Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective

Arthroscopic Subdeltoid Transfer of the Long Head of the Biceps Tendon to the Conjoint Tendon

Surgical intervention is often recommended for refractory pathology affecting the biceps-labrum complex. Tenodesis of the long head of the biceps tendon (LHBT) is a widely accepted treatment modality; however, the optimal technique remains elusive. Arthroscopic subdeltoid transfer of the LHBT to the conjoint tendon, as described in this technical note, continues to demonstrate excellent clinical results. Its advantages include soft tissue-to-soft tissue healing, an advantageous biomechanical construct, and comprehensive evaluation and decompression of the LHBT including the extra-articular bicipital tunnel. The primary limitation of this procedure is the perceived learning curve for safe navigation within the subdeltoid space.

Postoperative Rehabilitation After Superior Labrum Anterior Posterior Repair

The 4-phase rehabilitation protocol outlined in this article provides a comprehensive 26-week program to return patients with superior labrum anterior posterior repairs to their preinjury states. It is guided by the principle of gradual return to preinjury function while preserving the integrity of the surgical repair. Objective criteria are present at the conclusion of each phase to ensure patients are progressing appropriately. The goal is to allow patients to return to their previous functional ability in their sport-specific or occupational-specific training.

Nonoperative Treatment of the Biceps-Labral Complex

The long head of the biceps and superior labrum should be evaluated as an interdependent functional unit. A focused patient history and physical examination including multiple provocative tests should be performed alongside advanced imaging studies to obtain an accurate diagnosis. Nonoperative treatment modalities including nonsteroidal anti-inflammatory drugs, glucocorticoid injections, and a standardized physical therapy regimen should be exhausted before operative intervention. Significant improvements in pain, functional outcomes, and quality of life are achieved in patients treated nonoperatively. Although these outcomes are less consistent for overhead athletes, return to play and performance metrics seem comparable to those who undergo surgery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, case series.

Clinical outcomes and return to play in softball players following SLAP repair or biceps tenodesis

BACKGROUND

Shoulder pain due to labral tears and biceps tendonitis is commonly found in softball players. Surgical options include labral repair and biceps tenodesis. Although past studies are limited by heterogeneous study groups from multiple sports, this is the first study that assesses clinical outcomes and return to play rates for fast-pitch softball players.

PURPOSE/HYPOTHESIS

The purpose of this study was to evaluate the clinical outcomes and return to play for fast-pitch softball players treated for a superior labrum anterior posterior (SLAP) tear and recalcitrant biceps tendonitis with a biceps tenodesis compared with a traditional SLAP repair. We hypothesized that the biceps tenodesis would have comparable outcomes with a faster return to play compared with SLAP repair.

METHODS

We performed a retrospective analysis on fast-pitch softball players treated surgically for SLAP tear, recalcitrant biceps tendonitis, or a combination between 2001 and 2019 at our institution. Inclusion criteria were fast-pitch softball players who underwent biceps tenodesis or a SLAP repair with greater than 2-year follow-up. Exclusion criteria involved slow-pitch softball players, patients with less than 2-year follow-up, and patients who had undergone concomitant procedures on the ipsilateral shoulder at the time of SLAP repair or biceps tenodesis. Follow-up was either self-reported through OBERD, a patient-reported outcomes (PRO)-managing software, or achieved over the phone. Follow-up data included American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, Andrews Carson Score, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score, Numeric Rating Scale for Pain, and our institution-specific return-to-play questionnaire. We statistically compared players who underwent biceps tenodesis or a SLAP repair, and compared pitchers with position players using Student t tests and Fisher exact test with statistical significance determined to be P < .05.

RESULTS

From 60 eligible patients identified, follow-up outcome data were successfully captured for 47 (78%). Of the 18 SLAP repair patients, 17 (94%) returned to full competition at an average of 7.9 months. Of the 29 patients who underwent biceps tenodesis, 27 (93%) returned to full competition at an average of 7.1 months. Statistical analysis of PRO scores for each group found no significant differences between any of the measures used to evaluate patient outcomes, including no statistical difference in pitchers compared with position players.

CONCLUSION

In conclusion, this study demonstrated comparable outcomes between SLAP repairs and biceps tenodesis procedures among our study group of fast-pitch softball players. There was no significant difference between RTP times between the 2 groups.

