Factors Influencing Surgeon's Choice of Procedure for Anterior Shoulder Instability: A Multicenter Prospective Cohort Study


      To investigate preoperative factors associated with selection of surgical treatment for anterior shoulder instability.


      Patient demographics, initial physical examinations, and patient-oriented outcome questionnaires were collected prospectively from 26 shoulder surgeons at 10 sites. Symptom duration, number of dislocations, sport, history of prior stabilization procedure, Hill-Sachs/glenoid bone loss, pain level, and failure of conservative treatment were recorded. Statistical analysis was performed with Fisher's exact test and logistic regression analysis.


      A total of 564 patients who underwent surgical treatment for anterior shoulder instability from November 2012 to June 2017 were enrolled. Of these, 426 shoulders underwent arthroscopic stabilization alone, 38 underwent arthroscopic stabilization with remplissage, 28 underwent open Bankart repair, and 72 underwent a Latarjet procedure. Predictors for undergoing Latarjet (P < .003) were symptom duration (75% had symptoms for >1 year), number of dislocations (47% had >5 dislocations), revision surgery (69%), Hill-Sachs lesion size (45% had a lesion between 11% and 20% of the humeral head), and glenoid bone loss (75% of Latarjet patients had 11% to 30% loss). Predictors for undergoing open Bankart repair (P < .001) were number of dislocations (32% had >5 dislocations), revision surgeries (54%), and glenoid bone loss (11% of open Bankart patients had 11% to 20% loss). History of prior shoulder surgery was the only significant predictor of open versus arthroscopic Bankart procedure. Prediction models showed athletes involved in high-risk sports were 2.61 times more likely to have a Latarjet (P < .01).


      Indications for the Latarjet were: humeral and glenoid bone loss, duration of symptoms, number of dislocations, and revision stabilizations. Athletes involved in high-risk sports were more likely to undergo the Latarjet procedure, even if other predictive factors were not present. The open Bankart procedure was the least common procedure performed, with a history of prior shoulder surgery being the only predictor for use when treating recurrent instability.

