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

Lower Reoperation and Higher Return-to-Sport Rates After Biceps Tenodesis Versus SLAP Repair in Young Patients: A Systematic Review

Purpose

To evaluate patient-reported outcomes, return to sport, and adverse events after SLAP repair versus biceps tenodesis (BT) in a young patient population undergoing treatment of SLAP tears.

Methods

We performed a systematic review and meta-analysis of the PubMed (MEDLINE), Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for comparative studies discussing outcomes after SLAP repair and BT in patients younger than 40 years with at least 1 year of follow-up.

Results

Four studies were included, comprising a total of 274 patients who underwent treatment of SLAP tears with SLAP repair (169 patients) or BT (105 patients). Most patients were male patients (79.8%) and athletes (74.5%). Preoperative and postoperative pain visual analog scale scores decreased similarly in both groups (range, 6.6-6.7 preoperatively to 0.8-2.6 postoperatively in SLAP repair group vs 5.6-7.3 preoperatively to 0.7-1.9 postoperatively in BT group). Similar and substantial American Shoulder and Elbow Surgeons Standardized Shoulder Assessment score increases were observed after both procedures (range, 40.6-45.8 preoperatively to 75.4-92.0 postoperatively in SLAP repair vs 41.9-55.0 preoperatively to 85.7-91.2 postoperatively in BT group). Patient satisfaction rates were similar but showed slightly higher ranges after BT (8.5-8.8 vs 8.0-8.2). Rates of return to sport were higher after BT (63%-85% vs 50%-76%), with higher odds of returning to sport after BT reported by all studies. Surgical complications were rare after SLAP repair and BT. Rates of reoperation were substantially higher after SLAP repair (3%-15% vs 0%-6%), with 3 of 4 studies reporting no reoperations after BT. BT comprised 78% to 100% of reoperation procedures after SLAP repair.

Conclusions

Postoperative pain, function, and patient satisfaction were similar after SLAP repair and BT in patients younger than 40 years. There are higher rates of reoperation and lower rates of return to sport after SLAP repair than after BT.

Level of Evidence

Level III, systematic review of Level III studies.

Posterior repair of isolated type 2 superior labrum anterior-posterior lesion prevents external rotation deficiency: long-term outcome study

PURPOSE

This study aimed to evaluate the outcomes of arthroscopic type 2 superior labrum anterior-posterior (SLAP) lesion repair in the general population and compare clinical outcomes according to patient age and repair site.

METHODS

Between 2005 and 2018, patients who underwent arthroscopic repair for isolated type 2 SLAP lesions were retrospectively reviewed. Baseline characteristics, pre- and postoperative [1-year and > 2-year (final)] shoulder range-of-motion, and functional scores, comprising the pain visual analogue scale (PVAS), functional VAS, and American Shoulder and Elbow Surgeons (ASES) score, were evaluated. Return to overhead activities and subjective satisfaction were assessed at the final follow-up, and patients were divided by age [group YB (< 40 years] and group OB (≥ 40 years)] and repair site [group P (only posterior labrum repair) and group AP (anterior and posterior labrum repair)]. Overall patient outcomes were analysed and compared between groups.

RESULTS

This study included 54 patients (45 men) with a mean age of 37.1 ± 8.3 years. The mean follow-up was 90.8 ± 51.3 months. Two patients experienced early failure, and one patient had a ruptured biceps tendon during the follow-up period. Final functional scores improved compared to their preoperative scores in all patients, except three (all p < 0.001). Fifty patients (98.0%) were satisfied, and 39 patients (76.5%) were able to perform overhead sports without restriction. In 25 patients who attended more than 7 years of follow-up (mean, 11.3 ± 2.7 years), 21 patients (84%) had an ASES score ≥ 80, and all patients had PVAS ≤ 2. There was no significant difference in clinical outcomes between groups YB and OB. The final median external rotation was significantly more restricted in group AP than in group P (40 [25-65] vs. 60 [50-70], p = 0.002).

CONCLUSION

Arthroscopic type 2 SLAP repair induced good short- and long-term clinical outcomes, return to overhead activities, and subjective satisfaction in the general population, regardless of age, due to the careful evaluation of patient history, physical examination, and imaging studies. However, performing only posterior repair seems sufficient since anterior labral SLAP lesion repair can limit ER. Isolated type 2 SLAP lesion posterior repair only is, thus, recommended to reduce external rotation deficit risk and increase satisfaction, regardless of patient age.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level IV.

