Arthroscopic Superior Labral Anterior Posterior Research Articles

Outcomes Following Combined Posterior Labral and SLAP Repair in Military Patients Younger Than 35 Years

Background: Members of the military are known to experience disproportionately high rates of both glenohumeral instability and superior labrum anterior-posterior (SLAP) tears when compared with civilian populations. Although the outcomes after simultaneous repair of Bankart and SLAP lesions have been well described, there is a paucity of literature available regarding the operative management of posterior instability with concomitant superior labral pathology. Purpose: To compare outcomes of combined arthroscopic posterior labral and SLAP repair with those of isolated posterior labral repair. Study Design: Cohort study; Level of evidence, 3. Methods: All consecutive patients younger than 35 years who underwent arthroscopic posterior labral repair from January 2011 to December 2016 with a minimum follow-up of 5 years were identified. From this cohort of eligible patients, all individuals who had undergone combined SLAP and posterior labral repair (SLAP cohort) versus posterior labral repair alone (instability cohort) were then identified. Outcome measures including the visual analog scale score, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, Rowe instability score, and range of motion were collected pre- and postoperatively and scores were compared between groups. Results: In total, 83 patients met the inclusion criteria for the study. All patients were active-duty military at the time of surgery. The mean follow-up was 93.79 ± 18.06 months in the instability group and 91.24 ± 18.02 months in the SLAP group (P = .5228). Preoperative SANE and ASES scores were significantly worse in the SLAP group. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no significant differences in any outcome scores or range of motion between groups. In total, 39 patients in the instability cohort and 37 in the SLAP cohort returned to preinjury levels of work (92.86% vs 90.24%, respectively; P = .7126), and 38 instability patients and 35 SLAP patients returned to preinjury levels of sporting activity (90.48% vs 85.37%, respectively; P = .5195). Two patients in the instability group and 4 patients in the SLAP group were medically discharged from the military (4.76% vs 9.76%; P = .4326), and 2 patients in each cohort had experienced treatment failure at the final follow-up (4.76% vs 4.88%; P > .9999). Conclusion: Combined posterior labral and SLAP repair led to statistically and clinically significant increases in outcome scores and high rates of return to active-duty military service that did not differ significantly from the results after isolated posterior labral repair. The results of this study indicate that simultaneous repair is a viable treatment option for the management of combined lesions in active-duty military patients <35 years of age.

Midterm Outcomes Following Combined Biceps Tenodesis and Anterior Labral Repair in Active Duty Military Patients Younger Than 35 Years

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.

Biceps Tenodesis as an Attractive Alternative to Superior Labral Anterior-Posterior (SLAP) Repair for Type II SLAP Lesions in Active-Duty Military Patients Younger Than 35 Years

Background: Biceps tenodesis has been suggested as a superior surgical technique compared with isolated labral repair for superior labral anterior-posterior (SLAP) tears in patients older than 35 years. The superiority of this procedure in younger patients, however, is yet to be determined. Purpose: To compare the outcomes of arthroscopic SLAP repair with those of arthroscopic-assisted subpectoral biceps tenodesis for type II SLAP tears in active-duty military patients younger than 35 years. Study Design: Cohort study; Level of evidence, 3. Methods: Preoperative and postoperative evaluations with a minimum 5-year follow-up including the visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) shoulder score were administered, and scores were compared between 2 groups of patients younger than 35 years. One group included 25 patients who underwent SLAP repair, and the second group included 23 patients who underwent arthroscopic-assisted subpectoral biceps tenodesis. Results: The preoperative patient age (P = .3639), forward flexion (P = .8214), external rotation (P = .5134), VAS pain score (P = .4487), SANE score (P = .6614), and ASES score (P = .6519) did not vary significantly between the 2 study groups. Both groups demonstrated statistically significant increases in function as measured by the ASES and SANE and decreases in pain as measured by the VAS at a minimum of 5 years postoperatively. Also at a minimum of 5 years postoperatively, patients in the tenodesis group had lower pain (1.3 vs 2.6, respectively; P = .0358) and higher SANE (84.0 vs 63.3, respectively; P = .0001) and ASES (85.7 vs 75.4, respectively; P = .0342) scores compared with those in the repair group. Failure rate was 20.0% in the repair group versus 0.0% in the tenodesis group (P = .0234). Conclusion: Active-duty military patients younger than 35 years with type II SLAP tears had more predictable improvement in pain, better functional outcomes, and lower failure rates after biceps tenodesis compared with SLAP repair for type II SLAP tears. Overall, the results of this study indicate that arthroscopic- assisted subpectoral biceps tenodesis is superior to arthroscopic SLAP repair for the treatment of type II SLAP tears in military patients younger than 35 years.

