Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder. MATERIALS AND METHODS: From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography. RESULTS: SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography. CONCLUSION: MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon.     

The diagnosis and treatment of superior labrum,anterior and posterior (SLAP) lesions

The advent of shoulder arthroscopy, as well as our improved understanding of shoulder anatomy and biomechanics, has led to the identification of previously undiagnosed lesions involving the superior labrum and biceps tendon anchor. Although the history and physical examination, as well as improved imaging modalities such as magnetic resonance arthrography, are extremely important in understanding the abnormalities, the definitive diagnosis of superior labrum, anterior and posterior lesions is best made through diagnostic arthroscopy. Treatment of these lesions is directed according to its type. In general, type I and III lesions are debrided, whereas type II and many type IV lesions are repaired. The purpose of this article is to review the anatomy, biomechanics, classification, diagnosis, and current treatment recommendations for these lesions, as well as to review the literature.     

SLAP lesions: a treatment algorithm

Tears of the superior labrum involving the biceps anchor are a common entity, especially in athletes, and may highly impair shoulder function. If conservative treatment fails, successful arthroscopic repair of symptomatic SLAP lesions has been described in the literature particularly for young athletes. However, the results in throwing athletes are less successful with a significant amount of patients who will not regain their pre-injury level of performance. The clinical results of SLAP repairs in middle-aged and older patients are mixed, with worse results and higher revision rates as compared to younger patients. In this population, tenotomy or tenodesis of the biceps tendon is a viable alternative to SLAP repairs in order to improve clinical outcomes. The present article introduces a treatment algorithm for SLAP lesions based upon the recent literature as well as the authors’ clinical experience. The type of lesion, age of patient, concomitant lesions, and functional requirements, as well as sport activity level of the patient, need to be considered. Moreover, normal variations and degenerative changes in the SLAP complex have to be distinguished from “true” SLAP lesions in order to improve results and avoid overtreatment. The suggestion for a treatment algorithm includes: type I: conservative treatment or arthroscopic debridement, type II: SLAP repair or biceps tenotomy/tenodesis, type III: resection of the instable bucket-handle tear, type IV: SLAP repair (biceps tenotomy/tenodesis if >50 % of biceps tendon is affected), type V: Bankart repair and SLAP repair, type VI: resection of the flap and SLAP repair, and type VII: refixation of the anterosuperior labrum and SLAP repair.     

Superior labral repair

Advances in shoulder arthroscopy have led to a greater understanding of the importance of lesions of the superior labrum and biceps tendon complex. Diagnosis of superior labrum anterior to posterior tears requires a high index of suspicion and is made by careful attention to the history, physical examination, and magnetic resonance arthrography. The diagnosis is confirmed with arthroscopy. The form of treatment is dependent on the type of tear and the stability of the superior labrum and biceps anchor. Appropriate treatment of the tear and any associated pathologies should lead to reliable improvements in the patient's symptoms. The purpose of this review article is to describe the anatomy, pathophysiology, classification, indications, and surgical technique of arthroscopic repair of superior labral tears. The surgical technique we present involves using 1 anchor with 2 sutures to anchor the superior labrum anterior to posterior tear to the superior glenoid tubercle.     

Antero-posterior lesions of the superior glenoid labrum. Magnetic resonance evaluation

