Bony Lesions Research Articles

Brown's tumor of mandible as a manifestation of primary hyperparathyroidism

Abstract Hypercalcemia and increased or abnormal serum levels of parathyroid hormone are indicators of primary hyperparathyroidism (HPT). Brown tumor of bone is a rare nonneoplastic lesion that arises due to abnormal bone metabolism caused by HPT. The reported prevalence of brown tumor is 0.1%. In today's world, however, skeletal illness caused by primary HPT is quite rare. Patient consent was obtained. Here, we present a rare case of bony lytic lesion in the mandible that raised suspicion of giant cell lesion, compelling further investigations. The patient underwent blood investigations which revealed hypercalcemia. Ultrasonography revealed a hypoechoic mass on the left inferior thyroid lobe. An incisional biopsy was done which revealed hemorrhagic fibrovascular connective tissue in a background of multinucleated giant cells; the mandibular lesion was classified as a giant cell lesion. A final diagnosis of Brown tumor of the mandible was made based on the investigations. The left parathyroidectomy was done. Curettage of the mandibular lesion was done surgically. The patient was on follow-up for 6 months and showed no signs of recurrence. Although Brown tumor of mandible is a rare lesion, it should be considered a differential diagnosis for osteolytic lesions of the jaw. Early diagnosis can help to prevent late outcomes of the disease.

Malignant Cells in Urine Cytology: Not Always High-Grade Urothelial Carcinoma

Abstract The main purpose of urine cytology is the detection of high-grade urothelial carcinoma (HGUC). When malignant cells of nonurothelial origin are present, it is often misdiagnosed as HGUC due to the rarity of this event and difficulty in distinguishing subtle cytomorphologic differences. To arrive at the appropriate diagnosis, evaluation of urine cytology specimens requires correlation with clinical and radiologic findings and utilization of cytologic-histologic correlation. We present the case of a 64-year-old woman with gross hematuria. Imaging located an infiltrative mass involving the left renal pelvis, highly suggestive of urothelial carcinoma. Lymphadenopathy and multiple bony lesions in the spine were concerning for metastatic disease. Urine cytology specimens taken during cystoscopy contained malignant cells, which were interpreted as HGUC. The workup of a subsequent lymph node biopsy showed a metastatic high grade carcinoma of renal origin with SMARCB1 loss. This finding led to the reexamination of the urine cytology specimens, revealing the malignant cells were not HGUC but rather renal carcinoma. This case highlights a potential pitfall in the evaluation of urine cytology and the importance of cytologic-histologic correlation.

Osteosarcoma/Ewing Sarcoma

Osteosarcoma/Ewing Sarcoma

Multifocal Unicameral Bone Cysts in a Middle-Aged Patient Treated with Three Different Methods: A Rare Case Report

Background: Primarily diagnosed in the first two decades of life, unicameral bone cysts (UBCs) are benign cystic lesions of the bone. More than 90% of UBCs are located in the proximal femur or proximal humerus of skeletally immature patients, however in this case report we report a middle-aged patient with multiple lesions in unusual sites.
 Case Report: A 42-year-old patient presented to our institute with multiple bony lesions in the right and left tibias, proximal radius, ulna, and the second metacarpus. The lesions were later pathologically proven to be UBCs. A multimodality treatment approach was selected including decompression-only, extended curettage, bone grafting, and prophylactic fixation based on the lesion size and anatomic location. All these methods proved to be effective with no disease relapse and complete radiographic obliteration of the cavities.
 Conclusion: UBCs could occur in much older patients than generally believed and the proper method of treatment should be individualized based on the lesion’s characteristics.

MRI Allows Accurate Measurement of Glenoid Bone Loss.

MRI Allows Accurate Measurement of Glenoid Bone Loss.

Cytopathology of the distant metastasis of papillary carcinoma of thyroid.

