title: Redefining "Critical" Bone Loss in Shoulder Instability: Functional Outcomes Worsen With "Subcritical" Bone Loss.
abstract: BACKGROUND
  Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the "critical" cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, "subcritical" amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability.
  
  
  OBJECTIVE
  To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability.
  
  
  METHODS
  Cohort study; Level of evidence, 3.
  
  
  METHODS
  Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable.
  
  
  RESULTS
  The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences (P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure (P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile's increasing bone loss predictive of a worse functional outcome.
  
  
  CONCLUSIONS
  While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that "critical" bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability.
authors.affiliation: Tripler Army Medical Center, Honolulu, Hawaii, USA jshaha6@gmail.com.
authors.forename: James S
authors.initials: JS
authors.lastname: Shaha
authors.affiliation: Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: Jay B
authors.initials: JB
authors.lastname: Cook
authors.affiliation: Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Song
authors.affiliation: Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Rowles
authors.affiliation: Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: Craig R
authors.initials: CR
authors.lastname: Bottoni
authors.affiliation: University of Utah, Salt Lake City, Utah, USA.
authors.forename: Steven H
authors.initials: SH
authors.lastname: Shaha
authors.affiliation: Tripler Army Medical Center, Honolulu, Hawaii, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Tokish
mesh_terms: D000328:Adult; D001182:Arthroscopy / Q000379:methods*; D001862:Bone Resorption / Q000473:pathology*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D004204:Joint Dislocations / Q000601:surgery; D007593:Joint Instability / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D012008:Recurrence; D012189:Retrospective Studies; D012540:Scapula / Q000473:pathology / Q000601:surgery; D012785:Shoulder Joint / Q000473:pathology / Q000601:surgery*; D055815:Young Adult
keywords: arthroscopic; bone loss; glenoid; instability