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The Diagnosis and Treatment of Superior Labrum, Anterior and Posterior (SLAP) Lesions
Abstract
The advent of shoulder arthroscopy, as well as our improved understanding of shoulder anatomy and biomechanics, has led to the identification of previously undiagnosed lesions involving the superior labrum and biceps tendon anchor. Although the history and physical examination, as well as improved imaging modalities such as magnetic resonance arthrography, are extremely important in understanding the abnormalities, the definitive diagnosis of superior labrum, anterior and posterior lesions is best made through diagnostic arthroscopy. Treatment of these lesions is directed according to its type. In general, type I and III lesions are debrided, whereas type II and many type IV lesions are repaired. The purpose of this article is to review the anatomy, biomechanics, classification, diagnosis, and current treatment recommendations for these lesions, as well as to review the literature.
... When there is no benefit after a trial of conservative treatment for SLAP I, debridement seems to be the preferred subsequent procedure. Traumatic and degenerative causes, age of the patient, and type of sport are just a few of the factors that influence the treatment choice [5,7,8]. Consensus on the optimal surgical treatment of SLAP II lesions has not been reached in the literature yet. ...
... The operating field was prepared and draped according to our hospital protocol. After establishing the posterior portal, a thorough 15-point inspection of the shoulder, as described by Snyder [7], was performed and all pathological findings were noted. Subsequently, intraarticular tenodesis of the LHB (long head of biceps) was performed at the bicipital sulcus entrance using an all-suture, doubleloaded, anchor (JuggerKnot 2.9 mm, Soft Anchor; Zimmer Biomet), followed by removal of the remainder of the LHB. ...
... A systemic review from Shin et al. [41] analyzing 13 articles found comparable functional outcomes of patients with SLAP lesions treated with repair techniques vs biceps tenodesis. Stathellis et al. [42] recommends resection of the bucket handle tear of the superior labrum for SLAP III lesions, which was also identified as an efficient approach by some other authors [7,29]. The algorithm Stathellis et al. [42] provide for approach to SLAP IV lesions dictates tenodesis, performing biceps tenotomy shows a higher rate of leaving a cosmetic deformity but may be preferred in case of elderly patients [11,35,43]. ...
Purpose
A type IX SLAP (superior labrum anterior to posterior) lesion involves 360° of the glenohumeral labrum. Only rare reports have been published analyzing the risk factors of this lesion and the success of its arthroscopic management. The aim of our study is to evaluate predisposing factors that lead to SLAP IX and to assess the clinical outcome after arthroscopic treatment. Our treatment algorithm is also presented.
Methods
We report on a series of six patients treated in our institution between January 2014 and January 2019 who underwent shoulder arthroscopy and were intraoperatively found to have a SLAP lesion type IX. Arthroscopic labral repair and biceps tenodesis were indicated in all patients. American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Rowe Score and Constant Murley Shoulder Score (CS) were used for clinical evaluation. Patients were evaluated preoperatively and at 12 weeks, 1 year and 2 years postoperatively.
Results
We analyzed six patients of which 83% were males (5/6 patients). The average age at the time of surgery was 37.16 (range 30–42 years). The dominant arm was affected in 50% of patients (3/6 patients). A significant postoperative improvement was seen in all six patients. 83% (5/6) of patients returned to their pre-injury activity level. Average values of all three measured scores show a significant increase comparing preoperative to postoperative period (P-value < 0.05). All patients were able to return to work.
Conclusions
The final diagnosis was established intraoperatively as 83% (5/6) of radiology reports differed from subsequent arthroscopic findings. The mechanism of injury in all our cases was high energy trauma with traction, arm in abduction or anteflexion. We observed great success with arthroscopic treatment as high percentage of our patients returned back to work and sports.
... Overhead athletes are the most prone to suffer SLAP tears [6]. The SLAP tear is classified into four subtypes depending on the extent of the labral tear and biceps anchor damage [7]. However, it has been further subdivided to delineate ten different types of SLAP tears [8,9]. ...
... There is still a controversy about which surgical technique is preferred and if surgical treatment is the best option [14,15]. Although some authors support the fact that nonsurgical treatment is unsuccessful [7], others promote nonsurgical treatment [16,17]. Return-to-play for overhead athletes ranged from 22% to 94%, and recent research shows around 64% success in nonsurgical treatment [18]. ...
The glenohumeral joint (GHJ) is one of the most critical structures in the shoulder complex. Lesions of the superior labral anterior to posterior (SLAP) cause instability at the joint. Isolated Type II of this lesion is the most common, and its treatment is still under debate. Therefore, this study aimed to determine the biomechanical behavior of soft tissues on the anterior bands of the glenohumeral joint with an Isolated Type II SLAP lesion. Segmentation tools were used to build a 3D model of the shoulder joint from CT-scan and MRI images. The healthy model was studied using finite element analysis. Validation was conducted with a numerical model using ANOVA, and no significant differences were shown (p = 0.47). Then, an Isolated Type II SLAP lesion was produced in the model, and the joint was subjected to 30 degrees of external rotation. A comparison was made for maximum principal strains in the healthy and the injured models. Results revealed that the strain distribution of the anterior bands of the synovial capsule is similar between a healthy and an injured shoulder (p = 0.17). These results demonstrated that GHJ does not significantly deform for an Isolated Type II SLAP lesion subjected to 30-degree external rotation in abduction.
... Studies of SLAP lesions suggest that most patients have pain, mechanical symptoms, notably, loss of range of motion, or inability to perform at their previous activity level [5,6]. The poor sensitivity and specificity of clinical examination tests and difficulties with the interpretation of advanced imagery [2,[12][13][14] make the clinical diagnosis difficult. ...
... We determined that the O'Brien and crank tests were not sensitive clinical indicators for detecting glenoid labral tears [2]. The poor sensitivity and specificity of these clinical examination tests and others combined with difficulties with the interpretation of advanced imagery [12][13][14] make the clinical diagnosis of SLAP tears extremely challenging. ...
Superior labral anterior to posterior (SLAP) tears in overhead athletes can be a career-ending injury because of the high failure rates with surgical intervention. There are many factors for this including the failure to establish the correct diagnosis, inadequate nonoperative management, the repair of normal variants of the superior labrum by inexperienced surgeons, and improper poor surgical technique. SLAP lesions rarely occur in isolation and can be associated with other shoulder disorders. The mechanism of injury can be an acute episode of trauma or a history of repetitive overhead use as in baseball pitchers or volleyball players. The physical exam findings can be confusing as these injuries often occur with other shoulder pathology. There is no single physical exam finding that is pathognomonic for SLAP tears. Nonoperative treatment should always be undertaken for a minimum of 3 months before surgery is recommended. If this fails to return the overhead athlete to competitive participation, a diagnostic arthroscopy with SLAP repair can yield excellent results if the proper technique is employed. The technique that we describe can be technically demanding but can be reproduced and give excellent results with a predictable return to play for overhead athletes.
... One of the main reasons why the diagnosis is so difficult is the presence of an additional pathology in 70% of patients with a SLAP lesion. Rotator cuff pathology was found in 40% of these patients, glenohumeral joint subluxation and dislocation in 19%, humeral head chondral pathology in 15% and acromioclavicular arthritis in 11% (Nam & Snyder, 2003;Snyder, 2003;Snyder & et al., 1990). ...
... The general impression was indicated as a fall on an outstretched arm. It should be noted that slap lesions are often accompanied by an anterior instability (Barber, Field & Ryu, 2008;Nam & Snyder, 2003). ...
Uterus pelvis boşluğunda mesane ve rektum arasında yer alan düz kastan oluşmuş boşluklu bir iç genital organdır. Uterus, embriyonal gelişimine gestasyonun dördüncü haftasında başlayıp 20. haftasında tamamlar. Uterusun duvar yapısı lümenden itibaren endometrium, ortada myometrium, dış kısımda perimetriumdan oluşur. Endometrium, döllenmiş yumurta hücresinin beslenmesi ve embriyonun implantasyonu için hayati bir tabakadır ve iki alt bölüme ayrılır. Bunlar; bazal tabaka ve fonksiyonal tabakadır. Menstrual siklusta endometriumun fonksiyonal tabakası dökülür ve mentruasyon sonrasında bazal tabakanın çoğalması ile yenilenir. Bu değişiklikler esas olarak östrojen ve progesteron hormonları etkisi altında gerçekleşir. Uterus bezlerinin (endometriyal bezlerin) 2/3‟si bazal tabaka içinde bulunur ve bu bezler; glikoz, lipid, protein salgılar. İmplantasyonda, yumurta hücresinin beslenmesinde ve plasentanın gelişiminde dönüştüğü spongioz yapısıyla önemi göz ardı edilemeyecek elzem bezlerdir. Fetus ile ilişkili ekstra embriyonik keselerin ve plasentanın gelişiminde de önemli rol oynayan uterus bezleri ilk ve ikinci trimestrilerde karbonhidrattan ve lipitten zengin salgıları ile bu yapıları destekler. Ek olarak, uterin bezlerinde sentezlenen iki glikoproteinin; güçlü immünsüpresif özelliklere sahip olan glikodelin A ve musin-1 (MUC-1) 'in ve bunun yanında lösemi inhibitör faktör (LIF)‟ün, implantasyonun organize edilmesinde anahtar rol oynadığı bilinmektedir. Uterus bezleri fetusun sadece beslenmesi, implantasyonu ve gebeliğin devamı için değil bunlara ek olarak büyüme faktörlerinin de kaynaklarından biridir. Bez epiteli ve luminal sekresyonda çeşitli büyüme hormonları tanımlanmıştır. Bu nedenlerle, uterus bezlerinin yapısındaki ve salgılarındaki herhangi bir anormallik erken gebelik kayıplarına neden olabilmektedir. Sonuç olarak, bazı hormonal değişiklikler (insülin, testesteron gibi), sistemik hastalıklarda (diyabet, hipertansiyon gibi) ya da ve klinik uygulamalar (küretaj gibi) sonucu uterus bezleri üzerinde oluşan etkilere yönelik ayrıntılı çalışmaların yeteri kadar olmadığı görüldü. Bu eksikliklere yönelik ayrıntılı histolojik ve moleküler çalışmalar yapılabileceği ve bu çalışmaların klinisyenler için önemli olabileceği düşünülmektedir.
Anahtar Kelimeler: Uterus, Uterus Bezleri, İmplantasyon
... One of the main reasons why the diagnosis is so difficult is the presence of an additional pathology in 70% of patients with a SLAP lesion. Rotator cuff pathology was found in 40% of these patients, glenohumeral joint subluxation and dislocation in 19%, humeral head chondral pathology in 15% and acromioclavicular arthritis in 11% (Nam & Snyder, 2003;Snyder, 2003;Snyder & et al., 1990). ...
... The general impression was indicated as a fall on an outstretched arm. It should be noted that slap lesions are often accompanied by an anterior instability (Barber, Field & Ryu, 2008;Nam & Snyder, 2003). ...
... As the arthroscopic equipment and the understanding of SLAP lesions continue to evolve, more effective surgical treatment modalities are possibly emerging [13,15] . Clinical results of arthroscopic stabilization of SLAP lesions with suture anchors show success rates ranging from 71 to 97% [15] . ...
... As the arthroscopic equipment and the understanding of SLAP lesions continue to evolve, more effective surgical treatment modalities are possibly emerging [13,15] . Clinical results of arthroscopic stabilization of SLAP lesions with suture anchors show success rates ranging from 71 to 97% [15] . While some authors of late favor tenodesis rather than SLAP repair in some situations A. et al.. ...
... Specialtests for labrum damage have highly varied results and have questionable reliability for assisting in diagnosis [33]. SLAP lesions are best examined with a history of trauma with symptomsconsisting of deep pain on movement, possible popping or locking, and general instability [34]. ...
... Labrum damage is also usually accompanied by other shoulder disorders such as rotator cuff tears and ligament damage [34,35]. Issues such as recurrent dislocations are best diagnosed with magnetic resonance arthrography (MRA) and a suspected fracture should be examined with X-ray [25,36]. ...
