Humeral Avulsion Of The Glenohumeral Ligament 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.

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.

Arthroscopic Posterior HAGL Repair Using a Direct Transaxillary Portal

Humeral avulsion of the glenohumeral ligament (HAGL lesion) is a challenging problem in surgery for shoulder instability. Open and arthroscopic approaches and techniques have been described to address this issue. Especially posterior HAGL lesions increase the surgical complexity, as open anterior approaches provide limited visibility and access for successful repair. This article describes an alternative technique using an arthroscopic transaxillary approach to deploy the suture anchor with a perpendicular angle to the humeral bone, thus, improving the ability to perfectly position the anchor at the anatomic insertion of the inferior humeral ligament.

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.

Atypical Shoulder Instability Patterns in Adolescents Following Traumatic Anterior Shoulder Dislocation

Background: Traumatic anterior shoulder instability is common in the adolescent athlete, and when it is untreated, the recurrence rate is high. Atypical lesions—such as anterior glenoid periosteal sleeve, humeral glenohumeral ligament, and insertional tendon avulsions—may occur within this population, and accurate diagnosis and appropriate lesion management are key to treatment success. Purpose: To evaluate the age, skeletal immaturity, bone loss, and uncommon soft tissue lesions as correlates of posttraumatic anterior shoulder instability lesion patterns in an adolescent population. Study Design: Cross-sectional study, Level of evidence, 3. Methods: Consecutive patients ≤18 years of age (160 shoulders) treated within a single institution for traumatic anterior shoulder instability between June 2013 and June 2021 were reviewed. Demographics, injury mechanism, radiographic and magnetic resonance imaging of lesions, the presence of any bone loss, operative findings, and physeal status were recorded. An overall 131 shoulders met the inclusion criteria. Instability lesion type was analyzed categorically by age <15 or ≥15 years; individual age was assessed for correlation with any bone loss present. Atypical lesions—anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, subscapularis avulsion—were assessed for correlations with age, open physeal status, and the presence of any bone loss. Results: An overall 131 shoulders (mean, 15.3 years; range, 10.5-18.3) were identified for this study: 55 in patients <15 years old and 76 in patients ≥15 years old. Bony injuries such as Bankart and Hill-Sachs lesions were more common in the ≥15-year-old group (P = .044 and P = .024, respectively). Bony Bankart injuries were found at a rate of 18.2% in the <15-year-old group, as compared with 34.2% in the ≥15-year-old group (P < .05). Anterior labral periosteal sleeve avulsions were more common in the <15-year-old group (n = 13 [23.6%] vs n = 8 [10.5%]; P < .044), as were all atypical lesions combined (n = 23 [41.8%] vs n = 13 [17.1%]; P < .0018]. Conclusion: In this series of anterior shoulder instability in children and adolescents, instability lesions varied significantly by age. Bone loss was associated with older age at presentation, and atypical lesions were more common in patients <15 years of age. Treatment teams should be aware of less common soft tissue injuries in this young age group and ensure careful review of adequate imaging for proper diagnosis and treatment in these younger patients.

In-Season Management of Shoulder Instability: How to Evaluate, Treat, and Safely Return to Sport.

Anterior glenohumeral instability is a common injury in contact and collision athletes, and in-season management remains a controversial topic. Several recent studies have examined non-operative and operative management of in-season athletes after instability events. Non-operative treatment is associated with faster return to play and higher rates of recurrent instability. Dislocations and subluxations have similar rates of recurrent instability but non-operatively treated subluxations have a quicker return to play than dislocations. Operative treatment is often a season ending decision but is associated with high rates of return to sport and significantly lower rates of recurrent instability. Indications for in-season operative intervention may include critical glenoid bone loss (>15%), an off-track Hill-Sachs lesion, an acutely reparable bony Bankart lesion, high-risk soft tissue injures such as a humeral avulsion of the glenohumeral ligament or displaced anterior labral periosteal sleeve avulsion, recurrent instability, insufficient time remaining in season to rehabilitate from injury, and inability to successfully return to sport with rehabilitation. It is the role of the team physician to appropriately educate athletes on risks and benefits of operative and non-operative treatment strategies and guide athletes through the shared decision-making process that balances these risks against their long-term health and athletic career goals.

Treatment of the ‘The Naked Humeral Head’: Repair of Supraspinatus Avulsion, Subscapularis Tear, and Humeral Avulsion of the Glenohumeral Ligament

A humeral avulsion of the glenohumeral ligament, or HAGL, lesion is a rare yet debilitating shoulder injury, which can lead to recurrent instability, pain, and overall shoulder dysfunction. The diagnosis is often difficult, requiring both high clinical suspicion, as well as identification on magnetic resonance imaging. In patients with an anterior HAGL, repair often requires an open approach. In extremely rare circumstances, the initial traumatic event that causes a HAGL can also cause disruption of the supraspinatus and subscapularis insertions on the humeral head. We have termed this the “naked humeral head”. The purpose of this technical note is to describe our preferred technique to surgically treat the naked humeral head by repairing a supraspinatus avulsion fracture, HAGL lesion, and complete subscapularis tear.

