Superior Labrum Anterior And Posterior Research Articles

Long head of the biceps tendon plays a role in stress absorption and humeral head restriction during the late cocking and deceleration phases of overhead throwing: a finite element study

BackgroundEmerging evidence suggests that the long head of the biceps (LHBT) may play a role in stabilizing the glenohumeral joint, and this has led to controversy around the efficacy of biceps tenotomy for superior labral anterior and posterior (SLAP) lesions. Therefore, the aim of this finite element analysis (FEA) study was to determine the stress absorption and humeral head translation restriction effects of the LHBT within the glenohumeral joint during the late cocking and deceleration phases of overhead throwing with a view to resolving the controversy around tenotomy. MethodsEight FEA models were created using computed tomography and magnetic resonance imaging data from normal glenohumeral joints. The models represented four LHBT conditions: uninjured, subpectoral tenodesis, tenotomy, and type II SLAP lesions. The late cocking and deceleration phases of the overhead throwing were simulated for each model. The impacts of the four LHBT conditions on glenohumeral joint stress absorption and humeral head displacement restriction were studied based on 1) stress and related distributions on the cartilage, labrum, capsule, and LHBT and 2) humeral head translation variation. ResultsThe FEA analysis showed that the magnitude of the contact stress on the articular cartilage, labrum, and capsule was the lowest in the uninjured models, followed by the subpectoral tenodesis, tenotomy, and type II SLAP lesion models. Humeral head translation was the most restricted in the subpectoral tenodesis models, followed by the tenotomy and type II SLAP lesion models. ConclusionFinite element analysis demonstrated that the LHBT plays a significant role in stress absorption and displacement restriction in the late cocking and deceleration phases of overhead throwing. Subpectoral tenodesis of the LHBT exhibited lesser amount of stress and humeral head translation than those of tenotomy, thereby making it a better option for patients who engage in overhead throwing.

Spontaneous resolution of spinoglenoid ganglion cyst: a case series

BackgroundSpontaneous resolution of a spinoglenoid notch ganglion cyst (SGC) without surgical treatment has been rarely reported; however, we have encountered this phenomenon occasionally. Therefore, we aimed to describe a case series of consecutive patients with SGC in whom it spontaneously resolved without surgical treatment. MethodsWe retrospectively reviewed 12 patients with magnetic resonance imaging (MRI)-confirmed SGC in whom it resolved without surgical treatment between January 2011 and March 2023. We included patients without abnormally increased signal intensity or muscle atrophy due to denervation from suprascapular neuropathy on MRI. Resolution of the SGC was confirmed via MRI or ultrasound at the follow-up visit, and suprascapular neuropathy was assessed using electromyography and nerve conduction studies when needed. For functional assessments, the visual analog scale (VAS) for pain and active range of motion of the shoulder were used to compare pre- and post-resolution follow-ups. ResultsEleven men and one woman with a median age of 54.0 years (interquartile range [IQR] 37.0–65.3) were included in this study. The SGCs resolved spontaneously at a median of 13.2 months with an IQR of 8.2–23.0 after initial evaluation using MRI. The SGCs were multiloculated cysts with superior labrum anterior and posterior (SLAP) II–IX lesions, with a median diameter of 2.5 cm (IQR 2.0–2.8). The median VAS for pain (pre-resolution 5.0 [IQR 4.0–7.0] vs. post-resolution 1.0 [IQR 0.0–1.0], P = 0.002) and internal rotation at the back (pre-resolution 8.0 [IQR 7.0–10.3] vs. post-resolution 7.5 [IQR 7.0–8.0], P = 0.034) were significantly improved after the resolution. ConclusionsSurgical treatment may not be necessary in all cases of SGC. Nonsurgical treatment may be a viable option in the absence of suprascapular nerve involvement or SLAP-related physical findings.

