Arthroscopic repair of superior labral anterior-posterior lesions

OVERVIEW

Chapter synopsis

Superior labrum, anterior-to-posterior, lesions, a.k.a. “SLAP” lesions, continue to present problems both in terms of making an accurate diagnosis of a symptomatic SLAP lesion and in terms of decision-making as to the ideal treatment. This chapter discusses preoperative considerations, surgical technique, and results. In addition it provides a list of references that a shoulder surgeon can use to optimize patient outcomes and minimize complications when dealing with potential SLAP lesions.

Important points

The most important consideration in the management of SLAP lesions is establishing the proper diagnosis. Symptomatic SLAP lesions are fairly rare and must be differentiated from degenerative tearing, compensatory peel-back (i.e., throwing athletes), and normal anatomic variants.
In overhead throwing athletes, selecting a treatment to recommend can be extremely challenging, given the risks of both non-surgical and surgical intervention.
Agreement among history, physical examination findings, imaging, and arthroscopic findings is ideal.
Although a repair can be quick and relatively easy, requiring only a few steps, the steps are very precise and must be performed with careful dexterity.

Clinical/surgical pearls

If the history, examination findings, and magnetic resonance imaging (MRI) scans all do not agree, be sure to carefully rule out other shoulder pathology before “fixing”/tightening a superior labrum.
Be sure to be comfortable identifying normal anatomic variants such as the Buford complex, sublabral foramen, and a degenerative labrum.
Three standard surgical portals are recommended for a SLAP repair; however, a posterolateral accessory portal, also known as the Wilmington portal, can be necessary for placing suture anchors for tears extending posteriorly.
The anterosuperior portal (ASP) is the most important portal and should be placed before the anterior midglenoid portal, using a spinal needle under direct visualization.
Debridement of labrum and bone must remove all damaged tissue and create an optimal healing environment in a poorly vascularized area.

Clinical/surgical pitfalls

SLAP repair steps have been simplified, but they must be carried out with the utmost precision.
Surgical pitfalls occur when portals are improperly placed, anchors are improperly placed (e.g., at poor angles, too proud, too loose), cartilage is iatrogenically damaged (e.g., drill bit skiving, suturing devices cutting cartilage), or stitching is careless (e.g., overtightening the biceps, multiple passes through labrum).
Tightening a degenerative or compensatory detachment of the superior labrum will generally lead to ongoing pain and often require further surgery.

Video available

: Arthroscopic repair of a type II SLAP lesion with knots and single-anchor technique
: Knotless repair of a type II SLAP lesion with use of a Wilmington portal

Introduction

Tears of the superior labrum were first described by Andrews and colleagues in 1985 and later named and classified by Snyder and colleagues at the Southern California Orthopedic Institute in 1990. Since that time, the treatment of superior labral anterior-posterior (SLAP) lesions has evolved from debridement to repair using drill holes, tacks, metal suture anchors, and now peek, biocomposite or all-suture suture anchors. With minor variations in technique only, most surgeons currently advocate the use of one or more suture anchors on the edge of the glenoid to stabilize and restore labral and biceps anchor anatomy. With only level III and IV evidence available in the literature and a good deal of confusion regarding an accurate diagnosis of symptomatic SLAP lesions, there is still a great deal to be learned about managing the detachment of the superior labrum and biceps. This chapter represents our current management strategy, based upon a combination of experience, expert opinion, and peer-reviewed research.

Preoperative considerations

History

A thorough history is essential in elucidating an injury to the superior labrum. Typically, the patients with true symptomatic SLAP lesions are either young male athletes who report shoulder pain exacerbated by overhead activity, or male or female patients who have sustained a traumatic traction or compression injury to the shoulder. The third situation where a SLAP must be considered is in association with a posterosuperior paralabral glenoid cyst. These cysts often are associated with atraumatic posterior shoulder pain, burning, weakness, or atrophy. In the absence of chronic overuse such as with throwing, a trauma to the shoulder, or a paralabral cyst, the diagnosis of a true symptomatic SLAP lesion should almost always be dismissed.

Signs and symptoms

Patients with symptomatic SLAP lesions often describe sharp, severe, intermittent posterior pain associated with popping, snapping, catching, or locking, similar to mechanical symptoms that may be associated with a meniscal tear in the knee. ^, SLAP lesions must be differentiated from other pathologic processes of the shoulder, such as instability, impingement, rotator cuff tear, and acromioclavicular joint disease. Without a clear history of throwing overuse or trauma, the diagnosis must be questioned. For many surgeons, the most common encounters of supposed SLAP lesions involve patients with shoulder pain who have been improperly diagnosed with a “SLAP tear” on their magnetic resonance imaging (MRI) report.

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