Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: prospective evaluation at a minimum two-year follow-up

Return to Play and Prior Performance in Major League Baseball Pitchers After Repair of Superior Labral Anterior-Posterior Tears

Background:

The published return-to-play (RTP) rates for Major League Baseball (MLB) pitchers who have undergone surgical repair of superior labrum anterior-posterior (SLAP) tears vary widely and are generally accepted to be lower in the subset of competitive throwers. The efficacy of surgical treatment for MLB players is largely unknown.

Purpose:

To examine the RTP rate and performance of MLB pitchers who have undergone SLAP tear repair between 2003 and 2010.

Study Design:

Descriptive epidemiological study.

Methods:

A retrospective review of MLB pitchers undergoing SLAP repair was performed using the MLB disabled list. Data collected included the following player statistics: earned run average (ERA), walks plus hits per inning pitched (WHIP), and innings pitched (IP). The mean values for performance variables both before and after surgery were compared. A definition of return to prior performance (RTPP) was established as an ERA within 2.00 and WHIP within 0.500 of preoperative values.

Results:

Twenty-four MLB players met inclusion criteria, of which 62.5% were able to RTP at the MLB level after SLAP repair surgery. Of those able to RTP, 86.7% were able to RTPP. However, the overall rate of RTPP, including those unable to RTP, was 54.2%. Mean performance analysis of the RTP group revealed a statistically significant decrease in IP for MLB pitchers throwing a mean 101.8 innings before injury and 65.53 innings after injury (P = .004).

Conclusion:

Of those pitchers able to RTP, chances of a full recovery were good (86.7%). Our results indicate the need for future research aimed at proper surgical selection of who will return to play, as they will likely achieve full recovery. We believe this information can help surgeons advise high-level overhead-throwing athletes about expected outcomes for surgical treatment of SLAP tears.

Tobacco use is associated with increased rates of infection and revision surgery after primary superior labrum anterior and posterior repair

BACKGROUND

Although the general health consequences of tobacco use have been well defined, the effects of perioperative tobacco use on arthroscopic shoulder procedures remain largely unknown. The purpose of this study is to use a national database to investigate the relationship between tobacco use and rates of superior labrum anterior and posterior (SLAP) repair failure and postoperative infection after primary SLAP repair compared with matched controls.

METHODS

A national private-payer insurance database was queried for patients who underwent arthroscopic primary SLAP from 2005-2012. These patients were divided into tobacco use and non-tobacco use cohorts using International Classification of Diseases, Ninth Revision coding. The non-tobacco use patients were then matched to the patients with coded tobacco use. Both cohorts were assessed for postoperative infection within 90 days and subsequent ipsilateral revision SLAP repair or biceps tenodesis within up to 7 years postoperatively.

RESULTS

The incidences of revision SLAP repair or revision to a biceps tenodesis (P = .023) and postoperative infection (P = .034) were significantly higher in patients who used tobacco versus matched controls.

CONCLUSIONS

SLAP repair in patients who use tobacco is associated with significantly increased rates of postoperative infection and revision SLAP repair or conversion to a biceps tenodesis.

Superior Labral Anterior-Posterior (SLAP) Tears in the Military

Context:

Given the notable physical demands placed on active members of the military, comprehension of recent trends in management and outcomes of superior labral anterior-posterior (SLAP) tears in this patient population is critical for successful treatment.

Evidence Acquisition:

Electronic databases, including PubMed, MEDLINE, and Embase, were reviewed for the years 1985 through 2016.

Study Design:

Database review.

Level of Evidence:

Level 5.

Results:

Active members of the military are at increased risk of sustaining shoulder injuries, particularly SLAP tears. Recent trends in management of SLAP lesions have shifted toward operative intervention. In the correct patient population, repairs of superior labrum tears demonstrate improved function and pain. Surgical repair of SLAP tears, especially in young and active military personnel, is supported.

Conclusion:

Military personnel are at greater risk of suffering a SLAP tear in comparison with their civilian counterparts. Surgical repair of these lesions is advocated in this subpopulation when the patient is younger than approximately 36 years of age, and if older, biceps tenodesis is likely superior.

Subsequent Shoulder Surgery After Isolated Arthroscopic SLAP Repair

PURPOSE

To quantify the incidence of and identify the risk factors for subsequent shoulder procedures after isolated SLAP repair.

METHODS

New York's Statewide Planning and Research Cooperative System database was searched between 2003 and 2014 to identify individuals with the sole diagnosis of a SLAP lesion who underwent isolated arthroscopic SLAP repair. Patients were longitudinally followed up for a minimum of 3 years to analyze for subsequent ipsilateral shoulder procedures.

RESULTS

Between 2003 and 2014, 2,524 patients met our inclusion criteria. After 3 to 11 years of follow-up, 10.1% of patients (254 of 2,524) underwent repeat surgical intervention on the same shoulder as the initial SLAP repair. The mean time to repeat shoulder surgery was 2.3 ± 2.1 years. Subsequent procedures included subacromial decompression (35%), debridement (26.7%). repeat SLAP repair (19.7%), and biceps tenodesis or tenotomy (13.0%). After isolated SLAP repair, patients aged 20 years or younger were more likely to undergo arthroscopic Bankart repair (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.36-6.21; P = .005), whereas age older than 30 years was an independent risk factor for subsequent acromioplasty (OR, 2.3; 95% CI, 1.4-3.7; P < .001) and distal clavicle resection (OR, 2.5; 95% CI, 1.1-5.5; P = .030). The need for a subsequent procedure was significantly associated with Workers' Compensation cases (OR, 2.4; 95% CI, 1.7-3.2; P < .001).

CONCLUSIONS

We identified a 10.1% incidence of subsequent surgery after isolated SLAP repair, often related to an additional diagnosis, suggesting that clinicians should consider other potential causes of shoulder pain when considering surgery for patients with SLAP lesions. In addition, the number of isolated SLAP repairs performed has decreased over time, and management of failed SLAP repair has shifted toward biceps tenodesis or tenotomy over revision SLAP repair in more recent years.

LEVEL OF EVIDENCE

Level III, case-control study.

Current Practice for the Surgical Treatment of SLAP Lesions: A Systematic Review

PURPOSE

To analyze current literature reporting surgical treatment of SLAP lesions to examine the consistency of reported surgical details (surgical indications, surgical technique, and postoperative rehabilitation) that are deemed important for best treatment outcomes and to try to establish a consensus regarding treatment.

METHODS

A systematic review of papers reporting surgical treatment of a SLAP lesion was performed. Each paper was analyzed for the description of (1) the arthroscopic indications for surgery; (2) surgical aspects including type, location, and number of anchors and sutures; (3) description of criteria for determination of completeness of the repair; and (4) postoperative rehabilitation details. These findings were also analyzed to determine whether a consensus could be developed regarding surgical treatment.

RESULTS

Twenty-six papers were included, with 12 focused on isolated SLAP repair and 14 focused on combined SLAP repair with other lesions; 54% did not report indications for surgery. Reporting of the anchor/suture details was not consistent, with 35% reporting some variation of 12:00 placement but 31% not reporting the position of placement; 89% of papers did not report the criteria for determining completeness of the repair; 85% reported general postoperative rehabilitation guidelines, but only 4% reported in-depth details.

