Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability

Introduction

Capsulolabral repair for anterior shoulder instability has been shown to provide reliable clinical outcomes. [1], Murphy AI, Hurley ET, Hurley DJ, Pauzenberger L, Mullett H. Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up. J Shoulder Elbow Surg 2019;28(11):2084-9. https://doi.org/10.1016/j.jse.2019.04.057.[2], Waterman BR, Burns TC, McCriskin B, Kilcoyne K, Cameron KL, Owens BD. Outcomes after bankart repair in a military population: predictors for surgical revision and long-term disability. Arthroscopy 2014;30(2):172-7. https://doi.org/10.1016/j.arthro.2013.11.004.[3], Rossi LA, Tanoira I, Brandariz R, Pasqualini I, Ranalletta M. Reasons Why Athletes Do Not Return to Sports After Arthroscopic Bankart Repair: A Comparative Study of 208 Athletes With Minimum 2-Year Follow-up. Orthop J Sports Med 2021;9(7):23259671211013394. https://doi.org/10.1177/23259671211013394.[4] Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am 2000;82-a(7):991-1003. https://doi.org/10.2106/00004623-200007000-00011. However, even though arthroscopic instability repair techniques have improved over the last decades, there remains a significant risk of recurrence after the index surgical stabilization. [4], Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am 2000;82-a(7):991-1003. https://doi.org/10.2106/00004623-200007000-00011.[5], Imhoff AB, Ansah P, Tischer T, Reiter C, Bartl C, Hench M, et al. Arthroscopic repair of anterior-inferior glenohumeral instability using a portal at the 5:30-o’clock position: analysis of the effects of age, fixation method, and concomitant shoulder injury on surgical outcomes. Am J Sports Med 2010;38(9):1795-803. https://doi.org/10.1177/0363546510370199.[6], Kang RW, Frank RM, Nho SJ, Ghodadra NS, Verma NN, Romeo AA, et al. Complications associated with anterior shoulder instability repair. Arthroscopy 2009;25(8):909-20. https://doi.org/10.1016/j.arthro.2009.03.009.[7], Larrain MV, Montenegro HJ, Mauas DM, Collazo CC, Pavón F. Arthroscopic management of traumatic anterior shoulder instability in collision athletes: analysis of 204 cases with a 4- to 9-year follow-up and results with the suture anchor technique. Arthroscopy 2006;22(12):1283-9. https://doi.org/10.1016/j.arthro.2006.07.052.[8], Lenters TR, Franta AK, Wolf FM, Leopold SS, Matsen FA, 3rd. Arthroscopic compared with open repairs for recurrent anterior shoulder instability. A systematic review and meta-analysis of the literature. J Bone Joint Surg Am 2007;89(2):244-54. https://doi.org/10.2106/jbjs.E.01139.[9] Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am 1978;60(1):1-16. Rates of recurrent shoulder instability after primary anterior capsulolabral repair have been reported to range between 4% to 60% of cases, while revision surgery is performed in up to 15% of these patients.[10], Lau BC, Johnston TR, Gregory BP, Bejarano Pineda L, Wu M, Fletcher AN, et al. Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2020;8(5):2325967120922571. https://doi.org/10.1177/2325967120922571.[11], Waterman BR, Leroux T, Frank RM, Romeo AA. The Evaluation and Management of the Failed Primary Arthroscopic Bankart Repair. J Am Acad Orthop Surg 2020;28(15):607-16. https://doi.org/10.5435/jaaos-d-17-00077.[12] Haskel JD, Wang KH, Hurley ET, Markus DH, Campbell KA, Alaia MJ, et al. Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies. J Shoulder Elbow Surg 2022;31(1):209-16. https://doi.org/10.1016/j.jse.2021.06.021.