... Four types of superior labrum anterior to posterior (SLAP) lesions were initially described according to Snyder et al. [23]. However in the last years, several classifications have reported an increasing number of different types of SLAP lesions. ...
... However in the last years, several classifications have reported an increasing number of different types of SLAP lesions. The clinical usefulness of these last is not well established [23,58]. ...
Football is a very popular sport with more than 260 million active practitioners worldwide, and its practice puts in risk the players of every age, at all playing levels and field positions, to an injury. Due to the way football is played, the injury incidence is higher in the lower than in the upper extremity, but goalkeepers (GK), however, due to the specificity of this job, are prone to upper-extremity injury, with a five times higher incidence compared to outfield players.
... In addition to repetitive microtrauma, acute direct trauma is also among the factors implicated in the etiology (26). The importance of the biceps-superior labrum complex in shoulder stability has been stated in many studies (9,10,19,22), and it has been reported that especially SLAP lesions may contribute to the glenohumeral translation and lead to anterior shoulder instability (2,14,17). ...
... Morgan and co-workers (1998) (5) subdivided them into "three subtypes, according to the location of the superior glenoid labrum injury: IIA anterior 37%, IIB posterior 31% and IIC combined 31%" clinical assessment is generally nonspecific in SLAP lesions, . Arthroscopy found to be the gold standard for diagnosis during which an unstable biceps anchor will displace when pulled and arch away from the superior glenoid 5 mm or more, normal sublabral holes, cord-like middle glenohumeral ligaments, and Buford complexes will similarly appear without significant fraying or hemorrhage (6) .A positive "drive through sign" or being able to move the arthroscope from superiorly to inferiorly may also indicate laxity of the ligament support a SLAP tear (7) . ...
... It allows the surgeon to identify all the structures of the glenohumeral joint such as the labrum, glenohumeral ligaments, humeral head, joint capsule and the undersurface of the rotator cuff [11] . With its 20 power magnification, it permits the detection of pathological features that may not be seen with the naked eye [12] . Although MRI is an important imaging tool as mentioned above, arthroscopy remains the reference standard in diagnosing shoulder pathologies against which alternative diagnostic modality should be compared. ...
Background: Shoulder injuries tend to present mainly as pain and often leads to considerable disability. It is essential that a diagnosis of the shoulder pathology is made and treatment started immediately to attain prompt recovery and avoid chronicity and complications.
The current gold standard diagnostic investigation is arthroscopy. MRI is a proven sensitive and accurate non-invasive tool for detecting internal derangement and assessing overall joint structures, but many studies have reported false positive and negative results.
The aim of the study is to compare the accuracy of the two Diagnostic Modalities, Arthroscopy and MRI, in bony and ligamentous structure injury of the shoulder joint.
Methods: Twenty one cases of the age group 18-60 years presenting with shoulder pain following injury were included in our study, where MRI was performed followed by Arthroscopy. The data were analyzed for sensitivity, specificity, positive predictive value and negative predictive value and the correlation between MRI and Arthroscopy is done with the help of these statistics.
Results: In the study highest sensitivity was found in full-thickness Supraspinatus tear, Bankart’s lesion and Hill-Sachs lesion. The highest specificity and highest positive predictive value was found in Impingement syndrome, full thickness supraspinatus tear, Hill-Sachs lesion and Adhesive capsulitis. The highest negative predictive value was found in full-thickness supraspinatus tear, Bankart’s lesion and Hill-Sachs lesion.
Conclusion: MRI is an accurate, practical, efficient, non-invasive diagnostic modality in shoulder injuries, specially in conditions like full- thickness supraspinatus tear, impingement syndrome, Hill-Sachs lesion and Bankart’s lesion.
... Several studies identified accompanying pathologies in 70% of the patients with SLAP lesions. Various incidence rates have been reported for comorbidities including rotator cuff tears (40%), anterior instability (15%), chondral pathology in the humeral head occurred (15%), and arthritis in the acromioclavicular joint (11%) (11) . We did not find any studies in the literature including only the patients with isolated type 2-3 SLAP lesions as we did in this present study. ...
Objective: We compared the clinical outcomes after arthroscopic repair to those after biceps tenotomy in patients with isolated superior labrum anterior posterior (SLAP) Type 2-3 lesions. Methods: A total of 48 patients with isolated SLAP Type 2-3 lesions, who underwent either arthroscopic repair (n=024) or tenotomy (n=24) were included in the study. CONSTANT shoulder scores in the postoperative 40th month were compared between both groups. Tenotomy was performed for the second time in 6 patients who did not benefit from arthroscopic repair, and their CONSTANT scores estimated before and 12 months after tenotomy were compared. Results: The clinical outcomes were evaluated in the arthroscopic repair group. Preoperative and postoperative CONSTANT scores were 43.87 (8.32), and 71.41 (9.75) (p<0. 001), respectively. In the tenotomy group pre-, and postoperative CONSTANT scores were 40.25(8.63), and 90.04 (4.04) (p<0.001), respectively. There was not a significant difference between the two groups in terms of the preoperative scores (p=0.146), however, the comparison of the postoperative scores revealed a significant difference (p<0.001). The mean CONSTANT score was 50.3 (±5.64) at the end of 27th month, and the mean postoperative CONSTANT score was 86.8 (±7.16) at the 12th month in six patients whose complaints did not resolve and underwent repeat arthroscopic tenotomy (p<0.001). Conclusion: In our opinion, there is no criterion for repair or tenotomy in isolated SLAP lesions. In these patients, tenotomy may be preferred in the first place because it results in more favourable outcomes compared to repair. The cause of the pain that persists after repair of the SLAP lesion should not be considered as an incorrect, inadequate repair or a complication. In the first place, intolerable biceps tendinitis should be considered.
... The initial treatment recommendations for BLC injury included arthroscopic debridement and SLAP repair. [4][5][6] Early results showed poor long-term outcomes after debridement alone; therefore, arthroscopic repair of the biceps anchor became the gold standard for operative management. Studies of arthroscopic repair initially reported excellent results, based on various patient-reported, shoulder-specific outcome measures, with rates of successful outcomes ranging from 75% to 97%. ...
The goal of this study was to investigate the level of play that can be expected in a young, athletic population after biceps tenodesis and transfer. The authors hypothesized that both return to play rates and clinical improvement would be high after biceps tenodesis and transfer among young athletes. They conducted a retrospective review of patients who underwent biceps tenodesis and transfer procedures with a minimum follow-up of 24 months. Eligible patients were contacted for consent and asked to complete a questionnaire on patient-reported, shoulder-specific outcome measure scores, level of postoperative play, and other relevant information. The study included 41 patients with a mean age of 21.3 years. Patients reported a mean Kerlan-Jobe Orthopaedic Clinic (KJOC) score of 71.7, Disabilities of the Arm, Shoulder and Hand (DASH)-Sports score of 21.3, Single Assessment Numeric Evaluation (SANE) score of 79.4, and Numeric Rating Scale (NRS) pain score of 1.8. Scores for all patient-reported outcome measures were statistically better (P<.05) for patients who underwent biceps transfer (n=24) compared with biceps tenodesis (n=17). Of the participants, 26 (63%) played a primary overhead throwing sport. Most of the patients (95%) returned to play, and of those who returned to play, 67% returned to their preoperative level or higher. Although biceps tenodesis and transfer procedures have been designated primarily for older patients with biceps-labral complex injuries, the high return to play rates and outcome scores of patients in this case series show that biceps tenodesis and transfer can provide effective surgical treatment for a younger athletic population with biceps-labral complex injuries. [Orthopedics. 2021;44x(x):xx-xx.].
... Accurate delineation of the exact extent of the injury and identification of the sub-type of instability are an essential pre-requisite for selection of appropriate surgical management technique with an aim to optimize the clinical outcome [2,3] . Diagnostic arthroscopy, the present "Gold Standard" in shoulder instability, helps in the assessment of the structural damage present and planning of the appropriate surgical repair [4] . The invasive nature of arthroscopy with its associated complications preclude its use as a definitive modality of choice in all patients of shoulder instability, with its use mainly limited to patients who fail to respond to conservative management and or in patients with recurrent dislocations [3] . ...
Background: Shoulder joint is an extremely mobile joint with reduced stability. Pain and discomfort due to shoulder joint instability is common cause of orthopedic referrals in young individuals. Diagnostic Arthroscopy is the gold standard in evaluation and planning of definitive repair surgeries. Recent advancements in MR technology with increased accessibility of the general population to MR facilities have enabled non-invasive detection of pathologies associated with shoulder instability. The present study was aimed at determining the diagnostic value of shoulder MRI in shoulder instability as compared to arthroscopy. Materials and Methods: MRI and subsequent arthroscopic evaluation of 182 patients with shoulder pain and instability admitted to a busy orthopedic referral center was done after performing adequate clinical examination and necessary investigations. Results: Sensitivity and specificity of MRI was 95.87% & 89.41%, for detection of Bankart's lesion, 98.24% & 93.24% respectively for Hill Sach's lesion and 86.36% & 97.37% respectively for SLAP tears. High sensitivity and specificity was also found for rotator cuff tears. Conclusion: MRI can give an adequate information with regards to the pathology involved in shoulder instability and can help provide valuable input in planning of repair surgeries and can very well help to avoid unnecessary arthroscopic procedure.
... It allows direct visualization of the intra-articular structures under a magnification of almost ×20. [6] However, the procedure is invasive and thus carries the risks of complications, such as infection, damage to adjacent structures (e.g., musculocutaneous nerve or articular cartilage), and fluid extravasation, in addition to observational errors and anesthetic risks as well. ...
Background: Shoulder arthroscopy is currently considered the gold standard in diagnosing shoulder pathologies. Although magnetic resonance imaging (MRI) has an established accuracy in determining labral injuries following glenohumeral instability, the opinions of surgeons and radiologists regarding MRIs are still inconsistent till date. The aim of this study was to carry out a diagnostic evaluation of MRI vis-a-vis shoulder arthroscopy for the assessment of Bankart and Hill-Sachs lesions in subjects of anterior shoulder instability. Subjects and Methods: This was a diagnostic evaluation study, estimating the accuracy of MRI in diagnosing lesions encountered in shoulder dislocations vis-a-vis shoulder arthroscopy. Ninety participants of anterior shoulder dislocation were evaluated preoperatively with a shoulder MRI. The study participants were later subjected to a diagnostic shoulder arthroscopy and managed operatively on a case-to-case basis. Results: The sensitivity and specificity of MRI to diagnose a Bankart lesion were 90.78% and 85%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) were 97% and 63% for the same. The sensitivity and specificity of MRI to diagnose a Hill–Sachs lesion were 92.68% and 85.71%, respectively. The PPV and NPV were 84.44% and 93.33% for the same. The diagnostic accuracy for MRI detection of Bankart lesion was 91% and of Hill–Sachs lesion was 88.89%. Conclusions: MRI is a very sensitive and specific tool in the detection of lesions commonly associated with shoulder instability, namely Bankart and Hill–Sachs lesions.
... The superior glenoid labrum of the shoulder joint, which is related to the intraarticular insertion of the long head of the biceps tendon, is a common site of injury and degeneration [2][3][4]. When this biceps-labral complex of the glenoid labrum hurts, it caused severe damage to the stability of the shoulder joint, causing instability and pain of the shoulder [5]. Andrews et al. [6] used the term superior labrum anterior posterior (SLAP) to describe these lesions, and Snyder et al. classified the lesions into four subtypes. ...
Objective
Labral repair and biceps tenotomy and tenodesis are routine operations for type II superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their superiority is lacking. We conducted this systematic review and meta-analysis to compare the clinical outcomes of arthroscopic repair versus biceps tenotomy and tenodesis intervention.
Methods
The eight studies were acquired from PubMed, Medline, Embase, CNKI, and Cochrane Library. The data were extracted by two of the coauthors independently and were analyzed by RevMan 5.3. Mean differences (MDs), odds ratios (ORs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration’s Risk of Bias Tool and Newcastle–Ottawa Scale were used to assess risk of bias.
