Inferior Glenohumeral Ligament Research Articles

MR imaging signs of shoulder adhesive capsulitis: analysis of potential differentials and improved diagnostic criteria.

To evaluate the prevalence of shoulder adhesive capsulitis (AC) signs on MR studies of patients with various common shoulder conditions. MR images of 316 patients were retrospectively evaluated. Patients were divided into three groups: controls (66 patients), clinical AC (63 patients), and study group (187 patients). The final diagnosis of AC was reached clinically. The study group was composed of patients with focal and massive rotator cuff tears, active hydroxyapatite deposition disease, fractures around the shoulder, and post-surgery. The following AC signs were evaluated: inferior glenohumeral ligament (IGHL) thickening; coracohumeral ligament (CHL) thickening; and hyperintensity of the inferior glenohumeral ligament, which was graded in four classes. The IGHL signal intensity was statistically higher in patients with fractures than in controls (P = 0.008). There was no statistically significant difference in IGHL signal between the AC group and patients with massive rotator cuff tears and active hydroxyapatite deposition disease (P > 0.1). IGHL thickness in patients with fractures, massive rotator ruptures, and active hydroxyapatite deposition disease was significantly higher compared to controls (P < 0.02) and significantly lower compared to the AC group (P < 0.0001). Based on these findings, a grading system for fibro-inflammatory capsular changes is proposed. MR AC signs are frequent in patients with shoulder conditions other than AC; however, in these patients, capsular changes are less prominent than in patients with clinical AC.

Stabilizing Mechanisms in Patients Treated Using Hill-Sachs Remplissage With Bankart Repair in Abduction-External Rotation Position.

Hill-Sachs lesion (HSL) remplissage with Bankart repair (RMBR) provides a minimally invasive solution for treating HSLs and glenoid bone defects of <25%. The infraspinatus tendon is inserted into the HSL during the remplissage process, causing the infraspinatus to shift medially, leading to an unknown effect on glenohumeral alignment during the resting abduction-external rotation (ABER) and muscle-active states. The purpose of this study was to evaluate the possible check-rein effect and muscle-active control in stabilizing the glenohumeral joint after RMBR in vivo. We hypothesized that the check-rein effect and active control would stabilize the glenohumeral joint in the ABER position in patients after RMBR. Controlled laboratory study. We included 42 participants-22 patients in group A who met the inclusion criteria after RMBR and 20 healthy participants in group B without shoulder laxity. Three-dimensional magnetic resonance imaging was performed to analyze the alignment relationship of the glenohumeral joint with and without muscular activity. Ultrasonic shear wave elastography was used to evaluate the elastic properties of the anterior capsule covered with the anterior bands of the inferior glenohumeral ligament. Patients who underwent RMBR demonstrated more posterior (-1.81 ± 1.19 mm vs -0.76 ± 1.25 mm; P = .008) and inferior (-1.05 ± 0.62 mm vs -0.45 ± 0.48 mm; P = .001) shifts of the humeral head rotation center and less anterior capsular elasticity (70.07 ± 22.60 kPa vs 84.01 ± 14.08 kPa; P = .023) than healthy participants in the resting ABER state. More posterior (-3.17 ± 0.84 mm vs -1.81 ± 1.19 mm; P < .001) and less-inferior (-0.34 ± 0.56 mm vs -1.05 ± 0.62 mm; P < .001) shifts of the humeral head rotation center and less anterior capsular elasticity (36.57 ± 13.89 kPa vs 70.07 ± 22.60 kPa; P < .001) were observed in the operative shoulder during muscle-active ABER than in resting ABER states. The check-rein effect and muscle-active control act as stabilizing mechanisms in RMBR during the ABER position. Stabilizing mechanisms in RMBR during the ABER position include the check-rein effect and muscle-active control.

A cadaveric study of the posterior band of the inferior glenohumeral ligament of the shoulder and its dynamic behaviour in different arm positions.