The most common reasons for recurrent instability after soft tissue-based anterior shoulder stabilization include bony glenoid defects, engaging Hill-Sachs lesions, capsular redundancy, and traumatic events. [13], Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 2006;88(8):1755-63. https://doi.org/10.2106/jbjs.E.00817.[14], Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg 2004;13(3):279-85. https://doi.org/10.1016/j.jse.2004.01.008.[15], Bartl C, Schumann K, Paul J, Vogt S, Imhoff AB. Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability. Am J Sports Med 2011;39(3):511-8. https://doi.org/10.1177/0363546510388909.[16], Arner JW, Ruzbarsky JJ, Bradley JP, Provencher MT. Management of Complex and Revision Anterior Shoulder Instability. Arthroscopy 2022;38(5):1396-7. https://doi.org/10.1016/j.arthro.2022.03.009.[17] Muench LN, Imhoff AB. The unstable shoulder: what soft tissue, bony anatomy and biomechanics can teach us. Knee Surg Sports Traumatol Arthrosc 2021;29(12):3899-901. https://doi.org/10.1007/s00167-021-06743-0. There is a strong consensus from a clinical and health economic standpoint that bone-block transfers are a suitable procedure in this situation. [18], Ali ZS, Hurley ET, Jamal MS, Horan MP, Montgomery C, Pauzenberger L, et al. Low rate of recurrent instability following the open Latarjet procedure as a revision procedure for failed prior stabilization surgery. Knee Surg Sports Traumatol Arthrosc 2021;29(7):2110-7. https://doi.org/10.1007/s00167-020-06155-6.[19], Rossi LA, Tanoira I, Gorodischer T, Pasqualini I, Ranalletta M. Recurrence and Revision Rates With Arthroscopic Bankart Repair Compared With the Latarjet Procedure in Competitive Rugby Players With Glenohumeral Instability and a Glenoid Bone Loss <20. Am J Sports Med 2021;49(4):866-72. https://doi.org/10.1177/0363546520988154.[20] Makhni EC, Lamba N, Swart E, Steinhaus ME, Ahmad CS, Romeo AA, et al. Revision Arthroscopic Repair Versus Latarjet Procedure in Patients With Recurrent Instability After Initial Repair Attempt: A Cost-Effectiveness Model. Arthroscopy 2016;32(9):1764-70. https://doi.org/10.1016/j.arthro.2016.01.062. However, the high risk of development of premature osteoarthritis and graft osteolysis, with pooled mean rates of 28% and 30%, respectively, remain a concern with non-anatomic stabilization procedures such as the Latarjet procedure.[21] DeClercq MG, Martin MD, Whalen RJ, Cote MP, Midtgaard KS, Peebles LA, et al. Postoperative Radiographic Outcomes Following Primary Open Coracoid Transfer (Bristow-Latarjet) Vary in Definition, Classification, and Imaging Modality: A Systematic Review. Arthroscopy 2023. https://doi.org/10.1016/j.arthro.2023.09.032. Thus, in the absence of severe glenoid bone defects and engaging Hill-Sachs lesions, arthroscopic capsulolabral revision repair (ACRR) has been proposed as a suitable surgical approach, holding the advantages of anatomic labral repair, reduced morbidity, and simultaneous treatment of concomitant intra-articular pathologies. [11], Waterman BR, Leroux T, Frank RM, Romeo AA. The Evaluation and Management of the Failed Primary Arthroscopic Bankart Repair. J Am Acad Orthop Surg 2020;28(15):607-16. https://doi.org/10.5435/jaaos-d-17-00077.[15], Bartl C, Schumann K, Paul J, Vogt S, Imhoff AB. Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability. Am J Sports Med 2011;39(3):511-8. https://doi.org/10.1177/0363546510388909.[16], Arner JW, Ruzbarsky JJ, Bradley JP, Provencher MT. Management of Complex and Revision Anterior Shoulder Instability. Arthroscopy 2022;38(5):1396-7. https://doi.org/10.1016/j.arthro.2022.03.009.[22] Lee JH, Shin SJ. Revision Arthroscopic Labral Repair Using All-Suture Anchors in Patients With Subcritical Glenoid Bone Loss After Failed Bankart Repair: Clinical Outcomes at 2-Year Follow-up. Orthop J Sports Med 2023;11(3):23259671231151418. https://doi.org/10.1177/23259671231151418.

Preoperative planning and risk factor analysis

Prior to scheduling a patient with recurrent anterior instability after an index soft-tissue stabilization for ACRR, a detailed analysis of patient-specific and anatomic risk factors for subsequent failure should be performed.

