Unstable isolated SLAP lesion: clinical presentation and outcome of arthroscopic fixation

Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment

Lesions of the superior glenoid labrum and biceps anchor are a well-recognized cause of shoulder pain. Advances in shoulder arthroscopy have led to improvements in recognizing and managing superior labral anterior-posterior (SLAP) tears. Recent biomechanical studies have postulated several theories for the pathogenesis of SLAP tears in throwing athletes and the effect of these injuries on normal shoulder kinematics. Advances in soft-tissue imaging techniques have resulted in improved accuracy in diagnosing SLAP tears. However, the diagnosis of clinically relevant SLAP tears remains challenging because of the lack of specific examination findings and the frequency of concomitant shoulder injuries. Definitive diagnosis of suspected SLAP tears is confirmed on arthroscopic examination. Advances in surgical techniques have made it possible to achieve secure repair in selected patterns of injury. Recent outcomes studies have shown predictably good functional results and an acceptable rate of return to sport and/or work with arthroscopic treatment of SLAP tears.

Combined arthroscopic repair of a type IV SLAP tear and Bankart lesion

Lesions of the superior labrum can be a source of significant shoulder pain and disability. SLAP (superior labrum anterior-posterior) tears have been classified into many different types. A type IV SLAP tear is a bucket-handle tear of the superior labrum with extension into the biceps tendon. This relatively uncommon SLAP tear, if present, has been shown to be frequently associated with other pathology including Bankart lesions. We present an arthroscopic technique for combined repair of a type IV SLAP tear and Bankart lesion. Steps include initial reduction of the bucket-handle portion of the superior labral injury, repair of the anterior-inferior labral detachment, and, finally, repair of the superior labrum and biceps tendon split.

Poor outcomes after SLAP repair: descriptive analysis and prognosis

PURPOSE

In the first part of this study, we analyzed a subset of patients to determine what factors may have been present in those with poor outcomes after SLAP repair. In part 2, we evaluated clinical outcomes of these patients after further treatment.

METHODS

We completed a retrospective medical record review of consecutive patients presenting between 2000 and 2007 with pain, stiffness, and/or mechanical symptoms after a SLAP repair. To evaluate for similarities among this cohort, data collection included demographics, age at initial SLAP repair, history of trauma, medical history, nonoperative and operative treatments, and physical examination. Outcome measures included patient satisfaction and the Simple Shoulder Test questionnaire. Subsequent treatment was then reviewed, investigating whether patients received physical therapy, cortisone injection, and/or revision surgery in an attempt to improve satisfaction. Outcome measures again included patient satisfaction and the Simple Shoulder Test questionnaire.

RESULTS

We found 40 shoulders in 39 patients who met inclusion criteria. The mean age at the time of initial SLAP repair was 43 years. Of the patients, 30 (75%) presented with pain and decreased range of motion, 9 (22.5%) presented with pain but full range of motion, and 1 (2.5%) presented with pain and mechanical symptoms but full range of motion. The mean Simple Shoulder Test score upon presentation after SLAP repair was 3.04 out of 12 (SD, 2.18; range, 0 to 7). We included 34 shoulders in the analysis of treatment outcome. Of these, 29% (10 of 34) were satisfied after conservative treatment, 62% (13 of 21) were satisfied after revision surgery, and 68% (23 of 34) were satisfied overall after either type of further treatment. The mean Simple Shoulder Test score after further treatment was 8.73 out of 12 (SD, 3.45; range, 0 to 12).

CONCLUSIONS

In this study 71% of patients (mean patient age, 43 years) with a poor outcome after SLAP repair were dissatisfied with conservative treatment. Therefore, once a patient has a poor outcome after SLAP repair, there is a high chance of conservative treatment failing. Although patients have better outcomes with operative intervention, 32% will continue to have a suboptimal result.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Outcomes after arthroscopic repair of type-II SLAP lesions

BACKGROUND

To our knowledge, there has been no prospective study on the results of arthroscopic repair of superior labrum-biceps anchor complex (SLAP) tears with use of modern techniques. The purpose of the present study was to prospectively evaluate the minimum two-year results for patients with type-II SLAP tears that were treated with arthroscopic suture anchor fixation.

