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HAGL Tears in traumatic instability – Detection on MR-Arthrogram

Authors: R Saqib, J Harris, L Funk

Background: Humeral avulsion of the glenohumeral ligaments (HAGL) is a recognised cause of shoulder instability and can be isolated or in conjunction with other abnormalities such as labral tears, rotator cuff tears or Hill-Sachs lesions. Biomechanical cadaveric studies suggest that the inferior glenohumeral ligament would fail at the humeral insertion in as many as 25% of cases.1 However, clinical series suggest a lower incidence of HAGL ranging from 2.4% to 9.3% of patients undergoing arthroscopy for anterior instability. 2,3,4 No previous study has correlated the incidence of HAGL on MR-Arthrogram (MRA) with arthroscopy. 

Aims: Our aim was to assess the accuracy of MRA in detecting HAGL tears compared with arthroscopy.

Methods: 122 patients with pre-operative MRA underwent arthroscopic surgery for instability in a 1-year period. All scans were reviewed by senior musculoskeletal radiologists and an experienced shoulder surgeon. All arthroscopies were performed by a single surgeon and HAGL tears were specifically recorded. 
Results: The incidence of HAGLs was 5% on both arthroscopy and MRA.  The sensitivity of MRA in detecting HAGL was 0.66 and the specificity was 0.33. The positive predictive value was 0.66 and negative predictive vale was 0.33.

Conclusions: MRA appears to be sensitive in detecting HAGL, but not specific. This may be due to associated soft tissue oedema seen on MR with early scans after injury.


References:
  1. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC. Tensile properties of the inferior glenohumeral ligament. J Orthop Res. 1992;10:187-194.
  2. Bokor DJ, Conboy VB, Olson C. Anterior instability of the gleno- humeral joint with humeral avulsion of the glenohumeral ligament: a review of 41 cases. J Bone Joint Surg Br. 1999;81:93-96.
  3. Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy. 2005;21:632e1-6.
  4. Wolf EM, Cheng JC, Dickson K. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy. 1995;11:600-607.



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