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Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: a Call for Further Quantitative Studies Jorge Chahla, M.D., Ph.D., Zachary S

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Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: a Call for Further Quantitative Studies Jorge Chahla, M.D., Ph.D., Zachary S Systematic Review Systematic Review of the Anatomic Descriptions of the Glenohumeral Ligaments: A Call for Further Quantitative Studies Jorge Chahla, M.D., Ph.D., Zachary S. Aman, B.A., Jonathan A. Godin, M.D., M.B.A., Mark E. Cinque, M.D., CAPT Matthew T. Provencher, M.D., M.C., U.S.N.R., and Robert F. LaPrade, M.D., Ph.D. Purpose: To perform a systematic review of the glenohumeral ligament anatomic attachments on the glenoid and humeral neck. Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase from 1980 to present. The inclusion criteria were as follows: cadaveric or clinical anatomic studies that qualitatively or quantitatively described the glenoid and humeral attachments of the glenohumeral ligaments in the English-language literature. Imaging and animal studies, editorial articles, and surveys were excluded from this study. Results: The 15 included studies analyzed a total of 983 shoulders. Only 5 studies reported quantitative measurements. The most common glenoid superior glenohumeral ligament attachment described was in the anterolateral region of the supraglenoid tubercle and was inserting on the humerus in close vicinity to the subscapularis tendon insertion. The superior labrum and lesser tuberosity were the most commonly reported middle glenohumeral ligament attachments. The inferior glenohumeral ligament was most commonly described to attach between the 2- and 4-o’clock positions of the glenoid and distally near the surgical neck of the humerus. Conclusions: There were limited quantitative data on the attachments of the glenohumeral ligaments. Although the literature was discordant, the most common descriptions of the attachments were as follows: The anterolateral region of the supraglenoid tubercle, the superior labrum, and the glenoid (between the 2- and 4-o’clock positions) were the medial attachments for the superior glenohumeral ligament, middle glenohumeral ligament, and inferior glenohumeral ligament, respectively. Laterally, they inserted on the humerus in close vicinity to the subscapularis tendon insertion, on the lesser tuberosity, and near the surgical neck of the humerus, respectively. Clinical Relevance: The glenohumeral ligaments are important anatomic structures contributing to the dynamic stability of the glenohumeral joint. Further detailed quanti- tative descriptions of their attachments are required for truly anatomically based repairs. he glenohumeral joint is intrinsically unstable, and and arthroscopic and open stabilization procedures are Tthus an integrated system of ligaments is required to among the most common shoulder surgical procedures. maintain the stability of the joint.1 Anterior glenohumeral Although the glenohumeral ligaments (GHLs) were instability is not infrequent in young athletic populations,2 first described by Flood3 in 1829, there is no consensus From the Steadman Philippon Research Institute (J.C., Z.S.A., J.A.G., Arthrex. R.F.L. is on the Editorial Board of the American Journal of Sports M.E.C., M.T.P.) and The Steadman Clinic (M.T.P., R.F.L.), Vail, Colorado, Medicine; is a committee member of the American Orthopaedic Society for U.S.A. Sports Medicine and Knee Surgery, Sports Traumatology, Arthroscopy The authors report the following potential conflicts of interest or sources of (KSSTA) and ISAKOS; is a paid consultant for and receives royalties from funding: J.A.G. receives grant support from DJO; educational support from Arthrex, Smith & Nephew, and Ossur; and receives research support from Arthrex and Smith & Nephew; travel expenses from Arthrex; and education Linvatec, Smith & Nephew, Arthrex, and Ossur. Full ICMJE author disclo- support, grant support, and food and beverage from DJO, Smith & Nephew, sure forms are available for this article online, as supplementary material. and Arthrex and food and beverage from Zimmer Biomet Holdings, Stryker, Received July 25, 2018; accepted November 21, 2018. Supreme Orthopedic Systems, and Centrix Orthopedics. M.T.P. is on the Address correspondence to Robert F. LaPrade, M.D., Ph.D., The Steadman Editorial Board of Arthroscopy, Orthopaedics, Knee, and SLACK; is a Clinic, 181 W Meadow Dr, Ste 1000, Vail, CO 81657, U.S.A. E-mail: committee member of the American Orthopaedic Society for Sports Medicine, [email protected] American Shoulder and Elbow Surgeons, International Society of Arthros- Ó 2018 by the Arthroscopy Association of North America copy, Knee Surgery, and Orthopaedic Sports Medicine (ISAKOS), AAOS, 0749-8063/18909/$36.00 Arthroscopy