Arthroscopic Treatment of Superior Labral Anterior Posterior (SLAP) Tears

 

 

 

DEFINITION

Superior labral anterior posterior (SLAP) tears are characterized by injury to the superior glenoid labrum, with anterior to posterior detachment of the superior labrum.25

Tears can occur with or without involvement of the biceps tendon origin.4

 

 

ANATOMY

 

The superior glenoid labrum is composed of fibrocartilaginous tissue between the hyaline cartilage of the glenoid surface and the joint capsule fibrous tissue.22

 

This fibrocartilaginous tissue serves as the attachment between the labrum and glenoid.

 

The vascular supply of the glenoid labrum does not come from the underlying glenoid but rather from penetrating branches of the suprascapular, circumflex scapular, and posterior humeral circumflex arteries in the surrounding capsule and periosteal tissue.

 

There is histologic evidence that vascularity is decreased in the anterior, anterosuperior, and superior aspects of the glenoid labrum,7 although no distinct vascular transition zone has been described.15

 

The inner portion of the glenoid labrum is avascular.23

 

PATHOGENESIS

 

An intact labrum enhances concavity compression and increases the effective diameter of the glenoid, improving joint stability.15

 

The long head of the biceps functions to depress the humeral head and serves as an adjunct anterior stabilizer of the shoulder.12,14

 

Disruption of the biceps anchor and the superior labrum, as seen in type II SLAP tears, can result in glenohumeral instability.

 

The most common mechanisms for SLAP tears include forceful traction loads to the arm, direct compression loads, and repetitive overhead throwing activities.17 Direct traction injury to the biceps tendon has also been linked with SLAP tears.4

 

However, there is evidence that up to a third of patients with SLAP lesions have no preceding trauma.20

 

Snyder's original classification of SLAP tears is most commonly used.25

 

 

 

Type I: fraying of superior labrum with intact biceps anchor Type II: detached superior labrum and biceps anchor

 

Type III: bucket-handle tear of superior labrum with intact biceps anchor

 

Type IV: bucket-handle tear of superior labrum with extension into the biceps tendon

 

Snyder's classification has been expanded to reflect associated injury to the anterior labrum and other structures.18

NATURAL HISTORY

 

Conservative nonoperative treatment of SLAP tears is usually unsuccessful.

 

Simple débridement of unstable SLAP tears (type II and IV) is generally not recommended because the results are poor.8

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Traction and compression are the two primary mechanisms of injury for SLAP tears.

 

A SLAP tear should be considered in a patient with a history of a traction or compression injury with persistent mechanical symptoms such as catching or locking.

 

Several clinical tests have been described that focus on the examination of the biceps tendon anchor on the superior glenoid. The Speed, Yergason, O'Brien, and load-compression tests are commonly used.

 

 

Speed and Yergason tests: Pain with the maneuvers suggests a SLAP tear.

 

O'Brien test: Pain with downward pressure applied to the internally rotated arm that is relieved with supination suggests a SLAP tear.

 

Load-compression test: Painful clicking or popping suggests a SLAP tear.

 

Type II SLAP tears found in younger patients are commonly associated with instability and a Bankart lesion, whereas type II SLAP tears found in patients older than 40 years of age are often associated with rotator cuff

pathology.16

 

Although no single clinical test can predictably be used to diagnose a SLAP tear,13 the examiner should use all of these tests, along with the history and a high clinical index of suspicion, to make the diagnosis of a SLAP tear.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Although conventional radiographs (anteroposterior and supraspinatus outlet and axillary views) are the standard for initial evaluation of a patient with shoulder complaints, magnetic resonance imaging (MRI) is the most sensitive imaging tool for evaluating the superior glenoid labrum, with a sensitivity and specificity of

about 90%.3

 

 

The use of contrast arthrography MRI may improve the overall accuracy of MRI for diagnosing SLAP tears.19 Despite advances in imaging techniques, the gold standard for the diagnosis of a SLAP tear is arthroscopy.

