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erome G. Enad, CDR, MC, USN, Robert J. Gaines, LCDR, MC, USN, Sharese M. White, LT, MC, USN,

nd Christopher A. Kurtz, CDR, MC, USN, Portsmouth, VA

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he purpose of this retrospective study was to deter-ine the efficacy of arthroscopic superior labrumnterior-posterior (SLAP) repair in a military popula-

ion. In this study, 27 patients (of 30 consecutive pa-ients) who had suture anchor repair of a type II SLAPesion were evaluated at a mean of 30.5 months post-peratively. Fifteen patients had isolated tears,hereas twelve also had a concomitant diagnosis. At

ollow-up, the overall mean American Shoulder andlbow Surgeons score was 86.9 points and the meanniversity of California, Los Angeles score was 30.4oints. The results were excellent in 4 patients, good

n 20, and fair in 3. Of the patients, 96% returned toull duty (mean, 4.4 months). Patients treated for con-omitant diagnoses and a SLAP tear had significantlyigher American Shoulder and Elbow Surgeons scoresnd tended to have higher University of California, Losngeles scores than those treated for an isolated SLAP

ear. The findings indicate that arthroscopic SLAP re-air in military patients results in a high rate of return

o duty. The results suggest that concomitant shoulderathology should be treated at the time of SLAP re-air. (J Shoulder Elbow Surg 2007;16:300-305.)

ith the increased utilization of shoulder arthros-opy, tears of the superior labrum anterior-posteriorSLAP) are becoming a more recognized cause ofhoulder pain and dysfunction.3,16,18,31 Given thathe biceps anchor may play a role in shoulder stabil-ty,9,14,17,21,27 it has been suggested that repair of aLAP lesion should be performed in patients who areoutinely involved in strenuous activity. Whereas ear-ier reports described reattachment of the torn labrumia direct suturing,7 a staple,36 or absorbable tack

rom the Bone & Joint Sports Medicine Institute, Naval MedicalCenter.

eprint requests: Jerome G. Enad, MD, CDR, MC, USN, Bone &Joint Sports Medicine Institute, Naval Medical Center, 620 JohnPaul Jones Cir, Portsmouth, VA 23708 (E-mail: jerome.enad@med.navy.mil).opyright © 2007 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2007/$32.00

ioi:10.1016/j.jse.2006.05.015

00

evices,19,22,28–30,34 current techniques have evolvednto arthroscopic SLAP repair with suture anchor fix-tion. Biomechanical studies have shown the fixationtrength of suture anchor repair to be secure,5,35 andecent reports have found favorable results with thisethod of repair.8,12,13,18,25,31

Because of the unique physical demands within theilitary, a variety of shoulder disorders occur in thisopulation. Recently, we have recognized an increas-

ng prevalence of SLAP tears causing dysfunction inctive military patients. The purpose of this study was

o examine the results of arthroscopic SLAP repair inn active-duty military population.

ETHODS

ubjectsThirty consecutive cases of type II SLAP repairs were

tudied in accordance with the standards of our institutionaleview board. The criteria for inclusion in the study were1) a type II SLAP tear as confirmed by intraoperativessessment; (2) shoulder pain, instability, or mechanicalatching interfering with strenuous or sporting activities;3) symptoms unresponsive to at least 3 months of nonopera-ive treatment; and (4) the patient being an active-duty memberf a military service during the entire course of treatment. Thexclusion criteria were (1) a history of frank shoulder disloca-ion or evidence of a Bankart lesion, (2) any labral tearsther than type II SLAP lesions, (3) rotator cuff tear greater

han 50% in thickness (or repairable), (4) previous shoulderurgery, and (5) acromioclavicular disease (impingement,rthrosis, or instability). Between October 2001 and June003, a retrospective review identified 164 shoulder ar-

hroscopies performed on active-duty military patients. Ofhese patients, 42 had a SLAP lesion. Two patients with aype I SLAP lesion, one with a type V SLAP lesion, and nineith concomitant acromioclavicular pathology were ex-luded. The remaining 30 patients comprise the populationn this study.

