Redefining “Critical” Bone Loss in Shoulder Instability

Shaha, James S.; Cook, Jay B.; Song, Daniel J.; Rowles, Douglas J.; Bottoni, Craig R.; Shaha, Steven H.; Tokish, John M.

doi:10.1177/0363546515578250

Cited by 512 publications

(229 citation statements)

References 45 publications

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“…13,33,50 More recently, the lower limit of this bone loss has been questioned, with so-called “subcritical” bone loss of 13.5% leading to suboptimal outcomes with arthroscopic treatment. 58 Additionally, others have recommended use of the so-called “glenoid track” concept based off 3-dimensional CT reconstructions to preoperatively ascertain whether a Hill-Sachs lesion is engaging (ie, “off track”) and requires additional (eg, remplissage) or more aggressive initial management (Figure 1). 24,37,66 …”

Section: Discussionmentioning

confidence: 99%

“…63 Contrary to previously established thresholds, lower Western Ontario Shoulder Instability (WOSI) scores were seen after arthroscopic Bankart reconstruction in military patients with subcritical glenoid bone loss of greater than 13.5%, even in patients who did not sustain a recurrence of instability. 58 The additive effect of bipolar, subcritical bone loss compromises the biomechanical efficacy of the Bankart procedure, even with as little as 2 mm anterior glenoid defect. 1 These studies underscore the importance of patient-reported measures in outcome reporting, careful scrutiny of preoperative imaging, and personalized surgical management, as these extend beyond the traditional limited endpoints of instability recurrence and surgical revision.…”

Section: Managementmentioning

confidence: 99%

“…Military surgeons have made several landmark contributions toward this end, and this trend has continued into the modern era among American military colleagues. 2,5,11,12,18,19,25,38,41-43,48,51,55,57-59,61,63-65 Accordingly, so-called military “warrior athletes” embody a physically active patient subset at high risk for anterior shoulder instability that is ideal for further focus in this article.…”

mentioning

confidence: 99%

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Anterior Shoulder Instability in the Military Athlete

Waterman

Owens

Tokish

2016

Sports Health: A Multidisciplinary Approach

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Context:Given its young, predominately male demographics and intense physical demands, the US military remains an ideal cohort for the study of anterior shoulder instability.Evidence Acquisition:A literature search of PubMed, MEDLINE, and the Cochrane Database was performed to identify all peer-reviewed publications from 1950 to 2016 from US military orthopaedic surgeons focusing on the management of anterior shoulder instability.Study Design:Clinical review.Level of Evidence:Level 4.Results:The incidence of anterior shoulder instability events in the military occurs at an order of magnitude greater than in civilian populations, with rates as high as 3% per year among high-risk groups. With more than 90% risk of a Bankart lesion and high risk for instability recurrence, the military has advocated for early intervention of first-time shoulder instability while documenting up to 76% relative risk reduction versus nonoperative treatment. Preoperative evaluation with advanced radiographic imaging should be used to evaluate for attritional bone loss or “off-track” engaging defects to guide comprehensive surgical management. With complex recurrent shoulder instability and/or cases of clinically significant osseous lesions, potential options such as remplissage, anterior open capsular procedures, or bone augmentation procedures may be preferentially considered.Conclusion:Careful risk stratification, clinical evaluation, and selective surgical management for at-risk military patients with anterior shoulder instability can optimize the recurrence risk and functional outcome in this population.

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Section: Discussionmentioning

confidence: 99%

Section: Managementmentioning

confidence: 99%

mentioning

confidence: 99%

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Anterior Shoulder Instability in the Military Athlete

Waterman

Owens

Tokish

2016

Sports Health: A Multidisciplinary Approach

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“…Patients who had greater than 13.5% GBL experienced significantly higher WOSI scores than would be considered clinically unacceptable with regard to their outcome even in the setting of no recurrence of instability. This led the authors to conclude that the threshold for bone loss should be redefined as a value less than 15%, especially in highly active patients [17]. Similarly Dickens et al investigated subcritical bone loss in American football players undergoing arthroscopic anterior shoulder stabilization.…”

Section: Indications/contraindicationsmentioning

confidence: 99%

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes

DeFroda

Bokshan

Stern

et al. 2017

Curr Rev Musculoskelet Med

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Purpose of Review Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability. Recent Findings Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. Summary When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

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“…More recently, though, subcritical levels of bone loss (≥13.5%) have been associated with poor functional outcomes in patients who did not experience recurrent instability, suggesting that the historic threshold of 20% to 25% glenoid bone loss representing the most important anatomic factor influencing the type of operative strategy employed should be re-evaluated using patient-reported outcome measures. 63 This may be pertinent to the epileptic population, who exhibit higher failure rates due to powerful uncontrolled seizures disrupting surgical repairs. 67…”

Section: Pathoanatomymentioning

confidence: 99%