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Biceps Tenodesis and Superior Labrum Anterior to Posterior (SLAP) Tears

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Biceps Tenodesis and Superior Labrum Anterior to Posterior (SLAP) Tears 5 Points on Biceps Tenodesis and Superior Labrum Anterior to Posterior (SLAP) Tears Mandeep S. Virk, MD, Annemarie K. Tilton, BS, and Brian J. Cole, MD, MBA njuries of the superior labrum–biceps complex (SLBC) presentation of SLAP tears, though localization and character- have been recognized as a cause of shoulder pain since ization of pain are variable and nonspecific.7 The mechanism Ithey were first described by Andrews and colleagues1 in of injury is helpful in acute presentation (traction injury; fall 1985. Superior labrum anterior to posterior (SLAP) tears are on outstretched, abducted arm), but an overhead athlete may relatively uncommon injuries of the shoulder, and their true present with no distinct mechanism other than chronic, re- incidence is difficult to establish. However, recently there petitive use of the shoulder.8-11 Numerous provocative physi- has been a significant increase in the reported incidence and cal examination tests have been used to assist in the diagnosis operative treatment of SLAP tears.2 SLAP tears can occur in of SLAP tear, yet there is no consensus regarding the ideal isolation, but they are commonly seen in association with physical examination test, with high sensitivity, specificity, other shoulder lesions, including rotator cuff tear, Bankart and accuracy.12-14 Magnetic resonance arthrography, the gold lesion, glenohumeral arthritis, acromioclavicular joint pa- standard imaging modality, is highly sensitive and specific thology, and subacromial impingement. (>95%) for diagnosing SLAP tears. Although SLAP tears are well described and classified,3-6 SLAP tear management is based on lesion type and se- our understanding of symptomatic SLAP tears and of their verity, age, functional demands, and presence of coexisting contribution to glenohumeral instability is limited. Diag- intra-articular lesions. Management options include non- nosing a SLAP tear on the basis of history and physical ex- operative treatment, débridement or repair of SLBC, biceps amination is a clinical challenge. Pain is the most common tenotomy, and biceps tenodesis.15-19 In this 5-point review, we present an evidence-based anal- ysis of the role of the SLBC in glenohumeral stability and the Dr. Virk is Assistant Professor, Division of role of biceps tenodesis in the management of SLAP tears. Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, NYU Langone Medical Role of SLBC in stability Center, NYU Hospital for Joint Diseases, New York, New York. Ms. Tilton is Sports Medicine of glenohumeral joint Research Fellow, Department of Orthopaedic The anatomy of the SLBC has been well described,20,21 Surgery, and Dr. Cole is Associate Chairman 1 and there is consensus that SLBC pathology can be and Professor in Department of Orthopaedic Surgery, Professor in Department of Anatomy a source of shoulder pain. The superior labrum is relatively and Cell Biology, and Section Head of Car- more mobile than the rest of the glenoid labrum, and it tilage Restoration Center, Rush University provides attachment to the long head of the biceps tendon Medical Center, Chicago, Illinois. (LHBT) and the superior glenohumeral and middle gleno- Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest humeral ligaments. in relation to this article. The functional role of the SLBC in glenohumeral stability Acknowledgment: The authors thank Mat- and its contribution to the pathogenesis of shoulder instability thew E. Gitelis, BS, Research Fellow in the are not clearly defined. Our understanding of SLBC function Department of Orthopaedic Surgery at Rush is largely derived from simulated cadaveric experiments of University Medical Center, for assistance with manuscript preparation. SLAP tears. Controlled laboratory studies with simulated type Address correspondence to: Brian J. Cole, II SLAP tears in cadavers have shown significantly increased MD, MBA, Department of Orthopaedic Sur- glenohumeral translation in the anterior-posterior and superi- gery, Rush University Medical Center, 1611 W or-inferior directions, suggesting a role of the superior labrum Harrison St, Suite 300, Chicago, IL 60612 (tel, 22-26 312-432-2352; fax, 708-409-5179; email, brian. in maintaining glenohumeral stability. Interestingly, there [email protected]). is conflicting evidence regarding restoration of normal gle- Am J Orthop. 