REVIEW ARTICLE

Superior Labral Repair Ronald V. Gregush, MD and Stephen J. Snyder, MD

detail the anatomy, classification, treatment, and results Abstract: Advances in have led to a of treatment of tears of the superior labrum. greater understanding of the importance of lesions of the superior labrum and biceps tendon complex. Diagnosis of ANATOMY superior labrum anterior to posterior tears requires a high index Histologic sections of the glenoid labrum reveal a of suspicion and is made by careful attention to the history, triangular fibrocartilaginous structure. The labrum is physical examination, and magnetic resonance arthrography. continuous with the adjacent hyaline articular cartilage of The diagnosis is confirmed with arthroscopy. The form of the glenoid on its inner side and the fibrous tissue of the treatment is dependent on the type of tear and the stability of capsule on its outer side.5–7 The labrum is interspersed the superior labrum and biceps anchor. Appropriate treatment with sparse elastin fibers in adults.5 Similar to the of the tear and any associated pathologies should lead to reliable meniscus in the , the labrum is relatively poorly improvements in the patient’s symptoms. The purpose of this vascularized. The blood supply originates from vessels review article is to describe the anatomy, pathophysiology, emanating from the capsule or the periosteum and not classification, indications, and surgical technique of arthroscopic from the underlying bone. Additionally, the superior and repair of superior labral tears. The surgical technique we present anterosuperior portions of the labrum are more poorly involves using 1 anchor with 2 sutures to anchor the superior vascularized than the rest of the labrum.7 The glenoid labrum anterior to posterior tear to the superior glenoid labrum undergoes several age-related changes; vascularity tubercle. and the number of chondrocytes, both decrease with 5 Key Words: SLAP, superior labrum, single anchor double suture increasing age. technique It is important to recognize that there is a wide spectrum of normal anatomic variation in the region of (Sports Med Arthrosc Rev 2007;15:222–229) the superior labrum and the biceps origin. In a cadaveric study of the origin of the long head of the biceps tendon, Vangsness et al8 noted that about half of the biceps he advent of shoulder arthroscopy has led to the tendon originates from the supraglenoid tubercle and half Trecognition of numerous lesions and pathologic from the superior labrum. The superior labrum attach- conditions that were not easily identifiable through open ment of the biceps tendon can be quite variable, ranging surgical techniques alone. The significance of lesions of from most of the tendon arising from the anterior labrum the glenoid labrum, in particular, was poorly understood with only a small contribution from the posterior labrum, until the shoulder could be examined arthroscopically. to all of the labral attachment coming from the posterior Andrews et al1 first described lesions of the anterosuper- labrum with no contribution from the anterior labrum. In ior labrum in throwing athletes in 1985. Snyder et al2 more than half of the specimens, the primary labral provided the first comprehensive description and classi- attachment of the biceps tendon was posterior superior.8 fication of tears of the superior labrum in 1990 and coined The attachment of the labrum to the glenoid bone is the term superior labrum anterior to posterior (SLAP) also varied. The superior portion of the labrum has been tears. He noted the lesion to be relatively uncommon, described as having a meniscoid appearance, as it is with an incidence of 6% in his study population (present typically attached peripherally but has a central free edge in 140 of 2375 arthroscopic cases). Other investigators that is draped over the glenoid.7,9 This small normal cleft have reported an incidence between 6%3 and 12%.4 The can make the diagnosis of a SLAP lesion difficult. The interest in this relatively uncommon lesion has generated glenoid articular cartilage normally extends around the over 100 publications on this topic. Though uncommon, corner to the peripheral attachment of the superior these lesions are an important source of pain in the labrum. Absence of cartilage is suggestive of injury. The shoulder and need to be recognized. This review will anterior, inferior, and posterior portions of the labrum show less variability and are usually firmly attached to the glenoid. From the Southern California Orthopedic Institute, Van Nuys, CA. A sublabral foramen below the anterosuperior Stephen J. Snyder is a consultant for and receives royalties from labrum at the 2-o’clock position is also a well-described Linvatec Inc (Largo, FL). normal anatomic variant and should not be reattached Reprints: Stephen J. Snyder, MD, Southern California Orthopedic 10,11 Institute, 6815 Noble Ave., Van Nuys, CA 91405 (e-mail: ssnyder@ to the bone. One variation that is particularly scoi.com). important for the arthroscopist to recognize is the Buford Copyright r 2007 by Lippincott Williams & Wilkins complex.12 The Buford complex describes a robust,

