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Arthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion
Case Report
Arthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion Yoshiaki Kon, M.D., Hiroyuki Shiozaki, M.D., and Hiroyuki Sugaya, M.D.
Abstract: 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° angled arthroscope, and an anterior-inferior trans-subscapularis tendon portal were considered key factors to accomplish this procedure. Key Words: HAGL lesion—Recurrent anterior glenohumeral instability—Shoulder arthroscopy—Arthroscopic repair—Suture anchor.
S
ince the late 1980s, as arthroscopy has been incorporated in the treatment of glenohumeral instabilities, several studies have focused on the humeral aspect of capsular pathology. In 1942, Nicola1 first described the pathology of anterior glenohumeral instability caused by an avulsion of the capsule from its humeral attachment site. In 1995, Wolf et al.2 named this capsular condition a humeral avulsion of the glenohumeral ligament (HAGL) lesion and reported an arthroscopically assisted repair technique without suture anchors. Thereafter, the HAGL lesion has been widely recognized by surgeons as the most difficult pathology to address under all-arthroscopic control.
From the Department of Orthopaedic Surgery, Saiseikai Niigata Daini Hospital (Y.K., H.Sh.), Niigata; and the Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine Center (H.Su.), Chiba, Japan. Address correspondence and reprint requests to Yoshiaki Kon, M.D., Department of Orthopaedic Surgery, Saiseikai Niigata Daini Hospital, 280-7 Teraji, Niigata 9500086, Japan. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America Cite this article as: Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2005;21:632.e1-632.e6 [doi:10.1016/j.arthro.2005. 02.004]. 0749-8063/05/2105-4328$30.00/0 doi:10.1016/j.arthro.2005.02.004
The purpose of this case report is to introduce our unique method for all-arthroscopic repair with suture anchors in the beach-chair position and report its postoperative outcomes. CASE REPORTS Case 1 A 30-year-old, right-hand– dominant woman initially dislocated her right shoulder during a motocross accident. She reported 5 subsequent episodes of anterior-inferior subluxation, even during minimally traumatic events. She also frequently complained of a “shifting” sensation in the right shoulder during daily activity. Physical examination revealed a positive apprehension sign with the shoulder in external rotation at 60°, 90°, and 120° of abduction. There was no evidence of inferior and posterior apprehension, effusion, muscular atrophy, neurologic involvement, or impingement. Some innate ligamentous laxity was observed, as evidenced by a hypermobile thumb and hyperextended elbow. We routinely perform 2 imaging examinations for patients with recurrent anterior glenohumeral instability: magnetic resonance arthrography (MRA) and
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 21, No 5 (May), 2005: pp 632.e1-632.e6
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FIGURE 1. Case 1: (A) Preoperative MRA showed a leak of the contrast medium through the glenohumeral ligament at its humeral insertion site (arrow). The labrum and the glenohumeral ligament were intact on the glenoid rim. (B) A 3D-CT scan with the humeral head eliminated showed normal morphology in the en face view.
3-dimensionally reconstructed computed tomography (3D-CT) with the humeral head eliminated. The preoperative MRA revealed a leak of the contrast medium through the glenohumeral ligament at its humeral insertion site. However, the MRA did show an intact ligament labral complex on the glenoid rim (Fig 1A). The 3D-CT with the humeral head eliminated showed almost normal osseous morphology in the en face view (Fig 1B). Examination under anesthesia confirmed marked anterior and anterior-inferior glenohumeral instability in comparison with the contralateral asymptomatic shoulder. Mild posterior and inferior laxities were present, but they were equivalent with the contralateral side. Arthroscopic examination showed no significant Bankart lesion and no HillSachs lesion. Inspection of the humeral insertion of the anterior-inferior glenohumeral ligament (AIGHL) revealed a HAGL lesion, and the subscapularis tendon was visualized through the HAGL lesion (Fig 2). Surgical Techniques Patient Positioning: We performed all shoulder surgeries in the beach-chair position under general anesthesia. The patient’s arm position can be adjusted freely in various directions, which is helpful for visualization and access to the lesion. Portals and Arthroscope: Three portals were useful: posterior, anterior, and anterior-inferior (5 o’clock).3,4 The arthroscope was introduced through a standard posterior portal. Following intra-articular investigation by diagnostic arthroscopy using a standard 30° angled arthroscope, a 70° angled arthroscope was used to visualize the HAGL lesion through this posterior portal.
