Knotless 1.8 FiberTak® soft anchors or SwiveLock® anchors provide options for repairing HAGL and reverse HAGL (RHAGL) lesions.

Shoulder

Procedure

Knotless 1.8 FiberTak® soft anchors and SwiveLock® anchors offer solutions for repairing HAGL and RHAGL lesions.

Adam Anz, MD (Gulf Breeze, FL), demonstrates how the unique tensioning repair suture of Knotless FiberTak® soft anchors is used for an inferior HAGL repair. After reviewing the patient’s preoperative symptoms and MRI to identify the HAGL injury, Dr. Anz shares pearls for portal position, suture management, and repair tensioning. Each knotless repair suture is pretensioned, but final tension is delayed, keeping the “repair window” open. After three anchors are pretensioned, final tension is applied to all three repair sutures to complete the repair.

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Inferior HAGL Repair Technique With Knotless 1.8 FiberTak® Soft Anchors

Hello. My name is Adam and I'm an orthopedic surgeon at the Andrews Institute. With shoulder instability, you sometimes are approached with curveballs along the way. And Hagel lesions can sometimes take us by surprise, but are rarely available to be repaired. Arthroscopically. So the glenohumeral ligament, as you see in this video, attaches from our glenoid to our humerus, and it can evolve from the humerus as much as it can be involved with the label repair on the glenoid. As this in this case, you see, the clear avulsion of the humeral side of the glenohumeral ligament are our standard Hagel lesions. Now, Hagel lesions can be inferior, as you see in this case, they can be anterior or they can be posterior. In this case, as she was a 30 year old Air Force pilot who had had a hyperextension injury while performing chest flies and five years of pain and disability. She'd been through multiple rounds of physical therapy and multiple injections, and had not improved, and was still having feelings of instability that she could not trust her shoulder on the MRI. Arthrorome you can see the contrast extravasation here inferiorly on this coronal view, and you can see it extravasation here on this sagittal view. So clearly in this patient she has glenohumeral instability. And as you look here, she's sitting in terms of her humerus in relation to her glenoid inferiorly. And as we lift her up with some distraction and traction, you can clearly see the Hagel lesion. And you can clearly see how our humerus is sitting inferiorly. So some technical pearls as we use a standard anterior portal for working. And we use two posterior portals, a posterior superior for viewing and the posterior inferior for working. And that posterior inferior gives you the nice trajectory with the curved drill and insertion guide for the FiberTak to get that angle that you need. We also use a disposable camera inferiorly because it traps and helps us control the capsule. And you place those anchors through the posterior inferior portal, and we close the capsule at the end of the case. Now we're going to go into the cadaver lab and show you some technical pearls for inferior haggles. All right, let's see. First, the curved drill guide. So the black arrow you want to face back into the bone like I'm doing here. And now we're going to set the anchor with the drill guide in place. And then I can use the drill guide to deliver my repair suture for my anterior capture. So we're delivering the repair suture. You don't want to grab all the sutures. And now I'll pull the repair suture out the front, and I'll come back and tension my passing mechanism here. And now I'll just use the 90 to come through and get a good bite of capsule. Now we'll come in and grab. Shuttle our repair suture. And we'll pull the slack out of our repair suture. So now that we've shown you some technical pearls in the cadaver, we'll go back to our case presentation. Now, through our posterior inferior portal, we placed two knotless FiberTak suture anchors here. And the advantage of placing these anchors is that you can pass the repair Pair sutures. Load the repair and start your tensioning without closing your window that you're working through as well. So in this case we use three knotless anchors. We place them at the inferior humeral articular margin. And we prepared the margin with a curette. Now again that knotless mechanism allows you to pass the repair sutures but not close your window for viewing purposes. So now we're starting our tensioning process that's closing up that window that we had for repair. So the knotless mechanism allows for observed and controlled tensioning, which is something that's really nice when it comes together. We placed a third anchor most posteriorly for our final tensioning. You can see that her normal anatomy was clearly restored and her normal stability was clearly restored as well, because her humeral head is now sitting over glenoid. And as we try to lift up and look underneath that articular margin, we just don't have that same instability. Hopefully this case example will help you in any cases that you may meet along the way. So if you see a haggle, you won't run from it.

