• The scapula is attached to the axial skeleton by the acromioclavicular and sternoclavicular joints [42].
• The glenoid is connected with the flat body of the scapula by the scapular neck [42].
• The coracoid process curves forwards from the superior surface of the scapular neck [42].
• The acromion curves forwards from the scapular spine [42].
• The highest concentration of bony mass in the scapula is found in the glenoid, the scapular neck, and the lateral border of the scapular body [42].
• Two bony pillars transmit compressive forces from the glenoid fossa: the lateral pillar and the spinal pillar [42].
• The weakest bone in the scapula is located primarily in the central part of the biomechanical body, specifically in the infraspinous fossa [42].
• The weakest area of the circumference of the biomechanical body of the scapula is the spinomedial angle [42].
• The coracoid process serves as the origin for the coracobrachialis muscle and the short head of the biceps tendon [43].
• The pectoralis minor muscle inserts onto the medial coracoid process [43].
• The acromion has three ossification centers: the metacromion, mesoacromion, and preacromion [43].
• Failure of fusion of the acromial ossification centers results in os acromiale [43].

Vascular Supply

• The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [40].
• 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 [40].
• The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [40].
• The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch, known as the artery of Laing or arcuate artery [40].
• The ascending branch of the anterior humeral circumflex artery 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 [40].
• Injury to the arcuate artery may result in osteonecrosis of the humeral head [40].
• Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [40].
• The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [43].
• The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [43].

Soft Tissue Stabilizers

• The glenohumeral joint stability is provided by the interaction of dynamic and static stabilizers [40].
• Dynamic stabilizers include the rotator cuff, which stabilizes the joint via joint compression [43].
• Static stabilizers include articular congruity, the glenoid labrum, concavity-compression, negative intra-articular pressure, and the glenohumeral capsule and ligaments [43].
• The glenoid labrum provides concavity and up to 50% of marginal glenoid socket depth [43].
• The rotator interval is defined medially by the base of the coracoid, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [43].
• The rotator interval contains the coracohumeral ligament, the superior glenohumeral ligament, and the intra-articular portion of the long head of the biceps tendon [43].
• Laxity of the rotator interval results in inferior laxity (the sulcus sign) [43].
• Contracture of the rotator interval is seen with adhesive capsulitis [43].
• The coracohumeral ligament restricts external rotation in adduction and is a static restraint to inferior and posterior translation in adduction and external rotation [43].
• The superior glenohumeral ligament is a primary static restraint against anterior translation with the arm at the side [43].
• With the coracohumeral ligament, the superior glenohumeral ligament forms a pulley that provides restraint against medial subluxation of the long head of the biceps tendon [43].
• The middle glenohumeral ligament is a primary static restraint against anterior translation with the arm in external rotation and 45° of abduction [43].
• The anterior band of the inferior glenohumeral ligament is a primary static restraint against anterior-inferior dislocation of the glenohumeral joint in 90° of abduction and external rotation [43].
• The posterior band of the inferior glenohumeral ligament is a primary static restraint against posterior-inferior translation in internal rotation and adduction [43].
• The subscapularis is the largest and strongest of the rotator cuff tendons [54].
• The subscapularis is responsible for active internal rotation of the humerus and contributes to the stability of the shoulder [54].
• The subscapularis forms the anterior portion of the transverse plane "force couple" of the rotator cuff to balance forces across the joint [54].
• Untreated subscapularis tears can lead to dynamic anterior instability and glenohumeral arthrosis [54].
• The subscapular bursa lies between the subscapularis tendon and the neck of the scapula and communicates with the joint cavity between the superior and middle glenohumeral ligaments [44].
• The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [44].
• The subscapular bursa often houses loose bodies in the shoulder and is a region where synovitis may be most intense [44].
• Synovial recesses in the anterior capsule are variations in the opening of the subscapularis bursa [44].
• DePalma described six common variations or types of recesses in the anterior capsule [44].
• Type 1 recesses (30.2%) have one synovial recess above the middle glenohumeral ligament [44].
• Type 2 recesses (2.0%) have one synovial recess below the middle glenohumeral ligament [44].
• Type 3 recesses (40.6%) have one recess above and one below the middle glenohumeral ligament [44].
• Type 4 recesses (9.0%) have one large recess above the inferior ligament, with the middle glenohumeral ligament being absent [44].
• Type 5 recesses (5.1%) have the middle glenohumeral ligament manifested as two small synovial folds [44].
• Type 6 recesses (11.4%) have no synovial recesses, although all the ligaments are well defined [44].
• Enlargement of the rotator interval can cause instability in certain shoulders [44].
• The average area of the rotator interval is 20.96 mm [44].
• Dynamic testing shows that subscapularis and supraspinatus dimensions as well as the total area of the rotator interval decrease significantly with internal rotation and open with external rotation [44].

