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Review Article
2026
:5;
100664
doi:
10.1016/j.jorep.2025.100664

Outcomes after surgical shoulder stabilization in epileptic patients: A systematic review

, , , , , ,
a Hackensack Meridian School of Medicine, Nutley, NJ, USA
b Rothman Orthopaedic Institute, Philadelphia, PA, USA
c New York University Langone Orthopedics, New York, NY, USA
d University of Miami Miller School of Medicine, Miami, FL, USA
e Mount Sinai Orthopedics, New York, NY, USA
f Northwell Orthopedics, Tarrytown NY, USA

⁎Corresponding author: Brandon J. Erickson. berickson@northwell.edu

Received: , Accepted: ,
The Authors
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Patients who experience seizures with uncontrollable muscle jerks are at increased risk of shoulder dislocation. While many studies have evaluated outcomes after shoulder stabilization in the general population, no systematic review has been performed to summarize shoulder stabilization outcomes for epileptic patients. The authors hypothesized that patients suffering from epilepsy will have a higher postoperative instability rate and higher reoperation rate than what has been reported following shoulder stabilization in the general population.

The PubMed, SportDiscus, and Ovid Medline databases were queried to identify original research studies evaluating post-operative outcomes after shoulder stabilization in epileptic patients. Studies were only included if post-operative outcomes specific to epileptic patients were reported. Included non-randomized studies were evaluated for study quality using the Methodological Index for Non-Randomized Studies (MINORS) score. Recurrent instability and revision rates were pooled across all included studies, and weighted averages were calculated for patient-reported outcome scores (Rowe, Oxford, SSV scores).

Overall, 311 studies were screened and 11 studies were included with a mean MINORS score of 8.8 ± 2.1. There were 157 shoulders in 142 patients with epilepsy who underwent surgical stabilization with an average age of 32.9 ± 10.5 years of age. The most common surgical procedures performed were the Latarjet procedure (34 %). At a mean of 6 years follow-up, 31 (19.7 %) of the 157 included shoulder experienced recurrent instability events, including 28 dislocations, 1 subluxation, and 2 apprehension sensations. Also, 27 shoulders (17.2 %) underwent revision surgery of various modalities. Of note, two patients were also in need of revision surgery but did not undergo the procedure yet as their epilepsy was not under sufficient control.

While patients suffering from epilepsy still benefit from shoulder stabilization surgery, they are roughly 3x more likely to experience recurrent instability and 4x more likely require revision surgery than non-epileptic patients. While two patients could not undergo revision due to their postoperative medical management of epilepsy, optimizing medical management throughout the postoperative period is crucial. Both epileptic treatment and standard post-operative rehabilitation should be emphasized to optimize post-operative outcomes in epileptic patients.

Abstract

Highlights

•While patients suffering from epilepsy still benefit from shoulder stabilization surgery, they are several times more likely to experience recurrent instability and require revision surgery than non-epileptic patients•Both epileptic treatment and standard post-operative rehabilitation should be emphasized to optimize post-operative outcomes in epileptic patients.

Keywords

Instability
Arthroscopy
Epilepsy
Seizure
1

1 Introduction

Epilepsy is a neurological disorder characterized by recurrent seizures, affecting millions of individuals worldwide.1 While the primary focus in epilepsy management has traditionally been on seizure control and quality of life improvements, there exists a significant subset of epileptic patients who also experience secondary complications due to the chronic nature of their condition.2 Patients who experience intense seizures with uncontrollable muscle jerks are at increased risk for injury, including shoulder dislocation.3–5 Recurrent shoulder instability can be treated conservatively with physical therapy or through surgical stabilization procedures.6

Several factors play an important role in a patient’s recovery following surgery including sport participation, adherence to rehabilitation protocol, and presence of comorbidities such as epilepsy5 Seizures in the post-operative period can negatively impact recovery due to risk of further injury to the shoulder joint and damage to hardware.7 Epilepsy is viewed as a relative contraindication to surgery for this reason, however proper medical management can make patients a good candidate for surgery.8