CONCLUSIONS

This review demonstrated a wide variability in the reported surgical aspects and that a relatively high percentage of papers did not report many of the details. This lack of precision and consistency makes analysis of individual papers and comparison between papers and their outcomes difficult and does not allow a consensus regarding current practice to be developed. These findings may be some of the factors responsible for the variability in treatment outcomes and suggest that efforts could be directed toward consistency in documenting and reporting surgical indications, surgical techniques, surgical endpoints, and efficacious rehabilitation programs.

LEVEL OF EVIDENCE

Level IV, systematic review of level III-IV studies.

Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears

BACKGROUND

Uncertainty remains in the natural course of superior labrum anterior-posterior (SLAP) tears treated conservatively with rehabilitation and activity modification. Our purpose was to evaluate clinical outcomes after nonoperative treatment of type II SLAP tear in young active patients and to identify factors related to negative outcomes.

METHODS

We retrospectively reviewed 63 patients who initially underwent nonoperative treatment for isolated type II SLAP tear. Assessments were made at baseline and at 6 months, and telephone survey was used to evaluate the final outcome. All included patients underwent a consistent nonoperative treatment protocol, and patient-specific data on the outcome were assessed. Failure was defined as abandonment of nonoperative management for surgery at any time points, <20-point improvement in American Shoulder and Elbow Surgeons score at final follow-up, or inability to return to activities.

RESULTS

At the average follow-up of 21 months, pain relief and function improved significantly (American Shoulder and Elbow Surgeons score, 54.2-86.4; Visual Analog Scale score, 4.6-1.7; P < .05) in 45 patients (71.4%) with successful nonoperative treatment. Eighteen patients (28.5%) were either dissatisfied with treatment or had arthroscopic surgery and were considered a failure group. Multivariate analysis showed that failure of nonoperative treatment is strongly linked with history of trauma, positive compression-rotation test result, and participation in overhead activities (P < .05).

CONCLUSIONS

An initial trial of nonoperative management may be considered in young active patients with isolated SLAP tear. Patients with history of trauma, mechanical symptoms, and demand for overhead activities are less likely to succeed.

High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders

Background:

The incidence of superior labral surgery has increased in the past decade in the United States, and a contributing factor could be an increased rate of superior labral tears diagnosed with magnetic resonance imaging (MRI). Prior MRI studies of the asymptomatic shoulder have focused on rotator cuff pathology or pathology in a narrow and specific group of athletes. Labral abnormalities have not previously been thoroughly evaluated in asymptomatic middle-aged individuals.

Purpose:

To evaluate the prevalence of superior labral tears diagnosed by MRI in the asymptomatic shoulders of middle-aged people (age range, 45-60 years).

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 53 asymptomatic adults (age range, 45-60 years) with no history of surgery or injury to either shoulder were included in the study. Physical examinations of all shoulders were performed. Noncontrast MRI (1.5 T) was performed in 1 randomly determined shoulder of each subject. Two fellowship-trained musculoskeletal radiologists who were blinded to the purpose of the study and ages of the subjects evaluated each MRI.

Results:

Radiologists interpreted the MRIs as consistent with superior labral tears in 55% and 72% of the cohort. Comparison of the radiological evaluations of the superior labra were moderate (κ = 0.410, P = .033). There were no differences in readings for superior labral tear regarding age (P = .87), sex (P = .41), whether the dominant shoulder underwent MRI (P = .99), whether the subject worked a physical job (P = .08), or whether the subject participated in overhead sports for a period of 1 year (P = .62).

Conclusion:

Superior labral tears are diagnosed with high frequency using MRI in 45- to 60-year-old individuals with asymptomatic shoulders. These shoulder MRI findings in middle-aged populations emphasize the need for supporting clinical judgment when making treatment decisions for this patient population.

Clinical Relevance:

To avoid overtreatment, physicians should realize that superior labral tears diagnosed by MRI in individuals between the ages of 45 and 60 years may be normal age-related findings.

Current Practice for the Diagnosis of a SLAP Lesion: Systematic Review and Physician Survey

PURPOSE

To evaluate current practice reported in the literature for making a SLAP lesion diagnosis and compare the findings with a survey sent to experienced shoulder surgeons assessing how they make a SLAP diagnosis.

METHODS

We performed a systematic review of articles reporting surgical repair of SLAP lesions, documenting the use of 4 diagnostic areas of evaluation: history, clinical examination, imaging, and diagnostic arthroscopy. A survey was distributed electronically to 175 surgeons with expertise in shoulder surgery. The survey listed common components within the 4 diagnostic areas and asked surgeons to indicate components they used in establishing the diagnosis. The 4 diagnostic areas were ranked from 1 to 4 (most to least important).

RESULTS

Of the articles, 23% reported using all 4 diagnostic areas, 58% used 3 areas, and 19% used 2 areas or fewer. Thirty-five percent did not report history components, 31% did not report clinical examination elements, 27% did not report imaging findings, and 4% did not report arthroscopic findings. Eight percent reported using a comprehensive history and examination but without describing specific symptoms or tests. The most common components reported in the literature were pain (42%), the active compression test (65%), magnetic resonance imaging/arthrography (65%), and tear/unstable biceps-labral complex (27%). A total of 70 surgeons (40%) responded to the survey. More specific history components, examination maneuvers, and imaging/arthroscopy variants were reported on the survey compared with the literature. Diagnostic arthroscopy and history ranked as the most important for a SLAP diagnosis.

CONCLUSIONS

The current literature and practice for making the SLAP diagnosis are variable and inconsistent. The SLAP diagnosis appears to be a clinical impression; however, the criteria described within the literature vary among the evaluation areas and differ from the results of the survey. These types of variability may have a significant influence on consistency and accuracy in making the diagnosis of the SLAP injury, developing the subsequent treatment, and maximizing outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies with cross-sectional survey.

Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards

Surgical treatment of superior labral anterior posterior (SLAP) lesion becomes more and more frequent which is the consequence of evolving progress in both, imaging and surgical technique as well as implants. The first classification of SLAP lesions was described in 1990, a subdivision in four types existed. The rising comprehension of pathology and pathophysiology in SLAP lesions contributed to increase the types in SLAP classification to ten. Concerning the causative mechanism of SLAP lesions, acute trauma has to be differed from chronic degeneration. Overhead athletes tend to develop a glenohumeral internal rotation deficit which forms the basis for two controversial discussed potential mechanisms of pathophysiology in SLAP lesions: Internal impingement and peel-back mechanism. Clinical examination often remains unspecific whereas soft tissue imaging such as direct or indirect magnetic resonance arthrography has technically improved and is regarded to be indispensable in detection of SLAP lesions. Concomitant pathologies as Bankart lesions, rotator cuff tears or perilabral cysts should be taken into consideration when planning a personalized therapeutic strategy. In addition, normal variants such as sublabral recess, sublabral hole, Buford complex and other less common variants have to be distinguished. The most frequent SLAP type II needs a sophisticated approach when surgical teatment comes into consideration. While SLAP repair is considered to be the standard operative option, overhead athletes benefit from a biceps tenodesis because improved patient-reported satisfaction and higher rate of return to pre-injury level of sports has been reported.

