Treatment of Recurrent Shoulder Dislocation in Turkey

It may begin with a single shoulder dislocation during sports or a fall, after which the joint slips out of place again and again, because once the shoulder has dislocated it becomes easier to dislocate again. Some patients feel that the shoulder is unstable and begin to avoid activities they once performed with ease.

Recurrent dislocation is often linked to injuries of the glenoid labrum or the ligaments surrounding the joint, and it may be accompanied by loss of part of the bone at the rim of the socket in which the head of the humerus sits. Treatment depends on the cause of the instability and on any associated injuries; non-surgical treatment may be enough in some cases, while surgery is discussed in others.

When surgery is discussed, two operations that differ in both goal and technique are commonly mentioned: the Bankart repair, which re-secures the soft tissues, and the Latarjet procedure, which adds bony support. The surgeon chooses between them after examination, imaging, and an estimate of bone loss and of the pattern of injury.

• Recurrent shoulder dislocation means that the joint dislocates or partially slips out of place more than once; anterior (forward) dislocation is the most common.
• Factors associated with recurrence include a labral (Bankart) injury, loss of bone at the rim of the glenoid socket, and a Hill-Sachs lesion in the humeral head.
• Evaluation relies on the medical history, clinical examination, and imaging; a CT scan may be requested to estimate bone loss.
• Physical therapy and activity modification may be tried first in some cases.
• Bankart and Latarjet are two operations that differ in principle. Neither is superior in every patient, and there is no single agreed-upon threshold for choosing between them.
• Outcomes, the likelihood of re-dislocation, complications, and recovery time vary between studies, patients, and centers.
• Cost is estimated initially and is not finalized until imaging and medical reports have been reviewed.

What Is Recurrent Shoulder Dislocation?

The shoulder is the joint most prone to dislocation in the body, and anterior dislocation is the most common type. A dislocation may be complete, in which the head of the humerus comes fully out of the socket, or partial, in which the head slips and then returns. The ligaments may stretch or tear when a dislocation occurs, and after a first dislocation, recurrence becomes easier.

The AAOS calls repeated slipping or dislocation after the initial injury "chronic shoulder instability," and distinguishes between complete dislocation and partial dislocation (subluxation).

This article addresses recurrent anterior instability after an injury. It does not cover a first-time acute dislocation or multidirectional instability associated with ligament hypermobility, as these conditions are managed differently. Nor does it cover shoulder replacement, rotator cuff repair, or the treatment of arthritis.

How Does the Shoulder Joint Work?

The head of the humerus sits in a socket in the shoulder blade called the glenoid. A ring of tissue called the labrum surrounds the rim of the socket, and the capsule and ligaments around the joint help keep the head in place.

Instability arises when these structures are damaged, when part of the bone that cradles the head is lost, or when both occur together.

Why Does Dislocation Recur?

Dislocation does not recur in everyone who has experienced it once, and no single factor explains recurrence in all patients. The sources mention factors associated with the likelihood of recurrence:

• Young age at the first injury, male sex, participation in sports, and the presence of a bone deficiency. Dislocation is seen most often in adolescents and people in their twenties, especially athletes in contact sports.
• Injury to the labrum and stretching of the capsule and ligaments.
• Loss of bone from the rim of the glenoid and a Hill-Sachs lesion in the humeral head. Bone loss may increase with repeated dislocations, which is why treatment planning may change over time.

Bankart Injury, Bone Loss, and Hill-Sachs Lesion

Bankart Injury

This is detachment of the labrum together with the capsule from the rim of the socket at its anterior-inferior portion, and it is usually associated with anterior dislocation. The injury may involve soft tissue only, which is a soft-tissue Bankart lesion. It may be accompanied by a fracture of the glenoid rim, in which case it is called a Bony Bankart lesion.

The presence of a Bankart injury does not mean that every patient needs a Bankart operation. The choice of treatment depends on the amount of bone loss, the Hill-Sachs lesion, the patient's activity level, and other factors.

Bony Bankart

A review published in the Polish Journal of Radiology defines the bony injury as detachment of the anterior-inferior labrum accompanied by a fracture of the glenoid rim. The review stresses that measuring the bone defect is important for treatment decisions, but acknowledges that there is no consensus on the percentage of loss that raises the risk of re-dislocation.

