Published 9/10/2025
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Daniel Herrera; Rodnell Busigó Torres, BS; Ronald A. Navarro, MD, FAAOS, FAOA
At the AAOS 2025 Annual Meeting, leading experts gathered for a Spanish-language session titled “Current Concepts in the Surgical Management of Anterior Shoulder Instability.” The session featured presentations from Gonzalo E. Gomez, MD, orthopaedic surgeon at SportsMed Academy in Buenos Aires, Argentina; Myriam A. Capasso, MD, shoulder and sports medicine specialist in Caracas, Venezuela; Francisco Cruz López, MD, founding partner of the Mexican Society of Shoulder and Elbow Surgeons; and Emilio Calvo, MD, PhD, MBA, director of the Department of Orthopaedic Surgery and Traumatology and professor of orthopaedics at the Fundacion Jimenez Diaz in Madrid, Spain. Joaquín Sánchez-Sotelo, MD, FAAOS, physician-scientist at Mayo Clinic in Rochester, Minnesota, expertly moderated the panel.
The symposium provided a comprehensive overview of traditional and novel surgical techniques, focusing on their biomechanical rationale, clinical outcomes, technical complexity, and future directions. Central to the discussion were the comparative merits of the Latarjet procedure and emerging alternatives such as free bone grafting, remplissage, and dynamic anterior stabilization (DAS).
Biomechanics and surgical philosophy
The experts acknowledged the Latarjet procedure as a gold standard for addressing anterior shoulder instability, particularly in patients with significant glenoid bone loss. Its dual mechanism — bone augmentation and dynamic stabilization from the conjoint tendon — was praised for reliably preventing recurrent dislocation. However, concerns remain regarding its steep learning curve, potential for early complications, and risk of altering joint kinematics (e.g., reduced external rotation).
In contrast, free bone grafting has gained traction for its anatomical precision and customizable graft size. Techniques using iliac crest autografts and distal tibia allografts allow tailored reconstruction of glenoid bone defects. Nevertheless, the lack of vascularization in free grafts increases the risk of resorption and nonunion, especially when cadaveric allografts are used. Autografts, particularly from the iliac crest, showed lower resorption rates but presented logistical and patient-acceptance challenges.
Fixation techniques and technical considerations
Panelists emphasized that graft fixation is a critical determinant of success, regardless of technique. A variety of methods, such as screws, suture buttons, and tapes, were reviewed. A strong consensus emerged favoring screw fixation for its biomechanical stability and surgical predictability. Although less invasive, suture-button systems were criticized for posterior tensioning requirements, which limit control over graft placement and may cause mechanical impingement or suboptimal contact with the anterior glenoid. Particular technical nuances were discussed regarding avoiding graft fracture and ensuring proper orientation, especially when working with smaller autografts such as scapular spine bone.
Innovations: Remplissage and DAS
Emerging options were explored, including remplissage (which combines posterior capsulolabral reinforcement with humeral head containment, commonly used in the United States and Europe) and DAS (commonly used in Europe and limited in the United States). Although remplissage presents a promising anatomical alternative that preserves range of motion, its application remains limited to specific patient clinical presentations. DAS, involving transfer of the long head of the biceps to simulate the inferior glenohumeral ligament, has shown potential in low-demand patients, typically older individuals or those with minimal athletic or overhead activity. However, concerns about graft durability, particularly in athletic or hyperlax populations, limit its widespread adoption.
Posterior instability and bipolar bone loss
Although less frequent, posterior instability was also addressed. Panelists noted that posterior glenoid bone loss, although generally more tolerated than anterior defects, becomes clinically significant beyond 10% of the articular surface. Bone block procedures for posterior instability, although biomechanically viable, are associated with higher graft resorption rates and lower long-term stability. Techniques borrowed from anterior procedures have been adapted, but anatomical differences between anterior and posterior glenoid morphology necessitate tailored approaches.
A recurring theme was the importance of recognizing bipolar bone loss (simultaneous defects) in both the glenoid and humeral head (e.g., Hill-Sachs lesions). Failure to accurately assess these combined injuries, especially off-track lesions, was consistently cited as a cause of surgical failure. Experts advocated for comprehensive imaging protocols and emphasized the critical role of intraoperative evaluation with imaging.
Arthroscopy, osteoarthritis, and technique selection
Surgeons debated the implications of arthroscopic procedures on long-term joint health, particularly the development of osteoarthritis. Excessive anchor use, prolonged operative times, overuse of radiofrequency, and poor management of capsular tension were all cited as modifiable risk factors. Open procedures, though more invasive, may reduce some of these risks in selected patients. Surgeons were urged to balance innovation with restraint, emphasizing individualized treatment algorithms over procedural dogma.
