Griffith et al.

M u s c ul o s kel et a l I m ag i n g • O r i g i na l R e s e a rc h
CT Versus Arthroscopy of
Glenoid Bone Loss

CT Compared with Arthroscopy

in Quantifying Glenoid Bone Loss
James F. Griffith1 OBJECTIVE. This study investigated the accuracy of CT in determining the presence and
Patrick S. H. Yung2 severity of glenoid bone loss in patients with unilateral anterior shoulder dislocation.
Gregory E. Antonio1 SUBJECTS AND METHODS. Fifty patients (45 males, five females; mean age, 28.7
Polly H. Tsang1 years; age range, 14–56 years) with anterior shoulder dislocation underwent shoulder CT exam-
Anil T. Ahuja1 ination before arthroscopy (mean time interval between CT and arthroscopy, 28.5 days; range,
9–73 days). Thirteen (26%) of the 50 patients had a single dislocation, whereas the remaining 37
Kai Ming Chan2
patients (74%) had recurrent dislocation (mean, 8.2 dislocations; range, 2–50 dislocations).
American Journal of Roentgenology 2007.189:1490-1493.

Griffith JF, Yung PSH, Antonio GE, Tsang PH,
Ahuja AT, Chan KM
RESULTS. Glenoid bone loss was evident in 41 (82%) of the 50 patients at arthroscopy. Com-
pared with arthroscopy, CT had a sensitivity in detecting glenoid bone loss of 92.7%; specificity,
77.8%; positive predictive value, 95.0%; and negative predictive value, 70.0%. Three false-nega-
tive CT assessments had 5%, 10%, and 10% glenoid bone loss, respectively, at arthroscopy. Two
false-positive CT assessments had 8.7% and 5.7% glenoid bone loss on CT, although no bone loss
was apparent at arthroscopy. There was a strong correlation between CT and arthroscopy with re-
spect to the severity of glenoid bone loss (r = 0.79, 95% CI = 0.659–0.877, p < 0.0001).
CONCLUSION. CT has both a high sensitivity and a high specificity for detecting gle-
noid bone loss, and agreement with arthroscopy regarding the severity of glenoid bone loss is
good. CT can be used to assess glenoid bone loss and the need for bone augmentation surgery.

lenoid bone loss is a common ac- comparative standard. This study compared

G companiment of anterior shoulder

Keywords: arthroscopy, bone loss, CT, glenoid bone,
shoulder, shoulder dislocation, sports medicine
DOI:10.2214/AJR.07.2473
Received April 27, 2007; accepted after revision
June 1, 2007.
1Department of Diagnostic Radiology and Organ Imaging,
The Chinese University of Hong Kong, Prince of Wales
Hospital, 30-32 Ngan Shing St., Shatin, Hong Kong SAR,
China. Address correspondence to J. F. Griffith.
2Department of Orthopaedics and Traumatology, The
Chinese University of Hong Kong, Prince of Wales Hospital,
Shatin, Hong Kong SAR, China.
AJR 2007; 189:1490–1493
0361–803X/07/1896–1490
© American Roentgen Ray Society
dislocation, particularly recurrent
dislocation [1–3]. If glenoid bone
loss is severe, bone augmentation of the ante-
rior glenoid rim should be performed rather
than capsulolabral repair alone to try to pre-
vent further dislocation [1]. Failure to address
glenoid bone loss is one of the main risk fac-
tors for recurrence of shoulder instability af-
ter Bankart repair [4]. Although severe de-
grees of glenoid bone loss are apparent on
axial radiography [5], glenoid bone loss can
be quantified more definitively using arthros-
copy [6] or CT examination [2].
Arthroscopic assessment of glenoid bone
loss is based on measuring the distance from
the glenoid bare spot to the anterior and pos-
terior glenoid rims (Figs. 1 and 2). CT assess-
ment of glenoid bone loss is based on compar-
ison of glenoid width on the affected shoulder
with glenoid width on the contralateral nor-
mal shoulder in subjects with unilateral dislo-
cation (Fig. 3). No study, to our knowledge,
has compared the accuracy of CT in predict-
ing glenoid bone loss using arthroscopy as a
the accuracy of CT in determining the pres-
ence and severity of glenoid bone loss in pa-
tients with unilateral shoulder dislocation.
Subjects and Methods
Patients
Fifty patients (45 males, five females; mean age,
28.7 years; age range, 14–56 years) with anterior
shoulder dislocation underwent shoulder CT exam-
ination before shoulder arthroscopy with measure-
ment of glenoid loss. The institutional ethics com-
mittee approved the study, for which all patients
provided informed consent. Inclusion criteria ne-
cessitated that patients have unilateral dislocation
with at least one radiographically documented an-
terior shoulder dislocation. Exclusion criteria were
bilateral shoulder dislocations, an interval of more
than 80 days between CT and arthroscopy, and gle-
noid bone loss not measured at the time of arthros-
copy. All patients had unilateral dislocation (33 on
the right side, 17 on the left side). Thirteen (26%)
of the 50 patients had a single dislocation, whereas
the remaining 37 (74%) patients had recurrent dis-
location. The number of recurrent dislocations
ranged from two to 50 dislocations, with a mean of

