SLAP Repairs With Combined Procedures Have Lower Failure Rate Than Isolated Repairs in a Military Population: Surgical Outcomes With Minimum 2-Year Follow-up

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

Level-IV.

Biceps Tenodesis cannot be used as primary treatment option in baseball pitchers with intact rotator cuff muscles

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.

Supraspinatus repair and biceps tenodesis in competitive CrossFit athletes allow for a 100% of return to sport

PURPOSE

The shoulder is the most commonly injured body part in CrossFit training. The aim of this study is to report the clinical and MRI results of an arthroscopic repair of supraspinatus tear associated with SLAP lesion in competitive CrossFit athletes.

METHODS

Competitive CrossFit athletes affected by a full-thickness supraspinatus tear associated with SLAP lesion secondary to training injury were prospectively enrolled in the study. Clinical diagnosis was confirmed with MRI (> 1.5 T). Functional evaluation was done using the Constant Score (CS) and ASES score (ASES). All lesions were treated with single-row repair and biceps tenodesis. Minimum follow-up (clinical, MRI) was 24 months.

RESULTS

Nineteen patients were available at the final follow-up. The average age was 43-year-old (range 28-52, SD 8), 12 were males and 7 females. Pre-operative CS and ASES were 67 (range 61-77, SD 7) and 71 (range 62-79, SD 5), respectively. At the 24-month follow-up, 19/19 athletes resumed intensive training and 17/19 returned to competitions. CS and ASES rose to 90 (p = 0.039) and 93 (p = 0.04), respectively. At the final follow-up, MRI indicated complete healing of the tendon in 15 (79%) cases and 4 (21%) cases with type II Sugaya repair integrity. Two of the patients of the latter group did not return to their usual training level and showed type II (Kibler) scapular dyskinesis.

CONCLUSIONS

Arthroscopic repair of the supraspinatus tendon associated with biceps tenodesis led to a 100% of return-to-CrossFit training and 90% rate of individuals resuming competitions at 24 months of follow-up. MRI showed 15 (79%) cases of complete healing and 4 (21%) cases with type II Sugaya repair integrity; biceps tenodesis clinically failed only in 1 case and the athlete complained of a decrease in the competitions scores and opted to discontinue CrossFit competitions.

LEVEL OF EVIDENCE

IV.

Isolated type II SLAP tears undergo reoperation more frequently

PURPOSE

There is discrepancy in the reported reoperation rate and factors associated with reoperation after type II SLAP repair. The aim was to determine the incidence and factors associated with unplanned reoperation and repair failure after type II SLAP repair.

METHODS

Five-hundred and thiry-nine patients with SLAP repairs were identified from 2005 to 2016. Patient characteristics were recorded and subgroup analyses performed. Multivariable logistic regression was used to identify factors independently associated with unplanned reoperation and SLAP repair failure.

RESULTS

Sixty-six of 539 patients (12%) had unplanned reoperation after SLAP repair. Additional procedures during SLAP repair were associated with fewer unplanned reoperations (OR 0.57; P = 0.046). Age < 40 was associated with unplanned reoperation (55% vs 40%; P = 0.032), but this was not an independent association. Forty-five of 539 patients (8.3%) had SLAP repair failure (defined by repeat SLAP repair or biceps tenodesis/tenotomy). Smoking (OR 3.1; P = 0.004) and knotless suture anchors (OR 3.4; P = 0.007) were associated with SLAP repair failure. Isolated SLAP repair was associated with SLAP repair failure (64% vs 46%; P = 0.020), but this was not an independent association. In those who did not have an isolated SLAP repair, knotless suture anchors (19% vs 3.4%; P = 0.024) were associated with repair failure.

CONCLUSION

After type II SLAP repair, roughly 1 in 10 patients may undergo reoperation. Isolated SLAP repair is independently associated with unplanned reoperation.

LEVEL OF EVIDENCE

Level III.

The majority of patients return to athletic activity following biceps tenodesis

PURPOSE

Biceps tenodesis is widely used as a primary treatment for long head of the biceps brachii pathology and superior labral anterior and posterior (SLAP) lesions. However, rates and timing of full return to sports (RTSs)/duty have not been systematically analysed. This systematic review examines the literature to ascertain the rate and timing of return to athletic activity, and the availability of specific criteria for safe return to atheletic activity following the biceps tenodesis.

METHODS

Based on PRISMA guidelines, this systematic review utilised the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to athletic activity following biceps tenodesis. Statistical analysis was performed using SPSS.

