SLAP Tears repair vs tenodesis

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SLAP Tears repair vs tenodesis

  1. 1. SLAP TearsRepair Vs Biceps TenodesisBijay SinghConsultant Orthopaedic SurgeonMedway Foundation NHS Trust
  2. 2. OverviewHistoryAnatomySigns & SymptomsDiagnosticsResultsManagement Algorithm
  3. 3. History• 1985– First Described by Andrews et al• 1990– Snynder & Karzel classified
  4. 4. SLAP Tears• 1983–James Andrews at the AOSSM Meeting–73 base ball pitchers & other throwingathletes–Hypothesis:• Biceps tendon is subjected to large forces duringthrowing• Most tears – near the antero-superior portion nearorigin of biceps tendon• Biceps tendon lifts the labrum off the glenoid
  5. 5. Methods & Results• 120 arthroscopy – 73 throwingathletes–35 pitchers– (22 prof, 9 college, 4 high school)–Football, Softball, Tennis, Volleyball• Symptoms–95% pain whilst throwing–47% Popping or catching during throwing• Signs
  6. 6. • 60% - Anterosuperior• 23% - Antero & Postero Superior• 83% - tearing of glenoid labrum insome portion of antero superior regionin the area of the biceps tendon /labrum complex• 45% partial supraspinatus tendon tear
  7. 7. Onyekwelu et al: The rising Incidence of SLAPrepairs JSES, 2012, 21, 728-31• Surgical cases: 55%• Ambulatory cases: 135%• SLAP Repair: 464%
  8. 8. Current Literature• No Level I or II publicationsrelated to treatment of SLAPtears
  9. 9. Anatomy• Superior Labrum–Triangular structure coposed offibrous & fibrocartilagenous tissue• LHB–Supra-glenoid tubercle – 60%–Superior labrum – 40%• Significant variation
  10. 10. Anatomical Variants• Sublabral Foramen–3 – 12% incidence–Labrum detached from the glenoid infront of the biceps between 9 – 12 o’clockfor left & 12 – 3 o’clock for right• Buford complex–1.5 – 2%–Absence of antero superior labrum–Cord like MGHL attaching to bicepstendon
  11. 11. Anatomical Variants
  12. 12. Relevant Biomechanics• Not fully understood• Provides transational & rotationalstability• LHB Tenotomy–Increased proximal migration by 16%• Cadaveric Model–SLAP causes increased translation &ER
  13. 13. Pathophysiology
  14. 14. Mechanism of Injury• Andrews et al–Deceleration traction injury from pull ofbiceps• Burkhart et al–Contracture of posterior shoulder capsule• Grossman et al–Postero-superior humeral head migration• Another:
  15. 15. • Repetitive throwing places shoulderat extremes of motion• Complex series of of co-coordinatedmotions to efficiently transfer largeforces & high amounts or energyfrom legs, back & trunk• Altered range of motion• Eccentric contractions
  16. 16. GIRD– Deficit in IR of at least 20compared to the contra-lateral side
  17. 17. Diagnosis• Injury–Traction–Compression of shoulder–Repetitive over head athletic use• Pain–Poorly located–Located globally
  18. 18. • Duration of symptoms• Anterior shoulder pain in dominantarm• Clicking or Popping during throwing• Night pain• Weakness• Instability
  19. 19. Tests• OBrien Active Compression• Speed• Dynamic Labral Shear (Mayo Shear)• Biceps Load II (Kim)• Resisted Supination External Rotation (Labral Tension)• Upper Cut• Kibler Anterior Slide• Compression Rotation
  20. 20. OBriens test• shoulder at 90 of flexion, 10 ofhorizontal adduction, andmaximum internal rotation withthe elbow in full extension• downward force at the wrist• patient resists the down- wardforce• pain as ‘‘on top of the shoulder’’(acromioclavicular joint) or‘‘inside the shoulder’’ (SLAPlesion)
  21. 21. Speed Test• Patient Sitting• elbow extended andthe forearm in fullSupination• Resisted activeflexion from 0 to 60
