JOREP 4 (2025) 100494

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Journal of Orthopaedic Reports

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Research Article

Tailoring surgical management of recurrent anterior shoulder instability: A

simplified algorithm and long-term functional outcome analysis
Vejaya Kumar a , Karthik Selvaraj Murugappan b,*, Pradeep Baskaran c , Rohith Daniel d ,
David V. Rajan e
a
Assistant Professor, Department of Orthopaedics, Vinayaka Mission’s Medical College & Hospital, Vinayaka Mission’s Research Foundation (VMRF-DU), Karaikal,
India
b
Consultant Orthopedic & Arthroscopic surgeon, KS Ortho Care, Coimbatore, India
c
Consultant Orthopedic & Arthroscopic surgeon, Devadoss Hospital, Madurai, India
d
Consultant Orthopedic & Arthroscopic surgeon, Rollands Hospital, Trivandrum, India
e
Senior Consultant Orthopedic & Arthroscopic surgeon, Ortho One Orthopaedic Speciality Centre, Coimbatore, India

1. Introduction February 2018 at our Institute. The exclusion criteria included patients
with (a) Bilateral Shoulder Instability (b) Multi directional Instability (c)
Decision making in recurrent instability of shoulder is still a subject Prior surgeries on the Shoulder (d) Habitual Dislocations. Institutional
of debate. The most popular management algorithm of recurrent insta­ review board and Ethical committee clearances were obtained. We hy­
bility of shoulder is the Instability Severity Index Score (ISIS).1,2 This pothesized that results with this new protocol provide good functional
scoring system consider age, hyperlaxity, type of sport and x-ray evi­ outcome in terms of functional scores. Before surgery patients were
dence of bone loss in humerus & glenoid.1 The disadvantages of ISIS enquired regarding age, reason for first dislocation, dominant arm,
Score include the use of X-rays for the evaluation of bone loss3 and not number of dislocations, sleep dislocations, nature of their jobs and type
taking into account the quality of labral tissue. It has been well estab­ of sports involved in.
lished that CT scans are the gold standard to assess bone loss.4 With Physical Examination included assessment of Beighton Score (four
Yamamoto et al.5 introducing the glenoid track concept, which utilizes a out of nine was considered as hyperlaxity), measurement of range of
3D CT Scan to assessb if a Hill Sach lesion is non-engaging (on-track) or motion, anterior instability tests (Apprehension, relocation & release)
engaging (off-track), we can easily predict the relation of the glenoid etc. Pre-operative functional scoring of the affected side was also done
and humeral lesions along with bipolar bone loss.6 We have developed using the Rowe Score, Western Ontario Shoulder Instability Index
an algorithm which takes into account most of the causal factors for (WOSI) Score & Oxford Shoulder Instability Score (OSIS), WOSI Score
failure of surgeries as well as incorporates the recent concept in bipolar was expressed as a percentage of 2100. These shoulders were then
bone loss. radiologically evaluated using a MRI Scan (labrum assessment) and a 3D
This study aims at proposing an algorithm (protocol) for managing CT Scan, which is used to assess (a) Glenoid Index (b) the type of Hill
recurrent shoulder instability (anterior) and to assess the functional Sach (on/off track).7 Once the evaluation was over, these patients were
outcome of patients treated using this protocol prospectively. We hy­ assessed as per our algorithm (Fig.A) and the appropriate surgery was
pothesize that patients treated according to this protocol will have good chosen for them. All patients received one among the three surgeries (a)
functional outcome with improved shoulder function scores. Arthroscopic Bankart Repair (ABR) (b) Arthroscopic Bankart Repair
with Remplissage or (c) Latarjet Procedure.
2. Methodology We used the ‘best fit circle method’ for assessment of Glenoid Index
(GI) as described by Charles Nofsinger and Aaron J. Bois et al. in their
This is a prospective observational study (sample size by convenient studies.8,9 In this method we obtain the glenoid end face view in the 3D
sampling). The study included patients who underwent shoulder insta­ CT and draw the widest circle possible over inferior glenoid, utilizing the
bility surgeries based on our algorithm (Fig. 1) between March 2014 and uninvolved postero-inferior glenoid border as the template (Fig. 2a).

