Arthroscopic treatment of glenoid labral tears

Location of Shoulder Glenoid Labral Tears: A Study of 1763 Consecutive Patients

BACKGROUND

Anterior shoulder labral tearing has historically been considered the most common location of shoulder labral pathology. Recently, smaller studies have reported that posterior labral involvement may be more common than previously recognized.

PURPOSE

To examine the location of surgically repaired labral tears by a single surgeon over a consecutive 23-year period.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 1763 consecutive patients who underwent arthroscopic or open shoulder labral repair by a single seniorsports medicine fellowship-trained orthopaedic surgeon between April 2000 and April 2023 were retrospectively reviewed. Current Procedural Terminology codes were used to identify patients, which included 29806, 29807, 29822, and 29823. Exclusion criteria included isolated shoulder manipulation or glenohumeral joint or labral debridement that did not include repair. Intraoperative glenoid labral tears observed were categorized into 7 broad categories: (1) anterior labral tears, (2) posterior labral tears, (3) superior labral anterior posterior (SLAP) type II tears (A, B, or C), (4) SLAP type V tears, (5) SLAP type VIII tears, or (6) circumferential labral tears (combined SLAP, anterior, and posterior labral tear). Shoulders diagnosed with multiple tear patterns (ie, anterior and posterior) were also noted.

RESULTS

During the 23-year period, 1763 patients underwent arthroscopic or open labral repair; they included 1295 male and 468 female patients, ranging in age from 12 to 70 years, with a mean age of 23.2 years and median age of 19 years. Overall, 28.4% of tears involved the anterior labrum, 64.9% involved the posterior labrum, and 59.6% involved the superior labrum. Regarding isolated tears, 9.3% were isolated anterior labral tears, 19.7% were isolated posterior labral tears, 11.5% involved the anterior and posterior labrum, 22.2% were isolated superior (SLAP type II-IV) tears, 3.63% were isolated SLAP type V tears, 29.8% were isolated SLAP type VIII tears, and 4.1% were circumferential tears.

CONCLUSION

Posterior shoulder labral tearing was more common than anterior tearing in a large consecutive series of 1763 patients who underwent surgical repair. This highlights the importance of posterior labral pathology, which sometimes may be overlooked because of more vague complaints, with pain and loss of function being the most common.

Variability of glenoid labral tear patterns: a study of 280 sequential surgical cases

BACKGROUND

Glenoid labrum tears are a common cause of shoulder pain and instability and tear patterns have historically been ascribed into categorical descriptions such as anterior, posterior, and superior labral tears (SLAP [superior labrum anterior and posterior]) with multiple subtypes. Although often quoted as representing no more than 10% of instabilities, posterior shoulder instability may be more common than previously recognized. The purpose of this study was to review observed labral tear patterns and compare incidence and morphologies to historical descriptions.

METHODS

All patients undergoing arthroscopic or open labral repair (Current Procedural Terminology codes 29806, 29807, 23455, 23460, 23462, 23465) by 2 fellowship-trained shoulder surgeons from July 2012 to May 2019 were retrospectively reviewed. Labral tears were categorized into 3 groups: exclusively anterior to the midline of the glenoid, exclusively posterior, and those crossing the midline of the glenoid. Chief complaint, mechanism of injury, hand dominance, preoperative MRI interpretation by surgeon, and independent radiologist were analyzed for each tear type.

RESULTS

During the 7-year period, 280 patients underwent arthroscopic or open labral repair. Sixty percent of tears were traumatic, with dislocation being the most common traumatic mechanism at 31.4%. Ten distinct tear patterns were identified: 3 types of 90° tears (anteroinferior, posteroinferior, and posterosuperior), 4 types of 180° tears (anterior, posterior, inferior, and SLAP), 2 types of 270° tears (anteroinferior and anterosuperior), and 360° labral tears. A total of 134 tears (47.9%) were classified as posterior, and 72 tears (25.7%) were anterior. Seventy-four tears (26.4%) were combined anterior-posterior tears. Labral tears involving some portion of the posterior labrum constituted 74% of tears. A significant association between tear location and primary complaint (P < .001) was noted. Patients with anterior tears complained of only instability in 62.5% of cases, and only pain in 22%. Patients with posterior labral tears complained primarily of pain in 68% of cases, and instability in 21%. There was an accurate preoperative diagnosis given by both radiologists and surgeons on 30% (n = 63) of the tears.

CONCLUSION

There is a wide variety of labral tear patterns identified at the time of surgery, and the incidence of posterior labral tears is higher than previously described. Isolated Bankart lesions are relatively rare and are often associated with more extensive labral lesions. Patients with posterior labral pathology more often complain of pain rather than instability, whereas patients with anterior labral tears more often complain of instability.

Common animal models lack a distinct glenoid labrum: a comparative anatomy study

Purpose

Development and validation of an animal model of labral healing would facilitate translation of novel surgical and biological strategies to improve glenolabral healing. The purpose of this study was to characterize the anatomic and histological properties of the shoulder labrum in rat, rabbit, dog, pig, goat, and humans. Given the demonstrated similarities in size and structural morphology in other joints, it was hypothesized that the goat glenoid with surrounding capsulolabral complex would most closely resemble that of humans in terms of dimensions and structure, as observed grossly and histologically.

Methods

Cadaveric glenohumeral joints from rats (n = 8), New Zealand white rabbits (n = 13), Mongrel dogs (n = 9), Spanish goats (n = 10), Yorkshire pigs (n = 10), and humans (n = 9) were freshly harvested. Photographs were taken of the glenoid with its surrounding capsulolabral complex. Linear dimensions of the glenoid articular surface were measured. It was determined where the capsulolabral complex was continuous with, or recessed from, the articular glenoid surface. The glenoid was divided into 6 equal segments radiating out toward 12, 2, 4, 6, 8, and 10 o’clock positions. Samples were sectioned and stained with Safranin O/Fast green and Mallory Trichrome. Insertion of the capsulolabral tissue onto the glenoid was qualitatively assessed and compared with gross morphology.

Results

Dimensions of the goat glenoid most closely paralleled dimensions of the human glenoid. A capsulolabral complex was continuous with the glenoid surface from ~ 9 to 12 o’clock in the rats, 7 to 12 o’clock in rabbits, 5 to 12 o’clock in the dogs, and 9 to 12 o’clock in goats, 6 to 12 o’clock in pigs, and 2 to 8 o’clock in humans. In contrast to humans, no other species demonstrated an organized fibrocartilaginous labrum either macroscopically or histologically.

Conclusion

The animals in the present study did not possess a discrete fibrocartilaginous labrum by gross or histological evaluation, as directly compared to humans. While models using these animals may be acceptable for examining other shoulder pathologies, they are not adequate to evaluate labral pathology.

Level of evidence

Basic Science Study; Anatomy and Histology; Cadaveric Animal Model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-021-00383-6.

The 50 Most-Cited Papers on Bankart Lesions

Purpose

To analyze the 50 most-cited articles pertaining to “Bankart lesions,” also known as anteroinferior labral tears, by means of citation analysis as well as to provide analysis and summary of the origins and trends of research on Bankart lesions.

Methods

Scopus was used to query the literature on Bankart lesions. Included articles were related to Bankart lesions and the indications, risk factors, techniques, and outcomes of arthroscopic and open Bankart repair. The 50 most-cited articles were analyzed in the following areas: year of publication, citations in the most recent year, total citation count, contributing authors, institutions, countries, and journals, article classifications, and level of evidence.

Results

Years of publication ranged from 1938 to 2013. There were 608 total citations in the most recent year. Total citation count was 12,441. Regarding country, journal, and authorship, United States, R. A. Arciero, and Arthroscopy were the highest respective contributors. Rush University had the greatest number of publications. The most common article classification was clinical outcomes. Of 49 clinical articles, the most frequent Level of Evidence was IV. The majority of the top 50 Bankart literature consisted of case series and retrospective studies performed in the United States.

Conclusions

Our findings are consistent with the hypothesis that the 50 most-cited articles about Bankart lesions are predominantly U.S.-based, produced by academic orthopaedic groups, clinical outcomes articles, and of Level IV and V evidence. This list of articles should serve as a reference tool for any orthopaedist looking to review Bankart literature.

The majority of patients return to athletic activity following biceps tenodesis

PURPOSE

Biceps tenodesis is widely used as a primary treatment for long head of the biceps brachii pathology and superior labral anterior and posterior (SLAP) lesions. However, rates and timing of full return to sports (RTSs)/duty have not been systematically analysed. This systematic review examines the literature to ascertain the rate and timing of return to athletic activity, and the availability of specific criteria for safe return to atheletic activity following the biceps tenodesis.