SLAP tears and return to sport and work: current concepts

Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.

Return to Play After Biceps Tenodesis and Transfer in a Young, Athletic Population

The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis and transfer. The authors hypothesized that both return to play rates and clinical improvement would be high after biceps tenodesis and transfer among young athletes. They conducted a retrospective review of patients who underwent biceps tenodesis and transfer procedures with a minimum follow-up of 24 months. Eligible patients were contacted for consent and asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores, level of postoperative play, and other relevant information. The study included 41 patients with a mean age of 21.3 years. Patients reported a mean Kerlan-Jobe Orthopaedic Clinic (KJOC) score of 71.7, Disabilities of the Arm, Shoulder and Hand (DASH)-Sports score of 21.3, Single Assessment Numeric Evaluation (SANE) score of 79.4, and Numeric Rating Scale (NRS) pain score of 1.8. Scores for all patient-reported outcome measures were statistically better (P<.05) for patients who underwent biceps transfer (n=24) compared with biceps tenodesis (n=17). Of the participants, 26 (63%) played a primary overhead throwing sport. Most of the patients (95%) returned to play, and of those who returned to play, 67% returned to their preoperative level or higher. Although biceps tenodesis and transfer procedures have been designated primarily for older patients with biceps-labral complex injuries, the high return to play rates and outcome scores of patients in this case series show that biceps tenodesis and transfer can provide effective surgical treatment for a younger athletic population with biceps-labral complex injuries. [Orthopedics. 2021;44(1):e13-e18.].

National Trends in the Repair of Isolated Superior Labral Tear from Anterior to Posterior in Korea

BACKGROUND

The optimal treatment for superior labral tear from anterior to posterior (SLAP) lesions is controversial. Thus, we aimed to investigate the national surgical trends in isolated SLAP repair in Korea.

METHODS

We analyzed a nationwide database from the Korean Health Insurance Review and Assessment Service from 2008 to 2017. We investigated the trends in SLAP repair by time, sex, age, and the type of health care institution.

RESULTS

From 2008 to 2017, 27,850 isolated SLAP repairs were identified. Age-adjusted incidence rate of isolated SLAP repair increased by 692% from 1.07/100,000 in 2008 to 8.48/100,000 in 2012 (P = 0.005). However, the incidence rate declined significantly after 2012 (P = 0.032) and was 5.28/100,000 in 2017. Sex-specific incidence rate of isolated SLAP repair was 2.3 times higher in men than in women. The decline since 2012 was most evident in patients aged ≥ 40 years (P = 0.01); however, the incidence rates of isolated SLAP repair during the study period were similar between patients aged ≥ 40 years and those aged < 40 years. Moreover, hospitals with 30-100 beds had the greatest change in the number of isolated SLAP repair cases.

CONCLUSION

In Korea, the incidence of isolated SLAP repair increased dramatically until 2012; since then, it has declined. Although the decrease in isolated SLAP repair later in the study was evident in those aged ≥ 40 years, the incidence rate was still relatively high in patients aged ≥ 40 years.

Posterior Labral Repairs of the Shoulder Among Baseball Players: Results and Outcomes With Minimum 2-Year Follow-up

BACKGROUND

There is a paucity of information regarding the treatment of posterior labral tears of the shoulder for baseball players. Reports regarding treatment and postoperative outcomes are more limited than its anterior and superior counterparts.

PURPOSE

To evaluate the clinical presentation, surgical findings, postoperative outcomes, and rate of return to sport after arthroscopic repair of posterior labral injuries of the shoulder among baseball players.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Retrospective review was performed of baseball players who underwent arthroscopic posterior labral repair between 2009 and 2015 by a single surgeon, with a minimum 2-year follow-up. The group was composed of 32 male patients involved in recreational (6.3%), high school (43.8%), college (31.3%), and professional (18.8%) baseball, with a mean age of 20.5 years. Patients were categorized by chief complaint, clinical findings, surgical findings, and concomitant procedures performed. Pre- and postoperative measures included pain scale, range of motion, American Shoulder and Elbow Surgeons shoulder score, return to play, and patient satisfaction.