222 Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007 Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007 Superior Labral Repair cordlike middle glenohumeral attached to the a fall onto an outstretched or a sudden pull on the superior labrum at the anterior base of the biceps tendon. arm. In 2 large retrospective reviews of patients with There is no anterior superior labrum but a normal injuries to the superior labrum, approximately 65% of anterior inferior labrum. This condition is relatively rare, patients could recall an acute traumatic episode that led present in only 1.5% to 2.5% of .12,13 If the to the development of shoulder pain.4,15 The second, Buford complex is mistakenly reattached to the glenoid, somewhat less common, mechanism is an overuse injury external rotation and elevation will be significantly of the shoulder, commonly seen in overhead athletes. restricted. A thorough discussion of the mechanisms for the development of pain and dysfunction in the shoulder of CLASSIFICATION the overhead athlete is beyond the scope of this review. It is worthwhile, however, to briefly present the 2 competing Snyder et al2 classified SLAP tears into 4 basic types theories that have been proposed to explain the develop- (Fig. 1). In type I, there is fraying and degeneration of the ment of superior labral lesions in the overhead athlete: superior labrum, but with a stable biceps anchor. This is a the peel-back model, championed by Burkhart and relatively common finding during routine arthroscopy in Morgan,16 and the glenoid internal impingement model middle-aged and older patients and is usually only a advocated by Jobe and Sidles17 and Walch et al.18 The minor problem. In type II, the labrum and biceps anchor models fundamentally differ in the sequence of events that are detached from the superior glenoid and the whole lead to the development of superior labral tears in the complex arches away from the glenoid . Morgan et throwing athlete. al14 subdivided type II tears based on anatomic location Morgan et al14 have proposed a model coined the into 3 types: anterior, posterior, and combined anterior ‘‘peel-back’’ model to describe a cascade of events that and posterior. A type III tear consists of a bucket-handle leads to shoulder pain in the overhead athlete and, tear of the superior labrum, although the biceps anchor ultimately, may lead to the development of a posterior and remaining labrum is firmly attached to the glenoid. A SLAP lesion. The inciting event is a contracture of the type IV tear has a similar appearance to a type III tear; posterior and inferior capsule of the shoulder secondary however, there is extension of the bucket-handle tear of to scarring over time. This leads to a glenohumeral the labrum into the biceps tendon. The torn portions may internal rotation deficit of the affected shoulder, relative displace into the but the remainder of the biceps and to the nonaffected shoulder. Cadaveric studies have labrum are firmly attached. Maffet et al4 have expanded shown that a contracture of the posterior inferior capsule on this system to include 3 additional lesions which they results in a posterior and superior shift of the humeral coined types V-VII. In type V, an anterior-inferior head during the cocking phase of throwing, when the arm continues superiorly to include a type II is in maximum abduction and external rotation.19 SLAP tear as well; in type VI, an unstable flap tear of the Shifting the glenohumeral contact point posterosuper- labrum is present in addition to a type II SLAP tear; and iorly increases the shear forces at the posterosuperior in type VII, a type II tear extends anteriorly through the labrum. Additionally, in the cocked position, the peel- capsule beneath the middle glenohumeral ligament. back forces are maximized. Burkhart and Morgan16 arthroscopically observed that with the arm in maximal PATHOPHYSIOLOGY abduction and external rotation, the biceps tendon The etiology of superior labral lesions is controver- assumed a more vertical and posterior angle. This change sial. There seem to be 2 distinct mechanisms that are in the angle of the biceps shifts the biceps vector more responsible for causing SLAP tears. The first, and most posteriorly and creates a twist at the base of the biceps common, mechanism is an acute traumatic injury, such as tendon. The result is transmission of a torsional force to

