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Hurley ET, Baker R, Danilkowicz RM, Levin JM, Klifto CS, Dickens JF, Taylor DC, Lau BC. Similar outcomes between biceps tenodesis and SLAP repair for SLAP tears in younger patients - A meta-analysis. J ISAKOS 2024; 9:79-83. [PMID: 37797939 DOI: 10.1016/j.jisako.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/12/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVES The purpose of this study is to systematically review the comparative studies in the literature to ascertain if biceps tenodesis or superior-labrum anterior to posterior (SLAP) repair results in superior clinical outcomes in the treatment of type II SLAP tears in patients under 40. METHODS A systematic search of articles in Pubmed, EMBASE and The Cochrane Library databases was carried out according to the PRISMA guidelines. Cohort studies comparing biceps tenodesis to repair in type II SLAP tears in patients under 40 were included. Clinical outcomes were extracted including return to play, reoperations, ASES, and VAS for pain. All statistical analysis was performed using Review Manager. A p-value of <0.05 was considered to be statistically significant. RESULTS Five studies were included. Biceps tenodesis resulted in comparable rates of return to play compared to SLAP repair (78.5% vs 67.7%, p = 0.33), and there was no significant difference in return to play in overhead athletes (83.6% vs 74%, p = 0.82). There was no significant difference in ASES score (87.2 vs 86.2, p = 0.27) or VAS score for pain (1.8 vs 2.1, p = 0.48). There was no significant difference in re-operation rates (2.9% vs 10.8%, p = 0.22). CONCLUSION This study found that biceps tenodesis has no significant difference in rates of return to play in athletes, as well as in functional outcome scores and rates of revision surgery in younger patients compared to SLAP repair. LEVEL OF EVIDENCE Level III, Systematic review of Level III studies.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA.
| | - Rafeal Baker
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Richard M Danilkowicz
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Jay M Levin
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Christopher S Klifto
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Jonathan F Dickens
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Dean C Taylor
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Brian C Lau
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, 27705, USA
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Scanaliato JP, Green CK, Sandler AB, Hurley ET, Hettrich CM, Parnes N. Establishing the Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptomatic State After Arthroscopic Posterior Labral Repair for Posterior Glenohumeral Instability. Am J Sports Med 2024; 52:207-214. [PMID: 38164689 DOI: 10.1177/03635465231210289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Posterior glenohumeral instability is an increasingly recognized cause of shoulder pain and dysfunction among young, active populations. Outcomes after posterior stabilization procedures are commonly assessed using patient-reported outcome measures including the Single Assessment Numeric Evaluation (SANE), the Rowe instability score, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale (VAS) for pain. The clinical significance thresholds for these measures after arthroscopic posterior labral repair (aPLR), however, remain undefined. PURPOSE We aimed to define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the SANE, Rowe score, and ASES score as well as the VAS pain after aPLR. Additionally, we sought to determine preoperative factors predictive of reaching, as well as failing to reach, clinical significance. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS This study was a retrospective analysis of patient-reported outcome scores collected from patients who underwent aPLR between January 2011 and December 2018. To determine the clinically significant threshold that corresponded to achieving a meaningful outcome, the MCID, SCB, and PASS were calculated for the SANE, Rowe score, ASES score, and VAS pain utilizing either an anchor- or distribution-based method. Additionally, univariate and multivariate logistic regression analyses were performed to determine the factors associated with achieving, or not achieving, the MCID, SCB, and PASS. RESULTS A total of 73 patients with a mean follow-up of 82.55 ± 24.20 months were available for final analysis. MCID, SCB, and PASS values for the VAS pain were 1.10, 6, and 3, respectively; for the ASES score were 7.8, 34, and 80, respectively; for the SANE were 10.15, 33, and 85, respectively; and for the Rowe score were 11.3, 60, and 90, respectively. To meet the MCID, male sex (odds ratio [OR], 1.1639; P = .0293) was found to be a positive predictor for the VAS pain, and a lower preoperative SANE score (OR, 0.9939; P = .0003) was found to be a negative predictor for the SANE. Dominant arm involvement was associated with lower odds of achieving the PASS for the ASES score (OR, 0.7834; P = .0259) and VAS pain (OR, 0.7887; P = .0436). Patients who reported a history of shoulder trauma were more likely to reach the PASS for the SANE (OR, 1.3501; P = .0089), Rowe score (OR, 1.3938; P = .0052), and VAS pain (OR, 1.3507; P = .0104) as well as the SCB for the ASES score (OR, 1.2642; P = .0469) and SANE (OR, 1.2554; P = .0444). A higher preoperative VAS pain score was associated with higher odds of achieving the SCB for both the VAS pain (OR, 1.1653; P = .0110) and Rowe score (OR, 1.1282; P = .0175). Lastly, concomitant biceps tenodesis was associated with greater odds of achieving the SCB for the ASES score (OR, 1.3490; P = .0130) and reaching the PASS for the SANE (OR, 1.3825; P = .0038) and Rowe score (OR, 1.4040; P = .0035). CONCLUSION To our knowledge, this study is the first to define the MCID, SCB, and PASS for the ASES score, Rowe score, SANE, and VAS pain in patients undergoing aPLR. Furthermore, we found that patients who reported a history of shoulder trauma and those who underwent concomitant biceps tenodesis demonstrated a greater likelihood of achieving clinical significance. Dominant arm involvement was associated with lower odds of achieving clinical significance.
