Background:
Recent evidence has specified indications for performing superior labral anterior posterior (SLAP) repair and biceps tenodesis (BT) for the treatment of bicipital-labral lesions in the ...shoulder. Trends in performance of these procedures are expected to reflect the growing body of research regarding this topic.
Purpose:
To report practice trends for the surgical treatment of SLAP lesions utilizing the American Board of Orthopaedic Surgery (ABOS) database, particularly in older patients.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
The ABOS database was retrospectively queried between 2012 and 2017 by Current Procedural Terminology (CPT) codes for SLAP repair (29807), open BT (23430), and arthroscopic BT (29828). The patient population was excluded if any concomitant open shoulder procedure was performed. Trends over time were evaluated with respect to case volume, patient age, surgeon subspecialty, and whether a concomitant arthroscopic rotator cuff repair (RCR) was performed (CPT 29827).
Results:
A total of 9908 cases met inclusion/exclusion criteria: 4632 performed with RCR and 5276 performed without. The mean age of patients without RCR was 40.8 ± 13.8 years, while for those receiving RCR it was 55.0 ± 9.9 years (P < .001). In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period (P < .001). A significantly greater proportion of patients receiving open and arthroscopic BT were older than 35 years of age, compared with those receiving SLAP repair (P < .001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed (P < .001) over the study period. With respect to BT, open BT was performed more frequently in the cohort without RCR (74.5%) than in the cohort with RCR (52.1%) (P < .001). Similarly, arthroscopic BT was performed more commonly in the cohort with RCR (47.9%) than in the cohort without RCR (25.5%) (P < .001).
Conclusion:
The ABOS database revealed significantly reduced rates of SLAP repairs performed in recent times. Trends with age remained consistent over time, in that SLAP repairs were predominantly performed in younger patients. Open BT was performed more frequently overall, but with an increased proportion of arthroscopic BT occurring with RCR. Arthroscopic BT was performed much more frequently with RCR than without.
Surgical management of superior labral anterior to posterior (SLAP) tears remains controversial. Current management utilizes 2 well-established procedures: biceps tenodesis and SLAP repair. This ...study evaluates the complications associated with arthroscopic SLAP repair vs. an open or arthroscopic biceps tenodesis to further elucidate optimal surgical management.
In this retrospective cohort study, the TriNetX database was utilized to evaluate patients who underwent repair of SLAP lesions (International Classification of Diseases, Tenth Revision code: S43.43) from May 15, 2003, to May 15, 2023. Three patient cohorts were evaluated: those who underwent arthroscopic SLAP repair (Current Procedural Terminology CPT code: 29807), those who underwent arthroscopic biceps tenodesis (CPT code: 29828), and those who underwent open tenodesis of the biceps (CPT code: 23430). Cohorts were propensity matched for type 2 diabetes, nicotine dependence, alcohol-related disorders, body mass index, and demographic factors such as age at event, ethnicity, race, and sex. The outcomes evaluated were disruption of surgical wound, deep vein thrombosis, mononeuropathy of upper limb, shoulder contusion, humeral fracture, sepsis, deceased, acute postoperative pain, revision, shoulder stiffness, and rotator cuff strain. All outcomes were evaluated within 1 year postprocedure.
A total of 11,081 arthroscopic SLAP repairs, 9960 arthroscopic biceps tenodesis, and 9420 open biceps tenodesis were matched. Compared with patients who underwent arthroscopic biceps tenodesis, those who underwent arthroscopic SLAP repair were 1.8 times more likely to undergo revision (2.9% vs. 1.6%, P < .0001). Compared with those who underwent open biceps tenodesis, patients who had SLAP repair performed were 1.4 times more likely to undergo revision (3.1% vs. 2.3%, P = .013) and 1.6 times more likely to have a subsequent rotator cuff strain diagnosis (5.1% vs. 3.2%, P = .0002). Compared with patients who underwent SLAP repair, those who underwent arthroscopic biceps tenodesis exhibited 1.3 times more instances of acute postoperative pain (5.2% vs. 4.0%, P = .011). Similarly, open biceps tenodesis exhibited 1.8 times more instances of acute postoperative pain (6.9% vs. 3.8%, P < .0001) and 1.3 times more shoulder stiffness (11.8% vs. 9.0%, P < .0001).
In the last 20 years, patients who underwent SLAP repair were associated with higher risk of revision surgery and subsequent rotator cuff strain diagnosis. Conversely, patients who underwent biceps tenodesis were associated with higher rates of acute postoperative pain and shoulder stiffness.
