Superior Labrum Anterior To Posterior Research Articles

Risk factors for the development of Superior Labrum Anterior to Posterior (SLAP) tears in physically demanding occupations: a systematic review and meta-analysis

Background: Currently, available evidence indicates people in physically demanding occupations (e.g., military or sport) may be at a higher risk of injury to the labrum than other occupations, with mechanisms involving acute forceful trauma or sustained mechanical forces exerted across the shoulder or hip joint. Therefore, the aim of this systematic review was to identify and synthesise findings from studies which reported the incidence or prevalence of Superior Labrum Anterior to Posterior (SLAP) tears in physically demanding occupations, and the risk factors associated with their development. Methods: This review was conducted according to the PRIMSA-P guidelines and registered on the Open Science Framework. PubMed, EBSCO, Scopus, Web of Science, CINAHL and ProQuest databases were systematically searched using the following key terms: ‘labral tear’, ‘work’ and ‘risk’. Key findings from the included studies were extracted, including risk factors, prevalence or incidence and risk ratios (e.g., relative risk, hazard ratios, and incidence rate ratios). Each study included in the review was critically appraised to assess its methodological quality, using the Critical Appraisal Skills Programme (CASP) toolkit for cohort studies, and the Joanna Briggs Institute (JBI) case series critical appraisal tool for a case series study. Meta-analysis was conducted using the Cochrane Collaborations software package, Review Manager (RevMan, version 5.3). A random effects model was selected due to the variability in participant demographics and other characteristics across the included studies. OR and 95% CI were calculated. Results: Six articles met the eligibility criteria, and these included three studies on professional athlete populations, two on military populations, and one study reporting on SLAP tears arising from workplace accidents or as a condition arising from occupational tasks. The methodological quality scores of the included studies ranged from 50% to 92%, with an average score of 73%. SLAP tears comprised 3.1% of shoulder injuries recorded over a 15-year period in the NFL and reported incidence in military populations was 2.13 [95% CI 2.11 to 2.16] per 1,000 person-years. Identified risk factors include younger age, male sex, acute weight-bearing and overhead movements, gameplay (as opposed to training), Army or Marine Corps service and enlisted rank. Meta-analysed data comprised from the military and sporting population studies, indicated strong evidence (p < 0.001; OR 11.40 [95% CI 5.65 to 23.02]; I2 = 35%) for the role of direct contact or trauma in developing SLAP tears compared to indirect or non-contact tasks. Discussion: The findings showed individuals of male sex and of younger age, are at increased risk of sustaining SLAP tears. The results of the meta-analysis provided strong evidence that direct contact or trauma to the glenohumeral joint resulting from collisions or force directed to the shoulder from an abducted arm position was more likely to be associated with shoulder labrum tears (primarily SLAP, although inclusive of Bankart and other labral tears) than other forms of indirect force applied to the shoulder or non-contact mechanisms. Impact: Tackling, blocking, collisions, repeated overhead shoulder lifting, combat sports, and sporting tasks predispose physically demanding occupations to increases in SLAP injury risk. Conflict of interest statement: This research was funded by the Department of Veterans’ Affairs.

Combined Bankart and SLAP repair: patient-reported outcome measurements after a minimum 5-year follow-up.

Anterior shoulder instability is typically characterized by detachment of the anteroinferior labrum (Bankart lesion). Some patients also sustain a superior labrum anterior-to-posterior (SLAP) injury. The purpose of this study was to compare the medium-term clinical results of isolated anterior Bankart repairs (ABR) with those of combined Bankart and SLAP repair (ABR + SLAP). Data on all patients treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected from medical charts. The minimum follow-up was 5years. Patients were interviewed to assess patient-reported outcome measurements (PROM) as determined by the American Shoulder and Elbow Surgeons Score (ASES), the Subjective Shoulder Score (SSV), and the Disabilities of the Arm, Shoulder, and Hand Score (DASH), as well as their quality of life (QOL: SF12 questionnaire). Information on complications, re-operations, and recurrent instability was recorded and evaluated as well. A total of 150 patients (88% males) with a mean age 23.7years (range 15-40) were included. Forty-two patients following ABR + SLAP repair were compared to 108 patients following ABR alone, with a mean follow-up of 7.8years (range 5-10.7). The rate of re-dislocation was similar in both groups (26% for ABR + SLAP vs 20% for ABR, p = .44). There were no significant differences in functional outcome between the ABR + SLAP and the ABR alone groups (SSV 86.7 vs 86.5, p = .93, ASES 89.6 vs 86.5, p = .11, and DASH 4.9 vs 7, p = .17), or in QOL outcome (SF12 physical 95.6 vs 93.3, p = .27, SF12 mental 84.4 vs 85.7, p = .63). Surgical repair for anterior shoulder instability and a coexisting SLAP lesion yields clinical results as good as those of isolated ABR, as evidenced by similar PROM and re-dislocation rates after medium-term follow-up. III.

