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Arthroscopic Treatment of Superior Labral (Slap) Tears 39 13282_SM-05.qxd 4/9/10 8:03 AM Page 38 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 arm 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 joint 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 Bankart lesion, 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 rotator cuff 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 shoulder.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 arthroscopy. 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 scapula 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. 38 13282_SM-05.qxd 4/9/10 8:03 AM Page 39 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.
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