Humeral Avulsion Of Glenohumeral Ligament Research Articles

Clinical Outcomes and Return to Sports After Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament: A Meta-Analysis.

This study aimed to evaluatethe clinical outcomes and the frequency of return to sport after the arthroscopic repair of a humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion.Web of Science, Scopus, and Medline via PubMed and OVID were searched to identify the relevant citations. Screening and data extraction were performed independently. The Comprehensive Meta-Analysis software was used for all statistical analyses (CMA; USA version 3.3.070). A total of 18 articles (n = 832 patients; of whom, 379 patients had HAGL) were included. The fixed-effect estimate showed that the percentage of patients who returned to their sports was 89.1% (95% CI = 85% to 92.2%). The mean duration to return was estimated to be 6.65 months (95% CI = 5.10 to 8.20). Postoperatively, the meanWestern Ontario Shoulder Instability Index (WOSI), Oxford Shoulder Instability Score (OSIS), and Subjective Shoulder Value (SSV) scores were 88.60 (95% CI = 86.18 to 90.98), 15.02 (95% CI = 7.42 to 22.63), and 86.90 (95% CI = 80.79 to 93.00), respectively. The Rowe score improved significantly postoperatively with a mean difference (MD) of54.47 (95% CI = 39.28 to 69.66). The University of California - Los Angeles (UCLA) shoulder score increased significantly post-arthroscopic repair (MD = 10.91, 95% CI = 10.07 to 11.76). The current evidence suggests that arthroscopic repair of HAGL lesions is associated with a high percentage of return to sports and improved Rowe score, WOSI, UCLA shoulder score, OSIS scale, and SSV score. The quality of the included studies is moderate; however, these findings are promising and call for further multicenter, prospective studies.

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Critical Analysis Review.

Posterior humeral avulsions of the inferior glenohumeral ligament represent an increasingly recognized but likely underdiagnosed source of posterior shoulder instability and pain. Injuries are commonly reported in athletic individuals who have sustained injury by either traumatic or atraumatic mechanisms; the ligament is most susceptible to injury with the shoulder in flexion, adduction, and internal rotation. Posterior humeral avulsions of the glenohumeral ligament often occur in the setting of concurrent injuries to the posterior or inferior labrum. Diagnosis is often challenging due to nonspecific symptoms and physical examination findings; a magnetic resonance arthrogram generally is utilized to identify avulsion from the humeral attachment; however, a definitive diagnosis is often made at the time of arthroscopic evaluation. In patients with persistent discomfort and limitations following nonoperative management, operative fixation, primarily utilizing arthroscopic techniques, can be performed to restore motion and glenohumeral stability.

Paper 73: Patient Factors Associated with Humeral Avulsion of Glenohumeral Ligament (HAGL) Lesions: An Analysis of the MOON Shoulder Instability Cohort

Objectives:We sought to identify pre-operative physical exam findings, imaging findings, and surgical management trends associated with humeral avulsion of the glenohumeral ligament (HAGL) lesions by utilizing a large, multicenter orthopedic outcomes database.Methods:Patients with anterior shoulder instability who underwent surgical management from 2012 to 2020 at 11 orthopedic centers were prospectively enrolled. Patients with a HAGL lesion identified intra-operatively were compared to patients without a HAGL lesion; patients with isolated posterior HAGL lesions were excluded from data analysis. Pre-operative patient demographics, physical examination, and imaging findings were collected; intra-operative findings and surgical procedures performed were also recorded. Student’s T-test, Fisher Exact test and Chi Square test were used to compare groups and determine risk factors. Logistic regression analysis was performed to determine independent risk factors associated with need for an open stabilization procedure, and odds ratio (OR) and 95% confidence interval (95% CI) were calculated. Significance was set at p<0.05.Results:From 2012 to 2020, 22 HAGL lesions were identified in 1002 patients (2.2%). Baseline demographics, including age, gender, BMI, and number of lifetime shoulder dislocations, were similar between the HAGL and non-HAGL groups. As compared to non-HAGL patients, HAGL patients were less likely to have a Hill Sachs lesion (51.8% vs. 27.3%, p=0.02) or an anterior labral tear (81.7% vs. 63.6%, p=0.03) on pre-operative MRI. On pre-operative physical examination, HAGL patients demonstrated increased external rotation when their affected arm was positioned in 90° of abduction as compared to non-HAGL patients (90° vs. 85°, p=0.01). The most common procedure performed amongst all patients was an arthroscopic Bankart repair (45.5% of the HAGL patients and 78.9% of the non-HAGL group); however, HAGL patients were more likely than non-HAGL patients to undergo an open stabilization procedure (68.2% vs. 10.7%, p<0.001) and less likely to undergo an arthroscopic stabilization procedure (72.7% vs. 94.7%, p<0.001). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization procedure (OR 31.3, 95% CI 11.0 – 88.9, p<0.001).Conclusions:Patients with anterior shoulder instability and a HAGL lesion are less likely to exhibit classic pre-operative imaging findings associated with anterior shoulder instability, such as Hill Sachs lesions or anterior labral pathology. Increased external rotation at 90° of shoulder abduction on pre-operative physical exam may suggest presence of a HAGL lesion. Other demographic factors, including age, gender, BMI, and number of lifetime shoulder dislocations, do not differ significantly between patients with and without HAGL lesions. Patients with HAGL lesions undergo open stabilization procedures more frequently than patients without HAGL lesions.

