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Technical Note| Volume 12, ISSUE 2, e285-e289, February 2023

Glenoid Avulsion of the Glenohumeral Ligament Repair Through a Single Working Portal

Open AccessPublished:January 18, 2023DOI:https://doi.org/10.1016/j.eats.2022.11.004
Glenoid Avulsion of the Glenohumeral Ligament Repair Through a Single Working Portal
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      Abstract

      Glenoid avulsion of the glenohumeral ligament (GAGL) is a traumatic cause of shoulder instability. GAGL lesions are a rare shoulder pathology most commonly reported as a source of anterior shoulder instability, with no current reports implicating this pathology as a cause of posterior instability. Satisfactory surgical repairs of GAGL lesions with anterior shoulder instability have been well documented; however, this Technical Note highlights the successful repair of a posterior GAGL lesion through a single working portal with suture anchor fixation of the posterior capsule.

      Technique Video

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      Glenoid avulsion of glenohumeral ligament (GAGL) lesion repair through single working portal. After arthroscopic identification of the torn inferior glenohumeral ligament (IGHL) on the posterior labrum with a probe, a posterior stabilization is performed. A curved Spectrum suture lasso (Arthrex) loaded with a No. 0 polydioxanone (PDS) suture is introduced into the glenohumeral joint. A bite that encompasses both the avulsed IGHL and the posterior labrum is made with the suture lasso, and the No. 0 PDS suture is fed through the suture lasso. A ring grasper is then used to retrieve the No. 0 PDS suture and to tie this suture outside the portal to a No. 2 extra-strength shuttle suture, and the No. 0 PDS is used to shuttle the extra-strength suture around the GAGL lesion in a looped fashion, creating a racking-hitch stitch. Next, with a drill guide, a pilot hole is drilled at the 7-o'clock position of the glenoid. The No. 2 shuttle suture is loaded onto a 2.9-mm PushLock suture anchor, which is subsequently tapped into the pilot hole, securing it to the glenoid. An arthroscopic suture cutter is then used to cut the suture. This process is repeated with the Spectrum suture lasso passed through the IGHL and labrum, and the No. 0 PDS suture is funneled into the capsule. The No. 2 suture is shuttled through, and a racking-hitch stitch is created. Next, the pilot hole is created with the drill and drill guide, and the 2.9-mm PushLock suture anchor is tapped into the glenoid. The No. 2 suture is cut, and this process is repeated a final time, starting with the Spectrum suture lasso passed through the IGHL and labrum. The No. 0 PDS is funneled into the labrum, and a ring grasper is used to tie the No. 2 suture to the No. 0 PDS outside the portal. The No. 2 suture is then shuttled through the IGHL and labrum, and a racking-hitch stitch is created. Next, by use of the drill and drill guide, the pilot hole is created and the 2.9-mm PushLock suture anchor is tapped in. After GAGL repair, a probe is used to ensure stability of the repair, with care taken to confirm appropriate tautness. The capsule is closed with No. 0 PDS passed through the capsule, and No. 2 suture is shuttled and tied from outside in, completing the surgical procedure.

      Technique Video

      See video under supplementary data.