PURPOSE: To assess MR potentials in the evaluation of superior glenoid labrum disease and possible associated conditions of the rotator cuff and of the anterior mechanism of the shoulder. MATERIAL AND METHODS: We retrospectively evaluated 51 patients (age range 18 to 53 years) with a diagnosis of anteroposterior lesion of the superior glenoid labrum. MR examinations were performed with a 0.2 T permanent magnet and a dedicated coil, using T1- and T2-weighted SE sequences on mostly coronal-oblique planes. Slice thickness was 4 mm. In 8 cases, the examination was completed with intra-articular injection of contrast agent. Twenty-eight patients were submitted to surgery (arthrotomy in 7 cases; arthroscopy in 21 cases). RESULTS: We considered only the cases with surgical confirmation and divided them into 2 groups: 15 patients with isolated alteration of the superior glenoid labrum and 13 patients with an anteroposterior lesion of the glenoid labrum associated with disease of the rotator cuff or of the anterior mechanism of the shoulder. MRI demonstrated 5 cases of superior labrum irregularities at the level of its glenoid insertional portion (type I lesion); 6 cases of detachment of the superior portion of the labrum (type II); 9 cases of bucket handle tear of the superior labrum with involvement of the insertional portion of the long head of the biceps tendon (type III); 8 cases of superior labrum tear extending within the long head of the biceps tendon (type IV). In the patients with associated disease MRI demonstrated supraspinatus tendon tear in 5 cases, lesion of the labrum also in its anteroinferior portion in 1 case, Hill-Sachs intraspongious fracture with involvement of the inferior glenohumeral complex in 1 case, and complete tear of the rotator cuff in 7 cases. Subsequent surgery always confirmed the presence of associated lesions, while the superior labrum lesion was not confirmed in 3 patients. In 4 cases, surgical findings provided a different classification of the lesion type than MRI. DISCUSSION: In the presence of a type I anteroposterior lesion of the superior glenoid labrum, coronal MRI can depict the loss of the triangular shape of the labrum. Type II lesions show detachment of the labrum, which appears on the MR images as a high signal intensity band passing through the labrum with caudocranial orientation. A superior glenoid labrum tear with a low signal intensity area within the joint indicates a type III lesion. Complete tear of the superior glenoid labrum with involvement of the long head of the biceps tendon demonstrated on the coronal T1-weighted SE and T2-weighted GE sequences is a sign of a type IV lesion. CONCLUSIONS: MRI can be a valuable diagnostic technique in type III and IV lesions of the superior glenoid labrum. It often provides important information about the possible presence of associated diseases, especially of the rotator cuff, which are helpful for treatment planning.     

Diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior lesions of the shoulder

OBJECTIVE: The purpose of this study was to evaluate the diagnostic performance of MR arthrography in the assessment of superior labral anteroposterior (SLAP) lesions of the shoulder with emphasis on the classification of SLAP lesions. MATERIALS AND METHODS: Two hundred sixty-five MR arthrograms including 68 MR arthrograms of patients with arthroscopically proven SLAP lesions of the shoulder and 197 MR arthrograms of patients with an intact superior labrum and biceps anchor were retrospectively reviewed in random order. MR arthrography was performed using triplanar T1-weighted spin-echo sequences and a coronal oblique T2-weighted fast spin-echo sequence. MR arthrograms were evaluated by two radiologists with agreement by consensus, and the results were compared with arthroscopic findings. RESULTS: Of 68 SLAP lesions, seven (10%) were arthroscopically classified as type I, 41 (60%) as type II (including 20 type II lesions with coexisting Bankart lesions [29%]), 14 (21%) as type III, and six (9%) as type IV. Compared with arthroscopy as the gold standard, MR arthrography showed a sensitivity of 82% and a specificity of 98% for the overall detection of SLAP lesions. MR arthrographic grading and arthroscopic grading were concurrent in 45 (66%) of 68 arthroscopic diagnoses. Of the surgically confirmed SLAP lesions, involvement of the biceps insertion and SLAP type II lesions with coexisting Bankart lesions were assessed correctly in 75% and 95% of cases, respectively. CONCLUSION: MR arthrography is a highly effective method for the detection of SLAP lesions, but this technique is limited in the classification of different types of SLAP lesions. However, for preoperative planning MR arthrography provides accurate information about the stability of the biceps insertion and the presence of associated anteroinferior labral injuries.     