RESULTS

A variety of tear patterns were identified; 32% involved 90° of the posterior superior labrum; 35% involved the posterior 180°; and 32% involved 90° of the posterior inferior labrum. The dominant mechanism of injury was throwing (34.4%). The most common chief complaint was pain (n = 25, 78%), followed by pain and instability symptoms (n = 6, 18.8%), with only 3% citing isolated sensation of instability. Magnetic resonance imaging clearly identified tear patterns in 75% of cases. American Shoulder and Elbow Surgeons scores significantly improved ( P < .0001), increasing on average 30.9 points from the preoperative mean of 65.4 to a postoperative mean of 96.3. No significant range of motion deficits were noted. Tear size and number of anchors utilized did not influence outcomes. Ninety-four percent of athletes returned to play, 61% at previous levels, and 6% did not return. Pitchers had a lower return to previous level of play than position players (41% vs 86%, P = .0113).

CONCLUSION

Arthroscopic treatment of posterior labral tears of baseball players was effective in improving pain and function, resulting in 94% patient satisfaction and 94% return to sport, with 61% returning to previous level of play. Patient presentation is variable, with a majority of patients citing pain rather than instability.

Effectiveness of biceps tenodesis versus SLAP repair for surgical treatment of isolated SLAP lesions: A systemic review and meta-analysis

BACKGROUND

Type II superior labrum anterior and posterior (SLAP) lesions could induce chronic shoulder pain and impaired movement. Current management of Type II SLAP lesions consists of two well-established surgical procedures: arthroscopic biceps tenodesis and SLAP repair. However, which technique is preferred over the other is still a controversy.

METHODS

We performed a systematic electronic database search on Cochrane Central Register of Controlled Trials, MEDLINE and Embase to identify articles equating superior labral repair with biceps tenodesis, which were reported before August 2017 which included the phrase "superior labral anterior posterior" or "SLAP." The randomised controlled clinical trials that met our criteria were evaluated for quality of methodology. The results obtained were further analysed and correlated to present the benefits and drawbacks comparing the two SLAP repair surgical procedures.

RESULT

Based on our inclusion and exclusion criteria, we identified five articles (204 patients) that were included in this meta-analysis. The results indicate that prevalence of patients return to preinjury sports level and the patients satisfaction were found to be significantly better in tenodesis group than in the SLAP repair group (p < 0.05). As for the patient age, VAS score, American Shoulder and Elbow Surgeons score, University of California at Los Angeles score, postoperative stiffness and reoperation rates, no significant differences were evident among the two groups, thus supporting the results reported in the current literatures (p > 0.05).

CONCLUSIONS

Both the surgical treatments, SLAP repair and the biceps tenodesis, are efficacious in pain alleviation and recovery of shoulder function. But, compared with SLAP repair, biceps tenodesis showed higher rate of patient satisfaction and return to preinjury sports participation.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Impart better understanding regarding discrepancies in the outcomes between biceps tenodesis and SLAP repair in treating patients with isolated Type II SLAP lesions.

Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis

PURPOSE

To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear.

METHODS

A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness.

RESULTS

Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644.

CONCLUSIONS

When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair.

LEVEL OF EVIDENCE

Level III, economic decision analysis.

Biceps Tenodesis and Intra-articular Decompression for Treatment of Superior Labral Tear from Anterior to Posterior and Associated Paralabral Cyst in Active Duty Military

Background

To examine the outcomes of combined biceps tenodesis and indirect, intra-articular arthroscopic paralabral cyst decompression for the treatment of active duty military patients with superior labral from anterior to posterior tears and associated paralabral cysts.

Methods

Retrospective chart review of all active duty patients at our institution from 2011 to 2014 with superior labral from anterior to posterior tears and associated paralabral cysts at the spinoglenoid notch treated with biceps tenodesis and indirect arthroscopic cyst decompression. Patient charts were examined for pre- and post-operative parameters including strength, range of motion, visual analog scale pain score, American Shoulder and Elbow Surgeon Score, and Single Assessment Numeric Evaluation Score.

Results

Seven patients met study criteria. All patients presented with chronic shoulder pain and decreased external rotation strength, and three patients had clinically apparent muscular atrophy. Pre- and post-operative assessment showed external rotation strength increased from a median of 4 (range 4-4) to 5 (range 4-5; p-value = 0.014), Single Assessment Numeric Evaluation increased from a median of 50 (range 0-70) to 75 (range 30-95; p-value = 0.031), American Shoulder and Elbow Surgeon increased from a median of 46.0 (range 32.0-58.0) to 66.5 (range 58.0-98.0; p-value = 0.068), and visual analog scale pain score decreased from a median of 3 (range 1-8) to 0 (range 0-5; p-value = 0.017). Median follow-up was 66 wk (range 36-138 wk). The change was statistically significant (p <0.05) for external rotation strength, Single Assessment Numeric Evaluation, and VAS reduction. Post-operatively, all patients returned to full duty at a median of 20 wk (range 12-36 wk).