Pathophysiology of Instability

• Injury with the arm in extension, abduction, and external rotation favors anterior dislocation [28].
• Electoshock, seizures, or a fall on the flexed and adducted arm are commonly associated with posterior dislocation [28].
• In posterior humeral head dislocation, the humeral head internally rotates and translates posteriorly on the glenoid [14].
• Posterior translation places stress on the soft-tissue stabilizers including the posterior labrum and posterior inferior glenohumeral ligament [14].
• As the humeral head translates further posteriorly, it dislocates and the anteromedial aspect of the humeral head contacts and rests on the posterior rim of the glenoid [14].
• This contact may result in an impaction (impression) fracture of the humeral head known as a reverse Hill-Sachs lesion [14].
• Posterior instability represents only 10% of all instability [14].
• Recurrent posterior instability will typically occur within the first 8 months after the initial dislocation [14].
• Recurrent posterior instability occurs in 17.7% of shoulders [14].
• Risk factors for recurrent posterior instability include patients younger than 40 years old and a seizure as the mechanism of primary dislocation [14].
• The principal cause of failure after a posterior soft tissue repair is recurrent instability [56].
• Unless excellent dynamic stabilization is regained so that concavity compression rather than capsular restraint is the dominant mechanism of stability, tightened posterior soft tissues are likely to stretch out as motion is regained [56].
• The posterior capsule is thin and often translucent in its normal state [56].
• Stretching out of posterior soft tissues after surgical tightening is hastened if the posterior soft tissues are of poor quality, if the patient voluntarily or habitually tries to translate the shoulder posteriorly, or if large bony defects cause unphysiologic dependency on soft tissues for stability [56].
• Posterior repair can produce a shoulder that is too tight, which can push the shoulder out anteriorly [56].
• Insufficient posterior laxity can limit flexion, cross-body adduction, and internal rotation [56].
• Attempted posterior opening wedge osteotomy of the glenoid can result in an intra-articular fracture, avascular necrosis of the osteotomized fragment, or excessive anterior inclination and anterior instability [56].
• Posterior bone blocks placed in an excessively prominent position can cause severe degenerative joint disease [56].
• The axillary nerve may be injured as it exits the quadrangular space during posterior instability surgery [56].
• The nerve to the infraspinatus may be injured in the spinoglenoid notch during posterior instability surgery [56].
• Static anterior subluxation is a fixed anterior position of the humeral head on the glenoid fossa [49].
• Static anterior subluxation is often manifest clinically as moderate to severe shoulder pain, partly caused by impingement under the coracoid and coracoacromial arch and loss of anterior elevation [49].
• The cause of static anterior subluxation without previous operation seems to be a combination of a subscapularis tear, a supraspinatus tear, and fatty degeneration of the infraspinatus muscle [49].
• Static anterior subluxation has been irreversible with soft tissue procedure [49].
• Static posterior subluxation is a fixed posterior position of the humeral head on the glenoid fossa on CT or MRI scans with the arm in neutral rotation [49].
• Static posterior subluxation is most frequently but not always associated with congenital dysplasia of the glenoid or with degenerative glenohumeral joint disease [49].
• Static posterior subluxation may be present without any rotator cuff deficiencies [49].
• Most authors have found static posterior subluxations to be irreversible [49].
• Inferior subluxation of the shoulder is characterized by straight inferior translation of the humerus relative to the glenoid fossa [49].
• Inferior subluxation after trauma and surgery, if not associated with permanent nerve injury, usually resolves within 6 weeks but always resolves within 2 years [49].
• Inferior subluxation caused by infection tends to result in joint surface destruction and only successful treatment of infection results in resolution of the inferior subluxation [49].
• Inferior subluxation caused by neurologic injury or shortening of the humerus remains symptomatic unless the primary problem can be resolved [49].
• The SICK scapula is an extreme form of scapular dyskinesis characterized by scapular malposition, inferior medial border prominence, coracoid pain, and dyskinesis of scapular movement [62].
• The SICK scapula predisposes the shoulder to labral and rotator cuff tears because the scapula sits in a more protracted and upwardly tilted orientation [62].
• This position leads to anterior tension, posterior compression, and increased glenohumeral angulation [62].
• With glenoid protraction, the anterior band of the inferior glenohumeral ligament tightens, limiting anterior translation of the humeral head [62].
• Over time, the anterior band of the inferior glenohumeral ligament becomes susceptible to chronic strain due to glenoid protraction [62].
• Simultaneously, the posterior edge of the glenoid is brought toward the humerus, placing the posterosuperior labrum and rotator cuff at risk of injury [62].
• Excessive protraction increases glenohumeral angulation, which in a thrower will result in the arm lagging behind the body [62].
• Excessive external rotation exacerbates the biceps peel-back effect and can result in posterosuperior glenoid impingement with preexisting scapular protraction [62].
• A total of 60 out of 64 (94%) throwers with proven posterosuperior labral tears showed patterns of dynamic scapular dyskinesis [62].
• Type I SICK scapula stems from weak lower trapezius and serratus anterior muscles and inflexibility of pectoralis major and minor [62].
• Type II SICK scapula is predominantly caused by upper and lower trapezius and rhomboid weakness [62].
• Type III SICK scapula is associated with impingement lesions and involves superomedial winging of the scapula [62].
• Labral tears resulting in 270 near-circumferential pathology predispose patients to recurrent instability [31].
• When 270 labral tears are associated with Hill-Sachs lesions, recurrent instability risk is significantly increased and can result in substantially lower clinical outcomes [31].
• Young males aged 16 to 20 years have the highest risk for shoulder instability [31].
• The glenohumeral joint provides inherent stability given the lack of bony stability [31].
• The labrum is a fibrocartilaginous structure anchoring the joint capsule and shoulder ligaments that encircles the glenoid and adds volumetrically to the concavity of the shoulder [31].
• The glenoid labrum is often injured during shoulder instability events [31].

