SLAP Tear Surgical Treatment Options PDF

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Summary of the different surgical interventions that can be given to treat a SLAP tear...

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DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

SLAP Tear Surgical Treatment Options - SLAP Debridement - Removal of any excess or damaged portion of the labrum, which causes the symptoms of catching and pain in the affected shoulder - This is only suitable for minor tears without the involvement of the biceps tendon - This requires a stable biceps anchor for the debridement to be effective, otherwise debriding the damaged portion of the labrum will not resolve the symptoms - Advantages of Debridement: - Simple debridement is a low cost and time-saving procedure that has the advantage of maintaining the anatomy of the long head of biceps - SLAP Repair - Arthroscopic surgical reattachment of the damaged labrum to the bone of the shoulder socket using suture anchors - The anchor is seated into the bone and the sutures are wrapped around the labrum and tied snugly to the bone, restoring the normal anatomy of the shoulder - Indicated for people who want to remain active and who have an otherwise healthy shoulder - Advantages SLAP repair: - A SLAP repair restores the normal anatomy of the shoulder by reattaching the labrum in its normal position. - Once healed, the SLAP repair allows normal function of the previously damaged labrum and biceps attachment. - Disadvantage of SLAP repair: - Labral repair has the highest costs and associated surgical time and may lead to increased stiffness after surgery. - Biceps Tenodesis or Tenotomy - The biceps tendon is cut from it is attached to the labrum and is reinserted into another area - Common surgical option for people over 40 years of age and those who have concomitant biceps tendonitis or tearing - This can also be an arthroscopic procedure - Advantages of biceps tenodesis: - The rehabilitation is often not as restrictive as is the case with a SLAP repair. - The results of surgery are usually more predictable, as healing of a SLAP repair may not be as reliable. - Compared with SLAP repair, biceps tenodesis showed a higher rate of patient satisfaction and return to preinjury sports participation. - Biceps tenotomy is also low cost and time-saving; however, since the LHB is released from its attachment in the shoulder joint, the anatomy is not preserved and results in decreased strength and possible development of a 'Popeye' deformity.

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

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YOUSAF, Moza

Biceps tenodesis has higher costs and time than the other two approaches, but has the advantage of preserving the LHB anatomy and power, and a lower possibility of developing complications.

A Journal Article on the Controversies about the Different Treatment for SLAP Lesions Non-operative treatment ● Initial treatment ● Pain relief and clinical outcome improvement can be expected after non-operative treatment of superior labral tears, especially in young, active patients. ● Less likely to benefit: patients with history of trauma, mechanical symptoms and demand for overhead activities. Arthroscopic Systems ● According to Onyekwelu et al., from 2002 to 2010, the number of arthroscopic SLAP repairs increased by 464%, from 765 to 4313. ○ A population-based incidence of 4.0/100 000 in 2002 and 22.3/100 000 in 2010. ○ The mean age of patients undergoing arthroscopic SLAP repair was 37 ± 4 years in 2002 and 40 ± 14 years in 2010. ● Conclusion: there is a substantial increase in the number of arthroscopic SLAP repairs compared with the rising rate of outpatient orthopaedic surgical procedures and a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs. Trends in SLAP repairs over time - between 2004-2014 (According to Erickson et al.) ● There were 9765 patients who underwent arthroscopic shoulder procedures. ○ 619 underwent a SLAP repair (6.3%) ● Most SLAP repairs were performed on type-II SLAP tears. ● NOTE: The percentage of SLAP repairs compared with the total number of shoulder arthroscopic surgeries and total number of patients who underwent SLAP repair significantly decreased over time. ● NOTE: Conversely, the number and percentage of biceps tenodesis increased over time. Treatment Algorithm for SLAP Lesions (According to Brockmeyer et al.) Type I