Intraobserver and Interobserver Reliability of the Snyder and Expanded SLAP Classification System: A Video Study

Background: Superior labral anterior and posterior (SLAP) tears are a common finding in overhead athletes. The original classification system produced by Snyder in 1990 contained 4 types of SLAP tears and was later expanded to 10 types. The classification has been challenging because of inconsistencies between surgeons making diagnoses and treatments based on the diagnosis. Furthermore, patient factors—such as age and sports played—affect the treatment algorithms, even across similarly classified SLAP tears. Purpose: To (1) assess the interobserver and intraobserver reliability of the Snyder and expanded SLAP (ESLAP) classification systems and (2) determine the consistency of treatment for a given SLAP tear depending on different clinical scenarios. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: A total of 20 arthroscopic surgical videos and magnetic resonance imaging scans of patients with SLAP tears were sent to 20 orthopaedic sports medicine surgeons at various stages of training. Surgeons were asked to identify the type of SLAP tear using the Snyder and ESLAP classifications. Surgeons were then asked to determine the treatment for a SLAP tear using 4 clinical scenarios: (1) in the throwing arm of an 18-year-old pitcher; (2) in the dominant arm of an 18-year-old overhead athlete; (3) a 35-year-old overhead athlete; (4) or a 50-year-old overhead athlete. Responses were recorded, and the cases were shuffled and sent back 6 weeks after the initial responses. Results were then analyzed using the Fleiss kappa coefficient (κ) to determine interobserver and intraobserver degrees of agreement. Results: There was moderate intraobserver reliability in both the Snyder and ESLAP classifications (κ = 0.52) and fair interobserver reliability for both classification systems (Snyder, κ = 0.31; ESLAP, κ = 0.30; P < .0001) among all surgeons. Additionally, there was only fair agreement (κ = 0.30; P < .0001) for the treatment modalities chosen by the reviewers for each case. Conclusion: This study demonstrated that SLAP tears remain a challenging problem for orthopaedic surgeons in diagnostics and treatment plans. Therefore, care should be taken in the preoperative discussion with the patient to consider all the possible treatment options because this may affect the postoperative recovery period and patient expectations.

Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability

To compare lesion prevalence and treatment outcomes in patients with primary and recurrent anterior shoulder instability. Patients who were admitted to the institution with a diagnosis of anterior shoulder instability and who underwent arthroscopic surgery between July 2006 and February 2020 were retrospectively evaluated. Minimum follow-up duration of the patients was 24 months. The recorded data and Magnetic Resonance Imaging (MRI) of the patients were examined. Patients over 40 years of age, with a history of shoulder region fracture, inflammatory arthritis, a history of epilepsy, multi-directional instability, non-traumatic dislocation, and off-track lesions were excluded from the study. Shoulder lesions were documented and patient outcome evaluation was made with the Oxford Shoulder Score (OSS) and Visual Analog Scale (VAS). A total of 340 patients were included in the study. The mean age of patients was 25.6 (±6.49). Recurrent instability group had significantly higher rate of Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) lesions compared to primary instability group (40.6% vs 24.6% respectively) (p=0.033). 25 patients (43.9%) had Superior Labrum Anterior and Posterior (SLAP) lesions in primary instability group and 81 patients (28.6%) had SLAP lesions in recurrent instability group (p=0.035). OSS increased for both primary (from 35 (16-44) to 46 (36-48)) (p=0.001) and recurrent instability groups (from 33 (6-45) to 47 (19-48)) (p=0.001). There was no significant difference between the groups regarding postoperative VAS and Oxford scores (p>0.05). Successful results were obtained in patients younger than 40 years old with both primary and recurrent anterior shoulder instability after arthroscopic treatment. ALPSA lesion prevalence was higher while SLAP lesion prevalence was lower regarding the patients with recurrent instability. Postoperative OSS was comparable between the patient groups however failure rate was higher in the recurrent instability patients.

Poster 199: Rate of arthroscopic rotator cuff repair performed at ambulatory surgery centers remains low despite significant cost savings for the healthcare system

