Inferior Glenohumeral Ligament Complex Research Articles

Valeur prédictive du test d’hyperabduction de Gagey pour identifier les lésions du ligament glénohuméral inférieur

IntroductionClinical tests that can identify inferior glenohumeral ligament (IGHL) complex injuries are indispensable for the diagnosis of shoulder instability. Gagey's hyperabduction test has been developed to diagnose IGHL hyperlaxity, however, it is unclear whether the test is able to accurately diagnose an IGHL lesion. The aim of this study was to (1) determine the diagnostic performance of the Gagey test in identifying an IGHL lesion and (2) determine if a positive Gagey test is more predictive for an anterior or posterior IGHL lesion thanks to the heatmapping of the lesions. It was hypothesized that a Gagey test can accurately predict IGHL lesions, but would not be able to distinguish between anterior and inferior IGHL lesions. MethodsA retrospective diagnostic accuracy study was conducted including all consecutive patients who underwent glenoid labral repair between January 2005 and September 2021 with a documented Gagey test prior to surgery. Using arthroscopic findings as a reference standard, the diagnostic performance characteristics of the Gagey test for each type of IGHL lesion (anterior, posterior and combined) were calculated and labral heatmapping was used to depict its localisation. ResultsA total of 167 patients were included, with a mean age of 29±10 years. The sensitivity, specificity and accuracy of the Gagey test on determining an IGHL lesion were 46%, 38% and 46%, respectively. The positive and negative predictive values were 88% and 7%, respectively. Heatmapping of the labral lesions demonstrated that a positive Gagey test was most predictive of anterior IGHL and axillary pouch tears and non-predictive of posterior IGHL lesions. DiscussionThe Gagey test demonstrated a low sensitivity and specificity to identify an IGHL lesion and therefore the hypothesis could not be confirmed. However, the Gagey test has a high positive predictive value to diagnose anterior IGHL lesions. Further prospective research with a more evenly distribution of lesions is needed to investigate the clinical value of the Gagey test to identify these lesions. Based on this data, the Gagey test seems especially important to support the results of other clinical tests such as the apprehension, relocation and surprise tests. Level of evidenceIII, retrospective case-control study.

Predictive value of Gagey's hyperabduction test in identifying inferior glenohumeral ligament lesions

IntroductionClinical tests that can identify inferior glenohumeral ligament (IGHL) complex injuries are indispensable for the diagnosis of shoulder instability. Gagey's hyperabduction test had been developed to diagnose IGHL hyperlaxity, however, it is unclear whether the test is able to accurately diagnose an IGHL lesion. The aim of this study was to (1) determine the diagnostic performance of the Gagey test in identifying an IGHL lesion and (2) determine if a positive Gagey test is more predictive for an anterior or posterior IGHL lesion thanks to the heatmapping of the lesions. It was hypothesized that a Gagey test can accurately predict IGHL lesions, but would not be able to distinguish between anterior and inferior IGHL lesions. MethodsA retrospective diagnostic accuracy study was conducted including all consecutive patients who underwent glenoid labral repair between January 2005 and September 2021 with a documented Gagey test prior to surgery. Using arthroscopic findings as a reference standard, the diagnostic performance characteristics of the Gagey test for each type of IGHL lesion (anterior, posterior and combined) were calculated and labral heatmapping was used to depict its localisation. ResultsA total of 167 patients were included, with a mean age of 29±10 years. The sensitivity, specificity and accuracy of the Gagey test on determining an IGHL lesion were 46%, 38% and 46%, respectively. The positive and negative predictive values were 88% and 7%, respectively. Heatmapping of the labral lesions demonstrated that a positive Gagey test was most predictive of anterior IGHL and axillary pouch tears and non-predictive of posterior IGHL lesions. DiscussionThe Gagey test demonstrated a low sensitivity and specificity to identify an IGHL lesion and therefore the hypothesis could not be confirmed. However, the Gagey test has a high positive predictive value to diagnose anterior IGHL lesions. Further prospective research with a more evenly distribution of lesions is needed to investigate the clinical value of the Gagey test to identify these lesions. Based on this data, the Gagey test seems especially important to support the results of other clinical tests such as the apprehension, relocation and surprise tests. Level of EvidenceIII, Retrospective Case-Control study.