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.

Anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior lesions: A cadaveric study and preliminary report.

This study aims to investigate the anatomical relationships of the transmuscular portal to its surrounding structures in arthroscopic treatment of superior labrum anterior posterior (SLAP) lesions in a human cadaveric model. In this anatomic study, bilateral shoulder girdles of 12 adult formalin embalmed cadavers were used. All cadavers were male, and the mean age was 63.4±7.3 years. The portal entry point was determined as midway between the anterior and posterior borders of the acromion, approximately 1 cm lateral from the edge of the acromion. After a guidewire was placed in the glenoid cavity at the 12 o'clock position where the SLAP lesion typically occurs, a switching stick was inserted there. Each glenoid was then drilled with a 2.4 mm drill through an arthroscopic cannula. Subsequently, anatomical dissection was executed to assess the relationship of the transmuscular portal with the suprascapular nerve, axillary nerve, supraspinatus tendon, acromion, and biceps tendon. Lastly, the shortest distance between the aforementioned structures with the drill was measured by a sensitive caliper to determine whether there was a penetration of the structures. Differences between the right and left sides were analyzed. The mean distance between the portal and the axillary nerve was 55.5 mm±6.0 mm, and the mean length of the suprascapular nerve was 61.2 mm±7.0 mm. The mean distance between the portal and the supraspinatus tendon was 2.8 mm±1.5 mm. No penetration of the axillary nerve, suprascapular nerve, and supraspinatus tendon was observed in any cadaver. No differences were detected for measured anatomical parameters between the right and left sides (p>0.05). Findings from this cadaveric study revealed that the transmuscular portal may allow for a reliable anchor placement without any nerve or tendon penetration during arthroscopic SLAP repair. Level V.

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

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. 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. 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 59months. 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. 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. III.

Stiffness: friend or foe? A cohort study evaluating the effect of early postoperative stiffness on the outcomes of patients who underwent superior labral repair

Postoperative stiffness is a commonly reported complication after type II superior labrum anterior-posterior (SLAP) repair. It is unclear whether patients with postoperative stiffness, classified as external rotation to the side of ≤20°, ultimately will have greater functional outcomes at ≥2 years after surgery. We hypothesized that postoperative stiffness would result in improved functional outcomes at ≥2 years after surgery. Sixty-five consecutive arthroscopic SLAP repair cases performed by a single surgeon were retrospectively reviewed using prospectively collected patient-ranked outcomes and examiner-determined assessments preoperatively and at 1 week, 6 weeks, 24 weeks, and a minimum of 2 years after surgery. Patients were allocated to the stiffgroup and the non-stiffgroup based on their external rotation at 6 weeks after repair. Of the patients, 16 (27%) had ≤20° of external rotation at 6 weeks postoperatively. These patients, comprising the stiff group, had more pain and more difficulty with overhead activities early on than patients in the non-stiff group (very severe vs. severe, P < .05), but by 2 years, they had less difficulty and less pain with overhead activities, less patient-reported stiffness, and less severe pain at night than isolated SLAP repair patients with >20° of external rotation at 6 weeks (P < .05). This study suggests that in patients who underwent SLAP repair, early postoperative stiffness (at 6 weeks as assessed by ≤20° of external rotation), while problematic early, is associated with improved functional outcomes in the longer term, with patients in the stiff group reporting less pain and difficulty with overhead activities at ≥2 years after surgery.

Superior Labral Injuries in Elite Gymnasts: Symptoms, Pathology, and Outcomes After Surgical Repair.

