The trans-rotator cuff approach to SLAP lesions: technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years

Role of hedgehog signaling in the pathogenesis and therapy of heterotopic ossification

Heterotopic ossification (HO) is a pathological process that generates ectopic bone in soft tissues. Hedgehog signaling (Hh signaling) is a signaling pathway that plays an important role in embryonic development and involves three ligands: sonic hedgehog (Shh), Indian hedgehog (Ihh) and desert hedgehog (Dhh). Hh signaling also has an important role in skeletal development. This paper discusses the effects of Hh signaling on the process of HO formation and describes several signaling molecules that are involved in Hh-mediated processes: parathyroid Hormone-Related Protein (PTHrP) and Fkbp10 mediate the expression of Hh during chondrogenesic differentiation. Extracellular signal-regulated kinase (ERK), GNAs and Yes-Associated Protein (YAP) interact with Hh signaling to play a role in osteogenic differentiation. Runt-Related Transcription Factor 2 (Runx2), Mohawk gene (Mkx) and bone morphogenetic protein (BMP) mediate Hh signaling during both chondrogenic and osteogenic differentiation. This paper also discusses possible therapeutic options for HO, lists several Hh inhibitors and explores whether they could serve as emerging targets for the treatment of HO.

Type V superior labrum anterior to posterior repair: a systematic review

BACKGROUND

The purpose of this study is to systematically review the evidence in the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following type V superior labrum anterior to posterior (SLAP) repair.

METHODS

Two independent reviewers performed a literature search based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, utilizing the EMBASE, MEDLINE, and the Cochrane Library Databases. Studies were included if they had clinical outcomes on the patients undergoing type V SLAP repair. Statistical analysis was performed using SPSS (IBM, Armonk, NY, USA). A P value of <.05 was considered to be statistically significant.

RESULTS

Our review found 13 studies, including 451 shoulders meeting our inclusion criteria. The majority of patients were males (89.3%), with an average age of 25.9 years (range 15-58) and a mean follow-up of 53.8 months. The Rowe score was the most utilized functional outcome score, with a weighted mean of 88.5. Additionally, the mean Constant score was 91.0, the mean American Shoulder and Elbow Surgeons score was 88.3, the mean subjective shoulder value score was 85.5%, and the mean visual analog scale pain score was 1.2. The overall rate of return to play was 84.8%, with 80.2% returning to the same level of play. The overall reoperation rate was 6.1%, with a recurrent dislocation rate of 8.2%. In the studies comparing type V SLAP and isolated Bankart repair, there were statistically insignificant differences in visual analog scale pain scores (mean difference; 0.15, 95% confidence interval, -0.13 to 0.44, I2 = 0%, P = .29) and recurrence rates (risk ratio; 1.38, 95% confidence interval, 0.88-2.15, I2 = 0%, P = .16).

CONCLUSION

Arthroscopic repair of type V SLAP tears results in excellent functional outcomes, with high return to play rates in athletes. There are low rates of reoperations and recurrent dislocations. Additionally, in comparison to an isolated Bankart repair, SLAP repair does not increase recurrence rates or postoperative pain.

Return to Sport at Preinjury Level is Common After Surgical Treatment of SLAP Lesions: A Systematic Review and a Meta-analysis

BACKGROUND

Patients undergoing surgery for Superior-Labrum-anterior-to-posterior (SLAP) lesions are often worried about their return to sport performance. This systematic review determined the rate of return to sport and return to sport at the previous level (RTSP) after surgery for SLAP lesion.

MATERIALS AND METHODS

The PRISMA guidelines were followed. Meta-analysis of data through forest plot projections was conducted. Studies were divided and analyzed according to the type of interventions (isolated slap repair or SLAP repair with rotator cuff debridement and biceps tenodesis).

RESULTS

The mean overall rate of return to sport after the procedures was 90.6% and the mean overall rate of return to sport at the previous level after the procedures was 71.7%. RTSP rates of the whole population were 71% (95% CI: 60%-80%), 66% (95% CI: 49%-79%), and 78% (95% CI: 67%-87%) for isolated SLAP repair, SLAP repair with the rotator cuff debridement and biceps tenodesis, respectively. A lack of subgroup analysis for the specific performance demand or type of lesion related to the surgical technique used might induce a high risk of bias.

DISCUSSION

Return to sports at the previous level after surgically treated superior labrum anterior to posterior lesion is possible and highly frequent, with the highest rates of RTSP in patients treated with biceps tenodesis. More studies and better-designed trials are needed to enrich the evidence on indications of SLAP surgical treatment in relation to specific sports-level demand.

LEVEL OF EVIDENCE

Level-IV.

Midterm Outcomes Following Combined Biceps Tenodesis and Anterior Labral Repair in Active Duty Military Patients Younger than 35 Years

BACKGROUND

Superior labrum anterior-posterior (SLAP) lesions and anterior instability are common causes of shoulder pain and dysfunction among active-duty members of the United States military. However, little data have been published regarding the surgical management of type V SLAP lesions.

PURPOSE

To compare the outcomes of arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair with those of arthroscopic SLAP repair (defined as contiguous repair spanning from the superior labrum to the anteroinferior labrum) for type V SLAP tears in active-duty military patients younger than 35 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive patients from January 2010 to December 2015 who underwent arthroscopic SLAP repair or combined biceps tenodesis and anterior labral repair for a type V SLAP lesion with a minimum 5-year follow-up were identified. The decision to perform type V SLAP repair versus combined biceps tenodesis and anterior labral repair was based on the condition of the long head of the biceps tendon (LHBT). Labral repair was performed in patients who had a type V SLAP tear with an otherwise clinically and anatomically healthy LHBT. Combined tenodesis and repair was performed in patients with evidence of LHBT abnormalities. Outcomes including the visual analog scale (VAS) score, the Single Assessment Numeric Evaluation (SANE) score, the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were collected preoperatively and postoperatively, and scores were compared between the groups.

RESULTS

A total of 84 patients met the inclusion criteria for the study. All patients were active-duty service members at the time of surgery. A total of 44 patients underwent arthroscopic type V SLAP repair, and 40 patients underwent anterior labral repair with biceps tenodesis. The mean follow-up was 102.59 ± 20.98 months in the repair group and 94.50 ± 27.11 months in the tenodesis group (P = .1281). There were no significant differences in preoperative range of motion or outcome scores between the groups. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all); however, compared with the repair group, the tenodesis group reported significantly better postoperative VAS (2.52 ± 2.36 vs 1.50 ± 1.91, respectively; P = .0328), SANE (86.82 ± 11.00 vs 93.43 ± 8.81, respectively; P = .0034), and ASES (83.32 ± 15.31 vs 89.90 ± 13.31, respectively; P = .0394) scores. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the SANE and ASES between the groups. Overall, 34 patients in each group returned to preinjury levels of work (77.3% vs 85.0%, respectively; P = .3677), and 32 patients (72.7%) in the repair group and 33 patients (82.5%) in the tenodesis group returned to preinjury levels of sporting activity (P = .2850). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between the groups (P = .0923, P = .1602, and P = .2919, respectively).

CONCLUSION

Both arthroscopic-assisted subpectoral biceps tenodesis combined with anterior labral repair and arthroscopic SLAP repair led to statistically and clinically significant increases in outcome scores, marked improvements in pain, and high rates of return to unrestricted active duty in military patients with type V SLAP lesions. The results of this study suggest that biceps tenodesis combined with anterior labral repair produces comparable outcomes to arthroscopic type V SLAP repair in active-duty military patients younger than 35 years.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

Biceps Tenodesis Versus Superior Labral Anterior and Posterior (SLAP) Lesion Repair for the Treatment of SLAP Lesion in Overhead Athletes: A Systematic Review and Meta-analysis

BACKGROUND

Superior labral anterior and posterior (SLAP) lesions are common injuries in overhead athletes. As a surgical treatment for SLAP lesions, SLAP repair has been traditionally performed. Recently, biceps tenodesis has been performed as an alternative treatment option; however, there is no review for outcome comparisons between these 2 procedures in overhead athletes.

PURPOSE

The aim of this study was to compare the outcomes of SLAP repair versus biceps tenodesis, especially in overhead athletes with SLAP lesions.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

An electronic literature search was performed in Medline, Embase, Scopus, and the Cochrane Library. The studies were appraised using the Methodological Index for Non-randomized Studies (MINORS) tool. Studies that had a minimum follow-up of 2 years, included only patients with SLAP lesions without other major shoulder pathologies, and included only patients who engaged in overhead sports were included. The functional outcomes of the American Shoulder and Elbow Surgeons (ASES) score, rate of return to sport, rate of return to preinjury level of sport, and complication rate were subjected to meta-analysis.

RESULTS

A total of 332 articles were identified, and 13 were included in the systematic review. Even though the postoperative ASES scores were slightly higher in the biceps tenodesis group than in the SLAP repair group, no statistically significant differences were found between the groups (biceps tenodesis, 95% CI = 91.71-96.75, I² = 0.00; SLAP repair, 95% CI = 85.47-94.46, I² = 16.3; P = .085) The rate of return to sport and the return to preinjury level of sport were slightly higher in the biceps tenodesis group than in the SLAP repair group; however, in meta-analysis these factors did not reach statistical significance (return to sport: biceps tenodesis, 95% CI = 0.66-0.91, I² = 0.00; SLAP repair, 95% CI = 0.68-0.93, I² = 70.23; P = .94) (return to preinjury level of sport: biceps tenodesis, 95% CI = 0.61-0.89, I² = 17.78; SLAP repair, 95% CI = 0.53-0.82, I² = 58.07; P = .37). The biceps tenodesis group showed a lower complication rate compared with the SLAP repair group without statistical significance (biceps tenodesis, 95% CI = 0.013-0.145, I² = 0.00; SLAP repair, 95% CI = 0.049-0.143, I² = 0.00; P = .25).

