superior labral tears: fact or fiction? · 2017-12-05 · outcomes after slap repair clinical...

8/8/2017

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SUPERIOR LABRAL TEARS:

Fact or Fiction?Michael G. Ciccotti, MD

The Everett J. and Marian Gordon Professor of Orthopaedics

Chief, Division of Sports Medicine Rothman Institute

Thomas Jefferson UniversityHead Team Physician, Philadelphia Phillies

Rothman Institute of Orthopaedics at Thomas Jefferson University

Faculty Disclosure

Consultant – Stryker Endoscopy

Consultant – Venture MD

Research Support – Arthrex

Board/Committee Membership – Orthopaedic Learning Center BOD

MLB Medical Advisory Committee

MLB Elbow Research Study Group

AOSSM Fellowship Match Committee

AJSM Medical Publishing Board of Trustees


“What is that?”

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Fibrocartilage

Periosteal/Capsular vascularity

Biceps attachment

Normal Superior LabrumAnatomy


Biceps attachment site

Deepens glenoid

Distributes contact pressure between humerus & glenoid – Washer Effect

Attachment site for glenohumeral ligaments & capsule

Pressure sensor for proprioception

Harryman, 1992Pagnani, 1995

Lee, 2005Veeger, 2007

Lee, 2008Kibler, 2011Superior Labrum is Important

for the Overhead Athlete!

Normal Superior LabrumBiomechanics


Predictable Series of Events in Throwers

Progressive Osseous changes

Scapular and Cuff weakness

Post. Soft Tissue contracture

Post-sup. Instability in ABD and EXT ROT.

Peel-back mechanism occurs

SLAP injury occurs with post-sup cuff injury

General population is not routinely exposed to this “cascade of events”

. . . but throwers are!

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GENERAL POPULATION

vs.THROWERS

What’s the Evidence?

SLAP Tears:Fact or Fiction?


Research Data

Epidemiologic

Biomechanical

Imaging

Clinical



Incidence Studies

Epidemiologic Evidence

. . . epidemiologic data document SLAP tears occur in overhead throwing athletes

• General Population (Snyder et al, AJSM 1990)

• Throwing Athlete (Andrews et al, AJSM 1996)

• Throwers & Non-throwers (Burkhart et al, Arthroscopy 2000)

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• Traction vs. peel-back (Kuhn et al, Arthroscopy 2003)

• Peel-back mechanism (Andrews et al, AJSM 2004)

• Post-superior shift of humeral head with tight post-capsule (Tibone et al, AJSM 2008)

Biomechanical Studies

Biomechanical Evidence

. . . biomechanical evidence that overhead throwing generates SLAP tears


MRA correlated with operative findings: sensitivity – 89%; specificity –

88%; accuracy – 89%

Direct MR arthrography is optimal protocol; indirect MR arthrography an alternative

Diagnosis can be made without contrast, and at low field strengths

Richetti, Arthroscopy 2013Kooima, Radiology 2003

Popovic, IJSM 2001Chandnani, AJR 1995

. . . imaging studies document SLAP

pathology

Imaging Evidence

Imaging Studies


Retrospective and Prospective Studies documenting a range of outcomes after SLAP repair

Clinical Studies

Clinical Evidence

. . . clinical evidence documents varying % of

return to play after treatment of SLAP tears in

overhead athletes

Snyder, AJSM 2003Burkhart, CSM 2003

Cohen, SH 2008Friel, JSES 2010

Forsythe, JBJS 2011Neuman, AJSM 2011

Sayde, CORR 2012Schroder, Arthroscopy 2012

Fedoriw, AJSM 2014Rossy, SH 2016

Chalmers, KSSTA 2016

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Look more closely . . . Look more closely . . .



Nonoperative Treatment of SuperiorLabrum Anterior Posterior Tears

Edwards, Ahmad, Levine et al, AJSM, 2010

39 patients with clinically documented SLAP retrospectively reviewed

Minimum 1 yr follow-up with Validated Scores

Nonoperative Pt Group – all with improvements in pain, function and quality of life

Return to Play in Nonop Group – 71% of all athletes; 66% of overhead athletes

“A trial of nonoperative treatment should be considered in patients with a SLAP tear”

Clinical Evidence


Return to Play After Treatment of Superior Labral Tears in Pro Baseball Players

Fedoriw, Ramkumar, Lintner et al, AJSM, 2014

68 players with clinically documented SLAP retrospectively reviewed

“Return to Play” (RTP) vs “Return to Prior Performance” (RPP)

21 pitchers successful nonop: 40% RTP; 22% RPP

27 pitchers required operative tx: 48% RTP; 7% RPP

Clinical Evidence

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Return to Play After Type II SLAP Lesion Repairs in Athletes

Sayde, Cohen, Ciccotti et al, CORR, 2012

Systematic Review – 1950 to 2010

506 patients with Type II SLAP Repair

83% G/E subjectively

63% overhead athletes return to prior level

Tremendous variation in operative technique and postop rehabilitation

Clinical Evidence


Results of Arthroscopic Repair of Type II SLAP Lesions in Overhead AthletesReturn to Preinjury Playing Level

Brian Neuman MD, Brittany Boisvert MD, Brian Reiter MD, Kevin Lawson BS, Michael Ciccotti MD, Steven CohenMD