non-operative treatment or arthroscopic debridement

Type II

SLAP repair or biceps tenotomy/tenodesis

Type III

resection of the unstable 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

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

Type VII

GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

refixation of the anterosuperior labrum and SLAP repair

-Results after repair of type-II lesions depend on the method of fixation and patient demands. Surgical success rates were reported from 71% to 88% -One study reported persistent night pain in > 40% of such patients and return to play in only 48% of athletes treated with these devices. The Use of Suture Anchors (According to Domb et al.) ➢ He compared three commonly used suture anchor configurations for repair of type-II SLAP lesions: ○ a single simple suture anterior to the biceps; ○ two simple sutures, one anterior and one posterior to the biceps; ○ a single mattress suture through the biceps anchor. ➢ When type-II SLAP lesions were subjected to cyclic traction, the load to strain failure was greater with a single anchor and mattress suture than with one or two anchors with simple sutures around the labrum. (According to McCulloch et al.) ➢ They examined whether there was a difference in external rotation between type-II SLAP repairs consisting of anchors placed only posterior to the biceps insertion compared with repairs with an additional anchor placed anterior to the biceps. ➢ FINDINGS: placement of an anterior anchor had the greatest effect on external rotation, whereas presence of one or two anchors posteriorly did not affect glenohumeral rotation. (According to Morgan et al.) ➢ 97% good to excellent clinical results and an 84% return to sport rate in a series of 102 suture anchor SLAP repairs (average patient age 33 years (15 to 72)). ○ The presence of rotator cuff pathology had a negative impact on clinical outcome. ➢ 94% good to excellent results in 34 patients (average patient age 26 years (16 to 35)) at an average of 33 months following surgery. ○ Return to pre-injury level of function was reported to be 91%, only 22% of patients were able to return to the same level of sporting activity. SLAP Repair or to Biceps Tenodesis (According to Boileau et al.) ●

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Abstract: Evaluated ten men with an average age of 37 years (19 to 57) who had a SLAP repair performed with suture anchors and compared this group to 15 patients (nine men and six women) with an average age of 52 years (28 to 64) who underwent arthroscopic biceps tenodesis performed with an absorbable interference screw to the proximal humerus. SLAP repair group: The Constant score improved from 65 to 83 points; however, 60% of the patients were disappointed because of persistent pain or inability to return to their previous level of sports participation. Tenodesis group: The Constant score improved from 59 to 89 points, and 93% were satisfied or very satisfied.

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

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GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

Conclusion: Thirteen patients (87%) were able to return to their previous level of sports participation following biceps tenodesis, compared with only 20% after SLAP repair. Four patients with failed SLAP repairs underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to their previous level of sports activity.

Approaches OPERATIVE MANAGEMENT Type 1 lesions ● ●

Treated with debridement only and rarely considered a source of clinical symptoms Arthroscopic shaving without damaging biceps anchor is enough for the surgical treatment of these types of lesions.

Type 2 lesions ● ● ●

The most common form seen in clinical practice with visible detachment of the biceps anchor from the supraglenoid tubercle. Surgical treatment has evolved from isolated arthroscopic debridement to surgical repair of the lesion. Can be treated with arthroscopic fixation of the superior labrum to establish biceps anchor stability.

Type 3 lesions ● ● ●

The mobile labral fragment can easily be debrided by an arthroscopic shaver. No need to repair this type of injury After the resection of the free fragment, a pain free shoulder can be established.

Notes: -

There is limited information in the literature about the types other than type 2 lesions. There are different surgical repair options for SLAP tears – nonabsorbable, absorbable and knotless anchors. Metallic anchors have been used over time. However, some complications like articular were reported. Bioabsorbable tacks and anchors were used. There are some bad results with persistent pain and disability. The newer versions of absorbable anchors are proven to have equal pull-out strength as metallic anchors, with reported lower complication rates. Knotless anchors are another option with shorter operation time and no knot at the joint which may be a cause for irritation.

SURGICAL TECHNIQUE

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

Positioning ● ● ●

Patient in the lateral decubitus position. Arm is suspended at an approximately 30° angle of abduction and 10° of forward flexion. 3 to 5 kilograms of skin traction is applied to distract the arm.

