Humeral Avulsion of the Glenohumeral Ligament: Indications for Surgical Treatment and Outcomes—A Systematic Review

Abstract

Background:The inferior glenohumeral ligament, the most important static anterior stabilizer of the shoulder, becomes disrupted in humeral avulsion of the glenohumeral ligament (HAGL) lesions. Unfortunately, HAGL lesions commonly go unrecognized. A missed HAGL during an index operation to treat anterior shoulder instability may lead to persistent instability. Currently, there are no large studies describing the indications for surgical repair or the outcomes of patients with HAGL lesions.Purpose:To search the literature to identify surgical indications for the treatment of HAGL lesions and discuss reported outcomes.Study Design:Systematic review; Level of evidence, 4.Methods:Two reviewers completed a comprehensive literature search of 3 online databases (MEDLINE, EMBASE, and Cochrane Library) from inception until May 25, 2016, using the keywords “humeral avulsion of the glenohumeral ligament” or “HAGL” to generate a broad search. Systematic screening of eligible studies was undertaken in duplicate. Abstracted data were organized in table format, with descriptive statistics presented.Results:After screening, 18 studies comprising 118 patients were found that described surgical intervention and outcomes for HAGL lesions. The mean patient was 22 years (range, 12-50 years), and 82% were male. Sports injuries represented 72% of all HAGL injuries. The main surgical indication was primary anterior instability, followed by pain and failed nonoperative management. Commonly associated injuries in patients with identified HAGL lesions included a Bankart lesion (15%), Hill-Sachs lesions (13%), and glenoid bone loss (7%). Reporting of outcome scores varied among the included studies. Meta-analysis was not possible, but all included studies reported significantly improved postoperative stability and function. There were no demonstrated differences in outcomes for patients treated with open versus arthroscopic surgical techniques. All but 2 patients undergoing operative management for HAGL lesions were able to return to sport at their previous levels; these included Olympians and professional athletes.Conclusion:HAGL lesions typically occur in younger male patients and are often associated with Bankart lesions and bone loss. Open and arthroscopic management techniques are both effective in preventing recurrent instability.

Mini-open Repair of the Floating Anterior Inferior Glenohumeral Ligament: Combined Treatment of Bankart and Humeral Avulsion of the Glenohumeral Ligament Lesions

“…Literature regarding the surgical treatment and outcomes of concomitant anterior HAGL and Bankart lesions is limited. 4 , 5 , 6 , 7 , 11 , 14 , 15 , 16 To date, there is no consensus regarding the optimal surgical technique for treatment of these combined lesions. Several reports have described all-arthroscopic as well as open repair techniques to treat anterior instability.…”

“…Several reports have described all-arthroscopic as well as open repair techniques to treat anterior instability. 4 , 5 , 6 , 7 , 11 , 15 , 16 Shah and Selesnick 14 proposed arthroscopically repairing the Bankart lesion with a subsequent mini-open HAGL repair procedure. Our surgical technique emphasizes addressing the HAGL lesion and Bankart lesion concurrently with an open procedure, making sure the humeral head is reduced before performing the Bankart repair to avoid overconstraint of the joint and possible restriction of motion.…”

“… 1 , 2 , 3 , 4 , 5 , 6 Humeral avulsion of the glenohumeral ligament (HAGL) injuries have been found to more commonly occur in younger male patients. 7 The cause of a HAGL lesion is typically a high-energy traumatic event, such as an anterior dislocation of the shoulder, and it rarely occurs as an isolated injury. 1 …”

“…When indicated, surgical intervention for isolated HAGL and Bankart lesions has been shown to be effective in biomechanical studies, 12 , 13 early outcome studies, 4 , 5 , 6 , 7 , 14 , 15 , 16 and systematic reviews. 1 , 7 , 17 Case series and case report studies have reported a full return to activities after floating aIGHL treatment, 4 , 5 , 6 , 11 , 14 , 15 , 16 , 18 yet more outcome studies are needed to validate the treatment protocols used to address these injuries. The purpose of this Technical Note is to describe our preferred technique to surgically treat a floating aIGHL, consisting of an anterior HAGL and concomitant Bankart lesion repair through a mini-open approach ( Video 1 ).…”

The Original Mini-Open Technique for Repair of Humeral Avulsion of the Glenohumeral Ligament

“…These lesions are more commonly seen in adults >35 years old after an initial dislocation event, 3 with a reported incidence of 7.5% to 9.3% in primary dislocation events. 4 The inferior glenohumeral ligament (IGHL) complex is a hammock-like structure that spans the inferior aspect of the glenoid, made up of both anterior (aIGHL) and posterior (pIGHL) bands, with an axillary pouch spanning the 2 bands 5 (Fig 1). The anterior band has fibers that insert into the labrum medially and fibers that insert into the neck of the glenoid laterally.…”