The Outcome of Type II SLAP Repair: A Systematic Review
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Systematic Review The Outcome of Type II SLAP Repair: A Systematic Review Kalyan Gorantla, M.S., Corey Gill, M.D., and Rick W. Wright, M.D. Purpose: The purpose of this study was to systematically review the literature regarding the outcome of arthroscopic repair of type II SLAP lesions in order to assess the effectiveness of current methods of treatment. Methods: We performed a systematic review of the results of repair of type II SLAP lesions. Inclusion criteria included outcome studies of repair of type II SLAP lesions with minimum 2-year follow-up and Level IV evidence or higher published in the English language in peer-reviewed journals. Results: There is no Level I or II evidence for SLAP repair outcome. Regarding the general outcome after type II SLAP repair, the percentage of good and excellent results ranged from 40% to 94%. Return to previous level of play ranged from 20% to 94%. Overhead athletes are the most challenging to return to the previous level of performance for this diagnosis, and their return rate reflects this. Five studies reported these results, and the rate of return ranged from 22% to 64% for baseball players. Conclusions: Arthroscopic repair of type II SLAP tears results in overall excellent results for individuals not involved in throwing or overhead sports. The results of type II SLAP repair in throwing or overhead athletes are much less predictable. Future studies should be prospective in nature and at least use a longitudinal prospective cohort design to determine predictors of outcome. Level of Evidence: Level IV, systematic review of Level III and IV studies. T he superior glenoid labrum is a common site of injury in overhead-throwing athletes because of its relation to the insertion of the long head of the type I, type II, type III, and type IV. Type II SLAP tears have been shown to occur frequently,3 causing symptoms in active individuals, and thus are the topic biceps brachii tendon on the glenoid rim. Andrews et of this systematic review. al.1 first described labral injuries, which would ulti- Type II SLAP lesions are characterized by the com- mately be deemed SLAP tears, in 1985 in 73 over- bined detachment of the superior labrum and biceps head-throwing athletes. In 1990 Snyder et al.2 coined tendon from the peripheral edge of the glenoid. The the term “SLAP” (superior labrum, anterior and pos- first attempts to treat this lesion involved arthroscopic terior) to describe the tear in that region. Snyder went debridement of the labrum, which proved to be an on to classify SLAP tears into 4 different categories: insufficient long-term solution.4,5 Reattachment of the superior labrum to the glenoid rim is the prevailing method for treating this injury, and many devices have From the Indiana University (K.G.), Indianapolis, Indiana; and been used to accomplish this task, including metal Department of Orthopaedic Surgery, Washington University screws, staples, sutures, suture anchors, and bioab- School of Medicine (C.G., R.W.W.), St Louis, Missouri, U.S.A. sorbable tacks. The purpose of this study is to system- The authors report no conflict of interest. Received June 24, 2009; accepted August 26, 2009. atically review the literature regarding the outcome of Address correspondence and reprint requests to Rick W. Wright, arthroscopic repair of type II SLAP lesions to assess M.D., Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, Ste 11300 West the effectiveness of current methods of treatment. The Pavilion, St Louis, MO 63110, U.S.A. E-mail: wright@wudosis literature regarding type II SLAP tears has been dom- .wustl.edu inated by studies pertaining to the physical examina- © 2010 by the Arthroscopy Association of North America 0749-8063/10/2604-9395$36.00/0 tion and imaging tests used to make the diagnosis. doi:10.1016/j.arthro.2009.08.017 There have been systematic reviews and meta-analy- Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 26, No 4 (April), 2010: pp 537-545 537
