Repair of a Reverse HAGL: A 2-Portal Technique

Abstract

Background:

Glenohumeral joint stability is reliant on a combination of static and dynamic constraints. Humeral avulsion of the posterior band of the inferior glenohumeral ligament (HAGL) is an exceedingly rare injury. These injuries can be difficult to diagnose and can lead to continued pain, dysfunction, and recurrent instability. There is a paucity of literature regarding surgical management of reverse HAGL lesions.

Indications:

Many intrasubstance reverse HAGL lesions can be managed nonoperatively with rehabilitation focused on improving shoulder stability. Although the incidence of recurrent instability in patients with reverse HAGL lesions is unknown, the acute detached humeral lesions in athletes are often treated surgically to restore normal shoulder.

Technique Description:

The patient was placed in a standard beach chair position, and the standard portals were made for a diagnostic shoulder arthroscopy. The anterior portal was the primary viewing portal. Using the initial posterior skin incision, instruments were introduced through the defect from the retracted posterior band of the inferior glenohumeral ligament. Using a combination of the 30° and 70° arthroscope, the HAGL was mobilized from the infraspinatus musculature. Two knotless suture devices (1.8-mm suture anchor, 2.6-mm suture anchor) were used to reduce the reverse HAGL lesion to an anatomical position, and the posterior capsule was closed thereafter.

Results:

Only case studies and a single case series have been published pertaining to reverse HAGL repair techniques and related outcomes. When diagnosed and treated appropriately, arthroscopic repairs yield promising results with a high percentage of patients returning to prior level of activity or returning to prior participation level in sport. However, outcome data are limited given the rare occurrence of this injury pattern.

Discussion/Conclusion:

Reverse HAGL pathology can be treated effectively with arthroscopic surgical repair to restore the normal capsular anatomy and prevent recurrent instability and persistent posterior shoulder pain. Using a 2-portal approach with posterior capsular closure is a minimally invasive operation that allows for appropriate management of these rare injuries.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video illustrates the surgical technique for a reverse humeral avulsion of the glenohumeral ligament (HAGL) repair using a 2-portal technique as performed by the senior author.

The authors’ financial and professional disclosures can be seen here.

This video aims to provide pertinent information regarding reverse HAGL lesions. We will present a case, discuss radiographic imaging, and provide video demonstration of the surgical approach and repair using a 2-portal technique. Briefly, we will comment on the postoperative rehabilitation course with a focus on return to play and existing literature regarding reverse HAGL repairs in athletes.

Humeral-sided avulsions of the glenohumeral ligaments are rare injuries that occur in the setting of shoulder instability. When the diagnosis is missed, these injuries can lead to recurrent instability or continued pain and shoulder dysfunction. Posterior or reverse HAGL lesions are even less common than anterior glenohumeral avulsion injuries.^1,9 Often, they present with concomitant pathology.^2,4 Historically, this pathology has been difficult to diagnose as it is easily missed on even gold standard imaging. There is a paucity of literature and outcomes data regarding reverse HAGL repairs given the infrequent occurrence of this injury.^5,6,7,9,10

This case example is of a 21-year-old male, collegiate lacrosse player with aspirations to play professionally. He experienced acute posterior shoulder pain following a fall onto an outstretched arm during a game. Based on his description, the arm was forward flexed and adducted across his body when it was axially loaded. He reported a subluxation-type event that required on-field manipulation by the athletic training staff. Following the initial injury, he has been unable to participate in training due to persistent posterior shoulder pain.

For posterior shoulder instability, a careful, detailed history is critical for diagnosis with nonspecific shoulder complaints and clinical findings being typical. As is common, this patient’s physical examination findings were subtle. He demonstrated discomfort with the O’Brien test and Kim test and had pain and mild increased translation with posterior load and shift. Although we recommend a thorough instability assessment in this setting, it must be acknowledged that the common shoulder instability tests are neither sensitive nor specific for the detection of reverse HAGL injuries. ⁸

The gold standard imaging modality following a shoulder instability event is a magnetic resonance arthrogram. The presence of anterior humeral head edema should heighten suspicion for posterior labral or capsular pathology, as this finding is indicative of a posterior shoulder subluxation or dislocation event. On axial views, T2-weighted images will show joint fluid extravasation beyond the capsular ligaments into the infraspinatus and teres minor. On coronal views, there should be careful evaluation of the inferior glenohumeral ligamentous complex that attaches just inferior to the articular margin. True HAGL lesions will convert the standard U-shaped structure of the axillary pouch into more of a J-shape. For reverse HAGL lesions, the J-shape is less pronounced and fluid extravasation will occur beyond the axillary pouch as seen in this image. ³

In this case, you can visualize anterior humeral head edema indicative of a posterior instability event. Next, you can see the gadolinium tracking along the humerus beyond the avulsed posterior band of the inferior glenoid ligament. Here is the coronal sequence redemonstrating the injury. There is no evidence of superior labrum or rotator cuff pathology.