      Posterior shoulder instability accounts for up to 2.7% to 10% of cases of shoulder instability
      • Brelin A.
      • Dickens J.F.
      Posterior shoulder instability.
      Sports Med Arthrosc Rev. 2017; 25: 136-143
      , 
      • Bokshan S.L.
      • Kotchman H.M.
      • Li L.T.
      • DeFroda S.F.
      • Cameron K.L.
      • Owens B.D.
      Incidence of posterior shoulder instability in the United States military: Demographic considerations from a high-risk population.
      Am J Sports Med. 2021; 49: 340-345
      , 
      • Shields D.W.
      • Jefferies J.G.
      • Brooksbank A.J.
      • Millar N.
      • Jenkins P.J.
      Epidemiology of glenohumeral dislocation and subsequent instability in an urban population.
      J Shoulder Elbow Surg. 2018; 27: 189-195
      and is most often encountered in young, active male patients, younger than 40 years, particularly athletes or military personnel.
      • Bokshan S.L.
      • Kotchman H.M.
      • Li L.T.
      • DeFroda S.F.
      • Cameron K.L.
      • Owens B.D.
      Incidence of posterior shoulder instability in the United States military: Demographic considerations from a high-risk population.
      Am J Sports Med. 2021; 49: 340-345
      ,
      • Shields D.W.
      • Jefferies J.G.
      • Brooksbank A.J.
      • Millar N.
      • Jenkins P.J.
      Epidemiology of glenohumeral dislocation and subsequent instability in an urban population.
      J Shoulder Elbow Surg. 2018; 27: 189-195
      Although nonoperative treatment is generally preferred in lower-demand patients with posterior shoulder instability, surgical management can be considered in young and active patient groups. The most common inciting factors for posterior shoulder instability include attenuation and microtrauma to the posterior capsule and labrum; a traumatic posterior force leading to shearing of the chondrolabral junction and capsulolabral detachment; and finally, insidious onset of stretching and laxity of the posterior capsule and posterior static stabilizers.
      • Antosh I.J.
      • Tokish J.M.
      • Owens B.D.
      Posterior shoulder instability.
      Sports Health. 2016; 8: 520-526
      One described injury is avulsion of the inferior glenohumeral ligament (IGHL) from the glenoid with an intact labrum, referred to as “glenoid avulsion of the glenohumeral ligament” (GAGL). GAGL lesions have previously only been described in the literature as a cause of anterior shoulder instability; no study to date has explored the role of these lesions as a potential cause of posterior shoulder instability. Because the IGHL is implicated in preventing excessive posterior translation when the arm is in abduction and internal rotation, forced abduction and internal rotation can lead to disruption of this ligament and thereby serve as a mechanism for posterior shoulder instability.
      • Mannem R.
      • DuBois M.
      • Koeberl M.
      • Kosempa D.
      • Erickson S.
      Glenoid avulsion of the glenohumeral ligament (GAGL): A case report and review of the anatomy.
      Skeletal Radiol. 2016; 45: 1443-1448
      On physical examination, patients with posterior GAGL lesions will typically present with a positive posterior apprehension sign.
      • Cotter E.J.
      • Hannon C.P.
      • Christian D.
      • Frank R.M.
      • Bach Jr., B.R.
      Comprehensive examination of the Athlete's shoulder.
      Sports Health. 2018; 10: 366-375
      The diagnosis is confirmed with magnetic resonance imaging (MRI), which can show a tear of the posterior band of the IGHL at the glenoid insertion. The purpose of this Technical Note is to describe the successful repair of a posterior GAGL lesion and review the literature regarding the evaluation and management of this pathology.

      Technique

      Preoperative Evaluation

      The diagnosis of a GAGL lesion is made based on a detailed history and physical examination and is confirmed with MRI. In our case, the patient's initial injury was due to a pedestrian-versus-automobile accident. The patient presented with chief concerns of recurrent posterior shoulder dislocations and instability and was initially treated with closed reduction before presenting to our clinic. MRI of the shoulder showed a tear of the posterior band of the IGHL at the glenoid insertion with pericapsular edema and a reverse Hill-Sachs fracture on the anterior-superior aspect of the humeral head (Fig 1). Given the patient's desire to maintain an active lifestyle, a decision was made to pursue surgical management for posterior shoulder stabilization with intended repair of the GAGL lesion.
      Figure thumbnail gr1
      Fig 1Preoperative coronal magnetic resonance imaging of the right shoulder depicts a glenoid avulsion of the glenohumeral ligament (GAGL) lesion visible with fluid extravasation in the inferior glenohumeral recess (H, head; F, foot.).

      Patient Positioning

      An interscalene nerve block is placed in the upper extremity, followed by induction of general anesthesia. The patient is positioned in the lateral decubitus position on the contralateral side to the injury with an arm holder holding the affected extremity. The head and bony prominences are well padded with cushions, and the operative site is prepared and draped in the usual sterile fashion.

      Arthroscopic Portal Placement

      A standard posterior portal is made using a No. 11 blade for the incision. The glenohumeral joint is entered using a blunt trocar and scope sheath. Diagnostic arthroscopy of the glenohumeral joint is then performed, examining the glenoid surface, glenohumeral head, biceps tendon, labrum, rotator cuff, and axillary recess. In our patient, the glenohumeral head had a Hill-Sachs impaction fracture. Next, an anterior portal is created under needle localization. An 8.25-mm cannula is placed in the posterior portal with the aid of a switching stick, and the arthroscope is moved to the anterior portal. A probe is then introduced through the posterior portal to evaluate the labrum for any further pathology, and a tear in the IGHL on the posterior aspect of the labrum is confirmed (Fig 2, Video 1).
      Figure thumbnail gr2
      Fig 2Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope showing the posterior glenoid avulsion of the glenohumeral ligament (GAGL) lesion. The patient is positioned in the left lateral decubitus position. (H, humerus.)