While many studies have evaluated outcomes after shoulder stabilization in the general and athletic populations, fewer studies have evaluated outcomes in epileptic patients, and no systematic review has been performed to summarize shoulder stabilization outcomes for these epileptic patients. Therefore, the purpose of this systematic review was to evaluate post-operative recurrent instability and revision rates in epileptic patients following shoulder stabilization surgery. The authors hypothesized that patients suffering from epilepsy will have a higher postoperative instability rate and higher reoperation rate than what has been reported following shoulder stabilization in the general population.

2

2 Materials and methods

This systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with no Institutional Review Board approval or funding required.9 The PubMed, SportDiscus, and Ovid Medline databases were queried to identify original research studies evaluating post-operative outcomes after shoulder stabilization in epileptic patients. The following keyword search was used: ((bankart) OR (latarjet) OR (remplissage) OR (total shoulder arthroplasty) OR (TSA) OR (reverse total shoulder arthroplasty) OR (rTSA) OR (bone buttress) OR (capsular shift) OR (hemiarthroplasty) OR (Open Reduction Internal Fixation) OR (Shoulder stabilization)) AND (() OR (epilepsy) OR (epileptic) OR (seizure)).

Inclusion/Exclusion Criteria: Studies were screened by 2 independent reviewers with discrepancies being decided by a 3rd reviewer. Studies were included if post-operative outcomes after any shoulder stabilization procedures were evaluated, and if outcomes specific to epileptic patients were reported. Articles were excluded if they were review articles or case reports, if they did not isolate outcomes for patients who underwent shoulder stabilization, or if they did not isolate outcomes for epileptic patients. There were no exclusion criteria set based on article language or publication year.

2.1

2.1 Assessment of study quality

Included non-randomized studies were evaluated for study quality using the Methodological Index for Non-Randomized Studies (MINORS) score.10 Studies were scored for each question as a 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate) by two independent authors, with discrepancies being rectified by a third member. Non-comparative studies included eight questions for the MINORS score resulting in a total potential score ranging from 0 (poor study quality) to 16 (high study quality), while comparative studies instead included 12 questions with a total potential score ranging from 0 to 24.

2.2

2.2 Data collection and abstraction

Demographic variables collected from the included studies include level of evidence, patient age and sex, follow-up duration, surgical procedure, and treatment of epilepsy. Post-operative outcomes of interest collected include recurrent instability, revision, and patient-reported outcomes such as the Rowe score.

2.3

2.3 Statistical analysis

Recurrent instability and revision rates were pooled across all included studies. Weighted averages were calculated for age and patient-reported outcomes (Rowe, Oxford, SSV scores). Statistical significance was set at p < 0.05.

3

3 Results

Overall, 311 studies were screened and 11 studies were included in this systematic review (Fig. 1).3,5,8,11–18 The mean MINORS score of included studies was 8.8 ± 2.1.

Flow chart of PRISMA study screening.
Fig. 1 Flow chart of PRISMA study screening.

There were 157 shoulders in 142 patients with epilepsy who underwent surgical stabilization with an average age of 32.9 ± 10.5 years of age (Table 1). 140 of the 142 (98.6 %) of epileptic patients experienced recurrent dislocations prior to surgical intervention. Six of 11 studies detailed medical management of epilepsy prior to surgery with some studies seeking neurological advice preoperatively and other studies requiring a patient to be seizure-free for 1 year before undergoing surgery. The most common surgical procedures performed was the Latarjet procedure (54 shoulders).

