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

Ill-defined return to sport criteria and inconsistent unsuccessful return rates caused by various reasons not necessarily related to treatment after superior labral treatments: A systematic review

PURPOSE

The aims of this systematic review were to determine (1) which criteria are used to determine return to sport (RTS), (2) the number of patients that are unable to RTS following any superior labral pathophysiology treatment and (3) which reasons are reported for not returning.

METHODS

A systematic review was performed across 5 databases, including studies that report rates for RTS following any treatment of superior labral pathophysiology. Study quality was assessed using the MINORS criteria. Definitions for nRTS were extracted as reported in the studies. The ranges of no return to sport (nRTS) and no return to pre-injury level (nRTPL) were summarized. Reasons for nRTS and nRTPL were categorized using a predefined coding scheme.

RESULTS

Among 45 studies with level of evidence ranging from II to IV, 1857 patients were involved in sports, 78% (n=1453) of whom underwent superior labral reattachment, 21% (n=381) biceps tenodesis, and 9.4% (n=175) non-operative treatment. None of the studies provided criteria for RTS and two studies provided criteria for return to pre-injury level (RTPL). The ranges of nRTS and nRTPL varied following superior labral reattachment (0-60%, n=206; 0-89%, n=424, respectively), biceps tenodesis (0-25%, n=43; 3,8-48%, n =78) and nonoperative treatment (11-75%, n=62; 18-100%, n=78). Reasons for nRTS and nRTPL were related to physical sensations (pain, feeling of instability, discomfort, weakness, lack of motion), psychological factors (fear of reinjury, lack of confidence), personal factors (lifestyle change, social reasons) and injury at another site.

CONCLUSION

Criteria for determining successful RTS and RTPL following superior labral pathophysiology treatment were not reported by the majority of studies. The nRTS and nRTPL rates varied greatly within and between treatments. The reasons for this unsuccessful return were diverse and related to physical sensations, psychological factors, personal factors and injury unrelated to treatment.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

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.

Patient outcomes and return to play after arthroscopic rotator cuff repair in overhead athletes: a systematic review

BACKGROUND

Rotator cuff tear injuries in overhead athletes are common and may lead to chronic pain and joint disability, impairing sport participation and leading to premature retirement. The improvement of the patient reported outcome measures (PROMs) was evaluated, as were the time and level of return to sport and the rate of complication in overhead athletes who had undergone arthroscopic rotator cuff repair.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In September 2022, the following databases were accessed: Pubmed, Web of Science, Google Scholar and Embase. No time constraints were used for the search. All the clinical trials investigating arthroscopic rotator cuff repair in overhead athletes were accessed.

RESULTS

Data from 20 studies were collected. The mean length of the follow-up was 40 months. All PROMs improved at last follow-up: Kerlan-Jobe Orthopaedic Clinic score (P = 0.02), visual analogue scale (P = 0.003), Constant score (P < 0.0001), University of California Los Angeles Shoulder score (P = 0.006) and American Shoulder and Elbow Surgeons' score (P < 0.0001). Elevation also improved (P = 0.004). No difference was found in external and internal rotation (P = 0.2 and P = 0.3, respectively). In total, 75.4% (522 of 692 of patients) were able to return to play within a mean of 6.4  ±  6.0 months. Of 692 patients, 433 (62.5%) were able to return to sport at pre-injury level. Fourteen out of 138 patients (10.1%) underwent a further reoperation. The overall rate of complications was 7.1% (20 of 280).

CONCLUSION

Arthroscopic reconstruction of the rotator cuff is effective in improving function of the shoulder in overhead athletes, with a rate of return to sport in 75.4% of patients within an average of 6.4 months.

LEVEL OF EVIDENCE

III, systematic review.

TRIAL REGISTRATION

Not applicable.

A High Rate of Return to Running Is Seen After Both Arthroscopic and Open Shoulder Surgery

PURPOSE

To determine the percentage of patients who report the ability to run 1 mile at various time points after arthroscopic and open shoulder surgery.