Perioperative Opioid Analgesics and Hallux Valgus Correction Surgery: Trends, Risk Factors for Prolonged Use and Complications

In the setting of an opioid epidemic, this study aims to provide evidence on opioid use trends, risk factors for prolonged use, and complications from perioperative opioid consumption in hallux valgus surgery. A national database was queried for patients who underwent hallux valgus correction. Regression analysis identified: (1) risk factors for prolonged postoperative narcotic use; and (2) association between preoperative/prolonged postoperative narcotic use and postoperative complications. A linear regression analysis was used to determine trends. About 20,749 patients were included, of which 3464 patients were prescribed narcotics preoperatively and 4339 were identified as prolonged postoperative narcotic prescription users. Preoperative prescriptions were identified as risk factors for prolonged use. Perioperative narcotic use was observed to be a risk factor for poor outcomes. About 21% of patients were identified as prolonged postoperative narcotic prescription users. Patients undergoing hallux valgus corrective surgery should be counseled regarding their increased risk of complications when using narcotics.

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.

Lower Reoperation and Higher Return-to-Sport Rates After Biceps Tenodesis Versus SLAP Repair in Young Patients: A Systematic Review

Purpose

To evaluate patient-reported outcomes, return to sport, and adverse events after SLAP repair versus biceps tenodesis (BT) in a young patient population undergoing treatment of SLAP tears.

Methods

We performed a systematic review and meta-analysis of the PubMed (MEDLINE), Scopus, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science databases for comparative studies discussing outcomes after SLAP repair and BT in patients younger than 40 years with at least 1 year of follow-up.

Results

Four studies were included, comprising a total of 274 patients who underwent treatment of SLAP tears with SLAP repair (169 patients) or BT (105 patients). Most patients were male patients (79.8%) and athletes (74.5%). Preoperative and postoperative pain visual analog scale scores decreased similarly in both groups (range, 6.6-6.7 preoperatively to 0.8-2.6 postoperatively in SLAP repair group vs 5.6-7.3 preoperatively to 0.7-1.9 postoperatively in BT group). Similar and substantial American Shoulder and Elbow Surgeons Standardized Shoulder Assessment score increases were observed after both procedures (range, 40.6-45.8 preoperatively to 75.4-92.0 postoperatively in SLAP repair vs 41.9-55.0 preoperatively to 85.7-91.2 postoperatively in BT group). Patient satisfaction rates were similar but showed slightly higher ranges after BT (8.5-8.8 vs 8.0-8.2). Rates of return to sport were higher after BT (63%-85% vs 50%-76%), with higher odds of returning to sport after BT reported by all studies. Surgical complications were rare after SLAP repair and BT. Rates of reoperation were substantially higher after SLAP repair (3%-15% vs 0%-6%), with 3 of 4 studies reporting no reoperations after BT. BT comprised 78% to 100% of reoperation procedures after SLAP repair.

Conclusions

Postoperative pain, function, and patient satisfaction were similar after SLAP repair and BT in patients younger than 40 years. There are higher rates of reoperation and lower rates of return to sport after SLAP repair than after BT.

Level of Evidence

Level III, systematic review of Level III studies.

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

PURPOSE

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).

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

LEVEL OF EVIDENCE

IV, cross-sectional study.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

Arthroscopic Rotator Cuff Repair Results in Lower Two-Year Reoperation Rates Compared With Open Rotator Cuff Repair in a Large Cross-sectional Cohort

PURPOSE

To use a large, contemporary database to perform a cross-sectional analysis of current practice trends in rotator cuff repair (RCR) for the treatment of full-thickness rotator cuff tear (RCT) and determine outcomes of arthroscopic and open RCR, including hospital readmissions and 2-year reoperation rates with accurate laterality tracking using International Classification of Diseases, Tenth Revision (ICD-10) codes.

METHODS

The PearlDiver Mariner dataset was used to query patients with full-thickness RCTs from 2010 to 2017. Propensity-score matching was performed to account for differences in age and comorbidities and allow for comparison between those undergoing open RCR and arthroscopic RCR. Subsequent procedures were tracked using ICD-10 codes to identify ipsilateral surgery within 2 years of index surgery. Hospital and emergency department admission within 30 days of surgery were investigated.

RESULTS

Of 534,076 patients diagnosed with full-thickness RCT, 37% underwent RCR; 73% of which were arthroscopic. From 2010 to 2017, arthroscopic RCRs increased from 65% to 80%, whereas open RCRs decreased from 35% to 20% (P < .0001). Younger patients underwent arthroscopic RCR more frequently, and patients who underwent open RCR had greater rates of 30-day emergency department (7.0%) and hospital readmission (2.0%) compared with arthroscopic RCR (6.3%, 1.0%, respectively) (P < .0001). For 24,392 patients with ICD-10 coding and 2-year follow-up, 10.4% of patients required reoperation, with the most common procedure being revision RCR, and 1.3% required conversion to arthroplasty. Open RCRs were more likely to require subsequent surgery (11.3%) compared with arthroscopic RCR (9.5%) (P < .0001). Patients aged 50 to 59 had the greatest rate of reoperation (14.0%), but no patients younger than age 40 years required reoperation, and no patients younger than age 50 years required conversion to arthroplasty.

