Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability

Traumatic anterior dislocation of the shoulder: factors affecting the progress of the traumatic anterior dislocation

Background

The aim of this study was to identify the factors that affect the progress of a traumatic anterior dislocation of the shoulder.

Methods

Two hundred and thirty-eight patients (246 shoulders) with a traumatic anterior dislocation were enrolled in this study. The mean age at the time of surgery was 25 years (range, 14 to 47 years). There were 214 men and 24 women.

Results

One hundred and sixty-four shoulders (67%) were younger than 20 years at the time of the first dislocation. Patients younger than 20 years showed a shorter interval of redislocation (p = 0.001) and a higher frequency of dislocation (p = 0.001). Athletic patients experienced their first dislocation at a younger age (p = 0.023) and showed a shorter interval of redislocation (p = 0.001) than their non-athetic counterparts. The incidence of classic and non-classic Bankart lesions was unaffected by age at the time of the first dislocation, interval between the first and second dislocation or the frequency of dislocation. Patients with bony Bankart lesions had a higher frequency of dislocation (p = 0.043).

Conclusions

The age at the time of the first dislocation and athletic activity were related to early redislocation and a high frequency of dislocation. Bony Bankart lesions were observed more often in patients with a higher frequency of dislocation. Early surgical treatment is a good option for young athletic patients with a bony Bankart lesion and a short interval between the first and second dislocation.

Irreparable capsule tears in initial surgery for glenohumeral instability: report of two cases treated with iliotibial band autograft

Anterior shoulder instability due to massive capsular tearing can usually be repaired by suturing the torn ends together with a satisfactory result. The purposes of this report are to demonstrate the presence of capsular deficiency irreparable by primary sutures even in an initial surgical intervention and to ponder the cause of primary irreparability. We documented the surgical reconstructive technique using the iliotibial band and the subsequent postoperative results in two cases. To our knowledge, there have been no such cases with primarily irreparable capsular tear.

Complications associated with anterior shoulder instability repair

Anterior shoulder instability is a common orthopaedic problem, and the surgical treatment, both open and arthroscopic, has been shown to effectively restore stability and prevent recurrence. However, despite success with these surgical techniques, there are several clinically relevant complications associated with both open and arthroscopic techniques for anterior shoulder stabilization. These complications can be subdivided into preoperative, intraoperative, and postoperative and include entities such as nerve injury, chondrolysis, incomplete treatment of associated lesions, and subscapularis dysfunction. When they occur, complications may significantly impact patient outcomes and function. Therefore, surgeon awareness and identification of the factors associated with these complications may help prevent occurrence. Although failure of instability repair can be classified as a complication of surgery, it requires an entirely separate discussion and is therefore not addressed in this article. Because most of the previously published studies on anterior shoulder instability have emphasized surgical technique and clinical outcomes, the purpose of this article is to define the complications associated with anterior instability repair and provide recommendations on techniques that may be used to help avoid them.

Clinical update: MR imaging of the shoulder

Magnetic resonance imaging has become an important diagnostic adjunct in the evaluation of shoulder conditions, and the technology continues to evolve. Direct magnetic resonance arthrography can improve detection of labral and rotator cuff pathology, especially partial thickness tears of the rotator cuff. Special positioning, such as abducted-externally rotated views, improves visualization of the rotator cuff and posterior superior labrum in throwing athletes. Diagnosis-specific sequencing such as fat suppression, spin-echo and proton-density techniques, and higher power magnets (3.0 T) allow for an unprecedented level of soft tissue detail. Clinical expertize is required to differentiate between normal anatomic variants, incidental findings, and true pathology. Although magnetic resonance imaging findings may be diagnostic in some cases, clinical correlation with history and physical examination findings is critical.

Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion: anterior and posterior techniques

Humeral avulsion of the inferior glenohumeral ligament complex is an unusual pathology, often implicated in traumatic shoulder instability. Traditional open techniques involve at least partial detachment of the subscapularis, and arthroscopic techniques are limited by neurovascular boundaries. The technique described here presents an anterior and posterior arthroscopic approach that can be used individually or in combination to treat different types of humeral avulsion of the inferior glenohumeral ligament lesions. The anterior approach is based on anatomic guidelines described in the literature. The posterior approach is based on the arthroscopic and cadaveric anatomic studies described by one of the authors (D.N.B.); use of the recently described axillary pouch portal (Bhatia portal) permits safe arthroscopic instrumentation access in the entire inferior glenohumeral recess and provides adequate access to the posteroinferior aspect of the humeral head. The differential mattress stitch technique ensures secure fixation of the avulsed ligaments and eliminates excessive capsular redundancy. Technical tips to avoid complications are discussed, and a detailed rehabilitation protocol is presented.

