There were two types of origin of the anteroinferior capsulolabrum at the glenoid of the glenohumeral joint in adults. In 80%, the attachment was primarily from the labrum, showing similarities to other direct ligament or tendon insertion sites, such as that of the supraspinatus. 4 Characteristic of these direct insertion sites, the collagen fibers met the attachment at a right angle in a sequence of four distinct zones (ligament, fibrocartilage, mineralized fibrocartilage, and bone). 38 This labral attachment of the anterior band of the inferior glenohumeral ligament was relatively long, 19 especially the zone of fibrocartilage at the anterosuperior margin of the anterior band of the inferior glenohumeral ligament, in contrast to other direct insertion sites. At more caudal locations, the capsulolabrum appeared disorganized near the glenoid, likely representing a change in direction of the collagen bundles. Here the orientation was no longer longitudinal as at the midsubstance, but was primarily in a radial fashion 13 to form the circular system of collagen bundles of the labrum. The fibrous glenoid labrum was formed by the origin of the capsuloligamentous structures to be an extension of the articular cavity for added joint stability.
In 20% of the glenohumeral joints, the anteroinferior capsuloligamentous structures originated primarily from the glenoid bone. Especially at the 3 o’clock location, it was similar to the tibial insertion of the medial collateral ligament as described by Woo and coworkers. 39 Dense collagen fibers met the attachment at the bone at an acute angle as an indirect insertion. Superficial and deep fibers were present. The superficial fibers ran parallel to the bone surface, blending in with the periosteum and the deep fibers attached straight to the bone.
The anteroinferior capsuloligamentous structures have been reported to have labral origin. 24,25,32 Others described the anterior band of the inferior glenohumeral ligament as being intimately attached to the labrum and the rim of glenoid bone, 8 implying it was not consistent. However, when there was an attachment to the neck of the glenoid it was described as well-developed, rather than simply a thickening in the capsule. Gohlke and coworkers 13 also reported that the origin of fibers at the 3 o’clock location on the glenoid was anchored most commonly to the glenoid bone. In their description, these fibers inserted mostly at an acute angle but were part of the middle glenohumeral ligament. Histologic cross sections of the glenohumeral joint as reported in 1962 by Moseley and Overgaard 24 also showed attachments to the glenoid bone.
The fibers described in the current study were from sections through and inferior to, the 3 o’clock location on the glenoid. Although the relationship of these fibers to the anterior capsular ligaments was difficult to ascertain from the histologic sections, fibers in this location on the glenoid correspond to the origin of the anterior band of the inferior glenohumeral ligament. 8,36 One histologic study found two attachments of the anterior band of the inferior glenohumeral ligament at the glenoid, one into the labrum and another into the anterior glenoid rim and neck. 19 Study of joints from humans before birth found the origin solely from the labrum in 77% and from the glenoid neck in 23%. 35 This correlated very closely with the results of the current study in glenohumeral joints from adults indicating that variation in origin of the anterior band of the inferior glenohumeral ligament is congenital and not acquired. Because joints from elderly individuals were studied, this also indicates there is little change with aging.
A severe Bankart lesion, poor tissue quality, too few repair sutures, failure to properly plicate the capsuloligamentous structures, recurrent injury from contact sports, large number of preoperative dislocations, and mistreatment of multidirectional instability have been associated with failure after surgical repair. 6,14,18,20,28,33 Variation in pathoanatomy from different anteroinferior capsulolabral origin types also may account for some failures. In the majority of joints, the anterior band of the inferior glenohumeral ligament ruptures with the labrum when dislocation occurs. However, if the anterior band of the inferior glenohumeral ligament originated primarily from the glenoid, it may rupture, stretch, or tear but leave the labrum intact. Repair focused on the labrum may then neglects the anterior band of the inferior glenohumeral ligament injury so that it no longer can function as the primary static restraint to anterior instability. Misunderstanding of this anatomy also may partly explain the discrepancy in results between the traditional open technique of Bankart lesion repair, from outside the glenohumeral joint, and arthroscopic repair which involves repair from the inside. In the first, both attachments are repaired routinely whereas in the latter the labral attachment is repaired and depending on the surgical technique the glenoid attachment may or may not be repaired.
In adults, there are two types of origin of the anteroinferior capsulolabrum, the location of the anterior band of the inferior glenohumeral ligament. A Type I origin, where the ligament arises from the glenoid rim, labrum and neck, occurs in 80% of cases. The second, is a Type II origin, where the ligament arises entirely from the glenoid neck and occurs in 20% of cases. This variability should be considered when selecting the technique of repair for surgical treatment of anterior glenohumeral dislocation.
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Patrick J. McMahon, MD; and Thay Q. Lee, PhD—Guest Editors