UNIVERSITY OF PENNSYLVANIA ORTHOPAEDIC JOURNAL good or excellent results with low recurrence rates after conservative treatment. Although some of the most competitive adolescent athletes will undergo surgical repair after primary dislocation, pressure to finish a season, as well as peer and scholarship pressures can influence the decision to continue participating in sports despite recurrences of shoulder instability. The clinician should bear these influences in mind when recommending a particular treatment, as the risk of recurrent instability when returning to play untreated is significant. Several studies highlight the inefficacy of the non-operative approach in the adolescent population. In a retrospective cohort study of 65 pediatric patients aged 15-18 years, 19/27 (70%) of patients managed non-operatively developed recurrent instability, while only 5/38 (13%) of those treated arthroscopically developed recurrent instability. A previously published review by the senior author of 32 patients with Bankart lesions aged 11-18 years followed over an average of 25.2 months sought to determine the potential benefit of arthroscopic repair following primary dislocation. The study compared 16 patients with Bankart lesions undergoing arthroscopic repair after primary dislocation to 16 patients undergoing arthroscopic repair after an average of 10.5 months of non-operative management. The authors concluded immediate Bankart repair limits multiple recurring shoulder dislocations that hinder quality of life and potentially lead to future negative sequelae. Similar conclusions have been drawn when comparing the efficacy of non-operative treatment to the Latarjet procedure among skeletally immature patients. Khan et al retrospectively compared 23 nonoperative patients with 26 patients undergoing the Latarjet procedure and found no significant differences between groups regarding functional scores and pain levels yet 92% of the postsurgical group returned to the same level of preinjury activity compared to only 52% of the nonoperative group. Non-operative management (physical therapy or activity modification) is most appropriate for a younger child with low activity demands and a single dislocation of the non-dominant shoulder with no symptoms. Operative intervention Introduction Pediatric shoulder instability commonly results from traumatic anterior dislocation of the humeral head. Male adolescents aged 15-17 years participating in contact or collision sports have the highest risk of primary and recurrent dislocation. In contrast to adolescents, children younger than 10 years seldom develop shoulder instability. Adolescents are generally at a higher risk than their younger counterparts due to the dramatic increase in collision sports participation that occurs when children begin middle school at the onset of adolescence. Depending on the severity of instability and the patient’s activity level, patients can range from being relatively asymptomatic to being unable to participate in sports or even engage in regular activities of daily living. Children and adolescents are at increased risk of developing recurrent shoulder instability as they are typically eager to return to sport and less likely to adhere to an appropriate course of physical therapy. Limiting recurrences decreases the risk of future negative sequelae such as traumatic labral and cartilage injury. Since non-operative treatments often fail in this highly active population, a number of surgical techniques are used to address specific defects of soft and bony tissue. In this article, we discuss our approach to shoulder instability in the highrisk pediatric patient.