Patient History

It is essential to differentiate patient-specific risk factors associated with the failure of soft tissue repair, which should focus on the type of primary instability (direction of dislocation, type and mechanism of event at onset of instability, number of previous dislocations, potential concomitant muscular disbalances or generalized joint hyperlaxity), the onset and severity of recurrence (differentiation between subluxation or dislocation, onset of symptoms already during activities of daily life, sleep or in midrange motion, potentially indicating severe instability), demographic risk factors (age < 20 years [23] Wasserstein D, Dwyer T, Veillette C, Gandhi R, Chahal J, Mahomed N, et al. Predictors of dislocation and revision after shoulder stabilization in Ontario, Canada, from 2003 to 2008. Am J Sports Med 2013;41(9):2034-40. https://doi.org/10.1177/0363546513492952. and male sex [24] Porcellini G, Campi F, Pegreffi F, Castagna A, Paladini P. Predisposing factors for recurrent shoulder dislocation after arthroscopic treatment. J Bone Joint Surg Am 2009;91(11):2537-42. https://doi.org/10.2106/jbjs.H.01126.) and behavioral risk factors (involvement in contact sports or a heavy physical occupation).

Physical Examination

The physical examination should include tests for anterior instability (anterior apprehension test, relocation release tests) and posterior instability (Jerk test, Kim test), as well as the load and shift test for increased anterior and posterior humeral translation. In addition, detecting any signs of capsular hyperlaxity such as a positive sulcus sign, a positive hyperabduction test according to Gagey, a passive external rotation > 90°, and a Beighton score of ≥4 points is of substantial clinical relevance. Treatment of patients presenting with antero-inferior instability and concomitant hyperlaxity remains a major challenge, due to hyperlaxity being an independent risk factor for recurrent instability and a predictor for failure following primary and revision arthroscopic Bankart repair. [25] Rupp MC, Rutledge JC, Quinn PM, Millett PJ. Management of Shoulder Instability in Patients with Underlying Hyperlaxity. Curr Rev Musculoskelet Med 2023;16(4):123-44. https://doi.org/10.1007/s12178-023-09822-6. As previous studies demonstrated a reduction of capsular volume by 57% in the setting of combined anteroinferior and posteroinferior capsular plication [26], Lubowitz J, Bartolozzi A, Rubinstein D, Ciccotti M, Schweitzer M, Nazarian L, et al. How much does inferior capsular shift reduce shoulder volume? Clin Orthop Relat Res 1996(328):86-90. https://doi.org/10.1097/00003086-199607000-00015.[27] Wiater JM, Vibert BT. Glenohumeral joint volume reduction with progressive release and shifting of the inferior shoulder capsule. J Shoulder Elbow Surg 2007;16(6):810-4. https://doi.org/10.1016/j.jse.2007.02.117., these patients may benefit from an additional suture anchor placed posteroinferiorly at the 7 o’clock position to create a superomedial capsular shift[25] Rupp MC, Rutledge JC, Quinn PM, Millett PJ. Management of Shoulder Instability in Patients with Underlying Hyperlaxity. Curr Rev Musculoskelet Med 2023;16(4):123-44. https://doi.org/10.1007/s12178-023-09822-6.

Surgical History

To determine technical risk factors potentially associated with failure of soft tissue repair, a review of surgical documents relevant for the index shoulder stabilization should include available preoperative imaging, surgical reports, and if possible arthroscopic footage. Imaging performed prior to the index stabilization should be assessed for risk factors such as glenoid bone loss, prevalence of a special labral tear configurations (anterior labroligamentous periosteal sleeve avulsion (APLSA) / humeral avulsion glenohumeral ligament (HAGL)/ superior labrum anterior posterior (SLAP)/ glenolabral articular disruption (GLAD)/Perthes lesion), increased capsular volume indicative of joint hyperlaxity, or a dysplastic labrum, which were potentially overlooked at the index surgery. Further, the number, type and positioning of anchors inserted at index stabilization as well as the compliance during rehabilitation should be assessed.

