Clinical Outcomes in Patients With Humeral Avulsion Glenohumeral Ligament Lesions in the Setting of Anterior Shoulder Instability: A Retrospective Comparative Study

Long-term Outcomes After Open Repair of Humeral Avulsion of the Glenohumeral Ligament

Background

There is a lack of data regarding the long-term clinical outcomes of open repair of humeral avulsion of the glenohumeral ligament (HAGL).

Purpose

To examine the long-term patient outcomes, prevalence of related shoulder lesions, and return to sports in patients who have had open HAGL repair.

Study Design

Case series; Level of evidence, 4.

Methods

Included were 47 patients who underwent open repair of an HAGL lesion between 1995 and 2013. Clinical results were assessed using the Western Ontario Shoulder Instability Index (WOSI). Recurrence of instability, additional surgeries, confidence in the shoulder, level and type of sport before and after surgery, and return to sports were documented.

Results

The mean follow-up duration was 105 months (range, 16-247 months). The mean postoperative WOSI score was 410. Postoperatively, 10 patients experienced a recurrence of instability. Subgroup analysis of patients who reported recurrence demonstrated significantly worse WOSI scores compared with patients who did not experience recurrence (730 [95% CI, 470-990] vs 320 [95% CI, 210-430], respectively; P = .007). Before surgery, 33 patients participated in competitive sports, compared with 22 patients after surgery. No postoperative neurologic or vascular complications were recorded. In 51% of patients, a labral tear was noted as a concomitant injury.

Conclusion

Open repair of an HAGL lesion restored shoulder stability with good results. However, recurrence was significant (21%) with longer follow-up, and return to sports was affected. Associated lesions were prevalent.

Case report: unusual posteromedial capsular lesion with posterior lateral meniscus root tear in two patients with constitutional genu recurvatum presenting after an acute ACL injury

Ramp lesions of the medial meniscus and posterior lateral meniscus root tears (LMPRT) can be present simultaneously in up to 8% of patients undergoing anterior cruciate ligament (ACL) reconstruction. The prevalence of these complex and highly unstable meniscal tears increases exponentially with the severity of the injury. The posteromedial capsule (PMC) has often been disregarded in the past when discussing ligamentous and meniscal injuries, but the recent interest in ramp lesions has drawn surgeons' attention to the posteromedial structures of the ACL injured knee. While the meniscocapsular junction is commonly repaired in unstable ramp lesions, in the current literature there is no report regarding proximal PMC lesions, be they in isolation or associated with complex meniscal injuries.We report here two cases of proximal posteromedial capsular lesions associated with medial meniscus instability and posterior lateral root tears after ACL injury. The first case involves a meniscus ramp lesion associated with a proximal PMC tear and a posteromedial fluid collection in the muscle plane on magnetic resonance in a 22-year-old male soccer player. The second case involves a 21-year-old female soccer player who presented with a PMC lesion after hyperextension/valgus knee injury. The capsular lesions were repaired to restore capsular tension and improve medial meniscus posterior horn stability.

Clinical Outcomes and Return to Sports After Arthroscopic Repair of Humeral Avulsion of the Glenohumeral Ligament: A Meta-Analysis

This study aimed to evaluate the 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 mean Western 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) of 54.47 (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.

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

Purpose

To provide an updated overview of recent literature regarding the clinical indications, management, and outcomes of humeral avulsions of the glenohumeral ligament (HAGL) lesion.

Methods

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.

Results

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.

Conclusions

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.