The Outcome of Type II SLAP Repair: A Systematic Review

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-                                                           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
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
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
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
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

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-
  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
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
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
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OUTCOME OF TYPE II SLAP REPAIR                                                     545

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