Humeral Avulsion Of The Glenohumeral Ligament Lesions Research Articles

Factors Associated With Humeral Avulsion of Glenohumeral Ligament Lesions in Patients With Anterior Shoulder Instability: An Analysis of the MOON Shoulder Instability Cohort.

Humeral avulsion of the glenohumeral ligament (HAGL) lesions are an uncommon cause of anterior glenohumeral instability and may occur in isolation or combination with other pathologies. As HAGL lesions are difficult to detect via magnetic resonance imaging (MRI) and arthroscopy, they can remain unrecognized and result in continued glenohumeral instability. To compare patients with anterior shoulder instability from a large multicenter cohort with and without a diagnosis of a HAGL lesion and identify preoperative physical examination findings, patient-reported outcomes, imaging findings, and surgical management trends associated with HAGL lesions. Cross-sectional study; Level of evidence, 3. Patients with anterior glenohumeral instability who underwent surgical management between 2012 and 2020 at 11 orthopaedic centers were enrolled. Patients with HAGL lesions identified intraoperatively were compared with patients without HAGL lesions. Preoperative characteristics, physical examinations, imaging findings, intraoperative findings, and surgical procedures were collected. The Student t test, Kruskal-Wallis H test, Fisher exact test, and chi-square test were used to compare groups. A total of 21 HAGL lesions were identified in 915 (2.3%) patients; approximately one-third (28.6%) of all lesions were visualized intraoperatively but not identified on preoperative MRI. Baseline characteristics did not differ between study cohorts. Compared with non-HAGL patients, HAGL patients were less likely to have a Hill-Sachs lesion (54.7% vs 28.6%; P = .03) or an anterior labral tear (87.2% vs 66.7%; P = .01) on preoperative MRI and demonstrated increased external rotation when their affected arm was positioned at 90° of abduction (85° vs 90°; P = .03). Additionally, HAGL lesions were independently associated with an increased risk of undergoing an open stabilization surgery (odds ratio, 74.6 [95% CI, 25.2-221.1]; P < .001). Approximately one-third of HAGL lesions were missed on preoperative MRI. HAGL patients were less likely to exhibit preoperative imaging findings associated with anterior shoulder instability, such as Hill-Sachs lesions or anterior labral pathology. These patients underwent open procedures more frequently than patients without HAGL lesions.

Outcomes following arthroscopic repair of humeral avulsion of the glenohumeral ligament (HAGL) lesion: A systematic review

PurposeThe purpose of this systematic review was to evaluate patient outcomes following arthroscopic surgical management for a humeral avulsion of the glenohumeral ligament (HAGL) lesion. MethodsBased 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. ResultsOverall, 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%). ConclusionThe 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.

A Bibliometric Analysis of the Most Cited Research on Humeral Avulsions of the Glenohumeral Ligament: A Paucity of High-Level Evidence

To identify the 25 most-cited articles on humeral avulsion of the glenohumeral ligament (HAGL) lesions and characterize them based on number of citations, citation density, source journal, year of publication, geographic origin, article type, and level of evidence. The Science Citation Index Expanded database was queried for all possible publications regarding HAGL lesions. The 25 most-cited articles from 1976 to 2021 relevant to the topic were selected for further analysis. Articles were characterized based on the number of citations, citation density, year of publication, source journal, country of origin, article type, article subtype, and level of evidence. The number of citations for individual articles ranged from 21 to 182 (mean ± standard deviation: 44.72 ± 36.87). Ten countries contributed to the 25 most cited articles, with 14 of the 25 (56%) articles published in the United States. Furthermore, the top 25 cited articles were published in 9 journals, with the majority in Arthroscopy-The Journal of Arthroscopic and Related Surgery (n= 15, 60%). There were 15 (60%) articles classified as "Clinical," 9 (36%) as "Review/Expert Opinion," and 1 (4%) as "Basic Science." All clinical studies met the standard for level IV evidence. This bibliometric analysis provides a list of the 25 most cited articles related to HAGL lesions, providing a reference of impactful articles for medical educators. The lack of high level of evidence "Clinical" studies demonstrates that higher-quality research is needed to establish guidelines for the treatment and management of HAGL lesions. A list of the 25 most-cited articles regarding recurrent glenohumeral instability can serve as a comprehensive reference for practitioners, educators, researchers, and orthopaedic trainees.