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Affiliation(s)
- John P Scanaliato
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Clare K Green
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | | | | | - Carolyn M Hettrich
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nata Parnes
- Department of Orthopedics, Carthage Area Hospital, Carthage, New York, USA
- Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Green CK, Scanaliato JP, Sandler AB, Patrick CM, Dunn JC, Parnes N. Concomitant Biceps Tenodesis Does Not Portend Inferior Outcomes After Anterior Glenohumeral Stabilization. Am J Sports Med 2023; 51:3851-3857. [PMID: 37975490 DOI: 10.1177/03635465231209731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Military patients are known to suffer disproportionately high rates of glenohumeral instability as well as superior labrum anterior to posterior (SLAP) tears. Additionally, a concomitant SLAP tear is frequently observed in patients with anterior shoulder instability. Even though biceps tenodesis has been demonstrated to produce superior outcomes to SLAP repair in military patients with isolated SLAP lesions, no existing studies have reported on outcomes after simultaneous tenodesis and anterior labral repair in patients with co-existing abnormalities. PURPOSE To evaluate outcomes after simultaneous arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair in military patients younger than 40 years. We also sought to compare these outcomes with those after repair of an isolated anterior labral tear. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS This study is a retrospective analysis of all military patients younger than 40 years from a single base who underwent arthroscopic anterior glenohumeral stabilization with or without concomitant biceps tenodesis between January 2010 and December 2019. Patients with glenoid bone loss of >13.5% were not eligible for inclusion. Outcome measures including the visual analog scale (VAS) for pain, the Single Assessment Numeric Evaluation (SANE), the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were administered preoperatively and postoperatively, and scores were compared between groups. RESULTS A total of 82 patients met inclusion criteria for the study. All patients were active-duty service members at the time of surgery. The mean follow-up was 87.75 ± 27.05 months in the repair + tenodesis group and 94.07 ± 28.72 months in the isolated repair group (P = .3085). Patients who underwent repair + tenodesis had significantly worse preoperative VAS pain (6.85 ± 1.86 vs 5.02 ± 2.07, respectively; P < .001), ASES (51.78 ± 11.89 vs 62.43 ± 12.35, respectively; P = .0002), and Rowe (26.75 ± 7.81 vs 37.26 ± 14.91, respectively; P = .0002) scores than patients who underwent isolated repair. Both groups experienced significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no statistically significant differences in postoperative outcome scores or range of motion between groups. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the VAS pain, SANE, ASES, and Rowe scores between groups. Overall, 37 of the 40 (92.50%) patients in the repair + tenodesis group and 40 of the 42 (95.24%) patients in the isolated repair group returned to unrestricted active-duty military service (P = .6045). In addition, 38 (95.00%) patients in the repair + tenodesis group and 40 (95.24%) patients in the isolated repair group returned to preinjury levels of sporting activity (P = .9600). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between groups (P = .9421, P = .9400, and P = .6045, respectively). CONCLUSION The findings of this study indicate that simultaneous biceps tenodesis and labral repair was a viable treatment option for the management of concomitant SLAP and anterior labral lesions in young, active military patients younger than 40 years.