Physical Examination Maneuvers for SLAP Lesions: A Systematic Review and Meta-analysis of Individual and Combinations of Maneuvers

Background: Superior labrum anterior to posterior (SLAP) lesions are targeted on physical examination using a variety of provocative maneuvers. Purpose/Hypothesis: The purpose was to conduct a systematic review on the performance of physical examination maneuvers in diagnosing SLAP lesions and to perform a meta-analysis comparing the sensitivity and specificity of these examinations both individually and in combination. The null hypothesis stated that there would be no significant difference in the sensitivity or specificity of the included physical examination tests, neither individually nor in combination. Study Design: Meta-analysis and systematic review; Level of evidence, 4. Methods: A systematic review was performed with the inclusion criteria of studies that reported either the sensitivities and specificities or the number of true-positive, true-negative, false-positive, or false-negative results for at least 1 maneuver for identifying SLAP lesions. A meta-analysis was performed to determine the sensitivity and specificity of individual maneuvers. Additional analysis determined the performance of these maneuvers when combined in series and parallel. In series, all must be present to be considered positive. In parallel, any single positive test forces the overall combination to be considered positive. Only tests that were included in ≥3 studies were considered in the meta-analysis and those included in ≥4 studies were considered in the combination analysis. Results: Overall, 862 studies were identified, 18 of which were included in the systematic review and meta-analysis. The physical examinations included were the O’Brien (n = 16), speed (n = 8), Yergason (n = 6), anterior slide (n = 8), crank (n = 7), Jobe (n = 5), dynamic labral shear (n = 3), Kim 2 (n = 3), and biceps groove tenderness tests (n = 3). All combinations of 2 to 5 maneuvers in both series and parallel were considered. The O’Brien and crank test combination was the most sensitive 2-test combination in both parallel and series. The Yergason and anterior slide test combination was the most specific 2-test combination in parallel and series. Conclusion: This systematic review and meta-analysis reports an updated meta-analysis considering the sensitivity and specificity of common physical examination maneuvers used in the diagnosis of SLAP lesions and considers these values for tests in both series and parallel combinations. The present analysis demonstrates improved specificities when tests are considered in series and improved sensitivities when considered in parallel combination.

Postoperative imaging of the shoulder

Imaging of the postoperative shoulder joint includes complex, diagnostically challenging changes regarding the anatomical structures. Case-based presentation of common surgical procedures, expected postoperative findings, and typical complications. Interdisciplinary evaluation of (didactically instructive) cases and discussion of pertinent literature and expert opinions. Presentation of normal postoperative findings and complications after subacromial decompression, surgical treatment of rotator cuff lesions, SLAP (superior labral anterior to posterior) lesions/lesions of the long biceps tendon, Bankart lesions as well as instability-related procedures and after shoulder arthroplasty. Discussion of the appropriate use of imaging methods with afocus on magnetic resonance imaging (MRI), which are supplemented by computed tomography (CT), and conventional x‑ray images. The broad spectrum of complex findings as well as the evermore developing and thereby changing surgical procedures result in significant challenges in the radiological evaluation of the postoperative shoulder joint. To differentiate physiological reactions from pathological changes it is necessary to have general knowledge of the common surgical procedures, expected postoperative findings and possible complications. A variety imaging modalities can be used to further advance diagnostic precision.

