Imaging of Patients Suspected of SLAP Tear: A Cost-Effectiveness Study.

BACKGROUND. Superior labrum anterior and posterior (SLAP) tears are a common shoulder pathology. Although MRI is the imaging reference standard for diagnosis of this pathology, the cost-effectiveness of common MRI strategies is unclear. OBJECTIVE. The primary objective of our study was to determine the cost-effectiveness of the common MRI-based strategies used for the diagnosis of SLAP tears. METHODS. We created decision analytic models from the perspective of the U.S. health care system over a 2-year time horizon for a hypothetical population of 25-year-old patients with a previous diagnosis of SLAP tear. We used the decision models to compare the differences in incremental cost-effectiveness of the common MRI strategies, which included combinations of 1.5-T and 3-T MR arthrography (MRA) and unenhanced MRI protocols, and the resulting treatment applied for these patients. Input data on cost, probability, and utility estimates were obtained through a comprehensive literature search. The primary effectiveness outcome was quality-adjusted life years. Costs were estimated in 2017 U.S. dollars. RESULTS. When all imaging strategies were considered, the unenhanced 3-T MRI-based imaging strategy was the preferred and dominant option over 3-T MRA and 1.5-T imaging (MRI and MRA). When the model was run without 3-T imaging as an option, 1.5-T MRA was the favored option. Probabilistic sensitivity analyses confirmed the same preferred imaging strategy results. CONCLUSION. An unenhanced 3-T MRI-based strategy is the most cost-effective imaging option for patients with suspected SLAP tear. When 3-T imaging is not available, 1.5-T MRA is more cost-effective than 1.5-T MRI. The main driver of these results is the fact that 3-T MRI and 1.5-T MRA are the most specific tests in these respective scenarios, which results in fewer false-positives, prevents unnecessary surgeries, and leads to decreased costs. CLINICAL IMPACT. Our cost-effectiveness model findings complement prior diagnostic accuracy work, helping produce a more comprehensive approach to define imaging utility for radiologists, clinicians, and patients with SLAP tears who have access to various types of MRI options.

Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review.

BACKGROUND: Superior labrum anterior-posterior (SLAP) tears are common shoulder injuries, especially in overhead athletes. Often, initial management of these injuries is nonsurgical with focused rehabilitation. The purpose of this review was to evaluate the outcomes of nonsurgical management of SLAP tears in athletes. METHODS: A systematic review was performed for articles published before March 2021 using key search terms pertaining to clinical studies evaluating the nonsurgical treatment of SLAP tears in adult patients published in English-language literature. Abstracts and manuscripts were independently reviewed by 2 co-authors to determine eligibility. Return-to-play rate and return-to-prior-athletic-performance rate were determined by combining results across studies. RESULTS: Five articles met the inclusion criteria. There were 244 total athletes (162 elite or higher-level athletes). The mean ages ranged from 20.3 to 38.0 years. Type II SLAP tears were most common; baseball, softball, and weightlifting were the most common sports involved. The return-to-play rate was 53.7% in all athletes and 52.5% in elite or higher-level athletes. In athletes who were able to complete their nonoperative rehabilitation program, the return-to-play rate was 78% in all athletes and 76.6% in elite or higher-level athletes. The overall rate of return to prior performance was 42.6%, which increased to 72% for those athletes who were able to complete their rehabilitation. Patients who discontinued the rehabilitation protocol in favor of surgery had an average of 8 physical therapy sessions compared with 20 sessions for patients with successful nonoperative treatment. The timing of return to play was generally less than 6 months in studies that reported it. Patient-reported outcomes, including the American Shoulder and Elbow Surgeons score and visual analog scale, all improved significantly after nonsurgical treatment. Factors associated with failure of nonsurgical management included older age, participation in overhead sports (especially baseball pitchers), traumatic injury, positive compression rotation test, concomitant rotator cuff injury, longer baseball career, longer symptomatic period, and the presence of a Bennett spur. CONCLUSIONS: Overall, nonoperative treatment of SLAP tears in athletes can be successful, especially in the subset of patients who are able to complete their rehabilitation program before attempting a return to play. Although nonoperative treatment should be considered the first line of treatment for most SLAP tears, there are some factors that may be associated with failure of conservative treatment; therefore, further high level, prospective studies would be beneficial to identify those athletes most likely to respond favorably to nonoperative treatment.