* Corresponding author. KS Ortho Care, 34, Thiyagi Shanmuga Nagar, Singanallur, Coimbatore, India.
E-mail addresses: dr.vejay87@[Link], reviveosc@[Link] (V. Kumar), karthikselvarajsports@[Link] (K. Selvaraj Murugappan), docpradeepms@gmail.
xom (P. Baskaran), [Link]@[Link] (R. Daniel), davidvrajan@[Link] (D.V. Rajan).

[Link]
Received 6 August 2024; Accepted 17 October 2024
Available online 22 October 2024
2773-157X/© 2024 The Authors. Published by Elsevier B.V. on behalf of Prof. PK Surendran Memorial Education Foundation. This is an open access article under
the CC BY-NC-ND license ([Link]
V. Kumar et al. Journal of Orthopaedic Reports 4 (2025) 100494

Glenoid Index is given by glenoid width (b-a)/diameter of the circle (b). 2.1. Operative technique
If the glenoid Index is less than 0.80, it means that there is marked
glenoid bone; hence we perform Latarjet procedure for such patients. If For ABR, after general anesthesia, patient is turned to lateral posi­
the Glenoid Index is more than 0.80, we ascertain whether the patient tion. Standard shoulder portals (Posterior, Antero superior & Antero
has a high functional demand. Anyone whose work involved carrying or inferior) were used. First step was to prepare the anterior glenoid fol­
lifting heavy loads on a regular basis was deemed to have a high func­ lowed by attachment of the torn labrum onto the anteroinferior glenoid
tional demand. In an Indian scenario such professions include manual using anchors with double loaded sutures. Three or four 3mm suture
laborers, farmers, porters, construction workers, mechanics etc. Pro­ anchors were used for this purpose. Inferior capsular shift was routinely
fessional athletes involved in contact sports or sports which required performed. Remplissage when indicated was performed through the
regular upper limb usage were also considered to have a high functional Postero-lateral portal using the standard knot technique.11 A single 5
demand. Such patients also received Latarjet procedure. mm suture anchor preferably double loaded was placed in the valley of
All other patients received ABR unless they had one or more of the Hill Sach lesion and the bites were taken through the infraspinatus
high risk factors. These included (a) Hyperlaxity (b) Intra operative tendon with the capsule (capsulotenodesis). The tying of the remplissage
finding of poor quality of labrum and (c) Positive ‘off-track’ lesion in knots were done only after labral repair was complete. We performed
humeral head. If any one of these high risk factors, we perform a open Latarjet procedures using the standard deltopectoral approach.12
Remplissage procedure along with ABR. We osteotomised the coracoid at its base leaving the conjoint tendon
Assessment of Hill Sach (HS) lesions are again done using 3D CT scan intact, which was then brought to the anterior glenoid after splitting the
as per the method described by Giacomo et al.7 His method involves subscapularis horizontaly. Coracoid fixation was done using two 4mm
calculating two values. First is the Glenoid track width (G.T.) given by partially threaded cancellous screws onto the antero inferior glenoid
83 % of glenoid’s original width minus glenoid bone loss i.e. 0.83b – a after decorticating the opposing surfaces using a burr.
(Fig. 2a). Second is Hill Sach Interval(H.I.), given by the distance
present within the insertion of rotator cuff and the medial edge of HS
2.2. Postoperative management
lesion as seen on 3D view showing the Head of humerus (Fig. 2b). If HI is
more than GT, it means that the Hill Sach lesion lies outside the tracking
Post-operative protocol was identical for all patients. Shoulders were
of glenoid and hence the lesion is termed as ‘off-track.7,10 These lesions
placed in an arm sling for three weeks & were allowed elbow and wrist
are engaging in nature and require a remplissage procedure. If HI is less
ROM. At 3 weeks, gentle exercises like pendulum and Range of Move­
than the GT, the lesion is completely confined in the tracking of glenoid
ment (ROM) exercises of shoulder were initiated with assistance. Active
and hence the lesion is termed as ‘on-track’ which is non-engaging in
ROM was started at 6 weeks. Active resistance exercises were started 3
nature. These lesions need not be addressed as they do not contribute to
months postoperatively with a light rubber band. Light Sports activity
the instability of shoulder. The assessment of labral quality was done by
were permitted after 3 months & contact sports after 6 months.
the operating surgeon intra operatively. The labrum was classified as
poor quality if there is a capsular rent or labral tissue loss was found.
2.3. Follow up

Standardized follow-up of patient was done at 6 weeks, 12 weeks 24

weeks, 9 months,12 months and at every year postoperatively. They

Fig. 1. Algorithm for the management of recurrent anterior instability of shoulder.

