Skip to main content
SpringerLink
Log in

Assessing Bone Loss in the Unstable Shoulder: a Scoping Review

  • Outcomes Research in Orthopedics (O Ayeni, Section Editor)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

The aim of this scoping review is to identify and summarize findings published in the literature over the past 5 years related to methods for assessment of bone loss in anterior shoulder instability.

Recent Findings

Of the 113 clinical studies included in this review, 76 reported a cutoff for glenoid bone loss when determining the patients indicated for one of the many stabilization procedures investigated. Bone loss on the glenoid side was evaluated most commonly with three-dimensional computed tomography (3D CT), and either linear or surface area–based methods were employed with the use of a best-fit circle. When combined with plain CT, the two methods comprise up to 70% of the reported measurement techniques for glenoid bone loss (79 of 113 studies). On the humeral side, Hill-Sachs lesions were assessed more heterogeneously, though plain CT or 3D CT remained the methods of choice in the majority of studies (43 of 68, 63.2%). Lastly, the glenoid track was assessed by 27 of 113 studies (23.9%), again most commonly with 3D CT (13 studies) and plain CT (seven studies).

Summary

The assessment of glenoid and humeral bone loss is essential to treatment decisions for patient with recurrent anterior shoulder instability. Glenoid bone loss is most commonly assessed using cross-sectional imaging, most often 3D CT, and some variation of a best-fit circle applied to the inferior portion of the glenoid. Hill-Sachs lesion assessment was also commonly done using three-dimensional imaging; however, there was more variability in assessment methods across studies and there is an obvious need to unify the approach to humeral bone loss assessment for the purposes of improving treatment decisions and to better assess on-track and off-track lesions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Cutts S, Prempeh M, Drew S. Anterior shoulder disloctation. Ann R Coll Surg Engl. 2009;91:2–7.

    Article  Google Scholar 

  2. Zacchilli MA, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Jt Surg - Ser A. 2010;92:542–9.

    Article  Google Scholar 

  3. Pougès C, Hardy A, Vervoort T, Amouyel T, Duriez P, Lalanne C, Szymanski C, Deken V, Chantelot C, Upex P, Maynou C. Arthroscopic Bankart repair versus immobilization for first episode of anterior shoulder dislocation before the age of 25: a randomized controlled trial. Am J Sports Med. 2021;49:1166–74.

    Article  Google Scholar 

  4. Leroux T, Wasserstein D, Veillette C, Khoshbin A, Henry P, Chahal J, Austin P, Mahomed N, Ogilvie-Harris D (2014) Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada. Am J Sports Med 42:442–450. Describes the epidemiology of anterior shoulder instability in a Canadian population.

  5. Vermeiren J, Handelberg F, Casteleyn PP, Opdecam P. The rate of recurrence of traumatic anterior dislocation of the shoulder - a study of 154 cases and a review of the literature. Int Orthop. 1993;17:337–41.

    Article  CAS  Google Scholar 

  6. Larrain MV, Botto GJ, Montenegro HJ, Mauas DM. Arthroscopic repair of acute traumatic anterior shoulder dislocation in young athletes. Arthroscopy. 2001;17:373–7.

    Article  CAS  Google Scholar 

  7. Brophy RH, Marx RG. Osteoarthritis following shoulder instability. Clin Sports Med. 2005;24:47–56.

    Article  Google Scholar 

  8. Ode GE, Ling D, Finocchiaro A, Lai EY, Taylor SA, Dines J, Dines D, Warren R, Gulotta L. Clinical characteristics and patient-reported outcomes of total shoulder arthroplasty after anterior stabilization: a retrospective matched control study. J Shoulder Elb Surg. 2020;29:S59–66.

    Article  Google Scholar 

  9. Calandra JJ, Baker CL, Uribe J. The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthrosc J Arthrosc Relat Surg. 1989;5:254–7.

    Article  CAS  Google Scholar 

  10. Hill HA, Sachs MD (1940) The grooved defect of the humeral head. Radiology 35:690–700. Initial descripton of the Hill-Sachs lesion.