Objectives: The objectives of this study are to 1) understand the differences in costs between rotator cuff repair (RCR) performed in ambulatory surgery center (ASC) versus outpatient hospital (OH) settings; 2) determine the patient’s out-of-pocket expenditure and surgeon reimbursement; and 3) characterize trends in expenditure for RCR over time. Methods: We identified patients who had undergone outpatient arthroscopic RCR in the United States (U.S.) using the IBM MarketScan Commercial Claims and Encounters Database. The database was chosen for its large, national sample of privately insured patients. Patients who had Current Procedural Terminology (CPT) code 29827 between April 1, 2013 and June 30, 2018 were included. Revision RCR procedures and procedures with a concomitant arthroscopic or open biceps tenodesis, Bankart repair, superior labrum anterior and posterior (SLAP) repair, lysis of adhesions (CPT: 29828, 23430, 29806, 29807, 29825) were excluded. Day-of-surgery expenditure was identified by summing all claims billed with an “immediate-procedure-related code” in a 3-day window surrounding the date of the procedure (Procedure Date ± 1 Day). The day-of-surgery expenditure was broken down into anesthesia services, nerve block, operating room facility, surgical team, patient out-of-pocket expenditure, and other expenditures. Median and interquartile range were calculated for each variable. The breakdown of day- of-surgery expenditure and patient out-of-pocket expenditure between the OH and ASC settings were compared using two-tailed Mann Whitney U Tests. Spearman Rank Order Correlation was done for all variables to test for association between expenditure and year to determine trends over time. All values were inflation adjusted to 2018 dollars using the consumer price index for medical care. Results: A total of 43,020 patients were identified; 24,850 in the OH setting and 18,170 in the ASC setting. This converts to an ASC utilization of 42 percent over the study period. In 2018, ASC utilization was at 45%. We found that RCR performed in the OH setting resulted in 55% greater day-of-surgery expenditure (p<0.001) than in the ASC setting. In the OH setting, operating room facility cost was 35% greater (p <0.001), anesthesia services was 7.4% greater (p<0.001), but nerve block was 2.4% lower (p<0.001) (Figure 1). Additionally, for RCRs performed in the OH setting, Spearman coefficients demonstrated that immediate procedure cost (rho = 0.209, p < 0.001) increased along with expenditure for anesthesia services (rho = 0.085, p < 0.001), nerve block (rho = 0.135, p < 0.001), and operating room facility cost (rho = 0.108, p < 0.001) over our study period. For RCRs performed in the ASC setting, immediate procedure cost (rho = 0.309, p < 0.001) increased along with expenditure for anesthesia services (rho = 0.116, p < 0.001), nerve block (rho = 0.086, p < 0.001), and operating room facility cost (rho = 0.148, p < 0.001). Surgical team reimbursement was 6.3% greater in the ASC setting (p < 0.001), but decreased over time in both the ASC (rho = -0.069, p < 0.001) and OH (rho = -0.046, p < 0.001) settings. Lastly, there was no difference in patient out-of-pocket expenditure for RCRs performed in the OH setting vs. ASC setting (Table 1). However, patient out-of-pocket expenditure for RCRs is increasing in both settings (OH: rho = 0.147, p < 0.001; ASC: rho = 0.203, p < 0.001). Conclusions: RCR performed in an ASC setting results in significant cost savings for payers with a slight change in surgeon reimbursement and no change in patient-out-of-pocket expenditure. Most of the cost savings came from operating room facility expenditure. For the surgeon, surgical team reimbursements are higher in the ASC setting. However, the overall trend in surgical team reimbursement is downwards in both the ASC and OH settings whereas the cost per RCR to the healthcare system is increasing. Thus, surgeon reimbursement is becoming a smaller percentage of the immediate procedure cost and should not be further cut when policy makers evaluate strategies to decrease the economic burden of RCRs on the healthcare system, especially when the cost savings from performing a RCR far outweigh both the amount the surgeon is reimbursed as well as the difference in surgeon reimbursement between an ASC and OH. For a healthcare system, especially under a population health perspective, the incentive to perform RCRs at an ASC is significant. The cost savings come from almost every breakdown category. The cost savings achieved per RCR in an ASC vs. an OH equals about $4,000. With nearly 400,000 RCRs performed per year, the U.S. healthcare system could save a projected $1.6 billion per year on RCRs alone when the surgery is performed in an ASC. Thus, our study shows that there is a clear financial advantage to the healthcare system for RCRs being done at ASCs, although the patient does not realize these cost savings. [Table: see text]

SLAP Repair Versus Biceps Tenodesis in Patients Younger Than 40 Years: A Cost-Effectiveness Analysis.

