HAGL

DefinitionHAGL Arthroscopy

 

Humeral Avulsion of Glenohumeral Ligament

 

Incidence

 

Bokor et al JBJS Br 1999

- 514 cases surgical treatment traumatic instability

- incidence 7.5%

- 25% associated SSC tear

- likelihood of HAGL if no Bankart or MDI 27%

 

Bhatia KSSTA 2012

- 10% incidence of HAGL

 

Bigliani et al J Ortho Research 1992

- cadaveric dislocations

- 25% HAGL

 

Why the difference with cadavers

- ? differences in tissue

- HAGL lesions heal / don't always cause instability

 

Type

 

Bony avulsions (BHAGL)

 

Soft tissue

- humeral

- humeral and bankart (floating)

- posterior / Reverse HAGL

 

Pathology

 

Pouliart J Should Elbow Surg 2006

- cadaveric study

- extensive capsular injury +/- SSC required for HAGL to cause instability

 

MRA

 

Normal

 

Shoulder MRI Normal Humeral IGHL InsertionMRI Normal IGHL

 

Abnormal

- J sign

 

HAGL MRI

 

Arthroscopy

 

Normal

 

Normal Humeral Attachment IGHL

 

Abnormal

 

HAGL

 

Management

 

1.  HAGL

 

Open Technique

 

Detach lower half SSC

- L Shaped tenotomy

- repair IGHL to surgical NOH

 

Arthroscopic Technique

 

Burkhart

- 70o scope

- 5 o'clock portal through SSC with arm adducted

- danger to MCN if arm abducted at all with insertion 5 o'clock portal

- ensure good angle to proximal humerus with needle, for insertion of anchors

- may use suture passers from posterior portal

 

HAGL 1HAGL 2HAGL 3

 

2.  Bankart + HAGL (Floating)

 

Options

- arthroscopic repair both

- open repair both

- arthroscopic repair bankart, open HAGL

- arthroscopic repair bankart, leave HAGL

 

Kim et al Arthroscopy Supplement 2006

- all arthroscopic, 8 good results

 

Rhee et al J Should Elbow Surg 2007

- 4 floating HAGL, open treatment

- loss 15o ER
- elected to leave humeral side in volleyballer for risk of loss of ER

 

Bhatia KSSTA 2012

- subscap sparing approach in 7 patients

- good outcome