Quick answer: Each time a shoulder dislocates, it can wear away bone from the front of the socket (glenoid) and dent the back of the ball (a Hill-Sachs lesion). When there is little bone loss, an arthroscopic labral (Bankart) repair works well. As bone loss increases, soft-tissue repair alone fails more often, and the best results usually come from adding a remplissage or rebuilding the socket with bone: a Latarjet procedure or a distal tibia allograft (DTA) [1–4]. A CT scan that measures both sides of the "bipolar" bone loss is the key to choosing.
Why Shoulders Keep Dislocating
The shoulder is a large ball sitting on a shallow socket. A rim of cartilage called the labrum deepens the socket, and the capsule and ligaments hold the ball in place. A dislocation usually tears the labrum off the front of the socket (a Bankart lesion). Without treatment, younger and more active patients have a high chance of dislocating again; see First-Time Shoulder Dislocation in Athletes.
With repeated dislocations, the damage is no longer only soft tissue:
- Glenoid bone loss: the front edge of the socket chips or wears away, making the socket narrower and shallower. Severe loss gives the socket an "inverted pear" shape [5].
- Hill-Sachs lesion: each time the ball slips out, the back of the ball strikes the socket rim and leaves a dent.
Together these are called bipolar bone loss, and the way the two interact determines how likely the shoulder is to slip out again [5, 6].
On-Track vs. Off-Track: How Surgeons Measure Risk
The glenoid track concept compares the width of the remaining socket with the size and position of the Hill-Sachs dent [6, 7]:
- On-track: the dent stays on the socket as the arm moves, so the ball cannot catch on the rim.
- Off-track: the dent can drop over the front edge of the socket and lever the ball out.
Off-track lesions, glenoid bone loss, younger age, contact or high-level sports and a high Instability Severity Index Score are the risk factors most often linked to failure of an arthroscopic Bankart repair [8]. Even some "on-track" shoulders that are close to the edge, with a distance to dislocation under 8 mm, have higher failure rates [9].
How Much Bone Loss Is "Too Much"?
For years, 20–25% loss of the socket width was considered the "critical" threshold above which a bone procedure is needed. Newer research suggests the threshold is lower:
- In a study of active patients, bone loss above 13.5% led to clinically worse shoulder scores after arthroscopic Bankart repair, even in patients who did not dislocate again. The quarter of patients with the most bone loss had a 27.8% failure rate compared with 7.3% in the others [1].
- In active-duty service members with "subcritical" bone loss of 13.5–24%, patients treated with an open Latarjet had better function scores and far fewer permanent physical restrictions (3 vs. 16 patients) than those treated with arthroscopic Bankart repair [10].
Because of this, the decision is based on the full picture (bone loss on both sides, age, sport and number of dislocations) rather than one cutoff.
The Treatment Options
Arthroscopic Bankart repair
Through small incisions, the torn labrum and ligaments are reattached to the socket with anchors. It is the right operation for many patients with little or no bone loss. In a long-term systematic review of 1,652 repairs, the re-dislocation rate was 15.1% after arthroscopic Bankart repair, compared with 2.7% after Latarjet; Latarjet had a higher complication rate [3]. More on shoulder instability surgery.
Bankart repair with remplissage
When the Hill-Sachs dent is significant but socket bone loss is limited, a remplissage ("filling in") stitches the back of the rotator cuff into the dent so it can no longer catch on the socket. In a 2024 meta-analysis, adding remplissage significantly lowered recurrence, dislocation and instability-related revision, and increased return to sport, with an average loss of only about 1° of external rotation at the side [2, 11].
Latarjet procedure
The Latarjet moves a small piece of bone (the coracoid) with its attached tendon to the front of the socket, held with screws. It works three ways: it widens the socket, the tendon acts as a sling in front of the ball, and the repaired capsule adds stability. Long-term reviews show:
- At 10+ years: recurrent instability in 8.5% (re-dislocation 3.2%), revision in 3.7%, 84.9% return to sport and 86.1% good or excellent outcomes [4].
- At 15+ years: 93.5% of patients satisfied, recurrent instability in 7.7% and revision in 5.15% [12].
- Arthritis changes on X-ray are common in the long term after any instability treatment, including Latarjet, and some patients have residual pain [4, 12, 13].
More on the Latarjet procedure.
