SLAP lesions: a retrospective multicenter study

Isolated type II superior labral anterior posterior lesions: age-related outcome of arthroscopic fixation

BACKGROUND

Superior labral anterior posterior tears have been described as symptomatic lesions in shoulders of patients of varying ages. It is unknown if age affects clinical outcome of arthroscopic fixation of type II superior labral anterior posterior repairs.

HYPOTHESIS

Clinical outcome of arthroscopic fixation of isolated type II superior labral anterior posterior tears differs between younger (<40 years) and older (> or =40 years) patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Clinical results of arthroscopic fixation of isolated unstable type II superior labral anterior posterior repairs were compared between 25 patients younger than 40 years (group 1) and 25 patients aged 40 years or older (group 2). Patients with concomitant procedures, prior/subsequent shoulder surgeries, and use of non-suture anchor devices were excluded. Outcomes at a minimum 1-year follow-up were assessed using range of motion measurements and the American Shoulder and Elbow Surgeons questionnaire as compared with preoperative data. Ability and time to return to prior level of activity were assessed.

RESULTS

At a mean 3-year follow-up, there were statistically significant improvements in American Shoulder and Elbow Surgeons scores for both groups (P < .0001) but no significant difference between final American Shoulder and Elbow Surgeons scores (group 1, 91; group 2, 87; P > .198). Both groups demonstrated good or excellent results in >80% of patients. A traumatic mechanism of injury (P = .0346) and presence of osteoarthritis (P = .0401) were independent factors resulting in significantly lower postoperative scores. There were statistically significant differences in preoperative and postoperative range of motion for internal rotation (group 1, P = .0321) and forward elevation (group 2, P = .0003). Return to prior level of activity was similar between younger and older age groups: 80% versus 74%. Time to return to sport was prolonged for group 2 (11.0 months) compared with group 1 (8.45 months). Patients without osteoarthritis were significantly more likely to return to previous levels of activity than were those who had osteoarthritis (P = .0044).

CONCLUSION

Good to excellent results and high return to prior level of activity can be expected for the majority of properly indicated patients who undergo isolated type II superior labral anterior posterior repairs, regardless of age. Subtle deficits in range of motion were experienced by both age groups; this did not seem to affect final outcomes. The presence of osteoarthritis was associated with lower American Shoulder and Elbow Surgeons scores and inability to return to prior level of activity. Time to return to activity was prolonged for the older group.

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.

Biomechanical comparison of a knotless suture anchor with standard suture anchor in the repair of type II SLAP tears

PURPOSE

To compare the biomechanical strength of knotless suture anchors and standard suture anchors in the repair of type II SLAP tears.

METHODS

Five pairs of cadaveric shoulders (10 shoulders) were dissected free of soft tissue except for the glenoid labrum and long head of the biceps tendon. Type II SLAP tears were created and repaired with 1 of 2 anchors: the Mitek Lupine suture anchor or the Mitek Bioknotless suture anchor (DePuy Mitek, Raynham, MA). All specimens were preloaded to 10 N, and loaded for 25 cycles in 10 N increments to a maximum of 200 N. If specimens were still intact after 200 N, they were loaded to ultimate failure. The load at which 2 mm of gapping occurred, load to ultimate failure, mode of failure, and the number of cycles to failure were compared using the Wilcoxon signed-rank test.

RESULTS

Load to 2-mm gapping was lower (P = .042) for knotless anchors (70 N) versus knotted anchors (104 N), with similar differences for ultimate failure (74 N v 132 N; P = .043), cycles to 2-mm gapping (133 v 219 cycles; P = .042), and cycles to failure (143 v 297; P = .043). Eight of 10 specimens failed at the soft tissue interface (4 knotless, 4 knotted) and 2 failed by anchor pullout (1 knotted, 1 knotless).

