Shoulder Instability Repair: Why It Fails

  • Emilio CalvoEmail author
  • Gia Rodriguez-Vaquero
  • David Haeni


Management of the unstable shoulder after a failed stabilization procedure can be difficult and challenging. We need a deep and detailed understanding of the shoulder anatomy and its restraints to determine the origin of the patient’s primary pathology. Key factors for shoulder stabilization surgery are an adequate patient selection, precise surgical technique selection and fulfillment, identification and correction of anatomy abnormalities, and integration of patient and surgeon expectation. When any of these requirements fail, our surgery can fail too. It is important to identify why the initial procedure failed and perform a meticulous evaluation of the patient: background of trauma and detailed patient’s history, a complete physical exam, and imaging.

In this chapter, we will analyze common risk factors and causes for failure of primary shoulder instability repair, components for appropriate evaluation, and the different surgical options available for revision stabilization.


Shoulder Anterior instability Arthroscopy Stabilization Failure 


  1. 1.
    Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency Departments in the United States. J Bone Joint Surg Am. 2010;92:542–9. Scholar
  2. 2.
    Dumont GD, Russell RD, Robertson WJ. Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. Curr Rev Musculoskelet Med. 2011;4:200–7. Scholar
  3. 3.
    Bankart ASB. Recurrent or habitual dislocation of the shoulder-joint. Br Med J. 1923;2:1132–3.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Rosenberg BN, Richmond JC, Levine WN. Long-term followup of Bankart reconstruction. Incidence of late degenerative glenohumeral arthrosis. Am J Sports Med. 1995;23:538–44. Scholar
  5. 5.
    Hobby J, Griffin D, Dunbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg Br. 2007;89:1188–96. Scholar
  6. 6.
    Freedman KB, Smith AP, Romeo AA, et al. Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for recurrent anterior instability of the shoulder: a meta-analysis. Am J Sports Med. 2004;32:1520–7. Scholar
  7. 7.
    Franceschi F, Longo UG, Ruzzini L, et al. Arthroscopic salvage of failed arthroscopic Bankart repair: a prospective study with a minimum follow-up of 4 years. Am J Sports Med. 2008;36:1330–6. Scholar
  8. 8.
    Millar NL, Murrell GAC. The effectiveness of arthroscopic stabilisation for failed open shoulder instability surgery. J Bone Joint Surg Br. 2008;90:745–50. Scholar
  9. 9.
    Walch G. Chronic anterior instability of the shoulder in adults. Summary. Rev Chir Orthop Reparatrice Appar Mot. 2000;86(Suppl 1):147–9.PubMedGoogle Scholar
  10. 10.
    Nourissat G, Neyton L, Metais P, et al. Functional outcomes after open versus arthroscopic Latarjet procedure: a prospective comparative study. Orthop Traumatol Surg Res. 2016;102:S277–9. Scholar
  11. 11.
    Millett PJ, Clavert P, Warner JJP. Open operative treatment for anterior shoulder instability: when and why? J Bone Joint Surg Am. 2005;87:419–32. Scholar
  12. 12.
    Meehan RE, Petersen SA. Results and factors affecting outcome of revision surgery for shoulder instability. J Shoulder Elbow Surg. 2005;14:31–7. Scholar
  13. 13.
    Sisto DJ. Revision of failed arthroscopic bankart repairs. Am J Sports Med. 2007;35:537–41. Scholar
  14. 14.
    Huber H, Gerber C. Voluntary subluxation of the shoulder in children. A long-term follow-up study of 36 shoulders. J Bone Joint Surg Br. 1994;76:118–22.CrossRefPubMedGoogle Scholar
  15. 15.
    Zabinski SJ, Callaway GH, Cohen S, Warren RF. Revision shoulder stabilization: 2- to 10-year results. J Shoulder Elbow Surg. 1999;8:58–65.CrossRefPubMedGoogle Scholar
  16. 16.
    Johansson K. Multidirectional instability of the glenohumeral joint: an unstable classification resulting in uncertain evidence-based practice. Br J Sports Med. 2016;50:1105–6. Scholar
