Glenoid Track Instability Management Score:

Radiographic Modification of the Instability Severity

Index Score
Giovanni Di Giacomo, M.D., Liam A. Peebles, B.A., Mattia Pugliese, M.D., M.Sc.,
Travis J. Dekker, M.D., Petar Golijanin, B.S., Anthony Sanchez, B.S., and
CAPT Matthew T. Provencher, M.D., MC, USNR

Purpose: The purpose of this study is (1) to test the proposed treatment algorithm, the Glenoid Track Instability Man-
agement Score (GTIMS), which incorporates the glenoid track concept into the instability severity index score (ISIS), and
(2) to compare treatment decision-making using either GTIMS versus ISIS in 2 cohorts of patients with operatively treated
anterior instability. Methods: A multicenter, retrospective review of two consecutive groups consisting of 72 and 189
patients treated according to ISIS and GTIMS, respectively, was conducted. Inclusion criteria for all patients were
2
confirmed traumatic anterior shoulder instability events and a physical examination demonstrating a positive anterior
apprehension and relocation test. The GTIMS was graded for all 189 patients in the cohort, which uses 3-dimensional
computed tomography as the sole radiographic parameter to assess on-track (0 points) versus off-track (4 points) Hill-
Sachs lesions. This method differs from ISIS, which uses multiple plain radiographs for the 4-point imaging portion of
the score. Outcomes scores were compared within the GTIMS and ISIS groups, as well as between them for overall
comparisons based on the Western Ontario Shoulder Instability Index (WOSI), the Single Assessment Numerical Eval-
uation (SANE) score, and the mean rates of recurrent instability. Results: A total of 261 consecutive patients from 2009
to 2014 who presented with recurrent anterior shoulder instability were treated according to either ISIS (n ¼ 72/261,
27.6%) or GTIMS (n ¼ 189/261, 72.4%). At a mean follow-up time of 33.2 months (range 24-49 months), the overall
cohort mean ISIS of 2.9  2.2 (range 0-9) was significantly higher than the mean GTIMS of 1.9  1.9 (range ¼ 0-9, P <
.001). Of the 72 ISIS treated patients, 50 (69.4%) had an ISIS score of
4 and underwent a Latarjet, and the 22 patients
(30.6%) with an ISIS score of < 4 underwent an arthroscopic Bankart repair. Based on GTIMS in the 189-patient cohort,
using the same cutoff of 4 to indicate the need for a Latarjet, 162 patients were treated with arthroscopic Bankart repair
(85.7%) and 27 with Latarjet (14.3%). The overall outcomes improved for patients treated with a Latarjet in both groups
(GTIMS WOSI from 1099 [47.7% normal] to 395 [81.3% normal]; GTIMS SANE from 48 to 81; ISIS WOSI from 1050
[50% normal] to 345 [83.4% normal]; ISIS SANE from 50 to 84; P < .01). Similar positive outcomes were seen in patients
treated with arthroscopic Bankart repair (GTIMS WOSI from 1062 [49.2% normal] to 402 [80.6% normal]; GTIMS SANE
from 49 to 82; ISIS WOSI from 1080 [51.8% normal] to 490 [76.7% normal]; ISIS SANE from 48 to 77; P < .01). Of note,
the patients with arthroscopically indicated ISIS had significantly worse outcomes scores than those treated arthro-
scopically according to GTIMS (P < .01). Of the 189 patients graded with GTIMS, there would have been 33 more Latarjet
procedures recommended based on ISIS score. Thus the distribution of procedures based on ISIS versus GTIMS was
significantly different (c2 ¼ 45.950; P < .001), indicating a higher rate of recommending Latarjets when using ISIS versus
GTIMS. Conclusions: When ISIS scoring and plain radiograph parameters only are used, this predicted a 2-fold increase
in recommending a Latarjet versus GTIMS scoring criteria, which uses advanced imaging and the on- and off-track
principle to more conservatively delineate anterior instability treatment with promising postoperative patient out-
comes. Overall, there were minimal differences in outcomes between GTIMS and ISIS Latarjet patients; however, better

From the Department of Shoulder Surgery, Concordia Hospital for Special
Surgery (G.D.G), Rome, Italy; The Steadman Clinic (T.J.D., M.T.P.) and the
Steadman Philippon Research Institute (L.A.P., A.S., M.T.P.), Vail, Colorado,
U.S.A.; Geisel School of Medicine at Dartmouth (P.G.), Hanover, New
Hampshire, U.S.A.; and Trauma & Orthopaedics Department, University of
Rome “La Sapienza” (M.P.), Rome, Italy.
The authors report the following potential conflicts of interest or sources of
funding: M.T.P. is a consultant for Arthrex and JRF Ortho; and has patent
numbers (issued): 9226743, 20150164498, 20150150594, 20110040339;
and receives royalties from Arthrex and SLACK (publishing royalties). Full
ICMJE author disclosure forms are available for this article online, as
supplementary material.
Received January 26, 2019; accepted July 11, 2019.
Address correspondence to CAPT Matthew T. Provencher, M.D., MC,
USNR, Orthopedic Shoulder and Knee Surgeon, The Steadman Clinic,
Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 400,
Vail, CO 81657, U.S.A. E-mail: mprovencher@thesteadmanclinic.com
Ó 2019 by the Arthroscopy Association of North America
0749-8063/18639/$36.00
https://doi.org/10.1016/j.arthro.2019.07.020

