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Yaka H, Erdem TE, Özer M, Kanatli U. Can the presence of SLAP-5 lesions be predicted by using the critical shoulder angle in traumatic anterior shoulder instability? Skeletal Radiol 2024:10.1007/s00256-024-04708-1. [PMID: 38758391 DOI: 10.1007/s00256-024-04708-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/03/2024] [Accepted: 05/12/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Although SLAP-5 lesions are associated with recurrent dislocations, their causes and pathomechanisms have not been fully elucidated. This study aimed to investigate the association between SLAP-5 lesions and scapular morphology in traumatic anterior shoulder instability (ASI). We hypothesized that there may be a relationship between SLAP-5 lesions and scapular morphology in traumatic ASI patients. MATERIALS AND METHODS The study included 74 patients with isolated Bankart lesions and 69 with SLAP-5 lesions who underwent arthroscopic labral repair for ASI. Critical shoulder angle (CSA) was measured on the roentgenograms, while glenoid inclination (GI) and glenoid version (GV) were measured on magnetic resonance imaging (MRI) by two observers in two separate sessions blinded to each other. Both groups were compared in terms of CSA, GI, and GV. RESULTS The mean ages of Bankart and SLAP-5 patients were 28.4±9.1 and 27.9±7.7 (P=0.89), respectively; their mean CSA values were 33.1°±2.6° and 28.2°±2.4°, respectively (P<0.001). The ROC analysis's cut-off value was 30.5°, with 75.0% sensitivity and 76.7% specificity (AUC = 0.830). SLAP-5 lesions were more common on the dominant side than isolated Bankart lesions (P=0.021), but no difference was found between the groups in terms of GI and GV (P=0.334, P=0.081, respectively). CONCLUSIONS In ASI, low CSA values appeared to be related to SLAP-5 lesions, and the cut-off value of CSA for SLAP lesion formation was 30.5° with 75.0% sensitivity and 76.7% specificity. Scapula morphology may be related to the SLAP-5 lesions, and CSA can be used as an additional parameter in provocative diagnostic tests and medical imaging techniques for the detection of SLAP lesions accompanying Bankart lesions. LEVEL OF EVIDENCE III retrospective case-control study.
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Affiliation(s)
- Haluk Yaka
- Department of Orthopaedics & Traumatology, School of Medicine, Necmettin Erbakan University, Konya, Turkey.
| | - Turgut Emre Erdem
- Department of Orthopaedics & Traumatology, Pazarcık State Hospital, Kahraman Maraş, Turkey
| | - Mustafa Özer
- Department of Orthopaedics & Traumatology, School of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ulunay Kanatli
- Department of Orthopaedics & Traumatology, Gazi University School of Medicine, Ankara, Turkey
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Mercouris P, Mercouris M. Superior labrum anterior to posterior lesions: Part 1 - Imaging and anatomy with arthroscopic classification. SA J Radiol 2023; 27:2706. [PMID: 37928928 PMCID: PMC10623653 DOI: 10.4102/sajr.v27i1.2706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/27/2023] [Indexed: 11/07/2023] Open
Abstract
The glenoid labrum deepens the glenoid fossa and allows for the attachment of the long head of the biceps tendon and the glenohumeral ligaments, contributing to the stability of the glenohumeral joint. The superior labrum is a common site of labral injury, especially in athletic activities involving overhead activity. The acronym SLAP (superior labrum anterior to posterior or anteroposterior) lesion was introduced by Snyder and colleagues in 1990 to describe superior labral tears. The article will review the optimal technique to image the glenoid labrum, covering normal labral anatomy with special emphasis on the anatomic variants of the labrum that can be mistaken for SLAP tears by means of colour illustrations, magnetic resonance imaging and correlative arthroscopy images. Contribution The illustrated review functions as a crucial radiological guide for both radiologists and orthopaedic surgeons. The combination of illustrations, MR and correlative arthroscopic images enhances the comprehension of normal labral anatomy and its variants. The review underscores the significance of understanding anatomic variations that may be misinterpreted as pathology. This understanding is vital in guiding orthopaedic management for patients, ensuring appropriate treatment strategies.
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Affiliation(s)
- Peter Mercouris
- Diagnostic Radiologist, Lake, Smit & Partners, Gateway Private Hospital, Durban, South Africa
| | - Matthew Mercouris
- Department of Orthopaedics, Mitchell’s Plain District Hospital, Cape Town, South Africa
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Benes M, Kachlik D, Kopp L, Kunc V. Prevalence of the anterosuperior capsulolabral anatomical variations and their association with pathologies of the glenoid labrum: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:6295-6303. [PMID: 37351607 PMCID: PMC10491707 DOI: 10.1007/s00402-023-04932-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023]
Abstract
PURPOSE Differentiating the anatomical variations of the anterosuperior portion of the glenoid labrum from pathologies is important to avoid unnecessary iatrogenic complications resulting from inaccurate diagnosis. Additionally, the presence of several variations was reported to be conductive to lesions involving the glenoid labrum. Thus, the aim of this study was to state the prevalence rates of the sublabral recess, sublabral foramen, and the Buford complex, and to verify their association with labral lesions. METHODS Systematic search of electronic databases was conducted to gain potentially eligible literature. Suitable studies were selected in a two-round screening, and relevant data were subsequently extracted. Calculation of the pooled prevalence estimates, including sub-analyses on cohort size, study type, and geographical variance, was conducted. Pooled analysis of risk ratios (RR) was used to assess the conductive nature of the discussed variants to superior labrum anterior to posterior (SLAP) lesions. RESULTS The screening resulted in selection of 20 studies investigating the morphological features of the glenoid labrum, consisting of 7601 upper limbs. On the bases of random-effects meta-analysis the sublabral recess, sublabral foramen and Buford complex occur with a pooled prevalence of 57.2% (95% CI 30.0-84.4%), 13.5% (95% CI 8.2-18.9%), and 3.0% (95% CI 1.5-4.5), respectively. Moreover, individuals with Buford complex have RR 2.4 (95% CI 1.3-4.7) of developing SLAP lesions, especially type II (95.5%; 95% CI 86.1-100%), whereas such risk for sublabral recess and sublabral foramen was not statistically significant. CONCLUSION Morphological variants of the glenoid labrum posing diagnostic confusion are frequently observed. Gradually, the Buford complex may be a predisposing factor for sustaining a SLAP lesion.
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Affiliation(s)
- Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Lubomir Kopp
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- Clinic of Trauma Surgery, Masaryk Hospital, Usti nad Labem, Czech Republic
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
- Clinic of Trauma Surgery, Masaryk Hospital, Usti nad Labem, Czech Republic.
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4
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Funakoshi T, Takahashi T, Shimokobe H, Miyamoto A, Furushima K. Arthroscopic findings of the glenohumeral joint in symptomatic anterior instabilities: comparison between overhead throwing disorders and traumatic shoulder dislocation. J Shoulder Elbow Surg 2023; 32:776-785. [PMID: 36343790 DOI: 10.1016/j.jse.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The term shoulder instability refers to a variety of mechanisms and clinical presentations. One of the common pathologies of throwing disorders is internal impingement with anterior instability. Most throwing athletes with symptomatic internal impingement with anterior instability exhibit positive apprehension and relocation test results, whereas those with recurrent anterior shoulder instability display positive apprehension test results. While the glenoid labrum-inferior glenohumeral ligament complex is a significant critical stabilizer for the prevention of anterior shoulder dislocation, the characteristics of the essential lesion in internal impingement with anterior instability have not been determined yet. This study aimed to compare the intra-articular lesion of athletes with internal impingement related to the overhead throwing motion in athletes with a traumatic shoulder dislocation. METHODS Sixty-one athletes (all men; mean age, 25.2 ± 12.6 yr) who underwent an arthroscopic procedure were divided into 2 groups: 25 in the throwing group and 36 in the dislocation group. All shoulders had subtle glenohumeral instability defined by a positive anterior apprehension test and a relocation test. Those with voluntary and multidirectional instability and large glenoid bone loss (more than 25%) were excluded from the current study. All shoulders were evaluated for the following evidence: rotator cuff injury, superior labrum tear anterior and posterior lesions, labral pathologies including Bankart lesions, osteochondral lesions to the humeral head, biceps tendon fraying or rupture, and inferior glenohumeral ligament and middle glenohumeral ligament (MGHL) conditions. RESULTS Arthroscopic findings of the throwing group showed more supraspinatus injuries (92% and 25%, P < .001), type II superior labrum tear anterior and posterior lesions (60% and 3%, P < .001), posterosuperior labral lesions (92% and 39%, P < .001), and hypoplastic MGHLs (56% and 6%, P < .001) and lesser Bankart lesions (8% and 92%, P < .05) than those of the dislocation group. CONCLUSIONS These results indicate that the characteristic lesions of internal impingement with anterior instability in throwing athletes include partial thickness rotator cuff tears, superior labrum tear anterior and posterior lesions, posterosuperior labral tears, and hypoplastic MGHLs. As expected, the physiopathology of internal impingement with anterior instability in throwing athletes may be related to the dysfunction of the anterosuperior glenohumeral capsular ligament, including the MGHL, rather than the inferior glenohumeral ligament as in traumatic anterior shoulder dislocations. These findings would be useful for defining treatment strategies for internal impingement with anterior instability in overhead throwing athletes.
