Anterior Shoulder Instability Part III—Revision Surgery, Rehabilitation and Return to Play, and Clinical Follow-Up—An International Consensus Statement


      The purpose of this study was to establish consensus statements via a modified Delphi process on revision surgery, rehabilitation and return to play, and clinical follow-up for anterior shoulder instability.


      A consensus process on the treatment using a modified Delphi technique was conducted, with 65 shoulder surgeons from 14 countries across 5 continents participating. Experts were assigned to one of 9 working groups defined by specific subtopics of interest within anterior shoulder instability.


      The primary relative indications for revision surgery include symptomatic apprehension or recurrent instability, additional intra-articular pathologies, and symptomatic hardware failure. In revision cases, the differentiating factors that dictate treatment are the degree of glenohumeral bone loss and rotator cuff function/integrity. The minimum amount of time before allowing athletes to return to play is unknown, but other factors should be considered, including restoration of strength, range of motion and proprioception, and resolved pain and apprehension, as these are prognostic factors of reinjury. Additionally, psychological factors should be considered in the rehabilitation process. Patients should be clinically followed up for a minimum of 12 months or until a return to full, premorbid function/activities. Finally, the following factors should be included in anterior shoulder instability-specific, patient-reported outcome measures: function/limitations impact on activities of daily living, return to sport/activity, instability symptoms, confidence in shoulder, and satisfaction.


      Overall, 92% of statements reached unanimous or strong consensus. The statements that reached unanimous consensus were indications and factors affecting decisions for revision surgery, as well as how prior surgeries impact procedure choice. Furthermore, there was unanimous consensus on the role of psychological factors in the return to play, considerations for allowing return to play, as well as prognostic factors. Finally, there was a lack of unanimous consensus on recommended timing and methods for clinical follow-up.

      Level of Evidence

      Level V, expert opinion.

      Key Words

      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


        • Hurley E.T.
        • Manjunath A.K.
        • Bloom D.A.
        • et al.
        Arthroscopic Bankart repair versus conservative management for first-time traumatic anterior shoulder instability—A systematic review & meta-analysis.
        Arthroscopy. 2020; 36: 2526-2532
        • Tokish J.M.
        • Kuhn J.E.
        • Ayers G.D.
        • et al.
        Decision making in treatment after a first-time anterior glenohumeral dislocation: A Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.
        J Shoulder Elbow Surg. 2020; 29: 2429-2445
        • Tokish J.M.
        • Thigpen C.A.
        • Kissenberth M.J.
        • et al.
        The nonoperative Instability Severity Index Score (NISIS): A simple tool to guide operative versus nonoperative treatment of the unstable shoulder.
        Sports Health. 2020; 12: 598-602
        • Ciccotti M.C.
        • Syed U.
        • Hoffman R.
        • Abboud J.A.
        • Ciccotti M.G.
        • Freedman K.B.
        Return to play criteria following surgical stabilization for traumatic anterior shoulder instability: A systematic review.
        Arthroscopy. 2018; 34: 903-913
        • Hurley E.T.
        • Montgomery C.
        • Jamal M.S.
        • et al.
        Return to play after the Latarjet procedure for anterior shoulder instability: A systematic review.
        Am J Sports Med. 2019; 47: 3002-3008
        • Glazebrook H.
        • Miller B.
        • Wong I.
        Anterior shoulder instability: A systematic review of the quality and quantity of the current literature for surgical treatment.
        Orthop J Sports Med. 2018; 6 (2325967118805983)
        • Bishop J.Y.
        • Hidden K.A.
        • Jones G.L.
        • Hettrich C.M.
        • Wolf B.R.
        • Moon Shoulder Group
        Factors influencing surgeon's choice of procedure for anterior shoulder instability: A multicenter prospective cohort study.
        Arthroscopy. 2019; 35: 2014-2025
        • Bois A.J.
        • Mayer M.J.
        • Fening S.D.
        • Jones M.H.
        • Miniaci A.
        Management of bone loss in recurrent traumatic anterior shoulder instability: A survey of North American surgeons.
        JSES Int. 2020; 4: 574-583
        • Donohue M.A.
        • Mauntel T.C.
        • Dickens J.F.
        Recurrent shoulder instability after primary Bankart repair.
        Sports Med Arthrosc Rev. 2017; 25: 123-130
        • Dekker T.J.
        • Peebles L.A.
        • Bernhardson A.S.
        • et al.
        Risk factors for recurrence after arthroscopic instability repair—The importance of glenoid bone loss >15%, patient age, and duration of symptoms: A matched cohort analysis.
        Am J Sports Med. 2020; 48: 3036-3041
        • Mahure S.A.
        • Mollon B.
        • Capogna B.M.
        • Zuckerman J.D.
        • Kwon Y.W.
        • Rokito A.S.
        Risk factors for recurrent instability or revision surgery following arthroscopic Bankart repair.
        Bone Joint J. 2018; 100-B: 324-330
        • Dekker T.J.
        • Peebles L.A.
        • Bernhardson A.S.
        • et al.
        Limited predictive value of the Instability Severity Index Score: Evaluation of 217 consecutive cases of recurrent anterior shoulder instability.
        Arthroscopy. 2021; 37: 1381-1391
        • Ali Z.S.
        • Hurley E.T.
        • Jamal M.S.
        • et al.
        Low rate of recurrent instability following the open Latarjet procedure as a revision procedure for failed prior stabilization surgery.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 2110-2117
        • Waterman B.R.
        • Leroux T.
        • Frank R.M.
        • Romeo A.A.
        The evaluation and management of the failed primary arthroscopic Bankart repair.
        J Am Acad Orthopaed Surg. 2020; 28: 607-616
      1. Davey MS, Hurley ET, O'Doherty R, et al. Open Latarjet procedure in athletes following failed prior instability surgery results in lower rates of return to play. Arthroscopy In press.

