This article presents a systematic review focused on surgical techniques for the treatment of recurrent anterior shoulder instability. The review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA®) guidelines (22), ensuring methodological integrity. The review was registered in PROSPERO (ID =). Methodological issues were addressed using the guidance provided by the Cochrane Handbook for Systematic Reviews of Interventions (23).

The PICOS® model was used to define the inclusion criteria (24): P (Population): "patients with recurrent shoulder instability," I (Intervention): "shoulder stabilization surgery," C (Comparators): "comparison groups of multidisciplinary interventions," O (Outcome): "shoulder mobility, dislocation rate, return-to-play (RTP) rate, pain," and S (Study design): "any study design" (Fig. 1).

A structured search was conducted in MEDLINE/PubMed, Web of Science (WOS), ScienceDirect, Cochrane Library, SciELO, EMBASE, SPORTDiscus, and Scopus. The search was completed on January 30, 2025. Search terms included a combination of Medical Subject Headings (MeSH) and free-text keywords related to concepts such as shoulder instability, surgical techniques, and arthroscopic procedures. Specifically, the following search equation was used: ["shoulder instability" (MeSH Terms) OR "shoulder dislocation" (All Fields)] AND ["Latarjet outcomes"] AND ["Dynamic Anterior Stabilization Shoulder" (MeSH Terms)] AND ["Trillat Shoulder" (MeSH Terms)] AND ["Shoulder Ligamentoplasty" (MeSH Terms)]. This searches equation retrieved all relevant articles in the field. Additionally, the reference sections of the included articles were examined using the "snowballing method" (25), which involves reviewing the citations within retrieved studies. All titles and abstracts from the search were screened to identify duplicates and any potentially missing studies (C.G.-R. and A.V.-S). Titles and abstracts were selected for full-text review. The search for published studies was conducted independently by two different authors (C.G.-R. and A.V.-S), and any disagreements were resolved through discussion between them.

Studies reporting effectiveness outcomes in terms of diagnostic accuracy or performance related to the surgical management of shoulder instability were selected. The systematic review included original studies on surgical techniques for treating severe shoulder instability. Systematic reviews, meta-analyses, conference abstracts, opinion pieces, and posters were excluded. Only studies with a minimum sample size of 10 participants were included. For effectiveness studies, only those that employed at least one arthroscopic shoulder stabilization technique were considered. The surgical techniques examined for comparison included arthroscopic Latarjet, arthroscopic Trillat, Dynamic Anterior Stabilization, and shoulder ligamentoplasty.

For the articles retrieved during the search, the following inclusion criteria were applied to the final selection: (I) studies published in peer-reviewed journals with full-text availability; (II) articles analyzing the effects of stabilization surgeries in patients with shoulder instability; (III) original research articles published in peer-reviewed journals with an impact factor; (IV) studies involving patients treated with arthroscopic Latarjet, arthroscopic Trillat, Dynamic Anterior Stabilization, or shoulder ligamentoplasty; (V) study populations consisting of patients who underwent arthroscopic techniques for the treatment of recurrent shoulder instability; (VI) studies that included preoperative and/or postoperative clinical evaluations; (VII) studies published in English and/or Spanish. The following exclusion criteria were applied to experimental research protocols: (I) lack of reliable measurements; (II) studies with fewer than 10 participants; (III) use of open surgical techniques; (IV) fixation methods involving metal buttons or staples; (V) abstracts, non-peer-reviewed articles, and book chapters.

Titles and abstracts of publications identified through the search strategy were reviewed for full-text selection and cross-checked to eliminate duplicates. All studies assessed for eligibility and classified as relevant were retrieved, and their full texts were peer-reviewed by two authors (C.G.-R. and A.V.-S). Additionally, the reference sections of all relevant articles were examined using the snowballing strategy (25). Based on the information provided in the full-text articles, inclusion and exclusion criteria were applied to select eligible studies for inclusion in this systematic review. Any disagreements were resolved through discussion between the two authors (C.G.-R. and A.V.-S).

