High Yield Overview

ANTERIOR SHOULDER INSTABILITY

Bankart | Hill-Sachs | Bone Loss | Bankart vs Latarjet

95%Anterior dislocations

25%Bone loss threshold

67%Recurrence under 20 years

LatarjetIf significant bone loss

BONE LOSS THRESHOLD

Less than 15%

PatternMinimal bone loss

TreatmentArthroscopic Bankart repair

15-25%

PatternModerate bone loss

TreatmentConsider Latarjet or augmented Bankart

Greater than 25%

PatternSignificant bone loss

TreatmentLatarjet or bone graft indicated

Critical Must-Knows

Bankart lesion (labral tear) occurs in 90%+ of traumatic anterior dislocations
Hill-Sachs lesion (humeral head defect) in 65-70% of first dislocations
Greater than 25% glenoid bone loss = Latarjet or bone graft required
Engaging Hill-Sachs increases recurrence - Latarjet or remplissage needed
Age is strongest predictor of recurrence - 67% in under 20 years old

Examiner's Pearls

"
ISIS score predicts recurrence - greater than 6 suggests bony procedure
"
On-track vs off-track concept for Hill-Sachs engagement
"
Latarjet provides bone augmentation, sling effect, and capsular repair
"
Arthroscopic Bankart has higher recurrence than open in young athletes

Clinical Imaging

Imaging Gallery

4-panel (A-D) multimodal bony Bankart imaging: (A) AP X-ray with crescentic bone fragment at inferior glenoid (arrow), (B) axial CT showing glenoid bone loss with white arrow, (C) sagittal CT demonstr — 4-panel (A-D) multimodal bony Bankart imaging: (A) AP X-ray with crescentic bone fragment at inferior glenoid (arrow), (B) axial CT showing glenoid boCredit: Wong PK et al. - Int J Emerg Med via Open-i (NIH) - PMC4519440 (CC-BY 4.0)

Single arthroscopic image of Bankart lesion in right shoulder - shows detached anteroinferior labrum with hemorrhage, smooth humeral head above, and frayed labral tissue. — Single arthroscopic image of Bankart lesion in right shoulder - shows detached anteroinferior labrum with hemorrhage, smooth humeral head above, and fCredit: Cooke SJ et al. - Sports Med Arthrosc Rehabil Ther Technol via Open-i (NIH) - PMC2654032 (CC-BY 4.0)

4-panel (a-d) glenoid bone loss case with Latarjet procedure: (a) Hill-Sachs lesion on AP X-ray, (b) axial CT with measurements showing significant glenoid bone loss (23.5mm width, 6.3mm deficit), (c) — 4-panel (a-d) glenoid bone loss case with Latarjet procedure: (a) Hill-Sachs lesion on AP X-ray, (b) axial CT with measurements showing significant glCredit: Open-i / NIH via Open-i (NIH) (CC-BY 4.0)

Anterior shoulder dislocation X-rays before and after reduction — Anterior shoulder dislocation: (a) X-ray at time of injury showing the humeral head displaced anteriorly from the glenoid fossa - note the loss of normal glenohumeral alignment. (b) Post-reduction X-ray demonstrating restored anatomical position with the humeral head centered in the glenoid.Credit: Takase F et al., Case Rep Orthop (PMC4082929) - CC-BY

Critical Exam Concepts

Bone Loss is KEY

Greater than 25% glenoid bone loss requires bony augmentation (Latarjet or bone graft). Simple Bankart will fail. Measure on CT with 3D reconstruction.

On-Track vs Off-Track

Off-track Hill-Sachs engages the glenoid and causes instability. Requires Latarjet or remplissage. On-track lesions do not engage and can be treated with Bankart.

Age Predicts Recurrence

Under 20 years: 67% recurrence. 20-40 years: 30-40%. Over 40: 10-15%. Young athletes with contact sports have highest recurrence after conservative treatment.

Latarjet Triple Effect

Latarjet provides: 1) Bone augmentation for glenoid, 2) Sling effect of conjoint tendon, 3) Capsulolabral repair. Addresses multiple pathologies.