Humeral avulsion of the glenohumeral ligament: injury pattern and arthroscopic repair techniques

The arthroscopic treatment of a humeral avulsion of the glenohumeral ligaments lesion allows for a safe, reproducible, and effective way to reestablish the inferior glenohumeral ligament and capsular complex to the humerus.

Shoulder biomechanics

The biomechanics of the glenohumeral joint depend on the interaction of both static and dynamic-stabilizing structures. Static stabilizers include the bony anatomy, negative intra-articular pressure, the glenoid labrum, and the glenohumeral ligaments along with the joint capsule. The dynamic-stabilizing structures include the rotator cuff muscles and the other muscular structures surrounding the shoulder joint. The combined effect of these stabilizers is to support the multiple degrees of motion within the glenohumeral joint. The goal of this article is to review how these structures interact to provide optimal stability and how failure of some of these mechanisms can lead to shoulder joint pathology.

Humeral avulsion of the glenohumeral ligaments: the HAGL lesion

BACKGROUND

Anterior instability of the shoulder is a frequently encountered clinical problem that is seen after avulsion of the capsulolabral complex from the glenoid rim (Bankart lesion). Recently, it has been determined that avulsion of the glenohumeral ligaments is an infrequent but important cause of recurrent instability after shoulder injury. Although the various forms of this injury have been described in the literature, no standardized nomenclature exists. This is of concern given the need for different surgical approaches to repair the various forms of this injury and therefore the inherent need to accurately convey the location of the avulsion and presence of concomitant injuries.

HYPOTHESIS

Based on the available literature for humeral avulsion of the glenohumeral ligament lesions, a nomenclature can be created to enhance the understanding and improve communication about these uncommon but important pathologic changes that occur with shoulder instability.

STUDY DESIGN

Systematic review.

METHODS

The findings pertaining to 6 patients with humeral avulsion of the glenohumeral ligament lesions encountered at our institution were combined with a literature search of the MEDLINE database conducted using the PubMed search engine of the National Library of Medicine and National Center for Biotechnology Information.

RESULTS

The West Point nomenclature was developed to clearly describe the various forms of humeral avulsion of the gleno-humeral ligament lesions encountered as well as their associated injuries.

CONCLUSIONS

The West Point nomenclature provides a practical and easy to understand means by which to classify humeral avulsion of the glenohumeral ligament lesions. This allows for more effective communication, which should result in improved clinical care.

Arthroscopic shoulder stabilization: is there ever a need to open?

Recent studies show comparable results of arthroscopic shoulder stabilization techniques compared with the gold standard open Bankart reconstruction. Great technical advances and ever-increasing surgeon experience have rendered pathology once deemed an indication for open surgery as treatable by arthroscopic means. With this movement toward a more universal application of all-arthroscopic techniques, we might consider the following question: Is there ever a need to open? To answer this question, we must first consider normal anatomy and then appreciate the contribution of deranged pathoanatomy to recurrent instability in each individual case. The surgeon must then determine whether this is best addressed via an arthroscopic or open technique. Arthroscopy, as compared with open stabilization procedures, holds the potential benefits of decreased morbidity rates, early functional rehabilitation, and improved range of motion. Despite potential advantages, arthroscopic stabilization is clearly contraindicated when a significant pathologic lesion contributing to recurrent instability cannot be adequately addressed as a result of the limitations of current techniques or instrumentation. On the basis of this principle, we believe that sizable glenohumeral bone defects remain the only absolute contraindication to an all-arthroscopic approach. Many complicating issues, such as attenuated capsule, humeral avulsion of the glenohumeral ligament lesions, cases of revision surgery, and collision or contact athletes, exist and warrant close attention. We prefer to think of these situations as "challenges" for which both arthroscopic and open surgery should be considered, rather than as true contraindications to arthroscopic shoulder stabilization. We are, by no means, advocating arthroscopic treatment in all cases of shoulder instability, because this would represent a gross oversimplification of the issues at hand. However, we do acknowledge that the steadfast contraindications to arthroscopic shoulder stabilization are decreasing every day.