MR arthrographic findings of SLAP lesion type V

PURPOSE: The purpose of this study was to determine the findings of MR arthrography of the shoulder and to assess the role of MR arthrography in the diagnosis of superior labrum anterior to posterior (SLAP) lesion type V. METHODS AND MATERIALS: Two radiologists retrospectively reviewed fat-suppressed T1-weighted MR arthrography images of six patients who were diagnosed with SLAP lesion type V by arthroscopy. Each imaging plane, including the transverse, oblique coronal, oblique sagittal, and oblique transverse in abductor external rotation (ABER) position were evaluated for the following three findings: tear of the superior labrum at biceps tendon insertion, Bankart lesion, and continuity of the two former findings. RESULTS: Tear of the superior labrum was shown in all patients on oblique coronal images. Bankart lesion was noted in five patients on the transverse images and in four on the oblique sagittal images. On the oblique transverse images in ABER position, Bankart lesion was shown in all patients. The continuity of the two former findings was noted in three patients on the ABER positioned images. Therefore, three patients could be diagnosed as having SLAP lesion type V by MR arthrography in our series. CONCLUSION: It is difficult to detect all three findings of SLAP lesion type V in one imaging plane, however, a combination of multi-directional images may increase the feasibility of MR arthrography in diagnosing SLAP lesion type V.     

Incidence of SLAP lesions in a military population

OBJECTIVES: SLAP (superior labrum anterior and posterior) lesions are a recognised cause of shoulder pain and instability. They can occur following a direct blow, biceps traction and compression injuries, and are commonly seen in overhead athletes. Military personnel are physically active and often subjected to trauma. We assessed the incidence of SLAP lesions within a military population presenting with shoulder symptoms. METHODS: A retrospective review, of all shoulder arthroscopies performed by a single surgeon between June 2003 and December 2004 at a district general hospital serving both a military and civilian population, was undertaken. The presentation and incidence of SLAP lesions were recorded for both military and civilian patients. RESULTS: One hundred and seventy eight arthroscopies were performed on 70 (39.3%) military and 108 (60.7%) civilian patients. The average age was 42.3 (range 17-75), 50 females and 128 males were included. Indications for arthroscopy included pain (75.3%), instability (15.7%), pain and instability (7.9%), or "other symptoms" (1.1%). 39 SLAP lesions (22%) were found and grouped according to the Snyder classification--20.5% type 1, 69.3% type 2, 5.1% type 3, 5.1% type 4. Patients with a history of trauma or symptoms of instability were more likely to have a SLAP lesion (p<0.0001). The incidence of SLAP lesions in the military patients was 38.6% compared to 11.1% in civilian patients (p<0.0001). After allowing for the increased incidence of trauma and instability in the military, SLAP lesions were still more common in the military patients (p<0.001). CONCLUSIONS: There is a higher than average incidence of SLAP lesions in military patients compared to civilian patients. They tend to present with a history of trauma, as well as symptoms of pain and instability. Given the high incidence in military personnel, this diagnosis should be considered in military patients presenting with shoulder symptoms, and there should be a low threshold for shoulder arthroscopy.     

上方盂唇前后向撕裂的肩关节MR造影评价

目的 评价肩关节MR造影对上方盂唇前后向撕裂(SLAP损伤)的诊断价值.方法 由2名影像诊断医师独立回顾分析137例经肩关节镜证实的肩关节造影MR图像,判定有无SLAP损伤,并进行分型.SLAP损伤分4型:Ⅰ型为上盂唇毛糙,Ⅱ型为肱二头肌腱盂唇复合体从关节孟撕裂,Ⅲ型为上盂唇桶柄状撕裂,Ⅳ型为上盂唇桶柄状撕裂并同时累及肱二头肌长头腱.计算肩关节MR造影对SLAP损伤的敏感度、特异度和准确度,以及与肩关节镜分型的符合率.采用Kappa统计计算2名影像诊断医师评价的一致性.结果 137例患者中,肩关节镜证实SLAP损伤59例,包括SLAP损伤Ⅰ型6例(10.2%)、Ⅱ型50例(84.7%)、Ⅲ型3例(5.1%).肩关节MR造影的敏感度、特异度和准确度医师甲分别为86.4%(51/59)、78.2%(61/78)和81.8%(112/137),医师乙分别为88.1%(52/59)、84.6%(66/78)和86.1%(118/137).2名影像诊断医师的评价一致性极好(K=0.796).肩关节MR造影与肩关节镜的分型符合率医师甲为83.1%(49/59),医师乙为79.7%(47/59).结论 肩关节MR造影是评价SLAP损伤比较可靠的影像方法.     

