Lesions involving the superior labrum in throwing athletes were first described by Andrews et al.¹ in 1985. Snyder et al.,² in 1990, coined the term SLAP (superior labrum, anterior to posterior) tear, to describe a tear of the superior labrum which begins posteriorly and extends anteriorly to involve the anchor of the tendon of the long head of the biceps.

Initially, SLAP lesions were treated with simple debridement alone.¹ Poor results of debridement alone are generally attributed to uncertain healing and continued instability. Subsequently, arthroscopic stapling techniques were developed to secure the biceps anchor.³ This technique necessitates staple removal 3 to 6 months postoperatively. Transosseous suture techniques tied over the infraspinatus fascia were developed in 1993 providing good results, but were technically demanding.⁴ That same year, results of cannulated screw stabilization under arthroscopic guidance were reported.⁵ Again, screw removal was required, and additional complications were noted, including articular damage and screw loosening. Bioabsorbable anchor stabilization was described at this time but was extensively complicated by implant breakage and reoperation for removal of loose fragments.⁶

Most recently, the use of suture anchors in the stabilization of SLAP lesions has come into favor. Good clinical results and lower complication/reoperation rates have been shown.^7,8,9

Diagnosis of a SLAP tear may be challenging. Several mechanisms of injury have been proposed, such as traction/rotation (as in an overhead athlete),¹ superior shear and traction,^10,11 and “peel back.”¹² Several clinical examinations have been described, such as the active compression test,¹³ the crank test,¹⁴ and the biceps load test¹⁵ in order to aid in the diagnosis. Plain radiographs should be obtained but are usually not helpful in making the diagnosis. Magnetic resonance imaging with intra-articular gadolinium enhancement is the diagnostic test of choice.^16,17 Once a patient has failed conservative treatments for shoulder pain, instability, and mechanical symptoms, a diagnostic arthroscopy is performed.

Indications for the arthroscopic treatment of SLAP lesions are usually based on classification of tears by Snyder et al.¹⁰ (Fig. 16-1). Types I and III lesions are generally treated with debridement of unstable labral tissue. The bucket handle fragment in type III lesions is resected and the residual rim is evaluated for stability and repair if possible. Type II lesions are treated with arthroscopic fixation of the superior labrum to the glenoid rim spanning the biceps anchor. The treatment of type IV lesions depends on the amount of torn biceps tendon associated with the labral tear. Treatment of these injuries also depends on the age and activity of the patient. If less than 50% of the biceps tendon is involved, the unstable biceps tissue can be resected and the remaining labrum can be repaired to the glenoid. In an older patient with more than 50% of the biceps tendon involved, biceps tenotomy or tenodesis is usually performed. In younger patients, biceps tenodesis and suture anchor repair is currently recommended.

The patient is placed under general anesthetic. An intercalene block is recommended for postoperative pain control. This can be done in the preoperative area or in the
operating room. The patient is then positioned in a lateral decubitus position, and the affected extremity is hung in 10 to 15 lb of traction. The extremity is prepped and draped in usual sterile fashion. The skin markings then become important visual aids. A standard posterior portal is created first, and a diagnostic arthroscopy of the glenohumeral joint is performed. Fluid infusion through gravity or a pump may be used. If a pump is used, the pressure need not be more than 35 mm Hg. Bleeding is rarely encountered during this procedure. Keeping the pressure low will prevent extravasation and swelling. An anterior portal is created next, through the rotator interval. We prefer an outside-in technique of portal placement for accurate cannula positioning high in the rotator cuff interval to give the proper angle of approach to the glenoid for anchor placement. A 5- or 8-mm cannula may be used. A hooked probe is then inserted and the superior labrum is examined (Fig. 16-2). A periosteal elevator is then used to separate the labrum from the glenoid (Fig. 16-3). A shaver is introduced and the superior glenoid is debrided to a bony base (Fig. 16-4). At this point, a second cannula is inserted through a lateral acromial (portal of Wilmington). A spinal needle should be used to determine accurate portal placement (Fig. 16-5). The second cannula should be placed at approximately at the midacromial dimension and immediately adjacent to the lateral edge of the acromion. This cannula will penetrate the posterior supraspinatus and anterior infraspinatus in their muscular portions medial to the rotator cuff cable, not through the crescent area of the rotator cuff tendon lateral to the cable (Fig. 16-5). Prior to cannula placement, a straight snap is introduced and the portal enlarged through the cuff muscle and superior capsule. A switching stick can then be inserted, followed by a dilator to allow easier placement of the cannula (Fig. 16-6A,B,C). A
Bio-SutureTak suture anchor loaded with no. 2 FiberWire (Arthrex, Inc, Naples, Fla) is then placed in the glenoid rim posterior to the biceps tendon (Fig. 16-7A,B). The suture limb closest to the labrum is then retrieved from the anterior cannula (Fig. 16-8). A SutureLasso (Arthrex, Inc, Naples, Fla) is then inserted through the lateral acromial portal and passed through the superior labrum (Fig. 16-9A). The looped end of the wire inside the SutureLasso is then advanced into the joint and retrieved from the anterior portal (Fig. 16-9B,C). The suture limb is then threaded through the loop of the wire and the wire is pulled out from the lateral acromial portal, thus shuttling one limb of suture through the labrum (Fig. 16-10). The other suture limb is then retrieved through the anterior superior portal. An arthroscopic sliding knot is then used and advanced down to the labrum with a knot pusher (Fig. 16-11). Care is taken to place the knot behind the labrum and not into the joint. The steps are then carried out through the other portal, after placing a second anchor anterior to the biceps tendon (Fig. 16-12).