Table 1 Study quality and patient demographics of included studies.
Study MINORS score Level of Evidence Sample Size Age (years) Surgeries Glenoid Bone Loss Epilepsy Treatment
Thangarajah 201722 11 3 8 (7M/1F) 33 ± 9 (17–44) Resurfacing hemiarthroplasty (5) and anatomical TSA (3) >20 % of the anterior-posterior diameter Neurological advice was sought pre-op in all cases to optimize the treatment of epilepsy.
Hutchinson 19959 5 3 13 (9M/4F) 29.1 (19–46) Bone buttress Mean 33 % Operation was delayed until control of the epilepsy was improved.
Mittal 202113 11 4 8 (6M/2F) 31.6 ± 6.7 (20–40) Eden-Hybinette procedure >25 % – – –
Thon 202125 11 3 9 (8M/1F) 29.2 (20–37) 10 shoulders: Latarjet Mean 20.8 % – – –
Thangarajah 201421 7 3 6 (4M/2F) 31 ± 6 (22–38) Glenohumeral arthrodesis – – – Neurological advice was sought preoperatively in all cases to optimize epilepsy treatment.
Dzidzishvili 20225 11 3 19 (15M/4F) 28.7 ± 7.2 21 shoulders: Arthroscopic Latarjet – – – – – –
Raiss 201217 7 3 12 (10M/2F) 31 (23–55) 14 shoulders: Open Latarjet – – – – – –
Bühler 20023 7 3 26 (17M/9F) 43.5 ± 20 (18–84) 34 shoulders: Allograft (9), Eden-Hybinette (7), Reposition (5), Putti-Platt (3), Bankart (3), Other (7) – – – – – –
Erşen 20177 9 3 9 (6M/3F) 31.3 Open Latarjet – – – All patients had Latarjet procedure after neurologic evaluation and treatment.
Thangarajah 201624 9 3 5 (4M/1F) 47 (32–64) Fixed-fulcrum rTSA – – – Neurological advice was sought preoperatively in all cases to optimize epilepsy treatment.
Guity 20228 9 3 27 (23M/4F) 28.3 ± 6.2 (17–42) 29 shoulders: Arthroscopic Bankart with concomitant remplissage Mean 12.1 % Well-controlled epilepsy under the supervision of a neurologist so that the patient was seizure-free for at least 1 year.

At a mean of 6 years follow-up, 31 (19.7 %) of the 157 included shoulder experienced recurrent instability events, including 28 dislocations, 1 subluxation, and 2 apprehension sensations (Table 2). There were 27 shoulders (17.2 %) that underwent revision surgery of various modalities. Two more patients were in need of revision surgery but did not undergo the procedure yet as their epilepsy was not under sufficient control. All athletes in the study were able to return to sport, however only 8 out of 19 (42 %) were able to return to sport at the same level.

Table 2 Recurrent instability and revision rates.
Study Sample Size Surgeries Follow-up (Years) Recurrent Dislocation Recurrent Instability Revision Type of Revision
Thangarajah 201722 8 (7M/1F) Resurfacing hemiarthroplasty (5) and anatomical TSA (3) 4.7 ± 1.7 (2–7.5) 0 (0 %) 0 (0 %) 2 (25 %) 1 TSA, 1 glenoid replacement
Hutchinson 19959 13 (9M/4F) Bone buttress 2.7 (.75–5.1) 0 (0 %) 0 (0 %) 0 (0 %) – – –
Mittal 202113 8 (6M/2F) Eden-Hybinette procedure 2.5 (2–4) 0 (0 %) 0 (0 %) 0 (0 %) – – –
Thon 202125 9 (8M/1F) 10 shoulders: Latarjet 3.4 (2.2–4.8) 5 (50 %) 5 (50 %) 2 (20 %) 2 Unclear
Thangarajah 201421 6 (4M/2F) Glenohumeral arthrodesis 3.3 ± 2.6 (1–6.6) 0 (0 %) 0 (0 %) 2 (33 %) 1 compression plating, 1 ORIF
Dzidzishvili 20225 19 (15M/4F) 21 shoulders: Arthroscopic Latarjet 5.8 1 (5 %) 2 (10 %) 1 (5 %) 1 Eden-Hybinette procedure
Raiss 201217 12 (10M/2F) 14 shoulders: Open Latarjet 8.3 (1–20) 6 (43 %) 6 (43 %) 5 (36 %) 5 iliac allograft bone buttress procedures; 2 with concomitant Putti-Platt, 1 with concomitant capsular shift
Bühler 20023 26 (17M/9F) 34 shoulders: Allograft (9), Eden-Hybinette (7), Reposition (5), Putti-Platt (3), Bankart (3), Other (7) 10 (2–21) 10 (29.4 %) 10 (29.4 %) 10 (29.4 %) 3 Eden-Lange-Hybinette, 2 Reposition, 1 derotation osteotomy, 1 bone block, 1 Bankart + bone block, 1 allograft and Bristow, 1 Bankart
Erşen 20177 9 (6M/3F) Open Latarjet 3.3 (2–11) 1 (9 %) 1 (9 %) 1 (9 %) 1 Iliac bone graft
Thangarajah 201624 5 (4M/1F) Fixed-fulcrum rTSA 4.7 ± .3 (4.3–5) 0 (0 %) 0 (0 %) 0 (0 %) – – –
Guity 20228 27 (23M/4F) 29 shoulders: Arthroscopic Bankart with concomitant remplissage 6.7 ± 3.2 (1.5–2.7) 5 (17.2 %) 7 (24.1 %) 4 (13.8 %) 4 Latarjet

