Recurrent Anterior Shoulder Instability in a Contact Athlete

Open (or arthroscopic) Latarjet coracoid transfer, with anterior capsule repair.

Reasoning:

• 18% glenoid bone loss with an off-track Hill-Sachs lesion puts him in the zone where soft-tissue repair alone has an unacceptable failure rate, especially in a collision athlete. The "glenoid track" concept means his humeral head engages the anterior rim before reaching the safe zone; restoring glenoid width is the only way to convert it back on-track.
• A Bankart repair would reattach the labrum but leave a deficient arc. The recurrence rate in contact athletes with this degree of bone loss is high.
• Adding a remplissage to a Bankart addresses the Hill-Sachs lesion but does nothing for the glenoid deficiency, and it tethers the shoulder in a position a fly-half needs for passing.
• The Latarjet restores bone stock and provides a dynamic sling effect from the conjoint tendon in abduction and external rotation.
• Alternatives worth discussing: distal tibial allograft or iliac crest bone block (no coracoid donor-site or conjoined tendon issues, but more demanding and slower to incorporate). Counsel honestly on Latarjet risks: graft nonunion or fracture, osteolysis, musculocutaneous nerve injury, infection, and the difficulty of salvage if it fails - offset against a recurrence rate of roughly 2–5%.

Phased pathway:

• Weeks 0–4: sling for comfort and protection; immediate elbow, wrist, and hand motion; gentle pendulum and assisted external rotation within a safe range (typically to 0–30°). Avoid active forward elevation early.
• Weeks 4–8: progress passive to active-assisted motion; begin isometric deltoid and cuff work; protect the graft from loading.
• Weeks 8–16: progressive strengthening, scapular control, and proprioception; radiographic assessment of graft consolidation around 8–12 weeks before loading it.
• Weeks 16–24: contact-specific drills, tackling technique, and graded exposure; return to contact generally no earlier than 4–6 months.

Return-to-play criteria, not a calendar date: pain-free full range, strength within about 10% of the contralateral side, radiographic graft union, and completed sport-specific contact progressions.

The timing conflict: surgery now ends this season; a 6-month return puts him at mid-season next year. If he wants to finish the current season, he can be braced and given a clear statement of risk - bone loss will not improve, and further dislocations may make reconstruction harder. Document the discussion either way; do not promise a fixed 6-month return.

The reasoning shifts from reconstruction of a defect to prevention of recurrence in a first-time dislocator, and the answer becomes a genuine shared decision.

• Recurrence risk without surgery in a male under 25 is high - commonly quoted at 40–80% - and immobilization in external rotation has not been shown to reliably reduce it. A brace allows sport but does not eliminate risk.
• Arthroscopic stabilization reduces recurrence substantially but is not risk-free, requires months of rehabilitation, and would end his season if done now.
• Bone loss of 10% with an on-track lesion is within the range where soft-tissue stabilization is reasonable; unlike the first patient, he does not need a bone block.
• Practical approach: if he elects to finish the season, brace him for contact, optimize cuff and scapular strength, and plan stabilization at the end of the season. If he elects surgery now, counsel that same-season return is unrealistic. Either way, explain that each further dislocation adds bone loss and may change the operation offered later - which is the strongest argument for not simply "playing through" recurrent instability.