Warner (1997) — Combined Bankart and HAGL lesion associated with anterior shoulder instability.

Combined Bankart and Hagl Lesion Associated with Anterior Shoulder Instability.

Warner, Beim·Arthroscopy·1997·95 citations·Shoulder & Elbow

This is a case report of a 15-year-old football player with recurrent traumatic anterior shoulder instability of the dominant arm. Arthroscopy showed both a Bankart lesion and a humeral avulsion of the glenohumeral ligaments (HAGL). The authors describe this combined bipolar capsular injury and its open anatomic repair.

Study Snapshot

Design

Case report

Setting: Shoulder Service, University of Pittsburgh

Outcome(s)

Clinical outcome after open repair at 26-month follow-up

Subjects

1 patient (15-year-old male athlete)

Open deltopectoral repair of both Bankart and HAGL lesions

Follow-up

26 months

Key Findings

The Bankart lesion is capsulolabral separation from the glenoid and is the most common instability pathology, seen in about 80% of cases. This paper's point is that it is not the only lesion to look for.
A HAGL lesion is a humeral-sided avulsion of the glenohumeral ligaments and was seen in 9% of the Wolf series (6 of 64 shoulders). Capsular pathology beyond a pure Bankart may be present in over 35% of instability cases.
The IGHL complex fails at multiple sites under load, which is why a humeral avulsion can accompany a Bankart:
–Glenoid insertion: 40%
–Humeral insertion: 25%
–Mid-substance: 35%
This is the first reported combined Bankart and HAGL lesion, which the authors call a bipolar capsular injury. Both ends of the capsule were torn in the same shoulder, along with a small Hill-Sachs lesion.
Repair was open through a deltopectoral approach, tensioning the capsule in 60° abduction, 20° flexion, and 60° external rotation where the IGHL is near maximal length. This avoids over-tightening from a two-sided repair.
At 26 months the patient had symmetric motion, full sports participation, and preinjury throwing velocity.

Board PearlA missed humeral-sided HAGL lesion can defeat a Bankart-only repair, so inspect both ends of the capsule in anterior instability.

Clinical Relevance

Anterior instability is a spectrum, and the glenoid-sided Bankart is not always the whole story. When a patient has recurrent instability despite an apparent Bankart, or the labral pathology does not fully explain the exam, look for a HAGL lesion on the humeral side of the IGHL.

This matters because a missed humeral avulsion is a cause of failed Bankart-only repair, and the surgical plan changes if you find one. Remember the IGHL failure pattern: glenoid in 40%, humeral insertion in 25%, mid-substance in 35%, which is why a bipolar injury is possible.

When repairing, tension the capsule in abduction and external rotation where the IGHL is near maximal length, so you do not over-tighten a two-sided repair.

Core

Combined Bankart and Hagl Lesion Associated with Anterior Shoulder Instability.

Combined Bankart and Hagl Lesion Associated with Anterior Shoulder Instability.

Study Snapshot

Key Findings

Clinical Relevance

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Combined Bankart and Hagl Lesion Associated with Anterior Shoulder Instability.

Study Snapshot

Key Findings

Clinical Relevance

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Combined Bankart and Hagl Lesion Associated with Anterior Shoulder Instability.

Study Snapshot

Key Findings

Clinical Relevance

Related Articles

Combined Bankart and Hagl Lesion Associated with Anterior Shoulder Instability.

Study Snapshot

Key Findings

Clinical Relevance

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