Results
Eight studies including two randomized controlled trials (RCTs) and six observational studies were assessed. The methodological quality of the trials ranged from low to moderate. The pooled results of UCLA score, SST score, and complications showed that the differences were not statistically significant between the two interventions. The difference of ASES score and satisfaction rate was statistically significant between arthroscopic repair and biceps tenotomy and tenodesis intervention, and arthroscopic biceps tenotomy and tenodesis treatment was more effective. Sensitivity analysis proved the stability of the pooled results, and there were too less included articles to verify the publication bias.
Conclusions
Both arthroscopic repair and biceps tenotomy and tenodesis interventions had benefits in type II SLAP lesions. Arthroscopic biceps tenotomy and tenodesis treatment provides better clinical outcome in ASES score and satisfaction rate and comparable complications compared with arthroscopic repair treatment. In view of the heterogeneity and confounding factors, whether these conclusions are applicable should be further determined in future studies.
... This is achieved by placing the arm in abduction and external rotation which applies tension to the biceps and can cause the labrum to "peel-away" from the glenoid [12,31]. Other signs of a pathological labrum-biceps complex include signs of reactive synovitis under the labrum, excessive sublabral recess beyond the edge of the glenoid cartilage and hypermobility of more than 5mm on biceps manipulation [32]. ...
... Es importante identifi ar los diferentes tipos de lesiones SLAP para tomar la de isión del tratamiento orre to ya que las lesiones SLAP tipo II y IV uando el tendón del bí eps presenta buena alidad se re omienda re onstruión, mientras que las lesión SLAP tipo III se re omienda rese ión de la lesión, y las lesiones SLAP tipo I al ser ambios degenerativos del labrum superior no ne esitan de tratamiento quirúrgi o. [2][3][4][5][6][7][8][14][15][16][17]19,21,22 La re onstru ión artros ópi a de la lesión SLAP da exelentes resultados en pa ientes que no realizan deportes de lanzamiento y resultados no predi tivos en deportistas de lanzamiento. Se ne esitan estudios prospe tivos randomizados nivel I de eviden ia para determinar de manera predi tiva resultados a largo plazo. ...
RESUMEN El dolor de hombro es un motivo de consulta frecuente en pacientes deportistas de lanzamientos o pacientes que realizan actividades por encima de la cabeza, pudiendo ser la lesión SLAP el motivo de su disfunción. La cascada patológica que lleva a la lesión SLAP consiste en una combinación de contractura capsular posteroinferior y disquinesia escapular, que producirá el fenómeno de despegamiento o peel back de la inserción de la porción larga del bíceps, resultando en la desinserción del labrum superior e inestabilidad de la unidad funcional bíceps labrum. Las diferentes maniobras de examen físico varían en sensibilidad y especificidad por lo que es útil complementar el diagnóstico con RNM o artroRNM para demostrar la alteración anatómica, pero el diagnóstico definitivo lo dará la artroscopia. Muchas de las lesiones SLAP pueden requerir de tratamiento quirúrgico para la reinserción de la unidad funcional bíceps labrum y el tratamiento de patología asociada, pero aun es controvertido el tratamiento definitivo de la lesión SLAP. ABSTRACT Shoulder pain is a frequent complaint in overhead athletes or patient with overhead activities and SLAP lesion a possible cause of their dysfunction. The pathological cascade leading to the SLAP lesion is a combination of posterior inferior capsular contracture and scapular dyskinesia. These abnormalities are responsible for the peel back phenomenon with detachment of the biceps-labrum complex leading to biceps-labrum instability. Different sensitivity and specificity of the physical exam have been published. It is useful to complement the clinical diagnosis with MRI or MR Arthrogram to demonstrate the lesion; however arthroscopy will confirm the diagnosis. Some of SLAP lesions may require surgical treatment to restore biceps labrum function and to treat the associated pathology, but treatment of SLAP lesion remains controversial. INTRODUCCIÓN HistóriDamente desDripta en 1985 por Andrews y Dol. 1 pero DlasifiDada por Snyder y Dol. 2 en 1990, la lesión SLAP (Superior Labrum Anterior to Posterior) haDe referenDia a la desinserDión del labrum superior de posterior haDia anterior inDluyendo la inserDión del tendón del bíDeps en el labrum superior; 2-7 desDribiendo un patrón de inestabilidad del labrum superior que Dompromete la estabilidad funDio-nal de la unidad bíDeps labrum, Dausadas por traumas agu-dos, aDtividades deportivas, laborales o de la vida diaria, rea-lizadas por enDima de la Dabeza. 2,5-7,8,9,10 HistóriDamente la inDidenDia de la lesión SLAP publiDada por Snyder y Dol. 2,6-7 fue del 3,9%. ReDientemente Weber y Dol. 11 en un estudio de seguimiento de la base de dato de la AmeriDan Board of OrthopaediDs Surgeons, entre el 2003 y el 2008, publiDan una inDidenDia del 10,1% Don una distri-buDión según sexo del 78,8% masDulinos y 21,6% femeni-nos, y un promedio de edad de 36,4 años para los paDientes masDulinos y de 40,9 años en paDientes femeninos. Las lesiones SLAP aislada o freDuentemente asoDiada a inestabilidades o rupturas del manguito rotador, puede ser la Dausa de la disfunDión del hombro, 10,12 debido al poten-Dial dolor, sensaDión de brazo muerto y rigidez subjetiva que muDhas veDes aDompaña el Duadro del hombro doloroso. 13-15 FISIOPATOLOGÍA DE LA LESIÓN SLAP En el entendimiento de la pato-anatomía de la lesión SLAP WalDh, 16 desDribió el pinzamiento glenohumeral posterosu-perior o impigment interno, Domo el pinzamiento que su-fre el tendón del manguito rotador entre el labrum superior y el troquiter Don el hombro en abduDDión de 90 grados Don rotaDión externa de 90 grados. Jobe, 17 dándole el Drédi-to a WalDh y Dol. 16 Domo los desDriptores de este síndrome; apliDa este DonDepto en los deportistas de lanzamiento des-Dribiendo un espeDtro de patología de lesión del manguito rotador, el labrum superior e inDluso el borde superior de la glena, haDiendo referenDia de que en los deportistas de lan-zamiento empeoraría el pinzamiento posterosuperior debi-do al estiramiento repetitivo y progresivo de las estruDtu-ras Dapsulo ligamentarias anteriores. 17 HalbreDht y Dol., 18 en desaDuerdo Don la teoría de Jobe 17 de que la inestabilidad anterior empeoraría el pinzamiento posterosuperior, de-mostró en su trabajo que un hombro que se subluxa ante-riormente tendrá menor DontaDto posterosuperior sin posi-bilidad de realizar un pinzamiento interno. Burkhart y Dol. 19 demuestran Dlaramente de que el proDeso patológiDo mas importante en el deportista de lanzamiento es la perdida de
... 3 Superior labrum anterior to posterior (SLAP) lesions are still uncommon shoulder injuries, with an incidence of 6%, diagnosed during arthroscopic procedures, according to Snyder et al. 4 Clinical and imaging diagnoses have low sensitivity and specificity, 5 and this condition may contribute to a major functional deficit and shoulder pain. 6 Lo and Burkhart 7 defined the triple labral lesion as a condition that involves unusual lesions of the glenoid labrum: superiorly, a SLAP lesion type II; anteroinferiorly, Bankart lesions; and posteroinferiorly, lesions such as the reverse Bankart (Fig. 1). ...
Objective
To evaluate the functional outcomes of patients submitted to arthroscopic repair of triple labral lesion.
Methods
This was an analytical retrospective study of patients who underwent arthroscopic treatment of triple labral lesion from March 2005 to December 2014. Patients with at least one year of postoperative follow-up were included. A total of nine patients were evaluated. The mean age was 32.3 years and the dominant side was affected in five patients. Patients were functionally assessed regarding the range of motion (ROM) in elevation, external rotation with the arm close to the body the arm in abduction of 90°, and internal rotation, and by the Carter–Rowe score. The degree of satisfaction was assessed at the end of the follow-up period.
Results
Three patients had less than five episodes of instability, four patients had between five and ten episodes, and two patients had more than ten episodes. Seven patients had positive O’Brien test for SLAP lesions and positive apprehension test in abduction and external rotation, and only one patient had apprehension in adduction and internal rotation. Three patients persisted with positive O’Brien test and one with apprehension in abduction and external rotation at the end of follow-up. The range of motion was complete in all cases. The median Carter–Rowe score increased from 40 preoperatively to 90 (p = 0.008).
Conclusion
The arthroscopic repair of triple labral lesions allows for the restoration of the stability of the glenohumeral joint, achieving excellent functional results.
... [3,4] anterior acromial spur an os-acromiale or a degenerative AC joint injury can also be conducted. [6] When a diagnosis is not clearly on conventional radiographs, Magnetic resonance imaging takes its place. SLAP lesions are usually very nicely depicted in multiplanar T1-and T2-weighted sequences of MR imaging. ...
The Superior Labrum Anterior-to-Posterior lesion (SLAP) is a term refers to a tear involving the superior glenoid labrum. These lesions are most common among athletes who perform overhead arm movements. The condition typically is a result of a fall on an outstretched hand or the repetitive overhead activity of hand that causes traction on the shoulder. SLAP lesions present a specific type and pattern of injury that includes mainly the partial or complete detachment of the superior labrum and or the long head of biceps tendon. Patients present with SLAP lesions mostly complains about pain in the shoulder while performing overhead movements and often develop mechanical popping or catching sensation in the shoulder. Our case report reviews the typical clinico-radiological findings and management of the SLAP lesion.
... 5 Essa patologia pode contribuir para um importante déficit funcional e dor no ombro. 6 Lo e Burkhart et al. 7 definiram a tríplice lesão labial como uma patologia que envolve lesões incomuns do lábio glenoidal: superiormente, a lesão Slap tipo II; anteroinferiormente, as lesões de Bankart; e posteroinferiormente, as lesões como o Bankart reverso ( fig. 1). ...
Avaliar os resultados funcionais dos pacientes submetidos a reparo artroscópico da tríplice lesão labral do ombro.
... O tratamento conservador não proporciona cicatrização da lesão (12) . O desbridamento artroscópico é indicado e realizado nas lesões tipo I e na presença de desinserção labial; porém, neste último tipo, não mostrou bons resultados no seguimento em longo prazo, sendo o reparo artroscópico da lesão considerado o tratamento de escolha (2,(8)(9)(10)(11)(12)(13)(14) . ...
Objective:
To evaluate the results and complications from arthroscopic suturing of SLAP lesions.
Methods:
Seventy-one patients who underwent arthroscopic suturing of SLAP lesions between July 1995 and May 2008 were evaluated. The procedures were performed by the Shoulder and Elbow Surgery Group of the Department of Orthopedics and Traumatology, Fernandinho Simonsen Wing, Santa Casa de São Paulo, Brazil. Associated lesions were seen in 68 of the 71 patients evaluated (96%), and the other three (4%) had SLAP lesions alone.
Results:
The associated lesions most frequently found in the patients under 40 years of age were labral lesions (69%), while in patients aged 40 years or over, impact syndrome with or without rotator cuff injury was the most commonly associated condition (71.4%). According to the UCLA method, 79% of our results (56 cases) were good or excellent. Postoperative complications occurred in 15 cases (21%); among these, the most common was the presence of residual pain (46.6%), followed by adhesive capsulitis (33.3%).
Conclusions:
There was a great association between SLAP lesions and other shoulder lesions, which varied according to the patients' age groups. Arthroscopic suturing of the SLAP lesions provided excellent results in the majority of the cases, but complications occurred in 21%.