Isolated type II SLAP tears undergo reoperation more frequently.

PURPOSE: There is discrepancy in the reported reoperation rate and factors associated with reoperation after type II SLAP repair. The aim was to determine the incidence and factors associated with unplanned reoperation and repair failure after type II SLAP repair. METHODS: Five-hundred and thiry-nine patients with SLAP repairs were identified from 2005 to 2016. Patient characteristics were recorded and subgroup analyses performed. Multivariable logistic regression was used to identify factors independently associated with unplanned reoperation and SLAP repair failure. RESULTS: Sixty-six of 539 patients (12%) had unplanned reoperation after SLAP repair. Additional procedures during SLAP repair were associated with fewer unplanned reoperations (OR 0.57; P = 0.046). Age < 40 was associated with unplanned reoperation (55% vs 40%; P = 0.032), but this was not an independent association. Forty-five of 539 patients (8.3%) had SLAP repair failure (defined by repeat SLAP repair or biceps tenodesis/tenotomy). Smoking (OR 3.1; P = 0.004) and knotless suture anchors (OR 3.4; P = 0.007) were associated with SLAP repair failure. Isolated SLAP repair was associated with SLAP repair failure (64% vs 46%; P = 0.020), but this was not an independent association. In those who did not have an isolated SLAP repair, knotless suture anchors (19% vs 3.4%; P = 0.024) were associated with repair failure. CONCLUSION: After type II SLAP repair, roughly 1 in 10 patients may undergo reoperation. Isolated SLAP repair is independently associated with unplanned reoperation. LEVEL OF EVIDENCE: Level III.

Arthroscopic treatment of type II superior labral anterior to posterior (SLAP) lesions in a younger population: minimum 2-year outcomes are similar between SLAP repair and biceps tenodesis.

PURPOSE: Compared to a relatively older population over 30-40 years of age, the efficacy of biceps tenodesis for type II SLAP lesions in a younger population is not well studied. The purpose of this study was to compare outcomes between biceps tenodesis and labral repair for type II SLAP lesions in a young active population. METHODS: Patients aged 15-40 who underwent primary arthroscopic biceps tenodesis or SLAP repair for type II SLAP tears between 2009 and 2016 were included. Shoulders with intraarticular chondral damage, full thickness rotator cuff tear, rotator cuff repair, labral repair outside of the superior labrum, bony subacromial decompression, and acromioclavicular joint resection were excluded. Patient-reported outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand Sports/Performing Arts Module (DASH-sport), visual analog scale (VAS) for pain, and satisfaction. Return to sport rates were also recorded. RESULTS: Fifty-three patients (20 tenodesis, 33 repair) were available for minimum 2-year follow-up. Postoperatively, there were no significant differences in mean ASES, DASH-sport, VAS, and satisfaction between groups [ASES: tenodesis 86.3 vs. repair 86.4 (n.s.); DASH-sport: 11.0 vs. 22.5 (n.s.); VAS: 1.85 vs. 1.64 (n.s.); satisfaction: 8.50 vs. 8.00 (n.s.)]. Rate of return to pre-injury level of performance/competition in sport/physical activity was also similar between groups [tenodesis 63% vs. repair 50% (n.s.)]. CONCLUSIONS: In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions. The results of this study suggest that indications for arthroscopic tenodesis can safely be expanded to a younger patient group than has previously been demonstrated in the literature. LEVEL OF EVIDENCE: III.

Comparison between 3D isotropic and 2D conventional MR arthrography for diagnosing rotator cuff tear and labral lesions: A meta-analysis.

