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

Outcomes of primary arthroscopic shoulder stabilization in active patients over 40-results at a mean follow-up of 7 years

Background

The purpose of this study is to report clinical outcomes, return to activity, redislocation rate, and rate of conversion to arthroplasty for active patients over age 40 undergoing primary arthroscopic shoulder stabilization.

Methods

Patients over 40 years of age who underwent arthroscopic capsulolabral repair for shoulder instability between December 2005 and January 2018 with a minimum of 2-year postoperative follow-up were enrolled in this retrospective, monocentric study. Clinical outcome scores including the 12-Item Short-Form Survey, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand, Single-Assessment Numeric Evaluation, and visual analog scale pain were collected. Additionally, it was determined which patients reached the minimal clinically important difference and the patient-acceptable symptom state for the ASES score. Bivariate analysis was utilized to determine if there was any association between baseline demographic and clinical factors with the outcome scores.

Results

Of a total of 814 patients assessed for eligibility, an aggregate of 40 patients were included and 33 patients (8 females) were available for follow-up. The average age was 49.4 ± 7.6 years. At an average follow-up of 7.0 ± 3.6 years, all the outcome scores significantly improved compared to baseline. These included ASES (69.9 ± 19 to 95.8 ± 7.6, P < .001); the Quick Disabilities of the Arm, Shoulder, and Hand score (29.7 ± 17.7 to 3.9 ± 5.4, P < .002); Single Assessment Numeric Evaluation score (53.5 ± 29.3 to 91.6 ± 14.3, P < .003); the 12-Item Short-Form Survey (45.6 ± 8.8 to 55.2 ± 5.7, P < .001); and the visual analog scale (2.1 ± 2.1 to 0.3 ± 1, P < .002). The minimal clinically important difference was reached by 72.7% of the patients and 81.8% reached the patient-acceptable symptom state threshold for the ASES score. Postoperative shoulder stability improved substantially and significantly. Median postoperative satisfaction was 10/10 (range 1-10). Ninety-five-point-six percent of the patients returned to sport, with 91.0% of the patients able to return to preinjury level. One patient (3%) underwent revision surgery for osteoarthritis, in the form of comprehensive arthroscopic management procedure. The presence of cartilage defects cartilage defects Outerbridge grade >2 (P = .020) and posterior labral lesions (P = .03) at index surgery were significantly associated with inferior outcomes in the ASES score.

Conclusion

Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. However, the presence of high-grade cartilage lesions and the presence of a posterior labral tear were associated with inferior clinical outcomes.

Long-term results of arthroscopic repair of type II SLAP lesions in sports: assessment of return to pre-injury playing level and critical risk factors for complication

PURPOSE

The management of isolated SLAP lesions is still debated especially in athletes. Aims of the study were: 1. to analyse our algorithm to treat SLAP lesions starting from the selection of patients for surgery and 2. to correlate the familiarity for diabetes and hypothyroid disorders with post-operative results.

METHODS

Seventy-eight patients with isolated SLAP lesion were arthroscopically treated using knotless anchors and microfractures. All patients had a pre-operative and post-operative clinical examination according to Walch-Duplay, Constant, Rowe and Dash scores and interviewed for familiarity to diabetes and hypothyroid disorders.

RESULTS

About 68.8% of patients solved pain with rehabilitation. About 29% of patients returned to the sports activities. About 32% of patients were no responder to physiotherapy and were arthroscopically treated. About 53.9% of patients responded excellent, 34.7% good, 3.8% medium and 7.6% poor results according to Walch-Duplay score. The Constant score increased from 64 to 95, the Rowe score from 48 to 96. The outcomes were significantly worse in patients with familiarity for diabetes.

CONCLUSIONS

Microfractures and knotless anchor give long-term good results for the treatment of SLAP lesions in athletes. The familiarity for diabetes is an important risk factor that can lead to decreased outcomes.

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.

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.

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.

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.

Arthroscopic treatment of type II superior labral anterior to posterior (SLAP) lesions in a younger population: minimum 2-year outcomes are similar between SLAP repair and biceps tenodesis

PURPOSE

Compared to a relatively older population over 30-40 years of age, the efficacy of biceps tenodesis for type II SLAP lesions in a younger population is not well studied. The purpose of this study was to compare outcomes between biceps tenodesis and labral repair for type II SLAP lesions in a young active population.

METHODS

Patients aged 15-40 who underwent primary arthroscopic biceps tenodesis or SLAP repair for type II SLAP tears between 2009 and 2016 were included. Shoulders with intraarticular chondral damage, full thickness rotator cuff tear, rotator cuff repair, labral repair outside of the superior labrum, bony subacromial decompression, and acromioclavicular joint resection were excluded. Patient-reported outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand Sports/Performing Arts Module (DASH-sport), visual analog scale (VAS) for pain, and satisfaction. Return to sport rates were also recorded.