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V. Kumar et al. Journal of Orthopaedic Reports 4 (2025) 100494

were assessed for the shoulder stability & range of motion. Functional was 30 and median WOSI Score was 61. The mean pre-operative
assessment was done using OSIS, Rowe and the WOSI Scores. abduction was 178.44◦ , forward flexion was 179.19◦ , extension was
32.88◦ , internal rotation in abduction was 88.31◦ and external rotation
2.4. Statistical analysis was 81.94◦ .

Arithmetic mean, standard deviation, range, frequency were used for 3.2. Post-operative assessment
descriptive data analysis. All continuous variables are presented in terms
of mean ± standard deviation of the mean. Wilcoxon signed rank test Out of 125 patients who were under reguar follow up and the mean
was used for comparing the functional scores. Ranges of motion were follow up period was 32 (24–48) months. The mean, post-operative
compared using the Paired t-test. A p-value less than 0.01 was consid­ abduction was 179.5◦ , the forward flexion was 179.69◦ , the extension
ered as significant statistically. Statistical analysis was performed using was 33.06◦ and internal rotation was 88.19◦ . All these ranges of motion
the SPSS version 28 software package. were comparable to the preoperative ranges as indicated by their
insignificant p-values. However, the mean post-operative external
3. Results rotation (ER) was 76.63◦ , significantly lower than preoperative external
rotation of 81.94◦ (p-value: 0.01) (Table no 2)
Out of 210 patients who were operated for recurrent shoulder At 32 months of mean follow-up, the median post-operative OSIS
instability, 160 patients satisfied the inclusion criteria. 35 patients were was improved to 44 from the pre-operative value of 17 (p value 0.001).
excluded from the study due to lost follow up. 125 patients who had The median post-operative WOSI Score also significantly improved to 19
minimum 2 years follow up were considered for the study (Fig. 3). 25 from 61 (p value 0.001) and the median Rowe Score was 85 compared to
patients had a glenoid index less than 0.80 and all of them received a pre-operative Score of 30 (p value 0.001) (Table no3). Based on the
Latarjet procedure. Out of the remaining 100 patients, 15 patients had Rowe Score it was seen that 11 (13.75 %) patients had excellent
high functional demands (9 professional athletes and 6 manual workers) outcome, 61 (76.25 %) patients had good outcome and 8 (10 %) patients
and all of them also received Latarjet procedure. The remaining 85 pa­ had fair outcome after surgery.
tients were assessed if they had any high risk factors. We found that 35 There were no re-dislocations in our entire follow up & 80 % patients
patients did not have any of the high risk factors and hence were treated returned to previous level of activity. One patient had superficial he­
with ABR. The remaining 50 patients had one or more of the high risk matoma in Latarjet group which had resolved without intervention. One
factors and hence received remplissage procedure along with ABR patient had stiffness (ER & Abduction) in Bankart’s & Remplissage
(Fig. 3). Group, which had improved in 6 months to the mean post-operative
range. One patient had infraspinatus weakness (Suprascapular nerve
3.1. Patient’s characteristics (Table 1) neuropraxia) in Latarjet Group, which had recovered in 3 [Link]
were no other major complications in any of our patients.
The patient’s age on average was 27.19 (16–41) years. The per­
centage of females was 10 % (8 patients) six of them underwent 4. Discussion
arthroscopic Bankart Repair and two of them underwent Latarjet pro­
cedure. 62 patients had dominant arm involvement. Average number of The follow up results of patients who underwent surgery based on
dislocations at presentation was 4.5 (2–17). This was highest in the this algorithm indicate a good outcome. None of them had redislocation.
group that underwent Latarjet procedure which had a mean of 5.65 prior The decision to offer a particular surgery to a traumatic shoulder
dislocations. Twelve patients gave history of sleep dislocations. The instability patient should be based on several factors. Most importantly,
average Beighton Score was 3.35 and 23 (18.4 %) patients were our understanding in the recent years about gleniod and humeral bone
hyperlax. Based on the CT Scan evaluation, the mean Glenoid Index was loss has influenced our decision making. However, in addition we have
0.88. About 120 patients (96 %) had a HS lesion. The mean width of the to consider other important factors like age, occupational demand,
HS lesions was 1.25 cm and the mean depth was 0.23 cm. Out of the 120 hyperlaxity & labral quality. Each of these or a combination of these
HS lesions, 21 (17.5 %) were off-track while 99 (82.5 %) were on-track factors can influence the results of surgery. An effort to include these
in nature. The preoperative, median OSIS was 17, median Rowe Score factors was pioneered by Boileau14 with ISIS Score.

