SLAP Tears repair vs tenodesis
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SLAP Tears Repair Vs Biceps
Tenodesis
Bijay SinghConsultant Orthopaedic
SurgeonMedway Foundation NHS Trust
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OverviewHistoryAnatomySigns & SymptomsDiagnosticsResults Management Algorithm
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History
• 1985
– First Described by Andrews et al
• 1990
– Snynder & Karzel classified
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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
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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
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• 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
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Onyekwelu et al: The rising Incidence of SLAP repairs JSES, 2012, 21, 728-31
• Surgical cases: 55%
• Ambulatory cases: 135%
• SLAP Repair: 464%
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Current Literature
•No Level I or II publications related to treatment of SLAP tears
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Anatomy• Superior Labrum– Triangular structure coposed of fibrous &
fibrocartilagenous tissue
• LHB– Supra-glenoid tubercle – 60%
– Superior labrum – 40%
• Significant variation
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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
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Anatomical Variants
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Relevant Biomechanics• Not fully understood• Provides transational & rotational stability• LHB Tenotomy – Increased proximal migration by 16%
• Cadaveric Model–SLAP causes increased translation & ER
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Pathophysiology
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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
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• 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
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GIRD
–Deficit in IR of at least 20 compared to the contra-lateral side
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Diagnosis• Injury– Traction
–Compression of shoulder
–Repetitive over head athletic use
• Pain–Poorly located
– Located globally
• No reliable tests
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• Duration of symptoms• Anterior shoulder pain in
dominant arm• Clicking or Popping during
throwing• Night pain• Weakness• Instability
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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
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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)
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Speed Test• Patient Sitting• elbow extended
and the forearm in full Supination
• Resisted active flexion from 0 to 60
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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
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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
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• Upper Cut– Elbow flexed 90, forearm supinated, patient making a fist
– Bringing the hand up quickly – boxing upper cut
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Sleeper Stretch for Posterior Capsular
Contracture
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Accuracy of Clinical TestsJones & Galluch et al
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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
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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
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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
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Investigations &
Classification
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Imaging
• No specific radiographic findings pathognomonic for SLAP lesion
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• MR Arthrogram gold standard
– 90% accuracy
– Coronal Oblique Sequences
– ABER position
– High incidence of false positive MRI
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Arthroscopic Classification
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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
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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
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Clinical Results
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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
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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!!!
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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%
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• 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
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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)
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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
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Results
• SST, ASES, SF12 & VAS all significantly better
• Non athletes showed larger improvement in scores & movements
• 54% (7) returned to previous level sport
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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
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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
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6/10 disappointed / dissatisfied1/15 disappointed / dissatisfied87% returned to sports in tenodesis20% returned to sports in repair
4 tenodesis later returned
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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
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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
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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
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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
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My ExperienceSLAP ASAD ACJ Cuff
Repair
NHS 21 7 2 3
PP 24 4 1 1
Total 45 11 3 4
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NHS PP Total2008-09 4 0 4
2010 9 4 132011 7 8 152012 1 12 132013 0 0 0Total 21 24 45
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Complications / Issues
9/45 = 20%
Stiffness - 1 patient - resolved
Redo - 2 patient (fall)
Tenodesis - 2 (1 awaiting)
ASAD - 3
Ongoing unexplained pain - 2
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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
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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