The inferior glenohumeral ligament (IGHL) is composed of three parts: the anterior branch or band (AB), the axillary pouch and the posterior band (PB). The latter has rarely been studied. We aim to describe the PB of the IGHL and its dynamic behaviour in different arm positions. Twelve fresh cadaveric shoulders were used and the two bands (AB and PB) of the IGHL were dissected and isolated, taking away all muscle, ligaments and capsule. Characteristics of the bands were studied in five positions: maximum external rotation (ER1), abduction (ABD), internal rotation (IR), ABD external rotation (ER2) and anterior elevation-adduction-IR (Hawkins-Kennedy test position). Progressive and randomized sectioning of the bands and capsule with a scalpel was performed to study its impact on mobility and translation of the glenohumeral joint. The bands that tensioned first werein ER1, the AB at 97 ± 9° (80-110); in ER2, the AB at 81 ± 19° (30-100); in IR, the PB at 64 ± 9° (50-80); and in ABD, the PB at 87 ± 10° (70-105). Isolated sectioning of the AB had no effect on ABD, whilst isolated sectioning of the PB allowed greater ABD. In ER2, the AB limited anterior translation. After sectioning the AB, anterior translation remained limited by the PB, which wrapped around the humeral head and locked the joint by pressing the two joint surfaces tightly together. In Hawkins-Kennedy position anterior elevation-adduction-IR, the AB is the first constraint and the posterior translation was limited by the PB alone only in four cases. When the IGHL is isolated, ligament limitation of glenohumeral ABD seems to be uniquely dependent on the PB. In the Hawkins and Kennedy position, the AB is the first constraint. In the case of an isolated lesion to the AB, the PB participates in anterior stabilization of the shoulder by wrapping around the humeral head that cannot dislocate. These findings confirm the role of the PB in glenohumeral joint stability. Level IV.

Bankart Repair Versus Bristow-Latarjet Procedure in Treating Anterior Shoulder Dislocation: A Systematic Review

Introduction: Anterior shoulder dislocation affects an estimated 11/100,000 individuals annually, primarily involving the inferior glenohumeral ligament and causing recurrent instability. Surgical approaches like anatomical labral repair and the Bristow-Latarjet procedure are common for managing these issues. This systematic review aimed to compare the clinical and functional outcomes of Bankart repair and the Bristow-Latarjet procedure in treating anterior shoulder dislocation. Methods: Following PRISMA guidelines, a comprehensive search was conducted across PubMed, Google Scholar, Science Direct, and the Cochrane Library, resulting in 154 studies. From these, 4 studies were selected: two retrospective cohorts, one prospective cohort, and one case-control, encompassing 414 patients. Among them, 257 patients underwent the Bristow-Latarjet procedure, while 157 received Bankart repair. Inclusion criteria covered English-language studies evaluating clinical outcomes such as SSV, WOSI, Rowe scores, movement loss, and arthropathy rates, with no demographic restrictions, while non-English studies were excluded. Quality evaluation employed classifications by the Oxford Center for Evidence-based Medicine, GRADE criteria, and AHRQ for assessing evidence strength, bias, and quality. Results: The systematic review selected 4 studies from the 154 identified, incorporating a total of 414 patients. Of these, 257 underwent the Bristow-Latarjet procedure, and 157 received Bankart repair. The studies comprised two retrospective cohorts, one prospective cohort, and one case-control study. Conclusion: The review revealed no significant difference in functional outcomes between Bankart repair and the Bristow-Latarjet procedure for anterior shoulder dislocation. The choice between these methods depends largely on surgeon preference and technological accessibility. However, more comprehensive, high-quality studies are needed to better guide the selection between these procedures. Keywords: Anterior shoulder dislocation; Glenohumeral ligament; Bankart repair; Bristow-Latarjet procedure.

MRI Findings of Periarticular Lesions with Isolated Greater Tubercle Fractures and Dislocation.

To identify MRI findings for injuries to periarticular soft tissue structures that were related to isolated greater tubercle fracture. 16 patients (mean age: 53.8, range 30-71 yrs) were enrolled and diagnosed with isolated greater tubercle (GT) fracture with CT and MRI and underwent shoulder arthroscopy from September 2009 to April 2019. Two musculoskeletal radiologists were blinded to the patient history and arthroscopic surgical findings and reviewed patient's CT and MRI. Fracture displacement, fracture center, and presence of bony Bankart lesion with Hill sachs lesion were checked on shoulder CT. Soft tissue injuries, including rotator cuff injury, deltoid muscle injury, long head of biceps tendon injury, capsular injury, glenoid injury, and injury location of the subscapularis and infraspinatus were checked on shoulder MRI. MRI showed supraspinatus injury (56.3%), subscapularis injury (56.3%), deltoid muscle injury (25%), infraspinatus injury (25%), teres minor muscle injury (37.5%), injury of the long head of the biceps tendon (43.8%), inferior glenohumeral ligament tear (87.5%), superior labral anterior-toposterior lesion (25%), Bankart lesion (18.8%), and Hill-Sachs lesion (6.3%). 88.9% of subscapularis injuries and 75% of infraspinatus injuries showed caudal predominance. All of the patients with infraspinatus injuries showed concomitant teres minor muscle injuries. In order of frequency, the fracture centers were anterior (25%), posterior (31.3%), and all (43.8%). For patients with Bankart and Hill- Sachs lesions, the fracture center included the posterior portion in all cases. MRI and active arthroscopic examinations may be valuable when an isolated GT avulsion fracture is identified on X-ray examination.