Conclusion

The use of biceps tenodesis in conjunction with indirect, intra-articular arthroscopic paralabral cyst decompression is an effective technique in an active patient population with superior labral from anterior to posterior tear with associated paralabral cyst.

Are Outcomes After Meniscal Repair Age Dependent? A Systematic Review

PURPOSE

To determine if the failure rate and functional outcome after arthroscopic meniscus suture repair are age dependent.

METHODS

A systematic review was conducted using a computerized search of the electronic databases MEDLINE and ScienceDirect in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Extracted data from each included study were recorded on a standardized form. Studies were included if they (1) were English-language studies in peer-reviewed journals, (2) used a distinct age cut-off to evaluate outcome of meniscal surgery for those above and below the specified cut-off, and (3) used meniscal repairs using suture based technique with inside-out, outside-in, or all-inside techniques. Review papers, case reports, technique papers, non-English language publications, abstracts, and data on meniscal repairs using meniscal screws, arrows, or darts were excluded.

RESULTS

15 of 305 identified articles met the inclusion/exclusion criteria. There were 1,141 menisci treated in 1,063 patients. Seven and 8 studies met the inclusion/exclusion criteria for analysis for the age thresholds of 25 years and 30 years, respectively, demonstrating no difference in failure rates relative to age threshold. Four of 6 studies that met analysis criteria found no difference in failure rates above or below an age threshold of 35 years. No significant difference in failure in patients younger than 40 than patients older than 40 was found for 4 of the 5 studies in that arm of the review.

CONCLUSIONS

Analysis of the composite data in this systematic review reveals that no significant difference exists when evaluating meniscal repair failure rate as a function of age above or below the given age thresholds.

LEVEL OF EVIDENCE

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

Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective

BACKGROUND

Data regarding risk factors for revision surgery after superior labral anterior-posterior (SLAP) repair are limited to institutional series.

PURPOSE

To define risk factors for revision surgery after SLAP repair among patients in a large national database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A national insurance database was queried for patients undergoing arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) for the diagnosis of a SLAP tear. Patients without a CPT modifier for laterality were excluded. Revision surgery was defined as (1) subsequent ipsilateral SLAP repair (CPT 29807), (2) ipsilateral arthroscopic debridement for the diagnosis of a SLAP tear (CPT 29822 or 29823, with diagnosis code 840.7), (3) subsequent ipsilateral arthroscopic biceps tenodesis (CPT 29828), (4) subsequent ipsilateral open biceps tenodesis (CPT 23430), and (5) subsequent biceps tenotomy (CPT 23405). Multivariable binomial logistic regression analysis was performed to identify risk factors for revision surgery after SLAP repair, including patient demographics/comorbidities, concomitant diagnoses, and concomitant procedures performed. Odds ratios (ORs), 95% CIs, and P values were calculated. The estimated financial impact of revision surgery was also calculated.

RESULTS

There were 4751 patients who met inclusion and exclusion criteria. Overall, 121 patients (2.5%) required revision surgery after SLAP repair. Regression analysis identified numerous risk factors for revision surgery, including age >40 years (OR, 1.5; 95% CI, 1.2-1.8; P = .045), female sex (OR, 1.5; 95% CI, 1.3-1.8; P = .010), obesity (OR, 1.8; 95% CI, 1.5-2.2; P = .001), smoking (OR, 2.0; 95% CI, 1.6-2.4; P < .0001), and diagnosis of biceps tendinitis (OR, 3.5; 95% CI, 3.0-4.2; P < .0001) or long head of the biceps tearing (OR, 5.1; 95% CI, 4.1-6.3; P < .0001) at or before the time of surgery. Concomitant rotator cuff repair and distal clavicle excision were not significant risk factors for revision surgery. The cost of revision surgery averaged almost $9000.

CONCLUSION

Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery. The high cost of revision surgery highlights the importance of appropriate indications to avoid the need for subsequent procedures.

Subsequent Shoulder Surgery After Isolated Arthroscopic SLAP Repair

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, case-control study.

Comparison of satisfied and dissatisfied patients 2 to 5 years after anatomic total shoulder arthroplasty

BACKGROUND

With an increasingly large number of patients undergoing total shoulder arthroplasty (TSA) combined with increased requirements for public reporting of patient outcomes, there is a greater need to better understand the underlying factors related to patient satisfaction. The purpose of this study was to compare patient demographics, nonorthopedic comorbidities, patient-reported outcome scores, and range of motion of patients who reported being either satisfied or dissatisfied with their procedure at midterm follow-up.