CONCLUSION

The results of biceps tenodesis, compared with SLAP repair, were not inferior in the surgical treatment of overhead athletes with SLAP lesions with regard to the ASES score, rate of return to sport, rate of return to preinjury level of sport, and complication rate. Further high-level, randomized controlled studies are needed to confirm this result.

Trans-Rotator Cuff Approach for Spinoglenoid Cysts: Tips and Traps

In this study, we introduce an arthroscopic technique for posterior-superior capsular fenestration and spinoglenoid cyst resection completely via a trans-rotator cuff approach. This approach can provide a full field of view and allow evaluation of the scope of the cyst under direct vision, which reduces the risk of recurrence and injury to the suprascapular neurovascular bundle.

Biceps Tenodesis Has Greater Expected Value Than Repair for Isolated Type II SLAP Tears: A Meta-analysis and Expected-Value Decision Analysis

PURPOSE

To use an expected-value decision analysis to determine the optimal treatment decision between repair and biceps tenodesis (BT) for an isolated type II SLAP injury.

METHODS

An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. To determine outcome probabilities, a decision tree was constructed (repair vs BT) and a meta-analysis was conducted. To determine outcome utilities, we evaluated 70 patients with a chief complaint of shoulder pain regarding age, sex, Shoulder Activity Level, and visual analog scale score in terms of potential outcome preferences. Statistical fold-back analysis was performed to determine the optimal treatment. One-way sensitivity analysis determined the effect of changing the reinjury rate on the expected value of BT.

RESULTS

The overall expected value was 8.66 for BT versus 7.19 for SLAP repair. One-way sensitivity analysis showed that BT was the superior choice if reinjury rates were expected to be lower than 28%. Meta-analysis of 23 studies and 908 patients revealed that the probability of a "well" outcome was significantly greater for BT (87.8%; 95% confidence interval [CI], 74.9%-94.6%; I² = 0.0%) than for SLAP repair (62.9%; 95% CI, 55.9%-69.3%; I² = 65.9%; P = .0023). The rate of reinjury was 1.5% for BT (95% CI, 0.05%-33.8%; I² = 0.0%) and 6.4% for repair (95% CI, 4.2%-9.6%; I² = 24%), which was not statistically significantly different (P = .411). A total of 50 participants (mean age, 25.4 years [standard deviation, 8.9 years]; 76% male patients; 50% overhead athletes) met the inclusion criteria. Forty-six percent of participants had a high Shoulder Activity Level score.

CONCLUSIONS

Decision analysis showed that BT is preferred over repair for an isolated type II SLAP tear based on greater expected value of BT versus repair. Meta-analysis showed more frequent favorable outcomes with BT. Surgeons can use this information to tailor discussions with patients.

LEVEL OF EVIDENCE

Level IV, meta-analysis of Level I-IV studies.

Is timing of superior labrum anterior to posterior (SLAP) repair important? A cohort study evaluating the effect of the duration of symptoms prior to surgery on the outcomes of patients who underwent type II SLAP repair

Background

The management of superior labrum anterior to posterior (SLAP) tears is somewhat controversial. It is unclear if the length of time between symptom onset and surgery affects SLAP repair outcomes.

Methods

Sixty-one SLAP repairs were retrospectively reviewed pre-operatively and post-operatively at 1, 6, 24 weeks, and > 2 years post-surgery. Patients were allocated to an 'early repair' or 'late repair' group based on time between symptom onset and surgery.

Results

Of the 61 patients, 22 patients had surgery within six months of symptom onset. Pre-operatively, 'late repair' patients played a higher level of sport than 'early repair' patients prior to injury. Post-operatively, both groups had similar outcomes up to six months, though at six months 'early repair' patients reported a higher level of work than 'late repair' patients (p = 0.01). At > 2 years after surgery, 'early repair' patients had reduced pain and difficulty with overhead activities (p = 0.002), less stiffness (p = 0.001) and were more satisfied than 'late repair' patients (p = 0.04).

Conclusions

Up to six months post-operatively, the time between symptom onset and surgery has limited effect on functional outcomes. However, at > 2 years after surgery, earlier repairs ( < 6 months) are interestingly associated with better functional outcomes. Further studies are required to determine if this is a causal relationship.

Biceps Tenodesis Combined With Arthroscopic Posterior Labral Repair for Type VIII SLAP Lesions in Active-Duty Military Patients Yields Excellent Return to Military Duty

PURPOSE

To report short-term outcomes following biceps tenodesis combined with arthroscopic posterior labral repair of type VIII SLAP lesions in active-duty military patients.

METHODS

All consecutive patients from January 2012 through December 2018 who underwent biceps tenodesis combined with arthroscopic posterior labral repair of type VIII SLAP tears performed by the senior surgeon with complete outcome scores and minimum 2.5 years follow-up were identified. Exclusion criteria included concomitant glenoid microfracture, rotator cuff repair, or other capsulolabral repair. Outcome measures were completed by patients within 7 days before surgery and at latest follow-up. Biceps tenodesis performed was a mini-open, through a subpectoral approach, using a double-loaded 2.9mm suture-anchor.

RESULTS

Thirty-two patients met the inclusion criteria for the study. All patients were active-duty military at time of surgery. Average follow-up was 73.53 ± 22.37 months. Thirty-one patients achieved the minimal clinically important difference, 30 of 32 reached the substantial clinical benefit, and 31 of 32 met the patient acceptable symptomatic state, as defined for the American Shoulder and Elbow Surgeons Shoulder Score. Similarly, 30 of 32 patients reached the minimal clinically important difference, 29 of 32 achieved the substantial clinical benefit, and 32 of 32 met the patient acceptable symptomatic state for the Single Assessment Numeric Evaluation. There were no significant changes in forward flexion, external rotation, or internal rotation between pre- and postoperative measurements. Three patients reported postoperative complications and 1 patient progressed to further surgery. Thirty (93.75%) patients remained on active-duty military service and were able to return to preinjury levels of activity.

CONCLUSIONS

Active-duty military patients with type VIII SLAP tears had statistically and clinically significant increases in outcome scores, marked improvement in pain, and high rates of return to unrestricted active-duty following mini-open subpectoral biceps tenodesis combined with posterior labral repair.

LEVEL OF EVIDENCE

IV, retrospective case series.

Combined Bankart and SLAP repair: patient-reported outcome measurements after a minimum 5-year follow-up

BACKGROUND

Anterior shoulder instability is typically characterized by detachment of the anteroinferior labrum (Bankart lesion). Some patients also sustain a superior labrum anterior-to-posterior (SLAP) injury. The purpose of this study was to compare the medium-term clinical results of isolated anterior Bankart repairs (ABR) with those of combined Bankart and SLAP repair (ABR + SLAP).

METHODS

Data on all patients treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected from medical charts. The minimum follow-up was 5 years. Patients were interviewed to assess patient-reported outcome measurements (PROM) as determined by the American Shoulder and Elbow Surgeons Score (ASES), the Subjective Shoulder Score (SSV), and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as their quality of life (QOL: SF12 questionnaire). Information on complications, re-operations, and recurrent instability was recorded and evaluated as well.

RESULTS

A total of 150 patients (88% males) with a mean age 23.7 years (range 15-40) were included. Forty-two patients following ABR + SLAP repair were compared to 108 patients following ABR alone, with a mean follow-up of 7.8 years (range 5-10.7). The rate of re-dislocation was similar in both groups (26% for ABR + SLAP vs 20% for ABR, p = .44). There were no significant differences in functional outcome between the ABR + SLAP and the ABR alone groups (SSV 86.7 vs 86.5, p = .93, ASES 89.6 vs 86.5, p = .11, and DASH 4.9 vs 7, p = .17), or in QOL outcome (SF12 physical 95.6 vs 93.3, p = .27, SF12 mental 84.4 vs 85.7, p = .63).

CONCLUSION

Surgical repair for anterior shoulder instability and a coexisting SLAP lesion yields clinical results as good as those of isolated ABR, as evidenced by similar PROM and re-dislocation rates after medium-term follow-up.

LEVEL OF EVIDENCE

III.

Primary Double-Pulley SLAP Repair in an Active-Duty Military Population With Type II SLAP Lesions Results in Improved Outcomes and Low Failure Rates at Minimum Six Years of Follow-up

Purpose

To report mid-term outcomes of active-duty patients younger than the age of 35 years with shoulder type II SLAP lesions following our technique for double-pulley SLAP repair (DPSR).

Methods

All consecutive patients aged 18 to 35 years from January 2014 through December 2015 who underwent primary DPSR by the senior surgeon with complete outcome scores were identified. The clinical significance measures (patient acceptable symptomatic state [PASS], substantial clinical benefit [SCB], minimal clinically important difference [MCID]) have not yet been fully defined for type II SLAP repair procedures, so the values for biceps tenodesis were used as a stand-in. Patients were excluded if they were lost to follow-up of if they underwent a concomitant rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up.