[Magnetic resonance imaging of glenohumeral instability: new concepts]

The shoulder is the most unstable joint in the human body and is therefore susceptible not only to acute dislocations but also to minimal states of subluxation related to overuse. The latter condition is known as microinstability and is translated clinically into internal impingement syndromes. Both in dislocations due to acute traumatism and in microinstability, a series of injuries to the glenoid lip, glenohumeral capsule, the articular cartilage, the head of the humerus, the tendons of the rotator cuff, the long tendon of the biceps, the glenohumeral ligaments, and coracohumeral ligament can occur. Glenoid lip lesions are the most common and may present as isolated lesions or in combination with lesions of any of the other structures. These lesions most often affect the anteroinferior margin of the glenoids (the classic Bankard lesion), with different characteristics and variations on its location, (Bankard variants). Another predominant location of glenoid lip lesions is the superior margin (SLAP lesions). Magnetic resonance imaging (MRI), especially after intra-articular injection of contrast material, has shown great diagnostic accuracy in this type of lesions, although the interpretation of these images requires knowledge not only of the different lesions and combinations of lesions, but also of the normal variants that can easily be confused with these lesions.

Anterior shoulder instability with humeral avulsion of the glenohumeral ligament lesion

Humeral avulsion of the glenohumeral ligament (HAGL) is a rare lesion. The purpose of this study was to analyze the clinical manifestations of HAGL lesions in patients who underwent operative treatment for anterior shoulder instability. Six patients with HAGL lesions were studied. Four patients had an HAGL lesion associated with a Bankart lesion, and two had an isolated HAGL lesion. The range of motion at final follow-up showed a loss of 1 degree in forward flexion and of 15 degrees in external rotation. During an operation to treat anterior shoulder instability, a thorough examination for not only Bankart lesions but also other associated lesions, including an HAGL lesion, should be considered to lower the risk of redislocation. In repairing an HAGL lesion, the surgeon should keep in mind the possibility of a postoperative loss of external rotation and follow an active rehabilitation protocol to obtain successful results.

Arthroscopic management of traumatic anterior shoulder instability in collision athletes: analysis of 204 cases with a 4- to 9-year follow-up and results with the suture anchor technique

PURPOSE

The purpose of this study was to determine the effectiveness of arthroscopy in the selection of surgical procedure and treatment of both acute and recurrent traumatic anterior shoulder instability in rugby players by use of pre-established selection criteria. We describe the injury mechanisms, analyze the pathologic lesions and treatment indications based on surgical findings, and assess the results in patients treated with the arthroscopic suture anchor technique.

METHODS

From November 1996 to November 2001, 204 rugby players with acute or recurrent traumatic anterior instability underwent an initial arthroscopic examination. Criteria such as type of Bankart lesion, tissue quality, and presence of bony defects were evaluated and used to determine the method of stabilization: arthroscopy or open stabilization. Open surgery was indicated in patients with bone humeral deficiencies greater than one fourth of the articular humeral head, bone glenoid deficiencies greater than 25% of the glenoid extension, capsular laxity with poor tissue quality, and humeral avulsion of the glenohumeral ligament; all other patients underwent arthroscopic reconstruction via the bone suture anchor technique.

RESULTS

The mean follow-up was 5.9 years (range, 3.9 to 8.9 years). We performed arthroscopic stabilization in 39 cases of acute instability; only 1 case (2.5%) required the mini-open technique for reinsertion of humeral avulsion of the glenohumeral ligament. Of 158 cases of recurrent instability, 121 underwent arthroscopic stabilization, and 37 (23.4%) required reconstruction with open surgery. The main cause was bony deficiency (treated with the Latarjet procedure). The results of the arthroscopic reconstructions were evaluated by use of the Rowe scale and analyzed according to stability and range of motion. Good or excellent results were found in 94.9% of cases in the acute instability group and in 91.8% in the recurrent instability group, the poor results were due to instability recurrence. In the acute instability group there were 2 cases of recurrence (5.1%) while playing rugby. In the recurrent instability group there were 10 recurrences (8.3%).

