Glenohumeral arthropathy after arthroscopic anterior shoulder stabilization

doi:10.1016/j.arthro.2004.01.027

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 20, Issue 4, April 2004, Pages 402-406

https://doi.org/10.1016/j.arthro.2004.01.027 Get rights and content

Abstract

Purpose: We present 5 cases of iatrogenic arthropathy after arthroscopic Bankart reconstruction using a metallic suture anchor. Type of Study: Retrospective case series. Methods: Five patients with pain and crepitus on motion were referred to our institution for further evaluation of the previous procedure on anterior shoulder instability. Screw-type metallic suture anchors were used in all cases. All patients were men, with an average age of 23 years (range, 21 to 26). Surgical records on previous procedure were reviewed, and the clinical symptoms were evaluated using a visual analogue scale (VAS), the Simple Shoulder Test (SST), and the Rowe scoring system. The secondary surgery for each patient was performed at an average of 12 months (range, 7 to 20) after the initial arthroscopic stabilization, except in one patient who wanted to postpone the revision surgery. Results: Protrusion of the anchor tip was seen in all and chondral defects in the humeral head with some degree of synovitis were also seen. Slight differences between preoperative and postoperative pain were seen, but almost no improvement in function, including range of motion, stability, and average Rowe score were seen after the second procedure. Patients who underwent revision surgery were dissatisfied with the final outcomes. Conclusions: Careful attention should be paid when using a metallic suture anchor. A secure, buried placement of the anchor is required in arthroscopic Bankart reconstruction. Poorly placed suture anchors may damage the glenohumeral joint, and if these are not corrected either at arthroscopic surgery or shortly after, the results can be suboptimal. If a patient complains of unusual mechanical symptoms after using anchors, radiographs should be performed. This kind of serious complication can be discovered earlier to prevent the severe destruction of the glenohumeral joint. Level of Evidence: Level IV.

Section snippets

Methods

Five patients who experienced severe pain with crepitus during motion were referred to our institution for further evaluation after a previous arthroscopic stabilization for traumatic anterior shoulder instability, performed at other hospitals. Subnormal symptoms, including a sharp aching pain and catching sensation, were noticed with increased motion, and the degree of these symptoms increased with time. Cases were reviewed using records of the index surgery, and patients were examined using a

Results

At the initial physical examination in our institution, a marked limited range of motion with a sharp pain and loud crepitus during midrange abduction and rotation occurred. VAS for pain was an average of 1.4 at rest and 7 during motion, and VAS for instability was, on average, 7 for abduction and external rotation. The mean preoperative range of motion was 130° (range, 100° to 170°) of elevation, 30° (range, 20° to 60°) of external rotation, and internal rotation to the spinous process of the

Discussion

The metallic suture anchor is a common device used in the stabilization of shoulder instability, in both open and arthroscopic surgery, and complications from this hardware have been well documented.12 However, the majority of the literature concerns interarticular migration of hardware about the glenohumeral joint. Zuckerman and Matsen9 reported on 37 patients with complications of the glenohumeral joint related to the use of a screw or staple after open surgery. Ten of 37 patients (27%) had

Conclusions

The causative factor for arthropathy after using a metallic suture anchor was presumed to be misplacement of the hardware, which had not been loosened. If a patient complains of unusual symptoms such as sharp pain and catching sensation, or of an unexpected marked motion limitation during early rehabilitation after anchor implantation, the surgeon should consider the possibility of a malpositioned anchor. Clinicians should check radiographs if unexpected symptoms develop and misplacement of a

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Stability
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Comparison of arthroscopic and open anterior shoulder stabilizationA two- to six-year follow-up study
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Two- to five-year follow up of arthroscopic Bankart reconstruction using a suture anchor technique
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There are more references available in the full text version of this article.

Cited by (35)