DIFFERENTIAL DIAGNOSIS

 

 

Glenohumeral instability Rotator cuff pathology

 

Acromioclavicular joint pathology

 

 

P.34

NONOPERATIVE MANAGEMENT

 

Physical therapy is the mainstay of nonoperative treatment of most shoulder injuries.

 

 

Selective intra-articular injections with local anesthetic and corticosteroids can be diagnostic and occasionally therapeutic.

 

The rehabilitation program should focus on achieving and maintaining a full range of motion and strengthening the rotator cuff and scapula stabilizers.

 

Although physical therapy may be useful for regaining range of motion and strength, most patients with SLAP tears will continue to have symptoms despite physical therapy.

 

SURGICAL MANAGEMENT

 

Surgical treatment of SLAP tears should be considered for patients who have persistent symptoms despite appropriate conservative management.

 

Contraindications for SLAP repair include patients who are high-risk surgical candidates (ie, the risk of anesthetic complications outweighs the possible benefits of successful repair).

 

Preoperative Planning

 

Preoperative assessment of glenohumeral instability is paramount to understanding the pathophysiology of a patient's shoulder complaints.

 

Associated instability and any other coexisting pathology must also be addressed at the time of SLAP repair.

 

Positioning

 

 

Beach-chair position Lateral decubitus position

 

This may be preferred for cases of suspected labral pathology, especially if associated with posterior instability, because this position allows improved visualization and access with distraction.

 

 

No more than 10 to 15 pounds of traction should be used owing to increased risk of brachial plexus injuries. A comprehensive exam under anesthesia should routinely be performed to assess for any instability.

Approach

 

The primary goal of any SLAP repair is to stabilize the biceps anchor and address any coexisting pathology.

 

 

After a thorough diagnostic evaluation, SLAP lesions are treated according to Snyder25 (see the Techniques section).

 

 

Standard anterosuperior and anteroinferior portals are established.

 

Accessory portals may also be established depending on the location of the SLAP tear.

 

 

TECHNIQUES

• Type I Slap Tears

   

  Type I SLAP tears may be treated using a motorized shaver to simply débride the degenerative or frayed tissue.

   

  Care must be taken not to detach the biceps anchor from the superior glenoid.

• Type II Slap Tears

 

 

Type II SLAP tears are the most commonly encountered SLAP tears (TECH FIG 1). They represent detachment of the biceps anchor from the superior glenoid labrum.

 

As such, the primary goal of any repair should be to securely reattach the superior labral tissue to the

superior glenoid.

 

 

 

TECH FIG 1 • Arthroscopic view of type II SLAP lesion.

 

Glenoid Preparation

 

After identifying the detachment by direct probing, a 4.5-mm motorized shaver is used to gently débride any frayed or degenerative tissue.

 

A motorized burr is used to débride the superior glenoid to exposed, bleeding bone (TECH FIG 2).

 

 

 

TECH FIG 2 • Preparing superior glenoid with burr.

 

 

P.35

 

 

 

 

TECH FIG 3 • A,B. Drilling suture anchor through lateral portal.

 

Accessory Portal Placement

 

An accessory transrotator cuff portal is made using an outside-in technique. No cannula is inserted because this portal will be used only to insert the anchor.

 

This portal may be adjusted anteriorly or posteriorly depending on the location of the SLAP tear.

 

A spinal needle is used to ensure that the correct trajectory is achieved to place the anchor at about a 45-degree angle to the glenoid face.

 

A no. 11 blade knife is used to make the skin incision, but a cannula is not inserted because this portal will be used only to insert the suture anchor drill guide and anchor after drilling.

Suture Anchor Placement

 

The suture anchor drill guide is placed on the glenoid face at about a 45-degree angle to the face, ensuring that the anchor will be solidly in bone (TECH FIG 3).

 

The suture anchor may be single- or double-loaded with nonabsorbable no. 2 braided suture, depending on preference.