BACKGROUND: Although 3D-isotropic MR arthrography has been characterized as a substitute imaging tool for rotator cuff tear (RCT) and labral lesions, it has not been commonly used in clinical practice because of controversy related to image blurring and indistinctness of structural edges. PURPOSE: To perform a comparison of the diagnostic performance of 3D-isotropic MR arthrography and 2D-conventional MR arthrography for diagnosis of RCT (solely RCT, full/partial-thickness supraspinatus [SST]-infraspinatus [IST] tear, or subscapularis [SSc] tear) and labral lesions. STUDY TYPE: Meta-analysis. POPULATION: Patients with shoulder pain. FIELD STRENGTH/SEQUENCE: 3D-isotropic and 2D-conventional MR arthrography at 3.0T or 1.5T. ASSESSMENT: PubMed and EMBASE were searched following the PRISMA guidelines. STATISTICAL TESTS: Bivariate modeling and hierarchical summary receiver operating characteristic modeling were performed to compare the overall diagnostic performance of 3D-isotropic and 2D-conventional MR arthrography. Multiple-subgroup analyses were performed for diagnosing RCT, full/partial-thickness SST-IST tear, SSc tear, and labral lesions. Meta-regression analyses were performed according to subject, study, and MR arthrography characteristics including 3D-isotropic sequences (turbo spine echo [TSE] vs. gradient echo [GRE]). RESULTS: Eleven studies (825 patients) were included. Overall, 3D-isotropic MR arthrography had similar pooled sensitivity (0.90 [95% CI, 0.87-0.93]) (P = 0.95) and specificity (0.92 [95% CI, 0.87-0.95]) (P = 0.99), relative to 2D-conventional MR arthrography (sensitivity, 0.91 [95% CI, 0.86-0.94]); specificity, 0.92 [95% CI, 0.87-0.95]). Multiple-subgroup analyses showed that sensitivities (P = 0.13-0.91) and specificities (P = 0.26-0.99) on 3D-isotropic MR arthrography for diagnosing RCT, full/partial-thickness SST-IST tear, SSC tear, and labral lesions were not significantly different from 2D-conventional MR arthrography. On meta-regression analysis, 3D-TSE sequence demonstrated higher sensitivity (P < 0.01) than 3D-GRE for RCT and labral lesions. DATA CONCLUSION: 3D-isotropic MR arthrography can replace 2D-conventional MR arthrography. 3D-isotropic MR arthrography using TSE sequence is recommended for more accurate diagnosis, as it demonstrates increased sensitivity. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;48:1034-1045.

Regional histologic differences in the long head of the biceps tendon following subpectoral biceps tenodesis in patients with rotator cuff tears and SLAP lesions.

PURPOSE: The purpose of this study was to quantify the regional histology of the long head of the biceps tendon (LHBT) and compare the histopathology present to clinical findings in patients with rotator cuff tears and SLAP lesions. METHODS: Prospectively enrolled patients undergoing an open subpectoral LHBT tenodesis in the setting of a rotator cuff (RTC) tear or SLAP lesion. Perioperative data were collected and the excised LHBT was analyzed by a fellowship trained pathologist. Tendons were sectioned into proximal (biceps anchor), middle (bicipital groove), and distal (myotendinous junction) portions. Sections were stained with Movat's pentachrome stain and digitized for analysis. Comparisons were made between the histologic findings present in the setting of a rotator cuff tear with those seen in the setting of a SLAP tear. RESULTS: 39 tendons were analyzed: 20 from patients with SLAP lesions (mean age of 44.7 years, range 23-60 years) and 19 from patients with rotator cuff tears (mean age of 58.7 years, range 43-71). Patients with the most pathologic tendons in the bicipital groove were significantly older (59.4 vs. 50.4 years; p < 0.05), reported higher pre-operative VAS scores (6.6 vs. 5.0; p < 0.02), and demonstrated lower pre-operative ASES scores (41.6 vs. 50.7; p < 0.05). The RTC group showed significantly more mucinous degeneration at both the proximal (p < 0.03) and the middle (p < 0.01) tendon portions compared to the SLAP group. In both groups, the portions of proximal tendon showed significantly (p < 0.05) more mucinous degeneration than distal portions. CONCLUSION: Regional histologic differences exist in the LHBT. Rotator cuff patients showed the most degenerated tendon in the bicipital groove and these patients tended to be older and have higher VAS and lower ASES scores. Surgeons should consider performing a subpectoral biceps tenodesis as the bicipital groove portion of the tendon may be very degenerated, especially in patients with rotator cuff disease. Additional research is warranted to distinguish whether treating the biceps differently in distinct geographic regions affects patient outcomes. LEVEL OF EVIDENCE: II.