  17. 17.
    Kim S-H, Park J-C, Park J-S, Oh I. Painful jerk test: a predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med. 2004;32:1849–55.CrossRefPubMedGoogle Scholar
  18. 18.
    Sachs RA, Williams B, Stone ML, et al. Open Bankart repair: correlation of results with postoperative subscapularis function. Am J Sports Med. 2005;33:1458–62. Scholar
  19. 19.
    Probyn LJ, White LM, Salonen DC, et al. Recurrent symptoms after shoulder instability repair: direct MR arthrographic assessment—correlation with second-look surgical evaluation. Radiology. 2007;245:814–23. Scholar
  20. 20.
    Schaeffeler C, Waldt S, Bauer JS, et al. MR arthrography including abduction and external rotation images in the assessment of atraumatic multidirectional instability of the shoulder. Eur Radiol. 2014;24:1376–85. Scholar
  21. 21.
    Calvo E, Granizo JJ, Fernández-Yruegas D. Criteria for arthroscopic treatment of anterior instability of the shoulder: a prospective study. J Bone Joint Surg Br. 2005;87:677–83. Scholar
  22. 22.
    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;89:1470–7. Scholar
  23. 23.
    Ahmed I, Ashton F, Robinson CM. Arthroscopic Bankart repair and capsular shift for recurrent anterior shoulder instability: functional outcomes and identification of risk factors for recurrence. J Bone Joint Surg Am. 2012;94:1308–15. Scholar
  24. 24.
    Voos JE, Livermore RW, Feeley BT, et al. Prospective evaluation of arthroscopic bankart repairs for anterior instability. Am J Sports Med. 2010;38:302–7. Scholar
  25. 25.
    Flinkkilä T, Hyvönen P, Ohtonen P, Leppilahti J. Arthroscopic Bankart repair: results and risk factors of recurrence of instability. Knee Surg Sports Traumatol Arthrosc. 2010;18:1752–8. Scholar
  26. 26.
    Wasserstein D, Dwyer T, Veillette C, et al. Predictors of dislocation and revision after shoulder stabilization in Ontario, Canada, from 2003 to 2008. Am J Sports Med. 2013;41:2034–40. Scholar
  27. 27.
    Randelli P, Ragone V, Carminati S, Cabitza P. Risk factors for recurrence after Bankart repair a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20:2129–38. Scholar
  28. 28.
    Marquardt B, Garmann S, Schulte T, et al. Outcome after failed traumatic anterior shoulder instability repair with and without surgical revision. J Shoulder Elbow Surg. 2007;16:742–7. Scholar
  29. 29.
    Cho NS, Hwang JC, Rhee YG. Arthroscopic stabilization in anterior shoulder instability: collision athletes versus noncollision athletes. Arthroscopy. 2006;22:947–53. Scholar
  30. 30.
    Rhee YG, Ha JH, Cho NS. Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair. Am J Sports Med. 2006;34:979–85. Scholar
  31. 31.
    Uhorchak JM, Arciero RA, Huggard D, Taylor DC. Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports. Am J Sports Med. 2000;28:794–9. Scholar
  32. 32.
    Castagna A, Delle Rose G, Borroni M, et al. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. 2012;28:309–15. Scholar
  33. 33.
    Mazzocca AD, Brown FM, Carreira DS, et al. Arthroscopic anterior shoulder stabilization of collision and contact athletes. Am J Sports Med. 2005;33:52–60. Scholar
  34. 34.
    Grana WA, Buckley PD, Yates CK. Arthroscopic Bankart suture repair. Am J Sports Med. 1993;21:348–53. Scholar
  35. 35.
    Bühler M, Gerber C. Shoulder instability related to epileptic seizures. J Shoulder Elbow Surg. 2002;11:339–44. Scholar
  36. 36.
    Thangarajah T, Lambert S. The management of recurrent shoulder instability in patients with epilepsy: a 15-year experience. J Shoulder Elbow Surg. 2015;24:1723–7. Scholar
  37. 37.
    Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984;66:159–68.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Tauber M, Resch H, Forstner R, et al. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 2004;13:279–85. Scholar
  39. 39.