Results

Overall, 22 of 41 (53.7%) patients met the inclusion criteria for the study, and all were active-duty military at time of surgery. In total, 21 of 22 (95.5%) patients met the PASS, whereas 20 of 22 (90.9%) achieved SCB and 22 of 22 (100.0%) exceeded the MCID for their operative shoulder as determined by the American Shoulder and Elbow Surgeons score. In total, 19 of 22 (86.4%) patients met the PASS, whereas 22 of 22 (100.0%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the Single Assessment Numeric Evaluation. In addition, 21 of 22 (95.5%) met the PASS, whereas 22 of 22 (100%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the pain visual analog scale. Pre- and postoperative range of motion did not vary significantly. In total, 18 of 22 (81.8%) of patients remained on active duty and were able to return to preinjury work and recreation activity levels. In 2 patients (9.09%), the repair did not heal.

Conclusions

Mid-term outcomes in this population of young, active-duty patients undergoing DPSR for type II SLAP tears demonstrate a statistically and clinically significant improvement in patient-reported outcomes and an overall return to active-duty rate of 81.8%.

Level of Evidence

Level IV, therapeutic case series.

Postoperative Pain and Paresthesia in Labral Repairs of the Shoulder: Location Does Matter

Background:

Favorable outcomes have been reported regarding postoperative shoulder pain and function after repair of anteroinferior (Bankart) glenohumeral labral tears. However, the outcomes of patients after repair of isolated superior labral anterior-posterior (SLAP) tears are a contentious topic. The authors have also anecdotally noted that patients evaluated with labral tears complained of numbness and tingling in their ipsilateral hand.

Purpose:

To determine if there is a difference in the temporal outcomes of shoulder pain and hand paresthesia in patients with SLAP tears versus Bankart tears after arthroscopic repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were 66 consecutive patients who underwent arthroscopic labral repair at a single institution between August 2018 and February 2021. The prevalence and magnitude of shoulder pain as well as numbness and tingling of the hand were assessed using questions from the L’Insalata Shoulder Questionnaire and the Boston Carpal Tunnel Questionnaire preoperatively and at 1 week, 6 weeks, 12 weeks, and 6 months after surgery.

Results:

Preoperatively, patients with SLAP lesions reported a higher prevalence of shoulder pain during sleep compared with those with Bankart tears (P < .05). Postoperatively, patients who underwent SLAP repair reported a larger proportion and more severe magnitude of shoulder pain during rest, overhead activities, and sleep compared with those who underwent Bankart repair (P < .05). Only patients who underwent Bankart repair reported improvements in the prevalence and magnitude of their shoulder pain during rest, overhead activities, and sleep by 6 months postoperatively compared with preoperative levels (P < .05). Preoperatively, 30% of patients with Bankart repairs and 40% of patients with SLAP repairs reported hand tingling, while 35% and 50%, respectively, reported hand numbness. The prevalence and magnitude of hand tingling and numbness were not significantly different between groups at any time point.

Conclusion:

Study results indicated that patients who underwent SLAP repair experienced worse shoulder pain outcomes compared with those who underwent Bankart repair using the same anchor and surgical technique. Only patients who underwent Bankart repair reported improvements in their hand numbness after surgery. Therefore, labral tear location does matter with respect to shoulder pain and hand numbness.

Midterm Outcomes After Arthroscopic Repair of Type VIII SLAP Lesions in Active Duty Military Patients Younger Than 35 Years

Background

Superior labrum from anterior to posterior (SLAP) lesions represent a significant cause of shoulder pain and disability among active duty members of the US military. However, few data exist regarding the surgical management of type VIII SLAP lesions.

Hypothesis

We hypothesized that arthroscopic repair would decrease pain and increase function at the midterm follow-up and allow for a high rate of maintenance of active duty status.

Study Design

Case series; Level of evidence, 4.

Methods

Consecutive active duty military patients were identified from January 2011 through June 2015 who underwent arthroscopic repair of type VIII SLAP lesions performed by a single surgeon. Patients were excluded if they underwent glenoid microfracture, other capsulolabral repair, or rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up: pain visual analog scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, and Rowe instability score.

Results

A total of 30 patients met the inclusion criteria for the study. The mean ± SD follow-up was 96.60 ± 10.91 months. At final follow-up, the mean visual analog scale score improved from 8.17 ± 1.6 to 1.63 ± 1.90 (P < .0001), the Single Assessment Numeric Evaluation score from 41.65 ± 16.78 to 87.63 ± 13.02 (P < .0001), the American Shoulder and Elbow Surgeons score from 36.47 ± 10.26 to 88.07 ± 13.94 (P < .0001), and the Rowe score from 35.33 ± 6.56 to 90.00 ± 14.68 (P < .0001). Three patients reported postoperative complications, and 1 progressed to further surgery. Overall, 90% of patients remained on active duty military service and were able to return to preinjury levels of work and recreational activity. The failure rate, defined as persistent instability or activity-limiting pain, was 10%.

Conclusion

The results of this study demonstrated favorable outcomes for the majority of patients after arthroscopic repair of type VIII SLAP lesions at midterm follow-up, supporting repair as a viable treatment option for type VIII SLAP tears in this patient population.

Biceps Tenodesis as an Attractive Alternative to Superior Labral Anterior-Posterior (SLAP) Repair for Type II SLAP Lesions in Active-Duty Military Patients Younger Than 35 Years

BACKGROUND

Biceps tenodesis has been suggested as a superior surgical technique compared with isolated labral repair for superior labral anterior-posterior (SLAP) tears in patients older than 35 years. The superiority of this procedure in younger patients, however, is yet to be determined.

PURPOSE

To compare the outcomes of arthroscopic SLAP repair with those of arthroscopic-assisted subpectoral biceps tenodesis for type II SLAP tears in active-duty military patients younger than 35 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Preoperative and postoperative evaluations with a minimum 5-year follow-up including the visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) shoulder score were administered, and scores were compared between 2 groups of patients younger than 35 years. One group included 25 patients who underwent SLAP repair, and the second group included 23 patients who underwent arthroscopic-assisted subpectoral biceps tenodesis.

RESULTS

The preoperative patient age (P = .3639), forward flexion (P = .8214), external rotation (P = .5134), VAS pain score (P = .4487), SANE score (P = .6614), and ASES score (P = .6519) did not vary significantly between the 2 study groups. Both groups demonstrated statistically significant increases in function as measured by the ASES and SANE and decreases in pain as measured by the VAS at a minimum of 5 years postoperatively. Also at a minimum of 5 years postoperatively, patients in the tenodesis group had lower pain (1.3 vs 2.6, respectively; P = .0358) and higher SANE (84.0 vs 63.3, respectively; P = .0001) and ASES (85.7 vs 75.4, respectively; P = .0342) scores compared with those in the repair group. Failure rate was 20.0% in the repair group versus 0.0% in the tenodesis group (P = .0234).

CONCLUSION

Active-duty military patients younger than 35 years with type II SLAP tears had more predictable improvement in pain, better functional outcomes, and lower failure rates after biceps tenodesis compared with SLAP repair for type II SLAP tears. Overall, the results of this study indicate that arthroscopic- assisted subpectoral biceps tenodesis is superior to arthroscopic SLAP repair for the treatment of type II SLAP tears in military patients younger than 35 years.

Trans-cuff portals heal by 6 weeks: an ultrasonography-based study

Background

Various arthroscopic portals have been described for repair of superior labrum anterior-posterior (SLAP) lesions. The difficulty in doing repair through the rotator interval and the problems in direction and placement of anchors still persist. Functional outcomes of the patients after treating them using trans-cuff portal are well established in literature, but the actual healing of the portal is not clear. We made a sincere effort to identify healing of the trans-cuff portal with ultrasound guidance and functional outcome using American Shoulder and Elbow Surgeons Shoulder Score (ASES score), Constant Shoulder Score, and Oxford Shoulder Score.

Material and methods

Twenty-two patients with SLAP or labral tears and normal contralateral shoulders were included. Surgery was performed using the trans-cuff portal as a viewing or working portal for biceps repair and labral repair. Rehabilitation was initiated from day 1 and followed up on 6 weeks, 3 months and, 6 months with a maximum follow-up duration of 2 years. Ultrasound was used to measure the depth of healing and graded at 6 weeks of follow-up postoperatively. Functional outcomes were measured using ASES score, Constant Shoulder Score, and Oxford Shoulder Score measured at 6 months.

Results

Seventeen patients were of grade 1 (complete healing); 1 patient was of grade 2 (more than 50% healing); 1 of grade 3 (less than 50% healing), and 3 were lost to follow-up. Fourteen patients out of 19 had excellent ASES scores, 4 patients had good scores, and 1 patient was considered as poor with an average ASES score of 84.51 (range 93-48) and standard deviation of 10.37. The ASES score indicated that healing of the rotator cuff portal is directly related to the functional outcome of the shoulder. The Constant Shoulder Score and Oxford Shoulder Score on the contrary were statistically not significant indicating no relation of the Oxford and Constant scores with healing of the rotator cuff portals.

Conclusion

Trans-cuff portal is safe, gives proper angle for insertion of anchors, and can be used for repair of SLAP lesions with ease. Ultrasonography helps in confirming the healing of portal.

Stiffness: friend or foe? A cohort study evaluating the effect of early postoperative stiffness on the outcomes of patients who underwent superior labral repair

BACKGROUND AND HYPOTHESIS

Postoperative stiffness is a commonly reported complication after type II superior labrum anterior-posterior (SLAP) repair. It is unclear whether patients with postoperative stiffness, classified as external rotation to the side of ≤20°, ultimately will have greater functional outcomes at ≥2 years after surgery. We hypothesized that postoperative stiffness would result in improved functional outcomes at ≥2 years after surgery.