        • Hurley E.
        • Bloom D.
        • Manjunath A.
        • Jazrawi L.
        • Strauss E.
        Outcomes of revision surgery for a failed prior Latarjet procedure: A systematic review.
        Bull Hosp Jt Dis (2013). 2020; 78: 210-216
        • Lau B.C.
        • Hutyra C.A.
        • Gonzalez J.M.
        • et al.
        Surgical treatment for recurrent shoulder instability: Factors influencing surgeon decision making.
        J Shoulder Elbow Surg. 2021; 30: e85-e102
        • Hurley E.T.
        • Matache B.A.
        • Colasanti C.A.
        • et al.
        Return to play criteria among shoulder surgeons following shoulder stabilization.
        J Shoulder Elbow Surg. 2021; 30: e317-e321
        • Hurley E.T.
        • Fried J.W.
        • Alaia M.J.
        • Strauss E.J.
        • Jazrawi L.M.
        • Matache B.A.
        Immobilisation in external rotation after first-time traumatic anterior shoulder instability reduces recurrent instability: A meta-analysis.
        J ISAKOS. 2021; 6: 22-27
        • Shinagawa K.
        • Sugawara Y.
        • Hatta T.
        • Yamamoto N.
        • Tsuji I.
        • Itoi E.
        Immobilization in external rotation reduces the risk of recurrence after primary anterior shoulder dislocation: A meta-analysis.
        Orthop J Sports Med. 2020; 8 (2325967120925694)
        • Kee Y.M.
        • Kim J.Y.
        • Kim H.J.
        • Sinha S.
        • Rhee Y.G.
        Fate of coracoid grafts after the Latarjet procedure: Will be analogous to the original glenoid by remodelling.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 926-932
        • O'Neill D.C.
        • Christensen G.
        • Kawakami J.
        • et al.
        Revision anterior glenohumeral instability: Is arthroscopic treatment an option?.
        JSES Int. 2020; 4: 287-291
        • Yon C.J.
        • Cho C.H.
        • Kim D.H.
        Revision arthroscopic Bankart repair: A systematic review of clinical outcomes.
        J Clin Med. 2020; 9: 3418
        • Leroux T.S.
        • Saltzman B.M.
        • Meyer M.
        • et al.
        The influence of evidence-based surgical indications and techniques on failure rates after arthroscopic shoulder stabilization in the contact or collision athlete with anterior shoulder instability.
        Am J Sports Med. 2017; 45: 1218-1225
        • Brown L.
        • Rothermel S.
        • Joshi R.
        • Dhawan A.
        Recurrent instability after arthroscopic Bankart reconstruction: A systematic review of surgical technical factors.
        Arthroscopy. 2017; 33: 2081-2092
        • Neri B.R.
        • Tuckman D.V.
        • Bravman J.T.
        • Yim D.
        • Sahajpal D.T.
        • Rokito A.S.
        Arthroscopic revision of Bankart repair.
        J Shoulder Elbow Surg. 2007; 16: 419-424
        • Ryu R.K.
        • Ryu J.H.
