Treatment

Labral Repair

Dustin L. Richter, MD
Jourdan Cancienne, MD
Stephen F. Brockmeier, MD

Abstract

Superior labrum anterior and posterior (SLAP) tears are commonly a result of a traction injury and are often seen in overhead athletes. Type II SLAP tears, characterized by a detached biceps tendon anchor, are the most common type of SLAP tear to require surgical repair. Indications for arthroscopic repair of SLAP lesions continue to evolve. The strongest indication for, as well as the situation with the best expected outcome following repair, is an active younger patient with consistent history, physical examination, and imaging findings, in whom nonoperative management has failed and who has no identifiable concomitant pathologic abnormality. Current literature suggests that repair of type II SLAP lesions provides significant improvement in patient-reported outcome scores and satisfaction. However, this improvement may not translate to return to preinjury activity levels, especially in elite overhead athletes. This chapter reviews the pertinent anatomy and diagnosis, then elaborates on the surgical indications and our preferred SLAP repair technique. Lastly, the current evidence for management of these injuries is reviewed.

Keywords: Biceps anchor tear, Biceps labral complex injury, SLAP repair, SLAP tear, Type II SLAP tear

Introduction

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Superior labrum anterior and posterior (SLAP) tear is are commonly a result of a traction injury and is often seen in overhead athletes. It may occur as an isolated lesion or may be associated with other concomitant pathology such as internal impingement or partial-thickness articular-sided rotator cuff tear.
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Type II SLAP tear, characterized by a detached biceps tendon anchor, is the most common type of SLAP tear to require surgical repair.
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Indications for arthroscopic repair of SLAP lesions continue to evolve. The strongest indication for, and the situation with the best-expected outcome following repair, is an active younger patient with consistent history, physical examination, and imaging findings, in whom nonoperative management has failed and who has no identifiable concomitant pathologic abnormality (i.e., biceps, rotator cuff).
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Portal placement is critical for an effective anatomic repair. The most important suture in the SLAP repair is the suture loop placed posterior to the biceps at the corner of the glenoid to resist torsional peel-back.
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Current literature suggests that repair of type II SLAP lesions provides significant improvement in patient-reported outcome scores and satisfaction. However, this improvement may not translate to return to preinjury activity levels, especially in elite overhead athletes.

Anatomy and Background

The long head of the biceps tendon originates from the supraglenoid tubercle on the scapula and is an intraarticular structure continuous with the superior glenoid labrum ( ). In a cadaveric study, the bicipital insertion on the labrum was classified as entirely or predominantly posterior in 55% of cases, split equally between anterior and posterior in 37%, and predominantly anterior in 8% ( ). Several anatomic variants of both the anterosuperior labrum and the long head of the biceps have been described in the literature ( ). Proximally, the long head of the biceps receives its blood supply from the anterior humeral circumflex artery, whereas the labrum is supplied separately by branches of the suprascapular, circumflex scapular, and posterior circumflex humeral arteries. The anterosuperior labrum and glenoid represent a vascular watershed region without a robust blood supply, a feature that can lead to both tearing and difficulty healing after surgical repair ( ).

The term “superior labrum anterior to posterior” (SLAP) describes the superior aspect of the glenoid labrum, starting posteriorly and extending anteriorly, including the origin of the long head of the biceps. Andrews et al, in 1985, first described disruption of the long head of the biceps (LHB) anchor and superior labrum from the glenoid. Snyder et al, in 1990, coined the term SLAP lesion and designated the first four anatomic classifications ( Fig. 19A.1 ) Type II SLAP tears are the most commonly repaired of the various types. These lesions occur when the superior labrum detaches medially from the glenoid bone—leaving the superior glenoid neck uncovered for at least 5 mm from the corner of the glenoid. This creates a gap between the articular cartilage and the labral attachment onto the bone.

Since the original description and classification, there has been a substantial amount of research focusing on the anatomy, pathogenesis, clinical diagnosis, and arthroscopic treatment of the SLAP tear ( ; ; ). Once thought to be unique to overhead athletes, SLAP lesions are increasingly being diagnosed and recognized as a major source of shoulder pain and dysfunction in cohorts of older, nonthrowing patients ( ) Furthermore, SLAP lesions are typically encountered with concomitant shoulder pathology. In a review of 2375 shoulder arthroscopies with 140 SLAP lesions, noted that 29% of these lesions were accompanied by a partial-thickness tear of the rotator cuff, 11% by a full-thickness tear of the rotator cuff, and 22% by an anterior Bankart lesion; isolated SLAP lesions were present in only 6% of cases. noted a similar occurrence of isolated SLAP lesions (11.8%) in a review of 712 shoulder arthroscopies.

Later research has reported an overall decrease in the rate of isolated arthroscopic SLAP repairs, whereas the rates of biceps tenodesis and tenotomy have increased ( ). Despite this decrease, there remain a significant number of patients who present with symptomatic, isolated SLAP lesions and who are candidates for repair. This chapter provides a current and comprehensive review of SLAP tears, including evaluation and diagnosis, nonoperative management, surgical indications and technique, rehabilitation, and expected outcomes.