METHODS

Sixty-five consecutive arthroscopic SLAP repair cases performed by a single surgeon were retrospectively reviewed using prospectively collected patient-ranked outcomes and examiner-determined assessments preoperatively and at 1 week, 6 weeks, 24 weeks, and a minimum of 2 years after surgery. Patients were allocated to the stiff group and the non-stiff group based on their external rotation at 6 weeks after repair.

RESULTS

Of the patients, 16 (27%) had ≤20° of external rotation at 6 weeks postoperatively. These patients, comprising the stiff group, had more pain and more difficulty with overhead activities early on than patients in the non-stiff group (very severe vs. severe, P < .05), but by 2 years, they had less difficulty and less pain with overhead activities, less patient-reported stiffness, and less severe pain at night than isolated SLAP repair patients with >20° of external rotation at 6 weeks (P < .05).

CONCLUSION

This study suggests that in patients who underwent SLAP repair, early postoperative stiffness (at 6 weeks as assessed by ≤20° of external rotation), while problematic early, is associated with improved functional outcomes in the longer term, with patients in the stiff group reporting less pain and difficulty with overhead activities at ≥2 years after surgery.

The Top 50 Most-Cited Papers in the Diagnosis and Management of SLAP Tears

Purpose

To identify and characterize the top 50 most-cited articles regarding SLAP tears.

Methods

Referencing the methodology of previous citation analyses, varying Boolean searches were performed using the Web of Science database and the search terms yielding the greatest number of results was used. The top 50 most-cited articles were identified and the following data points were gathered from each article: author, institution, country of origin, year of publication, publishing journal, level of evidence, and citation density.

Results

The total number of citations was 7834, with a median of 106 citations. The top 50 list was largely composed of diagnostic level I, II, and III studies (5, 7, and 8 total publications, respectively) and therapeutic level III (6 publications) or level IV (10 publications). Most articles originated from the United States (40). In total, 19 of the top 50 most-cited articles were published in the American Journal of Sports Medicine, followed by Arthroscopy (15) and the Journal of Bone and Joint Surgery (5).

Conclusions

Our analysis demonstrated a correlation with earlier publications being cited more frequently than recent studies. Importantly, the current study found that therapeutic studies in the most cited list were largely level III or level IV evidence. This makes the management of SLAP tears seem anecdotal, with little in the way of high-impact level I or level II therapeutic studies. We must reconsider our current understanding of SLAP tears and their management with more studies that demonstrate a clearer treatment algorithm for these common injuries of the shoulder.

Clinical Relevance

Given the complexity of SLAP tears, this list of the most-cited articles can provide a reference point to better guide practice, resident education, and future areas of orthopaedic research.

The Fifty Most-Cited Articles Regarding SLAP Lesions

Purpose

To identify and evaluate the top 50 most-cited articles pertaining to SLAP tears.

Methods

The ISI Web of Knowledge database was used to conduct a query for articles pertaining to SLAP tears. Our query was conducted in April 2020 with multiple Boolean operative combinations performed by 2 independent reviewers. Articles on the final list were further reviewed to extract the following data: manuscript title, first author, total citation count, year of publication, citation density since publication, current citation rate since 2013, journal, country of origin, and level of evidence.

Results

Our initial search yielded 2,597 articles. Within this cohort, the top 50 publications pertaining to SLAP tears were identified that met our search criteria. The top article was cited 802 times while the 50th ranked article was cited 46 times. The average number of citations per publication was 131, whereas the average citation density since year of publication was 7.3. No strong correlations were found between citation density and year published. Twelve journals published articles pertaining to SLAP tears, with Arthroscopy accounting for the greatest number (15 articles, 30%). Most articles were graded with a level of evidence (LOE) of IV (n = 24, 48%), followed by review articles without LOE (n = 8, 16%). Only 2 articles achieved an LOE of I (4%). Articles typically addressed the arthroscopic management (n = 11, 22%), whereas anatomy/classification (n =10, 20%), and outcomes (n = 9, 18%) also were reported.

Conclusions

This review provides a quantitative analysis of the most-referenced literature pertaining to SLAP tears. This body of knowledge helps surgeons search for literature regarding these injuries and identify trends regarding SLAP tear research.

Clinical Relevance

This research provides practitioners with an easily accessible and comprehensive collection of the major contributions regarding SLAP tears and offers insight into future areas for research.

Anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior lesions: A cadaveric study and preliminary report

OBJECTIVE

This study aims to investigate the anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior (SLAP) lesions in a human cadaveric model.

METHODS

In this anatomic study, bilateral shoulder girdles of 12 adult formalin embalmed cadavers were used. All cadavers were male, and the mean age was 63.4±7.3 years. The portal entry point was determined as midway between the anterior and posterior borders of the acromion, approximately 1 cm lateral from the edge of the acromion. After a guidewire was placed in the glenoid cavity at the 12 o'clock position where the SLAP lesion typically occurs, a switching stick was inserted there. Each glenoid was then drilled with a 2.4 mm drill through an arthroscopic cannula. Subsequently, anatomical dissection was executed to assess the relationship of the transmuscular portal with the suprascapular nerve, axillary nerve, supraspinatus tendon, acromion, and biceps tendon. Lastly, the shortest distance between the aforementioned structures with the drill was measured by a sensitive caliper to determine whether there was a penetration of the structures. Differences between the right and left sides were analyzed.

RESULTS

The mean distance between the portal and the axillary nerve was 55.5 mm±6.0 mm, and the mean length of the suprascapular nerve was 61.2 mm±7.0 mm. The mean distance between the portal and the supraspinatus tendon was 2.8 mm±1.5 mm. No penetration of the axillary nerve, suprascapular nerve, and supraspinatus tendon was observed in any cadaver. No differences were detected for measured anatomical parameters between the right and left sides (p>0.05).

CONCLUSION

Findings from this cadaveric study revealed that the transmuscular portal may allow for a reliable anchor placement without any nerve or tendon penetration during arthroscopic SLAP repair.

LEVEL OF EVIDENCE

Level V.

Comparing clinical outcomes between rotator cuff repairs, SLAP repairs, and combined repairs

BACKGROUND

Superior labrum lesion from anterior to posterior (SLAP) often presents together with other shoulder pathologies such as rotator cuff tear (RCT), but it is uncertain if repairing both SLAP and RCT has superior clinical outcomes over isolated repairs of SLAP and RCT.

MATERIALS AND METHODS

This was a retrospective cohort study with prospectively collected data, reviewing 157 patients who underwent arthroscopic repair of either RCT, SLAP (type II lesion), or both. Before surgery and after 6 weeks, 12 weeks, and 24 weeks, shoulder objective range of motion and strength were measured, patient-reported function and pain was assessed by the modified L'Insalata questionnaire with a Likert scale, and complications after each repair were examined.

RESULTS

At 24 weeks after surgery, the combined group (n = 22) and SLAP group (n = 47) had significantly higher forward flexion (165° ± 4° and 167° ± 4° vs. 154° ± 3°, P = .01 and P = .01), external rotation strength (82 ± 6 N, 81 ± 6 N vs. 61 ± 3 N, P = .01 and P = .01), and abduction strength (94 ± 14 N, 78 ± 8 N vs. 53 ± 3 N, P = .001 and P = .02) compared with the rotator cuff tear repair (RCR) group (n = 88). The combined group also had stronger internal rotation than the RCR group (107 ± 12 N vs. 72 ± 4 N, P = .02). Function and pain improved from "severe-moderate" to "moderate-mild" in all groups after surgery.

CONCLUSION

Repairing RCT and SLAP tears together results in significant clinical benefits compared to repairing just RCT and analogous results against SLAP-only repair.

THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Reviews on superior labral anterior to posterior (SLAP) injuries have been reported in the literature. However, current reviews have not focused on the success of athletes return to their previous level of sport or athletic performance.

Hypothesis/Purpose

Systematically review return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury while reporting any additional performance metrics and outcome measures.

Study Design

Systematic Review & Meta-Analysis.

Methods

A computer assisted literature search of MEDLINE, CINAHL, Embase and SportDiscus databases utilizing keywords related to RTS post-surgery for SLAP tear was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized for study methodology. Quality assessment utilized the MINORS scale.

Results

Twenty-two studies (617 athletes) qualified for analysis. Based on limited evidence from level 3b to 4 studies, athletes RTS post intervention for SLAP injury occurred at a rate of 93% (95% CI:87 to 98%) and overall RTSP rate was 72% (95% CI:60 to 83%). The mean time to RTS post intervention was reported in 59% of studies at 6.9 ± 2.9 months. Patient reported outcome measures (PROM's) were reported in 86% of studies. There was limited reporting of performance statistics, rehabilitation guidelines, return to sport criteria, and information regarding SLAP diagnosis in the available studies. None of the included studies reported post-surgical athletic performance or career longevity.

Conclusions

Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS from RTSP and neither athletic performance nor career longevity were reported in any included studies. Future studies of higher quality are required for this determination.

Level of Evidence

Level 1a.

The glenoid labrum: does labral lesion location matter?

Background

The glenoid labrum can be torn in 1 or more locations. It is undetermined if the location of the labral tear alters patient outcomes after repair.