56 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 36, No 1 (January), 2020: pp 56-67
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 GLENOID TRACK INSTABILITY MANAGEMENT SCORE
outcomes were seen in patients indicated for arthroscopic Bankart repair according to GTIMS and on-off track computed
tomography scanning indications. Level of Evidence: II, Prospective Cohort Study.
See commentary on page 68
T he instability severity index score (ISIS), originally
proposed by Balg and Boileau,1 rates patients on a
10-point scale based on preoperative risk factors to
identify those who are at high risk for recurrent insta-
bility after an arthroscopic Bankart repair. Patients who
score >6 have been reported to have a 70% risk of
recurrent instability after arthroscopic Bankart repair,
and therefore a Bristow-Latarjet procedure has been
recommended in these patients. When determining
ISIS, a total of 6 risk factors are considered, 2 of which
are radiographic; first, recognition of a Hill-Sachs lesion
on an anteroposterior (AP) shoulder radiograph with
the shoulder in external rotation (2 points) and, second,
contour loss of the inferior glenoid on a true AP
shoulder radiograph (2 points). Clinical risk factors
include age 20 years (2 points), involvement in
competitive sports (2 points), contact sports or those
involving forced overhead activity (1 point), and
shoulder hyperlaxity (1 point).
ISIS has been examined across multiple cohorts.
Rouleau et al.2 demonstrated the reliability of ISIS in a
cohort of 114 patients and reported an intraclass cor-
relation coefficient of 0.933 across 5 pairs of indepen-
dent evaluators. Although ISIS demonstrates reliability
between raters, evidence of the score’s validity has been
inconsistent. In 141 patients, Phadnis et al.3 confirmed
that ISIS is a valid preoperative tool but reported a 70%
recurrence of instability after arthroscopic Bankart
repair in patients scoring
4. Therefore it was suggested
that a cutoff score of 4, instead of 6, be used for a
Latarjet procedure. Thomazeau et al.4 similarly sug-
gested that an ISIS 4 is ideal for arthroscopic Bankart
repair. In contrast, Bouliane et al.5 concluded that ISIS
was incapable of predicting recurrent instability in their
cohort of 110 patients at 2 years after arthroscopic
Bankart repair.
The glenoid track concept may provide a more
relevant method to account for bone loss in patients
with recurrent shoulder instability than identification
of glenoid or humeral head bone loss on radiographs
as seen in ISIS. Therefore the purpose of this study is
(1) to test the proposed treatment algorithm, the
“Glenoid Track Instability Management Score”
(GTIMS), which incorporates the glenoid track
concept into ISIS, and (2) to compare treatment
decision-making using either GTIMS versus ISIS in 2
cohorts of patients with operatively treated anterior
instability. It was hypothesized that GTIMS would
more selectively identify patients at risk of recurrent
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57
instability or failure based on patient-reported out-
comes after arthroscopic repair and avoid over-
estimating clinically irrelevant, or on-track, bone loss,
ultimately producing comparable clinical outcomes
(recurrence rates, SANE and WOSI scores) to patients
treated according to ISIS.
Methods
Two institutional boardeapproved (Blinded for
Review), multicenter retrospective reviews were per-
formed of consecutive patients who presented with
recurrent traumatic anterior shoulder instability from
2009 to 2014 and were subsequently included in either
the ISIS reference cohort or the GTIMS treatment
cohort. Patients were included in this study if they
presented with
2 confirmed traumatic anterior
shoulder instability events and a physical examination
result demonstrating positive anterior apprehension
and relocation test results. Patients were excluded from
this study if they demonstrated bilateral shoulder
injury, previous ipsilateral shoulder surgery, rotator
cuff tear, or physical examination demonstrating
shoulder pain without instability or voluntary or
multidirectional shoulder instability. In accordance
with the guidelines of the institution’s ethics committee
(Blinded for Review), all patients provided informed
consent as part of their agreement to participate in the
study.
In addition to the positive apprehension sign and
relocation test required to be included in this study,
physical examination included evaluation of anterior
and inferior shoulder hyperlaxity. Anterior hyperlaxity
was defined as external rotation of >90 with arms at
the side (reaching the frontal plane), and inferior laxity
was determined through use of the Gagey hyper-
abduction test.6,7
To detect bone loss, both shoulder radiography and
computed tomography (CT) were used. More specif-
ically, an AP shoulder radiograph with the shoulder
positioned in external rotation and a true AP radio-
graph of the affected shoulder were performed for all
patients. The AP shoulder radiography with the shoul-
der in external rotation was used to detect the presence
of a Hill-Sachs lesion (Fig 1). The true AP shoulder
radiograph was used to determine whether there was
loss of contour, or disruption of the sclerotic line, along
the anteroinferior glenoid (Fig 2). All patients also un-
derwent preoperative bilateral shoulder CT scanning
with 3-dimensional (3D) reconstructions as described in
58 G. DI GIACOMO ET AL.