atient examinationThe preoperative history was reviewed for a mechanism

f injury (overt trauma or repetitive trauma) and a self-eported visual analog scale pain score from 0 (no pain) to0 (as bad as it could be). Physical examination includedctive range of motion, active compression20 and crank15

ests, and examination maneuvers to identify subacromial

mpingement26 and to rule out gross instability1 or acromi-

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J Shoulder Elbow Surg Enad et al 301Volume 16, Number 3

clavicular disease.26 Magnetic resonance imaging (MRI)ith or without contrast arthrography was performed when

he clinical diagnosis or surgical plan was uncertain. TheRI study was suggestive of a SLAP tear when the labrumas detached and displaced from the superior glenoid orhen a branched linear or stellate focus of abnormally

ncreased contrast signal intensity was seen between therticular cartilage margin and attachment of the labrum oriceps anchor on coronal oblique views.10,33 A presump-

ive diagnosis of a superior labral tear was made from anyombination of at least 3 of the following: (1) a history ofrauma (acute or repetitive), (2) internal pain or clicking,3) positive active compression test or compression-rotationest, and (4) suggestive appearance on MRI for SLAP tear.he indications for surgery were shoulder pain, instability, orechanical catching interfering with the performance of stren-ous or sporting activity. Symptoms were unresponsive toctivity modifications, anti-inflammatory medications, and ainimum of 3 months of a formal rehabilitation regimen.

urgical procedureAll surgeries were done with the patient under general

nesthesia in the lateral decubitus position. Initial diagnos-ic arthroscopy was performed from a standard posteriorortal, and specific sites of examination included the gle-ohumeral articular surfaces, the biceps tendon and an-hor, the entire glenoid labrum, and the rotator cuff.11 Annstable superior labral tear was confirmed when the la-rum could be displaced by more than 5 mm off of therticular cartilage margin of the glenoid when tension waslaced on the biceps tendon with a probe13 (Figure 1). Annterior-superior portal through the rotator interval wasstablished as both a diagnostic (arthroscopic) and a work-ng (instrument) portal, and a posterior-lateral portal of

ilmington18 was added in cases with a posterior-superiorabral tear. All repairs were performed with biodegradableuture anchors (Panalok [DePuy Mitek, Raynham, MA] in2 patients and Bio-SutureTak [Arthrex, Naples, FL] in 18

igure 1 Arthroscopic photograph of unstable posterior SLAP tearf right shoulder in lateral decubitus position.

atients after a change in our facility’s utilization of im- p

lants). After debridement of unstable labral flaps andbrasion of nonarticular bony bed, suture anchors were

nserted onto the glenoid rim at an angle of approximately5°. Generally, suture anchors were placed at any combi-ation of the 10-, 11-, 1-, and 2-o’clock positions on thelenoid depending on the anterior and posterior extent ofuperior labral detachment. A single vertical stitch fromach anchor was placed around the inner edge of theabrum centrally and through the capsulolabral tissue pe-ipherally via an arthroscopic piercing instrument loadedith a shuttle suture (Linvatec, Largo, FL) or by use of a

uture lasso (Arthrex) (Figure 2). A sliding arthroscopic knoteinforced with alternating half-hitches was used to secure theabrum to the glenoid (Figure 3). Arthroscopic subacromialecompression with coracoacromial ligament resectionas performed in patients identified to have concomitant

ubacromial impingement on preoperative assessment.artial-thickness rotator cuff tears were debrided with aotorized shaver when considered to be less than 50%

n thickness.All patients were prescribed the same postoperative

ehabilitative protocol (Table I) under the supervision of ahysical therapist. Sling immobilization, pendulum exer-ises, and active elbow and wrist exercises were initiatedostoperatively for the first 3 to 6 weeks. In addition, at 3 toweeks, passive and active-assisted range-of-motion exer-