Cyst formation and bony ingrowth inside coil-type open-architecture anchors used for arthroscopic remplissage: a volumetric computed tomographic study of 50 anchors
2023, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
A variety of anchors can be used for arthroscopic remplissage, including metallic,19 resorbable,15 and all-suture25 anchors; these anchors have been used successfully with few anchor-related complications.1,16 Metallic anchors in instability surgery are an option from which most surgeons shy away, as chondral lesions associated with malpositioned or exposed anchors can be fearsome.20 The use of absorbable anchors in the humerus has been associated with osteolysis and bone cyst formation in 10%-30% of cases,7,13,17 probably because of a combination of giant cell reaction and synovitis.
The use of anchors in the proximal humerus during arthroscopic surgery can cause localized bone loss due to osteolysis and cyst formation. The purpose of this study was to use computed tomography (CT) to evaluate the incidence of implant-related bone loss and cyst formation after implantation of polyetheretherketone (PEEK) coil-type open-architecture anchors during remplissage for the management of Hill-Sachs defects (HSDs) in patients with shoulder instability.
This was a single-cohort, observational study with a minimum of 12 months of follow-up. Subjects undergoing arthroscopic instability surgery with HSD requiring remplissage were included. The volume of the bone defects and the degree of bony ingrowth into the anchor were measured on CT images.
Thirty-one participants (28 males, 3 females; mean age 29.4 years, standard deviation [SD] 10.6) in whom 50 anchors (4.5-mm Healicoil PEEK double-loaded anchors) were used were evaluated with a CT performed at a mean of 14.1 (SD 3.74) months after surgery. Full bony ingrowth inside the anchor was found in 15 anchors (30%, range 17.8%-44.5%); clear ossification with a thin lucent rim was found in 10 anchors (20%, range 10.0%-33.7%); discontinuous ossification was found in 8 anchors (16%, range 7.2%-29.1%); and no ossification was observed inside 17 anchors (34%, range 21.2%-48.7%). Regarding bone defect size, no bone defect was identified in 15 anchors (30%, 95% CI 17.9%-44.6%), a partial bone defect was found in 17 anchors (34%, 95% CI 21.2%-48.7%), hole enlargement was found in 17 anchors (34%, 95% CI 21.2%-48.7%), and 1 anchor caused a cyst larger than twice the size of the hole made for anchor insertion (2%, 95% CI 0.1%-8.6%). At the 1-year evaluation, none of the participants presented recurrence or residual apprehension.
The use of PEEK coil-type open-architecture anchors for remplissage during instability surgery caused large cystic lesions in less than 10% of anchors. There was full bony ingrowth in one-third of anchors, and partial cancellous bone ingrowth occurred in another third of anchors.
Anchor Arthropathy of the Shoulder Joint After Instability Repair: Outcomes Improve With Revision Surgery
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
To report clinical and patient-reported outcome measures (PROMs) in patients undergoing revision surgery after diagnosis of anchor-induced arthropathy.
Patients who underwent revision arthroscopic shoulder surgery and were diagnosed with post-instability glenohumeral arthropathy performed from January 2006 to May 2018 were included in the current study. Patients were excluded if they underwent prior open shoulder procedures, if glenoid bone loss was present, or if prerevision imaging and records were incomplete or not available. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, exam findings before revision surgery, and surgical intervention. PROMs were prospectively collected before surgery and at minimum 2-year follow-up.
Fourteen patients were included with a mean (± standard deviation) age at presentation of 35.2 ± 12.1 years (range 16 to 59). The follow-up rate was 86%, with a mean follow-up of 3.8 years (range 1.1 to 10.6). Mean time to development of arthropathy symptoms was 48.2 months (range <1 month to 13.8 years), all presenting with pain and decreased range of motion on exam. At time of revision surgery, all patients underwent either open or arthroscopic removal of previous implants, including anchors and suture material. Six patients underwent additional revision stabilization procedures, 1 underwent total shoulder arthroplasty, and 7 underwent arthroscopic intraarticular debridement, capsular release, and chondroplasty with or without microfracture. Pain significantly improved in 79% of patients (P = .05). Significant improvements in all PROMs were observed, including 12-item Short Form (43.8 to 54.8, P < .01); Disabilities of the Arm, Shoulder, and Hand, shortened version (31.8 to 8.4, P < .01); Single Assessment Numeric Evaluation (47.0 to 84.5, P < .05); and American Shoulder and Elbow Surgeons (61.6 to 92.1, P < .01). Average external rotation significantly improved, from 31° ± 22° to 52° ± 24° (P = .02).
Rapid intervention after diagnosis, through either revision arthroscopic or open debridement and stabilization, can lead to significant improvement in range of motion, pain, and overall patient function and satisfaction.
IV, retrospective case series.
Postoperative Stiffness and Pain After Arthroscopic Labral Stabilization: Consider Anchor Arthropathy
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
We found pain (87%) in combination with loss of motion to be the most reliable predictors of anchor arthropathy. Several previous studies have concluded that if a patient complains of pain, stiffness, mechanical symptoms and/or catching sensation, the surgeon should consider implant arthropathy as a possible etiology.8,19 Our study validates this in a larger cohort of 23 patients.
To describe the key clinical, imaging, and arthroscopic characteristics of anchor arthropathy after arthroscopic shoulder stabilization procedures and, secondarily, to define risk factors for the development of anchor-induced arthropathy.
A total of 23 patients who underwent revision arthroscopic shoulder surgery and were diagnosed with glenohumeral arthropathy were retrospectively identified from prospectively collected data registries between January 2000 and May 2018. Data included initial diagnosis and index procedure performed, presenting arthropathy symptoms including duration, and examination findings before revision surgery. Pre-revision imaging was used to assess presence of glenohumeral osteoarthritis and chondromalacia, anchors/sutures, loose bodies, and labral pathology. The same parameters were recorded intraoperatively during revision surgery. Descriptive statistics were performed for demographic data and means with standard deviations were calculated for continuous data. A McNemar–Bowker test was used to analyze marginal homogeneity between preoperative imaging and intraoperative findings.