METHODS

Based on PRISMA guidelines, this systematic review utilised the EMBASE, MEDLINE, and The Cochrane Library Databases. Eligible for inclusion were clinical studies reporting on return to athletic activity following biceps tenodesis. Statistical analysis was performed using SPSS.

RESULTS

This review identified 17 studies including 374 cases meeting the inclusion criteria. The majority of patients were men 260 (69.7%), with an median age of 42.2 years (range 16-88) and a mean follow-up of 37.4 months. The overall rate of RTS was 217/269 (80.7%), with 43/59 (72.9%) returning to the same level. In overhead athletes, the overall rate of return to play was 39/49 (79.6%). Among military personnel, the overall rate of return to duty was 61/74 (82.4%). The average time to RTS was 5.4 (range 3-11) months. 10 (58.8%) Studies reported a recommended time window within which patients were allowed to return to full activity. Specific criteria for return to play were not reported in any of the identified studies.

CONCLUSION

While overall rate of return to athletic activity was reportedly high following biceps tenodesis, one in four patients were not able to resume athletic activity at the same level. At present, there is no objective assessment of when patients can return to full activity reported in the literature.

LEVEL OF EVIDENCE

IV.

Return to Play After Biceps Tenodesis and Transfer in a Young, Athletic Population

The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis and transfer. The authors hypothesized that both return to play rates and clinical improvement would be high after biceps tenodesis and transfer among young athletes. They conducted a retrospective review of patients who underwent biceps tenodesis and transfer procedures with a minimum follow-up of 24 months. Eligible patients were contacted for consent and asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores, level of postoperative play, and other relevant information. The study included 41 patients with a mean age of 21.3 years. Patients reported a mean Kerlan-Jobe Orthopaedic Clinic (KJOC) score of 71.7, Disabilities of the Arm, Shoulder and Hand (DASH)-Sports score of 21.3, Single Assessment Numeric Evaluation (SANE) score of 79.4, and Numeric Rating Scale (NRS) pain score of 1.8. Scores for all patient-reported outcome measures were statistically better (P<.05) for patients who underwent biceps transfer (n=24) compared with biceps tenodesis (n=17). Of the participants, 26 (63%) played a primary overhead throwing sport. Most of the patients (95%) returned to play, and of those who returned to play, 67% returned to their preoperative level or higher. Although biceps tenodesis and transfer procedures have been designated primarily for older patients with biceps-labral complex injuries, the high return to play rates and outcome scores of patients in this case series show that biceps tenodesis and transfer can provide effective surgical treatment for a younger athletic population with biceps-labral complex injuries. [Orthopedics. 2021;44(1):e13-e18.].

Rates of Subsequent Shoulder Surgery Within Three Years for Patients Undergoing SLAP Repair Versus Biceps Tenodesis

Purpose

To investigate the demographics of patients for whom SLAP repair or biceps tenodesis was performed, as well as to compare rates of additional shoulder surgery for these 2 procedures within 3 years postoperatively.

Methods

Using the MarketScan Commercial Database, we examined all patients with SLAP tear who underwent arthroscopic SLAP repair or open or arthroscopic biceps tenodesis within the encompassed time period (2003-2014). Rates of repeat shoulder surgery within 3 years were evaluated, as were comparative demographics.

Results

In total, 25,142 patients initially underwent SLAP repair, of whom 11.5% had subsequent shoulder surgery within 3 years. A total of 840 patients initially underwent biceps tenodesis as treatment for a SLAP tear, of whom 13.0% underwent additional shoulder surgery within 3 years. Rates of subsequent shoulder surgery between the 2 procedural groups did not statistically differ (P = .19). Patients who underwent SLAP repair were younger than those who underwent tenodesis (mean age 38.3 vs 49.3 years, P < .01). For patients requiring additional surgery, the SLAP repair group had a greater representation of those ≥35 years old, whereas the tenodesis group had a greater representation of those <35 years old (P < .01). Male patients experienced an increase in rate of subsequent shoulder surgery when initially undergoing tenodesis versus SLAP repair (13.3% vs 11.1%, P < .01).

Conclusions

The rates of additional shoulder surgery for patients undergoing SLAP repair and biceps tenodesis were similar within 3 years of the index procedure. Patients who underwent SLAP repair were younger than those who underwent tenodesis. Of those requiring additional surgery, patients initially treated with SLAP repair were older (≥35 years) and those treated with tenodesis were younger (<35 years). Male patients experienced an increase in rate of subsequent shoulder surgery when initially treated with tenodesis versus SLAP repair.

Level of Evidence

III, retrospective comparative study.

Arthroscopic Circumferential Labral Repair for Patients With Multidirectional Instability: A Comparative Outcome Study

Background:

Circumferential tears of the glenohumeral labrum are an uncommon injury, comprising 2.4% of all labral lesions. Currently, the clinical outcomes of arthroscopic circumferential labral repair for patients with instability and combined anterior, posterior, and superior labral tears are not well-known.

Hypothesis:

Patients treated with arthroscopic circumferential shoulder labral repairs will have inferior clinical outcomes and higher failure rates compared with patients who have isolated arthroscopic anterior labral repairs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was performed to identify patients aged 18 years and older who underwent circumferential arthroscopic stabilization for recurrent instability as compared with an age-matched control group of arthroscopic primary anterior labral repairs. Age at surgery, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, Simple Shoulder Test (SST) score, 12-Item Short Form Health Survey (SF-12) score (mental and physical), and overall patient satisfaction with surgery were assessed for each group.

Results:

A total of 35 consecutive patients (36 shoulders) who underwent an arthroscopic 360° circumferential labral repair were compared with a matched group of 31 patients who underwent an isolated arthroscopic anterior labral repair. The mean follow-up period was 34.3 and 56.8 months, respectively. No significant difference was found between the 2 groups for overall satisfaction with the surgery or recurrent instability. At the time of the follow-up survey, 22% of the patients experienced pain and 25% of the patients experienced instability in the circumferential repair group, whereas 15% of the patients experienced some level of pain and 30% of patients experienced a subjective sense of subtle instability in the isolated repair group. The ASES scores were 87.3 in the combined labral repair group and 93.3 in the isolated anterior group (P = .35), SST scores were 10.7 and 11.3 (P = .70), SF-12 mental scores were 54.6 and 56.8 (P = .80), SF-12 physical scores were 53.2 and 54.2 (P = .98), and age at time of the surgery was 26.7 and 24.6 years (P = .33), respectively. There was no difference between the 2 groups in pre- and postoperative range of motion (P > .05).

Conclusion:

There was no difference in shoulder stability and function in patients after 360° combined labral repairs versus anterior labral repair alone. With proper patient selection, patients can expect similar outcomes despite the more extensive surgical procedure and complex postoperative rehabilitation protocol for circumferential repairs.

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

Introduction:

Optimal treatment of type II superior labrum anterior and posterior (SLAP) tears is controversial. There has been a recent trend towards biceps tenodesis over SLAP repair in older patients. Few surgeons have performed combined biceps tenodesis and SLAP repair with inferior results.

Case Report:

This case describes a 46-year-old patient who had persistent pain and stiffness after combined biceps tenodesis and SLAP repair for a type II SLAP tear. His pain and motion improved after arthroscopic superior capsular release.

Conclusion:

Failed SLAP repair is often multifactorial and a thorough workup is needed. Combined biceps tenodesis and SLAP repair can cause pain, stiffness, and dysfunction which can be successfully treated with arthroscopic superior capsular release.

Arthroscopic Knot Removal for Failed Superior Labrum Anterior-Posterior Repair Secondary to Knot-Induced Pain

BACKGROUND

Studies on failed superior labrum anterior-posterior (SLAP) repair are increasing. However, the number of reports on treatment options for failed SLAP repair remains quite low, and the clinical results vary between different study groups.

PURPOSE

To describe the clinical presentation of failed SLAP repair due to knot-induced pain and evaluate the efficacy of arthroscopic knot removal.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The authors retrospectively reviewed records of 11 patients (mean age, 24.6 ± 8.6 years; range, 17-43 years) with stable, healed SLAP lesions with knot-induced pain after arthroscopic fixation of unstable type II SLAP lesions. All patients demonstrated a positive compression-rotation test before knot removal. The mean follow-up duration after knot removal was 48.0 ± 37.4 months (range, 24-156 months). The mean duration between primary fixation and knot removal was 21.2 ± 14.7 months (range, 8-56 months).