FIGURE 1. Snyder classification of SLAP tears. A, Type I SLAP—fraying and degeneration of the superior labrum. B, Type II SLAP— detachment of the superior labrum and biceps anchor from the superior glenoid. C, Type III SLAP—bucket-handle tear of the superior labrum. D, Type IV SLAP—bucket-handle tear of the superior labrum with extension into the biceps tendon. r 2007 Lippincott Williams & Wilkins 223 Gregush and Snyder Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007 the posterior superior labrum. If the biceps anchor is result from an acute trauma or from a chronic overuse incompetent (SLAP tear), then the posterosuperior injury. The typical patient with a symptomatic SLAP tear labrum is observed to peel-back offthe glenoid medially is a young male. In 2 large series of patients with injuries onto the scapular neck, with the arm in maximal of the superior labrum, 88% and 91% were male.4,15 The abduction and external rotation. The combination of average age in the series of Snyder et al15 was 38 years. It increased shear forces to the posterosuperior labrum in is rare to see a patient with a symptomatic SLAP tear who overhead athletes with a posterior capsular contracture is not an overhead athlete or who has not sustained a and the repeated exposure of the throwing shoulder to the traumatic injury. The most common complaints of dynamic peel-back phenomenon ultimately can lead to a individuals with SLAP tears are pain, frequently exacer- posterosuperior detachment of the glenoid labrum and a bated by overhead activities, and mechanical symptoms type II SLAP tear. Surgical management of these patients such as catching, locking, or popping.2 involves repair of the SLAP lesion and release of the Physical examination findings in patients with contracted posteroinferior capsule, if it cannot be SLAP tears are nonspecific. A number of physical manually stretched preoperatively through a focused examination findings have been described specifically to physical therapy program. help diagnose SLAP tears, including the compression- Jobe and Sidles17 and Walch et al18 both indepen- rotation test,2 the anterior slide test,25 the crank test,26 the dently proposed the internal impingement model of SLAP O’Brien active compression test,27 the SLAP prehension lesions. The basis of pathology in this model is instability test,28 the pain provocation test,29 the biceps load test of the anteroinferior capsulolabral complex. Anterior II,30 and the resisted supination external rotation test.31 instability allows anterior translation of the humeral Although the initial reports of most of these tests show a head. In a position of maximal abduction and external high positive predictive value, in many instances these rotation, this increased anterior translation of the results have not been reproducible.32–36 Parentis et al36 can lead to pathologic impingement of the performed a prospective study evaluating 9 different undersurface of the rotator cuffagainst the posterior provocative tests for the diagnosis of SLAP tears and superior glenoid rim and labrum. SLAP tears are the found that, although the most sensitive tests were the result of repeated abutment of the humeral head on the active compression test, Hawkins and Neer impingement labrum. According to this model, the treatment for tests,37,38 Speed biceps tension test,39 and the Jobe patients would consist of tightening of the anterior relocation tests, no test was specific for SLAP lesions.40 capsule to restore the normal balance of the humeral It is important to assess the total arc motion of the head in the glenoid. Anterior capsular plication has had a glenohumeral joint in all patients, but especially in the reported success rate of 77% to 81% of throwers overhead athlete. This is most easily performed with returning to their preinjury level of performance for at the patient lying supine so that the can be least one season.20,21 stabilized on the examining table by downward pressure Regardless of the etiology of the SLAP lesion, there applied to the anterior aspect of the shoulder by the is no doubt that it is a destabilizing force on the shoulder. examiner. Internal and external rotation can then be Several cadaveric studies have confirmed that type II measured with the arm in the 90-degree abducted position SLAP lesions lead to increased instability of the to assess for a glenohumeral internal rotation deficit. A glenohumeral joint.22–24 Rodosky et al22 demonstrated side-to-side difference of >20 degrees should be con- that detachment of the superior glenoid labrum dimin- sidered pathologic. ished the force required to translate the humeral head on Although arthroscopy remains the gold standard the glenoid. Additionally, their data suggested that the for diagnosis of a SLAP lesion, imaging studies can aid superior labral complex and biceps tendon increase the greatly in the diagnosis of a patient with labral pathology. shoulder’s resistance to torsional forces in the abducted Plain radiographs of the shoulder are recommended for and externally rotated position. Pagnani et al23 demon- any patient with shoulder pain; however, they are not strated that lesions that destabilized the biceps anchor helpful for the diagnosis of labral tears. Conventional resulted in increased anteroposterior and superoinferior magnetic resonance imaging (MRI) can be helpful in the translation of the humeral head on the glenoid. More diagnosis of labral lesions of the shoulder but a MR recently, Panossian et al24 confirmed that creation of a should be ordered for any patient in whom a type II SLAP tear led to significant increases in total labral tear is suspected (Fig. 2). Karzel and Snyder41 glenohumeral range of motion, internal rotation, external initially described the use of MR arthrography in the rotation, anterosuperior translation, and inferior transla- shoulder in 1993. Since then, a number of studies have tion. Detachment of the superior labrum can have a shown a high sensitivity and specificity of MR arthro- profound impact on glenohumeral kinematics and stabi- graphy for the diagnosis of lesions of the glenoid lity of the shoulder. labrum.42–44

