SLAP tears and return to sport and work: current concepts

Qualitative Research in Return to Sport: a Current Review of the Literature

PURPOSE OF REVIEW

Return to sport (RTS) is an important metric tied to patient satisfaction after receiving treatment for a sports-related injury. Recently, there has been an explosion of literature on RTS; yet a comprehensive review encompassing multiple injuries does not exist. Furthermore, RTS has historically been defined by quantitative measures that assess strength, function, and pain but little consideration has been given to psychologic factors nor has there been an open-ended forum for athletes to share with health care providers which factors they feel are most influential for RTS. This review also serves to heighten surgeons' awareness of underlying psychologic/psychosocial factors affecting RTS.

RECENT FINDINGS

Qualitative studies which employ open-ended questioning of athletes who have undergone surgical management of superior labral anterior-posterior (SLAP) tears, shoulder instability, ulnar collateral ligament (UCL) rupture, femoral acetabular impingement (FAI), and anterior cruciate ligament (ACL) tear demonstrate that fear of reinjury, lack of social support, and unrealistic expectations are all barriers to RTS. Qualitative studies give health care providers unique insight into the perspectives of their patients so that unmet postoperative needs can be addressed to facilitate RTS. Sports psychologists, coaches, athletic trainers, and physical therapists should create a positive environment to address these needs and provide optimal, holistic care to return athletes to the field safely. Though time consuming, further qualitative research is necessary to understand the unique factors affecting RTS in athletes.

Image-Based Numerical Analysis for Isolated Type II SLAP Lesions in Shoulder Abduction and External Rotation

The glenohumeral joint (GHJ) is one of the most critical structures in the shoulder complex. Lesions of the superior labral anterior to posterior (SLAP) cause instability at the joint. Isolated Type II of this lesion is the most common, and its treatment is still under debate. Therefore, this study aimed to determine the biomechanical behavior of soft tissues on the anterior bands of the glenohumeral joint with an Isolated Type II SLAP lesion. Segmentation tools were used to build a 3D model of the shoulder joint from CT-scan and MRI images. The healthy model was studied using finite element analysis. Validation was conducted with a numerical model using ANOVA, and no significant differences were shown (p = 0.47). Then, an Isolated Type II SLAP lesion was produced in the model, and the joint was subjected to 30 degrees of external rotation. A comparison was made for maximum principal strains in the healthy and the injured models. Results revealed that the strain distribution of the anterior bands of the synovial capsule is similar between a healthy and an injured shoulder (p = 0.17). These results demonstrated that GHJ does not significantly deform for an Isolated Type II SLAP lesion subjected to 30-degree external rotation in abduction.

3-Tesla T2 Mapping Magnetic Resonance Imaging for Evaluation of SLAP Lesions in Patients with Shoulder Pain: An Arthroscopy-Controlled Study

This study investigated the ability of T2 mapping to assess the glenoid labrum and to differentiate between healthy labral substances and superior labral anterior posterior (SLAP) lesions using arthroscopy as the gold standard. Eighteen patients (mean age: 52.4 ± 14.72 years, 12 men) with shoulder pain were examined using 3-Tesla T2 mapping. All the patients underwent shoulder arthroscopy. Using morphological sequences for correlation, regions of interest covering the entire labral substance were placed in the corresponding T2 maps. The diagnostic cutoff values, sensitivities, and specificities, as well as the inter-reader correlation coefficients (ICCs) determined by two independent radiologists, were calculated. The mean T2 value was 20.8 ± 2.4 ms for the healthy labral substances and 37.7 ± 10.63 ms in the patients with SLAP lesions. The maximum T2 value in normal labrum (21.2 ms) was lower than the minimum T2 value in the patients with SLAP lesions (27.8 ms), leading to sensitivities, specificities, and positive and negative predictive values of 100% (95% CI 54.1-100.0) for all the cutoff values between 21.2 and 27.8 ms. The ICCs ranged from 0.91 to 0.99. In summary, the data suggest that evaluation and quantification of the labral (ultra)structural integrity using T2 mapping may allow discrimination between arthroscopically confirmed SLAP lesions and a healthy glenoid labrum. T2 mapping may therefore be helpful in diagnosing patients with suspected labral damage.

A stabilizing role of the glenoid labrum: the suction cup effect

BACKGROUND

The glenoid labrum acts as a bumper, deepening glenoid concavity and amplifying the concavity-compression mechanism, and serves as the scapular attachment for glenohumeral ligaments. The role of the posterosuperior labrum in anteroinferior glenohumeral stability, and the role of the anterior labrum in posterior stability has been debated. The purpose of this study was to quantify the contribution of anteroinferior and posterosuperior labral tears to loss of glenohumeral stability in multiple directions.

METHODS

Fourteen fresh-frozen cadaveric shoulders were tested on a custom stability ratio measurement apparatus. The peak force that was required to translate the humeral head in anterior, anteroinferior, posterior, and posteroinferior directions was measured under 5 conditions: intact labrum (n = 14), anteroinferior labral tear (n = 7), posterosuperior labral tear (n = 7), combined labral tear (n = 14), and no labrum (n = 14). The stability ratio was defined as the peak translational force divided by the compressive force. Within force-translation curves, we defined the suction cup effect as the force required to release the negative pressure created by an intact labrum.

RESULTS

The suction cup effect was usually present with the intact labrum and always disappeared after removal of the labrum for anterior (100% vs. 0%) and posterior (86% vs. 0%) translations (P < .001). After creation of an anteroinferior labral tear, the stability ratio for posterior direction decreased (P < .001) and the suction cup effect disappeared (P < .001). After creation of a posterosuperior labral tear, stability ratios in the anterior and anteroinferior directions decreased (P ≤ .006) and the suction cup effect disappeared (P ≤ .015). The stability ratio for anterior and anteroinferior testing was more diminished by posterosuperior labral tears than anteroinferior labral tears, and the stability ratio for posterior testing was more diminished by anteroinferior labral tears than posterosuperior labral tears.

CONCLUSION

Anteroinferior labral tears decreased posterior stability and posterosuperior labral tears decreased anterior and anteroinferior stability, largely because of loss of the suction cup effect.

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

BACKGROUND

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.

HYPOTHESIS

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.

STUDY DESIGN

Economic and decision analysis; Level of evidence, 4.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

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

BACKGROUND

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).

METHODS

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 5 years. 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.

RESULTS

A total of 150 patients (88% males) with a mean age 23.7 years (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 7.8 years (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).

CONCLUSION

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.

LEVEL OF EVIDENCE

III.