Management of recurrent shoulder instability in patients with epilepsy

Epileptic patients with anterior shoulder instability: are there specific bone lesions? A case control study

HYPOTHESIS

Chronic epilepsy may cause important bipolar bony lesions. We aim to compare the specific pathoanatomic metrics of the bony lesions in chronic shoulder anterior instability that occur in patients with epilepsy vs. patients without epilepsy.

METHODS

From 2006 to 2020, we included epileptic and nonepileptic patients with anterior recurrent shoulder instability. We randomly adjusted the patients of the 2 groups according to the sex, age, and type of management. We included 50 patients. For each included patient, we performed an in-depth analysis and comparison of the glenoid bone loss based on the computed tomography scan: PICO method (patient/population, intervention, comparison and outcomes) using the best-fit circle; and the Hill-Sachs lesion: the depth and width were given as a percentage of the humeral head diameter on an axial view. We also evaluated the engaging character of the involved lesion using the on-track vs. off-track analysis. Those characteristics were compared between the 2 groups.

RESULTS

We found a glenoid bone loss in 32 patients. Glenoid bone loss was not significantly greater in patients with epilepsy (P = .052). A Hill-Sachs lesion was found in 42 patients (22 in the group with epilepsy and 20 in the group without epilepsy). Hill-Sachs lesions were significantly deeper and larger in the group with epilepsy (depth: 22% vs. 9%, P < .001; width: 43% vs. 28%, P = .003). In the group with epilepsy, 90% of the bone lesions were off-track vs. 30% in the group without epilepsy. Thus, the patients with epilepsy presented more engaging bony lesions than patients without epilepsy (P = .001) (OR = 23).

CONCLUSIONS

In a population of patients with epilepsy who had shoulder instability, Hill-Sachs lesions are larger and deeper than in normal patients with shoulder instability. By contrast, there is no significant difference regarding the characteristics of the glenoid bone loss if present. This implies that bone lesions in instable shoulders of patients with epilepsy need at least a bony stabilization procedure on the humeral side in the majority of cases.

Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations

BACKGROUND

Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion's characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients.

METHODS

Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed.

RESULTS

A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury.

CONCLUSIONS

Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.

Latarjet operation carries three times the risk of failure in seizure versus non-seizure recurrent anterior dislocation of the shoulder joint: outcome of a systematic review with meta-analysis

BACKGROUND

Recurrent anterior shoulder dislocation (RASD) in cases of seizure disorders (SDs) total 50%-80% of all SD-associated shoulder instabilities. Based on the extent of bone loss, treatment options include bony and soft-tissue reconstructions, arthroplasty, and arthrodesis. The primary objective of this paper was to review the treatment options for RASD in SDs.

METHODS

Several bibliographic databases were searched for RASD treatment options in SD patients. The demographic outcome measures, the failure rate (defined as the relative risk of recurrence of dislocation postoperation), and the postoperative seizure recurrence rate were recorded.

RESULTS

We pooled 171 cases (187 shoulders) from 11 studies. Of these, one, five, two, two, and one reports studied Bankart's operation with remplissage (27 cases/29 shoulders), the Latarjet procedure (106/118), bone block operation (21/23), arthroplasty (11/11), and arthrodesis (6/6), respectively, in treating SD-associated RASD. The relative risk of failure between SD and non-SD patients was 3.76 (1.3610.38) after the Latarjet operation. The failure rates were 17% and 13% for Bankart's operation with remplissage and the Latarjet procedure in SD patients, respectively, but 0% each for bone block operation, arthroplasty, and arthrodesis. The total rate of seizure recurrence after operation was 33% of the pooled cases.

CONCLUSIONS

SD recurrence in the postoperative period, the size of the bone block, and the muscular attachments to a small coracoid autograft are the determinants of failure among various reconstructive operations in SD-associated RASD. Level of evidence: III.

Management of a Failed Distal Tibial Allograft Procedure for Anterior Shoulder Instability in a Patient With Epilepsy: A Case Report

Shoulder instability episodes are observed in high-energy injuries, such as seizures. In this case report, we highlight the management of a failed distal tibial allograft procedure for recurrent shoulder instability in a patient with a bony Bankart lesion and epilepsy. The patient was treated with an iliac crest autograft and a proximal humerus osteochondral allograft procedure. To our knowledge, the use of an iliac crest autograft for glenoid bone loss and a proximal humerus osteochondral allograft after several failed shoulder instability procedures in a patient with epilepsy has not been reported.

Management of Shoulder Instability in Patients with Seizure Disorders

PURPOSE OF REVIEW

Patients with seizure disorders commonly suffer shoulder dislocations and subsequent instability. Due to high rates of recurrence and bone loss, management of this instability and associated pathology has proven to be more complex than that of patients without seizure disorders. The ultimate goal of this review is to outline the various treatment modalities and their respective outcomes in this complex patient population.

