Original Article
Posterior Humeral Avulsion of the Glenohumeral Ligament: A Clinical Review of 9 Cases

https://doi.org/10.1016/j.arthro.2007.02.006Get rights and content

Purpose: The purpose of this article is to report the characteristic conditions in which a posterior humeral avulsion of the glenohumeral ligament (PHAGL) lesion occurs, defining also the different possibility of association with other intra-articular shoulder pathologies. Methods: We identified in our database 16 consecutive patients with a PHAGL lesion who underwent surgical treatment. Six of these patients had previous failed anterior shoulder stabilization, and 1 patient failed thermal shrinkage for a multidirectional instability and were not included in this study. The 9 remaining patients were enrolled in this study. All 9 patients developed a PHAGL lesion after a sports-related trauma. Clinical symptoms reported by the patients and clinical examination data were variable depending also on associated intra-articular shoulder pathology. The diagnosis of a PHAGL lesion was not made in any of the cases preoperatively. All 9 patients underwent arthroscopic repair of the PHAGL lesion. During the surgical procedure, any additional intra-articular shoulder lesion was treated. Patients were evaluated preoperatively and postoperatively for pain and range of motion using standardized shoulder scales including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) rating score, and Constant score. Results: Arthroscopic evaluation revealed that PHAGL was seen as an isolated lesion in only 3 patients. At a mean follow-up of 34.2 months, all patients were pain free and reported a complete resumption of sports and daily living activities. Two patients had a limitation of internal rotation to the T11 level. The UCLA score improved from 16.3 to 34.7, the Constant score improved from 52.3 to 80.2, and the SST score improved from 7.9 to 4.2. Conclusions: The PHAGL lesion is challenging to diagnose clinically. It can be the cause of posterior instability or a component of the spectrum of shoulder instability and associated with anterior labral or capsular pathology. Because physical examination can be misleading, a gadolinium-magnetic resonance arthrogram and comprehensive arthroscopic evaluation visualizing from the anterior and posterior portals can confirm the diagnosis. We repaired the PHAGL lesions arthroscopically along with all associated shoulder abnormalities resulting in a good outcome. Level of Evidence: Level IV, therapeutic cases series.

Section snippets

Methods

Between January 2001 and December 2003, 16 consecutive patients underwent an arthroscopic repair of a PHAGL lesion. In 7 patients, the PHAGL lesion was found after a previous shoulder surgery, and they were excluded from this study. Six of these patients underwent previous anterior shoulder stabilization, open in 4 and arthroscopic in the other 2 cases. One patient underwent thermal capsule shrinkage to treat multidirectional shoulder instability.

The remaining 9 patients were retrospectively

Associated Abnormalities

In 3 cases, the PHAGL lesion was associated with a posterior Bankart lesion that was repaired during the same surgical procedure. In 1 case, a SLAP type III lesion was treated with debridement of the bucket-handle labral tear and repair of the SLAP lesion. An anterior Bankart lesion was found in 1 case and an ALPSA lesion was found in another; both of these lesions were repaired during the same surgical procedure. Only in the remaining 3 cases (33%) was a PHAGL present as an isolated lesion.

Discussion

The PHAGL lesion has recently been recognized as a cause of shoulder pain, discomfort, and posterior instability.8, 9, 10 The IGHL plays a key role in anterior shoulder instability. The avulsions of this ligament and of the labrum (Bankart lesion) from the glenoid have been established as primary lesions in anterior inferior instability in both clinical and cadaveric studies.12, 13 Bankart lesions are thought to be responsible for anterior shoulder instability in 45% to 100% of cases.

Conclusions

This study suggests that clinical diagnosis of PHAGL lesions is very difficult because specific findings are lacking, and symptoms and signs can be variable because of associated lesions. It can be an isolated cause of posterior instability but also be a part of the spectrum of shoulder instability. Proper recognition of the capsular avulsion is essential and, because physical examination can be misleading, a gad-MRI or an arthroscopic examination can help with the diagnosis. We repaired the

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The authors report no conflict of interest.

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