The impact of external beam radiation therapy on shoulder surgical outcomes: a case series study

External beam radiation therapy (XRT) is a commonly used treatment adjunct in patients with breast cancer and is known to cause soft tissue dysfunction. However, data on XRT as a preoperative risk factor for shoulder surgery is limited. The purpose of this study was to assess whether prior history of breast cancer treated with XRT has an impact on surgical complications or outcomes. We hypothesize that patients treated with XRT will have a higher rate of surgical complications and lower outcomes. A 20-year retrospective chart review across a large, academic health care system was performed. Inclusion criterion comprised any patient with history of breast cancer of the upper-outer or axillary region treated with XRT. Patients also must have undergone a surgical procedure to the ipsilateral shoulder with at least 1-year postoperative follow-up. Patients were stratified by demographics, hand dominance, and surgery type. Postoperative outcomes including range of motion (ROM) and visual analog scale (VAS) scores for pain were also collected. Eighteen patients were identified (100% female) with an average age of 66.3 years (standard deviation 10.5 years). Ten shoulders underwent rotator cuff repair (RCR), 4 total shoulder arthroplasty (TSA), 3 reverse shoulder arthroplasty (RSA), and 1 arthroscopic superior labrum anterior to posterior (SLAP) repair. Four patients treated with RCR (40%) experienced postoperative complications related to their procedure. These included scapular winging, adhesive capsulitis, stiffness, and one retear. Two patients treated with shoulder arthroplasty (28.6%) experienced postoperative complications that included lymphedema and periprosthetic fracture following a mechanical fall in one RSA patient and periprosthetic infection in a TSA patient. ROM across all groups improved, most significantly in forward flexion and internal rotation among RCR patients (P<.001). Furthermore, a statistically significant improvement in VAS scores was achieved in each group (6.2±2.14 preoperation, 1.06±1.75 postoperation; P<.001). When compared to national averages, complication rates in our cohort were higher (40% vs. 10%-17% in RCR patients and 28.6% vs. 4%-14% in arthroplasty patients). On further scrutiny, many of these complications were independent of a history of XRT and many resolved with appropriate therapy. Most importantly, functional outcomes as measured by ROM and pain scores showed appropriate improvement consistent with normal populations without history of XRT. Thus, our results suggest that performing shoulder surgery after ipsilateral XRT for breast cancer is likely safe and may offer improved pain and ROM compared to forgoing surgery without necessarily increasing the risk for postoperative complication.

Paper 05: Glenoid Labral Tears are associated with Increased Neurofilament Innervation

Objectives:Pain is a common presentation following glenohumeral labral injuries. However, the source of that pain is undetermined. We aimed to determine if there is a differential expression of nerve fibres around the glenoid labrum and if torn labra have increased neuronal expression compared to untorn labra.Methods:Labral tissue was collected at 3, 5, 9 and 12 o clock during total shoulder arthroplasty (n = 7). Samples were also collected at 3, 5 and 12 o clock during rotator cuff repair (n = 16), anterior labral repair (n = 6), type II superior labral anterior to posterior (SLAP) repair (n = 4) and capsular release for idiopathic capsulitis (n = 5). Sections were immunostained with antibodies to neurofilament, a specific neuronal marker which is used to identify central and peripheral nerve fibres, and the concentration and intensity of immunostained-positive cells assessed.Results:The concentration of neurofilament staining was similar in the superior, anterior, posterior and inferior glenoid labrum in untorn labra (8 neurofilament expressing cells/mm2, p > 0.05). Torn labra exhibited a 3-4-fold increase in neuronal expression which was isolated to the location of the tear in SLAP (p = 0.09) and anterior labral tears (p = 0.02). The concentration of neurofilament expressing cells in torn glenoid labrum samples were comparable to the glenoid labrum of adhesive capsulitis samples (p > 0.05). Figure 3. Mean (SD) neurofilament expressing cells per mm2 at 12 o’clock (A), 3 o’clock (B) and 5 o’clock (C) using labral tissue from patients with either a; RCT (n = 16), anterior labral tear (n = 6), SLAP tear (n = 4) or a frozen shoulder (n = 5). *p <0.05 compared using a one-way ANOVA with post-hoc analysis.Conclusions:This study supports the hypothesis that following a traumatic tear of the anterior or superior labrum, the labrum in that region becomes populated with new nerves fibres and that these fibres are likely to be responsible for many of the symptoms noted by patients with superior (SLAP) and/or anterior labral (Bankart) tears.