Methods

A total of 252 labral repair cases were retrospectively reviewed using prospectively collected patient-ranked outcomes and examiner-determined assessments preoperatively, at 1 week, 6 weeks, 24 weeks, and at a minimum of 2 years after surgery.

Results

Preoperatively, patients who underwent a superior labral repair reported worse pain at night and during activity than patients who subsequently underwent an isolated anterior labral repair or a combined anterior and superior labral repair (P < .05). After surgery, patients who underwent an isolated superior labral repair reported more severe pain at night and during activity, increased stiffness, and less satisfaction with their shoulder than patients who had an isolated anterior (P < .05) or a combined anterior and superior labral repair (P < .05).

Conclusions

Patients with isolated superior labral repairs have more pain both before and after repair than patients who undergo anterior or anterior and superior labral repairs.

Arthroscopic Circumferential Labral Repair for Patients With Multidirectional Instability: A Comparative Outcome Study

Background:

Circumferential tears of the glenohumeral labrum are an uncommon injury, comprising 2.4% of all labral lesions. Currently, the clinical outcomes of arthroscopic circumferential labral repair for patients with instability and combined anterior, posterior, and superior labral tears are not well-known.

Hypothesis:

Patients treated with arthroscopic circumferential shoulder labral repairs will have inferior clinical outcomes and higher failure rates compared with patients who have isolated arthroscopic anterior labral repairs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was performed to identify patients aged 18 years and older who underwent circumferential arthroscopic stabilization for recurrent instability as compared with an age-matched control group of arthroscopic primary anterior labral repairs. Age at surgery, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, Simple Shoulder Test (SST) score, 12-Item Short Form Health Survey (SF-12) score (mental and physical), and overall patient satisfaction with surgery were assessed for each group.

Results:

A total of 35 consecutive patients (36 shoulders) who underwent an arthroscopic 360° circumferential labral repair were compared with a matched group of 31 patients who underwent an isolated arthroscopic anterior labral repair. The mean follow-up period was 34.3 and 56.8 months, respectively. No significant difference was found between the 2 groups for overall satisfaction with the surgery or recurrent instability. At the time of the follow-up survey, 22% of the patients experienced pain and 25% of the patients experienced instability in the circumferential repair group, whereas 15% of the patients experienced some level of pain and 30% of patients experienced a subjective sense of subtle instability in the isolated repair group. The ASES scores were 87.3 in the combined labral repair group and 93.3 in the isolated anterior group (P = .35), SST scores were 10.7 and 11.3 (P = .70), SF-12 mental scores were 54.6 and 56.8 (P = .80), SF-12 physical scores were 53.2 and 54.2 (P = .98), and age at time of the surgery was 26.7 and 24.6 years (P = .33), respectively. There was no difference between the 2 groups in pre- and postoperative range of motion (P > .05).

Conclusion:

There was no difference in shoulder stability and function in patients after 360° combined labral repairs versus anterior labral repair alone. With proper patient selection, patients can expect similar outcomes despite the more extensive surgical procedure and complex postoperative rehabilitation protocol for circumferential repairs.

Outcomes for Arthroscopic Repair of Combined Bankart/SLAP Lesions in the Treatment of Anterior Shoulder Instability: A Systematic Review and Meta-analysis

Background

Arthroscopic repair of combined Bankart/superior labral anteroposterior (SLAP) lesions is commonly performed to treat anterior shoulder instability, the clinical outcomes of which have not been widely studied.

Purpose

To compare the clinical outcomes for arthroscopic repair of combined Bankart/SLAP lesions in the treatment of anterior shoulder instability and to ascertain whether it is inferior to isolated Bankart repair.

Study Design

Systematic review; Level of evidence, 3.

Methods

A systematic review of the literature was performed through use of the MEDLINE, EMBASE, and Cochrane Library databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Study bias was assessed using the MINORS (Methodological Index for Non-Randomized Studies) scoring system. Randomized controlled trials, prospective or retrospective cohort studies, and case-control studies were included, whereas systematic reviews, literature reviews, conference abstracts, case reports, case series, and non-peer-reviewed studies were excluded to guarantee the quality of the study. Data on outcomes including recurrence rate, functional scores, and range of motion (ROM) were pooled, with statistical analysis performed. A P value of <.05 was considered statistically significant.

Results

The review included 7 studies with a total of 520 patients. The pooled recurrence rate after combined Bankart/SLAP repair was 6.47% (9/139). Significant improvements of postoperative versus preoperative functional scores were observed, including a reduction in the visual analog scale score for pain (mean ± SD: 0.99 ± 1.36 vs 4.13 ± 2.26; P < .00001) and an increase in mean Rowe score (89.56 ± 11.46 vs 43.16 ± 8.87; P < .00001) and mean Constant score (91.41 ± 7.57 vs 59.70 ± 5.63; P < .00001). In terms of ROM, no reduction was found in external rotation (66.56° ± 13.33° vs 67.22° ± 14.27°; P = .21), and a significant increase in abduction was found (157.67° ± 4.11° vs 144.18° ± 8.28°; P < .00001). No statistically significant difference was found between arthroscopic repair of combined Bankart/SLAP lesions and isolated Bankart repair regarding recurrence rate, functional scores, or ROM.

Conclusion

Of the pooled data, patients who underwent arthroscopic repair of combined Bankart/SLAP lesions in treatment of anterior shoulder instability showed a low recurrence rate, favorable functional scores, and no significant restriction on ROM, all of which were not significantly worse than outcomes of isolated Bankart repair. Therefore, combined repair was proven to be a viable option for extensive labral lesions.

Rotator Cuff Sparing Arthroscopic SLAP Repair With Knotless All-Suture Anchors

Arthroscopic repair of SLAP tears is a common shoulder procedure, especially in overhead athletes. Repair techniques have evolved over the last 20 years, and the optimal technique remains elusive. In many cases, a transrotator cuff portal placed lateral to the acromion is used to access the superior glenoid. However, violating the rotator cuff is not desirable in an overhead athlete, and this approach can be associated with an increased risk of postoperative morbidity. The purpose of this Technical Note is to describe our preferred surgical technique with a rotator cuff-sparing approach for arthroscopic SLAP repair with all-suture anchors.

Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes

For overhead athletes and, in particular, baseball pitchers, the rates of success and return to play for those who have undergone arthroscopic repair of type II SLAP lesions are poor, ranging from 7% to 62%. The reasons for the poor results and high failure rates in overhead athletes with type II SLAP repairs are multifactorial and are a combination of many factors. These factors include the failure to establish the diagnosis and treat these athletes preoperatively; the inability of the operating surgeon to differentiate normal anatomic variants from pathologic SLAP lesions at the time of surgery; the surgical technique, which may violate the rotator cuff; or the placement of suture anchors, which restricts external rotation and alters overhead throwing mechanics. The proper diagnosis of SLAP lesions can be difficult because SLAP tears rarely occur in isolation and are often associated with other shoulder pathology. A proper history detailing the onset of symptoms and whether there was an acute episode of trauma or a history of repetitive use is critical. It is important to remember that no single physical examination finding is pathognomonic for SLAP tears. When seen in isolation, SLAP tears may mimic impingement syndrome (52%) or even anterior instability (39%). Surgical treatment of type II SLAP lesions should not be undertaken lightly in overhead athletes. If a 3-month rehabilitation period followed by a return to sports over the following 3 months does not allow the athlete to return to his or her preinjury level, diagnostic arthroscopy with SLAP repair is a reasonable option and can yield excellent results using the proper techniques. The technique described in detail in this article and our video can be technically demanding, but with the key points outlined, it can be reproduced and provide excellent results for overhead athletes undergoing SLAP repair. By not violating the rotator cuff, using a mattress configuration and keeping the suture knot away from the articular surface, and by not going anterior to the biceps tendon for repair, external rotation and strength can be preserved, leading to an excellent result with a predictable return to play for overhead athletes.

Labral Repair Versus Biceps Tenodesis for Primary Surgical Management of Type II Superior Labrum Anterior to Posterior Tears: A Systematic Review

PURPOSE

To examine the outcomes of SLAP repair versus biceps tenodesis (BT) for the index treatment of isolated type II SLAP tears.

METHODS

A search of PubMed, MEDLINE, and EMBASE was performed in April 2018 for English-language studies that presented outcomes data on patients with isolated type II SLAP tears treated with either SLAP repair or BT at the primary surgical time point.

RESULTS

Twenty-three studies (i.e., 2 randomized control trials, 7 retrospective cohort, 3 prospective cohort, 4 case-control, and 7 case series) were included. Isolated type II SLAP tears were treated via SLAP repair in 781 patients with a mean age of 35 years (range, 22-58 years) and a mean postoperative follow-up of 35 months (range, 3-63 months). BT was performed in 100 patients with a mean age of 44 years (range, 18-64 years) and a mean postoperative follow-up of 32 months (range, 24-75 months). Similar postoperative scores were noted in both the SLAP repair and BT groups for American Shoulder and Elbow Surgeons, Constant, University of California, Los Angeles, and visual analog scale pain scores. The rate of return to sports was 20% to 95% for SLAP repair and 73% to 100% for BT. Reoperation rates for SLAP repair and BT were 2.9% to 40% and 0% to 15.3%, respectively.