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Diplock B, Hing W, Marks D. The long head of biceps at the shoulder: a scoping review. BMC Musculoskelet Disord 2023; 24:232. [PMID: 36978047 PMCID: PMC10044783 DOI: 10.1186/s12891-023-06346-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND This review aimed to explore the available literature to update our understanding of the long head of biceps (LHB) at the shoulder. Synthesise our findings to identify emergent themes and knowledge gaps to inform future research and management directions. METHODS PubMed, Embase, Cinahl, SportDiscus, CENTRAL, and Web of Science were searched from inception to 31st December 2021. Articles were included if they referenced adult participants > 18 years of age and were written in English. RESULTS 214 articles were included in the final analysis, and results were categorised into six emergent themes: (1) Anatomy - Normal anatomical variation of the biceps from aberrant origins, third and fourth accessory heads, and an absence of the LHB tendon (LHBT) are not necessarily benign, with shoulder pain and instability a commonly reported theme. (2) Function - Bicep's role in glenohumeral elevation and stability in healthy shoulders is minimal. In contrast, LHB has a more significant role in shoulder stability and humeral head depression in subjects with rotator cuff failure or an absent LHBT. (3) Pathology - There is an association between LHB tendinopathy, rotator cuff disease, LHBT instability and occult rotator cuff tears. Early recruitment and hyperactivity of the LHB in subjects with symptomatic rotator cuff tears and instability suggest a potential compensatory role. (4) Assessment - The limited diagnostic utility of special orthopaedic tests in assessing LHBT pathology was a consistent theme. The utility of magnetic resonance imaging and ultrasound to identify full-thickness tendon tears and instability of the LHBT was moderate to high. However, the utility of clinical tests and imaging may be underestimated due to arthroscopy's limitations in fully visualising the proximal LHBT. (5) Non-Surgical Management - Ultrasound-guided injections into the biceps sheath show greater accuracy and patient outcomes than blinded injections; however, the entry of injectate into the intraarticular glenohumeral joint may have unwanted complications. (6) Surgical management - For the surgical management of biceps pathology with or without rotator cuff pathology, both biceps tenodesis and tenotomy report similar improvements in pain without any significant adverse effect on strength or function. Tenodesis favoured higher overall constant scores and a lower incidence of Popeye deformity and cramping arm pain, with tenotomy trending to be more cost and time effective. For patients with a healthy LHBT, rotator cuff repair with adjunctive tenodesis or tenotomy fails to provide additional clinical improvements compared to rotator cuff repair in isolation. CONCLUSIONS The scoping review highlights the variability of biceps anatomy, which is not necessarily benign and suggests a minimal role of the LHB in shoulder elevation and stability in healthy individuals. In contrast, individuals with rotator cuff tears experience proximal humeral migration and demonstrate hyperactivity of the LHB, suggesting a potential compensation role. The observed prevalence of LHBT pathology with rotator cuff tears is well established; however, the cause-and-effect relationship between LHBT pathology and rotator cuff disease is undetermined. The diagnostic utility of clinical tests and imaging to exclude LHBT pathology may be understated due to the limitations of arthroscopy to visualise the proximal LHBT fully. Rehabilitation programs for the LHB are understudied. Similar post-surgical clinical outcomes are observed for tenodesis and tenotomy for biceps and rotator cuff-related shoulder pain. Subjects undergoing biceps tenodesis are less likely to have cramping arm pain and a Popeye deformity than patients undergoing biceps tenotomy. The significance of routine surgical removal of the LHBT and sequelae on rotator cuff tear progression to failure and long-term shoulder function is unknown, and further research is required. PRE-REGISTRATION OSF: https://osf.io/erh9m.
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Affiliation(s)
- Brendan Diplock
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia.
| | - Wayne Hing
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia
| | - Darryn Marks
- Faculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia
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6
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Sudah SY, Menendez ME, Garrigues GE. Nonoperative Treatment of the Biceps-Labral Complex. Phys Med Rehabil Clin N Am 2023; 34:365-375. [PMID: 37003658 DOI: 10.1016/j.pmr.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
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.
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Affiliation(s)
- Suleiman Y Sudah
- Department of Orthopedics, Monmouth Medical Center, 300 2nd Avenue, Long Branch, NJ 07740, USA
| | - Mariano E Menendez
- Oregon Shoulder Institute at Southern Oregon Orthopedics, 2780 East Barnett Road, 200, Medford, OR 97504, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, Midwest Orthopaedics at Rush, 1611 West Harrison Street, Orthopedic Building, Suite 400, Chicago, IL 60612, USA.
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Funakoshi T, Furushima K, Takahashi T, Miyamoto A, Urata D, Yoshino K, Sugawara M. Anterior glenohumeral capsular ligament reconstruction with hamstring autograft for internal impingement with anterior instability of the shoulder in baseball players: preliminary surgical outcomes. J Shoulder Elbow Surg 2022; 31:1463-1473. [PMID: 35063639 DOI: 10.1016/j.jse.2021.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/08/2021] [Accepted: 12/12/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Shoulder pain and dysfunction are common in baseball players, and although "internal impingement" is recognized as one of the most common pathologies of shoulder dysfunction, the optimal surgical treatment for internal impingement with anterior instability of the shoulder remains controversial. This study evaluated baseball players' preliminary outcomes following anterior glenohumeral capsular ligament reconstruction for internal impingement with anterior instability of the shoulder. METHODS Twelve baseball players (all male; mean age, 20.5 ± 2.2 years) with internal impingement and anterior instability managed via anterior glenohumeral capsular ligament reconstruction were examined. The mean follow-up period was 25.3 ± 4.6 months. Anterior glenohumeral capsular ligament reconstruction was performed with a knee hamstring autograft for balanced stability and laxity with two major targets: to prevent hyperangulation and translation in horizontal abduction and to mimic the individual arm cocking position at the final decision of tension. Preoperative and final follow-up evaluations were performed using Jobe's postoperative grading system; the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score; Disabilities of the Arm, Shoulder and Hand sports module; plain radiographs; and magnetic resonance imaging. RESULTS Jobe's postoperative grading system score, the Kerlan-Jobe Orthopaedic Clinic Overhead Athletes Shoulder and Elbow Score, and the Disabilities of the Arm, Shoulder and Hand sports module score improved significantly from 20.4 ± 12.2, 28.4 ± 8.3, and 80.2 ± 11.1 points preoperatively to 88.8 ± 13.6, 80.8 ± 7.7, and 22.4 ± 18.7 points postoperatively, respectively (P < .001, .0025, <0.001, respectively). Both clinical and imaging evaluations revealed improved internal impingement with anterior instability after anterior glenohumeral capsular ligament reconstruction. The mean external rotation at abduction significantly decreased from 113° preoperatively to 104° postoperatively. At follow-up, 10 of the 12 athletes (83.3%) returned to their prior competitive level. Plain radiographs and magnetic resonance imaging revealed no obvious loosening of the graft or screws. CONCLUSIONS Anterior glenohumeral capsular ligament reconstruction resulted in preferable clinical outcomes for young baseball players who experienced pain during the throwing motion. Stabilization of the glenohumeral joint with autografting of the knee hamstring may thus represent a solution for internal impingement with anterior instability in overhead throwing athletes.
