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.
Key points
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Superior labral anterior to posterior (SLAP) repair failure is unclear and likely multifactorial.
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Current evidence offers no consensus on the dynamic muscular role of the long head of the biceps tendon in the glenohumeral joint.
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SLAP repairs result in slightly higher outcomes but at an increased complication rate and rehabilitation.
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Arthroscopic SLAP repairs remain the gold standard; however, clinicians are cautious in older patients and overhead athletes.
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The authors recommend tenodesis in the revision setting.
Introduction
Superior labral anterior to posterior (SLAP) tears were first recognized by Andrews and colleagues nearly 30 years ago in throwing athletes. Snyder and colleagues later classified these injuries into 4 basic subtypes.
Type I lesions are characterized by fraying at the inner margin of the labrum, which can be considered a normal part of the aging process. Type II lesions are the most common variant, consisting of a separation of the biceps and labrum from the superior glenoid, erythema at the SLAP anchor insertion, and a minimum of 5 mm of excursion ( Fig. 1 ). A sulcus of 1 to 2 mm is considered normal. Intraoperatively placing the arm in abduction and external rotation and arthroscopically observing the peel-back phenomenon can confirm the diagnosis. Type II SLAP lesions have also been further subclassified into anterior, posterior, and combined, wherein the direction of tear propagation progresses to concomitant directional microinstability and partial-thickness rotator cuff tears (ie, posterior extension predicted posterior microinstability and posterior partial rotator cuff tears). Type III lesions are characterized by an intact biceps complex junction at the superior glenoid but with a bucket-handle–type tear within the superior labral complex. A type IV tear is a type III tear with a concomitant separation of the superolabral junction with the glenoid, thus, also meeting the diagnosis of a type II lesion.
Maffet and colleagues expanded the original classification to include type V through VII lesions. Type V lesions are SLAP lesions in continuity with anteroinferior Bankart-type labral lesions and type VI lesions involve biceps tendon separation with an unstable flap of the labrum. In type VII lesions, the superior-labrum biceps tendon separation extends below the middle glenohumeral ligament. SLAP tears have been further characterized into 10 subtypes based on concurrent instability and posterior extension.
The optimal management of patients with suspected SLAP tears remains controversial. At a minimum, patients should undergo 3 months of conservative management before surgical options are explored. Conservative treatment begins with rest, activity modification, and oral anti-inflammatory prescriptions. A formal physical therapy protocol should be instituted to address any scapular dyskinesis and rotator cuff imbalance with open and closed chain exercises. Stretching of the posterior capsule via the sleeper stretch may also be effective. If these initial measures are successful, the authors advance therapy to include core and trunk strengthening, followed by a formal throwing protocol.
The incidence of surgically treated SLAP tears has risen dramatically over the past decade. Arthroscopic repair of type II SLAP tears that have failed to respond to conservative treatment is currently the standard of care. Numerous prospective trials have shown good to excellent surgical outcomes at 2-year follow-up ( Table 1 ). Furthermore, a recent meta-analysis of outcomes after arthroscopic surgical repair of type II SLAP lesions showed that 83% of patients had good-to-excellent satisfaction scores and 73% of athletes returned to their preinjury level of play.
| Study | Enrollment | ASES Mean a | Standard Deviation | Mean Follow-up |
|---|---|---|---|---|
| Provencher et al, 2013 | 179 | 88.2 | 5.3 | 40.4 |
| Denard et al, 2012 | 55 | 86.2 | NR | 77.0 |
| Brockmeier et al, 2009 | 47 | 97.0 | 10.8 | 32.4 |
| Friel et al, 2010 | 48 | 83.3 | NR | 40.8 |
| Silberberg et al, 2011 | 32 | 93.9 | 13.0 | 37.0 |
a The average ASES score of 361 patients undergoing repair is 88.8.
Despite the overall good to excellent outcomes and high patient satisfaction, challenges remain in the care of these lesions in overhead athletes, older patients, and patients who develop postoperative stiffness. Functional results of overhead athletes are inferior to those of the general population; on average, one-third of overhead athletes are unable to return to their previous level of function after SLAP repair. Postoperative stiffness is the most common complication. Most patients require 6 months to regain full range of motion. In addition, up to one-fifth of patients lack full range of motion 5 years postoperatively. For instance, in a large prospective series involving military patients, mean forward flexion and external rotation were significantly reduced at final follow-up. Older patients also tend to have significantly worse functional results.
Biceps tenodesis has been proposed as a surgical alternative, particularly in older patients and overhead athletes. Biceps tenodesis has a low complication rate, a high rate of postoperative patient satisfaction, and excellent functional outcomes. This article discusses the role of biceps tenodesis in the management of SLAP tears.
Introduction
Superior labral anterior to posterior (SLAP) tears were first recognized by Andrews and colleagues nearly 30 years ago in throwing athletes. Snyder and colleagues later classified these injuries into 4 basic subtypes.