RESULTS

Fifty-three patients (20 tenodesis, 33 repair) were available for minimum 2-year follow-up. Postoperatively, there were no significant differences in mean ASES, DASH-sport, VAS, and satisfaction between groups [ASES: tenodesis 86.3 vs. repair 86.4 (n.s.); DASH-sport: 11.0 vs. 22.5 (n.s.); VAS: 1.85 vs. 1.64 (n.s.); satisfaction: 8.50 vs. 8.00 (n.s.)]. Rate of return to pre-injury level of performance/competition in sport/physical activity was also similar between groups [tenodesis 63% vs. repair 50% (n.s.)].

CONCLUSIONS

In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions. The results of this study suggest that indications for arthroscopic tenodesis can safely be expanded to a younger patient group than has previously been demonstrated in the literature.

LEVEL OF EVIDENCE

III.

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.

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.

Comparison between SLAP Repair and Biceps Tenodesis with Concomitant Rotator Cuff Repair in Patients Older than 45 Years: Minimum 2-Year Clinical and Imaging Outcomes

Backgroud

There is controversy over how to surgically treat symptomatic superior labrum anterior to posterior (SLAP) tears in middle-aged patients with concomitant rotator cuff tears. The aim of the study was to compare the clinical and imaging outcomes of SLAP repair versus biceps tenodesis (BT) each combined with arthroscopic rotator cuff repair (ARCR).

Methods

We retrospectively reviewed 35 patients older than 45 years who underwent arthroscopic surgery to manage concomitant SLAP tears and rotator cuff tears. In addition to ARCR, 17 patients underwent SLAP repair, whereas 18 patients underwent BT. Shoulder range of motion (ROM), visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and University of California at Los Angeles (UCLA) score were used for clinical assessment. The integrity of rotator cuff repair and change of superior labrum-biceps complex were evaluated by postoperative magnetic resonance imaging (MRI).

Results

There was significant improvement in the pain VAS and all functional scores in both groups (p < 0.001) at a mean followup of 29.4 ± 11.4 months (range, 24–84 months) postoperatively. Shoulder ROM showed significant improvement postoperatively (p < 0.05). No significant difference in outcomes could be found between the 2 groups after surgery. The retear rate of rotator cuff repair on MRI was 11.8% in the SLAP repair group and 11.1% in the BT group.

Conclusions

In middle-aged patients with combined SLAP lesions and rotator cuff tears, both SLAP repair and BT can be safe adjuncts to ARCR.

Outcomes of Arthroscopic Biceps Tenodesis for the Treatment of Failed Type II SLAP Repair: A Minimum 2-Year Follow-Up

Background

To retrospectively review surgical outcomes of prospectively collected data on a series of patients who underwent revision of a type II SLAP repair to arthroscopic biceps tenodesis due to an unsuccessful outcome.

Methods

A retrospective review was performed on a cohort of patients who underwent arthroscopic biceps tenodesis for a failed type II SLAP repair from 2010 to 2014. Range of motion (ROM) in four planes was measured pre-and postoperatively. In addition, all patients completed the American Shoulder Elbow Surgeons (ASES) standardized shoulder assessment form, the Visual Analogue Scale (VAS) for pain, and the Short Form-12 (SF-12) scores.

Results

Overall, 26 patients met inclusion criteria. All 26 patients were available for follow-up at a minimum of two years (100% follow-up). The mean age of the patients was 37(range 26-54), 85% were male, and 58% were overhead laborers. Clinical as well as statistical improvement was noted following tenodesis across all outcome measurements (P<0.01). Additionally, ROM improved in all four planes (P<0.01). The rate of return to work was 85% with workers' compensation status leading to inferior outcomes. Two complications were noted which required an additional surgery.

Conclusion

Arthroscopic biceps tenodesis demonstrates to be an effective treatment for a failed type II SLAP repair with improved patient satisfaction, pain relief, and range of motion at two-years follow-up with a low complication rate.

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 of Primary Biceps Subpectoral Tenodesis in an Active Population: A Prospective Evaluation of 101 Patients

PURPOSE

To evaluate the surgical outcomes of a primary subpectoral biceps tenodesis for long head of the biceps tendon (LHBT) pathology in a large cohort of prospectively, serially collected, patients in a young active population that has known high physical demands and requirements of their shoulder to perform their vocation.

