Sports activity after arthroscopic superior labral repair using suture anchors in overhead-throwing athletes

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.

An anatomical investigation of clock face landmarks around the glenoid for shoulder arthroscopy orientation

BACKGROUND

For shoulder arthroscopy, few anatomical landmarks are available and inexperienced surgeons tend to be adrift due to the limited visual field of the scope. The purpose of this study was to demonstrate the useful landmarks around the glenoid for accurate orientation, and also the safe distance to avoid suprascapular nerve injury during surgical procedures around the glenoid.

METHODS

In 15 human solution-fixed cadavers, a cross-section of the shoulder joint on the labrum surface was created. The positions of the principal anatomical structures surrounding the glenoid were marked on the labrum and measured using our clock face indication system. In 9 shoulders the distances from the labral surface to the spinoglenoid notch were recorded. As an indicator of the scapula size, the distances between the superior and inferior angles of the scapula were also measured.

RESULTS

The average landmark positions in the right shoulder were as follows: center of the attachment of the long tendon 11:59, anterior edge of the supraspinatus 11:59, posterior edge of the base of the coracoid process 12:13, superior edge of the subscapularis 1:03, anterior edge of the base of the coracoid process 1:25, inferior edge of the subscapularis 5:27, inferior edge of the teres minor 6:21, border of the infraspinatus and teres minor 7:43, center of the scapula spine 10:06, border of the supra and infraspinatus 10:27. The average distance from the labral surface to the spinoglenoid notch was 23.17 mm, and that from the superior to inferior angle was 144.93 mm. The Pearson correlation coefficient for these distances was 0.007.

CONCLUSIONS

The locations of anatomical landmarks surrounding the glenoid were reliably demonstrated using our clock face indication system. The expected distance from the labral surface to the suprascapular nerve was approximately 23 mm, irrespective of the size of the scapula.

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.

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.

SLAP lesions: a treatment algorithm

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors' clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from "true" SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.

Slap Lesions in Middle-aged Patients: Biceps Repair or Tenodesis? What Should We Perform for Long Biceps Tendon?

Background/Purpose

Superior labrum anterior and posterior (SLAP) lesion repair poses a significant discussion due to its high failure rate. The purpose of this study was to determine in which indications it is better to perform a tenodesis than a straight anatomical repair. The hypothesis was that in middle-aged patients and in those who did not suffer from a traumatic lesion, it is better to perform a long biceps tendon (LBT) tenodesis than a straight anatomical repair.

Methods

A total of 22 patients between the ages of 19 years and 55 years who underwent SLAP lesion repair between 2007 and 2011 were reviewed. The cases were divided into the following two groups: those with an isolated SLAP lesion (15 patients) and those with both a SLAP and a Bankart lesion (7 patients). This was a level IV longitudinal and retrospective study.

Results

Eight patients had persistent postoperative pain, which required to be revised from an anatomical repair to an LBT tenodesis. All of these patients were in the isolated SLAP lesion group. The average time between primary surgery and revision was 21.6 months. Patients over the age of 45 years had significantly poorer results after the repair.

Conclusion

Biceps tenodesis is a feasible therapeutic alternative to anatomical repair for the treatment of SLAP lesions in middle-aged patients; the reinsertion failure rates for this type of lesion are rather discouraging due to the high percentage of revision surgeries that must be carried out after the primary intervention.

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.

TRANSLATION TO PORTUGUESE LANGUAGE AND CROSS-CULTURAL ADAPTATION OF THE MODIFIED ROWE SCORE FOR OVERHEAD ATHLETES

Objetctive: Study was to translate and culturally adapt the modified Rowe score for overhead athletes.

METHODS

The translation and cultural adaptation process initially involved the stages of translation, synthesis, back-translation, and revision by the Translation Group. It was than created the pre-final version of the questionnaire, being the areas "function" and "pain" applied to 20 athletes that perform overhead movements and that suffered SLAP lesions in the dominant shoulder and the areas "active compression test and anterior apprehension test" and "motion" were applied to 15 health professionals.

RESULTS

During the translation process there were made little modifications in the questionnaire in order to adapt it to Brazilian culture, without changing the semantics and the idiomatic concept originally described.

CONCLUSION

The questionnaire was easily understood by the subjects of the study, being possible to obtain the Brazilian version of the modified Rowe score for overhead athletes that underwent surgical treatment of the SLAP lesion.

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.

Superior Labrum Anterior Posterior Lesions and Associated Injuries: Return to Play in Elite Athletes

Background:

Superior labrum anterior posterior (SLAP) lesions often cause shoulder pain, dysfunction, and instability. Professional athletes require a high level of shoulder function for competition and overhead activities.