The anterior portal was created just superior to the intra-articular subscapularis tendon and just lateral to the conjoined tendon using an outside-in technique. This portal was used as a working portal without cannulas. In the case of the HAGL lesion, we also created an anterior-inferior (5 o’clock) portal.3,4 This 5-o’clock portal was located about 2 cm distal from the coracoid process. A blunt trocar (4 mm in diameter) was introduced into the joint with a “slalom approach.”3 Only for this portal, we inserted a small cannula (5 mm in diameter; Smith & Nephew, Endoscopy Division, Andover, MA) along with the trocar, for the purpose of intrusion of the subscapularis muscle and preventable injuries to the musculocutaneous nerve and the axillary nerve. Repair Techniques: With the patient’s shoulder internally rotated and using the 70° angled arthroscope, we obtained adequate visualization of the HAGL lesion. The anchor insertion at an optimal position on the humerus was the most critical part of the surgeries. Once the appropriate anchoring point was determined, to make sure that restoration of the appropriate tension of the AIGHL could be achieved, a grasper was introduced through the anterior portal and the avulsed edge of the AIGHL was brought upward and laterally to its original insertion site to simulate the repair. To prepare the bone bed, the original humeral insertion site of the AIGHL was decorticated with a bone cutter burr (Smith & Nephew, Endoscopy Division). Subsequently, 2 bioabsorbable Panalok suture anchors (Depuy Mitek, Norwood, MA) were placed into the humeral bone bed at the previously determined anchoring point.
FIGURE 2. Case 1: Arthroscopic view from the posterior portal of the right shoulder. The subscapularis tendon (SUB) was visualized through the tear of the AIGHL.
ARTHROSCOPIC HAGL LESION REPAIR
FIGURE 3. Case 1: Arthroscopic view from the posterior portal using a 70° angled arthroscope. (A) After preparing the bone bed of the humerus, sutures from a bioabsorbable suture anchor were introduced through the edge of the avulsed AIGHL. The sutures were then introduced through the ligament. (B) Next, the sutures were tied securely in a mattress fashion. The configuration of the tied knot was inside the joint. After repairing the HAGL lesion with 2 suture anchors, the AIGHL was tightened up. (H, humeral head.)
A looped No. 2-0 nylon suture was passed through the edge of the AIGHL with a Caspari suture punch. A No. 2 nonabsorbable suture from the suture anchor was introduced through the AIGHL using an intraarticular suture-relay technique. We used a mattress stitch to tie these sutures intra-articularly because it was necessary for the configurations of the tied knots to be inside the joint. Furthermore, the mattress stitch allowed for the torn edge of AIGHL to be fixed with broader “surface contact” rather than single “point contact” (Fig 3A). All-arthroscopic HAGL lesion repair with 2 suture anchors was accomplished as described earlier, and the tension of the repaired AIGHL was confirmed (Fig 3B). Immediate postoperative examination under anesthesia showed appropriate anterior and anterior-inferior glenohumeral stability. Postoperatively, the shoulder was immobilized in a sling for 3 weeks. At 24 months after the arthroscopic surgery, the patient had no recurrence and no apprehension. Only a small loss of external rotation at 90° of abduction remained in comparison with the contralateral side, but the patient did not feel inconvenienced in her daily life and she returned to motocross racing. She scored 100 on the postoperative Rowe rating scale at the 24-month follow-up.
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of subluxation during minimally traumatic accidents while playing baseball. We could not detect a distinct Bankart lesion, capsular tear, or HAGL lesion on a preoperative MRA, but did note a Hill-Sachs lesion. A 3D-CT with the humeral head eliminated showed almost normal morphology in the en face view. A slight obtuse contour of the glenoid rim was visible in the anterior-inferior oblique view. Physical examination revealed a positive apprehension sign and pain with the shoulder externally rotated at 60°, 90°, 120°, and 180° of abduction. No inferior and posterior apprehension was noted. There was no evidence of innate ligamentous laxity, effusion, muscular atrophy, neurologic involvement, or impingement. Arthroscopic surgery was performed under general anesthesia in the beach-chair position. Examination under anesthesia confirmed anterior and anterior-inferior glenohumeral instability in comparison with the contralateral asymptomatic shoulder. Arthroscopic examination revealed a detached-type Bankart lesion from 7 o’clock to 9:30 o’clock on the glenoid clock, and a significant HAGL lesion. This case was a “combined Bankart and HAGL lesion” that Warner and Beim have previously reported5 (Fig 4). There was no midsubstance capsular tear, but there was a shallow Hill-Sachs lesion. The subscapularis tendon was visualized through the tear of the AIGHL. All-arthroscopic HAGL lesion repair with suture anchors was performed, as described earlier (Fig 5A). After the repair of the HAGL lesion, an arthroscopic Bankart repair using 3 suture anchors (at 7, 8, and 9 o’clock on the glenoid clock) was performed (Fig 5B). After these procedures, examination under anesthesia veri-
Case 2 The next patient was a 20-year-old right-hand– dominant man. He initially dislocated his left shoulder making a “diving catch” during baseball practice. He reported sustaining more than 20 subsequent episodes
FIGURE 4. Case 2: Viewing from the posterior portal of the left shoulder, the subscapularis tendon was visible through the HAGL lesion.
