Advertisement

Accurate Assessment of the Hill-Sachs Lesion: There Is No Information About the Accuracy of Quantification of These Lesions

      Optimal assessment of a Hill-Sachs lesion is an important aspect of shoulder instability management, as it is shown to be associated with recurrent dislocations.
      • Olds M.
      • Ellis R.
      • Donaldson K.
      • Parmar P.
      • Kersten P.
      Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: A systematic review and meta-analysis.
      A Hill-Sachs lesion is present in >84% of patients after a first-time dislocation and >88% after recurrent dislocations.
      • Nakagawa S.
      • Iuchi R.
      • Hanai H.
      • Hirose T.
      • Mae T.
      The development process of bipolar bone defects from primary to recurrent instability in shoulders with traumatic anterior instability.
      ,
      • Yiannakopoulos C.K.
      • Mataragas E.
      • Antonogiannakis E.
      A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability.
      Therefore, we read “Accuracy and Reliability of Imaging Modalities for the Diagnosis and Quantification of Hill-Sachs Lesions: A Systematic Review” by Vopat et al.
      • Vopat M.L.
      • Peebles L.A.
      • McBride T.
      • Cirone I.
      • Rider D.
      • Provencher M.T.
      Accuracy and reliability of imaging modalities for the diagnosis and quantification of Hill-Sachs lesions: A systematic review.
      with great interest. The authors conclude that the studies in the review demonstrate acceptable accuracy with regard to both diagnosing and quantifying Hill-Sachs lesions. However, considering the importance of this subject, we would like to argue the strength of this conclusion.
      In the systematic review, 2 components are evaluated: accuracy and reliability. A clinical test or measurement with high accuracy gives a value that is close to the actual value that an observer intends to measure. A test with a high reliability demonstrates the same value when the test is repeated under the same conditions. Therefore, a test with high reliability can still have low accuracy (when the outcome is not close to the actual value). A test that is both accurate and reliable is considered valid, and the best available test under reasonable conditions is considered the gold standard.
      The authors showed that the included studies report only reliability for quantifying Hill-Sachs lesions on 2- and 3-dimensional computed tomography (2D-CT and 3D-CT) and magnetic resonance imaging and angiography (MRI and MRA) and do not report accuracy for any of these modalities. With regard to quantification of Hill-Sachs lesions, they showed that only the study by Cicak et al.
      • Cicak N.
      • Bilic R.
      • Delimar D.
      Hill-Sachs lesion in recurrent shoulder dislocation: Sonographic detection.
      reported accuracy for quantification of Hill-Sachs lesions on ultrasound and radiography. However, the reported 97% accuracy for ultrasound and 84% accuracy for radiography are not for quantification but for detection of Hill-Sachs lesions, with surgical findings as the reference standard (which they used as a gold standard).
      • Cicak N.
      • Bilic R.
      • Delimar D.
      Hill-Sachs lesion in recurrent shoulder dislocation: Sonographic detection.
      Hence, Cicak et al. did measure volume but did not determine accuracy for their measuring method. This may also be the reason Vopat et al.
      • Vopat M.L.
      • Peebles L.A.
      • McBride T.
      • Cirone I.
      • Rider D.
      • Provencher M.T.
      Accuracy and reliability of imaging modalities for the diagnosis and quantification of Hill-Sachs lesions: A systematic review.
      found possible bias in the reference standard with the QUADAS-2 tool for the study. Therefore, none of the studies seem to report accuracy for quantification of Hill-Sachs lesions, and we believe the conclusion stating that different imaging modalities show acceptable accuracy in quantifying Hill-Sachs lesions cannot be drawn.
      Measuring bony lesions can be difficult, as has recently been shown for measurement of bony Bankart lesions.
      • Verweij L.P.E.
      • Schuit A.A.
      • Kerkhoffs G.
      • Blankevoort L.
      • van den Bekerom M.P.J.
      • van Deurzen D.F.P.
      Accuracy of currently available methods in quantifying anterior glenoid bone loss: Controversy regarding gold standard—A systematic review.
      Vopat et al.
      • Vopat M.L.
      • Peebles L.A.
      • McBride T.
      • Cirone I.
      • Rider D.
      • Provencher M.T.
      Accuracy and reliability of imaging modalities for the diagnosis and quantification of Hill-Sachs lesions: A systematic review.
      discuss that the literature confirms 3D-CT as the gold standard in quantifying humeral bone loss, which is shown to be the case for identifying these lesions. However, a gold standard for quantifying lesions should consist of a modality (such as 3D-CT) in combination with a measuring method. Methods that are currently available often use 2D measurements to measure 3D volume,
      • Verweij L.P.E.
      • Schuit A.A.
      • Kerkhoffs G.
      • Blankevoort L.
      • van den Bekerom M.P.J.
      • van Deurzen D.F.P.
      Accuracy of currently available methods in quantifying anterior glenoid bone loss: Controversy regarding gold standard—A systematic review.
      such as a line or a circle, which was also the case in the study by Cicak et al.
      • Cicak N.
      • Bilic R.
      • Delimar D.
      Hill-Sachs lesion in recurrent shoulder dislocation: Sonographic detection.
      For bony Bankart lesions, these measurements are used to determine recurrence risk; however, this concept has been challenged, as these measurements are not proven to be accurate.
      • Verweij L.P.E.
      • Schuit A.A.
      • Kerkhoffs G.
      • Blankevoort L.
      • van den Bekerom M.P.J.
      • van Deurzen D.F.P.
      Accuracy of currently available methods in quantifying anterior glenoid bone loss: Controversy regarding gold standard—A systematic review.
      ,
      • Moroder P.
      • Damm P.
      • Wierer G.
      • Bohm E.
      • Minkus M.
      • Plachel F.
      • et al.
      Challenging the current concept of critical glenoid bone loss in shoulder instability: Does the size measurement really tell it all?.
      The size of bony lesions is associated with recurrence, and a proper quantification can therefore be important in determining recurrence risk,
      • Olds M.
      • Ellis R.
      • Donaldson K.
      • Parmar P.
      • Kersten P.
      Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: A systematic review and meta-analysis.
      for example, when determining whether a Hill-Sachs lesion is on or off track.
      • Vopat M.L.
      • Peebles L.A.
      • McBride T.
      • Cirone I.
      • Rider D.
      • Provencher M.T.
      Accuracy and reliability of imaging modalities for the diagnosis and quantification of Hill-Sachs lesions: A systematic review.
      2D measurements were not proven to be accurate in quantifying bony lesions, and we believe a 3D approach is most suitable to find an appropriate gold standard.
      • Verweij L.P.E.
      • Schuit A.A.
      • Kerkhoffs G.
      • Blankevoort L.
      • van den Bekerom M.P.J.
      • van Deurzen D.F.P.
      Accuracy of currently available methods in quantifying anterior glenoid bone loss: Controversy regarding gold standard—A systematic review.
      ,
      • Moroder P.
      Glenoid bone loss measurements in shoulder instability—Precise but not accurate.
      In conclusion, we do not believe that current evidence demonstrates how Hill-Sachs lesions can be accurately measured. In our opinion, 3D measurements may be valuable in accurately measuring the volume and relevance of a Hill-Sachs lesion.