Classification

• The Instability Severity Index Score is a pre-operative score used to select patients for arthroscopic or open shoulder stabilisation [16].
• The ABC classification is a system for classifying posterior shoulder instability [22].
• Type II SLAP lesions are classified into three subtypes based on their relationships to superior instability and rotator cuff tears [22].
• The "on-track" classification is applied to Hill-Sachs lesions in the context of anterior shoulder stabilization procedures [1].
• The "off-track" classification identifies Hill-Sachs lesions as a risk factor for recurrence of instability after arthroscopic Bankart repair [71].
• The "engaging" classification is applied to Hill-Sachs lesions in the treatment of recurrent shoulder instability [11].
• The "significant bipolar glenohumeral bone loss" classification identifies a high-risk population for combined arthroscopic Latarjet and Hill-Sachs remplissage procedures [9].

Clinical Presentation

History

• The history should define the mechanism of injury, including the position of the arm, the amount of force applied, and the point of force application [28].
• In 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 [28].
• The history solicits evidence of neurologic or rotator cuff problems after previous episodes of shoulder instability [28].
• Previous treatment of recurrent instability and the effectiveness of this treatment should be documented [28].
• Patients with traumatic anterior shoulder dislocation report a shoulder in abduction and external rotation receiving a hit to the arm in full outstretched motion [53].
• Young patients often report a history of the shoulder “coming out” or “slipping out,” then popping back in, which may indicate recurrent shoulder subluxation or instability [53].
• Patients may complain of anterolateral and anterior shoulder pain with overhead activities and motion [53].
• The most common complaint of shoulder instability is pain coupled with restricted shoulder motion [55].
• Patients with anterior shoulder instability experience symptoms of apprehension with shoulder abduction and external rotation [55].
• Patients with anterior shoulder instability can experience symptoms of pain and instability with placement of the arm in an overhead position [55].
• Risk factors associated with treatment failure include age, gender, presence of osseous Bankart, 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 [59].