Poster 107: Biomechanical Effect of “AIGHL Reconstruction” for Bankart Lesion in Thrower’s Shoulder: A Novel Surgical Treatment to Maintain Maximum Shoulder External Rotation Angle after Surgery

Objectives: For anterior shoulder instability, antero-inferior labral repair (Bankart repair) is a reliable surgery to prevent shoulder dislocation. However, in biomechanical and clinical studies, maximum shoulder external rotation angle is reported to be decreased by about 10 degrees due to shortening of the anterior band of the inferior glenohumeral ligament (AIGHL) length after Bankart repair. For overhead throwing athletes, the 10 degrees reduction in shoulder external rotation makes it difficult to return to the previous performance level, although it does not affect daily activity. To prevent shortening of the AIGHL length, an AIGHL reconstruction was developed using fascia lata graft. Preliminary clinical results in overhead throwing athletes showed that a throwing program could start with complete restoration of maximum shoulder external rotation angle 3 months after AIGHL reconstruction. In this study the effect of AIGHL reconstruction on shoulder external rotation and anterior stability for simulated Bankart lesion in a cadaveric model of a thrower’s shoulder was evaluated (Fig. 1). Methods: Eight cadaveric shoulders were tested at 60° of glenohumeral abduction (90° of shoulder abduction) to simulate throwing motion. Glenohumeral translations at 60° and 90° of external rotation, maximum humeral rotational range of motion, and humeral head shift were measured using goniometer and MicroScribe 3D-digitizer. Each specimen was subjected to five experimental stages: (1) intact condition; (2) simulation of thrower’s shoulder by anterior capsular stretching based on previously reported method; (3) creation of Bankart lesion (AIGHL and the labrum were detached at glenoid side); (4) Bankart repair using three suture anchors; and (5) AIGHL reconstruction using allograft of fascia lata. In the AIGHL reconstruction, allograft was patched between the detached AIGHL and glenoid at maximum shoulder external rotation position to restore the original AIGHL length (Fig. 2). For statistical analysis, linear mixed-effects model and Tukey’s post-hoc analysis were used. Results: After 20% stretching, shoulder external rotation and anterior translation were significantly increased (intact 128.3° and 2.8mm, thrower’s shoulder 141.9° and 7.3mm, p&lt;0.001). Creation of Bankart lesion significantly increased anterior translation (8.3mm) compared with intact condition (p=0.021). Bankart repair completely restored anterior translation (3.0mm) to intact level; however, maximum shoulder external rotation angle after Bankart repair (134.8°) was significantly less than that in thrower’s shoulder (p=0.009). AIGHL reconstruction completely restored anterior translation (6.5mm) to thrower’s shoulder without decreasing maximum shoulder external rotation angle (144.4°) compared with thrower’s shoulder (Fig. 3 &amp; 4). At maximum humeral external rotation, the humeral head was significantly shifted superiorly after creation of Bankart lesion compared with intact condition(p=0.005). After Bankart repair, the humeral head was significantly shifted inferiorly from the Bankart lesion (p=0.003) and was significantly inferior relative to the position after AIGHL reconstruction (p=0.007). Conclusions: While Bankart repair completely restored anterior translation to the intact level (tighter than thrower’s shoulder), AIGHL reconstruction completely restored to the thrower’s level. Furthermore, maximum shoulder external rotation angle was maintained after AIGHL reconstruction although Bankart repair decreased external rotation significantly. Therefore, AIGHL reconstruction can be a useful surgical option for Bankart lesion in overhead throwing athletes to restore anterior stability while maintaining maximum shoulder external rotation angle after surgery.

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.