Predictors of throwing velocity in youth and adolescent pitchers

BACKGROUND

Shoulder and elbow injuries are a common cause of pain, dysfunction, and inability to play in overhead throwers. Pitch velocity plays an integral part in the etiology of these injuries; however, the demographic and biomechanical correlates with throwing velocity remain poorly understood. We hypothesized that pitchers with higher velocity would have shared demographic and kinematic characteristics.

METHODS

Normal preseason youth and adolescent pitchers underwent dual-orthogonal high-speed video analysis while pitch velocity was collected with a radar gun. Demographic and pitching history data were also collected. Kinematic data and observational mechanics were recorded. Multivariate regression analysis was performed.

RESULTS

A total of 420 pitchers were included, with a mean pitching velocity of 64 ± 10 mph. After multivariate logistic regression analysis, the most important correlates with pitch velocity were age (P < .001; R(2) = 0.658), height (P < .001; R(2) = 0.076), separation of the hips and shoulders (P < .001; R(2) = 0.027), and stride length (P < .001; R(2) = 0.016); in combination, these 4 variables explained 78% of the variance in pitch velocity. Each year of age was associated with a mean 1.5 mph increase in velocity; each inch in height, with 1.2 mph; separation of the hips and shoulders, with 2.6 mph; and a 10% increase in stride length, with 1.9 mph.

CONCLUSION

Pitch velocity is most strongly correlated with age, height, separation of the hips and shoulders, and stride length.

SLAP Repairs With Combined Procedures Have Lower Failure Rate Than Isolated Repairs in a Military Population: Surgical Outcomes With Minimum 2-Year Follow-up

BACKGROUND

Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. The physical requirements of military service may contribute to an increased risk of injury. Limited data are available regarding the success of superior labral anterior posterior (SLAP) repairs in an active military population.

PURPOSE

To quantify the rate of clinical failure and surgical revision after isolated and combined SLAP repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive active-duty servicemembers undergoing arthroscopic repair of type II SLAP lesions at a single institution between 2006 and 2012 were identified. Patients with less than 2-year clinical follow-up and nonmilitary status were excluded. Demographic variables, surgical variables, and occupational outcomes were extracted from electronic medical records and confirmed with the US Army Physical Disability Agency database. Failure was defined as subsequent revision surgery or medical discharge with persistent shoulder complaints.

RESULTS

A total of 192 patients with SLAP repair were identified with a mean follow-up of 50.0 months (SD, 17.0 months). Isolated SLAP repair occurred in 31.3% (n = 60) versus 68.8% (n = 132) with concomitant procedures. At final follow-up, 37.0% (n = 71) of patients reported some subjective activity-related shoulder pain. Postoperative return to duty occurred in 79.6% (n = 153), and only 20.3% (n = 39) were discharged with continuing shoulder disability. The combined rotator cuff repair (96%; P = .023) and anteroinferior labral repair group (88%; P = .056) had a higher rate of functional return than isolated SLAP repair (70%). Thirty-one (16.1%) patients were classified as surgical failure and required revision. Of these, the majority of patients undergoing biceps tenodesis (76%) returned to active duty, as compared with revision SLAP repair (17%). Lower demand occupation and the presence of combined shoulder injuries (P = .011 and .016, respectively) were significantly associated with a lower risk of medical discharge and revision surgery, respectively.

CONCLUSION

Favorable outcomes can be anticipated in the majority of military servicemembers after arthroscopic SLAP repair, particularly with combined shoulder injuries. Revision surgery occurred in 16% of patients after primary SLAP repair.

CLINICAL RELEVANCE

Isolated repair of unstable SLAP lesions and/or increased upper extremity demands are associated with higher failure rates in this population.

Return to Preinjury Levels of Participation After Superior Labral Repair in Overhead Athletes: A Systematic Review

CONTEXT

Athletes often preoperatively weigh the risks and benefits of electing to undergo an orthopaedic procedure to repair damaged tissue. A common concern for athletes is being able to return to their maximum levels of competition after shoulder surgery, whereas clinicians struggle with the ability to provide a consistent prognosis of successful return to participation after surgery. The variation in study details and rates of return in the existing literature have not supplied clinicians with enough evidence to give overhead athletes adequate information regarding successful return to participation when deciding to undergo shoulder surgery.

OBJECTIVE

To investigate the odds of overhead athletes returning to preinjury levels of participation after arthroscopic superior labral repair.

DATA SOURCES

The CINAHL, MEDLINE, and SPORTDiscus databases from 1972 to 2013.

STUDY SELECTION

The criteria for article selection were (1) The study was written in English. (2) The study reported surgical repair of an isolated superior labral injury or a superior labral injury with soft tissue debridement. (3) The study involved overhead athletes equal to or less than 40 years of age. (4) The study assessed return to the preinjury level of participation.

DATA EXTRACTION

We critically reviewed articles for quality and bias and calculated and compared odds ratios for return to full participation for dichotomous populations or surgical procedures.

DATA SYNTHESIS

Of 215 identified articles, 11 were retained: 5 articles about isolated superior labral repair and 6 articles about labral repair with soft tissue debridement. The quality range was 11 to 17 (42% to 70%) of a possible 24 points. Odds ratios could be generated for 8 of 11 studies. Nonbaseball, nonoverhead, and nonthrowing athletes had a 2.3 to 5.8 times greater chance of full return to participation than overhead/throwing athletes after isolated superior labral repair. Similarly, nonoverhead athletes had 1.5 to 3.5 times greater odds for full return than overhead athletes after labral repair with soft tissue debridement. In 1 study, researchers compared surgical procedures and found that overhead athletes who underwent isolated superior labral repair were 28 times more likely to return to full participation than those who underwent concurrent labral repair and soft tissue debridement (P < .05).

CONCLUSIONS

The rate of return to participation after shoulder surgery within the literature is inconsistent. Odds of returning to preinjury levels of participation after arthroscopic superior labral repair with or without soft tissue debridement are consistently lower in overhead/throwing athletes than in nonoverhead/nonthrowing athletes. The variable rates of return within each group could be due to multiple confounding variables not consistently accounted for in the articles.

Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear

The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis for bicipital tendonitis with a superior labral anterior-posterior (SLAP) tear. Patients undergoing primary subpectoral biceps tenodesis for arthroscopically confirmed SLAP tears with signs or findings of bicipital tendonitis were included. An independent observer collected data prospectively as part of a data repository, which was then analyzed retrospectively. Primary outcome measures were the American Shoulder and Elbow Surgeons (ASES) score and pain relief via visual analog scale (VAS). Secondary outcome measures included the Simple Shoulder Test (SST), Constant, Single Assessment Numeric Evaluation (SANE), and Short Form 12 (SF-12) scores. Twenty-eight patients with a mean±SD age of 43.7±13.4 years and a mean±SD follow-up of 2.0±1.0 years met inclusion criteria. Workers' compensation was involved with 43% of cases, and 46% of the included patients were manual laborers. Eight (32%) patients were athletes, and 88% of the athletes were overhead athletes. Intraoperatively, 15 (54%) patients had type I SLAP tears, 10 (36%) had type II SLAP tears, 1 (3%) had a type III SLAP tear, and 2 (7%) had type IV SLAP tears. Significant improvements were seen in the following outcome measures pre- vs postoperatively: ASES score (58±23 vs 89±18; P=.001), SST score (6.3±3.6 vs 10.6±3.3; P=.001), SANE score (54±24 vs 88±25; P=.003), VAS score (3.8±2.0 vs 1.1±1.8; P=.001), SF-12 overall score (35±6 vs 42±6; P=.001), and SF-12 physical component score (39±6 vs 50±10; P=.001). Overall satisfaction was excellent in 80% of patients. Subpectoral biceps tenodesis demonstrates excellent clinical outcomes in select patients with SLAP tears. [Orthopedics. 2015; 38(1):e48-e53.].

Postoperative restoration of upper extremity motion and neuromuscular control during the overhand pitch: evaluation of tenodesis and repair for superior labral anterior-posterior tears

BACKGROUND

Superior labral anterior-posterior (SLAP) tears are a common cause of shoulder pain and dysfunction in overhand throwers. Treatment outcomes remain unpredictable, with a large percentage of athletes unable to return to sport. There is considerable debate about the optimal treatment between debridement, repair, and tenodesis.

HYPOTHESIS

Labral repair more closely restores neuromuscular control and motion during the overhand pitch than tenodesis of the long head of the biceps.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen pitchers, including 7 uninjured controls, 6 players pitching after SLAP repair, and 5 players pitching after subpectoral biceps tenodesis (BT), underwent simultaneous surface electromyographic measurement at 1500 Hz and motion analysis at 120 Hz with a 14-camera markerless motion analysis system and high-speed video (120 Hz) to confirm accurate motion tracking. Patients had undergone surgery at least 1 year previously and had returned to pitching with a painless shoulder.

RESULTS

No significant differences were observed in the long head of the biceps muscle, short head of the biceps muscle, deltoid, infraspinatus, or latissimus activity between controls, patients after SLAP repair, and patients after BT. The variability from pitch to pitch for each study participant was similar between groups. Based on visual inspection of the activity time plots, BT appeared to more closely restore the normal pattern of muscular activation within the long head of the biceps muscle than did SLAP repair. There were no significant differences between controls and postoperative patients in the majority of pitching kinematics; however, pitchers after SLAP repair showed significantly altered patterns of thoracic rotation (P = .034) compared with controls and were significantly less likely to fall into previously published normal values for lead knee flexion at front foot contact (P = .019).

CONCLUSION

While both BT and SLAP repair can restore physiologic neuromuscular control, pitchers who undergo SLAP repair may exhibit altered patterns of thoracic rotation when compared with controls and pitchers who undergo BT.

CLINICAL RELEVANCE

While both tenodesis and SLAP repair can restore physiologic neuromuscular control, SLAP repair may alter pitching biomechanics.

Etiology, Diagnosis, and Management of Failed SLAP Repair

In general, favorable outcomes have been achieved with arthroscopic repair of superior labral anterior-posterior (SLAP) tears. However, some patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment to alleviate their symptoms. The cause of persistent pain or recurrent symptoms after repair is likely multifactorial; therefore, careful preoperative workup is required to elucidate the cause of pain. Review of the details of previous surgical procedures is crucial because certain fixation methods are prone to failure or can cause additional injury. Failed SLAP repair can be managed with nonsurgical or surgical options. Nonsurgical modalities include physical therapy and strengthening programs, anti-inflammatory agents, and activity modification. Surgical options include revision SLAP repair and biceps tenotomy or tenodesis with or without revision SLAP repair. Outcomes after surgical management of failed SLAP repair are inferior to those of primary repair. Select patients may be better served by primary biceps tenodesis rather than SLAP repair.

Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions

BACKGROUND

Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions.

HYPOTHESIS

Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data.

RESULTS

Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity.

CONCLUSION

This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

Biceps tenodesis is a viable option for salvage of failed SLAP repair

BACKGROUND

Outcomes of arthroscopic superior labral anterior-posterior (SLAP) repairs have been well reported with generally favorable outcomes. Unfortunately, a percentage of patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment. The purpose of this study was to evaluate the surgical outcomes of biceps tenodesis for failed SLAP repairs.

METHODS

A retrospective review of all patients undergoing biceps tenodesis was completed. Inclusion criteria were previous SLAP repair and subsequent revision biceps tenodesis. Exclusion criteria were additional shoulder procedures including rotator cuff repair, instability procedures, and preoperative frozen shoulder. Objective outcomes were postoperative assessments with Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 36-Item Health Survey. Physical examination was conducted to determine postoperative range of motion and strength compared with the nonoperative shoulder.

RESULTS

A cohort of 24 patients was identified, and of these, 17 patients (71%) completed the study at 2 years' follow-up. The average postoperative Constant score was 84.4; American Shoulder and Elbow Surgeons score, 75.5; Single Assessment Numeric Evaluation score, 73.1%; Simple Shoulder Test score, 9.2; and Veterans RAND 36-Item Health Survey score, 76.1. Postoperative range of motion of the operative shoulder returned to near that of the asymptomatic nonoperative shoulder. Workers' compensation status led to inferior results.

CONCLUSIONS

Options for patients with a failed prior SLAP repair are limited. As a salvage operation for failed SLAP repair, biceps tenodesis serves the majority of patients well, with favorable outcomes by validated measures and excellent shoulder range of motion and elbow strength at 2 years' follow-up. Workers' compensation status may predispose patients to poorer outcomes.

The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs

BACKGROUND

The incidence and arthroscopic treatment of superior labral anterior posterior (SLAP) tears have increased over the past decade. Recent evidence has identified factors associated with poor outcomes, including age, overhead activity, and concomitant rotator cuff tears. Biceps tenodesis has also been suggested as an alternative treatment to repair. Moreover, there are no studies demonstrating effective treatment strategies for failed type II SLAP repairs.

PURPOSE

To prospectively evaluate the surgical outcomes of biceps tenodesis for patients who undergo elected revision surgery after an arthroscopically repaired type II SLAP tear.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

After institutional review board approval, 46 patients who met failure criteria for an arthroscopically repaired type II SLAP tear elected to undergo open subpectoral tenodesis by 2 fellowship-trained surgeons from 2006 to 2010 at a tertiary care military treatment facility. Objective outcomes were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) scores and an independent physical examination. Statistical analysis was performed via analysis of variance.

RESULTS

Of the 46 patients, 42 completed the study (91% follow-up rate). The mean age of the patients was 39.2 years, 85% were male, and the mean follow-up period was 3.5 years (range, 2.0-6.0 years). The rate of return to active duty and sports was 81%. There was a clinically and statistically significant improvement across all outcome assessments after revision surgery (preoperative mean scores: ASES = 68, SANE = 64, WOSI = 65; postoperative mean scores: ASES = 89, SANE = 84, WOSI = 81) (P < .0001) and shoulder range of motion (preoperative mean values: forward flexion = 135°, abduction = 125°; postoperative mean values: forward flexion = 155°, abduction = 155°) (P < .0001). There was 1 case of transient musculocutaneous nerve neurapraxia.