footprint. If there was no bony defect of the glenoid,

this line represented the medial margin of the glenoid
track. When a bony defect of the glenoid was identi-
fied (d), the distance d was subtracted from the 83%
line to obtain the medial margin of the true glenoid
track (line G1 in Fig 3B). In those cases where the Hill-
Sachs lesion was located within the glenoid track, it
was determined to be an “on-track” Hill-Sachs lesion.
When the lesion extended more medially over the
medial margin of the glenoid track, it was scored as an
“off-track” Hill-Sachs lesion (Fig 3B). In all cases, 3D
images were obtained by the shaded surface display
technique and rendered to display the complete
shoulder region with the humeral head digitally sub-
tracted from the glenohumeral joint.
The sex, age, number of prior subluxation and
dislocation events, type of sport played, and level of
sport participation were recorded for each participant.
Sports were divided into the following categories:
contact, overhead, forced overhead, and any other
sport. More specifically, contact sports included high-
impact activities (e.g. football, rugby), overhead sports
involved hitting movements (e.g., weightlifting, field
hockey, and tennis), and forced overhead sports con-
sisted of overhead hitting movements and sudden stops
(e.g., volleyball, basketball, and wrestling). All other
Fig 1. Anteroposterior radiograph of the left shoulder posi-
sports, mostly nonimpact sports (e.g., rowing, fencing,
tioned in external rotation. A Hill-Sachs lesion is visualized
(arrows). This finding would add 2 of the possible 10 points in
the instability severity index score.

previous studies.8-10 To obtain an appropriate CT scan

to be used for the quantitative measurements of the
glenoid track concept, the patient was placed in the CT
gantry with both shoulders in neutral position with
respect to the scanning field. CT scans were performed
on a 64-slice Siemens Somatom dual-source scanner
(200 mA, 120 kV [peak]) with a slice thickness of 1 mm
(Siemens, Erlanger, Germany).11
To measure an en-face view of the glenoid for each
shoulder, both the affected and contralateral shoulder
CT 3D reconstructions were generated. Given that the
average difference in area of the glenoid face between
the left and right shoulder is minimal12-15 and previ-
ously reported as only 1.8%,14 the contralateral gle-
noid was used as a reference. To determine the defect
size, the greatest horizontal distance of the glenoid
(width) was measured on both shoulders. Using the
intact glenoid width as a reference, the defect size
(d) was calculated as follows: d ¼ Intact glenoid
width  Injured glenoid width (Fig 3A).
Next, using the posterior view of the humeral head,
the medial margin of the rotator cuff footprint and the Fig 2. True anteroposterior radiograph of a right shoulder
Hill-Sachs lesion were identified. Then, a line was set demonstrates loss of the sclerotic glenoid line (arrows) due to
located at a distance equal to 83% of the glenoid an anterior glenoid rim deficiency. This finding would add 2
width from the medial margin of the rotator cuff of the possible 10 points in the instability severity index score.

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 GLENOID TRACK INSTABILITY MANAGEMENT SCORE 59

Fig 3. Three-dimensional computed tomography reconstructions of (A) a glenoid with a bony defect and (B) a humeral head
with medium-sized Hill-Sachs lesion. With the contralateral glenoid used as a reference (100%), 83% width is determined,
which is the distance from the medial margin of the footprint of the rotator cuff to the medial margin of the glenoid track. Then
the defect width (d) is subtracted from this 83% length to obtain the glenoid track width for this case (black double-headed
arrow). Dotted line (R) represents the medial margin of the rotator cuff attachment. Dotted line G1 indicates the location of
the medial margin of the glenoid track. If there had been no glenoid bony defect, the medial margin of the glenoid track would
have been dotted line G2. In this case, the Hill-Sachs lesion extends medially beyond the medial margin of the glenoid track
(dotted line G1), so this is an off-track lesion.

and sailing), were labeled as “other.” Level of sports
participation was also noted and categorized as either
competitive, recreational, or none. Competitive sport
participation was defined as competing as part of a
team, regardless of level, in regular matches, as well as
involvement in the team’s training sessions.1,3
When determining ISIS, a total of 6 risk factors were
considered with a total of 10 points possible as origi-
nally described by Balg and Bolieau.1 First, clinical risk
factors for instability were added including patient age
20 years or below (2 points), participation in contact
sports or those involving forced overhead activity (1
point), involvement in competitive sports (2 points),
and shoulder hyperlaxity (1 point). Next, radiographic
findings were considered including the presence of
contour loss of the anteroinferior glenoid on a true AP
shoulder radiograph (2 points) and the presence of a
Hill-Sachs lesion on an anteroposterior (AP) radiograph
with the shoulder in external rotation (2 points). Points
were summed for a total ISIS.
For GTIMS, a total of 10 points were possible. Points
were allocated in the same way as ISIS for all criteria
except those related to imaging. In GTIMS, evaluation
of bone loss was based on 3D CT evaluation of the
shoulder and the glenoid track concept. “On-track”
lesions were given 0 points and “off-track” lesions were
given 4 points (Tables 1 and 2; Fig 4).
To validate the efficacy of GTIMS as a new treatment
algorithm to guide operative decision making, the
outcomes of the 189-patient cohort treated according to
GTIMS in this study were compared with a cohort of 72
patients that were treated with surgery according to
ISIS. Western Ontario Shoulder Instability Index
(WOSI) Single Assessment Numerical Evaluation
(SANE) scores were recorded both before and after
surgery by the first and senior authors (blinded for re-
view) at a minimum of 2 years’ follow-up for both
cohorts of patients to allow for adequate time to return
to activity. The SANE is a simple, patient-based shoul-
der function assessment tool that helps surgeons assess
how the patient would rate their postoperative shoul-
der function as a percentage of normal (0% to 100%
scale, 100% being normal).16 The WOSI is comprised of
21 questions assessing (1) physical symptoms; (2)
sports, recreation, and work; (3) lifestyle; and (4)
emotions.17 The score ranges from 0 to 2100, with a
higher score indicating a worse outcome. At the same
time of follow-up, patients reported if they had