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

Background: Performing open subpectoral biceps tenodesis in overhead athletes with a superior labrum anterior to posterior (SLAP) tear may affect their ability to return to overhead sports. Purpose: To investigate clinical outcomes in overhead athletes undergoing biceps tenodesis for the treatment of symptomatic, isolated SLAP tears involving the biceps-labral complex. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review of overhead athletes who underwent biceps tenodesis for a SLAP tear was performed. The American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, subjective shoulder value (SSV), patient satisfaction, willingness to undergo surgery again, revision procedures, and return to play were evaluated. Psychological readiness to return to sport was evaluated using the SLAP–Return to Sport after Injury (SLAP-RSI) score. A P value of <.05 was considered to be statistically significant. Results: The current study included 44 overhead athletes. The mean age was 34.9 years (range, 16-46 years), 79.5% were male, and the mean follow-up was 49.0 months (range, 18-107 months). Overall, 81.8% of patients returned to play their overhead sport after biceps tenodesis, and 59.1% of patients returned to the same or higher level of play. It took patients, on average, 8.7 months to return to play after biceps tenodesis. The mean SLAP-RSI score was 69.4, and 70.5% of patients passed the SLAP-RSI threshold of 56. The mean ASES score, VAS score, SSV, and satisfaction were 92.0, 0.8, 80.6, and 87.9%, respectively. No patients in our cohort required revision surgery. Conclusion: This study found that athletes undergoing biceps tenodesis for the treatment of a symptomatic, isolated SLAP tear had a high rate of return to play, good functional outcomes, and a low rate of revision surgery.

Comparison of labral repair and biceps tenodesis concomitant with arthroscopic rotator cuff repair in patients between the age of 40 and 60

Aim: Superior labrum anterior to posterior (SLAP) lesions are frequently accompanied by rotator cuff tear (RCT). The optimal treatment for type 2 and 4 SLAP lesions with RCT were not established. We aimed to compare the clinical results of SLAP repair and biceps tenodesis (BT) concomitant with arthroscopic rotator cuff repair (ARCR) in patients between 40 and 60 years old. &#x0D; Material and Method: Forthy three patients (16 male, 27 females) who received ARCR concomitant with SLAP repair or BT for full-thickness rotator cuff tear were evaluated retrospectively. The patients were divided into the two groups based on treatment methods (SLAP repair, Group 1, 20 patients), (BT, Group 2, 23 patients). American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, visual analogue scale scores (VASs), and range of motion (ROM) values were used as outcome tools. &#x0D; Results: The mean age of the patients was 48.8±5.03 years. There was no difference in preoperative shoulder and pain scores (P

Isolated Infraspinatous Atrophy from a Spinoglenoid Cyst: A Case Report

We present a case of a 26-year-old gentleman with isolated right infraspinatus atrophy arising from a spinoglenoid cyst of the right shoulder. He presented two years following his shoulder injury and failed conservative rehabilitation alone. At initial arthroscopic surgery, a superior labral anterior to posterior (SLAP) tear was diagnosed and the spinoglenoid cyst was debrided without formal labral repair. The patient’s condition did not improve, and second arthroscopy was performed three months following the first with suture anchor repair of the labral tear and cyst decompression. Post-operative magnetic resonant imaging (MRI) scans showed complete resolution of the cyst and recovery of infraspinatus muscle bulk at six months. At final follow-up 18 months post SLAP repair, he has regained full shoulder function and has returned to recreational sports. Our case highlights the importance of proper management of SLAP tears in resolving spinoglenoid cysts by demonstrating the outcomes from two different surgical methods in the same patient.

Open Subpectoral Biceps Tenodesis Versus Arthroscopic Repair For SLAP Tears In Patients Under 30

The purpose of the current study is to compare the outcomes of biceps tenodesis (BT) to arthroscopic repair (AR) for superior labrum anterior-to-posterior (SLAP) tears in patients under the age of 30.