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Affiliation(s)
| | | | | | | | - Daigo Urata
- Keiyu Orthopaedic Hospital, Tatebayashi, Japan
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8
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Siebenlist S, Hinz M, Scheiderer B. Behandlung der SLAP-Verletzung des jungen Sportlers. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00488-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Özer M, Kaptan AY, Ataoglu MB, Cetinkaya M, Ayanoglu T, Ince B, Kanatli U. The Buford complex: prevalence and relationship with labral pathologies. J Shoulder Elbow Surg 2021; 30:1356-1361. [PMID: 32949757 DOI: 10.1016/j.jse.2020.08.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 08/16/2020] [Accepted: 08/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study aimed to determine the prevalence of the Buford complex and to investigate its association with labral pathologies (superior labrum anterior-posterior [SLAP] lesion and anterior, posterior, or multidirectional instability) using a very large patient database. Furthermore, the prevalence of the Buford complex in patients without any labral pathology was also determined. METHODS A total of 3129 consecutive shoulder arthroscopy procedures were retrospectively evaluated for the presence of the Buford complex and coexisting labral pathologies. The relationships between the Buford complex and SLAP lesions, as well as instability, were evaluated statistically. RESULTS The Buford complex was observed in 83 shoulders (2.65%). SLAP lesions were significantly more frequent in patients with the Buford complex than in those without it (81.9% vs. 33.1%, P < .001) Shoulders with the Buford complex presented a lower frequency of anterior instability (10.8% vs. 19.3%, P = .052) and a higher frequency of posterior instability (1.2% vs. 0.9%, P = .789). The prevalence of the Buford complex in patients with and without labral pathologies was 4.6% and 0.3%, respectively (P < .001). CONCLUSIONS This study, to our knowledge, includes the largest cohort in the literature reporting the prevalence of the Buford complex (2.65%). In the 1461 patients without labral tears or multidirectional instability, the prevalence of the Buford complex was 0.3%. This result suggests that the real prevalence of the Buford complex might be lower than that reported previously. In addition to the aforementioned conclusions, the identification of the Buford complex should prompt a thorough evaluation for concomitant SLAP lesions.
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Affiliation(s)
- Mustafa Özer
- Department of Orthopaedics & Traumatology, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey.
| | - A Yigit Kaptan
- Department of Orthopaedics & Traumatology, Dr. Sami Ulus Education and Research Hospital, Ankara, Turkey
| | - M Baybars Ataoglu
- Department of Orthopaedics & Traumatology, Gazi University School of Medicine, Ankara, Turkey
| | - Mehmet Cetinkaya
- Spinal Unit of Orthopaedics, Stellenbosch University, Tygerberg Academic Hospital, Cape Town, Western Cape, South Africa
| | - Tacettin Ayanoglu
- Department of Orthopaedics & Traumatology, Bolu Abant İzzet Baysal University, Bolu, Turkey
| | - Bulent Ince
- Department of Orthopaedics & Traumatology, Magnet Hospital, Ankara, Turkey
| | - Ulunay Kanatli
- Department of Orthopaedics & Traumatology, Gazi University School of Medicine, Ankara, Turkey
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Christensen GV, Smith KM, Kawakami J, Chalmers PN. Surgical Management of Superior Labral Tears in Athletes: Focus on Biceps Tenodesis. Open Access J Sports Med 2021; 12:61-71. [PMID: 33981168 PMCID: PMC8107051 DOI: 10.2147/oajsm.s266226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/21/2021] [Indexed: 01/02/2023] Open
Abstract
Superior labrum anterior-posterior (SLAP) lesions are common in overhead athletes. Though some patients have asymptomatic lesions, many tears cause pain and diminished athletic performance. Accurate diagnosis of SLAP lesions can be challenging as the sensitivity and specificity of both the physical exam and advanced imaging is questionable. Management is also difficult, as treatment can be life-altering or career-ending for many athletes. If first-line nonoperative treatment fails, surgical options may be considered. The optimal surgical management of SLAP lesions in athletes is debated. Historically, return to play (RTP) rates among athletes who have undergone arthroscopic SLAP repair have been unsatisfactory, prompting clinicians to seek alternate surgical options. Biceps tenodesis (BT) has been postulated to eliminate biceps tendon-related pain in the shoulder and is increasingly used as a primary procedure for SLAP lesions. The purpose of this text is to review the current literature on the surgical management of SLAP lesions in athletes with an emphasis on the role of BT.
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Affiliation(s)
- Garrett V Christensen
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Karch M Smith
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Jun Kawakami
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
| | - Peter N Chalmers
- Department of Orthopaedic Surgery, University of Utah Health, Salt Lake City, UT, USA
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LeVasseur MR, Mancini MR, Hawthorne BC, Romeo AA, Calvo E, Mazzocca AD. SLAP tears and return to sport and work: current concepts. J ISAKOS 2021; 6:204-211. [PMID: 34272296 DOI: 10.1136/jisakos-2020-000537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 01/02/2023]
Abstract
Superior labrum, anterior and posterior (SLAP) lesions are common and identified in up to 26% of shoulder arthroscopies, with the greatest risk factor appearing to be overhead sporting activities. Symptomatic patients are treated with physical therapy and activity modification. However, after the failure of non-operative measures or when activity modification is precluded by athletic demands, SLAP tears have been managed with debridement, repair, biceps tenodesis or biceps tenotomy. Recently, there have been noticeable trends in the operative management of SLAP lesions with older patients receiving biceps tenodesis and younger patients undergoing SLAP repair, largely with suture anchors. For overhead athletes, particularly baseball players, SLAP lesions remain a difficult pathology to manage secondary to concomitant pathologies and unpredictable rates of return to play. As a consequence, the most appropriate surgical option in elite throwers is controversial. The objective of this current concepts review is to discuss the anatomy, mechanism of injury, presentation, diagnosis and treatment options of SLAP lesions and to present current literature on outcomes affecting return to sport and work.
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Affiliation(s)
- Matthew R LeVasseur
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Michael R Mancini
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Benjamin C Hawthorne
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
| | - Anthony A Romeo
- Musculoskeletal Institute, DuPage Medical Group, Downers Grove, Illinois, USA
| | - Emilio Calvo
- Department of Orthopaedic Surgery, Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, USA
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12
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Fukuda A, Uemura T, Nishimura A, Kato K, Sudo A. Arthroscopic Treatment of Primary Synovial Chondromatosis of the Subscapular Bursa: A Case Report. J Orthop Case Rep 2020; 9:40-43. [PMID: 32548026 PMCID: PMC7276592 DOI: 10.13107/jocr.2019.v09.i06.1580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Synovial chondromatosis is a rare metaplastic disorder of the synovial membrane. Primary synovial chondromatosis of the shoulder joint is a rare localization and extra-articular localization around the shoulder is much less common. Case Report We report a rare case of a 13-year-old boy with primary synovial chondromatosis of the subscapular bursa. Computed tomography and magnetic resonance imaging showed that multiple cartilaginous loose bodies were found in the subscapular bursa and the glenohumeral joint. Arthroscopic removal of loose bodies and synovectomy of the subscapular bursa was performed through sublabral foramen. Conclusion Pre-operative investigation for the precise location of the lesions was important for the planning the operative procedure. Arthroscopic removal of loose bodies and synovectomy was useful treatment options for synovial chondromatosis of the subscapular bursa.
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Affiliation(s)
- Aki Fukuda
- Department of Orthopaedic Surgery, Suzuka Kaisei Hospital, Suzuka, Mie 513-0836, Japan
| | - Takeshi Uemura
- Department of Orthopaedic Surgery, Suzuka Kaisei Hospital, Suzuka, Mie 513-0836, Japan
| | - Akinobu Nishimura
- Department of Orthopaedic and Sports Medicine, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
| | - Ko Kato
- Department of Orthopaedic Surgery, Suzuka Kaisei Hospital, Suzuka, Mie 513-0836, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Mie 514-8507, Japan
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13
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Kandeel AAM. Type V superior labral anterior-posterior (SLAP) lesion in recurrent anterior glenohumeral instability. J Shoulder Elbow Surg 2020; 29:95-103. [PMID: 31471245 DOI: 10.1016/j.jse.2019.05.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The literature has reported debatable diagnostic accuracy of clinical provocative tests for a type II superior labral anteroposterior (SLAP) lesion, especially in the context of a type V SLAP (concurrent Bankart and type II SLAP) lesion. This study was conducted to determine whether the investigated provocative tests offer reliable predictive values in the diagnosis of type II SLAP lesions in patients with recurrent anterior glenohumeral (GH) instability. METHODS This prospective case-control study carried out between September 2014 and September 2018 included 51 patients with post-traumatic recurrent anterior GH instability. Patients were prospectively evaluated for type II SLAP lesions by 9 provocative tests: Jobe relocation test, abduction-external rotation test, anterior slide test, biceps load test I, biceps load test II, pain provocation test, labral tension test, crank test, and the O'Driscoll dynamic labral shear test. The results of these tests were compared with findings of diagnostic arthroscopic GH examinations (control). RESULTS Statistical analysis revealed the mean age of the studied group to be 26.1 ± 7.56 years, with male predominance (50 patients; 98.04%). Arthroscopic examination revealed a Bankart lesion in isolation and in association with a type II SLAP lesion (ie, a type V SLAP lesion) in 15 (29.4%) and 36 (70.6%) patients, respectively. The anterior slide test yielded the highest positive and lowest negative likelihood ratios (2.91 and 0.52, respectively). CONCLUSION Except for the anterior slide test, which can be validated for the clinical diagnosis of type II SLAP lesions in patients with traumatic recurrent anterior GH instability, the investigated tests offer poor predictive values and should be cautiously used in clinical practice.