Physical Examination

• An acutely dislocated shoulder is usually very painful, and muscles are in spasm in an attempt to stabilize the joint [28].
• In anterior dislocation, the humeral head may be palpable anteriorly [28].
• In anterior dislocation, the posterior and lateral aspect of the shoulder shows a hollow beneath the acromion [28].
• In anterior dislocation, the arm is held in slight abduction [28].
• In anterior dislocation, passive and active motions are limited by pain [28].
• 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 [28].
• The axillary nerve is the most commonly injured nerve in up to 42% of traumatic anterior shoulder dislocations [53].
• A thorough neurovascular exam, including assessment of the axillary nerve, should be performed [53].
• 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 [55].
• Documentation of active and passive ROM of the shoulder for internal and external rotation as well as forward flexion and abduction is important [55].
• Marked loss of motion is seen with persistent dislocations and rotator cuff lesions [55].
• Rotator cuff testing is an essential part of the shoulder instability examination particularly in patients over the age of 40 years [55].
• The belly press or bear hug test is the most effective test to evaluate the function of the subscapularis in the acutely injured patient [55].
• Testing of resisted shoulder abduction in the first 30 degrees of shoulder flexion with the arm internally rotated is effective for evaluating the supraspinatus [55].
• Evaluation of the infraspinatus is performed by applying resisted external rotation with the elbow flexed to 90 degrees [55].
• The anterior apprehension sign is performed by placing the arm into an abducted (90 degrees) and maximally externally rotated position with the patient in the supine position, resulting in a feeling of pain, discomfort, and potential instability [55].
• 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 [55].
• The 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 [55].
• A feeling of pain or apprehension is a positive result for the anterior release test [55].
• The apprehension and relocation tests assess anterior GH instability [53].
• The patient should be lying in supine position on the examination table with their arm abducted to 90 degrees and externally rotated for the apprehension and relocation tests [53].
• A positive relocation test occurs when the patient feels a slipping sensation or fear of an impending dislocation that is improved with applying a posterior force to the GH joint [53].
• The sulcus sign is performed at 0 degrees of abduction by applying downward traction on the humerus [53].
• Dimpling or a “gap” formed in the GH joint is a positive sulcus sign, indicating laxity of the superior GH ligament [53].
• 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 [53].
• Grade 0 on the load and shift test means normal translation [53].
• Grade 1 on the load and shift test indicates translation to rim and back, less than 1 cm [53].
• Grade 2 on the load and shift test indicates translation over the rim followed by spontaneous reduction, 1 to 2 cm [53].
• Grade 3 on the load and shift test indicates translation over the rim without spontaneous reduction, greater than 2 cm [53].
• Generalized joint laxity should be assessed using the Beighton score (0–9 point scale) [53].
• Inspection of the anterior and posterior aspects of the shoulders can best be accomplished by having the patient sit on a low stool with the examiner standing behind the patient [28].
• Asymmetry of the shoulder contours can often best be visualized by viewing the shoulders from above while standing behind the patient [28].
• 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 [59].
• 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 [59].
• Grade 1+ on the load-and-shift test corresponds to the translation of the humeral head to the edge of the glenoid [59].
• Grade 2+ on the load-and-shift test corresponds to the humeral head being subluxated over the glenoid rim but reducing spontaneously [59].
• Grade 3+ on the load-and-shift test corresponds to a frank dislocation of the humeral head over the glenoid rim that does not reduce spontaneously [59].