  11. Spatschil A, Landsiedl F, Anderl W, Imhoff A, Seiler H, Vassilev I, Klein W, Boszotta H, Hoffmann F, Rupp S. Posttraumatic anterior-inferior instability of the shoulder: arthroscopic findings and clinical correlations. Arch Orthop Trauma Surg. 2006;126:217–22.

    Article  CAS  Google Scholar 

  12. Edwards TB, Boulahia A, Walch G. Radiographic analysis of bone defects in chronic anterior shoulder instability. Arthrosc - J Arthrosc Relat Surg. 2003;19:732–9.

    Article  Google Scholar 

  13. Čičak N, Bilić R, Delimar D. Hill-Sachs lesion in recurrent shoulder dislocation: sonographic detection. J Ultrasound Med. 1998;17:557–60.

    Article  Google Scholar 

  14. Nakagawa S, Ozaki R, Take Y, Iuchi R, Mae T. Relationship between glenoid defects and Hill-Sachs lesions in shoulders with traumatic anterior instability. Am J Sports Med. 2015;43:2763–73.

    Article  Google Scholar 

  15. Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthrosc - J Arthrosc Relat Surg. 2007;23:985–90.

    Article  Google Scholar 

  16. Balg F, Boileau P. The instability severity index score: a simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Jt Surg - Ser B. 2007;89:1470–7.

    Article  CAS  Google Scholar 

  17. Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elb Surg. 2009;18:317–28.

    Article  Google Scholar 

  18. Lo IKY, Parten PM, Burkhart SS (2004) The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthrosc - J Arthrosc Relat Surg 20:169–174. Describes an important concept in the recognition of significant glenoid bone loss.

  19. Itoi E, Lee SB, Berglund LJ, Berge LL, An KN. The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study. J Bone Jt Surg - Ser A. 2000;82:35–46.

    Article  CAS  Google Scholar 

  20. Yamamoto N, Itoi E, Abe H, Kikuchi K, Seki N, Minagawa H, Tuoheti Y. Effect of an anterior glenoid defect on anterior shoulder stability: a cadaveric study. Am J Sports Med. 2009;37:949–54.

    Article  Google Scholar 

  21. Chen AL, Hunt SA, Hawkins RJ, Zuckerman JD. Management of bone loss associated with recurrent anterior glenohumeral instability. Am J Sports Med. 2005;33:912–25.

    Article  Google Scholar 

  22. Shin SJ, Koh YW, Bui C, Jeong WK, Akeda M, Cho NS, McGarry MH, Lee TQ. What is the critical value of glenoid bone loss at which soft tissue bankart repair does not restore glenohumeral translation, restricts range of motion, and leads to abnormal humeral head position? Am J Sports Med. 2016;44:2784–91.

    Article  Google Scholar 

  23. Shin SJ, Kim RG, Jeon YS, Kwon TH (2017) Critical value of anterior glenoid bone loss that leads to recurrent glenohumeral instability after arthroscopic bankart repair. Am J Sports Med 45:1975–1981. Reports 17.3% as a new cutoff for critical bone loss, lending support to the idea of subcritical bone loss amounts.

  24. Shaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR, Shaha SH, Tokish JM. “Subcritical” glenoid bone loss increases redislocation rates in primary arthroscopic bankart repair. Orthop J Sport Med. 2014. https://doi.org/10.1177/2325967114S00025.

  25. Shaha JS, Cook JB, Song DJ, Rowles DJ, Bottoni CR, Shaha SH, Tokish JM. Redefining “critical” bone loss in shoulder instability. Am J Sports Med. 2015;43:1719–25.

    Article  Google Scholar 

  26. Dickens JF, Owens BD, Cameron KL, DeBerardino TM, Masini BD, Peck KY, Svoboda SJ (2017) The effect of subcritical bone loss and exposure on recurrent instability after arthroscopic bankart repair in intercollegiate American football. Am J Sports Med 45:1769–1775. Reports 13.5% as a new cutoff for significant bone loss in collegiate football players, lending support to the idea of subcritical bone loss amounts.