538 K. GORANTLA ET AL. ses performed examining the diagnostic tests for sisted of staple fixation of the SLAP tear. During SLAP tears.6-8 Significantly fewer studies have eval- arthroscopic repair, 2 patients also underwent partial uated the outcome of repair of these tears. cuff debridement, 1 underwent rotator cuff debridement and bursectomy, and 1 underwent bursectomy. A sec- METHODS ond-look arthroscopy was performed at a mean of 3.9 months (range, 3 to 6 months) to remove the staples. At We performed a systematic review of the results of 6 months, throwing was permitted. The patients were repair of type II SLAP lesions. Inclusion criteria in- evaluated by 2 measurements: (1) the pain rating sys- cluded outcome studies of repair of type II SLAP tem of Tibone et al.10 and (2) the relation of pain to lesions with minimum 2-year follow-up. Additional function. The results showed that the outcome was inclusion criteria included English-language studies excellent in 5 cases, good in 3, fair in 1, and poor in with Level IV or higher evidence published in peer- 1 (Table 1). Thus 80% of the cases had a successful reviewed journals. Exclusion criteria included any la- (good to excellent) outcome. Of 10 patients, 5 (50%) bral tear other than a type II SLAP tear; treatment that returned to their preinjury level of play. An indepen- consisted of simple debridement; treatment associated dent examiner was not identified, potentially introduc- with full-thickness rotator cuff repair, Bankart recon- ing detection bias. struction, or inferior labral repair; and less than 2 years’ In 2001 Samani et al.11 performed a Level IV ret- follow-up. The authors (K.G., C.G., and R.W.W.) inde- rospective case series evaluating the outcome of ar- pendently searched PubMed for articles published throscopic stabilization of type II SLAP lesions using between 1950 and 2009 and EMBASE for articles bioabsorbable tacks. The study consisted of 25 pa- published between 1966 and 2009. The Cochrane da- tients with a mean age of 36 years (range, 17 to 58 tabase was searched for previous SLAP systematic years). Of the patients, 23 were male. Regarding con- reviews. The reference lists of identified articles were comitant procedures, 13 patients underwent arthro- searched, and a hand review of appropriate journals scopic debridement of partial-thickness rotator cuff that were published during the last 6 months was tears, 19 required subacromial decompression, and 1 performed (The American Journal of Sports Medicine, had a full-thickness cuff tear repaired. All patients Arthroscopy, Journal of Shoulder and Elbow Surgery, were available at a mean follow-up of 35 months The Journal of Bone and Joint Surgery [American and (range, 24 to 51 months). The patients were re-exam- British versions], and Clinical Orthopaedics and Re- ined and University of California, Los Angeles lated Research). Database search terms included “su- (UCLA)12 and American Shoulder and Elbow Sur- perior labrum, anterior and posterior,” “SLAP,” “type geons (ASES)13 scores obtained. The ASES score II SLAP,” and “type II SLAP outcome.” All authors averaged 42 preoperatively and improved to 92 at independently performed the literature search. follow-up. The UCLA score averaged 18 preopera- tively and improved to 32 at follow-up. On the basis RESULTS of UCLA scores, the result was rated as excellent in 9 patients, good in 13, fair in 2, and poor in 1. Of the 25 The search performed on July 26, 2009, yielded 77 patients, 24 were athletes, 20 of whom returned to studies that met the first-pass inclusion criteria. Ab- their previous level of activity. Two had a lower level stracts were reviewed, resulting in 39 articles that of activity for unrelated reasons, and two had a lower were retrieved and reviewed. Full-text review resulted level for shoulder-related reasons. An independent in 12 studies that met the inclusion/exclusion criteria examiner was not identified, potentially introducing and were included in this systematic review (Table 1). detection bias. Two authors (K.G. and R.W.W.) independently per- In 2002 O’Brien et al.14 published a Level IV ret- formed quality appraisal, and potential flaws and bi- rospective case series evaluating the surgical treat- ases were identified. ment of type II SLAP tears using a trans–rotator cuff In 1991 Yoneda et al.,9 in a Level IV retrospective approach. The study consisted of 31 patients with a case series, reviewed the results of arthroscopic repair mean age of 39 years (range, 16 to 71 years). An of a type II SLAP lesion in 10 athletes (7 baseball, 2 absorbable tack was used to secure the superior la- volleyball, and 1 badminton). The mean age of the brum back to the glenoid rim. Six patients also under- patients was 17.8 years (range, 14 to 23 years), and all went subacromial decompression. The patients were were available for follow-up, which averaged 37.4 re-evaluated at a mean follow-up of 3.7 years (range, months (range, 24 to 47 months). The procedure con- 2.0 to 7.4 years). They were evaluated clinically by