Investigations

Radiographic Evaluation

• The purpose of shoulder imaging 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 [27].
• 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 [27].
• Standardized plain films are almost always sufficient to garner the information needed, and there is information that can be gathered from properly taken plain films that cannot be obtained from CT scans [27].
• Although CT scans may offer a few degrees of increased precision in the measurement of glenoid version, this precision does not improve the quality of the surgery or the clinical outcome [27].
• Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome [27].
• The first key radiographic view is the anteroposterior (AP) in the plane of the scapula taken so that the x-ray beam passes through the glenohumeral joint [27].
• The AP view in the plane of the scapula shows the superoinferior position of the humeral head relative to the glenoid, the presence of osteophytes on the humeral head and glenoid, narrowing of the joint space, and the degree of medial displacement of the humerus in relation to the lateral acromial line [27].
• The AP view also shows the quality of the humeral and glenoid bone, the presence of loose bodies, and whether there is humeral head collapse or deformity [27].
• The second key radiographic view is the axillary view taken with the arm in the functional position of elevation in the plane of the scapula and oriented so that both the spinoglenoid notch and the scapular neck are visible [27].
• The axillary view shows a different perspective of the humeral anatomy, the amount of glenoid bone, the shape of the glenoid, its version in relation to the plane of the scapula, and the relationship of the humeral head to the glenoid fossa [27].
• The axillary view is referred to as the “truth view” because it demonstrates the glenohumeral relationships in the functional position of elevation [27].
• CT scans have the disadvantage of being taken with the arm in the adducted position, whereas the axillary truth view is taken with the arm in elevation [27].
• Many “axillary views” sent for consultation are taken without standardization, making it impossible to determine the important features of the glenohumeral joint [27].
• When taken properly, standardized anteroposterior and axillary views indicate the thickness of the cartilage space between the humerus and the glenoid, relative positions of the humeral head and the glenoid, presence of osteophytes, degree of osteopenia, and extent of bony deformity and erosion [27].
• Joint space narrowing is most evident on the axillary truth view as opposed to images made with the arm at the side [27].
• The axillary truth view enables the detection of posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [27].
• The degree of posterior subluxation can be measured as the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [27].
• The point of contact of the humeral articular surface on the glenoid articular surface reflects the degree of centering of the net humeral joint reaction force on the glenoid [27].
• Malcentering of the joint reaction force leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components [27].
• 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 [48].
• 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 [51].
• Critical relationships, such as the degree of centering of the humeral head, change with the position of the arm [51].
• Shoulder pathology may be found in a large number of different bones and soft tissues [51].
• Overlying and superimposed structures as well as metallic implants may complicate imaging the structures of interest [51].
• Surgeons need to develop a judicious approach to imaging that yields the information necessary to treat the patient while avoiding the tendency to "over-image" [51].

Magnetic Resonance Imaging

• Magnetic resonance imaging (MRI) is useful to identify osteonecrosis of the humeral head, or a bone tumour [48].
• MRI can identify labral tears and rotator cuff tears, although the accuracy for these is enhanced by combining the scan with arthrography [48].

Computed Tomography

• Computed tomography (CT) is helpful for planning fracture surgery and shoulder joint replacement [48].

Ultrasound

• Ultrasound is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [48].
• Ultrasound can be useful in guiding injections or barbotage (aspirating calcific deposits in the rotator cuff) [48].
• The most commonly performed joint examination using ultrasonography is the shoulder examination [46].
• The accuracy of shoulder ultrasonography depends on the skill of the scanner operator and an awareness of pitfalls that are encountered [46].

Arthroscopy

• Arthroscopy is useful for diagnosing and treating subacromial impingement, intra-articular lesions, detachment of the glenoid labrum and rotator cuff tears [48].
• Among patients undergoing arthroscopy at the time of open Latarjet, most required an additional procedure, including extensive debridement (89.1%) that would not have otherwise been performed with a Latarjet alone [19].
• Excluding extensive debridements, an additional arthroscopic procedure was required in 9.2% of cases among patients undergoing arthroscopy at the time of open Latarjet [19].
• Among patients requiring additional arthroscopic procedures who had a preoperative MRI, the MRI identified pathology in only 1 case (0.5%) [19].
• Extensive debridement during arthroscopy represents a therapeutic intervention that provides clinical benefit, rather than a routine or incidental finding [19].