Arthroscopic Bennett Lesion Resection: A Novel Technique

Background: Bennett lesion is ossification of the posterior inferior glenohumeral ligament complex. Though often asymptomatic, these lesions can become painful and interfere with throwing ability. Indications: The Bennett lesion is relatively common among elite throwers, present in 22% to 25% of asymptomatic pitchers. Suggested causes of this lesion include traction on the posterior joint and posterior impingement in the late cocking phase. These lesions can become painful due to displacement and irritation of the joint capsule and axillary nerve. Therefore, efficient arthroscopic treatment of symptomatic lesions is essential. Technique Description: The patient is positioned in the lateral decubitus position, and the glenohumeral joint is accessed via posterior and anterior portals. Once the lesion is identified, it may be probed and debrided via the posterior portal. A posterior capsular release is performed, and 4.0 mm burr resection of the lesion is started, viewing from the anterior portal with a 70° arthroscope. Direct visualization through the posterior portal can be used to verify complete lesion resection. If there is a true tear of the posterior labrum, this can be repaired with a knotless suture anchor back to the glenoid, but usually there is delamination that can be left alone after addressing the Bennett lesion. Results: We have found good success treating Bennett lesions via the above technique. This is supported by previous literature as well, with return to preinjury levels ranging from 69% to 85% following arthroscopic resection. Discussion/Conclusion: Four diagnostic criteria have been described to ensure accurate diagnosis: detection of a bony spur at the posterior glenoid rim on plain x-ray films, best seen on Stryker notch and Bennett view; posterior shoulder pain while throwing; tenderness at the posteroinferior aspect of the glenohumeral joint; and improvement in pain following lidocaine injection. Magnetic resonance imaging is also an excellent diagnostic tool to detect early enthesopathic changes in the posterior glenoid or periosteum, as well as labral pathology. Following arthroscopic resection, 88% of patients were satisfied with their treatment when using these diagnostic criteria. Accurate diagnosis and efficient treatment of Bennett lesions are imperative in the throwing athlete, and when performed correctly, our technique provides significant and lasting improvement for patients.

Locating the rotator cable during subacromial arthroscopy: bursal- and articular-sided anatomy.

The rotator cable (RCa) is an important articular-sided structure of the cuff capsular complex that helps prevent suture pull out during rotator cuff repairs (RCRs) and plays a role in force transmission. Yet, the RCa cannot be located during bursal-sided RCRs. The purpose of this study is to develop a method to locate the RCa in the subacromial space and compare its bursal- and articular-sided dimensions. In 20 fresh-frozen cadaveric specimens, the RCa was found from the articular side, outlined with stitches, and then evaluated from the bursal side using an easily identifiable reference point, the intersection of a line bisecting the supraspinatus (SS) tendon and posterior SS myotendinous junction (MTJ). Four bursal-sided lengths were measured on the SS-bisecting line as well as the RCa's outside anteroposterior base. For the articular-sided measurements, the rotator cuff capsular complex was detached from bone and optically scanned creating 3D solid models. Using the 3D models, 4 articular-sided lengths were made, including the RCa's inside and outside anteroposterior base. The RCa's medial arch was located 9.9 ± 5.6 mm from the reference point in 10 intact specimens and 4.1 ± 2.4 mm in 10 torn specimens (P = .007). The RCa's width was 10.9 ± 2.1 mm, and the distance from the lateral edge of the RCa to the lateral SS insertion was 13.9 ± 4.8 mm. The bursal- and articular-sided outside anteroposterior base measured 48.1 ± 6.4 mm and 49.6 ± 6.5 mm, respectively (P = .268). The average inside anteroposterior base measurement was 37.3 ± 5.9 mm. The medial arch of the RCa can be reliably located during subacromial arthroscopy using the reference point, analogous to the posterior SS MTJ. The RCa is located 10 mm in intact and 4 mm in torn tendons (P = .007) from the posterior SS MTJ. If the above 6-mm shift in location of the RCa is not taken into consideration during rotator cuff suture placement, it could negatively affect time zero repair strength. The inside anteroposterior base of the RCa measures on average 37 mm; therefore, rotator cuff tears measuring >37 mm are at risk of rupturing part or all of the RCa's 2 humeral attachments, which if not recognized and addressed could impact postoperative function.

Mapping of the Inferior Glenohumeral Ligament for Suture Pullout Strength: A Biomechanical Analysis.