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Affiliation(s)
- Clare K Green
- George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - John P Scanaliato
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Alexis B Sandler
- William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Cole M Patrick
- William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - John C Dunn
- William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nata Parnes
- Carthage Area Hospital, Carthage, New York, USA
- Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Goncharov EN, Koval OA, Bezuglov EN, Vetoshkin AA, Goncharov NG, Ramirez MDJE, Khachaturovich OS, Montemurro N. A Comparative Analysis Between Conservative Treatment, Arthroscopic Repair, and Biceps Tenodesis in Superior Labral Anterior-Posterior (SLAP) Lesions. Cureus 2023; 15:e47512. [PMID: 38022173 PMCID: PMC10663969 DOI: 10.7759/cureus.47512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 12/01/2023] Open
Abstract
Background "Throwing shoulder" hinders athletes' shoulder functions, causing pain, weakness, and performance reduction due to anatomical, physiological, and biomechanical factors. Anatomical issues include superior labral anterior-posterior (SLAP) injuries, rotator cuff injuries, and glenohumeral instability. Methods This study compared arthroscopic labral repairs in patients under 40 years old with shoulder injuries between 2015 and 2017. Sixty eligible patients were divided into three groups: conservative treatment, arthroscopic repair, and tenodesis. Measures included pain, functional scores, and the range of motion pre-/post-operation. Results At the last follow-up, pain relief and functional improvement were most significant with tenodesis (97% pain relief, 95% functional improvement), followed by repair (85% pain relief, 70% functional improvement), and least in conservative treatment (45% pain relief, 40% functional improvement). While all treatments significantly reduced pain and improved function (p<0.001), tenodesis demonstrated the highest effectiveness, suggesting it as a potentially preferred method. Significant improvements in pain relief and function were observed across all methods; however, surgical options suggested improved outcomes. Conclusion Our study compares conservative treatment, arthroscopic labral repair, and biceps tenodesis (BT) for SLAP lesions, highlighting significant pain relief and functional improvement across all. Conservative treatment suits patients with milder symptoms, while arthroscopic repair addresses larger tears. As the effectiveness of arthroscopic treatment is not inferior to conservative one, BT excels in cases of substantial bicep involvement.
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Affiliation(s)
| | | | | | | | | | | | | | - Nicola Montemurro
- Department of Neurosurgery, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, ITA
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Green CK, Scanaliato JP, Sandler AB, Adler A, Dunn JC, Parnes N. Simultaneous Arthroscopic Rotator Cuff Repair and Glenoid Microfracture in Active-Duty Military Patients Younger Than 50 Years: Outcomes at Midterm Follow-up. Orthop J Sports Med 2023; 11:23259671231202282. [PMID: 37859753 PMCID: PMC10583522 DOI: 10.1177/23259671231202282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/04/2023] [Indexed: 10/21/2023] Open
Abstract
Background While concomitant full-thickness rotator cuff tears and glenoid osteochondral defects are relatively uncommon in younger patients, military patients represent a unique opportunity to study this challenging injury pattern. Purpose/Hypothesis To compare the outcomes of young, active-duty military patients who underwent isolated arthroscopic rotator cuff repair (ARCR) with those who underwent ARCR plus concurrent glenoid microfracture (ARCR+Mfx). It was hypothesized that ARCR+Mfx would produce significant improvements in patient-reported outcome measures. Study Design Cohort study; Level of evidence, 3. Methods This was a retrospective analysis of consecutive active-duty military patients from a single base who underwent ARCR for full-thickness rotator cuff tears between January 2012 and December 2020. All patients were <50 years and had minimum 2-year follow-up data. Patients who underwent ARCR+Mfx were compared with those who underwent isolated ARCR based on the visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion. Results A total of 88 patients met the inclusion criteria for this study: 28 underwent ARCR+Mfx and 60 underwent isolated ARCR. The mean final follow-up was 74.11 ± 33.57 months for the ARCR+Mfx group and 72.87 ± 11.46 months for the ARCR group (P = .80). There were no differences in baseline patient characteristics or preoperative outcome scores between groups. Postoperatively, both groups experienced statistically significant improvements in all outcome scores (P < .0001 for all). However, the ARCR+Mfx group had significantly worse VAS pain (1.89 ± 2.22 vs 1.03 ± 1.70; P = .05), SANE (85.46 ± 12.99 vs 91.93 ± 12.26; P = .03), and ASES (86.25 ± 14.14 vs 92.85 ± 12.57; P = .03) scores. At the final follow-up, 20 (71.43%) patients in the ARCR+Mfx group and 53 (88.33%) patients in the ARCR group were able to remain on unrestricted active-duty military service (P = .05). Conclusion Concomitant ARCR+Mfx led to statistically and clinically significant improvements in patient-reported outcome measures at the midterm follow-up. However, patients who underwent ARCR+Mfx had significantly worse outcomes and were less likely to return to active-duty military service than those who underwent isolated ARCR. The study findings suggest that ARCR+Mfx may be a reasonable option for young, active patients who are not candidates for arthroplasty.