ises were begun in forward elevation, internal rotation,nd external rotation with the arm adducted. After 6 weeks,rogressive strengthening of the rotator cuff and the scap-lar stabilizers was begun. Three months after the opera-ion, patients progressed to an aggressive exercise pro-ram. Full participation in throwing sports was allowedfter 6 months. Criteria to return to full active duty were1) greater than 80% of preoperative motion regained,2) greater than 80% of strength regained (as measured byhe patient’s self-reported ability to achieve at least 80% ofhe number of consecutive pushups or pullups achieved onis or her last preinjury fitness test), and (3) ability to

igure 2 A loop within a suture hook is used to pass the suturehrough the capsulolabral tissue.

erform the physical requirements of the patient’s military

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302 Enad et al J Shoulder Elbow SurgMay/June 2007

ccupational specialty confidently (the criteria for whicharied widely depending on specific job requirements).

ollow-up evaluationAt a minimum of 24 months postoperatively, patients

ere evaluated by use of the American Shoulder and Elbowociety (ASES) score26 and the University of California, Losngeles (UCLA) scoring system.6 The ASES score is tabu-

ated from a self-reported visual analog scale pain scorefrom 0 to 10) and a questionnaire on which the patientvaluates his or her activities of daily living. The UCLAhoulder score divided results into the following categories,s described by Ellman et al6: excellent (34-35 points),ood (28-33 points), fair (21-27 points), and poor (0-20oints). Patients were further evaluated with regard to return

o full active duty (ie, achieved or not achieved), level ofeturn to competitive sports (ie, higher, same, lower, ornable), and overall satisfaction (ie, satisfied or not satis-ed). Descriptive data are reported as the number of pa-ients in each subgroup and percentages. The differences inean scores between 2 subgroups were analyzed with thenpaired t test. Multivariate analysis was done by use of a2 test. P � .05 was considered significant.

ESULTS

Of 30 patients, 27 (90%) were available for clin-cal follow-up at a mean of 30.5 months (range,4-42 months). Of the repairs, 24 were performed on

he dominant side and 6 on the nondominant side,ncluding 27 right and 3 left shoulders. The mean aget treatment was 31.6 years (range, 22-41 years).

igure 3 Suture anchor fixation of the labrum is completed androbed for stability.

reoperatively, 15 patients had a history of overt a

rauma and 15 had a history of repetitive trauma. Allatients reported their primary symptom as pain, 5ad mechanical catching, and 2 complained of painith weakness. None had a history of frank disloca-

ion. Symptoms had been present for a mean of 10.4onths (range, 4-16 months).On preoperative physical examination, 28 of 30

atients had a positive active compression test. Sev-nteen had a positive compression-rotation test. MRIndings were suggestive of superior labral pathologyn 24 of 26 patients. Two MRI scans did not show aLAP tear that was suggested by history and physicalnd confirmed at surgery (false-negative rate, 7.7%).superior labral tear associated with a spinoglenoid

yst was identified on MRI in 4 patients. None ofhese 4 patients exhibited any physical signs of neu-ologic deficit. Eight other patients were noted to haveigns of stage II subacromial impingement.26

ntraoperative findings

None of the shoulders had increased translationxceeding grade 1 with the load-shift and inferiorulcus maneuvers compared with the contralateralide.1 Associated findings at arthroscopy included 6atients with chondromalacia of the humeral head orlenoid articular surface, 8 with subacromial bursitis,nd 4 with partial-thickness tears of the rotator cuff (2ere articular-sided, 2 were bursal-sided, and all 4ere in patients with signs and symptoms of subacro-ial impingement syndrome identified preopera-

ively). There were no Bankart tears, Hill-Sachs le-ions, or full-thickness rotator cuff tears. A mean of.2 anchors per patient (range, 1-4) were placed forepair.

linical results

The clinical results are summarized in Table II. Theean pain score improved significantly, from 5.0reoperatively to 1.3 postoperatively (P � .0001).he overall mean ASES score at follow-up was 86.9oints (range, 53.3-100 points). The mean postoper-tive UCLA score was 30.4 points (range, 22-35oints). On the basis of UCLA scores, there were 4xcellent, 20 good, 3 fair, and 0 poor results.