The chondral print sign: what does it really mean?

BACKGROUND: The chondral print (CP) sign is a chondral change on the humeral head underneath the long head of the biceps (LHB) tendon. Several suggested causative links have been described, but the pathologic mechanism remains unclear. METHODS: We designed this prospective cohort association study of 102 consecutive shoulder arthroscopies to investigate proposed associations of CP with LHB, rotator cuff, labral pathology, and other chondral lesions. Data collection was by a specifically designed pro forma, and statistical analysis was performed. RESULTS: We identified 24 patients (23.5%) with the CP sign. Patients were a mean age of 58 years. Shoulders with positive CP sign had associated pathologies: 16 superior labral anteroposterior (SLAP) tears, 4 LHB instabilities, and 11 other LHB lesions. We also recorded other chondral lesions, 10 humeral head and 12 on the glenoid surface. The overall arthroscopic appearance of CP signs could be classified into 3 different types. Statistical analysis revealed that the CP sign is not statistically associated with LHB instability, any other LHB pathologies, rotator cuff tears, or instability. The CP sign was statistically positively associated with SLAP lesions (but only if type 1 were included). There was a weak association of CP sign with age and a positive association of SLAP lesions with other (non-CP) humeral chondral lesions. CONCLUSIONS: Our prospective association study cannot determine the cause of the CP sign. It does not seem to be a reliable sign of LHB instability or of other LHB pathology. There is an association with age and degenerative SLAP lesions.

Variable reporting of functional outcomes and return to play in superior labrum anterior and posterior tear.

BACKGROUND: Outcomes assessments after superior labrum anterior and posterior (SLAP) tear/repair are highly varied, making it difficult to draw comparisons across the literature. This study examined the inconsistency in outcomes reporting in the SLAP tear literature. We hypothesize that there is significant variability in outcomes reporting and that although most studies may report return to play, time to return reporting will be highly variable. METHODS: The PubMed, Medline, Scopus, and Embase databases were systematically reviewed for studies from January 2000 to December 2014 reporting outcomes after SLAP tear/repair. Two reviewers assessed each study, and those meeting inclusion criteria were examined for pertinent data. Outcomes included objective (range of motion, strength, clinical examinations, and imaging) and subjective (patient-reported outcomes, satisfaction, activities of daily living, and return to play) measures. RESULTS: Of the 56 included studies, 43% documented range of motion, 14% reported strength, and 16% noted postoperative imaging. There was significant variation in use of patient-reported outcomes measures, with the 3 most commonly noted measures reported in 20% to 55% of studies. Return to play was noted in 75% of studies, and 23% reported time to return, with greater rates in elite athletes. Eleven studies (20%) did not report follow-up or noted data with <12 months of follow-up. CONCLUSIONS: The SLAP literature is characterized by substantial variability in outcomes reporting, with time to return to play noted in few studies. Efforts to standardize outcomes reporting would facilitate comparisons across the literature and improve our understanding of the prognosis of this injury.

Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears.

BACKGROUND: Uncertainty remains in the natural course of superior labrum anterior-posterior (SLAP) tears treated conservatively with rehabilitation and activity modification. Our purpose was to evaluate clinical outcomes after nonoperative treatment of type II SLAP tear in young active patients and to identify factors related to negative outcomes. METHODS: We retrospectively reviewed 63 patients who initially underwent nonoperative treatment for isolated type II SLAP tear. Assessments were made at baseline and at 6 months, and telephone survey was used to evaluate the final outcome. All included patients underwent a consistent nonoperative treatment protocol, and patient-specific data on the outcome were assessed. Failure was defined as abandonment of nonoperative management for surgery at any time points, <20-point improvement in American Shoulder and Elbow Surgeons score at final follow-up, or inability to return to activities. RESULTS: At the average follow-up of 21 months, pain relief and function improved significantly (American Shoulder and Elbow Surgeons score, 54.2-86.4; Visual Analog Scale score, 4.6-1.7; P < .05) in 45 patients (71.4%) with successful nonoperative treatment. Eighteen patients (28.5%) were either dissatisfied with treatment or had arthroscopic surgery and were considered a failure group. Multivariate analysis showed that failure of nonoperative treatment is strongly linked with history of trauma, positive compression-rotation test result, and participation in overhead activities (P < .05). CONCLUSIONS: An initial trial of nonoperative management may be considered in young active patients with isolated SLAP tear. Patients with history of trauma, mechanical symptoms, and demand for overhead activities are less likely to succeed.