    Porcellini G, Campi F, Pegreffi F, et al. Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment. J Bone Joint Surg Am. 2009;91:2537–42. Scholar
  40. 40.
    Wolf EM, Siparsky PN. Glenoid avulsion of the glenohumeral ligaments as a cause of recurrent anterior shoulder instability. Arthroscopy. 2010;26:1263–7. Scholar
  41. 41.
    Flury M, Rickenbacher D, Audigé L. Arthroscopic treatment of anterior shoulder instability associated with a HAGL lesion-a case series. J Shoulder Elbow Surg. 2016;25:1989–96. Scholar
  42. 42.
    Savoie FH, Holt MS, Field LD, Ramsey JR. Arthroscopic management of posterior instability: evolution of technique and results. Arthroscopy. 2008;24:389–96. Scholar
  43. 43.
    Kim S-H, Ha K-I, Kim Y-M. Arthroscopic revision Bankart repair: a prospective outcome study. Arthroscopy. 2002;18:469–82. Scholar
  44. 44.
    Boileau P, Villalba M, Héry J-Y, et al. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88:1755–63. Scholar
  45. 45.
    An VVG, Sivakumar BS, Phan K, Trantalis J. A systematic review and meta-analysis of clinical and patient-reported outcomes following two procedures for recurrent traumatic anterior instability of the shoulder: Latarjet procedure vs. Bankart repair. J Shoulder Elbow Surg. 2016;25:853–63. Scholar
  46. 46.
    Thal R. Knotless suture anchor: arthroscopic bankart repair without tying knots. Clin Orthop. 2001;390:42–51.CrossRefGoogle Scholar
  47. 47.
    Cho NS, Lubis AMT, Ha JH, Rhee YG. Clinical results of arthroscopic bankart repair with knot-tying and knotless suture anchors. Arthroscopy. 2006;22:1276–82. Scholar
  48. 48.
    Bigliani LU, Kelkar R, Flatow EL, et al. Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin Orthop. 1996;330:13–30.CrossRefGoogle Scholar
  49. 49.
    Griffith JF, Antonio GE, Tong CWC, Ming CK. Anterior shoulder dislocation: quantification of glenoid bone loss with CT. AJR Am J Roentgenol. 2003;180:1423–30. Scholar
  50. 50.
    Saito H, Itoi E, Sugaya H, et al. Location of the glenoid defect in shoulders with recurrent anterior dislocation. Am J Sports Med. 2005;33:889–93. Scholar
  51. 51.
    Ji J-H, Kwak D-S, Yang P-S, et al. Comparisons of glenoid bony defects between normal cadaveric specimens and patients with recurrent shoulder dislocation: an anatomic study. J Shoulder Elbow Surg. 2012;21:822–7. Scholar
  52. 52.
    Shibata H, Gotoh M, Mitsui Y, et al. Risk factors for shoulder re-dislocation after arthroscopic Bankart repair. J Orthop Surg. 2014;9:53. Scholar
  53. 53.
    Yamamoto N, Itoi E, Abe H, et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elbow Surg. 2007;16:649–56. Scholar
  54. 54.
    Hartzler RU, Bui CNH, Jeong WK, et al. Remplissage of an off-track Hill-Sachs lesion is necessary to restore biomechanical glenohumeral joint stability in a bipolar bone loss model. Arthroscopy. 2016;32:2466–76. Scholar
  55. 55.
    Di Giacomo G, Itoi E, Burkhart SS. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy. 2014;30:90–8. Scholar
  56. 56.
    Tokish JM, Shaha JS, Cook JB, et al. Predictive value and clinical validation of the “on-track” vs. “off-track” concept in bipolar bone loss in anterior glenohumeral instability. Orthop J Sports Med. 2015;3:2325967115S00089. Scholar
  57. 57.
    Anderl W, Kriegleder B, Heuberer PR. All-arthroscopic implant-free iliac crest bone grafting: new technique and case report. Arthroscopy. 2012;28:131–7. Scholar
  58. 58.
    Walch G. Luxation récidivante antérieure de l’épaule. Rev Chir Orthop. 1991;77:177–91.Google Scholar
  59. 59.
    Young DC, Rockwood CA. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am. 1991;73:969–81.CrossRefPubMedGoogle Scholar
  60. 60.
    Cuéllar A, Cuéllar R, de Heredia PB. Arthroscopic revision surgery for failure of open Latarjet technique. Arthroscopy. 2017;33:910–7. Scholar
  61. 61.