CONCLUSIONS

The results of this study suggest that repair of a type II SLAP with a Mitek knotted suture anchor and mattress suture configuration through the biceps anchor is stronger than repair with a Mitek knotless suture anchor. The most likely method of repair failure was at the suture-soft tissue interface regardless of the type of anchor used. The application of a suture anchor that requires arthroscopic knot tying may be preferable to a knotless anchor for the surgical repair of type II SLAP tears.

CLINICAL RELEVANCE

Repair of type II SLAP tears with knotless suture anchors may allow for the avoidance of arthroscopic knot tying but is weaker than repair with standard suture anchors.

SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization

Superior labral anterior posterior (SLAP) tears are an abnormality of the superior labrum usually centered on the attachment of the long head of the biceps tendon. Tears are commonly caused by repetitive overhead motion or fall on an outstretched arm. SLAP lesions can lead to shoulder pain and instability. Clinical diagnosis is difficult thus imaging plays a key diagnostic role. The normal anatomic variability of the capsulolabral complex can make SLAP lesions a diagnostic challenge. Concurrent shoulder injuries are often present including rotator cuff tears, cystic changes or marrow edema in the humeral head, capsular laxity, Hill-Sachs or Bankart lesion. The relevant anatomy, capsulolabral anatomic variants, primary and secondary findings of SLAP tears including MR arthrography findings, types of SLAP lesions and a practical approach to labral lesions are reviewed.

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.

Clinical assessment of superior glenoid labral lesions: a systematic review

Superior labral anterior posterior (SLAP) lesions of the glenoid have proven difficult to diagnose clinically. SLAP-lesion-specific physical examination tests have been developed to improve clinical acumen. Initial reported performance of these tests has not been reproduced by independent investigation. We hypothesized SLAP-specific physical examination tests could not provide a definitive diagnosis of a SLAP lesion. We further intended to elucidate factors responsible for the variable performance of SLAP-specific tests. A review of the literature through Medline and Embase database searches was conducted. All studies with level of evidence of III or better involved in the reporting of diagnostic accuracy of SLAP-specific physical examination tests were included and reviewed. Each instance of independent evaluation of a SLAP-specific examination showed poorer examination performance than in the originating study. Considerable variability existed between independent evaluations of a given SLAP-specific examination as well. We concluded SLAP-specific physical examination results cannot be used as the sole basis of a diagnosis of a SLAP lesion. Differences in patient populations between studies and the accompanying differences in SLAP lesion prevalence and comorbid conditions played the greatest role in test result variance.

Biomechanical comparison of 3 suture anchor configurations for repair of type II SLAP lesions

PURPOSE

Our purpose was to compare 3 commonly used suture anchor configurations for repair of type II SLAP lesions.

METHODS

Biomechanical testing was performed on 3 groups of 7 cadaveric shoulders by use of an optical linear strain measurement system. Standardized type II SLAP lesions were created and repaired via 3 suture anchor configurations: (1) a single simple suture anterior to the biceps; (2) two simple sutures, one anterior and one posterior to the biceps; and (3) a single mattress suture through the biceps anchor. Cyclic traction was applied to the biceps tendon, and strain failure (defined as 2 mm of permanent displacement), yield, and pullout loads were measured.

RESULTS

The mean load to strain failure was 63 N in group 1, 70 N in group 2, and 106 N in group 3. The mean load to ultimate failure was 140 N in group 1, 194 N in group 2, and 194 N in group 3. Strain failure load was significantly higher in the mattress suture group than in either of the other two groups (P < .05). Groups 2 and 3 both had a significantly higher load to ultimate failure than group 1.

CONCLUSIONS

When type II SLAP lesions were subjected to cyclic traction, the load to strain failure was greater with a single anchor and mattress suture than with one or two anchors with simple sutures around the labrum. Fixation with two simple sutures appears to provide intermediate load to strain failure.

CLINICAL RELEVANCE

The results of this study suggest that a single anchor with a mattress suture may be a biomechanically advantageous construct for the repair of type II SLAP lesions.