Biceps tenodesis is a viable option for salvage of failed SLAP repair.

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.

Location of Shoulder Glenoid Labral Tears: A Study of 1763 Consecutive Patients.

BACKGROUND: Anterior shoulder labral tearing has historically been considered the most common location of shoulder labral pathology. Recently, smaller studies have reported that posterior labral involvement may be more common than previously recognized. PURPOSE: To examine the location of surgically repaired labral tears by a single surgeon over a consecutive 23-year period. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 1763 consecutive patients who underwent arthroscopic or open shoulder labral repair by a single seniorsports medicine fellowship-trained orthopaedic surgeon between April 2000 and April 2023 were retrospectively reviewed. Current Procedural Terminology codes were used to identify patients, which included 29806, 29807, 29822, and 29823. Exclusion criteria included isolated shoulder manipulation or glenohumeral joint or labral debridement that did not include repair. Intraoperative glenoid labral tears observed were categorized into 7 broad categories: (1) anterior labral tears, (2) posterior labral tears, (3) superior labral anterior posterior (SLAP) type II tears (A, B, or C), (4) SLAP type V tears, (5) SLAP type VIII tears, or (6) circumferential labral tears (combined SLAP, anterior, and posterior labral tear). Shoulders diagnosed with multiple tear patterns (ie, anterior and posterior) were also noted. RESULTS: During the 23-year period, 1763 patients underwent arthroscopic or open labral repair; they included 1295 male and 468 female patients, ranging in age from 12 to 70 years, with a mean age of 23.2 years and median age of 19 years. Overall, 28.4% of tears involved the anterior labrum, 64.9% involved the posterior labrum, and 59.6% involved the superior labrum. Regarding isolated tears, 9.3% were isolated anterior labral tears, 19.7% were isolated posterior labral tears, 11.5% involved the anterior and posterior labrum, 22.2% were isolated superior (SLAP type II-IV) tears, 3.63% were isolated SLAP type V tears, 29.8% were isolated SLAP type VIII tears, and 4.1% were circumferential tears. CONCLUSION: Posterior shoulder labral tearing was more common than anterior tearing in a large consecutive series of 1763 patients who underwent surgical repair. This highlights the importance of posterior labral pathology, which sometimes may be overlooked because of more vague complaints, with pain and loss of function being the most common.

Quality Assessment of YouTube Content on SLAP Tears.

OBJECTIVES: Superior labrum anterior posterior (SLAP) tears can cause shoulder pain, disability, instability, and humeral head translation. YouTube has become an increasingly popular source of medical information, but little is currently known in terms of quality control of the uploaded content. The purpose of this study was to assess the quality of YouTube videos related to the diagnosis and treatment of Superior Labrum Anterior Posterior (SLAP) tears. METHODS: YouTube was queried in August 2021 using the two predetermined keywords: 'SLAP tear' and 'superior labral tear.' The first 50 videos were analyzed by two independent reviewers and scored using 3 scoring systems: Global Quality Scale (GQS), the Journal of the American Medical Association (JAMA), and the Shoulder-Specific Score (SSS) to determine video accuracy and reliability. Title, number of views, video duration, video source, content type, views/day, number of likes, number of dislikes, days since upload, like ratio (Like × 100/ [Like + Dislike]) and Video Power Index (VPI) (Like ratio × View ratio/100) were all recorded and analyzed. RESULTS: The scores of most videos were low, with a mean JAMA score of 2.5 (1-4, SD 0.73), a mean GQS of 2.66 (0.5-4.5, SD 0.99) and a mean SSS of 7.13 (0-18, SD 4.39). There were significantly higher mean scores for JAMA, GQS, and SSS in the academic and independent physician categories, with a mean JAMA score of 3.11, GQS score of 3.39, and SSS score of 11 for academic sources and a mean JAMA score of 2.83, GQS score of 3.23, and SSS score of 9.23 for independent physician sources. JAMA score was significantly and positively correlated with video duration (r = 0.405, p = 0.006). Views, likes, dislikes, publication dates, and VPI were not significantly correlated with any scoring scale. CONCLUSION: YouTube videos on the diagnosis and management of SLAP tears have low overall quality and reliability scores. Independent physician and academic institution sources received higher mean scores for JAMA, GQS, and SSS. Video quality was not correlated with number of views.