1490 AJR:189, December 2007

 CT Versus Arthroscopy of Glenoid Bone Loss

A B C
Fig. 1—45-year-old man with recurrent shoulder dislocation.
A–C, Calibration probe inserted through posterior arthroscopic portal with tip of probe at posterior margin (A), bare spot (B), and anterior margin (C). Distance from posterior
margin to bare spot is longer than from bare spot to anterior margin, thus indicating glenoid bone loss.
American Journal of Roentgenology 2007.189:1490-1493.

A B
Fig. 2—Photographs of arthroscopic probe.
A and B, Overall view of calibrated arthroscopic probe (A) and localized view of calibrated tip (B). Tip is marked at intervals of 1 mm.

Fig. 3—CT images reconstructed en face to glenoid

fossae in 37-year-old man with recurrent unilateral
dislocation.
A, Normal side shows normal curved anterior glenoid
rim (arrows). Glenoid width (solid line), measured at
right angles to long axis of glenoid (dashed line),
measures 28.4 mm.
B, On dislocated side, there is anterior straight line to
anterior glenoid rim (arrows). Glenoid width (solid line),
measured at right angles to long axis of glenoid
(dashed line), measures 24.7 mm. Glenoid bone loss is
difference in glenoid width (3.7 mm) divided by normal
width (28.4 mm) × 100 = 13% glenoid bone loss.
A B

8.2 dislocations. CT preceded arthroscopy in all
cases. The mean time between CT examination and
arthroscopy was 28.5 days (range, 9–73 days).
CT Examination Technique and Analysis
Each patient underwent simultaneous CT exam-
ination of both shoulders with his or her arms posi-
tioned by the chest wall on an MDCT scanner
(LightSpeed 16 Plus, GE Healthcare) that used 16
× 0.625 mm acquisitions with 400 mA, 120 kV, and
a pitch of 1:1.75. The scanning plane extended
from the acromion to just below the glenoid. Dou-
ble oblique reconstruction of each glenoid was used
to obtain oblique sagittal images en face to the gle-
noid articular surface (Advantage Windows, ver-
sion 4.2, GE Healthcare) (Fig. 3). On this image, a
line was drawn along the long axis of the glenoid
(Fig. 3). The width of the glenoid was measured at
right angles to this long axis though the midportion
of the inferior glenoid (Fig. 3). The presence of an
anterior straight line along the anterior glenoid rim
was noted and measured (Fig. 3). A single investi-
gator performed all CT measurements and assess-
ments unblinded to clinical information.
Glenoid bone loss was diagnosed provided two
criteria were present—namely, an anterior straight
line to the glenoid rim on the image obtained en face
to the glenoid articular margin and a relative reduc-
tion in glenoid width of the dislocating shoulder com-
pared with the normal side [2]. The anterior margin of
the normal glenoid has a curved contour [2]. Any
straightening of that counter was deemed to represent
an anterior straight line [2]. An anterior straight line
or relative reduction in glenoid width in isolation was
not deemed sufficient to constitute glenoid bone loss.
The percentage of glenoid bone loss was calculated