OUTCOME OF TYPE II SLAP REPAIR 539 use of 5 different measurements of outcome: (1) Thirty patients were found to have grade 1 partial L’Insalata Shoulder Rating Questionnaire,15 (2) ASES articular-side rotator cuff tears and were treated by score, (3) active compression test, (4) visual pain scale (0 arthroscopic debridement. Patients were re-evaluated to 5 points), and (5) patient satisfaction. The mean by an independent examiner at a mean follow-up of 41 L’Insalata score was 87.0 points (SD, 14.1), the months (range, 24 to 58 months). They were assessed mean ASES score was 87.2 points (SD, 16.7), and the by use of the modified Rowe grading system.18 Ac- mean pain score was 1.5 points (range, 0 to 5 points). cording to this scoring system, the results were graded Overall satisfaction with the procedure averaged 3.7 as excellent in 30 patients, good in 6, fair in 4, and points (range, 0 to 5 points): 23 patients rated the poor in 0, translating into a success rate of 90%. Of the procedure as good to excellent, 6 patients rated the 40 athletes, 30 (75%) were able to return to their outcome as fair, and 2 patients were completely un- preinjury level of performance without limitation. satisfied with the treatment. Of the 31 patients, 16 Baseball players returned to their preinjury level of (52%) were able to return to their preinjury level of play in 12 of 19 cases (63%), whereas other overhead performance, 11 had a lower level, 2 were inactive, athletes returned in 18 of 21 cases (86%). and 2 were not commented upon. One patient sus- In 2006 Cohen et al.,19 in a Level IV retrospective tained reinjury, requiring repeat repair. An indepen- case series, examined the results of arthroscopic repair dent examiner was not identified, potentially introduc- of isolated type II SLAP lesions using bioabsorbable ing detection bias. tacks. The patient population consisted of 39 individ- In 2002 Kim et al.16 published a Level IV retro- uals with a mean age of 34 years (range, 16 to 56 spective study evaluating the results of arthroscopic years). All 39 patients were available to complete the repair of isolated superior type II SLAP tears using L’Insalata questionnaire at a mean follow-up of 44 suture anchors. The patient population comprised 34 months (range, 25 to 97 months). The results for the individuals (30 male) with a mean age of 26 years L’Insalata score averaged 86.7 for the group. Despite (range, 16 to 35 years). The 34 patients were available this good average score, only 27 of 39 patients (69%) for follow-up at a mean of 33 ⫾ 9 months (range, 24 had a self-rated good to excellent outcome, 7 had a fair to 49 months). The investigators evaluated the patients outcome, and 5 had a poor outcome. Of the 29 athletes using the UCLA scoring system, and the patients included in the study, 14 (48%) were able to return to evaluated shoulder function as a percentage of the their preinjury level of athletics. Only 3 of 8 throwers shoulder’s preinjury level using a visual analog scale returned to their previous level of play. Of the 39 (VAS). According to the UCLA scoring system, the patients, 33 were able to return for a physical ex- outcome was graded as excellent in 27 patients, good amination and to complete the ASES questionnaire. in 5, fair in 2, and poor in 0, for a success rate of 94%. There was a statistically significant difference in The patient assessment showed a slightly different ASES scores between the group of patients who un- outcome, with a satisfactory result in 91% of the cases derwent the rotator interval approach and those who (31 of 34 cases). The authors compared the difference had a trans–rotator cuff approach (P ⬍ .05). The in outcome between 2 subgroups: (1) non-overhead former group had a good to excellent rating of 82% (9 sports and (2) overhead sports. A statistically signifi- of 11 cases), and those in the latter group had a cant difference (P ⫽ .024) between the 2 groups was success rate of 55% (12 of 22 cases). An independent found, where 100% of patients in the non-overhead examiner was not identified, potentially introducing sports activity group had a good to excellent result detection bias. whereas 89% of patients in the overhead sports activ- In 2007 Coleman et al.20 reviewed the results of a ity group had a good to excellent result. Overall, 14 of