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Affiliation(s)
- Clare K. Green
- School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - John P. Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Alexis B. Sandler
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Adam Adler
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - John C. Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nata Parnes
- Department of Orthopaedic Surgery, Carthage Area Hospital, Carthage, New York, USA
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Green CK, Scanaliato JP, Sandler AB, Czajkowski H, Rolf RH, Dunn JC, Parnes N. Midterm Outcomes Following Combined Biceps Tenodesis and Anterior Labral Repair in Active Duty Military Patients Younger than 35 Years. Am J Sports Med 2023:3635465231169238. [PMID: 37196664 DOI: 10.1177/03635465231169238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Superior labrum anterior-posterior (SLAP) lesions and anterior instability are common causes of shoulder pain and dysfunction among active-duty members of the United States military. However, little data have been published regarding the surgical management of type V SLAP lesions. PURPOSE To compare the outcomes of arthroscopic-assisted subpectoral biceps tenodesis and anterior labral repair with those of arthroscopic SLAP repair (defined as contiguous repair spanning from the superior labrum to the anteroinferior labrum) for type V SLAP tears in active-duty military patients younger than 35 years. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS All consecutive patients from January 2010 to December 2015 who underwent arthroscopic SLAP repair or combined biceps tenodesis and anterior labral repair for a type V SLAP lesion with a minimum 5-year follow-up were identified. The decision to perform type V SLAP repair versus combined biceps tenodesis and anterior labral repair was based on the condition of the long head of the biceps tendon (LHBT). Labral repair was performed in patients who had a type V SLAP tear with an otherwise clinically and anatomically healthy LHBT. Combined tenodesis and repair was performed in patients with evidence of LHBT abnormalities. Outcomes including the visual analog scale (VAS) score, the Single Assessment Numeric Evaluation (SANE) score, the American Shoulder and Elbow Surgeons (ASES) shoulder score, the Rowe instability score, and range of motion were collected preoperatively and postoperatively, and scores were compared between the groups. RESULTS A total of 84 patients met the inclusion criteria for the study. All patients were active-duty service members at the time of surgery. A total of 44 patients underwent arthroscopic type V SLAP repair, and 40 patients underwent anterior labral repair with biceps tenodesis. The mean follow-up was 102.59 ± 20.98 months in the repair group and 94.50 ± 27.11 months in the tenodesis group (P = .1281). There were no significant differences in preoperative range of motion or outcome scores between the groups. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all); however, compared with the repair group, the tenodesis group reported significantly better postoperative VAS (2.52 ± 2.36 vs 1.50 ± 1.91, respectively; P = .0328), SANE (86.82 ± 11.00 vs 93.43 ± 8.81, respectively; P = .0034), and ASES (83.32 ± 15.31 vs 89.90 ± 13.31, respectively; P = .0394) scores. There were no differences in the percentage of patients who achieved the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state for the SANE and ASES between the groups. Overall, 34 patients in each group returned to preinjury levels of work (77.3% vs 85.0%, respectively; P = .3677), and 32 patients (72.7%) in the repair group and 33 patients (82.5%) in the tenodesis group returned to preinjury levels of sporting activity (P = .2850). There were no significant differences in the number of failures, revision surgical procedures, or patients discharged from the military between the groups (P = .0923, P = .1602, and P = .2919, respectively). CONCLUSION Both arthroscopic-assisted subpectoral biceps tenodesis combined with anterior labral repair and arthroscopic SLAP repair led to statistically and clinically significant increases in outcome scores, marked improvements in pain, and high rates of return to unrestricted active duty in military patients with type V SLAP lesions. The results of this study suggest that biceps tenodesis combined with anterior labral repair produces comparable outcomes to arthroscopic type V SLAP repair in active-duty military patients younger than 35 years.
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Affiliation(s)
- Clare K Green
- The George Washington University, Washington, District of Columbia, USA
| | - John P Scanaliato
- William Beaumont Army Medical Center, Fort Bliss, Texas, USA
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Alexis B Sandler
- William Beaumont Army Medical Center, Fort Bliss, Texas, USA
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Hunter Czajkowski
- Carthage Area Hospital, Carthage, New York, USA
- Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
| | - Robert H Rolf
- Beacon Orthopaedics & Sports Medicine, Cincinnati, Ohio, USA
- TriHealth, Cincinnati, Ohio, USA
| | - John C Dunn
- William Beaumont Army Medical Center, Fort Bliss, Texas, USA
- Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Nata Parnes
- Carthage Area Hospital, Carthage, New York, USA
- Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Biceps Tenodesis in Patients Age 35 Years and Younger Yields Favorable Clinical Outcomes With Variable Rates of Return to Sport and Complications: A Systematic Review. Arthroscopy 2023; 39:830-837. [PMID: 36528216 DOI: 10.1016/j.arthro.2022.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/08/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To systematically evaluate reported clinical outcomes, return-to-sport (RTS) rates, and complications following biceps tenodesis in patients aged 35 years and younger and compare outcomes between overhead and nonoverhead athletes. METHODS A literature search was performed by querying Scopus, EMBASE, and PubMed computerized databases from database inception through August 2022 in accordance with the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies that evaluated clinical outcomes following biceps tenodesis in patients aged 35 years or younger were included. Study quality was assessed via the Methodological Index for Non-Randomized Studies criteria. Clinical outcomes, RTS rates, and complications were aggregated. RESULTS Nine studies from 2011 to 2022 comprising 161 patients (mean age, 25 years; range, 19.7-28.9 years) were included. At an average follow-up of 59 months, postoperative American Shoulder and Elbow Surgeons score ranged from 81.6 to 96 and the mean visual analog scale score ranged from 0 to 2.1. Mean overall RTS rate ranged from 35% to 100% for the entire patient cohort 35% to 86% among overhead athletes, and 46% to 100% among nonoverhead athletes. Among the overhead athletes, 24 were baseball pitchers. 17% to 100% able to return to sport at any level. Complications were reported in 0% to 19% of patients. 0 to 18% of patients underwent revision surgery. CONCLUSIONS Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported RTS rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure. LEVEL OF EVIDENCE IV; Systematic Review of Level III and IV studies.
