Open and Arthroscopic Treatment of Humeral Avulsions of the Glenohumeral Ligament (HAGL)
Background, Diagnosis, and Interpretation
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Injuries to the inferior glenohumeral ligament (IGHL) and capsulolabral complex may occur at the glenoid origin (40%) or present as an intrasubstance tear (35%) or tear at the humeral insertion (25%).
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The incidence of humeral avulsion of the glenohumeral ligament (HAGL) is 1%9% in patients presenting with glenohumeral instability (Fig. 9-1).
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Figure 9-1 Coronal T2-weighted MRI images of a right shoulder demonstrating normal-appearing inferior capsular attachment on the anatomic neck of the humerus as a normal “U”-shaped structure (A). An example of a right shoulder with HAGL lesion is presented (B), as demonstrated by an abnormal “J”-shaped axillary pouch and associated signal intensity of the inferior capsule indicating soft tissue edema.
Also noted is a displaced fracture to the greater tuberosity.
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Special attention should be paid to intrasubstance tears of the IGHL and capsule, which appear parallel to its fibers. This may present similarly to an HAGL but without frank capsular detachment at the humeral insertion and can be repaired with side-to-side sutures passed and tied arthroscopically. In these cases, imaging is consistent with escape of fluid from the capsule and a positive “J sign” on MRI, but an intact humeral attachment is seen arthroscopically. 1 , 2
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Biomechanical studies show that large anterior HAGL lesions increase glenohumeral rotation and translation. Repair of these large HAGL lesions restores range of motion (ROM) and translational stability similar to native condition. 3 , 4
Open Repair
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Positioning
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Beach chair, with patient elevated 45 degrees Arm holder as preferred
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Approach
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The arm is positioned so that it is forward-flexed in line with the body and in neutral rotation to assist with the surgical approach.
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An incision is made over the deltopectoral interval, slightly more vertically than otherwise would be used for shoulder arthroplasty or proximal humeral work. The incision should extend from superior border of the coracoid to just above the axillary fold, ~7 cm.
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Dissection with cautery is carried through fat until deep muscular fascia is reached. The cephalic vein (typically found proximally and medially in the wound) is identified, the plane medial to the vein is dissected, and the vein is retracted laterally. Crossing veins are ligated with cautery.
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The deep deltopectoral interval is developed and retracted with a selfretaining retractor (Kolbel retractor, George Tiemann & Co., Hauppauge, NY).
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The clavipectoral fascia is incised with Metzenbaum scissors lateral to the muscular component of the conjoint tendon.
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The Kolbel retractor is adjusted to retract the proximal conjoint tendon medially, with care not to place excessive tension on the musculocutaneous nerve.
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The arm is externally rotated to place tension on the subscapularis tendon. Landmarks include the long head of the biceps tendon and the bicipital groove laterally and the upper border of the subscapularis tendon and rotator interval
proximally.
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Tenotomy and release
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An L-shaped subscapularis tenotomy is made with a vertical limb 1 cm medial to the insertion on the lesser tuberosity at the superolateral corner of the subscapularis and the transverse limb inferiorly (Fig. 9-2). This maintains a 1-cm cuff of subscapularis tendon insertion laterally for repair. We begin this tenotomy inferiorly.
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Figure 9-2 The L-shaped incision made in the inferior portion of subscapularis insertion 1.5 cm medial to the lesser tuberosity. (Arciero RA, Mazzocca AD. Mini-open repair technique of HAGL (humeral avulsion of the glenohumeral ligament) lesion. Arthroscopy. 2005;21(9):1152.)
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The upper two-thirds of the subscapularis typically appear more tendinous, while the lower one-third typically appears more muscular. At this junction, a transverse plane is developed parallel to the fibers of the subscapularis with two small Freer elevators.
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The plane between the upper two-thirds of the subscapularis (superficial) and the anterior capsule (deep) is developed with a small periosteal elevator, which is left in place to place tension on the subscapularis tendon.
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With the subscapularis insertion still attached but retracted, the inferior capsule is examined to confirm that the capsule is completely avulsed from the
humerus, because sometimes only a portion of the capsule is avulsed. In cases of incomplete capsular detachment, we detach only a portion of the subscapularis, instead of its entirety.
