Reverse humeral avulsion glenohumeral ligament and infraspinatus rupture with arthroscopic repair: a case report

Repair of a Reverse Humeral Avulsion of the Glenohumeral Ligament and a Supraspinatus Tear in a Division I Collegiate Football Player: A Case Report

CASE

We present the case of a 21-year-old male, collegiate division I wide receiver, with a humeral avulsion of the posterior glenohumeral ligament (RHAGL) and near-full-thickness supraspinatus tear after falling on his outstretched arm. He returned to full collegiate participation with symptom resolution after arthroscopic repair of each tear.

CONCLUSION

This case report emphasizes the importance of imaging studies in the diagnosis of RHAGL and details a treatment approach that provided an excellent result in a young, active patient. This information will bring attention to these rare injuries and provides reference for providers who encounter patients with similar symptoms or pathology.

Imaging Posterior Instability of the Shoulder

Posterior instability of the shoulder is much less common than anterior instability with a clinical presentation that is often less obvious, making the diagnosis more challenging and more easily missed. We describe the imaging findings of posterior instability so the radiologist can make the diagnosis and provide a detailed description, enabling the surgeon to make more informed decisions regarding management and surgery.

Isolated infraspinatus musculotendinous junction tear treated with open repair and dermal allograft augmentation: a case report with 5-year outcome

We report the 5-year outcome of an isolated, atraumatic full-thickness infraspinatus myotendinous junction tear treated with open surgical repair. The index patient developed severe pain and weakness in external rotation strength following a subacromial corticosteroid injection. Magnetic resonance imaging and ultrasound of the shoulder demonstrated a full-thickness myotendinous junction tear with extensive muscle edema, mild atrophy and a spinoglenoid notch varix. Due to persistent, worsening pain and presence of ER weakness, the patient underwent primary infraspinatus muscle–tendon repair with allograft augmentation via an arthroscopic-assisted open posterior approach. The patient had an uneventful postoperative course with a resolution of pain and improvement in ER strength, which is maintained at the latest 5-year follow-up. This case report highlights a favorable long-term outcome of an isolated infraspinatus myotendinous junction tear treated with primary muscle–tendon repair and dermal allograft augmentation.

Humeral Avulsion of the Glenohumeral Ligament: Diagnosis and Management

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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.

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A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity.

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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.

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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.

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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.

The glenohumeral ligaments: Superior, middle, and inferior: Anatomy, biomechanics, injury, and diagnosis

The three glenohumeral ligaments (superior, middle, and inferior) are discrete thickenings of the glenohumeral joint capsule and are critical to shoulder stability and function. Injuries to this area are a cause of significant musculoskeletal morbidity. A literature search was performed by a review of PubMed, Google Scholar, and OVID for all relevant articles published up until 2020. This study highlights the anatomy, biomechanical function, and injury patterns of the glenohumeral ligaments, which may be relevant to clinical presentation and diagnosis. A detailed understanding of the normal anatomy and biomechanics is a necessary prerequisite to understanding the injury patterns and clinical presentations of disorders involving the glenohumeral ligaments of the shoulder.

Posterior shoulder instability due to isolated reverse HAGL lesion in a young gymnast: A rare mechanism of injury and surgical technique

Humeral avulsion of the inferior glenohumeral ligament (HAGL) is a relatively important cause of shoulder instability, becoming a field of interest in the literature. Reverse HAGL lesions, a rare pathology compared to anterior disruptions; have been documented in only few cases as a notable cause of posterior instability. We describe in detail the mechanism of injury, diagnosis, arthroscopic repair and results.

Arthroscopic repair of a posterior bony humeral avulsion of the glenohumeral ligament with associated teres minor avulsion

Humeral avulsion of the inferior glenohumeral ligament (HAGL) has recently gained more recognition as a cause of shoulder instability. Posterior HAGL lesions, being much more infrequent than anterior disruptions, have only recently been documented as a notable cause of posterior instability. We detail the treatment of a previously unreported case of a posterior HAGL variant lesion consisting of a bony avulsion with involvement of the teres minor tendon. Arthroscopic fixation was facilitated by use of a "sheathless" arthroscopic approach with a 70° arthroscope and suture anchor.

