Greetings, everyone, and welcome to the OLC course. My name is JT Tokish from the Mayo Clinic in Arizona, and I get to speak with you today about a few alternative causes and fixes for shoulder instability, namely what happens when the classic Bankart is not the cause of the instability that the ligament tears off on the other side. We know that glenohumeral instability generally occurs on the labral side of the ligament complex, but on the opposite side, the so-called Hagel lesion is not an insignificant number of cases that it's responsible for. Wolff in 95 and Bocor in 1999 showed that Hagels could be up to 9 to 10% of cases overall. When should you be nervous about these? Well, Hagels do have some positional risk factors. Back in 1999, McMahon published that hyperabduction was a risk factor for Hagels, and then I've also seen this as well, and it's been published that in shoulders that have lower speeds of loading, Mao and Bigliani have both shown that the Hagel can be associated with this mechanism of action. When you see this, it's occasionally the wrestler who's placed into a half Nelson or has his arm in an abducted externally rotated position and is sort of stuck there, if you will, or rock climbers, for example, who are stuck in positions trying to get out. That lower speed of loading over time has been shown to be a risk factor for this, so just in the history, be a little bit hypervigilant for that as well. We know that Hagels are ligament tears off the humeral side. When it's anterior, we generally call this a Hagel, a humeral avulsion of the glenohumeral ligaments. There's been a bit of an alphabet soup as opposed to these, but they all basically recognize the same sort of pathology, a humeral-sided tear. When it's on the reverse side, we call it a regal or an R-H-A-G-A-L, a reverse humeral avulsion of the glenohumeral ligaments. Sometimes it can come off with a bone fleck, in which case, of course, we would call it a bagel, so a bony Hagel or a bony humeral avulsion. If there's a bony bone fleck on the backside, then that can be a regal, and you can have all kinds of fun with these different abbreviations if you wish, but basically, they should all be approached similarly with reattachment. The backside ones are much, much easier than the frontside ones, so we're going to demonstrate sort of the frontside one here for you. Well, how do we make an appropriate diagnosis of this? Well, again, we talked about history of hyperabduction, slower rate of loading with MMAs and submission defense or rock climbers. The physical examination is similar to normal instability. They will have apprehension. The one thing that's interesting, though, is that these patients tend to have more of an association with pain than do the classic Bankart counterpart, and that's a little bit unclear as to why that is, but most studies that talk about Hagels talk about a little bit higher incidence and higher severity of pain, so another thing to be thinking about. Certainly, the diagnosis-wise, the MRI is the gold standard, and we talk about a J sign, and so a J sign is where the humeral avulsion happens, and you can see the ligament, but it just doesn't quite reach up to the bottom of the humeral head there, but be careful about this because especially in chronics, right, so in acutes, when the anatomy is fresh, it's really easy to see, but in chronics, it can be really tricky, and in fact, Burkhardt and his group have published that they looked at six Hagels operatively. Three of them had been missed on MRIs and early diagnosis. They made the diagnosis at arthroscopy, and so just be careful that you can miss that at the time. So this is a classic MRI from one of my patients who had a Hagel. You can see up here, maybe this is close to a J sign, and you can see the inferior glenohumeral ligament is just not quite up on the face. The other thing that if you do get an MR arthrogram that you can see in the acute setting is, especially on this sagittal image below, you can see that the fluid just completely leaks out. That can happen in many cases, but when you see whenever there's a disruption in the capsule, you can see this J sign and things get moving. So this is the diagnostic arthroscopy, and what I'm doing here, this is a right shoulder. I'm viewing from the anterior superior portal. You can see a cannula coming in from the mid-glenoid portal, and you can see there's a traction stitch in here, and that's coming from the posterior portal. So just to get oriented here, and then I'd call your attention to a couple of things. The traction stitch is not in the labrum. The labrum is medial or to the right of it, as you can see here, and then the glenoid bone is over here, and so we don't want to make that mistake here. In addition to this, you can see that there's bare bone up at the top where the humerus is, and this is a common finding from an avulsion of this area, and so our job is to put this back up toward the top. So I just would show you the diagnosis of this. I'll pull on the traction stitch, and you can see that this is the ligament that we have to prepare. So one of the keys is to get the subscapularis off of the capsule here and separate this out so that we can mobilize it. The axillary nerve is going to be down around six o'clock, so at the four o'clock to five o'clock position, you're pretty safe. Okay, so how do we fix these when they are present? And so we'll... So