CONCLUSIONS

This study suggests that SLAP repair and BT are both acceptable as index treatment for isolated type II SLAP tears. SLAP repair remains the most commonly performed index procedure; however, BT appears equally efficacious and may represent an attractive alternative.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Return to Sport After the Surgical Treatment of Superior Labrum Anterior to Posterior Tears: A Systematic Review

Background:

Controversy exists as to the optimal treatment of superior labrum anterior to posterior (SLAP) tears in athletes. There are no systematic reviews evaluating return-to-sport (RTS) rates after arthroscopic SLAP repair and biceps tenodesis.

Purpose:

To compare the overall RTS rates in patients with primary type 2 SLAP tears who were managed with arthroscopic SLAP repair versus biceps tenodesis.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching the MEDLINE (PubMed), Embase (Elsevier), and Cochrane Library databases. Inclusion criteria were clinical studies that evaluated RTS rates after arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis. The studies were analyzed for quality and inclusion in the final analysis. Data relevant to RTS rates were then extracted and compiled, and outcomes were compared.

Results:

Of the 337 studies initially identified, 15 (501 patient-athletes) met inclusion criteria. These consisted of 195 patients who underwent isolated arthroscopic SLAP repair (mean age, 31 years; mean follow-up, 3.2 years), 222 patients who underwent arthroscopic SLAP repair with partial rotator cuff debridement (mean age, 22 years; mean follow-up, 5.1 years), and 84 patients who underwent biceps tenodesis (mean age, 42 years; mean follow-up, 3.3 years). The overall RTS rates were high for all 3 procedures (SLAP repair, 79.5%; SLAP repair with rotator cuff debridement, 76.6%; biceps tenodesis, 84.5%), with biceps tenodesis having the highest overall rate. Biceps tenodesis also had the highest RTS rate at the preinjury level (78.6%) compared with SLAP repair (63.6%) and SLAP repair with rotator cuff debridement (66.7%).

Conclusion:

Primary arthroscopic SLAP repair, arthroscopic SLAP repair with partial rotator cuff debridement, and biceps tenodesis all provide high RTS rates. Biceps tenodesis as an operative treatment of primary SLAP lesions may demonstrate an overall higher RTS rate when compared with traditional SLAP repair in older athletes. More, higher level studies are needed that control for age, level of activity, and type of sport (overhead vs nonoverhead) to determine the efficacy of biceps tenodesis as a primary alternative to arthroscopic SLAP repair in young athletes who present with type 2 SLAP tears.

Mkx-Deficient Mice Exhibit Hedgehog Signaling-Dependent Ectopic Ossification in the Achilles Tendons

Heterotopic ossification is the abnormal formation of mineralized bone in skin, muscle, tendon, or other soft tissues. Tendon ossification often occurs from acute tendon injury or chronic tendon degeneration, for which current treatment relies heavily on surgical removal of the ectopic bony tissues. Unfortunately, surgery creates additional trauma, which often causes recurrence of heterotopic ossification. The molecular mechanisms of heterotopic ossification are not well understood. Previous studies demonstrate that Mkx is a transcription factor crucial for postnatal tendon fibril growth. Here we report that Mkx^-/- mutant mice exhibit ectopic ossification in the Achilles tendon within 1 month after birth and the tendon ossification deteriorates with age. Genetic lineage labeling revealed that the tendon ossification in Mkx^-/- mice resulted from aberrant differentiation of tendon progenitor cells. Furthermore, tissue-specific inactivation of Mkx in tendon cells postnatally resulted in a similar ossification phenotype, indicating that Mkx plays a key role in tendon tissue homeostasis. Moreover, we show that Hedgehog signaling is ectopically activated at early stages of tendon ossification and that tissue-specific inactivation of Smoothened, which encodes the obligatory transducer of Hedgehog signaling, in the tendon cell lineage prevented or dramatically reduced tendon ossification in Mkx^-/- mice. Together, these studies establish a new genetic mouse model of tendon ossification and provide new insight into its pathogenic mechanisms. © 2018 American Society for Bone and Mineral Research.

Comparison of Curved and Straight Anchor Insertion for SLAP Repair: A Cadaveric Study

PURPOSE

To compare a curved drill guide with a straight guide for suture anchor placement into the posterosuperior glenoid from an anterolateral portal with respect to glenoid perforation, drill contact with the suprascapular nerve, and maximum load.

METHODS

Ten bilateral pairs of fresh human cadaveric shoulders were randomized to the curved technique on 1 side and the straight technique on the contralateral side. An anterolateral trans-rotator cuff portal was used for placement of anchors at the posterior (11 o'clock right shoulder) and far posterior (10 o'clock right shoulder) positions on the glenoid with a 24-mm drill stop, and the drill tip was marked with ink. Specimens were dissected for glenoid perforation and drill contact with the suprascapular nerve. The maximum load of each anchor was measured using a material testing system.

RESULTS

Glenoid perforation occurred in 30% in the curved group and 60% in the straight group overall (P = .01). Ink markings demonstrated a direct hit on the suprascapular nerve in most of the penetrations (13 of 18) but was not significantly different between the curved and straight guides (P = .25). Maximum load of the posterior anchor was greater in the curved group than that in the straight group (199.5 vs 146.7 N, respectively; P = .01).

CONCLUSIONS

The curved technique has a lower rate of glenoid perforation and greater maximum load than the straight technique. However, the curved technique can result in glenoid perforation and injury to the suprascapular nerve, and we do not recommend it.

CLINICAL RELEVANCE

Placing suture anchors through an anterolateral portal with a curved guide provides a more optimal trajectory with decreased risk of glenoid perforation and superior biomechanical strength than that with the straight guide, but it is not safe.

Outcome of arthroscopic SLAP repair using knot-tying-suture anchors compared with knotless-suture anchors in athletes

INTRODUCTION

Arthroscopic repair is one option for the surgical treatment of type II superior labrum tears from anterior to posterior (SLAP) lesions in athletes' shoulders.

MATERIALS AND METHODS

Sixty-one of 78 (78.2%) athletes were retrospectively examined after isolated arthroscopic SLAP repair (group 1/G1: 28x knot-tying anchors; group 2/G2: 33 knotless anchors; follow-up 24 months) and compared to two specific, separate matched volunteer athlete control groups (group 3/G3: 28 athletes matched to G1; group 4/G4: 33 athletes matched to G2). The assessment of G1-4 included numerical analogue scales (NASs: 1-15 scales) and the Athletic Shoulder Outcome Scoring System (ASOSS) score, and the Shoulder Sport Activity Score (SSAS). The preinjury status (FU-1), the status before surgery (FU0), and at follow-up (FU1) were assessed.

RESULTS

High external rotation at abduction (hER) was significantly worse in G1 than G2 (FU1: G1, 86.6° ± 7.7° versus = vs G2, 91.1° ± 10.7°; p = 0.03). The ASOSS and SSAS revealed significant impairment in G1-2 compared to G3-4 (ASOSS FU1: 83.9 ± 19.9 G1 vs 94.6 ± 7.7 G3; p = 0.002 and 80.3 ± 17.7 G2 vs 91.8 ± 9.1 G4; p = 0.002; SSAS 5.9 ± 2.7 G1 vs 6.9 ± 1.8 G3; p = 0.02 and 6.3 ± 2.5 G2 vs 7.4 ± 1.4 G4; p = 0.06), with 17-20% loss on ASOSS and 23-25% deficits on SSAS. The NAS analysis detected for pain (4 ± 3.5 vs 3.2 ± 2.6), satisfaction (2 ± 0.8 vs 1.8 ± 0.9), reduction of function (4.6 ± 3.9 vs 3.9 ± 3.8) and proficiency (9.6 ± 4.7 vs 10.9 ± 3.9) similar impairments in G1-2 (p > 0.05) and better results in G3 and G4 (all p < 0.001).

CONCLUSIONS

After SLAP repair, athletes showed underestimated impairment of shoulder sport resumption and proficiency with high rates of shoulder sports cessation. The present data favor the knotless fixation technique, because this fixation technique allowed bilaterally equivalent ranges of motions. The uninjured shoulder athletes also showed functional deficits with significant shoulder sport impairments, which must be considered in outcome analysis and for the rehabilitation program.

LEVEL OF EVIDENCE

III, retrospective cohort study.

National Athletic Trainers' Association Position Statement: Evaluation, Management, and Outcomes of and Return-to- Play Criteria for Overhead Athletes With Superior Labral Anterior-Posterior Injuries

OBJECTIVE

  To present recommendations for the diagnosis, management, outcomes, and return to play of athletes with superior labral anterior-posterior (SLAP) injuries.

BACKGROUND

  In overhead athletes, SLAP tears are common as either acute or chronic injuries. The clinical guidelines presented here were developed based on a systematic review of the current evidence and the consensus of the writing panel. Clinicians can use these guidelines to inform decision making regarding the diagnosis, acute and long-term conservative and surgical treatment, and expected outcomes of and return-to-play guidelines for athletes with SLAP injuries.

RECOMMENDATIONS

  Physical examination tests may aid diagnosis; 6 tests are recommended for confirming and 1 test is recommended for ruling out a SLAP lesion. Combinations of tests may be helpful to diagnose SLAP lesions. Clinical trials directly comparing outcomes between surgical and nonoperative management are absent; however, in cohort trials, the reports of function and return-to-sport outcomes are similar for each management approach. Nonoperative management that includes rehabilitation, nonsteroidal anti-inflammatory drugs, and corticosteroid injections is recommended as the first line of treatment. Rehabilitation should address deficits in shoulder internal rotation, total arc of motion, and horizontal-adduction motion, as well as periscapular and glenohumeral muscle strength, endurance, and neuromuscular control. Most researchers have examined the outcomes of surgical management and found high levels of satisfaction and return of shoulder function, but the ability to return to sport varied widely, with 20% to 94% of patients returning to their sport after surgical or nonoperative management. On average, 55% of athletes returned to full participation in prior sports, but overhead athletes had a lower average return of 45%. Additional work is needed to define the criteria for diagnosing and guiding clinical decision making to optimize outcomes and return to play.