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Klemt C, Toderita D, Reilly P, Bull AMJ. Biceps Tenodesis cannot be used as primary treatment option in baseball pitchers with intact rotator cuff muscles. Clin Biomech (Bristol, Avon) 2022; 100:105819. [PMID: 36410224 DOI: 10.1016/j.clinbiomech.2022.105819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/13/2022] [Accepted: 11/08/2022] [Indexed: 11/17/2022]
Abstract
UNLABELLED Background Surgeons remain hesitant to perform biceps tenodesis in athletes with type II superior labrum anterior-to-posterior tears due to the lack of reported clinical outcomes for individual overhead throwing sports and associated concerns that this may predispose the joint to instability. This study aimed to assess the effect of biceps tenodesis on shoulder stability for major overhead throwing sports to aid sport-specific surgical decision-making for athletes with type II superior labrum anterior-to-posterior tears. METHODS This is a combined modelling and experimental study. Motion data and external forces were measured from 13 participants performing five overhead throwing motions. These data served as input into a musculoskeletal shoulder model that quantifies shoulder stability and muscle loading. FINDINGS The loading of the long head of the biceps brachii decreases significantly following biceps tenodesis in three overhead throwing motions (p = 0.02). The loss in joint stability following biceps tenodesis is compensated by a non-significant increase in rotator cuff muscle force which maintains shoulder stability across all overhead throwing motions, except baseball pitching (p = 0.01). The presence of a full-thickness supraspinatus tear post biceps tenodesis further decreases shoulder stability in four of the five overhead throwing motions (p = 0.01). INTERPRETATION The study findings demonstrate that an increase in rotator cuff muscle force maintains joint stability for all overhead throwing motions post biceps tenodesis, except baseball pitching. As the presence of a full-thickness tear of the supraspinatus significantly reduces joint stability, biceps tenodesis may be used as a primary treatment in overhead throwing athletes with intact rotator cuff muscles, except baseball pitchers. LEVEL OF EVIDENCE Controlled Laboratory Study; Level of Evidence 3.
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Affiliation(s)
- Christian Klemt
- Department of Bioengineering, Imperial College London, London, UK
| | - Diana Toderita
- Department of Bioengineering, Imperial College London, London, UK
| | - Peter Reilly
- Department of Bioengineering, Imperial College London, London, UK
| | - Anthony M J Bull
- Department of Bioengineering, Imperial College London, London, UK.
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Sandler AB, Childs BR, Scanaliato JP, Dunn JC, Parnes N. SLAP Repair Versus Biceps Tenodesis in Patients Younger Than 40 Years: A Cost-Effectiveness Analysis. Orthop J Sports Med 2022; 10:23259671221140364. [PMID: 36479458 PMCID: PMC9720817 DOI: 10.1177/23259671221140364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/15/2022] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The surgical management of type II superior labrum anterior and posterior (SLAP) tears in patients younger than 40 years is controversial, but growing evidence suggests comparable outcomes between primary SLAP repair and primary biceps tenodesis, with lower rates of reoperations after primary biceps tenodesis. Given the relatively similar patient-reported outcomes, cost-effectiveness analyses of direct and indirect costs associated with the two procedures propound a valuable comparative technique. HYPOTHESIS In this value-based comparison of SLAP repair versus biceps tenodesis, we hypothesized that biceps tenodesis would be more cost-effective than SLAP repair in patients younger than 40 years. STUDY DESIGN Economic and decision analysis; Level of evidence, 4. METHODS A 1-month Markov cycle was simulated to reflect 10 years of health outcomes. Health states were selected based on outcomes that are especially important in assessing indirect costs for a younger, active patient population: return-to-sport rates, which demonstrate a return to baseline function, and reoperation rates. Transition state probabilities were obtained through an index systematic review and meta-analysis comparing labral repair and biceps tenodesis for the treatment of type II SLAP lesions in patients younger than 40 years. Health state utility and cost values were obtained from accepted values denoted in existing literature. RESULTS Both primary SLAP repair and primary biceps tenodesis yielded an average expected 8.1 quality-adjusted life years over the 10-year period. The average cost (in 2021 US$) was $16,619 for biceps tenodesis and $19,388 for SLAP repair. CONCLUSION In a younger patient population, SLAP repair and biceps tenodesis had comparable quality-adjusted life years and utility in the treatment of type II SLAP tears; however, SLAP repair cost $19,388, while biceps tenodesis cost $16,619, reflecting a 14% cost savings with biceps tenodesis. These findings can be extrapolated to further establish the role for these procedures in treating SLAP tears.