METHODS

Forty-seven patients with symptomatic type-II SLAP tears were evaluated preoperatively and at least two years postoperatively with use of the American Shoulder and Elbow Surgeons (ASES) and L'Insalata outcomes instruments and physical examination. The study group included thirty-nine male and eight female patients with a mean age of thirty-six years; thirty-four of the forty-seven patients were athletes. Patients with rotator cuff tears requiring repair or concomitant shoulder instability were excluded.

RESULTS

At an average of 2.7 years, the median ASES and L'Insalata scores were 97 and 93, respectively, compared with baseline scores of 62 and 65 (p < 0.05). The median patient-reported satisfaction rating was 9 (of 10); forty-one patients (87%) rated the outcome as good or excellent. The median patient-reported satisfaction rating was significantly higher for patients with a discrete traumatic etiology than for those with an atraumatic etiology (9 compared with 7); however, there was no significant difference between these groups in terms of the ASES or L'Insalata outcome scores. Overall, twenty-five (74%) of the thirty-four athletes were able to return to their preinjury level of competition, whereas eleven (92%) of the twelve athletes who reported a discrete traumatic event were able to return to their previous level of competition. There were five complications, including four cases of refractory postoperative stiffness.

CONCLUSIONS

Our findings indicate that favorable outcomes can be anticipated in the majority of patients after arthroscopic SLAP lesion repair. While only three of four patients overall may be capable of returning fully to their previous level of competition, patients with a distinct traumatic etiology have a greater likelihood of a successful return to sports.

Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion

BACKGROUND

Overhead athletes report an inconsistent return to their previous level of sport and satisfaction after arthroscopic SLAP lesion repair.

HYPOTHESIS

Arthroscopic biceps tenodesis offers a viable alternative to the repair of an isolated type II SLAP lesion.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-five consecutive patients operated for an isolated type II SLAP lesion between 2000 and 2004 were evaluated at a mean of 35 months postoperatively (range, 24-69). Patients with associated instability, rotator cuff rupture, posterosuperior impingement, or previous shoulder surgery were excluded. Ten patients (10 men) with an average age of 37 years (range, 19-57) had a SLAP repair performed with suture anchors. Fifteen patients (9 men and 6 women) with an average age of 52 years (range, 28-64) underwent arthroscopic biceps tenodesis performed with an absorbable interference screw. Arthroscopic diagnosis and treatment were performed by a single experienced shoulder surgeon, and all patients were reviewed by an independent examiner.

RESULTS

In the repair group, the Constant score improved from 65 to 83 points; however, 60% (6 of 10) of the patients were disappointed because of persistent pain or inability to return to their previous level of sports participation. In the tenodesis group, the Constant score improved from 59 to 89 points, and 93% (14/15) were satisfied or very satisfied. Thirteen patients (87%) were able to return to their previous level of sports participation following biceps tenodesis, compared with only 20% (2 of 10) after SLAP repair (P = .01). Four patients with failed SLAP repairs underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to their previous level of sports activity.

CONCLUSION

Arthroscopic biceps tenodesis can be considered an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation. The results of biceps reinsertion are disappointing compared with biceps tenodesis. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. As the age of the 2 treatment groups differed, these findings should be confirmed by future studies.

Superior labral lesions anterior to posterior-evaluation and arthroscopic management

Lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants. Treatment is determined by patient age, functional demands, and the type of lesion identified.

Physical examination and magnetic resonance imaging in the diagnosis of superior labrum anterior-posterior lesions of the shoulder: a sensitivity analysis

PURPOSE

The overall purpose of our study was to examine the sensitivity of physical examination, magnetic resonance imaging (MRI), and magnetic resonance (MR) arthrogram for the identification of arthroscopically confirmed SLAP lesions of the shoulder.

METHODS

An analysis of 51 consecutive patients with arthroscopically confirmed SLAP lesions and no history of shoulder dislocation was performed. Before undergoing surgery, all patients underwent a standardized physical examination and had either an MRI and/or MR arthrogram performed. Sensitivity analysis was then performed on the results of both the physical examination maneuvers and the radiologic imaging compared to the arthroscopic findings at surgery.

RESULTS

The sensitivity of O'Brien's (active compression) test was 90%, whereas the Mayo (dynamic) shear was 80% and Jobe's relocation test was 76%. The sensitivity of a physical examination with any 1 of these 3 SLAP provocative tests being positive was 100%. Neer's sign (41%) and Hawkin's impingement tests (31%) each had low sensitivity for SLAP lesions. The sensitivity of MRI for SLAP lesions was 67% when interpreted by the performing surgeon, 53% when read by a radiologist. When the MR arthrograms were analyzed alone, the sensitivity was 72% (surgeon) and 50% (radiologist), respectively.