METHODS

A retrospective review of prospectively collected data from an active military personnel with a diagnosis of a Type II SLAP tear or biceps tenosynovitis was performed. Outcomes were evaluated at a minimum follow-up time of 18 months based on preoperative and postoperative assessments of the Single Assessment Numeric Evaluation, Western Ontario Rotator Cuff index, biceps position, and return to active duty. Inclusion criteria were (1) SLAP tears on magnetic resonance arthrogram (classified into SLAP group), and (2) no SLAP tear but examination findings of biceps tendonitis (placed in the LHBT tendonitis group). Patients were excluded for full-thickness rotator cuff tears, high-grade partial thickness tears requiring repair, acromioclavicular joint pathology, and labral pathology outside of the SLAP lesion. Patients from both groups subsequently were treated with open, subpectoral tenodesis.

RESULTS

Over a 6-year period at a mean follow-up of 2.75 years (range 1.5-5.7 years), 125 active-duty military personnel with mean age of 42.6 years (range 26.3-56.5) were enrolled. A total of 101 of 125 patients (81%) completed study requirements at a mean of 2.75 years (range 1.5-5.7 years). In total, 40 patients were diagnosed with type II SLAP tears (39.6%) and 61 with biceps tendonitis without SLAP tear (60.4%). Following open, subpectoral tenodesis, there was a significant improvement in patient outcomes (Western Ontario Rotator Cuff = 54% preoperative vs 89% postoperative, Single Assessment Numeric Evaluation = 58 preoperative vs 89.5 postoperative, P < .01). In total, 82% of patients returned to full activity at a mean of 4.1 months. The biceps muscle measured relative to the antecubital fossa of operative (mean 3.20 cm) versus nonoperative (3.11 cm) was not clinically different (P = .57). There was an 8% complication rate, including 3 requiring revision, 2 superficial infections, and 3 transient neurapraxias.

CONCLUSIONS

Primary subpectoral open biceps tenodesis for SLAP tears or pathology of the LHBT provides significant improvement in shoulder outcomes with a reliable return to activity level with low risk for complications.

LEVEL OF EVIDENCE

Level IV (Case series).

Surgical management of type II superior labrum anterior posterior (SLAP) lesions: a review of outcomes and prognostic indicators

A Type II SLAP (superior labrum anterior posterior) lesion is a tear of the superior glenoid labrum with involvement of the long head of the biceps tendon insertion. In patients that do not improve with conservative treatment, there is a great deal of variability in the surgical management of these injuries that includes arthroscopic SLAP repair, arthroscopic SLAP repair with biceps tenodesis, biceps tenodesis alone and biceps tenotomy. Each surgical technique has specific effects on a patient's postoperative course and functional recovery. Rehabilitation strategies may be best formulated on an individual basis with an open line of communication between the operating surgeon and the physical therapist. Despite an increased incidence in treatment, there is currently no consensus on the optimal surgical procedure or treatment algorithm for Type II SLAP injuries. However, in middle-aged or older patients (>35) with Type II SLAP tears, either arthroscopic suprapectoral or mini-open subpectoral biceps tenodesis is recommended due to the higher failure rates observed with arthroscopic SLAP repair in this patient group. Although more patients present with a 'Popeye' sign after biceps tenotomy, long-term functional outcome is similar between biceps tenodesis compared to tenotomy. However, more patients will experience biceps fatigue or cramping after the tenotomy procedure. Biceps tenodesis is preferred in younger, more active patients, while tenotomy is preferred in the middle-aged or older and lower demand patients. The aim of this paper is to provide a brief description of the different surgical techniques employed to address Type II SLAP lesions (arthroscopic repair, biceps tenodesis, and biceps tenotomy) and provide a review of available literature regarding outcomes and prognostic factors associated with each technique.

Prospective study on effectiveness and safety of arthroscopic Bankart using a single anterior portal for patients with anterior shoulder instability

OBJECTIVE

To evaluate the effectiveness and safety of the arthroscopic Bankart repair technique using a single anterior portal in patients with anterior shoulder instability.

PATIENTS AND METHODS

Prospective study of 82 patients who underwent arthroscopic Bankart repair using a single anterior portal. Comparison with a historical series of 69 patients treated with two anterior portals. The patients were evaluated by the Rowe scale, and DASH (Disability of the Arm, Shoulder and Hand) and OIS (Oxford Instability Shoulder) questionnaires, range of motion and visual analogue scales for pain and patient satisfaction.

RESULTS

After a mean follow-up of 36 months, there were no significant differences between groups regarding clinical or functional scores, quality of life or patient satisfaction. Surgical time was significantly shorter in the 1-portal group. In group 1-portal there were 2 patients with neurapraxias and 2 re-dislocations, while in group 2-portals were 1 and 2, respectively. The worst functional results were associated with the presence of a type III SLAP lesion.