        Arthroscopic revision Bankart repair: A preliminary evaluation.
        Orthopedics. 2011; 34: 17
        • Lavoué V.
        • Gendre P.
        • Saliken D.
        • Brassac A.
        • Boileau P.
        The role of arthroscopic soft tissue reconstruction for failed Bristow-Latarjet procedure.
        Arthroscopy. 2019; 35: 2581-2588
        • Giannakos A.
        • Vezeridis P.S.
        • Schwartz D.G.
        • Jany R.
        • Lafosse L.
        All-arthroscopic revision Eden-Hybinette procedure for failed instability surgery: Technique and preliminary results.
        Arthroscopy. 2017; 33: 39-48
        • Boileau P.
        • Duysens C.
        • Saliken D.
        • Lemmex D.B.
        • Bonnevialle N.
        All-arthroscopic, guided Eden-Hybbinette procedure using suture-button fixation for revision of failed Latarjet.
        J Shoulder Elbow Surg. 2019; 28: e377-e388
        • Provencher M.T.
        • Peebles L.A.
        • Aman Z.S.
        • et al.
        Management of the failed Latarjet procedure: Outcomes of revision surgery with fresh distal tibial allograft.
        Am J Sports Med. 2019; 47: 2795-2802
        • Flurin P.H.
        • Antoni M.
        • Métais P.
        • Aswad R.
        Revision of failed Latarjet with the Eden-Hybinette surgical technique.
        Orthopaed Traumatol Surg Res. 2020; 106: 223-227
        • Tjong V.K.
        • Devitt B.M.
        • Murnaghan M.L.
        • Ogilvie-Harris D.J.
        • Theodoropoulos J.S.
        A qualitative investigation of return to sport after arthroscopic Bankart repair: Beyond stability.
        Am J Sports Med. 2015; 43: 2005-2011
        • Weekes D.G.
        • Campbell R.E.
        • Shi W.J.
        • et al.
        Prevalence of clinical depression among patients after shoulder stabilization: A prospective study.
        J Bone Joint Surg Am. 2019; 101: 1628-1635
        • Gerometta A.
        • Klouche S.
        • Herman S.
        • Lefevre N.
        • Bohu Y.
        The Shoulder Instability-Return to Sport after Injury (SIRSI): A valid and reproducible scale to quantify psychological readiness to return to sport after traumatic shoulder instability.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 203-211
        • Junior M.D.
        • Popchak A.
        • Wilson K.
        • Kane G.
        • Lin A.
        Criteria based return to sport testing is associated with lower recurrence rates following arthroscopic Bankart repair.
        J Shoulder Elbow Surg. 2021; 30: S14-S20
        • Hohmann E.
        • Cote M.P.
        • Brand J.C.
        Research pearls: Expert consensus-based evidence using the Delphi method.
        Arthroscopy. 2018; 34: 3278-3282
        • Hohmann E.
        • Brand J.C.
        • Rossi M.J.
        • Lubowitz J.H.
        Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus.
        Arthroscopy. 2018; 34: 349-351