SLAP repair and bicep tenodesis: a comparison of utilization and revision rates for SLAP tears.

Hypothesis: The management of superior labrum anterior to posterior (SLAP) tears typically consists of either repair or biceps tenodesis (BT). While repair is more frequently recommended in younger patients, patients older than 40 years are often treated with BT. The purpose of this study is to determine whether there has been a change in utilization of these procedures over the past decade with respect to patient age as well as compare reoperation rates between the two procedures. Methods: The Pearldiver database was queried to identify BT and SLAP repairs indicated for SLAP tears performed from 2010 to 2019. The primary outcome was utilization rate, stratified by age. A secondary outcome was 2-year shoulder reoperation rates. Trends were reported in terms of compounded annual growth rate. Outcome analysis was conducted using univariate and multivariable analysis. Results: From 2010 to 2019, SLAP repair was the most common procedure performed for SLAP tears. Regardless of age, BT performed for SLAP tear had a significantly increased utilization rate; whereas, SLAP repair had a significantly decreased utilization rate. SLAP repair was more commonly performed in younger patients compared to BT. Following multivariable analysis, patients who underwent SLAP repair had significantly higher odds (odds ratio (OR): 1.453; 95% confidence interval (CI): 1.26-1.68; P < .001) of requiring an arthroscopic reoperation within 2 years when compared to those who underwent BT with no significant difference with respect to 2-year open reoperation. Conclusion: Although SLAP repair is still more commonly used to treat SLAP tears than BT, especially for younger patients, the utilization of SLAP repair is decreasing while BT is increasing. The increased utilization of BT may be associated with lower rates of shoulder reoperation for problematic SLAP tears.

Return to Sport and Patient-Reported Outcomes After Subpectoral Biceps Tenodesis for SLAP Tear in Collegiate Gymnasts.

Background: The biceps superior labral complex is a known source of shoulder dysfunction in young, high-level athletes. Superior labral anterior-posterior (SLAP) repairs are often unsatisfactory for treating biceps-labral pathology in this demographic group, with high failure rates and poor return to sport (RTS). Minimal data have been published to demonstrate patient-reported outcomes (PROs) and RTS in gymnasts after treatment of SLAP pathologies. Hypothesis: Gymnasts undergoing biceps tenodesis for SLAP pathologies would have satisfactory PROs and satisfactory RTS. Study Design: Case series; Level of evidence, 4. Methods: Gymnasts aged ≤25 years who underwent open subpectoral biceps tenodesis for SLAP tears with or without biceps tendon pathology between August 20, 2014, and August 20, 2019, and who had minimum 2-year follow-up data were included in this study. Tenodesis was performed using a subpectoral technique with bicortical button fixation. The following PROs were included: RTS, postoperative activity level, 10-point visual analog scale for pain (VAS-Pain), American Shoulder and Elbow Surgeons (ASES), and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: Of 16 shoulders in 14 gymnasts undergoing biceps tenodesis for SLAP tear during the study period, a follow-up was obtained for 13 of 16 shoulders (81%) at 4.3 ± 1.5 years. The mean age of patients at the time of surgery was 21.8 ± 2.2 years, with 12 (92%) male patients. Biceps tenodesis was performed as the primary procedure for the diagnosis of SLAP tear in 12 patients (92%) and for failed prior SLAP repair in 1 patient (8%). PROs were excellent at the follow-up, with VAS-Pain scores of 1.8 ± 1.7, ASES scores of 89.1 ± 9.1, and DASH scores of 2.4 ± 3.2. After surgery, 8 (62%) patients returned to their prior level of collegiate gymnastics. Three (60%) of 5 patients did not return to collegiate gymnastics because of the end of eligibility, and 2 (40%) patients did not return to collegiate gymnastics because of knee injuries. Significantly higher DASH scores were noted in the group that did not RTS (P = .04). No patients experienced postoperative complications or reoperation. Conclusion: Biceps tenodesis was an effective primary operation for high-level gymnasts with SLAP tears, with a satisfactory rate of return to the same level of sport and excellent PROs.