Andy P. Hartman, MD, (San Diego, CA) presents a case of an acute infraspinatus tear with a reverse HAGL lesion. Dr. Hartman performs a knotless SpeedFix™ technique to arthroscopically repair the reverse HAGL and a knotless SpeedBridge™ technique to repair the infraspinatus using innovative SwiveLock® anchors and FiberWire® and FiberTape® sutures.

Infraspinatus Tear With Reverse HAGL

Hi, my name is Andy Hartman. I'm an orthopedic surgeon specializing in shoulder, elbow and hand from San Diego, California. Today, I'd like to present a case of a patient with an infraspinatus tear and a reverse Hagel injury. Our patients have a right hand dominant male who injured his left shoulder playing rugby. He was hit from behind, landing on the left shoulder, and another player then landed on him. You know, an immediate pain in the shoulder but denied any dislocation event. He describes difficulty with lifting in any overhead activity, and his injury was approximately two weeks prior to my initial evaluation on exam. He is five feet 11in and 210 pounds. He had normal sensation in his axillary, median, ulnar and radial nerves. He had active elevation of 60 degrees. External rotation 65 degrees. Abduction, external rotation to 65 degrees, three out of five. Strength and forward elevation and external rotation with pain. My immediate concern was an acute rotator cuff tear, and therefore an MRI was ordered. On the first image you can see on the coronal oblique, there is evidence of what appears to be a supraspinatus tear as we move more Remove more posteriorly. The infraspinatus tear is visible. This is confirmed on the axillary sequence, where you can clearly see there's a tear of the posterior portion of the infraspinatus highlighted here. As we move to the sagittal images, this also confirms the presence of a full thickness infraspinatus tear with retraction nearly to the glenoid. So at the time of surgery, an exam under anesthesia revealed full elevation 175 degrees. Abduction. External rotation 90 degrees. Abduction. Internal rotation to 60 degrees. There is no evidence of any anterior instability. He did have some posterior laxity, but I was unable to dislocate the shoulder. The setup was in a lateral position, standing superior to the patient, allowing full access to the shoulder. In this diagnostic arthroscopy, to my surprise, there was a complete humeral evasion of the posterior band of the inferior glenohumeral ligament, as well as the full thickness tear of the infraspinatus, but no tear of the supraspinatus. As we examine this tissue more carefully, you can see the posterior band of the aisle reduces very easily to its anatomic site. If we go back and look more carefully at the axillary sequence, you can see what I had initially thought was the infraspinatus is actually the posterior band of the ijl avulsion. As we proceed to the repair, I first agree to the footprint of the humeral attachment site and past the first suture. I then placed my first anchor at approximately the 7:00 position on the humeral head. I passed two additional sutures and two additional swivel lock anchors. I selected a 4.75mm swivel lock anchor as I wanted more fixation, but also wanted a knotless repair under his infraspinatus repair. After completion of the capsule repair, you can see that the humeral attachment site is restored and the tear of the infraspinatus is still visible. As we move to the subacromial space from a lateral viewing portal, the capsule repair is visualized along with the infraspinatus tear, and this tissue reduces anatomically to the footprint of the infraspinatus. A standard SpeedBridge double row repair was performed with the infraspinatus restoring an anatomic attachment of the tendon, and this is the post repair. You can see the tenon is reduced anatomically. And there's a small RAF between the infraspinatus and teres minor posteriorly. Postoperative rehab required an abduction sling for 4 to 6 weeks. Began active. Range of motion at four weeks. Full active range of motion at six weeks. Light strengthening at ten weeks and return to sport by eight months. He is now approximately eight months post op. He has no pain, no instability. Events describes no weakness, feels of the shoulder is normal. He's been able to resume weight training and other activities but has not returned to rugby. He has full range of motion of the shoulder and is very pleased. In all instability cases, it's important to assess the humeral attachment of the ijhl. In this particular case, with an acute tear, the infraspinatus, the probability of having a humeral avulsion is high. And looking back at the MRI, it was visible. Going forward, I would have a high suspicion for a humeral avulsion in the setting of an acute tear of the infraspinatus. With that said, this patient has done very well and has recovered normal function in his shoulder and is quite pleased. Thank you.

HAGL and RHAGL

HAGL and RHAGL Lesion Repair