Portals -

Three portals are used for this procedure: ● a standard posterior portal ● an anterior portal in the rotator interval ● a lateral portal adjacent to the anterolateral edge of the acromion ○ Note: No cannulas are used.

SLAP Repair Step 1: Diagnosis ● ●

Anterior portal is created in the rotator interval under direct vision Diagnosis of a SLAP tear is confirmed by probing the superior labrum

Step 2: Glenoid Neck Preparation ●

Viewing from the posterior portal, the surgeon prepares the neck of the glenoid with a tissue elevator, rasps, and a shaver, exposing the subchondral bone.

Step 3: Suture Passage ● ●

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A 19-gauge spinal needle is passed into the joint through the Neviaser portal. The trajectory of the needle is such that it enters the joint almost parallel to the face of the glenoid behind the insertion of the long head of the biceps. The needle is then passed through the superior labrum at the 1-o'clock position and exists just below the free edge of the labrum. A No. 2 FiberStick suture (Arthrex, Naples, FL) is passed through the needle and retrieved through the anterior portal using a suture retriever. The spinal needle is then carefully withdrawn until the tip is clear of the labrum but remains within the joint in the superior recess. The needle is repositioned approximately 0.5 cm posteriorly and passed through the labrum a second time. The tip of the needle is seen again just below the free edge of the labrum, this time with a loop of suture

Step 4: Suture Retrieval

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

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GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

The loop of suture is retrieved through the anterior portal. The needle is withdrawn, and the rest of the posterior suture limb is pulled out of the anterior portal. This leaves a horizontal mattress suture between the 12- and 1-o'clock positions. The surgeon repeats the process, passing a second mattress suture between the 12and 11-o'clock positions.

Step 5: Socket Preparation ●

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A spinal needle is passed from a point adjacent to the anterolateral edge of the acromion toward the glenoid face to determine the best trajectory for anchor placement. A stab incision is made, and a drill guide with a pointed sharp trocar is passed into the joint along the same path as the needle. The trocar is withdrawn, and the drill guide is positioned at the edge of the glenoid Two holes are drilled, one at the 11:30 clock-face position and one at the 12:30 clock-face position.

Step 6: Anchor Insertion ●

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The drill guide is withdrawn, and a suture retriever is passed along the same track to retrieve both limbs of the posterior suture. The ends of the suture are passed through the eyelet of a 2.9-mm BioComposite PushLock anchor (Arthrex), and if some tension is applied to the suture limbs, the anchor will slide easily down the previous track. Once the anchor is in place, the sutures can be tensioned and the anchor driven home. The suture tails are cut flush. The process is repeated to secure the anterior suture pair. At the completion of the procedure, 2 mattress sutures lie behind the superior labrum with almost no exposed suture material

General Indications for SLAP Repair: -

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Surgical repair is indicated when symptoms do not settle down adequately with time, or in some cases will be advised earlier depending on the exact type and size of SLAP tear present. If a 3-month trial of nonsurgical measures fails to alleviate the patient’s symptoms If the SLAP tear is present along with other tearing following a dislocation, then surgery will usually be required.

Indication for arthroscopic debridement:

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

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GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

Types I, III, and IV tears involving 1/3rd of the biceps tendon involved, causing severe symptoms that have failed nonoperative management

JOURNAL FINDINGS From a clinical trial findings: -

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Biceps tenodesis was found to be more effective treatment than SLAP repair for type II tears in patients older than 40 years. Pathologic findings with a stable biceps anchor (type III and some type IV lesions) often can be treated adequately with débridement of the unstable fragment alone. When resecting the unstable bucket-handle fragment, care must be taken to not destabilize the middle glenohumeral ligament. Type IV lesions may be treated with repair, biceps tenodesis, or biceps tenotomy. Young patients with minimal involvement of the biceps anchor are good candidates for débridement of the unstable fragment alone or direct suture anchor repair. Type II tears, active patients with a partial-thickness tear of the biceps tendon greater than 25%, chronic atrophic changes of the tendon, subluxation of the tendon from the bicipital groove, or tendon atrophy such that the tendon is less than 75% its normal width may benefit from biceps tenodesis. Low-demand patients with extensive partial-thickness tearing, evidence of subluxation, or both are candidates for biceps tenotomy. Type V through type X SLAP tears, which are a combination of superior labral injuries and disruption of the capsule and labrum, requires treatment directed at anatomic restoration of the labral and ligamentous attachments. Type IV lesions can be treated through a SLAP repair, biceps tenodesis, and biceps tenotomy whichever is indicated based on the patient’s age and the arthroscopic findings.