  22. 22. Dynamic Labral Shear Test(O’Driscoll)• Sitting or Supine• arm at side and elbow flexed 90• ER & Abd 90• Pain– deep and/or posterior– 90 to 120 abductionWhat I describe as Jobe’sWhat I describe as Jobe’sManeuver for painManeuver for pain
  23. 23. Biceps Load II Test – Kim II• Shoulder 120 abduction,elbow 90 flexion, andforearm in Supination• Apprehension position• Flex his or her elbow whilethe examiner resists thismovement• Positive test by pain
  24. 24. • Upper Cut– Elbow flexed 90, forearm supinated, patient making a fist– Bringing the hand up quickly – boxing upper cut
  25. 25. Sleeper Stretch forPosterior CapsularContracture
  26. 26. Accuracy of Clinical TestsJones & Galluch et al
  27. 27. ResultsShould be wary about relying on these tests whenShould be wary about relying on these tests whenassessing these indviduals with shoulder dysfunctionassessing these indviduals with shoulder dysfunction- they may have more than one pathology- they may have more than one pathology
  28. 28. Clinical Utility of Traditiional & New Tests in Diagnosis ofBiceps Tendon Injuries & SLAP LesionsKibler et al , AJSM, 37(9), 1840 – 1847)• 325 consecutive patients• 101 patients underwent surgery• 8 tests–Yergasons, Speed, Bear Hug, Belly Press,O’briens, Anterior Slide–Upper Cut & Modified Labral Shear
  29. 29. Meta-analysis of clinical testing for SLAP Tears;Meserve et al, AJSM, 37(11), 2252• Active compression, crank, and Speed tests aremore accurate for detecting labral tears than is theanterior slide test.• Sensitivity and Specificity values ranged from low tohigh.• Active compression test is the most sensitive andSpeed test the most specific.• Bicep load, passive compression, and Kim tests maybe good alternatives, but more research is warranted
  30. 30. Investigations&Classification
  31. 31. Imaging• No specific radiographic findingspathognomonic for SLAP lesion
  32. 32. • MR Arthrogram gold standard– 90% accuracy– Coronal Oblique Sequences– ABER position– High incidence of false positive MRI
  33. 33. Arthroscopic Classification
  34. 34. Agreement in Classification• Wolf et al – AJSM, 39(12), 2588 –2594–16 shoulder surgeons–Clinical variables in diagnosing &treating–50 arthroscopic videos of superiorlabrum–Three different occasions
  35. 35. Results• Job / Sports, Age & Physical examination mostimportant factor in treating• 1st& 3rdviewings – 28.5% different class• With clinical info – 71.5% different• Inter-surgeon agreement was moderatewithout clinical info & fair with clinical info
  36. 36. Clinical Results
  37. 37. A Prospective Analysis of 179 type 2 SLAP repairsProvencher et al: AJSM, Vol 20 (10)• 179/225 patients over 4 year period - Military Personnel– Age: 31.6 (18 – 45)– Male: Female 80%:20%– Follow up: 40.4 (26 – 62)– Traumatic: Atraumatic 47%:53%• ASES, WOSI, SANE significantly improved• Flexion & Abduction – significant improvement• ER, ABER, ABIR – no difference
  38. 38. Failure• ASES<70, Revision Surgery, Medical Board, Unable to return toduty• 66/179 = 38%–16 = Medical Board = medical discharge–50 = Revision Surgery (28%)• Tenodesis = 42• Tenotomy = 4• Debridement = 4• Logistic Regression
  39. 39. Long Term Results after SLAP Repair – 5 yr follow up of 107patientsSchroder et al: Arthroscopy, 2012, 28(11), 1601-07• Prospective Cohort Study• 1998 – 2002,• 171 patiens – 64 excluded• 43.8 yrs (20 – 68)• 71 male vs 36 females• Duration of Symptoms – 52 months
  40. 40. • 97 followed up for 5 years (4 – 8 yrs)• Modified Rowe, Pain, Stability, Function& Muscle Strength, ROM• 88.1% - Good to excellent in >40• 88.3% - Good to excellent in <40• 14 complications – not age related