      GAGL Repair

      After identification of the torn IGHL on the posterior glenoid, a posterior stabilization is performed. A curved Spectrum suture passer (Arthrex, Naples, FL) loaded with a No. 0 polydioxanone (PDS) suture is introduced into the glenohumeral joint. A bite that encompasses both the avulsed IGHL and the posterior capsule and labrum is made with the suture passer, and the No. 0 PDS suture is fed through the suture passer (Figs 3 and 4). A ring grasper is then used to retrieve the No. 0 PDS suture and to tie this suture to a No. 2 shuttle suture tape, and the No. 0 PDS is used to shuttle the suture tape around the GAGL lesion in a looped fashion, creating a racking-hitch stitch (Figs 5 and 6). Next, with a drill guide, a pilot hole is drilled at the 7-o'clock position on the glenoid fossa (Fig 7). The No. 2 shuttle suture tape is loaded onto a 2.9-mm PushLock suture anchor (Arthrex), which is subsequently tapped with a mallet into the pilot hole, securing it to the posterior capsule (Figs 8 and 9). An arthroscopic suture cutter is then used to cut the suture. This process of capsulolabral fixation is repeated at the 7:30–clock face and 8-o'clock positions, with placement of 3 suture anchors in total. After GAGL repair, a probe is used to ensure stability of the repair, with care taken to confirm appropriate tautness. The capsule is closed with No. 0 PDS passed through the capsule and No. 2 suture tape shuttled and tied from outside in, completing the surgical procedure (Fig 10).
      Figure thumbnail gr3
      Fig 3Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the Spectrum suture passer taking a bite of the capsule and labrum. The patient is positioned in the left lateral decubitus position. (H, humerus.)
      Figure thumbnail gr4
      Fig 4Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the passed suture being grabbed by a suture grasper. The patient is positioned in the left lateral decubitus position. (H, humerus.)
      Figure thumbnail gr5
      Fig 5Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the passing suture and a braided shuttle suture. The patient is positioned in the left lateral decubitus position.
      Figure thumbnail gr6
      Fig 6Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting reduction of the capsulolabral junction with the use of a racking-hitch stitch. The patient is positioned in the left lateral decubitus position. (H, humerus.)
      Figure thumbnail gr7
      Fig 7Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the drill guide for the creation of a pilot hole. The patient is positioned in the left lateral decubitus position. (H, humerus.)
      Figure thumbnail gr8
      Fig 8Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the suture anchor that will be anchored into the pilot hole. The patient is positioned in the left lateral decubitus position. (H, humerus.)
      Figure thumbnail gr9
      Fig 9Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the suture anchor tapped into the pilot hole. The patient is positioned in the left lateral decubitus position. (H, humerus.)
      Figure thumbnail gr10
      Fig 10Arthroscopic image of the right shoulder through the anterior portal with a 30° arthroscope depicting the final completed repair of the glenoid avulsion of the glenohumeral ligament (GAGL) lesion with the cannula repaired. The patient is positioned in the left lateral decubitus position. (H, humerus.)

      Final Examination and Postoperative Care

      The portal incisions are closed in a standard fashion and covered by an abundant dressing. The operative arm is then immediately placed into an immobilizer sling that will be used for the first 6 weeks after the operation. During the first 6 weeks postoperatively, passive range of motion of the operative shoulder is allowed; however, the patient is advised to avoid active range of motion.