SLAP lesions of the glenoid labrum diagnosed with MR imaging

Tears of the superior portion of the glenoid labrum in patients without shoulder instability have recently been described. These tears, which include the anchor of the biceps tendon to the labrum, have been labeled SLAP lesions (superior /abrum anterior to posterior). This study was performed to determine the magnetic resonance (MR) findings in patients with SLAP lesions. Retrospective review of the shoulder arthroscopy reports on patients who underwent MR imaging using a 1.5-T unit and subsequent arthroscopy by a single surgeon identified six patients with SLAP lesions (average age 36 years, range 17–65 years). MR images demonstrated atypical morphology indicative of tear in the superior portion of the labrum in four of the six patients, but only one tear had been identified preoperatively. Radiologists interpreting MR images of the shoulder should be aware of the MR findings of SLAP lesions as these tears can be a significant cause of patient disability and are difficult to diagnose clinically.     

SLAP lesions: anatomy, clinical presentation, MR imaging diagnosis and characterization

Superior labral anterior posterior (SLAP) tears are an abnormality of the superior labrum usually centered on the attachment of the long head of the biceps tendon. Tears are commonly caused by repetitive overhead motion or fall on an outstretched arm. SLAP lesions can lead to shoulder pain and instability. Clinical diagnosis is difficult thus imaging plays a key diagnostic role. The normal anatomic variability of the capsulolabral complex can make SLAP lesions a diagnostic challenge. Concurrent shoulder injuries are often present including rotator cuff tears, cystic changes or marrow edema in the humeral head, capsular laxity, Hill-Sachs or Bankart lesion. The relevant anatomy, capsulolabral anatomic variants, primary and secondary findings of SLAP tears including MR arthrography findings, types of SLAP lesions and a practical approach to labral lesions are reviewed.     

The diagnostic value of magnetic resonance arthrography of the shoulder in detection and grading of SLAP lesions: comparison with arthroscopic findings

Purpose

The purpose of the study is to determine the usefulness of magnetic resonance arthrography (MRA) in diagnosis and grading of superior labrum anterior to posterior (SLAP) lesions of the Glenoid Labrum Compared with surgery

Material and methods

This was a prospective study including fifty nine clinically diagnosed SLAP patients. The study was done during the period from January 2008 to June 2010. All patients were submitted to history taking, clinical examination and conventional MRI examination of the shoulder, MRA was done in patients with negative conventional MRI, all of these patients underwent arthroscopy for diagnosis wither open or arthroscopy for diagnosis and treatment and results were compared with MRA findings.

Main outcome measures

Sensitivity, specificity, positive and negative predictive values, and overall accuracy of MR arthrography in detection and grading of SLAP lesions of the gelnoid labrum.

Results

Out of fifty nine patients, 25 patients had positive MR findings in conventional MRI, and 34 patients had negative MR findings, who underwent MR arthrography; 10 out of them had normal arthrogram (only 6 of them underwent arthroscopy), 22 had SLAP (superior labrum anterior to posterior) lesions, one had Bankart's lesion and one had internal impingement syndrome. These results were compared with arthroscopy results.The overall sensitivity of MRA in detection of SLAP lesions was 90% while the specificity was 50%, negative predictive value (NPV) was 66.6% and positive predicative value (PPV) was 81.8%. MRA and arthroscopy results were concurrent in 79.3% patients.

Conclusion

MR arthrography is a sensitive minimally invasive technique for detection and grading of SLAP lesions, it can help in avoiding patients unnecessary diagnostic arthroscopy.     