Indications, management, and outcomes of humeral avulsions of the glenohumeral ligament: a systematic review.

To provide an updated overview of recent literature regarding the clinical indications, management, and outcomes of humeral avulsions of the glenohumeral ligament (HAGL) lesion. Medline, Cochrane and Embase were systematically searched using keywords "humeral avulsion of the glenohumeral ligament" and others to identify studies reporting on management of HAGL lesions. Studies were double-screened and reviewed by two blinded authors according to selection criteria. Data was systematically extracted on the following topics: demographics, mechanism of injury, indication for treatment, treatment, post-operative complications, associated injuries, and outcomes including clinical outcome scores, clinical evaluations, and return to activity. There were 14 studies included that evaluated a total of 119 patients with HAGL lesions. In these studies, 69% of patients were male with a mean age of 24 years. Sports (23.5%) and fitness training (41.2%) were the most common injury mechanisms. Instability was the most common indication for treatment, followed by pain and recurrent dislocations. 85 associated lesions were reported, with non-descript labral tears (34.5%) and Bankart lesions (22.4%) being the most common. Out of patients treated, 117 of 119 patients were treated operatively, with 60 open and 57 arthroscopic procedures. A variety of clinical outcome scores showed postoperative functional shoulder improvement and 97% of patients were able to return to some level of activity. HAGL lesions commonly present with associated injuries, necessitating a high clinical awareness of their presentation and management options to prevent undiagnosed lesions that can lead to persistent instability and pain. Surgical management yields good clinical outcomes.

Arthroscopic Repair of a “Floating” Posterior Inferior Glenohumeral Ligament

Background: Combined posterior glenoid labrum lesions with posterior humeral avulsion of the glenohumeral ligament, also known as the “floating” posterior inferior glenohumeral ligament (PIGL), occur infrequently. These combined lesions are frequently missed on magnetic resonance imaging in the workup of posterior shoulder instability. Correct identification of the “floating” PIGL lesion allows for appropriate preoperative planning and treatment to decrease the risk of recurrent posterior shoulder instability. Indications: A “floating” PIGL lesion is a cause of posterior shoulder instability and demonstrates increased translation when compared with isolated labral lesions. Surgical repair of an acute “floating” PIGL lesion with concomitant superior labral tear is described. Technique Description: The patient is placed in the lateral decubitus position. Standard posterior and anterior portals are created. In this case, a superior labral tear with anterior labral tear extension was also identified and repaired. The posterior labrum was repaired prior to the posterior humeral avulsion of the glenohumeral ligament (HAGL). The torn posterior labrum is mobilized and glenoid bony bed prepared. Short, 2.9-mm biocomposite knotless suture anchors loaded with suture tape are used for labral fixation. A 70° arthroscope is used to visualize the posterior HAGL from the anterior cannula and an additional posterior inferior portal established. The footprint of PIGL on the humerus is identified, debrided, and two 3.0-mm anchors loaded with suture placed. The sutures are passed through the capsule and PIGL and tied in a mattress pattern external to the capsule and ligament. The posterior portals are closed with nonabsorbable suture. Results: While few outcomes are described in the literature for the “floating” PIGL, the literature suggests good outcomes following surgical repair. Conclusion: The “floating” PIGL lesion is a rare cause of posterior shoulder instability. It is important to perform a thorough evaluation for concomitant pathology in patients with posterior shoulder instability as multiple structures can be injured. Arthroscopic repair of the posterior labrum and posterior humeral avulsion of the glenohumeral ligament can be performed to restore posterior stability to the shoulder in the setting of a “floating” PIGL.

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.

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.

Poster 144: Minimum 2-year Outcomes after Knotless All-Suture Anchor Bankart Repair