RESULTS

Sharp pain (100%) and clicking (64%) were the most common symptoms. The knot was positioned on the glenoid side in 5 patients and the labral side in 6 patients. The knots on the glenoid side had associated humeral head cartilage damage. The mean University of California at Los Angeles score significantly improved from 15.2 points to 31.7 points after knot removal ( P = .003) Additionally, the mean Constant score greatly improved from a mean of 56.5 points to 89.8 points ( P = .003). At a mean of 3 weeks after surgery, we observed dramatic pain relief. Six weeks after surgery, the compression-rotation test was negative in all patients.

CONCLUSION

The most common symptom of knot-induced pain after SLAP repair was persistent sharp pain followed by clicking. The knot appears to be a cause of pain in failed SLAP repairs, and arthroscopic knot removal can provide dramatic pain relief and significant improvement of clinical outcomes.

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

BACKGROUND

Data regarding risk factors for revision surgery after superior labral anterior-posterior (SLAP) repair are limited to institutional series.

PURPOSE

To define risk factors for revision surgery after SLAP repair among patients in a large national database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A national insurance database was queried for patients undergoing arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) for the diagnosis of a SLAP tear. Patients without a CPT modifier for laterality were excluded. Revision surgery was defined as (1) subsequent ipsilateral SLAP repair (CPT 29807), (2) ipsilateral arthroscopic debridement for the diagnosis of a SLAP tear (CPT 29822 or 29823, with diagnosis code 840.7), (3) subsequent ipsilateral arthroscopic biceps tenodesis (CPT 29828), (4) subsequent ipsilateral open biceps tenodesis (CPT 23430), and (5) subsequent biceps tenotomy (CPT 23405). Multivariable binomial logistic regression analysis was performed to identify risk factors for revision surgery after SLAP repair, including patient demographics/comorbidities, concomitant diagnoses, and concomitant procedures performed. Odds ratios (ORs), 95% CIs, and P values were calculated. The estimated financial impact of revision surgery was also calculated.

RESULTS

There were 4751 patients who met inclusion and exclusion criteria. Overall, 121 patients (2.5%) required revision surgery after SLAP repair. Regression analysis identified numerous risk factors for revision surgery, including age >40 years (OR, 1.5; 95% CI, 1.2-1.8; P = .045), female sex (OR, 1.5; 95% CI, 1.3-1.8; P = .010), obesity (OR, 1.8; 95% CI, 1.5-2.2; P = .001), smoking (OR, 2.0; 95% CI, 1.6-2.4; P < .0001), and diagnosis of biceps tendinitis (OR, 3.5; 95% CI, 3.0-4.2; P < .0001) or long head of the biceps tearing (OR, 5.1; 95% CI, 4.1-6.3; P < .0001) at or before the time of surgery. Concomitant rotator cuff repair and distal clavicle excision were not significant risk factors for revision surgery. The cost of revision surgery averaged almost $9000.

CONCLUSION

Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery. The high cost of revision surgery highlights the importance of appropriate indications to avoid the need for subsequent procedures.

SLAP lesions: a treatment algorithm

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors' clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from "true" SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.

Slap Lesions in Middle-aged Patients: Biceps Repair or Tenodesis? What Should We Perform for Long Biceps Tendon?

Background/Purpose

Superior labrum anterior and posterior (SLAP) lesion repair poses a significant discussion due to its high failure rate. The purpose of this study was to determine in which indications it is better to perform a tenodesis than a straight anatomical repair. The hypothesis was that in middle-aged patients and in those who did not suffer from a traumatic lesion, it is better to perform a long biceps tendon (LBT) tenodesis than a straight anatomical repair.

Methods

A total of 22 patients between the ages of 19 years and 55 years who underwent SLAP lesion repair between 2007 and 2011 were reviewed. The cases were divided into the following two groups: those with an isolated SLAP lesion (15 patients) and those with both a SLAP and a Bankart lesion (7 patients). This was a level IV longitudinal and retrospective study.

Results

Eight patients had persistent postoperative pain, which required to be revised from an anatomical repair to an LBT tenodesis. All of these patients were in the isolated SLAP lesion group. The average time between primary surgery and revision was 21.6 months. Patients over the age of 45 years had significantly poorer results after the repair.

Conclusion

Biceps tenodesis is a feasible therapeutic alternative to anatomical repair for the treatment of SLAP lesions in middle-aged patients; the reinsertion failure rates for this type of lesion are rather discouraging due to the high percentage of revision surgeries that must be carried out after the primary intervention.

Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards

Surgical treatment of superior labral anterior posterior (SLAP) lesion becomes more and more frequent which is the consequence of evolving progress in both, imaging and surgical technique as well as implants. The first classification of SLAP lesions was described in 1990, a subdivision in four types existed. The rising comprehension of pathology and pathophysiology in SLAP lesions contributed to increase the types in SLAP classification to ten. Concerning the causative mechanism of SLAP lesions, acute trauma has to be differed from chronic degeneration. Overhead athletes tend to develop a glenohumeral internal rotation deficit which forms the basis for two controversial discussed potential mechanisms of pathophysiology in SLAP lesions: Internal impingement and peel-back mechanism. Clinical examination often remains unspecific whereas soft tissue imaging such as direct or indirect magnetic resonance arthrography has technically improved and is regarded to be indispensable in detection of SLAP lesions. Concomitant pathologies as Bankart lesions, rotator cuff tears or perilabral cysts should be taken into consideration when planning a personalized therapeutic strategy. In addition, normal variants such as sublabral recess, sublabral hole, Buford complex and other less common variants have to be distinguished. The most frequent SLAP type II needs a sophisticated approach when surgical teatment comes into consideration. While SLAP repair is considered to be the standard operative option, overhead athletes benefit from a biceps tenodesis because improved patient-reported satisfaction and higher rate of return to pre-injury level of sports has been reported.

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

BACKGROUND

Injuries to the superior glenoid labrum represent a significant cause of shoulder pain among active patients. The physical requirements of military service may contribute to an increased risk of injury. Limited data are available regarding the success of superior labral anterior posterior (SLAP) repairs in an active military population.

PURPOSE

To quantify the rate of clinical failure and surgical revision after isolated and combined SLAP repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All consecutive active-duty servicemembers undergoing arthroscopic repair of type II SLAP lesions at a single institution between 2006 and 2012 were identified. Patients with less than 2-year clinical follow-up and nonmilitary status were excluded. Demographic variables, surgical variables, and occupational outcomes were extracted from electronic medical records and confirmed with the US Army Physical Disability Agency database. Failure was defined as subsequent revision surgery or medical discharge with persistent shoulder complaints.

RESULTS

A total of 192 patients with SLAP repair were identified with a mean follow-up of 50.0 months (SD, 17.0 months). Isolated SLAP repair occurred in 31.3% (n = 60) versus 68.8% (n = 132) with concomitant procedures. At final follow-up, 37.0% (n = 71) of patients reported some subjective activity-related shoulder pain. Postoperative return to duty occurred in 79.6% (n = 153), and only 20.3% (n = 39) were discharged with continuing shoulder disability. The combined rotator cuff repair (96%; P = .023) and anteroinferior labral repair group (88%; P = .056) had a higher rate of functional return than isolated SLAP repair (70%). Thirty-one (16.1%) patients were classified as surgical failure and required revision. Of these, the majority of patients undergoing biceps tenodesis (76%) returned to active duty, as compared with revision SLAP repair (17%). Lower demand occupation and the presence of combined shoulder injuries (P = .011 and .016, respectively) were significantly associated with a lower risk of medical discharge and revision surgery, respectively.

CONCLUSION

Favorable outcomes can be anticipated in the majority of military servicemembers after arthroscopic SLAP repair, particularly with combined shoulder injuries. Revision surgery occurred in 16% of patients after primary SLAP repair.

CLINICAL RELEVANCE

Isolated repair of unstable SLAP lesions and/or increased upper extremity demands are associated with higher failure rates in this population.

Disorders of the proximal and distal aspects of the biceps muscle

PROXIMAL ASPECT OF BICEPS: Tenodesis of the long head of the biceps may offer improved cosmesis, improved strength, and diminished activity-related pain compared with tenotomy, although comparative studies have shown similar outcomes in some patient populations. DISTAL ASPECT OF BICEPS: Operative treatment of both partial and complete distal biceps ruptures results in better outcomes compared with nonoperative care, although the optimal technique and fixation are yet to be determined. Nonoperative management is an acceptable treatment for patients willing to accept some loss of forearm supination and elbow flexion strength as well as changes in endurance and cosmesis.

Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes

BACKGROUND

Although there are multiple reports on surgical outcomes of type 2 superior labral anterior posterior (SLAP) repairs, a literature review noted a paucity of data on clinical and radiological outcomes in elite overhead athletes.