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Affiliation(s)
- Alexis B. Sandler
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Benjamin R. Childs
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - John P. Scanaliato
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - John C. Dunn
- Department of Orthopaedics, William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Nata Parnes
- Department of Orthopedic Surgery, Carthage Area Hospital, Carthage, New York, USA
- Department of Orthopedics, Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Scanaliato JP, Sandler AB, Baird MD, Dunn JC, Uhlinger J, Parnes N. Glenoid microfracture in active-duty military patients: minimum 5-year follow-up demonstrates 75% survival. JSES Int 2022; 7:86-92. [PMID: 36820416 PMCID: PMC9937841 DOI: 10.1016/j.jseint.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background To present midterm patient-reported outcomes and survivorship data of active-duty military patients undergoing microfracture for full-thickness cartilage defects of the glenoid. Methods All consecutive patients from January 2013 through December 2016 who underwent glenoid microfracture for full-thickness cartilage injuries with complete outcome scores were identified. Twenty patients met the final inclusion criteria for the study, and all were active-duty military at the time of surgery. A separate subgroup analysis was performed to determine if dominant-shoulder involvement portends worse outcomes. Results The mean follow-up was 81.45 ± 19.43 months (range, 60-108). Of the 20 patients, 5 required a secondary surgical procedure within 5 years of their index procedure, with an average time to failure of 45.6 ± 13.15 months. For the 15 patients who did not fail, there was a statistically significant increase in the mean American Shoulder and Elbow Surgeons score (57.20 vs. 88.27, P < .0001) and Single Assessment Numeric Evaluation (45.00 vs. 86.33, P < .0001). Mean pain decreased significantly as measured by the pain visual analog scale (5.40 vs. 1.37, P < .0001). Range of motion in forward elevation, external rotation, and internal rotation did not change significantly postoperatively (P = .4528, .4810, and .1919, respectively). Concomitant procedures did not predict changes in pain, American Shoulder and Elbow Surgeons, or Single Assessment Numeric Evaluation scores. A majority of patients (13/20, 65%) were able to remain on unrestricted military active-duty service, but 7 (35%) underwent medical discharge, including the 5 patients who had experienced treatment failure, plus 2 additional patients. Conclusion Glenoid microfracture can result in pain relief and symptomatic improvement for a select group of active-duty military patients, with 75% survivorship at 5 years. Approximately one in three (35%) patients, however, were unable to remain on active-duty military service.
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Affiliation(s)
- John P. Scanaliato
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, TX, USA
- Corresponding author: John P Scanaliato, MD, William Beaumont Army Medical Center, Department of Orthopaedic Surgery, 18511 Highlander Medics Street, Fort Bliss, TX 79918, USA.
| | - Alexis B. Sandler
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, TX, USA
| | - Michael D. Baird
- Walter Reed National Military Medical Center, Department of Orthopaedic Surgery, Bethesda, MD, USA
| | - John C. Dunn
- William Beaumont Army Medical Center, Department of Orthopaedic Surgery, El Paso, TX, USA
| | - Jason Uhlinger
- Carthage Area Hospital, Department of Orthopaedic Surgery, Carthage, NY, USA
| | - Nata Parnes
- Carthage Area Hospital, Department of Orthopaedic Surgery, Carthage, NY, USA
- Claxton-Hepburn Medical Center, Department of Orthopaedic Surgery, Ogdensburg, NY, USA
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Biceps Tenodesis Combined With Arthroscopic Posterior Labral Repair for Type VIII SLAP Lesions in Active-Duty Military Patients Yields Excellent Return to Military Duty. Arthroscopy 2022; 38:2620-2627. [PMID: 35367303 DOI: 10.1016/j.arthro.2022.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To report short-term outcomes following biceps tenodesis combined with arthroscopic posterior labral repair of type VIII SLAP lesions in active-duty military patients. METHODS All consecutive patients from January 2012 through December 2018 who underwent biceps tenodesis combined with arthroscopic posterior labral repair of type VIII SLAP tears performed by the senior surgeon with complete outcome scores and minimum 2.5 years follow-up were identified. Exclusion criteria included concomitant glenoid microfracture, rotator cuff repair, or other capsulolabral repair. Outcome measures were completed by patients within 7 days before surgery and at latest follow-up. Biceps tenodesis performed was a mini-open, through a subpectoral approach, using a double-loaded 2.9mm suture-anchor. RESULTS Thirty-two patients met the inclusion criteria for the study. All patients were active-duty military at time of surgery. Average follow-up was 73.53 ± 22.37 months. Thirty-one patients achieved the minimal clinically important difference, 30 of 32 reached the substantial clinical benefit, and 31 of 32 met the patient acceptable symptomatic state, as defined for the American Shoulder and Elbow Surgeons Shoulder Score. Similarly, 30 of 32 patients reached the minimal clinically important difference, 29 of 32 achieved the substantial clinical benefit, and 32 of 32 met the patient acceptable symptomatic state for the Single Assessment Numeric Evaluation. There were no significant changes in forward flexion, external rotation, or internal rotation between pre- and postoperative measurements. Three patients reported postoperative complications and 1 patient progressed to further surgery. Thirty (93.75%) patients remained on active-duty military service and were able to return to preinjury levels of activity. CONCLUSIONS Active-duty military patients with type VIII SLAP tears had statistically and clinically significant increases in outcome scores, marked improvement in pain, and high rates of return to unrestricted active-duty following mini-open subpectoral biceps tenodesis combined with posterior labral repair. LEVEL OF EVIDENCE IV, retrospective case series.