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60
Table 1. Patient Demographic Risk Factors Identified on ISIS
Score
ISIS Prognostic Factors
Age at surgery (years)
 20
> 20
Type of sport
Contact or forced overhead
Other
Level of competition in sport
Competitive
Recreational or none
Shoulder hyperlaxity
Confirmed anterior or inferior hyperlaxity
Normal laxity
Loss of sclerotic line of the glenoid on AP radiograph
Yes
No
Hill-Sachs lesion visible in external rotation on AP radiograph
Yes
No
Total ISIS
NOTE.Bone loss was evaluated based on AP shoulder radiographs in
ISIS. As originally proposed by Balg and Bolieau.
AP, anteroposterior; ISIS, instability severity index score.
experienced any recurrent instability in the form of
subluxation or dislocation and they were finally
assessed by the first and senior authors (blinded for
review) with the same preoperative physical examina-
tion results described above. Recurrent instability was
defined as a glenohumeral subluxation or dislocation,
which reduced spontaneously or required manual
reduction after anterior stabilization.
Outcomes scores and rates of recurrent instability
were first compared within each treatment cohort
(GTIMS and ISIS) for patients who were treated with a
Latarjet versus arthroscopic Bankart repair. Outcomes
scores were also collated across groups, where GTIMS
Latarjet outcomes were compared with those of pa-
tients treated with ISIS Latarjet and GTIMS arthroscopic
Bankart repair outcomes versus those of patients
treated arthroscopically according to ISIS. Furthermore,
the mean SANE and WOSI scores of the 33 patients
who would have been treated with a Latarjet according
to ISIS but instead received arthroscopic Bankart sta-
bilization based on GTIMS were compared with those of
patients treated with Latarjet in the separate ISIS
cohort.
Statistical Analysis
Data were analyzed using Statistica 7.0 (StatSoft, Inc.,
Tulsa, OK). The database included 189 cases classified
according to 4 patient historyebased variables (age if
< 20, type of sport, contact or competition sport, joint
hyperlaxity) plus 2 x-ray variables (presence/absence of
Hill-Sachs or glenoid bone lesion) for ISIS, or the on/off
track lesion variable for GTIMS. The Mann-Whitney U
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G. DI GIACOMO ET AL.
test was used to compare ISIS and GTIMS, which were
considered as ordinal variables because they are based
Score
on a rating system from 0 to 10. Any calculated P values
were considered to reach significance at .05.
2 A theoretical decision for arthroscopic Bankart repair
0 or Latarjet procedure was made based on ISIS and
GTIMS assigned to each patient. The 2 scores were
1 compared, and c2 values were computed. A score
4
0
points was used to indicate a Latarjet procedure, as
2 previously recommended for ISIS.2,3 To verify the
0 reliability of the measurements obtained, the intraclass
correlation coefficients (ICC) and Cronbach’s a values
1 were calculated for the variables obtained from the
0
x-ray films and CT scans.
2
0 Results
2
A total of 189 consecutive patients (165 male, 24
0 female) with recurrent shoulder instability were
10 included in the GTIMS cohort and 72 consecutive pa-
tients (54 male, 18 female) were included in the ISIS
cohort for this study. The mean ages were 31 years
(range, 16-39) and 26.4 (range, 19 to 43), respectively.
Table 3 summarizes the GITMS sample population. The
average follow-up period for both patient groups was
33.2 months with a 2-year minimum (range,
24-49 months). Overall, 324 patients met the inclusion
criteria for this study and received treatment, but 63
were lost to follow-up, leaving 261 (80.6%) patients
across both groups to be included in final analysis. In
the GTIMS group, 29 participants were <20 years of age
(15.3%), 109 played contact sports (57.7%), 53 played
competitive sports (28%), and 53 were found to have
joint hyperlaxity (28%). Forty-seven patients were
Table 2. Non-bone Loss Factors Were the Same in ISIS and
GTIMS
GTIMS Prognostic Factors Score
Age at surgery (years)
 20 2
> 20 0
Type of sport
Contact or forced overhead 1
Other 0
Level of competition in sport
Competitive 2
Recreational or none 0
Shoulder hyperlaxity
Confirmed anterior or inferior hyperlaxity 1
Normal laxity 0
Evaluation of bone loss on 3D CT
“On-Track” 0
“Off-Track” 4
Total GTIMS 10
NOTE.Bone loss was evaluated on 3D reconstructed shoulder CT
scans and categorized as “on-track” or “off-track” in GTIMS.
3D, Three-dimensional; CT, computed tomography; GTIMS, Glenoid
Track Instability Management Score.
 GLENOID TRACK INSTABILITY MANAGEMENT SCORE 61

Fig 4. (A) Without any bony

defect on the glenoid, the gle-
noid track (GT) is 83% of the
glenoid width. If the Hill-Sachs
lesion (HSL) is located within
the GT, it is considered on
track and at low risk of
engagement on the glenoid.
(B) With a bony defect on the
glenoid, the GT is considerably
less than 83% of the glenoid
width. If the HSL extends more
medially, it is considered off
track and at a much higher risk
of humeral head engagement.