Level IV retrospective case series that compared the the 34 patients (41%) were able to return to their outcome of type II SLAP repair with or without con- preinjury level of activity; however, only 4 of the 18 comitant acromioplasty. The study obtained follow-up overhead athletes (22%) were able to return to their in 50 of 73 patients who underwent type II SLAP preinjury level of performance without limits. An in- repair. Group 1 was composed of 34 patients who dependent examiner was not identified, potentially received treatment for isolated type II SLAP lesions. It introducing detection bias. appears from the description of the methods that the In 2005 Ide et al.17 examined the outcome of type II majority of these individuals were taken from the SLAP repair using suture anchors in overhead-throw- same patient pool that was used in the study of Cohen ing athletes in a Level IV case series. The 40 patients et al.,19 which leads to a redundancy in data. The mean had a mean age of 24 years (range, 15 to 38 years). age of this group was 34 years (range, 16 to 56 years),
540 K. GORANTLA ET AL. TABLE 1. Type II SLAP Repair Outcomes Concomitant Pathology Study Patients/Groups Repair Device (No. of Patients) Follow-up Yoneda et al.9 (1991) 10/1 Metal staple PRCT, 3; SI, 2 Mean, 37.4 mo (range, 24-47 mo) Samani et al.11 (2001) 25/1 Bioabsorbable PRCT, 13; SI, 19; nearly Mean, 35 mo (range, 24- tack FRCT, 1 51 mo) O’Brien et al.14 31/1 Bioabsorbable SI, 6 Mean, 3.7 yr (range, 2-7.4 (2002) tack yr) Kim et al.16 (2002) 34/1 Suture anchor N/A Mean, 33 ⫾ 9 mo (range, 24-49 mo) Ide et al.17 (2005) 40/1 Suture anchor PRCT, 30 Mean, 41 mo (range, 24- 58 mo) Cohen et al.19 (2006) 39/1 Bioabsorbable N/A Mean, 44 mo (range, 25- tack 97 mo) Coleman et al.20 50/2: isolated type II SLAP Bioabsorbable PRCT, not disclosed; SI, 16 Group 1: mean, 3.7 yr (2007) repair v SLAP repair tack (range, 2.6-6 yr); group with concomitant 2: mean, 3.3 yr (range, acromioplasty 2-7 yr) Enad et al.21 (2007) 27/1 Suture anchor PRCT, 4; chondrosis of Mean, 30.5 mo (range, humeral head or glenoid, 6; 24-42 mo) SI, 8 Enad and Kurtz22 36/2: isolated type II SLAP Suture anchor PRCT, 11; SI, 6; AC arthrosis, Group I: mean, 29.1 ⫾ 5.5 (2007) repair v SLAP repair 3; SI and AC arthrosis, 4; mo; group II: mean, with concomitant spinoglenoid cyst, 4; intra- 29.8 ⫾ 7.1 mo pathology repair articular loose body, 1 Yung et al.23 (2008) 16/1 Suture anchor N/A Mean, 27.6 mo (range, 24-31 mo) Boileau et al.24 (2009) 25/2: isolated type II SLAP Suture anchor N/A Mean, 35 mo (range, 24- repair v biceps tenodesis 69 mo) Brockmeier et al.25 47/1 Suture anchor PRCT, 24; SI, 23; AC, 4 Mean, 2.7 yr (range, 2.0- (2009) 4.1 yr) Abbreviations: PRCT, partial-thickness rotator cuff tear; SI, subacromial impingement; FRCT, full-thickness rotator cuff tear; preop, preoperatively; postop, postoperatively; N/A, not applicable; AC, acromioclavicular. and the mean time for follow-up was 3.7 years (range, groups’ SLAP tears were stabilized with a bioabsorb- 2.6 to 6 years). Sixteen patients formed group 2 and able tack. At follow-up, the patients completed a underwent SLAP repair, as well as a concomitant L’Insalata questionnaire, and a physical examination acromioplasty. The mean age of the combined group and ASES questionnaire were conducted by an inde- was 42 years (range, 33 to 71 years), and its mean time pendent examiner. According to both scoring systems, for follow-up was 3.3 years (range, 2 to 7 years). Both there was not a statistically significant difference in
OUTCOME OF TYPE II SLAP REPAIR 541 TABLE 1. Continued Outcome Measurement Return to Previous Level of Instrument and Results Outcome Performance Return to Play Potential Bias Pain rating system of Tibone 8/10 (80%) good to 5/10 (50%) Detection, selection et al.10 excellent, 1 fair, 1 poor UCLA mean, 18 preop and 22/25 (88%) good to 20/24 (83%) Detection, selection 32 postop; ASES mean, 42 excellent, 2 fair, 1 preop and 92 postop poor L’Insalata mean, 87; ASES 23/31 (74%) good to 16/31 (52%) Detection, selection mean, 87.2 excellent, 6 fair, 2 poor UCLA overall mean, 33.4; 32/34 (94%) good to 14/34 (41%), 100% of previous Overhead athletes, Detection, selection UCLA non-overhead mean, excellent, 2 fair, 0 level; 12/34, 90%-99% of 4/18 (22%) 34.3; UCLA overhead poor previous level with mild mean, 32.6 limitations; 8/34, moderate to severe limitations Modified Rowe mean, 27.5 36/40 (90%) good to 30/40 (75%) Baseball, 12/19 (63%); Selection