      Level of Evidence

      Level II, prospective prognostic cohort investigation.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bessiere C.
        • Trojani C.
        • Carles M.
        • Mehta S.S.
        • Boileau P.
        The open Latarjet procedure is more reliable in terms of shoulder stability than arthroscopic Bankart repair.
        Clin Orthop Relat Res. 2014; 472: 2345-2351
        • Bessiere C.
        • Trojani C.
        • Pelegri C.
        • Carles M.
        • Boileau P.
        Coracoid bone block versus arthroscopic Bankart repair: A comparative paired study with 5-year follow-up.
        Orthop Traumatol Surg Res. 2013; 99: 123-130
        • Blonna D.
        • Bellato E.
        • Caranzano F.
        • Assom M.
        • Rossi R.
        • Castoldi F.
        Arthroscopic Bankart repair versus open Bristow-Latarjet for shoulder instability: A matched-pair multicenter study focused on return to sport.
        Am J Sports Med. 2016; 44: 3198-3205
        • Burkhart S.S.
        • De Beer J.F.
        • Barth J.R.
        • Cresswell T.
        • Roberts C.
        • Richards D.P.
        Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss.
        Arthroscopy. 2007; 23: 1033-1041
        • Hovelius L.
        • Vikerfors O.
        • Olofsson A.
        • Svensson O.
        • Rahme H.
        Bristow-Latarjet and Bankart: A comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up.
        J Shoulder Elbow Surg. 2011; 20: 1095-1101
        • Neyton L.
        • Young A.
        • Dawidziak B.
        • et al.
        Surgical treatment of anterior instability in rugby union players: Clinical and radiographic results of the Latarjet-Patte procedure with minimum 5-year follow-up.
        J Shoulder Elbow Surg. 2012; 21: 1721-1727
        • Raynor M.B.
        • Horan M.P.
        • Greenspoon J.A.
        • Katthagen J.C.
        • Millett P.J.
        Outcomes after arthroscopic pancapsular capsulorrhaphy with suture anchors for the treatment of multidirectional glenohumeral instability in athletes.
        Am J Sports Med. 2016; 44: 3188-3197
        • Zimmermann S.M.
        • Scheyerer M.J.
        • Farshad M.
        • Catanzaro S.
        • Rahm S.
        • Gerber C.
        Long-term restoration of anterior shoulder stability: A retrospective analysis of arthroscopic Bankart repair versus open Latarjet procedure.
        J Bone Joint Surg Am. 2016; 98: 1954-1961
        • Boileau P.
        • Villalba M.
        • Hery J.Y.
        • Balg F.
        • Ahrens P.
        • Neyton L.
        Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.
        J Bone Joint Surg Am. 2006; 88: 1755-1763
        • Dumont G.D.
        • Russell R.D.
        • Browne M.G.
        • Robertson W.J.
        Area-based determination of bone loss using the glenoid arc angle.
        Arthroscopy. 2012; 28: 1030-1035
        • Milano G.
        • Grasso A.
        • Russo A.
        • et al.
        Analysis of risk factors for glenoid bone defect in anterior shoulder instability.
        Am J Sports Med. 2011; 39: 1870-1876
        • Thomazeau H.
        • Courage O.
        • Barth J.
        • et al.
        Can we improve the indication for Bankart arthroscopic repair? A preliminary clinical study using the ISIS score.
        Orthop Traumatol Surg Res. 2010; 96: S77-S83
        • Mook W.R.
        • Petri M.
        • Greenspoon J.A.
        • Horan M.P.
        • Dornan G.J.
        • Millett P.J.
        Clinical and anatomic predictors of outcomes after the Latarjet procedure for the treatment of anterior glenohumeral instability with combined glenoid and humeral bone defects.
        Am J Sports Med. 2016; 44: 1407-1416
        • Owens B.D.
        • Harrast J.J.
        • Hurwitz S.R.
        • Thompson T.L.
        • Wolf J.M.
        Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination.
        Am J Sports Med. 2011; 39: 1865-1869
        • Degen R.M.
        • Camp C.L.
        • Werner B.C.
        • Dines D.M.
        • Dines J.S.
        Trends in bone-block augmentation among recently trained orthopaedic surgeons treating anterior shoulder instability.
        J Bone Joint Surg Am. 2016; 98: e56
        • Bonazza N.A.
        • Liu G.
        • Leslie D.L.
        • Dhawan A.
        Trends in surgical management of shoulder instability.
        Orthop J Sports Med. 2017; 5 (2325967117712476)
        • Moroder P.
        • Odorizzi M.
        • Pizzinini S.
        • Demetz E.
        • Resch H.
        • Moroder P.
        Open Bankart repair for the treatment of anterior shoulder instability without substantial osseous glenoid defects: Results after a minimum follow-up of twenty years.
        J Bone Joint Surg Am. 2015; 97: 1398-1405
        • Neviaser R.J.
        • Benke M.T.
        • Neviaser A.S.