CONCLUSION

Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. The majority of patients obtained good to excellent outcomes using validated measures with a significant improvement in range of motion.

Postoperative imaging of bioabsorbable anchors in rotator cuff repair

BACKGROUND

Bioabsorbable anchors may lead to osteolysis and cyst formation. However, the prevalence of these outcomes is not known for rotator cuff repairs.

PURPOSE

To evaluate cyst formation after placement of bioabsorbable anchors for rotator cuff repairs and to verify whether bioabsorbable anchors degraded as intended and preserved bone stock for possible revision compared with metal anchors. The null hypothesis was that the rate and severity of cyst formation around the anchor are negligible.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between April 2008 and November 2011, a total of 209 patients (85 men, 124 women) underwent rotator cuff repair with bioabsorbable suture anchors (113 with polylactic acid enantiomers [PLLA] and 96 with poly-D,L-lactide from L-lactide and D-lactide [PLDLA]); the patients underwent magnetic resonance imaging (MRI) evaluation more than 10 months after surgery. The fluid signal around the anchor on T2-weighted MRI scans was graded as follows: grade 0, no fluid around anchor; grade 1, minimal fluid around anchor; grade 2, local fluid around anchor; grade 3, fluid collection around entire length of anchor with cyst diameter less than twice the anchor diameter; and grade 4, cyst diameter larger than grade 3. The integrity of repairs was also evaluated.

RESULTS

Cysts were observed in 97 instances (46.4%). There were 41 grade 1 cases (19.6%), 16 grade 2 (7.7%), 22 grade 3 (10.5%), and 18 grade 4 (8.6%). Healing of repaired tendon was observed in 131 patients (62.7%). There was no statistical difference in healing rate between patients with and without cyst formation (66.1% vs 58.8%; P = .276). Altered anchor shape and absorption were not observed in most of the patients. However, in 12 patients (6 with PLLA and 6 with PLDLA anchors), T2-weighted scans showed that the signal intensity of anchors had changed since surgery, which could indicate that absorption had taken place; nonetheless, even in these 12 patients, anchors were clearly visible on T1-weighted scans.

CONCLUSION

Osteolysis and cyst formation are common complications following the use of bioabsorbable anchors in rotator cuff repairs. Considering that adequate absorption of anchors and preservation of bone stock are the reasons for using bioabsorbable anchors, use of these anchors should be reconsidered because of possible interference with revision surgery.

The management of type II superior labral anterior to posterior injuries

Arthroscopic repair of type II superior labral anterior to posterior (SLAP) tears is currently the standard of care, with most patients obtaining good to excellent surgical results. However, overhead athletes and older patients have inferior outcomes. Recent clinical studies and biomechanical data suggest that a biceps tenodesis is a suitable alternative in select patients. This article reviews the literature to identify the biomechanical and clinical indications for performing a biceps tenodesis for type II SLAP lesions.

Footprint contact restoration between the biceps-labrum complex and the glenoid rim in SLAP repair: a comparative cadaveric study using pressure-sensitive film

PURPOSE

To compare pressurized footprint contact and interface pressure between the biceps-labrum complex and the superior glenoid rim after SLAP repair using 3 different techniques.

METHODS

Twenty-four fresh-frozen human cadaveric shoulders were divided into 3 groups. SLAP lesions were repaired by (1) 2 single-loaded anchors in a simple suture configuration (group T), (2) a double-loaded anchor in a simple suture configuration in a V shape (group V), or (3) a double-loaded anchor by use of a hybrid simple and mattress suture configuration (group H). Pressure-sensitive film quantified pressurized contact areas and interface pressures between the biceps-labrum complex and the glenoid rim after SLAP repair.

RESULTS

Groups T and V showed significantly larger contact areas than group H (P < .0001). However, there was no significant difference between groups T and V. Despite a substantial contact area around the biceps-labrum complex in group T, there was a lack of sufficient contact area just below the biceps anchor. Group V showed a uniform contact area around the entire biceps-labrum complex, but in group H the contact area was concentrated only around the posterior superior labrum, where the simple suture was used.

CONCLUSIONS

The methods using 2 single-loaded suture anchors and using 1 double-loaded suture anchor with a simple suture configuration showed significantly larger pressurized contact areas than the method using 1 double-loaded suture anchor with both a simple and mattress suture configuration. The interface pressure was not significantly different among groups.

CLINICAL RELEVANCE

Although there have been several kinds of repair techniques and biomechanical studies for the type II SLAP lesion, there has been no study about footprint restoration on the superior glenoid rim. This study analyzed and compared the footprint contact restoration after type II SLAP repair among 3 different techniques.

Subpectoral biceps tenodesis for failed type II SLAP repair

Superior labrum anterior-posterior lesions are a common cause of shoulder pain. The diagnosis, classification, and indications for surgical intervention remain controversial, and mixed outcomes are associated with primary repair. Given the increasing prevalence of primary superior labrum anterior-posterior repairs in the United States, more surgeons will need to treat patients with poor primary results. A retrospective review of prospectively collected data was performed on patients who underwent subpectoral biceps tenodesis for failed type II superior labrum anterior-posterior repair by a single surgeon between January 2008 and December 2011. Primary outcome variables included pain via the visual analog scale, American Shoulder and Elbow Surgeons score, and Short Form 12 score. Secondary outcome variables included the Simple Shoulder Test and Single Assessment Numeric Evaluation scores. Demographic and intraoperative information was recorded for each patient. A paired t test statistical analysis was performed with a P value less than .05 considered statistically significant. A total of 11 patients met the inclusion criteria. Of these patients, 9 (82%) completed postoperative surveys at a mean 26-month follow-up. Mean visual analog scale scores improved from 4.1 to 2.5 (P=.03), Simple Shoulder Test scores from 5.4 to 9.3 (P=.005), American Shoulder and Elbow Surgeons scores from 54.5 to 78.0 (P=.002), and Single Assessment Numeric Evaluation scores from 42.5 to 70.4 (P=.001). Mean SF-12 (physical component) improved from 35.5 to 47.9 (P=.018). No failures or peri- or postoperative complications occurred. No patients required additional surgery. The findings suggest that subpectoral biceps tenodesis as a salvage for failed type II superior labrum anterior-posterior repair demonstrates improved results. Larger scale comparative studies are required to justify this technique.

Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes

BACKGROUND

Although there are multiple reports on surgical outcomes of type 2 superior labral anterior posterior (SLAP) repairs, a literature review noted a paucity of data on clinical and radiological outcomes in elite overhead athletes.