Diagnosis

Patient presentation can be variable, but common symptoms include pain localized to either the posterior or the anterior glenohumeral joint line. The pain is often provoked by certain activities and is sometimes associated with mechanical catching in the joint and “dead-arm” episodes. In the overhead athlete population, pain can often be accompanied by fatigue, disordered shoulder mechanics, and diminished performance ( ) Throwing athletes may have pain in the late cocking phase and may note a decrease in velocity. Physical examination findings can be variable, and no single finding has been shown to be acceptably specific for the diagnosis of a SLAP lesion. When a SLAP lesion is suspected on the basis of history and examination, magnetic resonance imaging (MRI) with or without arthrography can further assist in the diagnosis.

Nonoperative Treatment

Initially, SLAP lesions should be treated conservatively with antiinflammatory medication, rest, and stretching exercises. Nonoperative management of SLAP lesions also relies on the successful identification and treatment of associated pathology. Scapular dyskinesia and glenohumeral internal rotational deficit (GIRD) should be identified and addressed with targeted therapy, including improved posterior capsular flexibility in patients with GIRD. The so-called sleeper stretch has up to a 90% success rate in resolving GIRD ( ). If several months of conservative treatment do not alleviate symptoms, surgical treatment should be considered.

Surgical Indications

Indications for arthroscopic repair of SLAP lesions continue to evolve and depend on several patient factors. Patients with consistent history, examination, and imaging findings who meet the following criteria may be best served by surgical repair:

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Failure of conservative measures
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Younger age (<35 years)
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Type II SLAP tear
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Absence of biceps tendon pathologic abnormality
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Member of active athletic population/overhead athlete

SLAP Repair Technique

See .

Video 19A.1

Arthroscopic SLAP repair utilizing a knotless anchor construct.

Arthroscopic SLAP repair is most commonly carried out with the patient in the beach-chair position. Portal placement is extremely important to allow for an effective anatomic repair. An anterior portal (often cannulated) placed high and slightly lateral provides a good angle for anchor placement. Once the diagnosis of a SLAP tear that is amenable to repair is confirmed, proceeding with the repair typically includes the use of accessory portals— namely the portal of Wilmington and/or the Neviaser portal ( ).

The SLAP tear site is then prepared. To facilitate healing, an arthroscopic rasp is used to mobilize the tear site and a high-speed bur can be used to remove cartilage and allow punctate bleeding to improve healing. The position and number of anchors for a SLAP repair can vary, but for most SLAP lesions the tear extends from the biceps anchor posteriorly, requiring one or two anchors placed posterior to the biceps anchor. We prefer small-diameter, biocomposite, absorbable, tap-in anchors because they are easier to control during insertion, limit the size of the perforation of the glenoid rim bone, and may diminish the risk of subsequent chondral injury due to anchor migration and prominence. We also favor knotless anchor constructs in this region to limit the potential for abrasion or irritation related to knot prominence ( Fig. 19A.2 ).

The high and lateral portal is used for superior labral anchor placement at the 11 o’clock/1 o’clock position. Posterior anchors are best placed through either a portal of Wilmington or posterolateral portal. For most SLAP tears, posterior anchors alone are sufficient to stabilize the biceps-labral complex and normalize the peel-back phenomenon. After anchor placement, the suture limb closest to the labrum is passed through the labrum and tied in a simple configuration, with care being taken to keep the knot away from the articular surface.

Postoperative Protocol

Patient compliance is crucial for successful outcomes, particularly in the early post-operative period. Our rehabilitation program is divided into four phases, which have previously been described ( ). Phase I (0–6 weeks) involves sling use and gentle passive range of motion. Phase II (7–12 weeks) includes weaning from the sling and isotonic rotator cuff strengthening. Phase III (13–20 weeks) focuses on full active and passive, painless range of motion with restoration of strength. No throwing or overhead sport progression is allowed until week 16. Phase IV (21–26 weeks) is the advanced strengthening phase with the progression of interval sports programs.

With successful rehabilitation, return to sport often takes at least 6 months from the time of surgery. Throwing athletes may take a year or longer to return, given the stresses placed on the anterior shoulder and eccentric load on the long head of the biceps tendon that their sport involves.

Pearls and Pitfalls

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Definitive diagnosis of SLAP lesions requires arthroscopy with direct visualization, probing, and dynamic testing for the peel-back sign.
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SLAP repairs are best performed arthroscopically with the use of suture anchors. Portal placement is critical for effective anatomic repair.
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The most important suture in the SLAP repair is the suture loop placed posterior to the biceps at the corner of the glenoid to resist torsional peel-back.
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Anchor placement anterior to the biceps tendon is described but may overconstrain the shoulder.
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Knots should be tied away from the articular surface or use of knotless constructs should be considered to avoid abrasion and chondral injury.

