SLAP Tears Repair Vs Biceps

Tenodesis

Bijay SinghConsultant Orthopaedic

SurgeonMedway Foundation NHS Trust

OverviewHistoryAnatomySigns & SymptomsDiagnosticsResults Management Algorithm

History

• 1985

– First Described by Andrews et al

• 1990

– Snynder & Karzel classified

SLAP Tears• 1983 – James Andrews at the AOSSM Meeting

–73 base ball pitchers & other throwing athletes

–Hypothesis:

• Biceps tendon is subjected to large forces during throwing• Most tears – near the antero-superior portion near origin of

biceps tendon• Biceps tendon lifts the labrum off the glenoid when its muscle

is stimulated

Methods & Results• 120 arthroscopy – 73 throwing athletes–35 pitchers

– (22 prof, 9 college, 4 high school)

– Football, Softball, Tennis, Volleyball

• Symptoms–95% pain whilst throwing

–47% Popping or catching during throwing

• Signs–79% demonstrable popping / catching

–72% anterior subluxation

• 60% - Anterosuperior• 23% - Antero & Postero Superior• 83% - tearing of glenoid labrum in some

portion of antero superior region in the area of the biceps tendon / labrum complex

• 45% partial supraspinatus tendon tear

Onyekwelu et al: The rising Incidence of SLAP repairs JSES, 2012, 21, 728-31

• Surgical cases: 55%

• Ambulatory cases: 135%

• SLAP Repair: 464%

Current Literature

•No Level I or II publications related to treatment of SLAP tears

Anatomy• Superior Labrum– Triangular structure coposed of fibrous &

fibrocartilagenous tissue

• LHB– Supra-glenoid tubercle – 60%

– Superior labrum – 40%

• Significant variation

Anatomical Variants• Sublabral Foramen–3 – 12% incidence– Labrum detached from the glenoid in front of the biceps between 9 – 12 o’clock for left & 12 – 3 o’clock for right

• Buford complex–1.5 – 2%–Absence of antero superior labrum–Cord like MGHL attaching to biceps tendon

Anatomical Variants

Relevant Biomechanics• Not fully understood• Provides transational & rotational stability• LHB Tenotomy – Increased proximal migration by 16%

• Cadaveric Model–SLAP causes increased translation & ER

Pathophysiology

Mechanism of Injury• Andrews et al–Deceleration traction injury from pull of biceps

• Burkhart et al–Contracture of posterior shoulder capsule

• Grossman et al–Postero-superior humeral head migration

• Another:–Peel-back mechanism

• Repetitive throwing places shoulder at extremes of motion

• Complex series of of co-coordinated motions to efficiently transfer large forces & high amounts or energy from legs, back & trunk

• Altered range of motion • Eccentric contractions

GIRD

–Deficit in IR of at least 20 compared to the contra-lateral side

Diagnosis• Injury– Traction

–Compression of shoulder

–Repetitive over head athletic use

• Pain–Poorly located

– Located globally

• No reliable tests

• Duration of symptoms• Anterior shoulder pain in

dominant arm• Clicking or Popping during

throwing• Night pain• Weakness• Instability

Tests• O'Brien Active Compression

• Speed

• Dynamic Labral Shear (Mayo Shear)

• Biceps Load II (Kim)

• Resisted Supination External Rotation (Labral Tension)

• Upper Cut

• Kibler Anterior Slide

• Compression Rotation

O'Brien's test• shoulder at 90 of flexion, 10 of

horizontal adduction, and maximum internal rotation with the elbow in full extension

• downward force at the wrist

• patient resists the down- ward force

• pain as ‘‘on top of the shoulder’’ (acromioclavicular joint) or ‘‘inside the shoulder’’ (SLAP lesion)

Speed Test• Patient Sitting• elbow extended

and the forearm in full Supination

• Resisted active flexion from 0 to 60

Dynamic Labral Shear Test (O’Driscoll)