CONCLUSIONS

Both techniques were satisfactory regarding functional outcomes and complications, except for type III SLAP lesions. Using only one anterior portal, the surgical time was shorter, and the costs were lower when dispensing with a second cannula and a suture passing instrument.

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.

Effect of Anterior Anchor on Clinical Outcomes of Type II SLAP Repairs in an Active Population

This study evaluated the role of anchor position in persistence of pain and/or revision biceps tenodesis after arthroscopic repair of type II superior labrum anterior and posterior (SLAP) lesions and assessed for patient- and injury-specific variables influencing clinical outcomes. Active-duty service members who underwent arthroscopic repair of type II SLAP lesions between March 1, 2007, and January 23, 2012, were identified. Patients with less than 2-year clinical follow-up; type I, III, and IV SLAP lesions; and primary treatment with biceps tenodesis and/or rotator cuff repair at the time of index surgery were excluded. Demographic, preoperative, and operative variables, including anchor positions, were reviewed and evaluated for association with outcomes. Total failure rate (defined as either surgical and/or clinical failure), anchor position, and return to military function were the primary outcomes of interest. Forty-nine patients underwent type II SLAP repairs with a mean follow-up of 52.3 months. Forty-eight (97.9%) were men, and mean age was 35.2 years. Eleven patients (22%) underwent subsequent subpectoral biceps tenodesis. Forty patients (82%) returned to military function, whereas 9 patients (18%) had medical discharge for significant, rate-limiting, shoulder pain. Age was a significant predictor of surgical failure. Patients with anchor position anterior to the biceps attachment had no increased risk of clinical or surgical failure compared with patients with only posterior-based anchors. Anchor placement anterior to the biceps tendon was not associated with inferior outcomes. Younger age was shown to be a poor prognostic factor in patients' ability to return to active duty. Revision with biceps tenodesis showed significant utility in achieving good clinical outcomes and return to duty in more than 90% of patients. Patient-, injury-, and surgery-specific variables need to be identified as prognostic indicators so that clinical outcomes can continue to be improved. [Orthopedics. 2019; 42(1):e32-e38.].

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.

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.

Imaging-Based Prevalence of Superior Labral Anterior-Posterior Tears Significantly Increases in the Aging Shoulder

Background

Superior labral anterior-posterior (SLAP) tears can be associated with pain and shoulder dysfunction. Relatively little is known about the age-related prevalence of SLAP tears.

Purpose

To investigate the age-related prevalence of imaging-diagnosed SLAP tears in a heterogeneous grouping of shoulder conditions in a large cohort at a single institution with multiple blinded reviewers.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A total of 281 shoulder magnetic resonance imaging (MRI) scans obtained over 8 months were reviewed by a musculoskeletal radiologist and an orthopaedic surgeon. The mean ± SD age of the group was 49.6 ± 15.5 years, and 107 of the patients were female (38.1%). Patients were divided into 4 age groups: 35 years or younger, 36 to 50 years, 51 to 65 years, and older than 65 years. Statistical analyses were completed by use of the Fisher exact test to compare proportions of SLAP tears between age groups, odds ratios to determine the likelihood of having a SLAP tear in each age group, and a logistic regression to control for associated abnormalities.

Results

There was a significant diffference in the proportion of SLAP tears found on the MRIs for each age group (P < .001). Patients were significantly more likely to have SLAP tears if aged 51 to 65 years (66.7%; odds ratio [OR], 2.00; 95% CI, 1.27-3.15) and if older than 65 years (81.2%; OR, 4.31; 95% CI, 2.36-7.88). No increased prevalence was observed in patients aged 35 years or younger (47.5%; OR, 0.91; 95% CI, 0.55-1.50) or 36 to 50 years (51.8%; OR, 1.08; 95% CI, 0.70-1.67). Logistic regression demonstrated that age was the only significant predictor for having a SLAP tear (P < .001). Kappa values were 0.46 to 0.65 between reviewers, indicating moderate to substantial agreement.

Conclusion

An increasing prevalence of MRI-based SLAP tears was observed with increasing patient age. Patients older than 50 years were significantly more likely to have superior labral abnormalities regardless of other shoulder injury or disease.

An Age and Activity Algorithm for Treatment of Type II SLAP Tears

Background

Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy.

Objective

To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level.

Methods

A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm.

Results

Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis.