To describe the cytomorphological features at distant metastatic sites apart from lymph nodes in papillary thyroid carcinoma (PTC). A total of eight cytology cases from seven patients reported as metastatic papillary carcinoma of thyroid were reviewed including available clinical and radiological details. The details clinical and cytological features were studied. There were a total of five males and two female patients. Two of these patients presented with lung nodules, two patients had bony lesion and lesion in kidney respectively and one patient had both bony and soft tissue lesions. Pleural fluid and bronchoalveolar lavage were received from remaining two patients. Cytology smears revealed papillary clusters and sheets of tumor cells, having round to oval nuclei with pale powdery chromatin, inconspicuous nucleoli and scant to moderate amount of cytoplasm. Nuclear features such as longitudinal nuclear grooves, intranuclear cytoplasmic inclusions were seen in all but one case. Nuclear enlargement and overlapping were variably present. The diagnosis of metastatic PTC at uncommon locations is difficult. Since many of these locations are amenable to fine needle aspiration or exfoliative cytology evaluation, clinical awareness, and identification of classic cytomorphologic features can offer quick and accurate diagnoses. In cases with occult or unknown PTC presenting with metastases, cytomorphology may help in the prompt suggestion of detecting primary tumor in the thyroid.

Hematolymphoid Tumors of the Oral and Maxillofacial Region: A clinicopathologic study of 41 cases

<h3>Introduction</h3> Oral hematolymphoid tumors represent a heterogeneous and complex group of neoplasms of lymphoid, plasma cell, histiocytic/dendritic, and myeloid origin. Our aim was to determine the frequency, classification, and clinicopathologic characteristics of all hematolymphoid tumors diagnosed at the Pacific Oral and Maxillofacial Pathology Laboratory (POMPL) in the past seven years. <h3>Materials and Methods</h3> Forty-one cases of hematolymphoid tumors were retrieved from the files of the POMPL and the data were analyzed with regard to clinical, histopathologic, and immunophenotypic features. <h3>Results</h3> Hematolymphoid tumors represented ∼0.1% of the total number of accessioned cases since Jan 2014. Male: Female ratio was 1.1:1. Anatomic distribution: 23 were intraosseous (15 in tooth-bearing areas and two in maxillary sinus) and 18 originated in soft tissue (10 palatal mucosa; 6 gingival; 1 buccal mucosa; 1 upper lip). The age range was 35 to 83 years (mean: 59.2 years; median: 61 years). Diagnoses: 26 were B-cell lymphomas (15 diffuse large B-cell lymphoma, 5 low-grade B-cell lymphoma, 5 follicular lymphoma, and 1 marginal zone lymphoma (MALT lymphoma); 8 plasmacytoma/myelomas; 2 T-cell lymphomas; 2 Langerhans cell histiocystosis, 2 myeloid sarcomas, and 1 atypical hematolymphoid proliferation. <h3>Conclusions</h3> Male and female patients are equally affected by hematolymphoid tumors in general and the most common type to involve the oral cavity is the diffuse large B cell lymphoma. Hematolymphoid tumors show a predilection for the tooth-bearing areas of the jaws and the palatal mucosa and typically appear as destructive bony lesions or red soft tissue swellings.

Intraosseous Benign Fibrous Histiocytoma of the Mandible

<h3>Introduction</h3> Fibrous histiocytomas are a diverse group of tumors that exhibit fibroblastic and histiocytic differentiation and are considered to be a true neoplasm. Intrabony fibrous histiocytomas of the jaws are rare, with most cases being reported in the femur, tibia, pelvis and occasionally the skull bones. <h3>Material and Methods</h3> This report describes a case of 69 year old male patient who presented with pain in the area of tooth #18 (mandibular left second molar) and an endo-perio lesion that perforated through the cortical bone which appeared to be multilocular on radiographs. Clinically, there was a buccal swelling and when the buccal bifurcation was probed, a 10mm depth was revealed with a purulent exudate emanating from the pocket. The bridge was sectioned at the junction of #19 and 20 pontic followed by extraction of tooth #18. Reflection of the mucosa revealed a large bony lesion destroying the buccal plate of bone in the area of teeth #18 and 19. The purulent material was primarily associated with the tooth #18 and not the overall lesion. The majority of the lesion was enucleated and removed. <h3>Results</h3> Histopathological examination revealed fragments of mildly inflamed connective tissue that demonstrated a focus of spindle or mesenchymal cells proliferating in a whorling or storiform pattern. The tissue contained large scattered deposits of mineralized material and fragments of vital bone. Immunohistochemical stains for Desmin, SMA, CD34 and factor XIIIa were negative while diffusely positive for CD68. The positivity for CD68 demonstrated that the lesion was composed of histiocytic cells. <h3>Conclusions</h3> Benign fibrous histiocytomas of the soft tissues are well recognized entities, the rare intra-bony counterpart shares clinical, radiographic and histological features with odontogenic tumors, non-ossifying fibromas, osteoblastomas and fibrous dysplasia, and therefore should be considered in the differential diagnosis of these lesions.