The surgical management of type II superior labrum anterior and posterior (SLAP) tears in patients younger than 40 years is controversial, but growing evidence suggests comparable outcomes between primary SLAP repair and primary biceps tenodesis, with lower rates of reoperations after primary biceps tenodesis. Given the relatively similar patient-reported outcomes, cost-effectiveness analyses of direct and indirect costs associated with the two procedures propound a valuable comparative technique. In this value-based comparison of SLAP repair versus biceps tenodesis, we hypothesized that biceps tenodesis would be more cost-effective than SLAP repair in patients younger than 40 years. Economic and decision analysis; Level of evidence, 4. A 1-month Markov cycle was simulated to reflect 10 years of health outcomes. Health states were selected based on outcomes that are especially important in assessing indirect costs for a younger, active patient population: return-to-sport rates, which demonstrate a return to baseline function, and reoperation rates. Transition state probabilities were obtained through an index systematic review and meta-analysis comparing labral repair and biceps tenodesis for the treatment of type II SLAP lesions in patients younger than 40 years. Health state utility and cost values were obtained from accepted values denoted in existing literature. Both primary SLAP repair and primary biceps tenodesis yielded an average expected 8.1 quality-adjusted life years over the 10-year period. The average cost (in 2021 US$) was $16,619 for biceps tenodesis and $19,388 for SLAP repair. In a younger patient population, SLAP repair and biceps tenodesis had comparable quality-adjusted life years and utility in the treatment of type II SLAP tears; however, SLAP repair cost $19,388, while biceps tenodesis cost $16,619, reflecting a 14% cost savings with biceps tenodesis. These findings can be extrapolated to further establish the role for these procedures in treating SLAP tears.

SLAP Injury and the Superior Labrum.

Injuries around the superior labrum are a common cause of shoulder dysfunction and pain. The injuries sustained result mainly from repetitive microtrauma but can also occur following a fall on outstretched hand. Both athletic and general populations can be affected. Injuries to the superior labrum are called superior labrum anterior and posterior (SLAP) tears. Based on cross-sectional imaging findings, the literature defines four main SLAP tears (I-IV) and six extended types (V-X). An accurate description of imaging findings of the SLAP tear type, along with concomitant findings, aids clinicians in treatment planning. We also briefly discuss management options, postoperative appearance of superior labral repair, and the diagnosis of a retear.

Arthroscopic Modified Double-Row Biceps Tenodesis versus Labral Repair for the Treatment of Isolated Type II SLAP Lesions in Non-Overhead Athletes.

ObjectiveTo evaluate the postoperative efficacy and the clinical outcomes of arthroscopic modified double‐row biceps tenodesis versus labral repair.MethodsA retrospective study was conducted in 56 patients with isolated type II superior labrum anterior and posterior (SLAP) lesions from March 2015 to November 2018. Thirty patients (male:female = 17:13) were treated with labral repair, and 26 patients (male:female = 15:11) were treated with modified double‐row biceps tenodesis. The average age of the labral repair group and the modified double‐row biceps tenodesis group were 42.8 ± 10.6 and 40.9 ± 10.2 years, respectively. Pre‐ and postoperative assessments with the visual analog scale (VAS), University of California Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores were compared between the two treatment groups. Additional outcome measures included patient satisfaction, the time to return to previous activities, workers' compensation status, and postoperative complications.ResultsAt a 2‐year follow‐up, the tenodesis group showed significant differences in postoperative VAS (1.5 to 1.8, respectively; p = 0.008), patient satisfaction (92.3% vs. 46.7%, p < 0.001), and recovery time to return to their previous activities (6.8 ± 1.8 vs. 8.1 ± 1.5, p = 0.007) compared to the labral repair group; however, there was no significant difference in postoperative ASES and UCLA scores between the two groups. Additionally, one patient in the tenodesis group developed persistent postoperative stiffness, which was resolved by conservative treatment. In the labral repair group, two patients presented with persistent postoperative night pain, three developed persistent postoperative stiffness, and two required a subsequent capsular release.ConclusionsCompared with the labral repair group, the arthroscopic modified double‐row biceps tenodesis showed more encouraging postoperative pain reduction, earlier recovery to previous activities, and higher patient satisfaction.