Background:
Members of the military are known to experience disproportionately high rates of both glenohumeral instability and superior labrum anterior-posterior (SLAP) tears when compared with ...civilian populations. Although the outcomes after simultaneous repair of Bankart and SLAP lesions have been well described, there is a paucity of literature available regarding the operative management of posterior instability with concomitant superior labral pathology.
Purpose:
To compare outcomes of combined arthroscopic posterior labral and SLAP repair with those of isolated posterior labral repair.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
All consecutive patients younger than 35 years who underwent arthroscopic posterior labral repair from January 2011 to December 2016 with a minimum follow-up of 5 years were identified. From this cohort of eligible patients, all individuals who had undergone combined SLAP and posterior labral repair (SLAP cohort) versus posterior labral repair alone (instability cohort) were then identified. Outcome measures including the visual analog scale score, Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, Rowe instability score, and range of motion were collected pre- and postoperatively and scores were compared between groups.
Results:
In total, 83 patients met the inclusion criteria for the study. All patients were active-duty military at the time of surgery. The mean follow-up was 93.79 ± 18.06 months in the instability group and 91.24 ± 18.02 months in the SLAP group (P = .5228). Preoperative SANE and ASES scores were significantly worse in the SLAP group. Both groups experienced statistically significant improvements in outcome scores postoperatively (P < .0001 for all), and there were no significant differences in any outcome scores or range of motion between groups. In total, 39 patients in the instability cohort and 37 in the SLAP cohort returned to preinjury levels of work (92.86% vs 90.24%, respectively; P = .7126), and 38 instability patients and 35 SLAP patients returned to preinjury levels of sporting activity (90.48% vs 85.37%, respectively; P = .5195). Two patients in the instability group and 4 patients in the SLAP group were medically discharged from the military (4.76% vs 9.76%; P = .4326), and 2 patients in each cohort had experienced treatment failure at the final follow-up (4.76% vs 4.88%; P > .9999).
Conclusion:
Combined posterior labral and SLAP repair led to statistically and clinically significant increases in outcome scores and high rates of return to active-duty military service that did not differ significantly from the results after isolated posterior labral repair. The results of this study indicate that simultaneous repair is a viable treatment option for the management of combined lesions in active-duty military patients <35 years of age.
Background Outcomes of arthroscopic superior labral anterior-posterior (SLAP) repairs have been well reported with generally favorable outcomes. Unfortunately, a percentage of patients remain ...dissatisfied or suffer further injury after SLAP repair and may seek additional treatment. The purpose of this study was to evaluate the surgical outcomes of biceps tenodesis for failed SLAP repairs. Methods A retrospective review of all patients undergoing biceps tenodesis was completed. Inclusion criteria were previous SLAP repair and subsequent revision biceps tenodesis. Exclusion criteria were additional shoulder procedures including rotator cuff repair, instability procedures, and preoperative frozen shoulder. Objective outcomes were postoperative assessments with Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 36-Item Health Survey. Physical examination was conducted to determine postoperative range of motion and strength compared with the nonoperative shoulder. Results A cohort of 24 patients was identified, and of these, 17 patients (71%) completed the study at 2 years' follow-up. The average postoperative Constant score was 84.4; American Shoulder and Elbow Surgeons score, 75.5; Single Assessment Numeric Evaluation score, 73.1%; Simple Shoulder Test score, 9.2; and Veterans RAND 36-Item Health Survey score, 76.1. Postoperative range of motion of the operative shoulder returned to near that of the asymptomatic nonoperative shoulder. Workers’ compensation status led to inferior results. Conclusions Options for patients with a failed prior SLAP repair are limited. As a salvage operation for failed SLAP repair, biceps tenodesis serves the majority of patients well, with favorable outcomes by validated measures and excellent shoulder range of motion and elbow strength at 2 years’ follow-up. Workers’ compensation status may predispose patients to poorer outcomes.
Labral repair and biceps tenodesis are routine operations for superior labrum anterior posterior (SLAP) lesion of the shoulder, but evidence of their efficacy is lacking. We evaluated the effect of ...labral repair, biceps tenodesis and sham surgery on SLAP lesions.
A double-blind, sham-controlled trial was conducted with 118 surgical candidates (mean age 40 years), with patient history, clinical symptoms and MRI arthrography indicating an isolated type II SLAP lesion. Patients were randomly assigned to either labral repair (n=40), biceps tenodesis (n=39) or sham surgery (n=39) if arthroscopy revealed an isolated SLAP II lesion. Primary outcomes at 6 and 24 months were clinical Rowe score ranging from 0 to 100 (best possible) and Western Ontario Shoulder Instability Index (WOSI) ranging from 0 (best possible) to 2100. Secondary outcomes were Oxford Instability Shoulder Score, change in main symptoms, EuroQol (EQ-5D and EQ-VAS), patient satisfaction and complications.