preop and 92.1 postop excellent, 4 fair, 0 other overhead poor athletes, 18/21 (86%) L’Insalata overall mean, 86.7; 27/39 (69%) good to 14/29 (48%) Throwing athletes, 3/8 Detection, selection L’Insalata non-throwers excellent, 7 fair, 5 (38%) mean, 90.8; L’Insalata poor throwers mean, 75.9; ASES mean, 86.8 L’Insalata SLAP mean, 87.1; 35/50 (70%) good to Selection L’Insalata combination excellent, 9 fair, 6 mean, 85.1; ASES SLAP poor mean, 86.5; ASES combination mean, 85.8 UCLA mean, 30.4; ASES 24/27 (89%) good to 20/26 (77%) Detection, selection mean, 86.9 excellent, 3 fair, 0 poor UCLA SLAP mean, 30.2; 33 of 36 (92%) good to Detection, selection UCLA combined pathology excellent, 3 fair, 0 mean, 30.8; ASES SLAP poor 84.1, ASES combined pathology mean, 91.8 UCLA mean, 31.4 31.3% excellent, 43.8% 15/16 (94%) Overhead athletes, Detection, selection good, 25% poor 12/13 (92%) Constant SLAP repair mean, SLAP repair, 4/10 (40%) SLAP repair, 2/10 (20%); Selection 83; Constant tenodesis satisfied; tenodesis, tenodesis, 14/15 (93%) mean, 89 13/15 (87%) satisfied L’Insalata median, 93; ASES 41/47 (87%) good to 25/34 (74%) Baseball, 7/11 (64%); median, 97 excellent other overhead athletes, 13/17 (76%) outcome between the 2 groups. The SLAP group patients who underwent arthroscopic type II SLAP achieved a good to excellent result in 65% of cases (22 repair rated their treatment as good to excellent, for a of 34 cases), a fair result in 7 cases, and a poor result success rate of 70%. The authors state that 47 of the 50 in 5 cases. The combined group rated the treatment patients in the study were able to return to their good to excellent in 81% of cases (13 of 16 cases), fair preinjury level of competition; however, the fact that in 2 cases, and poor in 1 case. Overall, 35 of 50 the results in 15 patients were graded as fair or poor
542 K. GORANTLA ET AL. raises questions regarding their successful return to 36 cases). However, there was a statistically signifi- sports. Follow-up of 68.5% and the demographic dif- cant difference in the mean ASES (P ⬍ .04) and VAS ferences in the 2 groups add concerns of attrition and (P ⬍ .02) scores. Group II had a higher ASES score selection bias to the study. (91.8 points [95% confidence interval (CI), 89.2 to In 2007 Enad et al.,21 in a Level IV retrospective 94.4]) and a lower VAS score (0.7 ⫾ 0.7 points [95% case series, examined the outcome of arthroscopic CI, 0.4 to 1.0]) compared with group I (84.1 points type II SLAP repair in a military population using [95% CI, 77.9 to 90.3] and 1.6 ⫾ 1.3 points [95% CI, biodegradable suture anchors. They treated 30 pa- 1.0 to 2.2], respectively). The cohort was only tients, 27 of whom were available for follow-up at a matched based on age, and thus selection bias may mean of 30.5 months (range, 24 to 42 months). These have been introduced by not also controlling for other 27 patients were military personnel with a mean age of issues, such as arm dominance, acute versus chronic 31.6 years (range, 22 to 44 years). Patients with con- onset, activity level, and so on. An independent ex- comitant subacromial impingement underwent sub- aminer was not identified, potentially introducing de- acromial decompression (8 patients), whereas patients tection bias. with partial-thickness rotator cuff tears were treated In 2008 Yung et al.23 evaluated the effectiveness of by arthroscopic debridement. The clinical results were type II SLAP repair in a Level IV retrospective case assessed with the ASES questionnaire and the UCLA series. The patient population consisted of 16 patients scoring system. According to the UCLA scores, the who underwent isolated type II SLAP repair with results were deemed excellent in 4 patients, good in suture anchors. The mean age of the patients was 24.2 20, fair in 3, and poor in 0, producing a success rate of years (range, 15 to 38 years), with a mean follow-up 89% (good to excellent results in 24 of 27). Of the 26 of 27.6 months (range, 24 to 31 months). Postopera- athletes, 20 (77%) were able to return to their prein- tively, all patients were re-examined and UCLA jury level of athletics. An independent examiner was scores obtained. The authors found that the percent- not identified, potentially introducing detection bias. age of patients with positive Speed, Yergason, and Enad and Kurtz22 performed a Level III retrospec- O’Brien tests significantly decreased postoperatively, tive cohort study in the same year. In the previous although an