Combined Arthroscopic Repair of a Type IV SLAP Tear and Bankart Lesion

Lesions of the superior labrum can be a source of significant shoulder pain and disability. SLAP (superior labrum anterior-posterior) tears have been classified into many different types. A type IV SLAP tear is a bucket-handle tear of the superior labrum with extension into the biceps tendon. This relatively uncommon SLAP tear, if present, has been shown to be frequently associated with other pathology including Bankart lesions. We present an arthroscopic technique for combined repair of a type IV SLAP tear and Bankart lesion. Steps include initial reduction of the bucket-handle portion of the superior labral injury, repair of the anterior-inferior labral detachment, and, finally, repair of the superior labrum and biceps tendon split.     

肩关节镜下缝线锚钉修复合并关节盂唇前后延伸撕裂的严重SLAP损伤

目的探讨肩关节镜下缝线锚钉修复合并关节盂唇上部从前到后的损伤（SLAP）的疗效。方法 2007年至2009年,结合体格检查、MRI和关节镜诊断为关节盂唇前后沿伸撕裂的SLAP损伤患者12例,关节镜下采用缝线锚钉治疗。其中SLAP-Ⅴ型损伤（Bankart损伤＋SLAPⅡ型损伤）7例,SLAP-Ⅷ型损伤（SLAPⅡ型损伤合并后下方盂唇撕裂）3例以及一种新的SLAP损伤类型2例,即SLAPⅢ型损伤＋前后盂唇撕裂并脱位。术前及术后随访采用ASES评分及Constant-Murley功能评估。结果所有患者平均随访27个月。术前及终末随访ASES评分为（77.4±3.7）分vs（94.3±2.6）分,两者比较差异有统计学意义（t=28.1,P〈0.05）;Constant-Murley评分为（78.1±4.6）对（93.9±3.7）分（t=28.9,P〈0.05）。术后无一例患者发现再脱位,且均重返伤前工作岗位。结论随着肩关节镜技术的不断进步,肩关节盂唇严重损伤的修复更加有效、微创及简便。     

镜下缝线锚钉修复肩关节上盂唇前后向合并前后延伸损伤的疗效分析

目的 探讨镜下缝线锚钉修复肩关节上盂唇前后向(SLAP)合并前后延伸损伤的疗效.方法 对2007年3月至2009年4月肩关节镜下缝线锚钉修复的12例盂唇SLAP合并前后延伸损伤患者的资料进行回顾性分析,男7例,女5例;年龄18～40岁,平均28.7岁;均为复合多向不稳定.镜下缝线锚钉治疗肩关节盂唇SLAP Ⅴ型损伤(Bankart损伤+SLAPⅡ型损伤)7例、SLAPⅧ型损伤(SLAPⅡ型损伤合并后下方盂唇撕裂)3例及SLAPⅢ型合并前后盂唇撕裂脱位2例.术前及术后随访均采用美国肩肘外科协会(ASES)评分、视觉模拟评分(VAS)及Constant-Murley评分评定疗效.结果 所有患者术后获11～22个月(平均17个月)随访.术前及末次随访时肩关节平均前屈上举分别为163.4°±8.6°和169.7°±4 2°;外展90°外旋为58.5°±13.6°和90.3°±5.5°;术后外展90°,患侧外旋角度较健侧受限8.4°±6 2°.术前及末次随访ASES评分分别为(77.4±3.7)分和(94.3±2.6)分,VAS评分分别为(7.2±1.4)分和(1.2±0.6)分,Constant-Murley评分分别为(78.1±4.6)分和(93.9±3.7)分,以上指标比较差异均有统计学意义(P＜0.05).术后未发生再脱位,均重返伤前工作岗位.结论 严重SLAP合并前后延伸损伤诊断困难,镜下能明确损伤类型,及时治疗,创伤小,并发症少,功能恢复快.     