Conclusion

Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

Is Anatomical Healing Essential for Better Clinical Outcome in Type II SLAP Repair? Clinico-Radiological Outcome after Type II SLAP Repair

Background

We hypothesized that anatomical healing in superior labrum anterior to posterior (SLAP) repair is associated with good clinical outcome. The purposes of this study were to assess the failure rate of anatomical healing after arthroscopic repair of SLAP lesions using computed tomography arthrography (CTA), investigate correlation of the rate with clinical outcomes, and identify prognostic factors for anatomical failure following SLAP repair.

Methods

We retrospectively evaluated the outcome of 43 patients at a minimum follow-up of 1 year after arthroscopic surgery for SLAP lesions or SLAP lesions associated with Bankart lesions. Twenty-eight patients underwent isolated SLAP repair and 15 patients underwent Bankart repair with SLAP repair. The anatomical outcome was assessed using CTA at 1 year after surgery. Clinical outcomes including visual analogue scale for pain and satisfaction and Constant score were assessed at the final follow-up. We investigated clinical failure that was defined as stiffness, loss of maximum rotation, deterioration of pain, and/or need for revision of surgery.

Results

Anatomical failure occurred in 32.6% of patients (14/43), whereas 16.3% of patients (7/43) had clinical failure. Clinicoradiological assessment revealed that clinical failure occurred only in 7.1% of patients (1/14) with unhealed SLAP lesions, whereas it occurred in 20.7% of patients (6/29) with healed SLAP lesions. Isolated SLAP repair resulted in a higher risk of anatomical failure (risk ratio, 7.0) than combined SLAP repair (p = 0.015). Nonoverhead activities were associated with higher risk of anatomical failure (risk ratio, 2.9; p = 0.041). Patients above 35 years of age had more risk of anatomical failure (risk ratio, 3.5; p = 0.010). Clinical outcomes significantly improved regardless of anatomical failure (p < 0.001) and were not significantly different between unhealed and healed repairs (all p > 0.05).

Conclusions

Since patients with unhealed SLAP lesions had less clinical failure than patients with healed SLAP lesions, anatomical healing does not seem essential for better clinical outcome of SLAP II repair, especially in patients with higher healing failure risk (isolated SLAP repair, nonoverhead activities, and above 35 years of age). Therefore, we believe the indications of SLAP repair should be narrowed to avoid overtreatment.

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.

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.

Subpectoral Biceps Tenodesis for Treatment of Isolated Type II SLAP Lesions in a Young and Active Population

PURPOSE

The purpose of this study was to evaluate outcomes following open subpectoral biceps tenodesis for the treatment of isolated type II SLAP lesions in patients 45 years of age or younger and evaluate the rate of return to sport.

METHODS

All patients included in the study were at least 2 years out from open subpectoral biceps tenodesis for treatment of an isolated type II SLAP lesion and were treated between December 2007 and March 2015. All patients older than 45, those who had prior surgery on the index shoulder, and those who had any concomitant reconstructive shoulder procedures were excluded. American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Single Assessment Numeric Evaluation (SANE), and Short-Form 12 Physical Component Summary (SF-12 PCS) scores were collected pre- and postoperatively along with postoperative patient satisfaction. Patient return to sport was evaluated by questionnaire.

RESULTS

Twenty patients with a mean age of 38 years (range 21-45) were included, of which 16 were available for follow-up. There was significant improvement in median pre- to postoperative outcome scores (ASES, 66-94 points, P = .001; QuickDASH, 31-8, P = .003; SANE, 60-92, P = .001, SF-12 PCS, 41-52 points, P = .002), with a median patient satisfaction of 8.5 points (range 1-10) at a mean follow-up of 3.4 years (range, 2.0-6.3 years). At final follow-up, all patients had returned to sport, with 73% of patients indicating a return to their previous or comparable level of sports. Subgroup analysis showed 80% of overhead athletes returned to the same or a comparable level postoperatively.

CONCLUSIONS

This study suggests that young patients around their 30s participating in sport at a recreational level may benefit from open subpectoral biceps tenodesis for a primary isolated SLAP II tear and would experience excellent outcomes, high satisfaction, and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV, therapeutic case study.

Controversies In The Surgical Management Of Shoulder Instability: Associated Soft Tissue Procedures

Background:

The glenohumeral joint is a ball-and-socket joint that is inherently unstable and thus, susceptible to dislocation. The traditional and most common anatomic finding is the Bankart lesion (anterior-inferior capsule labral complex avulsion), but there is a wide variety of anatomic alterations that can cause shoulder instability or may be present as a concomitant injury or in combination, including bone loss (glenoid or humeral head), complex capsule-labral tears, rotator cuff tears, Kim´s lesions (injuries to the posterior-inferior labrum) and rotator interval pathology.

