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Arthroscopic Treatment of Chapter 5 Superior Labral (SLAP) Tears

Brian Cole and John-Paul Rue

DEFINITION glenoid. The Speed, Yergason, O’Brien, and load-compression tests are commonly used. ■ Superior labral (SLAP) tears represent injury to the superior ■ Speed and Yergason tests: Pain with the maneuvers sug- aspect of the glenoid labrum, extending from anterior to pos- gests a SLAP tear. terior, including the biceps anchor.14 ■ O’Brien test: Pain with downward pressure applied to the ANATOMY internally rotated that is relieved with supination sug- gests a SLAP tear. ■ The superior glenoid labrum is composed of fibrocartilagi- ■ Load-compression test: Painful clicking or popping sug- nous tissue between the hyaline cartilage of the glenoid surface gests a SLAP tear. and the capsule fibrous tissue.13 ■ Type II SLAP tears found in younger patients are commonly ■ The vascular supply of the glenoid labrum does not come associated with instability and a , whereas type from the underlying glenoid, but rather from penetrating II SLAP tears found in patients older than 40 are often associ- branches of the suprascapular, circumflex scapular, and poste- ated with pathology.7 rior humeral circumflex arteries in the surrounding capsule ■ Although no single clinical test can predictably be used to and periosteal tissue. diagnose a SLAP tear, the examiner should use all of these ■ There is histologic evidence that vascularity is decreased in tests, along with the history and a high clinical index of suspi- the anterior, anterosuperior, and superior aspects of the gle- cion, to make the diagnosis of a SLAP tear. noid labrum.2 PATHOGENESIS IMAGING AND OTHER DIAGNOSTIC STUDIES ■ The long head of the biceps functions to depress the ■ Although conventional radiographs (anteroposterior and humeral head and serves as an adjunct anterior stabilizer of supraspinatus outlet and axillary views) are the standard for the .5,6 initial evaluation of a patient with shoulder complaints, mag- ■ Disruption of the biceps anchor and the superior labrum, netic resonance imaging (MRI) is the most sensitive imaging as seen in type II SLAP tears, can result in glenohumeral tool for evaluating the superior glenoid labrum, with a sensi- instability. tivity and specificity of about 90%.1 ■ Although SLAP tears are commonly associated with trauma ■ The use of contrast arthrography MRI may improve the such as traction or compression injuries, up to one third of pa- overall accuracy of MR for diagnosing SLAP tears.9 tients with SLAP lesions have no history of trauma.10 ■ Despite advances in imaging techniques, the gold standard ■ SLAP tears are commonly classified according to Snyder14 for the diagnosis of a SLAP tear is . as type I (fraying of superior labrum with intact biceps an- chor), type II (detached superior labrum and biceps anchor), DIFFERENTIAL DIAGNOSIS type III (bucket-handle tear of the superior labrum with intact ■ biceps anchor), and type IV (bucket-handle tear of the superior Glenohumeral instability ■ labrum with extension into the biceps tendon). Rotator cuff pathology ■ ■ Other variations have been described that reflect associated Acromioclavicular joint pathology injury to the anterior labrum and other structures.8 NONOPERATIVE MANAGEMENT NATURAL HISTORY ■ Physical therapy is the mainstay of nonoperative treatment ■ Conservative nonoperative treatment of SLAP tears is usu- of most shoulder injuries. ally unsuccessful. ■ Selective intra-articular injections with local anesthetic and ■ Simple débridement of unstable SLAP tears (type II and IV) corticosteroids can be diagnostic and occasionally therapeutic. is generally not recommended because the results are poor.3 ■ The rehabilitation program should focus on achieving and maintaining a full range of motion and strengthening the rota- PATIENT HISTORY AND PHYSICAL tor cuff and stabilizers. FINDINGS ■ Although physical therapy may be useful for regaining range ■ Traction and compression are the two primary mechanisms of motion and strength, most patients with SLAP tears will of injury for SLAP tears. continue to have symptoms despite physical therapy. ■ A SLAP tear should be considered in a patient with a history of a traction or compression injury with persistent mechanical SURGICAL MANAGEMENT symptoms such as catching or locking. ■ Surgical treatment of SLAP tears should be considered for ■ Several clinical tests have been described that focus on the patients who have persistent symptoms despite appropriate examination of the biceps tendon anchor on the superior conservative management.