Komplexe labrale Avulsionsverletzungen mit Extension in den SLAP-Komplex bei anteroinferiorer Schulterinstabilität

The Bankart-Perthes lesion is accepted as the pathognomonic finding for anterior inferior shoulder instability. Extensive injuries of the labral ring with involvement of the superior labrum anterior to posterior (SLAP) complex may occur. The aim of this study was to evaluate the prevalence of labral lesions with accompanying anteroinferior and superior extensions following anteroinferior shoulder instability. In addition the lesions were graduated according to common classification systems and the clinical as well as radiographic results were evaluated. Between January 2005 and November 2010 a total of 206 patients (40 female and 166 male, mean age 31.8?±?16.6 years) underwent primary arthroscopic surgery due to anteroinferior shoulder instability. Out of this cohort patients with anterior labral lesions that extended into the biceps tendon anchor were selected. For clinical evaluation the subjective shoulder value (SSV), Constant-Murley score (CMS), Rowe score (RS), Walch-Duplay score (WD), the Western Ontario shoulder instability index (WOSI), Melbourne instability shoulder score (MISS) and the long head of the biceps (LHB) score were documented. Furthermore, magnetic resonance imaging (MRI) was performed to evaluate the SLAP complex. Overall 15 patients (2 f?emale and 13 male, mean age 29.3?±?8.8 years) were evaluated revealing an additional lesion of the superior labrum with a prevalence of 7.3?%. In seven patients a SLAP V lesion, in two patients a SLAP IV and in six patients a SLAP III lesion with anteroinferior extension was observed. All of the bucked handle type lesions were reconstructed and nine patients could be completely evaluated using clinical and radiographic parameters. After an average follow-up of 59.5?±?12.1 months a mean SSV of 87?±?8?%, CMS 91.0?±?8.8 P, RS 83.3?±?11.2?%, WD 80.0?±?8.9 points, WOSI 73.1?±?23.5?%, MISS 81.5?±?10.5 points and LHB 94.0?±?9.7 points were evaluated. Recurrent dislocation was not obvious although one patient revealed a positive apprehension sign. On MRI an insufficiency of the SLAP reconstruction was not seen and the reconstructed bucket handle lesions seemed to be especially stable. Arthroscopic anterior shoulder stabilization in combination with a SLAP repair revealed good and excellent clinical results. The reconstruction of the biceps tendon anchor seems to be possible even in cases of complex pathologies.     

Effects of biceps tension on the torn superior glenoid labrum

The purpose of this study was to evaluate the role of the tension on the long head of the biceps tendon in the propagation of SLAP tears by studying the mechanical behavior of the torn superior glenoid labrum. A previously validated finite element model was extended to include a glenoid labrum with type II SLAP tears of three different sizes. The strain distribution within the torn labral tissue with loading applied to the biceps tendon was investigated and compared to the inact and unloaded conditions. The anterior and posterior edges of each SLAP tear experienced the highest strain in the labrum. Labral strain increased with increasing biceps tension. This effect was stronger in the labrum when the size of the tear exceeded the width of the biceps anchor on the superior labrum. Thus, this study indicates that biceps tension influences the propagation of a SLAP tear more than it does the initiation of a tear. Additionally, it also suggests that the tear size greater than the biceps anchor site as a criterion in determining optimal treatment of a type II SLAP tear. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:1545–1551, 2015.     

The arthroscopic SLAP refixation

Lesions of the superior glenoid labrum and the insertion of the biceps tendon are a common cause for shoulder pain in patients performing overhead sports.The therapeutic management depends on the type of lesion, and should be carried out using an arthroscopic procedure. While type I SLAP lesions should be treated conservatively or with simple debridement, SLAP II, IV, and V lesions, with a detachment of the labrumanchor- complex, should be refixed with suture anchors. Only in cases of type III lesions with a bucket handle-like lesion of the labrum, but stable insertion of the biceps tendon, a simple debridement can be performed. From the biomechanical point of view, large type III lesions should also be reconstructed. To improve the arthroscopic view for preparation of the glenoid neck, an intraarticular loop ("Imhoff-suspension sling") can prevent the posterosuperior labrum from falling into the joint. The arthroscopic SLAP refixation is a technically highly demanding procedure which provides good clinical results for the patient.     