Contraindication for SLAP repair:

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

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GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

Inadequate period of nonoperative treatment (relative) ANY evidence of degenerative disease upon imaging Smoker and age >40 Diabetics with poor control HgBA1c > 7 MRI findings not attributable to normal common variants (for example, labral overhang) Stiffness of the shoulder Inability or unwillingness to complete the post-operative program of keeping the shoulder in a sling or immobilizer and to perform the necessary rehabilitation. Shoulder arthritis

ABSOLUTE Contraindication for SLAP repair: ● ● ●

Patients who are high-risk surgical candidates (ie, the risk of anesthetic complications outweighs the possible benefits of successful repair) Presence of active infection and medical comorbidities—the risks of which outweigh the potential benefits of repair Presence of a normal superior labral anatomic variant such as a sublabral foramen or Buford complex rather than a SLAP tear

Note: In cases where a true SLAP tear exists, but the patient has one or more contraindications, a SLAP debridement (limited, extensive debridement), biceps tenotomy or tenodesis may be an alternative.

Precautions for SLAP Lesion Repair ● ● ●

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For SLAP lesions where the biceps tendon is detached, progress rehabilitation more cautiously than when the biceps remain intact. Limit passive or assisted elevation of arm to 60° for the first 2 weeks and to 90° at 3 to 4 weeks postoperatively. Perform only passive assisted humeral rotation with the shoulder in the plane of the scapula for the first 2 weeks (ER to only neutral or up to 15° and IR to 45°); during weeks 3 to 4, progress ER to 30° and IR to 60°. Avoid positions that create tension in the biceps, such as elbow extension with shoulder extension (as when reaching behind the back), during the first 4 to 6 weeks postoperatively. Postpone active contractions of the biceps (elbow flexion with supination of the forearm) for 6 weeks and resisted biceps exercises or lifting and carrying weighted objects until 8 to 12 weeks postoperatively depending on the extent and type of biceps repair; then progress cautiously. If the mechanism of injury was a fall onto the outstretched hand and arm causing joint compression, progress weight bearing exercises gradually. Avoid positions of abduction combined with maximum external rotation, as this places torsion forces on the base of the biceps attachment on the glenoid.

Potential Complications:

DESTREZA, Jomari LOPEZ, Renald Rhoi SERRANO, James Paul

GARCIA, Francheska Hope LLEVA, Krizzlie Anne MISLANG, Angel Maureen

YOUSAF, Moza

Most patients do not experience complications from shoulder arthroscopy. As with any surgery, however, there are some risks. Potential problems with arthroscopy include the following: - Infection - Excessive bleeding - Blood clots - Adhesive capsulitis - Shoulder stiffness - Residual pain - Damage to articular cartilage from anchor placement - Damage to blood vessels or nerves - Non-return to previous activity levels - Persistent rotator cuff tears near portals - Repair failure with aggressive rehabilitation REHABILITATION PROTOCOL Exercise: Maximum Protection Phase (begins 1 to 2 weeks and extends for about 6 weeks postoperatively) Goals and Interventions ● Control pain and inflammation ○ A sling for comfort when the arm is dependent or for protection when in public areas. ○ Cryotherapy and prescribed anti-inflammatory medication. ○ Shoulder relaxation exercises. ● Prevent or correct posture impairments ○ Spinal extension and scapular retraction exercises. ● Maintain mobility and control of adjacent regi...