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Affiliation(s)
- Amr Abdel-Mordy Kandeel
- Department of Orthopedics and Traumatology, Faculty of Medicine, Menoufia University, Menoufia Governorate, Egypt.
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14
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Aparisi Gómez MP, Aparisi F, Battista G, Guglielmi G, Faldini C, Bazzocchi A. Functional and Surgical Anatomy of the Upper Limb: What the Radiologist Needs to Know. Radiol Clin North Am 2019; 57:857-881. [PMID: 31351538 DOI: 10.1016/j.rcl.2019.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The anatomy of the upper limb is complex and allows for exceptional functionality. The movements of the joints of the shoulder, elbow, and wrist represent a complex dynamic interaction of muscles, ligaments, and bony articulations. A solid understanding and of the characteristics and reciprocal actions of the anatomic elements of the joints of the upper limb helps explain the mechanisms and patterns of injury. This article focuses on the anatomy and functionality of the shoulder, elbow, and wrist, with emphasis on the stabilizing mechanisms, to set the foundation for understanding the occurrence of pathologic conditions.
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Affiliation(s)
- Maria Pilar Aparisi Gómez
- Department of Radiology, National Women's Hospital, Auckland City Hospital, Greenlane Clinical Center, Auckland District Health Board, 2 Park Road, Grafton, Auckland 1023, New Zealand; Department of Radiology, Hospital Nisa Nueve de Octubre, Calle Valle de la Ballestera, 59, Valencia 46015, Spain.
| | - Francisco Aparisi
- Department of Radiology, Hospital Nisa Nueve de Octubre, Calle Valle de la Ballestera, 59, Valencia 46015, Spain
| | - Giuseppe Battista
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Sant'Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy
| | - Giuseppe Guglielmi
- Department of Radiology, University of Foggia, Viale Luigi Pinto 1, Foggia 71100, Italy
| | - Cesare Faldini
- 1st Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, Bologna 40136, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Via U. Foscolo 7, Bologna 40123, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Via G. C. Pupilli 1, Bologna 40136, Italy
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15
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Abstract
Knowledge of the pertinent anatomy, pathogenesis, clinical presentation and treatment of the spectrum of injuries involving the superior glenoid labrum and biceps origin is required in treating the patient with a superior labrum anterior and posterior (SLAP) tear.Despite the plethora of literature regarding SLAP lesions, their clinical diagnosis remains challenging for a number of reasons.First, the diagnostic value of many of the available physical examination tests is inconsistent and ambiguous.Second, SLAP lesions most commonly occur concomitantly with other shoulder injuries.Third, SLAP lesions have no specific associated pain pattern.Outcomes following surgical treatment of SLAP tears vary depending on the method of treatment, associated pathology and patient characteristics.Biceps tenodesis has been receiving increasing attention as a possible treatment for SLAP tears. Cite this article: EFORT Open Rev 2019;4:25-32. DOI: 10.1302/2058-5241.4.180033.
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Affiliation(s)
- Filippo Familiari
- Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro, Italy
| | - Gazi Huri
- Department of Orthopaedic and Traumatology, Hacettepe University, Ankara, Turkey
| | | | - Edward G McFarland
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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16
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Charles MD, Christian DR, Cole BJ. An Age and Activity Algorithm for Treatment of Type II SLAP Tears. Open Orthop J 2018; 12:271-281. [PMID: 30197708 PMCID: PMC6110066 DOI: 10.2174/1874325001812010271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/24/2018] [Accepted: 05/24/2018] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Michael D Charles
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
| | - David R Christian
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL 60612, USA
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17
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Glenohumeral Instability Related to Special Conditions: SLAP Tears, Pan-labral Tears, and Multidirectional Instability. Sports Med Arthrosc Rev 2018; 25:e12-e17. [PMID: 28777213 DOI: 10.1097/jsa.0000000000000153] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Glenohumeral instability is one of the more common conditions seen by sports medicine physicians, especially in young, active athletes. The associated anatomy of the glenohumeral joint (the shallow nature of the glenoid and the increased motion it allows) make the shoulder more prone to instability events as compared with other joints. Although traumatic dislocations or instability events associated with acute labral tears (ie, Bankart lesions) are well described in the literature, there exists other special shoulder conditions that are also associated with shoulder instability: superior labrum anterior/posterior (SLAP) tears, pan-labral tears, and multidirectional instability. SLAP tears can be difficult to diagnose and arthroscopic diagnosis remains the gold standard. Surgical treatment as ranged from repair to biceps tenodesis with varying reports of success. Along the spectrum of SLAP tears, pan-labral tears consist of 360-degree injuries to the labrum. Patients can present complaining of either anterior or posterior instability alone, making the physical examination and advanced imaging a crucial component of the work up of the patients. Arthroscopic labral repair remains a good initial option for surgical treatment of these conditions. Multidirectional instability remains one of the more difficult conditions for the sports medicine physician to diagnose and treat. Symptoms may only be reported as vague pain versus frank instability making the diagnoses particularly challenging, especially in a patient with overall joint laxity. Conservative management to include physical therapy is the mainstay initial treatment in patients without an identifiable structural abnormality. Surgical management of this condition has evolved from open to arthroscopic capsular shifts with comparable results.
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18
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Hita‐Contreras F, Sánchez‐Montesinos I, Martínez‐Amat A, Cruz‐Díaz D, Barranco RJ, Roda O. Development of the human shoulder joint during the embryonic and early fetal stages: anatomical considerations for clinical practice. J Anat 2018; 232:422-430. [PMID: 29193070 PMCID: PMC5807935 DOI: 10.1111/joa.12753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 11/30/2022] Open
Abstract
Although several studies have been published regarding the morphology and anatomical variations of the human shoulder joint, most have dealt with adult individuals. Those looking into the development of the joint have been focused on specific structures or have observed specimens in advanced gestational stages. The goal of this paper is to perform a complete analysis of the embryonic and early fetal development of the elements in the shoulder joint, and to clarify some contradictory data in the literature. In our study, serial sections of 32 human embryos (Carnegie stages 16-23) and 26 fetuses (9-13 weeks) were analyzed. The chondrogenic anlagen of the humerus and the medial border of the scapula can be observed from as early as Carnegie stage 17, whereas that of the rest of the scapula appears at stage 18. The osteogenic process begins in week 10 for the humeral head and week 11 for the scapula. At stage 19 the interzone becomes apparent, which will form the glenohumeral joint. In the next stage the glenohumeral joint will begin delaminating and exhibiting a looser central band. Denser lateral bands will join the humeral head (caput humeri) and the margins of the articular surface of the scapula, thus forming the glenoid labrum, which can be fully appreciated by stage 22. In 24-mm embryos (stage 21) we can observe, for the first time, the long head of the biceps tendon (which is already inserted in the glenoid labrum by week 9), and the intertubercular sulcus, whose depth is apparent since week 12. Regarding ligamentous structures, the coracohumeral ligament is observed at the end of Carnegie stage 23, whereas the primitive glenohumeral ligament already appeared in week 10. The results of this study provide a detailed description of the morphogenesis, origin and chronological order of appearance of the main intrinsic structures of the human shoulder joint during late embryonic and early fetal development. We expect these results to help explain several functional aspects of the shoulder joint, and to clarify some contradictory data in the literature regarding this complex anatomical and biomechanical structure, helping future researchers in their efforts.
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Affiliation(s)
- Fidel Hita‐Contreras
- Human Anatomy and Embryology, Department of Health SciencesUniversity of JaénJaénSpain
| | | | - Antonio Martínez‐Amat
- Human Anatomy and Embryology, Department of Health SciencesUniversity of JaénJaénSpain
| | - David Cruz‐Díaz
- Human Anatomy and Embryology, Department of Health SciencesUniversity of JaénJaénSpain
| | - Rafael J. Barranco
- Human Anatomy and Embryology, Department of Health SciencesUniversity of JaénJaénSpain
| | - Olga Roda
- Department of Human Anatomy and Embryology, School of MedicineUniversity of GranadaGranadaSpain
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19
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De Coninck T, Ngai SS, Tafur M, Chung CB. Imaging the Glenoid Labrum and Labral Tears. Radiographics 2017; 36:1628-1647. [PMID: 27726737 DOI: 10.1148/rg.2016160020] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The shoulder joint is the most unstable articulation in the entire human body. While this certainly introduces vulnerability to injury, it also confers the advantage of broad range of motion. There are many elements that work in combination to offset the inherent instability of the glenohumeral joint, but the glenoid labrum is perhaps related most often. Broadly, clinical unidirectional instability can be subdivided into anterior and posterior instability, which usually raise concern for anteroinferior and posteroinferior labral lesions, respectively. In the special case of superior labral damage, potential dislocation is blocked by structures that include the acromion; hence, while damage elsewhere commonly manifests as clinical instability, damage to the superior labrum is often described by the term microinstability. In this particular case, one of the radiologist's main concerns should be classic superior labral anteroposterior lesions. The glenoid labrum is also subject to a wide range of normal variants that can mimic labral tears. Knowledge of these variants is central to interpreting an imaging study of the labrum because misdiagnosis of labral variants as tears can lead to superfluous surgical procedures and decreased shoulder mobility. This article reviews labral anatomy and normal labral variants, describes their imaging features, and discusses how to discriminate normal variants from labral tears. Specific labral pathologic lesions are described per labral quadrant (anteroinferior, posteroinferior, and superior), and imaging features are described in detail. Online supplemental material is available for this article. ©RSNA, 2016.