AJR:189, December 2007 1491


TABLE 1: Frequency of True-Positive,
True-Negative, False-
Positive, and False-Negative
Cases for CT Assessment of
Glenoid Bone Loss in 50
Patients with Anterior
Shoulder Dislocation Who
Underwent Arthroscopic
Quantification of Glenoid
Bone Loss
Arthroscopy Findings
CT Findings Positive Negative
Positive 38 2
Negative 3 7
Note—CT performance for quantification of glenoid
bone loss: sensitivity = 92.7%, specificity = 77.8%,
positive predictive value = 95.0%, negative
predictive value = 70.0%.
as the difference in glenoid width compared with the
width of the normal nondislocating glenoid and was
American Journal of Roentgenology 2007.189:1490-1493.
expressed to the nearest first decimal point.
Arthroscopic Assessment
General anesthetic was used for all ar-
throscopies. With the patient under anesthesia and
supine, the shoulder was examined for anterior,
posterior, inferior, and multidirectional instability.
The patient was then turned to the lateral decubi-
tus position, with the trunk tilting backward 30°,
the arm was flexed to 20° and abducted to 45° un-
der traction with a weight of 3–4 kg. Three arthro-
scopic portals [7]—namely, the posterior, antero-
superior, and anteroinferior and mid glenoid
portals—were made, and diagnostic arthroscopy
was performed using a 4-mm arthroscope. Via the
posterior portal, an arthroscopic probe (calibrated
in 1-mm increments) was used to determine and
quantify the degree of anterior glenoid bone loss
with reference to the central bare spot of the gle-
noid (Figs. 1 and 2). The tip of the probe was first
placed against the posterior glenoid margin, then
against the bare spot in the middle of the inferior
glenoid, and finally against the anterior glenoid
margin. Arthroscopic measurements of glenoid
bone loss were reported in intervals of 5% (e.g.,
5%, 10%, 15% bone loss).
Statistical Analysis
SPSS software (version 14.0, SPSS) for Win-
dows (Microsoft) was used for statistical analyses.
Variables were expressed as mean and range or
mean ± SD, as appropriate. The sensitivity, speci-
ficity, and positive and negative predictive values
of CT compared with arthroscopy in the detection
of glenoid bone loss were calculated. The paired
Student’s t test was used to test for difference in
mean glenoid bone loss measured by CT and ar-
1492
Griffith et al.
−45
−40
−35
% Glenoid Bone Loss at CT
−30
−25
−20
−15
−10
−5
0
0 −5 −10 −15 −20 −25 −30 −35 −40 −45
% Glenoid Bone Loss at Arthroscopy
throscopy. Pearson’s correlation coefficient was
used to examine the correlation between CT and
arthroscopy in quantifying the percentage of gle-
noid bone loss.
Pearson’s correlation coefficient (r) of 1.0 de-
scribes a perfect positive linear correlation, whereas
r values of 0.2–0.4 indicate a mild correlation;
0.4–0.7, a moderate correlation; and 0.7–1.0, a
strong correlation. A 5% significance level was ap-
plied for all tests (p < 0.05).
Results
Glenoid bone loss was evident in 41 (82%)
of 50 patients at arthroscopy. The remaining
nine (18%) patients had no evidence of gle-
noid bone loss at arthroscopy. Glenoid bone
loss was evident in 40 (80%) of 50 patients on
CT examination. Applying arthroscopy as a
gold standard for glenoid bone loss, the sen-
sitivity, specificity, positive predicative value,
and negative predictive value of CT in pre-
dicting glenoid bone are shown in Table 1.
There were three false-negative CT assess-
ments. These patients did not meet the criteria
for glenoid bone loss on CT examination, al-
though arthroscopy showed 5%, 10%, and
10% glenoid bone loss, respectively. There
were two false-positive CT assessments. In
those cases, CT revealed 8.7% and 5.7% gle-
noid bone loss, although no bone loss was ap-
parent at arthroscopy.
No significant difference was found between
mean glenoid bone loss predicted by CT
(11.0% ± 8.1%; range, 0–33.0%) or by arthros-
copy (12.3% ± 8.8%; range, 0–40%) (p = 0.17).