Quick Decision Guide

Clinical Scenario	Bone Loss	Recommended Procedure	Key Consideration
First dislocation, non-athlete	Minimal	Conservative	Rehab, reassess if recurrent
Recurrent, young athlete	Less than 15%	Arthroscopic Bankart	Higher recurrence in contact sports
Recurrent, contact sport	15-25%	Consider Latarjet	Especially if engaging Hill-Sachs
Significant bone loss	Greater than 25%	Latarjet	Bankart will fail
Off-track Hill-Sachs	Any	Latarjet or remplissage	Address engaging defect

Mnemonic

BONEBankart vs Latarjet Decision

Bone loss greater than 25%

Latarjet required

Off-track Hill-Sachs

Engages = Latarjet or remplissage

Number of dislocations

Many = consider Latarjet

Extreme sports/contact

Higher demand = consider Latarjet

Memory Hook:Check the BONE factors to decide Bankart vs Latarjet!

Mnemonic

BSCLatarjet Triple Effect

Bone block

Augments deficient glenoid

Sling effect

Conjoint tendon acts as dynamic stabilizer

Capsular repair

Capsulolabral tissue sewn to bone block

Memory Hook:BSC - Latarjet gives Bone, Sling, and Capsular repair!

Mnemonic

ABCDEFISIS Score Components

Age less than 20

2 points

Bony lesion on radiograph

2 points

Contact/competitive sport

1 point

Decreased anterior hyperlaxity

1 point

Engaging Hill-Sachs

2 points

Frequent dislocations if greater than 5

2 points if positive

Memory Hook:ISIS score greater than 6 = consider Latarjet over arthroscopic Bankart!

Overview and Epidemiology

Age is the Strongest Predictor

Under 20 years: 67% recurrence after first dislocation. 20-40 years: 30-40%. Over 40: 10-15% (but higher rotator cuff tear risk). Young age and contact sports indicate early surgical consideration.

Epidemiology

Most common major joint dislocation
Incidence: 24/100,000/year
Peak age: 15-25 years (males)
Anterior = 95%, posterior = 2-4%
Contact sports overrepresented

Mechanism

Force to abducted, externally rotated arm
Direct blow to posterior shoulder
Fall on outstretched hand
Sports: tackling, overhead throwing
May be atraumatic in hyperlaxity

Pathophysiology and Mechanisms

Static Restraints

Glenohumeral ligaments: Primary static stabilizers.

IGHL (inferior glenohumeral ligament): Most important. Anterior band resists anterior translation in abduction/ER.

MGHL (middle): Variable anatomy. Resists anterior translation mid-range.

SGHL (superior): Resists inferior translation.

Labrum: Deepens glenoid by 50%, attachment for ligaments.

Bony Bankart vs Soft Tissue Bankart

Bony Bankart (glenoid fracture with labral avulsion) is associated with higher recurrence after arthroscopic repair than soft tissue Bankart. Consider Latarjet if significant bony fragment or greater than 15% glenoid bone loss.

Classification Systems

Glenoid Bone Loss Measurement

Bony Bankart lesion evaluation and surgical fixation — Bony Bankart lesion assessment and treatment: (a) X-ray showing osseous Bankart (glenoid rim fracture), (b) CT scan with precise bone loss measurement (A: 23.5mm width, B: 6.3mm depth) - essential for surgical planning, (c) post-operative X-ray showing two-screw fixation of the glenoid rim fragment, (d) healed glenoid at follow-up demonstrating successful bone union.Credit: Spiegl UJ et al., BMC Musculoskelet Disord (PMC3813982) - CC-BY

Best-fit circle method: 3D CT reconstruction. Fit circle to intact inferior glenoid. Measure deficiency.

Treatment thresholds:

Less than 15%: Arthroscopic Bankart likely sufficient
15-25%: Gray zone - consider Latarjet especially with engaging Hill-Sachs
Greater than 25%: Latarjet or bone graft required

Hill-Sachs assessment: Width and depth. Engaging vs non-engaging.

Clinical Assessment

History

Mechanism: ABER position, direct blow
Reduction: Spontaneous vs required reduction
Number of dislocations: Recurrence pattern
Sport level: Contact, overhead, competitive
Age at first dislocation: Predicts recurrence

Examination

Apprehension test: Positive with ABER
Relocation test: Relief with posterior force
Anterior load and shift: Grades translation
Sulcus sign: Inferior laxity (positive if greater than 2cm)
Generalized laxity: Beighton score

Apprehension-Relocation Test

Apprehension: Patient supine, arm abducted 90°, externally rotate. Positive = apprehension (not just pain). Relocation: Apply posterior force to humeral head. Relief of apprehension = positive. Most specific clinical test for anterior instability.