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Further release of the subscapularis tendon progresses from inferior to superior, medial to its insertion. We find needlepoint cautery helpful to start with a partial-thickness release of the subscapularis tendon to prevent injury to the anterior capsule, deep to the tendon.
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Tagging sutures are placed (we prefer a Mason-Allen type stitch) from inferior to superior as the release progresses.
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Once the tendon is fully released, the plane between the subscapularis and the anterior glenoid medially is bluntly developed, and the subscapularis is retracted medially.
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Alternatively, the upper half of the subscapularis can be preserved.
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An L-shaped tenotomy is made with the transverse limb at the inferior border of the subscapularis, splitting muscle fibers, and the vertical limb is 1.5 cm medial to lesser tuberosity traversing the inferior half of tendon, leaving the
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superior half of subscapularis tendon undisturbed. 9 The axillary nerve is palpated inferiorly.
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The subscapularis is tagged and retracted medially and superiorly.
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As the interval between the capsule and subscapularis is dissected, the HAGL lesion will become visible at the anteroinferior aspect of the glenohumeral neck. The remaining anterior capsule is released off the humeral neck and mobilized for repair.
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This is done as an inverse L-shaped capsulotomy, with the transverse limb along the rotator interval and the vertical limb on the border of the anatomic neck/articular margin of the humerus.
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The release of the anterior capsule is continued from superior to inferior. At the anteroinferior quadrant of the glenohumeral joint (5-6 o)clock on a right shoulder), the avulsion of the capsule from the humeral neck will be visible
extending posteroinferiorly (Fig. 9-3).
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Figure 9-3 Anterior view of dissection left shoulder. A. The plane between the subscapularis (yellow arrow) and anterior capsule (star) has been developed. With medial retraction (B) of these structures, the anatomic neck and capsular attachment on the humerus can be visualized.
Arthroscopic Repair
Positioning Pearls: Lateral Decubitus Position
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Lateral positioning can be used with the arm suspended or in traction, with the benefit of glenohumeral joint distraction to increase working space; however, this position may make it more difficult if intraoperative findings suggest a need to convert to an open procedure.
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General anesthesia is administered while the patient is on a padded beanbag. The patient is then positioned in the lateral decubitus position on the beanbag, taking care to place an axillary roll two fingerbreadths below the axillary fold. Hip and knee flexion is ensured, and adequate padding is placed for the “down side” elbow and wrist, greater trochanter, fibular head, and lateral malleolus, with pillows placed
between the legs.
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The operative arm should be placed in 40-50 degrees of abduction and 15 degrees of forward flexion, with 5-10 lb of balanced suspension.
Positioning Pearls: Beach Chair
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Advantages of beach chair positioning include improved orientation of anatomy and the ease to convert to open stabilization if needed.
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General anesthetic is preferred for maximal muscular relaxation.
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Before sitting the patient up, he or she is moved both proximally and toward the operative side to ensure that the buttocks will be centered at the break of the bed. Moving the patient to the operative side will maximize posterior exposure of the shoulder and allow space for manipulation of the arthroscopic instruments. The back of bed is elevated to 70 degrees, and the hips and knees are flexed to minimize pressure sores and nerve injuries in the lower extremities. A kidney post positioner can be used along the greater trochanter and iliac crest to protect the patient from excessive lateral translation. The nonoperative arm is placed on a well-padded arm holder or pillows.
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Ideally, exposure should extend to the medial border of the scapula posteriorly and medial to the coracoid anteriorly.
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An arm positioner such as SPIDER2 (Smith & Nephew, Memphis, TN) or Triman (Arthrex, Naples, FL) is used to maintain arm position.
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The head and neck should be in neutral position in both the coronal and sagittal planes.
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A large bump (three folded sheets wrapped in an elastic bandage) can be placed in the axilla with the arm maximally adducted to provide distraction of the glenohumeral joint.
Examination Under Anesthesia
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Passive ROM: forward flexion, abduction, external rotation with arm at the side, and external and internal rotation with 90 degrees of abduction
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Anterior, posterior, inferior load, and shift
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Grade 1+ humeral head unable to be translated over rim
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Grade 2+ humeral head able to translate over rim but spontaneously reduces Grade 3+ humeral head able to translate over rim and remains dislocated,
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requiring manual maneuver to reduce Sulcus sign
Common Portals Used for HAGL Repair
Standard posterior
2 cm inferior and 2 cm medial to posterolateral border of the acromion
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Anterior rotator interval
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Created just above the tendon of the subscapularis, can be created “inside out” or “outside in” with spinal needle localization.