 

If more than one suture anchor is to be used, the surgeon starts the repair posteriorly and works anteriorly to aid in visualization.

 

The anchor is placed in the same trajectory as the drill, ensuring that the drill guide is maintained in its proper orientation and position.

Suture Management

 

One limb (limb A) of the suture is retrieved out through the anterosuperior cannula using either a crochet hook or suture grasper.

 

 

 

TECH FIG 4 • A,B. The surgeon retrieves one limb of the anchor suture out the anterosuperior cannula (AS) and one limb out the anteroinferior cannula (AI).

 

 

A crochet hook is used to capture the other limb (limb B) of the anchor suture and bring it out the anteroinferior cannula (TECH FIG 4).

Suture Passage

 

Through the anterosuperior cannula and starting at the posterior edge of the tear superiorly, the surgeon passes a tissue penetrator (Spectrum, ConMed Linvatec, Largo, FL) through the labrum (TECH FIG 5A,B).

 

A 45-degree left-curved tissue penetrator is used for a right shoulder SLAP tear (45-degree right-curved for the left shoulder) loaded with a no. 1 monofilament or Shuttle Relay suture passer (ConMed

Linvatec, Largo, FL) as a pull-through suture.

 

An arthroscopic grasper inserted through the anteroinferior cannula is used to grasp the monofilament passing suture as it penetrates the superior labrum, and the free end is pulled out through the anteroinferior cannula (TECH FIG 5C,D).

 

A simple knot is tied in the passing suture (see TECH FIG 5D, inset) and the free end of limb B from the suture anchor is inserted through the loop. The suture is pulled gently but firmly through the anterosuperior portal so that the two ends of the anchor suture are together out of the anterosuperior portal (TECH FIG 5E,F). (If a Shuttle Relay suture passer is being used, the free end of the anchor suture is placed through the wire loop and the same steps are followed.)

 

The surgeon should ensure that the anchor is not unloaded of its suture during this process by maintaining continuous arthroscopic visualization of the anchor.

 

There should be no movement of the suture at the anchor eyelet.

 

 

P.36

 

 

 

TECH FIG 5 • A,B. Spectrum tissue penetrator loaded with monofilament passing suture through superior labrum. C,D. Shuttle relay passing suture retrieved through the anteroinferior cannula. E,F. The surgeon firmly pulls the shuttle relay suture through the anterosuperior cannula so that the two ends of the anchor suture are together in the anterosuperior cannula.

Knot Tying

 

Making sure that the post limb is off the glenoid surface, the surgeon ties the suture using either a sliding knot or a series of half-hitches, taking care to switch posts and alternate directions of the loops.

 

The excess suture is cut using an arthroscopic suture cutter.

 

 

 

TECH FIG 6 • A. Completed SLAP lesion repair using the technique described. B. Completed SLAP lesion repaired alternatively using knotless technique to eliminate the potential for knot impingement.

Additional Suture Anchor Placement

 

This procedure is repeated until the biceps anchor has been securely reattached to the superior glenoid (TECH FIG 6).

 

 

The surgeon should take care when securing the anterior aspect of the SLAP tears so that a normal labral foramen or an anterosuperior labral variant is not incorrectly identified as a SLAP tear, causing inadvertent tightness and resulting in decreased range of motion.

 

• Type III Slap Tears

  P.37

   

  Simple débridement of the labral bucket-handle tear is the preferred surgical technique for type III SLAP tears because the biceps anchor is intact.

• Type IV Slap Tears

   

  Type IV SLAP tears involve a bucket-handle tear of the superior labrum with a tear of the biceps tendon.

   

  The biceps anchor may be detached as well.

   

  Treatment is débridement of the labral tear and biceps tendon tear, with repair of the biceps anchor if needed, essentially converting the tear to a type II and then repairing the anchor detachment.

   

  In an older patient with significant biceps tendon degeneration, biceps tenodesis should be considered.

   

  Similarly, in a younger patient with a tear extending into the biceps tendon, repair of any tendon tears should be considered.