Key Examination Findings

Acute dislocation: Arm held in ER and abduction. Loss of deltoid contour. Humeral head palpable anteriorly.

After reduction: Assess for neurovascular injury (especially axillary nerve), rotator cuff integrity (over 40), and range of motion.

Bilateral anterior shoulder dislocation on chest X-ray — Chest radiograph demonstrating bilateral anterior shoulder dislocation with associated greater tuberosity fracture on the left side. Both humeral heads are visibly displaced anteriorly from their respective glenoid fossae. Greater tuberosity fractures occur in up to 15% of anterior dislocations and typically reduce with the shoulder - if persistently displaced more than 5mm, ORIF may be indicated.Credit: Meena S et al., J Nat Sci Biol Med (PMC3783813) - CC-BY

Investigations

Standard Views

AP true (Grashey view): Glenohumeral alignment.

Axillary lateral: Glenoid and humeral head relationship. Essential.

Scapular Y: Confirms dislocation direction.

West Point view: Anteroinferior glenoid (Bankart).

Stryker notch view: Hill-Sachs lesion visualization.

Radiographic Signs of Instability

Hill-Sachs visible on AP: Indicates significant lesion (engaged in ER). Glenoid loss visible on AP: Suggests greater than 20% bone loss. These simple radiograph findings prompt CT quantification.

Management Algorithm

First-Time Anterior Dislocation

Management Pathway

AcuteReduction and Assessment

Closed reduction under sedation. Post-reduction radiographs. Assess neurovascular status (axillary nerve). Sling immobilization.

ImagingMRI and/or CT

MRI: Assess labrum, rotator cuff. CT with 3D: Quantify bone loss. Essential for surgical planning.

ConservativeNon-Operative Option

Sling 3-6 weeks. Progressive ROM. Rotator cuff and periscapular strengthening. May be appropriate if: over 40 years old, low demand, no bone loss, non-contact sport.

SurgicalEarly Surgical Consideration

Consider if: under 20 years old, contact sports, significant bone loss, in-season athlete. Reduces recurrence from 67% to less than 10%.

Surgical Technique

Arthroscopic Bankart Repair

Surgical Steps

Step 1Positioning and Portals

Beach chair or lateral decubitus. Standard posterior viewing portal. Anterior portals for anchor placement.

Step 2Glenoid Preparation

Elevate labrum from glenoid neck. Decorticate glenoid rim to bleeding bone. Ensure adequate mobilization for tension-free repair.

Step 3Anchor Placement

3-4 anchors along anteroinferior glenoid rim (5 to 3 o-clock for right shoulder). Suture anchors or knotless.

Step 4Labral Repair

Mattress or simple sutures through labrum. Restore labral bumper. Capsular plication if redundant.

Anchor Placement

Anchors must be placed ON the glenoid rim (not neck) at the articular margin. At least 3 anchors. The 5:30 position (6:30 left shoulder) is critical to address the IGHL attachment. Avoid suprascapular nerve with superior anchors.

Complications

Complication	Procedure	Incidence	Prevention/Management
Recurrent instability	Bankart	10-20%	Proper patient selection, technique
Recurrent instability	Latarjet	0-5%	Rare if technique correct
Hardware complications	Latarjet	5-7%	Proper screw placement, length
Graft non-union/lysis	Latarjet	5%	Avoid over-medialization, good contact
Subscapularis weakness	Latarjet	Variable	Split (not tenotomy) preferred
Stiffness	Both	Variable	Early ROM, appropriate capsular tension
Nerve injury	Latarjet	Rare	Protect musculocutaneous and axillary

Latarjet Failure Causes

Most common causes of Latarjet failure: Graft malposition (too lateral or medial), graft non-union, screw pullout, missed HAGL lesion. Meticulous technique and preoperative planning essential.

Postoperative Care

Rehabilitation Protocol

Week 0-4Protection Phase

Sling immobilization. Elbow and hand exercises. Pendulum exercises only. No external rotation past neutral.

Week 4-8Early Motion

Wean sling. Gentle AROM. Limit external rotation (based on surgeon preference). Scapular stabilization exercises.

Week 8-12Progressive ROM

Full ROM by 12 weeks. Rotator cuff strengthening. Avoid apprehension positions.