The safety and efficacy of 2 anterior-inferior portals for arthroscopic repair of anterior humeral avulsion of the glenohumeral ligament: cadaveric comparison.

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.

Long-term Outcomes After the Open Latarjet Procedure for the Surgical Management of Humeral Avulsion of the Glenohumeral Ligament Lesions

Background: Recurrent anterior glenohumeral instability caused by a humeral avulsion of the glenohumeral ligament (HAGL) lesion has been studied, but very limited long-term evidence is available. Purpose: To retrospectively review patients with a HAGL lesion who underwent an open Latarjet procedure for recurrent anterior shoulder instability. Study Design: Case series; Level of evidence, 4. Methods: A total of 16 patients with complete clinical and radiological data were available for a review. Clinical outcomes were assessed by range of motion, apprehension testing, the visual analog scale for pain, the Walch-Duplay score, the Rowe score, the Constant-Murley score, the Subjective Shoulder Value, and return to sports. Radiographs were reviewed for osteoarthritis and complications. Results: The median age of patients at the time of surgery was 28 years (range, 18-42 years). All patients were male with no hyperlaxity. The median follow-up time was 10 years (range, 2.8-15 years). Postoperative range of motion showed recovered forward elevation (median, 175°), external rotation (median, 62°), and internal rotation (median, 9 points). Overall, 87% returned to sports, with 68% to the same level and 93% satisfied or very satisfied. Median clinical outcomes were the following: visual analog scale score, 1 (range, 0-2); Walch-Duplay score, 86 (range, 75-100); Rowe score, 95 (range, 90-100); Constant-Murley score, 77 (range, 74-79); and Subjective Shoulder Value, 88% (range, 80%-95%). There were no recurrent dislocations or subluxations. One patient described mild long-term pain, and 1 patient had persistent stiffness. Other complications included 12% with subjective apprehension, 1 patient with a wound infection, and another patient with delayed bone graft union. Additionally, 56% of cases had mild postoperative arthritis at the final follow-up. There were no reoperations. Conclusion: The open Latarjet procedure provided good outcomes with acceptable complication rates in the long term for patients with HAGL lesions. It is an effective treatment option and a safe alternative to arthroscopic or open HAGL repair.

Pathology and clinical outcomes after arthroscopic stabilization in shoulders with traumatic anterior instability older than 40 years: Comparison between shoulders with the first dislocation before or after 40 years (241)