Subpectoral versus suprapectoral biceps tenodesis yields similar clinical outcomes: a systematic review

ImportanceArthroscopic suprapectoral biceps tenodesis (ABT) and open subpectoral biceps tenodesis (OBT) are two surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior to posterior (SLAP) tears. There is insufficient knowledge regarding the clinical superiority of one technique over the other.ObjectiveTo systematically review the literature in order to compare the clinical outcomes and safety of ABT and OBT for treatment of LHBT or SLAP pathology.Evidence reviewA systematic review was performed by searching PubMed, the Cochrane Library and Embase to identify studies that compared the clinical efficacy of ABT versus OBT. The search phrase used was: (bicep OR biceps OR biceps brachii OR long head of biceps brachii OR biceps tendinopathy) AND (tenodesis). Patients were assessed based on the American Shoulder and Elbow Surgeons Score, the visual analogue scale, the Single Assessment Numeric Evaluation, Constant-Murley Score, clinical failure, range of motion, bicipital groove pain and strength. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and both the Cochrane Collaboration’s and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) risk of bias tools were used to evaluate risk of bias.FindingsEight studies (one level I, seven level III) met inclusion criteria, including 326 patients undergoing ABT and 381 patients undergoing OBT. No differences were found in treatment failure rates or patient-reported outcome scores between groups in any study. One study found OBT patients to experience significantly increased range of shoulder forward flexion when compared with ABT patients (p=0.049). Two studies found ABT patients to experience significantly more postoperative stiffness when compared with OBT patients (p<0.05).ConclusionsPatients undergoing ABT and OBT can be expected to experience similar improvements in clinical outcomes at latest follow-up without differences treatment failure or functional performance. ABT patients may experience an increased incidence of stiffness in the early postoperative period.Level of evidenceIII.

Developing a Clinical Prediction Model for Failed Nonoperative Management of SLAP Tears (220)

Objectives:Patients with a superior labral anterior to posterior (SLAP) tear of the shoulder are often initially treated non-operatively, but many do not respond and require surgery. Identifying patients who are likely to fail non-operative management and would benefit from early surgical intervention can shorten time of disability and limit resources utilized on unsuccessful treatments. The purpose of this study is to create a clinical prediction model to determine which patients are likely to fail non-operative treatment of SLAP tears and require surgical intervention.Methods:This was a case-control study consisting of patients treated at a single institution for isolated, non-degenerative SLAP tears. Patients with concomitant rotator cuff tears were excluded from this analysis. Patients were retrospectively surveyed using the Research Electronic Data Capture (REDCap) system regarding clinical features of their shoulder injury, non-operative treatments that they received, and key functional outcomes during their post-injury period. Responders underwent additional medical record review to identify other variables related to the clinical presentation and treatment of their shoulder injury.In order to simplify the predictive model and optimize its interpretability, the lasso (least absolute shrinkage and selection operator) method of penalized logistic regression analysis was used to identify the characteristics that were most closely associated with failure of nonoperative treatment. The data was randomly split into a training set and test set. Using the training set, the value of lambda which minimized cross-validation prediction error rate was determined (Figure 1). The final lasso model was then computed. The predictive accuracy of the final model was assessed using the test data set.Results:Overall, 189 patients were contacted and included in the analysis. The mean age of included patients was 29.9 +/- 6.7 years. Thirty-eight patients (20.1%) were female. One hundred and six patients (56.1%) failed non-operative management and required surgical intervention.The final lasso model identified a total of 9 variables that were significantly associated with failure of non-operative management of SLAP tears (Table 1). These predictors included pre-injury overhead sports participation, presence of specific symptoms, severity of pain, and the type of non-operative treatment modalities used. Injury to the dominant extremity, history of prior shoulder injury, patient age, use of NSAIDs, and occupation involving manual labor or overhead work were not associated with failure of nonoperative treatment. The predictive accuracy of the model was 70.3% (95% CI 53.0%, 84.1%). Sensitivity of the model was 81.0% and specificity was 56.3%.Conclusions:A clinical prediction model consisting of variables describing patient characteristics, specific symptoms, and the type of non-operative treatment modalities utilized was found to predict failure of non-operative management of SLAP tears with moderate accuracy. Further refinements of this prediction model, including the inclusion of additional physical examination and imaging variables, will be required before future iterations are tested in clinical practice.