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FIGURE 5. Case 2: (A) The HAGL lesion was repaired with a bioabsorbable suture anchor in a manner similar to that of case 1. (B) After repairing the HAGL lesion, an arthroscopic Bankart repair was performed. In this case, suture anchors were placed at 7, 8, and 9 o’clock on the glenoid clock. (H, humeral head; G, glenoid.)
fied firm anterior and anterior-inferior glenohumeral stability. Postoperatively, the shoulder was immobilized in a sling for 3 weeks. At 16 months after the surgery, the patient reported no instability and no apprehension with nearly full range of motion, and scored 100 on the postoperative Rowe rating scale. He does not feel inconvenienced in his daily life; he returned to baseball 12 months postoperatively and now plays at nearly his previous level. Case 3 A 25-year-old right-hand– dominant man initially dislocated his right shoulder when he fell down with his shoulder externally rotated while practicing Judo 4 years prior to the initial examination. He reported sustaining 4 subsequent episodes of subluxation while practicing Judo. A transaxial view of a preoperative MRA showed almost normal appearance. A 3D-CT with the humeral head eliminated showed almost normal morphology in the en face view. Physical examination
FIGURE 6. Case 3: The subscapularis tendon was visible through the HAGL lesion. (A) Arthroscopic view from the posterior portal of the right shoulder. (B) Viewing from the anterior portal, the MGHL and the upper side of the AIGHL are seen avulsed from the original humeral insertion site and sagging downward. (H, humeral head.)
FIGURE 7. Case 3: Viewing from the posterior portal using a 70° angled arthroscope. When the sutures were brought up through the anterior portal as a trial, tension of the MGHL and the AIGHL was sufficient. The sutures were tied securely in a mattress configuration. (H, humeral head.)
demonstrated a severely positive apprehension sign with the shoulder externally rotated at 90° and 120° of abduction and pain with the shoulder externally rotated at 60°, 90°, 120°, and 180° of abduction. There was no inferior and posterior apprehension and no innate ligamentous laxity. There was no evidence of effusion, muscular atrophy, neurologic involvement, or impingement. Arthroscopic surgery was performed under general anesthesia in the beach-chair position. Examination under anesthesia confirmed anterior and anterior-inferior glenohumeral instability in comparison with the contralateral asymptomatic shoulder. Arthroscopic examination revealed a detached-type Bankart lesion from 2 o’clock to 4 o’clock on the glenoid clock, and a HAGL lesion. The HAGL lesion in this case consisted of a detachment of the middle glenohumeral ligament (MGHL) and the superior portion of the AIGHL (Fig 6). This was also a case of a combined Bankart and HAGL lesion. There was a small and shallow Hill-Sachs lesion. The subscapularis tendon was visualized through the tear of the MGHL and the AIGHL. All-arthroscopic HAGL lesion repair with a suture anchor was performed, as previously described in case 1, and appropriate tension of the MGHL and AIGHL was restored. After repair of the HAGL lesion, an arthroscopic Bankart repair using 3 suture anchors (at 2, 3, and 4 o’clock on the glenoid clock) was performed (Fig 7). Following these procedures, examination under anesthesia verified firm anterior and anterior-inferior glenohumeral stability. Postoperatively, the shoulder was immobilized in a sling for 3 weeks. At 17 months after the operation, the patient had no evidence of recurrence or appre-
ARTHROSCOPIC HAGL LESION REPAIR hension and scored 92 on the postoperative Rowe rating scale. There was no significant loss of range of motion, but he had slight pain at the final range of forward flexion and external rotation. He did not feel inconvenienced in his job and he returned to Judo at his preinjury level. DISCUSSION Before arthroscopic examinations and surgeries became widespread, patients who suffered from recurrent anterior glenohumeral instability were operated on through open procedures. Therefore, it is possible that HAGL lesions may have often been ignored. But now we can detect the HAGL lesion with attentive arthroscopic intra-articular examination. We routinely check the AIGHL while viewing from the anterior portal. Wolf et al.2 described observing HAGL lesions in 9% of their cases of traumatic anterior glenohumeral instability. In our experience the appearance rate of HAGL lesions is 2.4%. In terms of preoperative examinations, we use 2 examinations routinely for patients with recurrent anterior glenohumeral instability: MRA and 3D-CT with the humeral head eliminated. MRA can more clearly detect an intra-articular anatomic breakage of soft tissue structure, and the 3D-CT with the humeral head eliminated