Once the inclusion and exclusion criteria were applied to each study, the following data were extracted: study source (author(s) and year of publication); sample population, including number of participants; weeks of immobilization; recurrence or dislocation rate; surgical technique used; type of study design; variables analyzed; results and conclusions; and intervention effects.

For each study, information was carefully collected from all eligible publications. Mean (±), standard deviation (SD), and sample size data were extracted from the tables of all included studies. Disagreements were subsequently resolved through discussion until consensus was reached.

Methodological quality and risk of bias were assessed independently by two authors (C.G.-R. and A.V.-S), with any disagreements resolved by a third reviewer (J.C.-G), in accordance with the Cochrane Collaboration Guidelines (26).

The Cochrane Risk of Bias tool included the following domains: (1) selection bias (random sequence generation, allocation concealment), (2) performance bias (blinding of participants and personnel), (3) detection bias (blinding of outcome assessment), (4) attrition bias (incomplete outcome data), (5) information bias (selective reporting), and (6) other sources of bias.

For each investigation, the criteria were shown as "low" if the criteria were met for low-risk bias (unlikely to seriously alter the results) or "high" if the criteria were for high-risk bias (seriously undermining the reliability of the results). If the risk of bias was unknown, it was considered "unclear" (it casts doubt on the results).

The systematic review followed the principles of the PRISMA® statement (22), a checklist designed to ensure transparency in systematic reviews and to improve their scientific credibility. PRISMA® includes 27 items and a flow chart with four stages, which includes items considered essential for the transparent communication of a systematic analysis.

The Physiotherapy Evidence Database (PEDro) scale was also used to assess the methodological quality of all selected studies. This scale is a commonly used tool in literature reviews and is designed to evaluate the quality of clinical trial designs (Table 1). It is based on a list developed by Verhagen (27) using the Delphi technique (28).

The PEDro scale has a total of 11 items. Item 1 refers to the external validity of the study, while items 2–9 refer to internal validity. Items 10 and 11 indicate whether the statistical information provided by the authors allows for accurate interpretation of the results. All items on the list are dichotomized as "yes", "no", or "not reported". Each item marked "yes" receives one point, while items marked "no" or "not reported" receive no points.

The first item of the PEDro scale was not considered in this review, as it relates to the evaluation of external validity. Therefore, only items 2 through 11 were used to assess methodological quality. As a result, the maximum possible score for an article was 10 points, and the minimum possible score was 0.

The evaluation of heterogeneity was another aspect considered in the review. Clinical heterogeneity refers to differences among types of patients, treatments, and outcomes. Methodological heterogeneity refers to variability in study designs and bias control.

The database search identified 963 publications. Of the 963 articles retrieved, 16 were excluded given that they were duplicates. A digital screening of sources generated 807 relevant studies, which were included for review. After a detailed review of titles, abstracts, and full texts, 64 publications met the inclusion criteria. Subsequently, 40 articles were excluded for not addressing the surgical techniques under review or for being editorials, surgical technique descriptions, citations, reviews, posters, commentaries, or comparative studies. Studies involving epileptic patients were also excluded.

From the final selection, 25 studies were included in the systematic review. Seven articles contained significant data on the arthroscopic Trillat technique [(29), (30), (31), (32), (33), (34), (35)]. Four articles reported significant findings related to the Dynamic Anterior Stabilization technique [(36), (37), (38), (39)]. Three articles presented relevant data on anterior shoulder ligamentoplasty [(40), (18), (41)]. Eleven articles provided significant information on the arthroscopic Latarjet technique [(42), (43), (44), (45), (46), (47), (48), (49), (50), (51), (52)] (Fig. 2).

The source of each study (author and year of publication), immobilization time, number of episodes of instability including recurrent dislocations and subluxations, surgical technique, type of study design, study variables, main findings, and the effects of the intervention are summarized in Table 2. A total of 25 original articles were included with significant data related to the arthroscopic techniques analyzed, specifically Trillat, Dynamic Anterior Stabilization (DAS), arthroscopic Latarjet, and shoulder ligamentoplasty procedures.