MR imaging of variants of the superior labral-bicipital complex and SLAP lesions

In the detection of SLAP (superior labral anterior to posterior) lesions of the shoulder MR arthrography shows a significantly higher sensitivity compared with conventional MR techniques and therefore, represents the method of choice in diagnostic imaging of the superior labral-bicipital complex. On the basis of morphological criteria it mostly allows distinction of traumatic lesions and anatomic variants of the superior labrum and the biceps anchor as well as classification of detected SLAP lesions (types 1-4 according to Snyder). However, the differentiation of a SLAP type 2 lesion and a sublabral recess can be very difficult, even if all distinction criteria are considered.     

Editorial Commentary: Indications for Shoulder SLAP Lesion Repair Versus Biceps Tenodesis Depend on Patient Age,Tear Type and Location,and Quality of Tissue

Whether to repair a shoulder SLAP lesion or perform a biceps tenodesis depends on a multitude of factors: patient age, activity or work level, type of SLAP tear, location of SLAP tear, and quality of labral tissue. Determining which procedure to perform does not have such a simple, one-size-fits-all solution. For patients younger than 40 years, repair of type 2 SLAP tears that do not directly affect the biceps anchor (i.e., those tears from the 12:30 clock-face position to the 2-o’clock position or from the 10-o’clock position to the 11:30 clock-face position) is generally successful. For tears at the biceps anchor in patients younger than 40 years, repair the SLAP tear but perform tenodesis of the biceps. For type 3 SLAP tears, debride the bucket-handle component and spare the biceps because it usually is not involved. For type 4 tears, perform tenodesis. In patients older than 40 years, type 2 and type 4 SLAP tears are predominantly treated with biceps tenodesis with debridement of the SLAP tear, if indicated. SLAP repair is rarely indicated in patients older than 40 years because the tissue is usually degenerative and frayed.     

Case Report Acute Complex SLAP Lesion

Summary: The SLAP lesion is a frequently observed lesion of the shoulder involving the superior glenoid labrum and long head biceps tendon. It is caused by falls onto an outstretched arm, inferior traction pull, abduction-external rotation injuries, anterior traction, and upward traction. The authors describe a complex SLAP lesion: type IV associated with an anterior Bankart lesion, that underwent arthroscopic treatment a few days after trauma. At 1-year follow-up of the patient, clinical evaluation and magnetic resonance imaging showed good healing of the long head biceps tendon and of the glenoid labrum, superior and anterior. In similar cases where evaluation is difficult because of shooting pain, drug resistance, and functional limitations of movements, we recommend arthroscopic evaluation a few days after trauma for better accuracy of imaging in the evaluation of acute lesions.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 8 (November-December), 1999: pp 3–3     

Damage to the glenoid labrum and expert assessment

AIM: Development of criteria for the medical-legal interpretation of different patterns of labral lesions according to the labrum pathology and mechanism of injury. METHODS: A metaanalysis of the literature concerning injuries and diseases of the shoulder involving the glenoid labrum was performed. RESULTS: Lesions of the superior, anterior and posterior labrum are rare and of different severity. Arthroscopically they are divided into distinct types. They develop either spontaneously together with intraarticular diseases, due to chronic fatigue or by injury. In this field the stability of the shoulder joint and the tension of the long head of the biceps tendon play an important role. There is no correlation between the type of lesion and mechanism of injury. With respect to medical-legal interpretation, the currently used classification of labral lesions is not very helpful or is even confusing. We therefore propose a new classification according to the meniscus pathology which shows a striking similarity to labral pathology. There are two types of labral lesions: Type one shows degenerative defects, which may be influenced by mechanical loading; type two follows from shoulder instability. CONCLUSIONS: Medical-legal interpretation of labral lesions should follow the same principles that were shown to be useful in knee joint instability and meniscal tears. Only traumatic luxations of the shoulder joint may lead to labral tears without any other alterations.     