Biceps Tenodesis Demonstrates Lower Reoperation Rates Compared to SLAP Repair for Treatment of SLAP Tears in a Large Cross-Sectional Population

To use a contemporary cross-sectional data set to evaluate trends in surgical treatment for superior labrum anterior and posterior (SLAP) tears and compare surgical outcomes with respect to 2-year revision surgery rates following index SLAP repair versus biceps tenodesis (BT). Patients diagnosed with a SLAP tear between 2010 and 2017 were queried using the Mariner PearlDiver database and stratified by demographic variables and surgical treatment with arthroscopic SLAP repair or arthroscopic/open BT. From 2015 to 2017, Current Procedural Terminology (CPT) and International Classification of Diseases 10th revision (ICD-10) codes were used to track ipsilateral subsequent reoperation within 2-years of index surgery. Between 2010 to 2017, 16.6% of 377,463 patients diagnosed with a SLAP tear underwent surgery (62.3% SLAP repair vs 37.7% BT). 52.4% of BT procedures were arthroscopic (47.6% open). The frequency of SLAP repairs decreased from 74.0% to 46.2% (61%), while the frequency of BTs increased from 26.0% to 53.8% (202%) during the study period. Patients under age 50 were more likely to undergo SLAP repair, and those undergoing BT were more likely to be over 50 with higher CCI and comorbidity risk. 6.3% of 16,186 patients identified with ICD-10 coding required reoperation within 2-years postoperatively. SLAP repair demonstrated a higher revision rate (6.8%; 95% CI, 6.3-7.4%) than BT (5.7%; 95% CI, 5.2-6.2%; P=.0002), (open 5.8% vs arthroscopic BT 5.5%). Arthroscopic debridement, including biceps tenotomy, revision SLAP repair, and revision BT were the most common subsequent procedures. Patients aged 40 to 49 had the highest rate of revision surgery (7.8%). The treatment trend for SLAP tears is changing, with SLAP repair becoming significantly less utilized and BT now becoming the preferred option, especially in patients over 50. Arthroscopic and open BT demonstrated slightly lower risk for reoperation than SLAP repair. IV, cross-sectional study.

The Injured Shoulder in High-Level Male Gymnasts, Part 2: Can Athletes Return to Competition After Surgery?

Background:The results of surgical treatment of shoulder injuries in high-level male gymnasts have not yet been documented.Purpose:To evaluate the functional and subjective results after surgical treatment of shoulder injuries in high-level gymnasts and the possibilities to return to sport at the same level.Study Design:Case series; Level of evidence, 4.Methods:Over a 20-year period (1994-2014), 23 high-level male gymnasts (26 shoulders) underwent surgery by a single experienced shoulder surgeon. At the time of surgery, 7 gymnasts competed at the international level, 12 at the national elite level, and 4 at the regional level. According to symptoms and anatomic lesions, the shoulders were classified into 2 groups: painful shoulders (n = 11) and unstable shoulders (n = 15). Fifteen capsulolabral repairs, 10 cuff debridements, 1 cuff repair, 4 SLAP (superior labral anterior and posterior) repairs, and 8 suprapectoral biceps tenodesis were performed. Twelve shoulders (46%) had >1 procedure performed. Outcomes assessment was performed by an independent observer at a mean of 5 years (range, 2-15 years) postoperatively. In addition, patients completed the Subjective Shoulder Value (range, 0%-100%).Results:After shoulder surgery, 21 (91%) of the 23 gymnasts returned to competitive gymnastics, and 20 gymnasts (87%) regained their preinjury level of sport. All international-level gymnasts returned to their preinjury level of sport. Three athletes (13%) underwent revision surgery, and 1 athlete (4%) ended his career without returning to competition. The postoperative period before resumption of competitive gymnastics was 9 ± 3.5 months (mean ± SD). Of the 15 gymnasts treated for shoulder instability with arthroscopic stabilization, 12 were able to return to their previous level of sport. All 8 gymnasts who had arthroscopic biceps tenodesis were able to return to their previous level of sport, as opposed to only 2 of 4 gymnasts treated with SLAP repair. The gymnastics-specific Subjective Shoulder Value score was 80% ± 11%.Conclusion:Most gymnasts who required surgical treatment for a shoulder injury were able to return to competition at their previous level, although there was a considerable postoperative recovery period. Current arthroscopic reconstruction techniques were effective for treating structural lesions and allowing return to high-level gymnastics.

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.

