Distant migration of a bioabsorbable implant in the shoulder

Abstract

Metal implants about the shoulder have been recognized to be associated with serious complications since the publication of Zuckerman and Matsen. 14 Zuckerman J.D. Matsen F.A. Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg. 1984; 66A: 175 Google Scholar Rockwood et al 10 Neer C.S. Rockwood Jr, C.A. Fractures and dislocations of the shoulder. in: Rockwood Jr, C.A. Green D.P. Fractures in adults. Lippencott, Philadelphia1984: 908-909 Google Scholar reported several cases of metal implant migrating at a distance from the shoulder, some with catastrophic and even fatal consequence. 13 Wirth M.A. Rockwood C.A. Migrations of a broken cerclage wire from the shoulder girdle into the heart: a case report. J Shoulder Elbow Surg. 2000; 9: 543 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Bioabsorbable implants were devised in part to mitigate these complications. These implants also offered the option of easier postoperative MRI imaging, and were purported to make revision surgery, should it be required, easier. Initial α polyester formulations using polyglycolic acid polymers resorbed fairly quickly. This created problems when longer fixation times were required. The relatively rapid hydrolysis of these implants also created a significant load of bioabsorption debris, resulting in reports of significant synovitis, local reaction, and even giant cell-like responses. 2 Berg E.E. Oglesby J.W. Loosening of a biodegradable shoulder staple. J Shoulder Elbow Surg. 1996; 5: 76-78 Abstract Full Text PDF PubMed Scopus (15) Google Scholar , 3 Burkart A. Imhoff A.B. Roscher E. Foreign-body reaction to the bioabsorbable Suretac device. Arthroscopy. 2000; 16: 91-95 Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar , 4 Cheng J.C. Wolf E.M. Chapman J.E. Johnston J.O. Pigmented villonodular synovitis of the shoulder after anterior capsulolabral reconstruction. Arthroscopy. 1997; 13: 257-261 Abstract Full Text PDF PubMed Scopus (15) Google Scholar , 6 Edwards D.J. Hoy G. Saies A.D. Adverse reaction to an absorbable shoulder fixation device. J Shoulder Elbow Surg. 1994; 3: 230-233 Abstract Full Text PDF PubMed Scopus (116) Google Scholar Implants with longer absorption times, involving different combinations of α polyesters were substituted. These implants have longer mechanical integrity, but the extended lifespan of these implants increases the risk of damage to the soft tissues if they become loose or break. Freehill et al 8 Freehill M.Q. Harms D.J. Huber S.M. Atlihan D. Buss D.D. Poly-L-lactic acid tack synovitis after arthroscopic stabilization of the shoulder. Am J Sports Med. 2003; 31: 643-647 PubMed Google Scholar reported a 20% incidence of chondral injuries with the use of bioabsorbable tacks in the shoulder, and other authors 12 Warner J.J.P. Miller M.D. Marks P. Fu F.H. Arthroscopic Bankart repair with the Suretac device Part I. Clinical observations. Arthroscopy. 1995; 11: 2-13 Abstract Full Text PDF PubMed Scopus (89) Google Scholar note a 10% incidence of tack synovitis. The time to complete hydrolysis of these implant in vivo is unknown; adverse reactions to these materials have occurred as late as 143 weeks after implantation. 5 Ciccone II, W.J. Motz C. Bentley C. Tasto J.P. Bioabsorbable implants in orthopaedics: new developments and clinical applications. J Am Acad Orthop Surg. 2001; 9: 280-288 Crossref PubMed Scopus (137) Google Scholar Anecdotal reports of bioabsorbable interference screws in the knee 13 Wirth M.A. Rockwood C.A. Migrations of a broken cerclage wire from the shoulder girdle into the heart: a case report. J Shoulder Elbow Surg. 2000; 9: 543 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar suggest a considerably longer duration of time prior to hydrolysis, further increasing the risk of complication related to loose or migrated implants. Many of these reports suggest that the risk of local injury with loose bioabsorbable implants approaches the risk of loose metal implants. This is of special concern, as these implants are invisible on plain radiographs and require magnetic resonance imaging (MRI) scanning to image the implant postoperatively. Extra-articular migration outside the shoulder of a bioabsorbable implant, however, has not been reported. We report a case of migration of a bioabsorbable shoulder implant outside the shoulder girdle requiring late open removal.