DIAGNOSIS TREATMENT The history of patients with SLAP lesions may be For treatment of type I lesions, arthroscopic quite variable. As mentioned previously, a SLAP tear can debridement of the frayed and degenerative edge is

224 r 2007 Lippincott Williams & Wilkins Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007 Superior Labral Repair

signs of a pathologic condition include areas of fraying, granulation tissue, or an unusually deep cleft between the bone and labrum (Fig. 3). Placing traction on the biceps tendon should demonstrate any loss of integrity at the labral attachment and instability of the . If traction on the tendon causes the labrum to arch away from bone, or demonstrates a gap of 5 mm or more, then the stability of the biceps anchor is questionable. Additionally, demonstration of the arthroscopic peel- back phenomenon is indicative of a posterosuperior labral detachment. The arm is released from traction and placed in maximal abduction and external rotation. If the posterosuperior labrum peels back offof the glenoid and rotates medially onto the scapular neck then the biceps anchor is incompetent. This finding is not present in shoulders with a normal biceps anchor.16 Frequently, however, the diagnosis of a type II SLAP tear can be difficult. Ultimately, the arthroscopist must rely on the patient’s history, physical examination, and findings at the time of arthroscopy to make the diagnosis. Over- FIGURE 2. MR arthrogram of a type II SLAP lesion. aggressive fixation of a normal biceps anchor may lead to a painful stiffshoulder. performed with preservation of the attachment of the The basic principle of treatment of type II SLAP labrum and biceps anchor. We prefer to treat type II tears is to securely reattach the labrum and biceps anchor lesions with suture anchor fixation to bone. Our preferred to the superior glenoid bone. Our preferred technique for technique is described in detail below. Type III lesions are the treatment of type II SLAP tears has evolved over treated similar to type I lesions, with debridement of the time. We initially treated these tears with a bioabsorbale bucket-handle tear of the labrum. The exception to this tack but have abandoned this method because of several treatment is the rare occasion when the middle gleno- reoperations that were required for removal of free- humeral ligament attaches to the anterior edge of the floating tack fragments that had broken off. We now displaced bucket-handle labral tear. When this occurs, prefer to use a nonabsorbable metal suture anchor, it is important to reattach the middle glenohumeral loaded with 2 strong nonabsorbable sutures, to securely ligament to bone, at the normal resting position, after reattach the labrum. excising the free fragment. The treatment of type IV tears can be challenging and is dependent on the involvement of the biceps tendon. If less than a third of the biceps tendon is involved and the biceps anchor is stable, our preference is, generally, to simply debride the torn edge of the biceps and labrum. If less than 1/3 of the biceps tendon is involved and there is associated detachment of the biceps anchor, we generally excise the torn edge of the biceps and labrum and perform a repair of the detached biceps anchor, similar to the repair of a type II SLAP tear described below. If more than one third of the biceps tendon is involved, consideration should be given to suturing of the biceps tendon and labrum, or even debridement of the torn edge of the labrum and tenodesis or tenotomy of the biceps tendon, particularly in older individuals. If a biceps tenotomy or tenodesis is performed in the setting of an unstable biceps anchor, we would not perform concomi- tant repair of the superior labrum after treatment of the biceps tendon. An important aspect of treatment of a type II SLAP tear is the ability to correctly identify it. As noted previously, the articular cartilage at the superior edge of the glenoid normally extends around the corner to the FIGURE 3. Arthroscopic appearance of a type II SLAP tear; peripheral attachment of the labrum. The absence of this note the redness and inflammation of the labrum and biceps normal articular cartilage raises suspicion of injury. Other anchor where it is detached. r 2007 Lippincott Williams & Wilkins 225 Gregush and Snyder Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007