CONCLUSIONS

The frequency of arthroscopic RCR has continued to increase compared to open RCR. In this large cross-sectional analysis, arthroscopic RCR demonstrated lower 2-year reoperation rates and 30-day readmission rates compared to open RCR.

LEVEL OF EVIDENCE

III, cross-sectional study.

Addressing Smoking in Musculoskeletal Specialty Care

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Physicians who advise patients to quit smoking substantially improve cessation rates, but cessation counseling is currently underperformed.

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Counseling, pharmacotherapy, and additional interventions can improve the chance of successful smoking cessation. Most patients require multiple attempts at quitting to be successful.

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A list of referral contacts and resources should be developed and routinely offered to these patients. The national Quitline (1-800-QUIT-NOW) provides free access to trained counselors and "quit coaches" for each state program in the United States.

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Government and private insurance plans in the United States are required (in most cases) to cover the cost of 2 quitting attempts per year including counseling referrals and medications.

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Several biopsychosocial factors that affect orthopaedic outcomes (weight, anxiety, depression, etc.) are also relevant to smoking cessation; management of these factors is thus potentially aggregately advantageous.

Isolated type II SLAP tears undergo reoperation more frequently

PURPOSE

There is discrepancy in the reported reoperation rate and factors associated with reoperation after type II SLAP repair. The aim was to determine the incidence and factors associated with unplanned reoperation and repair failure after type II SLAP repair.

METHODS

Five-hundred and thiry-nine patients with SLAP repairs were identified from 2005 to 2016. Patient characteristics were recorded and subgroup analyses performed. Multivariable logistic regression was used to identify factors independently associated with unplanned reoperation and SLAP repair failure.

RESULTS

Sixty-six of 539 patients (12%) had unplanned reoperation after SLAP repair. Additional procedures during SLAP repair were associated with fewer unplanned reoperations (OR 0.57; P = 0.046). Age < 40 was associated with unplanned reoperation (55% vs 40%; P = 0.032), but this was not an independent association. Forty-five of 539 patients (8.3%) had SLAP repair failure (defined by repeat SLAP repair or biceps tenodesis/tenotomy). Smoking (OR 3.1; P = 0.004) and knotless suture anchors (OR 3.4; P = 0.007) were associated with SLAP repair failure. Isolated SLAP repair was associated with SLAP repair failure (64% vs 46%; P = 0.020), but this was not an independent association. In those who did not have an isolated SLAP repair, knotless suture anchors (19% vs 3.4%; P = 0.024) were associated with repair failure.

CONCLUSION

After type II SLAP repair, roughly 1 in 10 patients may undergo reoperation. Isolated SLAP repair is independently associated with unplanned reoperation.

LEVEL OF EVIDENCE

Level III.

Biceps Tenodesis for Superior Labrum Anterior-Posterior Tear in the Overhead Athlete: A Systematic Review

BACKGROUND

Superior labrum anterior-posterior (SLAP) lesion is a common shoulder injury, particularly in overhead athletes. While surgical management has traditionally consisted of SLAP repair, high rates of revision and complications have led to alternative techniques, such as biceps tenodesis (BT). While BT is commonly reserved for older nonoverhead athletes, indications for its use have expanded in recent years.

PURPOSE

To determine functional outcomes and return-to-sport rates among overhead athletes after BT for SLAP tear.

STUDY DESIGN

Systematic review.

METHODS

A systematic review was performed for any articles published before July 2019. The search phrase "labral tear" was used to capture maximum results, followed by keyword inclusion of "SLAP tear" and "biceps tenodesis." Inclusion criteria included outcome studies of BT for isolated SLAP tear in athletes participating in any overhead sports, not limited to throwing alone. Abstracts and manuscripts were independently reviewed to determine eligibility. When clearly delineated, outcome variables from multiple studies were combined.