Anterosuperior labrum lesions of the shoulder joint: pathogenesis, arthroscopic treatment, and results

The anterosuperior labrum lesion of the shoulder without biceps anchor involvement is a rare injury, and it is unclear whether the refixation has advantages over resection. We describe the pathophysiology and treatment, and compare the functional outcome of these procedures of refixation and resection in 21 patients (median follow-up 6 months, range 5-16). The labrum was refixated in 11 cases. Clinical evaluation used the Constant score. Synovialitis in the area of the labral tear was detected in all cases. In refixation patients there was a significant postoperative improvement in Constant score (91.5 vs. 70). Débridement showed a greater increase in the Constant score range (92 vs. 48). An anterosuperior labrum lesion without involvement of the biceps anchor is a separate entity. The pathology is the consequence of degenerative labral lesions without loss of stability in the glenohumeral joint. In view of this background and the results of this study refixation of loose labral tears in anterosuperior labral lesions without loss of stability should not considered.     

盂肱关节前方不稳MR表现与关节镜手术所见比较

 目的 探讨盂肱关节前方不稳的关节镜检查和3.0T MRI表现。方法 收集45例盂肱关节前方不稳患者的MRI检查及关节镜检查资料,回顾性对照分析MRI与多角度镜头关节镜手术结果,总结损伤类型、程度,采用Kappa检验分析MRI与关节镜诊断结果的一致性,观察MRI对各种损伤诊断结果及敏感度。结果 盂唇损伤在盂肱关节前方不稳病变中占84.4%(38/45),其中前下盂唇损伤占 51.1%(23/45),盂唇损伤合并Hill-sachs损伤、关节囊损伤占44.2%(20/45),盂唇损伤合并骨性Bankart损伤占17.7%(8/45)。MRI诊断前下盂唇损伤、HAGL病变、Hill-sachs病变的敏感度分别为78.2%、71.0%、90.0%。MRI与关节镜诊断结果具有一致性,其中诊断肩胛下肌及肌腱损伤及骨性Bankart损伤的结果完全一致,诊断前下盂唇损伤、HAGL病变及Hill-sachs病变的一致性较好,诊断SLAP损伤一致性一般。结论 3.0T MRI能够较准确地显示盂肱关节前方不稳常见病变及MRI征象,为临床早期诊断和治疗提供依据。     

SLAP lesions of the glenoid labrum: CT arthrographic and arthroscopic correlation.

Tears in the superior part of the glenoid labrum in the anterior and posterior directions (SLAP, superior labrum anterior, posterior) result from injuries that place excessive stress on the tendon of the long head of the biceps brachii muscle. The intimate relationship of the tendon and the superior glenoid labrum promotes injury to the latter structure. Four types of SLAP lesions are seen at arthroscopy. Images from 17 patients with surgically proved SLAP lesions who had undergone preoperative computed tomographic (CT) arthrography were retrospectively reviewed to evaluate the value of CT arthrography in the detection and accurate depiction of these labral injuries. The authors compared the findings at videotaped arthroscopic surgery with those from CT arthrography and found that abnormalities of the labral-capsular apparatus could be detected with CT arthrography in 16 of the 17 patients. Furthermore, the CT arthrographic criteria developed during this review helped determine the type of tear in 15 of the 17 patients. CT arthrography appears to be useful in the evaluation of patients with suspected SLAP lesions.     

Imaging of degenerative and posttraumatic disease in the shoulder joint with ultrasound

This article reviews the examination technique of shoulder ultrasound, normal and abnormal ultrasound findings in acute (posttraumatic) and chronic (degenerative) lesions. Moreover, it reviews the effectiveness of ultrasound in relation to magnetic resonance (MR) imaging. Most authors report that full-thickness tears of the supraspinatus can reliably be diagnosed by ultrasound. However, the simple diagnosis of a full-thickness rotator cuff tear is no longer sufficient for surgical management. The precise localization and size of rotator cuff tears as well as the extent of muscle degeneration is important for surgical planning. For this aspect and for partial-thickness tears of the supraspinatus, for subscapularis lesions as well as for lesions of the long biceps tendons there is no consensus regarding the diagnostic value of ultrasound. To the present, ultrasound (contrary to MR imaging) has failed to demonstrate that it consistently influences the clinician's degree of confidence in the clinical diagnosis or the treatment plan. Therefore, some orthopedic surgeons prefer MR imaging to ultrasound in the evaluation of rotator cuff tears and other abnormalities of the glenohumeral joint. Moreover, MR imaging, especially when combined with arthrography, represents a one-step investigation, which not only allows for assessment of rotator cuff lesion but also of lesions of the labrum (Bankart lesions, SLAP lesions), the joint capsule and the biceps tendon. It also demonstrates muscle atrophy, which represents an important predictor of surgical outcome in rotator cuff repair.     