Biceps tendon and superior labral injuries

Twenty-two patients sustained injury to the biceps tendon, rotator cuff interval, or superior labrum. Seven patients with "interval lesions" underwent biceps tenodesis, one biceps repair, and three subscapularis repairs. All were satisfied, although one tenodesis failed with distal biceps retraction. Key arthroscopic findings included biceps or subscapularis fraying. Thirteen patients with "S.L.A.P. (superior labrum anterior to posterior) lesions" underwent labral debridement. All but one obtained pain relief. Eight cadaveric shoulders exhibited extreme anatomic variability of the bicipital origin/superior labral attachment. Biomechanical study showed anterior-superior and posterior-superior labral strain with simulated biceps contraction to be greatest in shoulder abduction (p < 0.01). Biceps tendon strain was greatest in shoulder adduction (p < 0.05). A continuum of injuries to the biceps tendon exist, from the rotator cuff interval to the labral attachment. Key arthroscopic findings may assist in the difficult diagnosis of interval lesions. Individual anatomy and mechanism of injury may determine the site of the lesion.     

The high frequency of superior labrum,biceps tendon,and superior rotator cuff pathologies in patients with subscapularis tears: A cohort study

Background

The purpose of this study was to assess the frequency of superior labrum anterior posterior (SLAP) lesions, long head of biceps tendon (LHBT) pathologies, and superior rotator cuff tears accompanying subscapularis tears. We hypothesised that LHBT lesions, superior rotator cuff tears, and especially SLAP lesions were very frequent with subscapularis tears.

Failure of polymerized lactic acid tacks in shoulder surgery

The purpose of this study was to evaluate 4 cases in which bioabsorbable polymerized lactic acid tacks failed after arthroscopic shoulder surgery. Four male elite athletes with recurrent shoulder pain were seen a mean of 7.5 months (range, 3-10 months) after initial arthroscopy. Three of the cases involved superior labrum anterior-to-posterior (SLAP) lesion stabilization, and the fourth case was a rotator cuff (RTC) repair. In the three labral repairs, the implant had broken and the unabsorbed fragments were visible with magnetic resonance imaging. The device used in the RTC repair showed no signs of absorption. All 4 patients underwent arthroscopic removal of the polymer tack fragments to alleviate their symptoms, 2 of whom had foreign-body reactions that required synovectomy. On the basis of clinical examination and magnetic resonance imaging, 2 of the SLAP lesions and the RTC tear had healed. The third patient with a SLAP lesion required arthroscopic debridement of a portion of the labrum. The intact RTC implant had backed out of its insertion point. In all 3 labral repairs, the polymerized lactic acid implant experienced a mechanical failure near the head-shaft junction. We theorize that the labral implants failed because of the variable rate of degradation along the shaft of the devices from the intraarticular to intraosseous regions.     

Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management

After the improvement in arthroscopic shoulder surgery, superior labrum anterior to posterior (SLAP) tears are increasingly recognized and treated in persons with excessive overhead activities like throwers. Several potential mechanisms for the pathophysiology of superior labral tears have been proposed. The diagnosis of this condition can be possible by history, physical examination and magnetic resonance imaging combination. The treatment of type 1 SLAP tears in many cases especially in older patients is non-operative but some cases need arthroscopic intervention. The arthroscopic management of type 2 lesions in older patients can be biceps tenodesis, but young and active patients like throwers will need an arthroscopic repair. The results of arthroscopic repair in older patients are not encouraging. The purpose of this study is to perform an overview of the diagnosis of the SLAP tears and to help decision making for the surgical management.     

Arthroscopic Repair of Combined Bankart and SLAP Lesions: Operative Techniques and Clinical Results

Background

To evaluate the clinical results and operation technique of arthroscopic repair of combined Bankart and superior labrum anterior to posterior (SLAP) lesions, all of which had an anterior-inferior Bankart lesion that continued superiorly to include separation of the biceps anchor in the patients presenting recurrent shoulder dislocations.

Methods

From May 2003 to January 2006, we reviewed 15 cases with combined Bankart and SLAP lesions among 62 patients with recurrent shoulder dislocations who underwent arthroscopic repair. The average age at surgery was 24.2 years (range, 16 to 38 years), with an average follow-up period of 15 months (range, 13 to 28 months). During the operation, we repaired the unstable SLAP lesion first with absorbable suture anchors and then also repaired Bankart lesion from the inferior to superior fashion. We analyzed the preoperative and postoperative results by visual analogue scale (VAS) for pain, the range of motion, American Shoulder and Elbow Surgeon (ASES) and Rowe shoulder scoring systems. We compared the results with the isolated Bankart lesion.