RESULTS

After full review, 8 articles met inclusion criteria (99 athletes; mean age, 19.8-47 years), with baseball and softball players the most common among them (n = 62). Type II SLAP tear was the most common diagnosis, and 0% to 44% of athletes had a failed previous SLAP repair before undergoing BT. Only 1 study included patients with concomitant rotator cuff repair. Open subpectoral BT was most commonly used, and complication rates ranged from 0% to 14%, with wound erythema, traumatic biceps tendon rupture, brachial plexus neurapraxia, and adhesive capsulitis being reported. Combined reported postoperative functional scores were as follows: American Shoulder and Elbow Surgeons, 81.7 to 97; 12-Item Short Form Health Survey physical, 50 to 54; visual analog scale for pain, 0.8-1.5; Kerlan Jobe Orthopaedic Clinic, 66 to 79; and satisfaction, 80% to 87%. The overall return-to-sports rate for overhead athletes was 70% (60 of 86). For studies that clearly delineated outcomes based on level of play/athlete, the combined return-to-sports rate was 69% (11 of 16) for recreational overhead athletes, 80% (4 of 5) for competitive/collegiate athletes, and 60% (18 of 30) for professionals.

CONCLUSION

BT in the overhead athlete offers encouraging functional outcomes and return-to-sports rates, particularly in the recreational athlete. It can be successfully performed as an index operation rather than SLAP repair, as well as in a younger patient population. Careful consideration should be given to elite overhead athletes, particularly pitchers, who tend to experience poorer outcomes.

Cost Comparison of Open and Arthroscopic Treatment Options for SLAP Tears

Purpose

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

Methods

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

Results

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

Conclusion

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

Level of Evidence

III, retrospective cohort study.

Management of Failed SLAP Repair: A Systematic Review

BACKGROUND

Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature.

QUESTIONS/PURPOSES

The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair.

METHODS

The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included.

RESULTS

A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery.

CONCLUSION

The most common reason for failed SLAP repair is persistent post-operative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.

Molecular Pattern and Density of Axons in the Long Head of the Biceps Tendon and the Superior Labrum

The type II superior labrum anterior to posterior (SLAP) repair is a viable option in young and demanding patients, although a prolonged period of pain after surgery is described in the literature. The reason for this fact remains unknown. Thus, the purpose of this study was to investigate the molecular pattern of the biceps tendon anchor, where the sutures for repair are placed. The long head of the biceps tendon (LHBT), including the superior labrum, was dissected in the setting of reverse total shoulder arthroplasty. Immunohistochemical staining was performed using neurofilament (NF) and protein gene product (PGP) 9.5 as general markers for axons and calcitonin gene-related peptide (CGRP) and substance P for nociceptive transmission. A quantitative assessment was performed according to the two regions of interest (ROIs), i.e., the anterosuperior (ROI I) and the posterosuperior labrum (ROI II). Eleven LHBTs with a mean age of 73 years (range: 66–87 years) were harvested intraoperatively. Six LHBTs were gained in osteoarthrosis and five in fractures. We found an inhomogeneous distribution of axons in the anterosuperior and posterosuperior parts of the labrum in all the specimens irrespective of the age, gender, and baseline situation. There was a significantly higher number (p < 0.01) as well as density (p < 0.001) of NF-positive axons in ROI I compared to ROI II. Nociceptive fibers were always found along the NF-positive axons. Thus, our results indicate that the biceps tendon anchor itself is a highly innervated region comprising different nerve qualities. The anterosuperior labrum contains a higher absolute number and density of axons compared to the posterosuperior parts. Furthermore, we were able to prove the presence of nociceptive fibers in the superior labrum. The results obtained in this study could contribute to the variability of pain after SLAP repair.

Labral Repair Versus Biceps Tenodesis for Primary Surgical Management of Type II Superior Labrum Anterior to Posterior Tears: A Systematic Review

PURPOSE

To examine the outcomes of SLAP repair versus biceps tenodesis (BT) for the index treatment of isolated type II SLAP tears.

METHODS

A search of PubMed, MEDLINE, and EMBASE was performed in April 2018 for English-language studies that presented outcomes data on patients with isolated type II SLAP tears treated with either SLAP repair or BT at the primary surgical time point.

RESULTS

Twenty-three studies (i.e., 2 randomized control trials, 7 retrospective cohort, 3 prospective cohort, 4 case-control, and 7 case series) were included. Isolated type II SLAP tears were treated via SLAP repair in 781 patients with a mean age of 35 years (range, 22-58 years) and a mean postoperative follow-up of 35 months (range, 3-63 months). BT was performed in 100 patients with a mean age of 44 years (range, 18-64 years) and a mean postoperative follow-up of 32 months (range, 24-75 months). Similar postoperative scores were noted in both the SLAP repair and BT groups for American Shoulder and Elbow Surgeons, Constant, University of California, Los Angeles, and visual analog scale pain scores. The rate of return to sports was 20% to 95% for SLAP repair and 73% to 100% for BT. Reoperation rates for SLAP repair and BT were 2.9% to 40% and 0% to 15.3%, respectively.