Shoulder pain is a frequent complaint in overhead athletes or patient with overhead activities and SLAP lesion is a possible cause of their dysfunction. The pathological cascade leading to the SLAP lesion is a combination of posterior inferior capsular contracture and scapular dyskinesia. These abnormalities are responsible for the peel back phenomenon with detachment of the biceps-labrum complex leading to biceps-labrum instability. Different sensitivity and specificity of the physical exam have been published. It is useful to complement the clinical exam with MRI or MR Arthrogram to diagnose the lesion, however arthroscopy will confirm the diagnosis. Some of SLAP lesions may require surgical treatment to restore biceps-labrum function and to treat the associated pathology, but treatment of SLAP lesion remains controversial.
Glenoid superior biceps-labral pathology diagnosis, treatment and outcomes is an evolving area of shoulder surgery. Historically, described as SLAP tears (Superior Labrum Anterior Posterior) these lesions were identified as a source of pain in throwing athletes. Diagnosis and treatments applied to these SLAP lesions resulted in less than optimal outcomes in some patients and a prevailing sense of confusion. The purpose of this paper is to perform a re-appraisal of the anatomy, examination, imaging and diagnosis by the ASES/SLAP Biceps Study Group. We sought to capture emerging concepts and suggest a more unified approach to evaluation and identify specific needs for future research.
Background
It remains unclear if young overhead athletes with isolated superior labrum anterior-posterior (SLAP) type 2 lesions benefit more from SLAP repair or subpectoral biceps tenodesis.
Purpose
To evaluate clinical outcomes and return to sport in overhead athletes with symptomatic SLAP type 2 lesions who underwent either biceps tenodesis or SLAP repair.
Study Design
Cohort study; Level of evidence, 3.
Methods
A retrospective analysis of prospectively collected data was performed in patients who underwent subpectoral biceps tenodesis (n = 14) or SLAP repair (n = 24) for the treatment of isolated type 2 SLAP lesions. All patients were aged <35 years at time of surgery, participated in overhead sports, and were at least 2 years out from surgery. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) score; Single Assessment Numerical Evaluation (SANE) score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; and the 12-Item Short Form (SF-12) physical component score. Return to sport and patient satisfaction were documented. Clinical failures requiring revision surgery and complications were reported.
Results
Preoperative baseline scores in both the tenodesis and SLAP repair groups were similar. There were no significant differences between the groups on any postoperative outcome measure: For biceps tenodesis versus SLAP repair, the ASES score was 92.7 ± 10.4 versus 89.1 ± 16.7, the SANE score was 86.2 ± 13.7 versus 83.0 ± 24.1, the QuickDASH score was 10.0 ± 12.7 versus 9.0 ± 14.3, and SF-12 was 51.2 ± 7.5 versus 52.8 ± 7.7. No group difference in return-to-sports rate (85% vs 79%; P = .640) was noted. More patients in the tenodesis group (80%) reported modifying their sporting/recreational activity postoperatively because of weakness compared with patients in the SLAP repair group (15%; P = .022). One patient in each group progressed to surgery for persistent postoperative stiffness, and 1 patient in the tenodesis group had a postoperative complication related to the index surgery.
Conclusion
Both subpectoral biceps tenodesis and SLAP repair provided excellent clinical results for the treatment of isolated SLAP type 2 lesions, with a high rate of return to overhead sports and a low failure rate, in a young and high-demanding patient cohort. More patients reported modifying their sporting/recreational activity because of weakness after subpectoral tenodesis.
PURPOSE
To use an expected-value decision analysis to determine the optimal treatment decision between repair or a biceps tenodesis (BT) for an isolated type II Superior Labral Anterior Posterior (SLAP) injury.
METHODS
An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. To determine outcome probabilities, a decision tree was constructed (repair vs BT) and a meta-analysis was conducted. To determine outcome utilities, we evaluated 70 patients with a chief complaint of shoulder pain with regard to age, sex, Shoulder Activity Level (SAL) and visual analog scale regarding potential outcome preferences. Statistical fold back analysis calculated optimal treatment. One-way sensitivity analysis determined the effect of changing the reinjury rate on the expected value of a biceps tenodesis.
RESULTS
The overall expected value for biceps tenodesis was 8.66 versus 7.19 for SLAP repair. One-way sensitivity demonstrated that biceps tenodesis was the superior choice if reinjury rates are expected to be less than 28%. Meta-analysis of 23 studies and 908 patients revealed the probability of a well outcome was significantly greater for BT (87.8%; 95% CI 74.9-94.6%, I²=0.0%) than SLAP repair (62.9%; 95% CI 55.9-69.3%, I²=65.9%; p=0.0023). Reinjury with BT was 1.5% (95% CI 0.05% to 33.8%, I²=0.0%) and repair 6.4% (95% CI 4.2%-9.6%, I²=24%) which was not statistically significantly different (p=0.411). 50 participants [mean age=25.4 (SD 8.9), male = 76%; overhead athletes = 50%] met inclusion criteria. Forty-six percent of participants had a SAL score of ‘high’.
CONCLUSIONS
Decision analysis demonstrated that biceps tenodesis is preferred over repair for an isolated type II SLAP tear based on greater expected value of BT versus repair. Meta-analysis demonstrated more frequent favorable outcomes with BT. Surgeons can use this information to tailor discussion with patients..
This chapter presents a case scenario of a 25‐year‐old baseball pitcher who has several months of atraumatic shoulder pain in his dominant arm. The clinical presentation and evaluation of superior labral tear anterior to posterior (SLAP) tears in overhead athletes can be highly variable. Operative treatment of SLAP tears results in poor return to play (RTP)/return to their prior performance (RTPP). Nonoperative treatment addressing glenohumeral internal rotation deficit, scapular dyskinesis, and other concomitant shoulder pathology can result in similar RTP/RTPP, even among athletes that have previously failed nonoperative treatment. Studies which quantitatively assess RTPP report significantly lower RTPP compared to those which only characterize athletes as returning to the same/higher level of competition. Overhead throwing athletes appear to have lower RTP compared to overhead nonthrowing athletes. The chapter provides recommendations for implementing evidence‐based practice in the clinical setting.
Purpose
To identify and characterize the top 50 most-cited articles regarding SLAP tears.
Methods
Referencing the methodology of previous citation analyses, varying Boolean searches were performed using the Web of Science database and the search terms yielding the greatest number of results was used. The top 50 most-cited articles were identified and the following data points were gathered from each article: author, institution, country of origin, year of publication, publishing journal, level of evidence, and citation density.
Results
The total number of citations was 7834, with a median of 106 citations. The top 50 list was largely composed of diagnostic level I, II, and III studies (5, 7, and 8 total publications, respectively) and therapeutic level III (6 publications) or level IV (10 publications). Most articles originated from the United States (40). In total, 19 of the top 50 most-cited articles were published in the American Journal of Sports Medicine, followed by Arthroscopy (15) and the Journal of Bone and Joint Surgery (5).
Conclusions
Our analysis demonstrated a correlation with earlier publications being cited more frequently than recent studies. Importantly, the current study found that therapeutic studies in the most cited list were largely level III or level IV evidence. This makes the management of SLAP tears seem anecdotal, with little in the way of high-impact level I or level II therapeutic studies. We must reconsider our current understanding of SLAP tears and their management with more studies that demonstrate a clearer treatment algorithm for these common injuries of the shoulder.
Clinical Relevance
Given the complexity of SLAP tears, this list of the most-cited articles can provide a reference point to better guide practice, resident education, and future areas of orthopaedic research.
Purpose
To identify and evaluate the top 50 most-cited articles pertaining to SLAP tears.
Methods
The ISI Web of Knowledge database was used to conduct a query for articles pertaining to SLAP tears. Our query was conducted in April 2020 with multiple Boolean operative combinations performed by 2 independent reviewers. Articles on the final list were further reviewed to extract the following data: manuscript title, first author, total citation count, year of publication, citation density since publication, current citation rate since 2013, journal, country of origin, and level of evidence.
Results
Our initial search yielded 2,597 articles. Within this cohort, the top 50 publications pertaining to SLAP tears were identified that met our search criteria. The top article was cited 802 times while the 50th ranked article was cited 46 times. The average number of citations per publication was 131, whereas the average citation density since year of publication was 7.3. No strong correlations were found between citation density and year published. Twelve journals published articles pertaining to SLAP tears, with Arthroscopy accounting for the greatest number (15 articles, 30%). Most articles were graded with a level of evidence (LOE) of IV (n = 24, 48%), followed by review articles without LOE (n = 8, 16%). Only 2 articles achieved an LOE of I (4%). Articles typically addressed the arthroscopic management (n = 11, 22%), whereas anatomy/classification (n =10, 20%), and outcomes (n = 9, 18%) also were reported.
Conclusions
This review provides a quantitative analysis of the most-referenced literature pertaining to SLAP tears. This body of knowledge helps surgeons search for literature regarding these injuries and identify trends regarding SLAP tear research.
Clinical Relevance
This research provides practitioners with an easily accessible and comprehensive collection of the major contributions regarding SLAP tears and offers insight into future areas for research.
PurposeThe purpose of this study was to evaluate the rate of return to play (RTP) in patients who underwent Type V superior labrum anterior–posterior (SLAP) repair compared to patients who underwent isolated Bankart repair in the setting of traumatic anterior shoulder instability.MethodsA retrospective review of patients who underwent arthroscopic Bankart repair and SLAP repair by a single surgeon between 2012 and 2017 was performed. Additionally, these were pair-matched in a 1:2 ratio for age, sex, sport and level of pre-operative play, with those undergoing isolated arthroscopic Bankart repair alone as a control group. RTP, level of RTP and the timing of RTP were assessed.ResultsThe study included a total of 96 patients, with 32 in the study group and 64 in the control group, and a mean follow-up of 59 months. Overall, there was no significant difference in the overall rate of return to play (26/32 (81.3%) vs 56/64 (87.5%), n.s), but there was a significantly higher rate of RTP at the same/higher level in the control group (14/32 (43.6%) vs 43/64 (67.2%), p = 0.0463). There was no significant difference in timing of RTP between the groups (n.s). There was no significant difference in recurrent instability (6/32 (18.8%) vs 5/64 (7.8%), n.s) but there was a significant difference in revision rates (5/32 (15.6%) vs. 2/64 (3.1%), p = 0.0392) between the Type V SLAP repair group and the control group.Conclusion
Following arthroscopic repair, patients with Type V SLAP tears had a similar overall rate of RTP when compared directly to a control group of patients who underwent arthroscopic Bankart repair alone. However, those who underwent Type V SLAP repair reported significantly lower rates of RTP at the same or higher level compared to the control group.Level of evidenceIII.
Objectives
The aim of this study is to demonstrate the importance of clinical diagnosis by comparing with preoperative physical examination and magnetic resonance imaging (MRI) images in patients who were arthroscopically diagnosed as having Superior Labrum Anterior–Posterior (SLAP) II lesions.Materials and Methods134 patients, arthroscopically diagnosed as SLAP II, established the study group, and 200 patients who underwent shoulder arthroscopy for the other pathologies established the control group. Preoperative clinical examination of the patients, MRI findings, and the arthroscopic findings of the patients were recorded.ResultsOut of the patients diagnosed with a SLAP II lesion, 107 (79.9) of those had an MRI finding while only 60 (30%) of the control group had it. The O’Brien test results of the patients diagnosed with SLAP were positive in 111 (82.8%) while those diagnosed with intact superior labrum were positive in 132 (66%). Of the 134 patients with a SLAP II lesion, 89 (66.4%) had both O’Brien test positiveness and MRI finding, and 129 (96%) had at least one positive result of the O’Brien test or MRI examinationConclusion
The O’Brien test and MRI examination are not capable enough to indicate a SLAP lesion one by one, because of the low sensitivity and specificity. But, combining the test with MRI findings provides more trustable information about the superior labrum.
Introduction: Shoulder pain is a significant cause of decreased
functional activity of an individual. The overall prevalence of
shoulder pain is 16-26%, which makes it the third most common
cause among musculoskeletal complaints. The cause of pain in
the shoulder is often difficult to evaluate, and diagnosis is usually
ambiguous because physical findings are poorly reproducible.