MR-arthrography in superior instability of the shoulder: correlation with arthroscopy

Purpose

This study was undertaken to evaluate magnetic resonance (MR) arthrography in the detection and classification of lesions that may cause superior instability.

Materials and methods

Forty-two consecutive patients with clinical signs of chronic superior instability of the shoulder underwent MR arthrography followed by arthroscopic surgery. For each patient we retrospectively reviewed the MR arthrography and surgical findings.

Results

We detected 31 superior labral anterior posterior (SLAP) lesions, all confirmed on arthroscopy with three cases of underestimation: in the detection of SLAP lesions, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MR arthrography were 100%; in the evaluation of the type of SLAP lesion, sensitivity was 100%, specificity was 78.5%, accuracy was 92.8%, PPV was 71.7% and NPV was 100%. All cases of capsular laxity (13/42) and biceps tendon lesions (3/42) were confirmed on arthroscopy with sensitivity, specificity, accuracy, PPV and NPV of 100%. Eleven cuff lesions were detected on MR arthrography, 10 of which confirmed at arthroscopy: sensitivity was 100%, specificity was 96.8%, accuracy was 97.6%, PPV was 90.9% and NPV was 100%. Associated lesions were found in 38/42 patients.

Conclusions

Superior instability is frequently associated with different anatomical variants or pathological conditions, such as SLAP lesions. The role of MR arthrography is to describe the key features of lesions affecting the superior portion of the shoulder, including location, morphology, extent, and associated injuries and leanatomical variants and to correlate these features with clinical symptoms.     

Superior labrum, anterior and posterior lesions. When and how to treat them

The treatment of patients with SLAP lesions requires an understanding of the normal and abnormal anatomy of the superior labrum. SLAP lesions have a role in rotator cuff disease and glenohumeral instability. Operative repair with suture anchors has been detailed.     

Variants of the superior labrum and labro-bicipital complex: a comparative study of shoulder specimens using MR arthrography, multi-slice CT arthrography and anatomical dissection

The purpose of the present study was to evaluate the anatomical variability of the superior labrum and to compare the value of MR arthrography and multi-slice CT arthrography in the diagnosis of variants of the labro-bicipital complex. Forty-three human shoulder specimens (age range and mean age at death, 61–89 years and 78.3 years) were examined with the use of MR arthrography and multi-slice CT arthrography prior to joint exploration and macroscopic inspection of the superior labrum and labro-bicipital complex. Two radiologists evaluated MR and CT arthrograms, and the results were compared with macroscopic assessments. Anatomical dissection of all shoulder specimens revealed a sublabral recess in 32/43 (74%) cases. The attachment of the superior labrum was categorised as type 1 in ten (23%) cases, as type 2 in eight (19%), as type 3 in ten (23%), and as type 4 in 14 (33%) cases. One superior labrum showed detachment consistent with a superior labral anteroposterior (SLAP) type 3 lesion. On MR arthrography and CT arthrography the attachment of the superior labrum was categorised in concordance with macroscopic assessments in 79% and 84% of cases, respectively. The anteroposterior extension of sublabral recesses was accurately determined with MR and CT arthrography in 59% and 81% of cases, respectively. The attachment of the superior labrum shows considerable variability. Thus, exact depiction of variants is essential in order to avoid the false positive diagnosis of a superior labral tear (SLAP or Andrews lesion). Both, MR arthrography and multi-slice CT arthrography were effective in the detection and classification of sublabral recesses.