found to have Hill-Sachs lesions (24.9%), 63 had gle- of 4.9  1.9 and an average GTIMS of 4.0  0.9
noid bone loss (33.3%), and 21 (11.1%) demonstrated (Z ¼ 2.708; P < .05).
bipolar bone loss. Nine were found to have “off-track” According to the ISIS and using cutoff
4 points to
lesions (4.8%). The average ISIS for the 189 patients indicate a Latarjet procedure for the 189 GTIMS-treated
treated according to GTIMS was 2.9  2.2 (median 3); patient group, 129 patients would have been treated
the average GTIMS was 1.9  1.9 (median 1). The with arthroscopic Bankart repair (68.3%) and 60
difference between the 2 scores was statistically signif- treated with Latarjet (31.7%). However, according to
icant, as indicated by the Mann-Whitney U test GTIMS and using the same cutoff of 4, ultimately 162
(Z ¼ 4.961; P < .05). The mean ISIS for the 72-patient patients were treated with arthroscopic Bankart repair
reference group that was treated base on ISIS was 3.9
 1.6 (median: 4).
Table 4. The Frequency Distributions of ISIS and GTIMS
The frequency distributions of ISIS and GTIMS for the Scores Across the 189 GTIMS-Treated Patient Cohort
GTIMS-treated group are summarized in Table 4,
respectively. Considering only patients age <20, the Score Frequency Cumulative Score
average ISIS was 5.0  1.9, and the average GTIMS was ISIS
4.4  1.4. The difference based on the U value of the 0 20 20 10.6
1 42 62 22.2
Mann-Whitney test did not reach statistical significance 2 27 89 14.3
(Z ¼ 0.730; P ¼ .465). Similar results were found in 3 40 129 21.2
patients with joint hyperlaxity (Z ¼ 1.247; P ¼ .211), 4 18 147 9.5
whose average values were 2.8  2.0 for ISIS and 2.1 5 21 168 11.1
 1.3 for GTIMS. However, in patients who played 6 5 173 2.6
7 8 181 4.2
contact sports, the average ISIS was 3.7  1.5, and the 8 5 186 2.6
average GTIMS was 2.5  1.0 (Z ¼ 4.721; P < .05). Last, 9 3 189 1.6
patients playing competitive sports had an average ISIS 10 0 189 0
GTIMS
0 29 29 15.3
Table 3. Description of 189 GTIMS Patient Cohort Based on 1 80 109 42.3
History and Imaging Findings 2 30 139 15.9
3 23 162 12.2
Frequency Percentage 4 13 175 6.9
Age < 20 29 15.3 5 4 179 2.1
Collision 109 57.7 6 1 180 0.5
Competitive 53 28 7 4 184 2.1
Hyperlaxity 53 28 8 0 184 0
Hill Sachs 47 24.9 9 3 187 1.6
Glenoid bone lesion 63 33.3 10 2 189 1.1
Off-track 9 4.8 GTIMS, Glenoid Track Instability Management Score; ISIS, insta-
GTIMS, Glenoid Track Instability Management Score. bility severity index score.

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62 G. DI GIACOMO ET AL.

Fig 5. Bubble chart representation of the volume of patients treated according the glenoid track instability management score
(GTIMS) that also received ISIS scoring. The blue, lower left quadrant, represents patients who scored < 4 according to both
GTIMS and the instability severity index score (ISIS) and were treated with arthroscopic Bankart repair. The orange, upper right,
quadrant represents patients that scored > 4 on both GTIMS and ISIS and were subsequently treated with an open Latarjet. The
grey, lower right, quadrant represents the 33 patients that scored < 4 for GTIMS but > 4 according to ISIS and were stabilized
arthroscopically. The average Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation
(SANE), and rates of recurrence (failure) for each subgroup is displayed in their respective quadrants.

(85.7%) and 27 with Latarjet (14.3%). Therefore 33
patients (17.5%) would have been treated with a
Latarjet according to ISIS but instead were treated with
arthroscopic Bankart repair due to GTIMS grading
(Fig 5). These differences were statistically significant
(c2 ¼ 45.950; P < .05).
In the 189-patient GTIMS cohort, bone loss was
assessed with 3D CT and the ICC value for the Hill-
Sachs lesions ranged from 0.889 to 0.932 and the
Cronbach a was 0.967. The ICCs for the evaluation of
the glenoid bone loss ranged from 0.941 to 0.976 and
the Cronbach a was 0.986. The last ICCs, that is, for the
evaluation of on/off track lesions, ranged from 0.894 to
0.946. The reliability of this measurement was
confirmed by the Cronbach a value of 0.975. For the
72-patient ISIS cohort, poor inter-rater and intrarater
reliabilities were uniformly reported when using ISIS
criteria and plain radiographs to assess bone loss. The
inter-rater k value for the Hill-Sachs lesions was 0.048
(95% CI ¼ 0.112 to 0.208, “poor agreement”) and
the intrarater k values ranged from 0.165
(55.7% observed agreement) to 0.093 (64.3% observed
agreement). The inter-rater k value for the detection of
glenoid bone loss was 0.194 (95% CI ¼ 0.024 to
0.412, “poor agreement”) and the intrarater k values
ranged from 0.146 (64.3% observed agreement) to
0.203 (60.0% observed agreement).
The postoperative outcomes of both the GTIMS (189
patients) and ISIS (72 patients) can be found in Table 5.
All patients treated in both the GTIMS and ISIS cohorts
demonstrated clinically relevant improvements in
WOSI scores according to MCID guidelines at the time
of follow-up, because all reported a minimum 220 point
improvement between preoperative and postoperative
WOSI scores.18 Of the 189 patients who were managed
with surgery according to GTIMS, 27 (14.3%) under-
went Latarjet procedures and 162 (85.7%) were treated
with an arthroscopic Bankart repair. Of the 72 patients
that were treated according to ISIS for comparison, 50
(69.4%) were treated with Latarjet procedures, and the
remaining 22 (30.6%) underwent arthroscopic Bankart
stabilizations. In the GTIMS treatment group, the 129
patients that were treated with arthroscopic Bankart
repair regardless of scoring algorithm (both GTIMS and
ISIS < 4) used had a mean postoperative WOSI and
SANE scores of 380 (81.9% of normal) and 82.1,
respectively. The 27 patients who qualified for open
Latarjet stabilization according to both GTIMS and ISIS
(GTIMS and ISIS
4) had mean postoperative WOSI
and SANE scores of 395 (81.2% normal) and 81.2,
respectively. The 33 patients (17.5%) that were treated
with GTIMS-based arthroscopic Bankart repair over an
ISIS-based Latarjet (GTIMS < 4, ISIS
4) had a mean
postoperative WOSI of 490 (76.7% of normal) and