PURPOSE

To determine midterm clinical outcomes of type 2 SLAP repairs in elite overhead athletes and whether labral integrity provides consistent return to play.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Medical records were retrospectively reviewed of 24 elite overhead athletes who underwent arthroscopic type 2 SLAP repairs. There were 18 men and 6 women, and their mean age was 22.7 years (range, 19-30 years); the majority of them (16/24) were baseball players. Four outcome measures were used: visual analog scale (VAS) for pain and satisfaction, American Shoulder and Elbow Surgeons (ASES) score, subjective feeling of recovery, and return to play. Multidetector computed tomographic arthrography was performed to evaluate labral integrity after surgery.

RESULTS

At a mean follow-up of 45.8 months (range, 24-68 months), overall pain and function improved significantly. The VAS for pain was 5.7 preoperatively and 2.0 postoperatively (P < .01), and VAS for satisfaction was 8.6. The ASES score was 55.8 preoperatively and 87.1 postoperatively (P < .01). The overall mean value of subjective feeling of recovery was approximately 76%. Twelve of 24 athletes (50%) returned to play after the operation. Although there was a trend toward higher return rate in the other overhead athletes (75%) compared with the baseball players (38%), this trend did not reach statistical significance (P = .097). Labral retear with clinical significance was noted in 2 athletes who failed to return to play. Osteolysis was observed in 2 athletes, 1 of whom had a retear. A statistical relation between the integrity of the repair and return to play was not found (P > .05).

CONCLUSION

Arthroscopic SLAP repairs show favorable clinical and radiological outcomes; however, the study findings raise a concern that return to play may still be problematic in elite baseball players. This study also indicates that labral healing does not ensure consistent return to play in elite overhead athletes.

Suture anchors or transglenoidal sutures for arthroscopic repair of isolated SLAP-2 lesions? A matched-pair comparison of functional outcome and return to sports

PURPOSE

Presumably, the technique of SLAP refixation has significant influence on outcome. This study analyzes and compares functional outcome and return to sports after arthroscopic suture anchor (SA) and arthroscopic transglenoidal suture (TS) repair of isolated SLAP-2 lesions.

METHODS

Twenty-four competitive amateur athletes constituted the two treatment groups of this retrospective matched-pair analysis. In the SA group (n = 12), the mean age was 39.1 years (±12.0) and the mean follow-up period was 4.0 years (±0.6). In the TS group (n = 12), the mean age was 33.8 years (±12.0) and the mean follow-up period was 3.7 years (±0.9). The minimum follow-up period was 2.0 years. Primary outcome measures were the absolute constant-score (CS), the subjective shoulder value (SSV) as well as the ability to return to sports.

RESULTS

The mean CS in the SA group was 91.6 (±5.5) compared to 81.3 (±15.5) in the TS group (p = 0.04). The mean SSV after SA repair was 96.9 (±4.6) compared to 80.0 (±20.8) after TS repair (p = 0.01). Both scores showed significantly higher standard deviations within the TS group (p < 0.05). Twelve of eighteen patients (67 %) were able to return to their overhead sports without restrictions (5/9 in the SA group and 7/9 in the TS group; p > 0.05). Fourteen of twenty-four patients (58 %) achieved their preinjury sports levels (8/12 in the SA group and 6/12 in the TS group; p > 0.05).

CONCLUSIONS

Superior objective and subjective shoulder function was obtained following arthroscopic SA repair compared to arthroscopic TS repair of isolated SLAP-2 lesions. In addition, results of SA repair were more predictable. However, nearly half of the athletes did not achieve full return to sports regardless of the applied technique of refixation.

The effect on external rotation of an anchor placed anterior to the biceps in type 2 SLAP repairs in a cadaveric throwing model

PURPOSE

This study examined whether there is a difference in external rotation (ER) between type 2 SLAP repairs consisting of anchors placed only posterior to the biceps insertion compared with repairs with an additional anchor placed anterior to the biceps.

METHODS

Seven cadaveric shoulders from donors with a mean age of 39.4 years were tested. Type 2 SLAP lesions were created, followed by a 3-anchor repair: a standard repair with 2 anchors posterior to the biceps plus an additional anchor anterior to the biceps. The specimens were placed on a material testing system machine and rotation was measured under a constant torque. The sutures were then removed sequentially from anterior to posterior during testing.

RESULTS

The average ER of the intact shoulder was 115.7° ± 2.6°. After SLAP tear creation and cyclic loading, the ER was 118.5° ± 2.6°, which decreased to 116.5° ± 2.6° after repair. This corresponds to a reduction of 2.0° of ER (P < .0001) with the repair. After release of the anterior anchor, the ER increased to 117.9° ± 2.6°, which corresponds to an increase in shoulder motion of 1.4° of ER (P = .0011). Additional release of the middle anchor, leaving only the posterior anchor intact, resulted in 118.0° ± 2.7° of ER, which corresponds to an increase of only 0.1° of ER (P = .7667).

CONCLUSIONS

Following type 2 SLAP repair in the cadaveric shoulder, removing the effect of the anchor anterior to the biceps resulted in a small but statistically significant increase in ER. The anterior anchor had the greatest effect on ER. The presence of 1 or 2 anchors posterior to the biceps did not have a significant effect on rotation.

CLINICAL RELEVANCE

When performing SLAP repairs on those in whom even a small loss of ER would be detrimental, such as baseball pitchers, avoidance of the use of an anchor anterior to the biceps should be considered.

The disabled throwing shoulder: spectrum of pathology-10-year update

In the 10 years since the current concept series entitled "The Disabled Throwing Shoulder: Spectrum of Pathology" was conceived and written, many studies have been reported that add much more information to the understanding of the disabled throwing shoulder (DTS). The editors of Arthroscopy and the authors of the original series believed that an update to the original series would be beneficial to provide an organized overview of current knowledge that could update the thought process regarding this problem, provide better assessment and treatment guidelines, and guide further research. A dedicated meeting, including current published researchers and experienced clinicians in this subject, was organized by the Shoulder Center of Kentucky. The meeting was organized around 5 areas of the DTS that were highlighted in the original series and appear to be key in creating the DTS spectrum and to understanding and treating the DTS: (1) the role of the kinetic chain; (2) the role and clinical evaluation of the scapula; (3) the role of deficits in glenohumeral rotation, glenohumeral internal rotation deficit, and total range-of-motion deficit in the causation of labral injury and DTS; (4) the role of superior labral (SLAP) injuries and rotator cuff injuries; and (5) the composition and progression of rehabilitation protocols for functional restoration of the DTS. The meeting consisted of presentations within each area, followed by discussions, and resulted in summaries regarding what is known in each area, what is not known but thought to be important, and strategies to implement and enlarge the knowledge base.

Short-term clinical results after arthroscopic type II SLAP repair

PURPOSE

The purpose of this study was to retrospectively review the clinical results of arthroscopic repair of type II SLAP lesions with respect to daily living activities and return to preinjury sports level.

PATIENTS AND METHODS

Twenty-one patients with an average age of 28 (range 18-44 years, respectively) underwent arthroscopic repair of isolated type II SLAP lesions. Surgery was performed by two of the senior authors with specialty training in arthroscopic shoulder surgery. Mean follow-up was 30.3 months (range 12-71 months, respectively). The clinical results were objectively measured using the individual relative Constant score (CS(indiv)).

RESULTS

At follow-up the mean CS(indiv) was 92 % (range 78-100 %). Restrictions to active motion were seen in six patients (28.6 %), four (19 %) in internal rotation and two (9.5 %) in external rotation but not all of these were restricted in their activities of daily living. Five patients (23.8 %) had an affected sleep, three patients (14.3 %) were limited in sports and one patient (4.7 %) was restricted at work. After surgery, 18 of 21 patients (85.7 %) regained preinjury sports level.

CONCLUSIONS

Although the rehabilitation process may be affected by a protracted period of pain, a long-term limitation of the range of motion (ROM) after surgery is very unlikely. The results in this study are encouraging and the authors recommend anatomic restoration and repair of type II SLAP lesions.

Demographic trends in arthroscopic SLAP repair in the United States

BACKGROUND

Treatment of superior labral anterior posterior (SLAP) tears remains controversial, particularly in older age groups. Repair, debridement, biceps tenodesis, tenotomy, and observation have been recommended depending on patient characteristics, but there have not been any large epidemiologic studies investigating treatment trends.

PURPOSE

To investigate current trends in SLAP repair across time, gender, age, and regions in the United States.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Patients who underwent arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) were identified using a publicly available national database of insurance records (PearlDiver Patient Records Database) during years 2004 through 2009. Factors identified for each patient included gender, age group, and region in the United States. Logistic regression analysis and the chi-square test were used for statistical measures.

