Secondary Arthropathy Due to Anterior Glenohumeral Instability and Analysis of Surgical Techniques: Does Any of Them Influence its Onset and Progression? State of The Art

Abstract

The primary objective of this review is to describe how the different surgical techniques available for the treatment of anterior shoulder instability influence the development of post-glenohumeral dislocation arthropathy (GHDA), a condition similar to osteoarthritis that can develop, particularly in patients with recurrent episodes.

In early stages, this condition does not cause major functional limitations, but in more advanced stages, it can significantly alter our patients' activities.

Post-instability surgery aims to restore stability and prevent progression to GHDA.

Despite the diversity of surgical approaches to treat anterior shoulder instability, the literature does not show significant differences in the progression towards arthropathy, emphasizing the relevance of addressing specific risk factors addressing specific risk factors and choosing a procedure according to our patient's needs.

Keywords

shoulder dislocation - anterior shoulder instability - arthropathy - Bankart surgery - Latarjet surgery

Introduction

The glenohumeral joint is the joint with the highest percentage of dislocations in our body, with up to 50% of all dislocations, with recurrence being one of the most common complications.[1] This condition produces degenerative joint changes over time, with its own definition known as post-glenohumeral dislocation arthropathy (GHDA) since the etiology is different.

It has been described that after a shoulder dislocation, the risk of developing severe arthropathy increases up to 20 times compared to the normal population.[2]

It is common that once the patient has a recurrence of dislocations, surgical treatment is required with the aim of avoiding new episodes and allowing activities of daily living and sports safely and without pain, avoiding joint instability.

Among the short-term objectives of post-instability surgery, it is essential to restore stability and function. In the long term, the objectives change, trying to avoid progression to GHDA that can cause alterations in joint mechanics associated with pain.

Post-glenohumeral dislocation arthropathy

After the first episode of dislocation, in medium and long-term follow-ups, the percentage of GHDA occurs between 12% and 56% after surgical management, regardless of the technique used.[3] It is widely described in the literature that this type of arthropathy is well tolerated and that, if the shoulder progresses towards arthropathy, only moderate and severe arthropathy according to the Samilson and Prieto classification would be symptomatic.[4]

Pellet et al., in a retrospective study of 39 patients who underwent open Bankart reconstruction surgery and were followed for at least 29 years, reported that 40% showed signs of arthropathy. The authors concluded that, despite satisfactory long-term outcomes regarding postoperative shoulder stability, it is not possible to halt degenerative progression through surgery.[5]

Samilson and Prieto carried out a study where they describe the GHDA classification, used to classify glenohumeral osteoarthritis, without studies that support this use, but allowing peer communication of the degree of joint damage found.[6]

Subsequently, in 2004, Buscayret[7] introduced a modification to this classification, which is widely used today, validated, and systematically reproducible. In this classification, Group 0 is considered normal; Group 1 (mild) presents osteophytes <3 mm on the inferior part of the epiphysis or the glenoid; Group 2 (moderate) includes osteophytes measuring 3 to 7 mm; Group 3 (advanced) includes osteophytes >7 mm; and Group 4 (joint collapse) is characterized by the absence of the joint space. The addition of Group 4 differentiates this classification from that of Samilson and Prieto. In their 6.5-year follow-up, a 20% incidence of arthropathy was documented, with half of the cases remaining asymptomatic until the final follow-up.

The natural history of this pathology was mainly described by Hovelius et al., in which they studied patients with a first episode of dislocation treated conservatively or surgically with a final follow-up of 25 years, this being the greatest strength of the study.[8] Within their results, they documented the presence of 56% of GHDA with a predominance of mild cases ([Chart 1]).

Chart 1: The occurrence of GHDA in the group studied by Hovelius et al. is described. It is noteworthy that all patients with dislocations developed GHDA by the end of the follow-up period, with a higher percentage of moderate and severe GHDA observed among those aged 26 to 29 years.