Three out of four studies found the ROWE scores improved pre-to post-operatively with a weighted mean increase of 70 points (21.0 vs. 91.0) across all 4 studies.12,14,16,19 Three studies compared pre- and post-operative Oxford and SSV scores with an weighted mean increase of 13.3 (12.6 vs. 25.9) and 22.0 (30.8 vs. 52.8), respectively.3,7,8 One study found that having a seizure in the postoperative period significantly increased the risk of recurrent dislocation (OR = 39.9, p = 0.04).5 Another study found that 5 of 19 patients had post op seizures, with none of these patients experiencing recurrent dislocation.12

4

4 Discussion

Shoulder instability is a common problem in patients with epilepsy. This study found that epileptic patients have unique struggles with attaining post-op outcomes that are on par with the general population after shoulder stabilization surgery. However, these patients still receive a clear benefit from undergoing surgery as opposed to non-operative management.

Belk et al. performed a systematic review of 5 randomized controlled trials looking at shoulder stabilization outcomes in the general population, comparing recurrent instability and revision rates for patients who had operative (n = 126) vs. non-operative (n = 133) management.20 Operative patients had a recurrent instability rate of 6 % which is significantly lower than the non-operative rate of 47 %.20 Additionally, they found that 4 % of patients who were initially treated operatively underwent revision surgery while 31 % of non-operative patients failed their conservative treatment and ultimately needed to have surgical stabilization.20 In contrast, this present study found that patients with epilepsy have a recurrent instability rate of 19.7 % and revision rate of 17.2 % following operative treatment. When compared to the findings from Belk et al., post-operative outcomes for patients with epilepsy are worse than post-operative outcomes for non-epileptic patients; however, post-operative epileptic patients have better outcomes than non-epileptic patients who undergo non-operative management.

Large amounts of glenoid bone loss were observed in several included studies which may contribute to heterogeneity of the included surgical procedures as well as poorer post-operative outcomes when compared to the general population. Bone loss among the cohort in this study averaged >20 % for four of the five studies that reported it.5,8,14–16 Shin et al. has described a glenoid bone loss of 17.3 % as the critical value for predicting recurrent instability following Bankart repair.21 Critical glenoid bone loss decreases the articular surface of the shoulder joint, decreasing the distance the humoral head needs to translate in order to dislocate. Higher degree of glenoid bone loss is an additional contributing factor for patients of this population and may help explain differences in postoperative outcomes when compared to non-epileptic patients. Additionally, large degrees of glenoid bone loss could impact surgical decision making and lead to more complicated procedures such as bone block. Further studies should investigate postoperative outcomes in epileptic and non-epileptic patients with similar degrees of glenoid bone loss to better determine whether epilepsy is an independent risk factor of recurrent instability.