METHODS

We identified 234 primary TSAs performed by a single surgeon for glenohumeral osteoarthritis with a minimum 2-year follow-up in a prospective shoulder arthroplasty registry. American Shoulder and Elbow Surgeons (ASES) score, patient satisfaction, and active forward flexion, abduction, and external rotation at 0° of flexion-abduction were assessed before and after TSA.

RESULTS

Of the 234 patients, 207 (88.5%) were satisfied with their procedure. Dissatisfied patients had significantly lower ASES scores both before and after surgery (P < .001) as well as a significantly lower preoperative to postoperative change in ASES score (P < .001). Similarly, dissatisfied patients demonstrated significantly lower changes in active forward flexion (P = .004), abduction (P = .02), and external rotation (P = .03). Patients with ASES score changes <12 points were 19 times more likely to be dissatisfied after TSA (95% confidence interval, 4.4-81.4; P = .0001).

CONCLUSION

Dissatisfied patients had significantly lower improvements in pain, function, and range of motion. Furthermore, a change in ASES score <12 points was associated with a 19-fold increase in the risk of being dissatisfied after TSA.

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

Background/Purpose

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

Methods

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

Results

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

Conclusion

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

Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review

BACKGROUND

Successful arthroscopic repair of symptomatic superior labral tears in young athletes has been well documented. Superior labral repair in patients older than 40 years is controversial, with concerns for residual postoperative pain, stiffness, and higher rates of revision surgery.

PURPOSE

To analyze the published data on the surgical treatment of superior labral injuries in patients aged ≥40 years, including those with concomitant injuries to the rotator cuff.

STUDY DESIGN

Systematic review.

METHODS

A systematic review of the literature was performed using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The MEDLINE database via PubMed and the Cochrane Database of Systematic Reviews were searched for articles related to superior labrum anterior-posterior (SLAP) tears. Studies were included if they met the following criteria: the study contained at least 1 group of patients who had undergone arthroscopic repair of a type II or IV SLAP lesion with a minimum 2-year follow-up, objective and/or functional scoring systems were used to evaluate postoperative outcomes, and the mean patient age was ≥40 years for at least 1 treatment arm or subgroup analysis. Studies were excluded if the article was a review or if the article included data for SLAP type I, III, or V to X tears or Bankart lesions.

RESULTS

While several authors reported equivalent outcomes of SLAP repair in patients both older than 40 years and younger than 40 years, others demonstrated significantly higher failure rates in the older cohort. Decreased patient satisfaction and increasing complications, including postoperative stiffness and reoperations, occur at higher rates as the patient age increases. The literature demonstrates that biceps tenotomy and tenodesis are reliable alternatives to SLAP repair and that biceps tenotomy is a viable revision procedure for failed SLAP repair. With concomitant rotator cuff tears, the evidence favors debridement or biceps tenotomy over SLAP repair.

CONCLUSION

While studies show that good outcomes can be obtained with SLAP repair in an older cohort of patients, age older than 40 years and workers' compensation status are independent risk factors for increased surgical complications. The cumulative evidence supports labral debridement or biceps tenotomy over labral repair when an associated rotator cuff injury is present.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term results after SLAP repair: a 5-year follow-up study of 107 patients with comparison of patients aged over and under 40 years

PURPOSE

The aims of this prospective cohort study were to assess the long-term results after isolated superior labral repair and to determine whether the results were associated with age.

METHODS

One hundred seven patients underwent repair of isolated SLAP tears. There were 36 women and 71 men with a mean age of 43.8 years (range, 20 to 68 years). Mean follow-up was 5.3 years (range, 4 to 8 years). Of the patients, 62 (57.9%) were aged 40 years or older. Follow-up examinations were performed by an independent examiner; 102 patients (95.3%) had a 5-year follow-up.

RESULTS

The Rowe score improved from 62.8 (SD, 11.4) preoperatively to 92.1 (SD, 13.5) at follow-up (P < .001). Satisfaction was rated excellent/good for 90 patients (88%) at 5 years. There was no significant difference in the results for patients aged 40 years or older and those aged under 40 years. Difficulty with postoperative stiffness and pain was reported by 14 patients (13.1%).