   

  PEARLS AND PITFALLS

   

  Indications

  • All associated pathology is identified and addressed (eg, instability, rotator cuff pathology, acromioclavicular joint disorders).

     

    Planning ▪ Lateral decubitus positioning is considered if posterior labral pathology is suspected.

     

    Portal placement

  • Proper technique must be used in placing portals at the beginning of the case, with attention to positioning of the portals both in the superoinferior plane and the mediolateral plane. Improperly placed portals can greatly increase the difficulty of this operation. A spinal needle is used to judge the angle of approach for each portal before making the portal to ensure that the correct trajectory is obtained.

 

Suture management

• When retrieving and handling anchor sutures, the surgeon should not place tension on either limb and should maintain continuous visualization of the anchor-suture interface to ensure that the anchor is not unloaded. The surgeon should take care to avoid twists because these can place increased stress on a suture or knot and lead to breakage. The surgeon should place one anchor at a time and tie each suture or remove and replace the cannula and place the suture outside the cannula for suture storage to prevent tangles during tying.

 

Other ▪ Articular cartilage damage is avoided by firmly seating the drill guide on the edge of the glenoid and avoiding skiving onto the glenoid face.

 

POSTOPERATIVE CARE

 

0 to 4 weeks: Sling at all times except for hygiene and exercises. (Active range of motion allowed in all planes except external rotation in abduction starting at 2 weeks.)

 

 

4 weeks: Discontinue sling. Start passive range of motion with emphasis on posterior capsule stretching. 6 weeks: External rotation in abduction allowed. Start strengthening.

3 months: Sports allowed except throwing (4 months).

OUTCOMES

Table 1 summarizes outcomes from studies of SLAP tear repairs.

 

 

COMPLICATIONS

Infection (rare)

Brachial plexus neuropathy secondary to traction of the arm in the lateral decubitus position

Care must be taken to ensure that the smallest amount of traction and distraction necessary is used, with close monitoring of the tension applied to neurovascular structures.

Persistent pain

 

 

 

Healed repair: Biceps tenodesis should be considered for pain relief. Failed repair

 

Repeat arthroscopy should be considered with revision repair.

 

Biceps tenodesis should be considered for severely degenerative or intractable cases.

 

 

P.38

 

 

Table 1 Results of Arthroscopic Superior Labral Anterior Posterior (SLAP) Lesion Repair

 

Study Surgical Procedure

Number of Patients Results

 

Cohen et al5

Bioabsorbable tacks

39 14/39 return to play at preinjury level, 3.7-y follow-up; 27/39 good to excellent results

 

Coleman et al6

Bioabsorbable tacks

50 65% good to excellent results at 3.4-y follow-up

 

Enad et al9 Suture anchor

fixation

27 24/27 good to excellent results

 

Funk and Snow10

Suture anchor fixation

18 95% return to play at preinjury level; 89% satisfaction

 

Yung et al26

Suture anchor fixation

16 87.5% good to excellent results

 

Boileau et al1

Suture anchor fixation

25 (2 groups: biceps tenodesis vs. SLAP repair)

13/15 satisfied tenodesis group; 4/10 SLAP repair group

 

Brockmeier et al2

Suture anchor fixation

47 41/47 good to excellent results at 2.7-y follow-up

 

Galano et al11

Suture anchor fixation

22 90% return to play at preinjury level

 

Neuman et al21

Suture anchor fixation

30 93.3% satisfaction rate

 

Sayde et al24

Bioabsorbable tacks, suture anchors, staples

506 (systematic review)

63% return to play at preinjury level

 

 

REFERENCES

1. Boileau P, Parratte S, Chinard C, et al. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med 2009;37(5):929-936.

    

    

2. Brockmeier SF, Voos JE, Williams RJ III, et al. Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg Am 2009;91(7):1595-1603.

