By far the most comments on my blog and emails that flood my inbox these days have to do with SLAP tears. I must admit that outside of ACL tears and rotator cuff issues, I find myself increasingly drawn to studying and researching this issue. It definitely is a source of great pain for many and an issue that medical professionals are challenged by today.
In my personal clinical experience, I see good, bad and in between outcomes. Through email and my blog I tend to read more on the not so good side from people who are seeking my expertise in how to resolve their issues. When I speak to surgeons, I find they are often hesitant to commit to a set algorithm of treatment, and they are not 100% sure what the right answer is in addressing these injuries as a whole.
If you read the literature, the success in terms of patient satisfaction and return to premorbid activity levels is not going to make you rush down to the operating room and opt for an arthroscopic repair if you are an overhead athlete (especially baseball players). However, other studies have presented more favorable data ranging from 63%-75% good-excellent satisfaction in other overhead athletes who have had the procedure done.
If you are unfamiliar with SLAP tears, I suggest reading my original post on them (click here). In today’s post, I wanted to present a quick recap on Type II SLAP tears and some new published research on the results of revision procedures where the primary repair failed.
Below are two images of a type II tear (MRI and operative view from the scope)
Keep in mind a type II tear means the biceps anchor/superior labrum has pulled away from the glenoid with resulting instability of the complex. This is the most common type of tear seen among injured people. In a study from the Kerlan-Jobe Orthopaedic Clinic in LA in the latest American Journal of Sports Medicine (June 2011 - click here for the abstract), they discussed a chart review of from 2003-2009 looking at patients who had undergone revision type II SLAP repairs.
After excluding certain patients, they were able to identify 12 subjects for the study (2 collegiate baseball players, 2 professional baseball players, 1 recreational sotfball player, 1 collegiate volleyball player, 5 workers’ compensation patients and 1 additional subject.
More details include:
- The mean age at time of revision was 32.6 years old
- 8 of 12 patients never got better after initial procedure
- 10 fo 12 subjects had involvement of the dominant arm
- The mean time to revision from original surgery was 13 +/- 6.7 months
- Chief complaint was pain and not instability
- 4 of the patients had isolated revisions, while others had other concomitant procedures done like debridement of partial cuff tears (7), while one patient had a distal clavicle excision and subacromial decompression
- All 12 patients had detachment of the central portion of the superior labrum directly underneath the biceps tendon
And now for the results for these patients who underwent the revision procedure. Among the overhead athletes (6), return to sports was at 41.3% of the previous level. For the baseball players, it was at 20.6%. No baseball player returned to pre-injury level, and neither professional baseball player (pitcher and a position player) never were able to return to baseball after surgery.
Workers’ compensation patients (5) were able to return to work at 57.5% of the previous level and return to sports at 43.75% of the previous level. Non-workers’ compensation patients (5) had a return to work at 96.7% of the previous level and return to sports at 61.9% of their previous level. So, what are the takeaways here?
A few key points to ponder and reflect on are:
- This is a level 4 study and retrospective look back at a relatively small number of patients with a high percentage of workers’ compensation patients (they tend to report poorer satisfaction and outcomes statistically)
- It is hard to tell if the 8 subjects who did not get relief from the primary repair ever truly healed although the authors are not sure if healing corresponds to resolution of clinical symptoms
- The presence of partial thickness rotator cuff tears is a complicating factor particularly in the return to overhead activity so it cannot be overlooked when analyzing this data
- Surgeons are not sure of the post-op pain generating mechanism. Boileau et al (AJSM 2009) reported better results with biceps tenodesis than with SLAP repair and treated 4 failed SLAP repairs successfully with tenodesis (average age was 52 in this study)
Overall, current research is not overly favorable for revision repairs of type II SLAP tears, particularly with with overhead athletes and workers’ compensation patients. Identifying the real pain causing mechanism at the time of the primary surgery is important as well, whether it be the cuff, arthritic change, spurring or the biceps itself.
Considering a tenodesis or tenotomy seems to merit strong consideration for active people seeking pain relief with no complaints of instability in the shoulder and future prospective studies are needed to help guide decision making and develop a more widely accepted treatment algorithm for this injury. I suggest conservative care at first - always. If this fails, seek multiple orthopaedic consults and proceed with caution prior to opting for surgery and expecting a quick and easy return to full function.