Arthroscopic Repair of a Posterior Bony Humeral Avulsion of the Glenohumeral Ligament With Associated Teres Minor Avulsion

Abstract

Humeral avulsion of the inferior glenohumeral ligament (HAGL) has recently gained more recognition as a cause of shoulder instability. Posterior HAGL lesions, being much more infrequent than anterior disruptions, have only recently been documented as a notable cause of posterior instability. We detail the treatment of a previously unreported case of a posterior HAGL variant lesion consisting of a bony avulsion with involvement of the teres minor tendon. Arthroscopic fixation was facilitated by use of a "sheathless" arthroscopic approach with a 70 arthroscope and suture anchor.G lenohumeral instability can result from a wide range of factors. Increased recognition has been given to the humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion. The typical HAGL lesion most commonly described is an avulsion of the anterior inferior glenohumeral ligament from its attachment on the humerus. 1,2 This leads to anterior instability, which occurs much more frequently than posterior instability. 3,4 The posterior HAGL lesion, however, has been described as a cause of posterior shoulder instability or pain. 5,6 Diagnosis can be difficult and is often delayed because of nonspecific shoulder pain or multiple potential etiologies for isolated posterior shoulder pain. These may include tears of the labrum, capsule, or rotator cuff or bony insufficiency. Posterior HAGL lesions have been documented in association with anterior and posterior Bankart lesions; anterior, superior, and posterior labral lesions; and anterior labral periosteal sleeve avulsion lesions. Both open repair and arthroscopic repair have subsequently been described. 5,7-9 Teres minor avulsions are rare and, when present, frequently occur in combination with supraspinatus, infraspinatus, or massive rotator cuff tears. [10][11][12] To our knowledge, there is no mention in the literature of a bony posterior HAGL lesion that also involves an isolated teres minor tendon avulsion. We describe the arthroscopic treatment of a traumatic posterior HAGL variant with a bony avulsion and a lesion involving the teres minor tendon. CaseA 16-year-old right handedominant male baseball player sustained a traumatic injury to his left shoulder when he ran into an outfield fence chasing a fly ball. He forcefully struck the wall with a direct blow to the anterior and lateral aspects of the shoulder. He described the sensation of a "slip" of his shoulder but did not sustain a frank dislocation. Radiographs obtained the day of injury yielded negative findings. His examination showed good active motion with minimal rotator cuff weakness. Conservative management for a shoulder strain was subsequently initiated.After 4 weeks of physical therapy, the patient still had persistent shoulder pain, localized anteriorly, with no symptomatic improvement. His physical examination at that time showed diffuse anterior tenderness to palpation. He had full active range of motion with The authors report the following potential conflict of interest or source of funding: P.A.S. rec...

Humeral Avulsion of the Glenohumeral Ligament: Indications for Surgical Treatment and Outcomes—A Systematic Review

“…Pain was a primary surgical indication for 11 patients in 3 trials. 6 , 26 , 30 A failed nonoperative management course, ranging from 1 to 22 months, was the surgical indication in 4 studies 13 , 20 , 22 , 25 comprising 31 patients. Preoperatively, HAGL lesions were confirmed by either magnetic resonance imaging or magnetic resonance arthrogram in 5 studies 1 , 7 , 12 , 22 , 32 for total of 44 total patients.…”

Arthroscopic repair of an isolated teres minor tear with associated posterior glenohumeral ligament avulsion

“…To our knowledge, this is the first description of this injury in the literature. The only other similar report describes a young patient with a shoulder instability event 11 . Also, few case reports have described posterior HAGL lesions in young patients with shoulder instability events,1, 4, 10 and although older, Lee et al 7 described an isolated teres minor tear in a 52-year-old patient who sustained a posterior dislocation.…”

“…Isolated teres minor tears are very rare, and only a few case reports have been published in the literature 6, 7, 11, 12. The teres minor functions as an external rotator of the glenohumeral joint and a secondary depressor of the humeral head.…”

Posterior and multidirectional instability

“…Historically, posterior bony humeral avulsions have been treated with open repair; recent reports have described an arthroscopic approach to these injuries (Smith et al, 2014). With the advent of arthroscopy and the development of advanced instrumentation and surgical technique, arthroscopic management is now considered the standard for addressing posterior and multidirectional instability.…”