    

    

3. Chandnani V, Yeager T, Deberardino T, et al. Glenoid labral tears: prospective evaluation with MR imaging, MR arthrography, and CT arthrography. AJR Am J Roentgenol 1993;161:1229-1235.

    

    

4. Chang D, Mohana-Borges A, Borso M, et al. SLAP Lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization. Eur J Radiol 2008;68:72-87.

    

    

5. Cohen DB, Coleman S, Drakos MC, et al. Outcomes of isolated type II SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack. Arthroscopy 2006;22(2):136-142.

    

    

6. Coleman SH, Cohen DB, Drakos MC, et al. Arthroscopic repair of type II superior labral anterior posterior lesions with and without acromioplasty: a clinical analysis of 50 patients. Am J Sports Med 2007;35(5):749-753.

    

    

7. Cooper D, Arnoczky S, O'Brien S, et al. Anatomy, histology, and vascularity of the glenoid labrum: an anatomical study. J Bone Joint Surg Am 1992;74A:46-52.

    

    

8. Cordasco F, Steinman S, Flatow E, et al. Arthroscopic treatment of glenoid labral tears. Am J Sports Med 1993;21:425-431.

    

    

9. Enad JG, Gaines RJ, White SM, et al. Arthroscopic superior labrum anterior-posterior repair in military patients. J Shoulder Elbow Surg 2007;16(3):300-305.

    

    

10. Funk L, Snow M. SLAP tears of the glenoid labrum in contact athletes. Clin J Sport Med 2007;17(1):1-4.

     

     

11. Galano GJ, Ahmad CS, Bigliani L, et al. Percutaneous SLAP lesion repair technique is an effective alternative to portal of Wilmington. Orthopedics 2010;33(11):803.

     

     

12. Healey J, Barton S, Noble P, et al. Biomechanical evaluation of the origin of the long head of the biceps tendon. Arthroscopy 2001;17:378-382.

     

     

13. Hegedus EJ, Goode AP, Cooke CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med 2012;46(14):964-978.

     

     

14. Itoi E, Kuechle D, Newman S, et al. Stabilizing function of the biceps in stable and unstable shoulders. J Bone Joint Surg Br 1993;75B:546-550.

     

     

15. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg 2009;17:627-637.

     

     

16. Kim T, Quaele W, Cosgarea A, et al. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am 2003;85A:66-71.

     

     

17. Knesek M, Skendzel JG, Dines JS, et al. Diagnosis and management of superior labrum anterior posterior tears in throwing athletes. Am J Sports Med 2013;41(2):444-460.

     

     

18. Maffet M, Gartsman G, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-98.

     

     

19. Magee T, Williams D, Mani N. Shoulder MR arthrography; which patient group benefits most? AJR Am J Roentgenol 2004;183:969-974.

     

     

20. Mileski R, Snyder S. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6: 121-131.

     

     

21. Neuman BJ, Boisvert CB, Reiter B, et al. Results of arthroscopic repair of type II superior labral anterior posterior lesions in overhead athletes: assessment of return to preinjury playing level and satisfaction. Am J Sports Med 2011;39(9):1883-1888.

     

     

22. Prodromos C, Ferry J, Schiller A, et al. Histological studies of the glenoid labrum from fetal life to old age. J Bone Joint Surg Am 1990;72A:1344-1348.

     

     

23. Sandhu B, Sanghavi S, Lam F. Superior labrum anterior to posterior (SLAP) lesions of the shoulder. Orthop Trauma 2010;25(3):190-197.

     

     

24. Sayde WM, Cohen SB, Ciccotti MG, et al. Return to play after type II superior labral anterior-posterior lesion repairs in athletes: a systematic review. Clin Orthop Relat Res 2012;470:1595-1600.

     

     

25. Snyder S, Karzel R, Del Pizzo W, et al. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279.

     

     

26. Yung PS, Fong DT, Kong MF, et al. Arthroscopic repair of isolated type II superior labrum anterior-posterior lesion. Knee Surg Sports Traumatol Arthrosc 2008;16(12):1151-1157.