The diagnosis therefore, requires multiple imaging modalities.
Therapeutic arthroscopy is “the current gold standard” for
diagnosing shoulder pathologies, however the procedure is
invasive, needs hospitalisation and anaesthesia.
Aim: To correlate the findings of Magnetic Resonance Imaging
(MRI) shoulder with the findings of shoulder arthroscopy and
subsequently determine sensitivity, specificity and accuracy of
MRI in diagnosing shoulder pathologies.
Materials and Methods: Forty two patients suffering from
chronic shoulder pain for a period of more than six weeks, having
symptoms of instability, clinical signs of tear or impingement,
or functional limitation of the affected shoulder were included
in this study. The patients included were in the age group of
18-80 years. Subsequently, MRI followed by arthroscopy of the
shoulder was done and the findings of MRI were compared to
that of arthroscopy using kappa statistics.
Results: In this study along with rotator cuff tear (26 patients),
subacromial bursitis (26 patients), was the other most common
shoulder pathology. The sensitivity of MRI in detecting shoulder
pathologies varied from poor (0.28) for Superior Labrum Anterior
Posterior (SLAP) lesion to very good (0.88) for Bankart’s tear
and (0.8) for synovial chondromatosis to excellent for rotator
cuff tears (0.92). Although sensitivity of MRI was variable for
different shoulder pathologies, specificity was comparatively
high in detecting all of the above shoulder pathologies. The
accuracy of MRI was highest (0.95) in diagnosing synovial
chondromatosis, followed by bankart’s lesion (0.92), and rotator
cuff tear (0.88).
Conclusion: MRI is a very useful and effective tool in diagnosing
various shoulder pathologies with exception of SLAP tears
where its sensitivity diminishes significantly.
The repetition of the abduction-external rotation movement of the arm during the overhead action carries an increased risk of overloading various structures around the shoulder. Pathologic contact between the posterior margin of the glenoid and the articular surface of posterosuperior rotator cuff tendons is known as posterior internal impingement. The chronic repeated compression or impingement leads to articular tears of the rotator cuff tendons as well as lesion of the superior labrum. Every overhead athlete requires a training program that strengthens all elements of the kinetic chain of the throwing motion. Patients with mild symptoms and early phases of the disorder need active rest, including a complete break from throwing along with physical therapy. Conservative management of SLAP lesions is often the first line of treatment. However, frequently, rehabilitation is unsuccessful; therefore, surgical intervention is often warranted to repair the labral lesion while addressing any concomitant pathology.
Introduction
Optimal treatment of type II superior labrum anterior and posterior (SLAP) tears is controversial. There has been a recent trend towards biceps tenodesis over SLAP repair in older patients. Few surgeons have performed combined biceps tenodesis and SLAP repair with inferior results.
Case Report
This case describes a 46-year-old patient who had persistent pain and stiffness after combined biceps tenodesis and SLAP repair for a type II SLAP tear. His pain and motion improved after arthroscopic superior capsular release.
Conclusion
Failed SLAP repair is often multifactorial and a thorough workup is needed. Combined biceps tenodesis and SLAP repair can cause pain, stiffness, and dysfunction which can be successfully treated with arthroscopic superior capsular release.
The shoulder is the most inherently unstable joint in the body, prone to high rates of anterior dislocations with subsequent injuries to soft tissue and bony stabilizing structures, resulting in recurrent shoulder instability. Advanced imaging utilizing magnetic resonance (MR) imaging and MR arthrography allows for thorough evaluation of lesions present in the unstable shoulder and is critical for preoperative planning. Arthroscopic shoulder stabilization in the appropriately selected patient can help restore stability and function. This review highlights correlations between MR imaging and arthroscopy of the most commonly reported soft tissue and bony injuries present in patients with shoulder instability.
Normal anatomic variants of the anterosuperior labrum are common and include the sublabral foramen and the Buford complex. The Buford complex is a rare variant found in a subset of patients with absent anterior-superior labral tissue and a “cordlike” middle glenohumeral ligament (MGHL) originating directly from the superior labrum at the base of the biceps tendon (Williams, Snyder, Buford Jr. Arthroscopy 10:241–7, 1994). The incidence of the Buford complex varies between 1.5% and 6% (Williams, Snyder, Buford Jr. Arthroscopy 10:241–7, 1994; Ide, Maeda, Takagi. Arthroscopy 20:164–8, 2004; Ilahi, Labbe, Cosculluela. Arthroscopy 18:882–6, 2002). A sublabral foramen variant may also be present with or without a “cordlike” middle glenohumeral ligament. When present, the Buford complex is typically associated with an absent superior glenohumeral ligament and a well-developed inferior glenohumeral ligament. Furthermore, this variant may predispose patients to possible superior labral injury (Bents, Skeete. J Shoulder Elb Surg 14:565–9, 2005; Rao, Kim, Chronopoulos, McFarland. J Bone Joint Surg Am 85-A:653–9, 2003).
The glenohumeral joint and surrounding structures that comprise the shoulder are subject to multiple forms of insult including impingement, tendon tears, labral tears, cartilage damage, and arthritis. Clinical examination is the first line in the workup of shoulder pain. Based on these observations, an algorithm is followed that includes further workup to make the diagnosis and ends in appropriate treatment. Radiographs are necessary for the initial workup of shoulder pain. They can demonstrate joint space narrowing, high riding shoulder ( suggestive of large rotator cuff tears), dislocation, subluxation, osteophytes, erosions, sclerosis, subchondral cysts, abnormal bone density, and soft tissue ossification and calcification. Beyond that, more sophisticated imaging studies may be needed to make the diagnosis. Occasionally that may be in the form of ultrasound or computed tomography (CT), but most often it is magnetic resonance imaging (MRI) that is the next step in the workup. Magnetic resonance imaging is able to evaluate the osseous and soft tissue structures of the joint and its surroundings. Magnetic resonance imaging can confirm clinical suspicions, show related abnormalities throughout the joint, and suggest pathology that was not clinically evident. This chapter discusses the capabilities, pitfalls, and limitations of MRI for evaluation of the shoulder.
RESUMEN Introducción: La lesión de SLAP se encuentra en permanente estudio en todos sus aspectos. La tendencia actual en su diagnóstico es considerar fundamentalmente la evaluación artroscópica. Nuestro Objetivo es evaluar la variabilidad intra e inter-observador en el diagnóstico artroscópico de la lesión de SLAP utilizando la clasificación de Snyder. Material y Método: 27 videos pertenecientes a pacientes con patología de SLAP fueron editados, mostrando la fase diagnóstica de la artroscopía de hombro, y enviados a 4 cirujanos ortopedistas especializados en artroscopía, a quienes se les solicitó determinar un diagnóstico respecto al labrum superior de acuerdo a la clasificación de Snyder. Finalmente, se obtuvo la variabilidad diagnóstica intra e inter-observador utilizando para ello el porcentaje de concordancia así como el coeficiente Kappa. Resultado: se analizaron 216 respuestas, entre los cirujanos con más de 5 años de experiencia obtuvimos una concordancia diagnóstica inter-observador (κ) casi perfecto, mientras que respecto a los datos obtenidos de los fellowship resultó en una variabilidad moderada. En ambos grupos la mayor discordancia se encontró en las Lesiones SLAP Tipo I, con marcada diferencia respecto al resto, siendo en su mayoría sobre-diagnosticadas como Lesiones Tipo II. Conclusión: Podemos decir que la variabilidad en el diagnóstico artroscópico tanto inter como intra-observador de la lesión SLAP disminuye considerablemente cuanto mayor experiencia posea el observador. Tipo de Estudio: Diagnóstico. Nivel de evidencia: III. Palabras Clave: Superior Labral Anterior Posterior (SLAP), Variabilidad Inter-observador, Variabilidad Intra-observador. ABSTRACT Introduction: SLAP lesion it is constantly study in all its aspects. Arthroscopic evaluation is the gold standard to diagnosis SLAP lesion. The purpose of this study is to evaluate the intra-and inter-observer variability for arthroscopic diagnosis of SLAP lesion using the Snyder classification. Method: Compact discs containing 27 video file showing the diagnostic phase of shoulder arthroscopy of approximately 15 seconds duration were sent to 4 orthopedic surgeons specializing in arthroscopy. Each surgeon was asked to review the videos and classify the superior labral anterior posterior lesion type (SLAP lesion). Finally, we obtained the intra-and inter-observer reliability by using the percentage concordance as well as the Kappa coefficient. Results: 216 responses were analyzed, among surgeons with over 5 years of experience we obtained a diagnostic inter-observer agreement (κ) almost perfect, while for the data obtained from the fellowship resulted in a moderate variability. In both groups, the largest discrepancy was found in the Type I SLAP lesions, with marked difference from the rest, being mostly over-diagnosed as type II lesions. Conclusion: we can say that there is substantial interobserver and intraobserver variability among experienced shoulder arthroscopic specialists with regard to diagnosis of superior labral anterior posterior tears. Study Design: Diagnostic. Level of evidence: III. INTRODUCCIÓN El estudio de la lesión de SLAP encuentra sus inicios hace aproximadamente 30 años, teniendo un salto en su difu-sión hacia los años '90 de la mano de Snyder, cuya clasifi-cación 1 es aun ampliamente reconocida por cirujanos or-topedistas en el mundo entero. Tanto es así que muchos especialistas basan su terapéutica en dicha clasificación. A pesar de ello, sucesivas investigaciones demostraron cierta limitación de la clasificación de Snyder para cate-gorizar con precisión aquellas lesiones labrales complejas. A raíz de esto en 1995 surge una modificación propuesta por Maffet y col., 2 quiénes adicionan a la anterior tres ti-pos de lesiones, y luego en el 98 Morgan y col. 3 proponen una sub-clasificación de la lesión SLAP tipo II de Snyder en tres entidades, con diferentes pronósticos para cada una de ellas. Por último Powel y col., 4 en el 2004, agregaron a la clasificación ya modificada por Maffet, tres tipos más sumando en la actualidad 10 tipos diferentes de lesiones SLAP. De momento a la fecha la fisiopatología, la biomecáni-ca, el diagnóstico como los tratamientos y sus resultados clínicos se encuentran en permanente investigación. 5-10 A
Objectivo: revisão da literatura atualizada sobre patologia da longa porção do bicípite braquial, incluindo os mais recentes avanços no que diz respeito à intervenção terapêutica e às controvérsias existentes na escolha da mesma. Fontes de dados: pesquisa na base de dados Pubmed, usando como termos chave long head of biceps brachii, tenotomy e tenodesis tendo sido seleccionados apenas artigos publicados nos últimos 15 anos. Outros artigos foram pesquisados a partir de referências dos anteriores. Síntese de dados: a revisão efetuada revelou que tanto a tenodese como a tenotomia são opções viáveis de tratamento e com elevada taxa de sucesso na omalgia com origem na longa porção do biceps. O nível de atividade e a idade do paciente são determinantes na opção da técnica cirúrgica. Na tenodese, a opção por técnica aberta ou artroscópica, proximal ou distal, com as diferentes possibilidades de fixação, deverá ser feita integrando diversas variáveis, incluindo a experiência do cirurgião. Outras modalidades cirúrgicas, como o desbridamento, ou a reparação da âncora bicipital são utilizadas em casos seleccionados. Conclusões: é muito importante realizar uma correta avaliação clínica, imagiológica e artroscópica das lesões da longa porção do bicípite. O seu papel na origem da omalgia não deve ser nunca negligenciado e deve ser sempre objeto de tratamento. Existem actualmente técnicas para o tratamento destas lesões que parecem mostrar resultados satisfatórios e promissores. Contudo, levantam-se ainda muitas questões quanto à escolha do melhor procedimento, pelo que é necessário efetuar mais estudos a longo prazo.
The proximal humerus tends to fracture into four distinct fragments: the humeral shaft, the greater and lesser tuberosities, and the articular surface [1]. Neer based his classification system on displacement of these fragments by greater than 1 cm or angulation of more than 45°. In a retrospective review, Neer found that 85 % of fractures were considered to be minimally displaced and nonoperative management led to satisfactory results. Displaced two-part greater tuberosity fractures, according to the above criteria, were treated with open reduction and internal fixation [1, 2].