Effect of different loads on the shoulder in abduction postures: a finite element analysis

Load can change the mechanical environment of dynamic and static stable structures of the shoulder joint, increase the risk of tissue damage and affect the stability of the shoulder joint, but its biomechanical mechanism is still unclear. Therefore, a finite element model of the shoulder joint was constructed to analyze the mechanical index changes of shoulder joint abduction under different loads. The stress of the articular side on the supraspinatus tendon was higher than that of the capsular side, with a maximum difference of 43% due to the increased load. For the deltoid muscle and glenohumeral ligaments, increases in stress and strain were obvious in the middle and posterior deltoid muscles and inferior glenohumeral ligaments. The above results indicate that load increases the stress difference between the articular side and the capsular side on the supraspinatus tendon and increases the mechanical indices of the middle and posterior deltoid muscles, as well as the inferior glenohumeral ligament. The increased stress and strain in these specific sites can lead to tissue injury and affect the stability of the shoulder joint.

Repair of a Reverse HAGL: A 2-Portal Technique

Background: Glenohumeral joint stability is reliant on a combination of static and dynamic constraints. Humeral avulsion of the posterior band of the inferior glenohumeral ligament (HAGL) is an exceedingly rare injury. These injuries can be difficult to diagnose and can lead to continued pain, dysfunction, and recurrent instability. There is a paucity of literature regarding surgical management of reverse HAGL lesions. Indications: Many intrasubstance reverse HAGL lesions can be managed nonoperatively with rehabilitation focused on improving shoulder stability. Although the incidence of recurrent instability in patients with reverse HAGL lesions is unknown, the acute detached humeral lesions in athletes are often treated surgically to restore normal shoulder. Technique Description: The patient was placed in a standard beach chair position, and the standard portals were made for a diagnostic shoulder arthroscopy. The anterior portal was the primary viewing portal. Using the initial posterior skin incision, instruments were introduced through the defect from the retracted posterior band of the inferior glenohumeral ligament. Using a combination of the 30° and 70° arthroscope, the HAGL was mobilized from the infraspinatus musculature. Two knotless suture devices (1.8-mm suture anchor, 2.6-mm suture anchor) were used to reduce the reverse HAGL lesion to an anatomical position, and the posterior capsule was closed thereafter. Results: Only case studies and a single case series have been published pertaining to reverse HAGL repair techniques and related outcomes. When diagnosed and treated appropriately, arthroscopic repairs yield promising results with a high percentage of patients returning to prior level of activity or returning to prior participation level in sport. However, outcome data are limited given the rare occurrence of this injury pattern. Discussion/Conclusion: Reverse HAGL pathology can be treated effectively with arthroscopic surgical repair to restore the normal capsular anatomy and prevent recurrent instability and persistent posterior shoulder pain. Using a 2-portal approach with posterior capsular closure is a minimally invasive operation that allows for appropriate management of these rare injuries. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

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.

Arthroscopic findings of the glenohumeral joint in symptomatic anterior instabilities: comparison between overhead throwing disorders and traumatic shoulder dislocation.

The term shoulder instability refers to a variety of mechanisms and clinical presentations. One of the common pathologies of throwing disorders is internal impingement with anterior instability. Most throwing athletes with symptomatic internal impingement with anterior instability exhibit positive apprehension and relocation test results, whereas those with recurrent anterior shoulder instability display positive apprehension test results. While the glenoid labrum-inferior glenohumeral ligament complex is a significant critical stabilizer for the prevention of anterior shoulder dislocation, the characteristics of the essential lesion in internal impingement with anterior instability have not been determined yet. This study aimed to compare the intra-articular lesion of athletes with internal impingement related to the overhead throwing motion in athletes with a traumatic shoulder dislocation. Sixty-one athletes (all men; mean age, 25.2±12.6yr) who underwent an arthroscopic procedure were divided into 2 groups: 25 in the throwing group and 36 in the dislocation group. All shoulders had subtle glenohumeral instability defined by a positive anterior apprehension test and a relocation test. Those with voluntary and multidirectional instability and large glenoid bone loss (more than 25%) were excluded from the current study. All shoulders were evaluated for the following evidence: rotator cuff injury, superior labrum tear anterior and posterior lesions, labral pathologies including Bankart lesions, osteochondral lesions to the humeral head, biceps tendon fraying or rupture, and inferior glenohumeral ligament and middle glenohumeral ligament (MGHL) conditions. Arthroscopic findings of the throwing group showed more supraspinatus injuries (92% and 25%, P<.001), type II superior labrum tear anterior and posterior lesions (60% and 3%, P<.001), posterosuperior labral lesions (92% and 39%, P<.001), and hypoplastic MGHLs (56% and 6%, P<.001) and lesser Bankart lesions (8% and 92%, P<.05) than those of the dislocation group. These results indicate that the characteristic lesions of internal impingement with anterior instability in throwing athletes include partial thickness rotator cuff tears, superior labrum tear anterior and posterior lesions, posterosuperior labral tears, and hypoplastic MGHLs. As expected, the physiopathology of internal impingement with anterior instability in throwing athletes may be related to the dysfunction of the anterosuperior glenohumeral capsular ligament, including the MGHL, rather than the inferior glenohumeral ligament as in traumatic anterior shoulder dislocations. These findings would be useful for defining treatment strategies for internal impingement with anterior instability in overhead throwing athletes.