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Trajectory is planned for placement of humeral anchor for HAGL repair, as well as possible glenoid anchor if needed for treatment of concurrent labral tear.
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Anterolateral superior
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Made with spinal needle localization in the lateralmost extent of the rotator interval
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Skin incision is just off the anterolateral border of the acromion; entry into the joint should be adjacent to the biceps tendon laterally and just anterior to the anterior margin of the supraspinatus tendon.
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Anteroinferior “5 o)clock portal”
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Made with spinal needle localization through the subscapularis muscle, ~2 cm inferior to the lateral border of the coracoid; entry into the joint should be visualized 1 cm inferior to the upper border of the subscapularis and as lateral as possible. 5 Follow with dilation using a blunt trocar, which is exchanged for a 5-mm cannula.
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The portal is created with the arm in neutral rotation and adduction to increase the distance from musculocutaneous nerve.
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Posteroinferior “7 o)clock portal”
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This portal is made with spinal needle localization while viewing from the anterolateral superior portal.
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A skin incision is made 3-4 cm lateral to the posterolateral border of the acromion, angled 30 degrees medially and slightly inferior.
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Placing a cannula through this portal is avoided to prevent damage to the posterior capsule, which would preclude repair.
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The suprascapular nerve is 28 mm away and the axillary nerve is 39 mm away (Davidson and Rivenburgh).
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Posterior axillary pouch portal
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This portal is made with spinal needle localization while viewing from the anterolateral superior portal.
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A skin incision is made 2 cm directly inferior to the posterolateral border of the acromion and 2 cm lateral to the standard posterior viewing portal.
Diagnostic Arthroscopy
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Standard diagnostic shoulder arthroscopy is done viewing from the posterior portal. For optimal viewing of an HAGL lesion, the shoulder is placed in abduction and external rotation for an optimal angle toward the humeral neck directly inferior to the articular surface.
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The typical HAGL lesion can be viewed through a standard posterior portal with a 30-degree arthroscope viewing toward the axillary pouch. 6 The IGHL fibers are seen traversing from the humeral neck to the glenoid neck. Disruptions in the fibers are seen as a capsular tear, and underlying fibers of subscapularis are seen through the defect. Internal and external rotation of the arm exposes the different portions of the ligaments (Fig. 9-4).
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Figure 9-4 A and B. Examples of HAGL lesions as viewed arthroscopically. Arrows: torn edge of IGHL; asterisk: bridging fibrous adhesions. H, humeral head; IGHL, inferior glenohumeral ligament. (Page RS, Bhatia DN. Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion: anterior and posterior techniques. Tech Hand Up Extrem Surg. 2009;13(2):98–103.) C. Arthroscopic view from posterior portal of a left shoulder. Humeral head on right; HAGL lesion is seen with detachment of the inferior capsule from the anatomic neck of the humerus (arrow).
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Working portals
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Using the standard posterior portal as the primary viewing portal, either a 30or 70-degree arthroscope is used. 7
Working portal option 1: Anterosuperior lateral portal with an 8.5-mm cannula (working) and an anteroinferior 5 o)clock portal with a 6-mm cannula (suture shuttle)
Working portal option 2: Anterior rotator interval portal with an 8.5-mm cannula (working) and a posteroinferior 7 o)clock portal with a 6-mm cannula (suture shuttle)
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Anterior viewing through the anterolateral superior viewing portal
Anterior HAGL lesions also can be viewed from the anterolateral superior portal, with the arthroscope anterior to the humeral head and looking laterally at the humeral capsular insertion.
Posterior HAGL (“reverse HAGL”) lesions can be viewed from the anterolateral superior portal, posterior to the humeral head, with the lens looking lateral at the humeral capsular insertion.
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Placement of a large bump (rolled sheets or drapes) high in the axilla, followed by adduction of the arm, can aid in distraction of the glenohumeral joint to increase the working space.
Alternatively, rolled gauze can be wrapped around the proximal humerus, with a loop made and then wrapped around an assistant (tied by the circulating nurse posteriorly) to provide a distractive force on the joint when the assistant “water-skis” on the gauze.