METHODS

We performed a retrospective review of prospectively collected data for all active-duty military patients aged 18 to 45 years who underwent shoulder surgery at a single institution over a 2-year period. The rehabilitation protocol discouraged running before 3 months, but all patients were able to return to unrestricted running at 3 months postoperatively. Patients were excluded if they lacked 1-year follow-up data. Parameters collected included demographic information and validated patient-reported outcome measures at the preoperative and short-term postoperative visits, as well as patients' ability to run at least 1 mile postoperatively.

RESULTS

A total of 126 patients were identified who underwent shoulder surgery with return-to-running data. Compared with baseline, significant improvements in patient-reported outcomes were shown at 1 and 2 years postoperatively (P = .001). The percentage of patients reporting the ability to run 1 mile postoperatively was 59% at 3 months, 74% at 4.5 months, 79% at 6 months, 83% at 12 months, and 91% at 24 months. There was no significant difference in patients undergoing shoulder surgery for instability versus non-instability diagnoses or in patients undergoing open versus arthroscopic anterior stabilization. All 11 patients unable to return to running at final follow-up had chronic lower-extremity diagnoses limiting their running ability.

CONCLUSIONS

Young military athletes undergoing arthroscopic and open shoulder surgery have a high rate of early return to running. Approximately 60% of patients report the ability to run 1 mile at 3 months postoperatively, and three-quarters of patients do so at 4.5 months. Age, sex, military occupation, underlying diagnosis or type of surgery did not influence the rate of return to running after shoulder surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Return to Sport and Patient-Reported Outcomes After Subpectoral Biceps Tenodesis for SLAP Tear in Collegiate Gymnasts

Background

The biceps superior labral complex is a known source of shoulder dysfunction in young, high-level athletes. Superior labral anterior-posterior (SLAP) repairs are often unsatisfactory for treating biceps-labral pathology in this demographic group, with high failure rates and poor return to sport (RTS). Minimal data have been published to demonstrate patient-reported outcomes (PROs) and RTS in gymnasts after treatment of SLAP pathologies.

Hypothesis

Gymnasts undergoing biceps tenodesis for SLAP pathologies would have satisfactory PROs and satisfactory RTS.

Study Design

Case series; Level of evidence, 4.

Methods

Gymnasts aged ≤25 years who underwent open subpectoral biceps tenodesis for SLAP tears with or without biceps tendon pathology between August 20, 2014, and August 20, 2019, and who had minimum 2-year follow-up data were included in this study. Tenodesis was performed using a subpectoral technique with bicortical button fixation. The following PROs were included: RTS, postoperative activity level, 10-point visual analog scale for pain (VAS-Pain), American Shoulder and Elbow Surgeons (ASES), and Disabilities of the Arm, Shoulder and Hand (DASH) scores.

Results

Of 16 shoulders in 14 gymnasts undergoing biceps tenodesis for SLAP tear during the study period, a follow-up was obtained for 13 of 16 shoulders (81%) at 4.3 ± 1.5 years. The mean age of patients at the time of surgery was 21.8 ± 2.2 years, with 12 (92%) male patients. Biceps tenodesis was performed as the primary procedure for the diagnosis of SLAP tear in 12 patients (92%) and for failed prior SLAP repair in 1 patient (8%). PROs were excellent at the follow-up, with VAS-Pain scores of 1.8 ± 1.7, ASES scores of 89.1 ± 9.1, and DASH scores of 2.4 ± 3.2. After surgery, 8 (62%) patients returned to their prior level of collegiate gymnastics. Three (60%) of 5 patients did not return to collegiate gymnastics because of the end of eligibility, and 2 (40%) patients did not return to collegiate gymnastics because of knee injuries. Significantly higher DASH scores were noted in the group that did not RTS (P = .04). No patients experienced postoperative complications or reoperation.

Conclusion

Biceps tenodesis was an effective primary operation for high-level gymnasts with SLAP tears, with a satisfactory rate of return to the same level of sport and excellent PROs.