The methodological quality and the risk of bias were evaluated following the guidelines of the Cochrane Collaboration (26). For each investigation, the criteria were rated as "low" if they were met for a low risk of bias (unlikely to severely alter the results), or "high" if they indicated a high risk of bias (significantly weakening the reliability of the results). If the risk of bias was unknown, it was considered "not clear" (indicating uncertainty about the results). Every included study was assessed for the risk of bias (26). The full assessments of study quality are shown in Figs. 3 and 4.

The methodological quality of the included and analyzed studies ranged from 3 to 9 points, with an average of 6.92 points. The distribution was as follows: 1 study scored 3 points, 4 studies scored 5 points, 2 studies scored 6 points, 7 studies scored 7 points, 10 studies scored 8 points, and 1 study scored 9 points.

Despite some variation in item scores, there was notable consistency in certain criteria that were clearly met across studies. Specifically, item 4 ("the groups were similar at baseline in relation to the indicators of prognosis"), item 10 ("the study provides specific and variability measures for at least one key result"), and item 11 ("the results of statistical comparisons among groups were reported for at least one key result") were consistently fulfilled. Conversely, none of the studies met item 3 ("the allocations were undisclosed"). Finally, one study met all quality criteria except for item 3 (Table 3).

With regard to the chronology of the 25 articles studied (Fig. 5), 13 have been published in the last 17 years; 6 in 2024 (30, 35, 43, 46, 48, 50); 4 in 2023 (34, 36, 38, 51); 5 in 2022 (31, 32, 33, 37, 52); and 2 in 2021 (39, 53). The remaining research corresponds to 8 studies, which are divided into 1 in 2019 (47); 2 in 2018 (29, 49); 1 in 2014 (44); and finally, 4 prior to 2010 (45, 42, 40, 41). The above shows the great interest and importance of use of surgical techniques for the treatment of shoulder instability.

The reviewed studies highlight the clinical utility of these arthroscopic techniques, each offering specific benefits based on patient anatomy and functional needs. The overall evidence supports the effectiveness and safety of these ones. Each technique offers distinct advantages based on anatomical deficits and functional demands, emphasizing the need for personalized surgical planning in the management of anterior shoulder instability.

All the above information is summarized in the following Table 4:

The main aim of this of this systematic review was to collect, synthesize, and integrate international research published across various scientific databases on surgical techniques such as shoulder ligamentoplasty, arthroscopic Latarjet, dynamic anterior stabilization, and arthroscopic Trillat for the treatment of shoulder instability.

Anterior shoulder instability is a common condition affecting both the general population and athletes, and represents one of the most frequent causes of functional limitation in the upper limb. Its pathophysiology is based on an imbalance between the dynamic and static stabilizers of the glenohumeral joint, predisposing individuals to recurrent episodes of dislocation and subluxation. This condition, in addition to causing pain and disability, increases the risk of progressive joint deterioration and the development of glenohumeral arthropathy, reinforcing the need for effective and personalized therapeutic intervention (4, 53).

The surgical treatment of anterior instability has evolved significantly over recent decades, transitioning from highly invasive open procedures to advanced arthroscopic techniques aimed at maximizing joint stability while minimizing tissue damage (54). Among the most widely used and studied techniques are Dynamic Anterior Stabilization (DAS), arthroscopic Latarjet, arthroscopic ligamentoplasty, and arthroscopic Trillat. These techniques have proven effective in different patient subgroups depending on the specific characteristics of their instability, the presence of bone deficits, and the quality of the capsuloligamentous tissue (17, 18, 19, 20).