Background:Superior labral anterior-posterior (SLAP) lesions are common among elite gymnasts and throwing athletes. Although SLAP lesions in throwers are well-described in the literature, no study has described the characteristics of SLAP lesions in gymnasts. We aimed to reveal the characteristics of SLAP lesions in gymnasts by comparing the location and extension of these lesions between gymnasts and throwers.Hypothesis:The location and arc of SLAP lesions in gymnasts will be different from those in throwing athletes.Study Design:Case series; Level of evidence, 4.Methods:This study included 27 shoulders in 20 males and 3 females with a mean ± SD age of 20 ± 2.5 years (range, 16-25 years). We performed debridement alone for shoulders with a stable lesion. Anterior and/or posterior labral repair was added for unstable SLAP lesions depending on the extension and stability of the lesions. We investigated symptoms, onset, return to sport (based on patient records), and subjective shoulder values. SLAP lesions were evaluated through use of the Snyder classification. The location and arc of SLAP lesions were determined from surgical records and videos and described by use of the right shoulder clockface method. During the same period, 65 baseball players (65 shoulders; all males; mean age, 23 ± 7.0 years; range, 16-44 years) underwent arthroscopic SLAP surgery. We compared the location and arc of SLAP lesions between gymnasts and baseball players.Results:Symptoms during gymnastics included pain (100%), apprehension (48%), or catching (11%). We found that 20 shoulders had symptom onset during gymnastics, most commonly during rings events. Type II SLAP lesions were found in 17 shoulders, type III in 2 shoulders, and type IV in 8 shoulders. The mean center of SLAP lesions was at the 11:40 clockface position in 27 gymnasts and 10:40 clockface position in 65 baseball players, and the difference was statistically significant (P < .001). The mean arc of SLAP lesions was 125° in gymnasts and 140° in baseball players, and the difference was not significant. We performed debridement in 2 shoulders (7%) and labral repair in 25 shoulders (93%). After surgery, all patients returned to gymnastics. The mean subjective shoulder value was 35 (range, 10-90) preoperatively and 76 (range, 40-100) postoperatively.Conclusion:SLAP lesions in gymnasts were significantly located anteriorly compared with those in baseball players. All patients returned to gymnastics after arthroscopic surgery. Secure repair of SLAP lesions may be important for good surgical outcomes, because 50% of patients experienced preoperative shoulder apprehension.

Superior Labrum Injuries in Elite Gymnasts: Symptom, Pathology, and Outcome after Surgical Repair

Objectives:Superior labral anterior-posterior (SLAP) lesions are common among gymnasts and throwing athletes. Although SLAP lesions in throwers are well described in the literature, no study has described the characteristics of SLAP lesions in gymnasts. We aimed to reveal the characteristics of SLAP lesions in gymnasts by comparing the location and extension of these lesions between gymnasts and throwers.Methods:This study included 27 shoulders in 20 male and 3 female patients with a mean age of 20 years (range, 16-25 years). We performed debridement alone for shoulders with a stable lesion. Anterior and/or posterior labrum repair was added for unstable SLAP lesions, depending on the extension and stability of the lesions. We investigated symptoms, onset, sports return based on patient records, and subjective shoulder values (SSVs). SLAP lesions were evaluated using the Snyder classification. The location and extension of SLAP lesions were determined from surgical records and videos, and described using the right shoulder clock-face method. During the same period, 65 baseball players (65 shoulders) underwent arthroscopic SLAP surgery. They were all men with a mean age of 23 years (range, 16-44 years). We also investigated the location and extension of SLAP lesions in baseball players for comparison. Statistical analysis was performed using the Mann-Whitney U-test for comparing the center and arc of SLAP lesions between gymnasts and baseball players. The Mann-Whitney U-test was also used to compare the preoperative and postoperative SSVs. The level of significance was set at P<0.05.Results:Symptoms during gymnastics included pain (100%), apprehension (48%), or catching (11%). Twenty shoulders had symptom onset during gymnastics, most commonly during rings events. Type II SLAP lesions were found in 17 shoulders, type III in 2 shoulders, and type IV in 8 shoulders. The mean center of SLAP lesions was located at 11:40 in 27 gymnasts and at 10:40 in 65 baseball players, and the difference was statistically significant (P<0.001). The mean arc of SLAP lesions was 125° in gymnasts and 140° in baseball players, and the difference was not significant (P=0,09) (Figure 1). We performed debridement (Figure 2) in 2 shoulders (7%) and labrum repair (Figure 3,4) in 25 shoulders (93%). After surgery, all patients returned to gymnastics. The mean SSV was 35 (range, 10-90) preoperatively and 76 (range, 40-100) postoperatively.Conclusion:SLAP lesions in gymnasts were significantly located anteriorly than those in baseball players. Most SLAP lesions in the shoulders of gymnasts had symptom onset during suspension events such as rings or bars, and half of the gymnasts complained of shoulder apprehension in addition to pain. Fixation of both the anterior and posterior labrum was performed in 63% of the patients, and all patients returned to gymnastics after arthroscopic surgery. Secure repair of SLAP lesions may be important for good surgical outcomes because gymnasts require a stable glenohumeral joint.Figure 1.Figure 2.