Purpose:

To evaluate elite athletes who had arthroscopic surgery for common shoulder pathologies and SLAP lesions with a follow-up of more than 3 years. The associated intra-articular pathologies and return to play were documented.

Study Design:

Case series; Level of evidence, 4.

Methods:

Thirty-five shoulders in 34 elite athletes (4 women and 30 men; mean age, 25 years [range, 18-32 years]) had arthroscopic repair of SLAP lesions and accompanying Bankart or rotator cuff tears between January 2008 and November 2011. The documentation included patient symptoms, physical examination, radiological analysis with radiographs, and magnetic resonance imaging. Shoulder function was evaluated preoperatively and at follow-up using American Shoulder and Elbow Surgeons (ASES) and Kerlan Jobe Orthopaedic Clinic (KJOC) scores. The mean follow-up was 52 months.

Results:

Isolated SLAP lesions were seen in 17.1% of patients, SLAP lesions and partial cuff tear occurred in 25.7%, associated Bankart lesions in 37.1%, full-thickness rotator cuff tears in 8.6%, Bankart and posterior labrum lesions in 8.6%, and Bankart and full-thickness rotator cuff tears in 2.9%. Return to play was a mean 6.4 ± 1.5 months. The mean postoperative ASES and KJOC scores were 89.6 ± 4.6 and 80.9 ± 6.8, respectively, compared with preoperative scores of 64.0 ± 7.2 and 50.5 ± 10.3 (t test, P < .01).

Conclusion:

The majority (88.2%) of professional athletes returned to their preinjury levels. SLAP lesions may frequently occur with Bankart lesions and rotator cuff tears. A high rate of return to sport at the same level of athletic performance can be achieved by anatomic repair and effective rehabilitation.

Labrum and rotator cuff injuries in the throwing athlete

The large amount of force imparted across the shoulder during the act of throwing makes the glenohumeral joint highly susceptible to injury in the athlete performing overhead throwing motions. The bony incongruity of the shoulder enables greater range of motion than any other joint in the body, but it also results in significant strain on the surrounding soft tissues during the throwing motion. Throwers can present with acute injuries, but more commonly they suffer from chronic overuse conditions resulting from repetitive overload. Proper management requires early recognition with treatment directed toward the athlete's safe return to sports. Failure to institute an appropriate management strategy may result in significant complications, including prolonged disability, progression of symptoms, and further injury. We discuss the functional anatomy, pathophysiology, clinical presentation, evaluation, and treatment of common injuries of the glenoid labrum and rotator cuff in the overhead throwing athlete.

Open subpectoral biceps tenodesis: reliable treatment for all biceps tendon pathology

Long head of the biceps (LHB) tendon pathology is a common cause of pain in the shoulder. Pathology encountered includes biceps tendon tears and tendonitis, biceps anchor or superior labral tears, and biceps subluxation or instability. Current surgical treatment options for LHB disorders include tenotomy and tenodesis. Tenodesis prevents cosmetic deformity and biceps cramping with activity. Open subpectoral tenodesis anatomically restores the length-tension relationship of the biceps muscle and removes all diseased biceps from the bicipital groove. The authors present their technique of open subpectoral tenodesis, which demonstrates a high success rate with consistent pain relief and dependable fixation.

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.

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.

Return to play after treatment of superior labral tears in professional baseball players

BACKGROUND

The published return-to-play (RTP) rates for athletes 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 nonsurgical treatment for this group is unknown.

HYPOTHESIS

Nonsurgical treatment of SLAP tears in professional baseball players leads to RTP before consideration of surgical treatment. Incorporating performance statistics and level of competition will result in lower calculated RTP rates than have been previously reported.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of 119 consecutive patients in a single professional baseball organization with persistent shoulder pain that limited the ability to compete was performed. Sixty-eight patients had magnetic resonance imaging-documented SLAP lesions. All patients had failed 1 attempt at rehabilitation but had continued with supervised physical therapy. Treatment was according to an algorithm focusing on the correction of scapular dyskinesia and posterior capsular contracture with glenohumeral internal rotation deficit (GIRD), followed by pain-free return to throwing. Those who failed 2 cycles of nonsurgical treatment were treated surgically. Success was defined by 2 different standards: (1) RTP, in accordance with previous studies; and (2) a more stringent standard of return to the same level/quality of professional competition (A, AA, AAA, etc) with the incorporation of a return to preinjury individual performance statistics (earned run average, walks plus hits per inning pitched), termed "return to prior performance" (RPP).

RESULTS

Sixty-eight athletes were identified with SLAP lesions. Twenty-one pitchers successfully completed the nonsurgical algorithm and attempted a return. Their RTP rate was 40%, and their RPP rate was 22%. The RTP rate for 27 pitchers who underwent 30 procedures was 48%, and the RPP rate was 7%. For 10 position players treated nonsurgically, the RTP rate was 39%, and the RPP rate was 26%. The RTP rate for 13 position players who underwent 15 procedures was 85%, with an RPP rate of 54%.