        Mid-term to long-term outcome of the open Bankart repair for recurrent traumatic anterior dislocation of the shoulder.
        J Shoulder Elbow Surg. 2017; 26: 1943-1947
        • Boileau P.
        • O'Shea K.
        • Vargas P.
        • Pinedo M.
        • Old J.
        • Zumstein M.
        Anatomical and functional results after arthroscopic Hill-Sachs remplissage.
        J Bone Joint Surg Am. 2012; 94: 618-626
        • Buza 3rd, J.A.
        • Iyengar J.J.
        • Anakwenze O.A.
        • Ahmad C.S.
        • Levine W.N.
        Arthroscopic Hill-Sachs remplissage: A systematic review.
        J Bone Joint Surg Am. 2014; 96: 549-555
        • Ko S.H.
        • Cha J.R.
        • Lee C.C.
        • Hwang I.Y.
        • Choe C.G.
        • Kim M.S.
        The Influence of arthroscopic remplissage for engaging Hill-Sachs lesions combined with Bankart repair on redislocation and shoulder function compared with Bankart repair alone.
        Clin Orthop Surg. 2016; 8: 428-436
        • Miyamoto R.
        • Yamamoto A.
        • Shitara H.
        • et al.
        Clinical outcome of arthroscopic remplissage as augmentation during arthroscopic Bankart repair for recurrent anterior shoulder instability.
        Open Orthop J. 2017; 11: 1268-1276
        • Rashid M.S.
        • Crichton J.
        • Butt U.
        • Akimau P.I.
        • Charalambous C.P.
        Arthroscopic "Remplissage" for shoulder instability: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 578-584
        • Garcia G.H.
        • Taylor S.A.
        • Fabricant P.D.
        • Dines J.S.
        Shoulder instability management: A survey of the American Shoulder and Elbow Surgeons.
        Am J Orthop (Belle Mead NJ). 2016; 45: E91-E97
        • Levine W.N.
        • Flatow E.L.
        The pathophysiology of shoulder instability.
        Am J Sports Med. 2000; 28: 910-917
        • Meehan R.E.
        • Petersen S.A.
        Results and factors affecting outcome of revision surgery for shoulder instability.
        J Shoulder Elbow Surg. 2005; 14: 31-37
        • Calvo E.
        • Granizo J.J.
        • Fernandez-Yruegas D.
        Criteria for arthroscopic treatment of anterior instability of the shoulder: a prospective study.
        J Bone Joint Surg Br. 2005; 87: 677-683
        • Balg F.
        • Boileau P.
        The Instability Severity Index Score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation.
        J Bone Joint Surg Br. 2007; 89: 1470-1477
        • Phadnis J.
        • Arnold C.
        • Elmorsy A.
        • Flannery M.
        Utility of the Instability Severity Index Score in predicting failure after arthroscopic anterior stabilization of the shoulder.
        Am J Sports Med. 2015; 43: 1983-1988
        • Mohtadi N.G.
        • Chan D.S.
        • Hollinshead R.M.
        • et al.
        A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: Two-year follow-up with disease-specific quality-of-life outcomes.
        J Bone Joint Surg Am. 2014; 96: 353-360
        • Rowe C.R.
        • Patel D.
        • Southmayd W.W.
        The Bankart procedure: A long-term end-result study.
        J Bone Joint Surg Am. 1978; 60: 1-16
        • Uchiyama Y.
        • Handa A.
        • Shimpuku E.
        • et al.
        Open Bankart repair plus inferior capsular shift versus arthroscopic Bankart repair without augmentations for traumatic anterior shoulder instability: A prospective study.
        J Orthop Surg (Hong Kong). 2017; 25 (2309499017727947)
        • Virk M.S.
        • Manzo R.L.
        • Cote M.
        • et al.
        Comparison of time to recurrence of instability after open and arthroscopic Bankart repair techniques.
        Orthop J Sports Med. 2016; 4 (2325967116654114)
        • Ialenti M.N.
        • Mulvihill J.D.
        • Feinstein M.
        • Zhang A.L.
        • Feeley B.T.
        Return to play following shoulder stabilization: A systematic review and meta-analysis.
        Orthop J Sports Med. 2017; 5 (2325967117726055)
        • Friedman L.G.
        • Griesser M.J.
        • Miniaci A.A.
        • Jones M.H.
        Recurrent instability after revision anterior shoulder stabilization surgery.
        Arthroscopy. 2014; 30: 372-381
        • Blackman A.J.
        • Krych A.J.
        • Kuzma S.A.
        • Chow R.M.
        • Camp C.
        • Dahm D.L.
        Results of revision anterior shoulder stabilization surgery in adolescent athletes.
        Arthroscopy. 2014; 30: 1400-1405
        • Ranalletta M.
        • Rossi L.A.
        • Bertona A.
        • Tanoira I.
        • Maignon G.D.
        • Bongiovanni S.L.
        Modified Latarjet procedure without capsulolabral repair for the treatment of failed previous operative stabilizations in athletes.
        Arthroscopy. 2018; 34: 1421-1427

      Linked Article