Surgical Treatment of Superior Labral/Biceps Pathology in the Overhead Thrower

Symptomatic superior labral anterior and posterior (SLAP) tears have become an increasingly common diagnosis, particularly within the competitive overhead athlete population. Type II SLAP tears are the most encountered variant in overhead throwing athletes. Given the high incidence of false positives on advanced imaging, corroborating the history and physical examination with imaging is paramount to accurately establish a SLAP lesion diagnosis. Previous studies have reported conflicting success rates with conservative management, but the number of pitching athletes able to return to prior level of performance with nonsurgical management strategies has been unsatisfactory. Although there has historically been a notable disconnect between the incidence of SLAP tears in the literature and the number of SLAP repairs in recent investigations, high-grade or unstable tears may be candidates for débridement, labral repair, biceps tenodesis, or less frequently, biceps tenotomy. Biceps tenodesis has been increasingly used for the management of these lesions, with recent studies reporting high rates of return to sport, high satisfaction, and good to excellent patient-reported outcomes in carefully selected athletes.

Superior-Labrum Anterior-Posterior Tears

Purpose

The purposes of this study were to determine why athletes did not return to play (RTP) following operative management of superior-labrum anterior-posterior (SLAP) tears, compare these athletes to those who did RTP, and evaluate the SLAP-Return to Sport after Injury (SLAP-RSI) score to assess the psychological readiness of athletes to RTP after operative management of SLAP tears.

Methods

A retrospective review of athletes who underwent operative management of SLAP tears with a minimum of 24-month follow-up was performed. Outcome data, including visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, patient satisfaction, and whether they would undergo the same surgery again was collected. Additionally, the rate and timing of return to work (RTW), the rate and timing of RTP, SLAP-RSI score, and VAS during sport were evaluated, with subgroup analysis among overhead and contact athletes. The SLAP-RSI is a modification of the Shoulder Instability-Return to Sport after Injury (SI-RSI) score, with a score >56 considered to be a passing score for being psychologically ready to RTP.

Results

The study included 209 athletes who underwent operative management of SLAP tears. A significantly higher percentage of patients who were able to return to play passed the SLAP-RSI benchmark of 56 compared to those who were unable to return (82.3% vs 10.1%; P < .001), and the mean overall SLAP-RSI scores were also significantly higher among those capable of returning to play (76.8 vs 50.0; P < .0001). Additionally, there was a significant difference between the two groups in every component of the SLAP-RSI score (P < .05 for all). Fear of reinjury and the feeling of instability were the most common reasons for not returning to play among contact athletes. Residual pain was the most common complaint among overhead athletes. A binary regression model predicting return to sports was performed, which demonstrated ASES score (odds ratio [OR]: 1.04, 95%; (confidence interval [CI]: 1.01-1.07; P = .009), RTW within 1 month after surgery (OR: 3.52, 95%; CI: 1.01-12.3; P = .048), and SLAP-RSI score (OR: 1.03, 95%; CI: 1.01-1.05; P = .001) were all associated with greater likelihood of return to sports at final follow-up.

Conclusions

Following the operative management of SLAP tears, patients who are unable to RTP exhibit poor psychological readiness to return, which may be due to residual pain in overhead athletes or fear of reinjury in contact athletes. Lastly, the SLAP-RSI tool in combination with ASES proved to be useful in identifying patients' psychological and physical readiness to RTP.

Level of Evidence

Level IV, prognostic case series.

High Rate of Return to Sporting Activity Among Overhead Athletes With Subpectoral Biceps Tenodesis for Type II SLAP Tear

PURPOSE

To evaluate the functional and athletic outcomes after primary subpectoral biceps tenodesis for type II SLAP tear in overhead athletes.

METHODS

All competitive elite athletes with type II SLAP tears undergoing biceps tenodesis by a single surgeon were isolated between 2007 and 2015. Exclusion criteria were applied to individuals not involved in overhead athletics, clinical follow-up <24 months, adjacent rotator cuff or labral repair, concomitant SLAP repair, and/or previous arthroscopic shoulder surgery. Patient-reported outcome measures included visual analog scale (VAS), Kerlan Jobe Orthopaedic Clinic shoulder score, and Single Assessment Numerical Assessment. Clinical and sporting outcomes were recorded using a sports-specific questionnaire.