PURPOSE

To determine midterm clinical outcomes of type 2 SLAP repairs in elite overhead athletes and whether labral integrity provides consistent return to play.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Medical records were retrospectively reviewed of 24 elite overhead athletes who underwent arthroscopic type 2 SLAP repairs. There were 18 men and 6 women, and their mean age was 22.7 years (range, 19-30 years); the majority of them (16/24) were baseball players. Four outcome measures were used: visual analog scale (VAS) for pain and satisfaction, American Shoulder and Elbow Surgeons (ASES) score, subjective feeling of recovery, and return to play. Multidetector computed tomographic arthrography was performed to evaluate labral integrity after surgery.

RESULTS

At a mean follow-up of 45.8 months (range, 24-68 months), overall pain and function improved significantly. The VAS for pain was 5.7 preoperatively and 2.0 postoperatively (P < .01), and VAS for satisfaction was 8.6. The ASES score was 55.8 preoperatively and 87.1 postoperatively (P < .01). The overall mean value of subjective feeling of recovery was approximately 76%. Twelve of 24 athletes (50%) returned to play after the operation. Although there was a trend toward higher return rate in the other overhead athletes (75%) compared with the baseball players (38%), this trend did not reach statistical significance (P = .097). Labral retear with clinical significance was noted in 2 athletes who failed to return to play. Osteolysis was observed in 2 athletes, 1 of whom had a retear. A statistical relation between the integrity of the repair and return to play was not found (P > .05).

CONCLUSION

Arthroscopic SLAP repairs show favorable clinical and radiological outcomes; however, the study findings raise a concern that return to play may still be problematic in elite baseball players. This study also indicates that labral healing does not ensure consistent return to play in elite overhead athletes.

A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure

BACKGROUND

There is a paucity of type 2 superior labrum anterior and posterior (SLAP) surgical outcomes with prospective data.

PURPOSE

To prospectively analyze the clinical outcomes of the arthroscopic treatment of type 2 SLAP tears in a young, active patient population, and to determine factors associated with treatment success and failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Over a 4-year period, 225 patients with a type 2 SLAP tear were prospectively enrolled. Two sports/shoulder-fellowship-trained orthopaedic surgeons performed repairs with suture anchors and a vertical suture construct. Patients were excluded if they underwent any additional repairs, including rotator cuff repair, labrum repair outside of the SLAP region, biceps tenodesis or tenotomy, or distal clavicle excision. Dependent variables were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability (WOSI) scores and independent physical examinations. A failure analysis was conducted to determine factors associated with failure: age, mechanism of injury, preoperative outcome scores, and smoking. Failure was defined as revision surgery, mean ASES score below 70, or an inability to return to sports and work duties, which was assessed statistically with the Student t test and stepwise logarithmic regression.

RESULTS

There were 179 of 225 patients who completed the follow-up for the study (80%) at a mean of 40.4 months (range, 26-62 months). The mean preoperative scores (WOSI, 54%; SANE, 50%; ASES, 65) improved postoperatively (WOSI, 82%; SANE, 85%; ASES, 88) (P < .01). The mean postoperative range of motion was 159° of flexion, 151° of abduction, and 51° of external rotation at the side, which was less than the mean preoperative range of motion (164° of flexion, 166° of abduction, and 56° of external rotation at the side). Of the 179 patients, 66 patients (36.8%) met failure criteria. Fifty patients elected revision surgery. Advanced age within the cohort (>36 years) was the only factor associated with a statistically significant increase in the incidence of failure. Those who were deemed failed had a mean age of 39.2 years (range, 29-45 years) versus those who were deemed healed with a mean age of 29.7 years (range, 18-36 years) (P < .001). The relative risk for failure for patients older than 36 years was 3.45 (95% CI, 2.0-4.9).

CONCLUSION

Arthroscopic SLAP repair provides a clinical and statistically significant improvement in shoulder outcomes. However, a reliable return to the previous activity level is limited; 37% of patients had failure, with a 28% revision rate. Age greater than 36 years was associated with a higher chance of failure. Additional work is necessary to determine the optimal diagnosis, indications, and surgical management for those with SLAP injuries.

Simple versus horizontal suture anchor repair of Bankart lesions: which better restores labral anatomy?

PURPOSE

The goal of this study was to determine which suture repair technique better restores glenoid labrum height: horizontal sutures or simple sutures.

METHODS

Sixteen cadaveric glenoids, 8 per repair technique, were used to measure native labral height at the 3:00 to 6:00 positions in half-hour increments. A Bankart lesion was then created from 3:00 to 6:30. Height measurements at each time point were again taken after creation of the Bankart lesion. Repair with a 3-mm knotted suture anchor was then performed at 3:30, 4:30, and 5:30 with either a simple or horizontal suture technique, and postrepair heights were measured across all time points.

RESULTS

Significant decreases in height, as compared with native height, were observed at 3:30, 4:30, and 5:30 in the simple repair group. Decreases in height of 1.4 mm (P = .044), 2.1 mm (P = .030), and 1.1 (P = .034) were observed at 3:30, 4:30, and 5:30. There was no significant decrease in height at these respective time points in the horizontal repair group.

CONCLUSIONS

The in vitro horizontal mattress suture technique better restores labral height and anatomy when compared with a simple suture technique in the repair of acute Bankart lesions.

CLINICAL RELEVANCE

Compared with the simple suture technique, horizontal suture repair may provide increased stability to the glenohumeral construct.

Diagnosis and management of superior labral anterior posterior tears in throwing athletes

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

The disabled throwing shoulder: spectrum of pathology-10-year update

In the 10 years since the current concept series entitled "The Disabled Throwing Shoulder: Spectrum of Pathology" was conceived and written, many studies have been reported that add much more information to the understanding of the disabled throwing shoulder (DTS). The editors of Arthroscopy and the authors of the original series believed that an update to the original series would be beneficial to provide an organized overview of current knowledge that could update the thought process regarding this problem, provide better assessment and treatment guidelines, and guide further research. A dedicated meeting, including current published researchers and experienced clinicians in this subject, was organized by the Shoulder Center of Kentucky. The meeting was organized around 5 areas of the DTS that were highlighted in the original series and appear to be key in creating the DTS spectrum and to understanding and treating the DTS: (1) the role of the kinetic chain; (2) the role and clinical evaluation of the scapula; (3) the role of deficits in glenohumeral rotation, glenohumeral internal rotation deficit, and total range-of-motion deficit in the causation of labral injury and DTS; (4) the role of superior labral (SLAP) injuries and rotator cuff injuries; and (5) the composition and progression of rehabilitation protocols for functional restoration of the DTS. The meeting consisted of presentations within each area, followed by discussions, and resulted in summaries regarding what is known in each area, what is not known but thought to be important, and strategies to implement and enlarge the knowledge base.

Arthroscopic repair of concomitant type II SLAP lesions in large to massive rotator cuff tears: comparison with biceps tenotomy

BACKGROUND

There are no studies examining superior labrum anterior and posterior (SLAP) repair combined with repair of large to massive rotator cuff tears, and it is unclear whether a combined SLAP repair would lead to better outcomes than biceps tenotomy.