Progress on arthroscopic surgery for recurrent anterior shoulder dislocation

The surgical treatment of recurrent anterior shoulder dislocation is a difficult problem in the field of sports injury medicine. The main reason focus on dynamic and osseous constraints of shoulder joint could not recover well. At present, arthroscopic surgery is used at home and abroad, and could receive statisfied postoperative effect, but the choice of specific surgical methods is still controversial. According to presence and size of glenoid and humeral skull defects, different treatments should be selected in clinic. The author recommends that no articular glenoid defect or glenoid defect <20%, choose Bankart surgery;articular glenoid defect <20% with Hill-Sachs bone defect <40%, choose Bankart surgery combined with remplissage surgery or ASA surgery;Glenoid defect 20% to 25%, choose "Sling";Glenoid defect 25% to 40%, choose Bristow-Latarjet; Glenoid or Hill-Sachs bone defect>40% or Bristow-Latarjet if the surgical repair fails, bone grafting is used. In addition, if (humeral avulsion of glenohumeral ligaments, HAGL) injury existed, HAGL injury repair should be used. In addition to considering the important factor of bone defects, it is necessary to combine patient's age, exercise level and surgeon's technique to comprehensively select the bestsurgical method.

Comparative study between open and arthroscopic surgical techniques in the management of recurrent anterior instability of the shoulder

Background: Present study was done to compare the effectiveness i.e. range of motion and incidence of failure rates, recurrence and pain of arthroscopic repair versus open surgical techniques for the management of recurrent anterior shoulder instability. Materials and Methods: Institution based open-label, comparative clinical study was done at Medical College and Hospital, Kolkata between March 2016 to August 2017 (1.5 years). Based on the result of a similar previous study, a sample size of 15 in each group was calculated. Therefore, 15 cases of anterior shoulder instability treated by arthroscopic method and 15 cases treated by open surgery have been selected for study. Inclusion criteria were patient with soft tissue Bankart’s lesion, bony Bankart’s lesion, humeral avulsion of glenohumeral ligament (HAGL), anterior labral posterior sleeve avulsion (ALPSA), glenoidlabrum and articular disruption and capsular stretch and injury. Study tools were used like Modified Rowe score, ASES (American Shoulder and Elbow Society) score and Goniometer. Operative techniques were used like arthroscopic capsulolabral repair and latarjet procedure. Results: About 14 (93.3%) patients were negative in bony apprehension test in arthroscopic technique. Approximately 15 (93.8%) patients were positive in bony apprehension test in Open technique. Association between bony apprehension test in two groups was not statistically significant (p difference was found between according to CT scan report in two groups (p=0.30910). Mean Rowe pain was significantly higher according in arthroscopic technique compare to open technique at 6W and 9W follow-up period. Mean Rowe stability was significantly higher according in arthroscopic technique compare to open technique at 6W and 9W follow-up period. Conclusion: Both arthroscopic and open surgical methods are utilized for management of anterior glenohumeral instability. The use of arthroscopy has increased significantly in today’s practice an

Arthroscopic Latarjet: Tips for Success

The Latarjet procedure remains the most favored technique in dealing with patients with recurrent shoulder instability, instability secondary to bony Bankart lesions, off-track lesions, bipolar lesions and in patients with Humeral avulsion of glenohumeral ligament (HAGL lesions). Traditionally this procedure has been performed as an open procedure; however, the Arthroscopic Latarjet procedure has been described with similar outcomes to that of open technique. This article describes our preferred technique for the Arthroscopic Latarjet procedure.