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

Objectives:Recent evidence has specified indications for performing Superior Labrum Anterior and 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. The purpose of this study was to report practice trends for the surgical treatment of SLAP lesions, particularly in older patients, as the management of isolated SLAP lesions remains controversial.Methods:The American Board of Orthopaedic Surgery (ABOS) database was retrospectively queried between 2012-2017 by Current Procedural Terminology 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. Separate trends were evaluated with and without concomitant arthroscopic rotator cuff repair (RCR, CPT: 29827).Results:A total of 9,908 cases met inclusion/exclusion criteria: 4,632 performed with RCR and 5,276 performed without. Mean age of patients without RCR was 40.8 +/- 13.8, while those receiving RCR was 55.0 +/- 9.9 years . In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period (p < 0.001). No significant change was noted in mean age of patients receiving arthroscopic BT, open BT, SLAP repair, and BT + SLAP. A significantly greater proportion of patients receiving open and arthroscopic BT were over 35 years old, compared to those receiving SLAP repair (p < 0.001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed (p < 0.001) over the study period. With respect to biceps tenodesis, in the RCR cohort, open was performed in 52.2% of cases while arthroscopic was performed in 47.8%, while in the cohort without RCR open was performed in 74.9% and arthroscopic was performed in 25.9%.Conclusion:The ABOS database reveals significantly reduced rates of SLAP repairs being performed. Trends with age remain consistent over time, in that SLAP repairs were predominantly performed in younger patients. Arthroscopic biceps tenodesis was performed much more frequently with RCR than without.

The majority of patients return to athletic activity following biceps tenodesis.

Biceps tenodesis is widely used as a primary treatment for long head of the biceps brachii pathology and superior labral anterior and posterior (SLAP) lesions. However, rates and timing of full return to sports (RTSs)/duty have not been systematically analysed. This systematic review examines the literature to ascertain the rate and timing of return to athletic activity, and the availability of specific criteria for safe return to atheletic activity following the biceps tenodesis. Based on PRISMA guidelines, this systematic review utilised the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to athletic activity following biceps tenodesis. Statistical analysis was performed using SPSS. This review identified 17 studies including 374 cases meeting the inclusion criteria. The majority of patients were men 260 (69.7%), with an median age of 42.2years (range 16-88) and a mean follow-up of 37.4months. The overall rate of RTS was 217/269 (80.7%), with 43/59 (72.9%) returning to the same level. In overhead athletes, the overall rate of return to play was 39/49 (79.6%). Among military personnel, the overall rate of return to duty was 61/74 (82.4%). The average time to RTS was 5.4 (range 3-11) months. 10 (58.8%) Studies reported a recommended time window within which patients were allowed to return to full activity. Specific criteria for return to play were not reported in any of the identified studies. While overall rate of return to athletic activity was reportedly high following biceps tenodesis, one in four patients were not able to resume athletic activity at the same level. At present, there is no objective assessment of when patients can return to full activity reported in the literature. IV.

A 15-Minute Incremental Increase in Operative Duration Is Associated With an Additional Risk of Complications Within 30 Days After Arthroscopic Rotator Cuff Repair.

Background:Operative time is a risk factor for short-term complications after orthopaedic procedures; however, it has yet to be investigated as an independent risk factor for postoperative complications after arthroscopic rotator cuff repair.Purpose:To determine whether operative time is an independent risk factor for complications, readmissions, and extended hospital stays within 30 days after arthroscopic rotator cuff repair.Study Design:Descriptive epidemiology study.Methods:The American College of Surgeons National Surgical Quality Improvement Program was queried for all hospital-based inpatient and outpatient arthroscopic rotator cuff repairs (Current Procedural Terminology code 29827) from 2005 to 2016. Concomitant procedures such as subacromial decompression, biceps tenodesis, superior labrum anterior and posterior (SLAP) repair, labral repair, and distal clavicle excision were also included, whereas patients undergoing arthroplasty were excluded from the study. Operative time was correlated with patient demographics, comorbidities, and concomitant procedures. All adverse events were correlated with operative time, while controlling for the above preoperative variables, using multivariate Poisson regression with a robust error variance.Results:A total of 27,524 procedures met inclusion and exclusion criteria. The mean age of patients was 58.4 ± 10.9 years, the mean operative time was 86.9 ± 37.4 minutes, and the mean body mass index was 30.4 ± 7.0 kg/m2. Concomitant biceps tenodesis, glenohumeral debridement, SLAP repair, labral repair, and distal clavicle excision significantly increased operative time (P < .001) but not the risk of adverse events (P > .05). The overall rate of adverse events was 0.88%. After adjusting for demographic and procedural characteristics, a 15-minute increase in operative duration was associated with an increased risk of anemia requiring transfusion (relative risk [RR], 1.27 [95% CI, 1.14-1.42]; P < .001), venous thromboembolism (RR, 1.17 [95% CI, 1.02-1.35]; P = .029), surgical site infection (RR, 1.13 [95% CI, 1.03-1.24]; P = .011), and extended length of hospital stay (RR, 1.07 [95% CI, 1.00-1.14]; P = .036).Conclusion:Although the rate of short-term complications after arthroscopic rotator cuff repair is low, incremental increases in operative time are associated with an increased risk of adverse events such as surgical site infection, pulmonary embolism, transfusion, and extended length of hospital stay. Efforts should be made to maximize surgical efficiency in the operating room through optimal coordination of the staff or increased preoperative planning.