Month 3-6Strengthening

Progressive resistance. Sport-specific training started. Avoid contact sports until 6 months (Latarjet may allow earlier).

Return to Sport

Bankart: Return to contact sports 6-9 months. Latarjet: Some allow earlier return (4-6 months) due to bony stability. Confirm graft healing on CT before high-risk activities.

Outcomes and Prognosis

Procedure-Specific Outcomes

Arthroscopic Bankart: 80-90% success in appropriate patients. Higher recurrence in young contact athletes, bone loss, and engaging Hill-Sachs.

Latarjet: 95-98% stability. Low recurrence even in high-risk groups. Some risk of OA long-term.

Prognostic Factors

Good prognosis: Older age, non-contact sport, minimal bone loss, first stabilization, compliant rehabilitation.

Poor prognosis: Age under 20, contact sports, significant bone loss, engaging Hill-Sachs, hyperlaxity, failed previous surgery.

Evidence Base and Key Studies

Age and Recurrence Risk

Hovelius L et al. • J Shoulder Elbow Surg (2008)

Key Findings:

255 primary dislocations followed 25 years
Age less than 22: 72% recurrence
Age 23-29: 56% recurrence
Age greater than 30: 27% recurrence

Clinical Implication: Young age is the strongest predictor of recurrence - consider early stabilization.

Limitation: Long follow-up but some loss to follow-up.

Bone Loss Threshold

Yamamoto N et al. • J Shoulder Elbow Surg (2010)

Key Findings:

Cadaveric study of glenoid bone loss
20% bone loss causes significant instability
25% bone loss leads to failure of Bankart repair
Bony procedure recommended greater than 20-25%

Clinical Implication: Greater than 25% glenoid bone loss requires bony augmentation.

Limitation: Cadaveric model, clinical variability.

Glenoid Track Concept

Yamamoto N et al. • Am J Sports Med (2007)

Key Findings:

Defined glenoid track for Hill-Sachs assessment
Off-track lesions engage and cause instability
On-track lesions do not engage
Guides need for Hill-Sachs treatment

Clinical Implication: On-track vs off-track determines if Hill-Sachs needs addressing.

Limitation: Original biomechanical study, clinical validation ongoing.

Latarjet vs Bankart in Contact Athletes

Blonna D et al. • Am J Sports Med (2016)

Key Findings:

Systematic review and meta-analysis
Latarjet: 3.4% recurrence in contact athletes
Bankart: 13.4% recurrence in contact athletes
Latarjet superior in high-risk athletes

Clinical Implication: Latarjet has lower recurrence in contact athletes than Bankart.

Limitation: Meta-analysis of heterogeneous studies.

ISIS Score Validation

Balg F et al. • Arthroscopy (2007)

Key Findings:

Instability Severity Index Score developed
10-point scale predicting recurrence
ISIS greater than 6: 70% recurrence after Bankart
Guides selection for Latarjet

Clinical Implication: ISIS score greater than 6 suggests Latarjet over arthroscopic Bankart.

Limitation: Single center derivation, external validation variable.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Young Athlete First Dislocation

EXAMINER

"An 18-year-old rugby player presents after his first anterior shoulder dislocation during a tackle. He required reduction in the emergency department. Radiographs show no fracture. How would you manage this?"

EXCEPTIONAL ANSWER

This is a first-time traumatic anterior shoulder dislocation in a young contact athlete - a high-risk scenario for recurrence. My initial management would include confirming the shoulder is reduced on post-reduction radiographs and assessing neurovascular status, specifically axillary nerve function (sensation over lateral deltoid). I would immobilize him in a sling for comfort. I would counsel him that at age 18, he has approximately 67% recurrence risk with conservative treatment, which increases further as a contact sport athlete. I would obtain an MRI to assess the labrum (expecting Bankart lesion in 90%+) and rotator cuff. I would also obtain a CT with 3D reconstruction to quantify any glenoid bone loss and assess the Hill-Sachs lesion. If there is minimal bone loss (less than 15%) and on-track Hill-Sachs, I would discuss early arthroscopic Bankart repair, which reduces recurrence to under 10%. If there is significant bone loss (greater than 25%) or off-track Hill-Sachs, I would recommend Latarjet procedure. For a first-line rugby player, I would have a low threshold for surgical stabilization given the high recurrence risk with conservative treatment.