CONCLUSIONS

This study suggests that SLAP repair and BT are both acceptable as index treatment for isolated type II SLAP tears. SLAP repair remains the most commonly performed index procedure; however, BT appears equally efficacious and may represent an attractive alternative.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Injuries of the Biceps and Superior Labral Complex in Overhead Athletes

PURPOSE OF REVIEW

To summarize the current anatomy, biomechanics, presentation, treatment, and outcomes of injuries to the biceps and superior labral complex in overhead athletes.

RECENT FINDINGS

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 40 years 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 40 years 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 (r² = 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 (r² = 0.882, P < .001). BT for the diagnosis of an isolated SLAP tear increased by 370.0% over the same period (r² = 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.

Effect of Anterior Anchor on Clinical Outcomes of Type II SLAP Repairs in an Active Population

This study evaluated the role of anchor position in persistence of pain and/or revision biceps tenodesis after arthroscopic repair of type II superior labrum anterior and posterior (SLAP) lesions and assessed for patient- and injury-specific variables influencing clinical outcomes. Active-duty service members who underwent arthroscopic repair of type II SLAP lesions between March 1, 2007, and January 23, 2012, were identified. Patients with less than 2-year clinical follow-up; type I, III, and IV SLAP lesions; and primary treatment with biceps tenodesis and/or rotator cuff repair at the time of index surgery were excluded. Demographic, preoperative, and operative variables, including anchor positions, were reviewed and evaluated for association with outcomes. Total failure rate (defined as either surgical and/or clinical failure), anchor position, and return to military function were the primary outcomes of interest. Forty-nine patients underwent type II SLAP repairs with a mean follow-up of 52.3 months. Forty-eight (97.9%) were men, and mean age was 35.2 years. Eleven patients (22%) underwent subsequent subpectoral biceps tenodesis. Forty patients (82%) returned to military function, whereas 9 patients (18%) had medical discharge for significant, rate-limiting, shoulder pain. Age was a significant predictor of surgical failure. Patients with anchor position anterior to the biceps attachment had no increased risk of clinical or surgical failure compared with patients with only posterior-based anchors. Anchor placement anterior to the biceps tendon was not associated with inferior outcomes. Younger age was shown to be a poor prognostic factor in patients' ability to return to active duty. Revision with biceps tenodesis showed significant utility in achieving good clinical outcomes and return to duty in more than 90% of patients. Patient-, injury-, and surgery-specific variables need to be identified as prognostic indicators so that clinical outcomes can continue to be improved. [Orthopedics. 2019; 42(1):e32-e38.].

An Age and Activity Algorithm for Treatment of Type II SLAP Tears

Background

Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy.

Objective

To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level.

Methods

A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm.

Results

Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis.

Conclusion

Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

Treatment for Symptomatic SLAP Tears in Middle-Aged Patients Comparing Repair, Biceps Tenodesis, and Nonoperative Approaches: A Cost-Effectiveness Analysis

PURPOSE

To evaluate the cost-effectiveness of nonoperative management, primary SLAP repair, and primary biceps tenodesis for the treatment of symptomatic isolated type II SLAP tear.

METHODS

A microsimulation Markov model was constructed to compare 3 strategies for middle-aged patients with symptomatic type II SLAP tears: SLAP repair, biceps tenodesis, or nonoperative management. A failed 6-month trial of nonoperative treatment was assumed. The principal outcome measure was the incremental cost-effectiveness ratio in 2017 U.S. dollars using a societal perspective over a 10-year time horizon. Treatment effectiveness was expressed in quality-adjusted life-years (QALY). Model results were compared with estimates from the published literature and were subjected to sensitivity analyses to evaluate robustness.

RESULTS

Primary biceps tenodesis compared with SLAP repair conferred an increased effectiveness of 0.06 QALY with cost savings of $1,766. Compared with nonoperative treatment, both biceps tenodesis and SLAP repair were cost-effective (incremental cost-effectiveness ratio values of $3,344/QALY gained and $4,289/QALY gained, respectively). Sensitivity analysis showed that biceps tenodesis was the preferred strategy in most simulations (52%); however, for SLAP repair to become cost-effective over biceps tenodesis, its probability of failure would have to be lower than 2.7% or the cost of biceps tenodesis would have to be higher than $14,644.

CONCLUSIONS

When compared with primary SLAP repair and nonoperative treatment, primary biceps tenodesis is the most cost-effective treatment strategy for type II SLAP tears in middle-aged patients. Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair.

LEVEL OF EVIDENCE

Level III, economic decision analysis.