can distinctly show the bony structure of the glenoid rim. Sugaya et al.6 developed a method of using 3D-CT with the humeral head eliminated to evaluate glenoid morphology in cases of recurrent anterior glenohumeral instability. In their study, the glenoid rim morphology of 100 consecutive shoulders in unilateral anterior glenohumeral instability was evaluated using 3D-CT images with the humeral head eliminated. They found the prevalence of glenoid rim lesions to be as high as 90%, with a bony Bankart lesion in 50% and glenoids with anomalous configurations in 40%. Case 1 described earlier had no Bankart lesion, no midsubstance capsular tear, and no Hill-Sachs lesion in the arthroscopic investigation. This was a so-called “pure” HAGL lesion. Furthermore, in this case, the preoperative 3D-CT with the humeral head eliminated showed almost normal morphology in the en face view. This normal glenoid rim morphology was one of the notable features of this case. Case 2 had a combined Bankart and HAGL lesion. In 1997, Warner et al.5 first described combined Bankart and HAGL lesions. In that case, an open repair was performed. Schippinger et al.7 reported a case of a HAGL lesion occurring after
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successful arthroscopic Bankart repair. In this case, an open arthrotomy was performed. Wolf et al.2 reported 6 cases of a HAGL lesion; 4 of these 6 cases were repaired arthroscopically. In their report, they described creating an additional anterior lateral portal and subsequently pulling all sutures out through this portal. Half of the sutures were separated and passed subfascially below the deltopectoral fascia while the other half of the sutures were passed subcutaneously below the skin. In this technique, the sutures were tied over the deltopectoral fascia and the suture knots were not inside the shoulder joint. Thus, strictly speaking, these techniques are not all-arthroscopic repairs. To our knowledge, no report has yet presented information about the meticulous surgical techniques required for an all-arthroscopic HAGL lesion repair, and in this report we have introduced our surgical techniques in detail. In our technique, the anchor insertion at an optimal position on the humerus is the most important stage of the HAGL lesion repair to restore the appropriate tension to the AIGHL. However, a successful outcome depends greatly on the surgical skill to manage the repair all-arthroscopically. Arthroscopic visualization is the most fundamental element to find the optimal position for the anchor. We obtained adequate visualization with the patient’s shoulder internally rotated in the arm-free beach-chair position, using a 70° angled arthroscope. The original humeral insertion of the AIGHL is hidden while inspecting with a regular 30° angled arthroscope through a posterior portal. Using a 70° angled arthroscope is sufficient to address this visual problem. In an effort to access the HAGL lesion, to facilitate restoring its original humeral insertion site and to insert anchors at an ideal position, a 5-o’clock portal was created. This portal was quite valuable as a working portal3,4 because instruments inserted through this portal can reach directly to the HAGL lesion and anchors can be introduced at an accurate angle. Furthermore, when we encountered a large HAGL lesion, we created an additional posteriorinferior working portal as necessary. In a case that requires a repair of the inferior aspect of the AIGHL, if an appropriate vertical angle to introduce anchors through the 5-o’clock portal cannot be obtained, this posterior-inferior portal may offer a more favorable angle. With these techniques, an all-arthroscopic HAGL lesion repair with suture anchors can be accomplished.
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Y. KON ET AL. REFERENCES
1. Nicola T. Anterior dislocation of the shoulder: The role of the articular capsule. J Bone Joint Surg Am 1942;25:614-616. 2. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. 3. Resh H, Wykypiel HF, Maurer H, Wambacher M. The anteroinferior (transmuscular) approach for arthroscopic repair of the Bankart lesion: An anatomic and clinical study. Arthroscopy 1996;12:309-322.
4. Davidson PA, Tibone JE. Anterior-inferior (5 o’clock) portal for shoulder arthroscopy. Arthroscopy 1995;11:519-525. 5. Warner JJP, Beim GM. Combined Bankart and HAGL lesion associated with anterior shoulder instability. Arthroscopy 1997; 13:749-752. 6. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am 2003;85:878-884. 7. Schippinger G, Vasiu PS, Fankhauser F, Clement HG. HAGL lesion occurring after successful arthroscopic Bankart repair. Arthroscopy 2001;17:206-208.
Arthroscopic Repair of a Humeral Avulsion of the Glenohumeral Ligament Lesion Yoshiaki Kon, M.D., Hiroyuki Shiozaki, M.D., and Hiroyuki Sugaya, M.D.