2015;44(11):XX-XX. Copyright nohumeral translation in cadaveric shoulders after repair of Frontline Medical Communications Inc. 2015. simulated SLAP lesions in the presence or absence of simulated All rights reserved. anterior capsular laxity.22,25-27 However, it is important to un- derstand the limitations of cadaveric experiments in order to www.amjorthopedics.com November 2015 The American Journal of Orthopedics® 1 5 Points on Biceps Tenodesis and SLAP Tears M. S. Virk et al appreciate and truly comprehend the results of these experi- primary arthroscopic biceps tenodesis (15 patients; mean ments. There are inconsistencies in the size of simulated type age, 52 years). Compared with the SLAP repair group, the II SLAP lesions in different studies, which can affect the degree biceps tenodesis group had significantly higher rates of sat- of glenohumeral translation and the results of repair.23-25,28 The isfaction and return to previous level of sports participa- amount of glenohumeral translation noticed after simulated tion. However, group assignments were nonrandomized, SLAP tears in cadavers, though statistically significant, is small and the decision to treat a patient with SLAP repair versus in amplitude, and its relevance may not translate to a clini- biceps tenodesis was made by the senior surgeon purely on cally significant level. The impact of dynamic components the basis of age (SLAP repair for patients under 30 years). of stability (eg, rotator cuff muscles), capsular stretch, and Ek and colleagues36 retrospectively compared the cases of 10 other in vivo variables that affect glenohumeral stability are patients who underwent SLAP repair (mean age, 32 years) and unaccounted for during cadaveric experiments. 15 who underwent biceps tenodesis (mean age, 47 years) for LHBT is a recognized cause of shoulder pain, but its con- type II SLAP tear. There was no significant difference between tribution to shoulder stability is a point of continued de- the groups with respect to outcome scores, return to play or bate. According to one school of thought, LHBT is a vestigial preinjury activity level, or complications. structure that can be sacrificed without any loss of stability. There continues to be significant debate as to which patient Another school of thought holds that LHBT is an important will benefit from primary SLAP repair versus biceps tenodesis. active stabilizer of the glenohumeral joint. Cadaveric studies Multiple factors are involved: age, presence of associated shoul- have demonstrated that loading the LHBT decreases glenohu- der pathology, occupation, preinjury activity level, and work- meral translation and rotational range of motion, especially er’s compensation status. Age has convincingly been shown to in lower and mid ranges of abduction.23,29,30 Furthermore, affect the outcomes of treatment of type II SLAP tears.34,35,37-40 LHBT contributes to anterior glenohumeral stability by resist- There is consensus that patients over age 40 years will benefit ing torsional forces in the abducted and externally rotated from primary biceps tenodesis for SLAP tears. However, the shoulder and reducing stress on the inferior glenohumeral evidence for this recommendation is weak. ligaments.31-33 Strauss and colleagues22 recently found that simulated anterior and posterior type II SLAP lesions in ca- Biceps tenodesis and failed SLAP daveric shoulders increased glenohumeral translation in all repair planes, and biceps tenodesis did not further worsen this ab- 3 The definition of a failed SLAP repair is not well normal glenohumeral translation. Furthermore, repair of documented in the literature, but dissatisfaction posterior SLAP lesions along with biceps tenodesis restored after SLAP repair can result from continued shoulder pain, abnormal glenohumeral translation with no significant dif- poor shoulder function, or inability to return to preinjury ference from the baseline in any plane of motion. Again, the functional level.15,41 The etiologic determination and treat- limitations of cadaveric studies should be considered when ment of a failed SLAP repair are challenging, and outcomes interpreting these results and applying them clinically. of revision SLAP repair are not very promising.42,43 Biceps tenodesis has been proposed as an alternative treatment to Biceps tenodesis as primary treat- revision SLAP repair for failed SLAP repair. McCormick and ment for SLAP tears colleagues41 prospectively evaluated 42 patients (mean age, 2 A growing body of evidence suggests that primary 39.2 years; minimum follow-up, 2 years) with failed type II tenodesis of LHBT may be an effective alternative SLAP repairs that were treated with open subpectoral biceps treatment to SLAP repairs in select patients.34-36 However, tenodesis. There was significant improvement in ASES, SANE, the evidence is weak, and high-quality studies comparing and Western Ontario Shoulder Instability Index (WOSI) out- SLAP repair and primary biceps tenodesis are required in come scores and in postoperative shoulder range of motion order to make a strong recommendation for one technique at a mean follow-up of 3.6 years. One patient had
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