CONCLUSIONS

Arthroscopic stabilization was possible in 97.5% of our patients with acute instability and 76.6% of patients with recurrent instability based on the selection criteria for this population. We were able to obtain excellent results in 90% of cases using the suture anchor technique in rugby players with our selection criteria.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Normal anatomy and common labral lesions at MR arthrography of the shoulder

MR arthrography of the shoulder is the most accurate imaging modality in demonstrating abnormalities of the glenoid labrum and associated structures. Tears of the labrum, the capsule or the gleno-humeral ligaments can lead to pain, catching, popping or instability. The anatomy of this region is complex. We present the normal anatomy of the glenoid labrum, biceps anchor and gleno-humeral ligaments together with their normal variants and then describe common labral-ligamentous pathologies.

Arthroscopic treatment of glenohumeral instability

Arthroscopic treatment of glenohumeral instability using modern suture anchor techniques has reported recurrence rates equal to open techniques, even in high-demand contact athletes. Compared with open procedures, arthroscopic stabilization leads to less morbidity and less stiffness, leading to improved postoperative function, especially in overhead athletes. This article highlights the technical aspects of arthroscopic treatment of anterior glenohumeral instability.

Arthroscopic stabilization in anterior shoulder instability: collision athletes versus noncollision athletes

PURPOSE

Collision athletes have been reported to be at high risk of redislocation after stabilization for anterior shoulder instability. However, few studies have compared the results of arthroscopic stabilization with collision and noncollision athletes. The purposes of this study were to analyze clinical outcomes of arthroscopic anterior shoulder stabilization in athletes and to compare the results between collision and noncollision athletes.

METHODS

A total of 29 athletes were enrolled in this study, including 14 collision athletes and 15 noncollision athletes. Mean age at the time of operation was 21.1 years, and mean follow-up period was 62.1 months (range, 25 to 117 months). All shoulders underwent arthroscopic stabilization.

RESULTS

Visual analogue scale score, Rowe score, and Constant score improved after surgery (P < .05), but no statistically significant difference was found between collision and noncollision groups (P < .05). In all, 19 athletes (65.5%) returned to near preinjury sports activity levels (90% or greater recovery) after operation. Five athletes (17.2%) experienced postoperative instability. One (3.4%) had subluxation and 4 (13.8%) had redislocation after surgery. Four cases in the collision group (28.6%) and 1 in the noncollision group (6.7%) had postoperative subluxation or dislocation (P = .118).

CONCLUSIONS

Arthroscopic stabilization for anterior instability of the shoulder is a reliable procedure with respect to shoulder function, range of motion, and postoperative return to sports activities in athletes. However, a high recurrence rate (17.2%) was observed among athletes. Compared with the noncollision group (6.7%), the collision group yielded a higher failure rate (28.6%) than was expected.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Simulated humeral avulsion of the glenohumeral ligaments: a new instability model

Humeral avulsion of the glenohumeral ligaments (HAGL) is an infrequent cause of shoulder instability. Experimental studies on this lesion are rare. This study was undertaken to determine the extent of humeral-based capsuloligamentous damage required for dislocation to occur. In 65 fresh cadaver shoulders, a humeral-sided ligamentous cutting sequence was done. After each step, degree of sulcus, translation, and instability were evaluated with an electromagnetic tracking device. There was a high degree of correlation between the amount of cut done and the resulting degree of instability. The order of the ligamentous cuts had no significant influence. For a dislocation to occur at least 3 zones had to be cut. Simulated HAGL can be used as a model for shoulder instability, although further experiments are needed to validate this model fully. Extensive capsuloligamentous lesions on the humeral side seem to be required before dislocation can occur. This may be a factor explaining the relative paucity of HAGL in clinical series.

Clinical outcome of anterior shoulder instability with capsular midsubstance tear: a comparison of isolated midsubstance tear and midsubstance tear with Bankart lesion

To analyze the clinical outcomes of patients with a midsubstance capsular tear for anterior shoulder instability, 21 shoulders with a midsubstance tear were reviewed. There were 7 isolated midsubstance tears (group I) and 14 combined midsubstance tears with Bankart lesions (group II). The Rowe score averaged 92.3 points with 6 excellent and 1 good one in group I. Group II scored 86.3 points with 8 excellent, 3 good, 2 fair, and 1 poor (P = .184). The Rowe score averaged 89.8 points for the cases with an arthroscopic procedure and 86.9 points with an open repair (P = .542). At the last follow-up, forward elevation increased by 6 degrees in group I and 8 degrees in group II (P = .432). External rotation decreased by 8 degrees and 16 degrees , respectively (P = .150). The clinical outcomes of anterior instability with a midsubstance tear were good in both groups. The loss of external rotation was greater in the cases with combined midsubstance tears and Bankart lesions than in those with an isolated midsubstance tear.