RESULTS

This review identified 17 studies including 374 cases meeting the inclusion criteria. The majority of patients were men 260 (69.7%), with an median age of 42.2 years (range 16-88) and a mean follow-up of 37.4 months. The overall rate of RTS was 217/269 (80.7%), with 43/59 (72.9%) returning to the same level. In overhead athletes, the overall rate of return to play was 39/49 (79.6%). Among military personnel, the overall rate of return to duty was 61/74 (82.4%). The average time to RTS was 5.4 (range 3-11) months. 10 (58.8%) Studies reported a recommended time window within which patients were allowed to return to full activity. Specific criteria for return to play were not reported in any of the identified studies.

CONCLUSION

While overall rate of return to athletic activity was reportedly high following biceps tenodesis, one in four patients were not able to resume athletic activity at the same level. At present, there is no objective assessment of when patients can return to full activity reported in the literature.

LEVEL OF EVIDENCE

IV.

Management of Failed SLAP Repair: A Systematic Review

BACKGROUND

Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature.

QUESTIONS/PURPOSES

The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair.

METHODS

The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included.

RESULTS

A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery.

CONCLUSION

The most common reason for failed SLAP repair is persistent post-operative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.

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.

Intra-articular arthroscopic biceps tenodesis with interference screw: clinical and isokinetic evaluation

Background

Although biceps tenodesis has been widely used to treat its pathologies, few studies looked at the objective evaluation of elbow strength after this procedure. The purpose of this study is to clinically evaluate patients submitted to long head of the biceps (LHB) tenodesis with interference screws through an intra-articular approach and analyze the results of an isokinetic test to measure elbow flexion and forearm supination strengths.

Methods

Patients who had biceps tenodesis were included in the study if they had a minimum follow-up of 24 months. Patients were excluded if they had concomitant irreparable cuff tears or previous or current contralateral shoulder pain or weakness. Postoperative evaluation was based on University of California-Los Angeles (UCLA) shoulder score and on measurements of elbow flexion and supination strength, using an isokinetic dynamometer. Tests were conducted in both arms, with velocity set at 60º/s with 5 concentric-concentric repetitions.

Results

Thirty-three patients were included and the most common concomitant diagnosis were rotator cuff tear (69%) and superior labrum anterior to posterior (SLAP) lesions (28%). The average UCLA score improved from 15.1 preoperatively to 31.9 in the final follow-up (P < .001). Isokinetic tests showed no difference in peak torque between the upper limbs. One patient had residual pain in the biceps groove. None of the patients had Popeye deformity. UCLA score and follow-up length did not demonstrate correlation with peak torque.

Conclusion

Arthroscopic proximal biceps tenodesis with interference screw, close to the articular margin, yielded good clinical results. Isokinetic tests revealed no difference to the contralateral side in peak torque for both supination and elbow flexion.

Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability

BACKGROUND

The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability.

METHODS

This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control).

RESULTS

Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively).

CONCLUSION

Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.

Imaging modality for measuring the presence and extent of the labral lesions of the shoulder: a systematic review and meta-analysis

BACKGROUND

Multiple published studies quantitatively analysing the diagnostic value of MRI, MR arthrography (MRA) and CT arthrography (CTA) for labral lesions of the shoulder have had inconsistent results. The aim of this meta-analysis was to systematically compare the diagnostic performance of MRI, MRA, CTA and CT.

METHODS

Two databases, PubMed and EMBASE, were used to retrieve studies targeting the accuracy of MRI, MRA, CTA and CT in detecting labral lesions of the shoulder. After carefully screening and excluding studies, the studies that met the inclusion criteria were used for a pooled analysis, including calculation of sensitivity and specificity with 95% confidence intervals (CIs) and the area under the hierarchical summary receiver operating characteristic (HSROC) curves.

RESULTS

The retrieval process identified 2633 studies, out of which two reviewers screened out all but 14 studies, involving a total of 1216 patients who were deemed eligible for inclusion in the meta-analysis. The results assessing the diagnostic performance of MRI vs. MRA for detecting labral lesions showed a pooled sensitivity of 0.77 (95% CI 0.70-0.84) vs. 0.92 (95% CI 0.84-0.96), a specificity of 0.95 (95% CI 0.85-0.98) vs. 0.98 (95% CI 0.91-0.99), and an area under the HSROC curve of 3.78 (95% CI 2.73-4.83) vs. 6.01 (95% CI 4.30-7.73), respectively.

CONCLUSION

MRA was suggested for use in patients with chronic shoulder symptoms or a pathologic abnormality. MRI is by far the first choice recommendation for the detection of acute labral lesions. CT should be a necessary supplemental imaging technique when there is highly suspected glenoid bone damage.

Return to Sport After Arthroscopic Superior Labral Anterior-Posterior Repair: A Systematic Review

CONTEXT

Superior labral anterior-posterior (SLAP) lesions often result in significant sporting limitations for athletes. Return to sport is a significant outcome that often needs to be considered by athletes undergoing the procedure.