Radiographic Assessment

The radiographic assessment should comprise standard antero-posterior, axillary, and scapular y-view radiographs, and magnetic resonance imaging (MRI) to detect signs of bone loss, static humeral head subluxation, chondral lesions, labral lesions or deficiency, and capsular redundancy. For sufficiently assessing risk factors for subsequent failure of soft-tissue stabilization procedures in the revision setting, this should be complemented by a computed tomography (CT) scan to precisely quantify bony deformities of the glenoid and humeral head.

Historically, 20% to 25% has been deemed the “critical” cut-off value where glenoid bone loss should be surgically addressed using a bone augmentation procedure.[28], Friedman LGM, Lafosse L, Garrigues GE. Global Perspectives on Management of Shoulder Instability: Decision Making and Treatment. Orthop Clin North Am 2020;51(2):241-58. https://doi.org/10.1016/j.ocl.2019.11.008.[29] Shaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR, Shaha SH, et al. Redefining «Critical» Bone Loss in Shoulder Instability: Functional Outcomes Worsen With «Subcritical» Bone Loss. Am J Sports Med 2015;43(7):1719-25. https://doi.org/10.1177/0363546515578250. However, a “subcritical” bone loss of 13.5% was recently found to significantly impair functional outcomes following arthroscopic Bankart repair, questioning if these patients would have benefitted from bone grafting.[29] Shaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR, Shaha SH, et al. Redefining «Critical» Bone Loss in Shoulder Instability: Functional Outcomes Worsen With «Subcritical» Bone Loss. Am J Sports Med 2015;43(7):1719-25. https://doi.org/10.1177/0363546515578250.Additionally considering the substantial inter-rater variability of bone loss measurements even in 3D-CT scans described by Lacheta et al.,[30] Lacheta L, Herbst E, Voss A, Braun S, Jungmann P, Millett PJ, et al. Insufficient consensus regarding circle size and bone loss width using the ratio-»best fit circle»-method even with three-dimensional computed tomography. Knee Surg Sports Traumatol Arthrosc 2019;27(10):3222-9. https://doi.org/10.1007/s00167-019-05391-9. we have lowered the threshold value for performing a bone augmentation technique in our treatment algorithm to a glenoid bone loss of > 10% of the inferior glenoid width.

In the setting of a bipolar bone defect, composed of glenoid bone loss and a Hill-Sachs lesion, the glenoid track concept has proven its validity in risk stratification. In case of an Hill-Sachs interval greater than the glenoid track, this “off-track” situation requires a bone-based reconstruction or more complex arthroscopic adjunct procedures.[17] Muench LN, Imhoff AB. The unstable shoulder: what soft tissue, bony anatomy and biomechanics can teach us. Knee Surg Sports Traumatol Arthrosc 2021;29(12):3899-901. https://doi.org/10.1007/s00167-021-06743-0. Interestingly, Cong et al. found that the inferior extension below the humeral equator (lower-edge angle >90°) of an otherwise on-track Hill-Sachs lesion is a highly predictive risk factor for recurrent instability after primary arthroscopic Bankart repair.[31] Cong T, Charles S, Reddy RP, Fatora G, Fox MA, Barrow AE, et al. Defining Critical Humeral Bone Loss: Inferior Craniocaudal Hill-Sachs Extension as Predictor of Recurrent Instability After Primary Arthroscopic Bankart Repair. Am J Sports Med 2024;52(1):181-9. https://doi.org/10.1177/03635465231209443. Consequently, we have recently included the lower-edge angle as a measure of Hill-Sachs caudal extension into our risk factor assessment, as some patients with on-track lesions may benefit from a remplissage procedure.[31] Cong T, Charles S, Reddy RP, Fatora G, Fox MA, Barrow AE, et al. Defining Critical Humeral Bone Loss: Inferior Craniocaudal Hill-Sachs Extension as Predictor of Recurrent Instability After Primary Arthroscopic Bankart Repair. Am J Sports Med 2024;52(1):181-9. https://doi.org/10.1177/03635465231209443.

Indication for arthroscopic capsulolabral revision repair

Considering the previously described risk factor analysis for failure, ACRR is performed at our institution in patients with recurrent anterior instability after an open or arthroscopic index surgical soft-tissue-based anterior stabilization procedure with a glenoid bone defect of less than 10% of the inferior glenoid width and non-engaging Hill-Sachs lesion. Further, ACRR is only performed in patients not regularly participating in collision sports or with very heavy physical occupation.