High Incidence of Anterior Shoulder Pain in Young Athletes Undergoing Arthroscopic Posterior Labral Repair for Posterior Shoulder Instability

PurposeThe purposes of this study were to determine the incidence of anterior shoulder pain in young athletes undergoing arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability and in patients with preoperative anterior shoulder pain treated without biceps tenodesis at the time of arthroscopic posterior labral repair who underwent a revision biceps tenodesis procedure at short-term follow up.MethodsA retrospective review was performed at a single institution over a 24-month period. The study included young patients who underwent an arthroscopic posterior labral repair for symptomatic unidirectional posterior shoulder instability. The electronic medical record, magnetic resonance arthrograms, and arthroscopic images were reviewed to exclude patients with posterior labral tears with anterior labral tear or SLAP (superior labrum anterior-to-posterior) tear extension on advanced imaging and arthroscopic examination. Data collected included the presence of preoperative tenderness to palpation of the biceps tendon in the groove, the results of a preoperative Speed test, postoperative Subjective Shoulder Value, the presence of postoperative anterior shoulder pain, and the need for a secondary biceps tenodesis.ResultsWe identified 65 patients who underwent arthroscopic labral repair for posterior shoulder instability. From this cohort, 26 patients with symptomatic unidirectional posterior shoulder instability underwent an arthroscopic posterior labral repair. The incidence of preoperative anterior shoulder pain with Zone 2 biceps groove tenderness and a positive Speed test was identified in 20 of 26 patients (76.9%). Of 26 patients, 5 (19%) had concomitant biceps tenodesis. The median postoperative Subjective Shoulder Value was 80 (interquartile range, 60-90) at median follow-up of 2.1 years. Of the 20 patients with preoperative anterior shoulder pain, 8 of 20 (40%) reported persistent anterior pain. One patient (4.7%) underwent a secondary biceps tenodesis.ConclusionsThere is a high incidence of anterior shoulder pain and Zone 2 biceps groove tenderness in patients undergoing isolated arthroscopic posterior labral repair for unidirectional posterior shoulder instability. At short-term follow-up, few patients required a secondary biceps tenodesis procedure; however, 30% of patients had persistent anterior shoulder pain.Level of EvidenceLevel IV, retrospective diagnostic case series.

Partial Rotator Cuff Repair With Biceps Rerouting and Double Tenodesis: An Efficient and Cost-Effective Biological Superior Capsular Reconstruction

Background: Chronic rotator cuff tears (RCTs) are common and are often only partially repairable. Surgical treatment is challenging in younger patients. Surgical options include partial repair, tendon transfer, subacromial spacer, superior capsular reconstruction (SCR), and reverse shoulder arthroplasty. The use of SCR has been expanded and commercialized. The proposed techniques are complex using free avascular grafts and up to 7 anchors with associated increase in theater time and nonrefunded cost. Biceps SCR has shown promising biomechanical resistance and seems to offer a simple and cost-effective alternative. Indications: Patients with RCTs (Goutallier stage ≥3, Patte 3) without arthritis that are at least partially repairable (infraspinatus and subscapularis) are candidates. Patients with mechanically intact long head of biceps (LHB) and superior labrum anterior to posterior (SLAP) anchor (minimal fraying of &lt;10% and fraying of SLAP without full-thickness tears acceptable) are also candidates. Technique: Key steps include arthroscopic release/lateral opening of the bicipital grove (15-20 mm) and placement of a first footprint anchor 8 to 10 mm posterior to the anatomical sulcus. Use of a 5-mm burr to create a new rerouting groove obliquely from the first anchor to the original groove, 15 to 20 mm caudal to the summit of the tubercle. Lasso-loop translation and tenodesis of the LHB to the first anchor. Use of a second caudal biceps tenodesis anchor with lasso-loops at the caudal end of the new groove. These 2 anchors create a rerouting bipedicle tenodesis performing the function of both an SCR and biceps tenodesis. Single-row, tension-free over-the-top repair of infraspinatus and the bursal layer of supraspinatus is completed with a third anchor on the rerouted biceps which remains in continuity. Results: The pilot series (n = 10) with a mean follow-up of 12 months (9-18 months) shows satisfactory outcomes. One patient developed a postoperative frozen shoulder and one a secondary Popeye deformity. Functional scores and patient satisfaction improved in all cases. The subjective shoulder value improved from a mean of 30% (10%-40%) preoperatively to 75% (60%-80%) postoperatively and the constant score from 30 points (20-40) to 68 points (60-71). Conclusion: As long as LHB and its SLAP anchor are adequate, biceps rerouting in combination with partial rotator cuff repair is a safe alternative to time-consuming and expensive commercialized SCR techniques.