RESULTS

Of 22 identified patients, 16 competitive overhead athletes (72.7%; 11 men, 5 women) with a mean age of 21.0 years were available at mean 4.5-year follow-up. Baseball or softball comprised the majority of patients (n = 9; 56.3%), followed by gymnastics (n = 2), swimming (n = 2), and other sports (n = 3). At mean 4.1 months postoperatively, 13 patients (81.3%) returned to previous level of athletic activity, whereas 2 patients (12.5%) failed to return to sporting activity and 1 (6.3%) returned at a lower level of competition. VAS pain significantly decreased from an average of 4.4 preoperatively to 1.7 postoperatively (P = .002), and mean Single Assessment Numerical Assessment scores also demonstrated significant improvement (55.4-76.7; P = .008). Final mean Kerlan Jobe Orthopaedic Clinic score was 74.0 (standard deviation 25.9), including 2 patients with suboptimal outcomes due to persistent pain. There were no significant differences in mean forward flexion or rotation in either the adducted or throwing position (P > .05), although small, significant decreases in postoperative active abduction were noted (165° vs 155°; P = .003).

CONCLUSIONS

In the current series of competitive overhead athletes, 81% of patients returned to previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear. Athletes reliably experienced significant decreased activity-related pain with athletic function.

LEVEL OF EVIDENCE

IV, case series.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

High Rate of Satisfaction and Return to Play at 5-Year Follow-Up After Arthroscopic Superior-Labrum Anterior-Posterior Repairs

PURPOSE

The purpose of this study was to evaluate the outcomes of patients 5 years postoperatively following arthroscopic SLAP repair, and to evaluate factors associated with satisfaction.

METHODS

A retrospective review of patients who underwent SLAP repair with a minimum of 5-year follow-up was performed. Recurrence, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder & Elbow Surgeons (ASES) score, satisfaction, whether they would undergo the same surgery again, and the rate, level and timing of return to play (RTP) were evaluated. Multilinear regression models were used to evaluate factors affecting postoperative satisfaction.

RESULTS

Overall, 122 patients who underwent SLAP repair were included, with a mean age of 33.4 years. 81% were males, and 58.2% were participating in sport preoperatively. The mean follow-up was 86.4 ± 14.4 months. At final follow up, the mean satisfaction was 87.7%, and the mean SSV was 82.9. Overall, the rate of RTP was 85.9%, with 64.8% returning at the same level at a mean of 10.5 ± 8 months. Ultimately, 13 (10.7%) patients had a further surgery, including 10 (8.2%) patients that had a biceps tenodesis. VAS during sport (P = .025), SSV (P < .001), and time to RTP (P = .0056), were associated with higher satisfaction.

CONCLUSION

There was a high rate of satisfaction at 5-year follow-up, with excellent patient-reported outcomes but with one-tenth of patients requiring revision surgeries. Additionally, while there was an overall high rate of RTP, there was only a modest rate of RTP at their preinjury level, and overhead athletes took longer to RTP.

LEVEL OF EVIDENCE

IV, case series.

Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review

BACKGROUND

Superior labrum anterior-posterior (SLAP) tears are common shoulder injuries, especially in overhead athletes. Often, initial management of these injuries is nonsurgical with focused rehabilitation. The purpose of this review was to evaluate the outcomes of nonsurgical management of SLAP tears in athletes.

METHODS

A systematic review was performed for articles published before March 2021 using key search terms pertaining to clinical studies evaluating the nonsurgical treatment of SLAP tears in adult patients published in English-language literature. Abstracts and manuscripts were independently reviewed by 2 co-authors to determine eligibility. Return-to-play rate and return-to-prior-athletic-performance rate were determined by combining results across studies.