The SADS (Single Anchor Double Suture) techni- each suture is also colored purple with a marking pen to que involves the use of a standard posterior portal and 2 facilitate suture management. anterior portals. Correct portal placement is essential for An appropriately sized bone punch or drill is placed obtaining a secure repair. The posterior portal is created through the anterosuperior portal and a pilot hole is using standard technique; the arthroscope is kept in this created on the glenoid neck directly below the biceps portal for the entire case. An anterosuperior portal is next tendon, 2 to 3-mm medial to the articular surface. The created using an outside-in technique after localization of punch is inserted at an angle of 45 degrees from the the portal with a spinal needle. This portal should be articular surface and care is taken not to skive off created approximately 2 cm from the anterolateral corner the bone. The suture anchor is inserted through the of the acromion and should be in the superior aspect of anterosuperior portal until the seating line is below the the rotator interval, just anterior and slightly superior to level of the bone (Fig. 5). The eyelet is oriented such that the biceps tendon. We then create an anterior mid-glenoid it and the sutures are perpendicular to the superior portal using an outside-in technique, entering just above labrum and the purple half of each of the sutures exits the the subscapularis tendon about midway between the eyelet superiorly and medially toward the biceps. We labrum and tuberosity. Plastic operating cannulas with secure the biceps anchor and labrum to the bone using a flow-restriction diaphragms are placed in the 2 anterior so-called stitch-of-Burns. This is a stitch that involves portals. bringing 2 separate sutures through 1 hole in the center of A 4.2-mm ‘‘full radius’’ shaver is inserted through the detached labrum and biceps anchor. the anterosuperior portal between the detached labrum The 2 halves of the suture which exit the eyelet on and glenoid and the soft tissues of the superior glenoid are the glenoid side (the undyed halves) are then brought out debrided, as well as any fraying of the labrum. If the the anterior mid-glenoid portal and stored outside the lesion extends more posteriorly, it may be helpful to place cannula with the aid of a switching stick. The other 2 the scope anterior and debride it through the posterior halves of the suture (the purple halves) are now also portal. The bone of the superior glenoid is relatively soft retrieved into the anterior mid-glenoid portal. A medium- and a shaver is usually adequate to decorticate it and sized Spectrum Crescent (Linvatec Inc, Largo, FL) suture expose the cancellous bone. Next we prepare the bone for hook with a shuttle relay or no. 1 monofilament suture is anchor insertion. We prefer to use a 4-mm Big Eye Revo then inserted through the anterosuperior cannula. The (Linvatec Inc, Largo, FL) metal suture anchor for our superior labrum and biceps anchor is punctured with the repairs. This anchor provides the advantage that it can suture hook directly on the superior side of the middle of be retrieved from the glenoid bone after insertion, if the biceps anchor, aiming the needle to exit just below the necessary, and its position can be monitored on x-ray torn labrum. The shuttle relay is retrieved out the anterior postoperatively. The anchor is loaded with 2 no. 2 mid-glenoid portal and used to carry the 2 purple sutures braided nonabsorbable sutures of different colors. We through the labrum and biceps anchor, into the ante- usually use a dark green and a white suture. By rosuperior portal. The white/purple suture is then convention, the green suture is loaded closer to the top retrieved from the anterior-superior cannula and into of the elongated oval eyelet of the anchor and the white the anterior mid-glenoid portal. The green partner suture suture is loaded on the deeper side of the eyelet, closer to the threads of the anchor (Fig. 4). At the end of the case, the green suture is tied first, thus allowing the use of a sliding knot with the other white suture, as well. Half of

FIGURE 4. Big Eye Revo (Linvatec Inc, Largo, FL) metal suture anchor loaded with 2 no. 2 braided sutures. Note that half FIGURE 5. Insertion of a metal suture anchor in the appro- of each suture has been colored purple for ease of suture priate position for repair of a type II SLAP tear. The anchor management; also note that the green suture has been loaded is inserted into the pilot hole until the seating line is below closer to the top of the eyelet. the surface.