Treatment

Arthroscopic Bankart Repair and Remplissage

• Arthroscopic Bankart Repair for anterior shoulder instability is associated with a decline in patient-reported outcomes over time [7].
• At a mean follow-up of 128.1 months, 25.0% of patients undergoing arthroscopic Bankart repair for on-track lesions experienced recurrent instability [8].
• At a mean follow-up of 128.1 months, 19.6% of patients undergoing arthroscopic Bankart repair for on-track lesions underwent subsequent surgery [8].
• The remplissage technique involves preparing the Hill-Sachs lesion by removing the pseudomembrane using electrocautery and a 4.5-mm shaver [67].
• In the remplissage technique, anchors are placed in the middle of the Hill-Sachs lesion, typically 1 cm from the insertion of the rotator cuff [67].
• The knotless suture staple remplissage technique provides a safe and efficient way to augment anterior stabilization [10].
• Ultrasound-assisted arthroscopic remplissage offers a safer and more effective alternative for treating recurrent shoulder instability with engaging Hill–Sachs lesions [11].
• The arthroscopic all-inside remplissage technique with a knotless tape bridge allows a complete glenohumeral view through a single superolateral portal [18].
• The arthroscopic all-inside remplissage technique with a knotless tape bridge simplifies the procedure [18].
• Arthroscopic remplissage with knotless all-suture anchors and concomitant Bankart repair is a reproducible technique that restores stability with minimal morbidity [25].

Bony Augmentation (Latarjet)

• The open Latarjet procedure via a deltopectoral approach is a reliable option to address complex glenohumeral instability [21].
• The open Latarjet procedure is effective in patients over 50 years old without associated cuff damage, despite a higher complication rate than in the younger population [5].
• The arthroscopic Latarjet using a 3 anterior portal technique is safe and reproducible for the treatment of recurrent anterior shoulder dislocations [6].
• The arthroscopic Latarjet may preserve proprioception but did not improve shoulder stability compared to the open Latarjet [37].
• In a two-center study of 80 patients, capsulolabral repair was performed in 72 patients (90%) during arthroscopic Latarjet using double suture-button fixation [13].
• In a two-center study of 80 patients, capsulolabral repair was not possible in 8 cases (10%) during arthroscopic Latarjet due to insufficient tissue quality [13].
• The modified arthroscopic Latarjet for glenoid rim fracture fixation uses a subscapularis split approach that permits orthogonal pin and screw positioning [32].
• The modified arthroscopic Latarjet for glenoid rim fracture fixation offers greater purchase on the glenoid vault via the subscapularis split approach [32].
• The metal-free arthroscopic Latarjet technique involves detaching the coracoacromial ligament from the lateral aspect of the coracoid process [33].
• The metal-free arthroscopic Latarjet technique involves resecting the pectoralis minor from the coracoid using a radiofrequency probe [33].
• The open Latarjet with metal-free cerclage fixation involves splitting the subscapularis slightly below the mid-level while maintaining the arm in adduction and external rotation [34].
• The open Latarjet with metal-free cerclage fixation involves detaching the capsuloligamentous complex from the 1- to 5-o'clock position [34].
• The open Latarjet with metal-free cerclage fixation involves lightly decorticating the anterior surface of the glenoid neck to enhance flush bony contact and healing potential [34].

Combined and Dynamic Stabilization Techniques

• Arthroscopic Latarjet combined with Hill-Sachs remplissage deserves consideration in a high-risk population including combined bone loss, recurrent anterior instability after failed previous stabilization procedures, and/or seizure [9].
• 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 [1].
• Combined arthroscopic and mini-open subpectoral dynamic anterior shoulder stabilization with biceps tendon produces a bumper that acts as a dynamic soft-tissue block on the anterior glenoid [15].
• The transosseous equivalent technique for bony Bankart repair is an arthroscopic variation that is simple and readily applied in any arthroscopic shoulder surgery practice [20].

Outcomes and Patient Counseling

• Studies have defined thresholds for the Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization [4].

Complications

Recurrence and Instability

• In patients with anterior shoulder instability, anterior anatomic glenoid reconstruction demonstrates lower redislocation rates than arthroscopic Bankart repair [23].
• The open Latarjet procedure has a reported recurrence rate as low as 1% to 3% [73].
• Subjective shoulder instability following anterior stabilization was not associated with an increased risk of dislocation [30].