how do we prepare to fix and fix this hagel? So this is, again, this patient. We are going to start with a traction stitch in the anterior capsule, what we're trying to repair, and we'll get moving on this. I think the critical things are first, again, liberating the capsule from the subscap to ensure that we've got a free capsule that we can reduce once the time comes. The next thing we do is biologically prepare the bone. I showed you the avulsion earlier, and so we just want to make sure that we've got a good, solid bleeding bone surface, and then from the mid-glenoid portal, leaning my anchor guide down, I can get an anchor through this portal up and directed nicely here. In this particular case, I think I could have gone a little lower, so I'm adding a second anchor, and don't be afraid to do this percutaneously, but there, I'm very happy with where the anchors sit at the very bottom of where the ligament had ebulsed from. Now we simply have to pass mattress sutures. I prefer mattresses, so I grab both sutures out of the back portal, which is my working portal, and then send a suture lasso at the bottom, and then very comfortable with most of us about how we do bank art repairs. So here's the first stitch. I tie it out the back, and we shuttle this as we would with normal techniques. That's the first stitch, and then we're just going to go through the rest of these. We'll pass mattress sutures along, and we'll have some help ... ... for two mattresses. We simply then tie them down with two mattresses, restoring the footprint, and very pleased with how that capsule can come together. Now as we take a look at this from the front, it looks like there's room maybe for one more, So we're just going to step along and do exactly the same thing once more, place an anchor, retrieve the sutures from the back portal, send a suture lasso, shuttle the sutures back, and then bring them back, giving us another mattress suture. So once we've done this, we tie it down, and we have a six-portion, three-portion repair of the inferior and middle glenohumeral ligament ebulsion off the front. You can see it there from the front. We're going to come to the back here, and it will allow us then to take a look at the backside. We can see the subscap, you can see the IGHL and the inferior capsule in the front, subscap across the top there, and we have a properly restored anterior inferior glenohumeral ligament complex. I'm sure everybody's interested in the outcomes of this guy. He's on bottom here, returning to chasing his dream, and I've now fixed his shoulder well enough where it allows him to get stuck three seconds into the match. He's pinned, and a little bit of an inglorious return to sport, but in that position, his shoulders are certainly stable. So on the outcomes, in terms of outcomes, this has been around a long time. Nicola described the procedure back in 1941, and open procedures have been described by Bock and Warren, Bocor, and then Field and Wolf have both done a scopic looks at this. Modern outcomes by re-open, six cases in JSCS 2007 with excellent stability. They lost a little bit of external rotation, and then Bocor did a very interesting study that I think bears witness to. They measured how far the axillary nerve is from this, and found that it was less than five millimeters from the free edge of the hagel, so please be careful. And if you haven't taken a look at Arciero's video on how to approach this through a mini-open approach, you can simply make your horizontal portion through your subscap just above the sisters, extend that vertically, and that takes you right to the hagel there. So please consider doing that. This is that paper, the mini-open, that will help you get there as well. So you can have reliable, good outcomes with this, and you just simply have to follow. Remember that you can be so low that you put the axillary nerve in place, so don't be afraid to go open approach for sure. So a couple of pearls as we close here. The use of a spinal needle to get the exact angle and trajectory for an anterior hagel. So while we use a mid-Glenoid portal, we certainly can go just a little bit lower down and do a trans-subscap portal if you wish to be able to access this from a low anterior portal. The trans-subscap portal for anchor placement can be done percutaneously, and only use it for the anchor. You don't need to place an entire cannula through there. For posterior hagels, the view is still from the anterior superior portal, and the posterior portal is generally all that's required. You just flip it, and you use your mid-Glenoid portal as your working portal, and it's actually quite easy to do, but the principles are the same. For inferior portals, it's best to work from posteriorly, and if you need to, a 70-degree scope can be helpful. Also remember this, the axillary nerve is close, so do not be afraid to use a modified open beach chair position. Just make your lateral incision after your deltoid pectoral approach right above the sisters, and then a vertical incision up from there. Once accomplished, you can be pretty safe about going around the bottom of that hagel if necessary. So with that, I'll say thank you very much. Enjoy your time in the lab. I wish I was there with you, and I can't wait until we get back to in-person meetings in this regard. Thank you all very much.

shoulder instability

Hagel lesion

labral side

MRI

ligament repair