Background/aim
For patients presenting with glenoid labral pathologies, there is little information on how operative interventions affect long-term outcomes and health-related quality of life (HRQoL). This study evaluated outcomes in operative and non-operative patients presenting with labral tears versus labral degenerations.
Methods
Participants completed a pain Visual Analogue Scale (VAS), the Veterans RAND 12-item Health Survey, Western Ontario Rotator Cuff Index, American Shoulder and Elbow Surgeons instrument, Scapular Assistance Test (SAT), Shoulder Activity Level, and Single Assessment Numeric Evaluation at baseline and at 6-month, 12-month and 2-year follow-ups. χ²and Student's t-test were used to test the differences between categorical and continuous variables. Analysis of variance investigated the differences between groups, and linear regression analyses explored the relationship of baseline characteristics with outcome scores.
Results
After 2 years, the operative cohort (n=68) significantly improved in all measures. The non-operative cohort (n=55) showed significant improvements in all scores except the mental component summary (MCS) and pain VAS. Labral tear patients (n=52) within the operative group (n=28) significantly improved in all measures except MCS. Non-operative labral tear patients (n=24) indicated significant improvements in all measures except MCS, VAS and SAT. Labral degeneration patients (n=71) within the operative group (n=27) significantly improved in all measures except MCS and SAT. Non-operative labral degeneration patients (n=44) indicated significant improvements in all measures except the physical component summary, MCS, VAS and SAT.
Conclusion
Patients who were surgically treated for labral tears or degenerations had significantly improved outcomes and HRQoL scores after 2 years compared with the non-operative cohort.
Background/aim
Health-related quality of life (HRQoL) is increasingly assessed within orthopaedic research. For those patients presenting with glenoid labral pathologies, there is little information on how baseline comorbidities affect long-term outcomes and HRQoL. This study aimed to investigate a model, including baseline comorbidities and demographics, to predict change in 2-year HRQoL scores in adult patients with glenoid labral tears or degenerations.
Methods
Participants provided Functional Comorbidity Index (FCI) scores and self-completed the Western Ontario Rotator Cuff (WORC) index at 6, 12 and 24 months. Univariable and multivariable linear regressions were performed to assess predictive quality of baseline comorbidities and demographics on the primary outcome measure of interest (change in WORC score).
Results
Multivariate regression with a continuous scaled FCI (β=617.8, p=0.042), age (by decade) (β=297, p<0.01), surgical group (β=−476.69, p<0.01) and an interaction term between FCI and age (β=−103.65, p=0.03) were significant predictors of change in WORC scores at 2-year follow-up (r²=0.293858). Multivariate regression with FCI scaled categorically reported only patients with three comorbidities (β=−454.06, p=0.057) and age (by decade) (β=156.87, p=0.04) as the only significant predictors of change in WORC scores at 2-year follow-up (r²=0.1279).
Conclusion
The continuous FCI model is better suited to predict future WORC and HRQoL scores among this patient population. Patients reporting with higher numbers of baseline comorbidities improved significantly more than patients with fewer comorbidities. This information on expected change in HRQoL scores among patients with a wide range of FCI scores at baseline may help guide treatment decisions based on these criteria.
An anatomic study was designed to test the hypothesis that the articular surface of the glenoid fossa and labrum produces a composite socket of significant depth. Measurements were obtained from 25 anatomic specimen shoulders. The glenoid articular surface and labrum combine to create a socket that is approximately 9 mm deep in the superoinferior (SI) direction and 5 mm deep in the anteroposterior (AP) direction. The circular, pliable, fibrous labrum contributes approximately 50% of the total depth of the socket. Detachment of the labrum anteriorly, as in a Bankart lesion, may reduce the depth of the socket in the AP direction from approximately 5.0 to 2.4 mm. These anatomic observations provide some evidence that the socket may be an important factor in shoulder stability. Further in vivo kinematic studies of shoulders will be needed to better define the stabilizing role of the glenoid-labral socket.
We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both.
To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder.
From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography.
SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography.
MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon.
Although magnetic resonance imaging is very sensitive and even though pathology in the rotator cuff is readily detected, it is often difficult to distinguish between complete rotator cuff tears, partial rotator cuff tears, and area of tendinitis. This article reports the results of a new technique for evaluation of shoulder pathology, which the authors have labeled magnetic resonance arthrography, and compares the results of magnetic resonance arthrography with those of conventional magnetic resonance imaging.
A retrospective analysis of 530 glenohumeral arthroscopies performed by three independent Belgian arthroscopists revealed the presence of 32 SLAP lesions, which represents an incidence of 6%. Since this is exactly the same percentage as found by Snyder et al., we report our data in this article. We classified 23 of the SLAP lesions using Snyder's classification, 7 needed the additional classification of Maffet et al., and 2 lesions were considered to be anatomic variations; 53% of the lesions were of type II. Concerning the mechanism of injury, we found comparable percentages of traction (22%) and compression (28%) injury as reported by Snyder, but also a high number (25%) of overhead sports activities as described by Andrews et al. Associated lesions were in close accordance with Snyder's data, but a relatively low incidence of rotator cuff injuries (10%) was present. Comparison of treatment regimens showed that the same percentage of lesions (34%) was fixed arthroscopically in both series. Only SLAP II, IV, and V lesions must be considered as unstable and in need of fixation. We confirm that patients' complaints and clinical symptoms are vague and inconsistent. Imaging, using computed tomographic arthrography or magnetic resonance, was performed in a minority of cases. Advantages and pitfalls of both techniques are discussed. Anatomic variations causing an extra-large sublabral hole are shown, and we warn about potential diagnostic and therapeutic errors in these cases. (Arthroscopy 1998 Nov-Dec;14(8):856-62.)
Introduction
There is no definitive clinical sign or symptom which is diagnostic for a superior labral anterior to posterior (SLAP) tear of the shoulder. The purpose of our research is to conduct a retrospective review of isolated SLAP lesions of the shoulder to determine if there are any specific signs, symptoms, or mechanism of injury which are diagnostic for SLAP lesions and the clinical results of operative treatment.
Methods
In a review of 2,375 shoulder arthroscopies, 140 SLAP lesions were identified, 23 of which had no other intra-articular or subacromial pathology. At the time of diagnostic arthroscopy, there were 19 type II, one type III, two type IV, and one complex type II/III SLAP lesion. There was no other intra-articular or subacromial pathology found including partial or complete rotator cuff tears.
Results
The mechanism of injury was a fall on an outstretched arm in seven patients, a direct blow to the shoulder in four patients, glenohumeral subluxation or dislocation in two patients, pain while lifting a heavy object in two patients, traction injury in two patients, and an insidious onset in one patient. Five patients experienced an acute onset of pain with overhead sporting activities. The most common complaint was pain and pain with overhead activities in all 23 patients. All patients complained of some sort of painful mechanical-like symptoms in their shoulder which caused pain. The majority of patients mimicked impingement-like symptoms with 12/23 (52%) had a positive Neer test, 8/23(35%) had a positive Hawkins test but all had a normal bursoscopy examination at the time of arthroscopy. All type II SLAP lesions were repaired with a suture anchor technique. The type III and type IV SLAP lesions were debrided. The complex type II and III SLAP lesion was debrided and repaired with a suture anchor technique. Average follow-up was 3.8 years. Using the UCLA shoulder Rating Scale, 17 (74%) had a good or excellent result, 3 (13%) had a fair result, and 2 (8.5%) had a poor result.
Conclusion
SLAP lesions may mimic impingement, rotator cuff pathology, or anterior instability. The subacromial space should always be evaluated at the time of surgery to make sure there is no evidence of subacromial impingement. In our study, all patients with isolated SLAP lesions had pain and pain with overhead activities and had complaints of painful mechanical-like symptoms in their shoulders but had a normal subacromial space. Treatment with suture anchors gave good or excellent results in 74% of patients.
Purpose: To discuss a new technique for the surgical treatment of type II SLAP lesions as well as the evaluation of the technique’s effectiveness with a minimum 2-year follow-up. Type of Study: Retrospective clinical follow-up study. Methods: We present a clinical follow-up of 31 patients who were treated arthroscopically for type II SLAP lesions using a trans-rotator cuff portal at an average follow-up time of 3.7 years. Patients were screened for concomitant procedures including rotator cuff repairs, shoulder stabilizations, thermal capsullographies, and previous surgeries. These patients were subsequently excluded from the study. Patients were given a standard physical examination of the upper extremity at our institution and they completed both the L’Isalata and American Shoulder and Elbow Surgeons questionnaires. Results: All 31 patients identified were available for follow-up at an average time of 3.7 years postoperatively (range, 2.0 to 7.4 years). The average L’Insalata score was 87.0 points (range, 46.1-100 points); the average ASES score was 87.2 points (range, 46.7-100 points). The average pain score was 1.5 (range, 0-5) and only 4 of the 31 patients complained of moderate pain with activity. Sixteen of the 31 patients returned to their preinjury level of sports; 11 of the 31 patients returned to limited activity and 2 patients were inactive at the time of follow-up. Overall satisfaction with the procedure averaged 3.79 points (range, 0-5 points): 22 patients rated overall satisfaction as good or excellent, 6 patients reported a fair outcome, and only 3 patients were unsatisfied with the results of the surgery. One patient who was unsatisfied with the procedure had reinjured his superior labrum and required a second operation. None of the 31 patients had symptoms suggestive of rotator cuff pathology. Of the 30 patients found to have a positive Active Compression test preoperatively, 26 of these patients now had a negative sign. Conclusions: The trans-rotator cuff approach allows for a more optimal placement of a biodegradable fixation device and/or suture anchors into the superior labrum. Furthermore, we believe that this approach does not compromise the function of the rotator cuff. The trans-rotator cuff technique is an effective and safe modality to address superior labral pathology.
Complete detachment of the glenoid labrum from the superior pole of the glenoid, which is associated with a destabilization of the origin of the long biceps tendon, leads to altered function in the shoulder joint. This is especially noticeable when the shoulder is used in overhead activities. Two operative techniques are described for reattachment of the glenoid labrum to the glenoid. In the first six patients the glenoid labrum was reattached with small cannulated titanium screws. In five patients these screws were inserted under arthroscopic control from a cranial direction. The labrum was always reattached just behind the origin of the long biceps tendon. The most favorable portal was identified by percutaneous probing with a Kirschner wire. If the superior glenoid pole could not be reached via a portal placed anterior or medial to the acromion, a hole was drilled through the acromion, and a transacromial approach was used. The screws were removed by arthroscopy after 3 to 5 months. In the last eight patients, absorbable tacks were used instead of screws. Of 18 patients who showed a complete detachment of the glenoid labrum from the superior pole of the glenoid with destabilization of the attachment of the biceps tendon, 14 underwent reattachment as described previously. The minimum follow-up time was greater than 6 months (mean follow-up time 18 months, maximum follow-up time 30 months). At follow-up, eight patients felt completely rehabilitated and had resumed their previous overhead activities (overhead sports). Four patients believed their conditions were improved. Two patients had not experienced any improvement. Of the patients who had not undergone reattachment and who had undergone shaving of the free margin of the glenoid labrum, only one had experienced improvement, while the other three patients did not report any improvement.
We studied the gross, histological, and vascular anatomy of the glenoid labrum in twenty-three fresh-frozen shoulders from cadavera to demonstrate its cross-sectional anatomy, its microvascularity, and its attachments. The superior and anterosuperior portions of the labrum are loosely attached to the glenoid, and the macro-anatomy of those portions is similar to that of the meniscus of the knee. The superior portion of the labrum also consistently inserts directly into the biceps tendon, while its inferior portion is firmly attached to the glenoid rim and appears as a fibrous, immobile extension of the articular cartilage. The arteries supplying the periphery of the glenoid labrum come from the suprascapular, circumflex scapular, and posterior circumflex humeral arteries. In general, the superior and anterosuperior parts of the labrum have less vascularity than do the posterosuperior and inferior parts, and the vascularity is limited to the periphery of the labrum. Vessels supplying the labrum originate from either capsular or periosteal vessels and not from the underlying bone.