Each patient regained full active forward flexionnd internal rotation compared with the preoperativeotion, and abduction and external rotation wereithin 5° of the preoperative measurements. Thereas no difference in UCLA (P � .20) and ASES (P �

30) scores depending on the type of bioabsorbableuture anchor used.

Of 26 patients who participated in competitiveports at a recreational level, 20 (76.9%) returned tohe same level or higher whereas 6 (23.1%) returnedo a lower level. No patient had to give up recre-

tional sports because of the shoulder. Of the 30

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J Shoulder Elbow Surg Enad et al 303Volume 16, Number 3

riginal patients, 29 (97%) returned to full militaryuty at a mean of 4.4 months (range, 2-7 months). At

he latest follow-up, 26 of 27 patients (96.2%) weretill on full duty. One patient did not return to full dutyecause of recurrent pain and catching and wasedically separated from the military. Of 27 patients,6 (96.2%) reported that they were satisfied with therocedure and result.

omparison between isolated SLAP tear and SLAP tearith concomitant diagnosis

According to a power analysis based on an � levelf .05 and power of 80%, it was determined that weeeded at least 12 subjects per comparison group toerform a significant analysis by use of postoperativeSES scores (criterion fulfilled in this study) and at

east 18 subjects per comparison group for UCLAcores (criterion not fulfilled in this study). The 15atients with an isolated SLAP tear had significantly

ower mean ASES scores (84.2 points) than the 12atients with associated diagnoses (91.5 points) (P �

able I Rehabilitation program after arthroscopic repair of type II SL

Time Goals Immobilization

wk Protective Sling use at all times Codman circu-3 wk Early motion Sling use except for

PROMPROM 0° to 9

to neutral w-6 wk Full motion, improved

neuromuscularfunction

Discontinue sling use Progressive PRposterior camanual sca

-16 wk Strengthening Continue stret

-4 mo Advancedstrengthening

Continue stretcapsular str

mo Functional Continue main

ROM, Passive range of motion.

able II Shoulder scores in 27 patients at minimum 2-yearollow-up

Shoulder score

UCLA ASES

ll patients (N � 27) 30.4 � 2.9 86.9 � 12.0solated SLAP tear (n � 15) 30.2 � 3.1 84.2 � 13.8*LAP tear plus other diagnosis (n � 12) 30.8 � 2.6 91.5 � 6.6*LAP tear and subacromial impingement(n � 8) 30.7 � 2.7 89.4 � 6.4

LAP tear with spinoglenoid cyst (n � 4) 31 � 2.8 94.6 � 6.6

ata are presented as mean � SD.The mean ASES score was significantly lower in the group with an isolatedLAP tear versus the combined group (SLAP tear with another associatediagnosis).

005). Patients with an isolated SLAP tear tended to u

ave lower mean UCLA scores (30.2 points) thanhose with associated diagnoses (30.8 points) (P � .5not significant]). Of the 15 patients in the group withn isolated SLAP tear, 13 (87%) had good or excel-

ent results and 2 had a fair result. Of the 12 patientsn the combined group (SLAP tear with other diag-oses), 11 (92%) had good or excellent results andhad a fair result. The time to return to duty and

ength of follow-up were not significantly differentetween subgroups (P � .6 and P � .4, respectively).

omplications

No intraoperative complications, nerve deficits, oround infections occurred in any patient. No clinical

igns of stiffness were found during the postoperativeeriod. There were no reoperations. Of the 3 patientsith fair results, none reported a reinjury. All 3 re-orted no pain at rest, but each had pain with stren-ous activities when the upper extremity was usedbove shoulder level. One of the three had under-one an isolated SLAP repair and attempted to return

o full military duty at 6 months postoperatively.ithin 3 months of his return to duty, the preoperative

ymptoms of pain and catching recurred without newnjury. He was dissatisfied with how the clinical symp-oms were affecting his work performance and wasedically separated from the military.