CONCLUSION

Nonsurgical treatment correcting scapular dyskinesia and GIRD had a reasonable success rate in professional baseball players with painful shoulders and documented SLAP lesions. The rate of return after surgical treatment of SLAP lesions was low for pitchers. The RTP and RPP rates were higher for position players than for pitchers. Nonsurgical treatment should be considered for professional baseball players with documented SLAP lesions, as it can lead to acceptable RTP and RPP rates.

Role of the superior labrum after biceps tenodesis in glenohumeral stability

BACKGROUND

Little is known about the role that a torn superior labrum (SLAP) plays in glenohumeral stability after biceps tenodesis. This biomechanical study evaluated the contribution of a type II SLAP lesion to glenohumeral translation in the presence of biceps tenodesis. The authors hypothesize that subsequent to biceps tenodesis, a torn superior labrum does not affect glenohumeral stability and therefore does not require anatomic repair in an overhead throwing athlete.

METHODS

Baseline anterior, posterior, and abduction and maximal external rotation glenohumeral translation data were collected from 20 cadaveric shoulders. Translation testing was repeated after the creation of anterior (n = 10) and posterior (n = 10) type II SLAP lesions. Translation re-evaluation after biceps tenodesis was performed for each specimen. Finally, anatomic SLAP lesion repair and testing were performed.

RESULTS

Anterior and posterior SLAP lesions led to significant increases in glenohumeral translation in all directions (P < .0125). Biceps tenodesis showed no significance in stability compared with SLAP alone (P > .0125). Arthroscopic repair of anterior SLAP lesions did not restore anterior translation compared with the baseline state (P = .0011) but did restore posterior (P = .823) and abduction and maximal external rotation (P = .806) translations. Repair of posterior SLAP lesions demonstrated no statistical difference compared with the baseline state (P > .0125).

CONCLUSIONS

With no detrimental effect on glenohumeral stability in the presence of a SLAP lesion, biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears. However, biceps tenodesis should be considered with caution as the primary treatment of SLAP lesions in overhead throwing athletes secondary to its inability to completely restore translational stability.

Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years

This study compared arthroscopic biceps tenodesis with biceps repair for isolated type II superior labrum anterior and posterior (SLAP) lesions in patients older than 35 years. The authors identified isolated type II SLAP lesions that were surgically managed over a 5-year period. Minimum 2-year follow-up data were available for 22 patients who underwent biceps repair (repair group) and for 15 patients who underwent a primary biceps tenodesis (tenodesis group). Mean age at surgery was 45.2±5.5 years in the repair group and 52.0±8.0 years in the tenodesis group. In the repair group, functional outcome improved from baseline to final follow-up using the American Shoulder and Elbow Surgeons (ASES) (47.5 to 87.4, respectively; P<.0001) and University of California, Los Angeles (UCLA) scores (18.5 to 31.2, respectively; P<.0001). In the tenodesis group, similar findings were observed for the ASES (43.4 to 89.9, respectively; P<.0001) and UCLA scores (19.0 to 32.7, respectively; P<.0001). No difference was found in functional outcome between the groups. Full range of motion recovery was delayed by approximately 3 months in the repair group compared with the tenodesis group (P=.0631). Two patients in the repair group required a secondary capsular release. Seventy-seven percent of patients in the repair group and 100% of patients in the tenodesis group were satisfied and returned to normal activity (P=.0673). In the current study, individuals older than 35 years with an isolated type II SLAP lesion had a shorter postoperative recovery, a more predictable functional outcome, and a higher rate of satisfaction and return to activity with a biceps tenodesis compared with a biceps repair. Based on these observations, biceps tenodesis is preferable to biceps repair for isolated type II SLAP lesions in nonoverhead athletes older than 35 years.

Disorders of the proximal and distal aspects of the biceps muscle

PROXIMAL ASPECT OF BICEPS: Tenodesis of the long head of the biceps may offer improved cosmesis, improved strength, and diminished activity-related pain compared with tenotomy, although comparative studies have shown similar outcomes in some patient populations. DISTAL ASPECT OF BICEPS: Operative treatment of both partial and complete distal biceps ruptures results in better outcomes compared with nonoperative care, although the optimal technique and fixation are yet to be determined. Nonoperative management is an acceptable treatment for patients willing to accept some loss of forearm supination and elbow flexion strength as well as changes in endurance and cosmesis.

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.

