[Superior labrum-biceps anchor complex]

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Magnetic resonance-guided direct shoulder arthrography for the detection of superior labrum anterior-posterior lesions using an open 1.0-T MRI scanner

Purpose

Direct magnetic resonance arthrography (MRA) offers increased diagnostic accuracy compared to conventional magnetic resonance imaging (MRI) in the detection of superior labrum anterior-posterior (SLAP) lesions. The aim of the present study was to present the technique of magnetic resonance-guided direct shoulder arthrography (MDSA), to evaluate the diagnostic value of this novel MRA procedure to detect SLAP lesions in comparison to the currently practiced MRI, and to correlate the radiological findings to the respective arthroscopic findings.

Material and methods

Fifty-six patients with clinical signs of a SLAP lesion underwent both MRI examination and MDSA prior to arthroscopic surgery. The MRI of both interventions were compared with the arthroscopic findings. Statistical analysis was performed using the McNemar test.

Results

Sensitivity, specificity, and accuracy for detecting SLAP lesions were 23%, 88%, and 54% on MRI and 80%, 81%, and 80% on MDSA, respectively. Sensitivity (p < 0.001) and accuracy (p = 0.001) in detection of SLAP lesions were significantly higher by MDSA whereas accuracy showed no significant differences (p = 0.625).

Conclusions

The MDSA can be performed in an open 1.0-T MRI scanner with a high level of technical success and a reasonable methodical effort. The modification of MRA provides the requirements as a practicable routine shoulder magnetic resonance examination including arthrography to detect SLAP lesions. The diagnostic value is significantly better than MRI examinations without included arthrography, which currently predominates the clinical practice to investigate shoulder pathology.

A systematic review and meta-analysis of diagnostic test of MRA versus MRI for detection superior labrum anterior to posterior lesions type II-VII

OBJECTIVE

To determine the diagnostic performance of magnetic resonance arthrography (MRA) and magnetic resonance imaging (MRI) in superior labrum anterior to posterior lesions (type II-VII) of the shoulder.

MATERIAL AND METHODS

PubMed and Scopus search engines, an electronic search of articles was performed from inception to February 19, 2016. Diagnostic performance of index tests was compared by the summary area under receiver operator characteristic curve (AUROC).

RESULTS AND CONCLUSIONS

In all, 117 of 493 studies were eligible and 32 studies (2,013 shoulders) and 11 studies (1,498 shoulders) were evaluated with MRA and MRI. The summary sensitivity, specificity, likelihood ratio (positive and negative) and AUROC were 0.87 (95 % confidence interval, CI: 0.82, 0.91), 0.92 (95 %CI: 0.85, 0.95), 10.28 (95 %CI: 5.84, 18.08), 0.14 (95 %CI: 0.10, 0.20) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRA, and 0.76 (95 %CI: 0.61, 0.86), 0.87 (95 %CI: 0.71, 0.95), 5.89 (95 %CI: 2.5, 13.86), 0.28 (95 %CI: 0.17, 0.47) and 0.94 (95 %CI: 0.92, 0.96) respectively for MRI. The diagnostic performance of MRA was superior to MRI by both direct and indirect comparisons for the detection of SLAP lesions.

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

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

Increased glenohumeral translation and biceps load after SLAP lesions with potential influence on glenohumeral chondral lesions: a biomechanical study on human cadavers

PURPOSE

The aim of the study was to evaluate the stabilizing function of the long head of biceps tendon (LHB) and its tension, both without and with the presence of SLAP lesion to analyze a potentially occurring humeral chondral print of LHB with consecutive glenohumeral chondral lesions in SLAP lesions.

METHODS

Testings were performed on 21 fresh frozen human cadaver shoulders with intact shoulder girdle by a 5 axis industrial robot with a force/moment sensor and 20 N joint compression, 50 N force in anterior, posterior, anterosuperior, and anteroinferior direction, and 0°, 30°, 60° of abduction. LHB was connected over a force measuring sensor with 5 N and 25 N preload. A type IIC SLAP lesion was created arthroscopically.

RESULTS

A significant increase in anterior and anteroinferior translation was evaluated, whereas the LHB tension increased significantly in at most anterior and anterosuperior direction. The highest increase in translation and LHB tension after SLAP lesion was measured in anterior translation in at most 60° of abduction. The glenohumeral translation was significantly higher in SLAP lesions without LHB tenotomy than after isolated LHB tenotomy.