Monoclonal Anti PD-1 Antibody (Pembrolizumab) Induced Granulomatous/Sarcoid-like Lesions in a Patient with Nasal Mucosal Melanoma: an Evolving Phenomenon of Targeted Therapies and Expanding the Differential Diagnosis for Granulomatous Inflammation

<h3>Introduction</h3> Immune checkpoint inhibitors and kinase inhibitors are now part of the treatment regimen of many cancers. Granulomatous/sarcoid-like lesions (GSL) involving the skin, lungs, lymph nodes, and other organs and tissues in patients treated with these medications, including those with mucosal melanoma, are an emerging phenomenon. GSL can be clinically and radiographically concerning for metastatic disease. <h3>Case Findings</h3> A 61-year-old female was diagnosed with primary melanoma involving the left nasal mucosa. Initial PET was negative for metastasis. The patient underwent medial maxillectomy with negative margins. Adjuvant therapy consisted of pembrolizumab 200 mg infusion every three weeks. <h3>Results</h3> Active surveillance included a subsequent PET scan with increased SUV localizing to the lungs, mediastinal and hilar lymph nodes, and a bony lesion of the right hip. FNA of the hip lesion demonstrated defined non-caseating granulomas. Histochemical and immunohistochemical stains were negative for microorganisms, and melanoma. Lung, mediastinal and hilar lesions were presumed similar. Steroid therapy resulted in regression of the GSL. <h3>Conclusions</h3> This case of nasal mucosal melanoma treated with pembrolizumab highlights the phenomenon of therapy related GSL. These are typically identified during routine surveillance and often mistaken for disease progression. Documentation of these lesions will avoid misdiagnosis of disease progression and influence treatment strategies for such lesions and continuance of therapy, if appropriate. This may represent a positive prognostic indicator. The mechanism of granuloma formation in this setting is speculative and includes, cytokine imbalance promoting granuloma formation characterized by either a hypoactive or hyperactive immune response or unmasking of subclinical sarcoidosis. Pathologists must be aware of this phenomenon occurring in patients receiving various targeted therapeutics for cancerous and some non-cancerous diseases. Thus, medication related granulomatous inflammation is an additional entity in the differential diagnosis of microscopically identified granulomatous inflammation.

Dislocation Arthropathy of the Shoulder.

Glenohumeral osteoarthrosis (OA) may develop after primary, recurrent shoulder dislocation or instability surgery. The incidence is reported from 12 to 62%, depending on different risk factors. The risk of severe OA of the shoulder following dislocation is 10 to 20 times greater than the average population. Risk factors include the patient’s age at the first episode of instability or instability surgery, bony lesions, and rotator cuff tears. For mild stages of OA, arthroscopic removal of intraarticular material, arthroscopic debridement, or arthroscopic arthrolysis of an internal rotation contracture might be sufficient. For severe stages, mobilization of the internal rotation contracture and arthroplasty is indicated. With an intact rotator cuff and without a bone graft, results for anatomical shoulder arthroplasty are comparable to those following primary OA. With a bone graft at the glenoidal side, the risk for implant loosening is ten times greater. For the functional outcome, the quality of the rotator cuff is more predictive than the type of the previous surgery or the preoperative external rotation contracture. Reverse shoulder arthroplasty could be justified due to the higher rate of complications and revisions of non-constrained anatomic shoulder arthroplasties reported. Satisfactory clinical and radiological results have been published with mid to long term data now available.