Retrospective analysis of arthroscopic superior labrum anterior to posterior repair: prognostic factors associated with failure

Background. The purpose of this study was to report on any prognostic factors that had a significant effect on clinical outcomes following arthroscopic Type II SLAP repairs. Methods. Consecutive patients who underwent arthroscopic Type II SLAP repair were retrospectively identified and invited to return for follow-up examination and questionnaire. Statistical analysis was performed to determine associations between potential prognostic factors and failure of SLAP repair as defined by ASES of less than 50 and/or revision surgery. Results. Sixty-two patients with an average age of 36 ± 13 years met the study criteria with a mean followup of 3.3 years. There were statistically significant improvements in mean ASES score, forward elevation, and external rotation among patients. Significant associations were identified between ASES score less than 50 and age greater than 40 years; alcohol/tobacco use; coexisting diabetes; pain in the bicipital groove on examination; positive O'Brien's, Speed's, and/or Yergason's tests; and high levels of lifting required at work. There was a significant improvement in ASES at final followup. Conclusions. Patients younger than 20 and overhead throwers had significant associations with cases requiring revision surgery. The results from this study may be used to assist in patient selection for SLAP surgery.

Suture anchors or transglenoidal sutures for arthroscopic repair of isolated SLAP-2 lesions? A matched-pair comparison of functional outcome and return to sports

PURPOSE

Presumably, the technique of SLAP refixation has significant influence on outcome. This study analyzes and compares functional outcome and return to sports after arthroscopic suture anchor (SA) and arthroscopic transglenoidal suture (TS) repair of isolated SLAP-2 lesions.

METHODS

Twenty-four competitive amateur athletes constituted the two treatment groups of this retrospective matched-pair analysis. In the SA group (n = 12), the mean age was 39.1 years (±12.0) and the mean follow-up period was 4.0 years (±0.6). In the TS group (n = 12), the mean age was 33.8 years (±12.0) and the mean follow-up period was 3.7 years (±0.9). The minimum follow-up period was 2.0 years. Primary outcome measures were the absolute constant-score (CS), the subjective shoulder value (SSV) as well as the ability to return to sports.

RESULTS

The mean CS in the SA group was 91.6 (±5.5) compared to 81.3 (±15.5) in the TS group (p = 0.04). The mean SSV after SA repair was 96.9 (±4.6) compared to 80.0 (±20.8) after TS repair (p = 0.01). Both scores showed significantly higher standard deviations within the TS group (p < 0.05). Twelve of eighteen patients (67 %) were able to return to their overhead sports without restrictions (5/9 in the SA group and 7/9 in the TS group; p > 0.05). Fourteen of twenty-four patients (58 %) achieved their preinjury sports levels (8/12 in the SA group and 6/12 in the TS group; p > 0.05).

CONCLUSIONS

Superior objective and subjective shoulder function was obtained following arthroscopic SA repair compared to arthroscopic TS repair of isolated SLAP-2 lesions. In addition, results of SA repair were more predictable. However, nearly half of the athletes did not achieve full return to sports regardless of the applied technique of refixation.

The effect on external rotation of an anchor placed anterior to the biceps in type 2 SLAP repairs in a cadaveric throwing model

PURPOSE

This study examined whether there is a difference in external rotation (ER) between type 2 SLAP repairs consisting of anchors placed only posterior to the biceps insertion compared with repairs with an additional anchor placed anterior to the biceps.

METHODS

Seven cadaveric shoulders from donors with a mean age of 39.4 years were tested. Type 2 SLAP lesions were created, followed by a 3-anchor repair: a standard repair with 2 anchors posterior to the biceps plus an additional anchor anterior to the biceps. The specimens were placed on a material testing system machine and rotation was measured under a constant torque. The sutures were then removed sequentially from anterior to posterior during testing.

RESULTS

The average ER of the intact shoulder was 115.7° ± 2.6°. After SLAP tear creation and cyclic loading, the ER was 118.5° ± 2.6°, which decreased to 116.5° ± 2.6° after repair. This corresponds to a reduction of 2.0° of ER (P < .0001) with the repair. After release of the anterior anchor, the ER increased to 117.9° ± 2.6°, which corresponds to an increase in shoulder motion of 1.4° of ER (P = .0011). Additional release of the middle anchor, leaving only the posterior anchor intact, resulted in 118.0° ± 2.7° of ER, which corresponds to an increase of only 0.1° of ER (P = .7667).

CONCLUSIONS

Following type 2 SLAP repair in the cadaveric shoulder, removing the effect of the anchor anterior to the biceps resulted in a small but statistically significant increase in ER. The anterior anchor had the greatest effect on ER. The presence of 1 or 2 anchors posterior to the biceps did not have a significant effect on rotation.

CLINICAL RELEVANCE

When performing SLAP repairs on those in whom even a small loss of ER would be detrimental, such as baseball pitchers, avoidance of the use of an anchor anterior to the biceps should be considered.

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.