Glenoid Bone Loss

This means loss of part of the bone at the anterior edge of the glenoid, either through a fracture at the time of injury or through erosion of the rim with repeated dislocation or slipping, which may create a cycle of recurrent episodes.

There is no single agreed-upon numerical threshold. This is the most important thing for patients to know about the figures in circulation:

• A review in SICOT-J states that loss exceeding 25% of the glenoid width usually calls for a bone graft, and that indications for Latarjet may begin at roughly 15% or more ("subcritical" loss).
• The Shaha study indicated that the historically accepted threshold was between 20% and 25%, and that its data suggest the "critical" threshold should be lower. The sample was 72 patients (73 shoulders) at a single military institution.
• A figure of 13.5% was used as a "subcritical" threshold in a study of collegiate football players: instability did not recur in 47 players whose loss was below 13.5%, and it recurred in the three who exceeded it. However, the study included only 50 players and excluded those whose loss exceeded 20% and those with off-track lesions, so its result cannot be generalized.
• In a 17-year follow-up after arthroscopic Bankart repair, poorer function was seen with initial loss exceeding 7%, but the researchers felt that this alone did not justify choosing a different treatment.

The figures differ according to the study, the method of measurement, and the population studied. For this reason, the operation should not be chosen on the basis of a single number; the decision rests with the surgeon after a complete evaluation.

Hill-Sachs Lesion

When the head of the humerus dislocates forward, the back of the head may be compressed against the anterior rim of the glenoid, producing a Hill-Sachs lesion. This lesion is analyzed in relation to the "glenoid track"; a lesion that engages the anterior rim (off-track) may cause partial slipping. Repeated slipping or dislocation may also erode the rim of the socket.

The Hill-Sachs lesion and glenoid bone loss are different problems in terms of location: the first is in the humeral head and the second is in the socket. They are considered together when planning treatment.

The Glenoid Track: On-Track and Off-Track

The glenoid track concept is used to determine whether a Hill-Sachs lesion will engage the anterior rim of the socket, whether or not there is glenoid bone loss. If it engages, it is called off-track; if it does not engage, it is called on-track. The SICOT-J review notes that the width of the track averages about 83% of the glenoid width.

The published framework suggests the following treatment strategy:

• On-track lesion with less than 25% loss: Bankart repair is often sufficient.
• Off-track lesion with less than 25% loss: remplissage is added to the Bankart repair.
• Loss exceeding 25%: a bone graft such as Latarjet is discussed.

This is one framework from a particular research school, not a global consensus; there is still a need for consensus on algorithms with validated thresholds. Remplissage is an additional procedure discussed in some cases, and it may reduce recurrence at the expense of shoulder motion. It is not the focus of this article.

How Is Shoulder Instability Diagnosed?

Evaluation begins with the medical history (how the first dislocation occurred and how many times it has recurred), after which the doctor examines the movement and stability of the shoulder. The AAOS notes that the doctor may request X-rays and magnetic resonance imaging (MRI), and sometimes a CT scan to estimate bone loss when dislocation recurs.

The tests required vary from patient to patient, and not every patient needs every imaging method. The type of operation cannot be determined before the images and reports have been reviewed.

When Is Non-Surgical Treatment Enough?

Surgery is not the only option for every patient. Treatment of chronic instability usually begins with activity modification, anti-inflammatory medication, and physical therapy to strengthen the shoulder muscles and improve control of them, and it may take several months to judge the result.

Non-surgical treatment is considered a good option for multidirectional instability and for a first dislocation in people without risk factors. In young athletes and people with risk factors, early surgical stabilization may be discussed, and surgeons debate this point.

Non-surgical treatment also has limits: it does not guarantee that dislocation will not recur, and it may not be enough when there is a structural injury or significant bone loss. Persistent symptoms alone do not automatically mean that surgery is needed before a medical evaluation.

When Is Surgery Discussed?

The surgeon discusses surgery according to the combination of factors rather than any single factor, including:

• Recurrent dislocation or a sense of instability despite treatment.
• A structural injury to the labrum or capsule.
• The amount of glenoid bone loss, and the presence of a Hill-Sachs lesion.
• The patient's age, sporting or occupational activity, and expectations.

