Updated: 6/4/2021

Humeral Avulsion Glenohumeral Ligament (HAGL)

0%
Topic
Review Topic
0
0
100%
0%
Evidence
1
0
0
Topic
Images
https://upload.orthobullets.com/topic/322184/images/anthagl.jpg
https://upload.orthobullets.com/topic/322184/images/antlig.jpg
https://upload.orthobullets.com/topic/322184/images/hagl_tear.jpg
https://upload.orthobullets.com/topic/322184/images/bonebed.jpg
https://upload.orthobullets.com/topic/322184/images/repaired.jpg
  • Summary
    • Humeral Avulsion of the Glenohumeral Ligament (HAGL) is an injury to the inferior glenohumeral ligament causing instability and/or pain and a missed cause of recurrent shoulder instability.
    • Diagnosis requires suspicions of injury and can be noted as an inferior pouch irregularity on MRI.
    • Non-operative first-line treatment for acute presentation includes sling immobilization and physical therapy while operative treatment is recommended for recurrent instability.
  • Epidemiology
    • Incidence
      • 1.6% of patients with shoulder pain
    • Demographics
      • male > female (94% male)
      • average age 25-30
    • Anatomic location
      • anterior band most common (93%)
      • medial (glenoid) versus lateral (humerus)
        • failure IGHL at labral complex - 40%
        • intrasubstance tear - 35 %
        • humeral insertion - 25%
    • Risk factors
      • 10% of recurrent anterior shoulder dislocators have HAGL
      • 27% of shoulder instability patients without bankart have HAGL
      • 18% of failed anterior stabilization have HAGL
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • hyperabduction and external rotation is the main mechanism
          • diving, Football, Basketball, Volleyball, Surfing, skiing, MVC
    • Associated conditions
      • orthopedic conditions
        • labral tears - 25%
        • rotator Cuff tears - 23%
        • Hill-Sachs Deformity - 17%
        • bony Bankart
  • Anatomy
    • Static stabilizers
      • glenohumeral ligaments
      • glenoid labrum
        • attachment of glenohumeral ligaments
        • deepens glenoid cavity
      • articular congruity and version
      • negative intraarticular pressure
    • Dynamic stabilizers
      • rotator cuff muscles
        • the primary biomechanical role of the rotator cuff is stabilizing the glenohumeral joint by compressing the humeral head against the glenoid
      • rotator interval
      • biceps long head
      • periscapular muscles
      • deltoid
    • Capsuloligamentous Complex
      • coracohumeral Ligament
      • superior glenohumeral ligament (SGHL)
      • middle glenohumeral ligament (MGHL)
      • inferior glenohumeral ligament (IGHL)
        • hammock-like Structure
          • anterior band - between 2 and 4 o'clock
          • posterior Band - between 7 and 9 o'clock
          • axillary pouch
        • 2 types of Insertion on Humerus
          • collar like attachment close to articular margin
          • V-shaped attachment close to cartilage rim with apex distal on metaphysis
    • Blood Supply
      • anastamosis of branches of humeral sided and scapular sided vessels
      • lateral: Anterior humeral circumflex artery, Posterior humeral circumflex artery
      • medial: Suprascapular artery, Circumflex scapular arteries
      • watershed area anterolaterally: near humeral insertion anterior capsule 3 cm medial to intertubercular groove
    • Nervous system
      • axillary nerve
        • close to HAGL lesion at 6'oclock position (2-7mm, overestimated on MRI by 2mm)
    • Biomechanics
      • most taught between 45 - 90 degrees abduction
      • anterior band of IGHL - anterior and inferior restraint
        • taught at 90 degrees abduction and external rotation
      • posterior band of IGHL- posterior and inferior restraint
        • taught at 90 degrees abduction and internal rotation
  • Classification
    • West Point Classification - by Bui-Mansfield
    • West Point Classification
      Based on 3 Factors:
      • Anterior or Posterior Involvement
      • Presence or Absence of Bony Avulsion
      • Presence of Associated Labral Pathology (Floating)
      Anterior 
       93%
      • Anterior HAGL
      55%
      • Anterior Bony HAGL
      17%
      • Floating AIGHL
      21%
      Posterior
      6%
      • Posterior HAGL
      2%
      • Posterior Bony HAGL
      0%
      • Floating PIGHL
      4%
  • Presentation
    • History
      • position of arm at injury
      • direction of instability
      • recurrent instability
      • failed surgery to correct instability
    • Symptoms