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Affiliation(s)
- Tineke De Coninck
- From the Department of Radiology, Ghent University Hospital, Ghent, Belgium (T.D.C.); Department of Radiology, University of California San Diego Medical Center, 200 W Arbor Dr, San Diego, CA 92103 (S.S.N., C.B.C.); Department of Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia (M.T.); and Radiology Service, VA San Diego Healthcare System, San Diego, Calif (C.B.C.)
| | - Steven S Ngai
- From the Department of Radiology, Ghent University Hospital, Ghent, Belgium (T.D.C.); Department of Radiology, University of California San Diego Medical Center, 200 W Arbor Dr, San Diego, CA 92103 (S.S.N., C.B.C.); Department of Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia (M.T.); and Radiology Service, VA San Diego Healthcare System, San Diego, Calif (C.B.C.)
| | - Monica Tafur
- From the Department of Radiology, Ghent University Hospital, Ghent, Belgium (T.D.C.); Department of Radiology, University of California San Diego Medical Center, 200 W Arbor Dr, San Diego, CA 92103 (S.S.N., C.B.C.); Department of Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia (M.T.); and Radiology Service, VA San Diego Healthcare System, San Diego, Calif (C.B.C.)
| | - Christine B Chung
- From the Department of Radiology, Ghent University Hospital, Ghent, Belgium (T.D.C.); Department of Radiology, University of California San Diego Medical Center, 200 W Arbor Dr, San Diego, CA 92103 (S.S.N., C.B.C.); Department of Radiology, Fundación Santa Fe de Bogotá, Bogotá, Colombia (M.T.); and Radiology Service, VA San Diego Healthcare System, San Diego, Calif (C.B.C.)
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20
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Abstract
The glenoid labrum is a critical structure within the gleno-humeral joint and commonly requires treatment by the shoulder surgeon. This review presents a concise summary of the embryology, anatomy, microscopy, biomechanical properties and clinical lesions involving the glenoid labrum. This knowledge will aid the clinician in understanding its function and pathology.
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Affiliation(s)
- Chris Smith
- University of Warwick, Clinical Sciences Research Institute, Coventry, UK
| | - Lennard Funk
- Department of Orthopaedics, Salford University, Salford, UK
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21
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Abstract
Imaging of the shoulder forms an important adjunct in clinical decision making in patients with shoulder instability. The typical lesions related with classic anterior and anteroinferior shoulder dislocation are an anteroinferior labral avulsion with or without bony fragment of bone loss – a (bony) Bankart lesion – and a posterolateral humeral head impaction fracture – the Hill-Sachs lesions. These are relatively straightforward to identify on imaging, although normal variants of the inferior labrum and variants of labral damage may cause confusion. Other capsuloligamentous lesions, often associated with less typical types of instability, are much more difficult to identify correctly on imaging, as they occur in the anterosuperior part of the glenohumeral joint with its many normal variants or because they result in more subtle, and therefore easily overlooked, changes in morphology or signal intensity. This paper aims at describing the appearance of the normal and pathologic glenohumeral joint related to shoulder instability. Ample reference will be given as to why identification of abnormalities, whether normal or pathologic, is important to the surgeon facing a treatment decision.
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22
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Abstract
Glenohumeral joint instability is usually an intimidating topic for most radiologists due to both the complexity of related anatomical and biomechanical considerations and the increasing number of classifications and acronyms reported in the literature in association with this condition. In this short review, we aim to demystify glenohumeral instability by first focusing on the relevant anatomy and pathophysiology. Second, we will review what the important imaging findings are and how to describe them for the clinician in the most relevant yet simple way. The role of the radiologist in assessing glenohumeral instability lesions is to properly describe the stabilizing structures involved (bone, soft-tissue stabilizers, and their periosteal insertion) to localize them and to attempt to characterize them as acute or chronic. Impaction fractures on the glenoid and humeral sides are important to specify, locate, and quantify. In particular, the description of soft-tissue stabilizers should include the status of the periosteal insertion of the capsulo-labro-ligamentous complex. Finally, any associated cartilaginous or rotator cuff tendon lesion should be reported to the clinician.
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23
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Jang SH, Seo JG, Jang HS, Jung JE, Kim JG. Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears. J Shoulder Elbow Surg 2016; 25:428-34. [PMID: 26671775 DOI: 10.1016/j.jse.2015.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 09/06/2015] [Accepted: 09/15/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Uncertainty remains in the natural course of superior labrum anterior-posterior (SLAP) tears treated conservatively with rehabilitation and activity modification. Our purpose was to evaluate clinical outcomes after nonoperative treatment of type II SLAP tear in young active patients and to identify factors related to negative outcomes. METHODS We retrospectively reviewed 63 patients who initially underwent nonoperative treatment for isolated type II SLAP tear. Assessments were made at baseline and at 6 months, and telephone survey was used to evaluate the final outcome. All included patients underwent a consistent nonoperative treatment protocol, and patient-specific data on the outcome were assessed. Failure was defined as abandonment of nonoperative management for surgery at any time points, <20-point improvement in American Shoulder and Elbow Surgeons score at final follow-up, or inability to return to activities. RESULTS At the average follow-up of 21 months, pain relief and function improved significantly (American Shoulder and Elbow Surgeons score, 54.2-86.4; Visual Analog Scale score, 4.6-1.7; P < .05) in 45 patients (71.4%) with successful nonoperative treatment. Eighteen patients (28.5%) were either dissatisfied with treatment or had arthroscopic surgery and were considered a failure group. Multivariate analysis showed that failure of nonoperative treatment is strongly linked with history of trauma, positive compression-rotation test result, and participation in overhead activities (P < .05). CONCLUSIONS An initial trial of nonoperative management may be considered in young active patients with isolated SLAP tear. Patients with history of trauma, mechanical symptoms, and demand for overhead activities are less likely to succeed.
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Affiliation(s)
- Suk-Hwan Jang
- Department of Orthopedic Surgery, Inje University, Seoul Paik Hospital, Seoul, Republic of Korea.
| | - Jeong-Gook Seo
- Department of Orthopedic Surgery, Inje University, Seoul Paik Hospital, Seoul, Republic of Korea
| | - Ho-Su Jang
- Department of Orthopedic Surgery, Inje University, Seoul Paik Hospital, Seoul, Republic of Korea
| | - Jae-Eun Jung
- Sports Medical Center, Inje University, Seoul Paik Hospital, Seoul, Republic of Korea
| | - Jin-Goo Kim
- Department of Orthopedic Surgery, Konkuk University Hospital, Seoul, Republic of Korea
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24
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Brockmeyer M, Tompkins M, Kohn DM, Lorbach O. SLAP lesions: a treatment algorithm. Knee Surg Sports Traumatol Arthrosc 2016; 24:447-55. [PMID: 26818554 DOI: 10.1007/s00167-015-3966-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 12/23/2015] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Matthias Brockmeyer
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany
| | - Marc Tompkins
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA.,TRIA Orthopaedic Center, Minneapolis, MN, USA
| | - Dieter M Kohn
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany
| | - Olaf Lorbach
- Department of Orthopedic Surgery, Saarland University, Kirrberger Str., 66421, Homburg/Saar, Germany.
