Capsulorraphy with Achilles allograft augmentation for shoulder instability in patients with Ehlers-Danlos syndrome

Abstract

Background: Surgical management of shoulder instability in patients with Ehlers-Danlos syndrome (EDS) remains challenging secondary to the pathologic nature of their connective tissue. Allograft reconstruction of the shoulder capsule in EDS has the potential to increase stability by providing healthier connective tissue. The purpose of this study was to report the surgical technique and outcome of open capsulorraphy and augmentation of the anterior capsule with an Achilles tendon allograft in patients with shoulder instability in the setting of EDS.

Methods: Five shoulders (4 patients) with EDS and severe anteroinferior or multidirectional instability underwent open capsular shift combined with Achilles allograft augmentation of the anterior capsule. Patients were evaluated for pain, motion, recurrent instability, subjective shoulder value, American Shoulder and Elbow Surgeons score, complications, and reoperations. The mean follow-up time was 3.6 years (range, 2-5 years).

Results: Shoulder stability was restored in 4 of 5 (80%) shoulders. At the final follow-up, the mean subjective shoulder value and American Shoulder and Elbow Surgeons scores were 84 and 77.3, respectively. One shoulder developed recurrent posterior instability after an injury 1.6 years after the index procedure. The mean pain visual analog scale was 7 preoperatively and 2 at the most recent follow-up. Before surgery, all patients reported the use of narcotic pain medication, whereas at the most recent follow-up, only the one patient who had experienced recurrence reported moderate pain. Except for the shoulder that required revision surgery for posterior shoulder instability, there were no complications or other reoperations.

Conclusion: Open capsulorraphy with Achilles allograft augmentation improved stability and pain in 4 of 5 shoulders with instability in the setting of EDS. In this small case series of patients with EDS, Achilles tendon allograft augmentation was safe and effective as a primary or revision surgical procedure for anterior shoulder instability. A larger patient cohort with longer follow-up is needed to confirm these findings.

Keywords: Achilles tendon allograft; Ehlers-Danlos syndrome; anterior inferior instability; joint hypermobility; shoulder.