Treatment Options

The glenoid labrum is a circumferential rim of fibrous tissue that surrounds the glenoid. The superior labrum is typically loosely attached to the glenoid with a triangular or wedge shape. In contrast, the inferior labrum is more securely attached to the glenoid and has a rounded appearance. The superior and anterior labra are less vascular compared to the inferior and posterior labra.9-11

The labrum serves as a point of attachment for several structures in the shoulder. The long head of the biceps tendon typically inserts near the 12 o'clock position. A recent study has shown that the biceps tendon originates from the supraglenoid tubercle alone in 30%, from both the supraglenoid tubercle and the superior labrum in 25%, and from the superior labrum alone in 45% of shoulders.12 Moreover, another study has demonstrated variability in the anterior versus posterior labral contribution to the biceps tendon attachment.13 The labrum also serves as an anchor for the superior, middle, and inferior gleno-humeral ligaments. By increasing the depth of the glenoid fossa, and through its attachments to the capsuloligamentous complex, the labrum significantly contributes to glenohumeral stability.11'14

Snyder et al15 classified superior labrum anterior to posterior (SLAP) tears into four types (Table 22-2). Type I lesions involve degenerative fraying of the superior labrum with an intact biceps anchor. Type II lesions involve detachment of the superior labrum and the biceps anchor from the glenoid rim. Type III lesions involve a bucket-handle superior labrum tear with an intact biceps anchor. Type IV lesions involve a bucket-handle superior labrum tear that extends into the biceps anchor.3 Maffet et al2 described other SLAP tear patterns that do no fit into this classification. Morgan et al16 further divided type II SLAP tears into three subgroups based on the location of the labrum-glenoid detachment. For the purposes of this chapter, types I through IV are addressed.

Table 22-2 SLAP Lesions: Classification1

Type I Torn superior labrum, no detachment

Type II Detached superior labrum ± biceps anchor

Type III Bucket-handle tear superior labrum, no detachment

Type IV Bucket-handle tear superior labrum, extension into biceps anchor

Initial conservative treatment should be considered for most patients. Nonsurgical treatment should consist of rest, antiinflammatory medication, and a rehabilitation program emphasizing scapular stabilization, capsular stretching, rotator cuff strengthening, and modalities. Many patients, including overhead athletes, will respond well to these measures, with complete resolution of symptoms and full return to activities. Patients should be counseled that the rehabilitation program might take several weeks before results are evident. Maintenance of shoulder conditioning will minimize the chance of further pain and dysfunction. Treatment options are outlined in Table 22-3.

Patients with persistent symptoms unresponsive to conservative measures should be considered for surgical management.4,9 Similar to other elective musculoskeletal procedures, the indications for surgery must be individualized. While some patients may be content to experience an occasional recurrence of symptoms to avoid surgery, others may prefer to optimize their outcome and minimize the risk of further symptoms by undergoing surgery. Patients who perform high-demand physical work or sports activities and those with a history of high-energy traumatic injury may be considered for early surgical treatment. This is especially true for those patients with associated glenohumeral instability and radiographic evidence of anterior/posterior labral detachment.4,9

As discussed previously, careful attention must be given to the evaluation of the symptoms, physical examination, and imaging. The true cause of a patient's shoulder pain can be elusive. Surgical repair of a SLAP lesion will not alleviate a patient's symptoms if the SLAP lesion is not the pain generator. Thus, surgical treatment of a SLAP tear is contraindicated if the diagnosis has not been appropriately made and other shoulder conditions have not been appropriately evaluated and treated. Operative management is contraindicated in patients with medical conditions that preclude elective surgery. Patients who are unable or unwilling to participate in postoperative rehabilitation and adhere to activity restrictions should not be treated surgically.

SURGERY

SLAP, superior labrum anterior to posterior.