226 r 2007 Lippincott Williams & Wilkins Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007 Superior Labral Repair of the green/purple suture is retrieved into the ante- noted in the series of Maffet et al4 with 5% of patients rosuperior portal, posterior to the biceps. At this point, with SLAP tears having an associated full thickness both limbs of the green suture should be in the rotator cufftear and 38% with some degree of partial anterosuperior portal. The green suture is tied first, thickness cufftearing. When treating patients with posterior to the biceps, using a sliding-locking knot combined injuries of the rotator cuffand superior labrum, backed up with 3 half-hitches. Because the purple/green it is important to determine whether the detachment of strand was passed through the labrum, it must be the superior labrum is truly pathologic. In a histologic designated as the ‘‘post’’ strand to insure the knot is study of the glenoid labrum of cadavera of varying situated behind the tissue and away from the joint ages, Prodromos et al5 showed that irregularities of the surface. The anterior-superior cannula is redirected labrum in individuals over the age of 30 years was not anterior to the biceps tendon and both white sutures are uncommon. Four of 17 specimens from individuals retrieved into it. They are also tied using a sliding-locking >30 years old at the time of death showed detachment knot. If these sutures do not slide, then they are tied using of the superior labrum. The labrum was thin or virtually a multiple half-hitch Revo knot ensuring that the purple absent in an additional 6 patients >30 years old at the strand is the post. The final step is to test the repair by time of death. It is the authors’ opinion that most type II pulling tension on the biceps tendon (Fig. 6). SLAP tears in individuals >50 years old are not Postoperatively, a 15-degree external rotation sling pathologic. That being said, if the history, physical is used to protect the shoulder for 4 weeks. We have examination, and arthroscopic findings point to superior found that using a 15-degree external rotation sling for labral pathology as the cause of an older patient’s pain we postoperative immobilization, instead of a neutral rota- would likely fix the tear. Decisions must be made on a tion sling, results in easier recovery of shoulder range of case-by-case basis. It is important for the arthroscopist to motion. The patient begins , wrist, and hand realize, however, that detachment of the superior labrum exercises immediately and then begins gentle pendulum in an older patient with an associated full thickness exercises at 1 week. Passive range of motion exercises are rotator cufftear may be a normal finding. In this started at 4 weeks and resistance exercises are allowed situation, we would be inclined to fix the rotator cuff between 6 and 8 weeks postoperatively. Vigorous throw- tear but not the SLAP lesion. Voos et al46 recently ing or strenuous lifting are generally not allowed for a reported on patients with combined arthroscopic labral minimum of 5 months and only if range of motion is (Bankart or SLAP) and rotator cuffrepairs. Fourteen of normal and the patient has no pain. the 30 patients in the series underwent combined At this point, we would like to address a few special arthroscopic SLAP and rotator cuffrepairs. Ninety situations that may present treatment dilemmas for the percent of patients in the entire group reported their arthroscopist. The first situation is a type II SLAP tear satisfaction as good to excellent after the procedure. associated with a full thickness rotator cufftear. The The other special situation we would like to briefly incidence of type II SLAP tears in the setting of full address is a type II SLAP tear combined with a tear of the thickness rotator cufftears is uncertain. In a study of 200 anterior capsulolabral structures (Bankart tear). An patients with full thickness rotator cufftears, 5 patients associated Bankart tear was noted in 22% of patients were noted to have unstable SLAP tears (incidence of with superior labral injuries in a series reported by the 2.5%).45 Conversely, in a large series of patients with senior author.15 In this situation, our preference is to fix SLAP tears, 11% were noted to have full thickness what is broken. We would have no concerns about fixing rotator cufftears, and another 29% were noted to have a SLAP tear and an associated Bankart tear. We would partial thickness rotator cufftears.15 Similar results were recommend placing these patients in a 15-degree external

FIGURE 6. Final appearance of a type II SLAP repair using the Single Anchor Double Suture (SADS) technique with a stitch-of-Burns. A, Arthroscopic appear- ance; B, artist’s rendition. r 2007 Lippincott Williams & Wilkins 227 Gregush and Snyder Sports Med Arthrosc Rev  Volume 15, Number 4, December 2007 rotation sling to minimize the risk of postoperative No single piece of history or physical examination finding shoulder stiffness, as we do for all of our type II SLAP is diagnostic for SLAP lesions. MR arthrography is the repairs. imaging study of choice for diagnosis of these lesions. Treatment is predicated on the type of SLAP tear. Type I RESULTS and III tears are treated with arthroscopic debridement alone. Treatment of type II tears involves arthroscopic Many authors have reported satisfactory results for stabilization of the biceps anchor/superior labrum com- the arthroscopic treatment of type II SLAP tears using plex and secure fixation to bone. Treatment of type IV modern fixation techniques.47–54 In a study of the long- tears is based on the involvement of the biceps tendon. term results of treatment of isolated SLAP tears Appropriate treatment of superior labral tears should performed at this institution, 26 patients with SLAP result in reliable improvements in pain and patient tears were evaluated, 18 of which had type II SLAP satisfaction. lesions. Twelve of the 18 patients were treated with suture anchor fixation and 6 were treated with abrasion of the REFERENCES glenoid rim alone. Using the University of California at 1. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears Los Angeles Shoulder Rating Scale, 74% of all patients related to the long head of the biceps. Am J Sports Med. 1985;13: had a good or excellent result and using the Rowe 337–341. shoulder rating scale, 83% had a good or excellent 2. Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the result.47 shoulder. Arthroscopy. 1990;6:274–279. 3. Handelberg F, Willems S, Shahabpour M, et al. SLAP lesions: a A number of different fixation devices have been retrospective study. Arthroscopy. 1998;14:856–862. used for fixation of unstable tears of the superior labrum. 4. Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps Pagnani et al48 evaluated patients who had underwent tendon complex lesions of the shoulder. Am J Sports Med. 1995;23: arthroscopic fixation of tears of the superior glenoid 93–98. 5. Prodromos CC, Ferry JA, Schiller AL, et al. Histological studies of labrum using a biodegradable implant and noted that the glenoid labrum from fetal life to old age. J Bone Joint Surg Am. 86% of patients had satisfactory results at 2-year follow- 1990;72:1344–1348. up. Samani et al49 reported on the results of fixation of 6. Snyder SJ, Rames RD, Wolbert E. Labral lesions. In: McGinty JB, type II SLAP tears using a bioabsorbable tack. They ed. Operative Arthroscopy. New York: Raven Press; 1991:491–499. noted satisfactory outcomes in 88% of patients. Paxinos 7. Cooper DE, Arnoczky SP, O’Brien SJ, et al. Anatomy, histology, 52 and vascularity of the glenoid labrum. An anatomical study. J Bone et al also reported positive results with the use of a Joint Surg Am. 1992;74:46–52. biodegradable tack to repair unstable tears of the superior 8. Vangsness CT Jr, Jorgenson SS, Watson T, et al. The origin of the labrum. At 6-month follow-up, a decrease of 73% in long head of the biceps from the scapula and glenoid labrum. An patients’ mean shoulder pain scores was observed. anatomical study of 100 shoulders. J Bone Joint Surg Br. 1994;76: 951–954. Numerous authors have reported on the results of 9. Detrisac DA, Johnson LL. Arthroscopic Shoulder Anatomy: the use of suture anchors for the fixation of unstable Pathologic and Surgical Implications. Thorofare, NJ: SLACK Inc; SLAP tears. Kim et al50 evaluated 34 patients at an 1986. average of 33 months who had undergone suture anchor 10. Johnson LL. The . An arthroscopist’s perspective of fixation. Ninety-four percent of patients had a satisfac- anatomy and pathology. Clin Orthop Relat Res. 1987;223:113–125. 11. Snyder SJ, Banas MP, Belzer JP. Arthroscopic evaluation and tory result according to the University of California at treatment of injuries to the superior glenoid labrum. Instr Course Los Angeles shoulder score and 91% returned to their Lect. 1996;45:65–70. preinjury level of activity. Ide et al51 treated 40 overhead 12. Williams MM, Snyder SJ, Buford D Jr. The Buford complex—the throwing athletes with type II SLAP tears using ‘‘cord-like’’ middle glenohumeral ligament and absent anterosuperior labrum complex: a normal anatomic capsulolabral variant. Arthro- nonabsorbable suture anchors. At a mean 41-month scopy. 1994;10:241–247. follow-up, modified Rowe scores indicated 90% good 13. Bents RT, Skeete KD. The correlation of the Buford complex and to excellent results. Seventy-five percent of patients were SLAP lesions. J Shoulder Elbow Surg. 2005;14:565–569. able to return to their preinjury level of throwing. 14. Morgan CD, Burkhart SS, Palmeri M, et al. Type II SLAP lesions: Coleman et al54 studied the treatment of patients with three subtypes and their relationships to superior instability and rotator cufftears. Arthroscopy. 1998;14:553–565. type II SLAP tears with and without an acromioplasty. 15. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the Fifty patients underwent fixation of the superior labral superior glenoid labrum. J Shoulder Elbow Surg. 1995;4:243–248. and 16 of these were treated with a concomitant 16. Burkhart SS, Morgan CD. The peel-back mechanism: its role in acromioplasty. Assessment of 2 different shoulder scores producing and extending posterior type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy. 1998;14:637–640. showed no difference between the 2 groups; however, 17. Jobe CM, Sidles J. Evidence of superior glenoid impingement upon subjectively, 81% of the 16 patients who also underwent the rotator cuff: anatomic, kinesiologic, MRI, and arthroscopic acromioplasty reported good or excellent results as findings. Presented at the 5th International Conference on Surgery compared with only 65% of the patients who did not of the Shoulder, Paris, France, 1992. have an acromioplasty. 