independent examiner was not identified. study Enad et al.21 compared the outcome of SLAP Preoperatively, all patients had poor UCLA scores repair between those patients with isolated SLAP in- (mean, 18). Postoperatively, 31.3% of patients had an juries and those with concomitant pathologies. How- excellent UCLA score, 43.8% had scores graded as ever, a power analysis determined that the study good, and 25.0% had scores graded as poor. Twelve of population was insufficient. As a result, this study thirteen overhead athletes were able to return to their supplements the previous study with additional sub- preinjury activity level, but the authors suggest that jects allowing the authors to compare a group of elite athletes likely have a longer period of rehabili- military personnel with isolated type II SLAP lesions tation before they are able to return to competition. (group I) with an age-matched cohort with concomi- In 2009 Boileau et al.24 compared the outcome of tant shoulder pathologies (group II). Thus this study type II SLAP repair with that of biceps tenodesis in a includes redundant data. Thirty-six patients were in- Level III cohort study. In this prospective study 10 cluded in this study, with an overall mean age of patients with a mean age of 37 years (range, 19 to 57 31.6 ⫾ 7.8 years (range, 22 to 41 years) and a mini- years) had SLAP repairs with suture anchors, whereas mum follow-up of 24 months (29.1 ⫾ 5.5 months in 15 patients with a mean age of 52 years (range, 28 to group I and 29.8 ⫾ 7.1 months in group II). Each 64 years) had a biceps tenodesis performed. Patients group contained 18 patients. All SLAP lesions were were not randomized, and treatment option was based arthroscopically repaired with bioabsorbable suture on the age of the patient and surgeon preference. The anchors. The patients were evaluated with the ASES authors found an increase in Constant score in both and UCLA scoring systems. The ASES pain score groups (65 to 83 in the SLAP repair group compared (VAS) was also used when the 2 groups were being with 59 to 89 in the biceps tenodesis group), but a compared. There was no significant difference in much higher percentage of patients were satisfied with UCLA scores between the 2 groups, with 16 of 18 the results of the surgery in the tenodesis group patients reporting good to excellent results in group I (87% v 40%). In addition, a higher percentage of (2 fair) and 17 of 18 reporting good to excellent results athletes returned to their previous level of sports par- in group II (1 fair), which translated into an overall ticipation in the tenodesis group compared with the success rate of 92% (good to excellent results in 33 of SLAP repair group (87% v 20%). In this study phys-
OUTCOME OF TYPE II SLAP REPAIR 543 ical examinations were performed by an independent has the potential to skew the results in a positive examiner. direction. The retrospective nature of 10 of the studies Brockmeier et al.25 prospectively evaluated the out- introduces potential selection bias. come of arthroscopic repair of type II SLAP lesions in The outcomes noted in these studies are varied 2009. Of 61 patients, 47 (77%) were evaluated at a (Table 1). The general outcome for type II SLAP mean of 2.7 years (range, 2.01 to 4.06 years) postop- repair as determined by the authors is reasonable, and eratively. Outcome measures included ASES and the percentage of good and excellent results ranged for L’Insalata scores, a patient-reported satisfaction rat- all patients from 40% to 94%. A careful review of ing, and return to preinjury level of competition. Pre- outcomes of patients shows that some subsets may not operative and postoperative physical examinations fare as well. A frequently used measure of treatment were carried out by independent examiners. The me- success is return to previous level of performance dian ASES score increased from 62 to 97 postopera- before injury/surgery. For all athletes in these studies, tively, and the L’Insalata score increased from 65 to this ranged from 20% to 94%. Overhead athletes are 93. The median patient-reported satisfaction was 9 of the most challenging to return to the previous level of 10 and was significantly higher in patients with a performance for this diagnosis, and their return rate discrete traumatic SLAP lesion compared with those reflects this. Five studies reported these results. Over- with atraumatic injury (9 v 7). In addition, a higher all, 69 of 107 overhead athletes (64%) returned to percentage of athletes with a traumatic injury returned their preinjury level of play. In the 2 studies that to their preinjury level of competition compared with specifically examined a separate subset of baseball athletes with atraumatic injury (92% v 64%). A return players, the rate of return was lower in baseball play- to the preinjury level of competition was reported in ers compared with other overhead athletes: 63% com- 20 of 28 overhead athletes (71%) and 7 of 11 baseball pared with 86% in the study by Ide et al.17 and 64% players (64%). compared with 76% in the study by Brockmeier et al.25 In addition, Yung et al.23 suggest that elite over- head athletes who return to their preinjury level of DISCUSSION play may need a longer course of rehabilitation than other patients before returning to competition. These A type II SLAP tear is an injury that commonly results show the necessity of reporting baseball play- afflicts active individuals. It has been noted to cause ers’ and throwing athletes’ results as a separate subset significant issues for overhead-throwing athletes, par- ticularly baseball pitchers. We have systematically when describing the outcome for type II SLAP re- reviewed the literature to evaluate the outcome of type pairs. II SLAP repair and identified 12 studies that met the Surprisingly, the studies did not show a negative inclusion/exclusion criteria. In general, depending on impact of concomitant shoulder pathology on type II outcome measured, type II SLAP repair resulted in SLAP repair. In fact, counter-intuitively, Enad and reasonable overall successful outcomes. However, the Kurtz22 in their case-control study showed improved majority of studies lacked a high Level of Evidence, UCLA and ASES scores for patients who underwent making it difficult to determine the true outcome and additional surgical procedures in conjunction with most effective treatment option. type II SLAP repair. The score differences were small Except for 2 prospective studies, essentially all of and may not represent clinically important differ- the studies represented retrospective case series (Table ences, but additional pathologic diagnoses at least did 1) and thus represent a low Level of Evidence. We not result in worse results. Similarly, Brockmeier et developed our inclusion/exclusion criteria to deter- al.25 reported higher patient satisfaction scores in pa- mine the outcome of repair of type II SLAP tears. We tients who underwent concomitant acromioplasty and believe a minimum 2-year follow-up is necessary for labral repair compared with those who had only labral this injury to allow adequate time for return to a full repair. ASES and L’Insalata scores were not signifi- season of sports and that shorter follow-up may not cantly different between the 2 groups, and no signif- represent true outcome of repair. Most studies suf- icant differences in any of the outcome measures were fered from a variety of biases. Only 4 studies used an seen in patients with concomitant partial-thickness independent examiner to perform the physical exam- rotator cuff debridement or subacromial bursectomy. ination and evaluation at follow-up. The other 8 stud- Coleman et al.20 reported slightly decreased L’Insalata ies leave open the possibility for detection bias, which and ASES scores in patients with concomitant pathol-
544 K. GORANTLA ET AL. ogy, but the differences were minimal and would not 2. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman represent clinically worse outcomes. MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274- 279. The results of these studies were most commonly 3. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries reported using 3 popular outcome measures: UCLA, to the superior glenoid labrum. J Shoulder Elbow Surg 1995; ASES, and L’Insalata shoulder scores. The UCLA 4:243-248. 4. Altchek DW, Warren RF, Wickiewicz TL, Ortiz G. Arthro- shoulder score was used in 5 studies, and mean scopic labral debridement. A three-year follow-up study. Am J scores postoperatively ranged from 30.2 to 33.4. Sports Med 1992;20:702-706. The ASES score was used in 7 studies, and postop- 5. Cordasco FA, Steinmann S, Flatow EL, Bigliani LU. Arthro- scopic treatment of glenoid labral tears. Am J Sports Med erative mean scores ranged from 84 to 97. Mean 1993;21:425-430, discussion 430-431. L’Insalata scores in 4 studies postoperatively 6. Dessaur WA, Magarey ME. Diagnostic accuracy of clinical ranged from 85.1 to 93. These relatively high and tests for superior labral anterior posterior lesions: A systematic review. J Orthop Sports Phys Ther 2008;38:341-352. similar mean scores show the importance of includ- 7. Jones GL, Galluch DB. Clinical assessment of superior gle- ing several types of outcome measure, including noid labral lesions: A systematic review. Clin Orthop Relat activity measures and return-to-play data. The Res 2007;455:45-51. 