AJSM, 2011

• 30 overhead athletes with isolated Type II SLAP • Avg ASES Score(0-100): 87.1• Avg KJOC Score(0-100): 71.6• ASES focuses on ADL’s and may give a falsely

elevated success rate

• The KJOC score better examines the demands of elite overhead athletes

• The outcome measures that we use impact our perception of success

Clinical Evidence


Be cautious of SLAP repair in patients over age 50 yrs, especially with concomitant rotator cuff pathology

Franceschi et al, AJSM 2008Weber et al, Sports Med, 2010Weber et al, AJSM, 2012

SLAP Tear in the Older Patient

Clinical Evidence

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The Experts


MLB Team Physician’s Survey

12 Question Survey on SLAP Injury

26/30 Team Physicians responded

26/26 – SLAP as true , identifiable pathology, but more often symptomatic in thrower than non-throwers

Rothman Institute, 2014


26/26 felt SLAP injuries may not heal in throwers when treated nonoperatively, but may become clinically asymptomatic

26/26 felt pitchers most often required operative treatment



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MLB Shoulder

StudyGroup

SLAP Tear in the Overhead Athlete


GENERAL POPULATION

vs.THROWERS

The evidence indicates it is real



IS IT WHAT

WE THINK?

. . . Diagnostic Precision?

SLAP Tear in the Overhead Athlete

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Clinical Evaluation

Physical Exam No single test or series of tests reliably

predicts a SLAP tear (McFarland, AJSM 2002; Stetson, AJSM 2002; Parentis, AJSM 2006)

Imaging Asymptomatic changes exist in the superior

labrum with age and in certain populations like overhead athletes (Richetti, JSES 2013;Connolly, JBJS 2013)

Arthroscopy Meniscoid/Hypermobile/Peel-Back Variants

(Davidson, JSES 2004: Burkhart, JSES, 2006)


IS IT REALLY ABNORMAL?


ARE THERE ANY

CLUES?


Clinical Utility of Traditional and New Tests in the Diagnosis of Biceps Tendon Injuries and

SLAP Lesions 325 consecutive patients with shoulder

pain underwent standardized clinical evaluation (6 traditional and 2 new tests)

Clinical exam correlated with surgical findings

Sensitivity, specificity, accuracy, +/-predictive value, and +/- likelihood ratio were calculated

Kibler, Sciascia, Hester et al, 2009

SLAP Tears:Physical Exam Pearls

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Superior Labrum – Modified DLS

Modified DLS Test was most accurate (0.84) and highest + likelihood ratio (31.57)

Modified DLS & O’Brien’s together provided best prediction

Kibler, Sciascia, Hester et al, 2009

SLAP Tears:Physical Exam Pearls


SLAP Tears:Imaging Pearls

Contrast undercutting the superior labrum at and/or posterior to the biceps root >2mm

Detachment of superior labrum from glenoid

Irregular borders of sublabralrecess anterior to biceps anchor

Peri-labral cyst formation


Labral-Glenoid interface

Tissue quality

Presence of exposed non-articular glenoid

Mobility of labrum

SLAP Tears:Arthroscopy Pearls

Need to Assess:

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Hemorrhage

Granulation tissue

Lift off >3-5mm

“Peel-back” in overhead athlete

Exposed non-articular glenoid

SLAP Tears:Arthroscopy Pearls

SLAP Tears:


The Mystery of the SLAPThe Mystery of the SLAP



General Population

General Population

Maybe . . .

. . . But less frequently symptomatic


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Overhand Athlete

Overhand Athlete

Yes . . .

…And often symptomatic




High level overhead/throwing athlete

Clinically straightforward Traumatic/repetitive micro-

traumatic history Positive exam findings Imaging illustrating superior

labral detachment Arthroscopic findings

consistent with abnormalities . . . but this may very well be a small percentage of SLAP tears overall!

. . . Repair it!


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Older patient/non-athlete/non-throwing recreational athlete

History inconsistent with SLAP Physical Exam ambiguous without

any clear cut “+” SLAP tests Imaging without superior labral

detachment Arthroscopic findings consistent

with normal variants


. . . Leave it alone!


Optimize results by . . .

Diagnostic Precision Specific Indications Nonconstraining Surgical

Techniques Broad Postop Rehab Precise Outcome Assessment

…continued research…

THANK YOU.

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12 Question Survey on SLAP Injury 12/26(46%) – no single test ideal 14/26(54%) – O’Brien’s Test most

precise 26/26 – MRI with Gad best imaging

study





39 patients with clinically documented SLAP retrospectively reviewed

Minimum 1 yr follow-up

Patient-derived Validated Scores: SF-36, VAS, ASES, SST, EuroQol

20 pts (51%) – initial/delayed operative tx 19 pts (49%) – successfully completed nonop tx

Clinical Evidence

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Nonoperative Pt Group – all with improvements in pain, function and quality of life

Return to Play in Nonop Group – 71% of all athletes; 66% of overhead athletes

“A trial of nonoperative treatment should be considered in patients with a SLAP tear”



Clinical Evidence

superior labral tears: fact or fiction? · 2017-12-05 · outcomes after slap repair clinical...

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