We outline our open technique for surgical repair of the “Naked Humeral Head” following a dislocation event resulting in an avulsion of the greater tuberosity, complete tear of the subscapularis, and a humeral avulsion of the glenohumeral ligament.
- Krueger V.S.
- Shigley C.
- Bokshan S.L.
- Owens B.D.
Arthroscopy and Approach
|Arthroscopy||Keep arthroscopic portion of case short in order to avoid fluid extravasation|
Minimize pressure as much as possible
Anterior portal should be made in line with the planned anterior open incision.
|If the posterior repair is required, perform the open portion first before returning to the posterior structures. Retractor placement during open surgery runs the risk of damaging posterior labral or rotator cuff repair.|
|Supraspinatus||Circumferential release should be performed prior to repair.|
Use the free needle to allow for each suture strand to be passed separately through the supraspinatus.
Ensure arm position is in 30° of abduction and 30° of internal rotation.
|Over-tensioning the supraspinatus risks potential failure of repair. If the tendon excursion is not adequate following complete release, consider medializing articular margin 5 mm and using stay sutures as a rip stop for medial repair sutures.|
|Humeral avulsion of the glenohumeral ligament||Capsular dissection and identification of the inferior glenohumeral ligament that is often entrapped in adhesions and scar|
Test arm to ensure position of 90° abduction and external rotation can be achieved following repair.
Ensure arm position is in neutral with 40-50° of external rotation.
|The loss of external rotation is at significant risk with this repair. Avoid taking too much capsule and testing range of motion following repair to avoid this.|
|Subscapularis||The best bone for this portion will be the medial aspect of the bicipital groove.|
Use the coracoid as the superior reference for the tendon placement.
Separately passing the sutures through the medial subscapularis similarly to the supraspinatus portion
Humeral Head Preparation
Repair of Supraspinatus
30° Internal Rotation
|Repair order: 1st|
Repair Construct: Speed bridge
Medial anchor placement: At articular margin. Pass sutures individually through tendon. A “spot weld” repair overlying the tissue adjacent to the anchor can take tension off of the bony avulsion.
Lateral anchor placement: Place anchors lateral to the greater tuberosity avulsion. This will allow direct compression over the full fractured fragment.
40-50˚ External Rotation
|Repair order: 2nd|
Repair Construct: 2 anchors; 3 mm biocomposite SutureTak suture anchors (Arthrex, Inc., Naples, FL) loaded with #2 FiberWire.
Anchor placement: Approximately 5 mm off of the articular margin, with the superior anchor at the mid aspect of the humeral head and the inferior anchor at the most inferior aspect of the humeral head and superior aspect of the calcar.
All sutures passed through capsule overlying anchor. Superior anchor repair stitch is then shuttled through inferior anchor looped shuttle suture, and vice versa. The sutures are then tied overtop of the capsule, creating a cross bridge construct
Neutral to slight external rotation
|Repair order: 3rd|
Repair construct: speed bridge
Medial anchor placement: Superior/inferior position is in line with anatomic subscapularis footprint. Medial/lateral position is at medial aspect of lesser tuberosity, just lateral to capsular repair.
Lateral anchor placement: Superior/inferior position is in line with anatomic subscapularis footprint. Medial/lateral position is at bicipital groove or just medial. This bone is very strong and should be tapped.
|Long head biceps tendon||Neutral||Repair Order: 4th|
Repair Construct: FiberLoop suture (Arthrex, Inc., Naples, FL)
Anchor Placement: Incorporate FiberLoop suture into inferior lateral row anchor from subscapularis repair. May back-up repair with incorporation into bicipital sheath or pectoralis major tendon, if necessary.
|Arthroscopy prior to the open portion of the procedure allows all potential injuries to be identified and evaluated.||Arthroscopy prior to the open portion of the procedure can distort tissue planes.|
|Arthroscopic debridement of the callus and hematoma can be easier for certain medial structures.||Open surgery can increase the risk of postoperative adhesions and can potentially increase pain.|
|Complete and direct visualization gives the best opportunity to avoid repair failure.||Overtightening the repair is theoretically easier to do with open surgery when compared to arthroscopy.|
Repair of Humeral Avulsion of the Glenohumeral Ligament
Repair of Subscapularis
- ICMJE author disclosure forms
- Humeral avulsion of glenohumeral ligaments.J Am Acad Orthop Surg. 2011; 19: 127-133
- Anterior shoulder instability management: Indications, techniques, and outcomes.Arthroscopy. 2020; 36: 2791-2793
- Humeral avulsion of the glenohumeral ligament: Diagnosis and management.JBJS Rev. 2022; 10https://doi.org/10.2106/JBJS.RVW.21.00140
- Anterior dislocation of the shoulder.J Bone Joint Surg Am. 1942; 24: 614-616
- Prospective evaluation of surgical treatment of humeral avulsions of the glenohumeral ligament.Am J Sports Med. 2017; 45: 1134-1140
- Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament.J Bone Joint Surg Br. 1999; 81-B: 93-96
- Arthroscopic repair of humeral avulsion of glenohumeral ligament lesions: Outcomes at 2-year follow-up.Orthop J Sports Med. 2021; 923259671211004970
- Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability.Arthroscopy. 1995; 11: 600-607
- Prevalence of HAGL lesions and associated abnormalities on shoulder MR examination.Skeletal Radiol. 2014; 43: 307-313
- Humeral avulsions of the glenohumeral ligament: Imaging features and a review of the literature.Am J Roentgenol. 2002; 179: 649-655
- Partial articular supraspinatus tendon avulsion: Should we repair? A systematic review of the evidence.J Shoulder Elbow Surg. 2020; 12: 253-264
- Ultrasound findings aid decisions to repair partial articular supraspinatus tendon avulsion.J Ultrasound Med. 2020; 39: 2005-2011
- Inferior glenohumeral ligament (IGHL) injuries: A case series of magnetic resonance (MR) imaging findings and arthroscopic correlation.Kans J Med. 2020; 13: 275-279
- Open repair of an anterior humeral avulsion of the glenohumeral ligament.Arthrosc Tech. 2017; 6: e1367-e1371
- Humeral avulsion of the glenohumeral ligaments: A systematic review.Arthroscopy. 2016; 32: 1868-1876
- Rotator Cuff Tear and Glenohumeral Instability.Clin Orthop Relat Res. 2014; 472: 2448-2456
- A large humeral avulsion of the glenohumeral ligaments decreases stability that can be restored with repair.Clin Orthop Relat Res. 2014; 472: 2372-2379
- The effect of humeral avulsion of the glenohumeral ligaments and humeral repair site on joint laxity: A biomechanical study.Arthroscopy. 2013; 29: 990-997
- Humeral avulsion of the glenohumeral ligament: Indications for surgical treatment and outcomes—A systematic review.Orthop J Sports Med. 2017; 52325967117723329
- Isolated fractures of the greater tuberosity of the proximal humerus.J Shoulder Elbow Surg. 2003; 12: 641-649
- Arthroscopic repair of isolated subscapularis tears: A systematic review of technique-specific outcomes.Arthroscopy. 2017; 33: 849-860
The authors report the following potential conflicts of interest or sources of funding: J. L. L., B.W.F., M.M., C.A.S. report employment at the Steadman Philippon Research Institute, which receives funding from Arthrex, Department of Defense, Office of Naval Research, DJO, MLB, Siemens, Ossur, Smith & Nephew, and XTRE, outside the submitted work. J.A.G. reports consulting fees from Bioventis, Smith & Nephew, and Mitek, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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