  41. 41. Results of Arthroscopic Superior LabralRepairs:Kim SH et al, JBJS, 84(A), 981-5• 34 arthroscopic repairs• 32/34 had satisfactory UCLA score• 31 regained pre-injury shoulderfunction• Overhead activity sports personshad significantly lower scores (97 vs90)
  42. 42. Outcome of Type II SLAP Repair – prospectiveanalysis:Friel et al, JSES, 2010, 19, 859-67• 48 patients• Age: 33 +/- 12 (16 – 59)• Athlete: 27 (overhead 11)• Traumatic / Atraumatic: 24• Associated procedures: 22• 3.4 yrs follow up ( 2 – 5.7 yrs)• Arthroscopic SLAP repairs providessignificant improvement in shoulderfunction
  43. 43. Results• SST, ASES, SF12 & VAS allsignificantly better• Non athletes showed largerimprovement in scores &movements• 54% (7) returned to previouslevel sport
  44. 44. SLAP Repair in presence of Cuff Tear in patients over 50years age:Franceschi et al , AJSM, 2008, 36(2), p 247 - 253• 63 patients > 50 with cuff tear– 31 had SLAP repair– 32 had biceps tenotomy• Average 2.9 yrs follow up• Results:– UCLA Score significantly better in tenotomy– Movements also better in tenotomy• Now routinely perform tenotomy
  45. 45. Boileau et al: AJSM 37(5), 929 - 93625 patients with isolated SLAP tears10 pts (men) had SLAP repair (37)15 pts (9+6) had tenodesis (52)9/10 & 11/15 collegiate orprofessional
  46. 46. 6/10 disappointed / dissatisfied1/15 disappointed / dissatisfied87% returned to sports in tenodesis20% returned to sports in repair4 tenodesis later returned
  47. 47. Non Operative Treatment for SLAP tears:Edwards et al, AJSM, 2010, 38(7), 1456-61• 371 patients with suspected SLAP• Diagnosis:– OBriens Test– Tender on Groove– MRI / MRA• 50 replied back – 39 included• 67% better / improved• 20 had surgery, 19 non op• All successful treatment returned to sports
  48. 48. Outcome of SLAP Repair – Systematic Review,Gorantla et al, Arthroscopy, 2010, 26(4), 537-45• Isolated Type II SLAP repair with 2 yrFU• No level I or II studies• 12 full studies met inclusion criteria• 2 prospective• 40 – 94% good to excellent
  49. 49. Gorantla et al• Excellent results for individuals notinvolved in throwing or overheadsports• Much less predictable in throwing &overhead athlete• 64% overhead athlete returned tosports
  50. 50. Controversies• Snyder et al–40% had not healed at second arthroscopy–Treated with debridement alone• Gorantla et al–64% overhead athletes returned to pre-injurylevel• Boileau et al–80% vs 40% = tenodesis vs repair–87% vs 20% = return to previous sports
  51. 51. My ExperienceSLAP ASAD ACJCuffRepairNHS 21 7 2 3PP 24 4 1 1Total 45 11 3 4
  52. 52. NHS PP Total2008-09 4 0 42010 9 4 132011 7 8 152012 1 12 132013 0 0 0Total 21 24 45
  53. 53. Complications / Issues9/45 = 20%Stiffness - 1 patient - resolvedRedo - 2 patient (fall)Tenodesis - 2 (1 awaiting)ASAD - 3Ongoing unexplained pain - 2
  54. 54. Decision Making?HistoryInjuryRepetitive throwing / heavy overhead workAgeSymptoms:Location of pain - anterior suggest LHBClicking / locking on throwing positionInstabilitySignsHelpful but not necessarily definitive
  55. 55. Obvious Biceps PathologyObvious Biceps Pathology(Tear / Type IV)(Tear / Type IV)TenodesisTenodesisFull thickness RCT /Full thickness RCT /Degenerate labrumDegenerate labrumTenodesisTenodesisH/o Trauma + MRI +H/o Trauma + MRI +Clinical SuspicionClinical SuspicionRepairRepairSLAPSLAPOther SymptomaticOther SymptomaticSurgical pathologySurgical pathologyDebride Labrum &Debride Labrum &Address Other pathologyAddress Other pathologyAge <40Age <40Repair SLAPRepair SLAP TenodesisTenodesisYesYesYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoSnyder et al: JSES, 2011, 82-Snyder et al: JSES, 2011, 82-8888

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