Methods:

A review of articles related to shoulder anatomy and soft tissue procedures that are performed during shoulder instability arthroscopic management was conducted by querying the Pubmed database and conclusions and controversies regarding this injury were exposed.

Results:

Due to the complex anatomy of the shoulder and the large range of movement of this joint, a wide variety of anatomic injuries and conditions can lead to shoulder instability, specially present in young population. Recognizing and treating all of them including Bankart repair, capsule-labral plicatures, SLAP repair, circumferential approach to pan-labral lesions, rotator interval closure, rotator cuff injuries and HAGL lesion repair is crucial to achieve the goal of a stable, full range of movement and not painful joint.

Conclusion:

Physicians must be familiarized with all the lesions involved in shoulder instability, and should be able to recognize and subsequently treat them to achieve the goal of a stable non-painful shoulder. Unrecognized or not treated lesions may result in recurrence of instability episodes and pain while overuse of some of the techniques previously described can lead to stiffness, thus the importance of an accurate diagnosis and treatment when facing a shoulder instability.

Surgical Management of the Aging Athlete

Epidemiologic data show that the number of middle aged (>40 yr) and elderly (>65 yr) individuals continues to increase steadily, creating an expanding need for sports medicine care. Management of injuries in this subset of patients is expanding well beyond sustaining a patient's ability to perform activities of daily living. In fact, many older individuals increasingly expect to maintain reasonably high activity levels throughout their lifespan as well as after musculoskeletal injury. While a number of the emerging physiologic benefits of physical activity in older patients have been outlined, no recent review has outlined the current best surgical techniques, rehabilitation protocols, and return-to-sport recommendations for older athletes after soft-tissue repair or reconstruction as well as joint replacement. The goal of orthopaedic care in the elderly patient is shifting from simple pain relief toward return to athletic activity.

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.

Shoulder Conditions: Diagnosis and Treatment Guideline

The following guideline covers a wide array of shoulder conditions seen in the workers' compensation, as well as the nonworkers' compensation, population. The guideline is intended to help establish work relatedness and aid in making the diagnosis of shoulder injuries and degenerative conditions. It also provides a nonoperative and operative guideline for the treatment of several shoulder conditions, not limited to rotator cuff tears, subacromial impingement syndrome, acromioclavicular arthritis and dislocations, as well as glenohumeral arthritis.

Systematic Review of Biceps Tenodesis: Arthroscopic Versus Open

PURPOSE

We present a systematic review of the recent literature regarding the use of arthroscopic and open methods of tenodesis for lesions of the long head of the biceps brachii and present an analysis of the subjective and objective outcomes after these 2 procedures.

METHODS

PubMed was carefully reviewed for suitable articles relating to biceps tenodesis, both open and arthroscopic. We included studies reporting on the clinical outcomes of these 2 procedures that were of Level I to IV evidence and were published in the English language. The primary clinical outcomes for each study were determined, normalized, and reported as the percentage of good or excellent results versus poor results based on the outcome scores and criteria laid out by the authors in each of the studies. The exclusion criteria included studies in which biceps tenodesis was performed in patients with concomitant rotator cuff repairs, nonhuman studies, and biomechanical studies.

RESULTS

A total of 16 studies met our inclusion criteria. Among all studies, a total of 205 arthroscopic tenodesis procedures and a total of 271 open tenodesis procedures were performed. Among the 271 open tenodesis patients, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%). Among the 205 patients who underwent arthroscopic tenodesis, 98% had a good or excellent outcome, with a poor outcome in 5 patients (2%).

CONCLUSIONS

Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identifiable differences in this review.

SLAP lesions: a treatment algorithm

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

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

Background/Purpose

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

Methods

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

Results

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

Conclusion

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

Arthroscopic repair of type II SLAP lesions: Clinical and anatomic follow-up

Aims:

The aim was to evaluate the clinical and anatomic outcome of arthroscopic repair of type II SLAP lesions.

Materials and Methods:

The senior author performed isolated repairs of 25 type II SLAP lesions in 25 patients with a mean age of 40.0 ± 12 years. All tears were repaired using standard arthroscopic suture anchor repair to bone. All patients were reviewed using a standardized clinical examination by a blinded, independent observer, and using several shoulder outcome measures. Patients were evaluated by magnetic resonance imaging arthrogram at a minimum of 1-year postoperatively.

Statistical Analysis Used:

Two-tailed paired t-test were used to determine significant differences in preoperative and postoperative clinical outcomes scores. In addition, a Fisher's exact test was used.

