Arthritis from a prominent suture anchor - anchor arthropathy

Here are the films of a man in his mid twenties who had a shoulder repair for recurrent instability 8 years ago. He now can perform only 5 of the 12 functions of the simple shoulder test. His x-rays suggest that one of the suture anchors used in his instability repair has become prominent.

Comment: The challenge with suture anchors placed on the glenoid surface is that they may appear to be buried beneath the surface of the cartilage at the time surgery, but with a small amount of cartilage wear or a slight shift in the position of the anchor, part of it becomes prominent so that it can rub on the humeral surface leading to secondary arthritis. 

This is a particularly serious issue in a very young patient and demonstrates that shoulder arthritis in young individuals is usually a different condition that what is commonly seen in individuals over the age of 50.

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Suture anchors - never out of the woods

These are the films of a patient having a suture anchor Bankart repair 20 years ago that successfully managed the anterior instability. However, two years ago the shoulder became increasingly painful and stiff. Radiographs suggested at least one prominent suture anchor.

The patient requested a total shoulder arthroplasty. At our surgery we found a prominent metal suture anchor in the inferior center of the glenoid that was abrading the humeral head.

               

  

Removal of the suture anchor left a substantial defect in the center of the inferior glenoid surface so that it was necessary to prepare the glenoid so that the two peg holes were in the superior rather than the usual inferior aspect of the glenoid.

 This provided secure fixation for the glenoid component and allowed our usual postoperative early assisted motion to 150 degrees before hospital discharge.

 An anteriorly eccentric humeral head component nicely managed a tendency for excessive posterior translation.

Comment: Presumably the suture anchor was initially covered with a thin layer of cartilage that, when it wore away, exposed the suture anchor that then led to anchor arthropathy.

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Total shoulder for anchor arthropathy

Suture anchors are often used in shoulder surgery.  There is a problem, however, when they are placed on the articular surface. Here is a case where a patient had a repair of a 'labral tear' with three suture anchors. The patient came to us with severe shoulder pain and limited motion, requesting a total shoulder arthroplasty. The preoperative films are shown below. They suggest that the suture anchors on the glenoid may be prominent.

At surgery, all three metallic anchors were protruding from the glenoid surface and excoriating the humeral articular surface. They were removed using the 'doodle-bug' technique. 

Postoperative films after the total shoulder are shown below.

Comment: It is important for the shoulder arthroscopist to assure that anchors are not placed on the articular surface and that they are well buried so that there is no chance that they rub on the humeral articular surface producing anchor arthropathy.

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Shoulder arthritis from suture anchors and screws; Latarjet

One of our first articles about the shoulder, published in 1984 concerned complications of hardware around the shoulder.  We observed that "Screws and staples are used frequently in the surgical treatment of glenohumeral joint problems. We analyzed a series of thirty-seven patients with complications related to the use of these implants. Twenty-one patients had problems related to the use of screws for affixing a transferred coracoid process to the glenoid. Sixteen patients had problems related to the use of staples: ten had undergone capsulorrhaphy, four had had advancement of the subscapularis, and two had had repair of a rotator cuff tear. The complaints at examination were shoulder pain (thirty-six patients), decreased glenohumeral motion (nineteen patients), crepitus with glenohumeral motion (sixteen patients), and radiating paresthesias (four patients). The time between placement of the implant and the onset of symptoms ranged from four weeks to ten years. The screws or staples had been incorrectly placed in ten patients, had migrated or loosened in twenty-four, and had fractured in three. Thirty-four patients required a second surgical procedure specifically for removal of the implant. At operation fourteen patients (41 per cent) were noted to have sustained a significant injury to the articular surface of the glenoid or humerus. The results in this group of patients indicated that screws and staples can produce complications that require reoperation and are capable of causing a permanent loss of joint function. Adequate surgical exposure and careful placement of the implant appear to be essential when these devices are used about the glenohumeral joint."

Here's yet another example of 'anchor arthropathy', which is the modern version of what we discussed 30 years ago. These films are of the right shoulder of a young person having had surgery for shoulder instability. After surgery the shoulder became stiff and painful and did not respond to exercises.