RESULTS

Five articles met the inclusion criteria. There were 244 total athletes (162 elite or higher-level athletes). The mean ages ranged from 20.3 to 38.0 years. Type II SLAP tears were most common; baseball, softball, and weightlifting were the most common sports involved. The return-to-play rate was 53.7% in all athletes and 52.5% in elite or higher-level athletes. In athletes who were able to complete their nonoperative rehabilitation program, the return-to-play rate was 78% in all athletes and 76.6% in elite or higher-level athletes. The overall rate of return to prior performance was 42.6%, which increased to 72% for those athletes who were able to complete their rehabilitation. Patients who discontinued the rehabilitation protocol in favor of surgery had an average of 8 physical therapy sessions compared with 20 sessions for patients with successful nonoperative treatment. The timing of return to play was generally less than 6 months in studies that reported it. Patient-reported outcomes, including the American Shoulder and Elbow Surgeons score and visual analog scale, all improved significantly after nonsurgical treatment. Factors associated with failure of nonsurgical management included older age, participation in overhead sports (especially baseball pitchers), traumatic injury, positive compression rotation test, concomitant rotator cuff injury, longer baseball career, longer symptomatic period, and the presence of a Bennett spur.

CONCLUSIONS

Overall, nonoperative treatment of SLAP tears in athletes can be successful, especially in the subset of patients who are able to complete their rehabilitation program before attempting a return to play. Although nonoperative treatment should be considered the first line of treatment for most SLAP tears, there are some factors that may be associated with failure of conservative treatment; therefore, further high level, prospective studies would be beneficial to identify those athletes most likely to respond favorably to nonoperative treatment.

Return to Play After Biceps Tenodesis for Isolated SLAP Tears in Overhead Athletes

BACKGROUND

Performing open subpectoral biceps tenodesis in overhead athletes with a superior labrum anterior to posterior (SLAP) tear may affect their ability to return to overhead sports.

PURPOSE

To investigate clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of overhead athletes who underwent biceps tenodesis for a SLAP tear was performed. The American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, subjective shoulder value (SSV), patient satisfaction, willingness to undergo surgery again, revision procedures, and return to play were evaluated. Psychological readiness to return to sport was evaluated using the SLAP-Return to Sport after Injury (SLAP-RSI) score. A P value of <.05 was considered to be statistically significant.

RESULTS

The current study included 44 overhead athletes. The mean age was 34.9 years (range, 16-46 years), 79.5% were male, and the mean follow-up was 49.0 months (range, 18-107 months). Overall, 81.8% of patients returned to play their overhead sport after biceps tenodesis, and 59.1% of patients returned to the same or higher level of play. It took patients, on average, 8.7 months to return to play after biceps tenodesis. The mean SLAP-RSI score was 69.4, and 70.5% of patients passed the SLAP-RSI threshold of 56. The mean ASES score, VAS score, SSV, and satisfaction were 92.0, 0.8, 80.6, and 87.9%, respectively. No patients in our cohort required revision surgery.

CONCLUSION

This study found that athletes undergoing biceps tenodesis for the treatment of a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery.

Current Controversies and Decision-Making in the Management of Biceps Pathologies

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Biceps tendon pathologies include a spectrum of injuries that range from mild tendinosis to complete tendon rupture.

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Tendinosis, the most common pathology, occurs more frequently with age and is likely related to chronic degeneration. On the other side of the spectrum of severity lies a rupture of the long head of the biceps tendon (LHBT), which may be accompanied by injury to the glenoid labrum.

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Superior labral anterior-posterior (SLAP) tears are frequently associated with biceps pathology. Surgical management for injuries of the bicipital-labral complex includes biceps tenodesis or tenotomy and SLAP repair. A consensus as to which of these procedures is the optimal choice has not been reached, and management may ultimately depend on patient-specific characteristics.

»

Due to the relatively low incidence of distal biceps tendon rupture, agreement on the optimal management strategy has not been reached. Surgical repair, or reconstruction in the case of a chronic rupture, is often chosen. However, nonoperative management has also been utilized in older, less-active patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

Level IV.