Results:

At a mean follow-up of 54-month, the mean American Shoulder and Elbow Surgeons Shoulder Index (ASES) scores improved from 52.1 preoperatively to 86.1 postoperatively (P < 0.0001) and the Simple Shoulder Test (SST) scores from 7.7 to 10.6 (P < 0.0002). Twenty-two out of the 25 patients (88%) stated that they would have surgery again. Of the 21 patients who had postoperative magnetic resonance imaging arthrographys (MRAs), 9 patients (43%) demonstrated dye tracking between the labrum bone interface suggestive of a recurrent tear and 12 patients (57%) had a completely intact repair. There was no significant difference in ASES, SST, and patient satisfaction scores in patients with recurrent or intact repairs.

Conclusions:

Arthroscopic repair of type II SLAP lesions demonstrated improvements in clinical outcomes. However, MRA imaging demonstrated 43% of patients with recurrent tears. MRA results do not necessarily correlate with clinical outcome.

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.

Subpectoral biceps tenodesis for bicipital tendonitis with SLAP tear

The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis for bicipital tendonitis with a superior labral anterior-posterior (SLAP) tear. Patients undergoing primary subpectoral biceps tenodesis for arthroscopically confirmed SLAP tears with signs or findings of bicipital tendonitis were included. An independent observer collected data prospectively as part of a data repository, which was then analyzed retrospectively. Primary outcome measures were the American Shoulder and Elbow Surgeons (ASES) score and pain relief via visual analog scale (VAS). Secondary outcome measures included the Simple Shoulder Test (SST), Constant, Single Assessment Numeric Evaluation (SANE), and Short Form 12 (SF-12) scores. Twenty-eight patients with a mean±SD age of 43.7±13.4 years and a mean±SD follow-up of 2.0±1.0 years met inclusion criteria. Workers' compensation was involved with 43% of cases, and 46% of the included patients were manual laborers. Eight (32%) patients were athletes, and 88% of the athletes were overhead athletes. Intraoperatively, 15 (54%) patients had type I SLAP tears, 10 (36%) had type II SLAP tears, 1 (3%) had a type III SLAP tear, and 2 (7%) had type IV SLAP tears. Significant improvements were seen in the following outcome measures pre- vs postoperatively: ASES score (58±23 vs 89±18; P=.001), SST score (6.3±3.6 vs 10.6±3.3; P=.001), SANE score (54±24 vs 88±25; P=.003), VAS score (3.8±2.0 vs 1.1±1.8; P=.001), SF-12 overall score (35±6 vs 42±6; P=.001), and SF-12 physical component score (39±6 vs 50±10; P=.001). Overall satisfaction was excellent in 80% of patients. Subpectoral biceps tenodesis demonstrates excellent clinical outcomes in select patients with SLAP tears. [Orthopedics. 2015; 38(1):e48-e53.].

Etiology, Diagnosis, and Management of Failed SLAP Repair

In general, favorable outcomes have been achieved with arthroscopic repair of superior labral anterior-posterior (SLAP) tears. However, some patients remain dissatisfied or suffer further injury after SLAP repair and may seek additional treatment to alleviate their symptoms. The cause of persistent pain or recurrent symptoms after repair is likely multifactorial; therefore, careful preoperative workup is required to elucidate the cause of pain. Review of the details of previous surgical procedures is crucial because certain fixation methods are prone to failure or can cause additional injury. Failed SLAP repair can be managed with nonsurgical or surgical options. Nonsurgical modalities include physical therapy and strengthening programs, anti-inflammatory agents, and activity modification. Surgical options include revision SLAP repair and biceps tenotomy or tenodesis with or without revision SLAP repair. Outcomes after surgical management of failed SLAP repair are inferior to those of primary repair. Select patients may be better served by primary biceps tenodesis rather than SLAP repair.

Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions

BACKGROUND

Surgical repair remains the gold standard for most type II and type IV superior labral anterior and posterior (SLAP) lesions that fail nonoperative management. However, most recently, there have been data demonstrating unacceptably high failure rates with primary repair of type II SLAP lesions. Biceps tenodesis may offer an acceptable, if not better, alternative to primary repair of SLAP lesions.

HYPOTHESIS

Subpectoral biceps tenodesis provides satisfactory, reproducible outcomes for the treatment of type II and type IV SLAP lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who underwent subpectoral biceps tenodesis and labral debridement for type II and type IV SLAP lesions by a single board-certified shoulder surgeon from 2006 to 2012 were evaluated. Exclusion criteria included those patients who underwent biceps tenodesis with an associated rotator cuff repair, anterior labral repair, or posterior labral repair. Outcome measures included the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, and demographic data.