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

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. To evaluate return to sport among individuals undergoing arthroscopic SLAP repair. Four databases (MEDLINE, EMBASE, PubMed, and Cochrane) were searched from database inception through January 29, 2018. English-language articles reporting on return-to-activity rates after arthroscopic SLAP repairs were included. Systematic review. Level 4. 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. 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. 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.

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.

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

Background:Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. The physical requirements of military service may contribute to an increased risk of injury. Limited data are available regarding the success of superior labral anterior posterior (SLAP) repairs in an active military population.Purpose:To quantify the rate of clinical failure and surgical revision after isolated and combined SLAP repair.Study Design:Cohort study; Level of evidence, 3.Methods:All consecutive active-duty servicemembers undergoing arthroscopic repair of type II SLAP lesions at a single institution between 2006 and 2012 were identified. Patients with less than 2-year clinical follow-up and nonmilitary status were excluded. Demographic variables, surgical variables, and occupational outcomes were extracted from electronic medical records and confirmed with the US Army Physical Disability Agency database. Failure was defined as subsequent revision surgery or medical discharge with persistent shoulder complaints.Results:A total of 192 patients with SLAP repair were identified with a mean follow-up of 50.0 months (SD, 17.0 months). Isolated SLAP repair occurred in 31.3% (n = 60) versus 68.8% (n = 132) with concomitant procedures. At final follow-up, 37.0% (n = 71) of patients reported some subjective activity-related shoulder pain. Postoperative return to duty occurred in 79.6% (n = 153), and only 20.3% (n = 39) were discharged with continuing shoulder disability. The combined rotator cuff repair (96%; P = .023) and anteroinferior labral repair group (88%; P = .056) had a higher rate of functional return than isolated SLAP repair (70%). Thirty-one (16.1%) patients were classified as surgical failure and required revision. Of these, the majority of patients undergoing biceps tenodesis (76%) returned to active duty, as compared with revision SLAP repair (17%). Lower demand occupation and the presence of combined shoulder injuries (P = .011 and .016, respectively) were significantly associated with a lower risk of medical discharge and revision surgery, respectively.Conclusion:Favorable outcomes can be anticipated in the majority of military servicemembers after arthroscopic SLAP repair, particularly with combined shoulder injuries. Revision surgery occurred in 16% of patients after primary SLAP repair.Clinical Relevance:Isolated repair of unstable SLAP lesions and/or increased upper extremity demands are associated with higher failure rates in this population.