RESULTS

From 2004 to 2009 there were 25,574 cases of arthroscopic SLAP repair identified, of which 75% were male patients and 25% were female patients. There was a significant rise in cases of SLAP repair from 2004 to 2009 as the incidence of SLAP repair increased from 17.0 for every 10,000 patients with an orthopaedic International Classification of Diseases, Ninth Revision (ICD-9) or CPT code in 2004 to 28.1 in 2009 (P < .0001). Age analysis revealed the highest incidence in the 20-29-year (29.1 per 10,000) and 40-49-year (27.8 per 10,000) age groups. Men (37.3 per 10,000) had a significantly higher incidence of repairs than did women (10.7 per 10,000). The West (24.6 per 10,000) and South (24.4 per 10,000) regions also demonstrated a higher incidence than the Midwest (20.5 per 10,000) and Northeast (20.1 per 10,000) regions (P < .0001).

CONCLUSION

Our analysis illustrates that surgeons are performing significantly more arthroscopic SLAP repairs each year. The highest incidence of repair is in the 20-29- and 40-49-year age groups, and a significant gender difference exists, with men having a threefold higher incidence of repair.

Long-term outcome after arthroscopic repair of type II SLAP lesions: results according to age and workers' compensation status

PURPOSE

The purpose of this study was to determine the long-term functional outcome of anatomic arthroscopic repair of type II SLAP lesions with suture anchors.

METHODS

We examined all arthroscopic repairs of isolated type II SLAP lesions from January 2002 through December 2007. Fifty-five patients were available for long-term follow-up at a mean of 77 months. The mean patient age at the time of surgery was 39.7 years (range, 17 to 65 years); 23 patients were aged younger than 40 years, and 32 patients were aged 40 years or older. Fourteen cases involved Workers' Compensation claims.

RESULTS

Overall, functional outcome was improved from baseline compared with final follow-up for both American Shoulder and Elbow Surgeons scores (44.1 points v 86.2 points, P < .001) and University of California, Los Angeles scores (19.1 points v 31.2 points, P < .001). According to the University of California, Los Angeles grading system, 87% of cases had good or excellent results. Although the percentage of good and excellent results among patients aged 40 years or older (81%) was lower than that among patients aged younger than 40 years (97%), this difference did not reach statistical significance (P = .219). The percentage of good and excellent results among the non-Workers' Compensation cases (95%) was significantly higher than that in Workers' Compensation cases (65%) (P = .009). Overall, patient satisfaction was reported in 91% of cases, and return to normal sport or activity was reported in 82% of cases.

CONCLUSIONS

In 87% of cases, a good or excellent functional outcome can be anticipated after arthroscopic repair of type II SLAP lesions with the described techniques. Variables associated with a poor outcome include Workers' Compensation cases and possibly older age (≥40 years).

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Concomitant arthroscopic SLAP and rotator cuff repair: surgical technique

BACKGROUND

The outcomes of combined arthroscopic repairs of a SLAP (superior labral anterior-posterior) lesion and a rotator cuff tear are not known. We compared the outcomes in a cohort of patients who had undergone concomitant arthroscopic repairs of a SLAP lesion and a rotator cuff tear with those in a cohort of patients with a stable biceps anchor who had undergone an isolated rotator cuff repair. We hypothesized that the results would be similar between the two cohorts with respect to the range of motion and preoperative and postoperative function.

METHODS

Thirty-four patients (average age, 56.9 years) underwent an arthroscopic repair of an unstable SLAP lesion along with a concomitant arthroscopic rotator cuff repair. Twenty-eight patients (average age, 59.6 years) underwent an isolated arthroscopic rotator cuff repair. The average durations of follow-up for the two groups were 40.9 and 42.7 months, respectively. All patients in both groups had a symptomatic full-thickness rotator cuff tear for which initial conservative treatment had failed. Patients with advanced supraspinatus fatty infiltration or advanced muscle atrophy were excluded from the study. American Shoulder and Elbow Surgeons (ASES) and Constant scores were determined preoperatively and postoperatively, as were measurements of the ranges of forward flexion, abduction, external rotation, and internal rotation. Dynamometer strength testing was performed on all patients as an adjunct to qualitative assessments, and normalized Constant scores were calculated to perform sex and age-matched functional assessments.

RESULTS

In the group treated with concomitant repairs of a SLAP lesion and a rotator cuff tear, the average ASES score improved from 22.6 to 96.4 points and the average normalized Constant score improved from 55.1 to 101.0 points. In the group treated with an isolated arthroscopic rotator cuff repair, the average ASES score improved from 34.3 to 92.3 points and the average normalized Constant score improved from 60.7 to 95.8 points. The average preoperative ASES score in the group with the concomitant repairs was significantly worse than that in the group with the isolated rotator cuff repair (p = 0.027). This difference is also probably clinically relevant. There was no significant difference between the groups with regard to the preoperative normalized Constant scores, but postoperatively the normalized Constant score was significantly higher in the group with the concomitant repairs (p = 0.006). The active range of motion did not differ between the groups, preoperatively or postoperatively.

CONCLUSIONS

Controversy surrounds the treatment of a SLAP lesion with concomitant treatment of a full-thickness rotator cuff tear. This study suggests that, in middle-aged patients, the results of combined SLAP lesion and rotator cuff repair can be comparable with those achieved with rotator cuff repair alone.

Percutaneous SLAP lesion repair technique is an effective alternative to portal of Wilmington

Athletes with superior labral tear from anterior to posterior (SLAP) lesions place large demands on their rotator cuff and often have partial articular-sided rotator cuff tears as part of an internal impingement process. A percutaneous technique that facilitates SLAP repair may decrease the rotator cuff morbidity associated with establishment of the standard Wilmington portal. The current study reports the clinical outcome of patients with SLAP lesions treated with a percutaneous repair technique. Twenty-two patients with SLAP lesions underwent percutaneous repair. Mean patient age was 26.9 years. Standard posterior viewing and anterior working portals were used. Anchor placement and suture passing were performed with a 3-mm percutaneous and transtendinous approach to the superior labrum. Knot tying was performed via the standard anterior working portal. Clinical outcomes were assessed with validated shoulder evaluation instruments. Mean follow-up was 31.1 months (±6.6 months). Improvement of shoulder evaluation scores from pre- to postoperative were as follows: American Shoulder and Elbow Surgeons score improved from 49.5 to 83.6, visual analog scale improved from 5.4 to 1.5, and Simple Shoulder Score improved from 6.4 to 11.0. All were significant improvements (P<.05). There was no significant difference in functional scores between Type II lesions versus combined lesions, or between patients with or without a concurrent low-grade rotator cuff tear. Ninety percent of athletes were able to return to sport at pre-injury level of function. Percutaneously-assisted arthroscopic SLAP lesion repair may minimize surgical morbidity to the rotator cuff and provides excellent results.

The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions

BACKGROUND

The majority of clinical outcome studies of type II superior labral anterior and posterior (SLAP) repair assess patients younger than age 40. Biceps tenotomy or tenodesis is often recommended for patients older than age 40 with superior labrum-biceps complex injury.

HYPOTHESIS

There is no difference in patient clinical outcomes comparing arthroscopic type II SLAP repair in patients younger or older than age 40.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Fifty-two patients stratified to groups younger than age 40 (21 patients; average age, 32.9 years) and older than age 40 (31 patients; average age, 55.1 years) were identified at a minimum 2-year follow-up (average, 28 months) after type II SLAP repair by a single surgeon using suture anchors. Outcome scores included American Shoulder and Elbow Society scores (ASES), Short Form-12 scores, Simple Shoulder Test scores, and visual analog pain scale.

RESULTS

At follow-up, there was no statistical difference in visual analog pain scale (P = .16), ASES scores (P = .07), Simple Shoulder Test scores (P =.41), Short Form-12 testing, or range of motion testing. Patients older than age 40 noted their shoulder to be 87% of normal; 26 of 31 (84%) were satisfied to completely satisfied, and 28 of 31 (90%) would have the surgery again. Patients younger than 40 noted their shoulder to be approximately 89% of normal; 20 of 21 (95%) were satisfied to completely satisfied, and 18 of 21 (86%) would have the same procedure performed again.

CONCLUSION

Our findings support that arthroscopic treatment of isolated type II SLAP repair using suture anchors can yield good to excellent results in patients older and younger than age 40. We found no statistically significant difference in patient outcome scores, satisfaction levels, or willingness to have the same procedure again when comparing arthroscopic SLAP repair in patients younger or older than age 40.

Management of the throwing shoulder: cuff, labrum and internal impingement

Repetitive throwing or other overhead activity places great stress on the shoulder. As a result, the shoulder is a common site of injury in athletes. Addressing throwing-related injuries requires an understanding of throwing biomechanics and pathology. Nonoperative treatment is directed at restoring strength, flexibility, and neuromuscular control to the entire kinetic chain. Surgery is indicated when nonoperative treatment fails, and is directed at correcting labral, capsular, and rotator cuff pathology.