MR Imaging of the Glenohumeral Ligaments

The glenohumeral ligaments, particularly the inferior one, are the major passive stabilizers of the joint, and the labrum functions as a site of ligamentous attachment. The strong union between the collagen fibers of the glenohumeral ligaments and the glenoid labrum is more resistant to injury than the union between the glenoid rim and the labrum. Labral tears associated with glenohumeral instability are therefore usually secondary to avulsion rather than impaction. This article reviews the normal MR imaging anatomy, variants and pitfalls of the glenohumeral ligaments, and the basic biomechanics of the glenohumeral ligaments. Examples of injuries involving these structures are provided.

Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair

BACKGROUND

Collision athletes are reported to be at high risk for redislocation after anterior stabilization of shoulder instability. Some authors have suggested that arthroscopic stabilization produces results similar to those of open stabilization.

PURPOSE

To evaluate the results of anterior shoulder stabilization in collision athletes and to compare the clinical results between the arthroscopic and open methods.

HYPOTHESIS

Open stabilization might produce better results than does arthroscopic stabilization in collision athletes.

STUDY DESIGN

Cohort study; Level of evidence, 4.

METHODS

Forty-eight shoulders of 46 collision athletes were enrolled for this study. The mean age of the patients at the time of surgery was 20 years, and the mean follow-up period was 72 months (range, 30-136 months). Sixteen shoulders underwent arthroscopic stabilization; 32 shoulders had open repairs.

RESULTS

Visual analog scale, Rowe, and Constant scores improved after surgery, but no statistically significant difference was found between the arthroscopic and open repair groups. Thirty-seven athletes (83%) returned to near-preinjury sports activity levels (>/= 90% recovery) after operation. Two patients (4%) had subluxation and 6 (12.5%) had redislocation after surgery. The number of shoulders with postoperative subluxation or dislocation was 4 (25%) in the arthroscopic group and 4 (12.5%) in the open group (P = .041). Revision surgery was performed on 5 shoulders (10.4%).

CONCLUSIONS

There were 8 (16.5%) instances of postoperative instability among the collision athletes studied. The arthroscopic group yielded a higher failure rate than did the open group. The authors believe open stabilization to be a more reliable method for anterior shoulder instability in collision athletes.

MR imaging in sports-related glenohumeral instability

Sports-related shoulder pain and injuries represent a common problem. In this context, glenohumeral instability is currently believed to play a central role either as a recognized or as an unrecognized condition. Shoulder instabilities can roughly be divided into traumatic, atraumatic, and microtraumatic glenohumeral instabilities. In athletes, atraumatic and microtraumatic instabilities can lead to secondary impingement syndromes and chronic damage to intraarticular structures. Magnetic resonance (MR) arthrography is superior to conventional MR imaging in the diagnosis of labro-ligamentous injuries, intrinsic impingement, and SLAP (superior labral anteroposterior) lesions, and thus represents the most informative imaging modality in the overall assessment of glenohumeral instability. This article reviews the imaging criteria for the detection and classification of instability-related injuries in athletes with special emphasis on the influence of MR findings on therapeutic decisions.

Recurrent anterior shoulder dislocation caused by a midsubstance complete capsular tear

BACKGROUND

A midsubstance complete capsular tear is one of the well-known causes of anterior glenohumeral instability. However, its prevalence and clinical picture have not been well elucidated. The purpose of this study was to examine the prevalence of isolated complete capsular tears and to assess the clinical features as well as the results of surgical treatment of recurrent anterior glenohumeral instability caused by such tears.