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes.

To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes. The biceps and superior labral complex is composed of anatomically distinct zones. The inability to accurately diagnose biceps lesions contributes to continued morbidity especially as arthroscopy and advanced imaging fail to fully evaluate the entire course of the biceps tendon. Superior labrum anterior and posterior (SLAP) repair, long head of biceps tenodesis, and tenotomy are the most common operative techniques for surgical treatment of biceps-labral complex (BLC) pathology. Labral repair in overhead athletes has resulted in mixed outcomes for athletes and is best indicated for patients under age 40years old. Injuries to the BLC are potentially challenging injuries to diagnose and treat, particularly in the overhead athlete. SLAP repair remains the treatment of choice for high-level overhead athletes and patients younger than 40years of age, while biceps tenodesis and tenotomy are preferred for older patients.

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

Background:The management of superior labrum anterior and posterior (SLAP) tears remains controversial, with surgical treatment options including SLAP repair, debridement, and open or arthroscopic biceps tenodesis (BT), based on patient factors and the type of tear.Hypothesis:We hypothesized that SLAP repair has become less frequently performed over time, while BT is more frequently performed, particularly in patients ≥ 40 years.Study Design:Descriptive epidemiology study.Methods:A retrospective query was performed using the Humana insurance database from years 2007 to 2016. For the management of a SLAP tear diagnosis (International Classification of Diseases–Ninth Edition [ICD-9] code: 840.7), independent and exclusive cohorts were formed using Current Procedural Terminology (CPT) codes for debridement (29822, 29823), SLAP repair (29807), open or arthroscopic BT (29828, 23430), and SLAP repair combined with BT (29828 OR 23430 AND 29807).Results:Of 46,650 diagnoses of a SLAP tear, there were 3347 patients who underwent operative management for an isolated SLAP tear from 2007 to 2016. There was a linear increase of SLAP tear diagnoses per year (r 2 = 0.800, P < .001) during this period. Overall, SLAP repair was performed in 1629 patients (48.7%), debridement was performed in 1076 patients (32.1%), BT was performed in 552 patients (16.5%), and combined SLAP repair and BT was performed in 90 patients (2.7%). There was a 69.3% decrease in isolated SLAP repair from 2007 to 2016 (r 2 = 0.882, P < .001). BT for the diagnosis of an isolated SLAP tear increased by 370.0% over the same period (r 2 = 0.800, P < .001). SLAP repair had an equivalent percentage of being performed in patients both older and younger than 40 years (P = .218). There was a 1500.0% increase in BT performed in patients older than 40 years during the study period. There were no statistical differences in the postoperative incidence of stiffness, surgical site infections, and reoperations between all surgical treatment groups (P > .05).Conclusion:An analysis of a large private-payer database revealed that surgical treatment of isolated SLAP tears in the United States has shifted from 2007 to 2016, with an increase in the frequency of BT and a decline in the frequency of SLAP repair, particularly in patients older than 40 years.

