24 Anterior Humeral Avulsion of the Glenohumeral Ligament Repair

10.1055/b-0039-167673

24 Anterior Humeral Avulsion of the Glenohumeral Ligament Repair

Nirav K. Patel, Kathryn Crum, and Christopher C. Dodson

Abstract

Humeral avulsion of the glenohumeral ligament (HAGL) occurs in 1 to 9% of patients, ¹ usually from anterior subluxations or dislocations causing avulsion of the capsule and inferior glenohumeral ligament (IGHL) from the humerus. They are an important and often difficult-to-diagnose cause of anterior shoulder instability, occurring in slightly older patients (>30–35 years) and with a higher risk of recurrent instability than those with Bankart lesions. Surgical repair of HAGL lesions can be performed via open or arthroscopic techniques in some cases, but open repair provides better access and thus remains the focus of the chapter.

24.1 Goals of Procedure

The goal of treatment of anterior glenohumeral joint instability is to return to stability, full range of motion, and strength. Specifically, the integrity of the anterior capsulolabral complex must be restored, with reattachment of the HAGL lesion.

24.2 Advantages

Repair of an HAGL lesion restores anterior glenohumeral stability and prevents recurrent episodes. This, in turn, reduces the long-term risks of glenohumeral arthritis or failure after operative Bankart repair.

24.3 Indications

Detached HAGL lesion and the following:

Recurrent anterior glenohumeral instability.
Recurrent pain despite activity modification and physical therapy.
Young athletes or manual laborers, who are at risk of recurrent instability.

24.4 Contraindications

Neuropathic shoulder.
Multidirectional instability.
Noncompliant patient.
Glenohumeral osteoarthritis.
Lack of symptoms.

24.5 Preoperative Preparation/Positioning

Routine preoperative imaging of the shoulder should include true anteroposterior (neutral and internal rotation), “scapular Y,” and axillary radiographs. These images allow evaluation for concentric glenohumeral alignment, glenoid hypoplasia, glenoid version, humeral head impaction fractures, and glenoid rim fractures. MRI shows the HAGL lesion best on sagittal oblique or coronal oblique T2, fat-suppressed images. An MRI arthrogram or joint effusion distends the joint and allows for better visualization of IGHL defects ( Fig. 24.1 ). Specifically, there is conversion of the fluid distended “U-shaped” axillary pouch into a “J-shaped” structure and extravasation of the contrast material or joint effusion across the torn humeral attachment. Based on the MRI findings, HAGL lesions can be classified using the West Point Classification system, ² which includes six types: anterior HAGL, anterior bony HAGL, floating anterior IGHL, posterior HAGL, posterior bony HAGL, and floating posterior IGHL.