      • severe persistent pain after instability event
      • recurrent instability
    • Physical exam
      • provocative tests
        • apprehension and relocation tests
        • load and shift
        • posterior stress and posterior jerk tests
        • sulcus sign in neutral and external rotation
      • Neurovascular
        • check axillary nerve function
  • Imaging
    • Radiographs
      • recommended views
        • true AP radiographs in neutral and internal rotation
        • scapular Y
        • axillary lateral
      • findings
        • glenoid rim fractures, hypoplasia, fractures of humeral head
      • optional views
        • Garth View
          • 45-degree oblique radiograph in anterior plane
          • fleck of bone inferior to anatomic neck - avulsion of medial cortex
        • arthrogram
          • normally dye appears in axillary pouch, biceps sheath, subcoracoid recess
            • HAGL - dye escapes inferiorly in crescent shape
    • CT
      • indications
        • lower utility than MRI
        • consider combination with arthrogram for contraindication to MRI
      • views
        • best seen on sagittal
      • findings
        • Oberlander described bony HAGL lesion posterior to MGHL
    • MRI
      • indications
        • gold standard for diagnosis of HAGL
        • recurrent instability or persistent pain after instability event
          • MR Arthrogram if more than 7 - 10 days from injury
      • views
        • coronal oblique T2 weighted fat suppressed MRI
        • sagittal oblique T2 weighted fat suppressed MRI
      • findings:
        • J Sign
          • pathopneumonic for HAGL
          • inferior pouch normally appears U - Shaped
          • HAGL has appearance of J - Shaped inferior pouch
            • dye may leak through tear inferiorly
          • chronic lesions may be difficult to see due to scar of IGHL to capsule
  • Differential
    • Anterior Bankart Tear/ Anterior Inferior Labrum tear
    • Posterior Bankart/ Posterior Inferior Labrum tear
  • Treatment
    • Nonoperative
      • sling immobilization and physical therapy
        • indications
          • first-line treatment when no instability present
        • outcomes
          • 90% recurrence rate of instability with non-operative treatment
    • Operative
      • open HAGL repair
        • indications
          • young person with primary shoulder dislocation, high recurrence rate
          • associated injuries
          • failed non-operative management
          • recurrent instability
          • persistent pain or instability after missed HAGL with Bankart repair
        • techniques
          • open anterior repair
            • indications
              • anterior HAGL
          • open posterior repair
            • indications
              • posterior HAGL
        • prognosis
          • low incidence of post-operative instability following open repair
          • no reported difference between open and arthroscopic repair
      • arthroscopic HAGL repair
        • indications
          • same as open repair
        • techniques
          • anterior arthroscopic repair
            • Indications
              • anterior HAGL
              • less soft tissue dissection compared to open
              • less damage to subscapularis compared to open
          • posterior arthroscopic repair
            • Indications
              • posterior HAGL
              • avoid splitting rotator cuff muscles
        • prognosis
          • no reported difference between open and arthroscopic repair
  • Techniques
    • Sling immobilization and physical therapy
      • Technique
        • 4 week sling immobilization
        • shoulder strengthening following sling immobilization period
    • Open Anterior Repair
      • advantages
        • visualization of neurovascular structures
        • less technically difficult
      • approach
        • deltopectoral approach
        • 3 subscapularis approaches
          • subscapularis tendon released leaving a 1cm cuff
          • subscapularis sparing technique described by Arciero and Mazzoca
            • L-shaped incision lower one third subscapularis tendon
          • subscapularis sparing technique by Bhatia
            • lower border subscapularis identified by anterior humeral circumflex
            • pectoralis major tendon retracted inferiorly
            • retract subscapularis superiorly
            • subscapularis is usually scarred inferiorly with a HAGL
      • technique
        • bone preparation