The Efficacy of Biceps Tenodesis in the Treatment of Failed Superior Labral Anterior Posterior Repairs

Background: The incidence and arthroscopic treatment of superior labral anterior posterior (SLAP) tears have increased over the past decade. Recent evidence has identified factors associated with poor outcomes, including age, overhead activity, and concomitant rotator cuff tears. Biceps tenodesis has also been suggested as an alternative treatment to repair. Moreover, there are no studies demonstrating effective treatment strategies for failed type II SLAP repairs. Purpose: To prospectively evaluate the surgical outcomes of biceps tenodesis for patients who undergo elected revision surgery after an arthroscopically repaired type II SLAP tear. Study Design: Case series; Level of evidence, 4. Methods: After institutional review board approval, 46 patients who met failure criteria for an arthroscopically repaired type II SLAP tear elected to undergo open subpectoral tenodesis by 2 fellowship-trained surgeons from 2006 to 2010 at a tertiary care military treatment facility. Objective outcomes were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index (WOSI) scores and an independent physical examination. Statistical analysis was performed via analysis of variance. Results: Of the 46 patients, 42 completed the study (91% follow-up rate). The mean age of the patients was 39.2 years, 85% were male, and the mean follow-up period was 3.5 years (range, 2.0-6.0 years). The rate of return to active duty and sports was 81%. There was a clinically and statistically significant improvement across all outcome assessments after revision surgery (preoperative mean scores: ASES = 68, SANE = 64, WOSI = 65; postoperative mean scores: ASES = 89, SANE = 84, WOSI = 81) (P < .0001) and shoulder range of motion (preoperative mean values: forward flexion = 135°, abduction = 125°; postoperative mean values: forward flexion = 155°, abduction = 155°) (P < .0001). There was 1 case of transient musculocutaneous nerve neurapraxia. Conclusion: Biceps tenodesis is a predictable, safe, and effective treatment for failed arthroscopic SLAP tears at a minimum 2-year follow-up. The majority of patients obtained good to excellent outcomes using validated measures with a significant improvement in range of motion.

Clinical and Radiological Outcomes of Type 2 Superior Labral Anterior Posterior Repairs in Elite Overhead Athletes

Background: Although there are multiple reports on surgical outcomes of type 2 superior labral anterior posterior (SLAP) repairs, a literature review noted a paucity of data on clinical and radiological outcomes in elite overhead athletes. Purpose: To determine midterm clinical outcomes of type 2 SLAP repairs in elite overhead athletes and whether labral integrity provides consistent return to play. Study Design: Case series; Level of evidence, 4. Methods: Medical records were retrospectively reviewed of 24 elite overhead athletes who underwent arthroscopic type 2 SLAP repairs. There were 18 men and 6 women, and their mean age was 22.7 years (range, 19-30 years); the majority of them (16/24) were baseball players. Four outcome measures were used: visual analog scale (VAS) for pain and satisfaction, American Shoulder and Elbow Surgeons (ASES) score, subjective feeling of recovery, and return to play. Multidetector computed tomographic arthrography was performed to evaluate labral integrity after surgery. Results: At a mean follow-up of 45.8 months (range, 24-68 months), overall pain and function improved significantly. The VAS for pain was 5.7 preoperatively and 2.0 postoperatively (P < .01), and VAS for satisfaction was 8.6. The ASES score was 55.8 preoperatively and 87.1 postoperatively (P < .01). The overall mean value of subjective feeling of recovery was approximately 76%. Twelve of 24 athletes (50%) returned to play after the operation. Although there was a trend toward higher return rate in the other overhead athletes (75%) compared with the baseball players (38%), this trend did not reach statistical significance (P = .097). Labral retear with clinical significance was noted in 2 athletes who failed to return to play. Osteolysis was observed in 2 athletes, 1 of whom had a retear. A statistical relation between the integrity of the repair and return to play was not found (P > .05). Conclusion: Arthroscopic SLAP repairs show favorable clinical and radiological outcomes; however, the study findings raise a concern that return to play may still be problematic in elite baseball players. This study also indicates that labral healing does not ensure consistent return to play in elite overhead athletes.