Is timing of superior labrum anterior to posterior (SLAP) repair important? A cohort study evaluating the effect of the duration of symptoms prior to surgery on the outcomes of patients who underwent type II SLAP repair.

The management of superior labrum anterior to posterior (SLAP) tears is somewhat controversial. It is unclear if the length of time between symptom onset and surgery affects SLAP repair outcomes. Sixty-one SLAP repairs were retrospectively reviewed pre-operatively and post-operatively at 1, 6, 24 weeks, and > 2 years post-surgery. Patients were allocated to an 'early repair' or 'late repair' group based on time between symptom onset and surgery. Of the 61 patients, 22 patients had surgery within six months of symptom onset. Pre-operatively, 'late repair' patients played a higher level of sport than 'early repair' patients prior to injury. Post-operatively, both groups had similar outcomes up to six months, though at six months 'early repair' patients reported a higher level of work than 'late repair' patients (p = 0.01). At > 2 years after surgery, 'early repair' patients had reduced pain and difficulty with overhead activities (p = 0.002), less stiffness (p = 0.001) and were more satisfied than 'late repair' patients (p = 0.04). Up to six months post-operatively, the time between symptom onset and surgery has limited effect on functional outcomes. However, at > 2 years after surgery, earlier repairs ( < 6 months) are interestingly associated with better functional outcomes. Further studies are required to determine if this is a causal relationship.

Anterior Shoulder Instability with Type IX Superior Labral Anterior to Posterior (SLAP) Lesion–about a Clinical Case

Lesions of the superior labrum anterior to posterior (SLAP) are often associated with repetitive movements of the shoulder above the head or traumatic history. Types V to X lesions are much rarer, and their prevalence has not yet been described in the literature. In this regard, we report the clinical case of a 34-year-old man, who reported multiple episodes of anterior dislocation of the right shoulder, which he reduced on its own. The patient described onset of instability after a fall with the upper limb in extension and abduction, 2 years before presentation to the authors. An arthro-magnetic resonance was performed that showed a rupture of the upper labrum that extending through the anterior to posterior region reaching the lower edge of the glenoid, with damage to the cartilage at the anterior portion of the glenoid. Surgical treatment was proposed, with di-agnostic arthroscopy and arthroscopic suture of the labrum using anchors. Four years after surgery, the patients presented with no pain complaints, without new episodes of dislocation. At physical examination, he presented a symmetrical range of motion, negative apprehension tests and negative rotator cuff strength tests. In the assessment of symptoms on the DASH scale, pre-surgery the patient obtained a score of 39.2, and four years later scored 1.6. In summary, although rare, extensive SLAP lesions are cause of significant morbidity for the patient and cause of accelerated degenera-tion of the glenohumeral joint, so surgical treatment, preferably arthroscopic, is recommended, with good clinical results.

Biceps tenodesis versus tenotomy: a systematic review and meta-analysis of level I randomized controlled trials

Biceps tenodesis and tenotomy are 2 surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior-to-posterior (SLAP) tears. The purpose of this systematic review was to compare the clinical outcomes and complications of biceps tenodesis and tenotomy for the treatment of LHBT or SLAP pathology during shoulder arthroscopy. We performed a systematic review by searching PubMed, the Cochrane Library, and Embase to identify level I randomized controlled trials that compared the clinical outcomes of biceps tenodesis vs. tenotomy. The search phrase used was as follows: biceps tenodesis tenotomy randomized. Patients were assessed based on the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, and Constant-Murley score, as well as postoperative range of motion, strength, and cosmetic deformity. Five studies (all level I) met the inclusion criteria, including 236 patients undergoing biceps tenodesis (mean age, 60.3 years) and 232 patients undergoing biceps tenotomy (mean age, 59.7 years). The mean follow-up period was 23.0 months. Overall, 6.8% of tenodesis patients experienced cosmetic deformity at latest follow-up compared with 23.3% of tenotomy patients (P < .001). No differences in Constant-Murley, visual analog scale, or American Shoulder and Elbow Surgeons scores were found between groups in any study, and of all the studies evaluating strength and range of motion at latest follow-up, only 1 found a significant difference between groups, in which tenodesis patients demonstrated significantly increased forearm supination strength (P = .02). One study found tenodesis patients to experience significantly more biceps cramping at 6-month follow-up compared with tenotomy patients (P = .043), although no differences in complication rates at latest follow-up were found in any study. Patients undergoing treatment for LHBT or SLAP pathology with either biceps tenodesis or tenotomy can be expected to experience similar improvements in patient-reported and functional outcomes. There is an increased rate of cosmetic deformity in patients undergoing biceps tenotomy compared with tenodesis.

