Arthroscopic HAGL Repair is a specialized technique developed by Dr. Chudik that arthroscopically repairs Humeral Avulsion of the Glenohumeral Ligaments, a less common but clinically significant cause of shoulder instability. Most orthopaedic surgeons treat HAGL lesions through open surgery because they are technically difficult to repair arthroscopically. Using special instruments and techniques, Dr. Chudik finds the majority of HAGL injuries are reparable arthroscopically, sparing patients the larger open exposure conventional treatment requires.
What Is Arthroscopic HAGL Repair?
In a typical anterior shoulder dislocation, the labrum and capsule tear off the glenoid (the shoulder socket), creating a Bankart lesion. In a HAGL injury, the same dislocation forces produce an avulsion at the humeral side instead: the inferior glenohumeral ligament tears off the humerus rather than the glenoid.
People who sustain a HAGL injury often have recurrent dislocations, subluxations, or instability symptoms that affect their daily activities, work, sports, or recreation. Repair of the torn ligaments is indicated, particularly in young active individuals after the first dislocation. Young patients have a high likelihood of recurrent dislocations, and delayed repair of HAGL ligaments is not always possible.
HAGL injuries are rare, often missed on MRI, and most orthopaedic surgeons (even those specializing in shoulder surgery) are not able to fix this type of tear arthroscopically. Conventional treatment is open surgery through a larger incision. Dr. Chudik developed special instruments and techniques that allow the majority of HAGL injuries to be repaired arthroscopically.
Development Rationale
The conventional treatment of HAGL lesions has historically been open surgery, with the surgeon working through a larger anterior incision to access the humeral attachment of the inferior glenohumeral ligament. The open approach provides direct visualization but disrupts the surrounding soft tissues, including the subscapularis tendon (which is detached and repaired in many open approaches). The subscapularis takedown introduces the risk of subscapularis failure during recovery.
Dr. Chudik developed the arthroscopic HAGL repair to:
- Avoid the open exposure and subscapularis takedown of conventional surgery
- Repair the torn ligaments through small portals using specialized instruments
- Preserve the subscapularis and surrounding soft tissues
- Allow the recovery profile of arthroscopic surgery rather than open repair
Recognition is the first challenge with HAGL injuries. Because they are often missed on MRI and not specifically tested for during routine arthroscopic shoulder surgery, the diagnosis depends on clinical suspicion plus careful intraoperative inspection. Dr. Chudik’s experience with shoulder instability across the full spectrum of pathology supports recognition of HAGL injuries that other surgeons might miss.
Who Is a Candidate?
Candidates typically have:
- A confirmed HAGL lesion on MRI arthrogram, or a HAGL lesion identified at arthroscopy
- Recurrent shoulder dislocations, subluxations, or instability symptoms
- Young active individuals after a first dislocation with a HAGL injury
- Active patients who require shoulder stability for sport, work, or daily activity
Older patients with an anterior dislocation are less likely to re-dislocate and may do well without surgery as long as they do not have an associated fracture or rotator cuff tear.
Contraindications include infection, inability to complete the postoperative program, and shoulder arthritis.
How the Procedure Is Performed
The procedure is performed as outpatient surgery under general anesthesia with an interscalene block. Dr. Chudik uses an arthroscopic approach through small portals.
After diagnostic arthroscopy confirms the HAGL lesion and rules out other pathology (Bankart tear, rotator cuff disease, biceps disease), the torn capsule and ligaments are mobilized off the inferior humerus. The humeral neck is prepared with a small burr to create a healing surface.
Repair is performed using sutures and small bio-absorbable anchors. The anchors are inserted into the humerus, and the sutures attached to the anchor are passed through the torn ligaments and tied to reattach the tissue. Special arthroscopic portals and instruments developed for this technique provide the access required to reach the inferior humerus without injuring the axillary nerve, which runs in close proximity.
Associated pathology (Bankart tear, rotator cuff injury, labral injury) is treated through the same arthroscopic portals when present.
Recovery and Rehabilitation
Recovery follows a protected protocol designed to allow the repaired capsule and ligaments to heal:
- Sling at all times for six weeks except for bathing, dressing, and exercises (this prohibits driving)
- Sleeping upright on a couch or recliner is often more comfortable
- Wound care: clean and dry for three days for arthroscopic surgery; light showering after three days; no submersion under water for three weeks
- Driving typically resumes at six weeks
- Return to school or sedentary work in less than one week while in the sling
- Physical therapy begins two to three days after surgery and continues for four to six months
By approximately four to six months following surgery, the repair has healed and shoulder motion, strength, and function are restored to allow a full return to activities. Return to sport or strenuous labor requires full restoration of shoulder motion and strength.
To prevent re-injury, Dr. Chudik recommends and provides extra shoulder stabilization training and testing before return to sport.
Risks and Outcomes
Specific surgical risks include:
- Infection
- Nerve injury (numbness, weakness, paralysis) of the shoulder and arm, which can occur with the dislocation itself
- Re-injury and recurrence of instability (re-dislocation or subluxation)
- Continued pain
- Subscapularis detachment, which is a risk if surgery is performed with open techniques (avoided with the arthroscopic approach)
- Stiffness or loss of motion
- Inability to return to the same level of competition
- Suture irritation (rare)
- Arthritis
Outcomes for the arthroscopic technique compare favorably with open repair while avoiding the subscapularis takedown and longer recovery of conventional open surgery. Missed HAGL lesions are a known cause of failed shoulder instability surgery, which is why recognition matters.
Why Dr. Chudik for Arthroscopic HAGL Repair
Dr. Chudik developed the special instruments and techniques that allow the majority of HAGL injuries to be repaired arthroscopically. Most orthopaedic surgeons, including those specializing in shoulder surgery, are not able to perform this repair arthroscopically and prefer the conventional open approach. For patients with HAGL injuries, the arthroscopic approach offers comparable structural repair with the recovery profile of arthroscopic surgery.