          • Medial humeral neck is rasped to remove scar tissue at 6 to 8 o'clock
        • instrumentation
          • suture anchor placed in inferior humerus necks
          • sutures pulled through anterior-inferior capsule
        • complications specific to this treatment
          • axillary nerve entrapment
            • use caution, nerve is within 3mm of inferior capsule
      • rehabilitation
        • anterior HAGL Protocol
          • 0 - 4 weeks
            • Sling
            • Passive forward flexion to 90 degrees, external rotation to 30 degrees with arm at the side
          • 4 - 10 weeks
            • Assisted active forward flexion to 140 degrees
            • External rotation to 40 degrees with arm at side
          • 10 - 12 weeks
            • External rotation permitted with 45 degrees of abduction
    • Open Posterior Repair
      • approach
        • Judet approach
          • deltoid bluntly spread in line with fibers
          • interval between infraspinatous and teres minor utilized
      • technique
        • bone work
          • Roughen bone inferiorly on humeral neck to create bleeding surface
        • instrumentation
          • Place suture anchors in inferior humeral neck
      • rehabilitation
        • posterior HAGL Protocol
          • 0 - 6 weeks
            • Passive abduction to 45 degrees, forward flexion to 45 degrees, external rotation to 30 degrees
            • Internal rotation limited to arm against belly
          • 6 weeks - 12 weeks
            • No internal rotation with the arm abducted more than 45 degrees
      • complications
        • Axillary nerve entrapment
          • use caution, nerve is within 3mm of inferior capsule
    • Anterior Arthroscopic Repair
      • approach
        • 3 portal approach
          • anterior superior portal under biceps
          • anterior inferior portal above or below subscapularis
          • posterior portal
        • accessory Portals
          • Anterior-inferior / 5 o'clock portal
            • 1 cm inferior to upper border subscapularis tendon
            • placed in neutral position to protect musculocutaneous nerve
          • 7 o'clock posterior-inferior portal - Davidson and Rivenburgh
            • 2 - 3 cm inferior to posterior viewing portal
          • Bhatia portal/ axillary pouch portal
            • 3 cm inferior to lower border of posterolateral acromial angle
            • 2 cm lateral to standard posterior portal
      • technique
        • bone work
          • humeral neck roughened with arthroscopic burr
          • suture anchors placed at IGHL insertion on humeral neck
        • soft tissue
          • suture passing device through 5 o'clock portal
          • horizontal mattress suture through capsular tissue to neck
        • instrumentation
          • suture lasso, suture anchors with curved guide
          • wait until all sutures are passed to tie knots
      • complications
        • axillary nerve damage
        • arthrofibrosis
    • Posterior Arthroscopic Repair
      • approach
        • may Switch viewing portal from posterior to anterior using 30 degree scope
        • accessory inferior-lateral posterior portal
      • technique
        • bone work
          • shaver and burr to posterior humeral neck
        • instrumentation
          • place 2 suture anchors into inferior humeral neck posteriorly
          • curved guide with all-suture anchor is helpful
        • soft tissue
          • use suture passer to pass sutures through posterior IGHL
          • repair IGHL to posterior humeral neck
          • tension sutures with arm externally rotated
          • repair IGHL 1st (before bankart) with combined injuries
  • Complications
    • Arthrofibrosis with Loss of External Rotation
      • Treatment
        • Physical Therapy for external rotation stretching
    • Axillary Nerve Injury
      • Axillary nerve is 10 mm inferior to the glenoid and 2.5 mm inferior to capsule
    • Chondrolysis
      • risk factors
        • reported with thermal capsulorrhaphy
        • overtightening anterior may be associated with accelerated posterior wear
    • Pulmonary Embolism
      • Incidence
        • 0.6% with shoulder arthroscopy
    • Recurrence of instability
      • Very Rare
      • Per systematic review: 0/25 operative, 9/10 nonoperative
      • Odds ratio 0.05 recurrence with operative vs nonoperative treatment (p=.006)
  • Prognosis
    • Good with adequate recognition and treatment
Flashcards (0)
Cards
1 of 0
Evidence (1)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (0)
Private Note