In the sources reviewed, we found no criterion based on the number of dislocation episodes alone for choosing surgery or its type. The AAOS states that surgery may be arthroscopic, with most procedures performed as day surgery without an overnight stay, or open, and that bone loss may require special treatment.

Arthroscopic Bankart Repair

Goal: To repair the labrum and capsule and re-secure them to the rim of the socket. The tissues are reattached to the bone with sutures and anchors inserted through small incisions using an arthroscope.

When it may be suitable: Soft-tissue repair is regarded as the widely accepted approach for instability in which soft-tissue injury predominates without significant bone loss, and it is the option favored by most surgeons.

Limitations:

• The review notes that the failure rate with modern anchors ranged from 5% to 15% in studies at 6 to 14 years, and reached 26.6% in another study, and that recurrence may be higher in contact athletes. These figures come from different studies and do not apply to every patient.
• The operation does not address every cause of instability; the likelihood that soft-tissue repair alone will succeed may decrease as bone loss increases.
• When an off-track Hill-Sachs lesion is present, the surgeon may add a remplissage procedure, which may reduce recurrence at the expense of shoulder motion.

The Latarjet Procedure

Goal: To transfer the coracoid process (a bony projection of the shoulder blade) together with its attached tendon to the anterior-inferior part of the glenoid through a split in the subscapularis muscle, and then to fix it, usually with screws. The operation works through combined effects: increasing the width of the glenoid, increasing tension in the lower third of the subscapularis muscle, and the dynamic "sling" effect of the tendon when the arm is raised and rotated outward.

When it is discussed: Reviews have described it as effective for recurrent anterior instability, particularly with glenoid bone loss or bone loss on both sides (the head and the socket), or when there is an irreparable capsule and ligament injury. It may also be used as a salvage procedure after failure of an initial soft-tissue repair.

Cautions:

• The operation is more complex than the Bankart repair, and transferring the coracoid process alters anatomy and carries a higher risk of nerve injury.
• It is not suitable for every patient; contraindications include a previous fracture or deformity of the coracoid process. Recurrent dislocation alone is not an automatic reason to perform it.
• The arthroscopic technique has a learning curve. A review of 11 observational studies found that open and arthroscopic surgery were similar in most outcomes, with differences in the rate of nonunion and of revision surgery.

The Difference Between Bankart and Latarjet, and How the Surgeon Chooses

The following compares the two operations on the most important aspects:

• Principle: Arthroscopic Bankart re-secures the labrum and capsule with anchors, whereas Latarjet adds a bone graft from the coracoid process together with a dynamic muscular effect.
• What each operation targets: Bankart targets soft-tissue tears; Latarjet is discussed when there is bone loss, an irreparable capsular injury, or failure of a previous repair.
• Bone loss: The likelihood of success with Bankart may decrease with significant loss, whereas Latarjet is discussed when loss is significant.
• Bone graft: Bankart does not require a graft; Latarjet does, and the graft must heal.
• Complications: Rates are low after Bankart in the reviews, with a possibility of underreporting. They are relatively higher after Latarjet and include graft and nerve problems.
• Likelihood of recurrent dislocation: Relatively higher after Bankart in several observational studies, and relatively lower after Latarjet in those studies.
• Rehabilitation: Protocols vary for both operations, with additional restrictions in some Latarjet protocols.

A note on reading this comparison: It does not mean that one operation is absolutely superior to the other. Patient characteristics differ between studies, most are observational, and the results of different studies cannot be combined as if they came from a single trial.

How Does the Surgeon Choose the Operation?

The surgeon weighs several elements together:

• The medical history, examination, and pattern of instability.
• The amount of glenoid bone loss.
• The Hill-Sachs lesion, and whether it is on-track or off-track.
• Whether the labrum and capsule are repairable.
• The patient's activity and demands.
• The surgeon's experience with the proposed procedure, since newer procedures have a learning curve.

One published framework is the one given in the glenoid track section above, but it is a single framework and there is no single agreed-upon threshold. Therefore, ask your surgeon why the proposed operation is favored for your case specifically.

Outcomes and the Likelihood of Recurrent Dislocation

A systematic review of studies with follow-up of five years or more estimated re-dislocation at about 15.1% after arthroscopic Bankart, 7.7% after open Bankart, and 2.7% after open Latarjet. However, the difference was statistically significant only between arthroscopic Bankart and open Latarjet, the available evidence is of low level, and a proportion of patients continued to report subjective instability or arthritic changes after five years regardless of the procedure.