Arthroscopic Repair of a Type VIII Superior Labrum Anterior Posterior Tear

Background: Type VIII superior labrum anterior posterior (SLAP) tears are described as SLAP type II tears with posterior extension to the posterior inferior glenohumeral ligament. These tears are a common source of pain, instability, and decreased function in active individuals, particularly overhead or throwing athletes. Indications: Type VIII SLAP tears can cause pain and loss of sports performance, especially in a throwing athlete. This patient is a quarterback and pitcher who had magnetic resonance imaging and arthroscopic evidence of a type VIII SLAP tear with pain and inability to throw at his preinjury level. Technique Description: In the lateral decubitus position, a standard posterior portal is established along with anterior and accessory lateral portals. A type VIII SLAP tear is identified and the arm is taken out of balanced suspension traction and placed in abduction and external rotation which shows displacement of the posterior labrum and peelback of the superior labrum indicating pathologic labral instability. The labrum is then elevated and glenoid prepared to achieve healthy bleeding bone. Tape sutures are then passed around the labrum and placed into a glenoid anchor starting superiorly and continuing the repair posteroinferiorly. Three anchors were placed in the superior labrum using a percutaneous technique, with 2 more placed from the posterior portal to complete the 5-anchor repair. The posterior portal is then closed with a single monofilament suture to prevent a potential stress riser in the capsule. Results: The literature suggests that athletes with type VIII SLAP tears can expect improved functional outcomes and high return to play rates (&gt;90%); however, only 50% to 70% of throwing athletes return to the same level of play. Discussion/Conclusion: Type VIII SLAP tears are an important cause of shoulder pain and dysfunction, particularly in overhead athletes. Arthroscopic repair of type VIII SLAP tears can improve functional outcomes and ability to return to sport; however, throwing athletes experience lower rates of return to previous level. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Anterior Bankart Repair With Superior Capsular Plication Causes Increased Mean Tension in Posterior Glenohumeral Capsule

The purpose of this study is to investigate if a biomechanical difference exists in the prerepair and postrepair states of the posterior inferior glenohumeral ligament (PIGHL) following anterior Bankart repair with respect to capsular tension, labral height, and capsular shift. In this study, 12 cadaveric shoulders were dissected to the glenohumeral capsule and disarticulated. The specimens were loaded to 5-mm displacement using a custom shoulder simulator, and measurements were taken for posterior capsular tension, labral height, and capsular shift. We measured the capsular tension, labral height, and capsular shift of the PIGHL in its native state and following repair of a simulated anterior Bankart lesion. We found that there was a significant increase in the mean capsular tension of the posterior inferior glenohumeral ligament (Δ= 2.12 ± 2.10 N; P= .005), as well as posterior capsular shift (Δ= .362 ± 0.365 mm; P= .018). There was no significant change in posterior labral height (Δ= 0.297 ± 0.667 mm; P= .193). These results demonstrate the sling effect of the inferior glenohumeral ligament. Although the posterior inferior glenohumeral ligament is not directly manipulated during an anterior Bankart repair, when the anterior inferior glenohumeral ligament is plicated superiorly, some of the tension is transmitted to the posterior glenohumeral ligament as a result of the sling effect. Anterior Bankart repair with superior capsular plication results in an increased mean tension of the PIGHL. Clinically, this may contribute to shoulder stability.

Arthroscopic Subscapularis Tendon Repair Using the Lasso-Loop Technique Through Anterolateral Viewing Portal

The subscapularis is the strongest muscle among the rotator cuff muscles, and it provides a coupled balanced force across the glenohumeral joint by resisting the infraspinatus in axial plane and the shearing force of deltoid in the coronal plane. It is important to repair subscapularis tears to maintain the coupled balanced force. Subscapularis tendon tears are difficult to diagnose and treat. Only a small portion of the subscapularis tendon is visualized during routine arthroscopy, as it is largely covered by the middle and inferior glenohumeral ligaments. Various repair techniques have been described in the literature. Here, we describe the anterolateral viewing portal for better visualization of subscapularis and our preferred technique, the lasso-loop technique, which provides better tissue grip and improved functional outcome.