Arthroscopic Repair versus Débridement

Surgical treatment of SLAP lesions is performed arthroscopi-cally. Characteristics of the tear pattern dictate the specific management. In general, SLAP tears that involve superior labrum and biceps tendon anchor detachment should be repaired. If the

Table 22-4 SLAP Lesions: Surgical Treatment Algorithm15

Type I

Débridement

Type II Suture anchor repair

Type III Débridement

Type IV Debridement (less than one third of biceps involved) Repair (more than one third of biceps involved)

SLAP superior labrum anterior to posterior.

Table 22-5 SLAP Lesions: Surgical Equipment

Arthrex Bio-SutureTak anchors threaded with FiberWire suture

Arthrex Bio-SutureTak instrumentation

Arthrex 90-degree suture lasso

Arthroscopic cannulas (Accufex, 5 x 76mm and 8 x 76mm)

Arthroscopic elevators

Beach chair table attachment (Schlein)

Knot pusher

Mallet

McConnell arm holder set

Shaver (Stryker 3.5 Aggressive Plus)

Standard arthroscopy equipment

Suture retriever x2

Two-lead arthroscopy tubing x2

SLAP superior labrum anterior to posterior.

superior labrum and biceps tendon anchor are firmly attached to the glenoid rim, the SLAP tear should be debrided.3,4 Table 22-4 outlines appropriate surgical treatment for different types of SLAP lesions.

Type I SLAP lesions involve degenerative fraying of the superior labrum with no labral or biceps detachment from the glenoid rim. Therefore, type I lesions should be treated with debridement as opposed to repair. Similarly, type III SLAP lesions involve a bucket-handle tear of the superior labrum with no labral or biceps detachment from the glenoid rim. Consequently, type III lesions should also be debrided to a smooth stable border of healthy tissue. In contrast, type II SLAP lesions involve detachment of the superior labrum and biceps anchor from the glenoid rim. Thus, type II lesions should be repaired. Type IV SLAP lesions involve a bucket-handle tear of the superior labrum that extends into the biceps anchor, effectively detaching the biceps tendon attachment from the glenoid. In general, if one third or more of the biceps tendon is involved, repair should be considered. Tears involving less than one third of the tendon may be debrided.3,4

Technique: Arthroscopic Superior Labrum Anterior to Posterior Lesion Repair

Regardless of technique used for the repair of type II SLAP lesions, direct repair of the biceps anchor to the superior glenoid is paramount. A recent biomechanical cadaveric study emphasized the importance of biceps anchor reattachment. The study demonstrated biomechanical failure after SLAP repair at the point of biceps tendon attachment regardless of repair technique.17

It is essential that all required instruments and implants are available and ready to use. There are several available instrument and anchor systems that can be used to perform an arthroscopic SLAP repair. A list of the authors' preferred equipment is provided in Table 22-5.

The patient may receive a general or regional anesthetic. Our preference is for a combined general anesthetic augmented with a regional interscalene block. The patient may be positioned in the sitting beach chair or lateral decubitus position. Our preference is the sitting beach chair position. Place the arm in the McConnell arm holder under moderate longitudinal traction in line with the torso and with the shoulder in 30 degrees of abduction.

Establish a standard posterior glenohumeral portal. Insert the arthroscope into the glenohumeral joint and perform a complete intra-articular examination. Carefully inspect the articular surfaces, biceps tendon, superior labrum, subscapularis tendon, rotator cuff undersurface and insertion, axillary recess, anterior labrum, and posterior labrum. Establish an anterior portal using the outside-in technique with spinal needle localization. This portal should be positioned high in the rotator interval. Proper portal placement is critical to achieve the angles required for effective SLAP repair. Insert an arthroscopic cannula (Accufex, 5 x 76mm). Attach a second two-lead arthroscopy tubing to this cannula for additional inflow and improved visualization. Insert an arthroscopic probe and repeat the arthroscopic examination paying close attention to injured structures. Probe the superior labrum and identify the size and location of the area of detachment (Fig. 22-1).