Outcome of arthroscopic repair of type II SLAP lesions in worker's compensation patients

PURPOSE

Arthroscopic stabilization has become the accepted treatment for type II superior labral anterior and posterior (SLAP) lesions. Short-term results using a variety of techniques were promising, but most reports focus on motivated athletes. The purpose of our report is to evaluate the results of arthroscopic fixation of type II SLAP lesions in 21 patients who suffered a work-related injury and are receiving workers' compensation. The hypothesis was that in patients with a single event trauma who were receiving workers' compensation, clinical results would be inferior to those previously reported.

METHODS

Twenty-two consecutive workers' compensation patients with type II SLAP lesions underwent arthroscopic stabilization between October 1994 and December 1996. All patients received suture anchors with nonabsorbable suture secured around the labrum for definitive fixation. Average age at surgery was 43 and average follow-up time was 27.9 months. Seventeen patients (89%) had an acromioplasty at the time of labral stabilization. Outcome was assessed by analysis of visual analog pain scale, simple shoulder test (SST) and general health status questionnaire (SF-36), subjective patient satisfaction, and ability to return to work.

RESULTS

Visual analog pain scales improved by an average of 3 points although all patients had significant complaints of pain at follow-up. Simple shoulder test responses showed improvement in 9 out of 12 categories. The SF-36 results showed significant improvements only in the bodily pain category and role: physical category. Five patients required reoperation for persistent pain. However, only seven patients (437%) returned to work at their previous functional level, nine patients (47%) returned to work but at less strenuous jobs, and three patients (16%) did not return to work.

CONCLUSIONS

Currently recommended treatment for type II SLAP lesions is arthroscopic stabilization. When this procedure is performed in workers' compensation, patients a with single event trauma to the shoulder, objective parameters, and patient self-assessment surveys do show improvement. However, results are inferior to those previously reported in the literature.

An evaluation of the provocative tests for superior labral anterior posterior lesions

BACKGROUND

Although our understanding of superior labral anterior posterior lesions has grown, the physical diagnosis remains imperfect.

STUDY DESIGN

Cohort study (diagnostic); Level of evidence, 2.

PURPOSE

To determine the most effective provocative maneuver with which to diagnose superior labral anterior posterior lesions.

METHODS

A series of 132 consecutive patients scheduled to undergo diagnostic shoulder arthroscopy were examined preoperatively over a 6-month period, and the final diagnosis in each case was made arthroscopically. The following assessments were included: active compression (O'Brien), anterior slide, pain provocation, crank, Jobe relocation, Hawkins, Neer, Speed, and Yergason tests.

RESULTS

The most sensitive diagnostic tools for type II superior labral lesions were the active compression, Hawkins, Speed, Neer, and Jobe relocation tests. When type I and type II lesions were combined, the results were similar. However, none of the sensitive tests were specific for either type I or type II lesions.

CONCLUSIONS

The authors' results contradict the current literature regarding provocative testing for both stable and unstable superior labral lesions. There is no single maneuver that can accurately diagnose superior labral anterior posterior lesions; arthroscopy remains the standard by which to diagnose such lesions.

Width of high signal and extension posterior to biceps tendon as signs of superior labrum anterior to posterior tears on MRI and MR arthrography

OBJECTIVE

The purpose of our study was to determine the accuracy of two signs for superior labrum anterior to posterior (SLAP) tears: increased width of high signal between the superior labrum and glenoid, and high signal posterior to the biceps tendon.

MATERIALS AND METHODS

Forty-one patients with SLAP tears and 40 patients without a tear at surgery who had undergone MRI or MR arthrography were retrospectively evaluated. The MR studies were combined and interpreted in a blinded manner. The reviewers measured the width of high signal that extended to the articular surface on oblique coronal images and determined whether the high signal extended posterior to the biceps. A Student's t test was used to determine statistical significance between the means of the signal width.