Fig. 2. Figure 2a: 3D CT scan of shoulder showing the glenoid en face view. A circle is drawn using the posteroinferior glenoid margin as template. Considering ‘a’
as amount of glenoid bone loss, ‘b’ as diameter of the circle. Glenoid Index (GI)= (b-a)/b and Glenoid Track (GT) = 0.83*b- a Figure 2b: 3D CT scan of shoulder
showing the posterior aspect of humeral head. Considering ‘X’ as the medial most margin of the Hill Sach lesion, ‘Y’ as the site of attachment of the rotator cuff. H.I-
Hill Sach Interval.

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Fig. 3. Patient selection Flow chart & Distribution of patients according to the protocol.

Table 1
Patient characteristics.
VARIABLE ALL PATIENTS ARTHROSCOPIC BANKART BANKART + REMPLISSAGE LATARJET

Age (mean years) 27.19 27.77 26 26.6

Female 8 6 0 2
Dominant arm involvement 62 38 7 17
Prior dislocations (mean) 4.5 4.05 4.85 5.65
Sleep dislocation 12 6 1 5
Beighton score (mean) 3.35 2.13 4.75 5.5
Glenoid index (mean cm) 0.88 0.94 0.88 0.76
Hill Sach width (mean cm) 1.25 0.91 2.10 1.66
Hill Sach depth(mean) 0.23 0.18 0.39 0.27
Off track 21 0 15 6
Hyperlax patients 23 0 21 2
Poor Labral quality 14 0 14 0

Latarjet when ISIS score and plain X-ray criteria are the only ones
Table 2
employed when compared to Glenoid track instability management
Range of motion.
scoring criteria (GTIMS), which defines anterior instability treatment
RANGE OF MOTION Pre- operative Post- operative P using precise imaging and the on-and-off track concept, with encour­
(mean) (mean) value
aging postoperative patient outcomes.
Abduction 178.44 179.50 0.344 His proposed modification of ISIS takes CT quantification of bone
Forward flexion 179.19 179.69 0.267
loss into account. However important factors like intraoperative
Extension 32.88 33.06 0.369
External Rotation in 81.94 76.63 0.01 assessment of labral quality have not been considered. Labral quality &
Abduction hyperlaxity in patients accounts for a prominent role in the success of
Internal Rotation in 88.31 88.19 0.596 instability surgery. In similar situations, where high risk factors of
Abduction imminent failure are present, we proposed to perform remplissage
procedure in addition to ABR.11
This algorithm gives additional indication for addition of remplis­
Table 3 sage to Arthroscopic Bankart’s surgery. The accepted indication for
Comparison of pre and post op functional scores (Wilcoxon signed rank test). remplissage is an engaging HS lesion. Boileau et al.14 performed
SCORE Pre-operative Post-operative p- value remplissage procedure in addition to ABR in patients with large
(median) (median) engaging Hill Sach lesions with good functional results. He identified
OSIS 17 44 0.001 engagement by direct visualization intra operatively. Intraoperative
WOSI (% of 2100) 61 19 0.001 assessment of engagement has some inherent flaws. However taking the
ROWE 30 85 0.001 arm into an engaging position creates tension on the repaired labrum
and is not advisable. The glenoid tracking principle, to identify off-track
HS lesions is a significant improvement in deciding the need for
But with further understanding of the bone loss assessment and
remplissage preoperatively. This also helps greatly in planning, pro­
quantification, ISIS might not be appropriate. Di Giacomo et al.13 opines
curing the necessary implants and instrumentations, assessing the
that the prediction was a two-fold increase in the recommendation for a
possible cost of surgery and discussing the prognosis with the patient