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 GLENOID TRACK INSTABILITY MANAGEMENT SCORE
Table 5. Preoperative and Postoperative Outcomes Scores and Rates of Recurrent Instability for the 189 Patient GTIMS-Based
Treatment Group and 72 Patient ISIS-Based Treatment Group
Preoperative WOSI,
Score (% Normal)
GTIMS treatment group
Latarjet (27 patients) 1099 (47.7%)
Arthroscopic Bankart (162 patients) 1062 (49.2%)
ISIS treatment group
Latarjet (50 patients) 1050 (50.0%)
Arthroscopic Bankart (22 patients) 1080 (51.8%)
GTIMS, Glenoid Track Instability Management Score; ISIS, instability severity index score; SANE, Single Assessment Numerical Evaluation;
WOSI, Western Ontario Shoulder Instability Index.
mean postoperative SANE score of 77.1 at 2-year
follow-up. Notably, the patients who received arthro-
scopic Bankart repairs according to ISIS (22/72) had
significantly worse WOSI and SANE scores than the
overall cohort of 162 patients treated arthroscopically
according to GTIMS (P < .01), because the mean WOSI
and SANE scores for the patients evaluated with ISIS
were 490 (76.7% of normal) and 77 compared with
402 (80.6%) and 82 for the patients evaluated with
GTIMS, respectively. When considering only the 33
patients who were treated with GTIMS-based arthro-
scopic Bankart repair over an ISIS-based Latarjet
(GTIMS < 4, ISIS
4), these patients demonstrated
comparable outcomes scores to the 22 patients stabi-
lized arthroscopically according to ISIS (WOSI ¼ 490
[76.7% of normal], SANE ¼ 77) but worse outcomes
than the 50 patients treated with ISIS-based Latarjet
(WOSI ¼ 345 [83.6% of normal], SANE ¼ 84).
The overall rate of recurrent instability after arthro-
scopic Bankart repair was 8.0% (13 of 162) in the
GTIMS-treated cohort and 4.5% (1 of 22) in the ISIS-
treated cohort. Notably, all recurrences were suffered
by patients who were either contact sport athletes
(n ¼ 5), soccer goal keepers (n ¼ 1), or patients
<19 years of age (n ¼ 7). Patients in the GTIMS-based
group, who would have been treated with arthroscopic
Bankart repair regardless of scoring algorithm (both
GTIMS and ISIS < 4), had a recurrent instability rate of
7.6% (10 of 129). Finally, marginally (but not signifi-
cantly) higher rates were observed in the subgroup of
patients treated with GTIMS-based arthroscopic Bank-
art repair over an ISIS-based Latarjet (GTIMS < 4, ISIS