Results

VAS for pain was decreased from preoperative 4.9 to postoperative 1.9. Mean ASES and Rowe shoulder scores were improved from preoperative 56.4 and 33.7 to postoperative 91.8 and 94.1, respectively. There were no specific complication and no significant limitation of motion more than 10 degree at final follow-up. We found the range of motions after the arthroscopic repair in combined lesions were gained more slowly than in patients with isolated Bankart lesions.

Conclusions

In recurrent dislocation of the shoulder with combined Bankart and SLAP lesion, arthroscopic repair using absorbable suture anchors produced favorable clinical results. Although it has technical difficulty, the concomitant unstable SLAP lesion should be repaired in a manner that stabilizes the glenohumeral joint, as the Bankart lesion can be repaired if the unstable SLAP lesion is repaired first.     

Editorial Commentary: I Have a Hip Labral Tear? Well,That Makes Sense Because I Had a Labral Tear in My Shoulder Too

Most acetabular labral tears are caused by abnormal osseous morphology, such as cam and/or pincer morphology and dysplasia. There is a high prevalence of asymptomatic cam morphology, pincer morphology, dysplasia, and acetabular labral tears in the general population. The addition of subjective patient symptoms and objective physical examination findings to imaging (plain radiographs, magnetic resonance imaging, and computed tomography) may yield the diagnosis of femoroacetabular impingement syndrome. Most glenoid labral tears (e.g., Bankart lesion, posterior labral tear, or SLAP tear) are caused by either glenohumeral instability or a degenerative process. Similarly to the acetabular labrum, there is a high prevalence of asymptomatic glenoid labral tears in an asymptomatic population. Hip pathomorphology (e.g., cam impingement) can have a significant biomechanical impact both upstream and downstream on the kinetic chain (lumbosacral spine, periarticular hip musculature [athletic pubalgia, core muscle injury, sports hernia], knee [anterior cruciate ligament], and shoulder and elbow). Thus, it is tempting to believe that the hip issue may cause the shoulder issue or that an innate genetic (or acquired) abnormality may predispose both joints to labral injury. However, the wise clinician will not be lured into this trap—correlation does not equal causation. Biomechanical studies that evaluate stress transfer from the hip to the shoulder, in addition to clinical studies that prospectively follow these groups, will help to answer this highly relevant question.     

Recurrent anterior shoulder instability in patients 40–60 years old. Accompanying injuries and patient outcomes of arthroscopic repair

BackgroundAccompanying injuries are frequently seen in middle aged patients with recurrent instability. The aim of this study was to elucidate the associated injuries, report patient outcomes of the following arthroscopic instability surgery regarding 40–60 years old patients with recurrent shoulder instability.MethodsPatients that underwent arthroscopic instability surgery due to recurrent shoulder instability between February 2008 and November 2015, and which were 40–60 years old were included and evaluated retrospectively. Minimum follow-up duration was 24 months. Anterior-inferior labral injuries and accompanying pathologies such as rotator cuff tears and SLAP lesions were documented. Postoperative patient-reported outcome evaluation was made using Oxford Shoulder Instability Score.ResultsAmong 355 patients that underwent arthroscopic instability surgery, 88 patients which had pathology of recurrent instability were in the range of 40–60 years old. Patients who had previous shoulder surgery or fracture (n = 8) epileptic seizure history (n = 3), neurologic deficit (n = 2) were excluded from the study. 75 patients were included with a mean follow-up 69 ± 23 months (32–125). The percentage of middle-aged and elderly (40–60 years old) was 24.8% among recurrent shoulder instability patients. 44% had isolated Bankart lesion whereas 56% revealed multiple pathologies. Bankart + SLAP lesions were found in 32%, whereas Bankart + Rotator Cuff tears in 26.7% (13 isolated supraspinatus, 4 supraspinatus + subscapularis, 1 isolated subscapularis full-thickness and 2 partial-thickness supraspinatus tears). The mean Oxford Shoulder Instability Score was 38.4 ± 5.2 (26–48). The scores of patients which were treated with labrum and rotator cuff repair (median 42, range 30–48) were significantly better than the patients who were treated with isolated labrum repair (median 39, range 20–46) (p = 0.015). There was no difference regarding patients with or without SLAP repair (median 39 vs 39 and range 30–48 vs 20–48, respectively) (p = 0.702).ConclusionsArthroscopic repair of capsulolabral lesions is a safe and successful technique in 40–60 years old patients. Furthermore, the presence of repaired rotator cuff tears led to even superior results. Accompanying SLAP lesions did not affect the results.Study designRetrospective Case Series.Level of evidence4, Retrospective Case Series.     