ISCUSSION

Failure to repair unstable SLAP lesions has beenhown to be unsatisfactory, with deteriorating resultsver time.2,4,24,32 The accepted standard of treat-ent for unstable type II SLAP lesions has evolved intorthroscopic repair with suture anchors.8,12,13,18,31

recent cadaveric study compared the biomechani-al strength of suture anchor repair with that of aioabsorbable tack.5 No significant difference in stiff-ess, load to permanent displacement, and load to

ion

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and flexibility Progressive rotator cuff, scapularstabilizers, biceps

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304 Enad et al J Shoulder Elbow SurgMay/June 2007

n advantage in the ability to control precise suturelacement with the suture anchor system. Anotherecent cadaveric study suggests that normal range ofotion and shoulder stability can be restored afterrthroscopic suture anchor repair of a type II SLAP

esion.23

Our study achieved overall favorable clinical re-ults with regard to shoulder scores and return to dutyfter arthroscopic suture anchor repair of type II SLAP

esions. Whereas the UCLA scoring system was orig-nally established to assess results of rotator cuff re-air,6 its use in previous studies of arthroscopic SLAPepair with suture anchors allows for direct compari-on with our results. Morgan et al18 reported good orxcellent results in 97% of 102 patients at 1-yearollow-up based on UCLA scores after repair of type IILAP lesions, including 46 of 53 overhead athletesaving excellent results. Kim et al13 reported that 94%f their patients had good or excellent results at aean follow-up of 33 months (mean UCLA score,3.4 points) after repair of 34 unstable, isolated SLAP

ears, including 91% of patients regaining their pre-njury level of function. Rhee et al25 reported a meanCLA score of 32.3 points at a mean follow-up of 33onths after suture anchor repair of isolated SLAP

ears in 30 of 44 patients. The mean UCLA score of0.4 points in active-duty military patients seen in ourtudy at a mean follow-up of 30.5 months comparesavorably with these previous reports, including goodr excellent clinical results in 87% of patients (13/15)ith isolated SLAP tears.Whereas thedaily physical demandsof eachactive-

uty patient vary widely depending on his or herilitary occupational specialty, all full-duty serviceembers must perform upper body strength testing

either pushups or pullups) as part of a semiannualtness evaluation. Therefore, this study is unique inhat each patient has a previously documented objec-ive preinjury level of fitness. In fact, this informationas useful in determining when the patient was ablehysically to return to full duty. Eventually, 97% of ouratients regained at least 80% of their previous levelt a mean of 4.4 months postoperatively and wereble to resume full duty at that time. Although we didot use the preinjury fitness score in the assessment ofhe final results, this information may serve as a simpleeference for postoperative evaluation in future stud-es. Although none of our military patients was anlite athlete, most participated in recreational sports,nd all of these athletes resumed playing their sport,

ncluding 76% returning to at least the same level asreoperatively.

This study included patients with concomitant diag-oses of subacromial impingement syndrome, partial-hickness rotator cuff tear, and spinoglenoid cyst for-ation in addition to the SLAP tear. However, we

elieve that the SLAP tear contributed to each pa-

ient’s symptoms based on the findings of the historyall patients had some form of trauma), physical ex-mination (positive active compression test in 28/30atients), and MRI (positive for SLAP tear in 24/26tudies) and, ultimately, arthroscopic confirmation ofhe lesion in all shoulders. The rate of associatedhoulder pathology found with SLAP tears is reportedo be as high as 76%.28 We found that patientsreated for an isolated SLAP tear had significantlyower ASES scores (and tended to have lower UCLAcores) at follow-up when compared with those whoad concomitant treatment for additional diagnoses.he findings suggest that SLAP tears do not alwaysccur in isolation and that concomitant subacromialmpingement or spinoglenoid cysts should be treatedt the time of SLAP repair.

