1. This study validated a novel 5-point grading system to assess bone response around suture anchors following shoulder labral reconstruction using MRI scans. 2. The validation study found moderate to substantial interrater and intrarater reliability among musculoskeletal radiologists and shoulder surgeons when using the grading system. 3. The results suggest the grading system is feasible for clinical use and the next steps are to provide rater training and validate the system in other medical centers to further improve reliability.

1. VALIDATION OF A NOVEL GRADING SYSTEM TO ASSESS
BONE RESPONSE AROUND SUTURE ANCHORS
FOLLOWING SHOULDER LABRAL RECONSTRUCTION
Haseem Raja
Professor Lennard Funk, Professor Waqar Bhatti

2. INTRODUCTION
GLENOID LABRUM
- Ring of fibrous cartilage that surrounds the
glenoid
- Increases contact surface area between glenoid
and humeral head
- Limits humeral head translation
- Increases overall depth of glenoid fossa
- Adds to the stabilising effect of LHB
REASON FOR LABRAL TEARS
- Trauma, e.g. shoulder dislocations
- Overhead throwing or hitting athletes
- Global laxity
- Natural degeneration with age

3. BRIEF LITERATURE REVIEW
• Suture anchors are routinely used for shoulder labral reconstruction procedures.
• There is paucity of literature on how the response of bone to suture anchor
should be measured following labral reconstruction.
• A new system, based on the use of magnetic resonance imaging (MRI), has been
developed by Professor Bhatti and his trainee which grades bone signal changes
around suture anchors using a five-point scale. This system has yet to be tested
on a clinical dataset.
GRADE SIGNAL ON T1 SIGNAL ON T2FS HYPOTHESIS
0 Normal Normal Normal post-
surgical change
up to 6 months.1 Normal Minimal bony oedema
2 Low Mild oedema
3 Low Cystic change Potentially
unstable4 Low Fluid surrounding anchor

4. AIMS OF STUDY
1. To calculate interrater reliability for the musculoskeletal radiologists and shoulder surgeons.
2. To calculate interrater reliability between the musculoskeletal radiologists and shoulder
surgeons.
3. To assess intrarater reliability among the raters.
Support the translation of the grading system to a novel study that compares the overall
bone response of an all-suture anchor with a biocomposite anchor following shoulder
labral reconstruction.

5. METHODS
1. A total of 10 patients were included in this validation study, amounting to a total of 36 suture
anchors.
2. MRI scan sequences (T1 and T2FS) for each suture anchor were carefully selected for scoring
and compiled in a PowerPoint presentation. All patient details were hidden. These images were
subsequently verified by a consultant MSK radiologist for being eligible to score.
3. An email containing the presentation with images of 31 suture anchors, including boxes for
comments and grading, were sent to 9 clinicians (6 MSK radiologists and 3 shoulder surgeons).
4. One week after the first grading, each rater entered the second phase of scoring and received a
second email with a new presentation, containing the same images in an automatically
randomised different order with a different number to prevent any recall bias.
5. The clinicians agreed to not access their first set of scores.
6. Only the study statistician (Raja) was unblinded to the correspondence between the two set of
scores.
7. Statistical analysis was completed by performing weighted kappa statistics on SPSS.

6. An example of how each suture anchor was graded in the validation study.

7. RESULTS
RATER
AGREEMENT BETWEEN FIRST SCORING
EXERCISE (%)
KAPPA VALUE (95%
CI)
Rater 1 vs Rater 2 15/31 (48) 0.514 (0.291–0.738)
Rater 1 vs Rater 3 16/31 (52) 0.484 (0.230–0.738)
Rater 1 vs Rater 4 15/31 (48) 0.494 (0.254–0.733)
Rater 1 vs Rater 5 14/31 (45) 0.335 (0.141–0.528)
Rater 1 vs Rater 6 17/31 (55) 0.556 (0.353–0.758)
Rater 2 vs Rater 3 20/31 (65) 0.603 (0.366–0.840)
Rater 2 vs Rater 4 21/31 (68) 0.693 (0.490–0.896)
Rater 2 vs Rater 5 16/31 (52) 0.433 (0.240–0.625)
Rater 2 vs Rater 6 13/31 (42) 0.463 (0.271–0.655)
Rater 3 vs Rater 4 19/31 (61) 0.478 (0.187–0.769)
Rater 3 vs Rater 5 16/31 (52) 0.316 (0.091–0.543)
Rater 3 vs Rater 6 10/31 (32) 0.300 (0.044–0.556)
Rater 4 vs Rater 5 16/31 (52) 0.415 (0.199–0.632)
Rater 4 vs Rater 6 13/31 (42) 0.493 (0.312–0.673)
Rater 5 vs Rater 6 19/31 (61) 0.389 (0.178–0.600)
.
Table 1: Interrater agreement of bone response around suture anchors.
SS vs SS
SS vs MSK
MSK vs MSK

8. RESULTS
RATER AGREEMENT BETWEEN FIRST AND SECOND SCORING EXERCISES (%) KAPPA VALUE (95% CI)
Rater 1 17/31 (55) 0.597 (0.391–0.804)
Rater 4 23/31 (74) 0.790 (0.646–0.934)
Rater 5 23/31 (74) 0.663 (0.444–0.882)
Rater 6 18/31 (58) 0.5691 (0.332-0.807)
.
Table 2: Intrarater agreement of bone response around suture anchors.
SS
MSK

9. SUMMARY
1. Validation study suggests that the grading system is feasible
and easy to use in the clinical setting.
2. Interrater and intrarater reliability of the grading system, on
the whole, showed moderate to substantial reliability.
3. Although these results could be further improved through
providing raters with a training module beforehand, the next
step should be to validate this grading system in other
centres.

10. ACKNOWLEDGEMENTS
Professor Lennard Funk
Professor Waqar Bhatti
Emma Torrence
Gulraiz Ahmed
Professor Jonathan
Harris
Andrew Dunn
Anand Kirwadi
Puneet Monga

11. THANK YOU