The severe anchor arthritis is apparent.

The individual is scheduled for a ream and run.

Here's another: two days ago we did a ream and run on a young active person with pain and stiffness after a Latarjet. The x-rays show where the screw and bone had been rubbing on the humerus.

At surgery the prominent screw head was seen to be rubbing on the humeral head 

and the bone graft rubbing on the medial humeral cortex.

"Adequate surgical exposure and careful placement of the implant appear to be essential when these devices are used about the glenohumeral joint."

More here.

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Suture anchor arthropathy - shoulder arthritis in a young person after surgery for instability

As we've pointed out in prior blog posts, shoulder arthritis in young individuals is not the same as in the individual over the age of 55 years. Many cases of arthritis in individuals under the age of 40 are due to problems with prior surgery. Here an MRI image of the shoulder in a person under 20 years who had surgery for instability with the implantation of a suture anchor. One can see the location of the suture anchor on the face of the glenoid and loss of the humeral articular cartilage.

At revision arthroscopy, these two images were collected, again showing the loss of humeral articular cartilage.

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Shoulder Arthritis in Athletes Following the use of Suture Anchors

Shoulder Arthroplasty in Athletes Following Metallic Suture Anchor. A 2-Year Follow-up Investigation after Removal of the Implants and Physiotherapy

One of our first shoulder articles (30 years ago) was on the complications of metal around the shoulder. 

These authors point to the risks associated with the use of suture anchors. While they emphasize complications associated with metallic anchors, similar complications can be associated with other anchor materials. 

They note that complications resulting from the use of suture anchors are typically due to a malpositioning of the implant within the joint, but they can also result from implant loosening, breakage,  migration, or osteolysis. These complications can cause damage to the glenohumeral joint surface. They underscore what we have repeatedly observed in patients referred to us with post arthroscopic arthritis, "the learning curve for the use of metallic suture anchors to correct shoulder instability is high and the effects of associated complications are extensive".

The authors report 20 patients who developed chondral injuries after metallic suture anchors were used to repair labral lesions. There were four patients with Superior Labral Anterior Posterior (SLAP) lesions, 13 with anterior shoulder instability, one with multidirectional instability, and two requiring rotator cuff repair. Radiographs revealed that in 100% of the cases, at least one of the suture anchors was malpositioned.

The patients were treated with suture anchor removal and rehabilitation. Many improved.

Noting that of the 20 patients presented in this study, only 1 patient with metal suture anchor-associated complications was recognized in the early postoperative period (5 weeks) while the remaining 19 patients were recognized after 3 months, the authors emphasize the need for close monitoring and early diagnosis of this problem so that timely intervention can prevent major damage.

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Suture anchor complications - a cautionary tale

Complications Observed Following Labral or Rotator Cuff Repair with Use of Poly-L-Lactic Acid Implants

Suture anchors are used to fix soft tissue to bone. While they are handy, they can be associated with a wide range of complications. If they are loose or prominent, they can damage the joint surface and lead to arthritis. Metal anchors have been found to be particularly problematic if they contact the joint surface. This led to the advent of absorbable suture anchors. However, the authors point to the problems experienced with rapid hydrolysis, breakage, premature degradation, and sterile abscess formation related to polyglycolic acid suture anchors.  This gave rise to the pursuit of anchors made from polylactic acid.

This report concerns a series of 44 patients with complications of PLLA implants to treat either labral or rotator cuff pathology. These patients had undergone secondary arthroscopic exploration because of  pain and loss of shoulder motion following prior labral or rotator cuff repair with PLLA implants.

Macroscopic pieces of anchor, giant cell reaction, polarizing crystalline material, papillary synovitis, and chondral damage were found in the majority of the cases.  The degree of chondral damage appeared to increase with longer elapsed times since the index surgery.  All patients having had a rotator cuff repair had recurrent cuff defects larger than the tear documented at the index procedure.

This article suggests that these implants can degrade in a manner that releases particulate debris into the joint creating the risk of joint damage. 

In the meanwhile, we continue to fix rotator cuffs with the tried and true transosseous repair to a trough without any form of suture anchor.

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