Background:Suture pullout during rehabilitation may result in loss of tension in the inferior glenohumeral ligament (IGHL) and contribute to recurrent instability after capsular plication, performed with or without labral repair. To date, the suture pullout strength in the IGHL is not well-documented. This may contribute to recurrent instability.Purpose/Hypothesis:A cadaveric biomechanical study was designed to investigate the suture pullout strength of sutures in the IGHL. We hypothesized that there would be no significant variability of suture pullout strength between specimens and zones. Additionally, we sought to determine the impact of early mobilization on sutures in the IGHL at time zero. We hypothesized that capsular plication sutures would fail under low load.Study Design:Descriptive laboratory study.Methods:Seven fresh-frozen cadaveric shoulders were dissected to isolate the IGHL complex, which was then divided into 18 zones. Sutures in these zones were attached to a linear actuator, and the resistance to suture pullout was recorded. A suture pullout strength map of the IGHL was constructed. These loads were used to calculate the load applied at the hand that would initiate suture pullout in the IGHL.Results:Mean suture pullout strength for all specimens was 61.6 ± 26.1 N. The maximum load found to cause suture pullout through tissue was found to be low, regardless of zone of the IGHL. Calculations suggest that an external rotation force applied to the hand of only 9.6 N may be sufficient to tear capsular sutures at time zero.Conclusion:This study did not provide clear evidence of desirable locations for fixation in the IGHL. However, given the low magnitude of failure loads, the results suggest the timetable for initiation of range-of-motion exercises should be reconsidered to prevent suture pullout through the IGHL.Clinical Relevance:From this biomechanical study, the magnitude of force required to cause suture pullout through the IGHL is met or surpassed by normal postoperative early range-of-motion protocols.

Inferior Glenohumeral Ligament (IGHL) Injuries: A Case Series of Magnetic Resonance (MR) Imaging Findings and Arthroscopic Correlation.

IntroductionThe inferior glenohumeral ligament (IGHL) complex commonly is assessed by both magnetic resonance imaging (MRI) and magnetic resonance (MR) arthrogram. Our study compared the accuracy of MR arthrogram compared to MRI using arthroscopic correlation as the gold standard.MethodsA retrospective review of cases reporting an IGHL injury was performed. Seventy-seven cases met inclusion criteria, while five had arthroscopic reports that directly confirmed or refuted the presence of IGHL injury. Two arthroscopic reports confirmed concordant IGHL injuries, while three arthroscopic reports mentioned discordant findings compared to MR. All three discordant cases involved MR arthrogram. Findings included soft tissue edema, fraying of the axillary pouch fibers, and cortical irregularity of the humeral neck. Of the two concordant cases, one was diagnosed by MRI, revealing an avulsion of the anterior band, while the second was diagnosed by MR arthrogram showing ill-defined anterior band fibers. Many cases involved rotator cuff or labral tears, which may have been the focus of care for providers, given their importance for shoulder stability. Additionally, a lack of diagnostic confidence in MR reports may have influenced surgeons in the degree to which they assessed the IGHL complex during arthroscopy.ConclusionRadiologists seemed more likely to make note of IGHL injuries when MR arthrograms were performed; meanwhile, all three discordant cases involved MR arthrogram reads. Therefore, additional larger studies are needed with arthroscopic correlation to elucidate MR findings that confidently suggest injury to the IGHL complex, to avoid false positive radiology reports.

Glenoid bone resorption after Bankart repair: finite element analysis of postoperative stress distribution of the glenoid

There are various modifications of the Bankart repair, and postoperative changes to the glenoid morphologyafter the repair are reported. Among the various procedures performed, a decrease in the lateral glenoid diameter might be related to the surgery that involves removal of the articular cartilage and repair of the labrum-anterior inferior glenohumeral ligamentcomplex on the glenoid surface. This is in contrast to cases without significant bony Bankart lesionsthat are not on the edge of the glenoid. Thus, this study aimed to compare glenoid rim stress after Bankart repair using 2 methods of finite element analysis: a method of removing the anteroinferior cartilage and repairing the glenohumeral ligament complex on the glenoidand a method of preserving the cartilage and repairing the glenohumeral ligament complex on the glenoid edge. Five preoperative computed tomography scans of patients with traumatic anterior instability who underwent arthroscopic Bankart repair were used. Two models simulating different surgical procedures were created as follows: in model G, a 5-mm-thick cartilage on the glenoid rim was removed between 2 and 7 o'clock, and the glenohumeral ligament complex was repaired on the medial edge of the glenoid bone where the cartilage was removed. In model E, the cartilage on the glenoid rim was not removed, and the glenohumeral ligament complex was repaired on the glenoid edge. The load stresses on the anteroinferior area of the glenoid after Bankart repair with models G and E were measured using finite element analysis. The stress on the glenoid at 3-4 o'clock was 3.16 MPa in model G and 6.42 MPa in model E (P = .043). The stress at 4-5 o'clock was 1.68 MPa in model G and 4.53 MPa in model E (P = .043). The stress at 5-6 o'clock was 2.26 MPa in model G and 3.93 MPa in model E (P = .043). Significantly lower load stresses were observed at the anteroinferior rim of the glenoid in model G than in model E.