Arthroscopic treatment of anterior shoulder instability associated with a HAGL lesion—a case series

Restoration of shoulder stability after humeral avulsion of glenohumeral ligament (HAGL) lesions can be achieved with arthroscopy, yet limited evidence exists on its benefit. We evaluated objective and subjective outcomes after arthroscopic refixation of a HAGL lesion. Between 2009 and 2012, 8 patients were treated arthroscopically for anterior shoulder instability associated with a HAGL lesion and invited for a follow-up examination. Radiographic assessment of joint centering and osteoarthritis, clinical assessment including Constant and Rowe scores, and complications as well as functional outcomes using the Western Ontario Shoulder Instability Index, Subjective Shoulder Value, and Simple Shoulder Test were documented. Six patients were postoperatively examined at a median time of 29 months (range, 12-38). Four patients had up to 6 previous luxation events. Two patients had a concomitant labral lesion, and another 2 had an associated rotator cuff tear. Positive preoperative apprehension and relocation test results for 5 patients were negative at follow-up. No neurologic lesion was noted both before and after surgery. Shoulder motion did not improve significantly; lower internal and external rotation relative to the contralateral shoulder was reported. The Rowe score improved significantly from baseline (median score change, 65 points; P = .027), with 2 and 4 patients rating "good" and "excellent" at follow-up, respectively. Final median Constant score, Western Ontario Shoulder Instability Index, Subjective Shoulder Value, and Simple Shoulder Test scores were 77.3 points, 91.0 points, 90%, and 87.5 points, respectively. Arthroscopic stabilization of a HAGL lesion is a safe, feasible, and reproducible technique. In our patient cohort, good shoulder stability could be achieved with high patient satisfaction.

Humeral avulsion of glenohumeral ligaments – Detection on magnetic resonance arthrography

BackgroundHumeral avulsion of the glenohumeral ligaments (HAGL) is an important cause of shoulder instability, with magnetic resonance arthrography (MRA) routinely being used for diagnosis. Our aim was to compare the diagnostic value of MRA to shoulder arthroscopy for the detection of HAGL lesions and to calculate its prevalence. MethodsPatients who underwent a shoulder arthroscopy with a single surgeon and pre-operative MRA between February 2011 and March 2012 for instability were identified. MRAs were reported by experienced musculoskeletal radiologists and compared to arthroscopy findings for the presence of HAGL lesions. Sensitivity, specificity, positive and negative predictive values, prevalence and positive and negative likelihood ratios were calculated. ResultsA total of 194 patients were identified with a HAGL lesion prevalence of 4.64% on arthroscopy. The sensitivity of MRA in detecting HAGL was 0.44 (CI: 0.14–0.79) and the specificity was 0.97 (CI: 0.94–0.99). The positive predictive value was 0.44 (CI: 0.14–0.79) and negative predictive value was 0.97 (CI: 0.94–0.99). The positive likelihood ratio was 16.44 (CI: 5.30–51.00) and negative likelihood ratio was 0.57 (CI: 0.32–1.02). ConclusionsMRA appears to be specific and accurate in excluding HAGL lesions, but not sensitive. HAGLs were associated with numerous other injuries such as bankart, SLAP and Hill–Sach lesions. The prevalence of 4.64% is comparable to previous studies.

Arthroscopic Repair of a Posterior Bony Humeral Avulsion of the Glenohumeral Ligament With Associated Teres Minor Avulsion

Humeral avulsion of the inferior glenohumeral ligament (HAGL) has recently gained more recognition as a cause of shoulder instability. Posterior HAGL lesions, being much more infrequent than anterior disruptions, have only recently been documented as a notable cause of posterior instability. We detail the treatment of a previously unreported case of a posterior HAGL variant lesion consisting of a bony avulsion with involvement of the teres minor tendon. Arthroscopic fixation was facilitated by use of a “sheathless” arthroscopic approach with a 70° arthroscope and suture anchor.

Paper 31: Arthroscopic Management of First-time Traumatic Anterior Shoulder Dislocation in Young Athletes: Evaluation and Results in 100 Cases with 7.4 years Follow-up

In the literature several publications show the advantages of the early arthroscopic stabilization after the first episode of traumatic shoulder dislocation. Nevertheless it is still considered by some authors a controversial topic. The purpose of this paper is a retrospective evaluation of our first 100 cases treated with arthroscopic stabilization. Between September 1989 and May 2005 100 arthroscopic stabilization of first time dislocation were performed in athletes. Mean age at surgery moment was 22 years. 78% of the patients were rugby players. Until October 1995 we used the Transglenoid suture technique in 23 cases and the others 77 cases were stabilized with Suture Anchor technique. The mean follow-up was 7.4 years (range: 3-19 years). Capsular tear with complete labrum detachment (type III lesion) was the most frequent surgical finding. Minor Bony Bankart lesions (<25%) were found in 19 cases. 75 cases (75%) of osteochondral Hill-Sachs lesions and 15 cases (15%) of bone HillSachs lesions were identified. We treated 2 cases of Humeral Avulsion of Glenohumeral ligament (HAGL) with arhtoscopic and mini open technique. According to the Rowe scale we obtained excellent and good results for 96% (74 cases) of the patients treated with the Suture Anchor Technique and in 87% (20 cases) of the patients treated with the Transglenoid technique. Return to sport was allowed after the 4th month, being at pre-injury level for all cases. The average time was 5.3 months (4-7). Many studies have shown a high percentage of redislocation after non-surgical treatment. Younger patients and practicing contact sports, over head sports or sports of high speed (snow skiing, motocross) increase this risk.