Surgical technique

Patient Positioning

General anesthesia as well as additional local anesthesia via an interscalene block are administered. The patient is positioned in the lateral decubitus position for sterile preparation and draping. The position of the patient is secured in a vacuum mattress and both ventral and dorsal support. For adequate distraction of the glenohumeral joint traction is applied to the operative arm via a sling and a gallows frame. A physical examination under anesthesia assessing pathologic humeral translation and subluxation or dislocation as well as capsular laxity is performed to confirm the diagnosis.

Diagnostic Arthroscopy

First, a standard posterior viewing portal is established parallel to the joint line. During a standard diagnostic arthroscopy labral configuration, capsular volume, and concomitant pathologies are documented. Special attention is given to the assessment of the Hill-Sachs lesion. An anteroinferior portal at the lateral upper edge of the subscapularis tendon is established. A cannula (Twist-In, Arthrex Inc., Naples, FL) is placed in the anteroinferior portal. Then an anterosuperior viewing portal is established in the rotator interval and posterior to the long head of the biceps tendon. Under visualization via the anterosuperior portal, a cannula (Gemini, Arthrex Inc., Naples, FL) is positioned in the posterior portal.

Tissue Mobilisation and Anchor Placement

Subsequently, the retracted labrum and the scarred capsule are mobilized from the scapular neck down to the 6:00 or even 7:00 o’clock position using an arthroscopic tissue elevator or an electrofrequency device in severe retracted and scarred tissue. Previous suture material and loose anchors are carefully removed. The glenoid rim is then debrided using a shaver or Bankart rasp and the anchor insertion sites are prepared with light decortication to allow healing of the capsulolabral complex (Figure 1). The goal of tissue mobilisation is a tension-free reduction of the capsulolabral tissue on the glenoid rim. By stopping the arthroscopic fluid inflow, a self-reduction of the tissue can be observed when the capsulolabral tissue is appropriately released from its adhesions and scarring.

Next, a subscapularis split portal is created and a curved drill guide (Arthrex Inc.) including a sharp obturator is inserted under arthroscopic visualization. The obturator is carefully removed, and the guide placed approximately 2 mm to the articular rim at the most inferior repair position (5:30 o’clock). Once the correct position is ensured in a 135° orientation to the glenoid plane, a flexible 1.8mm drill is used to drill the respective tunnel (Figure 2A). Via the drill guide, a 1.8mm knotless all-suture anchor (Fibertak, Arthrex Inc.) is gently driven in as far as the drill guide allows (Figure 2B).

The handle and drill guide are removed leaving the sutures in place, which are then pulled on all together to assess stability and allow for proper seating of the anchor. For precise and successful placement of the anchor it is critical not to change the drill guide’s position and orientation when retracting the drill from the joint.

Subsequently, the blue repair suture is retrieved through the posterior portal. Via the anteroinferior portal, a 25° curved tissue penetrator and shuttling device (Suture Lasso, Arthrex Inc.) is inserted and rotated to penetrate the capsulolabral complex and emerge at the chondrolabral junction just inferior to the anchor site (Figure 3A). A nitinol wire is shuttled through and retrieved via the posterior portal, which is then used to shuttle the repair suture back in standard fashion and pass it through the capsulolabral complex (Figure 3B).

After switching the arthroscope to the posterior portal, the blue repair suture and the shuttling suture are retrieved via the anterosuperior portal to avoid entanglement of the sutures. The repair suture is then loaded through the loop end of the shuttling suture and the free end of the shuttling suture (tape) is pulled to shuttle the repair suture through the anchor until the desired tension is achieved (Figure 4).

Before the free end of the shuttling suture is pulled it should be ensured that both ends of the shuttling suture are running smoothly through the anchor. Additional 2 to 3 anchors are then placed at the anterior glenoid ascendingly covering the 4:00, and 3:00 o’clock positions. At the end of surgery, the repair sutures are re-tensioned one by one from caudal to cranial to remove any remaining slack and are finally cut flush with the tissue (Figure 5). [15] Bartl C, Schumann K, Paul J, Vogt S, Imhoff AB. Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability. Am J Sports Med 2011;39(3):511-8. https://doi.org/10.1177/0363546510388909.