Abstract: 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° angled arthroscope, and an anterior-inferior trans-subscapularis tendon portal were considered key factors to accomplish this procedure. Key Words: HAGL lesion—Recurrent anterior glenohumeral instability—Shoulder arthroscopy—Arthroscopic repair—Suture anchor.
S
ince the late 1980s, as arthroscopy has been incorporated in the treatment of glenohumeral instabilities, several studies have focused on the humeral aspect of capsular pathology. In 1942, Nicola1 first described the pathology of anterior glenohumeral instability caused by an avulsion of the capsule from its humeral attachment site. In 1995, Wolf et al.2 named this capsular condition a humeral avulsion of the glenohumeral ligament (HAGL) lesion and reported an arthroscopically assisted repair technique without suture anchors. Thereafter, the HAGL lesion has been widely recognized by surgeons as the most difficult pathology to address under all-arthroscopic control.
From the Department of Orthopaedic Surgery, Saiseikai Niigata Daini Hospital (Y.K., H.Sh.), Niigata; and the Shoulder and Elbow Service, Funabashi Orthopaedic Sports Medicine Center (H.Su.), Chiba, Japan. Address correspondence and reprint requests to Yoshiaki Kon, M.D., Department of Orthopaedic Surgery, Saiseikai Niigata Daini Hospital, 280-7 Teraji, Niigata 9500086, Japan. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America Cite this article as: Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2005;21:632.e1-632.e6 [doi:10.1016/j.arthro.2005. 02.004]. 0749-8063/05/2105-4328$30.00/0 doi:10.1016/j.arthro.2005.02.004
The purpose of this case report is to introduce our unique method for all-arthroscopic repair with suture anchors in the beach-chair position and report its postoperative outcomes. CASE REPORTS Case 1 A 30-year-old, right-hand– dominant woman initially dislocated her right shoulder during a motocross accident. She reported 5 subsequent episodes of anterior-inferior subluxation, even during minimally traumatic events. She also frequently complained of a “shifting” sensation in the right shoulder during daily activity. Physical examination revealed a positive apprehension sign with the shoulder in external rotation at 60°, 90°, and 120° of abduction. There was no evidence of inferior and posterior apprehension, effusion, muscular atrophy, neurologic involvement, or impingement. Some innate ligamentous laxity was observed, as evidenced by a hypermobile thumb and hyperextended elbow. We routinely perform 2 imaging examinations for patients with recurrent anterior glenohumeral instability: magnetic resonance arthrography (MRA) and
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FIGURE 1. Case 1: (A) Preoperative MRA showed a leak of the contrast medium through the glenohumeral ligament at its humeral insertion site (arrow). The labrum and the glenohumeral ligament were intact on the glenoid rim. (B) A 3D-CT scan with the humeral head eliminated showed normal morphology in the en face view.
3-dimensionally reconstructed computed tomography (3D-CT) with the humeral head eliminated. The preoperative MRA revealed a leak of the contrast medium through the glenohumeral ligament at its humeral insertion site. However, the MRA did show an intact ligament labral complex on the glenoid rim (Fig 1A). The 3D-CT with the humeral head eliminated showed almost normal osseous morphology in the en face view (Fig 1B). Examination under anesthesia confirmed marked anterior and anterior-inferior glenohumeral instability in comparison with the contralateral asymptomatic shoulder. Mild posterior and inferior laxities were present, but they were equivalent with the contralateral side. Arthroscopic examination showed no significant Bankart lesion and no HillSachs lesion. Inspection of the humeral insertion of the anterior-inferior glenohumeral ligament (AIGHL) revealed a HAGL lesion, and the subscapularis tendon was visualized through the HAGL lesion (Fig 2). Surgical Techniques Patient Positioning: We performed all shoulder surgeries in the beach-chair position under general anesthesia. The patient’s arm position can be adjusted freely in various directions, which is helpful for visualization and access to the lesion. Portals and Arthroscope: Three portals were useful: posterior, anterior, and anterior-inferior (5 o’clock).3,4 The arthroscope was introduced through a standard posterior portal. Following intra-articular investigation by diagnostic arthroscopy using a standard 30° angled arthroscope, a 70° angled arthroscope was used to visualize the HAGL lesion through this posterior portal.