11. NATIONAL UNDERVALUATION OF CLEFT SURGICAL SERVICES: EVIDENCE FROM A COMPARATIVE ANALYSIS OF 50,450 CASES

PURPOSE: Relative value units (RVUs) are broadly used for billing and physician compensation, however the accuracy of RVU assignments has not been scientifically evaluated for craniofacial surgery. We hypothesize that unbalanced RVU allocation creates inappropriate disparities in value amongst procedures performed by cleft and craniofacial surgeons. METHODS: The Pediatric NSQIP database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012-2019 based on Current Procedural Terminology (CPT) code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Efficiency was defined as total RVUs divided by total operative time (i.e. RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using Student’s t-tests. RESULTS: The sample consisted of 69 CPT codes with 50,450 cases. In the top quartile, most CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%) (mean 15.65±4.22 RVUs/hour). The lowest quartile was comprised mainly of CPT codes for cleft procedures including surgeries for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%) (mean 7.39±0.98 RVUs/hour, p<0.001). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/hour) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour). CONCLUSION: The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care.

Evaluating Bone Loss in Anterior Shoulder Instability.

Anterior shoulder instability is a common orthopaedic condition that often involves damage to the bony architecture of the glenohumeral joint in addition to the capsulolabral complex. Patients with recurrent shoulder dislocations are at increased risk for glenohumeral bone loss, as each instability event leads to the accumulation of additional glenoid and/or humeral head bone defects. Depending on the degree of bone loss, successful treatment may need to address bony lesions in addition to injured soft-tissue structures. As such, a thorough understanding of methods for evaluating bone loss preoperatively, in terms of location, size, and significance, is essential. Although numerous imaging modalities can be used, three-dimensional imaging has proven particularly useful and is now an integral component of preoperative planning.

Recent advances on diagnosis and treatment of osteoid osteoma

Osteoid osteoma (OO) is a benign bony lesion with a characteristic radiologic feature of x-ray focus (nidus). The most common symptom indicating diagnosis is strong nocturnal pain that eases with nonsteroidal anti-inflammatory drugs (NSAID). Computed tomography (CT) is a method of choice for diagnosing and localizing the tumor. Osteoid osteoma can regress spontaneously, thus conservative treatment is one of the methods of choice. In the past open resection surgery had been a standard management of osteoid osteoma until radiofrequency ablation (RFA) was discovered in the early 1990s. Nowadays, there are a few minimally invasive treatment techniques that are used. CT-guided radiofrequency ablation is considered a gold standard technique these days. Many cases occur with late diagnosis, and delayed treatment despite of characteristic symptoms. Therefore, it is crucial to be familiar with the clinical features of osteoid osteoma, proper diagnostic patterns, and treatment schemes.

Arthroscopic Bony Bankart Repair Using Suture Suspension to Increase Bone Contact Area

Bony Bankart lesions are anteroinferior glenoid rim fractures associated with capsulolabral tears. Untreated bony Bankart lesion can cause recurrent dislocation. So, the large bony Bankart lesions should be treated by anatomical reduction and stabilization. This Technical Note describes an arthroscopic bony Bankart lesion repair using suture suspension to increase contact area to gain more contact area and tissue compression to maximize the stability of the repair.

Magnetic resonance imaging in differentiating between aggressive and non-aggressive bone tumors.

While radiography remains essential in the initial evaluation of bone lesions, tissue biopsy or further imaging is often required to clarify indeterminate radiographic features. Magnetic resonance imaging (MRI) assists radiologists in evaluating lesions with indeterminate features as it has advantages in delineating tumorous tissues and bone marrow. To evaluate the association factors of MRI for bony aggressiveness. A retrospective analysis of 226 MRI examinations from patients diagnosed with bone tumors in a tertiary hospital during 2008-2018 was performed. All the MR images were interpreted by musculoskeletal radiologists without diagnostic information. The bony lesions were categorized into aggressive and non-aggressive groups using tumor margin, cortical changes, periosteal reaction, joint extension, extraosseous soft tissue involvement, tumor homogeneity, and enhancement pattern from the MR images. Univariable and multivariable analysis were applied for each feature on the MRI scans. In addition, sensitivity and specificity were calculated for MRI diagnoses of aggressive bone lesions. In total, 180 aggressive and 46 non-aggressive bone lesions were examined on MRI. The sensitivity and specificity of MRI for differentiating between aggressive and non-aggressive bone lesions were 98.89% and 50%, respectively. Ill-defined margin, cortical break, cortical signal changes, sunburst and Codman's triangle periosteal reaction, joint extension, and tumoral and heterogeneous enhancement could be predictive signs for aggressive bone lesions. MRI can be a valuable tool to assist in distinguishing aggressive from non-aggressive bone lesions. In cases of indeterminate radiographic features, MRI could be used as an additional imaging to improve diagnostic accuracy and could reduce unnecessary invasive procedures.

