SLAP Repairs Versus Biceps Tenodesis in Athletes 15 min Power Points • Not all SLAP tears need surgery • Preservation of Native Anatomy GOAL • Not all labral repairs are equal • Kinetic chain MUST be addressed Power Points • Biceps DOES have a function • Tenodesis has consequences • Tenodesis relieves pain reliably BUT……long term effects uncertain ‘SLAPAHOLIC’ T. Romeo • One who fixes EVERY SLAP TEAR and anything that remotely looks like one! Not all SLAP Tears Need Surgery • SLAP tears way overdiagnosed • Beware of positive imaging study - negative exam • Slight labral separation may allow thrower to ‘get the slot’ MRI May OVERDIAGNOSE • Specificity ranges from 63% to 91% MRI and Anatomic Variants • Meniscoid labrum • Buford complex • Cord like MGHL • Age related attritional tear • ALL CAN LOOK LIKE SLAP TEARS ON MRI!! Meniscoid Labrum ‘Buford’ Complex Labral Tears are Part of the Aging Process! Pfahler et al JSES 2003 MANY LABRAL TEARS RESPOND TO REHAB!!!! Nonoperative Treatment of Superior Labrum Anterior Posterior Tears Improvements in Pain, Function, and Quality of Life Edwards et al • Approx. 50% of non operatively treated patients avoided surgery! Scapular strengthening, posterior capsular stretching Overtreat >>>> NIGHTMARE Make Sure History Consistent with SLAP “event” • Sudden loss of velocity (dead arm) • Large increase in pain • “mechanical symptoms” usually present • Rehab no longer effective Exam Hold Key!!! • Load Shift • Passive Distraction test • Mayo Shear • O’Brien’ Test (anterior) • Kim test • Relocation Test Mayo Shear Numero Uno in Literature Passive Distraction KIM Lesion KIM Test Surgery? • Failure of GOOD rehab Experienced shoulder therapist GIRD addressed Scapula Rehab Kinetic Chain Eval Mechanical Symptoms (SLAP EVENT, frayed labrum from prolonged internal impingement) MRI Confirmatory Kinetic Chain Must Be Addressed • Hip abductors • Spine Mobility • Internal Rotation deficit Lead Hip • Tight quads Lead Leg • Scapula Dyskinesis • Unrehabbed ankle sprain • Poor balance Need True Pathologic Labral Separation (fissuring, hemorrhage, abortive healing) for TRUE LABRAL TEAR Biceps Tenodesis • Becoming more frequent • Reliable pain relief • Higher ‘success’ labral repair (labral repair failure rates as high as 50%) • BUT IS IT GOOD FOR ATHLETES?????? Tenodesis • Reasonable for salvage of failed labral repair in presence of POOR tissue • Over age 35 reasonable option • NON PHYSIOLOGIC Don’t throw away labral repair!! • We can do a better labral repair • Many degenerative, aged related ‘tears’ should not be repaired • Tenodesis removes an important stabilizer (Biceps) • Biceps tendon – ‘ACL of the shoulder’: Craig Morgan MD Biceps Has a Role • Rodosky – Biceps confers anterior stability • Patzer – Superior labrum requires intact biceps to ensure stability • Warner – Joint compression afforded by biceps stabilizes joint Tenodesis: not a free ride • Kumar 1989 Severing of LHBT > decrease over 5mm in acromial humeral distance • Upward migration if humeral head may not cause symptoms initially! Hanypsiak AANA 2012 • Cadaveric study • Biceps loaded 10, 20 and 40N • Humeral translation measured 3D digitizer • Tenodesis caused posterior shift humerus late cocking, ant. superior shift follow through Do Better Labral repair • Bumper restoration only • Address posterior capsule • Avoid knot suture issues • Address interval laxity • FIX KINETIC CHAIN Surgery: Do it right and address all pathologic elements • SLAP Tear • Bankart • Kim Lesion • Interval Laxity • Posterior Tightness • Cuff Lesion Goals: Preserve native anatomy • Restore bumper • Avoid knot/suture morbidity • Avoid tensioning capsule • Address interval Labral Surgery • Lateral Decubitus • Traction • Kindness to tissue! • Percutaneous Portals! (avoid cannulas in cuff) Lateral Decub….great Access Surgical Goals • Fix true labral tears • (Plicate anterior capsule/interval if necessary) • Release posterior capsule if necessary • Fix cuff ONLY if full thickness…..otherwise debride or do partial repair Restore Labral Bumper • Lazarus 1996 – increase in glenolabral depth directly related to stability Be Wary of Capturing Anterior Capsule! Portals Surgical Tips Labral Repair Percutaneous anchor insertion Keep Knots Away !!!! Or…… go KNOTLESS Or…..use PDS (CDM) Prominent Knots Hard Suture Prediction? Percutaneous Portals Percutaneous Shuttling Address the Rotator Interval • Unrecognized source of labral repair failure • Potential attenuation with extensive throwing • Anterior biceps pain in late cocking Rotator Interval – Biceps Outlet ( Pulley/ Sling ) Arthroscopic Anatomy: SGHL, SS Tendon, CHL Morgan Mechanism of Injury: Throwing Across Body with High Flexion Angle during the Follow-Through Phase of Pitching Morgan Arthrogram MRI - Sagittal Oblique Images Goniometric Measurement (Degrees) The Sagittal Rotator Interval Angle Morgan Arthroscopic Findings - SGHL Injured: Dorsal Biceps Hyperemic Synovitis Morgan Operative Repair: 2 North-South Capsular Stitches between SGHL & MGHL Morgan Reliable Diagnostic Parameters for Rotator Interval Pathology: Clinical, MRI, & Scope • Digital Pain in the Upper Bicipital Groove. • Anterior Superior Shoulder Pain in ABER relieved by Jobe Relocation Maneuver. • Increased GH External Rotation and TMA on the Dominant versus the Non- dominant Shoulder. • Asymmetric Sulcus Sign on the Dominant versus the Non-dominant Shoulder ( Neutral and ER). • A Widened Rotator Interval on Sagittal Oblique Arthrogram MRI with Bicep Tendon “Drop – Out” from central in the Pulley. • Arthroscopic visualized Widened Biceps Outlet. • Hyperemic Biceps, SGHL, and Upper MGHL with Parallel Adhesions going into the Biceps Outlet. • Laxity in the Upper MGHL. Morgan Address Posterior Capsule • Posterior capsular release non responders of sleeper stretch more ‘mature’ throwers capsule should be thick…..if not, don’t do it!!! Fig. 6 0.1053/jars.2003.50128 ) Copyright © 2003 Arthroscopy Association of North America Term Hug Glenoid Address Rotator Cuff Hypertwist Leads to Failure Cuff Tear • Anterior– leading edge supraspinatus (tension) • Posterior- junction supra-infra. (internal impingement) • Laminated tears “PAINT” – partial articular intratendinous tear (shear) • May approach full thickness Internal Impingement ABER VIEW Cuff Testing Management Cuff • Debride if less than 80-90% • Side to side, laminar/intrasubstance tear repair • Do not advance leading edge cuff to bone! (they will never find the ‘slot’ again) • Cuff tear allows shoulder to ‘hypertwist’ Side to Side Repair – ‘In Situ’ Conway College Pitcher PASTA Take Home • Don’t be a slapaholic – choose wisely • If addressing labral tear…..be kind, and use percutaneous portals • Release posterior capsule in ‘stretch non responders’ • Don’t be a hero with the rotator cuff! Take Home • Restore native anatomy • Address the interval • Correct kinetic chain • Tenodesis LAST RESORT THANK YOU [email protected] .