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.

Anterior Shoulder Ligamentoplasty as a Treatment for Multidirectional Shoulder Instability

Multidirectional shoulder instability represents an ongoing challenge for orthopaedic surgeons, and multiple techniques have been described to treat this condition. We present a modified anterior shoulder ligamentoplasty, in which we perform an inferior glenohumeral ligament (IHGL) anteroinferior and posteroinferior plication and, subsequently, an anterior reinforcement ligamentoplasty with an allograft through the subscapularis tendon, with humeral and glenoid fixation. This arthroscopic technique allows shoulder stability in the throwing position, as the humeral head is not uncovered in abduction, and external rotation by ascending the subscapularis tendon.

Role of middle glenohumeral ligament in external shoulder rotation

The middle glenohumeral ligament (MGHL) is one of the three ligaments that stabilize the anterior capsule of the shoulder. Recent work suggests that it inserts distally into the deep layer of the subscapularis tendon. The role of the MGHL remains debated. The hypothesis of this study was that the MGHL plays a significant functional role in limiting external rotation of the shoulder while allowing a wide range of motion through its distal insertion into the subscapularis rather than directly onto the humerus. In a cadaveric study performed on 20 shoulders (10 subjects), the MGHL and the other anterior structures of the shoulder were successively cut according to a standardized protocol. At each stage, the external rotation range of the shoulder was measured with the arm at the side (ER 1) and in 90° abduction (ER 2) using a goniometer. After dissection, the structure of the MGHL and its distal insertion were analyzed. Cutting the MGHL led to significant increases in ER 1 but not in ER 2. Shoulder range of motion in ER 1 increased on average by 15±5° (P<.001) after cutting the MGHL and by 21±11° (P<.001) after subscapularis peel. The range of motion in ER 2 increased by 3±4° (P=.048) after cutting the MGHL, by 4±6° (P=.02) after subscapularis peel and by 25±8° (P<.001) after cutting the inferior glenohumeral ligament. The MGHL was present in all dissected shoulders. It was leaf-like in 12 cases, cord-like in 6 cases and had a vestigial appearance in 2 cases. The distal insertion was in all cases in the deep layer of the subscapularis in a thickening of the anterior capsule in the superior part of the muscle, except for two cases in which the tendinous part of the subscapularis was also involved. The MGHL limited shoulder external rotation by a similar amount as the subscapularis muscle. Further studies are required to understand the clinical relevance of these findings, notably for the treatment of shoulder stiffness.

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

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

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.

RECURRENT ANTERIOR SHOULDER DISLOCATION TREATED BY OPENINFERIOR GLENOHUMERAL LIGAMENT RECONSTRUCTION

The anterior capsulolabralcomplex repair with inferior glenohumeral ligament reconstruction has been encouraging predominantly in young active population, and heavy workers with traumatic anterior shoulder dislocation. The aim of this study was to assess the clinical outcome of patients who underwent inferior glenohumeral ligament reconstruction for recurrent traumatic anterior shoulder instability by the open method. A prospective study of 40 patients with a mean age of 30 years ( 20 – 50 years ) who underwent open reconstruction of the inferior glenohumeral ligament ( RIGHL) to treattraumatic recurrent anterior shoulder dislocation was conducted. All patients met the criteria for inclusion in the study. They had traumatic anterior shoulder dislocation with subsequent recurrent instability. All were males with no professional athletes among them. Detachment of the dominant shoulder from the glenoid marginwas found in all cases . No patient had surgical intervention before. Twenty patients had the right shoulder affected. All patients were evaluated by physical examination and followed for a minimum of 6 months (15-80 months). Rowe score was used for the clinical assessment of patients. The mean modified Rowe score was 93.3% (65% -100%) with 92.3% good and excellent results. There were 14 excellent, 10 good, 5 fair, and 3 poor results due to redislocation after major trauma ( RTA). There was no loss of range of motion compared to preoperative values. These observations point out that glenoid sided capsulolabral repair can reestablish shoulder stability in patients with recurrent traumatic anterior dislocation, and success rates comparable to those of other open anterior shoulder repair procedures can be achieved. Although arthroscopic repair for recurrent shoulder instability is a choice for most surgeons nowadays, open repair remains an excellent option and should not be forgotten especially with the lack of experience or arthroscopic availability.