Structural and Bony Complications

• Complications following the Latarjet procedure have been reported at a rate of 15% to 30% [73].
• Reported complications of the Latarjet procedure include nerve injury, graft mispositioning, osteolysis, nonunion, screw breakage, and prominence [73].
• Reoperation rates following the Latarjet procedure have been reported as high as 10% [73].
• The commonest reason for reoperation following the Latarjet procedure is related to screw malposition, screw prominence, and screw breakage [73].
• The presence of 2 screws within the glenoid adds to the complexity of a subsequent total shoulder arthroplasty [73].
• Patients with shoulder instability are at an increased risk of developing symptomatic osteoarthritis ultimately requiring a total shoulder arthroplasty [73].

Postoperative Symptoms and Outcomes

• The open Latarjet procedure is associated with a higher complication rate in patients over 50 years old than in the younger population [5].
• The duration of subjective shoulder instability was similar between the Latarjet and Bankart repair techniques [30].

Intraoperative Findings and Concomitant Procedures

• Among patients undergoing arthroscopy at the time of open Latarjet, 89.1% required extensive debridement that would not have otherwise been performed with a Latarjet alone [19].
• Excluding extensive debridements, an additional arthroscopic procedure was required in 9.2% of cases during concomitant arthroscopy at the time of open Latarjet [19].

Patient-Reported Outcomes and Long-Term Trajectory

• Patient-reported outcomes may decline over time following arthroscopic Bankart repair for anterior shoulder instability in patients who experience recurrent instability and underwent isolated arthroscopic Bankart repair compared to those who underwent arthroscopic Bankart repair with remplissage [36].
• At a mean follow-up of 128.1 months, 25.0% of patients experienced recurrent instability after arthroscopic Bankart repair for on-track lesions [8].
• At a mean follow-up of 128.1 months, 19.6% of patients underwent subsequent surgery after arthroscopic Bankart repair for on-track lesions [8].
• This study defines thresholds for the minimal clinically important difference and patient acceptable symptom state achievement at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization [4].

Return to Sport and Specific Populations

• In patients with anterior shoulder instability, anterior arthroscopic anatomic glenoid reconstruction demonstrates superior patient-reported return-to-sport rates than arthroscopic Bankart repair [23].
• In patients with anterior shoulder instability, anterior arthroscopic anatomic glenoid reconstruction demonstrates lower redislocation rates than arthroscopic Bankart repair [23].
• In patients with anterior shoulder instability, anterior arthroscopic anatomic glenoid reconstruction and arthroscopic Bankart repair have comparable recovery timelines despite the arthroscopic anatomic glenoid reconstruction group having higher glenoid bone loss [23].
• Shoulder stabilization using the Latarjet procedure is effective in patients over 50 years old without associated cuff damage [5].
• The complication rate for the open Latarjet procedure is higher in patients over 50 years old than in the younger population [5].

Concomitant Pathology and Technique-Specific Outcomes

• 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 subcritical glenoid bone loss and on-track Hill-Sachs lesion [1].
• Combined arthroscopic and mini-open subpectoral dynamic anterior shoulder stabilization with biceps tendon benefits from the onlay effect by producing a bumper that acts as a dynamic soft-tissue block on the anterior glenoid, which aids anterior shoulder stability [15].
• The all-inside arthroscopic distal clavicle bone block combined with Hill-Sachs remplissage procedure should be more reproducible to shoulder-trained surgeons without requiring a long learning curve [35].
• The all-inside arthroscopic distal clavicle bone block combined with Hill-Sachs remplissage procedure needs proof of long-term clinical evaluation [35].