CONCLUSIONS

All 3 physical examination maneuvers traditionally considered provocative for SLAP pathology (O'Brien's, Mayo shear, and Jobe's relocation) were sensitive for the diagnosis of SLAP lesions. MRI and MR arthrogram imaging had lower sensitivity than these physical examination tests in diagnosing SLAP lesions. Patient history, demographics, and the surgeon's physical examination should remain central to the diagnosis of SLAP lesions.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50: a randomized controlled trial

BACKGROUND

Arthroscopic management has been recommended for some superior labrum anterior and posterior (SLAP) lesions, but no studies have focused on patients over 50 years of age with rotator cuff tear and a type II SLAP lesion.

HYPOTHESIS

In patients over 50 years of age with an arthroscopically confirmed lesion of the rotator cuff and a type II SLAP lesion, there is no difference between (1) repair of both lesions and (2) repair of the rotator cuff tear without repair of the SLAP II lesion but with a tenotomy of the long head of the biceps.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the type II SLAP lesion (group 1). In the other 32 patients, we repaired the rotator cuff and tenotomized the long head of the biceps (group 2). Seven patients (2 in group 1 and 5 in group 2) were lost to final follow-up.

RESULTS

At a minimum 2.9 years' follow-up, statistically significant differences were seen with respect to the University of California, Los Angeles (UCLA) score and range of motion values. In group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a preoperative average rating of 10.4 (range, 6-14) to an average of 27.9 (range, 24-35) postoperatively (P < .001). In group 2 (biceps tenotomy and rotator cuff repair), the UCLA showed a statistically significant improvement from a preoperative average rating of 10.1 (range, 5-14) to an average of 32.1 (range, 30-35) postoperatively (P <.001) There was a statistically significant difference in total postoperative UCLA scores and range of motion when comparing the 2 groups postoperatively (P < .05).

CONCLUSIONS

There are no advantages in repairing a type II SLAP lesion when associated with a rotator cuff tear in patients over 50 years of age. The association of rotator cuff repair and biceps tenotomy provides better clinical outcome compared with repair of the type II SLAP lesion and the rotator cuff.

Arthroscopic Management of Superior Labral Anterior and Posterior (SLAP) and Associated Lesions: Clinical Features and Functional Outcome

Introduction: The superior labral anterior and posterior (SLAP) lesion is a cause of chronic shoulder pain and significant disability. This study aims to review the distribution of types of SLAP lesions, associated lesions and the outcome of arthroscopic management. Materials and Methods: This series involved all 33 patients who underwent arthroscopic management of SLAP and associated lesions by a single surgeon. The pre- and postoperative disability scores were assessed using the disabilities of the arm, shoulder and hand (DASH) outcome measure. Results: Type 2 SLAP lesion (64%) was the most common. Forty-eight per cent of the cases were associated with an ipsilateral shoulder lesion. A 10- point pre- and postoperative DASH score reduction was noted in 63% of the patients with isolated SLAP lesions and 73% of those with associated lesions. Conclusion: Arthroscopic management of the SLAP and its associated lesions results in improved functional outcome. The presence of associated lesions should be actively sought and managed in the same operative session. Key words: Arthroscopy, Rotator cuff, Shoulder

A biomechanical comparison of repair techniques in posterior type II superior labral anterior and posterior (SLAP) lesions

The purpose of this study was to compare the 3 different fixation methods of posterior type superior labral anterior posterior (SLAP) II lesion. Fifteen cadavers were randomly divided into 3 groups to compare the initial strength of 3 different fixation methods in posterior type II SLAP lesions. Group I used 1 anchor for 1-point fixation with a conventional simple suture; group II used 1 anchor passing both limbs through the posterior-superior labrum in a mattress fashion; and group III used 2 anchors for 2-point fixation with conventional simple sutures. Repair failure (2 mm permanent displacement of repaired site) and ultimate failure were measured. The mean load to (clinical) failure was 156 +/- 22 N in group I, 117 +/- 33 N in group II, and 161 +/- 44 N in group III. The mean load to ultimate failure was 198 +/- 6 N in group I, 189 +/- 23 N in group II, and 179 +/- 22 N in group III. The specimen stiffness was equivalent among groups. In mode of failure, clinical failure (more than 2 mm separations) first occurred between the markers on the biceps tendon just above (A) and below (B) compared to other markers, and ultimate failure occurred at the labral-implant interface. A single simple suture anchor repair in posterior type II SLAP seems sufficient to withstand the initial load without clinical failure. A mattress suture, although it anchors the biceps root, seems to be inferior than simple suture technique.