Humeral avulsion of glenohumeral ligaments

Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. HAGL lesions are the result of acute traumatic glenohumeral subluxation or dislocation. Anterior avulsion of the inferior glenohumeral ligament from the humeral neck is the more common lesion; however, posterior lesions are seen as well. Careful history and physical examination are critical in the diagnosis of HAGL lesions. MRI is the best imaging study for diagnosing these lesions. Injection of intra-articular contrast dye aids in visualization. Most HAGL lesions cause recurrent instability and require surgical repair. Arthroscopic repair with the use of accessory portals has yielded promising results. Excellent results have been achieved with open surgical management using a subscapularis incision. Mini-open techniques involve limited incision in the lower one half of the subscapularis.

Glenoid avulsion of the glenohumeral ligaments as a cause of recurrent anterior shoulder instability

Although the Bankart lesion is accepted as the primary pathology responsible for recurrent shoulder instability, recognition of other soft-tissue lesions has improved the surgical treatment for this common problem. Whereas humeral avulsion of the glenohumeral ligaments has been acknowledged as a cause of anterior shoulder instability, we have not found any reported cases of glenoid avulsion of the glenohumeral ligaments. We describe 3 cases of recurrent anterior shoulder instability due to glenoid avulsion of the glenohumeral ligaments. The avulsed ligaments were repaired to the labrum and glenoid, restoring the glenohumeral ligament-labral complex.

Posterior shoulder instability secondary to reverse humeral avulsion of the glenohumeral ligament

BACKGROUND

Posterior shoulder instability resulting from a disruption of the posterior capsular structures has been reported. We present the largest series of these injuries in the published literature, propose a definition and highlight the clinical presentation, radiological findings, and associated injuries.

MATERIALS AND METHODS

A retrospective review of a single shoulder surgeons database was performed identifying posterior instability cases associated with disruption of the posterior capsule. Chart, radiological imaging, and intra-operative findings were reviewed.

RESULTS

Nineteen patients were identified with an average age lower than the overall posterior instability group. All occurred via a traumatic mechanism, the most common being a forced cross-body adduction. The only consistent symptom was posterior joint line pain. MRI reporting was found to be only 50% sensitive, increased to 78.6% when reviewed by the treating surgeon. Associated injuries are common with 58% having a labral tear, 32% a SLAP lesion, 26% a reverse Bankart lesion, 21% a chondral injury, 21% rotator cuff injury, and 11% extension of the tear into the posterior band of the inferior glenohumeral ligament.

DISCUSSION

Disruption of the posterior capsule is a rare cause of recurrent posterior instability. There are no specific symptoms that identify the injury, though a mechanism of forced cross-body adduction should raise suspicion. Identification of the injury requires specific attention to the posterior capsule on MRI, preferably performed with the arm in slight external rotation and routine visualization of the posterior capsule via viewing from the anterior portal.

Imaging findings in posterior instability of the shoulder

Posterior shoulder instability refers to the symptoms and signs resulting from excessive posterior translation of the humerus. Magnetic resonance (MR) imaging is the radiological modality of choice in the diagnostic assessment of posterior instability. Computed tomography (CT) is useful in the evaluation of osseous abnormalities associated with posterior instability. A detailed description of the posterior osseous and labroligamentous abnormalities has evolved recently, and many variant lesions of the posteroinferior labrum and/or capsular structures have been described. As the recommended surgical management of lesions associated with posterior instability is a lesion-specific approach, awareness of the specific lesions that have been described in association with posterior instability helps in pre-surgical planning. The purpose of this article is to review the classification of, and injury mechanisms leading to, posterior shoulder instability and to describe imaging findings associated with posterior instability, with emphasis on MR imaging.