Key Evidence

• [L5] The method aims to improve stability and outcomes in patients with complex shoulder instability issues. [1] (10.1016/j.eats.2024.103256)
• [L5] The technique shows excellent clinical outcomes for glenoid reconstruction in recurrent anterior shoulder dislocation with significant bone loss. [2] (10.1016/j.eats.2025.103952)
• [L4] Concomitant arthroscopic rotator cuff repair and anterior shoulder stabilization is associated with low rates of recurrent instability but a meaningful risk of structural rotator cuff failure. [3] (10.1016/j.xrrt.2026.100868)
• [L4] This study defines thresholds for MCID and PASS achievement at a minimum 2-year follow-up for patients undergoing arthroscopic anterior shoulder stabilization. [4] (10.1177/23259671261442972)
• [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. [5] (10.1016/j.jseint.2025.101518)
• [L5] This simplified arthroscopic Latarjet technique is safe and reproducible in the treatment of recurrent anterior shoulder dislocations. [6] (10.1002/atn2.70147)
• [L3] Patients should be counseled pre-operatively on the expected outcomes over time following ABR of anterior shoulder instability. [7] (10.1177/2325967126s00552)
• [L4] At a mean follow-up of 128.1 months, 25.0% of patients experienced recurrent instability and 19.6% underwent subsequent surgery. [8] (10.1177/2325967126s00277)
• [L3] The combined procedure deserves consideration in a high-risk population including combined bone loss, recurrent anterior instability after failed previous stabilization procedures and/or seizure. [9] (10.1016/j.jseint.2024.08.148)
• [L5] This technique provides a safe and efficient way to augment anterior stabilization. [10] (10.1002/atn2.70058)
• [L5] This technique offers a safer and more effective alternative in treating recurrent shoulder instability with engaging Hill–Sachs lesions. [11] (10.1002/atn2.70181)
• [L4] The aim of this study was to evaluate the long-term clinical outcomes of arthroscopic Bankart repair using a standardized, modern technique with a minimum of three suture anchors in patients with traumatic anterior instability and to assess possible risk factors for recurrent instability. [12] (10.1016/j.jseint.2025.101490)
• [L4] [13] (10.1016/j.xrrt.2026.100792)
• [L5] [14] (10.1016/j.eats.2024.103285)
• [L5] It benefits from the onlay effect by producing a bumper that acts as a dynamic soft-tissue block on the anterior glenoid, which aids anterior shoulder stability. [15] (10.1016/j.eats.2025.103863)
• [L1] [16] (10.1136/bjsports-2021-104028)
• [L5] The technique allows a complete glenohumeral view through a single superolateral portal and simplifies the procedure. [18] (10.1016/j.eats.2023.04.021)
• [L4] [19] (10.1177/23259671261415839)
• [L5] This arthroscopic variation of a well-known technique is simple and readily applied in any arthroscopic shoulder surgery practice. [20] (10.1016/j.eats.2023.02.024)
• [L5] Despite various modifications to the technique over the years, the open Latarjet via a deltopectoral approach has been recognized as a reliable option to address complex glenohumeral instability. [21] (10.1016/j.eats.2025.103757)
• [L5] [22] (10.1016/j.eats.2023.03.009)
• [L3] In patients with anterior shoulder instability, anterior AAGR demonstrates superior patient-reported RTS rates and lower redislocation rates than ABR, with comparable recovery timelines despite the AAGR group having higher GBL. [23] (10.1177/23259671261440934)
• [L5] This reproducible technique restores stability with minimal morbidity. [25] (10.1002/atn2.70152)
• [L3] Its duration was similar between techniques, and its presence was not associated with an increased risk of dislocation. [30] (10.1177/23259671261470584)
• [L5] [31] (10.1016/j.eats.2022.06.022)
• [L5] The subscapularis split approach permits an orthogonal pin and screw positioning while offering greater purchase on the glenoid vault. [32] (10.1016/j.eats.2024.103293)
• [L5] [33] (10.1016/j.eats.2025.103727)
• [Paper] [34] (10.1016/j.eats.2022.11.030)
• [L5] This all-inside procedure should be more reproducible to shoulder-trained surgeons, without requiring a long learning curve, but need the proof of long-term clinical evaluation. [35] (10.1016/j.eats.2023.11.010)
• [L4] PROs may decline over time following ABR for anterior shoulder instability for patients who experience recurrent anterior shoulder instability and undergo isolated ABR compared to ABR with remplissage. [36] (10.1016/j.xrrt.2026.100719)
• [L3] The arthroscopic latarjet may preserve proprioception but did not improve shoulder stability compared to the open Latarjet. [37] (10.1016/j.jseint.2024.08.158)
• [Paper] [67] (10.1016/j.eats.2024.103292)
• [L5] [71] (10.1016/j.eats.2023.102904)
• [L5] [73] (10.1002/atn2.70182)

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