• Sitting or Supine

• arm at side and elbow flexed 90

• ER & Abd 90

• Pain

– deep and/or posterior

– 90 to 120 abduction

What I describe as What I describe as Jobe’s Maneuver for Jobe’s Maneuver for

painpain

Biceps Load II Test – Kim II

• Shoulder 120 abduction, elbow 90 flexion, and forearm in Supination

• Apprehension position• Flex his or her elbow

while the examiner resists this movement

• Positive test by pain

• Upper Cut– Elbow flexed 90, forearm supinated, patient making a fist

– Bringing the hand up quickly – boxing upper cut

Sleeper Stretch for Posterior Capsular

Contracture

Accuracy of Clinical TestsJones & Galluch et al

Results

Should be wary about relying on these tests Should be wary about relying on these tests when assessing these indviduals with shoulder when assessing these indviduals with shoulder

dysfunction - they may have more than one dysfunction - they may have more than one pathologypathology

Clinical Utility of Traditiional & New Tests in Diagnosis of Biceps Tendon Injuries & SLAP

LesionsKibler et al , AJSM, 37(9), 1840 – 1847)

• 325 consecutive patients• 101 patients underwent surgery• 8 tests – Yergasons, Speed, Bear Hug, Belly Press,

O’briens, Anterior Slide

–Upper Cut & Modified Labral Shear

Meta-analysis of clinical testing for SLAP Tears;

Meserve et al, AJSM, 37(11), 2252

• Active compression, crank, and Speed tests are more accurate for detecting labral tears than is the anterior slide test.

• Sensitivity and Specificity values ranged from low to high.

• Active compression test is the most sensitive and Speed test the most specific.

• Bicep load, passive compression, and Kim tests may be good alternatives, but more research is warranted

Investigations &

Classification

Imaging

• No specific radiographic findings pathognomonic for SLAP lesion

• MR Arthrogram gold standard

– 90% accuracy

– Coronal Oblique Sequences

– ABER position

– High incidence of false positive MRI

Arthroscopic Classification

Agreement in Classification

• Wolf et al – AJSM, 39(12), 2588 – 2594–16 shoulder surgeons–Clinical variables in diagnosing &

treating–50 arthroscopic videos of superior

labrum –Three different occasions–2nd sitting had clinical information

Results• Job / Sports, Age & Physical examination

most important factor in treating• 1st & 3rd viewings – 28.5% different class• With clinical info – 71.5% different• Inter-surgeon agreement was moderate

without clinical info & fair with clinical info

Clinical Results

A Prospective Analysis of 179 type 2 SLAP repairsProvencher et al: AJSM, Vol 20 (10)

• 179/225 patients over 4 year period - Military Personnel–Age: 31.6 (18 – 45)–Male: Female 80%:20%– Follow up: 40.4 (26 – 62)– Traumatic: Atraumatic 47%:53%

• ASES, WOSI, SANE significantly improved• Flexion & Abduction – significant improvement• ER, ABER, ABIR – no difference

Failure• ASES<70, Revision Surgery, Medical Board, Unable to return to duty

• 66/179 = 38%–16 = Medical Board = medical discharge

–50 = Revision Surgery (28%)

• Tenodesis = 42

• Tenotomy = 4

• Debridement = 4

• Logistic Regression–Age >36 only factor!!!

Long Term Results after SLAP Repair – 5 yr follow up of 107 patients

Schroder et al: Arthroscopy, 2012, 28(11), 1601-07

• Prospective Cohort Study• 1998 – 2002, • 171 patiens – 64 excluded• 43.8 yrs (20 – 68)• 71 male vs 36 females• Duration of Symptoms – 52 months• Trauma – 66%

• 97 followed up for 5 years (4 – 8 yrs)• Modified Rowe, Pain, Stability,

Function & Muscle Strength, ROM• 88.1% - Good to excellent in >40• 88.3% - Good to excellent in <40• 14 complications – not age related

Results of Arthroscopic Superior Labral Repairs:

Kim SH et al, JBJS, 84(A), 981-5

• 34 arthroscopic repairs• 32/34 had satisfactory UCLA score• 31 regained pre-injury shoulder

function• Overhead activity sports persons

had significantly lower scores (97 vs 90)

Outcome of Type II SLAP Repair – prospective analysis:

Friel et al, JSES, 2010, 19, 859-67• 48 patients

• Age: 33 +/- 12 (16 – 59)

• Athlete: 27 (overhead 11)

• Traumatic / Atraumatic: 24

• Associated procedures: 22

• 3.4 yrs follow up ( 2 – 5.7 yrs)

• Arthroscopic SLAP repairs provides significant improvement in shoulder function

Results

• SST, ASES, SF12 & VAS all significantly better

• Non athletes showed larger improvement in scores & movements

• 54% (7) returned to previous level sport

SLAP Repair in presence of Cuff Tear in patients over 50 years age:

Franceschi et al , AJSM, 2008, 36(2), p 247 - 253

• 63 patients > 50 with cuff tear– 31 had SLAP repair

– 32 had biceps tenotomy

• Average 2.9 yrs follow up • Results:– UCLA Score significantly better in tenotomy

– Movements also better in tenotomy

• Now routinely perform tenotomy

Boileau et al: AJSM 37(5), 929 - 936

25 patients with isolated SLAP tears10 pts (men) had SLAP repair (37)15 pts (9+6) had tenodesis (52)9/10 & 11/15 collegiate or professional

6/10 disappointed / dissatisfied1/15 disappointed / dissatisfied87% returned to sports in tenodesis20% returned to sports in repair

4 tenodesis later returned

Non Operative Treatment for SLAP tears:Edwards et al, AJSM, 2010, 38(7), 1456-61

• 371 patients with suspected SLAP• Diagnosis:– O'Brien's Test

– Tender on Groove

– MRI / MRA

• 50 replied back – 39 included• 67% better / improved• 20 had surgery, 19 non op• All successful treatment returned to sports• 71% returned to pre treatment sports• 64% returned to over head athletics

Outcome of SLAP Repair – Systematic Review, Gorantla et al, Arthroscopy, 2010, 26(4), 537-45

• Isolated Type II SLAP repair with 2 yr FU

• No level I or II studies• 12 full studies met inclusion criteria• 2 prospective• 40 – 94% good to excellent

Gorantla et al• Excellent results for individuals

not involved in throwing or overhead sports

• Much less predictable in throwing & overhead athlete

• 64% overhead athlete returned to sports

Controversies• Snyder et al–40% had not healed at second arthroscopy– Treated with debridement alone

• Gorantla et al–64% overhead athletes returned to pre-injury

level

• Boileau et al–80% vs 40% = tenodesis vs repair–87% vs 20% = return to previous sports

My ExperienceSLAP ASAD ACJ Cuff

Repair

NHS 21 7 2 3

PP 24 4 1 1

Total 45 11 3 4

NHS PP Total2008-09 4 0 4

2010 9 4 132011 7 8 152012 1 12 132013 0 0 0Total 21 24 45

Complications / Issues

9/45 = 20%

Stiffness - 1 patient - resolved

Redo - 2 patient (fall)

Tenodesis - 2 (1 awaiting)

ASAD - 3

Ongoing unexplained pain - 2

Decision Making?History

InjuryRepetitive throwing / heavy overhead work

Age Symptoms:

Location of pain - anterior suggest LHBClicking / locking on throwing positionInstability

SignsHelpful but not necessarily definitive

Obvious Biceps Obvious Biceps Pathology (Tear / Type Pathology (Tear / Type

IV)IV)

Tenodesis Tenodesis Full thickness RCT / Full thickness RCT / Degenerate labrumDegenerate labrum

Tenodesis Tenodesis H/o Trauma + MRI + H/o Trauma + MRI +

Clinical SuspicionClinical Suspicion

Repair Repair SLAPSLAP

Other Symptomatic Other Symptomatic Surgical pathology Surgical pathology

Debride Labrum & Debride Labrum & Address Other Address Other

pathologypathologyAge <40Age <40

Repair SLAPRepair SLAP TenodesisTenodesis

YesYes

YesYes

YesYes

YesYes

YesYes

NoNo

NoNo

NoNo

NoNo

NoNo

Snyder et al: JSES, 2011, Snyder et al: JSES, 2011, 82-8882-88