Abstract
Background:
Superior labral tears are frequently encountered during shoulder arthroscopy. Outcomes following superior labral anterior-posterior (SLAP) repairs in young athletes have been well documented. Superior labral repairs in older patient population continue to remain controversial due to concerns of postoperative complications including persistent preoperative symptoms, pain, stiffness, and higher rates of revision surgery.
Indications:
We present a case of a highly active 38-year-old woman who failed 1½ years of nonoperative management of a type IIB SLAP tear with extension to the posterior labrum. Her symptoms continued to limit her hobbies and work.
Technique:
A knotless single-anchor SLAP repair was performed along with debridement of the posterior frayed labrum. No biceps tenotomy or tenodesis was performed after full evaluation of the tendon failed to demonstrate evidence of synovitis, tendinopathy, or tear. The patient also did not have any concomitant shoulder pathology, including a rotator cuff tear or chondral lesion.
Results:
At 6 months, the patient had regained full range of motion similar to the contralateral side. She had returned to her normal activities and sports, including tennis.
Discussion/Conclusion:
Successful outcomes following SLAP repairs in patients over 35 years can be achieved, but treatment should be individualized with particular attention to concomitant pathology involving the rotator cuff, chondral surface, or biceps tendon which may require tenodesis or tenotomy.
This is a visual representation of the abstract.
Video Transcript
Superior labral anterior-posterior (SLAP) tears presented by Dr Steven Cohen and Dr John Matthews. None of the authors have a disclosure to mention.
The main function of the labrum is to increase glenohumeral stability and congruency. The superior labrum also provides an attachment site for the long head of the biceps tendon.
A SLAP tear is defined as a superior labral tear from anterior to posterior direction. It is most prevalent in overhead athletes. There are several associated conditions to be aware of in conjunction with SLAP tears, including internal impingement, glenohumeral internal rotation deficit (GIRD), articular-sided rotator cuff tears, and scapular dyskinesia. SLAP tears can occur secondary to contraction of the posterior capsule and inferior glenohumeral ligament, which results in translation of the contact point of the humeral head posterosuperiorly, resulting in increased shear force or peel back on the superior labrum. Once a SLAP tear occurs, there is increased strain on the anterior band of the inferior glenohumeral ligament.
There are several classification systems for describing SLAP tears. Type II tears are the most prevalent and represent detachment of the superior labrum and biceps from the glenoid rim.
Clinically, SLAP tears may present with a history of a popping sensation in the involved shoulder with associated deep vague shoulder pain that is worse with overhead activity. Occasionally, there may be a lag between time of injury and onset of symptoms. Patients may complain of intermittent mechanical symptoms.
On examination, it is important to inspect the shoulder contour and scapular motion, and look for any popeye deformity. Patients may complain of pain during palpation of the bicipital groove. Total arc of motion should be assessed and compared with the contralateral extremity. Patients may have pain with provocative maneuvers, including Speed/Yergason, O’Brien, and Crank tests.
Imaging studies including radiographs and magnetic resonance imaging (MRI) should be obtained. Plain radiographs tend to be normal. A T2-sequenced MRI is best for evaluation of the superior labrum. It is important to evaluate for a sublabral recess which may resemble a SLAP tear; however, the signal intensity extends medially and follows the contour of the glenoid cartilage as opposed to a SLAP tear that extends laterally and appears irregular. There may be associated paralabral cyst, rotator cuff tears, posterior capsular thickening, or cortical changes along the greater tuberosity with chronic impingement.
Once a SLAP tear is diagnosed, initial treatment includes rest, physical therapy, and anti-inflammatory medications. Therapy should address GIRD, scapular dyskinesia, and rotator cuff and core strengthening. The sleeper stretch demonstrated on the right is one form of stretching to address GIRD.
If the patient fails conservative management, operative intervention is warranted.
For this case, the patient was a highly active 38-year-old right hand–dominant woman with a 1.5-year history of progressively worsening right shoulder pain limiting her hobbies and work. She had prior nonoperative treatment including injections and extensive physical therapy without relief.
On examination, she was 5′2, 134 pounds. She had full painless cervical range of motion. Visual inspection of the shoulder demonstrated normal contour with no periscapular atrophy. She had 5 out of 5 strength in her bilateral rotator cuff muscles. Her range of motion on the right demonstrated 170° of abduction and forward flexion compared with 180° on the left. She had symmetric external rotation of 65°. Internal rotation on the right was limited to T10 compared with T7 on the left. Provocative test demonstrated pain with the O’Brien test, Mayo sheer test, and impingement signs with Hawkins and Neer test. She had a negative apprehension signs with Speed and Yergason tests.
Plain radiographs including an anteroposterior, scapular Y, and axillary views were obtained and did not demonstrate any significant degenerative changes or osseous abnormality. Coronal, axial, and saggital T2 MRI cuts of the right shoulder demonstrated a superior labral tear that extended laterally and posteriorly suggestive of a type IIB tear.