Fig. 4—Graph shows
correlation between
glenoid bone loss
measured at arthroscopy
and at CT examination.
Pearson’s correlation
coefficient (r) was 0.79,
with 95% CI of
0.659–0.877.
There was a strong correlation (r = 0.79) be-
tween CT and arthroscopy with respect to as-
sessments of the severity of glenoid bone loss
(r = 0.79, 95% CI = 0.659–0.877, p < 0.0001)
(Fig. 4).
Discussion
Identification and quantification of glenoid
bone loss are useful because that information
helps to predict the likelihood of further dis-
location and to determine the need for bone
augmentation surgery to restore shoulder sta-
bility [1, 4]. One cannot reliably predict the
degree of glenoid bone loss on the basis of the
number of dislocations alone [2]. Only re-
cently has attention focused on quantifying
glenoid bone loss, initially by arthroscopy
and later by CT examination [1–3, 6, 8].
CT is a reliable means of quantifying gle-
noid bone loss [2, 3, 8]. CT allows both gle-
noids to be examined simultaneously. CT as-
sessment of glenoid bone loss rests on
comparing the width of the glenoid in the
dislocating shoulder with that of the nondis-
locating shoulder in patients with unilateral
dislocation. Because a slight side-to-side
variation in glenoid width is normal and be-
cause the curved anterior glenoid margin
may occasionally be straight in subjects
without dislocation, two criteria should be
fulfilled before glenoid bone loss is diag-
nosed on CT examination [2]. First, on a re-
constructed image en face to the glenoid sur-
face, an anterior straight line should be
present, and, second, a relative reduction in
AJR:189, December 2007
 CT Versus Arthroscopy of Glenoid Bone Loss
glenoid width compared with the normal
contralateral side should be present.
It follows that CT cannot be used to quantify
glenoid bone loss in subjects with bilateral
shoulder dislocation. In this setting, the shape
of the glenoid will allow one to semiquantita-
tively categorize glenoid bone loss as absent,
mild, moderate, or severe, although the percent-
age of bone loss cannot be accurately quantified
because there is no normal glenoid for compar-
ison [2]. As a result, we included only patients
with unilateral dislocation in this study.
Sugaya et al. [3] described a method in which
a best-fit circle is applied to the inferior glenoid
on 3D reconstructed CT images. Those investi-
gators used size of the bone fragment, if present,
as a quantitative measure of bone loss and non-
quantitative visual comparison with the con-
tralateral side if no fragment was present [3]. No
quantitative comparison between arthroscopic
and CT evaluations was undertaken [3].
American Journal of Roentgenology 2007.189:1490-1493.
Itoi et al. [9] created osseous glenoid de-
fects on cadaveric scapula, recording scapular
length and width and the force required to in-
duce dislocation. An osseous defect resulting
in a glenoid width of less than 21% of the gle-
noid length produced instability. A limitation
of that study may be that these defects were
created on the anteroinferior margin of the
glenoid, whereas CT-based studies have
shown that bone loss occurs principally on the
anterior aspect rather than on the anteroinfe-
rior aspect of the glenoid [2, 8].
Other than CT, the method of quantifying
glenoid bone loss is arthroscopy [6]. Arthro-
scopic assessment involves identification of
the bare spot, an area where the cartilage is
thinned or absent in the center of the inferior
glenoid [5]. Using a calibrated probe inserted
through a posterior portal, the distance from
the posterior glenoid margin to the bare spot
should be equal to the distance from the bare
spot to the anterior glenoid margin if no bone
loss is present [6]. Reduction in the anterior
margin-to-bare spot distance relative to the
posterior margin-to-bare spot distance is an in-
dication and measure of glenoid bone loss [6].
Glenoid bone loss is common in patients