Posteroinferior Capsulolabroplasty

In patients with clinical signs of hyperlaxity or significant capsular laxity left after the anterior capsulolabral repair, an additional posteroinferior capsulolabroplasty is performed. The posteroinferior labrum is carefully mobilized without complete detachment through the posterior portal. Next, a posterolateral working portal 2 cm inferior and lateral to the posterior viewing portal is established using the curved guide including the sharp obturator under arthroscopic visualization from the anterosuperior portal. The guide is placed at the 7:00 o’clock position and the repair and shift is performed similarly to the anterior repair using a 1.8mm knotless all-suture anchor (Fibertak, Arthrex Inc.).

Postoperative rehabilitation

Postoperatively, patients were placed in a shoulder sling for 6 weeks along with the following allowed range of motion:

• 1st-3rd postoperative week: Active-assistive Abd./Add.: 45°/0°/0°, active-assistive Flex./Ext.: 45°/0°/0°, active assistive I.R./E.R.: 80°/0°/0°.
• 4th-6th postoperative week: Active-assistive Abd./Add.: 90°/0°/0°, active-assistive Flex./Ext.: 90°/0°/0°, active-assistive I.R./E.R.: 80°/0°/0°.
• From the 7th postoperative week on: Full range of motion allowed.
• From the 6th postoperative month: Overhead sports permitted.

During the time of rehabilitation exercises for stabilizing the scapular setting and scapulothoracic rhythm should be performed regularly.

Discussion

In a recent systematic review analyzing clinical outcomes after ACRR, it was found that 79.7% of patients reported experiencing good to excellent functional outcomes after a mean follow-up of 3.1 years.[12] Haskel JD, Wang KH, Hurley ET, Markus DH, Campbell KA, Alaia MJ, et al. Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies. J Shoulder Elbow Surg 2022;31(1):209-16. https://doi.org/10.1016/j.jse.2021.06.021. Postoperatively, the included patients achieved a mean Rowe score of 84.2, mean Constant score of 87.9, mean SST score of 10.8, and VAS score of 1.9.[12] Haskel JD, Wang KH, Hurley ET, Markus DH, Campbell KA, Alaia MJ, et al. Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies. J Shoulder Elbow Surg 2022;31(1):209-16. https://doi.org/10.1016/j.jse.2021.06.021.Another important outcome measure for postoperative success after ACRR is the assessment of return to sports and level of play after surgery, especially in these young and physically active patients usually suffering from recurrent shoulder instability.[32], Lau BC, Pineda LB, Johnston TR, Gregory BP, Wu M, Fletcher AN, et al. Return to Play After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2021;9(3):2325967120982059. https://doi.org/10.1177/2325967120982059.[33], Arce G, Arcuri F, Ferro D, Pereira E. Is selective arthroscopic revision beneficial for treating recurrent anterior shoulder instability? Clin Orthop Relat Res 2012;470(4):965-71. https://doi.org/10.1007/s11999-011-2001-0.[34], Boileau P, Richou J, Lisai A, Chuinard C, Bicknell RT. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy 2009;25(10):1075-84. https://doi.org/10.1016/j.arthro.2009.04.073.[35] Patel RV, Apostle K, Leith JM, Regan WD. Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder. J Bone Joint Surg Br 2008;90(11):1462-7. https://doi.org/10.1302/0301-620x.90b11.21072. In a systematic review evaluating sports activity after ACRR, the authors found an overall rate of return to sports of 78.5%, however, only 47.5% of patients returned to their pre-injury level of play.[12] Haskel JD, Wang KH, Hurley ET, Markus DH, Campbell KA, Alaia MJ, et al. Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies. J Shoulder Elbow Surg 2022;31(1):209-16. https://doi.org/10.1016/j.jse.2021.06.021. In addition, Lau et al. showed in a more recent systematic review that the weighted mean rate of return to play was 84.0% after a mean follow-up of 39.1 months, while the reported time to return to play showed a weighted average of 7.8 months.[32] Lau BC, Pineda LB, Johnston TR, Gregory BP, Wu M, Fletcher AN, et al. Return to Play After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2021;9(3):2325967120982059. https://doi.org/10.1177/2325967120982059.Interestingly, 69.7% of patients returned to the same level while 27.3% returned to a lower level of play.[32] Lau BC, Pineda LB, Johnston TR, Gregory BP, Wu M, Fletcher AN, et al. Return to Play After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2021;9(3):2325967120982059. https://doi.org/10.1177/2325967120982059.