Superior labral tears of the shoulder involve the biceps tendon and labrum complex which may be detached, displaced inferiorly, and interposed between the glenoid and the humeral head. We have treated ten young athletes with painful shoulders due to this lesion by arthroscopic stapling. Arthroscopy at the time of staple removal, after three to six months, showed that all the lesions had been stabilised. Clinical review at over 24 months showed an excellent or good result in 80%. The two relative failures were due in one to residual subacromial bursitis, and the other to multidirectional shoulder instability. Arthroscopic stapling can restore the shoulder anatomy, and it is recommended for active adolescent athletes with this lesion.
The relationship between the tendon of the long head of the biceps brachii muscle and the glenoidal labrum was investigated in a large number of dissected human shoulder joints. In about 70% of the specimens examined, the labrum was deficient at the posterosuperior margin of the glenoid because the tendon of the biceps coursed over this margin to blend with the labrum. Because of this, a small crescentic accessory facet was observed at the posterosuperior margin of the glenoid. In the majority of cases, the tendon of the biceps blended with the glenoidal labrum, and only a small part of the tendon attached to the supraglenoid tubercle. However, in 25% of the specimens, the major portion of the tendon was attached to the supraglenoid tubercle.
To help to resolve the controversy regarding the composition of the glenoid labrum, thirty-eight shoulders from cadavera were examined grossly and histologically. We used specimens for individuals of different ages so that we could determine what changes occur as a result of aging. In children and adults, the labrum appeared to be fibrocartilaginous tissue. The labrum was a separate anatomical structure that could be distinguished from the fibrous capsule of the shoulder. Neonatal labra were composed of primitive mesenchymal tissue containing only few chondrocytes that modulated into fibrocartilage in the first few years of life. Neonatal labra contained no elastin, whereas specimens from adults had rare elastin fibers. The labrum was sparsely vascularized throughout its substance, with no particular pattern of distribution. Vascularity decreased with increasing age of the individual.
A specific pattern of injury to the superior labrum of the shoulder was identified arthroscopically in twenty-seven patients included in a retrospective review of more than 700 shoulder arthroscopies performed at our institution. The injury of the superior labrum begins posteriorly and extends anteriorly, stopping before or at the mid-glenoid notch and including the "anchor" of the biceps tendon to the labrum. We have labeled this injury a "SLAP lesion" (Superior Labrum Anterior and Posterior). There were 23 males and four females with an average age of 37.5 years. Time from injury to surgery averaged 29.3 months. The most common mechanism of injury was a compression force to the shoulder, usually as the result of a fall onto an outstretched arm, with the shoulder positioned in abduction and slight forward flexion at the time of the impact. The most common clinical complaints were pain, greater with overhead activity, and a painful "catching" or "popping" in the shoulder. No imaging test accurately defined the superior labral pathology preoperatively. We divided the superior labrum pathology into four distinct types. Treatment was performed arthroscopically based on the type of SLAP lesion noted at the time of surgery. The SLAP lesion, which has not been previously described, can be diagnosed only arthroscopically and may be treated successfully by arthroscopic techniques alone in many patients.
Tears of the glenoid labrum were observed in 73 baseball pitchers and other throwing athletes who underwent arthroscopic examination of the dominant shoulder. Most of the tears were located over the anterosuperior portion of the glenoid labrum near the origin of the tendon of the long head of the biceps muscle into the glenoid. At arthroscopy, the tendon of the long head of the biceps appeared to originate through and be continuous with the superior portion of the glenoid labrum. In many cases it appeared to have pulled the anterosuperior portion of the labrum off the glenoid. This observation was verified at arthroscopy by viewing the origin of the biceps tendon into the glenoid labrum as the muscle was electrically stimulated. With stimulation of the muscle, the tendinous portion became quite taut, particularly near its attachment to the glenoid labrum, and actually lifted the labrum off the glenoid. Three-dimensional high-speed cinematography with computer analysis revealed that the moment acting about the elbow joint to extend the joint through an arc of about 50 degrees was in excess of 600 inch-pounds. The extremely high velocity of elbow extension which is generated must be decelerated through the final 30 degrees of elbow extension. Of the muscles of the arm that provide the large deceleration forces in the follow-through phase of throwing, only the biceps brachii traverses both the elbow joint and the shoulder joint. Additional forces are generated in the biceps tendon in its function as a "shunt" muscle to stabilize the glenohumeral joint during the throwing act.(ABSTRACT TRUNCATED AT 250 WORDS)
Recently, there have been attempts to improve the accuracy of MR imaging by distending the glenohumeral joint with fluid prior to imaging. This article reviews the techniques employed in performing MR arthrography, imaging characteristics of MR arthrography, and diagnostic use of the procedure.
The detachment of the superior labrum from anterior to posterior has previously been reported. This lesion has been classified into four types. It was our impression that not all superior labrum abnormalities fit into such a classification system and that the mechanism of injury was distinctly different. During a 5-year period, 84 of 712 (11.8%) patients had significant labral abnormalities; 52 of 84 patients (6.2%) had lesions that fit within the classification system (Type II, 55%; III 4%; IV, 4%), but 32 of 84 patients (38%) had significant findings that could not be classified. These unclassifiable lesions fit into three distinct categories. Two of three patients described a traction injury to the shoulder. Only 8% sustained a fall on an outstretched arm; 75% had a preoperative diagnosis of impingement based on consistent history and provocative testing; however, when examined under anesthesia, 43% of the shoulders were considered to have increased humeral head translation when compared with the other shoulder. Recognition of superior labrum-biceps tendon detachment should prompt the surgeon to investigate glenohumeral instability as the source of a patient's complaints.
Twenty-two patients were treated for symptomatic lesions of the superior glenoid labrum in association with instability of the tendinous insertion of the long head of the biceps brachii. A biodegradable implant was used to fix the labrum to the bony glenoid using an arthroscopic technique. At 2-year average follow-up, satisfactory results were obtained in 86% of the patients. Two patients, both of whom had undergone concomitant subacromial decompression, continued to complain of pain after the procedure; 3 patients had restricted motion postoperatively, and 1 required manipulation under anesthesia. Twelve of 13 overhead athletes were able to return to full premorbid function. Arthroscopic fixation of unstable lesions of the superior labrum led to a resolution of symptoms in the majority of patients. There were no complications related to the use of the biodegradable implant.
Two hundred consecutive shoulder arthroscopy videotapes were retrospectively reviewed, paying specific attention to the anatomy of the anterosuperior glenoid quadrant and especially the labroligamentous complex. Normal glenohumeral anatomy and all variations were carefully evaluated and recorded. Twenty-four (12%) patients had a sublabral foramen below the anterosuperior labrum; a "cord-like" middle glenohumeral ligament was present in 75% (18 of 24) of those cases or 9% of the study population. A smaller group of patients demonstrated a unique variant of normal capsulolabral anatomy that, for convenience, is termed the "Buford complex." This unusual variant was noted in 3 of the 200 (1.5%) shoulders and was distinguished by a "cord-like" middle glenohumeral ligament that originated directly from the superior labrum at the base of the biceps tendon and crossed the subscapularis tendon to insert on the humerus. There was no anterior-superior labral tissue present between this attachment and the midglenoid notch. This unusual-appearing anatomical variation may lead the surgeon to confuse this complex with a sublabral hole or a pathologic labral detachment. The labral tissue of the remaining three glenoid quadrants was normal. If the Buford complex is mistakenly reattached to the neck of the glenoid, as illustrated in our case example, severe painful restriction of rotation and elevation will occur.
The authors conducted a study to determine if the long head of the biceps muscle and its attachment at the superior glenoid labrum play a role in stability of the shoulder in an overhead position. Their study used a dynamic cadaveric shoulder model that simulated the forces of the rotator cuff and long head of biceps muscles as the glenohumeral joint was abducted and externally rotated. Their data suggest that the long head of the biceps muscle contributes to anterior stability of the glenohumeral joint by increasing the shoulder's resistance to torsional forces in the vulnerable abducted and externally rotated position. The biceps muscle also helps to diminish the stress placed on the inferior glenohumeral ligament. Detachment of the superior glenoid labrum is detrimental to anterior shoulder stability as it decreases the shoulder's resistance to torsion and places a greater magnitude of strain on the inferior glenohumeral ligament.
We prospectively compared MR imaging, MR arthrography, and CT arthrography to determine the sensitivity of each technique in detecting glenoid labral tears and in determining whether the labrum is detached or degenerated.
Thirty patients 19-39 years old (mean, 27 years old) who had either signs and symptoms of shoulder instability or shoulder pain of unexplained origin were referred for diagnostic imaging. Each patient underwent MR imaging, followed by MR arthrography after intraarticular injection of 25 ml of a dilute solution of gadopentetate dimeglumine. Twenty-eight of thirty patients underwent CT arthrography after intraarticular injection of air and radiographic contrast material. Each patient also underwent arthroscopy or open surgery.
At surgery, labral tears were found in 28 patients; a detached fragment was found in 26 patients. The labrum was found to be degenerated in 18. A labral tear was detected on MR images in 26 (93%) of 28, on MR arthrograms in 27 (96%) of 28, and on CT arthrograms in 19 (73%) of 26. A detached labral fragment was detected on MR images in 12 (46%) of 26, on MR arthrograms in 25 (96%) of 26, and on CT arthrograms in 13 (52%) of 25. Labral degeneration was detected on MR images in two (11%) of 18, on MR arthrograms in 10 (56%) of 18, and on CT arthrograms in four (24%) of 17. MR arthrography was the best of the three imaging techniques for showing the inferior part of the glenoid labrum and inferior glenohumeral ligament.
MR arthrography and MR imaging both showed labral tears with greater sensitivity than CT arthrography did. MR arthrography was the most sensitive of the three techniques for detecting a detached labral fragment and labral degeneration. Furthermore, MR arthrography afforded the best visualization of the inferior part of the labrum and the inferior glenohumeral ligament. MR imaging and MR arthrography also enabled direct visualization of rotator cuff disease and other unsuspected associated abnormalities.
Twenty consecutive patients with superior labral anterior and posterior lesions of the shoulder involving the biceps attachment to the labrum (Snyder types II and IV) were repaired arthroscopically and reviewed post-operatively to evaluate the efficacy of the technique in the management of this recently described injury pattern. Follow-up time averaged 21 months (range, 12 to 42). All patients were managed by an arthroscopic repair technique that included debridement of the frayed labrum and abrasion of the superior glenoid neck, followed by the placement of multiple sutures into the torn labrum-biceps tendon complex using a Caspari suture punch. Patients were reexamined, and the results were quantitated with the shoulder evaluation form of the American Shoulder and Elbow Surgeons and with the Rowe rating scale. On evaluation, all patients obtained good or excellent results. This suture technique is recommended in the management of unstable superior labral detachment lesions of the shoulder.
We studied the contributions of the long and short heads of the biceps (LHB, SHB) to anterior stability in 13 cadaver shoulders. The LHB and SHB were replaced by spring devices and translation tests at 90 degrees abduction of the arm were performed by applying a 1.5 kg anterior force. The position of the humeral head was monitored by an electromagnetic tracking device with or without an anterior translational force; with 0 kg, 1.5 kg or 3 kg loads applied on either LHB or SHB tendons in 60 degrees, 90 degrees or 120 degrees of external rotation; and with the capsule intact, vented, or damaged by a Bankart lesion. The anterior displacement of the humeral head under 1.5 kg force was significantly decreased by both the LHB and SHB loading in all capsular conditions when the arm was in 60 degrees or 90 degrees of external rotation. At 120 degrees of external rotation, anterior displacement was significantly decreased by LHB and SHB loading only when there was a Bankart lesion. We conclude that LHB and SHB have similar functions as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation, and that their role increases as shoulder stability decreases. Both heads of the biceps have been shown to have a stabilising function in resisting anterior head displacement, and consideration should therefore be given to strengthening the biceps during rehabilitation programmes for chronic anterior instability of the shoulder.