Discussion

The arthroscopic treatment of isolated SLAP lesions has produced variable and conflicting clinical results and outcomes. Several writers have reported substantially better patient outcome scores and satisfaction; however, these scores have not necessarily correlated with return to preinjury activity or play, particularly in elite athletes. , investigated the treatment of isolated type II SLAP lesions repaired with a bioabsorbable tack. They retrospectively studied 41 patients who underwent arthroscopic fixation with a mean follow-up of 3.7 years. They reported mean L’Insalata and American Shoulder and Elbow Society (ASES) scores of 86.7 and 86.8, respectively, with 71% of the cohort reporting good to excellent results. However, less than half of the 29 athletes in the cohort had returned to their preinjury playing level. SH evaluated 34 patients at a mean of 33 months following arthroscopic repair of an isolated SLAP lesion with suture anchors. These researchers reported that 94% of the patients had satisfactory UCLA shoulder scores and 91% had regained their preinjury level of shoulder function. However, patients who participated in overhead sports had significantly lower shoulder scores and a significantly lower percentage of return to preinjury level of shoulder function than those who did not participate in overhead activity.

were one of the first groups to prospectively evaluate outcomes of repair of SLAP tears using modern arthroscopic techniques. They reported on a cohort of 47 patients with symptomatic type II SLAP tears who were treated with arthroscopic suture anchor fixation and followed for a minimum of 2 years. At an average of 2.7-year follow-up, 87% of patients rated their outcomes as good or excellent; however, only 74% of athletes were able to return to their preinjury level of competition. Interestingly, these investigators also demonstrated that patients with a distinct traumatic etiology had a greater likelihood of a successful return to sports ( ).

used the Kerlan-Jobe Orthopaedic Clinic (KCOC) shoulder and elbow score and the ASES scoring system to evaluate 23 collegiate or professional overhead athletes more than 1 year after repair of type II SLAP lesions. At an average 3- to 8-month follow-up, 57% of patients had returned to pain-free play, 26% were playing with pain, and 17% were not playing because of pain; 96% of the patients had good to excellent ASES scores, but only 52% of the cohort had good to excellent KCOC scores. The group concluded that the rate of return to preinjury level of competition for elite overhead athletes after type II SLAP repairs was low despite high ASES scores and that the inability to return to play correlated with the presence of a partial-thickness rotator cuff tear. , compared the functional outcome and return to sport for arthroscopic repair of isolated type II SLAP lesions using suture anchors and for repair using transglenoidal sutures. They performed a matched-pair retrospective analysis of 24 competitive amateur athletes and reported constant scores of 91 and 81 in the suture anchor and transglenoidal suture groups, respectively; 67% of the total cohort was able to return to overhead sport without restrictions, whereas 58% achieved their preinjury sports level. The group concluded that suture anchor repair resulted in superior objective and subjective shoulder function; regardless of the technique used, however, nearly half of the athletes did not return to their preinjury level of sport. Finally, reviewed data from 24 elite overhead athletes with a mean follow-up of 45 months and reported average ASES scores of 87. However, only 50% of the athletes had returned to play after the operation, substantiating concerns that return to play after type II SLAP repairs remains problematic in elite overhead athletes.

conducted the largest study to date on type II SLAP repairs. The group prospectively collected clinical outcomes of 179 SLAP tear repairs in young, active patients at a mean follow-up of 40 months. Average outcome scores were 88 for ASES, 82% for the Western Ontario Shoulder Instability (WOSI) score, and 85% for the Single Assessment Numeric Evaluation (SANE) score. These researchers reported that 37% of the cohort met repair failure criteria, with 28% electing to undergo revision surgery. Age of 36 years or older was the only significant risk factor associated with a higher incidence of repair failure.

Other writers have investigated concomitant procedures that might improve outcomes of isolated SLAP repair. evaluated the effect of performing an acromioplasty at the time of a type II SLAP repair. They compared the clinical results in 34 patients who underwent an isolated type II SLAP repair with those in 16 patients who underwent a type II SLAP repair with an acromioplasty. Clinical outcome scores of the two groups were similar, with the combined group reporting slightly more “good” or “excellent” satisfaction ratings and significantly less postoperative clinical impingement.

Given the lack of conclusive evidence and often cited poor functional results for isolated SLAP tears in the young, active population, other writers have compared the outcomes of SLAP repair with those of biceps tenodesis. compared 10 patients who underwent repair with 15 patients who underwent arthroscopic biceps tenodesis for isolated type II SLAP tears. These investigators reported that 87% of the patients in the biceps tenodesis group were able to return to the previous level of sports participation, compared with only 20% of the SLAP repair group. They concluded that biceps tenodesis should be considered an effective alternative to SLAP repair in type II lesions that affords patients the ability to return to a preinjury level of sports participation ( Fig. 19A.3 ).