The anterior portal was created just superior to the intra-articular subscapularis tendon and just lateral to the conjoined tendon using an outside-in technique. This portal was used as a working portal without cannulas. In the case of the HAGL lesion, we also created an anterior-inferior (5 o’clock) portal.3,4 This 5-o’clock portal was located about 2 cm distal from the coracoid process. A blunt trocar (4 mm in diameter) was introduced into the joint with a “slalom approach.”3 Only for this portal, we inserted a small cannula (5 mm in diameter; Smith & Nephew, Endoscopy Division, Andover, MA) along with the trocar, for the purpose of intrusion of the subscapularis muscle and preventable injuries to the musculocutaneous nerve and the axillary nerve. Repair Techniques: With the patient’s shoulder internally rotated and using the 70° angled arthroscope, we obtained adequate visualization of the HAGL lesion. The anchor insertion at an optimal position on the humerus was the most critical part of the surgeries. Once the appropriate anchoring point was determined, to make sure that restoration of the appropriate tension of the AIGHL could be achieved, a grasper was introduced through the anterior portal and the avulsed edge of the AIGHL was brought upward and laterally to its original insertion site to simulate the repair. To prepare the bone bed, the original humeral insertion site of the AIGHL was decorticated with a bone cutter burr (Smith & Nephew, Endoscopy Division). Subsequently, 2 bioabsorbable Panalok suture anchors (Depuy Mitek, Norwood, MA) were placed into the humeral bone bed at the previously determined anchoring point.
FIGURE 2. Case 1: Arthroscopic view from the posterior portal of the right shoulder. The subscapularis tendon (SUB) was visualized through the tear of the AIGHL.
ARTHROSCOPIC HAGL LESION REPAIR
FIGURE 3. Case 1: Arthroscopic view from the posterior portal using a 70° angled arthroscope. (A) After preparing the bone bed of the humerus, sutures from a bioabsorbable suture anchor were introduced through the edge of the avulsed AIGHL. The sutures were then introduced through the ligament. (B) Next, the sutures were tied securely in a mattress fashion. The configuration of the tied knot was inside the joint. After repairing the HAGL lesion with 2 suture anchors, the AIGHL was tightened up. (H, humeral head.)
A looped No. 2-0 nylon suture was passed through the edge of the AIGHL with a Caspari suture punch. A No. 2 nonabsorbable suture from the suture anchor was introduced through the AIGHL using an intraarticular suture-relay technique. We used a mattress stitch to tie these sutures intra-articularly because it was necessary for the configurations of the tied knots to be inside the joint. Furthermore, the mattress stitch allowed for the torn edge of AIGHL to be fixed with broader “surface contact” rather than single “point contact” (Fig 3A). All-arthroscopic HAGL lesion repair with 2 suture anchors was accomplished as described earlier, and the tension of the repaired AIGHL was confirmed (Fig 3B). Immediate postoperative examination under anesthesia showed appropriate anterior and anterior-inferior glenohumeral stability. Postoperatively, the shoulder was immobilized in a sling for 3 weeks. At 24 months after the arthroscopic surgery, the patient had no recurrence and no apprehension. Only a small loss of external rotation at 90° of abduction remained in comparison with the contralateral side, but the patient did not feel inconvenienced in her daily life and she returned to motocross racing. She scored 100 on the postoperative Rowe rating scale at the 24-month follow-up.
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of subluxation during minimally traumatic accidents while playing baseball. We could not detect a distinct Bankart lesion, capsular tear, or HAGL lesion on a preoperative MRA, but did note a Hill-Sachs lesion. A 3D-CT with the humeral head eliminated showed almost normal morphology in the en face view. A slight obtuse contour of the glenoid rim was visible in the anterior-inferior oblique view. Physical examination revealed a positive apprehension sign and pain with the shoulder externally rotated at 60°, 90°, 120°, and 180° of abduction. No inferior and posterior apprehension was noted. There was no evidence of innate ligamentous laxity, effusion, muscular atrophy, neurologic involvement, or impingement. Arthroscopic surgery was performed under general anesthesia in the beach-chair position. Examination under anesthesia confirmed anterior and anterior-inferior glenohumeral instability in comparison with the contralateral asymptomatic shoulder. Arthroscopic examination revealed a detached-type Bankart lesion from 7 o’clock to 9:30 o’clock on the glenoid clock, and a significant HAGL lesion. This case was a “combined Bankart and HAGL lesion” that Warner and Beim have previously reported5 (Fig 4). There was no midsubstance capsular tear, but there was a shallow Hill-Sachs lesion. The subscapularis tendon was visualized through the tear of the AIGHL. All-arthroscopic HAGL lesion repair with suture anchors was performed, as described earlier (Fig 5A). After the repair of the HAGL lesion, an arthroscopic Bankart repair using 3 suture anchors (at 7, 8, and 9 o’clock on the glenoid clock) was performed (Fig 5B). After these procedures, examination under anesthesia veri-
Case 2 The next patient was a 20-year-old right-hand– dominant man. He initially dislocated his left shoulder making a “diving catch” during baseball practice. He reported sustaining more than 20 subsequent episodes
FIGURE 4. Case 2: Viewing from the posterior portal of the left shoulder, the subscapularis tendon was visible through the HAGL lesion.
