Arthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion

doi:10.1016/j.arthro.2005.02.004

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 21, Issue 5, May 2005, Pages 632.e1-632.e6

https://doi.org/10.1016/j.arthro.2005.02.004 Get rights and content

Abstract

We describe 3 cases of an all-arthroscopic technique for repair of a humeral avulsion of the glenohumeral ligament (HAGL) lesion and the postoperative clinical outcomes. From a technical perspective, the most critical part of the surgeries was the anchor insertion at an optimal position on the humerus in order to achieve proper tension of the glenohumeral ligament. The arm-free beach-chair position, which facilitates maximum internal rotation, use of a 70° angled arthroscope, and an anterior-inferior trans-subscapularis tendon portal were considered key factors to accomplish this procedure.

Section snippets

Case 1

A 30-year-old, right-hand-dominant woman initially dislocated her right shoulder during a motocross accident. She reported 5 subsequent episodes of anterior-inferior subluxation, even during minimally traumatic events. She also frequently complained of a “shifting” sensation in the right shoulder during daily activity.

Physical examination revealed a positive apprehension sign with the shoulder in external rotation at 60°, 90°, and 120° of abduction. There was no evidence of inferior and

Discussion

Before arthroscopic examinations and surgeries became widespread, patients who suffered from recurrent anterior glenohumeral instability were operated on through open procedures. Therefore, it is possible that HAGL lesions may have often been ignored. But now we can detect the HAGL lesion with attentive arthroscopic intra-articular examination. We routinely check the AIGHL while viewing from the anterior portal. Wolf et al.² described observing HAGL lesions in 9% of their cases of traumatic

References (7)

E.M. Wolf et al.
Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability
Arthroscopy
(1995)
P.A. Davidson et al.
Anterior-inferior (5 o’clock) portal for shoulder arthroscopy
Arthroscopy
(1995)
J.J.P. Warner et al.
Combined Bankart and HAGL lesion associated with anterior shoulder instability
Arthroscopy
(1997)

There are more references available in the full text version of this article.

Cited by (43)