These four techniques share the ability to achieve satisfactory outcomes in patients whose instability is influenced by both osseous and soft tissue risk factors. However, a key difference lies in the fact that ligamentoplasty is the only technique that does not alter the patient’s anatomy. It involves the repair of all possible structures, the potential execution of a remplissage to address humeral bone defects, and the addition of a ligamentous graft that does not modify the anatomy but acts as an adjunct to the patient’s natural structures. This also prevents glenohumeral dislocation in cases where abduction and external rotation are extreme enough for the humeral head to dislocate anteroinferiorly on the scapular glenoid (17).

This anatomical preservation is not present in DAS, Trillat, or arthroscopic Latarjet, establishing a significant distinction among these techniques. In the latter three, the anatomy is altered to enhance stabilization, and although the objective is effectively achieved, this factor is not without risks or potential future complications (17, 18, 19, 20). These must be carefully considered when determining the best surgical approach for each patient, particularly given that the target population is composed of young and active individuals.

The indicated measures were verified in terms of efficiency in the different studies analyzed in this review. There currently exist many literary proposals which attempt to consolidate these techniques in terms of prevention protocols, studying their effects in a complex manner. In spite of this, it was observed that preventive actions are not currently implemented systematically.

Therefore, the current scientific literature describes different surgical approaches that aim to balance anatomical preservation, joint stability, and functional recovery (Fig. 6). However, there is a clear need for more robust comparative data, particularly through randomized controlled trials, to guide optimal technique selection. This systematic review seeks to address this gap by providing a comprehensive analysis of the available evidence, helping clinicians better understand the indications, outcomes, and limitations of each arthroscopic technique used in the management of anterior shoulder instability.

The DAS technique has recently emerged as a less invasive alternative for shoulder stabilization in patients with anterior instability and subcritical bone loss. Its biomechanical principle involves transferring the long head of the biceps tendon through the subscapularis to create a sling effect that enhances joint stability under anterior stress. Unlike other techniques focused on osseous or capsular reconstruction, DAS utilizes the biceps' dynamic stabilizing function to provide active control of humeral translation (18).

Recent studies (39, 18, 38) have shown promising results with this technique. Clara de Campos Azevedo et al. (39) reported a significant reduction in recurrence rates and considerable improvement in postoperative functional scores in patients with subcritical instability treated with DAS. Similarly, Collin et al. (18) found that this technique preserves the range of motion without compromising shoulder function, offering a key advantage over more invasive procedures. Wu et al. (38) observed comparable return-to-sport rates between DAS and other traditional techniques, highlighting its effectiveness in postoperative rehabilitation.

However, DAS still presents certain challenges and limitations. Its indication is restricted to patients with mild to moderate bone loss, as its stabilizing effect may be insufficient in cases of critical bone loss. Additionally, the long-term clinical outcomes remain uncertain and under evaluation, requiring further data collection to determine its efficacy compared to more established techniques (36).

This technique would be indicated mainly in patients with recurrent shoulder instability and bone defects of less than 10%, particularly when associated with pathology of the bicep’s tendon or its superior glenoid insertion, and when the goal is to address both conditions while adding a tenodesis effect or sling effect to the subscapularis tendon.

Arthroscopic Latarjet is one of the most widely used techniques for treating anterior instability with critical bone loss. It involves the transfer of the coracoid process along with the conjoint tendon to the anteroinferior region of the glenoid, providing a dual stabilizing effect: the bone block increases contact surface area and prevents excessive humeral translation, while the tension generated by the conjoint tendon acts as a dynamic stabilizing mechanism (17).

Recent studies (42, 43, 44) have confirmed the effectiveness of arthroscopic Latarjet in preventing recurrence. Descamps et al. (42) reported that suture fixation instead of screws significantly reduced postoperative complications related to graft migration, osteolysis, and consolidation defects, improving procedural safety. Dumont et al. (43) demonstrated that the recurrence rate following surgery is low and comparable to that of open Latarjet, with the additional advantage of reduced surgical aggression and shorter recovery time. Boileau et al. (44) highlighted that this procedure is not only safe and reproducible but also offers superior aesthetic and functional outcomes compared to open techniques.