8. Hegedus EJ, Goode A, Campbell S, et al. Physical examina- shoulder score results reflected better outcomes tion tests of the shoulder: A systematic review with meta- than the return-to-play data did, thus emphasizing analysis of individual tests. Br J Sports Med 2008;42:80-92, this point. discussion 92. 9. Yoneda M, Hirooka A, Saito S, Yamamoto T, Ochi T, Shino K. Arthroscopic stapling for detached superior glenoid labrum. CONCLUSIONS J Bone Joint Surg Br 1991;73:746-750. 10. Tibone JE, Jobe FW, Kerlan RK, et al. Shoulder impingement syndrome in athletes treated by an anterior acromioplasty. Clin After this systematic review of the results of a Orthop Relat Res 1985:134-140. series of Level III and IV studies, we conclude that 11. Samani JE, Marston SB, Buss DD. Arthroscopic stabilization arthroscopic repair of type II SLAP tears results in of type II SLAP lesions using an absorbable tack. Arthroscopy 2001;17:19-24. overall excellent results for individuals not in- 12. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. volved in throwing or overhead sports. This is even End-result study of factors influencing reconstruction. J Bone true in patients with significant pathology treated Joint Surg Am 1986;68:1136-1144. concomitantly. The results of type II SLAP repair in 13. Richards RR, An KN, Bigliani LU, et al. A standardized method for the assessment of shoulder function. J Shoulder throwing or overhead athletes are much less pre- Elbow Surg 1994;3:347-352. dictable. Although some of these athletes have suc- 14. O’Brien SJ, Allen AA, Coleman SH, Drakos MC. The trans- cessful outcomes, the rate is typically much lower rotator cuff approach to SLAP lesions: Technical aspects for repair and a clinical follow-up of 31 patients at a minimum of in this group, especially when return to the previous 2 years. Arthroscopy 2002;18:372-377. level of performance is the criterion for success. 15. L’Insalata JC, Warren RF, Cohen SB, Altchek DW, Peterson Future studies should be prospective in nature and MG. A self-administered questionnaire for assessment of symptoms and function of the shoulder. J Bone Joint Surg Am at least use a longitudinal prospective cohort design 1997;79:738-748. to determine predictors of outcome. Randomized 16. Kim SH, Ha KI, Kim SH, Choi HJ. Results of arthroscopic studies could be designed to compare outcomes treatment of superior labral lesions. J Bone Joint Surg Am 2002;84:981-985. between patients with SLAP repairs and potential 17. Ide J, Maeda S, Takagi K. Sports activity after arthroscopic alternative therapies, such as biceps tenodesis or superior labral repair using suture anchors in overhead-throw- tenotomy. Reporting of outcomes at a minimum ing athletes. Am J Sports Med 2005;33:507-514. must include validated shoulder outcome measures, 18. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 1978;60: validated activity scales, and return-to-play data. 1-16. The outcomes must be reported separately for 19. Cohen DB, Coleman S, Drakos MC, et al. Outcomes of throwing and non-throwing athletes. If these criteria isolated type II SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack. Arthroscopy 2006;22: are followed, then we will obtain Level I or II 136-142. evidence and improve our ability to counsel patients 20. Coleman SH, Cohen DB, Drakos MC, et al. Arthroscopic as to expected outcomes for these repairs. repair of type II superior labral anterior posterior lesions with and without acromioplasty: A clinical analysis of 50 patients. Am J Sports Med 2007;35:749-753. 21. Enad JG, Gaines RJ, White SM, Kurtz CA. Arthroscopic REFERENCES superior labrum anterior-posterior repair in military patients. J Shoulder Elbow Surg 2007;16:300-305. 1. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum 22. Enad JG, Kurtz CA. Isolated and combined Type II SLAP tears related to the long head of the biceps. Am J Sports Med repairs in a military population. Knee Surg Sports Traumatol 1985;13:337-341. Arthrosc 2007;15:1382-1389.
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