Objectives:Knotless, all suture anchors have significant theoretical and technical advantages such as less bone removal, easier revision, lower profile so less risk for cartilage damage, but clinical results are lacking. The purpose of this study was to report on minimum 2-year outcomes after arthroscopic knotless all-suture Bankart repair in patients with anterior shoulder instabilityMethods:IRB approval was obtained prior to initiation of this study. Data was collected prospectively and retrospectively reviewed. Patients met inclusion criteria if they were a minimum 2 years out from a Bankart repair using all-suture, knotless anchors (FiberTak anchors) for the repairs by a single surgeon from September 2017 to June 2019. Patients were excluded if they had an anterior labroligamentous periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligament, glenolabral articular disruption lesion, or a rotator cuff repair. Outcome data was collected preoperatively and evaluated at a minimum follow-up of 2 years postoperatively using the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numeric Evaluation Score (SANE), Quick Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), the Short Form 12 physical component summary (SF-12 PCS), and patient satisfaction to assess surgical outcomes at final follow-up. Also included are several questions regarding shoulder pain, function and sports participation. Patients with re-dislocations and revision surgery were noted along with any surgical complications. Surgical failure was defined as revision instability surgery, re-dislocation requiring reduction with an ASES score less than 70 or a satisfaction score of 6 or less.Results:A total of 32 patients, 8 females and 24 males, with an average age of 28.5 (SD10.7) years at the time of surgery were included. Postoperative shoulder re-dislocations were reported in 5 cases (15.6%) with 2 patients progressing to a Latarjet (6.0%) at 2 & 3 years post-operatively. There were no postage stamp fractures noted. Moreover, the anchors did not interfere with revision surgery in any way. At final follow-up, mean PRO’s significantly improved over preoperative levels. ASES score improved from 58 to 93 (p<0.001), SANE improved from 58-94 (p<0.001), QuickDASH improved from 32.0 to 6.0 (p<0.001) and SF-12 PCS improved from 45.6 to 55.7 (p<0.001). Median postoperative satisfaction was 10/10 (range4-10). Patients reported a significant improvement in shoulder pain during competition (p<.001), and ability to compete in sports (p< .001). There was also significant improvement in painless use of arm for overhead activities (p= .001) and ability to throw a softball 20 yards (p= .001)Conclusions:The arthroscopic treatment of Bankart lesions with knotless all-suture anchors leads to results similar to clinical outcomes to prior studies, with the advantage of ease of revision. Long-term follow-up studies with large patient cohorts will show if the other theoretical advantages of these anchors are born out.

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.

Athletes with primary glenohumeral instability demonstrate lower rates of bone loss than those with recurrent instability and failed prior stabilization.

The purpose of this study was to compare the preoperative magnetic resonance arthrography findings in patients who underwent glenohumeral stabilization with a history of primary instability, recurrent instability, or failed stabilization. All patients who presented with glenohumeral instability and underwent stabilization performed by a single surgeon in our institution between 2008 and 2020 were considered for inclusion in this study. The magnetic resonance arthrography findings of all patients were recorded. Imaging findings were compared between patients with primary instability, those with recurrent instability, and those with failed prior stabilization. P < .05 was considered statistically significant. Overall, 871 patients were included, of whom 814 (93.5%) were male patients; the mean age was 23.1 years (range, 13-57 years). There were 200 patients with primary instability, 571 with recurrent instability, and 100 who required revision stabilization surgery, with no significant differences in demographic characteristics between the groups. A significantly higher amount of glenoid bone loss was noted in patients with recurrent instability (43.4%) and failed prior stabilization (56%) than in those with primary instability (26.5%) (P < .0001). Additionally, a significantly higher number of Hill-Sachs lesions were observed in patients with recurrent instability (70.1%) and failed prior stabilization (89%) than in those with primary instability (67.5%) (P < .0001). We found no significant differences between the groups regarding articular cartilage damage, glenolabral articular disruption, anterior labral periosteal sleeve avulsion, humeral avulsion of the glenohumeral ligaments, or superior labral anterior-posterior tears (P > .05). Patients presenting for stabilization with recurrent instability or following a failed stabilization procedure have higher rates of glenohumeral bone loss than those with primary instability. Therefore, stabilization of primary instability, particularly in high-functioning athletes with a view to preventing recurrence, may reduce the overall progression of glenohumeral bone loss and potential subsequent inferior clinical outcomes.

Humeral Avulsion of the Glenohumeral Ligament: Diagnosis and Management.

The most common type of humeral avulsion of the glenohumeral ligament (HAGL) is a purely ligamentous avulsion involving the anterior inferior glenohumeral ligament (IGHL), but other variants are seen, including posterior lesions and those with an osseous avulsion. A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity. HAGL lesions are most commonly seen in patients with anterior instability without a Bankart tear or in those with persistent symptoms despite having undergone a Bankart repair. Magnetic resonance imaging is the most sensitive imaging modality. An arthrogram is helpful with subacute and chronic lesions when the joint is not distended. Arthroscopy is the gold standard for diagnosis. While some have reported success with nonoperative management, surgical repair with either arthroscopic or open techniques has provided a high rate of successful outcomes; however, the literature is limited to mostly Level-IV and V evidence.

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.

Humeral Avulsion of the Glenohumeral Ligament in an Adolescent: A Case Report of a Relatively Rare but Clinically Relevant Orthopedic Entity

Humeral avulsion of the glenohumeral ligament (HAGL) is defined as a disruption of the fibers of the inferior glenohumeral ligament at its humeral insertion. It is a relatively rare but important entity, given its diagnostic and clinical implications and growing debate around the treatment of adolescent patients particularly those who participate in sports. While well described in the orthopedic literature, HAGL has not been often discussed in the radiology literature. This case report presents classic imaging characteristics of HAGL in an adolescent football player. In addition, this case report addresses the epidemiology, the causes, the subtypes, and some aspects of treatment of HAGL.

Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament for Anterior Shoulder Instability

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.