RESULTS

Between 2006 and 2012, a total of 36 subpectoral biceps tenodesis procedures were performed in 33 patients for type II or IV SLAP lesions. Twenty-six patients with 29 shoulder surgeries were available for follow-up. The average age was 46.7 years, with 16 male and 10 female patients participating in the study. The average follow-up was 40.17 months. There was a significant improvement in ASES and VAS scores: 48.1 and 6.4 preoperatively compared with 87.5 and 1.5 postoperatively, respectively (P < .001). There was no significant difference based on SLAP lesion type, patient age, or patient sex. Of 29 shoulders, 26 (89.66%) were able to return to the previous level of activity.

CONCLUSION

This study adds to the evolving literature supporting biceps tenodesis as a viable treatment for type II and IV SLAP lesions. Patient age had no effect on the outcomes. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to primary SLAP repair in patients with type II and IV SLAP tears.

Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management

After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.

Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis

BACKGROUND

It is still unclear which patients with isolated type II superior labrum anterior-posterior (SLAP) lesions benefit from either superior labral repair or biceps tenodesis. This study evaluates the indications and outcomes of patients with isolated type II SLAP lesions who have undergone either procedure.

METHODS

A retrospective analysis was performed of patients who had surgery for an isolated type II SLAP lesion between 2008 and 2011. There were 25 patients: 15 underwent biceps tenodesis, with a mean follow-up of 31 months (range, 26-43 months), and 10 underwent SLAP repair, with a mean follow-up of 35 months (range, 25-52 months). The mean age was 47 years (range, 30-59 years) in the tenodesis group and 31 years (range, 21-43 years) in the repair group.

RESULTS

At latest follow-up, both groups showed significant improvements in subjective shoulder value and pain score. No difference was observed in American Shoulder and Elbow Surgeons score (93.0 vs 93.5, P = .45), patient satisfaction (93% vs 90%, P = .45), or return to preinjury sporting level (73% vs 60%, P = .66). Analysis of the indications for treatment showed that in the large majority, tenodesis was performed in older patients (>35 years) and patients who showed degenerative or frayed labrums whereas SLAP repairs were performed in younger and more active patients with healthy-appearing labral tissue. There was only 1 failure in the tenodesis group, and in the SLAP repair group, there were 2 cases of postoperative stiffness; all were treated nonoperatively.

CONCLUSION

In this study, we show that both biceps tenodesis and SLAP repair can provide good to excellent results if performed in appropriately selected patients with isolated type II SLAP lesions.

Superior labral anterior posterior lesions of the shoulder

Superior labrum anterior and posterior (SLAP) lesion is of fairly recent description and its understanding is rapidly evolving. Its incidence and need for surgical treatment has increased exponentially in line with the increase in shoulder arthroscopies. It is of particular importance in the elite over head athlete and the young. A range of arthroscopic techniques and devices have been described with good functional results. The ability to return to pre injury level of sports remains a concern.

Subpectoral biceps tenodesis for failed type II SLAP repair

Superior labrum anterior-posterior lesions are a common cause of shoulder pain. The diagnosis, classification, and indications for surgical intervention remain controversial, and mixed outcomes are associated with primary repair. Given the increasing prevalence of primary superior labrum anterior-posterior repairs in the United States, more surgeons will need to treat patients with poor primary results. A retrospective review of prospectively collected data was performed on patients who underwent subpectoral biceps tenodesis for failed type II superior labrum anterior-posterior repair by a single surgeon between January 2008 and December 2011. Primary outcome variables included pain via the visual analog scale, American Shoulder and Elbow Surgeons score, and Short Form 12 score. Secondary outcome variables included the Simple Shoulder Test and Single Assessment Numeric Evaluation scores. Demographic and intraoperative information was recorded for each patient. A paired t test statistical analysis was performed with a P value less than .05 considered statistically significant. A total of 11 patients met the inclusion criteria. Of these patients, 9 (82%) completed postoperative surveys at a mean 26-month follow-up. Mean visual analog scale scores improved from 4.1 to 2.5 (P=.03), Simple Shoulder Test scores from 5.4 to 9.3 (P=.005), American Shoulder and Elbow Surgeons scores from 54.5 to 78.0 (P=.002), and Single Assessment Numeric Evaluation scores from 42.5 to 70.4 (P=.001). Mean SF-12 (physical component) improved from 35.5 to 47.9 (P=.018). No failures or peri- or postoperative complications occurred. No patients required additional surgery. The findings suggest that subpectoral biceps tenodesis as a salvage for failed type II superior labrum anterior-posterior repair demonstrates improved results. Larger scale comparative studies are required to justify this technique.