18. Walch G, Boileau J, Noel E, et al. Impingement of the deep surface of the supraspinatus tendon on the posterior superior glenoid rim: an arthroscopic study. J Shoulder Elbow Surg. 1992;1:238–243. CONCLUSIONS 19. Grossman MG, Tibone JE, McGarry MH, et al. A cadaveric model of the throwing shoulder: a possible etiology of superior labrum Pathology of the superior labrum is a relatively anterior-to-posterior lesions. 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Effect of lesions of the shoulder. A new technique of shoulder imaging. Clin Sports Med. superior portion of the glenoid labrum on glenohumeral translation. 1993;12:123–136. J Bone Joint Surg Am. 1995;77:1003–1010. 42. Bencardino JT, Beltran J, Rosenberg ZS, et al. Superior labrum 24. Panossian VR, Mihata T, Tibone JE, et al. Biomechanical analysis anterior-posterior lesions: diagnosis with MR arthrography of the of isolated type II SLAP lesions and repair. J Shoulder Elbow Surg. shoulder. Radiology. 2000;214:267–271. 2005;14:529–534. 43. Jee WH, McCauley TR, Katz LD, et al. Superior labral anterior 25. Kibler WB. Specificity and sensitivity of the anterior slide test in posterior (SLAP) lesions of the glenoid labrum: reliability and throwing athletes with superior glenoid labral tears. Arthroscopy. accuracy of MR arthrography for diagnosis. Radiology. 2001;218: 1995;11:296–300. 127–132. 26. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of a new 44. Waldt S, Burkart A, Lange P, et al. Diagnostic performance of MR physical examination in predicting glenoid labral tears. Am J Sports arthrography in the assessment of superior labral anteroposterior Med. 1996;24:721–725. lesions of the shoulder. Am J Roentgenol. 2004;182:1271–1278. 27. O’Brien SJ, Pagnani MJ, Fealy S, et al. The active compression 45. Gartsman GM, Taverna E. The incidence of glenohumeral joint test: a new and effective test for diagnosing labral tears and abnormalities associated with full-thickness, reparable rotator cuff acromioclavicular joint abnormality. Am J Sports Med. 1998;26: tears. Arthroscopy. 1997;13:450–455. 610–613. 46. Voos JE, Pearle AD, Mattern CJ, et al. Outcomes of combined 28. Berg EE, Ciullo JV. A clinical test for superior glenoid labral or arthroscopic rotator cuffand labral repair. Am J Sports Med. 2007. ‘‘SLAP’’ lesions. Clin J Sport Med. 1998;8:121–123. [Epub ahead of print March 2006]. 29. Mimori K, Muneta T, Nakagawa T, et al. A new pain provocation 47. Stetson WB, Snyder SJ, Karzel RP, et al. Long-term clinical follow- test for superior labral tears of the shoulder. Am J Sports Med. up of isolated SLAP lesions of the shoulder. Presented at the 65th 1999;27:137–142. Annual Meeting of the American Academy of Orthopaedic 30. Kim SH, Ha KI, Ahn JH, et al. Biceps load test II: a clinical test for Surgeons, New Orleans, March 23, 1998. SLAP lesions of the shoulder. Arthroscopy. 2001;17:160–164. 48. Pagnani MJ, Speer KP, Altchek DW, et al. Arthroscopic fixation of 31. Myers TH, Zemanovic JR, Andrews JR. The resisted supination superior labral lesions using a biodegradable implant: a preliminary external rotation test: a new test for the diagnosis of superior labral report. Arthroscopy. 1995;11:194–198. anterior posterior lesions. Am J Sports Med. 2005;33:1315–1320. 49. Samani JE, Marston SB, Buss DD. Arthroscopic stabilization of 32. Stetson WB, Templin K. The crank test, the O’Brien test, and type II SLAP lesions using an absorbable tack. Arthroscopy. 2001; routine magnetic resonance imaging scans in the diagnosis of labral 17:19–24. tears. Am J Sports Med. 2002;30:806–809. 50. Kim SH, Ha KI, Kim SH, et al. Results of arthroscopic treatment of 33. McFarland EG, Kim TK, Savino RM. Clinical assessment of three superior labral lesions. J Bone Joint Surg Am. 2002;84:981–985. common tests for superior labral anterior-posterior lesions. Am 51. Ide J, Maeda S, Takagi K. Sports activity after arthroscopic J Sports Med. 2002;30:810–815. superior labral repair using suture anchors in overhead-throwing 34. Guanche CA, Jones DC. Clinical testing for tears of the glenoid athletes. Am J Sports Med. 2005;33:507–514. labrum. Arthroscopy. 2003;19:517–523. 52. Paxinos A, Walton J, Rutten S, et al. Arthroscopic stabilization of 35. Jones GL, Galluch DB. Clinical assessment of superior glenoid superior labral (SLAP) tears with biodegradable tack: outcomes to labral lesions: a systematic review. Clin Orthop Relat Res. 2007; 2 years. Arthroscopy. 2006;22:627–634. 455:45–51. 53. Funk L, Snow M. SLAP tears of the glenoid labrum in contact 36. Parentis MA, Glousman RE, Mohr KS, et al. An evaluation of the athletes. Clin J Sport Med. 2007;17:1–4. provocative tests for superior labral anterior posterior lesions. 54. Coleman SH, Cohen DB, Drakos MC, et al. Arthroscopic repair of Am J Sports Med. 2006;34:265–268. type II superior labral anterior posterior lesions with and without 37. Hawkins RJ, Kennedy JC. Impingement syndromes in athletes. acromioplasty: a clinical analysis of 50 patients. Am J Sports Med. Am J Sports Med. 1980;8:151–158. 2007;35:749–753.

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