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Sandler AB, Scanaliato JP, Baird MD, Dunn JC, Parnes N. Lower Reoperation and Higher Return-to-Sport Rates After Biceps Tenodesis Versus SLAP Repair in Young Patients: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e1887-e1895. [PMID: 36312714 PMCID: PMC9596896 DOI: 10.1016/j.asmr.2022.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/11/2022] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Alexis B. Sandler
- George Washington University School of Medicine and Health Sciences, Washington, DC, U.S.A
- Address correspondence to Alexis B. Sandler, M.D., William Beaumont Army Medical Center/Texas Tech University Health Sciences Center, 18511 Highlander Medics Dr, El Paso, TX 79934, U.S.A.
| | - John P. Scanaliato
- Department of Orthopaedics, William Beaumont Army Medical Center, El Paso, Texas, U.S.A
| | - Michael D. Baird
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - John C. Dunn
- Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, Maryland, U.S.A
| | - Nata Parnes
- Department of Orthopaedic Surgery, Carthage Area Hospital, Carthage, New York, U.S.A
- Department of Orthopaedic Surgery, Claxton-Hepburn Medical Center, Ogdensburg, New York, U.S.A
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13
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Scanaliato JP, Eckhoff MD, Dunn JC, Czajkowski H, Fink WA, Parnes N. Long-term Results of Arthroscopic Repair of Full-Thickness Traumatic Rotator Cuff Tears in Active Duty Military Patients Under the Age of 40 Years. Am J Sports Med 2022; 50:2753-2760. [PMID: 35862618 DOI: 10.1177/03635465221107371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Arthroscopic rotator cuff repair is an effective procedure through which to decrease pain and increase strength, with favorable long-term outcomes demonstrated in older patient populations with full-thickness rotator cuff tears. The long-term outcomes after this procedure in younger, higher-demand patients, however, is not as clearly defined. PURPOSE To report on the long-term outcomes after arthroscopic rotator cuff repair of traumatic full-thickness rotator cuff tears in active duty military patients under the age of 40 years at the time of surgery. STUDY DESIGN Case series; Level of evidence, 4. METHODS Preoperative, midterm, and final evaluations were collected, including scores on the visual analog scale for pain, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons shoulder form. A total of 42 patients were screened for inclusion: 3 underwent additional surgical procedures on the operative shoulder and 2 were lost to follow-up, leaving 37 patients with mean follow-up of 104.51 months available for analysis. A subgroup analysis was performed comparing outcomes between patients with Southern California Orthopaedic Institute grade 1 or 2 tears and those with grade 3 or 4 tears. RESULTS At final follow-up, pain per the visual analog scale decreased to 1.16 from 8.03 (P < .0001); the Single Assessment Numeric Evaluation score increased to 87.32 from 48.24 (P < .0001); and the American Shoulder and Elbow Surgeons score increased to 88.68 from 41.00 (P < .0001). There was no statistically significant difference in outcome scores or range of motion between midterm and final follow-up. Improvement in outcome scores and range of motion at final follow-up did not vary between patients with small and large tears. Of 42 patients, 37 (88.1%) were able to return to full unrestricted active duty and sporting activity, while 5 (11.9%) were medically separated from the military. CONCLUSION Active duty military patients under the age of 40 years with traumatic full-thickness rotator cuff tears had statistically and clinically significant increases in outcome scores and decreases in pain after arthroscopic rotator cuff repair at long-term follow-up.