HYPOTHESIS

Tenotomy and rotator cuff repair would lead to better outcomes compared with those of combined SLAP and rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Our study population consisted of 36 patients who had undergone either combined SLAP and rotator cuff repair (when the biceps was too healthy to cut; group R = 16 patients) or tenotomy and rotator cuff repair (when any fraying or partial tear existed in the biceps tendon; group T = 20 patients) for concomitant type II SLAP lesions and large to massive rotator cuff tears. The cuff repair was performed in a single row for both groups. Outcomes were assessed by comparing range of motion as well as Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) scores between the 2 groups.

RESULTS

At the 2-year follow-up, both groups demonstrated significant improvements in functional shoulder scores and range of motion. However, group T had better SST scores (group T, 9.3 ± 1.6; group R, 7.8 ± 1.9; P = .012), ASES scores (group T, 88.6 ± 8.9; group R, 80.4 ±8.9; P = .009), UCLA scores (group T, 29.6 ± 3.0; group R, 26.0 ± 4.2; P = .007), and forward flexion (group T, 145.9° ± 13.0°; group R, 132.5° ± 15.3°; P = .008). The mean tear size and the degree of preoperative muscle atrophy and fatty infiltration on magnetic resonance imaging were similar between the groups.

CONCLUSION

For patients with concomitant type II SLAP lesions and large to massive rotator cuff tears, the outcomes of simultaneous arthroscopic SLAP and rotator cuff repair were inferior to those of arthroscopic biceps tenotomy and cuff repair in terms of functional shoulder scores and range of motion. Biceps tenotomy and rotator cuff repair may be a more reliable method to address concomitant type II SLAP lesions and large to massive rotator cuff tears in patients, although a randomized controlled trial is needed to confirm the results.

A new technique of arthroscopic fixation using double anchors for SLAP lesions

PURPOSE

The aim of this study was to evaluate the clinical and structural outcome of the new fixation technique of type-II SLAP repair using double anchors compared with conventional method.

METHODS

Twenty-eight patients with 29 shoulders, who were followed up for at least 1 year after surgery, were enrolled. Fourteen shoulders were treated using the new technique (group 1), and 15 shoulders using the conventional technique (group 2). The clinical outcomes were evaluated using two different functional scores, the pain VAS and range of motion. The postoperative labral integrity was determined by magnetic resonance imaging at 1 year after surgery.

RESULTS

At postoperative 6 months, all functional scores of group 1 were superior to group 2, particularly in pain VAS and Constant Scoring System. All ranges of motion in group 1 showed a better result than in group 2, particularly in forward flexion and external rotation at 90° abduction (88° ± 4.8 in group 1 and 84° ± 9.2 in group 2, P = 0.03). At postoperative 12 months and the last visit, all functional scores in group 1 were superior to those in group 2 and all external rotations at 90° of abduction in group 1 showed significantly better results than those of group 2. All patients in group 1 showed complete healing of the repaired SLAP lesion but one patient in group 2 showed partial detachments on the MRI.

CONCLUSIONS

This new technique provides anatomical restoration of a SLAP lesion and yields successful clinical and structural outcomes at a short-term follow-up.

LEVEL OF EVIDENCE

Randomized controlled trials, level II.

Biceps instability and Slap type II tear in overhead athletes

Type II lesions are common lesions encountered in overhead athletes with controversies arising in term of timing for treatment, surgical approach, rehabilitation and functional results. The aim of our study was to evaluate the outcomes of arthroscopic repair of type II SLAP tears in overhead athletes, focusing on the time elapsed from diagnosis and treatment, time needed to return to sport, rate of return to sport and to previous level of performance, providing an overview concerning evidence for the effectiveness of different surgical approaches to type II SLAP tears in overhead athletes. A internet search on peer reviewed Journal from 1990, first descriprion of this pathology, to 2012, have been conducted evaluating the outcomes for both isolated Slap II tear overhead athletes and those who presented associated lesions treated. The results have been analyzed according to the scale reported focusing on return to sport and level of activity. Apart from a single study, non prospective level I and II studies were detected. Return to play at the same level ranged form 22% to 94% with different range of technique utilized with the majority of the authors recommending the fixation of these lesions but biceps tenodesis can lead to higher satisfaction racte when directly compated to the anchor fixation. Associated pathologies such as partial or full tickness rotator cuff tear did not clearly affect the outcomes and complications rate. There is no consensus regarding timing and treatment for type II SLAP, especially in overhead athletes who need to regain a high level of performance.

Short-term clinical results after arthroscopic type II SLAP repair

PURPOSE

The purpose of this study was to retrospectively review the clinical results of arthroscopic repair of type II SLAP lesions with respect to daily living activities and return to preinjury sports level.

PATIENTS AND METHODS

Twenty-one patients with an average age of 28 (range 18-44 years, respectively) underwent arthroscopic repair of isolated type II SLAP lesions. Surgery was performed by two of the senior authors with specialty training in arthroscopic shoulder surgery. Mean follow-up was 30.3 months (range 12-71 months, respectively). The clinical results were objectively measured using the individual relative Constant score (CS(indiv)).

RESULTS

At follow-up the mean CS(indiv) was 92 % (range 78-100 %). Restrictions to active motion were seen in six patients (28.6 %), four (19 %) in internal rotation and two (9.5 %) in external rotation but not all of these were restricted in their activities of daily living. Five patients (23.8 %) had an affected sleep, three patients (14.3 %) were limited in sports and one patient (4.7 %) was restricted at work. After surgery, 18 of 21 patients (85.7 %) regained preinjury sports level.

CONCLUSIONS

Although the rehabilitation process may be affected by a protracted period of pain, a long-term limitation of the range of motion (ROM) after surgery is very unlikely. The results in this study are encouraging and the authors recommend anatomic restoration and repair of type II SLAP lesions.

Bone replacement of fast-absorbing biocomposite anchors in arthroscopic shoulder labral repairs

BACKGROUND

Newer generation biocomposite anchors are hypothesized to resorb more reliably and faster, while allowing for bone ingrowth and replacement.

PURPOSE

The purposes of this study were to (1) assess anchor resorption and bone ingrowth over time, (2) identify tunnel widening or potential reactions to the implants, (3) compare imaging findings for different sites of labral repair, and (4) determine patient subjective outcomes with the use of biocomposite anchors in glenoid labral repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We enrolled 22 patients to participate in a 24-month outcomes study that included subjective and objective outcome assessments after glenoid labrum repair surgery. Magnetic resonance imaging (MRI) was performed at 6 and 12 months to identify any potential reactions to implants. Computed tomography (CT) scans were performed at 12 and 24 months to determine anchor resorption and bone ingrowth. Sixteen patients and 47 anchors were available for follow-up at 24 months. An independent, fellowship-trained musculoskeletal radiologist read the scans. Subjective outcome scores measured at 24 months postoperatively included Simple Shoulder Test, Tegner activity scale, American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) shoulder scores.