While epilepsy does appear to be an important risk factor for post-operative recurrent instability, other factors such as bone loss also play a significant role in predicting outcomes. For example, Schwihla et al. looked at recurrent instability and revision following Bankart repair for patients who had on-track vs off-track Hill-Sachs lesions.22 Recurrent instability and revision rates were significantly higher for the off-track patients (74 % and 48 %) than on-track (27 % and 13 %).22 Additionally, Markes et al. investigated recurrent dislocations and revision rates following open and arthroscopic shoulder stabilization procedures.6 The researchers found an average dislocation rate of 4.0 % after open stabilization and 2.6 % after arthroscopic stabilization (p < 0.01).6 While this present study was not able to analyze revision and recurrence rates based on factors such as open vs. arthroscopic repair or on-track vs. off-track Hill-Sachs lesions in the epileptic population, these factors should be taken into account when evaluating whether a patient with epilepsy should undergo operative vs non-operative management of their shoulder instability.

With epileptic patients having relatively high rates of recurrent instability and revision, it is important to keep in mind other risk factors that might put an epileptic patient at a higher risk for a poor post-operative outcome. Cucchi et al. found that epileptic patients who suffered posterior dislocation and multidirectional instability were at a statistically significant highest risk for poor outcomes and dissatisfaction when compared to patients with anterior instability.23 Additionally, epileptic patients suffering a posterior proximal humerus fracture-dislocation (PHFD) had the highest rates of dissatisfaction when compared to any other sub-group.23 Other risk factors associated with posterior dislocations including PHFD were older age, male sex, and inadequate medical management of epilepsy.23 Careful consideration should be taken when evaluating an epileptic patient with shoulder instability for appropriate risk assessment based on the aforementioned factors so both the patient and the surgeon have appropriate expectations.

Roughly two-thirds of patients with epilepsy are able to become seizure free with medical therapy.24 Epilepsy surgery and other alternative therapies are options for patients who fail medical management. Despite a relatively high success rate of treatment, some patients may develop breakthrough seizures even after several years of being seizure free on a particular treatment regimen.25 Patients should follow up frequently with their providers to ensure proper management of their condition prior to and following surgical stabilization, with multifactorial management including medication blood level surveillance and lifestyle modifications, to improve their chance at having a favorable outcome.26

4.1

4.1 Limitations

There are several notable limitations of this systematic review. First, there is heterogenicity of glenoid bone loss and surgical procedure across studies. Future studies comparing epileptic and non-epileptic patients with similar glenoid bone loss should be considered. Also, all included studies were retrospective with an average MINORS score of 8.8, suggesting a limit in the quality of the data. Additionally, the data on recurrent instability for patients who had uncontrolled epilepsy is limited, as many of the studies excluded patients who were experiencing frequent seizures prior to operation. Finally, similar patient-reported outcomes were not reported across the included studies, limiting the conclusions drawn regarding patient-reported outcomes.

5

5 Conclusion

While patients suffering from epilepsy still benefit from shoulder stabilization surgery, they are several times more likely to experience recurrent instability and require revision surgery than non-epileptic patients. While two patients could not undergo revision due to their postoperative medical management of epilepsy, optimizing medical management throughout the postoperative period is crucial. Both epileptic treatment and standard post-operative rehabilitation should be emphasized to optimize post-operative outcomes in epileptic patients.

CRediT authorship contribution statement

Jordan T. Windsor: Writing – original draft, Data curation. Ryan W. Paul: Project administration, Methodology, Validation. Jay Zaifman: Data curation, Formal analysis, Validation. Andres R. Perez: Writing – original draft. Bradford O. Parsons: Writing – review & editing, Methodology. Laith M. Jazrawi: Writing – review & editing, Methodology. Brandon J. Erickson: Supervision, Conceptualization.

IRB approval

n/A.

Ethical statement

Not Applicable.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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