Return to high-level throwing after combination infraspinatus repair, SLAP repair, and release of glenohumeral internal rotation deficit

BACKGROUND

The overhead-throwing athlete is a unique patient, requiring an elite, precise functional ability. Superior labral tears are quite common, and the percentage of athletes who return to play after superior labrum anterior-posterior (SLAP) repair has been variable. A tear of the infraspinatus caused by either internal impingement or tension overload may compromise this return.

HYPOTHESIS

The rate of return to a level of play similar to or greater than the preinjury level after repair of combined SLAP and infraspinatus injuries will be lower than in previous reports of SLAP repair alone.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In the current study, we examined a series of overhead-throwing athletes with diagnoses of both a SLAP tear and a significant (>50%) tear of the infraspinatus tendon who underwent surgical repair of both injuries. We identified 17 high-level baseball players younger than 25 years who underwent simultaneous arthroscopic repairs of a SLAP tear with a standard suture anchor technique and of an infraspinatus tear with either a free polydioxanone (PDS) suture or suture anchor between 2005 and 2008. The postoperative records of all patients were reviewed to determine their ability to return to play and their postoperative level of performance. All patients were then contacted to determine their Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow score and their current sport participation level.

RESULTS

All 17 patients in the series attempted to return to their prior sport after completion of postoperative rehabilitation. Only 6 patients (35%) were able to return to the same or a superior preinjury level of performance. Five of the remaining 11 patients returned to play at a lower level, either playing the same position or else forced to switch to another position of play because of a decline in throwing velocity. Six patients were unable to return to play. No complications or reoperations occurred in any of the patients following surgery.

CONCLUSION

A significant (>50%) tear of the infraspinatus in combination with glenohumeral internal rotation deficit (GIRD) and SLAP tears in the throwing athlete results in a guarded prognosis in return to play at the same level. While the rates of return to play in overhead-throwing athletes with an isolated SLAP tear have historically been encouraging, the prognosis for an athlete with both a SLAP and infraspinatus tear is more guarded. These patients are not likely to return to their preinjury level of play.

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.

Rotator cuff injury as a complication of portal placement for superior labrum anterior-posterior repair

BACKGROUND

An accessory trans-rotator cuff portal is commonly used in shoulder arthroscopy, primarily in the repair of SLAP (superior labrum anterior-posterior) lesions. Improper placement of the trans-rotator cuff portal can result in damage to the rotator cuff near its attachment site.

METHODS

Six patients were studied, having been referred to our clinic after previous shoulder arthroscopy with SLAP repair. Review of operative notes showed that the rotator cuff had been described as normal in 5 patients and having a mild partial-thickness tear of the supraspinatus in 1 patient at the time of the first surgery. All patients underwent repeat shoulder arthroscopy within 10 to 22 months.

RESULTS

All 6 patients were found to have full-thickness rotator cuff tears at the time of the second surgery. The rotator cuff injuries appeared to be associated with portal placement from the previous SLAP repair. All patients underwent rotator cuff repair, and 3 had concomitant revision SLAP repair. All patients had clinical improvement, with a mean preoperative American Shoulder and Elbow Surgeons score of 45.3 and mean postoperative score of 90.5. Mean follow-up was 58.3 months.

CONCLUSIONS

Proper placement of a trans-rotator cuff portal should be performed cautiously, traversing the rotator cuff medial to the muscle-tendon junction. This report highlights the potential for injury to the rotator cuff tendons with improper placement of this portal. In patients with persistent pain after previous SLAP repair with a trans-rotator cuff portal technique, rotator cuff injury may be the source of symptoms. Revision surgery with rotator cuff repair can provide improvement.

Return to sports for professional baseball players after surgery of the shoulder or elbow

Background:

The purpose of this study was to assess major and minor league baseball players’ return to professional baseball at a preinjury level or higher after surgery of the shoulder or elbow.

Hypothesis:

The majority of athletes will be able to return to their preinjury level after surgery.

Study Design:

Case series.

Methods:

Over a 4-season period, prospective injury and surgery records were reviewed for one professional baseball club. Forty-four players underwent 51 procedures (28 shoulder and 23 elbow) by multiple experienced surgeons; 7 players underwent more than 1 procedure.

Results:

Twenty-eight shoulder surgeries were performed on 27 players: 19 pitchers and 8 position players. The majority of the procedures were labral repairs (n = 21). Nine players returned to their preoperative level; 2 advanced to a higher level; 5 returned to a lower level; and 11 retired from professional baseball. Only 2 of the 12 players at the high professional level (Major League Baseball, triple-A, double-A) returned to the same level. Twenty-three elbow surgeries were performed on 21 players (20 pitchers). The majority of the procedures were ulnar collateral ligament reconstructions (n = 12). Seven players returned to their preoperative level; 4 advanced to a higher level; 4 returned to a lower level; and 6 retired from professional baseball. Of the 12 players at the high professional level, 3 returned to the same or higher level.