Surgical treatment of significant glenoid bone defects and associated humeral avulsions of glenohumeral ligament (HAGL) lesions in anterior shoulder instability

Combined occurrence of humeral avulsion of glenohumeral ligament (HAGL) lesion and a significant glenoid bone defect is an unusual and previously undescribed association in traumatic anterior shoulder instability. The purpose of this study was (1) to report a retrospective case series of seven anterior bony instability patients who were diagnosed with this unusual association and (2) to evaluate the results of a modified Latarjet procedure and simultaneous HAGL repair using a new subscapularis-sparing approach. A retrospective review of the records of 64 anterior shoulder instability patients who underwent bony stabilization surgery was performed, and patients who underwent a combined reconstruction for significant glenohumeral bone defects (glenoid loss >20 %) and an associated HAGL lesion were identified. Pre- and postoperative follow-up clinical parameters and functional scores were documented (Oxford shoulder instability score [OSIS], Western Ontario shoulder instability index [WOSI]), Rowe score). Radiological assessment included measurement of the glenoid bone defect (CT scan) and evaluation of soft tissue lesions (MR arthrogram). Radiological and arthroscopic evaluation confirmed the combined lesion complex in 7 (11 %) patients. Follow-up evaluation (mean 20.6 months) suggested an excellent outcome (Rowe score: median 95, range 95-100); a statistically significant improvement was seen in the follow-up OSIS (median 12, range 12-14, p = 0.018) and WOSI score (median 28, range 17-102, p = 0.018) as compared to the preoperative score (median OSIS 50, range 32-53; median WOSI 1,084, range 919-1,195). Clinical tests for subscapularis function revealed a functional subscapularis muscle; no significant differences were detected in pre- versus postoperative internal rotation strength and in the operated versus normal contralateral shoulder (ns). The dual-window subscapularis-sparing approach provided adequate exposure for combined reconstruction of the humeral and glenoid lesions, and no complications were encountered. Significant glenoid defects are associated with HAGL lesions in approximately 1/10th of patients with bony instability. Combined reconstruction of these lesions via a subscapularis-sparing approach results in an excellent outcome and significant improvement in functional scores at a medium-term follow-up. Therapeutic study, Level IV.

Humeral Avulsion of Glenohumeral Ligaments

Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. HAGL lesions are the result of acute traumatic glenohumeral subluxation or dislocation. Anterior avulsion of the inferior glenohumeral ligament from the humeral neck is the more common lesion; however, posterior lesions are seen as well. Careful history and physical examination are critical in the diagnosis of HAGL lesions. MRI is the best imaging study for diagnosing these lesions. Injection of intra-articular contrast dye aids in visualization. Most HAGL lesions cause recurrent instability and require surgical repair. Arthroscopic repair with the use of accessory portals has yielded promising results. Excellent results have been achieved with open surgical management using a subscapularis incision. Mini-open techniques involve limited incision in the lower one half of the subscapularis.

Identification and management of “floating” posterior inferior glenohumeral ligament lesions

Recurrent posterior glenohumeral instability, although a less common clinical entity than anterior instability, must be recognized and appropriately treated for a successful outcome. Pathologic findings that may need to be addressed include posterior Bankart lesions, humeral avulsion of the posterior inferior glenohumeral ligament (PIGHL), intrasubstance ligament attenuation, and combined lesions. In this review, we present 2 patients with the same pathoanatomic findings of recurrent posterior shoulder instability secondary to posterior humeral avulsion of the glenohumeral ligament with an associated posterior Bankart lesion. This combination of pathology is referred to as a "floating PIGHL" lesion. We review both patient's preoperative clinical findings and imaging studies and detail the necessary steps for a successful repair.

Posterior Humeral Avulsion of the Glenohumeral Ligament (Posterior HAGL) Lesions: Correlation Between MRI, Clinical, and Arthroscopic Findings (SS-07)

Posterior Humeral Avulsion of the Glenohumeral Ligament (Posterior HAGL) Lesions: Correlation Between MRI, Clinical, and Arthroscopic Findings (SS-07)

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.