Nonoperative treatment of superior labrum anterior posterior tears: improvements in pain, function, and quality of life

BACKGROUND

Although there are multiple reports documenting successful outcomes with operative treatment of superior labrum anterior posterior (SLAP) tears, there are few reports on the results of nonoperative treatment.

HYPOTHESIS

Nonoperative treatment of SLAP tears will result in improved outcomes over pretreatment values using validated, patient-derived outcome instruments.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 371 patients with a diagnosis of labral tear at our institution were mailed a questionnaire that included the following validated, patient-derived outcome assessment instruments: Short Form 36 (SF-36), European Quality of Life measure (EuroQol), visual analog pain scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and simple shoulder test (SST). Sixty-six surveys did not reach the patients because of incorrect addresses, and 50 surveys were returned, for a 16.4% (50 of 305) response rate. Of the patients with a clinically documented SLAP lesion (positive O'Brien test, pain at the bicipital groove, and positive magnetic resonance imaging) and sufficient follow-up data (minimum 1 year), 39 patients who met the criteria returned the survey and 19 had nonoperative treatment. Twenty patients (51%) from the overall surveyed group were considered nonoperative treatment failures and had arthroscopic surgical reconstruction. Nonoperative treatment consisted of nonsteroidal anti-inflammatory drugs and a physical therapy protocol focused on scapular stabilization exercises and posterior capsular stretching. Statistical analysis was performed using the paired t test; values of P < .05 were considered significant.

RESULTS

At an average follow-up of 3.1 years, function improved significantly (ASES function 30.8 to 45.0 [P < .001]; ASES total 58.5 to 84.7 [P = .001], SST 8.3 to 11.0 [P = .02]) in those patients with successful nonoperative treatment. Quality of life also improved after treatment (EuroQol 0.76 to 0.89, P = .009). Pain relief was significant, as VAS pain scores decreased from 4.5 to 2.1 (P = .043). All patients with successful nonoperative treatment returned to sports. Seventy-one percent of all athletes were able to return to preparticipation levels, but only 66% of overhead athletes returned to their sport at the same or higher level.

CONCLUSION

Using validated, patient-derived outcome instruments, the present study shows that successful nonoperative treatment of superior labral tears results in improved pain relief and functional outcomes compared with pretreatment assessments. Although 20 patients (51%) in this group elected surgery and may be considered nonoperative treatment failures, those patients with successful nonoperative treatment had significant improvements in pain, function, and quality of life. Return to sports was comparable with patients with successful surgical treatment, although return to overhead sports at the same level was difficult to achieve (66%). Based on these findings, a trial of nonoperative treatment may be considered in patients with the diagnosis of isolated superior labral tear. In overhead athletes and in those patients where pain relief and functional improvement is not achieved, surgical treatment should be considered.

Concomitant arthroscopic SLAP and rotator cuff repair

BACKGROUND

The outcomes of combined arthroscopic repairs of a SLAP (superior labral anterior-posterior) lesion and a rotator cuff tear are not known. We compared the outcomes in a cohort of patients who had undergone concomitant arthroscopic repairs of a SLAP lesion and a rotator cuff tear with those in a cohort of patients with a stable biceps anchor who had undergone an isolated rotator cuff repair. We hypothesized that the results would be similar between the two cohorts with respect to the range of motion and preoperative and postoperative function.

METHODS

Thirty-four patients (average age, 56.9 years) underwent an arthroscopic repair of an unstable SLAP lesion along with a concomitant arthroscopic rotator cuff repair. Twenty-eight patients (average age, 59.6 years) underwent an isolated arthroscopic rotator cuff repair. The average durations of follow-up for the two groups were 40.9 and 42.7 months, respectively. All patients in both groups had a symptomatic full-thickness rotator cuff tear for which initial conservative treatment had failed. Patients with advanced supraspinatus fatty infiltration or advanced muscle atrophy were excluded from the study. American Shoulder and Elbow Surgeons (ASES) and Constant scores were determined preoperatively and postoperatively, as were measurements of the ranges of forward flexion, abduction, external rotation, and internal rotation. Dynamometer strength testing was performed on all patients as an adjunct to qualitative assessments, and normalized Constant scores were calculated to perform sex and age-matched functional assessments.

RESULTS

In the group treated with concomitant repairs of a SLAP lesion and a rotator cuff tear, the average ASES score improved from 22.6 to 96.4 points and the average normalized Constant score improved from 55.1 to 101.0 points. In the group treated with an isolated arthroscopic rotator cuff repair, the average ASES score improved from 34.3 to 92.3 points and the average normalized Constant score improved from 60.7 to 95.8 points. The average preoperative ASES score in the group with the concomitant repairs was significantly worse than that in the group with the isolated rotator cuff repair (p = 0.027). This difference is also probably clinically relevant. There was no significant difference between the groups with regard to the preoperative normalized Constant scores, but postoperatively the normalized Constant score was significantly higher in the group with the concomitant repairs (p = 0.006). The active range of motion did not differ between the groups, preoperatively or postoperatively.

CONCLUSIONS

Controversy surrounds the treatment of a SLAP lesion with concomitant treatment of a full-thickness rotator cuff tear. This study suggests that, in middle-aged patients, the results of combined SLAP lesion and rotator cuff repair can be comparable with those achieved with rotator cuff repair alone.

The outcome of type II SLAP repair: a systematic review

PURPOSE

The purpose of this study was to systematically review the literature regarding the outcome of arthroscopic repair of type II SLAP lesions in order to assess the effectiveness of current methods of treatment.

METHODS

We performed a systematic review of the results of repair of type II SLAP lesions. Inclusion criteria included outcome studies of repair of type II SLAP lesions with minimum 2-year follow-up and Level IV evidence or higher published in the English language in peer-reviewed journals.

RESULTS

There is no Level I or II evidence for SLAP repair outcome. Regarding the general outcome after type II SLAP repair, the percentage of good and excellent results ranged from 40% to 94%. Return to previous level of play ranged from 20% to 94%. Overhead athletes are the most challenging to return to the previous level of performance for this diagnosis, and their return rate reflects this. Five studies reported these results, and the rate of return ranged from 22% to 64% for baseball players.

CONCLUSIONS

Arthroscopic repair of type II SLAP tears results in overall excellent results for individuals not involved in throwing or overhead sports. The results of type II SLAP repair in throwing or overhead athletes are much less predictable. Future studies should be prospective in nature and at least use a longitudinal prospective cohort design to determine predictors of outcome.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment

Lesions of the superior glenoid labrum and biceps anchor are a well-recognized cause of shoulder pain. Advances in shoulder arthroscopy have led to improvements in recognizing and managing superior labral anterior-posterior (SLAP) tears. Recent biomechanical studies have postulated several theories for the pathogenesis of SLAP tears in throwing athletes and the effect of these injuries on normal shoulder kinematics. Advances in soft-tissue imaging techniques have resulted in improved accuracy in diagnosing SLAP tears. However, the diagnosis of clinically relevant SLAP tears remains challenging because of the lack of specific examination findings and the frequency of concomitant shoulder injuries. Definitive diagnosis of suspected SLAP tears is confirmed on arthroscopic examination. Advances in surgical techniques have made it possible to achieve secure repair in selected patterns of injury. Recent outcomes studies have shown predictably good functional results and an acceptable rate of return to sport and/or work with arthroscopic treatment of SLAP tears.

[Arthroscopic findings after shoulder dislocation]

BACKGROUND/AIM

Recurrent instability of the shoulder joint is frequently difficult to differentiate from diseased or injured rotator cuff or tendon of the forearm flexor (m. biceps brachii). Shoulder joint arthroscopy has been only recently introduced into instable shoulder joint lesion examination. The aim of this study was to present and analyse an arthroscopic finding on instable shoulder joint in order to determine causes and mechanisms of instability, as well as principles of surgical treatment.

METHODS

Arthroscopy of the shoulder joint was performed in 158 patients with at least one documented shoulder joint dislocation. These patients were divided into two groups. The group I included the patients with one to three dislocations, while the group II those with more than three dislocations. Preoperative diagnosis was based on anamnestic data and clinical examination using specific tests, and on the diagnosis of shoulder joint using radiography or computed tomography.

RESULTS

Out of the total number of the patients 138 (87.34%) had injury of the anterior patellar brim, 119 (75.32%) had failure of the anterior capsule, 126 (79.75%) had compressive cartilage injury of the posterior part of the head of the upper arm bone (Hill-Sachs lesion), 102 (64.56%) had insufficiency of glenohumeral tendon, 11 (6.96) had complete cut of the rotator cuff, 23 (14.56%) had injury of the posterior patellar brim, 12 (7.59%) had injury of the upper anterior-posterior patellar brim (SLAP).