  27. Burkhart SS, De Beer JF (2000) Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 16:677–694. Description of bipolar lesions and their significance.

  28. Di Giacomo G, Itoi E, Burkhart SS (2014) Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthrosc - J Arthrosc Relat Surg 30:90–98. Describes the assessment of bipolar lesions as on-track or off-track.

  29. Arciero RA, Parrino A, Bernhardson AS, Diaz-Doran V, Obopilwe E, Cote MP, Golijanin P, Mazzocca AD, Provencher MT. The effect of a combined glenoid and Hill-Sachs defect on glenohumeral stability: a biomechanical cadaveric study using 3-dimensional modeling of 142 patients. Am J Sports Med. 2015;43:1422–9.

    Article  Google Scholar 

  30. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005;8:19–32.

    Article  Google Scholar 

  31. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A (2003) Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Jt Surg - Ser A 85:878–884. First description of one of the most common methods for assessing glenoid bone loss.

  32. Baudi P, Righi P, Bolognesi D, Rivetta S, Rossi Urtoler E, Guicciardi N, Carrara M. How to identify and calculate glenoid bone deficit. Chir Organi Mov. 2005;90:145–52.

    CAS  PubMed  Google Scholar 

  33. Hardy P, Lopes R, Bauer T, Conso C, Gaudin P, Sanghavi S. New quantitative measurement of the Hill-Sachs lesion: a prognostic factor for clinical results of arthroscopic glenohumeral stabilization. Eur J Orthop Surg Traumatol. 2012;22:541–7.

    Article  Google Scholar 

  34. Nobuhara K. The shoulder: its function and clinical aspects. 2003. https://doi.org/10.1142/5412.

  35. Yamamoto N, Itoi E, Abe H, Minagawa H, Seki N, Shimada Y, Okada K. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. J Shoulder Elb Surg. 2007;16:649–56.

    Article  Google Scholar 

  36. Bakshi NK, Cibulas GA, Sekiya JK, Bedi A (2018) A clinical comparison of linear- and surface area–based methods of measuring glenoid bone loss. Am J Sports Med 46:2472–2477. Compares surface area-based and linear measurement techniques.

  37. Frank RM, Golijanin P, Vopat BG, Gross DJ, Chauhan V, Romeo AA, Provencher MT. Impact of sagittal rotation on axial glenoid width measurement in the setting of glenoid bone loss. Am J Orthop (Belle Mead NJ). 2018;47. https://doi.org/10.12788/ajo.2018.0041.

  38. Lacheta L, Herbst E, Voss A, Braun S, Jungmann P, Millett PJ, Imhoff A, Martetschläger F. Insufficient consensus regarding circle size and bone loss width using the ratio—“best fit circle”—method even with three-dimensional computed tomography. Knee Surgery, Sport Traumatol Arthrosc. 2019;27:3222–9.

    Article  Google Scholar 

  39. Rossi LA, Frank RM, Wilke D, et al (2021) Evaluation and management of glenohumeral instability with associated bone loss: an expert consensus statement using the modified delphi technique. Arthrosc - J Arthrosc Relat Surg 37:1719–1728. Expert consensus on evaluating bone loss in shoulder instability.

  40. Milano G, Saccomanno MF, Magarelli N, Bonomo L. Analysis of agreement between computed tomography measurements of glenoid bone defects in anterior shoulder instability with and without comparison with the contralateral shoulder. Am J Sports Med. 2015;43:2918–26.

    Article  Google Scholar 

  41. Lansdown DA, Cvetanovich GL, Verma NN, Cole BJ, Bach BR, Nicholson G, Romeo A, Dawe R, Yanke AB. Automated 3-dimensional magnetic resonance imaging allows for accurate evaluation of glenoid bone loss compared with 3-dimensional computed tomography. Arthrosc - J Arthrosc Relat Surg. 2019;35:734–40.

    Article  Google Scholar 

  42. Assunção JH, Gracitelli MEC, Borgo GD, Malavolta EA, Bordalo-Rodrigues M, Ferreira Neto AA. Tomographic evaluation of Hill-Sachs lesions: is there a correlation between different methods of measurement? Acta radiol. 2017;58:77–83.

