Advertisement

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Clinical Review of 9 Cases

      Purpose: The purpose of this article is to report the characteristic conditions in which a posterior humeral avulsion of the glenohumeral ligament (PHAGL) lesion occurs, defining also the different possibility of association with other intra-articular shoulder pathologies. Methods: We identified in our database 16 consecutive patients with a PHAGL lesion who underwent surgical treatment. Six of these patients had previous failed anterior shoulder stabilization, and 1 patient failed thermal shrinkage for a multidirectional instability and were not included in this study. The 9 remaining patients were enrolled in this study. All 9 patients developed a PHAGL lesion after a sports-related trauma. Clinical symptoms reported by the patients and clinical examination data were variable depending also on associated intra-articular shoulder pathology. The diagnosis of a PHAGL lesion was not made in any of the cases preoperatively. All 9 patients underwent arthroscopic repair of the PHAGL lesion. During the surgical procedure, any additional intra-articular shoulder lesion was treated. Patients were evaluated preoperatively and postoperatively for pain and range of motion using standardized shoulder scales including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) rating score, and Constant score. Results: Arthroscopic evaluation revealed that PHAGL was seen as an isolated lesion in only 3 patients. At a mean follow-up of 34.2 months, all patients were pain free and reported a complete resumption of sports and daily living activities. Two patients had a limitation of internal rotation to the T11 level. The UCLA score improved from 16.3 to 34.7, the Constant score improved from 52.3 to 80.2, and the SST score improved from 7.9 to 4.2. Conclusions: The PHAGL lesion is challenging to diagnose clinically. It can be the cause of posterior instability or a component of the spectrum of shoulder instability and associated with anterior labral or capsular pathology. Because physical examination can be misleading, a gadolinium-magnetic resonance arthrogram and comprehensive arthroscopic evaluation visualizing from the anterior and posterior portals can confirm the diagnosis. We repaired the PHAGL lesions arthroscopically along with all associated shoulder abnormalities resulting in a good outcome. Level of Evidence: Level IV, therapeutic cases series.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Nicola T.
        Anterior dislocation of the shoulder: The role of the articular capsule.
        J Bone Joint Surg Am. 1942; 25: 614-616
        • Bottoni C.R.
        • Franks B.R.
        • Moore J.H.
        • DeBerardino T.M.
        • Taylor D.C.
        • Arciero R.A.
        Operative stabilization of posterior shoulder instability.
        Am J Sports Med. 2005; 33: 996-1002
        • Mair S.D.
        • Zarzour R.H.
        • Speer K.P.
        Posterior labral injury in contact athletes.
        Am J Sports Med. 1998; 26: 753-758
        • Hawkins R.J.
        • Kopper G.
        • Johnston G.
        Recurrent posterior instability (subluxation) of the shoulder.
        J Bone Joint Surg Am. 1984; 66: 169-174
        • Hawkins R.J.
        • Bokor D.J.
        Clinical evaluation of shoulder problems.
        in: Rockwood Jr, C.A. Matsen III, F.A. The shoulder. WB Saunders, Philadelphia1990: 149-177
        • Tibone J.E.
        • Bradley J.P.
        The treatment of posterior subluxation in athletes.
        Clin Orthop Relat Res. 1993; 291: 124-137
        • Tibone J.E.
        • Brewster C.E.
        Posterior glenohumeral instability.
        in: Jobe F.E. Operative techniques of the upper extremity. Mosby-Year Book, Baltimore1996: 273-284
        • Chhabra A.
        • Diduch D.R.
        • Anderson M.
        Arthroscopic repair of a posterior humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion.
        Arthroscopy. 2004; 20: 73-76
        • Safran O.
        • DeFranco M.J.
        • Hatem S.
        • Iannotti J.P.
        Posterior humeral avulsion of the glenohumeral ligament as a cause of posterior shoulder instability.
        J Bone Joint Surg Am. 2004; 86: 2732-2736
        • Castagna A.
        • Garofalo R.
        • Conti M.
        • Randelli M.
        Reverse HAGL: A possible complication of a tight anterior gleno-humeral stabilization.
        Chir Organi Mov. 2005; 90: 201-207
        • Snyder S.J.
        Posterior instability.
        in: Snyder S.J. Shoulder arthroscopy. Ed 2. Lippincott Williams and Wilkins, Philadelphia2003: 121-131
        • Bankart A.S.B.
        The pathology and treatment of recurrent dislocation of the shoulder joint.
        Br J Surg. 1938; 26: 23-29
        • Rowe C.R.
        • Patel D.
        • Southmaid W.W.
        The Bankart procedure: A long-term end result.
        J Bone Joint Surg Am. 1984; 66: 159-168
        • Bigliani L.U.
        • Pollock R.G.
        • Soslowsky L.J.
        • et al.
        Tensile properties of the inferior glenohumeral ligament.
        J Orthop Res. 1992; 10: 187-197
        • Bokor D.J.
        • Conboy V.B.
        • Olson C.
        Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament.
        J Bone Joint Surg Br. 1999; 81B: 93-96
        • Field L.D.
        • Bokor D.J.
        • Savoie F.H.
        Humeral and glenoid detachment of the anterior inferior glenohumeral ligament: A cause of anterior instability.
        J Shoulder Elbow Surg. 1997; 6: 6-10
        • Reeves B.
        Arthrography of the shoulder.
        J Bone Joint Surg Br. 1966; 48: 424-435
        • Bui-Mansfield L.T.
        • Taylor D.C.
        • Uhorchak J.M.
        • Tenuta J.J.
        Humeral avulsions of the glenohumeral ligament: Imaging features and a review of the literature.
        AJR Am J Roentgenol. 2002; 179: 649-655
        • Hottya G.A.
        • Tirman P.F.
        • Bost F.W.
        • Montgomery W.H.
        • Wolf E.M.
        • Genant H.K.
        Tear of the posterior shoulder stabilizers after posterior dislocation: MR imaging and MR arthrographic findings with arthroscopic correlation.
        AJR Am J Roentgenol. 1998; 171: 763-768