How to Deal With Higher-Grade (Advanced) SLAP Lesions: Treatment of Type III, IV and V SLAP Tears


Chapter 45

How to Deal With Higher-Grade (Advanced) SLAP Lesions


Treatment of Type III, IV and V SLAP Tears



Fotios P. Tjoumakaris, and James P. Bradley

Introduction


The treatment of lesions of the superior labrum has advanced considerably over the past two decades of shoulder arthroscopy, as has understanding of this complex structure. A rarely recognized source of shoulder pain in the latter part of the 20th century has now become one of the largest indications for shoulder surgery in board-certified candidates. Although less common than superior labrum anterior and posterior (SLAP) types I and II tears, type III (bucket handle tear of the superior labrum), type IV (extension of the tear into the biceps tendon), and type V (type II lesion with an associated Bankart lesion) SLAP lesions of the shoulder have been associated with higher-demand occupations and recurrent glenohumeral instability. This chapter outlines the clinical history, examination, and radiographic findings of patients presenting with types III, IV, and V SLAP lesions of the shoulder, as well as details the arthroscopic methods of current treatment.

Procedure


Arthroscopic management of patients presenting with SLAP types III, IV, and V tears centers primarily on the treatment of the biceps tendon and debridement of the superior labrum in type III tears, treatment of the superior labrum and biceps tendon in type IV tears, and the combined treatment of the Bankart and type II SLAP lesion in type V tears. Treatment of type III tears consists primarily of debridement of the bucket handle tear of the superior labrum, with or without biceps tendon debridement or tenodesis of the long head of the biceps if the tear extends into the biceps tendon proper (a type IV tear). Patients with type V tears typically undergo arthroscopic pan-labral repair of the superior and anterior inferior labrum; however, in patients over the age of 35, there may be an indication for biceps tenodesis for treatment of the type II lesion.

Patient History



Patient Examination



Imaging



Treatment Options: Nonoperative And Operative





  1. • Conservative treatment consists of rest, antiinflammatory medication, cessation of inciting activities, and a structured physical therapy program focusing on rotator cuff and scapular strengthening. Patients with rotator cuff impingement symptoms can be offered corticosteroid injection (either intraarticularly or into the subacromial space).
  2. • Physical therapy may be continued for 6–8 weeks, and beyond that a slow transition back to activities can help determine if the patient can return to normal activities or sports. For throwing athletes, resumption of throwing should not proceed until the athlete has had an opportunity to complete a supervised and structured throwing program.


  3. • Conservative treatment may have moderate success in athletes and nonathletes alike and should be initiated first in the majority of patients. Exceptions may be those patients with type V SLAP lesions in whom recurrent glenohumeral instability is a component of their presenting complaint.
  4. • Surgical treatment is typically offered for those patients for whom conservative treatment fails or for high-demand patients (laborers, athletes). Arthroscopy is the gold standard of treatment for the majority of patients and has supplanted open techniques. Repair of the anterior inferior labrum and superior labrum is indicated in younger, more active patients with type V SLAP tears. Biceps tenodesis is an effective treatment option for patients over 35 years of age for the superior labrum tear (either open or arthroscopic) found in type V tears. Type III tears are typically treated with debridement of the torn labrum with or without biceps tenodesis if the tear extends into the long head of the biceps tendon (for a type IV tear).

Surgical Anatomy



Surgical Indications



Surgical Technique/Setup


Positioning





  1. • Surgery can be accomplished with the patient in the lateral decubitus or beach chair position.
  2. • Our preferred technique is the lateral decubitus position to allow for traction on the affected extremity that facilitates glenoid exposure during repair of type V SLAP lesions. The arm is placed at 45 degrees of abduction and 20 degrees of forward flexion during the procedure (see Fig. 45.3).


  3. • All bony prominences should be well padded and an axillary roll placed to prevent contralateral extremity brachial plexus injury.
  4. • The arthroscopic monitor typically faces opposite the surgeon, and the surgeon faces the posterior aspect of the shoulder. The table is turned at an angle of 45 degrees to prevent contamination of the surgical field with anesthesia equipment. Surgical equipment is located on a back table on the same side of the patient as the surgeon.

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on How to Deal With Higher-Grade (Advanced) SLAP Lesions: Treatment of Type III, IV and V SLAP Tears

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