Management of Recurrent Anterior Shoulder Dislocation
Operative management should be strongly considered from the initial episode of recurrent anterior shoulder instability to prevent progressive bone loss, minimize recurrence risk, and maximize return to sport at preinjury level 1.
Initial Diagnostic Approach
Start with standard shoulder radiographs including AP views in internal and external rotation plus an axillary or scapula-Y view 2. These views are essential—glenohumeral dislocations can be misclassified on AP views alone. Add a Stryker notch view to evaluate Hill-Sachs lesions 2.
Obtain CT without contrast if radiographs show complex fracture patterns or to precisely quantify glenoid bone loss, as this changes management in up to 41% of proximal humeral fractures 2. CT is crucial for measuring glenoid bone loss percentage, which directly determines surgical approach 1.
Surgical Decision Algorithm
The decision tree hinges on glenoid bone loss percentage:
Minimal Bone Loss (<13.5%)
- Arthroscopic Bankart repair is appropriate 1
- Add remplissage if Hill-Sachs lesion is off-track, near-track, or has subequatorial extension 1, 3
- This combination provides effective stabilization in patients with minimal bone loss and non-engaging Hill-Sachs lesions 3
Moderate Bone Loss (13.5-20%)
- Arthroscopic subscapularis augmentation using long head of biceps transposition is more effective than Bankart repair alone 4
- This technique better preserves external rotation function compared to standard Bankart repair with subscapularis augmentation 4
- At 1-year follow-up, this approach shows significantly less loss of external rotation angles 4
Significant Bone Loss (>20%)
- Open Latarjet procedure remains the most established option 1, 5
- Arthroscopic anatomic glenoid reconstruction with distal tibial allograft is a promising alternative offering near-anatomic reconstruction with excellent short-term outcomes 1
Critical Pitfalls
The glenoid track concept is crucial—failure to assess whether Hill-Sachs lesions are on-track versus off-track leads to inappropriate soft-tissue-only repairs that will fail 1. The indications for isolated soft-tissue procedures are now narrower than previously thought.
Timing matters: Delayed treatment leads to complex pathoanatomy including progressive bone loss 3. Even patients with 14-year histories of recurrent dislocations can be successfully treated, but earlier intervention prevents this complexity 3.
Latarjet complications: While effective, open Latarjet has relatively high complication rates (20% postoperative pain, plus risks of neurapraxia, re-dislocation, wound dehiscence, and screw breakage) 5. Set realistic patient expectations.
Arthroscopic vs Open Repair
For standard recurrent dislocations without significant bone loss, no statistically significant difference exists between arthroscopic and open repair in terms of redislocation rates, return to activity, or functional outcomes 6. Range of motion is marginally better with arthroscopic treatment 6. This makes arthroscopic approaches preferable when technically feasible.
Post-Operative Rehabilitation Protocol
Follow a five-phase protocol 7:
- Acute protection (0-3 weeks): Sling immobilization, education
- Movement and early strengthening (3-6 weeks): Initiate through-range resisted exercise
- Progressive strengthening (6-12 weeks): Advance resistance training
- Return to sport (>12 weeks): Criteria-based progression to contact sport
- High-level function: Sport-specific training
External rotation combined with abduction immobilization promotes superior early phase mobility and functional recovery compared to internal or external rotation alone, though differences disappear by 3 months 8.