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FIGURE 5. Case 2: (A) The HAGL lesion was repaired with a bioabsorbable suture anchor in a manner similar to that of case 1. (B) After repairing the HAGL lesion, an arthroscopic Bankart repair was performed. In this case, suture anchors were placed at 7, 8, and 9 o’clock on the glenoid clock. (H, humeral head; G, glenoid.)
fied firm anterior and anterior-inferior glenohumeral stability. Postoperatively, the shoulder was immobilized in a sling for 3 weeks. At 16 months after the surgery, the patient reported no instability and no apprehension with nearly full range of motion, and scored 100 on the postoperative Rowe rating scale. He does not feel inconvenienced in his daily life; he returned to baseball 12 months postoperatively and now plays at nearly his previous level. Case 3 A 25-year-old right-hand– dominant man initially dislocated his right shoulder when he fell down with his shoulder externally rotated while practicing Judo 4 years prior to the initial examination. He reported sustaining 4 subsequent episodes of subluxation while practicing Judo. A transaxial view of a preoperative MRA showed almost normal appearance. A 3D-CT with the humeral head eliminated showed almost normal morphology in the en face view. Physical examination
FIGURE 6. Case 3: The subscapularis tendon was visible through the HAGL lesion. (A) Arthroscopic view from the posterior portal of the right shoulder. (B) Viewing from the anterior portal, the MGHL and the upper side of the AIGHL are seen avulsed from the original humeral insertion site and sagging downward. (H, humeral head.)
FIGURE 7. Case 3: Viewing from the posterior portal using a 70° angled arthroscope. When the sutures were brought up through the anterior portal as a trial, tension of the MGHL and the AIGHL was sufficient. The sutures were tied securely in a mattress configuration. (H, humeral head.)
demonstrated a severely positive apprehension sign with the shoulder externally rotated at 90° and 120° of abduction and pain with the shoulder externally rotated at 60°, 90°, 120°, and 180° of abduction. There was no inferior and posterior apprehension and no innate ligamentous laxity. There was no evidence of effusion, muscular atrophy, neurologic involvement, or impingement. Arthroscopic surgery was performed under general anesthesia in the beach-chair position. Examination under anesthesia confirmed anterior and anterior-inferior glenohumeral instability in comparison with the contralateral asymptomatic shoulder. Arthroscopic examination revealed a detached-type Bankart lesion from 2 o’clock to 4 o’clock on the glenoid clock, and a HAGL lesion. The HAGL lesion in this case consisted of a detachment of the middle glenohumeral ligament (MGHL) and the superior portion of the AIGHL (Fig 6). This was also a case of a combined Bankart and HAGL lesion. There was a small and shallow Hill-Sachs lesion. The subscapularis tendon was visualized through the tear of the MGHL and the AIGHL. All-arthroscopic HAGL lesion repair with a suture anchor was performed, as previously described in case 1, and appropriate tension of the MGHL and AIGHL was restored. After repair of the HAGL lesion, an arthroscopic Bankart repair using 3 suture anchors (at 2, 3, and 4 o’clock on the glenoid clock) was performed (Fig 7). Following these procedures, examination under anesthesia verified firm anterior and anterior-inferior glenohumeral stability. Postoperatively, the shoulder was immobilized in a sling for 3 weeks. At 17 months after the operation, the patient had no evidence of recurrence or appre-
ARTHROSCOPIC HAGL LESION REPAIR hension and scored 92 on the postoperative Rowe rating scale. There was no significant loss of range of motion, but he had slight pain at the final range of forward flexion and external rotation. He did not feel inconvenienced in his job and he returned to Judo at his preinjury level. DISCUSSION Before arthroscopic examinations and surgeries became widespread, patients who suffered from recurrent anterior glenohumeral instability were operated on through open procedures. Therefore, it is possible that HAGL lesions may have often been ignored. But now we can detect the HAGL lesion with attentive arthroscopic intra-articular examination. We routinely check the AIGHL while viewing from the anterior portal. Wolf et al.2 described observing HAGL lesions in 9% of their cases of traumatic anterior glenohumeral instability. In our experience the appearance rate of HAGL lesions is 2.4%. In terms of preoperative examinations, we use 2 examinations routinely for patients with recurrent anterior glenohumeral instability: MRA and 3D-CT with the humeral head eliminated. MRA can more clearly detect an intra-articular anatomic breakage of soft tissue structure, and the 3D-CT