Predicting Patient Satisfaction With Maximal Outcome Improvement After Biceps Tenodesis

The goal of this study was to determine the threshold for achieving maximal outcome improvement (MOI) on the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Constant-Murley (CM) questionnaires that predict satisfaction after isolated biceps tenodesis without concomitant rotator cuff repair. A retrospective analysis of prospectively collected data was performed for patients undergoing isolated biceps tenodesis from 2014 to 2017 at a single institution with minimum 6-month follow-up. Receiver operating characteristic curve analysis was used to determine thresholds for MOI for the ASES, SANE, and CM questionnaires. Stepwise multivariate logistical regression analysis was performed to identify predictors for achieving the threshold for MOI. A total of 123 patients were included in the final analysis. Receiver operating characteristic analysis determined that achieving 43.1%, 62.1%, and 61.4% MOI was the threshold for satisfaction for the ASES, SANE, and CM questionnaires, respectively. Regression analysis showed that concomitant superior labrum anterior-posterior (SLAP) repair was predictive of achieving MOI on the ASES and SANE questionnaires, whereas partial rotator cuff tear was predictive of achieving MOI on the CM questionnaire (P<.05 for both). Further, workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors of achieving MOI on the SANE and CM questionnaires (P<.05 for all). Achieving MOI of 43.1%, 62.1%, and 61.4% is the threshold for satisfaction after biceps tenodesis for the ASES, SANE, and CM questionnaires, respectively. Concomitant SLAP repair was positively predictive of achieving MOI, whereas workers' compensation status, diabetes, history of ipsilateral shoulder surgery, and hypertension were negative predictors. [Orthopedics. 2021;44(3):e359-e366.].

Type V superior labral anterior-posterior tears results in lower rates of return to play

PURPOSE

The purpose of this study was to evaluate the rate of return to play (RTP) in patients who underwent Type V superior labrum anterior-posterior (SLAP) repair compared to patients who underwent isolated Bankart repair in the setting of traumatic anterior shoulder instability.

METHODS

A retrospective review of patients who underwent arthroscopic Bankart repair and SLAP repair by a single surgeon between 2012 and 2017 was performed. Additionally, these were pair-matched in a 1:2 ratio for age, sex, sport and level of pre-operative play, with those undergoing isolated arthroscopic Bankart repair alone as a control group. RTP, level of RTP and the timing of RTP were assessed.

RESULTS

The study included a total of 96 patients, with 32 in the study group and 64 in the control group, and a mean follow-up of 59 months. Overall, there was no significant difference in the overall rate of return to play (26/32 (81.3%) vs 56/64 (87.5%), n.s), but there was a significantly higher rate of RTP at the same/higher level in the control group (14/32 (43.6%) vs 43/64 (67.2%), p = 0.0463). There was no significant difference in timing of RTP between the groups (n.s). There was no significant difference in recurrent instability (6/32 (18.8%) vs 5/64 (7.8%), n.s) but there was a significant difference in revision rates (5/32 (15.6%) vs. 2/64 (3.1%), p = 0.0392) between the Type V SLAP repair group and the control group.

CONCLUSION

Following arthroscopic repair, patients with Type V SLAP tears had a similar overall rate of RTP when compared directly to a control group of patients who underwent arthroscopic Bankart repair alone. However, those who underwent Type V SLAP repair reported significantly lower rates of RTP at the same or higher level compared to the control group.

LEVEL OF EVIDENCE

III.

Ultrasound-Guided Biceps Tendon Sheath Injections Frequently Extravasate Into the Glenohumeral Joint

PURPOSE

To evaluate the frequency of glenohumeral joint extravasation of ultrasound (US)-guided biceps tendon sheath injections.

METHODS

Fifty shoulders with a clinical diagnosis of bicipital tenosynovitis pain received a US-guided biceps sheath injection with anesthetic, steroid, and contrast (5.0 mL mixture) followed immediately by orthogonal radiographs to localize the anatomic distribution of the injection. Radiographic evaluation of contrast localization was determined and interobserver reliability calculated.

RESULTS

All 50 postinjection radiographs (100%) demonstrated contrast within the biceps tendon sheath. In addition, 30 of 50 (60%) radiographs also revealed contrast in the glenohumeral joint. Interobserver reliability for determination of intraarticular contrast was good (kappa value 0.87).

CONCLUSIONS

US-guided bicipital sheath injections reproducibly result in intrasheath placement of injection fluid. Bicipital sheath injections performed with 5 mL of volume result in partial extravasation into the joint 60% of the time. These data may be useful for surgeons who use the results of diagnostic biceps injections for diagnosis and surgical decision-making.