CONCLUSIONS

Our results suggest that long-term outcomes after isolated labral repair for SLAP lesions are good and independent of age. Postoperative stiffness was registered in 13.1% of the patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Short-term clinical results after arthroscopic type II SLAP repair

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Demographic trends in arthroscopic SLAP repair in the United States

BACKGROUND

Treatment of superior labral anterior posterior (SLAP) tears remains controversial, particularly in older age groups. Repair, debridement, biceps tenodesis, tenotomy, and observation have been recommended depending on patient characteristics, but there have not been any large epidemiologic studies investigating treatment trends.

PURPOSE

To investigate current trends in SLAP repair across time, gender, age, and regions in the United States.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Patients who underwent arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) were identified using a publicly available national database of insurance records (PearlDiver Patient Records Database) during years 2004 through 2009. Factors identified for each patient included gender, age group, and region in the United States. Logistic regression analysis and the chi-square test were used for statistical measures.

RESULTS

From 2004 to 2009 there were 25,574 cases of arthroscopic SLAP repair identified, of which 75% were male patients and 25% were female patients. There was a significant rise in cases of SLAP repair from 2004 to 2009 as the incidence of SLAP repair increased from 17.0 for every 10,000 patients with an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or CPT code in 2004 to 28.1 in 2009 (P < .0001). Age analysis revealed the highest incidence in the 20-29-year (29.1 per 10,000) and 40-49-year (27.8 per 10,000) age groups. Men (37.3 per 10,000) had a significantly higher incidence of repairs than did women (10.7 per 10,000). The West (24.6 per 10,000) and South (24.4 per 10,000) regions also demonstrated a higher incidence than the Midwest (20.5 per 10,000) and Northeast (20.1 per 10,000) regions (P < .0001).

CONCLUSION

Our analysis illustrates that surgeons are performing significantly more arthroscopic SLAP repairs each year. The highest incidence of repair is in the 20-29- and 40-49-year age groups, and a significant gender difference exists, with men having a threefold higher incidence of repair.

Outcomes of revision arthroscopic type II superior labral anterior posterior repairs

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

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

HYPOTHESIS

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

EVALUATION OF RESULTS AND COMPLICATIONS FROM ARTHROSCOPIC SUTURE OF SLAP LESIONS

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

The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions

BACKGROUND

The majority of clinical outcome studies of type II superior labral anterior and posterior (SLAP) repair assess patients younger than age 40. Biceps tenotomy or tenodesis is often recommended for patients older than age 40 with superior labrum-biceps complex injury.

HYPOTHESIS

There is no difference in patient clinical outcomes comparing arthroscopic type II SLAP repair in patients younger or older than age 40.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Fifty-two patients stratified to groups younger than age 40 (21 patients; average age, 32.9 years) and older than age 40 (31 patients; average age, 55.1 years) were identified at a minimum 2-year follow-up (average, 28 months) after type II SLAP repair by a single surgeon using suture anchors. Outcome scores included American Shoulder and Elbow Society scores (ASES), Short Form-12 scores, Simple Shoulder Test scores, and visual analog pain scale.

RESULTS

At follow-up, there was no statistical difference in visual analog pain scale (P = .16), ASES scores (P = .07), Simple Shoulder Test scores (P =.41), Short Form-12 testing, or range of motion testing. Patients older than age 40 noted their shoulder to be 87% of normal; 26 of 31 (84%) were satisfied to completely satisfied, and 28 of 31 (90%) would have the surgery again. Patients younger than 40 noted their shoulder to be approximately 89% of normal; 20 of 21 (95%) were satisfied to completely satisfied, and 18 of 21 (86%) would have the same procedure performed again.

CONCLUSION

Our findings support that arthroscopic treatment of isolated type II SLAP repair using suture anchors can yield good to excellent results in patients older and younger than age 40. We found no statistically significant difference in patient outcome scores, satisfaction levels, or willingness to have the same procedure again when comparing arthroscopic SLAP repair in patients younger or older than age 40.

Imaging shoulder instability in the athlete

Athletes who partake in overhead or throwing activities frequently suffer from shoulder pain. Glenohumeral instability plays an important role in sports-related shoulder pain. Shoulder instability can be traumatic, atraumatic, or microtraumatic in origin. In athletes, atraumatic and microtraumatic instabilities can lead to secondary impingement and chronic damage to intra-articular structures. MR arthrography is the modality of choice for assessing glenohumeral instability and diagnosing labroligamentous injuries. This article reviews imaging of instability-related injuries in athletes, with special emphasis on MR imaging.