OBJECTIVE

To evaluate return to sport among individuals undergoing arthroscopic SLAP repair.

DATA SOURCES

Four databases (MEDLINE, EMBASE, PubMed, and Cochrane) were searched from database inception through January 29, 2018.

STUDY SELECTION

English-language articles reporting on return-to-activity rates after arthroscopic SLAP repairs were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data including patient demographics, surgical procedure, and return to activity were extracted. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

Of 1938 screened abstracts, 22 articles involving a total of 944 patients undergoing arthroscopic SLAP repair met inclusion criteria. Of the total included patients, 270 were identified as overhead athletes, with 146 pitchers. Across all patients, 69.6% (657/944 patients) of individuals undergoing arthroscopic SLAP repair returned to sport. There was a 69.0% (562/815 patients) return to previous level of play, with a mean time to return to sport of 8.9 ± 2.4 months (range, 6.0-11.7 months). The return-to-sport rate for pitchers compared with the return-to-activity rate for nonpitchers, encompassing return to work and return to sport, was 57.5% (84/146 patients) and 87.1% (572/657 patients), respectively, after arthroscopic SLAP repair.

CONCLUSION

Arthroscopic SLAP repair is associated with a fair return to sport, with 69.6% of individuals undergoing arthroscopic SLAP repair returning to sport. SLAP repair in pitchers has significantly decreased return to sport in comparison with nonpitching athletes. Athletes on average return to sport within 9 months postoperatively.

Superior labral anterior to posterior (SLAP) injury in the workplace

BACKGROUND AND OBJECTIVE

Superior labral anterior to posterior (SLAP) injuries are widely recognised as a cause of pain and dysfunction in the shoulders of active patients. The aims of the present study were to analyze SLAP injuries in the workplace, and to evaluate the reliability of physical examination and imaging techniques for the diagnosis of work-related SLAP injuries.

MATERIAL AND METHODS

Retrospective chart review of 58 SLAP injuries treated in our occupational health centre from 2005 to 2015 in 815 patients undergoing shoulder arthroscopy. Data were collected on mechanism of injury, clinical proceedings, complementary tests (contrasting the initial magnetic resonance imaging report with that of a radiologist specializing in musculoskeletal pathology), arthroscopy findings and treatments performed.

RESULTS

The most common mechanism of injury was acute injury while handling weight, in the majority of cases, above the head. SLAP injury was suspected in 41% of cases through anamnesis and physical exam, in 29% through the initial magnetic resonance imaging report, and in 52% through the specialised radiologist's report. In 78%, associated injuries were present, the most common being rotator cuff injuries.

CONCLUSIONS

SLAP injuries in the workplace are rare and are often a diagnostic finding during surgical intervention performed for a different associated injury. Arthro-magnetic resonance imaging and magnetic resonance imaging have lower reliability than physical exams in the diagnosis of work-related SLAP injuries. A radiologist specializing in musculoskeletal pathology could probably improve the reliability of imaging test interpretation in work-related SLAP injuries.

Trends in the Management of Isolated SLAP Tears in the United States

Background:

The management of superior labrum anterior and posterior (SLAP) tears remains controversial, with surgical treatment options including SLAP repair, debridement, and open or arthroscopic biceps tenodesis (BT), based on patient factors and the type of tear.

Hypothesis:

We hypothesized that SLAP repair has become less frequently performed over time, while BT is more frequently performed, particularly in patients ≥ 40 years.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective query was performed using the Humana insurance database from years 2007 to 2016. For the management of a SLAP tear diagnosis (International Classification of Diseases–Ninth Edition [ICD-9] code: 840.7), independent and exclusive cohorts were formed using Current Procedural Terminology (CPT) codes for debridement (29822, 29823), SLAP repair (29807), open or arthroscopic BT (29828, 23430), and SLAP repair combined with BT (29828 OR 23430 AND 29807).

Results:

Of 46,650 diagnoses of a SLAP tear, there were 3347 patients who underwent operative management for an isolated SLAP tear from 2007 to 2016. There was a linear increase of SLAP tear diagnoses per year (r² = 0.800, P < .001) during this period. Overall, SLAP repair was performed in 1629 patients (48.7%), debridement was performed in 1076 patients (32.1%), BT was performed in 552 patients (16.5%), and combined SLAP repair and BT was performed in 90 patients (2.7%). There was a 69.3% decrease in isolated SLAP repair from 2007 to 2016 (r² = 0.882, P < .001). BT for the diagnosis of an isolated SLAP tear increased by 370.0% over the same period (r² = 0.800, P < .001). SLAP repair had an equivalent percentage of being performed in patients both older and younger than 40 years (P = .218). There was a 1500.0% increase in BT performed in patients older than 40 years during the study period. There were no statistical differences in the postoperative incidence of stiffness, surgical site infections, and reoperations between all surgical treatment groups (P > .05).