The strengths of this study include a military popu-ation of nonsedentary adults, use of a uniform surgi-al technique, and use of a standard postoperativeherapy protocol in all patients. We also used stan-ard evaluation scores that allow comparison of ouresults to prior studies. We readily acknowledge thenherent limitations of a retrospective review and theack of a comparison group of patients undergoingrthroscopic debridement or nonoperative treatment.lthough the total number of patients was relativelymall, the sample represents the current prevalence ofhis condition in a military population.

In conclusion, arthroscopic SLAP repair via a su-ure anchor technique is a reliable procedure withespect to clinical results and postoperative return toull duty and recreational activity in a military popu-ation. Furthermore, concurrent treatment of associ-ted shoulder pathology does not compromise ulti-ate clinical results.

EFERENCES

1. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modifica-tion of the Bankart procedure for multidirectional instability of theshoulder. J Bone Joint Surg Am 1991;73:105-12.

2. Altchek DW, Warren RF, Wickiewicz TL, Ortiz G. Arthroscopiclabral debridement. A three-year follow-up study. Am J SportsMed 1992;20:702-6.

3. Andrews JR, Carson WG, McLeod WD. Glenoid labrum tearsrelated to the long head of the biceps. Am J Sports Med 1985;13:337-41.

4. Cordasco FA, Steinmann S, Flatow EL, Bigliani LU. Arthroscopictreatment of glenoid labral tears. Am J Sports Med 1993;21:425-30.

5. DiRaimondo CA, Alexander JW, Noble PC, Lowe WR, LintnerDM. A biomechanical comparison of repair techniques for type IISLAP lesions. Am J Sports Med 2004;32:727-33.

6. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint SurgAm 1986;68:1136-44.

7. Field LD, Savoie FH III. Arthroscopic suture repair of superiorlabral detachment lesions of the shoulder. Am J Sports Med1993;21:783-90.

8. Ide J, Maeda S, Takagi K. Sports activity after arthroscopicsuperior labral repair using suture anchors in overhead-throwing

athletes. Am J Sports Med 2005;33:507-14.

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

J Shoulder Elbow Surg Enad et al 305Volume 16, Number 3

9. Itoi E, Kuechle DK, Newman SR, Morrey BF, An KN. Stabilisingfunction of the biceps in stable and unstable shoulders. J BoneJoint Surg Br 1993;75:546-50.

0. Jee WH, McCauley TR, Katz LD, Matheny JM, Ruwe PA,Daigneault JP. Superior labral anterior posterior (SLAP) lesions ofthe glenoid labrum: reliability and accuracy of MR arthrographyfor diagnosis. Radiology 2001;218:127-32.

1. Jobe CM. Anatomy and surgical approaches. In: Jobe FW,editor. Operative techniques in upper extremity sports injuries. StLouis: Mosby; 1996. p. 160-1.

2. Kartus J, Kartus C, Brownlow H, Burrow G, Perko M. Repair oftype-2 SLAP lesions using Corkscrew anchors. A preliminaryreport of the clinical results. Knee Surg Sports Traumatol Arthrosc2004;12:229-34.

3. Kim SH, Ha KI, Kim SH, Choi HJ. Results of arthroscopic treatmentof superior labral lesions. J Bone Joint Surg Am 2002;84:981-5.

4. Kumar VP, Satku K, Balasubramaniam P. The role of the longhead of biceps brachii in the stabilization of the head of thehumerus. Clin Orthop 1989;244:172-5.

5. Liu SH, Henry MH, Nuccion SL. A prospective evaluation of anew physical examination in predicting glenoid labral tears. Am JSports Med 1996;24:721-5.

6. Maffet MW, Gartsman GM, Moseley B. Superior labrum-bicepstendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-8.

7. McMahon PJ, Burkart A, Musahl V, Debski RE. Glenohumeraltranslations are increased after a type II superior labrum anterior-posterior lesion: a cadaveric study of severity of passive stabilizerinjury. J Shoulder Elbow Surg 2004;13:39-44.

8. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAPlesions: three subtypes and their relationships to superior instabil-ity and rotator cuff tears. Arthroscopy 1998;14:553-65.

9. O’Brien SJ, Allen AA, Coleman SH, Drakos MC. The trans–rotator cuff approach to SLAP lesions: technical aspects for repairand a clinical follow-up of 31 patients at a minimum of 2 years.Arthroscopy 2002;18:372-7.

0. O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. Theactive compression: a new and effective test for diagnosinglabral tears and acromioclavicular joint abnormality. Am J SportsMed 1998;26:610-3.

1. Pagnani MJ, Deng XH, Warren RF, Torzilli PA, Altchek DW. Effect

of lesions of the superior portion of the glenoid labrum on glenohu-meral translation. J Bone Joint Surg Am 1995;77:1003-10.

2. Pagnani MJ, Speer KP, Altchek DW, Warren RF, Dines DM.Arthroscopic fixation of superior labral lesions using a biodegrad-able implant: a preliminary report. Arthroscopy 1995;11:194-8.

3. Panossian VR, Mihata T, Tibone JE, Fitzpatrick MJ, McGarry MH,Lee TQ. Biomechanical analysis of isolated type II SLAP lesionsand repair. J Should Elbow Surg 2005;14:529-34.

4. Payne LZ, Jokl P. The results of arthroscopic debridement ofglenoid labral tears based on tear location. Arthroscopy 1993;9:560-5.

5. Rhee YG, Lee DH, Lim CT. Unstable isolated SLAP lesion: clinicalpresentation and outcome of arthroscopic fixation. Arthroscopy2005;21:1099.

6. Richards RR, An KN, Bigliani LU, et al. A standardized method forthe assessment of shoulder function. J Shoulder Elbow Surg 1994;3:347-52.

7. Rodosky MW, Harner CD, Fu FH. The role of the long head of thebiceps muscle and superior glenoid labrum in anterior stability ofthe shoulder. Am J Sports Med 1994;22:121-30.

8. Samani JE, Marston SB, Buss DD. Arthroscopic stabilization oftype II SLAP lesions using an absorbable tack. Arthroscopy 2001;17:19-24.

9. Segmuller HE, Hayes MG, Saies AD. Arthroscopic repair ofglenolabral injuries with an absorbable fixation device. J Shoul-der Elbow Surg 1997;6:383-92.

0. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to thesuperior glenoid labrum. J Shoulder Elbow Surg 1995;4:243-8.

1. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAPlesions of the shoulder. Arthroscopy 1990;6:274-9.

2. Tomlinson RJ Jr, Glousman RE. Arthroscopic debridement of gle-noid labral tears in athletes. Arthroscopy 1995;11:42-51.

3. Tung GA, Entzian D, Green A, Brody JM. High-field and low-fieldMR imaging of superior glenoid labral tears and associatedtendon injuries. AJR Am J Roentgenol 2000;174:1107-14.

4. Warner JJ, Kann S, Marks P. Arthroscopic repair of combinedBankart and superior labral detachment anterior and posterior lesions:technique and preliminary results. Arthroscopy 1994;10:383-91.

5. Yian E, Wang C, Millett PJ, Warner JJ. Arthroscopic repair ofSLAP lesions with a bioknotless suture anchor. Arthroscopy 2004;20:547-51.

6. Yoneda M, Hirooka A, Saito S, Yamamoto T, Ochi T, Shino K.Arthroscopic stapling for detached superior glenoid labrum.

J Bone Joint Surg Br 1991;73:746-50.