Conclusion:

Following surgery, 21 of 44 players (48%) returned to the same or higher level of professional baseball. For those players performing at a high professional level, 5 of 22 (23%) returned to the same or higher level. Return to the same or higher level was more likely with elbow surgery than with shoulder surgery.

Clinical Relevance:

Elite throwing athletes may not return to the same level at a high rate following shoulder or elbow surgery.

Return to play after Type II superior labral anterior-posterior lesion repairs in athletes: a systematic review

BACKGROUND

Superior labral anterior-posterior (SLAP) lesions are a common cause of pain and disability in athletes. Individual studies have suggested low patient satisfaction with SLAP repairs in throwing athletes in particular and it is unclear how frequently athletes return to their previous level of competetion.

QUESTIONS/PURPOSES

We systematically reviewed the literature to determine (1) patient satisfaction and (2) return to play at previous level of competition among throwing athletes compared to all athletes who underwent repair of Type II SLAP tears using various types of fixation.

METHODS

We searched databases for English-language articles in peer-reviewed journals from 1950 to 2010 reporting Type II SLAP repairs with 2-year followup for our systematic review. A total of 506 patients with Type II SLAP tears were reviewed from 14 studies; of these, 327 had SLAP lesions repaired by anchor, 169 by tacks, and 10 by staples. Of the 506 patients, 198 were overhead athletes with a pooled subset of 81 identified baseball players.

RESULTS

For the entire patient population, 83% had "good-to-excellent" patient satisfaction and 73% returned to their previous level of play whereas only 63% of overhead athletes returned to their previous level of play. Anchor repair in overhead athletes resulted in a higher percentage of "good-to-excellent" patient satisfaction (88% versus 74%) and a slightly higher return to play rate (63% versus 57%) compared with tack repair.

CONCLUSIONS

Repair of Type II SLAP tears leads to a return to previous level of play in most patients. Overhead athletes appear to have a lower rate of return to level of previous of play. Anchor fixation appears to be the most favorable fixation in both subjective scores and return to previous level of play.

Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers' compensation status

PURPOSE

The purpose of this study was to determine the long-term functional outcome of anatomic arthroscopic repair of type II SLAP lesions with suture anchors.

METHODS

We examined all arthroscopic repairs of isolated type II SLAP lesions from January 2002 through December 2007. Fifty-five patients were available for long-term follow-up at a mean of 77 months. The mean patient age at the time of surgery was 39.7 years (range, 17 to 65 years); 23 patients were aged younger than 40 years, and 32 patients were aged 40 years or older. Fourteen cases involved Workers' Compensation claims.

RESULTS

Overall, functional outcome was improved from baseline compared with final follow-up for both American Shoulder and Elbow Surgeons scores (44.1 points v 86.2 points, P < .001) and University of California, Los Angeles scores (19.1 points v 31.2 points, P < .001). According to the University of California, Los Angeles grading system, 87% of cases had good or excellent results. Although the percentage of good and excellent results among patients aged 40 years or older (81%) was lower than that among patients aged younger than 40 years (97%), this difference did not reach statistical significance (P = .219). The percentage of good and excellent results among the non-Workers' Compensation cases (95%) was significantly higher than that in Workers' Compensation cases (65%) (P = .009). Overall, patient satisfaction was reported in 91% of cases, and return to normal sport or activity was reported in 82% of cases.

CONCLUSIONS

In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions with the described techniques. Variables associated with a poor outcome include Workers' Compensation cases and possibly older age (≥40 years).

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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.

Outcomes of revision arthroscopic type II superior labral anterior posterior repairs

BACKGROUND

Outcomes of arthroscopic type II superior labral anterior posterior (SLAP) repairs have been reported with success. However, published data regarding outcomes of revision arthroscopic type II SLAP repairs are lacking.

HYPOTHESIS

Outcomes of revision arthroscopic type II SLAP repairs are inferior to those of primary repairs.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective chart review was performed to identify patients who had undergone revision arthroscopic type II SLAP repairs at our institution. Patients who underwent concomitant rotator cuff repairs or labral repairs for instability were excluded. Twelve patients were contacted, and the following outcome data were prospectively gathered: American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction level, return to work, return to sports, and physical examination. Demographics and intraoperative report data were also collected from the charts.