Superior Labral Anterior to Posterior Tear Management in Athletes

Background:

The diagnosis and treatment of Superior Labrum Anterior to Posterior (SLAP) tears have been evolving and controversial. The lack of clear diagnostic criteria on physical examination, Magnetic Resonance Imaging (MRI), and arthroscopic evaluation clouds the issue. The high rate of MRI diagnosed SLAP lesions in the asymptomatic population of athletes and non-athletes warrants consideration when planning treatment for those with shoulder pain.

Objective:

To provide information on the evaluation, diagnosis and management of SLAP tears in athletes.

Methods:

The results of a structured non-operative rehabilitation program are discussed and compared to traditional surgical techniques. The evolution of the author’s treatment algorithm is presented. Results: The successful return to overhand throwing is more common with non-operative treatment than with surgical.

Conclusion:

A rehabilitation program focused on stretching the posterior capsule and correcting scapular posture is more successful than surgery for most throwers with SLAP lesions.

Diagnosis and Treatment of Injuries to the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

This review discusses the diagnostic and treatment challenges presented by injuries to the biceps and superior labral complex.

RECENT FINDINGS

A focused patient history, numerous physical examination maneuvers, and appropriate advanced imaging studies must be utilized to reach an accurate diagnosis. Nonoperative management, even in overhead athletes, has demonstrated relatively good outcomes, while operative outcomes have yielded mixed results. The surgeon must take into account a number of variables when choosing the appropriate surgical procedure: labral repair versus biceps tenodesis. Rehabilitation, either as nonoperative management or as a postoperative protocol, should focus on restoring glenohumeral and scapulothoracic strength, endurance, and full, pain-free range of motion, while correcting any deficiencies in balance or rhythm throughout the overhead motion. Despite the operative treatment challenges that SLAP tears present, with new techniques and proper patient selection, overhead athletes with injuries to the biceps and superior labrum complex can return to sport at a high level.

Evaluation of Risk to the Suprascapular Nerve During Arthroscopic SLAP Repair: Is a Posterior Portal Safer?

PURPOSE

The purpose of this study was to compare the risk of glenoid perforation during SLAP repair for suture anchors placed through an anterolateral portal versus a posterolateral portal of Wilmington.

METHODS

Ten bilateral cadaveric shoulders were randomized to suture anchor placement through an anterolateral portal on one shoulder and a posterolateral portal on the contralateral shoulder. Anchors were placed into anterior, posterior, and far posterior positions on the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for right shoulders). The shoulder was then dissected, and the distance from the suture anchor tip to the nerve was measured if perforation occurred. The maximum load and failure mechanism of each anchor was assessed with a materials testing system machine.

RESULTS

Only 2 of 20 anchors placed in the posterosuperior glenoid through the posterolateral portal perforated compared with 16 of 20 of the anchors placed through the anterolateral portal (P < .05). The mean distance from the perforated anchor tip to the suprascapular nerve was 2.5 ± 1.4 mm for the anterolateral portal and 4.4 ± 0.6 mm for the posterolateral portal (P = .18). We did not observe a significant difference in biomechanical strength (P > .05).

CONCLUSIONS

There is a high rate of glenoid perforation in close proximity to the suprascapular nerve when placing anchors in the posterosuperior glenoid through an anterolateral portal. Use of the posterolateral portal results in a much lower incidence of glenoid perforation for anchors placed in the posterosuperior glenoid, but there is a higher risk of glenoid perforation for an anchor placed in the anterosuperior glenoid from the posterolateral portal.

CLINICAL RELEVANCE

There is a higher risk of injury to the suprascapular nerve when suture anchors are placed in the posterosuperior glenoid through an anterolateral portal compared with a posterolateral portal for SLAP repair.

Current trends in the evaluation and treatment of SLAP lesions: analysis of a survey of specialist shoulder surgeons

Background

Controversies exist in the classification and management of superior labral anterior and posterior (SLAP) lesions. Our aims were to assess the concordance rate of a group of specialist shoulder surgeons on the diagnosis of SLAP types and to assess the current trends in treatment preferences for different SLAP types.

Methods

Shoulder surgeons (N = 103) who are members of the Shoulder and Elbow Society of Australia were invited to participate in a multimedia survey on the classification and management of SLAP lesions. Response rate was 36%. The survey included 10 cases, each containing a short clinical vignette followed by an arthroscopic video depicting varying types of SLAP lesions. Surgeons were asked to classify the lesions and to recommend treatment.

Results

There is low interobserver agreement in classifying SLAP lesions. The most common misdiagnosis of type I lesion was as a type II, and vice versa. Surgeons preferred to treat type II SLAP lesions in younger patients (<35 years) with labral repair and in older patients with biceps tenodesis. The most commonly preferred repair technique for type II lesion was with suture anchors placed both anterior and posterior to the biceps tendon. For all lesion types, biceps tenotomy was a far less commonly preferred procedure than biceps tenodesis.

Conclusion

There is poor agreement between contemporary surgeons in the classification and treatment of SLAP lesions. The age of the patient appears to play a significant factor in the surgeons' deciding to treat a SLAP lesion with repair vs. biceps tenodesis.

Return to Play and Outcomes in Baseball Players After Superior Labral Anterior-Posterior Repairs

BACKGROUND

Few studies have documented the outcomes of superior labral anterior-posterior (SLAP) repairs in baseball players. Furthermore, the results of these previous studies varied widely and were based on small numbers of patients. Hypothesis/Purpose: The purpose was to report return-to-play (RTP) rates and validated subjective outcome scores for baseball players after SLAP repair. It was hypothesized that RTP rates and outcomes would be significantly different between pitchers and nonpitchers, as well as among baseball levels.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A series of 216 baseball players was identified who had isolated SLAP repair or SLAP repair with debridement of partial-thickness (<25%) rotator cuff tear at our surgical centers. Patients were contacted by phone a minimum of 2 years after surgery and asked questions about their ability to RTP. Patients were also asked questions to complete the Western Ontario Shoulder Instability Index (WOSI), Veteran's RAND 12-Item Health Survey (VR-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) questionnaires. Statistical equivalence in RTP rate, VR-12, and WOSI scores was determined between players with and without concomitant rotator cuff debridement using 2 one-sided tests and risk difference measures. Differences in RTP were tested among baseball levels (high school, college, professional) and positions (pitcher vs nonpitcher) using chi-square analyses ( P < .05). Differences in outcomes scores were compared using t tests and analyses of variance ( P < .05).

RESULTS

Of the 216 baseball players, 133 were reached by phone for follow-up interview (mean, 78 months; range, 27-146 months). Overall, 62% successfully returned to play. There were no differences in RTP rates or subjective outcomes among baseball levels or between procedures. RTP rates were 59% for pitchers and 76% for nonpitchers ( P = .060). Subjectively, the percentage of patients who felt the same or better at follow-up compared to preinjury was significantly higher among nonpitchers (66%) than pitchers (43%). There was no difference in KJOC scores between the pitchers (75.3 ± 19.4) and nonpitchers (76.2 ± 17.4) who successfully returned to play, although these scores were well below the minimum desired score of 90 for healthy baseball players.

CONCLUSION

SLAP repair should continue to be considered as an option for SLAP tear treatment only after nonsurgical management has failed. Some players may be able to return to baseball after SLAP repair, although regaining preinjury health and performance is challenging.

Arthroscopic Repair of Type II SLAP Tears Using Suture Anchor Technique

Arthroscopic SLAP tear repair has become an increasingly used treatment for patients presenting with symptomatic SLAP tears after failed nonoperative management. Debridement, SLAP repair, and open or arthroscopic biceps tenodesis or tenotomy have been used for the treatment of SLAP tears. Various techniques for repair have been described, and furthermore, there is a high incidence of concomitant pathology of the shoulder. Repair remains an excellent option in isolated SLAP tears amenable to repair, with excellent outcomes in well-indicated patients. We present a method for repairing a SLAP tear using standard suture anchor fixation, anterior and posterior portals, and an accessory portal of Wilmington. Adequate labral repair can be achieved with this technique in patients with no concomitant biceps pathology. This report highlights this technique for SLAP repair in patients with isolated symptomatic SLAP tears that have failed conservative management.

Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography

PURPOSE

In the present prospective study, the functional outcomes of non-operative treatment were evaluated in patients aged between 30 and 45 years presenting SLAP lesion in diagnostic provocative tests and magnetic resonance (MR) arthrography.

METHODS

Forty-six patients with a symptomatic SLAP lesion who participated in recreational level of sports were prospectively enroled. SLAP lesion was diagnosed using combinations of several clinical tests and MR arthrography findings. All patients were treated with intra-articular corticosteroid injections, followed by rotator cuff and periscapular muscle-strengthening exercises. Patients with persistent discomfort after second injection underwent arthroscopic SLAP repair. Functional outcomes were evaluated using ASES and Constant scores, and pain and satisfaction for visual analogue scale (VAS).