RECENT FINDINGS

Optimization of medical management of seizure disorders is imperative. However, despite these efforts, the incidence of post-operative seizure activity continues to be a concern. These subsequent episodes increase the risk of further instability and failure of surgical procedures. Overall, the use of soft tissue procedures has proven to result in increased recurrence of instability compared to bone-block augmenting and grafting procedures. There are a variety of bone-block procedures that have been described for anterior and posterior instability. Despite their success in decreasing further instability, they are associated with several complications that patients should be informed of. There is no consensus regarding the optimal surgical management of shoulder instability in patients with seizure activity. A multidisciplinary approach to the management of the seizure activity is paramount to the success of their treatment. Further studies are required to evaluate the optimal timing and type of surgical intervention for individualized cases.

Mid-term results of arthroscopic Bankart repair and remplissage for recurrent anterior shoulder instability in patients with a history of seizures

Background

Seizure predisposes patients to shoulder dislocation. However, there is no consensus regarding the best management approach for recurrent shoulder dislocation in patients who have a history of seizures. In this study, we report the outcome of arthroscopic Bankart repair augmented by Remplissage for the recurrent anterior shoulder dislocation in a series of patients with a history of seizures.

Methods

In this retrospective study, 27 patients with 29 recurrent anterior shoulder dislocations who were treated with the arthroscopic Bankart repair were included. All cases had deep Hill-Sachs lesions according to Hardy classification that was managed with a Remplissage technique. Patients with a glenoid defect of more than 20% in the CT scan were excluded. Twenty-two patients had an epileptic seizure, while the remaining five patients had convulsions due to other causes. The mean age of the patients was 28.3 ± 6.2 years. The mean follow-up of the patients was 3.1 ± 1.2 years. Outcome measures included the shoulder range of motion that was compared with the non-injured side in the unilateral subjects and the shoulder function that was evaluated by the Rowe score and the Walch-Duplay score.

Results

The mean forward flexion, abduction, external rotation, and internal rotation were not significantly different between injured and non-injured shoulder (p = 0.34, p = 0.41, p = 0.11, p = 0.23). The mean Rowe score was 49.1 ± 7.8 before the surgery and 92.1 ± 6.4 at the last visit (p < 0.001). According to the Walch-Duplay score, the shoulders were categorized as excellent, good, and fair in 17 (58.7%), 11 (37.9%), and 1 (3.4%) shoulder, respectively. The overall rate of instability recurrence was 17.2% (n = 5).

Conclusion

In patients with a history of seizures, arthroscopic Bankart repair augmented by Remplissage could be regarded as a safe and efficient method for the treatment of recurrent anterior shoulder dislocation with glenoid defect < 20%.

Eden-Hybinette Procedure for Revision Surgery in Recurrent Anterior Shoulder Instability in Epilepsy

AIMS

The purpose of this study was to analyze the clinical outcomes after Eden-Hybinette procedure for revision surgery in recurrent anterior shoulder instability in patients with epilepsy.

MATERIALS AND METHODS

We retrospectively evaluated eight such patients between 2015 and 2018. Four patients had failed Latarjet/Bristow procedure and two had failed arthroscopic Bankart procedure, while two had history of both the procedures. After medical control of epilepsy, Eden-Hybinette procedure was performed in all patients. WOSI score and Rowe shoulder score was recorded preoperatively and in subsequent post-operative follow-up. A paired t test was used to analyze and compare preoperative and postoperative outcomes and was considered significant if p value was < 0.05.

RESULTS

The average follow-up was 30 months (range 24-48 months). There was no recurrence of shoulder instability. The mean WOSI score before surgery was 77.3 (range 70-83), which improved to 24.2 (range 19-30) at 24-month follow-up. The mean Rowe score before surgery was 11.3 (range 5-15), which improved to 81.8(range 65-90) at 24-month follow-up. The improvement in WOSI and Rowe score was found to be statistically significant [p value < 0.05].

CONCLUSIONS

We conclude that Eden-Hybinette is a useful revision procedure to manage recurrent anterior shoulder dislocation in patients with epilepsy. Optimum medical control of seizure is also an important factor in preventing recurrent shoulder instability.

Clinical and radiological examination of bony-mediated shoulder instability

The coexistence of glenoid and humeral head bone defects may increase the risk of recurrence of instability after soft tissue repair.

Revealed factors in medical history such as male gender, younger age of dislocation, an increasing number of dislocations, contact sports, and manual work or epilepsy may increase the recurrence rate of instability.