Type IX Superior Labrum Anterior and Posterior Lesion in a Professional Football Player: A Rare Pattern of Shoulder Instability in a Non-throwing Athlete.

Anterior shoulder instability is the most frequent type of glenohumeral instability, especially among young athletes. Superior labral anterior-posterior (SLAP) injuries involve the superior glenoid labrum where the long head of the biceps tendon (LHBT) inserts. There is still some debate regarding the pathogenesis, clinical presentation, and treatment of these lesions. We report a clinical case of an 18-year-old male professional football player with a rare type IX SLAP lesion. Given the recurrence of instability after prior nonoperative management, surgical treatment was seen as the best option, and a pan-labral arthroscopic repair suture anchor fixation was performed. Three months after undergoing a personalized postoperative rehabilitation program, he was able to return to full sport with the same competitive level, and no recurrent instability or other symptoms were reported throughout the 18-month follow-up period.

The Impact of Lateral Decubitus vs. Beach Chair Positioning on the Clinical Outcome of the Patients with Isolated SLAP Type II Repair: A Systematic Review and Meta-analysis.

Background: A superior labrum from anterior to posterior (SLAP) repairs can be performed in either beach chair (BC) or lateral decubitus (LD). The purpose of this study was to perform a systematic review and meta-analysis to compare the outcomes of surgical repair of type II SLAP injuries between the BC vs. LD positions. We hypothesized no statistically significant differences in the functional, pain, and motion outcomes between the BC vs. LD positions after type II SLAP repair. Methods: A comprehensive literature search was performed using MEDLINE, Scopus, Web of Science, Embase, and Cochrane to identify studies reporting outcomes after type II SLAP repair. Outcome measures consisted of pain using the visual analog score (VAS), range of motion (ROM), and functional scores, including the University of California at Los Angeles Shoulder (UCLA) score, American Shoulder and Elbow Surgeons (ASES), and Constant score. The outcomes were pooled and analyzed for eligibility and stratified into two subgroups for a random-effects model meta-analysis. Results: Of the 8,016 identified studies through a database search, 13 papers (378 patients) were eligible for statistical analysis in the BC and 10 articles (473 patients) were included in the LD group. The mean follow-up for BC and LD was 35 and 44 months, respectively. The SLAP repair in both positions demonstrated improvements in postoperative clinical outcomes and ROM. Comparing the two positions, the LD group demonstrated significantly greater improvements in VAS which contributed to better functional outcomes, while the BC group showed a significantly greater improvement in abduction. No other differences were identified including ASES, UCLA, and Constant score as well as remaining ROM. Conclusion: Based on the findings of this systematic review and meta-analysis, both the BC and LD positions provide patients better outcomes following operative repair of type II SLAPs. While LD represented a better improvement in functional outcome measures, the BC position demonstrated better abduction with no other significant differences between both positions. An individualized approach to position selection concerning the patient's complaint (pain vs. motion) as well as the surgeon's discretion is recommended.

Trends in Repair vs. Biceps Tenodesis for Superior Labrum From Anterior to Posterior (SLAP) Tear: An Epidemiological Study.