Objectives:Traumatic anterior shoulder instability is common in young population but sometimes seen in middle-aged and elderly patients. The higher incidence of rotator cuff tears has been reported in middle-aged and elderly patients with anterior shoulder instability than young population. We, however, had an impression through clinical experiences that the pathology, including the incidence of rotator cuff tears, might be different by age at the first dislocation. There have been few articles that reported the pathology of shoulders with anterior shoulder instability in older population. The purpose of this study was to investigate pathology and clinical outcomes in patients who underwent arthroscopic stabilization at 40 years or older and to compare them between shoulders with the first dislocation before or after 40 years.Methods:The inclusion criteria of this study were as follows: 1) shoulders that underwent arthroscopic stabilization between October 2005 and September 2017, 2) traumatic anterior shoulder instability, and 3) 40 year old or older. The exclusion criterion was < 2-year follow-up. Glenoid morphology was evaluated with preoperative 3-dimensional computed tomography, and the size of glenoid bone defect was measured. Intraoperative findings, including rotator cuff tear, Bankart lesion, and humeral avulsion of the glenohumeral ligament (HAGL) lesion, and surgical procedures were investigated with surgical records. Range of motion was assessed preoperatively and at the final follow-up. Postoperative re-dislocation was also investigated. The subjects were divided into two groups according to the age at the first dislocation: Group 1, < 40 years; Group 2, 40 years or older. The findings and outcomes were compared between the two groups. The unpaired t-test was used to compare continuous data between the groups, and the paired t-test was used for pre- and postoperative comparison of continuous data. The chi-square test was used for categorical variables. The level of significance was set at p < 0.05.Results:Between October 2005 and September 2017, 198 shoulders (198 patients) underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability at 40 years or older. Fifty-six shoulders were excluded due to < 2-year follow-up, and 142 shoulders (142 patients) were included in this study. They consisted of 69 males and 73 females with a mean age of 51 (range, 40-78) years. The mean follow-up was 4 (range, 2-12) years. Group 1 included 105 shoulders (52 males and 53 females] with a mean age of 48 (range, 40-77) years. Group 2 included 37 shoulders (17 male and 20 females) with a mean age of 59 (range, 40-78) years. Group 1 had a longer time from the first dislocation to surgery (P<.001) and larger number of dislocation (P<.001) than Group 2 (Table 1). Bony Bankart lesion was more frequently seen in Group 2 than Group 1 (P=.02), and bone defect was greater in Group 1 than Group 2 (P=.02). The incidence of Bankart lesion or HAGL lesion was not significantly different between the groups. There were 2 full-thickness (1 small and 1 medium) and 16 joint-side partial-thickness rotator cuff tears in Group 1, while 16 full-thickness (4 small, 4 medium, 5 large, and 3 massive) and 8 joint-side partial-thickness tears were found in Group 2. The difference in the incidence of rotator cuff tears was significant between the groups (P<.001).Arthroscopic Bankart repair (ABR) with or without augmentation was performed in 103 shoulders (98 %) in Group 1 and in 35 shoulders (95%) in Group 2 (Table 2). There were 2 isolated HAGL repairs (2 %) in Group 1 and 2 isolated rotator cuff repairs (6 %) in Group 2. Two shoulders (6%) in Group 2 experienced re-dislocation. Forward flexion showed significant improvement from 159 (range, 100-180) to 170 (range, 140-180) degrees in Group 1 and from 148 (range, 40-180) to 163 (range, 70-180) degrees in Group 2 (P<.001 for each). Postoperative forward flexion showed no significant difference between the groups. External rotation showed no postoperative changes in both groups, while Group 1 had significantly better pre- and postoperative external rotation than Group 2.Conclusions:This study demonstrated that the incidence of rotator cuff tears was much higher in shoulders with the first dislocation after 40 years compared to shoulders with the first dislocation before 40 years. Shoulders with the first dislocation before 40 years had larger glenoid bone loss, while 51% of shoulders with the first dislocation after 40 years retained bony fragments. The longer time from the initial injury to surgery might be associated with the larger glenoid bone loss and absorption of bone fragments. Both groups showed satisfactory outcomes with the low rate of complications.

Arthroscopic Repair of Humeral Avulsion of Glenohumeral Ligament Lesions: Outcomes at 2-Year Follow-up

Background:Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline.Purpose:To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions.Study Design:Case series; Level of evidence, 4.Methods:Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated.Results:There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions.Conclusion:HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament Lesion With Capsular Plication in the Lateral Decubitus Position

Humeral avulsion of the glenohumeral ligament (HAGL) lesions can lead to persistent shoulder instability. While rare, HAGL lesions may present as a concomitant injury following shoulder dislocation events. Traditionally, an open approach has been used to repair the inferior glenohumeral ligament and restore shoulder stability. Modern arthroscopic techniques and instrumentation have permitted a minimally invasive approach for treating HAGL lesions. While technically demanding, arthroscopic repair of HAGL lesions has demonstrated favorable outcomes with less soft-tissue disruption. The following Technical Note describes a safe and effective method for the arthroscopic repair of HAGL lesions. Our technique highlights the use of the lateral decubitus position, a 70° arthroscope, a curved anchor device, and a 90° SutureLasso device.