CONCLUSION

According to the obtained results it could be concluded that there is no a unique injury that leads to shoulder joint instability. It is necessary to point out to the significance of anamnesis and clinical examination in making diagnosis. Arthroscopic diagnostics is indicated in clinically unreliable findings as an additional method for determining operative treatment.

Poor outcomes after SLAP repair: descriptive analysis and prognosis

PURPOSE

In the first part of this study, we analyzed a subset of patients to determine what factors may have been present in those with poor outcomes after SLAP repair. In part 2, we evaluated clinical outcomes of these patients after further treatment.

METHODS

We completed a retrospective medical record review of consecutive patients presenting between 2000 and 2007 with pain, stiffness, and/or mechanical symptoms after a SLAP repair. To evaluate for similarities among this cohort, data collection included demographics, age at initial SLAP repair, history of trauma, medical history, nonoperative and operative treatments, and physical examination. Outcome measures included patient satisfaction and the Simple Shoulder Test questionnaire. Subsequent treatment was then reviewed, investigating whether patients received physical therapy, cortisone injection, and/or revision surgery in an attempt to improve satisfaction. Outcome measures again included patient satisfaction and the Simple Shoulder Test questionnaire.

RESULTS

We found 40 shoulders in 39 patients who met inclusion criteria. The mean age at the time of initial SLAP repair was 43 years. Of the patients, 30 (75%) presented with pain and decreased range of motion, 9 (22.5%) presented with pain but full range of motion, and 1 (2.5%) presented with pain and mechanical symptoms but full range of motion. The mean Simple Shoulder Test score upon presentation after SLAP repair was 3.04 out of 12 (SD, 2.18; range, 0 to 7). We included 34 shoulders in the analysis of treatment outcome. Of these, 29% (10 of 34) were satisfied after conservative treatment, 62% (13 of 21) were satisfied after revision surgery, and 68% (23 of 34) were satisfied overall after either type of further treatment. The mean Simple Shoulder Test score after further treatment was 8.73 out of 12 (SD, 3.45; range, 0 to 12).

CONCLUSIONS

In this study 71% of patients (mean patient age, 43 years) with a poor outcome after SLAP repair were dissatisfied with conservative treatment. Therefore, once a patient has a poor outcome after SLAP repair, there is a high chance of conservative treatment failing. Although patients have better outcomes with operative intervention, 32% will continue to have a suboptimal result.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Outcomes after arthroscopic repair of type-II SLAP lesions

BACKGROUND

To our knowledge, there has been no prospective study on the results of arthroscopic repair of superior labrum-biceps anchor complex (SLAP) tears with use of modern techniques. The purpose of the present study was to prospectively evaluate the minimum two-year results for patients with type-II SLAP tears that were treated with arthroscopic suture anchor fixation.

METHODS

Forty-seven patients with symptomatic type-II SLAP tears were evaluated preoperatively and at least two years postoperatively with use of the American Shoulder and Elbow Surgeons (ASES) and L'Insalata outcomes instruments and physical examination. The study group included thirty-nine male and eight female patients with a mean age of thirty-six years; thirty-four of the forty-seven patients were athletes. Patients with rotator cuff tears requiring repair or concomitant shoulder instability were excluded.

RESULTS

At an average of 2.7 years, the median ASES and L'Insalata scores were 97 and 93, respectively, compared with baseline scores of 62 and 65 (p < 0.05). The median patient-reported satisfaction rating was 9 (of 10); forty-one patients (87%) rated the outcome as good or excellent. The median patient-reported satisfaction rating was significantly higher for patients with a discrete traumatic etiology than for those with an atraumatic etiology (9 compared with 7); however, there was no significant difference between these groups in terms of the ASES or L'Insalata outcome scores. Overall, twenty-five (74%) of the thirty-four athletes were able to return to their preinjury level of competition, whereas eleven (92%) of the twelve athletes who reported a discrete traumatic event were able to return to their previous level of competition. There were five complications, including four cases of refractory postoperative stiffness.

CONCLUSIONS

Our findings indicate that favorable outcomes can be anticipated in the majority of patients after arthroscopic SLAP lesion repair. While only three of four patients overall may be capable of returning fully to their previous level of competition, patients with a distinct traumatic etiology have a greater likelihood of a successful return to sports.

Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion

BACKGROUND

Overhead athletes report an inconsistent return to their previous level of sport and satisfaction after arthroscopic SLAP lesion repair.

HYPOTHESIS

Arthroscopic biceps tenodesis offers a viable alternative to the repair of an isolated type II SLAP lesion.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Twenty-five consecutive patients operated for an isolated type II SLAP lesion between 2000 and 2004 were evaluated at a mean of 35 months postoperatively (range, 24-69). Patients with associated instability, rotator cuff rupture, posterosuperior impingement, or previous shoulder surgery were excluded. Ten patients (10 men) with an average age of 37 years (range, 19-57) had a SLAP repair performed with suture anchors. Fifteen patients (9 men and 6 women) with an average age of 52 years (range, 28-64) underwent arthroscopic biceps tenodesis performed with an absorbable interference screw. Arthroscopic diagnosis and treatment were performed by a single experienced shoulder surgeon, and all patients were reviewed by an independent examiner.

RESULTS

In the repair group, the Constant score improved from 65 to 83 points; however, 60% (6 of 10) of the patients were disappointed because of persistent pain or inability to return to their previous level of sports participation. In the tenodesis group, the Constant score improved from 59 to 89 points, and 93% (14/15) were satisfied or very satisfied. Thirteen patients (87%) were able to return to their previous level of sports participation following biceps tenodesis, compared with only 20% (2 of 10) after SLAP repair (P = .01). Four patients with failed SLAP repairs underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to their previous level of sports activity.

CONCLUSION

Arthroscopic biceps tenodesis can be considered an effective alternative to the repair of a type II SLAP lesion, allowing patients to return to a presurgical level of activity and sports participation. The results of biceps reinsertion are disappointing compared with biceps tenodesis. Furthermore, biceps tenodesis may provide a viable alternative for the salvage of a failed SLAP repair. As the age of the 2 treatment groups differed, these findings should be confirmed by future studies.

Superior labral lesions anterior to posterior-evaluation and arthroscopic management

Lesions of the superior labrum are complex and difficult to both diagnose and treat effectively. The clinical diagnosis is challenging due to the nonspecific history and physical examination. MRI has substantially improved our ability to detect SLAP tears, although experience is necessary to distinguish pathologic findings from normal anatomic variants. Treatment is determined by patient age, functional demands, and the type of lesion identified.

Arthroscopic repair of isolated type II superior labrum anterior-posterior lesion

The effectiveness of arthroscopic repair of type II superior labrum anterior-posterior lesion (SLAP) was unclear as previous studies examined this treatment with patients of combined types of SLAP lesions. To address this research gap, we evaluated the clinical and functional outcomes of arthroscopic repair for 16 patients (mean=24.2, SD=6.5) with clinical evidence of isolated type II SLAP lesion. After having arthroscopic stabilizations with Bioknotless suture anchors (Mitek), the patients were offered post-operative rehabilitation programs (e.g., physiotherapy) for 6 months. The symptoms of SLAP lesion and the functions of the shoulder were assessed pre-operatively and 28-month post-operatively by O'Brien test, Speed test, Yergason test, and University of California at Los Angeles rating for pain and function of the shoulder. Wilcoxon Signed Ranks test and McNemar test were employed to analyze the difference between assessment in pre-operation and post-operation phases. The result showed that patients' shoulder functions improved (UCLA Shoulder Score), and symptoms of SLAP lesion reduced (O'Brien test, Speed test, and Yergason test) significantly (P<0.05). Time for returning to play with pre-injury level was in average 9.4 months (range 4-24), and no complication or recurrence was detected. We concluded that arthroscopic repair is an effective operation of type II SLAP lesion with good clinical and functional outcomes; however, athletes with high demand of overhead throwing activities are likely to take longer duration of rehabilitation to attain full recovery.