When looking at failure rates after ACRR it has been shown that recurrence of instability ranged between 0% and 41.5% of cases at a mean follow-up of 39.5 months.[10] Lau BC, Johnston TR, Gregory BP, Bejarano Pineda L, Wu M, Fletcher AN, et al. Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2020;8(5):2325967120922571. https://doi.org/10.1177/2325967120922571. More specifically, the weighted mean recurrent instability rate was 16.0%, along with a weighted mean revision surgery rate of 9.0%.[10] Lau BC, Johnston TR, Gregory BP, Bejarano Pineda L, Wu M, Fletcher AN, et al. Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2020;8(5):2325967120922571. https://doi.org/10.1177/2325967120922571.In addition, Haskel et al. found an overall rate of recurrent instability of 26.2% of cases at a mean follow-up of 37.6 months.[12] Haskel JD, Wang KH, Hurley ET, Markus DH, Campbell KA, Alaia MJ, et al. Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies. J Shoulder Elbow Surg 2022;31(1):209-16. https://doi.org/10.1016/j.jse.2021.06.021.Interestingly, the number of previous surgeries and hyperlaxity have been shown to be significant risk factors for failure.[36] Shin JJ, Mascarenhas R, Patel AV, Yanke AB, Nicholson GP, Cole BJ, et al. Clinical outcomes following revision anterior shoulder arthroscopic capsulolabral stabilization. Arch Orthop Trauma Surg 2015;135(11):1553-9. https://doi.org/10.1007/s00402-015-2294-7. Further, the presence of off-track lesions, age of over 22 years, and ligamentous laxity have been described as independent predictors of recurrence.[37] Su F, Kowalczuk M, Ikpe S, Lee H, Sabzevari S, Lin A. Risk Factors for Failure of Arthroscopic Revision Anterior Shoulder Stabilization. J Bone Joint Surg Am 2018;100(15):1319-25. https://doi.org/10.2106/jbjs.17.01028.

In general, previous work pertaining to functional outcomes, return to sports as well as failure and revision rates after ACRR are limited to only a short- to mid-term follow-up ranging from 1.8 to 5.8 years.[10], Lau BC, Johnston TR, Gregory BP, Bejarano Pineda L, Wu M, Fletcher AN, et al. Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2020;8(5):2325967120922571. https://doi.org/10.1177/2325967120922571.[12], Haskel JD, Wang KH, Hurley ET, Markus DH, Campbell KA, Alaia MJ, et al. Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies. J Shoulder Elbow Surg 2022;31(1):209-16. https://doi.org/10.1016/j.jse.2021.06.021.[15], Bartl C, Schumann K, Paul J, Vogt S, Imhoff AB. Arthroscopic capsulolabral revision repair for recurrent anterior shoulder instability. Am J Sports Med 2011;39(3):511-8. https://doi.org/10.1177/0363546510388909.[32], Lau BC, Pineda LB, Johnston TR, Gregory BP, Wu M, Fletcher AN, et al. Return to Play After Revision Anterior Shoulder Stabilization: A Systematic Review. Orthop J Sports Med 2021;9(3):2325967120982059. https://doi.org/10.1177/2325967120982059.[38] Friedman LG, Griesser MJ, Miniaci AA, Jones MH. Recurrent instability after revision anterior shoulder stabilization surgery. Arthroscopy 2014;30(3):372-81. https://doi.org/10.1016/j.arthro.2013.11.019. Future studies will show if outcomes after undergoing ACRR, including functional scores, sports activity as well as failure and revision rates, will be maintained over the long-term.