Finite element analysis of the influence of anchorage number and location on Bankart repair strength of shoulder joint

To study the influence of the number and position of anchor nails on the Bankart repair by the finite element analysis. The 3D CT data of shoulder joints including normal adult volunteers were imported into Mimics 10.0 and Geomagic 2012 software to reconstruct the related tissues, and then meshed in Hypermesh 13.0 software to give material attributes. The position and number of MPC constraints were adjusted in Abaqus 6.14 to establish finite element model of shoulder joint under 6 working conditions including A model(normal control model), B model (Bankart damage control model), C model (1 anchor), D model (2 anchors), E model (3 anchors), F model (4 anchors). The humerus external rotation and forward load were added to simulate the fear test of the shoulder joint forward instability. (1)Normally, the inferior glenohumeral ligament complex accompanied by the external rotation of the humerus head has a wrinkle and a significant stress concentration around its anterior and posterior bundle terminations.(2)The stress of the anterior bundle and posterior bundle of the inferior glenohumeral ligament were increased by 52.33% and 45.67% respectively after Bankart's injury.(3)In each model of anchor repair, the stress concentration was obvious at the anchor site, and the stress of anterior and posterior bundle ligaments could be reduced; there were no obvious differences between C, D models and B model(P>0.05), and there were significant differences between E, F models and B model(P<0.05). One or two anchors can reduce the stress of the anterior and posterior bundles of the inferior glenohumeral ligament in the repair of Bankart's injury, but when the angle of rotation is large, the stress concentration in the anchor position increases significantly, leading to the increases of the risk of failure. The application of three or four anchors can enhance the constraints on the inferior glenohumeral ligament and reduce the stress of the anchor itself through the "load sharing" effect between anchors, so as to ensure the stability of the shoulder joint and provide a mechanical environment for the early rehabilitation of patients.

MR Arthrogram Features That Can Be Used to Distinguish Between True Inferior Glenohumeral Ligament Complex Tears and Iatrogenic Extravasation.

The purpose of this study is to identify features seen at shoulder MR arthrography that distinguish between iatrogenic contrast material extravasation and inferior glenohumeral ligament (IGHL) complex tears. MR arthrograms (n = 1740) were screened for extravasation through the IGHL complex. Cases were defined on the basis of surgical findings or definitive lack of extravasation in a fully distended joint immediately after contrast agent injection. The location of the disruption and the morphologic features of the torn margin were assessed and compared between groups. Anterior band disruption was present in eight of 16 patients with true tears and in zero of 19 patients with iatrogenic contrast material extravasation (p < 0.001). Isolated extravasation through the posterior half of the axillary pouch was present in 12 patients with iatrogenic extravasation, compared with none of the patients with true tears (p < 0.001). Thick ends were present in 10 of the true tears, whereas none of the cases of iatrogenic extravasation showed this finding (p < 0.001). Scarred margins were seen in eight true tears and none of the iatrogenic extravasation cases (p < 0.001). The presence of a torn anterior band, thick ligament, reverse-tapered caliber, and scarred appearance of the torn margin were shown to be 100.0% specific, and a torn posterior band showed 84.2% specificity for true tears. The presence of isolated involvement of the posterior portion of axillary pouch showed 63.2% sensitivity and 100.0% specificity for iatrogenic extravasation. A torn anterior band, a thickened ligament (> 3 mm), reverse-tapered caliber, and scarred margin were 100.0% specific for a tear. Isolated disruption of the posterior axillary pouch was 100.0% specific for iatrogenic extravasation.

Inferior glenohumeral ligament (IGHL) complex: anatomy, injuries, imaging features, and treatment options.

