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    Which Patients with SLAP Tears Benefit from Surgery?

    Dr. Timothy Reish answers questions from ICJR about non-operative versus operative treatment options for SLAP tears, including which patients are the best candidates for a surgical procedure.

    ICJR: What are the options for managing SLAP tears, and on which patients would you choose surgical repair?

    Timothy G. Reish, MD: SLAP tears were first described in the late 1980s by Dr. James Andrews and later classified by Dr. Stephen Snyder. Tears of the superior labral complex commonly result from trauma and repetitive overhead use in throwing/overhead athletes in the younger, more-active population. In the older population, superior labral tears are more likely to have a degenerative etiology, frequently in conjunction with osteoarthritis.

    In managing SLAP tears, the surgeon should try to discern how the superior labral complex pathology is causing the patient’s symptoms. SLAP tears cause symptoms in 3 ways:

    • Mechanical irritation
    • Biceps symptoms
    • Instability

    Successful outcomes in the management of this pathology hinge on treatment directed at how the SLAP lesion affects the patient.

    Non-operative management of superior labral lesions includes use of anti-inflammatory medication and physical therapy directed toward improving rotator cuff strength and shoulder mechanics to enhance the dynamic stability of the shoulder girdle. In the overhead athlete, physical therapy concentrates on improving throwing mechanics, as well as core and leg strength to ameliorate the stresses through the glenohumeral joint, thus reducing symptoms.

    Operative treatment options include arthroscopic debridement, SLAP repair with suture anchors, and operative treatment of the long head of the biceps with a tenotomy or tenodesis. The option the surgeon chooses depends on a variety of factors, including:

    • Age
    • Activity level
    • Side of dominance
    • Concomitant pathology
    • Results of the history and physical examination

    In my practice, most patients with SLAP tears undergo a course of conservative treatment and a slow advance back to their desired level of activity to determine if they are candidates for surgical treatment. As mentioned, if surgery is required for symptomatic patients, it is imperative for the surgeon to determine how the superior labral lesion manifests itself as glenohumeral symptoms. An examination under anesthesia is critical in helping the surgeon answer this question, as it may reveal a palpable click or varying degrees of instability. [3]

    In general, debridement is reserved for older, less-active patients who participate in less-rigorous sports. Similarly, debridement should be reserved for those SLAP tears that are causing purely mechanical symptoms, such as a bucket-handle tear, without instability and without involvement of the biceps tendon. Debridement should also be the treatment of choice in patients with concomitant degenerative joint disease.

    Repair should be considered for patients whose SLAP tears result in symptoms from subtle instability. This decision needs to be made based on many clinical variables. Younger, more-active, overhead athletes without biceps pathology and with instability without arthritic changes to the glenohumeral joint are candidates for repair with standard suture anchors to repair the labral complex anatomically back to the glenoid rim.  Over the last 10 years, shoulder surgeons have performed fewer and fewer SLAP repairs than in previous years due to unpredictable outcomes and less-than-optimal published results for return to sports in the overhead athlete. [1]

    Acceptable results have been achieved with either biceps tenotomy or tenodesis.  A diagnostic, ultrasound-guided, bicipital sheath injection in the office can aid the physician in eliciting whether the SLAP tear causes symptoms that propagate to the long head of the biceps. Tenodesis is my preferred treatment for patients whose SLAP tear causes biceps symptoms or whose SLAP tear extends into the biceps causing tearing. Further, patients who have undergone failed SLAP repair do very well after a tenodesis. [2]

    ICJR: What outcomes have you observed in surgical versus non-operative patients?

    Dr. Reish: The need for surgery to repair a SLAP tear often depends on:

    • Desire to return to sports
    • Side of dominance
    • Type of SLAP tear
    • Concomitant pathology

    Acceptable outcomes of non-operative treatment are generally seen in:

    • Less-active patients who are less likely to participate in overhead sports
    • Patients in whom the affected shoulder is not their dominant arm
    • Patients without other existing pathology, such as rotator cuff and biceps tendon tears

    Successful outcomes with surgical repair depend on technique and mode of repair to optimize the patient’s return to their desired level of activity.  SLAP repair in professional baseball players has proven unpredictable. [1]

    ICJR: What are the key points in SLAP repair?

    Dr. Reish: Arthroscopic SLAP repair starts with the appropriate placement of portals.  The “high & wide” rotator interval portal is crucial to allow the placement of an anchor between the 11 o’clock and 1 o’clock position. Posteriorly, a trans-cuff portal, or “portal of Wilmington,” can be used to drill anchors down the posterior aspect of the glenoid as needed.

    It is also imperative to avoid arthroscopic knots encroaching on the glenoid face, which may result in chondral abrasion on the humeral head. The development of knotless anchors can potentially alleviate this problem.

    Furthermore, the anterior labrum from the biceps anchor to the top of the inferior band of the inferior glenohumeral ligament is the most anatomically variable area in the shoulder. When repairing SLAP tears in the anterior, superior quadrant of the glenoid, the surgeon should ensure that rotator interval tissue, such as the middle glenohumeral ligament, is not incorporated into the repair. Otherwise, the patient may experience stiffness in external rotation and a suboptimal result.

    About the Expert

    Timothy G. Reish, MD, is Associate Professor of Orthopaedic Surgery at NYU Langone Medical Center, Division Head of Shoulder & Elbow at St. Francis Hospital, Port Washington, NY, and Director of the Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, New York, New York.

    Disclosures

    Dr. Reish has disclosed that he is a consultant for Conmed, Arthrex, and Catalyst and serves on the scientific advisory board for Conmed.

    References

    1. Fedoriw WW, Ramkumar P, McCulloch PC, Lintner DM. Return to play after treatment of superior labral tears in professional baseball players. Am J. Sports Med. 2014 May; 42(5): 1155-60. 
    2. Werner BC, Pehlivan HC, Hart JM, et al. Biceps tenodesis is a viable option for salvage of failed SLAP repair. Journal of Shoulder and Elbow Surg. 2014 Aug 23(8): e 179-84.
    3. Corpus KT, Camp CL, Dines DM, Altchek DW, Dines JS. Evaluation and treatment of internal impingement of the shoulder in overhead athletes. World J Orthop. 2016 Dec 18;7(12):776-784.