Background The purpose of this epidemiologic study was to report general trends in the number of superior labrum from anterior to posterior (SLAP) tear repairs and biceps tenodesis performed along with the patient and hospital characteristics within the period of 2016-2018. Methods National Ambulatory Surgery Sample (NASS) database was used as the source of data for this epidemiologic study of the United States population. Current Procedural Terminology (CPT) codes were utilized to identify patients that underwent SLAP repair or biceps tenodesis between 2016 and 2018. Results The national estimates of encounters from the NASS database reported 29,931 SLAP repairs in 2016 and each subsequent year saw a decline to 26,509 repairs in 2017 and 23,451 repairs in 2018 (p<0.0001). Conversely, in 2016 there were 19,221 biceps tenodeses and each subsequent year saw an increase to 21,625 biceps tenodeses in 2017 and 22,867 biceps tenodeses in 2018 (p<0.0001). Conclusion The results of our epidemiologic study found that the total number of SLAP repairs is decreasing while biceps tenodesis is increasing. SLAP repairs were performed for younger patients and biceps tenodeses were performed for older patients. This study demonstrates that clinical practice reflective of recent evidence regarding optimal age for SLAP repair is slow to change. While there is ongoing debate as to the gold standard for the surgical management of SLAP tear lesions, our study confirms that there is an increasing trend among orthopedic surgeons favoring biceps tenodesis which may reflect the increasing literature evidence supporting better clinical outcomes after biceps tenodesis compared to SLAP repair.

Isolated Infraspinatous Atrophy from a Spinoglenoid Cyst: A Case Report.

We present a case of a 26-year-old gentleman with isolated right infraspinatus atrophy arising from a spinoglenoid cyst of the right shoulder. He presented two years following his shoulder injury and failed conservative rehabilitation alone. At initial arthroscopic surgery, a superior labral anterior to posterior (SLAP) tear was diagnosed and the spinoglenoid cyst was debrided without formal labral repair. The patient's condition did not improve, and second arthroscopy was performed three months following the first with suture anchor repair of the labral tear and cyst decompression. Post-operative magnetic resonant imaging (MRI) scans showed complete resolution of the cyst and recovery of infraspinatus muscle bulk at six months. At final follow-up 18 months post SLAP repair, he has regained full shoulder function and has returned to recreational sports. Our case highlights the importance of proper management of SLAP tears in resolving spinoglenoid cysts by demonstrating the outcomes from two different surgical methods in the same patient.

Midterm Outcomes After Arthroscopic Repair of Type VIII SLAP Lesions in Active Duty Military Patients Younger Than 35 Years.

Background: Superior labrum from anterior to posterior (SLAP) lesions represent a significant cause of shoulder pain and disability among active duty members of the US military. However, few data exist regarding the surgical management of type VIII SLAP lesions. Hypothesis: We hypothesized that arthroscopic repair would decrease pain and increase function at the midterm follow-up and allow for a high rate of maintenance of active duty status. Study Design: Case series; Level of evidence, 4. Methods: Consecutive active duty military patients were identified from January 2011 through June 2015 who underwent arthroscopic repair of type VIII SLAP lesions performed by a single surgeon. Patients were excluded if they underwent glenoid microfracture, other capsulolabral repair, or rotator cuff repair. Outcome measures were completed by patients within 1 week before surgery and at latest follow-up: pain visual analog scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons shoulder score, and Rowe instability score. Results: A total of 30 patients met the inclusion criteria for the study. The mean ± SD follow-up was 96.60 ± 10.91 months. At final follow-up, the mean visual analog scale score improved from 8.17 ± 1.6 to 1.63 ± 1.90 (P < .0001), the Single Assessment Numeric Evaluation score from 41.65 ± 16.78 to 87.63 ± 13.02 (P < .0001), the American Shoulder and Elbow Surgeons score from 36.47 ± 10.26 to 88.07 ± 13.94 (P < .0001), and the Rowe score from 35.33 ± 6.56 to 90.00 ± 14.68 (P < .0001). Three patients reported postoperative complications, and 1 progressed to further surgery. Overall, 90% of patients remained on active duty military service and were able to return to preinjury levels of work and recreational activity. The failure rate, defined as persistent instability or activity-limiting pain, was 10%. Conclusion: The results of this study demonstrated favorable outcomes for the majority of patients after arthroscopic repair of type VIII SLAP lesions at midterm follow-up, supporting repair as a viable treatment option for type VIII SLAP tears in this patient population.

Biceps Tenodesis as an Attractive Alternative to Superior Labral Anterior-Posterior (SLAP) Repair for Type II SLAP Lesions in Active-Duty Military Patients Younger Than 35 Years.

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.