METHODS

Three hundred and three shoulders underwent surgery to treat recurrent anterior glenohumeral instability at our institution during a five-year period. Twelve (4.0%) of these shoulders had an isolated complete capsular tear as the main pathological condition. Those twelve patients (nine male and three female) were the subjects of the present study. The average age at the time of the operation was twenty-five years. Patient age; the cause of the initial dislocation; the position of the arm at the initial dislocation; and the findings of the preoperative physical examination, of computed tomographic arthrography, and at surgery were assessed. Eleven patients underwent arthroscopic capsular repair, and one was treated with an open capsular repair.

RESULTS

The twelve patients either did not have a Hill-Sachs lesion or had a chondral indentation-type of Hill-Sachs lesion. When assessed with arthrography, the Hill-Sachs lesions were small compared with those in shoulders with an isolated Bankart lesion and, interestingly, they were quite similar in size to those seen with humeral avulsion of the inferior glenohumeral ligament. The average Rowe score for the twelve patients improved from 30.4 points preoperatively to 90.4 points at an average of thirty-one months postoperatively.

CONCLUSIONS

The prevalence of isolated complete capsular tears causing recurrent glenohumeral instability was 4.0% (twelve of 303). These tears were associated with either a small or no Hill-Sachs lesion. We believe that a complete capsular tear should be recognized as one of the essential lesions causing recurrent anterior shoulder dislocation. Arthroscopic examination and repair can provide effective treatment.

Mini-open repair technique of HAGL (humeral avulsion of the glenohumeral ligament) lesion

This article describes a limited open technique to repair humeral avulsions of the glenohumeral ligament (HAGL). The main feature of this technique is the sparing of the superior 50% of the subscapularis tendon. Essentially, an L-type incision is made in the lower third of the subscapularis tendon approximately 1 cm medial to the lesser tuberosity. The transverse limb of this incision is made just superior to the anterior circumflex vessels. Beginning inferiorly, the subscapularis tendon is lifted up, exposing the humeral ligament avulsion. The HAGL lesion is then repaired with 2 or 3 suture anchors anatomically. The advantages of this technique are preservation of the important superior tendinous portion of the subscapularis tendon, thereby preserving strength, easier rehabilitation, and return to full activity.

A systematic approach to magnetic resonance imaging interpretation of sports medicine injuries of the shoulder

Magnetic resonance imaging has developed as a useful imaging modality in the evaluation of the athlete with shoulder pain. The multiplanar capabilities of magnetic resonance imaging make it ideal for detecting the anatomical variations of the osseous outlet that may contribute to the clinical syndrome of impingement. Its superb soft tissue contrast and spatial resolution allow for accurate differentiation between tendinopathy, partial-thickness tear, and full-thickness tear of the rotator cuff and also allow for detection of the subtle lesions of the capsule and labrum that are associated with shoulder instability. However, to accurately interpret the numerous images and pulse sequences obtained in a standard magnetic resonance examination of the shoulder, it is helpful to have a systematic approach to ensure that each of the pertinent anatomical structures are evaluated. This article will provide a systematic approach to the interpretation of a magnetic resonance examination of the shoulder. The normal imaging appearance of each anatomical structure will be described, and the most useful pulse sequences and imaging planes for the evaluation of each structure will be discussed. Finally, the signs of injury will be described and illustrated.

Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion

We describe 3 cases of an all-arthroscopic technique for repair of a humeral avulsion of the glenohumeral ligament (HAGL) lesion and the postoperative clinical outcomes. From a technical perspective, the most critical part of the surgeries was the anchor insertion at an optimal position on the humerus in order to achieve proper tension of the glenohumeral ligament. The arm-free beach-chair position, which facilitates maximum internal rotation, use of a 70 degrees angled arthroscope, and an anterior-inferior trans-subscapularis tendon portal were considered key factors to accomplish this procedure.

The HAGL lesion: an arthroscopic technique for repair of humeral avulsion of the glenohumeral ligaments

Glenoid avulsion of the capsulolabral complex and associated capsular laxity are well-described results of traumatic anterior dislocation. A less common consequence of traumatic anterior instability is the humeral avulsion of the glenohumeral ligaments (HAGL) lesion. An understanding of the arthroscopic pathoanatomy of the HAGL lesion will assist the surgeon in recognizing this uncommon entity. We describe a suture anchor technique for arthroscopic repair of HAGL lesions that anatomically reapproximates the torn edge of the glenohumeral ligament complex to its humeral head insertion. The technique is technically straightforward and does not require special equipment beyond that typical for arthroscopic labral repairs.