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Chapter 5 ARTHROSCOPIC TREATMENT OF SUPERIOR LABRAL (SLAP) TEARS 39

■ Contraindications for SLAP repair include patients who are this position allows improved visualization and access with high-risk surgical candidates (ie, the risk of anesthetic compli- distraction. cations outweighs the possible benefits of successful repair). ■ No more than 10 to 15 pounds of traction should be used Preoperative Planning owing to increased risk of brachial plexus injuries. ■ Preoperative assessment of glenohumeral instability is para- Approach mount to understanding the pathophysiology of a patient’s ■ shoulder complaints. The primary goal of any SLAP repair is to stabilize the bi- ■ ceps anchor and address any coexisting pathology. Associated instability and any other coexisting pathology ■ must also be addressed at the time of SLAP repair. After a thorough diagnostic evaluation, SLAP lesions are treated according to Snyder14 (see the Techniques section). Positioning ■ Standard anterosuperior and anteroinferior portals are ■ Beach-chair position established. ■ Lateral decubitus position ■ Accessory portals may also be established depending on ■ May be preferred for cases of suspected labral pathology, the location of the SLAP tear. especially if associated with posterior instability, because TECHNIQUES TYPE I SLAP TEARS

■ Type I SLAP tears may be treated using a motorized shaver ■ Care must be taken not to detach the biceps anchor from to simply débride the degenerative or frayed tissue. the superior glenoid.

TYPE II SLAP TEARS

■ Type II SLAP tears are the most commonly encountered ■ This portal may be adjusted anteriorly or posteriorly SLAP tears (TECH FIG 1). depending on the location of the SLAP tear. ■ They represent detachment of the biceps anchor from ■ A spinal needle is used to ensure that the correct tra- the superior glenoid labrum. jectory is achieved to place the anchor at about a ■ As such, the primary goal of any repair should be to 45-degree angle to the glenoid face. securely reattach the superior labral tissue to the su- ■ A no. 11 blade knife is used to make the skin incision, perior glenoid. but a cannula is not inserted because this portal will be used only to insert the suture anchor drill guide Glenoid Preparation and anchor after drilling. ■ After identifying the detachment by direct probing, a Suture Anchor Placement 4.5-mm motorized shaver is used to gently débride any ■ frayed or degenerative tissue. The suture anchor drill guide is placed on the glenoid ■ A motorized burr is used to débride the superior glenoid face at about a 45-degree angle to the face, ensuring to exposed, bleeding bone (TECH FIG 2). that the anchor will be solidly in bone (TECH FIG 3). ■ The suture anchor may be single- or double-loaded Accessory Portal Placement with nonabsorbable no. 2 braided suture, depending on preference. ■ An accessory trans-rotar cuff portal is made using an out- ■ If more than one suture anchor is to be used, the sur- side-in technique. No cannula is inserted because this geon starts the repair posteriorly and works anteri- portal will be used only to insert the anchor. orly to aid in visualization. ■ The anchor is placed in the same trajectory as the drill, ensuring that the drill guide is maintained in its proper orientation and position.

TECH FIG 1 • Arthroscopic view of type II superior labral an- terior posterior (SLAP) lesion. TECH FIG 2 • Preparing superior glenoid with burr. 13282_SM-05.qxd 4/9/10 8:03 AM Page 40

40 Part 1 SPORTS MEDICINE • Section I SHOULDER TECHNIQUES

A

A

AI

AS

B

TECH FIG 3 • Drilling suture anchor through lateral portal. Suture Management B ■ One limb (limb a) of the suture is retrieved out through TECH FIG 4 • The surgeon retrieves one limb of the anchor su- the anterior superior cannula, using either a crochet ture out the anterosuperior cannula (AS) and one limb out hook or suture grasper. the anteroinferior cannula (AI). ■ A crochet hook is used to capture the other limb (limb b) of the anchor suture and bring it out the anterior infe- the left shoulder) loaded with a no. 1 monofilament rior cannula (TECH FIG 4). or Shuttle Relay suture passer (ConMed Linvatec, Largo, FL) as a pull-through suture. Suture Passage ■ An arthroscopic grasper inserted through the anteroinfe- ■ Through the anterosuperior cannula and starting at the rior cannula is used to grasp the monofilament passing posterior edge of the tear superiorly, the surgeon passes suture as it penetrates the superior labrum, and the free a tissue penetrator (Spectrum, ConMed Linvatec, Largo, end is pulled out through the anteroinferior cannula FL) through the labrum (TECH FIG 5A,B). (TECH FIG 5C,D). ■ A 45-degree left-curved tissue penetrator is used for a ■ A simple knot is tied in the passing suture (see Tech Fig right shoulder SLAP tear (45-degree right-curved for 5D, inset) and the free end of limb b from the suture an-