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25
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Nishinaka N, Uehara T, Tsutsui H. Recurrent posterior dislocation of the shoulder associated with the Buford complex. J Clin Orthop Trauma 2016; 7:55-60. [PMID: 26908978 PMCID: PMC4735566 DOI: 10.1016/j.jcot.2015.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 08/14/2015] [Indexed: 10/23/2022] Open
Affiliation(s)
- Naoya Nishinaka
- Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama 227-8501, Japan,Corresponding author. Tel.: +81 45 974 6365; fax: +81 45 974 4610.
| | - Taishi Uehara
- Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama 227-8501, Japan
| | - Hiroaki Tsutsui
- Department of Sports Medicine and Orthopaedic Surgery, Showa University Fujigaoka Rehabilitation Hospital, 2-2-1 Fujigaoka, Aoba-ku, Yokohama 227-8518, Japan
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26
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Thompson JM, Carrino JA, Skolasky RL, Chhabra A, Fayad LM, Machado A, Soldatos T, Morrison WB, McFarland EG. Glenoid notch MRI findings do not predict normal variants of the anterior and superior labrum. Clin Radiol 2015; 70:e90-6. [PMID: 26050070 DOI: 10.1016/j.crad.2015.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 02/25/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Abstract
AIM To determine (1) the relationship of a glenoid notch to the presence of a normal labral variant in the anterior-superior glenoid labrum; (2) the inter- and intra-observer reliability of recognising a glenoid notch; and (3) whether magnetic resonance arthrography (MRA) is more reliable than non-contrast magnetic resonance imaging (MRI) in visualising a glenoid notch. MATERIALS AND METHODS From 1995 through 2010, 104 patients underwent MRI or MRA before diagnostic shoulder arthroscopy by the senior author. Five blinded musculoskeletal radiologists independently read the images twice to evaluate for the presence or absence of a glenoid notch. Fifty-nine (57%) patients had normal anterior-superior labral variants. The authors calculated the relationship of the readings to the arthroscopically determined presence or absence of a normal labral variant and the reading's diagnostic performance and rater reliability. RESULTS On average, 38% (range 9-65%) of the glenoid scans were read as notched. The sensitivity, specificity, positive predictive value, and negative predictive value of the notch relative to the presence of a normal variant were 43.1%, 71.2%, 70.2%, and 48% versus 44.3%, 77.5%, 79.4%, and 56.1% for MRI and MRA, respectively. The overall average intra-observer κ-values were 0.438 (range 0.203-0.555) and 0.346 (range -0.102 to 0.570) for MRI and MRA, respectively. The average interobserver intra-class correlation coefficient reliability values were 0.730 (range 0.693-0.760) and 0.614 (range 0.566-0.662) for MRI and MRA, respectively. CONCLUSIONS A notched glenoid on MRI lacks sufficient diagnostic performance and rater reliability for the clinical detection and prediction of normal anterior-superior labral variants.
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Affiliation(s)
- J M Thompson
- The Johns Hopkins School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - J A Carrino
- Department of Radiology and Imaging, Weill Medical College of Cornell University, Hospital for Special Surgery, New York, NY, USA
| | - R L Skolasky
- Spine Outcomes Center, The Johns Hopkins University, Baltimore, MD, USA
| | - A Chhabra
- Musculoskeletal Section, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - L M Fayad
- Musculoskeletal Section, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - A Machado
- Musculoskeletal Section, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - T Soldatos
- Musculoskeletal Section, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore, MD, USA
| | - W B Morrison
- Musculoskeletal Imaging Division, Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - E G McFarland
- Division of Shoulder Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA.
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27
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Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med 2015; 43:1274-82. [PMID: 24961444 DOI: 10.1177/0363546514536874] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Successful arthroscopic repair of symptomatic superior labral tears in young athletes has been well documented. Superior labral repair in patients older than 40 years is controversial, with concerns for residual postoperative pain, stiffness, and higher rates of revision surgery. PURPOSE To analyze the published data on the surgical treatment of superior labral injuries in patients aged ≥40 years, including those with concomitant injuries to the rotator cuff. STUDY DESIGN Systematic review. METHODS A systematic review of the literature was performed using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The MEDLINE database via PubMed and the Cochrane Database of Systematic Reviews were searched for articles related to superior labrum anterior-posterior (SLAP) tears. Studies were included if they met the following criteria: the study contained at least 1 group of patients who had undergone arthroscopic repair of a type II or IV SLAP lesion with a minimum 2-year follow-up, objective and/or functional scoring systems were used to evaluate postoperative outcomes, and the mean patient age was ≥40 years for at least 1 treatment arm or subgroup analysis. Studies were excluded if the article was a review or if the article included data for SLAP type I, III, or V to X tears or Bankart lesions. RESULTS While several authors reported equivalent outcomes of SLAP repair in patients both older than 40 years and younger than 40 years, others demonstrated significantly higher failure rates in the older cohort. Decreased patient satisfaction and increasing complications, including postoperative stiffness and reoperations, occur at higher rates as the patient age increases. The literature demonstrates that biceps tenotomy and tenodesis are reliable alternatives to SLAP repair and that biceps tenotomy is a viable revision procedure for failed SLAP repair. With concomitant rotator cuff tears, the evidence favors debridement or biceps tenotomy over SLAP repair. CONCLUSION While studies show that good outcomes can be obtained with SLAP repair in an older cohort of patients, age older than 40 years and workers' compensation status are independent risk factors for increased surgical complications. The cumulative evidence supports labral debridement or biceps tenotomy over labral repair when an associated rotator cuff injury is present.
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Affiliation(s)
- John Erickson
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Kyle Lavery
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - James Monica
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Charles Gatt
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Aman Dhawan
- Department of Orthopaedic Surgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
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Abstract
Throwers, or athletes who engage in repetitive overhead motions, are a unique subset of athletes that experience distinct shoulder injuries. Athletes engaged in baseball comprise the majority of patients seeking orthopedic care for throwing related injuries. Injuries specific to throwers most commonly involve the labrum and the undersurface of the rotator cuff. In addition, tissue changes in both the anterior and posterior glenohumeral capsule are common with repetitive overhead motions. These capsular changes alter. This article will examine the pathomechanics of injuries to throwers, elaborate means of diagnoses of cuff and labral injury and discuss recent advances in both non-operative and operative interventions, including preventative principles.
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Affiliation(s)
- Stuart D Kinsella
- Department of Orthopaedic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Stephen J Thomas
- Division of Nursing and Health Sciences, Neumann University, 1 Neumann Drive, Aston, PA 19104, USA
| | - G Russell Huffman
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104, USA
| | - John D Kelly
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104, USA.
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Vogel LA, Moen TC, Macaulay AA, Arons RR, Cadet ER, Ahmad CS, Levine WN. Superior labrum anterior-to-posterior repair incidence: a longitudinal investigation of community and academic databases. J Shoulder Elbow Surg 2014; 23:e119-26. [PMID: 24496049 DOI: 10.1016/j.jse.2013.11.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 10/11/2013] [Accepted: 11/06/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Superior labrum anterior-to-posterior (SLAP) lesion repair is controversial regarding indications and potential complications. METHODS Databases were used to determine the SLAP repair incidence compared with all orthopaedic procedures over a period of 10 years. In part A, the New York Statewide Planning and Research Cooperative System ambulatory surgery database was investigated from 2002 to 2009. In part B, the California Office of Statewide Health Planning and Development ambulatory surgery database was investigated from 2005 to 2009. In part C, the American Board of Orthopaedic Surgery (ABOS) database was investigated from 2003 to 2010. RESULTS In part A, from 2002 to 2009, there was a 238% increase in SLAP repair volume compared with a 125% increase in all orthopaedic procedures. In part B, from 2005 to 2009, there was a 20.17% increase in SLAP repair volume compared with a decrease of 13.64% in all orthopaedic procedures. In part C, among candidates performing at least 1 SLAP repair, there was no statistically significant difference in likelihood of performing a SLAP repair (95% confidence interval, 0.973-1.003) in 2010 as compared with 2003 (P > .10). CONCLUSIONS There has been a significant increase in the incidence of SLAP repairs in the past 10 years in statewide databases. This pattern was not seen in the ABOS database, in which the annual volume of SLAP repairs remained stable over the same period. This suggests that SLAP lesions have been over-treated with surgical repair but that part II ABOS candidates are becoming more aware of the need to narrow indications. LEVEL OF EVIDENCE Epidemiology study, database analysis.
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Affiliation(s)
- Laura A Vogel
- Department of Orthopaedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Todd C Moen
- W.B. Carrell Memorial Clinic, Dallas, TX, USA
| | - Alec A Macaulay
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raymond R Arons
- Department of Orthopaedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Edwin R Cadet
- Department of Orthopaedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Christopher S Ahmad
- Department of Orthopaedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - William N Levine
- Department of Orthopaedic Surgery, New York Presbyterian/Columbia University Medical Center, New York, NY, USA.
