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The all-arthroscopic Latarjet is gaining popularity among shoulder surgeons, although the procedure is technically demanding and potentially dangerous, placing the brachial plexus and axillary vessels at risk when using screws for fixation of the bone block from the front. Matsen once wrote that "lateral to the coracoid is the safe side, while medial to the coracoid is the suicide." However, creation of a portal medial to the coracoid during arthroscopic reconstruction of the glenoid is needed to permit accurate positioning of the screws (parallel to the glenoid surface) and coracoid bone block (flush to the glenoid surface). Our own clinical experience with the arthroscopic Latarjet over the last decade has shown us that the safety of the arthroscopic medial transpectoralis portal depends on 3 technical considerations: (1) the portal should always be established in an outside-in fashion from anterior to posterior; (2) passing through the pectoralis major muscle with a relatively superficial trajectory, using a switching stick oriented with a 45° orientation toward the tip of the coracoid; and (3) under visual control of the anterior extra-articular subdeltoid space to end up lateral to the coracoid process. If these conditions are respected, surgeons should not worry: medial to the coracoid can also be a safe side! An inside-out technique (introducing a switching stick from posterior to anterior) is forbidden, as this would end up piercing the neurovascular structures. Once the coracoid has been osteotomized and the conjoint tendon retracted distally, all instruments passing though the transpectoral portal are directly in contact with the neurovascular structures. This is why working through the medial transpectoralis portal should be done only with the help of a cannula or half-pipe. Ideally, the transpectoral portal should not be used as a "working portal" but as a "protecting portal" instead, placing a stick or spreader to protect the neurovascular structures. To avoid working through the anterior medial portal, we have proposed a much safer alternative that consists of drilling the glenoid from posterior to anterior (using a guide and remaining inside the glenohumeral joint) and using cortical-buttons (instead of screws) for coracoid fixation. In this modern technique, the transpectoral portal makes the arthroscopic safe as it allows the introduction of a spreader to retract the subscapularis muscle and protect the neurovascular structures during transfer and fixation of the coracoid bone block., (Copyright © 2020. Published by Elsevier Inc.)

Risk factors for recurrent instability are present and identifiable preoperatively and can be incorporated into a severity scoring system to help with patient selection. The Instability Severity Index (ISI) Score is a tool used to preoperatively identify patients at risk of failure after an arthroscopic Bankart procedure for recurrent anterior shoulder instability. This 10-point score is also designed to help guide the treating surgeon's decision on whether a soft-tissue stabilization or bone block augmentation procedure is indicated. The ISI scoring system has been criticized for its lack of generalizability outside of the French health care system. However, evidence has emerged establishing the ISI Score as a valuable tool with excellent external validity. The ISI scoring system, based on factors derived from a preoperative questionnaire, physical examination, and imaging studies, is helpful to distinguish between patients who will benefit from an arthroscopic Bankart procedure and those who will not. The higher the score, the higher the risk of recurrence of instability. Patients with an ISI Score of 3 points or less may attain very good results with an arthroscopic Bankart procedure compared with patients with an ISI Score of more than 3 points. Performing this procedure in patients with an ISI Score of more than 6 points leads to an increased risk of recurrence (≥50%) within 5 years and is totally inacceptable. We believe that the information gained from this scoring system will help surgeons in their daily practice to not only decide the right procedure for the right patient but also inform their patients preoperatively of the risks and benefits of an arthroscopic Bankart procedure. As such, the ISI Score is an important strategic tool for shoulder surgeons., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)