      Supplementary Data

      References

        • Olds M.
        • Ellis R.
        • Donaldson K.
        • Parmar P.
        • Kersten P.
        Risk factors which predispose first-time traumatic anterior shoulder dislocations to recurrent instability in adults: A systematic review and meta-analysis.
        Br J Sports Med. 2015; 49: 913-922
        • Nakagawa S.
        • Iuchi R.
        • Hanai H.
        • Hirose T.
        • Mae T.
        The development process of bipolar bone defects from primary to recurrent instability in shoulders with traumatic anterior instability.
        Am J Sports Med. 2019; 47: 695-703
        • Yiannakopoulos C.K.
        • Mataragas E.
        • Antonogiannakis E.
        A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability.
        Arthroscopy. 2007; 23: 985-990
        • Vopat M.L.
        • Peebles L.A.
        • McBride T.
        • Cirone I.
        • Rider D.
        • Provencher M.T.
        Accuracy and reliability of imaging modalities for the diagnosis and quantification of Hill-Sachs lesions: A systematic review.
        Arthroscopy. 2021; 37: 391-401
        • Cicak N.
        • Bilic R.
        • Delimar D.
        Hill-Sachs lesion in recurrent shoulder dislocation: Sonographic detection.
        J Ultrasound Med. 1998; 17: 557-560
        • Verweij L.P.E.
        • Schuit A.A.
        • Kerkhoffs G.
        • Blankevoort L.
        • van den Bekerom M.P.J.
        • van Deurzen D.F.P.
        Accuracy of currently available methods in quantifying anterior glenoid bone loss: Controversy regarding gold standard—A systematic review.
        Arthroscopy. 2020; 36: 2295-2313.e1
        • Moroder P.
        • Damm P.
        • Wierer G.
        • Bohm E.
        • Minkus M.
        • Plachel F.
        • et al.
        Challenging the current concept of critical glenoid bone loss in shoulder instability: Does the size measurement really tell it all?.
        Am J Sports Med. 2019; 47: 688-694
        • Moroder P.
        Glenoid bone loss measurements in shoulder instability—Precise but not accurate.
        Arthroscopy. 2020; 36: 2314-2315