Brown tumours of maxilla and mandible as index presentaion of primary hyperparathyroidism

It is rightly said that oral cavity is a mirror that may reflect and reveal many of the human body's internal secrets. Some of oral manifestations are disease specific and help in raising high degree of suspicion for an alert clinician. Hyperparathyroidism is one of such systemic disorder which can present in craniofacial regions as erosive bony lesions known as brown tumours resulting in a local destructive phenomenon. As histological examination alone is not sufficient for differentially diagnosing it, clinical, radiological correlation and laboratory data are necessary for its definitive diagnosis. It is essential that while dealing with such clinical presentations, the underlying systemic disease is rightly recognized using a high index of suspicion and performing targeted investigations to provide correct diagnosis and referral for proper treatment avoiding unnecessary orthopaedic intervention .Here, we report a case of brown tumors involving maxilla and mandible resulting from primary hyperparathroidism in a young female patient with history of recent femur fracture and orthopaedic treatment.

Synchronous follicular carcinoma and non-invasive follicular thyroid neoplasm with papillary like nuclear features in thyroid-A case report

Follicular carcinoma of the thyroid accounts for 5-15% of all the primary cancers of thyroid. Follicular carcinoma clinically manifests as a painless neck mass and rarely presents with metastatic bony lesion, the most common site being the spine. Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) constitute 10-20% of all thyroid cancers. The histopathological diagnosis of thyroid follicular carcinoma mandates demonstration of either capsular/vascular invasion. Differentiating between follicular carcinoma and NIFTP is challenging based on histology. Hence extensive sampling of the pathological specimen is required to differentiate the same. Herein we report a case of an elderly woman presented with a pathological fracture of the femur due to metastasis from follicular carcinoma of the thyroid with an incidental NIFTP of the left lobe of the thyroid.

Proximal humeral bone defect in reverse shoulder arthroplasty combined with latissimus-dorsi transfer is not related with a poor outcome

BackgroundReverse total shoulder arthroplasty (RSA) associated with modified L’Episcopo (isolated LD) or L’Episcopo (combined TM and LD) procedures had been confirmed to effectively overcome the expected external rotation deficit in patient with postero-superior massive cuff tear and teres minor deficiency. The objective of this study was to evaluate the radiological bony lesions of the lateral proximal humerus following RSA combined with tendon transfer, and to determine whether these bony lesions affect the clinical outcome. Material and methodsA retrospective review of 24 RSAs (mean age 68.71 years, range 52–83) associated with modified L’Episcopo procedure (9) and L’Episcopo procedure (15) was performed. X-rays were assessed for lateral cortex lesions and were categorized into either intact, irregular or complete lytic appearances. In addition, signs of stem loosening were assessed. Clinical outcome measures included range of motion, SSV, VAS, and Constant-Murley scores. ResultsWith a mean follow-up of 44.71 months (12–97; SD 27.42), eight (33.3%) patients demonstrated intact lateral cortex, eight (33.3%) irregular and eight (33.3%) lytic lesions. 40% of cemented stems demonstrated a deformed cortex compared to 74% of cementless stems. Radiolucent lines were detected in one cemented stem (p=0.046). GT resorption (p=0.147), condensations lines (p=0.449) and spot weld (p=0.342), appeared exclusively in non-cemented stem. Postoperatively all patients (24) demonstrated significant improvements in all clinical and functional parameters. A comparison between patient with (Group 2, 16 patients) and without bony lesions (Group 1, 8 patients) revealed no significant differences in functional scores and range of motion: Constant (p=0,61), VAS (p=0,61), SSV (p=0,66) and external rotation (p=0,34). ConclusionAt short-term follow-up, RSA combined with L’Episcopo or modified l’Episcopo procedure resulted in high incidence (67%) of lateral proximal humerus lesions. Radiolucent lines were noted in cemented stems whereas, signs of stress shielding and GT resorption appeared in non-cemented stems. Yet, no case of humeral loosening was detected and these lesions did not seem to affect the clinical outcome. The use of cemented straight standard-length humeral stems should be positively considered in RSA associated with LD\\TM tendon transfer. Level of evidenceIV; retrospective study.