It is noteworthy that the vast majority of arthropathy cases classified as moderate to severe are detected in patients older than 26 years at the time of the index episode. Additionally, there are no significant differences between the group with a single dislocation and those who underwent various surgical techniques. However, differences were observed in groups with bony or soft tissue healing, which exhibited a higher percentage of moderate to severe GHDA. The Latarjet technique showed a global GHDA incidence of 26%, with 15% of cases classified as moderate or severe according to Samilson. Regarding arthroscopic Bankart repairs, the number of studied patients was low; nonetheless, it was reported that up to 40% exhibited mild asymptomatic GHDA, with no cases classified as severe. The small sample size may have contributed to the high percentage of GHDA reported.[8]

It is common for subspecialists to discuss whether a specific technique determines the appearance of ALGH, and it is common to assume that non-anatomical techniques such as Latarjet surgery or the use of different bone grafts would have a greater tendency to develop it.

In other studies that analyze a comparative series of cases between surgical techniques, we must describe again the one published by Buscayret and Walch.[7] This is a multicenter study, with 570 cases, an average follow-up of 6.5 years, and 3 surgical techniques are studied; Latarjet that represented 49% of the sample, open Bankart 38%, and arthroscopic 13%.[9] It was documented that 8.5% of patients presented preoperative arthropathy, similar in all groups with a predominance of mild cases, without documenting advanced stages. In a similar follow-up time, no important differences were documented when analyzing post-Latarjet arthropathy and open Bankart surgery. With a follow-up of only 3 years and with a smaller series than the other groups, there was less occurrence of arthropathy in the Bankart group.

To better understand these findings, we normalized the follow-ups in relation to time, thus achieving a similar number of cases after 3 years of evolution. By making this adjustment, the differences decrease drastically and are similar between groups ([Chart 2]).

Chart 2: We highlight the findings of Walch and Buscayret regarding the incidence of GHDA, correlating percentage and severity based on Samilson's classification. A predominance of stage 1 and stage 4 cases is observed in open Bankart surgeries. When normalizing the follow-up time between groups, no significant differences are noted.

In their conclusions, they describe that patients most prone to developing GHDA are those who experienced an index dislocation episode at an older age, underwent surgery at an older age, and had a longer interval between the index episode and stabilization surgery, regardless of the technique used. They conclude that there are no significant differences among surgical techniques concerning the development of GHDA.

Contrary to this, Ogawa et al., in a 2010 case series of arthroscopic Bankart repairs, demonstrated that the number of preoperative dislocations does influence the occurrence and progression of GHDA and that this is unrelated to the type of surgical procedure performed.[10]

On the other hand, analyzing the incidence of arthropathy described in each technique in isolation, Imhoff together with Plath describes their results in 100 arthroscopic repairs followed for 10 years.[11] The hypothesis of their study was that arthropathy would be less frequent in patients undergoing arthroscopic Bankart repair compared to those treated with open Bankart repair. They documented a recurrence rate of 21% for arthroscopic repairs and 19% for open repairs. Among cases of GHDA, 69% were predominantly asymptomatic (Constant score of 94), and 40% were classified as mild. They also observed that GHDA did not correlate with the Constant score (P = .427). Significant associations were found between arthropathy and the number of dislocations, age at the first episode (with older age linked to more arthropathy), age at stabilization surgery, and the number of anchors used in the repair. They did not find differences related to the time elapsed from the first episode to surgery or the presence of a final external rotation deficit. At the 13-year follow-up, GHDA was commonly observed. The energy level causing the initial dislocation and the patient's age were identified as key factors for the development of GHDA. No clear association was found between the type of surgery performed and the occurrence of GHDA. The study concludes that avoiding preoperative recurrence is the most important factor for prevention and that the number of anchors used in the repair may predict GHDA, although it remains unclear whether this correlates with bone defects or the number of associated injuries. It is likely that this finding is secondary to greater chondral damage caused during the arthroscopic procedure.