We reviewed 52 consecutive patients who had under gone arthroscopic labral debridement. The average age was 29 and there were 35 men and 17 women. At operation, 27 patients had superior labrum anterior and posterior (SLAP) lesions, 20 patients had anteroinferior labral lesions, and 5 patients had posterior labral le sions.
Despite the fact that, preoperatively, none of these patients had a history of dislocations or clinically evident instability, 70% of the patients with superior labral lesions, and all of those with anteroinferior and posterior lesions had instability on examination under anesthesia. The average followup was 36 months. At 1 year after arthroscopy, 78% of the patients with superior lesions had excellent relief compared with 30% of the patients in the anteroinferior group. At 2 years followup, these results decreased to 63% and 25%, respectively, and only 45% of the patients with superior labral lesions and 25% of those with anteroinferior lesions had re turned to their previous athletic performance level. Four patients required a reoperation: 2 for instability and 2 for impingement. We conclude that occult instability is frequently present in patients with glenoid labral tears. The overall results are not encouraging, but this pro cedure may have an indication for short-term goals in competitive athletes or those who are willing to accept some compromise in function.
Although magnetic resonance imaging is very sensitive and even though pathology in the rotator cuff is readily detected, it is often difficult to distinguish between complete rotator cuff tears, partial rotator cuff tears, and area of tendinitis. This article reports the results of a new technique for evaluation of shoulder pathology, which the authors have labeled magnetic resonance arthrography, and compares the results of magnetic resonance arthrography with those of conventional magnetic resonance imaging.
Between 1985 and 1993 140 injuries of the superior glenoid labrum were identified on arthroscopic evaluation and were recalled from a data bank of 2375 shoulder procedures performed during that time. The average patient age was 38 years, and 91% of the patients were men. The most common problem was pain, with 49% of all patients noting mechanical catching or grinding in their shoulders. No preoperative imaging modality consistently defined disease in the superior labral area. Fifty-five percent of all lesions were type II, 21% were type I, 10% were type IV, 9% were type III, and 5% were complex. Twenty-nine percent of lesions were associated with a partial-thickness tear of the rotator cuff, 11% with a full-thickness tear, and 22% with an anterior Bankart lesion. Twenty-eight percent of the superior labral lesions seen were isolated and did not have any associated rotator cuff or anterior labral disease. Type I lesions were debrided. Fifty-six percent of type II lesions were debrided in conjunction with an abrasion of the underlying glenoid rim. More recently suture anchors have been used to stabilize type II lesions. Treatment of type III and IV lesions depended on the extent of labral tissue disruption and involved either debridement or suture repair. Repeat arthroscopies were performed on 18 shoulders. Three of five type lesions treated with debridement and glenoid abrasion were healed. Four of five type II lesions treated with an absorbable anchor were healed. Three type III and one type IV lesion treated with debridement had normal superior labrums. Two type IV injuries treated with suture repair had completely healed. Two complex type II and III injuries treated with debridement and anchor fixation were healed.
Progress in shoulder arthroscopy has led to the identification of previously undiagnosed lesions involving the superior labrum and the biceps tendon anchor. Additional research has substantiated the role of the long head of the biceps tendon in anterior and rotational glenohumeral stability. Careful attention to the history and physical examination and directed diagnostic imaging may arouse suspicion of injury to the biceps tendon and the superior labral complex. Identification of injuries to the superior labrum extending from anterior to posterior, or "SLAP" injuries, can be made with diagnostic glenohumeral arthroscopy. Appropriate treatment can then be based on the type of lesion encountered (generally, debridement of most type I and III lesions and repair of type II and many type IV lesions).
One hundred two type II SLAP lesions without associated anterior instability, Bankart lesion, or anterior inferior labral pathology were surgically treated under arthroscopic control. There were three distinct type II SLAP lesions based on anatomic location: anterior (37%), posterior (31%), and combined anterior and posterior (31%). Preoperatively, the Speed and O'Brien tests were useful in predicting anterior lesions, whereas the Jobe relocation test was useful in predicting posterior lesions. Rotator cuff tears were present in 31% of patients and were found to be lesion-location specific. In posterior and combined anterior-posterior lesions, a drive-through sign was always present (despite absence of anterior-inferior labral pathology or a Bankart lesion) and was eliminated by repair of the posterior component of the SLAP lesion. We conclude that SLAP lesions with a posterior component develop posterior-superior instability that manifests itself by a secondary anterior-inferior pseudolaxity (drive-through sign), and that chronic superior instability leads to secondary lesion-location-specific rotator cuff tears that begin as partial thickness tears from inside the joint.
A previously undescribed mechanism of injury for posterior Type II SLAP lesions is described. The primary feature of this mechanism is a torsional peel-back of the posterosuperior labrum. Secure fixation by posterior-superior placement of suture anchors into the posterosuperior corner of the glenoid is essential. The repair must be protected against torsional peel-back forces by avoiding external rotation beyond 0 degrees for 3 weeks.
To document the outcomes of arthroscopic stabilization of Snyder type II SLAP (superior labrum, anterior and posterior) lesions, using a bioabsorbable tack.
A case series.
Twenty-five SLAP lesions were repaired arthroscopically using a bioabsorbable tack. There were 22 recreational, 2 high school, and 1 professional athlete in this group. Shoulder function was surveyed at a mean follow-up of 35 months (range, 24 to 51 months) using the UCLA and ASES shoulder scoring algorithms.
Shoulder function improved in 24 of the 25 cases. Follow-up UCLA scores averaged 32 points with 9 patients scoring as excellent, 13 good, 2 fair, and 1 poor, for an overall success rate of 88%. ASES shoulder scores similarly improved from a preoperative average of 45 points to a postoperative average of 92. All but 2 of the athletes had returned to their preinjury level of sports participation.
Detachment of the superior labrum from the glenoid is recognized as a problematic injury in throwing athletes and others who engage in repetitive overhead activities. We conclude from our experience that using an absorbable tack to repair type II SLAP lesions is an effective treatment, even in athletes with high demands and expectations for shoulder function.
The purpose of this report is to describe the biceps load test II for evaluating the superior labral anterior and posterior (SLAP) lesions.
This is a double-blind study in consecutive data, which includes diagnostic accuracy of a test using sensitivity, specificity, and interexaminer reliability.
In the supine position, the arm is elevated to 120 degrees and externally rotated to its maximal point, with the elbow in the 90 degrees flexion and the forearm in the supinated position. The patient is asked to flex the elbow while resisting the elbow flexion by the examiner. The test is considered positive if the patient complains of pain during the resisted elbow flexion. The test is negative if pain is not elicited or if the pre-existing pain during the elevation and external rotation of the arm is unchanged or diminished by the resisted elbow flexion. A prospective study was performed in 127 patients to evaluate the diagnostic accuracy for the biceps load test II. Two independent examiners were assigned to perform the new diagnostic test. The results of the tests were confirmed during the arthroscopic examination.
A positive test result in 38 subjects correlated with a SLAP lesion in 35 patients and an intact biceps-superior labrum in 3 patients. A negative test result in 89 patients correlated with an intact superior labrum complex in 85 patients, whereas 4 patients with a negative test result had a type II SLAP lesion. The biceps load test II had a sensitivity of 89.7%, a specificity of 96.9%, a positive-predictive value of 92.1%, a negative-predictive value of 95.5%, and a kappa coefficient of 0.815. The abduction and external rotation of the shoulder during the test changes the relative direction of the biceps fiber in a position of oblique angle to the posterosuperior labrum. The resisted contraction of the biceps increases the pain generated on the superior labrum that is already peeled off the glenoid margin in the abducted and externally rotated position.
The biceps load test II is an effective diagnostic test for SLAP lesions.
The purpose of this study was to evaluate the results of arthroscopic repair of isolated superior labral lesions of the shoulder.
We evaluated thirty-four patients at a mean of thirty-three months (range, twenty-four to forty-nine months) following arthroscopic repair of an isolated superior labral lesion of the shoulder with suture anchors. The outcome of treatment was evaluated with the University of California at Los Angeles shoulder score and on the basis of the patient's ability to return to prior activities. There were thirty male patients and four female patients with a mean age of twenty-six years (range, sixteen to thirty-five years). Thirty patients were involved in athletic activities, and eighteen of them were engaged in overhead sports.
Repair of the superior labral lesion resulted in a satisfactory University of California at Los Angeles shoulder score for thirty-two patients (94%) and an unsatisfactory score for two. Thirty-one patients (91%) regained their preinjury level of shoulder function. The shoulder score and the return to activity were correlated with the type of sports activity (r = 0.291, p < 0.0001 and r = 0.373, p = 0.010, respectively. Patients participating in overhead sports had significantly lower shoulder scores and a lower percentage of return to their preinjury level of shoulder function compared with patients who were not engaged in overhead activity (p = 0.024 and 0.015, respectively).
Arthroscopic repair of an isolated superior labral lesion is successful in a majority of patients. However, the results in patients who participate in overhead sports are not as satisfactory as those in patients who are not involved in overhead sports.
Three tests (active compression, anterior slide, and compression rotation) are commonly used to diagnose superior labral anterior-posterior lesions.
We hypothesized that the accuracy, sensitivity, and specificity for these tests was less than that previously reported and that a click in the shoulder during manipulation was not specific for the study lesion.
Case-control study.
The three tests were performed on 426 patients who subsequently underwent shoulder arthroscopy. The results of physical examination were compared with the arthroscopic findings and analyzed for sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy.
At arthroscopy, 39 patients had type II to IV lesions (study group); the remaining 387 patients had type I lesion or no lesion (control group). The incidences of positive results were not statistically different between the groups (P > 0.05). Our findings were as follows: most sensitive test, active compression (47%); most specific test, anterior slide (84%); highest positive predictive value, active compression (10%); highest overall accuracy, anterior slide test (77%); lowest overall accuracy, active compression test (54%). The presence of a click and the location of the pain were not reliable diagnostic indicators.
The results of such tests should be interpreted with caution when considering surgery for a possible superior labral anterior-posterior lesion.
The effect on joint stability of repair of type II superior labrum and biceps anchor lesions is unknown.
Increased translations of the glenohumeral joint after a simulated type II lesion will be reduced after the lesion is repaired.
Controlled laboratory study.
A robotic/universal force-moment testing system was used to simulate load-and-shift and apprehension tests on eight cadaveric shoulders to determine joint kinematics of the shoulder after venting, creation of a type II lesion, and repair of the lesion.
At 30 degrees of abduction, anterior translation of the vented joint in response to an anterior load was 18.7 +/- 8.5 mm and was significantly increased to 26.2 +/- 6.5 mm after simulation of a type II lesion. Repair did not restore anterior translation (23.9 +/- 8.6 mm) to that of the vented joint. The inferior translation that also occurred during application of an anterior load was 3.8 +/- 4.0 mm in the vented joint and increased significantly to 8.5 +/- 5.4 mm with a simulated type II lesion. After repair, the inferior translation decreased significantly to 6.7 +/- 5.3 mm.
Repair of a type II lesion only partially restored glenohumeral translations to that of the vented joint.
Surgical techniques including improved repair of passive stabilizers injured in the type II lesion should be considered.
Glenoid labral tears: Prospective evaluation with MRI imaging, MR arthrography, and CT arthrography
- V P Chandnani
- Yeager
- Td
- T Deberardino
A new and effective test for diagnosing labral tears and AC joint pathology [abstract]
- O'brien
- Sj
- Pagnani
- Mj
- Mcglynn
- Sr
Magnetic resonance arthrography of the shoulder
- Pfj Tirman
- Applegate
- Gr
- Flannigan
- Bd
The trans-rotator cuff approach to SLAP lesions: Technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years
- O'brien
- Allen Sj
- A A Coleman
- Sh