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

The Original Mini-Open Technique for Repair of Humeral Avulsion of the Glenohumeral Ligament

Anterior shoulder dislocations commonly occur in the young, athletic population. The mechanism of dislocation occurs when the shoulder is placed in an abducted, externally rotated position while a forceful anterior moment is applied to the humerus. This position, combined with the force applied, results in an anterior and inferiorly directed dislocation of the humeral head away from the glenoid. Due to the limited stretching capacity of the glenohumeral capsule and associated glenohumeral ligaments, the force of the traumatic dislocation overcomes the tensile strength of these ligaments, resulting in a tear. Although the injury more commonly results in an avulsion of the anteroinferior capsulolabral complex from the glenoid, called a Bankart lesion, other injuries have been described. The anterior inferior glenohumeral ligaments (aIGHLs), may be torn from their humeral attachment, which is referred to as a humeral avulsion of the glenohumeral ligament (HAGL). Although other structures may be injured, the topic of this surgical technique focuses on a mini-open approach for repair of the HAGL lesion.

Incidence of Axillary Nerve Injury After Arthroscopic Shoulder Stabilization

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 theinitial 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.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligaments Based on Location

Humeral avulsion of the glenohumeral ligament (HAGL) can be a difficult problem to treat. HAGL lesions can be particularly challenging to repair when approached arthroscopically. Because of the technical difficulties of HAGL repair, the surgeon must be strategic to successfully address these lesions arthroscopically. The purpose of this article is to propose a surgical technique that can be used in the arthroscopic treatment of HAGL lesions based on their location.

Arthroscopic repair of HAGL lesions yields good clinical results, but may not allow return to former level of sport.

There is a paucity of evidence regarding mid- to long-term clinical outcomes of arthroscopic repair of humeral avulsion of the glenohumeral ligament (HAGL). This study investigated clinical outcomes, return to sport and the frequency of associated shoulder lesions. Eighteen patients underwent arthroscopic repair of a HAGL lesion between 2008 and 2015. Clinical outcome was evaluated using the Rowe Score, the Quick DASH Score (Q-DASH), the Oxford Shoulder Instability Score (OSIS), the ASES Score and Range of Motion (ROM). Return to sports and associated shoulder lesions were documented. Sixteen patients agreed to complete the shoulder scores and nine patients were available for clinical examination. Median time to follow-up was 59 months (range 16-104). The median Rowe Score and Q-DASH Score improved significantly from 33 to 85 points and 61 to 7 points, respectively (p = 0.001, p = 0.001). The median OSIS and ASES Score were 20 and 91 points. External rotation was significantly reduced compared to the contralateral side (p = 0.011). One recurrent dislocation was reported. No neurologic or vascular complications after surgery were reported. Five out of the nine patients did not return to sports at the same level. Associated shoulder lesions were found in 89% of the cases. Arthroscopic repair of a HAGL lesion is a reliable method to restore shoulder stability with good clinical results. However, limitations in external rotation and a reduction in sporting ability may persist at 59 months follow-up. Concomitant lesions are common. Case series, level IV.

Axillary Nerve Position in Humeral Avulsions of the Glenohumeral Ligament.

Background:The axillary nerve is at risk during repair of a humeral avulsion of the glenohumeral ligament (HAGL).Purpose:To measure the distance between the axillary nerve and the free edge of a HAGL lesion on preoperative magnetic resonance imaging (MRI) and compare these findings to the actual intraoperative distance measured during open HAGL repair.Study Design:Case series; Level of evidence, 4.Methods:A total of 25 patients with anterior instability were diagnosed as having a HAGL lesion on MRI and proceeded to open repair. The proximity of the axillary nerve to the free edge of the HAGL lesion was measured intraoperatively at the 6-o’clock position relative to the glenoid face. Preoperative MRI was then used to measure the distance between the axillary nerve and the free edge of the HAGL lesion at the same position. Distances were compared using paired t tests and Bland-Altman analyses.Results:The axillary nerve lay, on average, 5.60 ± 2.51 mm from the free edge of the HAGL lesion at the 6-o’clock position on preoperative MRI, while the mean actual intraoperative distance during open HAGL repair was 4.84 ± 2.56 mm, although this difference was not significant (P = .154). In 52% (13/25) of patients, the actual intraoperative distance of the axillary nerve to the free edge of the HAGL lesion was overestimated by preoperative MRI. In 36% (9/25), this overestimation of distance was greater than 2 mm.Conclusion:The observed overestimations, although not significant in this study, suggest a smaller safety margin than might be expected and hence a substantially higher risk for potential damage. We recommend that shoulder surgeons exercise caution in placing capsular sutures in the lateral edge when contemplating arthroscopic repair of HAGL lesions, as the proximity of the nerve to the free edge of the HAGL tear is small enough to be injured by arthroscopic suture-passing instruments.