with anterior shoulder dislocation, particularly
in those with recurrent dislocation [2]. Most of
the patients in this study had recurrent shoulder
dislocation. CT had a high sensitivity and spec-
ificity for the detection of glenoid bone loss.
We found that there was a strong correlation
(r = 0.79) between CT and arthroscopy in
quantifying the severity of glenoid bone loss.
The CT technique used has been shown to have
good inter- and intraobserver variability [2]
AJR:189, December 2007
and is quick to evaluate with reconstruction
and analysis taking 5–10 minutes.
The main limitations in using CT for assess-
ment of glenoid bone loss are threefold. First,
additional radiation exposure is incurred, but
this exposure can be minimized by limiting the
scanning plane to include both glenoids only.
Second, CT assessment possesses an inherent
error because of the known side-to-side varia-
tion in normal glenoid width. However, this er-
ror has been shown to be small [2], and as
shown in this study, the correlation with ar-
throscopy is good. Third, extra time, cost, and
effort are needed to include a CT examination
in the imaging algorithm for shoulder instabil-
ity, which typically comprises radiography and
MRI [10]. Further study may enable selection
of patients most likely to benefit from the ad-
ditional CT examination based on appearances
at MR examination.
Arthroscopic assessment of glenoid bone
loss was used as the gold standard in this study.
Other than CT, arthroscopy is the only known
method of quantifying glenoid bone loss. Ar-
throscopy is not the ideal gold standard for sev-
eral reasons. First, the bare spot may occasion-
ally comprise a bare area rather than a discrete
bare spot. Second, the calibrated probe inserted
via the posterior portal may not always be
aligned at right angles to the long axis of the
glenoid. Alignment away from the true short
axis of the glenoid tends to underestimate bone
loss. Third, the millimeter-spaced lines along
the calibration probe are counted visually via a
second scope inserted through an anterosupe-
rior portal. In practice, these finely spaced lines
can be difficult to count arthroscopically, so
quantifying the exact degree of glenoid loss can
be difficult even with direct inspection [1]. As a
result, arthroscopic measurements tend to be
approximations, with descriptions as mild,
moderate, or severe or, as in this study, with
measurements reported in intervals of 5% (e.g.,
5%, 10%, 15% bone loss) [1]. Fourth, a cadav-
eric study has shown that the bare area does not
consistently lie in the center of the glenoid and
tends to lie closer to the anterior rather than the
posterior glenoid margin [11]. The mean differ-
ence between the anterior-to-posterior glenoid
widths with the bare spot as a reference was 4.2
mm (range, 0.9–8.9 mm). This tends to lead to
overestimation of bone loss and has prompted
Kralinger et al. [11] to recommend preoperative
CT rather than arthroscopy to assess glenoid
bone loss in patients with shoulder dislocation.
There are two main limitations to our study.
First, although all arthroscopic measurements
were reported independently of the CT results,
the surgeon performing arthroscopy was aware
of the CT results at the time of arthroscopy. Pre-
operative quantitative assessment of glenoid
bone loss is now standard practice in our hospi-
tal, so withholding that information from the
surgeon during preoperative planning was not
justifiable. Second, the average time lag be-
tween CT examination and arthroscopy was
28.5 days, with a maximum of 73 days.
Whether any further dislocations occurred dur-
ing this interval was not documented.
In conclusion, CT has a high sensitivity
and specificity for detecting the presence of
glenoid bone loss evident at arthroscopy.
There is also good agreement (r = 0.79) be-
tween CT and arthroscopy regarding the se-
verity of glenoid bone loss.
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