Arthroscopic Bankart repair using suture anchors in athletes: patient selection and postoperative sports activity

PURPOSE

The purpose of this study was to evaluate the results in selected high-risk patients who underwent arthroscopic stabilization of shoulders with recurrent anterior instability.

HYPOTHESIS

Arthroscopic stabilization using suture anchors is useful for athletes younger than 25 years or for contact athletes without a large bone loss of glenohumeral articulation.

STUDY DESIGN

Prospective cohort study.

METHODS

The study group comprised 55 patients, with a mean follow-up of 42 months (range, 25-72 months). Thirty-two patients had recurrent dislocations, 14 had recurrent subluxations, and 9 had recurrent subluxations after a single dislocation. Rowe score, range of motion, recurrence, and sports activities were evaluated.

RESULTS

Mean Rowe score improved from 30.1 to 92.3 points; 45 scores (82%) were excellent, 5 (9%) good, 1 fair (2%), and 4 (7%) poor. Patients had lost a mean of 4 degrees of external rotation in adduction. Four (7%) had recurrence. The recurrence rate in contact athletes (9.5%, 2 of 21) was not statistically different from that in noncontact athletes (6%, 2 of 34). Forty-four (80%) returned at the same levels. The complete return rate in overhead-throwing athletes (68%, 17 of 25) was lower than that in nonoverhead athletes (90%, 27 of 30) (P = .0423). Five patients had unsatisfactory results.

CONCLUSION

Arthroscopic stabilization is a reliable procedure in selected high-risk patients.

Humeral Avulsion of the Posterior Band of the Inferior Glenohumeral Ligament: MR Arthrography and Clinical Correlation in 17 Patients

OBJECTIVE

The purpose of this article is to describe the MR arthrography findings of humeral avulsion of the posterior band of the inferior glenohumeral ligament in 17 patients. To elucidate the clinical importance of this abnormality, we also correlate our imaging findings with the presence of coexisting structural abnormalities; clinical presentation; and, when available, arthroscopic evaluation (n = 8).

CONCLUSION

Humeral avulsion or insufficiency of the posterior band of the inferior glenohumeral ligament can be easily detected using MR arthrography. This ligamentous abnormality may be seen in isolation, or it may occur in conjunction with posterior or, less often, anteroinferior capsulolabral abnormalities. The presence of this lesion in a subgroup of patients with the clinical diagnosis of multidirectional instability may offer insight into the causes and pathogenesis of this complex entity.

Arthroscopic repair of a posterior humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion

Recently, the humeral avulsion of the inferior glenohumeral ligament (HAGL) has been described as a cause of shoulder instability. All documented cases in the literature describe the avulsion as an anterior and lateral disruption leading to anterior instability. We detail a previously unreported case of a HAGL lesion involving the posterior band of the inferior glenohumeral ligament. Arthroscopic reattachment using an additional posteroinferior portal resulted in a successful repair.

Shoulder instability: return to play

Shoulder instability in the competitive athlete is a relatively common problem. The etiology of glenohumeral instability that can affect the athlete runs a wide spectrum, from an isolated traumatic dislocation to repeated microtrauma or congenital laxity. Although many athletes are able to adapt to a mild laxity that might only occasionally affect them, it can be much more difficult to adapt or return to play after a dislocation or repeated subluxation episodes. This article focuses on the return to play for competitive individuals after a glenohumeral dislocation or reconstructive surgery for shoulder instability.

Arthroscopic humeral avulsion of the glenohumeral ligaments (HAGL) repair

Humeral avulsion of the glenohumeral ligaments (HAGL lesion) is one of the pathologic lesions that occurs secondary to anterior glenohumeral instability. Although HAGL lesions occur less commonly than Bankart lesions in cases of anterior instability, it is necessary to understand this pathology and to make the necessary repair. An all-arthroscopic technique using suture anchors can be used to repair HAGL lesions, but it is a difficult and demanding technique. To facilitate this type of repair, the surgeon must be: (1) comfortable with both the 30 degrees and 70 degrees arthroscopes, (2) able to establish and use the 5-o'clock portal, (3) able to abduct and externally rotate the arm, and (4) able to ensure secure fixation of the glenohumeral ligaments to bone through adequate knot and loop security.