A spirited discussion also emerged regarding anchor number and placement during Bankart repairs. Some advocated for two anchors with double-loaded sutures, whereas others emphasized the biomechanical advantage of using three distinct anchor points to better distribute stress and reduce recurrence. This reflects ongoing efforts to refine surgical strategy based on patient-specific anatomy and activity level.
AI: Promise and prudence
The session concluded with a discussion on emerging artificial intelligence (AI) in shoulder surgery. AI was recognized for its growing role in preoperative planning, predictive modeling, surgical training, and clinical decision support.
As moderator Dr. Sánchez-Sotelo noted, “In my opinion, the field of AI has infiltrated, and will continue to infiltrate, many aspects of our professional lives, including shoulder surgery. For example, the treatment-selection algorithms shared during this session are based on an exhaustive analysis of published studies to date, but they have many imperfections. I am confident that in the not-so-distant future, predictive algorithms will further refine surgical indications. At the same time, in the field of computer vision, several research groups are working on developing algorithms that can automatically analyze CT or MRI images to identify and quantify glenoid bone loss, Hill-Sachs lesions, and other parameters.”
However, experts cautioned against overreliance on this technology, underscoring that AI should augment — not replace — clinical judgment. The “human factor,” with its blend of experience, intuition, and empathy, remains irreplaceable.
Toward personalized and evidence-based care
In summary, this multifaceted session highlighted the importance of individualized care, grounded in biomechanical principles, rigorous preoperative assessment, and evolving surgical techniques. Whether selecting Latarjet, free bone grafting, or novel stabilizing procedures, surgeons must consider patient-specific anatomy, pathology, and individualized functional demands. Integrating emerging technologies, including AI, offers exciting possibilities but must be coupled with surgical craftsmanship and clinical wisdom to truly advance the care of patients with shoulder instability.
Spanish-language sessions emphasize AAOS’ commitment to global education
AAOS’ ongoing efforts to support Spanish-language sessions at its Annual Meeting are both timely and necessary given the growing population of Spanish speakers in the United States, as well as the global reach of AAOS in Spanish-speaking countries. These sessions provide a platform for internationally renowned surgeons to share their unique perspectives in their native language.
Regarding the session “Current Concepts in the Surgical Management of Anterior Shoulder Instability,” Joaquín Sánchez-Sotelo, MD, FAAOS, shared, “From the attendees’ perspective, the greatest value they shared with me was the opportunity to participate in Q&A in Spanish. Many of them understand English quite well but feel uncomfortable asking questions in English during an English-language session. Dialogue in Spanish is incredibly valuable for the attendees. From the speakers’ perspective, coming from Latin America or Spain, it was truly an honor to be invited to present at the AAOS Annual Meeting. Finally, from AAOS’ perspective, sessions like these allow the organization to continue contributing to global education.”
AAOS’ continued support and expansion of these Spanish-language sessions have the potential to further enhance global dialogue and collaboration in orthopaedics.
Daniel Herrera is a fourth-year medical student at the Medical College of Georgia at Augusta University in Augusta, Georgia.
Rodnell Busigó Torres, BS, is a fourth-year medical student at the Icahn School of Medicine at Mount Sinai in New York.
Ronald A. Navarro, MD, FAAOS, FAOA, is a professor of orthopaedic surgery at the Kaiser Permanente School of Medicine in Pasadena, California, and president of the American Association of Latino Orthopaedic Surgeons.
Spanish-language sessions emphasize AAOS’ commitment to global education
AAOS’ ongoing efforts to support Spanish-language sessions at its Annual Meeting are both timely and necessary given the growing population of Spanish speakers in the United States, as well as the global reach of AAOS in Spanish-speaking countries. These sessions provide a platform for internationally renowned surgeons to share their unique perspectives in their native language.
Regarding the session “Current Concepts in the Surgical Management of Anterior Shoulder Instability,” Joaquín Sánchez-Sotelo, MD, FAAOS, shared, “From the attendees’ perspective, the greatest value they shared with me was the opportunity to participate in Q&A in Spanish. Many of them understand English quite well but feel uncomfortable asking questions in English during an English-language session. Dialogue in Spanish is incredibly valuable for the attendees. From the speakers’ perspective, coming from Latin America or Spain, it was truly an honor to be invited to present at the AAOS Annual Meeting. Finally, from AAOS’ perspective, sessions like these allow the organization to continue contributing to global education.”
AAOS’ continued support and expansion of these Spanish-language sessions has the potential to further enhance global dialogue and collaboration in orthopaedics.