Bone Fragment Resorption and Clinical Outcomes of Traumatic Bony Bankart Lesion Treated With Arthroscopic Repair Versus Open Latarjet

Background: Bony Bankart lesions can perpetuate chronic anterior glenohumeral instability. When surgical treatment is pursued, several factors need to be considered to obtain optimal outcomes. Purpose: To (1) quantitatively describe patterns of bone fragment resorption and associated risk factors for developing glenoid bone loss (GBL) and (2) to compare clinical and radiological results of attritional bone loss treated with either the arthroscopic Bankart or the open Latarjet procedure. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was conducted for patients who underwent arthroscopic stabilization (group A1, 10%-20% GBL; group A2, >20% GBL) or open Latarjet (group B, >10% GBL) for recurrent shoulder instability with bony Bankart lesion. Patient characteristics, number of dislocations, and Western Ontario Shoulder Instability Index (WOSI) scores were obtained. Pre- and postoperative computed tomography imaging was used to quantitatively describe patterns of bone fragment resorption. Results: A total of 120 consecutive patients (group A1, 40; group A2, 23; group B, 57) were included in the study, with a mean age of 25.6 years (range, 19-35 years). The average follow-up was 5.0 years for all groups (range, 4.83-5.16 years in group A1, 4.58-5.41 years in group A2, and 4.33-5.67 years in group B). The mean times between dislocation event and surgery were 12.8 months (range, 6-32 months) and 13.6 months (range, 6-38 months) for groups A and B, respectively. Redislocation rates were 7.5% in group A1 versus 13.0% in group A2, and only occurred in patients with ≥13.5% GBL. There were no redislocations for group B (0%). Patients had better WOSI scores in group B (234.1 ± 126.9) than in group A (576.1 ± 224.6) (P < .0001). In group A, smaller preoperative bone fragment size displayed a higher percentage of resorption after surgery (r = −0.64; P < .05). Conclusion: A significant inverse relationship exists between preoperative bone fragment size and percentage of postoperative resorption. Patients treated with arthroscopic bony Bankart repair who had final GBL ≥13.5% had worse outcomes. When planned GBL approaches 13.5% in high-demand patients, a smaller fragment size can result in worse clinical outcomes because of resorption. In these cases, choosing the open Latarjet procedure leads to better clinical results.

The Painful Anterior Apprehension Test - an Indication of Occult Shoulder Instability.

Introduction:To evaluate the clinical relevance of the painful anterior apprehension test in shoulder instability.Materials and methods:We performed a retrospective study of 155 patients that underwent arthroscopic anterior Bankart repair between 2014–2016. Exclusion criteria were previous ipsilateral shoulder surgery, bony Bankart lesions, glenohumeral osteoarthritis and concomitant surgery involving rotator cuff tears, biceps tendon pathology and superior labrum from anterior to posterior (SLAP) lesions. The study cohort was divided into three groups: apprehension test with apprehension only, apprehension test with pain only, and apprehension test with both apprehension and pain. Patient demographics, clinical characteristics, radiological imaging, arthroscopy findings and surgical outcomes (Constant, American Shoulder and Elbow Surgeons (ASES), SF-36 scores) were evaluated.Results:A total of 115 (74.2%) had apprehension only, 26 (16.8%) had pain only and 14 (9.0%) had pain and apprehension with the apprehension test. Univariate analysis showed significant differences between the groups in patients with traumatic shoulder dislocation (p=0.028), patients presenting with pain (p=0.014) and patients presenting with recurrent dislocations (p=0.046). Patients with a purely painful apprehension test were more likely to have a traumatic shoulder dislocation, more likely to present only with pain, and less likely to present with recurrent shoulder dislocations. Multivariate analysis showed that none of these factors alone were significant as single predictors for shoulder instability. All three groups were otherwise similar in patient profile, MRI and arthroscopic assessments, and clinical outcomes of surgery. Excellent clinical outcomes were achieved in all groups with no difference in pre-operative and post-operative scores across all groups at all time points.Conclusion:The painful apprehension test may suggest underlying shoulder instability.