Surgical management of glenohumeral instability in patients with Ehlers-Danlos syndrome/hypermobility spectrum disorder and their risk of reoperation

Background: This study aims to characterize the types of procedures performed on patients previously diagnosed with Ehlers-Danlos syndrome (EDS)/hypermobility spectrum disorder (HSD) and investigate rates of revision surgery following open, arthroscopic, or bony stabilization procedures in patients with and without a preoperative diagnosis of EDS/HSD.

Methods: This is a retrospective comparative study utilizing a large nationwide claims database. Records were queried between January 2011 and December 2021 for patients undergoing surgical management for glenohumeral instability using Current Procedural Terminology codes. Patients with preoperative diagnoses of EDS/HSD were identified using International Classifications of Disease, ninth revision and tenth revision billing codes. Multivariable logistic regression was used to analyze the distribution of surgical techniques performed for patients with HSD and compare rates of revision operation following open, arthroscopic, and/or bony procedures. Unadjusted and adjusted odds ratios (aOR) and 95% confidence intervals are reported for each comparison. A P value of .05 was used to signify statistical significance.

Results: Patients with preoperative diagnoses of EDS/HSD were significantly more likely to undergo open posterior (aOR = 3.47, 95% CI [2.13, 5.31]), open capsulorrhaphy (aOR = 5.04, 95% CI [3.97, 6.32]), and Latarjet (aOR = 1.84, 95% CI [1.33, 2.48]) procedures than patients without EDS/HSD. In contrast, these patients were significantly less likely to undergo arthroscopic Bankart repair (aOR = 0.48, 95% CI [0.40, 0.58]). Preoperative EDS/HSD was also associated with increased rates of secondary shoulder surgery (aOR = 2.63, 95% CI [2.01, 3.39]), but not necessarily ipsilateral revision shoulder surgery (aOR = 1.64, 95% CI [0.89, 2.77], P = .87).

Conclusions: The present study demonstrates that EDS/HSD results in greater likelihood of shoulder instability being surgically managed through open procedures as opposed to arthroscopic procedures, as well as greater likelihood of requiring subsequent surgical procedures. These findings provide critical insights to patients with EDS/HSD and their clinical providers for developing treatment plans for shoulder instability. Providers should educate patients with known hyperlaxity to make them aware of their increased odds of future reoperation. Surgeons should also prioritize assessment of ligamentous laxity in all patients and adjust individual treatment protocols accordingly.