Editorial Commentary: Should We Condemn the Shoulder Instability Severity Index Scoring System? Not at All!... Can We Improve Its Radiographic Component? Yes, We Can!

Abstract

Is patient selection necessary in shoulder instability surgery? Absolutely. The risk-benefit discussion that the surgeon must have with the patient before proposing an arthroscopic Bankart repair remains crucial to provide informed consent. The most important preoperative risk factors are incorporated in the instability severity index (ISI) score to assist surgeons in the decision-making process. This 10-point score is based on factors derived from a preoperative questionnaire, physical examination, and simple plain radiographs. Using this score at the first visit, the surgeon can explain to the patient and family why a Bankart repair may be contraindicated and why other surgical options may be more suitable. A recent study found that the ISI score has no limited predictive value when applied in a preselected population of military patients without severe bone loss or hyperlaxity. This is not surprising because the authors analyzed a preselected patient population with lower risk than the general population. The value of the ISI scoring system relies on the fact that this tool has been developed after evaluation of arthroscopic Bankart repair in an unselected patient population and that there is no need for sophisticated imaging studies to make the decision. This scoring system should not be condemned but complemented with preoperative advanced imaging studies (computed tomography [CT] scanning or magnetic resonance imaging) to assess the severity of the bone lesions more accurately. Today, the choice of the surgical procedure depends not only on the clinical risk factors included in the ISI score (age, type of sports, level of practice, hyperlaxity) but also on the presence, location and size of bony lesions, as identified and measured on advanced CT scanning images.

Classifications in Brief: The Instability Severity Index Score for Predicting Recurrent Shoulder Instability After Arthroscopic Bankart Repair

“…The score was meant to be easily obtainable in the outpatient office setting, using information that is available at the first visit, including a preoperative questionnaire, physical examination, as well as simple, plain radiographs [6]. Surgeons have used the ISI measure to guide the surgical management of anterior shoulder instability [6,43]. This score has been used to try to improve communication among physicians and has been widely adopted in clinical research.…”

“…The ISI score is a preoperative risk-stratification tool used to estimate the risk of recurrent shoulder instability after arthroscopic Bankart repair [2]. The score was meant to be easily obtainable in the outpatient office setting, using information that is available at the first visit, including a preoperative questionnaire, physical examination, as well as simple, plain radiographs [6]. Surgeons have used the ISI measure to guide the surgical management of anterior shoulder instability [6,43].…”