with the humeral head eliminated can distinctly show the bony structure of the glenoid rim. Sugaya et al.6 developed a method of using 3D-CT with the humeral head eliminated to evaluate glenoid morphology in cases of recurrent anterior glenohumeral instability. In their study, the glenoid rim morphology of 100 consecutive shoulders in unilateral anterior glenohumeral instability was evaluated using 3D-CT images with the humeral head eliminated. They found the prevalence of glenoid rim lesions to be as high as 90%, with a bony Bankart lesion in 50% and glenoids with anomalous configurations in 40%. Case 1 described earlier had no Bankart lesion, no midsubstance capsular tear, and no Hill-Sachs lesion in the arthroscopic investigation. This was a so-called “pure” HAGL lesion. Furthermore, in this case, the preoperative 3D-CT with the humeral head eliminated showed almost normal morphology in the en face view. This normal glenoid rim morphology was one of the notable features of this case. Case 2 had a combined Bankart and HAGL lesion. In 1997, Warner et al.5 first described combined Bankart and HAGL lesions. In that case, an open repair was performed. Schippinger et al.7 reported a case of a HAGL lesion occurring after
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successful arthroscopic Bankart repair. In this case, an open arthrotomy was performed. Wolf et al.2 reported 6 cases of a HAGL lesion; 4 of these 6 cases were repaired arthroscopically. In their report, they described creating an additional anterior lateral portal and subsequently pulling all sutures out through this portal. Half of the sutures were separated and passed subfascially below the deltopectoral fascia while the other half of the sutures were passed subcutaneously below the skin. In this technique, the sutures were tied over the deltopectoral fascia and the suture knots were not inside the shoulder joint. Thus, strictly speaking, these techniques are not all-arthroscopic repairs. To our knowledge, no report has yet presented information about the meticulous surgical techniques required for an all-arthroscopic HAGL lesion repair, and in this report we have introduced our surgical techniques in detail. In our technique, the anchor insertion at an optimal position on the humerus is the most important stage of the HAGL lesion repair to restore the appropriate tension to the AIGHL. However, a successful outcome depends greatly on the surgical skill to manage the repair all-arthroscopically. Arthroscopic visualization is the most fundamental element to find the optimal position for the anchor. We obtained adequate visualization with the patient’s shoulder internally rotated in the arm-free beach-chair position, using a 70° angled arthroscope. The original humeral insertion of the AIGHL is hidden while inspecting with a regular 30° angled arthroscope through a posterior portal. Using a 70° angled arthroscope is sufficient to address this visual problem. In an effort to access the HAGL lesion, to facilitate restoring its original humeral insertion site and to insert anchors at an ideal position, a 5-o’clock portal was created. This portal was quite valuable as a working portal3,4 because instruments inserted through this portal can reach directly to the HAGL lesion and anchors can be introduced at an accurate angle. Furthermore, when we encountered a large HAGL lesion, we created an additional posteriorinferior working portal as necessary. In a case that requires a repair of the inferior aspect of the AIGHL, if an appropriate vertical angle to introduce anchors through the 5-o’clock portal cannot be obtained, this posterior-inferior portal may offer a more favorable angle. With these techniques, an all-arthroscopic HAGL lesion repair with suture anchors can be accomplished.
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Y. KON ET AL. REFERENCES
1. Nicola T. Anterior dislocation of the shoulder: The role of the articular capsule. J Bone Joint Surg Am 1942;25:614-616. 2. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. 3. Resh H, Wykypiel HF, Maurer H, Wambacher M. The anteroinferior (transmuscular) approach for arthroscopic repair of the Bankart lesion: An anatomic and clinical study. Arthroscopy 1996;12:309-322.
4. Davidson PA, Tibone JE. Anterior-inferior (5 o’clock) portal for shoulder arthroscopy. Arthroscopy 1995;11:519-525. 5. Warner JJP, Beim GM. Combined Bankart and HAGL lesion associated with anterior shoulder instability. Arthroscopy 1997; 13:749-752. 6. Sugaya H, Moriishi J, Dohi M, Kon Y, Tsuchiya A. Glenoid rim morphology in recurrent anterior glenohumeral instability. J Bone Joint Surg Am 2003;85:878-884. 7. Schippinger G, Vasiu PS, Fankhauser F, Clement HG. HAGL lesion occurring after successful arthroscopic Bankart repair. Arthroscopy 2001;17:206-208.