A B C

TECH FIG 5 • A,B. Spectrum tissue penetrator loaded with monofilament passing suture through superior labrum. C,D. Shuttle relay passing suture retrieved through the anteroinferior cannula. (continued) 13282_SM-05.qxd 4/9/10 8:03 AM Page 41

Chapter 5 ARTHROSCOPIC TREATMENT OF SUPERIOR LABRAL (SLAP) TEARS 41 TECHNIQUES

D E F

TECH FIG 5 • (continued) E,F. The surgeon firmly pulls the shuttle relay suture through the anterosuperior cannula so that the two ends of the anchor suture are together in the anterosuperior cannula.

chor is inserted through the loop. The suture is pulled a series of half-hitches, taking care to switch posts and al- gently but firmly through the anterosuperior portal so ternate directions of the loops. that the two ends of the anchor suture are together out ■ The excess suture is cut using an arthroscopic suture of the anterosuperior portal (TECH FIG 5E,F). (If a Shuttle cutter. Relay suture passer is being used, the free end of the an- chor suture is placed through the wire loop and the same Additional Suture Anchor Placement steps are followed.) ■ This procedure is repeated until the biceps anchor has ■ The surgeon should ensure that the anchor is not un- been securely reattached to the superior glenoid (TECH loaded of its suture during this process by maintaining FIG 6). continuous arthroscopic visualization of the anchor. ■ The surgeon should take care when securing the ante- ■ There should be no movement of the suture at the rior aspect of the SLAP tears so that a normal labral anchor eyelet. foramen or an anterosuperior labral variant is not Knot Tying incorrectly identified as a SLAP tear, causing inad- vertent tightness and resulting in decreased range of ■ Making sure that the post limb is off the glenoid surface, motion. the surgeon ties the suture using either a sliding knot or

B

TECH FIG 6 • Completed superior labral anterior posterior (SLAP) lesion A repair.

TYPE III SLAP TEARS

■ Simple débridement of the labral bucket-handle tear is the preferred surgical technique for type III SLAP tears because the biceps anchor is intact. 13282_SM-05.qxd 4/9/10 8:03 AM Page 42

42 Part 1 SPORTS MEDICINE • Section I SHOULDER

TYPE IV SLAP TEARS

■ Type IV SLAP tears involve a bucket-handle tear of the ■ In an older patient with significant biceps tendon de- superior labrum with a tear of the biceps tendon. generation, biceps tenodesis should be considered. ■ The biceps anchor may be detached as well. ■ Similarly, in a younger patient with a tear extending ■ Treatment is débridement of the labral tear and biceps into the biceps tendon, repair of any tendon tears tendon tear, with repair of the biceps anchor if needed, should be considered. essentially converting the tear to a type II and then repairing the anchor detachment. TECHNIQUES

PEARLS AND PITFALLS Indications ■ All associated pathology is identified and addressed (eg, instability, rotator cuff pathology, acromioclavicular joint disorders). Planning ■ Lateral decubitus positioning is considered if posterior labral pathology is suspected. Portal ■ Proper technique must be used in placing portals at the beginning of the case, with attention to positioning placement of the portals both in the superoinferior plane and the medial-lateral plane. Improperly placed portals can greatly increase the difficulty of this operation. A spinal needle is used to judge the angle of approach for each portal before making the portal to ensure that the correct trajectory is obtained. Suture ■ When retrieving and handling anchor sutures, the surgeon should not place tension on either limb and should management maintain continuous visualization of the anchor–suture interface to ensure that the anchor is not unloaded. The surgeon should take care to avoid twists because these can place increased stress on a suture or knot and lead to breakage. The surgeon should place one anchor at a time and tie each suture or remove and replace the cannula and place the suture outside the cannula for suture storage to prevent tangles during tying. Other ■ Articular cartilage damage is avoided by firmly seating the drill guide on the edge of the glenoid and avoiding skiving onto the glenoid face.