Conclusion:

An analysis of a large private-payer database revealed that surgical treatment of isolated SLAP tears in the United States has shifted from 2007 to 2016, with an increase in the frequency of BT and a decline in the frequency of SLAP repair, particularly in patients older than 40 years.

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.

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.

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears in Active Patients Younger Than 40 Years: 2- to 5-Year Clinical Outcomes

This study characterized injury patterns and reported clinical outcomes of all-arthroscopic management of full-thickness rotator cuff tears among military patients younger than 40 years. A retrospective review was performed of prospective data for 42 patients younger than 40 years who underwent arthroscopic rotator cuff repair and, in some cases, concomitant labral repair. Preoperative and postoperative evaluations (minimum follow-up, 2 years; mean, 41 months; range, 24-66 months) included range of motion, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. Of the patients, 97.6% (41 of 42) had improved VAS, SST, and ASES scores. Mean VAS score improved from 8.09±1.51 to 1.19±1.85 (P<.01). Mean SSV improved from 47.88±19.56 to 89.45±14.04 (P<.01). Mean ASES score improved from 38.97±12.70 to 89.88±14.26 (P<.01). No difference for VAS, SSV, and ASES scores was noted between (1) all 42 patients, (2) the 26 patients who had rotator cuff repair but not labral repair, and (3) the 16 patients who had both rotator cuff repair and labral repair. Complications (7.1%; 3 of 42) included 2 postoperatively frozen shoulders and 1 retear of the rotator cuff. Of the patients, 95.2% (40 of 42) returned to their preoperative level of recreational and military job activity. Military patients younger than 40 years who have a full-thickness rotator cuff tear have a high prevalence of concomitant shoulder injury, especially labral tear. For patients younger than 40 years, arthroscopic rotator cuff repair, with or without labral repair, resulted in excellent clinical outcomes, a low risk of complications, and a high rate of return to the preoperative level of recreational and military job activity. [Orthopedics. 2018; 41(1):e52-e57.].

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.

Anterior Shoulder Instability in the Military Athlete

CONTEXT

Given its young, predominately male demographics and intense physical demands, the US military remains an ideal cohort for the study of anterior shoulder instability.

EVIDENCE ACQUISITION

A literature search of PubMed, MEDLINE, and the Cochrane Database was performed to identify all peer-reviewed publications from 1950 to 2016 from US military orthopaedic surgeons focusing on the management of anterior shoulder instability.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

The incidence of anterior shoulder instability events in the military occurs at an order of magnitude greater than in civilian populations, with rates as high as 3% per year among high-risk groups. With more than 90% risk of a Bankart lesion and high risk for instability recurrence, the military has advocated for early intervention of first-time shoulder instability while documenting up to 76% relative risk reduction versus nonoperative treatment. Preoperative evaluation with advanced radiographic imaging should be used to evaluate for attritional bone loss or "off-track" engaging defects to guide comprehensive surgical management. With complex recurrent shoulder instability and/or cases of clinically significant osseous lesions, potential options such as remplissage, anterior open capsular procedures, or bone augmentation procedures may be preferentially considered.

CONCLUSION

Careful risk stratification, clinical evaluation, and selective surgical management for at-risk military patients with anterior shoulder instability can optimize the recurrence risk and functional outcome in this population.

Pathomechanics and Magnetic Resonance Imaging of the Thrower's Shoulder

Repetitive, high-velocity overhead throwing can lead to several adaptive changes in the throwing shoulder, which over time lead to structural microtrauma and eventually overt injury. MR imaging is a useful imaging modality to evaluate these changes and to characterize their acuity and severity. Understanding the throwing motion and the effects of this motion on the structures of the shoulder can help radiologists to recognize these findings and provide useful information to referring physicians, which may affect the treatment of these athletes. This article reviews shoulder pathomechanics and MR imaging findings in overhead throwing athletes.

Editorial Commentary: On Kibler & Sciascia: What Did the Five Fingers Say to the Face? SLAP. A Systematic Review Wake-Up Call to Improve SLAP Repair Guidelines

Both the quality and quantity of reporting in the SLAP repair literature, especially the surgical indications and technical intraoperative characteristics, leaves significant room for improvement. In their systematic review, Kibler and Sciascia identify this considerable underlying imprecision. Based on the current literature, no consensus exists for establishing any criteria for a successful SLAP repair--surgical indications, characteristics (type, location, number of anchors), completeness of repair, or rehabilitation.

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.