The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs

Superior labrum anterior-posterior (SLAP) lesions of the shoulder that require surgical repair are relatively uncommon. However, recent observations suggest that there may be a rise in the incidence of SLAP lesion repair. The Statewide Planning and Research Cooperative Systems (SPARCS) database from the New York State Department of Health was used to acquire data for all outpatient ambulatory surgery procedures that were performed in New York State from 2002 to 2010. The data were reviewed and analyzed to compare the incidence of arthroscopic SLAP lesion repairs relative to other outpatient surgical procedures. Within New York State, from 2002 to 2010, the number of all ambulatory surgical procedures increased 55%, from 1,411,633 to 2,189,991. Correspondingly, the number of ambulatory orthopedic procedures increased 135%, from 118,126 to 278,136. In comparison, the number of arthroscopic SLAP repairs increased 464%, from 765 to 4,313 (P < .0001). This represented a population-based incidence of 4.0/100,000 in 2002 and 22.3/100,000 in 2010. The mean age of patients undergoing arthroscopic SLAP repair in 2002 was 37 ± 14 years. The mean age in 2010 was 40 ± 14 years (P < .0001). The data suggest a substantial increase in the number of arthroscopic SLAP repairs that is significantly more rapid than the rising rate of outpatient orthopedic surgical procedures. In addition, there is a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs.

Demographic Trends in Arthroscopic SLAP Repair in the United States

Background: Treatment of superior labral anterior posterior (SLAP) tears remains controversial, particularly in older age groups. Repair, debridement, biceps tenodesis, tenotomy, and observation have been recommended depending on patient characteristics, but there have not been any large epidemiologic studies investigating treatment trends. Purpose: To investigate current trends in SLAP repair across time, gender, age, and regions in the United States. Study Design: Descriptive epidemiology study. Methods: Patients who underwent arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) were identified using a publicly available national database of insurance records (PearlDiver Patient Records Database) during years 2004 through 2009. Factors identified for each patient included gender, age group, and region in the United States. Logistic regression analysis and the chi-square test were used for statistical measures. Results: From 2004 to 2009 there were 25,574 cases of arthroscopic SLAP repair identified, of which 75% were male patients and 25% were female patients. There was a significant rise in cases of SLAP repair from 2004 to 2009 as the incidence of SLAP repair increased from 17.0 for every 10,000 patients with an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or CPT code in 2004 to 28.1 in 2009 (P < .0001). Age analysis revealed the highest incidence in the 20-29–year (29.1 per 10,000) and 40-49–year (27.8 per 10,000) age groups. Men (37.3 per 10,000) had a significantly higher incidence of repairs than did women (10.7 per 10,000). The West (24.6 per 10,000) and South (24.4 per 10,000) regions also demonstrated a higher incidence than the Midwest (20.5 per 10,000) and Northeast (20.1 per 10,000) regions (P < .0001). Conclusion: Our analysis illustrates that surgeons are performing significantly more arthroscopic SLAP repairs each year. The highest incidence of repair is in the 20-29– and 40-49–year age groups, and a significant gender difference exists, with men having a threefold higher incidence of repair.