Avulsion of the superior labrum

Snyder et al. coined the term superior labral anterior and posterior (SLAP) lesion and classified SLAP lesion into 4 types. Morgan et al. developed a secondary classification of Snyder type II lesions based on the anatomic location. Maffet et al. found that some lesions could not be classified according to classification of Snyder et al.; types V to VII were added to the 4-part classification. In this study, we present the case of a patient with a superior labral tear that could not be classified to any of the reported classification. The superior labrum was detached with cartilage exposing the underlying bone of the glenoid.     

Die arthroskopische Bankart-Operation mit Hilfe von resorbierbaren Nahtankern

OBJECTIVE: Arthroscopic refixation of the labrum-ligament complex at the glenoid. INDICATIONS: Posttraumatic anterior or anterior-inferior shoulder instability with Bankart or ALPSA lesion (anterior labral periosteal sleeve avulsion). CONTRAINDICATIONS: Atraumatic shoulder instability. Instabilities due to blunted or frayed degeneration of the labrum-ligament complex. HAGL lesion (humeral avulsion of the glenohumeral ligaments) with humeral detachment of the glenohumeral ligaments. Larger bony glenoid defects. SURGICAL TECHNIQUE: Mobilization of the labrum-ligament complex from the neck of the glenoid, superior tightening and refixation at the glenoid rim with the aid of absorbable suture anchors. POSTOPERATIVE MANAGEMENT: Immobilization of the affected arm for 4 weeks in an immobilization bandage with abduction pillows. Daily pendulum exercises. Active flexion up to 70 degrees and abduction up to 40 degrees, all in neutral or internal rotation. Avoidance of external rotation for a total of 6 weeks. RESULTS: From January 1999 to December 2001, 58 patients with a Bankart or ALPSA lesion were treated with arthroscopic shoulder stabilization using absorbable suture anchors and slowly absorbable braided sutures. 56 patients underwent a follow-up clinical examination after, on average, 31 months (24-48 months). None of these patients had suffered more than five shoulder dislocations before the operation (average 2.8). Of the intraoperative lesions, a plain Bankart lesion was present in twelve patients (21.4%), 44 patients had an ALPSA lesion (78.6%), of which one in two were combined with an SLAP 2 or SLAP 3 lesion (superior labrum from anterior to posterior). In the evaluation using the Rowe Score, there was an excellent result for 40 patients (71.4%), and a good result for twelve (21.4%). Four patients suffered a repeat dislocation and were therefore classified as poor results (7.2%).     

Editorial Commentary: Subpectoral Biceps Tenodesis Is a Safe Alternative to Arthroscopic Repair for Unstable SLAP Tear in the Young Athlete: Should We Do the Last Operation First?

The clinical significance of structural pathology affecting the biceps-superior labrum complex may be highly variable. Among younger, physically active patients with symptomatic superior labrum anterior-posterior (SLAP) tears that have failed to respond to nonoperative treatment, we continue to lack clear high-level evidence to guide surgical decision making, including a decision between arthroscopic SLAP repair or primary biceps tenodesis for more unstable, type II lesions. Rates of patient satisfaction, return to play, return to prior level of activity, and secondary revision rate are widely reported, and we lack consensus for surgical best practice treatment. With the high rate of postoperative stiffness and revision reoperation and inconsistent functional outcomes after modern arthroscopic shoulder SLAP repair with knotless anchor technology, subpectoral biceps tenodesis may emerge as a primary alternative for treating the young athlete with unstable SLAP tears.