    Article  Google Scholar 

  43. Schneider AK, Hoy GA, Ek ET, Rotstein AH, Tate J, Taylor DMD, Evans MC. Interobserver and intraobserver variability of glenoid track measurements. J Shoulder Elb Surg. 2017;26:573–9.

    Article  Google Scholar 

  44. Gowd AK, Liu JN, Cabarcas BC, Garcia GH, Cvetanovich GL, Provencher MT, Verma NN. Management of recurrent anterior shoulder instability with bipolar bone loss: a systematic review to assess critical bone loss amounts. Am J Sports Med. 2019;47:2484–93.

    Article  Google Scholar 

  45. Gyftopoulos S, Beltran LS, Bookman J, Rokito A (2015) MRI evaluation of bipolar bone loss using the on-track off-track method: a feasibility study. Am J Roentgenol 205:848–852. MRI validation of the on-track/off-track assessment.

  46. Di Giacomo G, De Gasperis N. Measuring bone loss in the unstable shoulder: understanding and applying the track concept. Sports Med Arthrosc. 2020;28:153–8.

    Article  Google Scholar 

  47. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic bankart repair. J Bone Jt Surg - Ser A. 2006;88:1755–63.

    Article  Google Scholar 

  48. Cavalier M, Johnston TR, Tran L, Gauci MO, Boileau P. Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage. Bone Jt J. 2021;103(B):718–24.

    Article  Google Scholar 

  49. Yang JS, Mehran N, Mazzocca AD, Pearl ML, Chen VW, Arciero RA. Remplissage versus modified Latarjet for off-track Hill-Sachs lesions with subcritical glenoid bone loss. Am J Sports Med. 2018;46:1885–91.

    Article  Google Scholar 

  50. Kho J, Kholinne E, Lim S, Hong H, Kwak JM, Sun Y, Koh KH, Jeon IH. Arthroscopic bare spot method underestimates true bone defect in bony Bankart lesion. Arch Orthop Trauma Surg. 2019;139:1269–75.

    Article  Google Scholar 

  51. Ramos MRF, San Junior YAC, Alves LHP, Cruz FC, Mansur H. Is the bare spot reliable for the bone loss measurement? Shoulder Elb. 2019;11:106–12.

    Article  Google Scholar 

  52. Khan M, Bedi A, Degen R, Warner J, Bhandari M, Khan M (2022) A pilot multicenter randomized controlled trial comparing Bankart repair and remplissage with the Latarjet procedure in patients with subcritical bone loss (STABLE): study protocol. Pilot Feasibility Stud 8:1–9. Protocol for ongoing RCT comparing remplissage and Latarjet for patients with subcritical bone loss.

Download references

Author information

Authors and Affiliations

  1. Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada

    Kyle Gouveia & Moin Khan

  2. Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

    Syed Fayyaz H. Rizvi

  3. Faculty of Science, McMaster University, Hamilton, Ontario, Canada

    Danielle Dagher

  4. Northshore Orthopedic and Spine Institute, Chicago, IL, USA

    Asheesh Bedi

  5. Division of Orthopedic Surgery, University of Toronto, Toronto, Ontario, Canada

    Timothy Leroux

Authors
  1. Kyle Gouveia
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Syed Fayyaz H. Rizvi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Danielle Dagher
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Timothy Leroux
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Asheesh Bedi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Moin Khan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Moin Khan.

Ethics declarations

Conflict of Interest

The authors declare no existing conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Outcomes Research in Orthopedics

Supplementary information

Appendix Table 1

(DOCX 45.9 kb)

Appendix Fig. 3

(DOCX 142 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gouveia, K., Rizvi, S.H., Dagher, D. et al. Assessing Bone Loss in the Unstable Shoulder: a Scoping Review. Curr Rev Musculoskelet Med 15, 369–376 (2022). https://doi.org/10.1007/s12178-022-09773-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-022-09773-4

Keywords

Search

Navigation