Distal tibia allograft (DTA)
A DTA rebuilds the front of the socket with a piece of donor bone from the lower end of the tibia (shin bone). The tibia's curved, cartilage-covered surface closely matches the shape of the socket, which makes it useful for large defects, failed earlier surgery including a failed Latarjet, or when the coracoid is not suitable.
- In a 2025 systematic review (341 patients, average bone loss 20–33%), recurrent dislocation ranged from 0% to 2.0%, with large improvements in function scores [14].
- A 2024 meta-analysis of 329 patients found a 7.1% complication rate (most often hardware), recurrent subluxation in 1.2%, and redislocation requiring reoperation in 0.3%. Partial graft resorption was seen in 36.5% [15].
- Biomechanical studies show a near-anatomic reconstruction of the socket, with improved contact area and stability [14].
- Overall, outcomes with free bone blocks from donor bone (allograft) are comparable to the patient's own bone (autograft) [16, 17].
More on arthroscopic anatomic glenoid reconstruction with distal tibia allograft.
Which Operation Is Right for Me?
A general guide, always adjusted to the individual:
| Situation | Usual options |
|---|---|
| Little glenoid bone loss, on-track Hill-Sachs | Arthroscopic Bankart repair |
| Little glenoid bone loss, significant or near-track Hill-Sachs | Bankart repair + remplissage |
| Moderate or "subcritical" bone loss in a high-risk athlete | Latarjet, or Bankart + remplissage in selected patients |
| Large glenoid bone loss or off-track lesion | Latarjet or distal tibia allograft |
| Failed earlier stabilization, including failed Latarjet | Distal tibia allograft or other bone-block reconstruction |
Scoring systems that combine X-ray or CT findings with age, sport and laxity help guide the decision, and using CT-based glenoid track measurements may spare some patients an unnecessary Latarjet [7].
What Recovery Looks Like
Most stabilization operations are outpatient. A sling is worn for several weeks, followed by a structured physical therapy program. Return to contact or overhead sports is usually considered at around four to six months, once strength, motion and confidence have returned and, after a bone procedure, once imaging shows the bone has healed.
When to See a Shoulder Specialist
- Your shoulder has dislocated more than once, or slips partly out (subluxates)
- You feel apprehension with the arm overhead or out to the side
- A previous stabilization has failed
- You are a contact or overhead athlete with any dislocation
Evaluation includes an exam and usually a CT scan to measure bone loss on both the socket and the ball. See shoulder dislocation and instability and labral tears.
FAQs
Can a shoulder that keeps dislocating heal without surgery? The labrum and bone usually do not heal back in place on their own. Therapy can strengthen the muscles around the shoulder, but younger and active patients with repeated dislocations often continue to have instability without surgery.
Is Latarjet better than arthroscopic Bankart repair? For shoulders with significant bone loss or high-risk features, Latarjet has lower re-dislocation rates; it is a bigger operation with a higher complication rate [3]. For shoulders with little bone loss, arthroscopic repair, with or without remplissage, works well.
What is a distal tibia allograft? Donor bone from the end of the shin bone, shaped to rebuild the front of the socket. It is mainly used for large bone defects and failed earlier surgery, and has low re-dislocation rates in published studies [14, 15].
Will I lose motion after surgery? Most patients regain functional motion. Small losses of external rotation can occur. Adding remplissage cost about 1° of external rotation on average in a recent meta-analysis [11].