There were no significant between-group differences at any follow-up in any outcome. Between-group differences in Rowe scores at 2 years were: biceps tenodesis versus labral repair: 1.0 (95% CI -5.4 to 7.4), p=0.76; biceps tenodesis versus sham surgery: 1.6 (95% CI -5.0 to 8.1), p=0.64; and labral repair versus sham surgery: 0.6 (95% CI -5.9 to 7.0), p=0.86. Similar results-no differences between groups-were found for WOSI scores. Postoperative stiffness occurred in five patients after labral repair and in four patients after tenodesis.
Neither labral repair nor biceps tenodesis had any significant clinical benefit over sham surgery for patients with SLAP II lesions in the population studied.
ClinicalTrials.gov identifier: NCT00586742.
Purpose
The clinical influence of knot-tying or knotless anchor systems for the arthroscopic repair of SLAP lesions (superior labrum lesion from anterior to posterior) remain unclear.
Materials and ...methods
In a retrospective cohort analysis, 61 of 78 (78.2%) patients with isolated symptomatic SLAP II lesions were examined with a minimum of 24 months after arthroscopic SLAP repair compared to a control group: 28 patients with knot-tying anchors (group I, G1; 28.95 ± 9.48 years, 23 male/5 female), 33 with knotless anchors (group II, G2; 31 ± 10.09 years, 26 male/7 female) and 140 healthy volunteers (group III, G3; 30.9 ± 8.9 years, 109 male/31 female). The clinical assessment included an examination and estimated parameters of ADL (activities of daily living), the CS (Constant score), ASES (American Shoulder and Elbow score), DASH (disability of arm-shoulder hand) and the RS (Rowe score).
Results
The ROM analysis recorded no significant differences for the external rotation in 0° abduction (G1 63.75° ± 15.55° versus = vs G2 65.30° ± 18.15°;
p
ERG1 vs G2
= 0.72). The clinical outcomes revealed significantly decreased pain status in G1 for the O’brien test and in G2 for the Palm-up test, whereas Yergason test showed similar pain levels (
p
O’brien
= 0.03;
p
palm up
= 0.02;
p
yergason
> 0.5). The pulley associated rotator cuff tests revealed a significantly inferior force status in G2 compared to G1 (
p
lift-off
= 0.005,
p
Jobe
= 0.02) whereas the further rotator cuff assessments were equal. In general, the intervention group showed increased pain level and functional deficits compared to the G3. The score analysis detected no significant differences with
P
CSG1 vs G2
,
P
ASESG1 vs G2
,
P
DASHG1 vs G2
and
P
RSG1 vs G2
all > 0.05 and significant impairments compared to G3 in all scores
p
G1/G2 vs G3
< 0.05 (CS
G1
= 88.28 ± 14.42, CS
G2
=92.73 ± 9.24, CS
G3
= 96.2 ± 4.96; ASES
G1
= 81.10 ± 21.69, ASES
G2
= 85.35 ± 17.12, ASES
G3
= 94.95 ± 10.39,; DASH
G1
= 35.75 ± 13.44, DASH
G2
= 36.03 ± 17.55, DASH
G3
= 27.13 ± 6.52; RS
G1
= 90.71 ± 9.88, RS
G2
= 88.33 ± 11.22, RS
G3
= 92.96 ± 11.27).
Conclusions
The clinical assessment revealed for both anchor systems similar outcomes but showed general underestimated impairments after the SLAP repair surgery compared to the healthy control. The clinical status only marginally differed between both techniques, wherefore the present assessment of ADL allowed no recommendation of one of these two specific surgery technique for SLAP repair.
To use an expected-value decision analysis to determine the optimal treatment decision between repair or a biceps tenodesis (BT) for an isolated type II Superior Labral Anterior Posterior (SLAP) ...injury.
An expected-value decision analysis with sensitivity analysis was performed to systematically quantify the clinical decision. To determine outcome probabilities, a decision tree was constructed (repair vs BT) and a meta-analysis was conducted. To determine outcome utilities, we evaluated 70 patients with a chief complaint of shoulder pain with regard to age, sex, Shoulder Activity Level (SAL) and visual analog scale regarding potential outcome preferences. Statistical fold back analysis calculated optimal treatment. One-way sensitivity analysis determined the effect of changing the reinjury rate on the expected value of a biceps tenodesis.