KEY POINTS TO SCORE

67% recurrence risk at age 18 with conservative treatment

MRI for labrum, CT for bone loss quantification

Assess Hill-Sachs (on-track vs off-track)

Low threshold for surgery in young contact athletes

Bone loss greater than 25% = Latarjet required

COMMON TRAPS

✗Recommending conservative treatment without discussing recurrence risk

✗Not obtaining CT for bone loss quantification

✗Missing associated pathology (greater tuberosity fracture, rotator cuff)

✗Not assessing axillary nerve function

LIKELY FOLLOW-UPS

"What if CT shows 30% glenoid bone loss?"

"What is the ISIS score and how would it influence your decision?"

"What are the advantages of Latarjet over arthroscopic Bankart?"

VIVA SCENARIOChallenging

Scenario 2: Recurrent Instability with Bone Loss

EXAMINER

"A 24-year-old AFL player has had 5 anterior dislocations over 3 years. CT shows 22% glenoid bone loss and an engaging Hill-Sachs lesion. What would you recommend?"

EXCEPTIONAL ANSWER

This is recurrent anterior shoulder instability with moderate glenoid bone loss (22%) and an engaging (off-track) Hill-Sachs lesion. Given these factors, an arthroscopic Bankart repair would have an unacceptably high failure rate. I would recommend a Latarjet procedure. The bone loss is approaching the 25% threshold, and the engaging Hill-Sachs means that even with perfect soft tissue repair, the humeral head defect will catch on the reconstructed glenoid rim causing recurrent instability. The Latarjet provides a triple effect: bone block to augment the deficient glenoid, sling effect of the conjoint tendon, and capsular repair. This patient also has multiple risk factors - young age, contact sport, multiple dislocations, and bone loss - giving a high ISIS score. My surgical approach would be the classic open Latarjet via deltopectoral approach. I would osteotomize the coracoid, prepare the anterior glenoid through a subscapularis split, and fix the coracoid with two screws flush with the glenoid articular surface. Postoperatively, he would be in a sling for 4-6 weeks with progressive ROM and strengthening. Return to AFL would be at 4-6 months after confirming graft healing on CT.

KEY POINTS TO SCORE

22% bone loss + engaging Hill-Sachs = Latarjet

Arthroscopic Bankart would fail

Latarjet triple effect: bone, sling, capsule

High ISIS score supports Latarjet

Return to contact sport 4-6 months

COMMON TRAPS

✗Recommending Bankart for engaging Hill-Sachs

✗Not recognizing 22% bone loss as significant

✗Ignoring the engaging nature of Hill-Sachs

✗Not using CT for preoperative planning

LIKELY FOLLOW-UPS

"What are the complications of Latarjet?"

"How do you position the coracoid?"

"Could remplissage be used instead of Latarjet?"

VIVA SCENARIOCritical

Scenario 3: Failed Bankart Repair

EXAMINER

"A 22-year-old had arthroscopic Bankart repair 2 years ago but has had 3 further dislocations. CT shows the anchors are in place but there is now 18% glenoid bone loss. What is your approach?"

EXCEPTIONAL ANSWER

This is failed arthroscopic Bankart repair with ongoing instability and progressive bone loss. The fact that he has continued to dislocate despite repair suggests either initial technical issues or progressive bone loss with each dislocation. The current 18% bone loss, combined with failed soft tissue repair and young age with likely return to sport aspirations, indicates that repeat arthroscopic Bankart would have a very high failure rate. I would recommend revision to a Latarjet procedure. Before surgery, I would obtain a new CT to precisely measure bone loss and assess the existing anchors. I would also get an MRI to evaluate the labrum and any associated pathology. At surgery, I would perform an open Latarjet. The approach would be through the old deltopectoral incision. I would remove any loose or prominent anchor material. The coracoid transfer would augment the bone-deficient glenoid. The conjoint tendon sling provides dynamic stability. I would counsel him that revision surgery has slightly higher complication rates than primary Latarjet, but success rates remain high (greater than 90% stability). Return to sport would be 4-6 months after confirming graft union.

KEY POINTS TO SCORE

Failed Bankart with bone loss = Latarjet

Repeat Bankart has very high failure rate

Progressive bone loss after failed repair is common

Remove prominent anchors at revision

Latarjet addresses bone deficiency

COMMON TRAPS

✗Recommending repeat arthroscopic Bankart

✗Not recognizing progressive bone erosion

✗Not obtaining new imaging before revision

✗Ignoring anchors in planning revision

LIKELY FOLLOW-UPS

"What are causes of failed Bankart repair?"