Establish a lateral (transrotator cuff) portal through the sub-acromial space and the myotendinous portion of the supraspina-tus. Insert a spinal needle just lateral to the palpable acromial edge. Advance the needle through the supraspinatus directed toward the torn superior labrum. The needle angle should be very flat and perpendicular to the floor. Remove the needle and incise the skin longitudinally with a no. 11 blade scalpel. Advance the scalpel through the supraspinatus longitudinally at the same trajectory. Remove the scalpel and insert a switching stick into the joint through the incision and supraspinatus. Insert

Figure 22-1 Arthroscopic view of a type II SLAP (superior labrum anterior to posterior) lesion.

Figure 22-2 Suture anchor has been placed through the cannula and Figure 22-4 Final completed repair with two simple sutures.

seated into the superior glenoid, and one limb of the suture passed through the labrum (simple suture repair).

Figure 22-2 Suture anchor has been placed through the cannula and Figure 22-4 Final completed repair with two simple sutures.

seated into the superior glenoid, and one limb of the suture passed through the labrum (simple suture repair).

an arthroscopic cannula (Accufex, 8 X 76mm) over the switching stick.

Insert a shaver (Stryker 3.5 Aggressive Plus) through the anterior portal and gently débride the torn superior labrum. Use the shaver to prepare the repair site by exposing and decorticating the glenoid rim in the zone of detachment. An arthro-scopic elevator may also be used. Evaluate the size of the tear and decide how many anchors will be necessary to achieve a stable repair. In general, two anchors are typically used for a tear that extends from the 11 o'clock to the 1 o'clock positions.

Insert the Arthrex Bio-SutureTak metal cannulated guide through the lateral cannula and position it on the glenoid rim at the location for the anterior-most anchor. Insert the punch through the guide to create a small pilot hole. Insert the 2.75mm drill and advance until the chuck is flush with the guide. Remove the drill and insert a Bio-SutureTak anchor loaded with a single no. 2 FiberWire suture through the guide. Push the

Figure 22-3 An arthroscopic knot is tied.

anchor into the hole and advance with a mallet until the laser mark on the anchor inserter is flush with bone. Remove the anchor inserter. Shuttle the limbs of suture out the anterior cannula with a suture retriever.

Insert the Arthrex 90-degree suture lasso loaded with a looped no. 1 Prolene suture through the lateral cannula. Pierce the labrum superiorly with the suture lasso and advance the tip of the instrument under the detached labrum directed toward the anchor. Once the tip of the suture lasso is visible under the labrum, advance the Prolene suture loop into the joint. Grasp the loop with a suture retriever and shuttle the loop out of the anterior cannula. Select the posterior-most limb of FiberWire suture from the anchor and pass it through the prolene suture loop. Shuttle this limb of FiberWire suture through the labrum by removing the suture lasso and Prolene suture from the lateral cannula. Repeat the preceding steps to pass the second limb of FiberWire suture through the labrum. Shuttle the FiberWire suture limbs out the anterior cannula with a suture retriever. Superior labral lesions can be repaired with simple or mattress type sutures. Our preferred method is to use mattress for menis-coid type labrum anatomy and simple for smaller more atrophic labral anatomy (Fig. 22-2).

If additional anchors are required for stable repair, repeat the preceding steps for anchor insertion and suture placement. Once sufficient anchors and suture have been placed, secure the labrum down to the glenoid rim with standard arthroscopic knot-tying technique. Knots may be tied from either the anterior or lateral portal, depending on the location of the anchor and knot to be tied. The arthroscopic knot should be tied through the same portal that the anchor was placed (Fig. 22-3). When tying knots, start with the anterior-most anchor and work posteriorly. After tying each knot, cut the excess suture with the FiberWire arthroscopic suture cutter, leaving a short tail. Insert the arthroscopic probe and inspect the repair. The labrum should be firmly secured to the glenoid rim (Fig. 22-4).

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