Prevention and management of post-instability glenohumeral arthropathy

Abstract

Post-instability arthropathy may commonly develop in high-risk patients with a history of recurrent glenohumeral instability, both with and without surgical stabilization. Classically related to anterior shoulder instability, the incidence and rates of arthritic progression may vary widely. Radiographic arthritic changes may be present in up to two-thirds of patients after primary Bankart repair and 30% after Latarjet procedure, with increasing rates associated with recurrent dislocation history, prominent implant position, non-anatomic reconstruction, and/or lateralized bone graft placement. However, the presence radiographic arthrosis does not predict poor patient-reported function. After exhausting conservative measures, both joint-preserving and arthroplasty surgical options may be considered depending on a combination of patient-specific and anatomic factors. Arthroscopic procedures are optimally indicated for individuals with focal disease and may yield superior symptomatic relief when combined with treatment of combined shoulder pathology. For more advanced secondary arthropathy, total shoulder arthroplasty remains the most reliable option, although the clinical outcomes, wear characteristics, and implant survivorship remains a concern among active, young patients.

Keywords: Arthropathy; Dislocation; Glenohumeral; Instability; Latarjet.

Figure 1

Anteroposterior (A) and lateral (B) X-rays of a 39-year-old male with dislocation arthropathy status post instability procedure with metal anchors.

Figure 2

Flow-chart demonstrating decision algorithm for non-prosthetic cartilage treatment options.

Figure 3

Flow-chart depicting treatment options after loss of glenohumeral kinematics.

Figure 4

Flow-chart demonstrating decision algorithm for non-prosthetic vs prosthetic treatment options that include arthroscopic and open procedures.

Figure 5

Comprehensive arthroscopy management of glenohumeral arthropathy. A: Images from a 37-year-old male with instability arthropathy demonstrating preoperative anteroposterior radiograph with large inferior humeral head osteophyte and loss of glenohumeral joint space; B: Intra-operative fluoroscopy localization of extent of inferior humeral head osteophyte; C: Intra-operative arthroscopic image viewing from posterior portal, demonstrating inferior humeral neck (a) status post debridement of osteophyte, the arthroscopic shaver is on the inferior capsule; D: Post-operative anteroposterior radiograph demonstrating debridement of osteophyte and biceps tenodesis with a biocomposite screw.

Figure 6

Fresh osteochondral allograft transplantation. A: Intra-operative arthroscopic image of central humeral articular lesion while viewing from a posterior portal in a 39-year-old patient; B: After an open approach, preparation of the central lesion; C: Harvesting a corresponding osteochondral plug from a size-matched, fresh allograft humerus; D: Status post insertion of the osteochondral plug into the defect.