Despite these benefits, arthroscopic Latarjet remains technically demanding. It requires a high level of surgical expertise. Additionally, patient selection must be meticulous, as graft resorption, hardware-related complications, and glenohumeral arthropathy may present long-term challenges (45).

This technique, although effective, is not without complications. These may include potential neurological sequelae, especially in patients undergoing revision surgery or presenting with recurrent instability following prior treatments. It is particularly indicated in cases of severe, recurrent instability with extensive capsular and labral damage. The technique is especially relevant when unipolar bone loss exceeds 20% of the glenoid surface, notably when associated with humeral bone loss in the form of an off-track Hill-Sachs lesion. It is a technique that alters the native anatomy and, although highly effective, offers few clear alternative options in the event of failure. This is particularly critical when the joint is already compromised by both the initial instability and the consequences of the procedure or its failure. Therefore, except in selected cases, it should be considered a second-line treatment option.

Arthroscopic ligamentoplasty represents an intermediate surgical option between conventional capsulolabral repair and bone reconstruction techniques in the management of anterior shoulder instability. This technique aims to enhance capsular stabilization through the fixation of a synthetic or biological ligament graft. It increases resistance to humeral head translation while preserving joint mobility. It is the only one of the four techniques that does not alter the patient’s native anatomy. The procedure maintains bony integrity, reconstructs the capsuloligamentous structures, and adds mechanical support through the graft itself (18, 55).

Clinical studies (18, 43, 56) have demonstrated the potential benefits of arthroscopic ligamentoplasty. Cuéllar Gutiérrez et al. (18) reported favorable clinical outcomes in patients with recurrent anterior instability without significant bone loss, achieving a 90% satisfaction rate. These findings were supported by Sánchez et al., who described effective functional recovery and minimal postoperative morbidity in patients treated with synthetic anterior capsular reinforcement (18, 43). Collectively, these results suggest that arthroscopic ligamentoplasty may be a safe and effective surgical option in selected patients. It expands the range of techniques available for shoulder stabilization.

However, the role of arthroscopic ligamentoplasty remains a subject of ongoing discussion within the orthopedic community. One of the primary concerns is the variability in graft integration, which may influence the long-term success and mechanical reliability of the procedure. While short- and mid-term results appear promising, further studies are warranted to assess long-term durability, outcomes, and complications, particularly regarding graft behavior over time (57).

Arthroscopic ligamentoplasty offers a distinct approach to shoulder stabilization by reinforcing the capsular structures without altering the native anatomy. Clinical data support its ability to achieve satisfactory functional recovery and high patient satisfaction in properly selected cases (40, 41). Nevertheless, the long-term performance of the technique and the biological behavior of the graft require continued investigation to more clearly define its role in the surgical management of shoulder instability.

This technique should be more widely adopted. Its primary indication would be in patients with high functional demand and multi-recurrent instability, particularly in those with poor or suboptimal capsuloligamentous tissue quality. It is also indicated in cases of subcritical glenoid bone loss of less than 20%. This technique enables soft tissue repair where feasible and adds both a tenodesis and sling effect to the subscapularis without altering the patient's native anatomy, as the ligament can be placed either through the subscapularis tendon or above its superior border. The implants used have minimal impact on bone stock. The procedure reinforces the anterior capsule and ligaments by introducing a controlled block to extreme external rotation and abduction. All of this is achieved through a fully arthroscopic approach. Alternatively, it may be performed with a minimal axillary incision when the mini-invasive humeral fixation technique is chosen. Moreover, if the surgeon prefers to avoid the use of synthetic grafts due to concerns regarding their healing potential, the technique allows for the use of either an allograft or a tendon autograft. Therefore, it represents our treatment of choice in cases of severe instability in active patients with subcritical bone loss and compromised soft tissue quality.