      Discussion

      Posterior shoulder instability accounts for approximately 10% of all shoulder instability events in the young, active population, with proposed mechanisms of repetitive microtrauma to the posterior capsule and/or labrum, acute trauma with a strong posterior force leading to shearing of the chondrolabral interface, and gradual laxity and stretching of the posterior capsule and other shoulder stabilizers.
      • DeLong J.M.
      • Bradley J.P.
      Posterior shoulder instability in the athletic population: Variations in assessment, clinical outcomes, and return to sport.
      World J Orthop. 2015; 6: 927-934
      The GAGL lesion has been an attributed source of anterior shoulder instability; however, it has not previously been cited as a cause of posterior shoulder instability.
      • Mannem R.
      • DuBois M.
      • Koeberl M.
      • Kosempa D.
      • Erickson S.
      Glenoid avulsion of the glenohumeral ligament (GAGL): A case report and review of the anatomy.
      Skeletal Radiol. 2016; 45: 1443-1448
      ,
      • Riboh J.C.
      • Khair M.M.
      • Romeo A.A.
      Arthroscopic repair of a glenoid avulsion of the glenohumeral ligament.
      Arthrosc Tech. 2015; 4: e795-e799
      Riboh et al.
      • Riboh J.C.
      • Khair M.M.
      • Romeo A.A.
      Arthroscopic repair of a glenoid avulsion of the glenohumeral ligament.
      Arthrosc Tech. 2015; 4: e795-e799
      have reported repair using 2 anterior portals to address GAGL lesions as a cause of anterior shoulder instability; however, to our knowledge, this is the first case of posterior shoulder instability as a result of a GAGL lesion in which repair was performed through a single working portal. Recognition of the GAGL lesion as a cause of posterior shoulder instability is important because the glenohumeral ligaments are crucial in serving as static stabilizers of the shoulder joint.
      • O'Reilly O.C.
      • Andrews K.A.
      • Siparsky P.N.
      Understanding the glenoid avulsion of the glenohumeral ligaments as a cause of shoulder instability: Surgical and postsurgical management.
      Arthrosc Tech. 2019; 8: e1153-e1158
      ,
      • Wolf E.M.
      • Cheng J.C.
      • Dickson K.
      Humeral avulsion of the glenohumeral ligaments as a cause of anterior shoulder instability.
      Arthroscopy. 1995; 11: 600-607
      Proper identification of GAGL lesions is crucial to proper management and surgical planning. Pearls and pitfalls of our technique are presented in Table 1, and advantages and disadvantages are listed in Table 2.
      Table 1Pearls and Pitfalls
      Advantages
       A minimally invasive, arthroscopic approach allows for direct visualization of and access to the posterior band of the IGHL, as well as the ability to address intra-articular and concomitant shoulder pathology. In addition, operative time is reduced and less instrumentation is required.
       Use of a single portal decreases the risks associated with additional working portals for GAGL repair.
       Preparation of the glenoid surface and capsular tissue are performed prior to suture anchor fixation to ensure adequate healing of both the glenoid and labrum.
      Disadvantages
       There is a risk of neurovascular injury to the axillary nerve and potential for adhesive capsulitis.
       Precise suture anchor placement is required to avoid osseous glenoid disruption.
      GAGL, glenoid avulsion of glenohumeral ligament.
      Table 2Advantages and Disadvantages
      Pearls
       Suture anchors must be spaced appropriately within the glenoid fossa to ensure proper capsulolabral reduction.
       Diagnostic arthroscopy with proper portal placement is integral to identifying pathology given the location of the lesion within the capsulolabral complex.
      Pitfalls
       The surgeon should avoid disruption of the axillary nerve while working in the posterior portal owing to the proximity to the IGHL insertion and anatomy.
       Glenoid bone loss can potentially occur, and there is a risk of recurrent laxity with improper suture anchor placement.
      This Technical Note presents the arthroscopic repair of a posterior GAGL lesion through a single posterior working portal with suture anchor fixation. Arthroscopic GAGL repair with associated posterior capsulolabral reduction is performed to address laxity in the active patient who is expected to resume full functional activity. We aim to include our technique in the available literature on arthroscopic GAGL repair and report posterior GAGL lesions as a potential cause of posterior shoulder instability that physicians should add to their differential diagnosis during clinical examination and diagnostic arthroscopy.