Association of North America, Society of Military Orthopaedic https://doi.org/10.1016/j.arthro.2018.11.062 Surgeons, and San Diego Shoulder Institute; is a paid consultant for Arthrex and Joint Restoration Foundation (Allosource); and receives IP royalties from Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -,No- (Month), 2019: pp 1-10 1 2 J. CHAHLA ET AL. concerning the detailed anatomy of the GHLs. Because (sGHL), middle glenohumeral ligament (mGHL), of the anatomic variability and heterogeneous anterior band of the inferior glenohumeral ligament descriptions available in the literature, there is no clear (aIGHL), posterior band of the inferior glenohumeral understanding of the qualitative and quantitative ligament (pIGHL), and spiral GHL, including the anatomic characteristics of the GHLs. As orthopaedic glenoid attachment, humeral attachment, length of the surgical procedures are becoming more anatomically glenoid attachment, and any available qualitative or based, a clear consensus on the quantitative anatomic quantitative details regarding glenoid or humeral attachments of the GHLs should be defined because anatomy. The level of evidence of all available clinical they play an important role in the dynamic stability of studies was assigned according to the classification the glenohumeral joint. Recent literature has reported specified by Wright et al.6 For continuous variables, the that restoring the native anatomy after a GHL injury mean and range were collected if reported. can restore the shoulder’s native kinematics.4 Therefore, the purpose of this study was to perform a Results systematic review of previously described GHL The literature search identified 513 studies from the anatomic attachments on the glenoid and humeral aforementioned databases. After duplicates were neck. We hypothesized that there would be agreement removed, 489 articles were screened, and 15 articles in the described anatomic glenoid and humeral met the inclusion criteria (Fig 1). attachment sites for the GHLs. Study Demographic Characteristics Methods In the 15 included studies, 784 cadavers and a total of 983 shoulders were analyzed. The mean reported age of Article Identification and Selection the studied cadavers was 69.3 years (range, 18- A systematic review of cadaveric or clinical anatomic 103 years). The sex of the studied cadavers was only studies that qualitatively or quantitatively described reported for 291 cadavers (177 male and 114 female the glenoid and humeral attachments of the GHLs cadavers) (Table 1). Two studies additionally studied in the English-language literature was performed using the anatomy in a clinical setting, consisting of a total of the Cochrane Database of Systematic Reviews, the 149 patients. In the only study with reported patient Cochrane Central Register of Controlled Trials, PubMed demographic characteristics, there were 29 male and 20 (1980-2018), MEDLINE (1980-2018), and Embase female patients, with ranging in age from 28 to (1980-2018). This study was conducted in accordance 65 years. Only 5 studies reported a quantitative with the 2009 Preferred Reporting Items for Systematic description of an attachment site for any ligamentous 5 Reviews and Meta-Analyses (PRISMA) statement. structure.7,8,16,18 Registration of this systematic review was performed in March 2018 using the PROSPERO international Superior GHL prospective register of systematic reviews, and the Five studies described the anatomic glenoid attach- queries were performed in February 2018. The search ment of the sGHL,17-19,21 whereas 7 studies reported protocol can be found in Appendix Table 1 (available at on the anatomic humeral attachment of the www.arthroscopyjournal.org). sGHL.9,10,13,17-19,21 No studies reported quantitative The inclusion criteria were as follows: cadaveric or descriptions of either the glenoid or humeral attach- clinical anatomic studies that qualitatively or quantita- ments of the sGHL. The most common anatomic loca- tively described the glenoid and humeral attachments tion of the glenoid attachment and humeral insertion of the GHLs in the English-language literature. Radio- was in the anterolateral region of the supraglenoid graphic and imaging studies, animal studies, editorial tubercle and in close vicinity to the subscapularis articles, and surveys were excluded from this study. tendon insertion, respectively (Table 2). Two investigators (Z.S.A. and J.C.) independently reviewed the abstracts from all identified articles. If Medial GHL necessary, full-text articles were obtained for review to Five studies described the glenoid attachment of the 11,12,15,18,21 allow for further application of the inclusion and mGHL, whereas 5 studies reported on the 12,17-19,21 exclusion criteria. In addition, the reference lists from humeral attachment
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