The inferior glenohumeral ligament (IGHL) complex is comprised of three components supporting the inferior aspect of the shoulder. It consists of an anterior band, a posterior band, and an interposed axillary pouch. Injuries to the IGHL complex have a unifying clinical history of traumatic shoulder injury, which are often sports or fall-related, with the biomechanical mechanism, positioning of the arm, and individual patient factors determining the specific component of the ligamentous complex that is injured, the location of the injury of those components, and the degree of bone involvement. Several acronyms are employed to characterize these features, specifying whether there is involvement of a portion of the anterior band, posterior band, or midsubstance, and if there is avulsion from the humeral attachment, glenoid attachment, or both. Imaging recommendations for the evaluation of the IGHL complex include magnetic resonance imaging (MRI), and injuries to this complex are best visualized with magnetic resonance arthrography. Additionally, a brief description of clinical management of inferior glenohumeral ligament injuries is included.

Arthroscopic treatment of recurrent anterior shoulder instability with augmentation

Chronic anterior shoulder instability was found in cases with little soft tissue on the anterior portion of the joint, especially the anterior bundle of the inferior glenohumeral ligament (AIGHL) complex. Low volume and quality of the AIGHL complex tissue can lead to limitation of external rotation and difficulties to return to activities of daily living and overhead throwing sports. A new approach for the augmentation of chronic Bankart repair was developed for these cases based on a pilot study using polyglycolic acid sheets (PGA sheet). Favorable functional results without recurrence were obtained using the PGA sheet for augmentation of the AIHGL complex without any side effects. A long-term follow-up is necessary.

Arthroscopic Treatment for Multidirectional Instability

Multidirectional instability (MDI) was first described by Neer and Foster in 1980. Although there has been much confusion over the years with a blending of classifications, the inherent concept of symptomatic inferior instability with associated anterior and posterior instability remains the hallmark of the MDI shoulder. The MDI shoulder may be thought of as one of compensation, where the balance of the scapula and rotator cuff maintain the humeral head in the glenoid. Symptoms are seen when this balance is lost. The anatomical characteristic of the MDI shoulder is increased capsular volume with widening of the critical rotator interval structures (superior glenohumeral ligament and coracohumeral ligament) along with dysfunction of the entire inferior glenohumeral ligament complex. Management centers on nonoperative treatment, with pain control and scapular rebalancing exercises being the key to successful nonoperative management. Surgery is only indicated by a failure of nonoperative treatment and is focused on closing the rotator interval and decreasing capsular volume by shifting both the anterior and posterior capsule superiorly.

Humeral avulsions of the inferior glenohumeral ligament complex involving the axillary pouch in professional baseball players

Humeral avulsion of the inferior glenohumeral ligament is a rare injury in athletes and can involve different parts of the complex. Axillary pouch avulsion, in particular, has only recently been recognized in the literature, but has never been described in professional baseball pitchers. A retrospective review of professional baseball players presenting to our institution over 5years was performed. Patients with Bankart lesions or fractures were excluded. Preoperative MRI was retrospectively correlated with the clinical and arthroscopic findings, as available. Four professional baseball pitchers were identified, all who had axillary pouch humeral avulsions of the inferior glenohumeral ligament. There was a concomitant avulsion of the anterior band in one patient. Associated findings included labral tears (n = 2) and partial thickness tear of the rotator cuff (n = 2). Three patients ultimately had their axillary pouch avulsions repaired at most recent follow-up. APHAGL lesions can be seen in overhead athletes such as baseball pitchers and should be carefully considered as a potential cause of disability. Appropriate diagnosis is important to ultimately elucidate the optimal management of these lesions.

Regeneration of AIGHL complex for traumatic instability of the shoulder joint

We investigated the usefulness of biomaterials for the purpose of the regeneration of the soft tissues of traumatic instability of the shoulder joint. Based on experimental study, the polyglycolic acid sheet (PGA sheet) was the most suitable material for the regeneration of the soft tissues of traumatic instability of the shoulder joint. We clinically used the PGA sheet for the regeneration of the anterior bundle of inferior glenohumeral ligament complex (AIGHL complex) in cases of traumatic instability of the shoulder joint.

Anterior Dislocation of the Shoulder Associated with Bankart Lesion in a Patient with Poland's Syndrome: A Case Report and Review of the Literature

Poland's syndrome is a rare congenital entity characterized by unilateral partial or total hypoplasia of the major pectoralis muscle, breast and/or ipsilateral hand abnormalities. It has been reported in association with various structural and functional abnormalities. We report about a 23-year-old male kick-boxer with Poland's syndrome who presented in our department the history of two traumatic anterior shoulder dislocations due to boxing and self-reductions. Physical examination showed an instability of the left shoulder, and the MRI scans demonstrated a Bankart lesion. The patient had been treated with an arthroscopic Bankart repair; reattachment of the detached antero-inferior labrum down to the glenoid and repairing of the inferior gleno-humeral ligament complex. To our knowledge this is a first case report of a patient presenting with traumatic anterior shoulder dislocations due to kick-boxing associated with Poland's syndrome.