      Supplementary Data

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        Video 1

        Glenoid avulsion of glenohumeral ligament (GAGL) lesion repair through single working portal. After arthroscopic identification of the torn inferior glenohumeral ligament (IGHL) on the posterior labrum with a probe, a posterior stabilization is performed. A curved Spectrum suture lasso (Arthrex) loaded with a No. 0 polydioxanone (PDS) suture is introduced into the glenohumeral joint. A bite that encompasses both the avulsed IGHL and the posterior labrum is made with a curved suture passer, and the No. 0 PDS suture is fed through the suture lasso. A ring grasper is then used to retrieve the No. 0 PDS suture and to tie this suture outside the portal to a No. 2 braided suture, and the No. 0 PDS is used to shuttle the braided suture around the GAGL lesion in a looped fashion, creating a racking-hitch stitch. Next, with a drill guide, a pilot hole is drilled at the 7-o'clock position of the glenoid. The No. 2 shuttle suture is loaded onto a 2.9-mm PushLock suture anchor, which is subsequently tapped into the pilot hole, securing it to the glenoid. An arthroscopic suture cutter is then used to cut the suture. This process is repeated with the Spectrum suture lasso passed through the IGHL and labrum, and the No. 0 PDS suture is funneled into the capsule. The No. 2 suture is shuttled through, and a racking-hitch stitch is created. Next, the pilot hole is created with the drill and drill guide, and the 2.9-mm PushLock suture anchor is tapped into the glenoid. The No. 2 suture is cut, and this process is repeated a final time, starting with the Spectrum suture lasso passed through the IGHL and labrum. The No. 0 PDS is funneled into the labrum, and a ring grasper is used to tie the No. 2 suture to the No. 0 PDS outside the portal. The No. 2 suture is then shuttled through the IGHL and labrum, and a racking-hitch stitch is created. Next, by use of the drill and drill guide, the pilot hole is created and the 2.9-mm PushLock suture anchor is tapped in. After GAGL repair, a probe is used to ensure stability of the repair, with care taken to confirm appropriate tautness. The capsule is closed with No. 0 PDS passed through the capsule, and No. 2 suture is shuttled and tied from outside in, completing the surgical procedure.

      References

        • Brelin A.
        • Dickens J.F.
        Posterior shoulder instability.
        Sports Med Arthrosc Rev. 2017; 25: 136-143
        View in Article
        • Bokshan S.L.
        • Kotchman H.M.
        • Li L.T.
        • DeFroda S.F.
        • Cameron K.L.
        • Owens B.D.
        Incidence of posterior shoulder instability in the United States military: Demographic considerations from a high-risk population.
        Am J Sports Med. 2021; 49: 340-345
        View in Article
        • Shields D.W.
        • Jefferies J.G.
        • Brooksbank A.J.
        • Millar N.
        • Jenkins P.J.
        Epidemiology of glenohumeral dislocation and subsequent instability in an urban population.
        J Shoulder Elbow Surg. 2018; 27: 189-195
        View in Article
        • Antosh I.J.
        • Tokish J.M.
        • Owens B.D.
        Posterior shoulder instability.
        Sports Health. 2016; 8: 520-526
        View in Article
        • Mannem R.
        • DuBois M.
        • Koeberl M.
        • Kosempa D.
        • Erickson S.
        Glenoid avulsion of the glenohumeral ligament (GAGL): A case report and review of the anatomy.
        Skeletal Radiol. 2016; 45: 1443-1448
        View in Article
        • Cotter E.J.
        • Hannon C.P.
        • Christian D.
        • Frank R.M.
        • Bach Jr., B.R.
        Comprehensive examination of the Athlete's shoulder.
        Sports Health. 2018; 10: 366-375
        View in Article
        • DeLong J.M.
        • Bradley J.P.
        Posterior shoulder instability in the athletic population: Variations in assessment, clinical outcomes, and return to sport.
        World J Orthop. 2015; 6: 927-934
        View in Article
        • Riboh J.C.
        • Khair M.M.
        • Romeo A.A.
        Arthroscopic repair of a glenoid avulsion of the glenohumeral ligament.
        Arthrosc Tech. 2015; 4: e795-e799
        View in Article
        • O'Reilly O.C.
        • Andrews K.A.
        • Siparsky P.N.
        Understanding the glenoid avulsion of the glenohumeral ligaments as a cause of shoulder instability: Surgical and postsurgical management.
        Arthrosc Tech. 2019; 8: e1153-e1158
        View in Article
        • Wolf E.M.
        • Cheng J.C.
        • Dickson K.
        Humeral avulsion of the glenohumeral ligaments as a cause of anterior shoulder instability.
        Arthroscopy. 1995; 11: 600-607
        View in Article

      Article info

      Publication history

      Published online: January 18, 2023
      Accepted: November 2, 2022
      Received: August 3, 2022

      Footnotes

      The authors report the following potential conflicts of interest or sources of funding: J.C. receives personal fees from Arthrex for lectures and education material, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

      Identification

      DOI: https://doi.org/10.1016/j.eats.2022.11.004

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