POSTOPERATIVE CARE COMPLICATIONS ■ 0 to 4 weeks: Sling at all times except for hygiene and exer- ■ Infection (rare) cises. (Active range of motion allowed in all planes except ex- ■ Brachial plexus neuropathy secondary to traction of the arm ternal rotation in abduction starting at 2 weeks.) in the lateral decubitus position ■ 4 weeks: Discontinue sling. Start passive range of motion ■ Care must be taken to ensure that the smallest amount with emphasis on posterior capsule stretching. of traction and distraction necessary is used, with close ■ 6 weeks: External rotation in abduction allowed. Start monitoring of the tension applied to neurovascular struc- strengthening. tures. ■ 3 months: Sports allowed except throwing (4 months) ■ Persistent pain ■ Healed repair: Biceps tenodesis should be considered for OUTCOMES pain relief. ■ Table 1 summarizes outcomes from studies of SLAP tear repairs.

Table 1 Results of Arthroscopic Superior Labral Anterior Posterior (SLAP) Lesion Repair

Surgical No. of Average Study Procedure Patients Follow-up Results Cordasco et al, 19933 Débridement only 27 89% good or excellent results at 1-year follow-up; 63% excellent results at 2-year follow-up; only 44% return to competition at 2-year follow-up Field & Savoie, 19934 Arthroscopic suture repair 20 21 mo Rowe scale: 100% good or excellent results ASES scores: statistically significant increase in function score, decrease in pain score Morgan et al, 199811 Arthroscopic suture repair 102 1 year 97% good or excellent results 4% return to competition among overhead throwers O’Brien et al, 200212 Arthroscopic suture repair 31 (type II) 3.7 yr 71% good or excellent, 19% fair results (transrotator cuff portal) Average postoperative ASES score: 87.2

ASES, American Shoulder and Society. 13282_SM-05.qxd 4/9/10 8:03 AM Page 43

Chapter 5 ARTHROSCOPIC TREATMENT OF SUPERIOR LABRAL (SLAP) TEARS 43

■ Failed repair 7. Kim T, Quaele W, Cosgarea A, et al. Clinical features of the different ■ Repeat arthroscopy should be considered with revision types of SLAP lesions: an analysis of one hundred and thirty-nine repair. cases. J Bone Joint Surg Am 2003;85A:66–71. ■ Biceps tenodesis should be considered for severely de- 8. Maffet M, Gartsman G, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93–98. generative or intractable cases. 9. Magee T, Williams D, Mani N. Shoulder MR arthrography; which patient group benefits most? AJR Am J Roentgenol 2004;183: REFERENCES 969–974. 1. Chandnani V, Yeager T, Deberardino T, et al. Glenoid labral tears: 10. Mileski R, Snyder S. Superior labral lesions in the shoulder: prospective evaluation with MR imaging, MR arthrography, and CT pathoanatomy and surgical management. J Am Acad Orthop Surg arthrography. AJR Am J Roentgenol 1993;161:1229–1235. 1998;6:121–131. 2. Cooper D, Arnoczky S, O’Brien S, et al. Anatomy, histology, and vas- 11. Morgan C, Burkhard S, Palmeri M, et al. Type II SLAP lesions: three cularity of the glenoid labrum: an anatomical study. J Bone Joint Surg subtypes and their relationships to superior instability and rotator Am 1992;74A:46–52. cuff tears. Arthroscopy 1998;14:553–565. 3. Cordasco F, Steinman S, Flatow E, et al. Arthroscopic treatment of 12. O’Brien S, Allen A, Coleman S, et al. The trans-rotator cuff approach glenoid labral tears. Am J Sports Med 1993;21:425–431. to SLAP lesions: technical aspects for repair and a clinical follow-up of 4. Field L, Savoie F. Arthroscopic suture repair of superior labral de- 31 patients at a minimum of 2 years. Arthroscopy 2002;18:372–377. tachment lesions of the shoulder. Am J Sports Med 1993;21: 13. Prodromos C, Ferry J, Schiller A, et al. Histological studies of the gle- 783–790. noid labrum from fetal life to old age. J Bone Joint Surg Am 5. Healey J, Barton S, Noble P, et al. Biomechanical evaluation of the 1990;72A:1344–1348. origin of the long head of the biceps tendon. Arthroscopy 2001; 14. Snyder S, Karzel R, Del Pizzo W, et al. SLAP lesions of the shoulder. 17:378–382. Arthroscopy 1990;6:274–279. 6. Itoi E, Kuechle D, Newman S, et al. Stabilising function of the biceps 15. Verma NN, Cole BJ, Romeo AA. Arthroscopic repair of SLAP le- in stable and unstable . J Bone Joint Surg Br 1993;75B: sions. In: Miller MD, Cole BJ, eds. Textbook of Arthroscopy. 546–550. Philadelphia: Saunders, 2004:159–168.