RESULTS

Pain had significantly improved from 5.2 ± 2.2 to 1.0 ± 1.1 (p < 0.001) in all patients after the first corticosteroid injection. SLAP symptoms relapsed in 12 patients at an average of 2.4 months after the first injection. Symptoms were relieved in 5 of 12 patients after the second injection and strengthening exercises. The remaining seven patients underwent arthroscopic SLAP repair. Thirty-nine patients (85 %) who were treated non-operatively showed improved VAS, Constant, and ASES scores at final follow-up (p < 0.001).

CONCLUSIONS

Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment.

CLINICAL RELEVANCE

Non-operative management using combined intra-articular corticosteroid injection with rotator cuff and periscapular strengthening exercises could be applied as primary treatment for patients with symptomatic SLAP lesion who participate in recreational level of sports.

LEVEL OF EVIDENCE

IV.

Outcomes in patients with glenoid labral lesions: a cohort study

BACKGROUND/AIM

For patients presenting with glenoid labral pathologies, there is little information on how operative interventions affect long-term outcomes and health-related quality of life (HRQoL). This study evaluated outcomes in operative and non-operative patients presenting with labral tears versus labral degenerations.

METHODS

Participants completed a pain Visual Analogue Scale (VAS), the Veterans RAND 12-item Health Survey, Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons instrument, Scapular Assistance Test (SAT), Shoulder Activity Level, and Single Assessment Numeric Evaluation at baseline and at 6-month, 12-month and 2-year follow-ups. χ²and Student's t-test were used to test the differences between categorical and continuous variables. Analysis of variance investigated the differences between groups, and linear regression analyses explored the relationship of baseline characteristics with outcome scores.

RESULTS

After 2 years, the operative cohort (n=68) significantly improved in all measures. The non-operative cohort (n=55) showed significant improvements in all scores except the mental component summary (MCS) and pain VAS. Labral tear patients (n=52) within the operative group (n=28) significantly improved in all measures except MCS. Non-operative labral tear patients (n=24) indicated significant improvements in all measures except MCS, VAS and SAT. Labral degeneration patients (n=71) within the operative group (n=27) significantly improved in all measures except MCS and SAT. Non-operative labral degeneration patients (n=44) indicated significant improvements in all measures except the physical component summary, MCS, VAS and SAT.

CONCLUSION

Patients who were surgically treated for labral tears or degenerations had significantly improved outcomes and HRQoL scores after 2 years compared with the non-operative cohort.

Arthroscopic Knot Removal for Failed Superior Labrum Anterior-Posterior Repair Secondary to Knot-Induced Pain

BACKGROUND

Studies on failed superior labrum anterior-posterior (SLAP) repair are increasing. However, the number of reports on treatment options for failed SLAP repair remains quite low, and the clinical results vary between different study groups.

PURPOSE

To describe the clinical presentation of failed SLAP repair due to knot-induced pain and evaluate the efficacy of arthroscopic knot removal.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors retrospectively reviewed records of 11 patients (mean age, 24.6 ± 8.6 years; range, 17-43 years) with stable, healed SLAP lesions with knot-induced pain after arthroscopic fixation of unstable type II SLAP lesions. All patients demonstrated a positive compression-rotation test before knot removal. The mean follow-up duration after knot removal was 48.0 ± 37.4 months (range, 24-156 months). The mean duration between primary fixation and knot removal was 21.2 ± 14.7 months (range, 8-56 months).

RESULTS

Sharp pain (100%) and clicking (64%) were the most common symptoms. The knot was positioned on the glenoid side in 5 patients and the labral side in 6 patients. The knots on the glenoid side had associated humeral head cartilage damage. The mean University of California at Los Angeles score significantly improved from 15.2 points to 31.7 points after knot removal ( P = .003) Additionally, the mean Constant score greatly improved from a mean of 56.5 points to 89.8 points ( P = .003). At a mean of 3 weeks after surgery, we observed dramatic pain relief. Six weeks after surgery, the compression-rotation test was negative in all patients.

CONCLUSION

The most common symptom of knot-induced pain after SLAP repair was persistent sharp pain followed by clicking. The knot appears to be a cause of pain in failed SLAP repairs, and arthroscopic knot removal can provide dramatic pain relief and significant improvement of clinical outcomes.

Modelling the Functional Comorbidity Index as a predictor of health-related quality of life in patients with glenoid labrum disorders

Background/aim

Health-related quality of life (HRQoL) is increasingly assessed within orthopaedic research. For those patients presenting with glenoid labral pathologies, there is little information on how baseline comorbidities affect long-term outcomes and HRQoL. This study aimed to investigate a model, including baseline comorbidities and demographics, to predict change in 2-year HRQoL scores in adult patients with glenoid labral tears or degenerations.

Methods

Participants provided Functional Comorbidity Index (FCI) scores and self-completed the Western Ontario Rotator Cuff (WORC) index at 6, 12 and 24 months. Univariable and multivariable linear regressions were performed to assess predictive quality of baseline comorbidities and demographics on the primary outcome measure of interest (change in WORC score).

Results

Multivariate regression with a continuous scaled FCI (β=617.8, p=0.042), age (by decade) (β=297, p<0.01), surgical group (β=−476.69, p<0.01) and an interaction term between FCI and age (β=−103.65, p=0.03) were significant predictors of change in WORC scores at 2-year follow-up (r²=0.293858). Multivariate regression with FCI scaled categorically reported only patients with three comorbidities (β=−454.06, p=0.057) and age (by decade) (β=156.87, p=0.04) as the only significant predictors of change in WORC scores at 2-year follow-up (r²=0.1279).

Conclusion

The continuous FCI model is better suited to predict future WORC and HRQoL scores among this patient population. Patients reporting with higher numbers of baseline comorbidities improved significantly more than patients with fewer comorbidities. This information on expected change in HRQoL scores among patients with a wide range of FCI scores at baseline may help guide treatment decisions based on these criteria.

Arthroscopic Repair of Inferior Labrum Anterior to Posterior Lesions of the Shoulder Using a Combined "Double-Pulley" Simple Knot Technique

Inferior labrum anterior to posterior lesions as an isolated injury or as part of an extensive traumatic labral tear are uncommon and may present as multidirectional instability of the shoulder. These lesions are hard to visualize radiographically and many times are diagnosed only during surgery. Arthroscopic repair of these lesions requires advanced arthroscopic skills and is required for restoration of glenohumeral stability. We report a combined double-pulley simple knot technique that anatomically reconstructs the inferior labrum while overcoming the typical technical challenges, providing a large footprint for healing along the inferior glenoid rim and minimizing the amount of suture material in direct contact with the articular cartilage and the risk of knot migration.

Anterior Shoulder Instability with Concomitant Superior Labrum from Anterior to Posterior (SLAP) Lesion Compared to Anterior Instability without SLAP Lesion

BACKGROUND

The aims of this study were to investigate the clinical characteristics of patients with combined anterior instability and superior labrum from anterior to posterior (SLAP) lesions, and to analyze the effect of concomitant SLAP repair on surgical outcomes.

METHODS

We retrospectively reviewed patients who underwent arthroscopic stabilization for anterior shoulder instability between January 2004 and March 2013. A total of 120 patients were available for at least 1-year follow-up. Forty-four patients with reparable concomitant detached SLAP lesions (group I) underwent combined SLAP and anterior stabilization, and 76 patients without SLAP lesions (group II) underwent anterior stabilization alone. Patient characteristics, preoperative and postoperative pain scores, Rowe scores, and shoulder ranges of motion were compared between the 2 groups.

RESULTS

Patients in group I had higher incidences of high-energy trauma (p = 0.03), worse preoperative pain visual analogue scale (VAS) (p = 0.02), and Rowe scores (p = 0.04). The postoperative pain VAS and Rowe scores improved equally in both groups without significant differences. Limitation in postoperative range of motion was similar between the groups (all p-value > 0.05).

CONCLUSIONS

Anterior instability with SLAP lesion may not be related to frequent episodes of dislocation but rather to a high-energy trauma. SLAP fixation with anterior stabilization procedures did not lead to poor functional outcomes if appropriate surgical techniques were followed.

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.

A new anatomic technique for type II SLAP lesions repair

PURPOSE

A new and more anatomical technique for SLAP II lesions repair is described. It consists in the reattachment of the medial aspect of the biceps anchor to the superior glenoid neck with a mattress stitch posterior and medial to the biceps anchor and a simple stitch placed anteriorly to the biceps.

METHODS

From 2011 to 2012, 14 patients matching the inclusion criteria were selected for the study. A visual analogic scale, ROWE, UCLA, ASES and Constant scores were used to make evaluation. The passive ROM before surgery, at final follow-up, and the resumption of sports activities were analysed.

RESULTS

The Constant, ASES, UCLA and ROWE scores passed from 64.6 (SD 13.9), 76.9 (SD 22.4), 28.4 (SD 23.8) and 53.6 (SD 20.6) to, respectively, 92.6 (SD 11.8), 108.3 (SD 8.5), 33.6 (SD 2.7) and 96.5 (SD 7.2) at final follow-up. Of the four patients who had participated in agonistic overhead athletics preoperatively, all of them were able to return to their preinjury level. No complications were observed in the present study.

CONCLUSION

In our technique, the anatomy is respected leaving the articular aspect of the superior labrum loose and reinforcing the medial side. The clinical relevance of this work is that probably this technique could improve clinical results, giving a better mobility of the shoulder and a return to the same preoperative level in overhead athletes.

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.