Type I lesions are characterized by fraying at the inner margin of the labrum, which can be considered a normal part of the aging process. Type II lesions are the most common variant, consisting of a separation of the biceps and labrum from the superior glenoid, erythema at the SLAP anchor insertion, and a minimum of 5 mm of excursion ( Fig. 1 ). A sulcus of 1 to 2 mm is considered normal. Intraoperatively placing the arm in abduction and external rotation and arthroscopically observing the peel-back phenomenon can confirm the diagnosis. Type II SLAP lesions have also been further subclassified into anterior, posterior, and combined, wherein the direction of tear propagation progresses to concomitant directional microinstability and partial-thickness rotator cuff tears (ie, posterior extension predicted posterior microinstability and posterior partial rotator cuff tears). Type III lesions are characterized by an intact biceps complex junction at the superior glenoid but with a bucket-handle–type tear within the superior labral complex. A type IV tear is a type III tear with a concomitant separation of the superolabral junction with the glenoid, thus, also meeting the diagnosis of a type II lesion.
Maffet and colleagues expanded the original classification to include type V through VII lesions. Type V lesions are SLAP lesions in continuity with anteroinferior Bankart-type labral lesions and type VI lesions involve biceps tendon separation with an unstable flap of the labrum. In type VII lesions, the superior-labrum biceps tendon separation extends below the middle glenohumeral ligament. SLAP tears have been further characterized into 10 subtypes based on concurrent instability and posterior extension.
The optimal management of patients with suspected SLAP tears remains controversial. At a minimum, patients should undergo 3 months of conservative management before surgical options are explored. Conservative treatment begins with rest, activity modification, and oral anti-inflammatory prescriptions. A formal physical therapy protocol should be instituted to address any scapular dyskinesis and rotator cuff imbalance with open and closed chain exercises. Stretching of the posterior capsule via the sleeper stretch may also be effective. If these initial measures are successful, the authors advance therapy to include core and trunk strengthening, followed by a formal throwing protocol.
The incidence of surgically treated SLAP tears has risen dramatically over the past decade. Arthroscopic repair of type II SLAP tears that have failed to respond to conservative treatment is currently the standard of care. Numerous prospective trials have shown good to excellent surgical outcomes at 2-year follow-up ( Table 1 ). Furthermore, a recent meta-analysis of outcomes after arthroscopic surgical repair of type II SLAP lesions showed that 83% of patients had good-to-excellent satisfaction scores and 73% of athletes returned to their preinjury level of play.
| Study | Enrollment | ASES Mean a | Standard Deviation | Mean Follow-up |
|---|---|---|---|---|
| Provencher et al, 2013 | 179 | 88.2 | 5.3 | 40.4 |
| Denard et al, 2012 | 55 | 86.2 | NR | 77.0 |
| Brockmeier et al, 2009 | 47 | 97.0 | 10.8 | 32.4 |
| Friel et al, 2010 | 48 | 83.3 | NR | 40.8 |
| Silberberg et al, 2011 | 32 | 93.9 | 13.0 | 37.0 |
a The average ASES score of 361 patients undergoing repair is 88.8.
Despite the overall good to excellent outcomes and high patient satisfaction, challenges remain in the care of these lesions in overhead athletes, older patients, and patients who develop postoperative stiffness. Functional results of overhead athletes are inferior to those of the general population; on average, one-third of overhead athletes are unable to return to their previous level of function after SLAP repair. Postoperative stiffness is the most common complication. Most patients require 6 months to regain full range of motion. In addition, up to one-fifth of patients lack full range of motion 5 years postoperatively. For instance, in a large prospective series involving military patients, mean forward flexion and external rotation were significantly reduced at final follow-up. Older patients also tend to have significantly worse functional results.
Biceps tenodesis has been proposed as a surgical alternative, particularly in older patients and overhead athletes. Biceps tenodesis has a low complication rate, a high rate of postoperative patient satisfaction, and excellent functional outcomes. This article discusses the role of biceps tenodesis in the management of SLAP tears.
Causes of failure of SLAP repair
Surgical repair of type II SLAP lesions involves arthroscopic fixations of the labrum and biceps insertion to the superior glenoid. A variety of techniques have been devised for this anatomic repair, including suture anchor and bioabsorbable tack fixation. Irrespective of techniques, common causes of failure are recognized ( Fig. 2 ). Postoperative stiffness can be caused by intraoperative technical errors. Inadvertent restriction of physiologic biceps excursion from overtensioning the repair or from nonanatomic biceps anchor reduction can contribute to this. Overhead athletes are particularly prone to this complication. Sutures placed anterior to the biceps into the rotator interval tissue can lead to overtensioning of the anterior capsule, superior glenohumeral ligament, and even middle glenohumeral ligament, which can result in loss of external rotation ( Fig. 3 ).
