Arthroscopic Posterior HAGL Repair Using Direct Transaxillary Portal improves visualization and localization of the repair site

Avulsion of the inferior glenohumeral humeral ligament (HAGL lesion) results from posttraumatic shoulder instability with or without various injuries to the capsulolabral complex. Visualization and surgical access to the anatomic insertion of the inferior humeral ligament is challenging, and different ways have been attempted to minimize morbidity of the surgical approach, while improving the quality of repair. Open and arthroscopic approaches and techniques have been described.

To improve visualization and localization of the repair site and the direction and angle of suture anchor placement, a direct transaxillary arthroscopic portal for HAGL repair has be described in article by Sebastian Albers et al, published in ‘Arthroscopy Techniques’ journal.

The author's preferred method of positioning the patient is in a lateral decubitus position with double traction of the operated arm in the longitudinal and axial directions.

Two working cannulas are established (anterior and posterior) and a suture passing device is required. In a right shoulder with posterior HAGL lesion, the author prefers a left-angled 250 suture lasso.

Pearls:

 Complete arthroscopic procedure with excellent visualization of the lesion and the result of the HAGL repair.

 Minimally invasive.

 Subscapularis tendon remains intact and untouched.

 Insertion angle of the suture anchor is perpendicular to the bone resulting in low risk for pullout.

 Posterior HAGL lesions can be easily addressed during surgery without need to change positioning of the patient.

Pitfalls

 Neurovascular risk is potentially increased for the transaxillary passing of the suture guide.

 Passing of the Wissinger rod is highly dependent on experience.

 No direct visualization of the axillary structures is possible.

 Overtightening of the capsule can lead to stiffness and capsulorrhaphy arthropathy in the long term.

 No clear anatomical landmarks to define the entry point for the anterior and posterior transaxillary portal.

The author has successfully applied the transaxillary HAGL repair in a number of shoulder stabilizations with good clinical results without any complication.

For details of steps please refer to:

Arthroscopic Posterior HAGL Repair Using a Direct Transaxillary Portal

Sebastian Albers, Milad Farkhondeh Fal, Jörn Kircher.

Arthroscopy Techniques, Vol 12, No 7 (July), 2023: pp e1027-e1031

https://doi.org/10.1016/j.eats.2023.02.042