"What if 18% bone loss was present at initial surgery?"

"What is the role of free bone graft vs Latarjet?"

MCQ Practice Points

Bone Loss Threshold

Q: Above what percentage of glenoid bone loss is Latarjet/bony procedure required? A: Greater than 25%. At this level, Bankart repair will fail. 15-25% is the gray zone where engaging Hill-Sachs tips toward Latarjet.

Age and Recurrence

Q: What is the recurrence rate after first dislocation in patients under 20? A: 67%. Young age is the strongest predictor of recurrence. This justifies early surgical consideration in young athletes.

Latarjet Triple Effect

Q: What are the three stabilizing effects of the Latarjet procedure? A: 1) Bone block augmenting glenoid, 2) Sling effect of conjoint tendon, 3) Capsular repair to the bone block.

IGHL Function

Q: Which ligament is the primary static restraint to anterior translation? A: Inferior glenohumeral ligament (IGHL) - specifically the anterior band when the arm is abducted and externally rotated.

Bankart Lesion

Q: What percentage of traumatic anterior dislocations have a Bankart lesion? A: Greater than 90%. The anteroinferior labrum avulses with the IGHL attachment in almost all traumatic dislocations.

On-Track vs Off-Track

Q: What does an off-track Hill-Sachs lesion indicate? A: The Hill-Sachs engages the glenoid rim during movement, causing instability. Requires Latarjet or remplissage rather than simple Bankart.

Australian Context

Clinical Practice

Arthroscopic Bankart widely performed
Open Latarjet at specialist centres
Arthroscopic Latarjet gaining popularity
CT 3D reconstruction routine for bone loss
High proportion of contact sport athletes

Funding and Access

CT and MRI readily accessible
Public system wait times variable
Private insurance covers most procedures
Return to sport emphasis in athletes
Arthroscopic Latarjet growing in availability

Orthopaedic Exam Relevance

Anterior shoulder instability is a common viva topic. Be prepared to: quantify bone loss, explain on-track vs off-track concept, articulate Bankart vs Latarjet decision algorithm, describe surgical techniques, and know the ISIS score.

ANTERIOR SHOULDER INSTABILITY

High-Yield Exam Summary

Pathoanatomy

•Bankart lesion in greater than 90% of dislocations
•Hill-Sachs in 65-70% of first dislocations
•IGHL is primary static restraint
•Subscapularis is key dynamic stabilizer
•Bony Bankart reduces glenoid surface area

Bone Loss Thresholds

•Less than 15%: Arthroscopic Bankart likely sufficient
•15-25%: Gray zone - consider Latarjet if engaging HS
•Greater than 25%: Latarjet or bone graft required
•Off-track HS: Latarjet or remplissage
•Critical bone loss dramatically increases recurrence

Age and Recurrence

•Under 20 years: 67% recurrence
•20-40 years: 30-40% recurrence
•Over 40 years: 10-15% (but cuff tears)
•Young age = strongest predictor
•Male gender increases risk further

Latarjet Triple Effect (BSC)

•Bone block: Augments glenoid
•Sling effect: Conjoint tendon dynamics
•Capsular repair: Capsule sutured to block
•Benefits: Addresses bone loss and prevents engagement
•Ideal for high-risk contact athletes

ISIS Score greater than 6 = Consider Latarjet

•Age less than 20: 2 points
•Bony lesion on XR: 2 points
•Contact sport: 1-2 points
•Engaging Hill-Sachs: 2 points
•Shoulder hyperlaxity: 1 point

Outcomes

•Bankart: 10-20% recurrence overall
•Latarjet: 0-5% recurrence
•Latarjet superior in high-risk groups
•Both have high patient satisfaction
•Open Latarjet has higher complication rate than Bankart

Clinical Scenario

Bone Loss

Recommended Procedure

Key Consideration

First dislocation, non-athlete

Minimal

Conservative

Rehab, reassess if recurrent

Recurrent, young athlete

Less than 15%

Arthroscopic Bankart

Higher recurrence in contact sports

Recurrent, contact sport

15-25%

Consider Latarjet

Especially if engaging Hill-Sachs

Significant bone loss

Greater than 25%

Latarjet

Bankart will fail

Off-track Hill-Sachs

Any

Latarjet or remplissage

Address engaging defect

Arthroscopic Bankart Repair

Surgical Steps

Step 1Positioning and Portals

Beach chair or lateral decubitus. Standard posterior viewing portal. Anterior portals for anchor placement.