Arthroscopic Repair of Humeral Avulsion of Glenohumeral Ligament Lesion

Humeral avulsion of the inferior glenohumeral ligament complex is an unusual pathology, often implicated in traumatic shoulder instability. Traditional open techniques involve at least partial detachment of the subscapularis, and arthroscopic techniques are limited by neurovascular boundaries. The technique described here presents an anterior and posterior arthroscopic approach that can be used individually or in combination to treat different types of humeral avulsion of the inferior glenohumeral ligament lesions. The anterior approach is based on anatomic guidelines described in the literature. The posterior approach is based on the arthroscopic and cadaveric anatomic studies described by one of the authors (D.N.B.); use of the recently described axillary pouch portal (Bhatia portal) permits safe arthroscopic instrumentation access in the entire inferior glenohumeral recess and provides adequate access to the posteroinferior aspect of the humeral head. The differential mattress stitch technique ensures secure fixation of the avulsed ligaments and eliminates excessive capsular redundancy. Technical tips to avoid complications are discussed, and a detailed rehabilitation protocol is presented.

Arthroscopic repair of L-shaped tear of the anterior band of the inferior glenohumeral ligament complex in a pediatric patient: a technical note

The present study reports on a case of a 10-year-old patient with recurrent right shoulder instability after a traumatic event leading to a mid-substance tear of the anterior band of the inferior glenohumeral ligament complex in an L-shaped pattern. Arthroscopic repair consisting of a 2.4 mm bioabsorbable suture anchor at the apex and a four PDS sutures placed through the capsulolabral junction leads to an anatomic repair with excellent short-term results similar to those found in other studies. The injury pattern is thought to be about 1% of shoulder dislocations, but tear pattern recognition is critical for a successful repair and clinical result.

Capsular Tear in Line With the Inferior Glenohumeral Ligament: A Cause of Anterior Glenohumeral Instability in 2 Patients

Anterior glenohumeral instability typically involves lesions associated with the inferior glenohumeral ligament complex. Multiple lesions have been described in this setting, including Bankart, humeral avulsion of the inferior glenohumeral ligament complex, and mid-substance capsular tears. These lesions are indicative of the high-force traumatic nature of anterior shoulder dislocation. Two cases of recurrent anterior shoulder instability are presented with a capsular tear perpendicular to the usual orientation and not consistent to the amount of force involved in a dislocation. Arthroscopy revealed a capsular defect from the glenoid to the humeral head in the anterior inferior glenohumeral ligamentous complex in both. This lesion is an unusual circumstance, providing another pathology to include in the differential diagnosis of anterior glenohumeral instability.

The “Bony Bankart Bridge” Procedure: A New Arthroscopic Technique for Reduction and Internal Fixation of a Bony Bankart Lesion

Arthroscopic treatment of bony Bankart lesions can be challenging. We present a new easy and reproducible technique for arthroscopic reduction and suture anchor fixation of bony Bankart fragments. A suture anchor is placed medially to the fracture on the glenoid neck, and its sutures are passed around the bony fragment through the soft tissue including the inferior glenohumeral ligament complex. The sutures of this anchor are loaded in a second anchor that is placed on the glenoid face. This creates a nontilting 2-point fixation that compresses the fragment into its bed. By use of the standard technique, additional suture anchors are used superiorly and inferiorly to the bony Bankart piece to repair the labrum and shift the joint capsule. We call this the “bony Bankart bridge” procedure.

MRI of HAGL Lesions: Four Arthroscopically Confirmed Cases of False-Positive Diagnosis

The purpose of this article is to present the cases of four consecutive patients with preoperative MR diagnosis of humeral avulsion of the glenohumeral ligament (HAGL) who had no evidence of HAGL at arthroscopy. These four cases suggest that the diagnosis of HAGL should be reserved for arthroscopy and illustrate the difficulty in distinguishing HAGL from other abnormalities of the inferior glenohumeral ligament complex with MRI. Thus, MRI findings classically associated with HAGL should be more broadly described as defects of the inferior glenohumeral ligament complex. This terminology more accurately describes the abnormalities of the inferior glenohumeral ligament complex that may be depicted by MRI.