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Arthroscopic technique provides effective repair of HAGL lesions

Issue: January 2013

ByAnthony A. Romeo, MD

ByBernard R. Bach Jr., MD

ByFrank M. McCormick, MD

ByBenjamin Bruce, MD

ByAnil Gupta, MD

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Although there are no studies comparing the efficacy of arthroscopic vs. open repair of humeral avulsion of the glenohumeral ligament lesions, we believe that arthroscopic repair may provide less morbidity, earlier recovery and more rapid return to preoperative activity level vs. open repair. Successful arthroscopic treatment is predicated on satisfactory exposure and access to the proximal humerus though appropriate portal placement. In our experience, the lateral decubitus position with an axillary bump and the arm in 15° of flexion and 50° of abduction provides maximal access to this area.

A standard posterior portal for the lateral position is established, approximately 1 cm medial to the border of the acromion and 1.5 cm to 2 cm distal to this landmark. An anterior-superior working portal is created in the rotator interval with outside-in needle localization technique. In addition to evaluation of the inferior glenohumeral ligament (IGHL) and axillary pouch, a complete diagnostic arthroscopy should be completed to evaluate for labral pathology, rotator cuff tears or bony defects, and should include views from both the posterior and anterior portals.

Although there are various methods to arthroscopically address a humeral avulsion of the glenohumeral ligament (HAGL) lesion, the key principle is access to the inferior aspect of the glenohumeral joint from both anterior and posterior directions, as well as the ability to insert fixation on the humerus at the site of the attachment of the anterior band of the inferior glenohumeral ligament. This can be accomplished by establishing a posterior-inferior portal at the 7 o’clock position using an 8.25-mm cannula, and either percutaneous or cannula access from the 5 o’clock portal anteriorly. Establishing a safe 5 o’clock portal can be facilitated by using an 18-gauge spinal needle to confirm appropriate trajectory to the inferior aspect of the humerus. The skin incision will need to be medial in order to achieve a satisfactory angle onto the humerus (Figure 1). Keeping the trajectory towards the inferior humerus will avoid injury to the axillary nerve.

 

Figure 1. Portal placement on the anterior aspect of a right shoulder is demonstrated. Two superior portals run through the rotator interval and a 5 o’clock portal is used.

Images: Romeo A

A HAGL lesion should be addressed before any labral pathology. If both lesions are present, care should be taken to perform an anatomic repair of the ligament and avoid shortening the length of the ligament, which could result in an excessively tight anterior repair. After a standard debridement has been performed to improve visualization, simulated reduction of the torn lateral edge of the IGHL is performed with an arthroscopic grasper from either the anterior-inferior or posterior-inferior portals (Figure 2). With the arthroscope in the posterior portal, a burr is inserted through the anterior portal to prepare the humeral surface. If this angle does not provide the ability to prepare the humeral insertion site, it can also be approached through the 5 o’clock portal (Figure 3).

 

Figure 2. Reduction of the capsule to the humerus with an arthroscopic tissue grasper is shown.

 

Figure 3. This view from the anterior portal demonstrates the prepared surface of the humerus. 

A suture anchor is placed in the humerus after preparation of the bone with the burr. The anchor may be inserted through the 5 o’clock portal with external rotation of the humerus or a separate, percutaneous placement can be accomplished by a more medial portal. This is predetermined using a spinal needle to identify the best trajectory (Figures 4a and 4b). Internal or external rotation of the arm is often useful to provide full access to the anatomic footprint of the ligament insertion. Davidson critically evaluated this portal in a cadaver study. The distance from the portal and the axillary nerve was 39±4mm. The position of the arm had no effect on changing the distance from the nerve.

 

Figure 4a. Needle localization of the ideal trajectory for percutaneous anchor placement is shown. The skin incision may need to be on the chest wall in order to obtain satisfactory anchor placement on the humerus.

 

Figure 4b. A double-loaded suture anchor is inserted on the prepared surface of the humerus.

 

Figure 5. Two separate limbs from a double-loaded suture are retrieved from the anterior working portal.