In more recent meta-analyses of observational studies, the likelihood of recurrence and re-dislocation was higher after arthroscopic Bankart than after Latarjet: an analysis of 3,275 shoulders, and an analysis of 21 studies including 3 randomized trials, which also indicated that overall complications were higher after Latarjet.

These figures should be read with caution:

• Most studies are observational, and the patients selected for each operation may differ, so it cannot be concluded that one is better for every patient.
• Results in athletes or military samples should not be generalized to all patients.
• The absence of recurrent dislocation does not mean that the shoulder has returned completely to normal.
• Short-term results differ from long-term results.

Risks and Complications

Arthroscopic Bankart

A systematic review of complications after modified arthroscopic Bankart repair estimated the overall rate at about 0.67%, the most common being stiffness (about 0.32%) followed by persistent pain (about 0.17%). Recurrent instability remains the most prominent problem, and it is separate from this percentage. In 30-day complication data, the rate was 0.6% after arthroscopic Bankart and 1.0% after open Bankart. These figures should be read with caution, as another review noted the possibility of underreporting of complications in arthroscopic Bankart studies.

Latarjet

• A systematic review (35 studies, 2,560 operations) estimated the overall complication rate at about 16.1%: about 3.4% during surgery (nerve injuries about 1.9% and surgical fractures about 1.0%), about 6.5% afterward (the most common being graft nonunion, about 1.3%), and an unplanned additional operation in about 2.6%. Intraoperative complications were higher with the arthroscopic technique, and instability-related complications were lower.
• An older review with a broader definition of complications estimated the rate at about 30%.
• A short-term review estimated it at about 6.1% for open surgery and 6.8% for arthroscopic surgery, the most common being graft-related complications.
• In 30-day data, the rate was 5.5% after Latarjet-Bristow versus 0.6% after arthroscopic Bankart, with wound infection and venous thrombosis among the most frequently recorded after Latarjet-Bristow. The sample was small and follow-up was only 30 days.
• In a single-center study over 90 days, the complication rate did not differ between open and arthroscopic surgery.
• Graft healing: nonunion was higher in open surgery, and screw malposition was greater in arthroscopic surgery, but follow-up periods in most studies were short. The risk of nerve injury is higher with coracoid transfer.

The figures vary (from about 6% to about 30%) because the definition of a complication, the length of follow-up, and the population studied differ between studies. Risks are affected by the surgeon's experience and the patient's anatomy, and no operation is free of risk.

Recovery and Return to Work and Sport

There is no single protocol for all patients:

• Researchers who studied arthroscopic Bankart protocols published on the websites of academic orthopedic programs found them highly variable and different from consensus protocols.
• In a study of Latarjet protocols published online, all of them (31 protocols) recommended using a sling after surgery, with wide variation in exercises and motion goals, and many milestones were earlier than in Bankart protocols (level C recommendation).
• In a systematic review of 41 studies on Bankart with remplissage, protocols also varied, and only two of 27 comparative studies tailored the protocol to the procedure.

An example from a single institution (not a rule for every patient): a British hospital guideline (RJAH) provides for a sling for about 3 weeks after arthroscopic Bankart, return to manual work after about 12 weeks, and contact sports after about 6 months. The guideline treats Latarjet in the same way, with a restriction on biceps resistance for about 6 weeks.

Protocols usually progress from protecting the repair or graft, to restoring motion, then strength and muscular control, and then a gradual return to activities. Progress depends on the type of operation, the condition of the tissues, bone loss, graft healing, the surgeon's instructions, and the patient's response. The comparison study indicated that differences in the timing of milestones may contribute to the earlier return to sport reported in the literature after Latarjet compared with Bankart, but this hypothesis has not been well studied.

These sources do not set a single duration that suits all patients or all sports. Returning to training differs from returning to full competition, and returning to the previous level of performance cannot be guaranteed. Patients should not return early to activities that could expose the shoulder to dislocation, and no home program replaces the instructions of the surgeon and physical therapist.