Given these radiographic findings, the patient’s inability to participate in sport, and athletic aspirations, the decision was made to proceed with surgical management. The plan was to perform outpatient surgery using general anesthesia and a preoperative peripheral nerve block. The senior author prefers beach chair positioning for shoulder instability. Prior to instability surgery, a thorough examination under anesthesia is performed. This patient redemonstrated a 2+ posterior load and shift and felt stable anteriorly. The planned operative technique was to perform a left shoulder diagnostic arthroscopy with reverse HAGL repair.

Before we begin with the surgical technique, it is important to be able to recognize these injuries intraoperatively. As mentioned previously, they are frequently missed on advanced imaging. This intraoperative picture is pathognomonic for a retracted posterior capsular avulsion tear with visualization of the infraspinatus muscle belly through an intra-articular anterior viewing portal.

Here, we are looking from the anterior portal posteriorly. A separate capsular entry was performed within the capsular avulsion injury through the same posterior portal incision. An atraumatic grasper was being used to identify the avulsed posterior band of the inferior glenohumeral ligament and reduce it anatomically. Again, we evaluated the posterior and superior labrum and did not detect any pathology. Next, we viewed from the posterior portal to evaluate the injury from a different vantage point and plan anchor placement. A 70° camera was introduced to the anterior portal, and this aided in additional visualization inferiorly. After mobilization of the capsule from the infraspinatus muscle, an 1.8-mm all-suture knotless anchor with retensionable technology was inserted along the posterior inferior humeral neck. We then placed a looped suture through the capsule to serve as a traction stitch to allow for a more inferior capsular bite. A right curved 45° suture shuttle passer was used to shuttle a repair stitch. Next, a curved suture shuttle passing device was once again used in a more superior location compared with the repair stitch previously passed. The suture passing device was retrieved and used to shuttle the looped shuttling stitch from the anchor. The white and black shuttle suture was then used to pass the blue repair stitch through the knotless tensioning anchor to secure the inferior aspect of the reverse HAGL lesion.

The camera was brought to the posterior portal for visualization of the reduction. The image demonstrated the reduction of posterior capsular tissue to the humeral neck using the repair stitch.

Next, a self-punching, 2.6-mm all-suture knotless anchor with additional 1.7-mm suture tape was placed superior to the prior anchor. The prior looped suture traction stitch was used to shuttle the repair stitch. Next, we again used the 45° suture shuttle passer to pass the shuttling suture from the second anchor. The atraumatic grasper is used to separate the 1.7-mm suture tape from the white and black shuttling suture used for reducing the posterior capsule. The repair stitch was shuttled back into the second anchor and tensioned, which further reduces the capsular tissue to the humeral neck. Following this, the 2 limbs of the 1.7-mm suture tape are used in a mattress fashion to close down the remaining defect. Following arthroscopic knot tying of the tape, there was a small residual capsular defect. A 1.3-mm suture tape was then used to complete the capsular closure. Final evaluation of the final pictures was performed prior to instrument removal.

Placing the anterior portal high and lateral within the rotator interval allows for improved visualization. We also recommend utilization of a 70° scope to visualize the inferior anchor placement and for initial capsular passes. The comparison intraoperative images on the right demonstrate the improved view along the posterior inferior humeral neck while using the 70° lens. In addition, the angles for passing can be challenging with a 2-portal technique. The authors found that the use of a traction stitch can help elevate the tissue to aid with inferior passes. We recommend having a variety of passing devices available to assist with these unorthodox angles.

Postoperatively, the patient was placed into a sling. The postoperative rehabilitation protocol mirrors our protocol for posterior labral repair which consists of strict sling immobilization initially with guided return to full range of motion followed by progressive strengthening exercises. The goal for return to sport-related activity is usually around 4 or 5 months with progression back into full contact athletics. Return to sport is largely dependent on the type of sport, level of contact, and type of shoulder activity that is required for the athlete.

Published outcome studies are rare following posterior reverse HAGL repairs. In 2007, Castagna et al ⁵ published results on 9 patients who suffered sport-related injuries. None of the reverse HAGL lesions were diagnosed preoperatively despite gold standard imaging. Sixty-seven percent of the reverse HAGL lesions had concomitant pathology that was also addressed at the time of surgery. At a mean follow-up of 34 months, significant improvements were noted in shoulder scoring, and each patient was able to return to previous level of sport participation in this series.

Our references are listed here.

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