RESULTS

No adverse events were reported with the use of biocomposite anchors at the end of the study period. At 12 and 24 months, respectively, CT scans demonstrated that an estimated 68% and 98% of combined anchor material had been absorbed, 56% and 78% of the anchor material had been replaced by soft tissue of variable density, and 9% and 20% of total anchor volume was replaced by bone. No obvious mechanical failure of the labral repairs was detected on nonarthrogram MRI. Three of the 47 anchors showed bone cyst formation. Tunnel widening (expansion beyond tunnel diameter of 3 mm; 2.9-mm drill hole utilized) was seen in 55% of the anchors but decreased between 12 and 24 months, consistent with bone replacement. Tunnel widening was seen more in anteroinferior and posterior glenoid anchor locations (84% and 57%, respectively) than in superior labral anchors (13%). Subjective outcome scores at 24 months for ASES and UCLA shoulder scores averaged 88 and 30, respectively. All but one patient were satisfied with their outcome at 24 months.

CONCLUSION

Our imaging evaluation indicates resorption of newer generation biocomposite anchors with progressive bone replacement at 12 and 24 months while maintaining acceptable subjective outcomes.

Restoration of labral anatomy and biomechanics after superior labral anterior-posterior repair: comparison of mattress versus simple technique

BACKGROUND

Both simple and mattress repair techniques have been utilized with success for type II superior labral anterior-posterior (SLAP) lesions; however, direct anatomic and biomechanical comparisons of these techniques have yet to be clearly demonstrated.

HYPOTHESIS

For type II SLAP lesions, the mattress suture repair technique will result in greater labral height and better position on the glenoid face and exhibit stronger biomechanical characteristics, when cyclically loaded and loaded to failure through the biceps, compared with the simple suture repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six matched pairs of cadaveric shoulders were dissected, and a clock face was created on the glenoid from 9 o'clock (posterior) to 3 o'clock (anterior). For the intact specimen, labral height and labral distance from the glenoid edge were measured using a MicroScribe. A SLAP lesion was then created from 10 o'clock to 2 o'clock. Lesions were repaired with two 3.0-mm BioSuture-Tak anchors placed at 11 o'clock and 1 o'clock. For each pair, a mattress repair was used for one shoulder, and a simple repair was used for the contralateral shoulder. After repair, labral height and labral distance from the glenoid edge were again measured. The specimens were then cyclically loaded and loaded to failure through the biceps using an Instron machine. A paired t test was used for statistical analysis.

RESULTS

After mattress repair, a significant increase in labral height occurred compared with intact from 2.5 ± 0.3 mm to 4.3 ± 0.3 mm at 11 o'clock (P = .013), 2.7 ± 0.5 mm to 4.2 ± 0.7 mm at 12:30 o'clock (P = .007), 3.1 ± 0.5 mm to 4.2 ± 0.7 mm at 1 o'clock (P = .006), and 2.8 ± 0.7 mm to 3.7 ± 0.8 mm at 1:30 o'clock (P = .037). There was no significant difference in labral height between the intact condition and after simple repair at any clock face position. Labral height was significantly increased in the mattress repairs compared with simple repairs at 11 o'clock (mean difference, 2.0 mm; P = .008) and 12:30 o'clock (mean difference, 1.3 mm; P = .044). Labral distance from the glenoid edge was not significantly different between techniques. No difference was observed between the mattress and simple repair techniques for all biomechanical parameters, except the simple technique had a higher load and energy absorbed at 2-mm displacement.

CONCLUSION

The mattress technique created a greater labral height while maintaining similar biomechanical characteristics compared with the simple repair, with the exception of load and energy absorbed at 2-mm displacement, which was increased for the simple technique.

CLINICAL RELEVANCE

Mattress repair for type II SLAP lesions creates a higher labral bumper compared with simple repairs, while both techniques resulted in similar biomechanical characteristics.

Vertical versus horizontal suture configuration for the repair of isolated type II SLAP lesion through a single anterior portal: a randomized controlled trial

PURPOSE

To compare the clinical and functional outcomes of the repair of an isolated type II SLAP lesion by 2 different configuration techniques (vertical v horizontal suture) through a single anterior portal.

METHODS

We designed a prospective, double-blinded, randomized clinical trial. A junior orthopaedic surgeon, who made the initial diagnosis, used a 10-point visual analog scale for pain and subjective instability and the American Shoulder and Elbow Surgeons (ASES) scoring system and evaluated the range of motion. After a diagnostic arthroscopy that ascertained the presence of an isolated type II SLAP lesion, patients were randomized to receive either vertical suture configuration (group 1) or horizontal suture configuration (group 2), both through a single anterior portal. Thirty-two patients were included in the study. The mean follow-up time was 37 months.

RESULTS

The mean postoperative ASES score was 91.9 in group 1 versus 95.8 in group 2 (P > .05). The differences observed from preoperative ASES score for both groups to postoperative ASES score were statistically significant. The differences observed in preoperative range of motion from the contralateral healthy shoulder and the affected shoulder in both groups were all clinically and statistically significant. Comparing the overall range of motion of the affected limb postoperatively with the range of motion of the contralateral healthy shoulder and between both groups, we found no statistically significant differences in forward flexion (P = .067), external rotation (P = .101), or internal rotation (P = .343).

CONCLUSIONS

The results of this study suggest that the repair of an isolated type II SLAP lesion through a single anterior portal is clinically and functionally beneficial to patients regardless of the suture configuration performed (vertical or horizontal suture) because no differences were observed between these configurations after repair of an isolated type II SLAP lesion.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction

BACKGROUND

The majority of the literature on surgical outcomes of superior labral anterior posterior (SLAP) repairs has focused on short-term follow-up of 1 to 2 years, not allowing adequate time for full rehabilitation and return to maximum level of competition for all types of athletes. Also, previous studies have concentrated on using questionnaires that primarily evaluate patients' activities of daily living, which do not focus on sport-specific performance.

PURPOSE

To determine the midterm results of type II SLAP repairs in overhead athletes, focusing primarily on athletic performance as well as activities of daily living.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of 30 overhead athletes, who underwent an arthroscopic superior labral repair for a symptomatic type II SLAP tear between 2002 and 2007, was performed. Our study population included 22 male and 8 female patients with a mean age at the time of surgery of 24 years. Twenty-one patients participated in baseball or softball, and the remainder of patients were involved in javelin throwing or tennis. The average follow-up was 3.5 years. The outcome of treatment was evaluated using the American Shoulder and Elbow Society (ASES) scoring system, assessing activities of daily living, and the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, assessing sport-specific performance. In addition, the length of time to return to sport and the degree of successful performance were evaluated.

RESULTS

Repairs resulted in ASES scores comparable with those from prior published studies (average ASES score, 87.9). The KJOC score averaged 73.6. The athletes' perception was that they returned to approximately 84.1% of their preinjury level of function with a mean time to return to play of 11.7 months. There was a significant drop in the ASES to KJOC score for the baseball/softball players (87.9 ± 14.94 and 72 ± 19.24, respectively; P = .006). Patients reported an overall satisfaction rate of 93.3% with the procedure, with the majority being very satisfied.

CONCLUSION

Arthroscopic SLAP repairs show excellent results and a high rate of overall satisfaction; however, the outcomes are less reliable in throwers. The KJOC score provides a more stringent assessment of overhead athletes' function after SLAP repair than the ASES score. Our findings also indicate that SLAP repairs lead to improved shoulder function during routine daily activities but that consistent return to elite throwing sports may still remain somewhat problematic.