Cost of Treating Recurrent Shoulder Dislocation in Turkey

O9 Medical estimates the initial cost of treating recurrent shoulder dislocation in Turkey at between USD 3,000 and USD 4,000. This is a non-binding initial estimate issued by O9 Medical; it is not drawn from a scientific study or a medical body.

The final cost may be affected by whichever of the following factors apply:

• The type of operation recommended by the surgeon.
• The degree of instability.
• The presence of glenoid bone loss.
• The presence of a Hill-Sachs lesion.
• The complexity of the case.
• Previous operations.
• The need for additional procedures.
• The type of fixation devices used.
• The duration of surgery.
• The length of hospital stay.
• Tests and imaging.
• Physical therapy and rehabilitation needs.
• The patient's general health.

The final price is determined only after the case has been evaluated and the imaging and medical reports have been reviewed. Determining the type of operation is an essential part of determining the cost, since Bankart and Latarjet are different operations, and the treatment plan may differ from case to case.

When you receive the final offer, ask which items are included and which are not, such as accommodation, tests, physical therapy, and follow-up, and do not assume that they are included.

Treatment in Turkey and the Role of O9 Medical

O9 Medical helps patients understand the medical options available, arranges communication with medical providers, and collects previous medical reports and imaging and sends them for initial evaluation. It also explains the importance of obtaining a treatment plan suited to the patient's condition, and explains the organizational aspects of the medical journey.

Surgeons' experience with different procedures varies, and some procedures have a learning curve; it is therefore important to ask about the surgeon's experience with the specific operation proposed. The outcome of the operation or the permanent elimination of dislocation cannot be guaranteed, and the final decision is a medical one made by the surgeon after evaluating you; you should not be pushed toward a decision for surgery.

What to Prepare Before the Evaluation

These documents help the doctor understand your condition and decide on any additional tests; not all of them need to be available for every patient:

• Previous medical reports, and clinical examination reports if available.
• Details of previous dislocation episodes and, if possible, their number.
• X-ray, MRI, and CT images (and 3D images, if available) with their reports.
• A list of the treatments and medications you have used, and any previous shoulder injuries or operations.
• Chronic illnesses and current medications, and drug allergies, if any.
• The nature of your sport or work.

It is best to send the original images and reports, rather than relying on a description of symptoms alone.

Questions to Ask Your Surgeon

• What is the cause of the recurrent dislocation in my case?
• Do I have a Bankart injury? Is it soft-tissue or bony?
• Is there glenoid bone loss? How was it estimated?
• Is there a Hill-Sachs lesion? Is it on-track or off-track?
• Do I need a CT scan or 3D imaging?
• Can my condition be treated without surgery?
• Why do you specifically recommend Bankart or Latarjet?
• Do I have other injuries that need treatment?
• What are the realistic expected results, and what is the likelihood of recurrent dislocation in my case?
• What are the complications of the proposed operation?
• What is the physical therapy plan, and when can I return to work and sport?
• Do I need to change my sport?
• Is my condition suitable for traveling for the operation, and what follow-up is required after I return home?

There is no single answer to these questions; the aim is for your decision to be based on an individual evaluation.

Travel and Follow-Up After Returning Home

The timing of travel after surgery varies according to the operation and recovery. In the scientific sources we reviewed, we found no single approved period for travel after shoulder stabilization surgery, so the decision about travel rests with your surgical team.

Practical points that may help you:

• Keep the operative report, the rehabilitation instructions, and the images.
• Arrange in advance who will follow your rehabilitation in your home country, and agree on a follow-up plan with your team.
• If you have had a Latarjet procedure, ask about monitoring the healing of the bone graft according to the surgeon's plan.

When to Seek Urgent Care

Discharge guidance from a university hospital after shoulder arthroscopy advises contacting the medical team if pain increases or does not respond to medication, if the arm swells, if the arm or fingers become numb or turn blue, if there is bleeding, drainage, redness, or warmth at the wound, if there is fever or chills, or if there is persistent nausea and vomiting. It recommends calling emergency services immediately for chest pain or shortness of breath.

This is general guidance for shoulder arthroscopy procedures, and the instructions for your operation may differ; always follow the instructions of your surgical team, and do not rely on this list alone if you have any concern.

Medical note: this information is for general education. It does not replace consultation with a specialist doctor and is not a diagnosis or a prescription.