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Affiliation(s)
| | | | - John C Dunn
- William Beaumont Army Medical Center, El Paso, Texas, USA
| | | | - Walter A Fink
- Carson Tahoe Health Administration, Carson City, Nevada, USA
| | - Nata Parnes
- Carthage Area Hospital, Carthage, New York, USA.,Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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Primary Double-Pulley SLAP Repair in an Active-Duty Military Population With Type II SLAP Lesions Results in Improved Outcomes and Low Failure Rates at Minimum Six Years of Follow-up. Arthrosc Sports Med Rehabil 2022; 4:e1141-e1149. [PMID: 35747638 PMCID: PMC9210478 DOI: 10.1016/j.asmr.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/12/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose To report mid-term outcomes of active-duty patients younger than the age of 35 years with shoulder type II SLAP lesions following our technique for double-pulley SLAP repair (DPSR). Methods All consecutive patients aged 18 to 35 years from January 2014 through December 2015 who underwent primary DPSR by the senior surgeon with complete outcome scores were identified. The clinical significance measures (patient acceptable symptomatic state [PASS], substantial clinical benefit [SCB], minimal clinically important difference [MCID]) have not yet been fully defined for type II SLAP repair procedures, so the values for biceps tenodesis were used as a stand-in. Patients were excluded if they were lost to follow-up of if they underwent a concomitant rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up. Results Overall, 22 of 41 (53.7%) patients met the inclusion criteria for the study, and all were active-duty military at time of surgery. In total, 21 of 22 (95.5%) patients met the PASS, whereas 20 of 22 (90.9%) achieved SCB and 22 of 22 (100.0%) exceeded the MCID for their operative shoulder as determined by the American Shoulder and Elbow Surgeons score. In total, 19 of 22 (86.4%) patients met the PASS, whereas 22 of 22 (100.0%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the Single Assessment Numeric Evaluation. In addition, 21 of 22 (95.5%) met the PASS, whereas 22 of 22 (100%) achieved SCB and exceeded the MCID for their operative shoulder as determined by the pain visual analog scale. Pre- and postoperative range of motion did not vary significantly. In total, 18 of 22 (81.8%) of patients remained on active duty and were able to return to preinjury work and recreation activity levels. In 2 patients (9.09%), the repair did not heal. Conclusions Mid-term outcomes in this population of young, active-duty patients undergoing DPSR for type II SLAP tears demonstrate a statistically and clinically significant improvement in patient-reported outcomes and an overall return to active-duty rate of 81.8%. Level of Evidence Level IV, therapeutic case series.
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Green CK, Scanaliato JP, Fares AB, Czajkowski H, Dunn JC, Parnes N. Midterm Outcomes After Arthroscopic Repair of Type VIII SLAP Lesions in Active Duty Military Patients Younger Than 35 Years. Orthop J Sports Med 2022; 10:23259671221095908. [PMID: 35601738 PMCID: PMC9118435 DOI: 10.1177/23259671221095908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
Background Superior labrum from anterior to posterior (SLAP) lesions represent a significant cause of shoulder pain and disability among active duty members of the US military. However, few data exist regarding the surgical management of type VIII SLAP lesions. Hypothesis We hypothesized that arthroscopic repair would decrease pain and increase function at the midterm follow-up and allow for a high rate of maintenance of active duty status. Study Design Case series; Level of evidence, 4. Methods Consecutive active duty military patients were identified from January 2011 through June 2015 who underwent arthroscopic repair of type VIII SLAP lesions performed by a single surgeon. Patients were excluded if they underwent glenoid microfracture, other capsulolabral repair, or rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up: pain visual analog scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, and Rowe instability score. Results A total of 30 patients met the inclusion criteria for the study. The mean ± SD follow-up was 96.60 ± 10.91 months. At final follow-up, the mean visual analog scale score improved from 8.17 ± 1.6 to 1.63 ± 1.90 (P < .0001), the Single Assessment Numeric Evaluation score from 41.65 ± 16.78 to 87.63 ± 13.02 (P < .0001), the American Shoulder and Elbow Surgeons score from 36.47 ± 10.26 to 88.07 ± 13.94 (P < .0001), and the Rowe score from 35.33 ± 6.56 to 90.00 ± 14.68 (P < .0001). Three patients reported postoperative complications, and 1 progressed to further surgery. Overall, 90% of patients remained on active duty military service and were able to return to preinjury levels of work and recreational activity. The failure rate, defined as persistent instability or activity-limiting pain, was 10%. Conclusion The results of this study demonstrated favorable outcomes for the majority of patients after arthroscopic repair of type VIII SLAP lesions at midterm follow-up, supporting repair as a viable treatment option for type VIII SLAP tears in this patient population.
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Affiliation(s)
- Clare K. Green
- School of Medicine, The George Washington University, Washington, DC, USA
| | - John P. Scanaliato
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Austin B. Fares
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Hunter Czajkowski
- Department of Orthopaedic Surgery, Carthage Area Hospital, Carthage, New York, USA
- Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
| | - John C. Dunn
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Nata Parnes
- Department of Orthopaedic Surgery, Carthage Area Hospital, Carthage, New York, USA
- Claxton-Hepburn Medical Center, Ogdensburg, New York, USA
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