CONCLUSIONS

SLAP lesions lead to increased glenohumeral translation and concurrently LHB tension and load in at most anterior direction. The increased anterior glenohumeral instability and the increased LHB load pressing on the humeral head might cause glenohumeral chondral lesions with a typical chondral print-like lesion on the humeral head underneath the LHB.

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.

Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon

Lesions of the long head biceps tendon (LHB) are frequent causes of shoulder pain and disability. Biceps tenotomy and tenodesis have gained widespread acceptance as effective procedures to manage both isolated LHB pathology and combined lesions of the rotator cuff and biceps-labral complex. The function of the LHB tendon and its role in glenohumeral kinematics presently remain only partially understood because of the difficulty of cadaveric and in vivo biomechanical studies. The purpose of this article is to offer an up-to-date review of the anatomy and biomechanical properties of the LHB and to provide an evidence-based approach to current treatment strategies for LHB disorders.

Influence of SLAP lesions on chondral lesions of the glenohumeral joint

From 2004 to 2008 we evaluated 431 SLAP lesions during 3,395 shoulder arthroscopies and compared two groups of patients, one with SLAP lesion as group I and one without SLAP lesions as group II. Exclusion of type I SLAP lesions, rotator cuff tears and history of dislocation of the shoulder in both groups left 182 cases in group I, and additionally, exclusion of all-type SLAP lesions left 251 patients in group II. In group I, SLAP lesion-associated chondral lesions were present in 20% at the humerus (4% group II, p = 0.005), 18% at the glenoid (5% in group II, p = 0.05) and 14% glenohumeral (3% group II, p = 0.04). We observed a pattern of typical localization of SLAP-associated chondral lesions at the humerus underneath the biceps tendon (78%) and at the anterior half of the glenoid (63%) in group I in contrast to the central region of the humerus (82%) and the central region at the glenoid (55%) in group II. The association of SLAP and chondral lesions was not influenced by the presence of trauma or age of the patients. SLAP lesions seem to be a risk factor for subsequent early onset of osteoarthritis either caused by a bicipital chondral print or glenohumeral instability or a combination of both.

Arthroscopic rotator cuff repair in overhead-throwing athletes

BACKGROUND

When overhead-throwing athletes suffer from a rotator cuff tear, their ability to perform sporting activities is significantly impaired.

HYPOTHESIS

Arthroscopic rotator cuff repair allows amateur overhead-throwing athletes to return to their preoperative level of overhead-throwing sports.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-one overhead-throwing athletes (14 male and 7 female; average age, 58.9 years, range, 46-69 years) were reviewed for clinical outcome with the Constant Score and structural integrity of the repair on magnetic resonance imaging. The average follow-up was 25.7 months (24-29 months). Athletes were asked to retrospectively assess their sporting activity for pain, strength, endurance, and range of motion before onset of symptoms, preoperatively and at follow-up. They also were asked to evaluate their overall performance as a percentage of their original performance (0% to 100%). Retear rates and Constant Scores were compared with those of 32 patients who were not overhead-throwing athletes and who were operated on during the same time span.

RESULTS

Patients significantly improved their Constant Score from 54.9 to 84.2 (P < .001). Sporting activity was not significantly influenced by repair integrity; the retear rate was 23.8% (5/21). There was no significant difference for retear rate (25%; 8/32) or clinical outcome (Constant Score 84.5, P = .993) compared with patients who were not involved in overhead-throwing sports or any sports. All patients returned to their overhead-throwing sport an average of 6.3 months (3-12 months) after the surgery. Participation (2.1 per week) and duration (2.3 hours) of overhead-throwing activity postoperatively were not significantly lower than before the patient was injured (2.2 per week, P = .290; and 2.4 hours, P = .285). Patients estimated their overall activity level to be 91.9% of their original, noninjured condition, which was significantly improved from the preoperative condition of 34.8% (P < .001).

CONCLUSION

Arthroscopic rotator cuff repair led to good clinical results in this group of overhead-throwing athletes. Patients were able to return to overhead-throwing sports, most of them at the same preoperative level.

Posterosuperior suture granuloma impingement after arthroscopic SLAP repair using suture anchors: a case report

Arthroscopic refixation of the glenoid labrum has become a standard treatment of type II SLAP lesions although postoperative results are not uniformly good due to factors which are yet unclear. We present the case of an active overhead athlete with an intraarticular posterosuperior impingement syndrome arising from a suture granuloma formation complicating the postoperative course after arthroscopic SLAP repair. The symptoms resolved completely following revision arthroscopy during which the granuloma and the permanent sutures were removed. Implant related complications should be considered when patients present with recurrent pain after arthroscopic SLAP repair using suture anchors, in particular during overhead activity.