The overall expected value for biceps tenodesis was 8.66 versus 7.19 for SLAP repair. One-way sensitivity demonstrated that biceps tenodesis was the superior choice if reinjury rates are expected to be less than 28%. Meta-analysis of 23 studies and 908 patients revealed the probability of a well outcome was significantly greater for BT (87.8%; 95% CI 74.9-94.6%, I2=0.0%) than SLAP repair (62.9%; 95% CI 55.9-69.3%, I2=65.9%; p=0.0023). Reinjury with BT was 1.5% (95% CI 0.05% to 33.8%, I2=0.0%) and repair 6.4% (95% CI 4.2%-9.6%, I2=24%) which was not statistically significantly different (p=0.411). 50 participants mean age=25.4 (SD 8.9), male = 76%; overhead athletes = 50% met inclusion criteria. Forty-six percent of participants had a SAL score of ‘high’.
Decision analysis demonstrated that biceps tenodesis is preferred over repair for an isolated type II SLAP tear based on greater expected value of BT versus repair. Meta-analysis demonstrated more frequent favorable outcomes with BT. Surgeons can use this information to tailor discussion with patients..
Background:
Biceps tenodesis has been suggested as a superior surgical technique compared with isolated labral repair for superior labral anterior-posterior (SLAP) tears in patients older than 35 ...years. The superiority of this procedure in younger patients, however, is yet to be determined.
Purpose:
To compare the outcomes of arthroscopic SLAP repair with those of arthroscopic-assisted subpectoral biceps tenodesis for type II SLAP tears in active-duty military patients younger than 35 years.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
Preoperative and postoperative evaluations with a minimum 5-year follow-up including the visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) shoulder score were administered, and scores were compared between 2 groups of patients younger than 35 years. One group included 25 patients who underwent SLAP repair, and the second group included 23 patients who underwent arthroscopic-assisted subpectoral biceps tenodesis.
Results:
The preoperative patient age (P = .3639), forward flexion (P = .8214), external rotation (P = .5134), VAS pain score (P = .4487), SANE score (P = .6614), and ASES score (P = .6519) did not vary significantly between the 2 study groups. Both groups demonstrated statistically significant increases in function as measured by the ASES and SANE and decreases in pain as measured by the VAS at a minimum of 5 years postoperatively. Also at a minimum of 5 years postoperatively, patients in the tenodesis group had lower pain (1.3 vs 2.6, respectively; P = .0358) and higher SANE (84.0 vs 63.3, respectively; P = .0001) and ASES (85.7 vs 75.4, respectively; P = .0342) scores compared with those in the repair group. Failure rate was 20.0% in the repair group versus 0.0% in the tenodesis group (P = .0234).
Conclusion:
Active-duty military patients younger than 35 years with type II SLAP tears had more predictable improvement in pain, better functional outcomes, and lower failure rates after biceps tenodesis compared with SLAP repair for type II SLAP tears. Overall, the results of this study indicate that arthroscopic- assisted subpectoral biceps tenodesis is superior to arthroscopic SLAP repair for the treatment of type II SLAP tears in military patients younger than 35 years.
Background:
Studies on failed superior labrum anterior-posterior (SLAP) repair are increasing. However, the number of reports on treatment options for failed SLAP repair remains quite low, and the ...clinical results vary between different study groups.
Purpose:
To describe the clinical presentation of failed SLAP repair due to knot-induced pain and evaluate the efficacy of arthroscopic knot removal.
Study Design:
Case series; Level of evidence, 4.
Methods:
The authors retrospectively reviewed records of 11 patients (mean age, 24.6 ± 8.6 years; range, 17-43 years) with stable, healed SLAP lesions with knot-induced pain after arthroscopic fixation of unstable type II SLAP lesions. All patients demonstrated a positive compression-rotation test before knot removal. The mean follow-up duration after knot removal was 48.0 ± 37.4 months (range, 24-156 months). The mean duration between primary fixation and knot removal was 21.2 ± 14.7 months (range, 8-56 months).
Results:
Sharp pain (100%) and clicking (64%) were the most common symptoms. The knot was positioned on the glenoid side in 5 patients and the labral side in 6 patients. The knots on the glenoid side had associated humeral head cartilage damage. The mean University of California at Los Angeles score significantly improved from 15.2 points to 31.7 points after knot removal (P = .003) Additionally, the mean Constant score greatly improved from a mean of 56.5 points to 89.8 points (P = .003). At a mean of 3 weeks after surgery, we observed dramatic pain relief. Six weeks after surgery, the compression-rotation test was negative in all patients.
Conclusion:
The most common symptom of knot-induced pain after SLAP repair was persistent sharp pain followed by clicking. The knot appears to be a cause of pain in failed SLAP repairs, and arthroscopic knot removal can provide dramatic pain relief and significant improvement of clinical outcomes.
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