Is timing of superior labrum anterior to posterior (SLAP) repair important? A cohort study evaluating the effect of the duration of symptoms prior to surgery on the outcomes of patients who underwent type II SLAP repair

Is timing of superior labrum anterior to posterior (SLAP) repair important? A cohort study evaluating the effect of the duration of symptoms prior to surgery on the outcomes of patients who underwent type II SLAP repair

THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Reviews on superior labral anterior to posterior (SLAP) injuries have been reported in the literature. However, current reviews have not focused on the success of athletes return to their previous level of sport or athletic performance. Systematically review return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury while reporting any additional performance metrics and outcome measures. Systematic Review & Meta-Analysis. A computer assisted literature search of MEDLINE, CINAHL, Embase and SportDiscus databases utilizing keywords related to RTS post-surgery for SLAP tear was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized for study methodology. Quality assessment utilized the MINORS scale. Twenty-two studies (617 athletes) qualified for analysis. Based on limited evidence from level 3b to 4 studies, athletes RTS post intervention for SLAP injury occurred at a rate of 93% (95% CI:87 to 98%) and overall RTSP rate was 72% (95% CI:60 to 83%). The mean time to RTS post intervention was reported in 59% of studies at 6.9 ± 2.9 months. Patient reported outcome measures (PROM's) were reported in 86% of studies. There was limited reporting of performance statistics, rehabilitation guidelines, return to sport criteria, and information regarding SLAP diagnosis in the available studies. None of the included studies reported post-surgical athletic performance or career longevity. Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS from RTSP and neither athletic performance nor career longevity were reported in any included studies. Future studies of higher quality are required for this determination. Level 1a.

Effects of type II SLAP lesion repair techniques on the vascular supply of the long head of the biceps tendon: a cadaveric injection study

One option for the treatment of type 2 superior labral anterior to posterior (SLAP) lesions is arthroscopic repair. However, the fact that the vascular supply of the proximal long head of the biceps tendon (LHBT) arises from the soft tissue near the SLAP repair site must also be considered. The aims of this study were to evaluate the vascular channel of the proximal long head biceps tendon and to compare potential damage to the vascular supply with alternative SLAP techniques. Forty-five fresh cadaveric shoulders were divided into 3 groups: 9 shoulders each for the normal group and the created SLAP group, and 27 shoulders for the repaired SLAP group. SLAP group shoulders were repaired using one of 3 techniques: 2 anchors with simple sutures, 1 anchor with double sutures, or 1 anchor with a horizontal mattress suture. India ink was then injected into the acromial branch of the thoracoacromial artery. The proximal LHBT was resected for a histologiccross-sectional study. The intratendinous vascular distance was measured and compared among the groups. The vascular supply of the proximal LHBT arises from soft tissue lying anterior and dorsal to the tendon origin. In the normal shoulders, the average intratendinous vascular distance was 16.9 ± 1.5 mm(95% confidence interval: 15.8-18.1). A comparison of nonrepaired SLAPs with each of the repair techniques found that using 2 anchors with simple sutures showed no significant difference in vascular distance (P = .716), whereas the other techniques showed a significant disruption of the blood supply. The differences in vascular distance among the 3 repair techniques were statistically significant (P = .0001). The main vascular supply of the proximal LHBT comes from the anterior-dorsal direction. Some SLAP repair techniques can disrupt vascularization; however, the technique using 2 anchors with simple sutures, 1 anchor 3 mm anterior to the anterior border and 1 at the posterior border of the tendon, can preserve the vascularization of the LHBT.