RESULTS

The mean age at the time of revision arthroscopic type II SLAP repairs was 32.6 years (range, 19-67 years) with a mean follow-up of 50.5 months (range, 8-81 months). There were 5 workers' compensation patients and 6 overhead athletes. Pain was the chief complaint at the time of initial and revision SLAP repairs. The mean ASES score was 72.5, patient satisfaction level was 6.4 (scale of 0-10), mean return to work was at 57.8% of the previous level, and mean return to sports was at 42.2% of the previous level. In overhead athletes, mean return to sports was at 41.3% of the previous level, and none of the 4 baseball players returned to preinjury level. The mean values for all outcome data and range of motion values were lower in workers' compensation patients. There were no reported complications, but 2 patients required additional arthroscopic surgeries.

CONCLUSION

Arthroscopic revision type II SLAP repairs yield worse results than primary repairs as reported in the literature, with workers' compensation patients and overhead athletes doing especially worse. A larger prospective study of this relatively rare procedure is needed to better determine which patients may benefit from this procedure.

Superior labral anterior-posterior lesions in rock climbers—primary double tenodesis?

OBJECTIVE

Shoulder problems, especially SLAP (superior labral anterior-posterior) lesions, are frequent in rock climbers. Although various SLAP repair methods demonstrate 75% to 97% good functional outcomes in general population, the results in overhead athletes are inconsistent and the question whether a primary tenodesis is more efficient arises.

DESIGN

Prospective cohort study.

SETTING

The patients were treated as inpatient surgical patients, and the follow-up was performed after 6 months and 2 years.

PATIENTS

Six high-level rock climbers with SLAP lesions and degeneration of the long biceps tendon anchor or additional pulley lesions were surgically treated with primary tenodesis.

INTERVENTIONS

Primary tenodesis was performed for SLAP lesions in high-level climbers.

MAIN OUTCOME MEASURES

The postoperative outcome was assessed through physical examination after 6 months and 2 years, Constant-Murley score, re-establishment of initial climbing ability level, and self-perception of the function of the shoulder and climbing ability.

RESULTS

All climbers regained their initial climbing level after 6 months. The Constant-Murley score (mean, 97.3%) showed an excellent functional outcome. The self-perception of the shoulder function and climbing ability was 96.8% of normal.

CONCLUSIONS

The primary biceps tenodesis is proved to be a reliable alternative to arthroscopic SLAP repair in overhead athletes, especially if constant microtrauma persists.

Humeral head abrasion: an association with failed superior labrum anterior posterior repairs

HYPOTHESIS

An abrasion on the humeral head under the articulating portion of the biceps tendon has been observed in patients with pain and stiffness after superior labrum anterior posterior (SLAP) repair. This study examined this humeral head abrasion (HHA) and its association with various diagnoses involving pathology of the biceps-labral complex. We hypothesized that it would be more common in failed SLAP repairs than other diagnoses.

MATERIALS AND METHODS

A retrospective chart review was performed of 253 patients who underwent shoulder arthroscopy by a single surgeon during a 5-year period. Postoperative diagnoses were used to confirm one of the following diagnoses: failed SLAP repair, biceps tendonitis, SLAP lesion with biceps tendonitis, and isolated SLAP lesion. Operative reports and surgical images were analyzed to identify the presence or absence of HHA. Demographic data, including age, sex, handedness, and onset of injury, were also collected. The frequency of this lesion among the different diagnoses and patient characteristics was compared by χ² analysis.

RESULTS

HHA was observed in 13 of 18 patients (72.2%) with failed SLAP repairs, in 8 of 18 (44.4%) with biceps tendonitis, in 11 of 20 (55%) with SLAP lesion and biceps tendonitis, and in 1 of 71 (1.4%) with isolated SLAP lesions, significantly differing in frequency by diagnosis (P < .001). Patients with HHA were an older median age than those without (48 vs 40; P = .004).

DISCUSSION

HHA is common in patients with a pathologic biceps-labral complex, especially those with failed SLAP repair. We speculate that this lesion is due to inflammation of the biceps tendon resulting in increased biceps-humeral head contact pressure.

Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears

BACKGROUND

There are conflicting reports in the literature regarding the outcome of superior labral anterior posterior (SLAP) repairs in overhead athletes and a paucity of data demonstrating ability to return to prior level of competition.

HYPOTHESIS

Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score provides more accurate assessment of shoulder function and ability to return to previous level of athletic competition after SLAP lesion repair than does the conventional American Shoulder and Elbow Surgeons scoring system.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-three elite (collegiate or professional) overhead athletes who were more than 1-year status postarthroscopic repair of type II SLAP lesions were evaluated using both the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score and American Shoulder and Elbow Surgeons score. P values were computed using the analysis of variance model. Postoperative American Shoulder and Elbow Surgeons and Kerlan-Jobe Orthopaedic Clinic scores from subjects were compared with control values obtained from a healthy athletic cohort; the relationship between the scores was investigated using the linear regression model and assessed using Pearson correlations.