4): in this group, 3 of 33 (9.1%) experienced recur-
rent instability. For patients who qualified for open
Latarjet (GTIMS and ISIS
4), no cases of recurrent
instability were reported in either group.
Discussion
The most important finding of this study is that
incorporating the glenoid track concept into the
proposed GTIMS results in a significantly more con-
servative treatment algorithm than when using ISIS
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63
Postoperative WOSI, Preoperative Postoperative Recurrent Instability,
Score (% Normal) SANE (Score) SANE (Score) n (% Total)
395 (81.3%) 48 81 0 (0%)
402 (80.6%) 49 82 13 (8.0%)
345 (83.6%) 50 84 0 (0%)
490 (76.7%) 48 77 1 (4.5%)
alone; treating patients according to GTIMS, fewer
Latarjets, and more arthroscopic Bankart were per-
formed than if the patients had been treated according
to ISIS alone. In GTIMS, glenohumeral bone loss is
evaluated with CT to assess the geometric interplay of
boney lesions. This, in contrast to ISIS0 reliance on plain
radiographs, is likely to increase the predictive potential
of an instability scoring system, thereby enhancing
clinical decision-making. Although additional clinical
studies are needed to validate GTIMS, the current
literature on the glenoid track concept19-21 suggests that
GTIMS may more accurately predict failure after
arthroscopic Bankart repair and therefore more accu-
rately identify patients who should undergo a Latarjet.
Appropriate patient selection is critical when treating
shoulder instability. For this reason, Balg and Boileau1
developed the ISIS, which attempts to identify before
surgery the patients who are at risk for recurrent
shoulder instability after arthroscopic Bankart repair.
They determined that a score >6 was associated with a
70% risk of recurrent instability after arthroscopic
Bankart repair, and therefore a Bristow-Latarjet pro-
cedure was recommended in these patients. The
strength of the study by Balg and Boileau1 is the
development of a scoring system to improve preoper-
ative patient selection and that the factors identified can
be easily detected during routine clinical examination.
Although the authors agree that ISIS0 nonradiographic
risk factors are predictive of failure, 1 weakness with
ISIS is its evaluation of bone loss. Balg and Boileau1
state that evaluation of glenoid bone loss is difficult
on plain radiograph. In fact, Jankauskas et al.22 assessed
86 shoulders for loss of the radiographic anterior gle-
noid sclerotic line, and compared their findings with CT
scans. Of the 2 examiners, 1 correctly identified glenoid
bone loss through loss of the sclerotic line on x-ray films
in 56% of cases, and the other, 64%. They concluded
that radiographic loss of the sclerotic anterior glenoid
line is only moderately sensitive for glenoid bone loss.
Although more specific x-ray views to detect glenoid
lesions have been proposed by Garth et al.23 and Ber-
nageau et al.,24 they can be difficult to obtain in routine
64
clinical practice. For this reason, CT has been recom-
mended for preoperative planning in cases of gleno-
humeral instability with bone loss.25-27
The inability of ISIS to identify and address mean-
ingful bone loss may be responsible for the mixed re-
sults in using ISIS in clinical practice. This is
demonstrated in the present study by the fact that the
33 patients evaluated with GTIMS who would have
received a Latarjet according to ISIS but instead were
treated arthroscopically had equivalent outcomes
(WOSI ¼ 490, SANE ¼ 77) to the 22 patients evaluated
with ISIS who were also treated with arthroscopic
Bankart (WOSI ¼ 490, SANE ¼ 77). The authors pro-
pose that this may be due to the low sensitivity, and
thus high false-negative results, when radiography
alone is used to identify humeral or glenoid bone loss,
especially when compared with other imaging modal-
ities that are considerably more sensitive in detecting
such lesions such as CT and 3D CT. More simply put,
the use of ISIS may result in missed diagnoses of these
bone defects, notably smaller defects, which are off-
track or “borderline” off-track. Such lesions may not
necessarily result in something as apparent as a redis-
location, but also in residual instability, thus the rela-
tively high WOSI scores in the 22 patients with
arthroscopically treated ISIS evaluation. This is further
corroborated by the low interobserver and intra-
observer reliability of the ISIS score presented in the
results. In 141 patients, Phadnis et al.3 confirmed that
ISIS is a valid preoperative tool but reported a
70% recurrence of instability after arthroscopic Bankart
repair in patients scoring
4. Therefore it was suggested
that a cutoff score of 4, instead of 6, be used for a
Latarjet procedure. Thomazeau et al.4 similarly sug-
gested that an ISIS 4 is ideal for arthroscopic Bankart
repair. In contrast, Bouliane et al.5 concluded that ISIS
was incapable of predicting recurrent instability in their
cohort of 110 patients at 2 years after arthroscopic
Bankart repair.
At any given point, the ISIS threshold is a tradeoff
between risking recurrent instability and performing an
excessively high number of Latarjets, thus markedly
increasing the risk of postoperative complications. The
results presented in this study demonstrate that GTIMS
is not inferior to ISIS in effectively selecting candidates
for scope surgery, because there were no statistically
significant differences in rates of recurrent instability
between the GTIMS (8%) and ISIS (4.5%) arthroscopic
Bankart cohorts (P > .05). Moreover, arthroscopic
stabilization leaves the door open for revisional Latarjet
procedures in cases where the former procedure may
have failed. However, if a patient is initially treated
with a Latarjet, this could lead to a problematic sce-
nario in the future if it fails. Therefore one should be
cautious in not “abusing” Latarjet as a primary
procedure.
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G. DI GIACOMO ET AL.
Although inconsistent results have been reported with
ISIS, it is generally agreed that humeral head and glenoid
osseous integrity are critical components of shoulder
stability. However, it is not only just the presence of
glenohumeral bone loss, but also the interplay between
the glenoid and humeral lesions, as suggested by the
glenoid track concept, that contribute to recurrent
instability.5,21 According to the glenoid track concept,
which has been verified biomechanically and clini-
cally,19,28 a Hill-Sachs lesion may be characterized as
“on-track” or “off-track.”29 An off-track lesion is one
with bipolar bone loss that engages between the
Hill-Sachs lesion and glenoid rim and increases the risk of
recurrent stability if bone loss is not addressed. If the
Hill-Sachs lesion is “on-track,” it does not engage and is
believed to contribute less to recurrent stability. In 2007,