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Strauss EJ, Salata MJ, Sershon RA, Garbis N, Provencher MT, Wang VM, McGill KC, Bush-Joseph CA, Nicholson GP, Cole BJ, Romeo AA, Verma NN. Role of the superior labrum after biceps tenodesis in glenohumeral stability. J Shoulder Elbow Surg 2014; 23:485-91. [PMID: 24090980 DOI: 10.1016/j.jse.2013.07.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 07/14/2013] [Accepted: 07/16/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the role that a torn superior labrum (SLAP) plays in glenohumeral stability after biceps tenodesis. This biomechanical study evaluated the contribution of a type II SLAP lesion to glenohumeral translation in the presence of biceps tenodesis. The authors hypothesize that subsequent to biceps tenodesis, a torn superior labrum does not affect glenohumeral stability and therefore does not require anatomic repair in an overhead throwing athlete. METHODS Baseline anterior, posterior, and abduction and maximal external rotation glenohumeral translation data were collected from 20 cadaveric shoulders. Translation testing was repeated after the creation of anterior (n = 10) and posterior (n = 10) type II SLAP lesions. Translation re-evaluation after biceps tenodesis was performed for each specimen. Finally, anatomic SLAP lesion repair and testing were performed. RESULTS Anterior and posterior SLAP lesions led to significant increases in glenohumeral translation in all directions (P < .0125). Biceps tenodesis showed no significance in stability compared with SLAP alone (P > .0125). Arthroscopic repair of anterior SLAP lesions did not restore anterior translation compared with the baseline state (P = .0011) but did restore posterior (P = .823) and abduction and maximal external rotation (P = .806) translations. Repair of posterior SLAP lesions demonstrated no statistical difference compared with the baseline state (P > .0125). CONCLUSIONS With no detrimental effect on glenohumeral stability in the presence of a SLAP lesion, biceps tenodesis may be considered a valid primary or revision surgery for patients suffering from symptomatic type II SLAP tears. However, biceps tenodesis should be considered with caution as the primary treatment of SLAP lesions in overhead throwing athletes secondary to its inability to completely restore translational stability.
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Affiliation(s)
- Eric J Strauss
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Michael J Salata
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Robert A Sershon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.
| | - Nickolas Garbis
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Matthew T Provencher
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Vincent M Wang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kevin C McGill
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | | | - Gregory P Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony A Romeo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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McCormick F, Bhatia S, Chalmers P, Gupta A, Verma N, Romeo AA. The management of type II superior labral anterior to posterior injuries. Orthop Clin North Am 2014; 45:121-8. [PMID: 24267213 DOI: 10.1016/j.ocl.2013.08.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Arthroscopic repair of type II superior labral anterior to posterior (SLAP) tears is currently the standard of care, with most patients obtaining good to excellent surgical results. However, overhead athletes and older patients have inferior outcomes. Recent clinical studies and biomechanical data suggest that a biceps tenodesis is a suitable alternative in select patients. This article reviews the literature to identify the biomechanical and clinical indications for performing a biceps tenodesis for type II SLAP lesions.
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Affiliation(s)
- Frank McCormick
- Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 West Harrison Street, Suite 300, Chicago, IL 60612, USA.
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Plancher KD, Petterson SC. Arthroscopic Bankart Repair With Suture Anchors: Tips for Success. OPER TECHN SPORT MED 2013. [DOI: 10.1053/j.otsm.2013.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Mirkovic M, Green R, Taylor N, Perrott M. Accuracy of clinical tests to diagnose superior labral anterior and posterior (SLAP) lesions. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/108331905x43427] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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McDonald LCDRLS, Dewing CDRCB, Shupe LCDRPG, Provencher CDRMT. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg Am 2013; 95:1235-45. [PMID: 23824393 PMCID: PMC6948813 DOI: 10.2106/jbjs.l.00221] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- LCDR Lucas S. McDonald
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
| | - CDR Christopher B. Dewing
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
| | | | - CDR Matthew T. Provencher
- Department of Orthopaedics, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134-1112. E-mail address for L.S. McDonald:
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Garber AC, Argintar E, Shin SJ, McGarry MH, Tibone JE, Lee TQ. Kinematic effect of MGHL incorporation into Bankart repair. Orthopedics 2013; 36:653-8. [PMID: 23672898 DOI: 10.3928/01477447-20130426-31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Surgical treatment for traumatic shoulder instability has progressed in tandem with the evolution of the current understanding of the anatomy and biomechanics of the shoulder. Proponents of incorporating the middle glenohumeral ligament (MGHL) in Bankart repair believe this technique could increase repair strength. The purpose of this biomechanical study was to compare the range of motion and humeral head kinematic changes that result from including the MGHL in a Bankart repair in an effort to identify possible changes in shoulder biomechanics as a result of this addition in surgical repair.Six cadaveric shoulders were tested in 4 conditions: intact, Bankart lesion, repair excluding the MGHL, and repair including the MGHL. Each condition was tested for range of motion, glenohumeral translation, and humeral head apex position. Standard Bankart repair and repair with MGHL inclusion resulted in decreased range of motion, but no statistically significant difference was found between the 2 repair types (P=.846). Anterior translation was significantly reduced with both the Bankart repair (4.8 ± .9; P=.049) and included MGHL repair (4.6 ± 0.9; P=.029). No statistically significant difference was found between both repairs (P=.993). Although both repairs showed posterior displacement of the humeral head apex when in external rotation, this trend only reached statistical significance when compared with the Bankart lesion in 90° of external rotation (P=.0456); however, no significant difference was found between the 2 repairs (P=.999). Inclusion or exclusion of the MGHL in a Bankart repair does not significantly affect the range of motion, translation, or kinematics of the glenohumeral joint.
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Affiliation(s)
- Alexander C Garber
- Department of Orthopedic Surgery, University of Southern California, Los Angeles, California, USA
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Hanchard NCA, Lenza M, Handoll HHG, Takwoingi Y. Physical tests for shoulder impingements and local lesions of bursa, tendon or labrum that may accompany impingement. Cochrane Database Syst Rev 2013; 2013:CD007427. [PMID: 23633343 PMCID: PMC6464770 DOI: 10.1002/14651858.cd007427.pub2] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Impingement is a common cause of shoulder pain. Impingement mechanisms may occur subacromially (under the coraco-acromial arch) or internally (within the shoulder joint), and a number of secondary pathologies may be associated. These include subacromial-subdeltoid bursitis (inflammation of the subacromial portion of the bursa, the subdeltoid portion, or both), tendinopathy or tears affecting the rotator cuff or the long head of biceps tendon, and glenoid labral damage. Accurate diagnosis based on physical tests would facilitate early optimisation of the clinical management approach. Most people with shoulder pain are diagnosed and managed in the primary care setting. OBJECTIVES To evaluate the diagnostic accuracy of physical tests for shoulder impingements (subacromial or internal) or local lesions of bursa, rotator cuff or labrum that may accompany impingement, in people whose symptoms and/or history suggest any of these disorders. SEARCH METHODS We searched electronic databases for primary studies in two stages. In the first stage, we searched MEDLINE, EMBASE, CINAHL, AMED and DARE (all from inception to November 2005). In the second stage, we searched MEDLINE, EMBASE and AMED (2005 to 15 February 2010). Searches were delimited to articles written in English. SELECTION CRITERIA We considered for inclusion diagnostic test accuracy studies that directly compared the accuracy of one or more physical index tests for shoulder impingement against a reference test in any clinical setting. We considered diagnostic test accuracy studies with cross-sectional or cohort designs (retrospective or prospective), case-control studies and randomised controlled trials. DATA COLLECTION AND ANALYSIS Two pairs of review authors independently performed study selection, assessed the study quality using QUADAS, and extracted data onto a purpose-designed form, noting patient characteristics (including care setting), study design, index tests and reference standard, and the diagnostic 2 x 2 table. We presented information on sensitivities and specificities with 95% confidence intervals (95% CI) for the index tests. Meta-analysis was not performed. MAIN RESULTS We included 33 studies involving 4002 shoulders in 3852 patients. Although 28 studies were prospective, study quality was still generally poor. Mainly reflecting the use of surgery as a reference test in most studies, all but two studies were judged as not meeting the criteria for having a representative spectrum of patients. However, even these two studies only partly recruited from primary care.The target conditions assessed in the 33 studies were grouped under five main categories: subacromial or internal impingement, rotator cuff tendinopathy or tears, long head of biceps tendinopathy or tears, glenoid labral lesions and multiple undifferentiated target conditions. The majority of studies used arthroscopic surgery as the reference standard. Eight studies utilised reference standards which were potentially applicable to primary care (local anaesthesia, one study; ultrasound, three studies) or the hospital outpatient setting (magnetic resonance imaging, four studies). One study used a variety of reference standards, some applicable to primary care or the hospital outpatient setting. In two of these studies the reference standard used was acceptable for identifying the target condition, but in six it was only partially so. The studies evaluated numerous standard, modified, or combination index tests and 14 novel index tests. There were 170 target condition/index test combinations, but only six instances of any index test being performed and interpreted similarly in two studies. Only two studies of a modified empty can test for full thickness tear of the rotator cuff, and two studies of a modified anterior slide test for type II superior labrum anterior to posterior (SLAP) lesions, were clinically homogenous. Due to the limited number of studies, meta-analyses were considered inappropriate. Sensitivity and specificity estimates from each study are presented on forest plots for the 170 target condition/index test combinations grouped according to target condition. AUTHORS' CONCLUSIONS There is insufficient evidence upon which to base selection of physical tests for shoulder impingements, and local lesions of bursa, tendon or labrum that may accompany impingement, in primary care. The large body of literature revealed extreme diversity in the performance and interpretation of tests, which hinders synthesis of the evidence and/or clinical applicability.