Mini-open Repair of the Floating Anterior Inferior Glenohumeral Ligament: Combined Treatment of Bankart and Humeral Avulsion of the Glenohumeral Ligament Lesions

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.

Humeral Avulsion of the Glenohumeral Ligament: Indications for Surgical Treatment and Outcomes-A Systematic Review.

Background:The inferior glenohumeral ligament, the most important static anterior stabilizer of the shoulder, becomes disrupted in humeral avulsion of the glenohumeral ligament (HAGL) lesions. Unfortunately, HAGL lesions commonly go unrecognized. A missed HAGL during an index operation to treat anterior shoulder instability may lead to persistent instability. Currently, there are no large studies describing the indications for surgical repair or the outcomes of patients with HAGL lesions.Purpose:To search the literature to identify surgical indications for the treatment of HAGL lesions and discuss reported outcomes.Study Design:Systematic review; Level of evidence, 4.Methods:Two reviewers completed a comprehensive literature search of 3 online databases (MEDLINE, EMBASE, and Cochrane Library) from inception until May 25, 2016, using the keywords “humeral avulsion of the glenohumeral ligament” or “HAGL” to generate a broad search. Systematic screening of eligible studies was undertaken in duplicate. ed data were organized in table format, with descriptive statistics presented.Results:After screening, 18 studies comprising 118 patients were found that described surgical intervention and outcomes for HAGL lesions. The mean patient was 22 years (range, 12-50 years), and 82% were male. Sports injuries represented 72% of all HAGL injuries. The main surgical indication was primary anterior instability, followed by pain and failed nonoperative management. Commonly associated injuries in patients with identified HAGL lesions included a Bankart lesion (15%), Hill-Sachs lesions (13%), and glenoid bone loss (7%). Reporting of outcome scores varied among the included studies. Meta-analysis was not possible, but all included studies reported significantly improved postoperative stability and function. There were no demonstrated differences in outcomes for patients treated with open versus arthroscopic surgical techniques. All but 2 patients undergoing operative management for HAGL lesions were able to return to sport at their previous levels; these included Olympians and professional athletes.Conclusion:HAGL lesions typically occur in younger male patients and are often associated with Bankart lesions and bone loss. Open and arthroscopic management techniques are both effective in preventing recurrent instability.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament Lesion

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.

Concomitant Reverse Hill-Sachs Lesion and Posterior Humeral Avulsion of the Glenohumeral Ligament: Treatment With Fresh Talus Osteochondral Allograft and Arthroscopic Posterior Humeral Avulsion of the Glenohumeral Ligament and Labrum Repair

Chronic posterior glenohumeral joint instability can be a challenging clinical entity for patients and surgeons alike. In the setting of a posterior dislocation, a large anterior humeral impaction injury (reverse Hill-Sachs [HS]) may occur, leading to engagement of the humerus with the posterior glenoid bone, especially during internal rotation of the joint. A reverse HS is especially debilitating because of the significant portion of affected humeral head cartilage, and is made worse in the setting of ligamentous disruption such as a posterior humeral avulsion of the glenohumeral ligament (HAGL) lesions. Although several nonanatomic procedures to address these defects have been previously described, recent interest in anatomic reconstructions capable of restoring the cartilage surface of the humeral head has led to the use of bone grafts (autografts and allografts) to restore the articular contour of the humeral head in conjunction with anatomic repair of associated soft tissue injuries. We present our preferred technique for an anatomic repair of a posterior HAGL lesion in combination with reconstruction of an engaging reverse HS lesion using an unmatched hemitalar allograft.