One limb of the anchor suture is brought through the anterior portal, and the other limb through the posterior portal. If the anchor is loaded with two sutures, then each suture limb is passed before the knots are tied (Figure 5). The suture is passed through the anterior aspect of the ligament detachment, with the other end of the same suture passed through the posterior aspect of the ligament or the remaining intact capsule just beyond the posterior site of the humeral detachment (Figure 6a). When the suture is tied with a mattress configuration from within the glenohumeral joint, it will bring the ligament up ot the prepared humerus and incorporate the remaining intact ligament. There are numerous disposable and reusable arthroscopic suture-passing tools that can accomplish this task. A sliding knot is used to assist with reduction and fixation of the detached ligament and capsule. The arm should be in neutral abduction and rotation during tensioning of the repair. Once the humeral detachment is fixed, it is likely that side-to-side sutures will be indicated to close the portion of the tear that represents the medial-to-lateral split within the torn tissue and intact native capsule (Figure 6b). It should be noted that these sutures, including the sutures from the anchors, are tied on the intra-articular side of the capsule and ligaments to allow for full arthroscopic visualization.

More anterior anchors with similar fixation technique may be required to achieve satisfactory anatomic repair of the HAGL. The capsule should be fixed to the humerus after final anchor placement (Figure 7).

 

Figure 6a. A single-step suture passing device is used to pass the suture through the capsule.

 

Figure 6b. Side-to-side sutures are used to finish the repair. 

Postoperatively patients are placed in a shoulder immobilizer maintaining the arm in neutral or slight internal rotation for 4 weeks. Supine-assisted passive forward flexion to 90°, as well as external rotation to 20°, is started within 3 days to 5 days of the surgical procedure and continued for the first 4 weeks. Isometric exercises involving all rotator cuff components are begun at 2 weeks postoperatively. Resistance exercises are typically begun at 6 weeks, with more aggressive strengthening, including weight training, started by 3 months after surgery. By 4 months, sports-specific training is instituted, including a return to throwing program for overhead athletes. Full training without restrictions, including throwing from a pitching mound or collision sports, has been accomplished for most athletes by 6 months after surgery.

HAGL lesions can result from traumatic events or repetitive microtrauma. Nicola was the first to report that the inferior glenohumeral ligaments could fail at the humeral insertion site, in four out of five acute cases of dislocations, and in six out of 25 recurrent dislocators. Nicola evaluated the likely mechanism of this pathology, and found it to be in 105° of hyperabduction and external rotation.

Bigliani’s biomechanical cadaver study thoroughly evaluated the inferior glenohumeral ligament complex. In testing the ligament complex to failure, 25% resulted in HAGL-type lesions in an in vitro setting. The anterior band of the inferior glenohumeral ligament is the most common structure involved.

 

Figure 7. A repaired HAGL lesion is shown. 

Bach was the first to report on two cases of disruption of the lateral capsule and subsequent open repair. Both patients had a good result after open repair of the lateral capsule avulsion injury back to the humeral neck. Wolf, in his report on six HAGL lesions, was able to address this lesion arthroscopically in four of the six patients with tying sutures over top of the subscapularis. Bokor reported on 41 HAGL lesions and found these lesions to occur in a slightly older patient population, with the first time dislocation being violent in nature.

A HAGL should be ruled out in cases of anterior shoulder instability, even if a Bankart lesion is identified. MRI plays a pivotal role in preoperative diagnosis, but arthroscopy remains the gold standard for identification of this pathology. Once identified, the HAGL can be successfully managed with open or arthroscopic approaches. Appropriate patient selection and a thorough understanding of glenohumeral capsuloligamentous anatomy, and the ability to directly approach the site of the avulsion either through an open incision or unique arthroscopic portals is required to yield a successful outcome.

HAGL lesions can be repaired with open or arthroscopic techniques. Both are safe, reproducible, and effective at re-establishing the inferior glenohumeral ligament complex. In addition to typical patients with anterior instability symptoms, this lesion should be evaluated and treated in overhead athletes.

A note from the editors

Part 1 of this technique appeared in the December issue.