This chapter provides an analysis of Bankart repair failure and the efficacy of the Latarjet procedure as a salvage option. Arthroscopic Bankart repair is the procedure of choice in the setting of a Bankart lesion without significant glenoid bone loss and is most appropriate in low-demand patients with first-time shoulder instability, where it shows low rates of postoperative instability. Despite major advances, arthroscopic stabilization techniques are still associated with higher failure rates than traditional open procedures are.1 Failure can occur due to various factors, including inadequate tissue healing, insufficient surgical technique, glenoid and humeral bone loss, or patient-specific factors such as high physical activity levels or noncompliance with postoperative rehabilitation protocols.2, 3, 4 Such failures are reflected in anterior shoulder pain with activities of daily living, which becomes dramatically apparent when the shoulder redislocates.5 Redislocation has variously been attributed to the type and extent of the capsular lesion6, chondral and bone defects,7 technical errors, insufficient soft tissue tensioning, an unhealed Bankart or anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion,8 failure of surgical devices.9,10

Patients who are more likely to experience a redislocation can also be identified based on basic historical information such as sex, age, the time from the first dislocation to surgery,11 patient maturity, and self-control.12 Other important factors to consider are participation in highly demanding sports or activities,13 the number of previous dislocations, the type of immobilization, the rehabilitation program, and altered scapular kinematics.14

For these reasons, the isolated Bankart repair has lost interest among surgeons compared to the past, particularly when facing patients with glenoid bone loss. When indicating patients for arthroscopic Bankart repair, it is essential to evaluate both the glenoid and humeral bone loss (bipolar bone loss) along with a physical examination. In order to help distinguish patients who need soft tissue repair from those who will benefit from an open bony reconstruction, the Instability Severity Index Score (ISIS) was introduced many times ago (Table 1).15 Bankart repair alone is generally indicated when glenoid bone loss does not exceed 15%. Bone loss superior to 15% is an area of controversy.

Even in the absence of instability recurrence after the procedure, patients with glenoid bone loss greater than 13.5% had WOSI ratings much higher than what would be deemed clinically inappropriate.16 Also, patients with glenoid bone loss superior to 17,3% experienced significantly higher failure rates of their surgery;17 a grey zone exists between 13.5% and 17.3% glenoid bone loss, above which we talk about subcritical glenoid bone loss. This bone loss is responsible for impairing quality of life if addressed only with the Bankart repair. Bankart repair alone is also contraindicated when in the presence of a large, off-track Hill-Sachs lesion, due to a high failure rate.16 Moreover, an on-track Hill-Sachs lesion must be carefully evaluated because those close to being off-track are associated with worse outcomes.

Studies found that patients with a Hill-Sachs occupancy ratio ≥ 75% (peripheral-track Hill Sachs lesion) treated with the Bankart repair had a significantly lower WOSI score (subcritical humeral bone loss).18 Another study found that a Hill–Sachs interval to glenoid track width ratio > 0,7 is a significant predictor of higher risk for recurrent instability.19 Near-track lesions (those with a distance to dislocation < 8 mm) are also at risk of recurrence.20,21

Nevertheless, it should be noted that at the end range of motion, the risk of dislocation depends not only on the Hill-Sachs lesion but also on the glenoid bone loss. This is because glenoid bone loss is related to the mid-range stability of the shoulder (concavity-compression effect). With the decrease in glenoid concavity, shoulder stability decreases in the mid-range of movement22 (Fig. 1).

Di Giacomo et al.23 introduced a new treatment algorithm, the “Glenoid Track Instability Management Score” (GTIMS), which includes the glenoid track concept into ISIS as shown in Table 2. This scoring system considers the same nonbone loss risk factors as the ISI score but applies the on-/off-track concept to evaluate the risk related to bone loss.

In cases of subcritical glenoid bone loss, failed arthroscopic surgery, or off-track Hill-Sachs lesions, glenoid bone reconstruction procedures are indicated and are typically performed using bone graft transfer (bone block) or coracoid process transfer (Latarjet).

The primary goal of an open Latarjet procedure is to restore the osseous architecture of the anterior aspect of the glenoid and, ideally, global glenohumeral stability. Coracoid graft transfers are often successful for anteroinferior shoulder stabilization, with an extremely low failure rate even in salvage procedures.24, 25, 26 An additional benefit of this technique is from not only the bone block, but also the conjoined tendon after coracoid transfer. The extra stabilizing effect is described as a dynamic sling that supports the humeral head in the abduction-external rotation position, preventing dislocation.27 However, subtle injuries to the labrum and surrounding glenohumeral ligaments may be overlooked. Identifying secondary pathologies is critical, as attenuation and derangement of the anterior inferior glenohumeral ligament and capsule commonly result from repetitive instability events characteristic of hyperlaxity.23 For many years, the importance of the rotator interval to shoulder stability has been widely recognized and acknowledged.28,29 The anatomy of the rotator interval is complex, and it is defined as the tissue between the subscapularis and supraspinatus tendons, containing structures such as the superior glenohumeral ligament, joint capsule, and coracohumeral ligament.30 The coracohumeral ligament plays a crucial role in preventing inferior translation of the humeral head. Its significance cannot be overstated, as it provides vital support and stability to the shoulder joint. A persistent sulcus sign in external rotation indicates increased inferior humeral translation. The surgeon must consider any residual instability following reconstructive bone-block procedures caused by insufficiency of the soft-tissue stabilizers. Therefore, prudent evaluation of the integrity of the capsule and anteroinferior glenohumeral ligament is recommended. Careful preoperative evaluation and examination under anesthesia of hyperlaxity following coracoid transfer are imperative, and a capsular shift and/or coracohumeral ligament imbrication should be considered in patients with an increased risk of recurrence and clinical failure.31,32

There are concerns about whether the Latarjet procedure can convert all off-track Hill-Sachs lesions into on-track lesions. A Hill-Sachs interval wider than the glenoid track in a value greater than 7.45 mm has been identified as a risk factor for a persistent postoperative off-track lesion after the procedure, so it is recommended preoperative measurement of the glenoid track and the size of the coracoid process.26 In patients with large or very medial Hill-Sachs off-track defects associated with severe glenoid bone loss, or in cases of failure of the Latarjet procedures, larger free bone block procedures able to restore the glenoid track can be recommended. Techniques such as distal tibial allograft have been described with encouraging results.33