Failed shoulder instability surgery: State -of-the-art

Recurrent shoulder instability after failed surgical stabilization is a disabling and complex condition. Over time, clinical research has reshaped traditional approaches, emphasizing the importance of understanding patient-specific factors, accurate diagnosis, and anatomical reconstruction. A comprehensive evaluation is essential to identify failure causes, which typically include patient-related factors (such as young age, male sex, multiple dislocations, and delayed surgery), missed diagnoses (including glenoid bone loss, engaging Hill-Sachs lesions, and capsular laxity), and technical errors (such as malpositioned anchors or insufficient fixation). High-quality imaging with computed tomography (CT) and magnetic resonance imaging (MRI) arthrograms is critical for assessing glenoid and humeral bone defects, soft tissue integrity, and associated lesions. While the Latarjet procedure remains the most widely used technique for glenoid bone reconstruction, free bone grafts from the iliac crest or allografts like distal tibia are increasingly utilized. Arthroscopic revision capsulolabral repair with or without the remplissage procedure has shown promising outcomes in selected patients with subcritical bone loss and preserved soft tissue quality. However, the definition of subcritical bone loss varies widely, complicating treatment algorithms. Special populations, such as elderly patients, those with epilepsy, or high-demand athletes, pose additional challenges and require individualized strategies. Reverse shoulder arthroplasty has emerged as a salvage option in older patients with combined instability and cuff deficiency. In athletes, bone block procedures often provide more reliable outcomes than soft tissue repairs alone. Despite advances in surgical techniques, implants, and imaging, several issues remain unresolved. There is a lack of consensus on the optimal treatment for subcritical bone loss, limited high-level evidence comparing techniques, and variability in outcome definitions. Future research should aim to standardize shoulder instability treatment to create a more reproducible series supported by long-term data.