The arthroscopic Trillat technique is a minimally invasive and promising surgical option for the treatment of anterior shoulder instability in selected patients without significant bone loss. This procedure involves an arthroscopic coracoid osteotomy to reposition the coracoid process, thereby reducing the subcoracoid space and increasing tension on the conjoint tendon. This biomechanical modification helps limit humeral head translation and enhances joint stability (29).

Clinical studies (31, 32, 35) have reported positive outcomes, particularly in patients with hyperlaxity or chronic post-traumatic anterior instability. Labattut et al. (29) demonstrated satisfactory short- and mid-term outcomes with a low complication profile, minimal surgical time, and early return to activity. Chauvet et al. (30) confirmed these results with a two-year follow-up, showing sustained shoulder stability and functional recovery. Boileau et al. (34) further highlighted the effectiveness of the technique in two distinct populations: young athletes with hyperlaxity and older patients with recurrent dislocations and massive irreparable rotator cuff tears (MIRCTs) (33).

The main indications for this technique include recurrent anterior instability in the absence of significant glenoid or humeral bone defects, especially in patients with hyperlaxity. Arthroscopy provides superior visualization of the glenohumeral joint, allowing accurate coracoid osteotomy and secure fixation. The outcomes are encouraging, with improved shoulder stability and low recurrence rates. Kazum et al. (32) found the procedure effective for anterior/inferior hyperlaxity, with minimal postoperative complications. Moore et al. (58) also reported high functional scores and rapid return to sports in a multicenter study involving athletic populations.

Regarding complications, the technique is generally safe. Gonnachon et al. (30) reported mild subscapularis atrophy in some patients at 6-month follow-up, but without associated strength deficits at 1 year, likely related to implant positioning.

In summary, the arthroscopic Trillat technique represents a valuable alternative to procedures like Latarjet in cases of functional instability without significant bone loss. Its minimally invasive nature allows for faster recovery and reduced morbidity. However, optimal results depend on proper patient selection and technical precision. Further high-quality comparative studies and long-term follow-up are necessary to define its definitive role in shoulder stabilization algorithms.

The Trillat technique would be indicated in patients with severe instability and subcritical bone loss. It is particularly suited for cases in which the surgeon aims to achieve a tenodesis effect on the subscapularis without altering the anatomy of the subscapularis or other soft tissues. Instead, it acts exclusively on the bony anatomy of the coracoid process.

This systematic review brings together the latest evidence on four key arthroscopic techniques used to treat anterior shoulder instability: Arthroscopic Latarjet, Arthroscopic Trillat, Dynamic Anterior Stabilization (DAS), and Shoulder Ligamentoplasty. By comparing these different surgical approaches, the review provides valuable insights to help clinicians make informed decisions based on each patient's specific needs. Another strength is its broad scope, as it considers techniques suitable for various degrees of instability and bone loss. This makes it relevant to a wide range of cases.

However, the diversity of patient populations, follow-up times, and evaluation scales used—common in studies of this nature—can be considered limitations. The use of certain methodologies often excludes others that could provide additional, broadly relevant data.

It should also be noted that the conclusions of this review are based on articles identified through our search strategy and selected according to specific eligibility criteria. Therefore, there is always a possibility that some studies were not included due to classification issues or limitations in the search process.

Looking ahead, future research should prioritize well-designed randomized controlled trials (RCTs) and direct comparative studies (DCS). These are essential for establishing clearer clinical guidelines and identifying the most appropriate surgical techniques for each patient profile. Prospective cohort studies with long-term follow-up are also necessary to better understand the durability and effectiveness of each approach over time. Standardizing outcome measures would enhance comparability across studies. Subgroup analyses could further identify which techniques are best suited for specific patient characteristics. In addition, predictive models based on individual risk factors may help personalize surgical decision-making. Further research should also explore the use of advanced imaging techniques to assess healing and graft integration, as well as conduct cost-effectiveness analyses. Finally, continued innovation in minimally invasive procedures will be key to reducing complications and improving recovery times.