RESULTS

High-signal width was greater in patients with a SLAP tear than in the control group on both MRI and MR arthrography (both p = 0.003). The sensitivity and specificity of at least 2.0 mm on MRI are 39% (11/28) and 89% (24/27) and at least 2.5 mm on MR arthrography are 46% (6/13) and 85% (11/13). The sensitivity and specificity of high signal posterior to the biceps are 54% (15/28) and 74% (20/27) on MRI and 69% (9/13) and 54% (7/13) on MR arthrography.

CONCLUSION

Increased width of high signal has a moderate specificity but a poor positive predictive value for distinguishing a SLAP tear from a normal recess. In addition, labral signal posterior to the biceps tendon is not rare in patients with no SLAP tear.

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

PURPOSE

The purpose of this study was to describe the clinical presentation and sensitivity of testing of unstable isolated SLAP (superior labrum anterior posterior) lesions and to evaluate the efficacy of arthroscopic treatment.

TYPE OF STUDY

Case series.

METHODS

A retrospective review was made of 44 unstable SLAP lesions in 41 patients (40 male, 1 female) who did not have other pathologic shoulder findings. The mean follow-up period was 33 months (range, 25 to 67 months) and the mean age at the time of surgery was 24 years (range, 17 to 43 years). Twenty-six patients had an injury on the dominant shoulder and 3 had bilateral shoulder involvement. Arthroscopic fixation was performed with the use of a biodegradable tack (Suretac; Acufex, Mansfield, MA) in 14 cases, and with a screw-type metallic suture anchor (mini-Revo; Linvatec, Largo, FL) in 30 cases.

RESULTS

Pain (100%) and clicking (57%) were the most common symptoms. The compression-rotation test was positive in 84% of the patients before surgery. The average UCLA score at the last follow-up was 32.3 points; 22 cases were graded excellent, 16 good, and 6 poor. Based on the postoperative performance data collected from 33 athletes, 25 of them (76%) were able to return to their athletic activities. Among them, throwing athletes showed statistically better performance than did nonthrowing athletes (P = .011).

CONCLUSIONS

Pain, followed by clicking, was the most common symptom, and the most common sign was a positive compression rotation test. Arthroscopic treatment of unstable isolated SLAP lesions resulted in good or excellent UCLA scores in 86% of the patients. Throwing athletes showed more satisfactory results than nonthrowing athletes.

LEVEL OF EVIDENCE

Type IV, case series with no, or historical, control group.

The resisted supination external rotation test: a new test for the diagnosis of superior labral anterior posterior lesions

PURPOSE

To evaluate a new clinical test, the resisted supination external rotation test, for the diagnosis of superior labral anterior posterior lesions of the shoulder.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Forty athletes (average age, 23.9 years) with activity-related shoulder pain were enrolled in the study. The patients underwent 3 different tests designed specifically to detect superior labral anterior posterior lesions (the resisted supination external rotation test, the crank test, and the active compression test); the tests were performed in a random order on the affected shoulder. The results of the tests were compared with arthroscopic findings.

RESULTS

Out of 40 athletes, 29 (72.5%) had superior labral anterior posterior tears. The resisted supination external rotation test had the highest sensitivity (82.8%), specificity (81.8%), positive predictive value (92.3%), negative predictive value (64.3%), and diagnostic accuracy (82.5%) of all tests performed.

CONCLUSION

By re-creating the peel-back mechanism, the resisted supination external rotation test is more accurate than 2 other commonly used physical examination tests designed to diagnose superior labral anterior posterior tears in overhead-throwing athletes. By using this test in the context of a thorough clinical history and physical examination, lesions of the superior labrum can be more reliably diagnosed.

Incidence Of SLAP Lesions In A Military Population

OBJECTIVES

SLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, biceps traction and compression injuries, and are commonly seen in overhead athletes. Military personnel are physically active and often subjected to trauma. We assessed the incidence of SLAP lesions within a military population presenting with shoulder symptoms.