    Castagna A, Garofalo R, Melito G, et al. The role of arthroscopy in the revision of failed Latarjet procedures. Musculoskelet Surg. 2010;94(Suppl 1):S47–55. Scholar
  62. 62.
    Boileau P, Richou J, Lisai A, et al. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy. 2009;25:1075–84. Scholar
  63. 63.
    Gasbarro G, Giugale JM, Walch G, Lin A. Predictive surgical reasons for failure after coracoid process transfers. Orthop J Sports Med. 2016;4:2325967116676795. Scholar
  64. 64.
    Gupta A, Delaney R, Petkin K, Lafosse L. Complications of the Latarjet procedure. Curr Rev Musculoskelet Med. 2015;8:59–66. Scholar
  65. 65.
    Di Giacomo G, de Gasperis N, Costantini A, et al. Does the presence of glenoid bone loss influence coracoid bone graft osteolysis after the Latarjet procedure? A computed tomography scan study in 2 groups of patients with and without glenoid bone loss. J Shoulder Elbow Surg. 2014;23:514–8. Scholar
  66. 66.
    Di Giacomo G, Costantini A, de Gasperis N, et al. Coracoid graft osteolysis after the Latarjet procedure for anteroinferior shoulder instability: a computed tomography scan study of twenty-six patients. J Shoulder Elbow Surg. 2011;20:989–95. Scholar
  67. 67.
    Haeni DL, Opsomer G, Sood A, et al. Three-dimensional volume measurement of coracoid graft osteolysis after arthroscopic Latarjet procedure. J Shoulder Elbow Surg. 2017;26:484–9. Scholar
  68. 68.
    Giannakos A, Vezeridis PS, Schwartz DG, et al. All-arthroscopic revision eden-hybinette procedure for failed instability surgery: technique and preliminary results. Arthroscopy. 2017;33:39–48. Scholar
  69. 69.
    Mizuno N, Denard PJ, Raiss P, et al. Long-term results of the Latarjet procedure for anterior instability of the shoulder. J Shoulder Elbow Surg. 2014;23:1691–9. Scholar
  70. 70.
    Lunn JV, Castellano-Rosa J, Walch G. Recurrent anterior dislocation after the Latarjet procedure: outcome after revision using a modified Eden-Hybinette operation. J Shoulder Elbow Surg. 2008;17:744–50. Scholar
  71. 71.
    Calvo E, Rojas D, Morcillo D, et al. Management of the failed Latarjet procedure. In: Boileau P, editor. Shoulder concepts: arthroscopy, arthroplasty & fractures. Montpellier: Lippincott Williams & Wilkins; 2012.Google Scholar
  72. 72.
    Locher J, Wilken F, Beitzel K, et al. Hill-Sachs off-track lesions as risk factor for recurrence of instability after arthroscopic bankart repair. Arthroscopy. 2016;32:1993–9. Scholar
  73. 73.
    Mohtadi NGH, Chan DS, Hollinshead RM, 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;96:353–60. Scholar
  74. 74.
    Fabbriciani C, Milano G, Demontis A, et al. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy. 2004;20:456–62. Scholar
  75. 75.
    Archetti Netto N, Tamaoki MJS, Lenza M, et al. Treatment of Bankart lesions in traumatic anterior instability of the shoulder: a randomized controlled trial comparing arthroscopy and open techniques. Arthroscopy. 2012;28:900–8. Scholar
  76. 76.
    Araghi A, Prasarn M, St Clair S, Zuckerman JD. Revision anterior shoulder repair for recurrent anterior glenohumeral instability. Bull Hosp Jt Dis. 2005;62:102–4.PubMedGoogle Scholar
  77. 77.
    Tamai K, Higashi A, Tanabe T, Hamada J. Recurrences after the open Bankart repair: a potential risk with use of suture anchors. J Shoulder Elbow Surg. 1999;8:37–41.CrossRefPubMedGoogle Scholar

Copyright information

© ESSKA 2018

Authors and Affiliations

  • Emilio Calvo
    • 1
    Email author
  • Gia Rodriguez-Vaquero
    • 2
  • David Haeni
    • 3
  1. 1.Shoulder and Elbow Reconstructive Surgery Unit, Department of Orthopedic Surgery and Traumatology, Fundacion Jimenez DiazUniversidad AutónomaMadridSpain
  2. 2.Upper Extremity Surgery Unit, Department of Orthopedic Surgery and TraumatologyHospital General de VillalbaMadridSpain
  3. 3.Shoulder and Elbow Surgery Unit, LEONARDOHirslanden Klinik BirshofBaselSwitzerland

Personalised recommendations