Step 2Glenoid Preparation

Elevate labrum from glenoid neck. Decorticate glenoid rim to bleeding bone. Ensure adequate mobilization for tension-free repair.

Step 3Anchor Placement

3-4 anchors along anteroinferior glenoid rim (5 to 3 o-clock for right shoulder). Suture anchors or knotless.

Step 4Labral Repair

Mattress or simple sutures through labrum. Restore labral bumper. Capsular plication if redundant.

Anchor Placement

Complication

Procedure

Incidence

Prevention/Management

Recurrent instability

Bankart

10-20%

Proper patient selection, technique

Recurrent instability

Latarjet

0-5%

Rare if technique correct

Hardware complications

Latarjet

5-7%

Proper screw placement, length

Graft non-union/lysis

Latarjet

Avoid over-medialization, good contact

Subscapularis weakness

Latarjet

Variable

Split (not tenotomy) preferred

Stiffness

Both

Variable

Early ROM, appropriate capsular tension

Nerve injury

Latarjet

Rare

Protect musculocutaneous and axillary

Risk Factor	Points	Notes
Age less than 20 years	2	Young age highest recurrence
Competitive/contact sport	1-2	Higher demand
Shoulder hyperlaxity	1	Generalized ligamentous laxity
Hill-Sachs on AP radiograph	2	Visible = significant
Glenoid loss on AP radiograph	2	Visible = greater than 20%

Risk Factor	Points	Notes
Age less than 20 years	2	Young age highest recurrence
Competitive/contact sport	1-2	Higher demand
Shoulder hyperlaxity	1	Generalized ligamentous laxity
Hill-Sachs on AP radiograph	2	Visible = significant
Glenoid loss on AP radiograph	2	Visible = greater than 20%

Anterior Shoulder Instability

Anterior Shoulder Instability

ANTERIOR SHOULDER INSTABILITY

BONE LOSS THRESHOLD

Critical Must-Knows

Examiner's Pearls

Clinical Imaging

Imaging Gallery

Critical Exam Concepts

Bone Loss is KEY

On-Track vs Off-Track

Age Predicts Recurrence

Latarjet Triple Effect

Quick Decision Guide

BONEBankart vs Latarjet Decision

BSCLatarjet Triple Effect

ABCDEFISIS Score Components

Overview and Epidemiology

Epidemiology

Mechanism

Pathophysiology and Mechanisms

Static Restraints

Dynamic Restraints

Key Pathological Lesions

Bony Bankart vs Soft Tissue Bankart

Classification Systems

Glenoid Bone Loss Measurement

Glenoid Track Concept

Instability Severity Index Score

Clinical Assessment

History

Examination

Apprehension-Relocation Test

Key Examination Findings

Investigations

Standard Views

CT with 3D Reconstruction

MRI Assessment

Management Algorithm

First-Time Anterior Dislocation

Management Pathway

Recurrent Anterior Instability

Surgical Decision-Making

Procedure Selection

Surgical Technique

Arthroscopic Bankart Repair

Surgical Steps

Latarjet (Coracoid Transfer)

Surgical Steps

Coracoid Positioning

Remplissage Procedure

Complications

Postoperative Care

Rehabilitation Protocol

Return to Sport

Outcomes and Prognosis

Procedure-Specific Outcomes

Prognostic Factors

Evidence Base and Key Studies

Age and Recurrence Risk

Bone Loss Threshold

Glenoid Track Concept

Latarjet vs Bankart in Contact Athletes

ISIS Score Validation

Exam Viva Scenarios

Scenario 1: Young Athlete First Dislocation

Scenario 2: Recurrent Instability with Bone Loss

Scenario 3: Failed Bankart Repair

MCQ Practice Points

Australian Context

Clinical Practice

Funding and Access

ANTERIOR SHOULDER INSTABILITY

Pathoanatomy

Bone Loss Thresholds

Age and Recurrence

Latarjet Triple Effect (BSC)

ISIS Score greater than 6 = Consider Latarjet

Outcomes

Anterior Shoulder Instability