Outcomes following arthroscopic repair of humeral avulsion of the glenohumeral ligament (HAGL) lesion: A systematic review
2023, Journal of Clinical Orthopaedics and Trauma
The purpose of this systematic review was to evaluate patient outcomes following arthroscopic surgical management for a humeral avulsion of the glenohumeral ligament (HAGL) lesion.
Based on PRISMA guidelines, two independent reviewers performed a literature search to isolate studies on arthroscopic HAGL repair. The functional outcomes, return to play (RTP), and recurrent instability from each study were extracted and analyzed.
Overall, 7 manuscripts were included with 49 patients. The patient population was 61.4% male with a mean age of 24.8 years (15–42 years), and 41.9 months of follow-up on average (12–104 months). The Rowe score was the most frequently reported outcome measure with a weighted mean of 89. In total, 81.2% of patients reported being able to RTP post-operatively, with 70.5% reported being able to play at an equal or higher level. There was 1 recurrent dislocation (2%).
The current study found successful clinical outcomes following the arthroscopic management of HAGL lesions. Recurrent dislocation requiring revision was rare, with high rates of return to play including those who could return to the same level of play. However, the paucity of evidence does not permit a statement of best-practice to be made.
The safety and efficacy of 2 anterior-inferior portals for arthroscopic repair of anterior humeral avulsion of the glenohumeral ligament: cadaveric comparison
2022, Journal of Shoulder and Elbow Surgery
Humeral avulsion of the glenohumeral ligament (HAGL) lesions are associated with shoulder instability. Arthroscopic repair of anterior HAGL lesions typically requires the placement of an anterior-inferior (5-o'clock) portal, with different variations of this portal described. The purpose of this study was to determine the efficacy of described anterior-inferior shoulder arthroscopy portals for arthroscopic anterior HAGL repair, as well as evaluate the safety of these portals with respect to the surrounding neurovascular structures. Additionally, we sought to evaluate the effect of arm adduction vs. standard abduction during anterior-inferior portal creation.
HAGL lesions were created and repaired using an all-arthroscopic technique in 12 cadaveric shoulders (matched pairs). Half of the repairs were performed using a standard 5-o'clock portal, whereas the other half of the matched pairs were repaired using a medialized 5-o'clock portal. Repairs were timed, and the number of anchor pullouts was recorded. The shoulders were subsequently dissected to measure the proximity of the portal to the cephalic vein, musculocutaneous nerve, axillary nerve, and lateral cord of the brachial plexus.
The average time for HAGL repair was 18.0 ± 4.6 minutes. Repair times using the medial 5-o'clock portal (19.0 ± 3.3 minutes) vs. standard 5-o'clock portal (16.2 ± 5.8 minutes) were not significantly different (P = .37). From abduction to adduction, the cephalic vein distance from the standard 5-o'clock portal increased from 4.1 ± 4.7 mm to 5.2 ± 5.4 mm (P = .02); musculocutaneous nerve distance, from 14.4 ± 9.8 mm to 18.1 ± 10.8 mm (P = .005); axillary nerve distance, from 19.2 ± 9.6 mm to 19.8 ± 9.2 mm (P = .12); and distance of the lateral cord of the brachial plexus, 13.8 ± 6.6 mm to 16.7 ± 6.4 mm (P = .0006).
The arm abduction angle significantly affects the distance of the cephalic vein, musculocutaneous nerve, and lateral cord of the brachial plexus from the anterior-inferior portal, regardless of which portal—standard or medial 5-o'clock portal—is chosen. This portal should be created with the arm in adduction. Arthroscopic HAGL repair can be performed safely, although accurate anchor placement remains a challenge. There was no advantage to use of the medial 5-o'clock portal. With a curved guide, the standard 5-o'clock portal allows for reproducible anchor placement and is recommended for anterior HAGL repairs.
Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament for Anterior Shoulder Instability
2021, Arthroscopy Techniques
Humeral avulsion of the glenohumeral ligament (HAGL) is a rare cause of anterior shoulder instability. Recurrent instability and anterior shoulder pain could be caused by an unrepaired HAGL; therefore, making the diagnosis is crucial. Only a few articles describe arthroscopic HAGL repair. This uncommon technique uses lateral decubitus arthroscopy and standard Bankart instrumentation. Different methods used to facilitate visualization of the working space as well as anchor placements are described.
Incidence of Axillary Nerve Injury After Arthroscopic Shoulder Stabilization
2020, Arthroscopy - Journal of Arthroscopic and Related Surgery
To investigate the incidence of axillary nerve palsy after arthroscopic shoulder stabilization and to measure the distance between the nerve and capsule in shoulders with a capsular lesion.
This retrospective study included 2,027 shoulders (1,909 patients; 1,433 male and 476 female patients; mean age, 32 years [age range, 13-81 years]) subjected to arthroscopic soft-tissue stabilization for recurrent shoulder instability from 2005 to 2017. The exclusion criteria were bone grafting or transfer and preoperative axillary nerve symptoms. We retrospectively reviewed patient records and investigated the incidence and clinical features of axillary nerve palsy. We measured the closest distance between the axillary nerve and capsule on preoperative magnetic resonance images.
Postoperative axillary nerve palsy occurred in 4 shoulders (0.2% of all arthroscopic stabilizations). Capsular repair was performed in 2 shoulders (1.2% of 160 capsular repairs); humeral avulsion of the glenohumeral ligament (HAGL) repair, 1 shoulder (2% of 47 HAGL repairs); and isolated Bankart repair, 1 shoulder (0.05% of 1,941 Bankart repairs). The closest distance between the nerve and capsule was 3.4 ± 3.2 mm in shoulders with capsular or HAGL lesions and less than 1 mm in the 3 shoulders with palsy. The common symptoms in axillary nerve palsy cases were shoulder discomfort, delayed recovery of range of motion, and deltoid weakness and atrophy. A definitive diagnosis was made with electromyography in all cases. Nerve injury by a suture was confirmed during revision surgery in 3 shoulders subjected to capsular or HAGL repair during the initial operation. The palsy was transient and fully recovered in 1 shoulder with isolated Bankart repair.
The incidence of axillary nerve palsy after arthroscopic soft-tissue shoulder stabilization was low but higher in shoulders subjected to capsular or HAGL repair. We should always consider the possibility of axillary nerve palsy in shoulders that require capsular or HAGL repair.
Level IV, therapeutic case series.
Mini-open Repair of the Floating Anterior Inferior Glenohumeral Ligament: Combined Treatment of Bankart and Humeral Avulsion of the Glenohumeral Ligament Lesions
2018, Arthroscopy Techniques
Citation Excerpt :
For isolated HAGL lesions, both open and all-arthroscopic techniques have resulted in promising patient outcomes; however, these comparisons are limited to small case series and case studies.10,15,18,24 In 4 studies reporting the outcomes of 13 patients in total undergoing concomitant treatment of both lesions, 100% of patients returned to full activity without any evidence of recurrent instability or symptoms regardless of technique at a minimum of 12 months' follow-up.4,11,14-16 Potential shortcomings include stiffness and decreased range of external rotation.17,25
Anterior shoulder instability often results from avulsion of the anterior inferior glenohumeral ligament (aIGHL) off its insertion on the glenoid, yielding a Bankart lesion. Although less common, avulsion of the ligament attachment to the humerus results in a humeral avulsion of the glenohumeral ligament (HAGL) lesion. Combined Bankart and HAGL lesions, also termed the “floating aIGHL,” create a complex pathology that is not detailed significantly in the literature. We believe a mini-open approach is a viable and reproducible procedure for treatment because it allows for protection of the axillary nerve and other neurovascular structures while providing optimal exposure to both the humeral insertion site of the distal aIGHL and the Bankart lesion, ensuring anatomic restoration. The purpose of this Technical Note is to describe our preferred technique to surgically treat the floating aIGHL, consisting of an anterior HAGL and concomitant Bankart lesion repair through a mini-open approach.
Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament Lesion
2017, Arthroscopy Techniques
Humeral avulsion of the glenohumeral ligament (HAGL) is a lesion associated with anterior shoulder instability. Although uncommon, HAGL lesions are a significant contributor to shoulder pain and dysfunction and, if missed, can even be a cause of failed Bankart repair. HAGL lesions should generally be repaired surgically; however, given their low prevalence, there is no consensus on the optimal surgical approach. The purpose of this Technical Note is to describe our preferred surgical technique for the fixation of an HAGL lesion using an all-arthroscopic approach and a knotless suture anchor construct.

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: Cite this article as: Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2005;21:632.e1-632.e6 [doi:10.1016/j.arthro.2005.02.004].

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Case reportArthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion

Abstract

Section snippets

Case 1

Discussion

Arthroscopy

Arthroscopy

Arthroscopy

Case report
Arthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion