SLAP Repairs Versus Biceps Tenodesis

in Athletes 15 min

Power Points

• Not all SLAP tears need surgery

• Preservation of Native Anatomy GOAL

• Not all labral repairs are equal

• Kinetic chain MUST be addressed

Power Points

• Biceps DOES have a function

• Tenodesis has consequences

• Tenodesis relieves pain reliably BUT……long term effects uncertain

‘SLAPAHOLIC’ T. Romeo

• One who fixes EVERY SLAP TEAR and anything that remotely looks like one!

Not all SLAP Tears Need Surgery

• SLAP tears way overdiagnosed

• Beware of positive imaging study - negative exam

• Slight labral separation may allow thrower to ‘get the slot’

MRI May OVERDIAGNOSE

• Specificity ranges from 63% to 91%

MRI and Anatomic Variants

• Meniscoid labrum

• Buford complex

• Cord like MGHL

• Age related attritional tear

• ALL CAN LOOK LIKE SLAP TEARS ON MRI!!

Meniscoid Labrum

‘Buford’ Complex

Pfahler et al JSES 2003

Labral Tears are Part of the Aging Process!

Nonoperative Treatment of Superior Labrum Anterior Posterior Tears

Improvements in Pain, Function, and Quality of Life Edwards et al

• Approx. 50% of non operatively treated patients avoided surgery!

Scapular strengthening, posterior capsular stretching

MANY LABRAL TEARS RESPOND TO REHAB!!!!

Overtreat >>>> NIGHTMARE

Make Sure History Consistent with SLAP “event”

• Sudden loss of velocity (dead arm)

• Large increase in pain

• “mechanical symptoms” usually present

• Rehab no longer effective

Exam Hold Key!!!

• Load Shift

• Passive Distraction test

• Mayo Shear

• O’Brien’ Test (anterior)

• Kim test

• Relocation Test

Mayo Shear Numero Uno in Literature

Passive Distraction

KIM Lesion

KIM Test

Surgery?

• Failure of GOOD rehab

Experienced shoulder therapist

GIRD addressed

Scapula Rehab

Kinetic Chain Eval

Mechanical Symptoms (SLAP EVENT, frayed labrum from prolonged internal impingement)

MRI Confirmatory

Kinetic Chain Must Be Addressed

• Hip abductors

• Spine Mobility

• Internal Rotation deficit Lead Hip

• Tight quads Lead Leg

• Scapula Dyskinesis

• Unrehabbed ankle sprain

• Poor balance

Need True Pathologic Labral Separation (fissuring, hemorrhage, abortive healing) for TRUE LABRAL TEAR

Biceps Tenodesis

• Becoming more frequent

• Reliable pain relief

• Higher ‘success’ labral repair (labral repair failure rates as high as 50%)

• BUT IS IT GOOD FOR ATHLETES??????

Tenodesis

• Reasonable for salvage of failed labral repair in presence of POOR tissue

• Over age 35 reasonable option

• NON PHYSIOLOGIC

Don’t throw away labral repair!!

• We can do a better labral repair

• Many degenerative, aged related ‘tears’ should not be repaired

• Tenodesis removes an important stabilizer (Biceps)

• Biceps tendon – ‘ACL of the shoulder’: Craig Morgan MD

Biceps Has a Role

• Rodosky – Biceps confers anterior stability

• Patzer – Superior labrum requires intact biceps to ensure stability

• Warner – Joint compression afforded by biceps stabilizes joint

Tenodesis: not a free ride

• Kumar 1989 Severing of LHBT > decrease over 5mm in acromial humeral distance

• Upward migration if humeral head may not cause symptoms initially!

Hanypsiak AANA 2012

• Cadaveric study

• Biceps loaded 10, 20 and 40N

• Humeral translation measured 3D digitizer

• Tenodesis caused posterior shift humerus late cocking, ant. superior shift follow through

Do Better Labral repair

• Bumper restoration only

• Address posterior capsule

• Avoid knot suture issues

• Address interval laxity

• FIX KINETIC CHAIN

Surgery: Do it right and address all pathologic elements

• SLAP Tear

• Bankart

• Kim Lesion

• Interval Laxity

• Posterior Tightness

• Cuff Lesion

Goals: Preserve native anatomy

• Restore bumper

• Avoid knot/suture morbidity

• Avoid tensioning capsule

• Address interval

Labral Surgery

• Lateral Decubitus

• Traction

• Kindness to tissue!

• Percutaneous Portals! (avoid cannulas in cuff)

Lateral Decub….great Access

Surgical Goals

• Fix true labral tears

• (Plicate anterior capsule/interval if necessary)

• Release posterior capsule if necessary

• Fix cuff ONLY if full thickness…..otherwise debride or do partial repair

Restore Labral Bumper

• Lazarus 1996 – increase in glenolabral depth directly related to stability

Be Wary of Capturing Anterior Capsule!

Portals

Percutaneous anchor insertion

Keep Knots Away !!!! Or…… go KNOTLESS Or…..use PDS (CDM)

Surgical Tips Labral Repair

Prominent Knots Hard Suture Prediction?

Percutaneous Portals

Percutaneous Shuttling

Address the Rotator Interval

• Unrecognized source of labral repair failure

• Potential attenuation with extensive throwing

• Anterior biceps pain in late cocking

Rotator Interval – Biceps Outlet ( Pulley/ Sling ) Arthroscopic Anatomy: SGHL, SS Tendon, CHL

Morgan

Mechanism of Injury: Throwing Across Body with High Flexion Angle during the Follow-Through Phase of Pitching

Morgan

Arthrogram MRI - Sagittal Oblique Images Goniometric Measurement (Degrees)

The Sagittal Rotator Interval Angle

Morgan

Arthroscopic Findings - SGHL Injured: Dorsal Biceps Hyperemic Synovitis

Morgan

Operative Repair: 2 North-South Capsular Stitches between SGHL & MGHL Morgan

Reliable Diagnostic Parameters for Rotator Interval Pathology: Clinical, MRI, & Scope

• Digital Pain in the Upper Bicipital Groove. • Anterior Superior Shoulder Pain in ABER relieved by Jobe Relocation

Maneuver. • Increased GH External Rotation and TMA on the Dominant versus the Non-

dominant Shoulder. • Asymmetric Sulcus Sign on the Dominant versus the Non-dominant

Shoulder ( Neutral and ER). • A Widened Rotator Interval on Sagittal Oblique Arthrogram MRI with

Bicep Tendon “Drop – Out” from central in the Pulley. • Arthroscopic visualized Widened Biceps Outlet. • Hyperemic Biceps, SGHL, and Upper MGHL with Parallel Adhesions going

into the Biceps Outlet. • Laxity in the Upper MGHL.

Morgan

Address Posterior Capsule

• Posterior capsular release

non responders of sleeper stretch

more ‘mature’ throwers

capsule should be thick…..if not, don’t do it!!!

Fig. 6

0.1053/jars.2003.50128 )

Copyright © 2003 Arthroscopy Association of North America Term

Hug Glenoid

Address Rotator Cuff Hypertwist Leads to Failure

Cuff Tear

• Anterior– leading edge supraspinatus (tension)

• Posterior- junction supra-infra. (internal impingement)

• Laminated tears “PAINT” – partial articular intratendinous tear (shear)

• May approach full thickness

Internal Impingement

ABER VIEW

Cuff Testing

Management Cuff

• Debride if less than 80-90%

• Side to side, laminar/intrasubstance tear repair

• Do not advance leading edge cuff to bone! (they will never find the ‘slot’ again)

• Cuff tear allows shoulder to ‘hypertwist’

Side to Side Repair – ‘In Situ’

Conway

College Pitcher

PASTA

Take Home

• Don’t be a slapaholic – choose wisely

• If addressing labral tear…..be kind, and use percutaneous portals

• Release posterior capsule in ‘stretch non responders’

• Don’t be a hero with the rotator cuff!

Take Home

• Restore native anatomy

• Address the interval

• Correct kinetic chain

• Tenodesis LAST RESORT

THANK

YOU

johndak4@gmail.com