In physical examination, positive bony apprehension test, catching and crepitations in shoulder movement may suggest osseous deficiency.

Anteroposterior and axial views allow for the detection of particular bony lesions in patients with recurrent anterior shoulder instability.

Computed Tomography (CT) with multiplanar reconstruction (MPR) and various types of 3D rendering in 2D (quasi-3D-CT) and 3D (true-3D-CT) space allows not only detection of glenoid and humeral bone defects but most of all their quantification and relations (engaging/not-engaging and on-track/off-track) in the context of bipolar lesion.

Magnetic resonance imaging (MRI) is increasingly developing and can provide an equally accurate measurement tool for bone assessment, avoiding radiation exposure for the patient.

Cite this article: EFORT Open Rev 2020;5:815-827. DOI: 10.1302/2058-5241.5.200049

Surgical Stabilization of Shoulder Instability in Patients With or Without a History of Seizure: A Comparative Analysis

PURPOSE

To compare patients from a large multicenter cohort with a history of seizure and those without a history of seizure regarding preoperative and intraoperative findings and surgical procedures performed.

METHODS

Patients undergoing shoulder stabilization from 2011 to 2018 at 11 orthopaedic centers were prospectively enrolled. Those with a history of seizure were identified and compared with non-seizure controls. Preoperative demographic, history, physical examination, and imaging findings were collected. Intraoperative findings and surgical procedures performed were recorded. The Mann-Whitney test, χ² test, and logistic regression analysis were used to examine differences between the groups and define independent risk factors. Owing to the number of statistical tests performed, the false discovery method was used to determine adjusted P values to achieve α < .05.

RESULTS

During enrollment, 25 of 1,298 shoulder stabilization patients (1.9%) had a history of seizure. The sex ratio and age were similar between groups, as was posterior instability incidence (23.2% in control group vs 28.0% in seizure group). Seizure patients more frequently had more than 5 dislocations in the year preceding surgery (P = .016) and had increased preoperative radiographic evidence of bone loss (P < .001). Intraoperatively, seizure patients had a higher prevalence of reverse Hill-Sachs lesions (P < .001) and large (>30% of glenoid fossa) bony Bankart lesions (P < .001). Arthroscopic Bankart repair was the most common procedure in both groups. However, open procedures were performed in 15.6% of controls and 40.0% of seizure patients (P = .001). These procedures were most commonly bony procedures.

CONCLUSIONS

Seizure patients had more prior dislocations, had more preoperative bone loss, and underwent more open stabilization procedures than controls because of bone loss. Studies examining recurrence after stabilization will help establish appropriate management practices in this population.

LEVEL OF EVIDENCE

Level III, retrospective review of prospectively collected cohort.

The effectiveness of the Latarjet procedure for shoulder instability in patients with epilepsy

INTRODUCTION

Powerful contractions during epileptic seizures may cause shoulder dislocation and instability. The aim of the study is to evaluate the functional and radiographic results of the Latarjet procedure for anterior shoulder dislocation in patients with epilepsy and compare the functional results of these patients with the results of patients without epilepsy.

HYPOTHESIS

Is latarjet procedure effective in epileptic patients as non-epileptic patients with anterior shoulder instability?

MATERIAL AND METHOD

Eleven shoulders of 9 patients with epileptic seizures causing anterior shoulder instability were evaluated retrospectively. All patients had a Latarjet procedure after neurologic evaluation and treatment arrangement. Epileptic seizures after the operation and shoulder dislocation after a seizure were investigated. For functional evaluation, ROWE, ASES and Constant scores were utilized whereas standard X-ray views were used for radiologic evaluation. The results of epileptic patients with Latarjet procedure were compared with non-epileptic patients (53 patients, 54 shoulders) for anterior shoulder instability.

RESULTS

Three (33%) of the 9 epileptic patients had recurrent seizures after Latarjet procedure, whereas 1 of the 11 shoulders (9%) had dislocation after an epileptic seizure. Functional scores were found to be significantly improved in epileptic (P<0.001) and non-epileptic patients (P<0.001). No significant differences for functional results were found between epileptic and non-epileptic patients after Latarjet procedure for anterior instability (P>0.05). One shoulder of 11 in the patients with epilepsy group (9%) and one shoulder of the 54 shoulders non-epileptic patients group (1.8%) had a redislocation. The rate of postoperative redislocation was significantly higher in patients with epilepsy (P=0.008).

DISCUSSION

Epileptic patients have a high rate of recurrent seizures even with proper medical treatment. Significant functional improvements and shoulder stability may be achieved after Latarjet procedure in epileptic patients. These functional results were comparable with those of non-epileptic patients with Latarjet procedure for anterior shoulder instability.

LEVEL OF EVIDENCE

III (case-control study).