RESULTS

At a mean 38-month follow-up, 13 athletes were playing pain free at the time of the questionnaire administration, 6 were playing with pain, and 4 were not playing because of pain. Regarding American Shoulder and Elbow Surgeons scores, 22 athletes (96%) had good-excellent scores, whereas 1 (4%) had a fair score. The Kerlan-Jobe Orthopaedic Clinic scores revealed 9 excellent (39%), 3 good (13%), 4 fair (17%), and 7 poor (30%) results for the same study group. Of the 23 patients, 13 (57%) had returned to their pain-free preinjury levels of competition at final follow-up. The inability to return to this level of competition correlated with the presence of a partial-thickness rotator cuff tear (P = .0059). The Kerlan-Jobe Orthopaedic Clinic demonstrated better overall accuracy (85%) than did the American Shoulder and Elbow Surgeons (70%) in evaluating return to pain-free preinjury levels.

CONCLUSION

Return to preinjury level of competition for elite overhead athletes after type II SLAP lesion repairs was 57%, despite high American Shoulder and Elbow Surgeons scores. Return to play status correlated with the presence of a partial-thickness rotator cuff tear. The Kerlan-Jobe Orthopaedic Clinic score, designed specifically for the evaluation of the overhead athlete, was a more accurate assessment tool than was the American Shoulder and Elbow Surgeons in this population of elite overhead athletes with SLAP tears.

EVALUATION OF RESULTS AND COMPLICATIONS FROM ARTHROSCOPIC SUTURE OF SLAP LESIONS

Objective: To evaluate the results and complications from arthroscopic suturing of SLAP lesions. Methods: Seventy-one patients who underwent arthroscopic suturing of SLAP lesions between July 1995 and May 2008 were evaluated. The procedures were performed by the Shoulder and Elbow Surgery Group of the Department of Orthopedics and Traumatology, Fernandinho Simonsen Wing, Santa Casa de São Paulo, Brazil. Associated lesions were seen in 68 of the 71 patients evaluated (96%), and the other three (4%) had SLAP lesions alone. Results: The associated lesions most frequently found in the patients under 40 years of age were labral lesions (69%), while in patients aged 40 years or over, impact syndrome with or without rotator cuff injury was the most commonly associated condition (71.4%). According to the UCLA method, 79% of our results (56 cases) were good or excellent. Postoperative complications occurred in 15 cases (21%); among these, the most common was the presence of residual pain (46.6%), followed by adhesive capsulitis (33.3%). Conclusions: There was a great association between SLAP lesions and other shoulder lesions, which varied according to the patients' age groups. Arthroscopic suturing of the SLAP lesions provided excellent results in the majority of the cases, but complications occurred in 21%.

Results of concomitant rotator cuff and SLAP repair are not affected by unhealed SLAP lesion

HYPOTHESIS

To verify the anatomic results of combined repair of a full-thickness rotator cuff tear and superior labral anterior and posterior (SLAP) lesion. In addition, we compared the anatomic and functional outcomes according to the status of the repaired SLAP lesion.

METHODS

We enrolled 61 patients who underwent cuff repair with concomitant SLAP repair and were available for both functional and radiologic outcome evaluation at least 1 year after the operation. There were 40 male and 21 female patients with a mean age of 57.4 years (range, 39-70 years). We measured various clinical outcomes and evaluated the structural outcomes of the rotator cuff and the superior labrum and rotator cuff using computed tomography arthrography at the final follow-up visit. We also evaluated the functional outcome according to anatomic healing of the superior labrum.

RESULTS

Labral healing to the bony glenoid was achieved in 49 patients (80.3%), and anatomic healing of the rotator cuff was observed in 44 patients (72.1%). The retear rate of the rotator cuff was not statistically different with respect to labral healing status. All functional outcomes improved significantly (P < .001), and there were no statistical differences in functional outcome with respect to postoperative healing of the superior labrum.

CONCLUSIONS

An unhealed SLAP lesion did not preclude the successful outcome of concomitant rotator cuff repair. Therefore, repair of a concomitant SLAP lesion may not be an essential procedure for a successful outcome of a rotator cuff repair.

Superior labrum anterior to posterior (SLAP) rehabilitation in the overhead athlete

Due to the complexity of shoulder pathomechanics in the overhead athlete, injuries located in the superior aspect of the glenoid, known as superior labral anterior to posterior (SLAP) lesions, are often a surgical and rehabilitation challenge. In an effort to determine surgical versus conservative care of SLAP lesions a thorough clinical examination and evaluation are necessary. If surgery is identified as the treatment of choice, post operative rehabilitation will vary pending surgical findings including the extent and location of the SLAP lesion, and other concomitant findings and procedures. This manuscript will provide an overview of the pathology, examination and evaluation of SLAP lesions, surgical management and post operative rehabilitation following various SLAP categories.