LEVEL OF EVIDENCE

III, prospective cohort study, diagnosis.

Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis

Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance. Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes. If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated. Historically, return to play (RTP) rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions. The purpose of this text is to review the current literature on the surgical management of SLAP lesions in athletes with an emphasis on the role of BT.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears

Purpose

To identify cost drivers of open biceps tenodesis, arthroscopic biceps tenodesis, and arthroscopic SLAP repair in the setting of isolated SLAP tears and to perform a direct cost comparison between the procedures.

Methods

The 2014 State Ambulatory Surgery and Services Databases from 6 US states were used. Cases with Current Procedural Terminology codes 23430 (tenodesis of long tendon of biceps), 29807 (shoulder arthroscopy, repair of SLAP lesion), and 29828 (shoulder arthroscopy, biceps tenodesis) were selected, excluding patients who were >50 years old or had a concomitant rotator cuff repair. Generalized linear models were used to model costs based on surgical and patient variables.

Results

The mean patient age was 41.8 years for open biceps tenodesis, 31.6 for arthroscopic SLAP repair, and 41.3 for arthroscopic biceps tenodesis (P < .001). Open biceps tenodesis had cost reductions of $5,664 over arthroscopic biceps tenodesis (P = .001) and $2,320 over arthroscopic SLAP repair (P = .043). Male sex was associated with $3,798 more in costs (P < .001), presence of ≥1 comorbidities added $1,829 (P = .002), and each minute in the operating room added $37 (P < .001). Operative time for open biceps tenodesis averaged 114 minutes, and both arthroscopic procedures averaged 94 minutes (P < .001). Low-volume facilities were associated with $5,536 higher costs for arthroscopic biceps tenodesis (P = .001).

Conclusion

In patients aged ≤50 years with isolated SLAP tears, open biceps tenodesis provides cost savings over arthroscopic methods of treatment. There was no significant cost difference between arthroscopic SLAP repairs and arthroscopic biceps tenodesis. Given the increased emphasis on cost containment, surgeons should be aware of the procedural costs associated with the treatment of SLAP tears.

Level of Evidence

III, retrospective cohort study.

Biceps Squeeze Tenotomy: Technique to Improve Efficiency of Arthroscopic Biceps Tenotomy

Biceps tenotomy is a common procedure performed in arthroscopic shoulder surgery. Numerous studies have demonstrated the effectiveness of both biceps tenotomy and tenodesis to relieve pain and restore function for the diagnoses of bicipital tenosynovitis, SLAP tears, rotator interval pulley lesions, and failed SLAP repairs. It is also frequently performed as a concomitant procedure with arthroscopic rotator cuff repair. We report a technique to improve the efficiency of arthroscopic bicep tenotomy using a biceps squeeze maneuver. This is a simple method of manually squeezing the biceps muscle belly while performing the arthroscopic biceps tenotomy. This shortens and tensions the intra-articular portion of the tendon to facilitate a more safe and efficient procedure.

A comprehensive review of the normal, abnormal, and post-operative MRI appearance of the proximal biceps brachii

The biceps brachii myotendinous unit, particularly the long head of the biceps tendon and its labral attachment, is a common cause of shoulder and arm pain. Its complex anatomy and normal variations can present a challenge when interpreting MR images. The purpose of this manuscript is to review the proximal biceps anatomy, variants, pathology, and post-operative appearance as seen on MRI. Recent data regarding the accuracy of clinical examination and MRI will be summarized.

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

Backgroud

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

Methods

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

Results

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

Conclusions

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

Superior Labral Anterior Posterior Repair and Biceps Tenodesis Surgery: Trends of the American Board of Orthopaedic Surgery Database

BACKGROUND

Recent evidence has specified indications for performing superior labral anterior posterior (SLAP) repair and biceps tenodesis (BT) for the treatment of bicipital-labral lesions in the shoulder. Trends in performance of these procedures are expected to reflect the growing body of research regarding this topic.