Magnetic Resonance Arthrographic Demonstration of Association of Superior Labrum Anterior and Posterior Lesions With Extended Anterior Labral Tears

The objective of this study was to evaluate retrospectively the full extent of anterior labral tear and associated other labral tears on magnetic resonance arthrographic images in patients with anterior shoulder instability. One hundred ten magnetic resonance arthrography images with anterior labral tear were retrieved from the database of the Radiology Department. Two skeletal radiologists, one with 15 years of experience and the other with 5 years of experience analyzed the images in random order. Approval for the study was granted by the Ethics Committee. Statistical analyses were performed using SPSS software. The most common localization of the labral lesions was at the anterior-inferior part of the glenoid labrum (22.7%). The anterior labral tears were commonly associate with superior labrum anterior and posterior (SLAP) lesions (45%). The most common type of SLAP lesion was type V (23.6%). Superior Labrum Anterior and Posterior type V lesion was more often detected in patients with Bankart lesion (27.7%, P = 0.043). Isolated anterior labral tears are less than expected. In majority of the cases, a distinct tear at a different site of the labrum accompanies the anterior labral tear. Massive anterior labral tears are mostly seen together with SLAP lesions.

SLAP lesions: current controversies.

Knowledge of the pertinent anatomy, pathogenesis, clinical presentation and treatment of the spectrum of injuries involving the superior glenoid labrum and biceps origin is required in treating the patient with a superior labrum anterior and posterior (SLAP) tear.Despite the plethora of literature regarding SLAP lesions, their clinical diagnosis remains challenging for a number of reasons.First, the diagnostic value of many of the available physical examination tests is inconsistent and ambiguous.Second, SLAP lesions most commonly occur concomitantly with other shoulder injuries.Third, SLAP lesions have no specific associated pain pattern.Outcomes following surgical treatment of SLAP tears vary depending on the method of treatment, associated pathology and patient characteristics.Biceps tenodesis has been receiving increasing attention as a possible treatment for SLAP tears.Cite this article: EFORT Open Rev 2019;4:25-32. DOI: 10.1302/2058-5241.4.180033.

Effectiveness of biceps tenodesis versus SLAP repair for surgical treatment of isolated SLAP lesions: A systemic review and meta-analysis

BackgroundType II superior labrum anterior and posterior (SLAP) lesions could induce chronic shoulder pain and impaired movement. Current management of Type II SLAP lesions consists of two well-established surgical procedures: arthroscopic biceps tenodesis and SLAP repair. However, which technique is preferred over the other is still a controversy. MethodsWe performed a systematic electronic database search on Cochrane Central Register of Controlled Trials, MEDLINE and Embase to identify articles equating superior labral repair with biceps tenodesis, which were reported before August 2017 which included the phrase “superior labral anterior posterior” or “SLAP.” The randomised controlled clinical trials that met our criteria were evaluated for quality of methodology. The results obtained were further analysed and correlated to present the benefits and drawbacks comparing the two SLAP repair surgical procedures. ResultBased on our inclusion and exclusion criteria, we identified five articles (204 patients) that were included in this meta-analysis. The results indicate that prevalence of patients return to preinjury sports level and the patients satisfaction were found to be significantly better in tenodesis group than in the SLAP repair group (p < 0.05). As for the patient age, VAS score, American Shoulder and Elbow Surgeons score, University of California at Los Angeles score, postoperative stiffness and reoperation rates, no significant differences were evident among the two groups, thus supporting the results reported in the current literatures (p > 0.05). ConclusionsBoth the surgical treatments, SLAP repair and the biceps tenodesis, are efficacious in pain alleviation and recovery of shoulder function. But, compared with SLAP repair, biceps tenodesis showed higher rate of patient satisfaction and return to preinjury sports participation. The translational potential of this articleImpart better understanding regarding discrepancies in the outcomes between biceps tenodesis and SLAP repair in treating patients with isolated Type II SLAP lesions.

Superior Capsular Release After Failed Combined Superior Labral Repair And Biceps Tenodesis For Slap Tear

Introduction:Optimal treatment of type II superior labrum anterior and posterior (SLAP) tears is controversial. There has been a recent trend towards biceps tenodesis over SLAP repair in older patients. Few surgeons have performed combined biceps tenodesis and SLAP repair with inferior results.Case Report:This case describes a 46-year-old patient who had persistent pain and stiffness after combined biceps tenodesis and SLAP repair for a type II SLAP tear. His pain and motion improved after arthroscopic superior capsular release.Conclusion:Failed SLAP repair is often multifactorial and a thorough workup is needed. Combined biceps tenodesis and SLAP repair can cause pain, stiffness, and dysfunction which can be successfully treated with arthroscopic superior capsular release.