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V. Kumar et al. Journal of Orthopaedic Reports 4 (2025) 100494

prior to the surgery itself. Park et al.15 followed up 20 patients who algorithm does not consider this at present.
underwent ABR with remplissage and reported a recurrence of 15 % at A single ideal operation for instability does not exist, as the type of
29 months postop which is higher than our study. This difference may be patients and the nature of lesions vary greatly. To our knowledge there
attributed to the fact that glenoid bone loss was not taken into account in are only few studies which put forward such an algorithm for treating
their study. Nourissatet al16 had a recurrence rate of 6.5 % among pa­ recurrent instability of shoulder including all the high risk factors. This
tients who underwent remplissage along with ABR, but he did not study shows that this algorithm is a good guide for decision making
observe any reduction in external rotation. However in our study we while dealing with an unstable shoulder.
found a mean reduction of 5.31◦ in external rotation in abduction (p
value - 0.01). This observation was more in line with that of Zhu et al.,17 5. Conclusion
who also reported loss of external rotation in his post remplissage pa­
tients. Following the remplissage treatment, a mean decrease in external The results of our patients who underwent surgery based on our al­
rotation in adduction of 5.6◦ and a reduction in external rotation in gorithm at the follow up indicate a good outcome in terms of functional
abduction of 11.3◦ were also documented by Rashid et al.18 in their scores & a lower complication rate. These results are on par with the
systematic review. existing algorithms for shoulder instability. Hence, we feel that this
This algorithm extends the indications of remplissage to Capsular simple & reproducible algorithm is a suitable tool for decision making in
hyperlaxity & poor labral quality, apart from off track lesions. Probable managing recurrent anterior shoulder instability to get satisfactory
reason is remplissage in our hands has been a safe and simple adjuvant results.
to Bankart repair. In a scenario, where a bad labrum is encountered &
surgeon feels underconfident about the outcome of surgery, addition of Informed consent
remplissage as a backup procedure has given good results in short term.
We feel that poor labral quality patients need more suture anchors for Appropriate informed consent forms were obtained.
the repair and tend to have lower subjective shoulder scores after sur­
gery. Owenset al19 in their study stated poor labral quality as one of the Ethical standard
causal factors for failure of ABR. Park et al.20 showed that there was a
significant post-operative labral height decrease in patients with poor Our Instititional ethical committee has approved our study.
labral quality. A study by Ozbaydar et al.21 showed that patients who
had ALPSA lesion, which again is indicative of poor quality of labrum,
Credit author statement
had a higher failures of ABR procedure.
Su F et al.22 in their retrospective study included 65 patients found
All authors have contributed substantially to the conception, design,
that 27 patients (42 %) experienced recurrent instability at a mean of 2.3
analysis, and/or interpretation of the data in this manuscript and will
years after undergoing arthroscopic revision anterior stabilization
take public responsibility for the content.
following a failed index stabilization procedure. They concluded that
ligamentous laxity (p value − 0.031) was one of the independent pre­
Funding statement
dictors of recurrence. Ho AG et al.23 analysed the causes of failure post
anterior stabilization surgery & stressed the need to address the capsular
This research received no specific grant or financial support from any
laxity to prevent the recurrence. In any case, labral separation may or
funding agency/institute.
may not accompany anterior capsular stretching. Therefore, even after a
Bankart Repair, failure may be caused by persistently slack capsular
tissue. According to research by Rowe et al.,24 lesions associated with Declaration of competing interest
substantial capsular laxity were found in 83 % of patients who experi­
enced recurrent dislocations following surgical correction. Capsular On behalf of all authors, the corresponding author states that there is
hyperlaxity/high beighton Score can be addressed by addition of pos­ no conflict of interest.
terior glenoid anchor to tighten the hammock. However, we feel that the
remplissage can effectively tighten the posterior capsule and reduce Acknowledgement
capsular volume better than the glenoid anchor, as the suture holding of
the posterior capsule along with cuff tendon is better than the already NONE.
thin posterior inferior capsulolabral complex.
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