When proceeding with surgery to address a SLAP lesion, there are several preoperative factors to consider. First is the presence of additional pathology which may involve the chondral surface, paralabral cysts, rotator cuff tears, or lesions within the biceps tendon itself which may require a tenodesis or tenotomy. It is important to have this discussion with the patient preoperatively to manage postoperative expectations and outcomes. In addition, this patient’s MRI also demonstrated tear extension to involve the posterior labrum, which need to be addressed intraoperatively.
Finally, despite her age of 38 years, this patient was highly active and failed over 1.5 years of conservative management. Several studies, including that from Alpert and Neri et al, demonstrated no difference in functional outcomes following SLAP repairs in patients older and younger than 40 years. Denard, Katz, and Schroeder et al found different results with superior outcomes seen in patients less than 40 years undergoing SLAP repairs. In their systematic review, Erickson et al found good outcomes can be obtained with SLAP repairs in an older patient cohort, but may have higher risk of surgical complications. We recommend individualizing treatment for SLAP tears in older patients, especially those with concomitant pathology involving the rotator cuff, chondral surface, or biceps tendon.
The patient was subsequently taken to the operating room and positioned in beach chair. The arm was prepped and draped in the usual sterile fashion. Appropriate landmarks were then identified and marked. A diagnostic arthroscopy was then performed using the posterior portal. The middle glenohumeral ligament and subscapularis were identified, followed by the rotator cuff musculature that did not demonstrate any significant pathology. The scope was then placed into the axillary recess and then the posterior labrum was visualized, which demonstrated some fraying of its fibers. There was no significant chondral pathology involving the glenoid or humeral head.
The superior labrum was then probed followed by biceps tendon. The biceps tendon including the distal end within the bicipital groove was fully evaluated and appeared normal with no overlying synovitis, tendinopathy, or tearing. The decision was then made to perform a SLAP repair without a biceps tenotomy or tenodesis as the tendon itself was normal and there were no associated lesions involving the chondral surface or rotator cuff.
The glenoid base was then prepared using a shaver to create a bleeding bony base for repair. At this stage, one tip to consider is decompressing any associated labral cysts before anchor placement. Following base preparation, a spinal needle was used for proper angulation of the percutaneous trans-cuff drill guide. No cannula was used to limit the hole size within the cuff.
The drill guide was positioned along the superior edge of the glenoid. It is important to hold the guide firmly to prevent skiving inferiorly damaging the chondral surface or medially risking injury to the suprascapular nerve. One tip to prevent these errors involves using a mallet to gently tap the drill guide into the superior glenoid. Once you start drilling, you should note the presence of bony debris to ensure you are drilling into bone as opposed to skiving medially. Following this, the anchor was then placed through the guide sheath.
It is important to note that the anchor was placed posterior to the biceps insertion to prevent overconstraint of the shoulder. Following anchor placement, a spectrum was used to pass a monofilament suture for shuttling of the blue/white tape suture. The tape suture and the monofilament were then retrieved through the anterior portal.
The tape suture was then shuttled through the labrum. Following this, the blue and white tape suture was shuttled back through the anchor using the loop in the black and white shuttle suture. After this was performed, the SutureTak (Arthrex) was tensioned appropriately. Care was taken not to overtighten, which may lead to stiffness, pain, and lack of external rotation. After the desired tension was reached, the suture was cut flush with the glenoid surface.
The camera was then inserted in the anterior cannula, and the posterior labrum was inspected. A probe was used to evaluate the labrum which demonstrated a 50% tear from the 8 o’clock to 10 o’clock position. With the poor tissue quality and remaining aspect of the labrum attached, the decision to resect the torn portion with a shaver was made. Following resection of a portion of the posterior labrum, the remaining aspect was well attached.
Postoperatively, passive and active assisted flexion in the scapular plane is initiated at 1 to 4 weeks. It is important to advise the patient to avoid extreme ranges of abduction and external rotation as well as resisted biceps exercises. At weeks 4 to 6, it progressed to active range of motion and isometric exercises. At weeks 6 to 12, functional exercise and light strengthening are performed. After week 12, sport-specific training is performed. The typical return to play is around 6 months.
The most common complication following SLAP repairs is stiffness. Risk factors include repair in patients over the age of 45 years or concomitant rotator cuff repair. Treatment typically is centered around aggressive physical therapy. Occasionally, some patients may require surgical capsular release.
Repair failure is another potential complication, especially in patients over the age of 36 years. Provencher et al in their series of 179 patients found failures had a relative risk of 3.4 in patients over 36 years old.
In elite throwers, return to sport is variable and unpredictable.
There is also a risk to the suprascapular nerve if the drill bit skives medially or during decompression of a paralabral cyst.
Thank you.
Footnotes
Submitted February 3, 2021; accepted February 12, 2021.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.