Isolated and combined Type II SLAP repairs in a military population

The study compares the clinical results of isolated arthroscopic repair of Type II SLAP tears with those of combined treatment for Type II SLAP and other associated shoulder conditions. The population was composed of 36 aged-matched active duty males with a mean age of 31.6 years (range 22-41 years); mean follow-up was 29.1 months (range 24-42 months). Eighteen subjects in Group I had isolated Type II SLAP tears. Eighteen subjects in Group II had Type II SLAP tear and concomitant ipsilateral shoulder conditions, including subacromial impingement in six patients, acromioclavicular arthrosis in three patients, subacromial impingement and acromioclavicular arthrosis in four patients, spinoglenoid cyst in four patients, and intra-articular loose bodies in one patient. Arthroscopic SLAP repair was performed with biodegradable suture anchors. Subacromial decompression and spinoglenoid cyst decompression were performed arthroscopically. Distal claviculectomy was performed in open fashion. Loose bodies were removed arthroscopically. At minimum 2-year follow-up, the mean UCLA score for Group I (30.2 +/- 3.0 points) was not significantly different from Group II (30.8 +/- 2.0 points) (P = 0.48). The mean post-operative ASES score for Group I (84.1 +/- 13.4 points) was significantly lower than for Group II (91.8 +/- 5.4 points) (P < 0.04). The mean VAS pain score for Group I (1.6 +/- 1.3 points) was significantly higher than for Group II (0.7 +/- 0.7 points) (P < 0.02). Seventeen of 18 patients (94%) in each group returned to full duty. In a population of active duty males, arthroscopic repair of isolated Type II SLAP had comparable results with a cohort of Type II SLAP repairs treated in combination with other shoulder conditions, with the combined treatment group having significantly better results in two of three parameters measured. Return to duty rates were identical. Therefore, concurrent treatment of other associated extra-articular shoulder conditions improves the overall success of SLAP repair and the presence of these other conditions should be recognized and treated along with the SLAP tears in order to maximize clinical results.

Arthroscopic superior labrum anterior-posterior repair in military patients

The purpose of this retrospective study was to determine the efficacy of arthroscopic superior labrum anterior-posterior (SLAP) repair in a military population. In this study, 27 patients (of 30 consecutive patients) who had suture anchor repair of a type II SLAP lesion were evaluated at a mean of 30.5 months postoperatively. Fifteen patients had isolated tears, whereas twelve also had a concomitant diagnosis. At follow-up, the overall mean American Shoulder and Elbow Surgeons score was 86.9 points and the mean University of California, Los Angeles score was 30.4 points. The results were excellent in 4 patients, good in 20, and fair in 3. Of the patients, 96% returned to full duty (mean, 4.4 months). Patients treated for concomitant diagnoses and a SLAP tear had significantly higher American Shoulder and Elbow Surgeons scores and tended to have higher University of California, Los Angeles scores than those treated for an isolated SLAP tear. The findings indicate that arthroscopic SLAP repair in military patients results in a high rate of return to duty. The results suggest that concomitant shoulder pathology should be treated at the time of SLAP repair.

[SLAP lesions: treatment.]

The advent of shoulder arthroscopy, as well as our improved understanding of shoulder anatomy and biomechanics, has led to the identification of previously undiagnosed lesions involving the superior labrum and biceps tendon anchor. Although the history and physical examinations as well as improved imaging modalities (arthro-MRI, arthro-CT) are extremely important in understanding the pathology, the definitive diagnosis of superior labrum anterior to posterior (SLAP) lesions is accomplished through diagnostic arthroscopy. Treatment of these lesions is directed according to the type of SLAP lesion. Generally, type I did not need any treatment, type III are debrided, whereas type II and many type IV lesions are repaired. The purpose of this article is to review the anatomy, classification, diagnosis and current treatment recommendations of SLAP lesions.