Mean age at presentation was 33.4 ± 11.7 years (range 16-59, 17 male patients; 6 female patients). More than one half (13/23) developed symptoms within 10 months after index arthroscopic procedure (mean 32.2 ± 59.9 months, range <1 to 165.2 months) with 87% presenting with pain and 100% presenting with loss of motion on examination. Plain radiographs demonstrated humeral osteoarthritis in 57% (13/23) of patients, magnetic resonance imaging (MRI) revealed recurrent labral pathology in 19 of 23 (83%) patients, potential proud implants in 12 of 23 (52%), and loose bodies in 12 of 23 (52%). Intraoperatively, all had evidence of osteoarthritis; 22 of 23 (96%) had prominent implants. Humeral head chondromalacia was present in 21 of 23 patients (91%), the majority of which was linear stripe wear, and 6 of 23 (26%) had severe global glenohumeral osteoarthritis. Statistical analysis revealed a 54.5% (95% confidence interval 0.327-0.749) sensitivity of MRI identification of proud implants with a specificity of 100% (95% confidence interval 0.055-1). The ability of MRI to accurately assess chondromalacia of the humeral head (P = .342) or glenoid (P = .685) was not statistically significant.
Anchor arthropathy is characterized by symptoms of pain and stiffness on examination and in many cases develops early after stabilization surgery (<10 months). Implants were implicated in the majority of cases of humeral head chondromalacia. MRI scans may produce false-negative identification of proud implants and can be a poor predictor of the severity of chondromalacia and intra-articular pathology; thus, a high index of clinical suspicion is necessary in patients with motion loss and pain postoperatively.
Level IV, case series.
Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up
2019, Journal of Shoulder and Elbow Surgery
Citation Excerpt :
In addition, Aboalata et al1 found that the severity of osteoarthritis was substantially correlated to the number of preoperative dislocations, age of the patient at the time of the initial instability episode and surgery, and number of anchors used. However, Rhee et al28 did not find a direct relationship between arthropathy and misplaced sutures. Further focus and study on the patients who are most at risk of progressive arthropathy and development of strategies to reduce this risk are still needed to improve the long-term outcome of shoulder stabilization surgery and halt progression of instability arthropathy.
The purpose of this study was to systematically review the evidence in the literature to ascertain the functional outcomes and recurrences rates, as well as subsequent revision rates, following arthroscopic Bankart repair at a minimum of 10 years' follow-up.
Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library databases. Studies were included if they were clinical studies on arthroscopic Bankart repair with a minimum of 10 years' follow-up. Statistical analysis was performed using SPSS software.
Our review found 9 studies including 822 shoulders meeting our inclusion criteria. The majority of patients were male patients (75.5%), the average age was 28.0 years (range, 15-73 years), and the mean follow-up period was 149.4 months. The most commonly used functional outcome score was the Rowe score, with a weighted mean of 87.0. Overall, 77.6% of athletes were able to return to sports postoperatively. The overall rate of recurrent instability was 31.2%, with 16.0% of patients having recurrent dislocations, and the overall revision rate was 17.0%. Evidence of instability arthropathy was found in 59.4% of patients, with 10.5% of patients having moderate to severe arthropathy.
Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent long-term functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery. In addition, the high rate of instability arthropathy is a concern following arthroscopic Bankart repair in the long term.
Shoulder Arthroscopy
2016, Rockwood and Matsen’s The Shoulder
The painful labral repair
2015, Shoulder and Elbow Trauma and its Complications: The Shoulder: Volume 1
There are a significant number of patients with unsatisfactory outcomes following primary labral repair. Treatment of such patients can be challenging given the fact that multiple factors can contribute to failure of the primary repair, including ongoing shoulder pathology. Evaluation should begin with a thorough history and physical examination. Diagnostic workup should be initiated with more current imaging, consisting of at least plain films followed by MRI. Then, a meticulous analysis can be performed as to whether preoperative, intraoperative, or postoperative factors contributed to failure. Preoperative factors that contribute to a poor outcome following primary labral repair are an incorrect or incomplete diagnosis and/or inability to meet patient expectations. Intraoperative factors contributing to a poor outcome are morbidity of portal placement, inadequate, insufficient, or improper anchor placement; failure to address capsular pathology; or failure to address glenoid bony deficiency. Postoperative factors include infection, stiffness, failure of the primary repair to heal, and glenohumeral articular cartilage damage. Finally, after all of the above information has been analyzed, an appropriate treatment plan can be devised for the patient.

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Glenohumeral arthropathy after arthroscopic anterior shoulder stabilization

Abstract

Section snippets

Methods

Results

Discussion

Conclusions

Stability

Arthroscopic shoulder stabilization with suture anchorsTechnique, technology, and pitfalls

Clin Orthop

Arthroscopic treatment of anterior-inferior glenohumeral instabilityTwo to five-year follow-up

J Bone Joint Surg Am

Comparison of arthroscopic and open anterior shoulder stabilizationA two- to six-year follow-up study

J Bone Joint Surg Am

Two- to five-year follow up of arthroscopic Bankart reconstruction using a suture anchor technique

Am J Sports Med

Cartilage injuries in the shoulder caused by migration of suture anchors or mini screw

J Shoulder Elbow Surg