References
- Shaha JS, Cook JB, Song DJ, et al. Redefining "critical" bone loss in shoulder instability: functional outcomes worsen with "subcritical" bone loss. Am J Sports Med. 2015;43(7):1719-1725. PubMed 25883168 · doi:10.1177/0363546515578250
- Camus D, Domos P, Berard E, et al. Isolated arthroscopic Bankart repair vs. Bankart repair with "remplissage" for anterior shoulder instability with engaging Hill-Sachs lesion: a meta-analysis. Orthop Traumatol Surg Res. 2018;104(6):803-809. PubMed 29960091 · doi:10.1016/j.otsr.2018.05.011
- Rollick NC, Ono Y, Kurji HM, et al. Long-term outcomes of the Bankart and Latarjet repairs: a systematic review. Open Access J Sports Med. 2017;8:97-105. PubMed 28450792 · doi:10.2147/OAJSM.S106983
- Hurley ET, Jamal MS, Ali ZS, et al. Long-term outcomes of the Latarjet procedure for anterior shoulder instability: a systematic review of studies at 10-year follow-up. J Shoulder Elbow Surg. 2019;28(2):e33-e39. PubMed 30545784 · doi:10.1016/j.jse.2018.08.028
- Di Giacomo G, de Gasperis N, Scarso P. Bipolar bone defect in the shoulder anterior dislocation. Knee Surg Sports Traumatol Arthrosc. 2016;24(2):479-488. PubMed 26704802 · doi:10.1007/s00167-015-3927-7
- 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(1):90-98. PubMed 24384275 · doi:10.1016/j.arthro.2013.10.004
- Di Giacomo G, Peebles LA, Pugliese M, et al. Glenoid Track Instability Management Score: radiographic modification of the Instability Severity Index Score. Arthroscopy. 2020;36(1):56-67. PubMed 31864596 · doi:10.1016/j.arthro.2019.07.020
- Trasolini NA, Dandu N, Azua EN, et al. Inconsistencies in controlling for risk factors for recurrent shoulder instability after primary arthroscopic Bankart repair: a systematic review. Am J Sports Med. 2022;50(13):3705-3713. PubMed 34591717 · doi:10.1177/03635465211038712
- Li RT, Kane G, Drummond M, et al. On-track lesions with a small distance to dislocation are associated with failure after arthroscopic anterior shoulder stabilization. J Bone Joint Surg Am. 2021;103(11):961-967. PubMed 33764924 · doi:10.2106/JBJS.20.00917
- Min KS, Wake J, Cruz C, et al. Surgical treatment of shoulder instability in active-duty service members with subcritical glenoid bone loss: Bankart vs. Latarjet. J Shoulder Elbow Surg. 2023;32(4):771-775. PubMed 36375750 · doi:10.1016/j.jse.2022.10.011
- Ahmed AF, Polisetty TS, Wang C, et al. Higher return to sport and lower revision rates when performing arthroscopic Bankart repair with remplissage for anterior shoulder instability with a Hill-Sachs lesion: a meta-analysis. J Shoulder Elbow Surg. 2024;33(8):1836-1846. PubMed 38499236 · doi:10.1016/j.jse.2024.01.045
- Davey MS, Hurley ET, Kilkenny C, et al. Long-term outcomes of anterior shoulder instability treated with open Latarjet procedure: a systematic review of outcomes at a minimum 15-year follow-up. Shoulder Elbow. 2024;16(1):8-14. PubMed 38435043 · doi:10.1177/17585732221141062
- Gilat R, Lavoie-Gagne O, Haunschild ED, et al. Outcomes of the Latarjet procedure with minimum 5- and 10-year follow-up: a systematic review. Shoulder Elbow. 2020;12(5):315-329. PubMed 33123221 · doi:10.1177/1758573220945318
- Lorentz SG, Hurley ET, Meyer AM, et al. Distal tibial allograft for the treatment of shoulder instability provides excellent results with low rates of recurrent instability: a systematic review of clinical and biomechanical studies. Arthroscopy. 2025;41(11):4804-4814. PubMed 40373882 · doi:10.1016/j.arthro.2025.05.007
- Singh M, Byrne R, Chang K, et al. Distal tibial allograft for the treatment of anterior shoulder instability with glenoid bone loss: a systematic review and meta-analysis. Am J Sports Med. 2025;53(1):210-216. PubMed 38384193 · doi:10.1177/03635465231223124
- Gilat R, Wong SE, Lavoie-Gagne O, et al. Outcomes are comparable using free bone block autografts versus allografts for the management of anterior shoulder instability with glenoid bone loss: a systematic review and meta-analysis of "the non-Latarjet." Knee Surg Sports Traumatol Arthrosc. 2021;29(7):2159-2174. PubMed 32749510 · doi:10.1007/s00167-020-06194-z
- Villatte G, Martins A, Erivan R, et al. Use of allograft to reconstruct anterior bony glenoid defect in chronic glenohumeral instability: a systematic review. Arch Orthop Trauma Surg. 2020;140(10):1475-1485. PubMed 32524228 · doi:10.1007/s00402-020-03511-6
- American Academy of Orthopaedic Surgeons. Chronic Shoulder Instability. OrthoInfo. orthoinfo.org