A large humeral avulsion of the glenohumeral ligaments decreases stability that can be restored with repair

Abstract

Background: Humeral avulsion of the glenohumeral ligaments (HAGL) has become a recognized cause of recurrent shoulder instability; however, it is unknown whether small and large HAGL lesions have similarly destabilizing effects and if large lesion repair results in restoration of stability. Questions/purposes: In a cadaver model, we evaluated the effect of small and large HAGL lesions and large HAGL lesion repair on glenohumeral ROM, translation, and kinematics. Methods: We measured rotational ROM, humeral head translation under load, and humeral head apex position in eight cadaveric shoulders. Each specimen was tested in 60° glenohumeral abduction in the scapular and coronal planes under four conditions: intact, small HAGL lesion (mean ± SD length, 18 ± 1.8 mm), large HAGL lesion (36.8 ± 3.6 mm), and after large HAGL lesion repair. For each condition, we measured maximum internal and external rotation with 1.5 Nm of torque; glenohumeral translation in 90° external rotation with 15- and 20-N force applied in the anterior, posterior, superior, and inferior directions; and humeral head apex position throughout ROM. Repeated-measures ANOVA was used for statistical analysis. Results: Small HAGL lesions did not change ROM, translation, or kinematics from the normal shoulder; however, these parameters changed with large HAGL lesions. Maximum external rotation and total ROM increased in the scapular (13.8° ± 9.4°, p < 0.001; 19.0° ± 16.5°, p < 0.001) and coronal (21.4° ± 10.6°, p < 0.001; 29.1° ± 22.1°, p < 0.001) planes. With anterior force, anterior-inferior translation increased in both planes (mean increase for both loads and planes: anterior: 9.1 ± 9.5 mm, p < 0.01; inferior, 5.7 ± 6.6 mm, p < 0.03). In the coronal plane, posterior and inferior translation also increased (4.9 ± 5.4 mm, p < 0.01; 7.1 ± 9.9 mm, p < 0.03; averaged for both loads). The humeral head apex shifted 3.7 ± 4.9 mm anterior (p = 0.04) and 2.8 ± 2.6 mm lateral (p = 0.004) in the scapular plane and 3.7 ± 3.4 mm superior (p = 0.006) and 4.1 ± 2.6 mm lateral (p < 0.001) in the coronal plane. HAGL lesion repair decreased ROM and translation in both planes and restored humeral head position in maximum external rotation. Conclusions: Anterior large HAGL lesions increase ROM and glenohumeral translation. After large HAGL lesion repair, stability of the shoulder can be restored. Clinical Relevance: Surgeons should be aware of the possibility of HAGL lesions in patients with shoulder instability, and if large HAGL lesions are diagnosed, surgeons should consider repairing the lesions. © 2014 The Association of Bone and Joint Surgeons®.