METHODS

A retrospective review, of all shoulder arthroscopies performed by a single surgeon between June 2003 and December 2004 at a district general hospital serving both a military and civilian population, was undertaken. The presentation and incidence of SLAP lesions were recorded for both military and civilian patients.

RESULTS

One hundred and seventy eight arthroscopies were performed on 70 (39.3%) military and 108 (60.7%) civilian patients. The average age was 42.3 (range 17-75), 50 females and 128 males were included. Indications for arthroscopy included pain (75.3%), instability (15.7%), pain and instability (7.9%), or "other symptoms" (1.1%). 39 SLAP lesions (22%) were found and grouped according to the Snyder classification--20.5% type 1, 69.3% type 2, 5.1% type 3, 5.1% type 4. Patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion (p<0.0001). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p<0.0001). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p<0.001).

CONCLUSIONS

There is a higher than average incidence of SLAP lesions in military patients compared to civilian patients. They tend to present with a history of trauma, as well as symptoms of pain and instability. Given the high incidence in military personnel, this diagnosis should be considered in military patients presenting with shoulder symptoms, and there should be a low threshold for shoulder arthroscopy.

Current concepts in the recognition and treatment of superior labral (SLAP) lesions

Pathology of the superior aspect of the glenoid labrum (SLAP lesion) poses a significant challenge to the rehabilitation specialist due to the complex nature and wide variety of etiological factors associated with these lesions. A thorough clinical evaluation and proper identification of the extent of labral injury is important to determine the most appropriate nonoperative and/or surgical management. Postoperative rehabilitation is based on the specific surgical procedure as well as the extent, location, and mechanism of labral pathology and associated lesions. Emphasis is placed on protecting the healing labrum, while gradually restoring range of motion, strength, and dynamic stability of the glenohumeral joint. The purpose of this paper is to provide an overview of the anatomy and pathomechanics of SLAP lesions and review specific clinical examination techniques used to identify these lesions, including 3 newly described tests. Furthermore, a review of the current surgical management and postoperative rehabilitation guidelines is provided.

An anatomic evaluation of the active compression test

The goal of this study was to describe the anatomic relationships present during the active compression test. Four pairs of cadaveric shoulders were positioned to simulate the active compression test. The shoulders were embedded in polyurethane and evaluated in the axial and coronal planes with a planer. In the axial plane, all internally rotated shoulders demonstrated contact between the lesser tuberosity and subscapularis tendon and the superior aspect of the glenoid and labrum. In the externally rotated position, there was no contact between the superior structures of the shoulder. In the coronal plane, the internally rotated specimens revealed contact between the supraspinatus tendon and the lateral aspect of the acromion. There was no contact between the supraspinatus tendon and the acromion when the shoulders were externally rotated in the coronal plane. The results demonstrate that the active compression test can be used to assist in the diagnosis of superior labrum anterior-posterior lesions as well as other shoulder pathology.

Diagnostic Performance of MR Arthrography in the Assessment of Superior Labral Anteroposterior Lesions of the Shoulder

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior (SLAP) lesions of the shoulder with emphasis on the classification of SLAP lesions.

MATERIALS AND METHODS

Two hundred sixty-five MR arthrograms including 68 MR arthrograms of patients with arthroscopically proven SLAP lesions of the shoulder and 197 MR arthrograms of patients with an intact superior labrum and biceps anchor were retrospectively reviewed in random order. MR arthrography was performed using triplanar T1-weighted spin-echo sequences and a coronal oblique T2-weighted fast spin-echo sequence. MR arthrograms were evaluated by two radiologists with agreement by consensus, and the results were compared with arthroscopic findings.