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

We are writing this letter in reference to the recently published study by Byram et al,1Byram I.R. Dunn W.R. Kuhn J.E. Humeral head abrasion: an association with failed superior labrum anterior posterior repairs.J Shoulder Elbow Surg. 2011; 20: 92-97https://doi.org/10.1016/j.jse.2010.05.013Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar who evaluated a significant association of a humeral head abrasion underneath the long head of the biceps tendon (LHB) and failed superior labrum anterior posterior (SLAP) repairs. Interestingly, the authors found significantly associated humeral chondral lesions in failed SLAP repairs but not in untreated SLAP lesions, as we did. In our own series, we evaluated 182 SLAP lesions in 3395 consecutive shoulder arthroscopies.6Patzer T. Lichtenberg S. Kircher J. Magosch P. Habermeyer P. Influence of SLAP lesions on chondral lesions of the glenohumeral joint.Knee Surg Sports Traumatol Arthrosc. 2010; 18 (doi 10.1007/s00167-009-0938-2): 982-987Crossref PubMed Scopus (33) Google Scholar We thereby observed a significant association of humeral chondral lesions typically located underneath the LHB with nonoperatively treated SLAP lesions in about 20% compared with less than 5% without a SLAP lesion present. The association of SLAP lesions with glenohumeral chondral lesions was confirmed by a clinical and magnetic resonance imaging arthrography-controlled study by Lehmann et al,3Lehmann L.J. Dinter D. Monateseri S. Scharf H.P. Weckbach S. Osteoarthritis after SLAP lesion? Clinical and arthro-MRI evaluation after arthroscopic SLAP refixation.Sportverletz Sportschaden. 2009; 23 (doi 10.1055/s-0028-1109541): 155-160Crossref PubMed Scopus (8) Google Scholar who evaluated glenohumeral chondral lesions after failed as well as after not-failed SLAP repairs. In addition to that, we have typically observed anteriorly located chondral lesions of the glenoid in untreated SLAP lesions as well. It would be of interest to the readership of the Journal of Shoulder and Elbow Surgery whether the referenced study could confirm our observations of a localized chondral lesion at the anterior glenoid rim. In a subsequent biomechanical study4Patzer T. Habermeyer P. Hurschler C. Bobrowitsch E. Paletta J.R. Fuchs-Winkelmann S. et al.Increased glenohumeral translation and biceps load after SLAP lesions with potential influence on glenohumeral chondral lesions: a biomechanical study on human cadavers.Knee Surg Sports Traumatol Arthrosc. 2011; ([Epub ahead of print]. doi 10.1007/s00167-011-1423-2)Google Scholar on human cadavers, we looked for an explanation for our findings. We evaluated the well-known increasing anterior, anterosuperior and anteroinferior shoulder instability after SLAP lesions as well as a consecutively increasing LHB load after SLAP lesions. Thus, we have postulated that the combination of an increased anterior shoulder instability and the increased LHB load might be responsible for the humeral head abrasion in the form of the LHB acting as a windshield wiper on the humeral head. The typical chondral lesion at the glenoid rim might be explained by the increased anterior instability after SLAP lesions. However, based on our clinical study,5Patzer T. Kircher J. Lichtenberg S. Sauter M. Magosch P. Habermeyer P. Is there an association between SLAP lesions and biceps pulley lesions?.Arthroscopy. 2011; 27: 611-618https://doi.org/10.1016/j.arthro.2011.01.005Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar we could not confirm the study of Castagna et al,2Castagna A. Mouhsine E. Conti M. Vinci E. Borroni M. Giardella A. et al.Chondral print on humeral head: an indirect sign of long head biceps tendon instability.Knee Surg Sports Traumatol Arthrosc. 2007; 15 (doi 10.1007/s00167-006-0211-x): 645-648Crossref PubMed Scopus (39) Google Scholar who evaluated a humeral chondral print in association with biceps pulley lesions. We only found an association of a humeral head abrasion with SLAP lesions but not with biceps pulley lesions. Thus, due to our clinical and biomechanical findings, an isolated LHB instability might not be the reason for the chondral lesion alone. It would be of interest if the referenced study could deliver some further information about the presence of biceps pulley lesions and a possible association with humeral chondral lesions. The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. Humeral head abrasion: An association with failed superior labrum anterior posterior repairsJournal of Shoulder and Elbow SurgeryVol. 20Issue 1PreviewAn abrasion on the humeral head under the articulating portion of the biceps tendon has been observed in patients with pain and stiffness after superior labrum anterior posterior (SLAP) repair. This study examined this humeral head abrasion (HHA) and its association with various diagnoses involving pathology of the biceps-labral complex. We hypothesized that it would be more common in failed SLAP repairs than other diagnoses. Full-Text PDF

Results of Arthroscopic Repair of Type II Superior Labral Anterior Posterior Lesions in Overhead Athletes