Another study that analyzes arthroscopically operated patients included a total of 25 cases that were followed for 16 years. It describes that the most important factor in developing GHDA is smoking, without finding differences in the surgical time after the first episode. They did not describe significant functional alterations between Buscayret grades 1 and 3, but they did when this is stage 4.[12]

Analyzing the Latarjet technique, Walch et al. present their results in a long-term follow-up.[13] This is a retrospective study of 68 cases with an average follow-up of 20 years. 20% of cases without initial GHDA develop arthropathy, with a predominance of mild cases. Of the shoulders with GHDA after the first dislocation, half progressed to arthropathy, half of these cases were moderate stage, and half advanced. Within their results, performing a multivariate regression analysis, they describe that the risk factors for the appearance or progression of arthropathy are older age, high-demand or impact sports, and lateral position of the graft. They conclude that after 20 years of follow-up, it occurs in 23.5% after a Latarjet, with the majority of cases being mild and asymptomatic.

Hovelius and Gordins analyzed their post-Latarjet results with a follow-up of 34 years on average, this being, again, the most important strength of this study.[14] They describe the evolution to arthropathy in 61% of the cases, where half of these were classified as type 1 and 2. This is the study with the longest follow-up of this technique and documents differences with the results described previously, probably due to the follow-up time. It was documented that patients younger than 22 years at the time of the index episode had less arthropathy. 1% of their sample for each year elapsed at the final follow-up progresses towards moderate to severe arthropathy. This is the first study that reports cases that required shoulder arthroplasty to treat GHDA, this being probably associated with the follow-up time. Among their most frequent conclusions, they mention that the degree of GHDA at 35 years of follow-up follows the same natural history of glenohumeral dislocation in relation to the progression towards arthropathy and that restriction of external rotation does not increase GHDA.

The following chart demonstrates the progression of GHDA after the various stabilization techniques described. It highlights, at first glance, the high percentage of arthropathy progression in open techniques such as the Latarjet. This suggests that techniques compromising joint physiology may increase this likelihood. However, when normalizing the number of patients by procedures and years of follow-up, this trend tends to yield similar results regardless of the technique used. ([Chart 3])

Chart 3: This chart describes the percentage of GHDA occurrence over time, analyzed by surgical technique and compared to the progression of the natural history represented by a thick line. A trend is observed where all surgical procedures flatten the time/percentage curve of GHDA by the final follow-up.

In 2018 Moroder et al. analyzed 46 cases treated with iliac crest graft followed for 18 years. They report that patients evolve with excellent functional results, but with the development of arthropathy in 74% of patients, this being advanced in only 3% of the total cases, so they conclude that this procedure does not prevent the development of arthropathy.[15]

Finally, a meta-analysis presented by Verweij et al. in 2022, compares 36 articles and 9 different types of stabilization procedures with a minimum follow-up of 5 years. They conclude that there are differences in favor of the Latarjet technique versus orthopedic management, but that there would be no differences between this, capsular plication (capsular shift), and the Bristow technique.[16]

Conclusions

The patient's age at the time of the first dislocation (23 years or younger) is identified as a significant risk factor for the development of GHDA. High-impact sports also increase the likelihood of progression to post-dislocation arthropathy. The timing of the surgical procedure, particularly in patients under 40, as well as the use of specific grafts such as in the Latarjet procedure, may influence the risk of developing post-dislocation arthropathy, though no statistical clarity currently indicates that any particular technique significantly increases GHDA.

The reviewed studies suggest that avoiding preoperative dislocations is the most important factor in preventing post-dislocation arthropathy. Progression to this condition appears to be independent of the surgical technique used, although certain procedures might affect joint physiology and thereby influence arthropathy progression.

Preventing preoperative dislocations and adequately managing concomitant injuries are key factors in preventing post-dislocation arthropathy, regardless of the surgical approach used.

Conflicto de intereses

Ninguno.

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Publication History

Received: 05 June 2024

Accepted: 29 November 2024

Article published online:
26 December 2024