Preparation and Fixation Techniques 8
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An arthroscopic shaver and ablation device (anteroinferior 5 o)clock portal is ideal) are used to debride adhesions and perform synovectomy until the free lateral edge of the IGHL is identified.
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The avulsed capsular tissue is identified, and a grasper is used to assess tissue quality
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and mobility. If a concurrent labral tear is identified, treating the HAGL lesion before the labral repair helps avoid overtensioning of the medial aspect of the glenohumeral joint.
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An arthroscopic shaver, burr, or rasp is used to prepare a bony bed for reduction along the humeral neck.
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The trajectory for suture anchor placement in the inferior humeral neck is confirmed with a spinal needle.
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The arm is rotated as needed to get the appropriate angle.
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An anchor is inserted percutaneously, with the entry site on the skin between the standard posterior portal and the accessory posterior-lateral portal.
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Two or three suture anchors (we use 3.0-mm PEEK SutureTak suture anchors with no. 2 FiberWire, Arthrex, Naples, FL) are placed along the humeral neck, spaced 5-10 mm apart. The humerus is rotated as needed to achieve the proper angle for anchor placement (abduction and external rotation).
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After the suture anchors are placed, a single limb of suture is retrieved through the anterosuperior lateral portal, with the other suture limb remaining out of the percutaneous wound (or coming out of the anteroinferior portal).
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A curved suture passer is passed through the avulsed capsular tissue, and the PDS suture is shuttled through.
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Suture limbs are passed individually through the IGHL with a curved suture passer.
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Once it has penetrated the tissue, the PDS passing suture is retrieved with a grasper from the anterolateral superior portal.
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A single loop is tied in the PDS passing suture and used to snare the limb of suture from the anchor, which was previously retrieved from the anterolateral superior portal.
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The curved suture passer is removed, and the PDS suture is pulled from the 7
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o)clock portal to shuttle the suture through tissue and out the 7 o)clock suture. This process is repeated with the second suture, so that two limbs are coming out of the 7
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o)clock portal passed through in a horizontal mattress fashion. An arthroscopic knot is tied with the arm in slight abduction and slight external rotation (15 degrees) such that the knot lies intra-articular.
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Caution is required in passing sutures at the 6 o)clock position, and no more than 1 cm of tissue should be taken to avoid the risk of injury to the axillary nerve.
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Alternatively, a Viper suture passer (Arthrex, Naples, FL) from the 7 o)clock portal can be used to penetrate the avulsed capsule and retrieve the suture.
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The suture-passing sequence continues from posteroinferiorly to anterosuperiorly. As suture passage progresses anteriorly, a 5 o)clock portal, either percutaneous transsubscapularis or through a 5-mm cannula, will achieve the proper angle toward
the humeral neck.
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Caution is required when passing sutures to avoid the musculocutaneous nerve (arm in adduction and neutral rotation) and the axillary nerve.
Alternate Single-Portal Technique for Treatment of Anterior HAGL Lesions 7
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The humeral neck is prepared as above, and a suture anchor is placed along the inferior humeral neck. A single limb of suture is retrieved from the anteroinferior 5 o)clock portal.
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A curved suture shuttle is inserted from the anteroinferior 5 o)clock cannula, grabs a bite through the IGHL 5-10 mm medial, and the PDS passing suture is shuttled The suture shuttle is removed and the end of the suture exiting the cannula is tagged with a clamp.
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The suture retriever is used to grasp the free end of the PDS passing suture from anteroinferior cannula. A loop is created in the free end of the passing suture and tied around the free suture limb from the previously retrieved anchor.
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The anterior strand is shuttled through the IGHL and out the anteroinferior cannula.
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This is repeated for the second suture. The position of the suture strands determines the magnitude of capsular shift.
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An arthroscopic knot is tied through the anteroinferior cannula with the arm in slight abduction and slight external rotation (15 degrees) such that the knot lies intra-articular.
Arthroscopic Technique for Repair of Posterior HAGL Lesions
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Portals
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Standard posterior viewing portal with 30- or 70-degree arthroscope
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An axillary pouch portal is created 2 cm directly inferior to the posterolateral corner of the acromion with spinal needle localization, above the posterior band of the IGHL, and a working cannula is inserted. The angle for suture anchor placement along the inferior humeral neck is confirmed. Standard anterior portal in rotator interval (working)
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A shaver is introduced through the axillary pouch portal to debride adhesions and perform synovectomy. Preparation of the humeral neck is similar to that described above.