Background: The majority of the literature on surgical outcomes of superior labral anterior posterior (SLAP) repairs has focused on short-term follow-up of 1 to 2 years, not allowing adequate time for full rehabilitation and return to maximum level of competition for all types of athletes. Also, previous studies have concentrated on using questionnaires that primarily evaluate patients’ activities of daily living, which do not focus on sport-specific performance. Purpose: To determine the midterm results of type II SLAP repairs in overhead athletes, focusing primarily on athletic performance as well as activities of daily living. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of 30 overhead athletes, who underwent an arthroscopic superior labral repair for a symptomatic type II SLAP tear between 2002 and 2007, was performed. Our study population included 22 male and 8 female patients with a mean age at the time of surgery of 24 years. Twenty-one patients participated in baseball or softball, and the remainder of patients were involved in javelin throwing or tennis. The average follow-up was 3.5 years. The outcome of treatment was evaluated using the American Shoulder and Elbow Society (ASES) scoring system, assessing activities of daily living, and the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score, assessing sport-specific performance. In addition, the length of time to return to sport and the degree of successful performance were evaluated. Results: Repairs resulted in ASES scores comparable with those from prior published studies (average ASES score, 87.9). The KJOC score averaged 73.6. The athletes’ perception was that they returned to approximately 84.1% of their preinjury level of function with a mean time to return to play of 11.7 months. There was a significant drop in the ASES to KJOC score for the baseball/softball players (87.9 ± 14.94 and 72 ± 19.24, respectively; P = .006). Patients reported an overall satisfaction rate of 93.3% with the procedure, with the majority being very satisfied. Conclusion: Arthroscopic SLAP repairs show excellent results and a high rate of overall satisfaction; however, the outcomes are less reliable in throwers. The KJOC score provides a more stringent assessment of overhead athletes’ function after SLAP repair than the ASES score. Our findings also indicate that SLAP repairs lead to improved shoulder function during routine daily activities but that consistent return to elite throwing sports may still remain somewhat problematic.

Arthroscopic repair of type II superior labrum anterior posterior (SLAP) lesions in patients over the age of 45 years: a prospective study

Superior labrum anterior posterior (SLAP) lesions are a well-defined cause of shoulder pain and disability and may occur in conjunction with rotator cuff tears. This study was designed to prospectively evaluate the minimum 2year results of arthroscopic repair of type II SLAP lesions in patients over the age of 45years with and without rotator cuff tears. Thirty-five patients with symptomatic type II SLAP lesions were enrolled in the study. All patients underwent arthroscopic SLAP repair and simultaneous repairs were carried out in 17 of these patients who had concomitant full-thickness rotator cuff tears. Patients were grouped into two with regard to the presence of rotator cuff tears. The outcome was assessed by University of California at Los Angeles (UCLA) score and clinical examination (forward flexion/internal rotation/external rotation). At an average follow-up of 2.5years, both groups displayed significant improvements in UCLA score (31.2 vs. 11.8; p<0.01) and range of motion. Compared with the group that had SLAP and concomitant rotator cuff tears, patients in isolated SLAP group had significantly better scores in function (9.4 vs. 8.6; p=0.045) and patient satisfaction (4.9 vs. 4.5; p=0.039). No significant difference was found between two groups with respect to range of motion. The arthroscopic repair of symptomatic type II SLAP lesions yields favorable outcomes in patients over 45years of age and the presence of accompanying rotator cuff tears has a negative effect on the results.

Superior Labral Anterior-Posterior Lesions in Rock Climbers—Primary Double Tenodesis?

Shoulder problems, especially SLAP (superior labral anterior-posterior) lesions, are frequent in rock climbers. Although various SLAP repair methods demonstrate 75% to 97% good functional outcomes in general population, the results in overhead athletes are inconsistent and the question whether a primary tenodesis is more efficient arises. Prospective cohort study. The patients were treated as inpatient surgical patients, and the follow-up was performed after 6 months and 2 years. Six high-level rock climbers with SLAP lesions and degeneration of the long biceps tendon anchor or additional pulley lesions were surgically treated with primary tenodesis. Primary tenodesis was performed for SLAP lesions in high-level climbers. The postoperative outcome was assessed through physical examination after 6 months and 2 years, Constant-Murley score, re-establishment of initial climbing ability level, and self-perception of the function of the shoulder and climbing ability. All climbers regained their initial climbing level after 6 months. The Constant-Murley score (mean, 97.3%) showed an excellent functional outcome. The self-perception of the shoulder function and climbing ability was 96.8% of normal. The primary biceps tenodesis is proved to be a reliable alternative to arthroscopic SLAP repair in overhead athletes, especially if constant microtrauma persists.