PURPOSE

To report practice trends for the surgical treatment of SLAP lesions utilizing the American Board of Orthopaedic Surgery (ABOS) database, particularly in older patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The ABOS database was retrospectively queried between 2012 and 2017 by Current Procedural Terminology (CPT) codes for SLAP repair (29807), open BT (23430), and arthroscopic BT (29828). The patient population was excluded if any concomitant open shoulder procedure was performed. Trends over time were evaluated with respect to case volume, patient age, surgeon subspecialty, and whether a concomitant arthroscopic rotator cuff repair (RCR) was performed (CPT 29827).

RESULTS

A total of 9908 cases met inclusion/exclusion criteria: 4632 performed with RCR and 5276 performed without. The mean age of patients without RCR was 40.8 ± 13.8 years, while for those receiving RCR it was 55.0 ± 9.9 years (P < .001). In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period (P < .001). A significantly greater proportion of patients receiving open and arthroscopic BT were older than 35 years of age, compared with those receiving SLAP repair (P < .001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed (P < .001) over the study period. With respect to BT, open BT was performed more frequently in the cohort without RCR (74.5%) than in the cohort with RCR (52.1%) (P < .001). Similarly, arthroscopic BT was performed more commonly in the cohort with RCR (47.9%) than in the cohort without RCR (25.5%) (P < .001).

CONCLUSION

The ABOS database revealed significantly reduced rates of SLAP repairs performed in recent times. Trends with age remained consistent over time, in that SLAP repairs were predominantly performed in younger patients. Open BT was performed more frequently overall, but with an increased proportion of arthroscopic BT occurring with RCR. Arthroscopic BT was performed much more frequently with RCR than without.

SLAP Lesion and Injury of the Proximal Portion of Long Head of Biceps Tendon in Elite Amateur Wrestlers

BACKGROUND

Injuries to the proximal portion of the tendon of the long head of the biceps are challenging, and often only diagnosed at arthroscopy. However, it is important to be able to formulate a preoperative plan based on physical examination and imaging studies, so as to inform patients correctly, plan the likely procedure, and give indication to length and modalities of rehabilitation.

MATERIALS AND METHODS

Eleven elite wrestlers who suffered their injury between 2008 and 2018 were investigated retrospectively. We aimed to identify an association between the mechanism and the symptoms of the biceps-labral complex injury.

RESULTS

The injury was sustained at a mean age of 20.63 years, and most wrestlers were middle or light weight. All injuries occurred during shoulder movements in closed kinetic chain with the elbow extended, the forearm pronated and the shoulder slightly elevated. The surgical procedures performed were tenodesis in three wrestlers, reinsertion in seven wrestlers, and one tenotomy of the tendon of the long head of the biceps. The postoperative rehabilitation was shorter (1-3 month) in case of tenodesis or tenotomy, and markedly longer after reinsertion (6-9 months).

CONCLUSIONS

Injuries to the proximal part of long head of biceps tendon are relatively frequent in elite wrestlers, reflecting the high functional demands imposed on the upper limb. Though necessitating surgery, in these athletes, such injuries are not career ending, and most of our elite athletes returned to high performance levels after surgery.

Mini-open Subpectoral Biceps Tenodesis Using All-Suture Anchor

The proximal biceps tendon is a common source of shoulder pain and dysfunction. When patients continue to have pain after exhaustive nonoperative treatment, the long head of the biceps tendon can be effectively treated with a tenotomy or tenodesis. Although biceps tenotomy is a less complex and highly reliable treatment, there is the potential for suboptimal outcomes including muscle cramping, fatigue, cosmetic deformity, and supination weakness. Biceps tenodesis eliminates the source of shoulder pain while securing the tendon proximally. Currently, there are multiple techniques for performing a biceps tenodesis (arthroscopic, open suprapectoral, open subpectoral) and myriad fixation methods (bio-tenodesis screw, bone bridge, cortical button, all-suture anchor). Our article presents a technique for a mini-open subpectoral biceps tenodesis using an onlay technique with an all-suture anchor preloaded with needles. This technique allows efficient and proper tendon fixation while minimizing potential complications.