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

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

Purpose

The purpose of this systematic review was to evaluate patient outcomes following arthroscopic surgical management for a humeral avulsion of the glenohumeral ligament (HAGL) lesion.

Methods

Based 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.

Results

Overall, 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%).

Conclusion

The 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.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.