Isolated and combined Type II SLAP repairs in a military population

The study compares the clinical results of isolated arthroscopic repair of Type II SLAP tears with those of combined treatment for Type II SLAP and other associated shoulder conditions. The population was composed of 36 aged-matched active duty males with a mean age of 31.6 years (range 22-41 years); mean follow-up was 29.1 months (range 24-42 months). Eighteen subjects in Group I had isolated Type II SLAP tears. Eighteen subjects in Group II had Type II SLAP tear and concomitant ipsilateral shoulder conditions, including subacromial impingement in six patients, acromioclavicular arthrosis in three patients, subacromial impingement and acromioclavicular arthrosis in four patients, spinoglenoid cyst in four patients, and intra-articular loose bodies in one patient. Arthroscopic SLAP repair was performed with biodegradable suture anchors. Subacromial decompression and spinoglenoid cyst decompression were performed arthroscopically. Distal claviculectomy was performed in open fashion. Loose bodies were removed arthroscopically. At minimum 2-year follow-up, the mean UCLA score for Group I (30.2 +/- 3.0 points) was not significantly different from Group II (30.8 +/- 2.0 points) (P = 0.48). The mean post-operative ASES score for Group I (84.1 +/- 13.4 points) was significantly lower than for Group II (91.8 +/- 5.4 points) (P < 0.04). The mean VAS pain score for Group I (1.6 +/- 1.3 points) was significantly higher than for Group II (0.7 +/- 0.7 points) (P < 0.02). Seventeen of 18 patients (94%) in each group returned to full duty. In a population of active duty males, arthroscopic repair of isolated Type II SLAP had comparable results with a cohort of Type II SLAP repairs treated in combination with other shoulder conditions, with the combined treatment group having significantly better results in two of three parameters measured. Return to duty rates were identical. Therefore, concurrent treatment of other associated extra-articular shoulder conditions improves the overall success of SLAP repair and the presence of these other conditions should be recognized and treated along with the SLAP tears in order to maximize clinical results.

[Arthroscopic treatment of posterior shoulder instability: technique and results]

Posterior shoulder instability occurs in approximately 2-5% of all cases of shoulder instability and treatment is still challenging. Open capsular plication procedures are described, but significant complications and risks have been reported in the literature. Arthroscopy has led to a better understanding of the pathoanatomy of posterior shoulder instability in recent years. We present our operative technique and the results of arthroscopic posterior shoulder stabilisation for the management of posterior shoulder instability. Sixteen patients with posterior shoulder instability were treated by arthroscopic posterior stabilisation from January 2004 to March 2005. There were 11 male and 5 female patients. The mean age was 24 (15-45) years. Nine patients had a unidirectional posterior instability. Seven patients had a predominantly posterior instability based on a multidirectional instability. Fourteen patients were evaluated after a mean follow-up of 12 (6-18) and 20 (14-26) months. Stability, range of motion and function were assessed using the Rowe score. The average Rowe score improved from pre-operative 32 (20-40) points to post-operative 87 (40-100) points after the first follow-up and 90 (40-100) points after the second follow-up. Furthermore subjective shoulder function was evaluated using a visual analog scale. The average score improved from pre-operative 3 (0-6) points to post-operative 8 (4-10) points after the first and second follow-up. At the first follow-up 93% of the patients had a stable shoulder; 85% had a stable shoulder after arthroscopic stabilisation at the second follow-up. Arthroscopic treatment for posterior shoulder instability is a demanding procedure. Due to a special operative technique with specific instruments soft tissue pathologies found in this type of instability such as capsular redundancy and labral tears can be addressed. Our results show that it can be used as an effective tool for the treatment of posterior shoulder instability.

Arthroscopic superior labrum anterior-posterior repair in military patients

The purpose of this retrospective study was to determine the efficacy of arthroscopic superior labrum anterior-posterior (SLAP) repair in a military population. In this study, 27 patients (of 30 consecutive patients) who had suture anchor repair of a type II SLAP lesion were evaluated at a mean of 30.5 months postoperatively. Fifteen patients had isolated tears, whereas twelve also had a concomitant diagnosis. At follow-up, the overall mean American Shoulder and Elbow Surgeons score was 86.9 points and the mean University of California, Los Angeles score was 30.4 points. The results were excellent in 4 patients, good in 20, and fair in 3. Of the patients, 96% returned to full duty (mean, 4.4 months). Patients treated for concomitant diagnoses and a SLAP tear had significantly higher American Shoulder and Elbow Surgeons scores and tended to have higher University of California, Los Angeles scores than those treated for an isolated SLAP tear. The findings indicate that arthroscopic SLAP repair in military patients results in a high rate of return to duty. The results suggest that concomitant shoulder pathology should be treated at the time of SLAP repair.

Outcome of arthroscopic repair of type II SLAP lesions in worker's compensation patients

PURPOSE

Arthroscopic stabilization has become the accepted treatment for type II superior labral anterior and posterior (SLAP) lesions. Short-term results using a variety of techniques were promising, but most reports focus on motivated athletes. The purpose of our report is to evaluate the results of arthroscopic fixation of type II SLAP lesions in 21 patients who suffered a work-related injury and are receiving workers' compensation. The hypothesis was that in patients with a single event trauma who were receiving workers' compensation, clinical results would be inferior to those previously reported.

METHODS

Twenty-two consecutive workers' compensation patients with type II SLAP lesions underwent arthroscopic stabilization between October 1994 and December 1996. All patients received suture anchors with nonabsorbable suture secured around the labrum for definitive fixation. Average age at surgery was 43 and average follow-up time was 27.9 months. Seventeen patients (89%) had an acromioplasty at the time of labral stabilization. Outcome was assessed by analysis of visual analog pain scale, simple shoulder test (SST) and general health status questionnaire (SF-36), subjective patient satisfaction, and ability to return to work.

RESULTS

Visual analog pain scales improved by an average of 3 points although all patients had significant complaints of pain at follow-up. Simple shoulder test responses showed improvement in 9 out of 12 categories. The SF-36 results showed significant improvements only in the bodily pain category and role: physical category. Five patients required reoperation for persistent pain. However, only seven patients (437%) returned to work at their previous functional level, nine patients (47%) returned to work but at less strenuous jobs, and three patients (16%) did not return to work.

CONCLUSIONS

Currently recommended treatment for type II SLAP lesions is arthroscopic stabilization. When this procedure is performed in workers' compensation, patients a with single event trauma to the shoulder, objective parameters, and patient self-assessment surveys do show improvement. However, results are inferior to those previously reported in the literature.

Outcomes of isolated type II SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack

PURPOSE

The objective was to clinically evaluate the treatment of type II Slap lesions repaired surgically using a bioabsorbable device.

TYPE OF STUDY

Retrospective clinical follow-up study.

METHODS

Forty-one patients with isolated type II SLAP lesions who were treated with arthroscopic fixation were identified. Patients were excluded for rotator cuff tears, instability, or subacromial decompression. Patients completed the L'Insalata and the American Society of Shoulder and Elbow Surgeons (ASES) questionnaires, and underwent a thorough shoulder examination at a minimum of 2 years postoperatively.

RESULTS

At a mean of 3.7 years follow-up, 33 of 41 patients returned for physical examination and 6 others returned the L'Insalata questionnaire. The mean L'Insalata and ASES scores were 86.7 and 86.8, respectively; 27 patients reported their satisfaction as good to excellent but only 14 of the 29 athletes returned to their preinjury level of athletics. The average ASES scores were statistically different in patients who had their rotator cuff pierced versus those who did not (P< .05). In addition, 13 of 16 patients who experienced night pain had a cuff piercing approach.

CONCLUSIONS

Despite high outcome scores, overall patient satisfaction was only 71%. In addition, up to 41% continued to experience some degree of night pain. Patients treated with a rotator cuff piercing had a significantly poorer outcome. Moreover, the patients who were athletes performed poorer on their outcomes evaluation than did their nonathletic counterparts. Whereas the outcome scores overall were high, this problem is still difficult to treat successfully. This may be because of the high demands of athletes. The data also suggest that placing portals through the rotator cuff may be associated with poorer surgical outcomes.

LEVEL OF EVIDENCE

Level III.

The correlation of the Buford complex and SLAP lesions

The Buford complex has previously been thought to be a normal anatomic variant with minimal clinical significance. The purpose of this study was to determine a potential correlation of an arthroscopic finding of a Buford complex and superior labrum anterior-posterior (SLAP) lesions in patients. Two hundred fifty consecutive shoulder arthroscopies performed at one institution were reviewed retrospectively. Operative reports and arthroscopic pictures were carefully inspected, with particular attention paid to descriptions of labral variations and pathology. Two hundred thirty-five reports met criteria for study inclusion. Of the 235 cases, 6 had a Buford complex (2.5%), displaying a cordlike middle glenohumeral ligament and absent anterior-superior labral tissue. Of these 6 patients, 5 had a corresponding SLAP lesion (83.3%). Of the remaining 229 patients 40 had SLAP lesions (17.5%). The significant difference between these groups (P < .003) indicates that there is a correlation of patients with Buford complexes and SLAP lesions.