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Affiliation(s)
- Nigel C A Hanchard
- Health and Social Care Institute, Teesside University, Middlesbrough, UK.
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Affiliation(s)
- Michael B Zlatkin
- National Musculoskeletal Imaging (NMSI), Deerfield Beach, FL 33441, USA; School of Medicine, University of Miami, Miami, FL 33124, USA.
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Tuite MJ, Currie JW, Orwin JF, Baer GS, del Rio AM. Sublabral clefts and recesses in the anterior, inferior, and posterior glenoid labrum at MR arthrography. Skeletal Radiol 2013; 42:353-62. [PMID: 22893302 DOI: 10.1007/s00256-012-1496-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 07/24/2012] [Accepted: 07/25/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the prevalence of a normal variant cleft/recess at the labral-chondral junction in the anterior, inferior, and posterior portions of the shoulder joint. MATERIALS AND METHODS One hundred and three consecutive patients (106 shoulders) who had a direct MR arthrogram followed by arthroscopic surgery were enrolled in this IRB-approved study. Scans were carried out on a 1.5-T scanner with an eight-channel shoulder coil. The glenoid rim was divided into eight segments and the labrum in all but the superior and anterosuperior segments was evaluated by two radiologists for the presence of contrast between the labrum and articular cartilage. We measured the depth of any cleft/recess and correlated the MR findings with surgical results. Generalized estimating equation models were used to correlate patient age and gender with the presence and depth of a cleft/recess, and Cohen's kappa values were calculated for interobserver variability. RESULTS For segments that were normal at surgery, a cleft/recess was present within a segment on MR arthrogram images in as few as 7 % of patients (within the posteroinferior segment by observer 1), and in up to 61 % of patients (within the posterosuperior segment by observer 1). 55-83 % of these were only 1 mm deep. A 2- to 3-mm recess was seen within 0-37 % of the labral segments, most commonly in the anterior, anteroinferior, and posterosuperior segments. Age and gender did not correlate with the presence of a cleft/recess, although there was an association between males and a 2- to 3-mm deep recess (p = 0.03). The interobserver variability for each segment ranged between 0.15 and 0.49, indicating slight to moderate agreement. CONCLUSION One-mm labral-chondral clefts are not uncommon throughout the labrum. A 2- to 3-mm deep smooth, medially curved recess in the anterior, anteroinferior or posterosuperior labrum can rarely be seen, typically as a continuation of a superior recess or anterosuperior labral variant.
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Affiliation(s)
- Michael J Tuite
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792-3252, USA.
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Knesek M, Skendzel JG, Dines JS, Altchek DW, Allen AA, Bedi A. Diagnosis and management of superior labral anterior posterior tears in throwing athletes. Am J Sports Med 2013; 41:444-60. [PMID: 23172004 DOI: 10.1177/0363546512466067] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.
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Affiliation(s)
- Michael Knesek
- Department of Orthopaedic Surgery, University of Michigan, 24 Frank Lloyd Wright Drive, Lobby A, Ann Arbor, MI 48106, USA
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Short-term clinical results after arthroscopic type II SLAP repair. Wien Klin Wochenschr 2012; 124:370-6. [PMID: 22688135 DOI: 10.1007/s00508-012-0184-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 05/16/2012] [Indexed: 01/02/2023]
Abstract
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.
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Anatomic Variants and Pitfalls of the Labrum, Glenoid Cartilage, and Glenohumeral Ligaments. Magn Reson Imaging Clin N Am 2012; 20:213-28, x. [DOI: 10.1016/j.mric.2012.01.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Superior Labrum Anterior and Posterior Lesions and Microinstability. Magn Reson Imaging Clin N Am 2012; 20:277-94, x-xi. [DOI: 10.1016/j.mric.2012.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Jakanani GC, Botchu R, Rennie WJ. The MR arthrographic anatomy of the biceps labral insertion and its morphological significance with labral tears in patients with shoulder instability. Eur J Radiol 2012; 81:3390-3. [PMID: 22465122 DOI: 10.1016/j.ejrad.2012.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 02/29/2012] [Accepted: 03/01/2012] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Most of the fibres of the long head of biceps tendon attach on the superior labrum just posterior to the supraglenoid tubercle. AIM Our hypothesis was that posteriorly attached biceps tendons predispose to posterior superior labral tears and SLAP lesions. METHODS AND MATERIALS A prospective analysis of all MR shoulder arthrograms for shoulder instability referred from the shoulder specialist clinics, performed during a one year period were reviewed by two independent observers who were blinded to clinical history. The biceps attachment was classified into four groups according to the method described in an earlier cadaveric study into four groups; posterior-type 1, predominantly posterior-type 2, equal contributions to both anterior and posterior labrum-type 3 and predominantly anterior labral attachment-type 4. Data was analysed using Kappa statistics and Fischer's exact test. RESULTS 48 patients (33 males and 15 females) were included in this study with a mean age of 32 years. Majority, 22 patients (46%) had a type 1 attachment of the biceps on the superior labrum. There was moderate intra-observer and good interobserver agreement with a Kappa of 0.58 and 0.63 respectively. There was a significant association between a type 2 attachment and posterior tears (p≤0.04) and also between a type 2 attachment and SLAP tears (p≤0.04). CONCLUSION Our results suggest that variation in anatomy of biceps origin influences the type of labral tears that occur in patients with shoulder instability. The importance of these findings could influence selection of individuals in throwing sports like cricket and baseball.
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Powell SE, Nord KD, Ryu RK. The Diagnosis, Classification, and Treatment of SLAP Lesions. OPER TECHN SPORT MED 2012. [DOI: 10.1053/j.otsm.2012.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Superior Labral Anteroposterior Lesions of the Shoulder: Part 1, Anatomy and Anatomic Variants. AJR Am J Roentgenol 2011; 197:596-603. [DOI: 10.2214/ajr.10.7236] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Sandhu B, Sanghavi S, Lam F. Superior Labrum Anterior to Posterior (SLAP) lesions of the shoulder. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.mporth.2010.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Jia X, Yokota A, McCarty EC, Nicholson GP, Weber SC, McMahon PJ, Dunn WR, McFarland EG. Reproducibility and reliability of the Snyder classification of superior labral anterior posterior lesions among shoulder surgeons. Am J Sports Med 2011; 39:986-91. [PMID: 21285446 DOI: 10.1177/0363546510392332] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous studies of the reliability of classifications for superior labral anterior and posterior (SLAP) lesions suggest that intraobserver/interobserver reliability is poor. PURPOSE The goals were to (1) evaluate intraobserver/interobserver reliability of the Snyder classification of labrum tears among experienced surgeons, (2) determine the effect of simplifying that classification into normal versus abnormal labrums, (3) determine the reliability of subdividing type II SLAP lesions, and (4) evaluate the effect of videotape quality on diagnostic confidence. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS At 2 separate times, 5 experienced shoulder surgeons (all >10 years of practice) evaluated 90 videotapes of shoulder arthroscopy performed for SLAP lesions to identify lesion type, to grade video quality, and to determine degree of confidence in diagnosis. The results were compared for intraobserver reliability (κ analysis) and interobserver reliability (intraclass correlation coefficients) and effect of video quality on diagnostic confidence. Significance was set at P < .05. RESULTS When the choices were normal labrum or the 4 types of SLAP lesions, the intraobserver agreements (mean κ, 0.670) and interobserver agreements (mean correlation, 0.804) were substantial. When the labrums were divided into normal (normal and type I) and abnormal (types II-IV), the intraobserver agreements (mean κ, 0.792) and interobserver agreements (mean correlation, 0.648) were substantial. When the 3 type II SLAP lesion subvariants were evaluated, the intraobserver agreement (mean κ, 0.598) was moderate, and the interobserver agreement (mean correlation, 0.804) was substantial. The confidence of the diagnosis was highly correlated with the perceived video quality (average Pearson correlation, 0.718; P < .01). Repeated measures analysis showed a significant relationship between confidence and quality (parameter estimate, 0.732; standard error, 0.021; P < .01) adjusting for rater and review. CONCLUSION For experienced shoulder surgeons, the Snyder classification is a reliable system for identifying SLAP lesions.
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Affiliation(s)
- Xiaofeng Jia
- Departments of Biomedical Engineering, Physical Medicine and Rehabilitation, The Johns Hopkins University, Baltimore, Maryland, USA
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