Yamamoto et al.29 defined the zone of contact between
the glenoid and the head of the humerus as the “glenoid
track” and assessed the risk of a HilleSachs lesion
engaging with the glenoid rim with or without a glenoid
defect. Shaha et al.21 reported that the application of the
glenoid track concept proved to be superior to the use of
glenoid bone loss alone predicting postoperative stabil-
ity. In 57 shoulders over a 2-year period, they reported
8% recurrent instability after arthroscopic Bankart
repair in patients with on-track lesions versus 75%
recurrence in patients with off-track lesions. In the same
series, only 44% of patients with glenoid bone loss
>20% went on to recurrent instability, suggesting
greater predictive value in the glenoid track concept.21
Trivedi et al.19 and Metzger et al.19,28 similarly demon-
strated that an accurate assessment of glenohumeral
engagement using the glenoid track concept may simi-
larly predict recurrence after arthroscopic stabilization.
Moreover, when comparing patients with an on-track
lesion and those with an off-track lesion, Locher et al.30
reported that patients with off-track lesions were 8.3
times more likely to need revision surgery than those
with “on-track” Hill-Sachs lesions after arthroscopic
Bankart repair.
In the proposed GTIMS, the same “non-bone loss”
factors as assessed in ISIS were also considered,
assigning them the same values. However, CT evalu-
ation of glenohumeral bone loss according to the
glenoid track concept was added to the GTIMS criteria
for this study. On-track lesions received 0 points, and
off-track lesions received 4 points (Table 2).11 A
threshold
4 points was used to determine whether a
patient was stabilized with a Latarjet procedure,
similar to the most-recent suggestions for ISIS. When
comparing the surgical decision-making in both the
experimental (GTIMS) and reference (ISIS) patient
cohorts, significantly fewer patients underwent a
Latarjet procedure using GTIMS than would have if
surgical decision-making was based on ISIS alone.
According to ISIS, 60 of the 189 patients (32%) in the
 GLENOID TRACK INSTABILITY MANAGEMENT SCORE
GTIMS-treated cohort would have undergone a
Latarjet. Conversely, evaluating the same cases based
on the glenoid track concept alone (in the absence of
clinical factors), only 9 of 189 patients (5%) had off-
track lesions and would be recommended for a
Latarjet procedure. However, according the proposed
GTIMS using the combination of clinical and glenoid
track radiographic risk factors, 27 of 189 patients
(14%) were treated with a Latarjet.
A comparison between ISIS and GTIMS highlights the
approach of the pro-European school, which tends to
favor the use of the Latarjet procedure relative to North
America, which tends to favor arthroscopic Bankart
repair. We suggest that GTIMS has the potential to
identify patients at risk of recurrent instability after
arthroscopic repair with selectivity comparable to ISIS;
and perhaps even more interestingly, it may avoid
overestimating clinically irrelevant, or on-track, bone
loss, thereby preventing some patients from undergoing
an open surgical procedure that they do not need.
Moreover, this more-selective criteria avoids putting as
many patients at risk of developing common post-
operative complications that are seen after a Latarjet
procedure, including graft osteolysis, hardware com-
plications, and development of early-onset osteoar-
thritis.31-36 By using the ISIS score to guide operative
decision making, glenoid bone loss that is visible on
x-ray leads to Latarjet as a treatment option, therefore
those who end up being treated with Bankart repair
have excellent results, as they had minimal bone loss to
begin with. Moreover, patients with any visible bone
loss on x-ray film in the ISIS-treated patient cohort
were stabilized with a Latarjet, which may have
significantly decreased the risk of recurrent instability in
this group relative to the overall rates seen in the
GTIMS patient cohort.
The risk of using ISIS to guide operative management
plans is that a considerable number of patients who
could potentially do well with Bankart repair end up
having Latarjet performed and would have positive
outcomes regardless of the procedure that is performed.
The proposed GTIMS allows clinicians to extend the
indication for Bankart repair and consequently reserves
the recommendation for a Latarjet procedure for a
more select group of patients. In the cohort of 33
patients that would have undergone an ISIS-based
Latarjet but instead were treated with a GTIMS-based
Bankart repair, there was no significant difference be-
tween postoperative SANE and WOSI scores (77.1 and
490 [76.7% of normal], respectively) for this cohort
and those of the ISIS-based Latarjet patients in the
comparison cohort (84 and 345 [83.6% of normal,
respectively) (P > .05). This is has been acknowledged,
and, although mean patient outcomes scores were
marginally worse for the 33 GTIMS-treated patients, it
may be proposed that, with extended indications for
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65
Bankart repair in patients with on-track lesions using
GTIMS, the repair is performed more medially onto the
glenoid bone loss, resulting in restricted postoperative
external rotation, and thus worsening overall post-
operative WOSI scores in this select group of patients.
Limitations
We acknowledge the inherent limitations that may
arise during the retrospective review process and its
potential for biases. These include a limited follow-up
time of 2 years using 2 groups with different surgeons
and institutions and the collection of data by different
individuals at these institutions. However, Ahmed
et al37 demonstrated that more than half of arthroscopic
Bankart procedures that fail do so within 1 year due to
recurrent instability. The paucity of long-term out-
comes studies further limits this study’s ability to assess
the outcomes of patients treated according to the pro-
posed scoring system.
Conclusions
When using ISIS scoring and plain radiography
parameters only, this predicted a 2-fold increase in
recommending a Latarjet versus GTIMS scoring criteria,
which uses advanced imaging and the on- and off-track
principle to more conservatively delineate anterior
instability treatment with promising postoperative pa-
tient outcomes. Overall, there were minimal differences
in outcomes between GTIMS and ISIS Latarjet patients;
however, there were better outcomes seen in patients
indicated for arthroscopic Bankart repair according to
GTIMS and on-off track CT scan indications.
Acknowledgment
The authors would like to sincerely thank Daniel B.
Haber, M.D., Colin P. Murphy, B.A., and George San-
chez, B.S., for their preliminary contributions to the
present study in data collection and analysis.
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