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Suture anchors are inserted through the axillary pouch portal, and a single limb is retrieved through the anterior portal.
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A curved suture shuttle from the anterior portal cannula is used to pass the PDS shuttle suture, and sutures are shuttled to pass through the torn edge of the IGHL.
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Sutures are retrieved through the axillary pouch portal or the 5 o)clock portal. This is repeated, and sutures are tied with a mattress stitch.
Repair of HAGL Lesion
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The avulsed capsule from the humeral neck is identified, and the leading edge of the ligament is tagged with suture.
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The capsular insertion on the humeral neck is prepared with a curette, burr, or rasp. Two or three suture anchors (G4 Anchor, Mitek Sports Medicine, Raynham, MA or 3-mm PEEK SutureTak, Arthrex, Naples, FL) are placed along the humeral neck at the anatomic insertion of the glenohumeral ligaments.
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The shoulder is positioned in slight abduction, forward flexion, and external rotation for optimal tensioning.
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The position of repair is determined by examination of the contralateral extremity to determine how tight to make it. Usually, forward flexion allows reduction of the humeral head and about 30 degrees of abduction and external rotation.
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If the tear extends into the rotator interval, we repair it with the arm in maximal adduction and 30 degrees of external rotation.
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Sutures are passed through the capsule and glenohumeral ligaments in a horizontal mattress configuration and are tagged together. Once all sutures are passed, they are tied sequentially from inferior to superior.
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We routinely close the rotator interval with one or two sutures.
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The arm is maximally internally rotated, and the subscapularis tenotomy is reapproximated with heavy suture.
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The shoulder is gently moved through an ROM to ensure that the subscapularis repair remains intact and moves as a unit.
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The deltopectoral fascia is closed with interrupted suture (no. 2 Orthocord, DePuy Synthes Mitek Sports Medicine, Raynham, MA) in case further surgery is necessary; colored suture assists in locating the rotator interval.
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The deep dermal tissue is closed with deep buried 2-0 Vicryl.
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The skin is closed with no. 2-0 Prolene in a running subcuticular fashion, with an escape stitch.
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Sterile dressings are placed and the patient is placed in a shoulder immobilizer.
Postoperative Care
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Return to sport is allowed at 6 months postoperatively.
References
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Melvin JS, Mackenzie JD, Nacke E, Sennett BJ, Wells L. MRI of HAGL lesions: four arthroscopically confirmed cases of false-positive diagnosis. AJR Am J Roentgenol. 2008;191(3):730–734.
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Mizuno N, Yoneda M, Hayashida K, Nakagawa S, Mae T, Izawa K. Recurrent anterior shoulder dislocation caused by a midsubstance complete capsular tear. J Bone Joint Surg Am. 2005;87(12):2717–2723.
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Park KJ, Tamboli M, Nguyen LY, McGarry MH, Lee TQ. A large humeral avulsion of the glenohumeral ligaments decreases stability that can be restored with repair. Clin Orthop Relat Res. 2014;472(8):2372–2379.
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Southgate DF, Bokor DJ, Longo UG, Wallace AL, Bull AM. The effect of humeral avulsion of the glenohumera ligaments and humeral repair site on joint laxity: a biomechanical study. Arthroscopy. 2013;29(6):990–997.
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Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy. 2005;21(5):632.
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Parameswaran AD, Provencher MT, Bach BR, Verma N, Romeo AA. Humeral avulsion of the glenohumeral ligament: injury pattern and arthroscopic repair techniques. Orthopedics. 2008;31(8):773–779.
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Page RS, Bhatia DN. Arthroscopic repair of humeral avulsion of glenohumeral ligament lesion: anterior and posterior techniques. Tech Hand Up Extrem Surg. 2009;13(2):98–103.
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George MS, Khazzam M, Kuhn JE. Humeral avulsion of glenohumeral ligaments. J Am Acad Orthop Surg. 2011;19(3):127–133.
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Arciero RA, Mazzocca AD. Mini-open repair technique of HAGL (humeral avulsion of the glenohumera ligament) lesion. Arthroscopy. 2005;21(9):1152.