RESULTS

Of 68 SLAP lesions, seven (10%) were arthroscopically classified as type I, 41 (60%) as type II (including 20 type II lesions with coexisting Bankart lesions [29%]), 14 (21%) as type III, and six (9%) as type IV. Compared with arthroscopy as the gold standard, MR arthrography showed a sensitivity of 82% and a specificity of 98% for the overall detection of SLAP lesions. MR arthrographic grading and arthroscopic grading were concurrent in 45 (66%) of 68 arthroscopic diagnoses. Of the surgically confirmed SLAP lesions, involvement of the biceps insertion and SLAP type II lesions with coexisting Bankart lesions were assessed correctly in 75% and 95% of cases, respectively.

CONCLUSION

MR arthrography is a highly effective method for the detection of SLAP lesions, but this technique is limited in the classification of different types of SLAP lesions. However, for preoperative planning MR arthrography provides accurate information about the stability of the biceps insertion and the presence of associated anteroinferior labral injuries.

A biomechanical comparison of repair techniques for type II SLAP lesions

BACKGROUND

Multiple options exist for repair of superior labral tears.

PURPOSE

To compare commonly used fixation techniques for superior labral tears.

STUDY DESIGN

Biomechanical cadaveric study.

METHODS

A comparison of the initial strengths of fixation for type II superior labral anterior posterior (SLAP) lesions was performed in three cadaveric shoulder groups, each containing seven specimens. Two groups were repaired with screw-in anchors; one group had vertical sutures, the other horizontal. Group 3 was repaired using bioabsorbable tacks. Cyclic traction was applied to the biceps tendon. Repair failure (2 mm of permanent displacement) and ultimate failure were measured.

RESULTS

Specimen stiffness was similar between groups. The mean load to repair failure was 123 +/- 17 N in group 1, 114 +/- 11 N in group 2, and 95 +/- 13 N in group 3. The mean load to ultimate failure was 163 +/- 15 N, 161 +/- 12 N, and 145 +/- 12 N, respectively. Although the repair failure loads of groups 1 and 2 were 29% and 17%, respectively, greater than the tack group, the differences were not statistically significant (P >.05). All ultimate failures occurred at the labral-implant interface.

CONCLUSION

Initial fixation strength of tissue tack and suture anchor repairs of SLAP lesions are comparable.

The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions

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 examination, as well as improved imaging modalities such as magnetic resonance arthrography, are extremely important in understanding the abnormalities, the definitive diagnosis of superior labrum, anterior and posterior lesions is best made through diagnostic arthroscopy. Treatment of these lesions is directed according to its type. In general, type I and III lesions are debrided, whereas type II and many type IV lesions are repaired. The purpose of this article is to review the anatomy, biomechanics, classification, diagnosis, and current treatment recommendations for these lesions, as well as to review the literature.

Anatomy of the superior glenoid rim. Repair of superior labral anterior to posterior tears

BACKGROUND

Successful placement of a fixation device on the superior glenoid rim during superior labrum repairs requires accurate knowledge of the glenoid rim anatomy.

PURPOSE

To investigate the normal bony anatomy of the superior glenoid rim.

STUDY DESIGN

Descriptive anatomic study.

METHODS

Twenty cadaveric glenoid specimens were scanned to obtain cross-sectional images with peripheral quantitative computed tomography in three different positions, each perpendicular to the articular surface. Two straight lines were drawn along the interior bony margins of the articular surface and cortex, and image analysis software was used to calculate the angle between these lines. Three bony angles were measured.

RESULTS

The bony angles from the 10:30-, 12-, and 1:30-o'clock cross-sections were 55 degrees +/- 5 degrees, 64 degrees +/- 5 degrees, and 62 degrees +/- 8 degrees, respectively. The posterosuperior angle (at the 10:30-o'clock position) was statistically significantly lower than the superior and anterosuperior angles. Intraobserver variation was less than 3%.

CONCLUSIONS

The most superior point of the glenoid rim (12-o'clock position) seems to provide the most bone stock for anchor insertion. The available bone support was found to decrease posteriorly on the glenoid rim.