Prospective Evaluation of Surgical Treatment of Humeral Avulsions of the Glenohumeral Ligament

Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an infrequent but significant contributor to shoulder dysfunction, instability, and functional loss. Purpose: To prospectively identify patients with HAGL lesions and then conduct retrospective evaluation of the clinical history, examination findings, and surgical outcomes of these patients. Study Design: Case series; Level of evidence, 4. Methods: Over a 6-year period (2006-2011), patients with shoulder dysfunction and a HAGL lesion that was confirmed via magnetic resonance arthrogram (MRA) were prospectively evaluated with a minimum 2-year follow-up. Patient demographics, presentation, examination, and surgical findings were documented. Outcomes of return to activity as well as Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores were recorded at final follow-up. Anterior HAGL (aHAGL) lesions were repaired with a partial subscapularis tenotomy approach, while reverse (rHAGL) lesions were repaired arthroscopically. Results: Of 28 patients, 27 (96%) completed the study requirements at a mean of 36.2 months (range, 24-68 months). The sample contained 12 females (44%) and 15 males (56%), who had a mean age of 24.9 years (range, 18-34 years). The chief complaint reported was pain in 23 patients (85%), while only 4 (15%) patients complained primarily of recurrent instability symptoms. Fourteen patients (52%) had aHAGL lesions, 10 patients (37%) had rHAGL lesions, and 3 patients (11%) had combined aHAGL and rHAGL lesions. Ten patients (37%) had concomitant HAGL lesions and labral tears, whereas 17 patients (63%) had isolated HAGL lesion without labral tear. The 17 patients (63%) with aHAGL lesions or combined lesions underwent a partial subscapularis tenotomy approach, while the remaining 10 patients (37%) with rHAGL lesions underwent arthroscopic surgical repair. After surgery, WOSI outcomes improved from 54% to 88% and SANE outcomes improved from 50% to 91% (P < .01 for both), with no reports in recurrence of instability symptoms at final follow-up. Conclusion: This study demonstrated that patients with symptomatic HAGL lesions predominantly report shoulder pain and dysfunction, with few chief complaints of recurrent instability complaints. After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome.

Posterior Humeral Avulsion of the Glenohumeral Ligament and Associated Injuries

Background: Lesions associated with posterior humeral avulsion of the glenohumeral ligament (HAGL) can lead to persistent symptoms related to posterior shoulder instability and can be commonly missed or delayed in diagnosis. Purpose: To identify and characterize the MRI findings in patients with a posterior HAGL lesion. Study Design: Case series; Level of evidence, 4. Methods: This retrospective case series included 27 patients (28 shoulders) identified by search through the senior authors’ databases, with cross-reference to their institutional radiologic communication system for MRI review. Baseline patient demographic data were collected, including age and sex. All posterior HAGL lesions were identified on MRI and characterized as partial, complete, or floating lesions. All acute glenohumeral pathologic changes concurrent with the posterior HAGL were documented. Chondrolabral retroversion of the injured shoulder was measured on axial MRI. Results: The average age of the identified cohort was 33.6 years (range, 15-81 years), and 23 patients were male (86%). Posterior HAGL injuries were found to be complete tears (71%), partial tears (25%), and floating lesions (4%); concomitant bony HAGL avulsion was found in 7% of injuries. Additional traumatic glenohumeral disorders occurred in 93% of cases. The most common concurrent injuries were reverse Hill-Sachs lesions (36%), anterior Bankart lesions (29%), and posterosuperior rotator cuff tears (25%). Notably, concomitant anterior labral or capsular injury was found in 50% of patients, signifying bidirectional disruption of the capsule. In addition, increased chondrolabral version was found in this cohort (10.2° ± 3.7° retroversion). Conclusion: This study depicts the high association of combined injury with posterior HAGL lesions and increased chondrolabral retroversion. Findings on MRI related to a posterior HAGL injury could potentially be masked by additional injury and may occur with mechanisms that also lead to anterior glenohumeral disorders.