CLINICAL RELEVANCE

During superior labral repairs, the anchor or fixation device should be inserted at approximately a 30 degrees angle in relation to the articular surface for maximal bone support.

Clinical assessment of three common tests for superior labral anterior-posterior lesions

BACKGROUND

Three tests (active compression, anterior slide, and compression rotation) are commonly used to diagnose superior labral anterior-posterior lesions.

HYPOTHESIS

We hypothesized that the accuracy, sensitivity, and specificity for these tests was less than that previously reported and that a click in the shoulder during manipulation was not specific for the study lesion.

STUDY DESIGN

Case-control study.

METHODS

The three tests were performed on 426 patients who subsequently underwent shoulder arthroscopy. The results of physical examination were compared with the arthroscopic findings and analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy.

RESULTS

At arthroscopy, 39 patients had type II to IV lesions (study group); the remaining 387 patients had type I lesion or no lesion (control group). The incidences of positive results were not statistically different between the groups (P > 0.05). Our findings were as follows: most sensitive test, active compression (47%); most specific test, anterior slide (84%); highest positive predictive value, active compression (10%); highest overall accuracy, anterior slide test (77%); lowest overall accuracy, active compression test (54%). The presence of a click and the location of the pain were not reliable diagnostic indicators.

CONCLUSIONS

The results of such tests should be interpreted with caution when considering surgery for a possible superior labral anterior-posterior lesion.

Disorders of the superior labrum: review and treatment guidelines

Advancements in shoulder arthroscopy have led to a better understanding of the anatomy and disorders of the superior labrum biceps tendon anchor complex and the role that lesions of the superior labrum anterior and posterior lesions play in pain and instability of the shoulder. Various injury mechanisms have been suggested and studied and it is likely that different mechanisms produce different types and areas of damage to the superior labrum. Classification systems have been proposed to describe the specific pathoanatomy of lesions of the superior labrum anterior and posterior lesions and to guide treatment. Presenting symptoms often are nonspecific and physical examination maneuvers have varying degrees of sensitivity and specificity making diagnosis challenging. Diagnostic ability is enhanced by the ultimate diagnostic test, arthroscopy. A clear appreciation for the various lesions and the potential resulting joint dysfunction is necessary to determine the appropriate treatment of this complex region of the shoulder. The current authors review the anatomy, classification, presentation, evaluation and treatment results of superior labrum anterior and posterior lesions, and includes novel evaluation methods and treatment guidelines useful in treating these lesions.

Superior labral anterior posterior (SLAP) lesions of the glenoid labrum: reliability and accuracy of MR arthrography for diagnosis

PURPOSE

To determine the reliability and accuracy of magnetic resonance (MR) arthrography for the diagnosis of superior labral anterior posterior (SLAP) tears.

MATERIALS AND METHODS

The MR arthrograms in 80 patients who underwent arthroscopy and MR arthrography during a 54-month period were retrospectively reviewed. MR arthrograms were independently scored by three observers for the presence and type of SLAP lesion. Type I SLAP lesions were regarded as negative as they most often are not clinically relevant. Interobserver agreement for detection of SLAP lesions was calculated by using kappa coefficients. The differences in areas under the receiver operating characteristic (ROC) curves were assessed with a univariate z score test.

RESULTS

At arthroscopy, there were 25 SLAP tears: type II (n = 22), type III (n = 2), and type IV (n = 1). Sensitivity, specificity, and accuracy of each reader were 92%, 84%, and 86%; 92%, 82%, and 85%; and 84%, 69%, and 74%, respectively. Interobserver agreement for SLAP tears was substantial (kappa = 0.77) to moderate (kappa = 0.52, kappa = 0.44). The areas under the ROC curves for each reader were 0.94, 0.93, and 0.83, which were not significantly different.

CONCLUSION

MR arthrography of the shoulder is reliable and accurate for detection of SLAP tears.