The American Journal of Sports
Medicine
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A Prospective Analysis of 179 Type 2 Superior Labrum Anterior and Posterior Repairs: Outcomes and
Factors Associated With Success and Failure
Matthew T. Provencher, Frank McCormick, Christopher Dewing, Sean McIntire and Daniel Solomon
Am J Sports Med 2013 41: 880 originally published online March 4, 2013
DOI: 10.1177/0363546513477363
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In-Depth
A Prospective Analysis of 179
Type 2 Superior Labrum Anterior
and Posterior Repairs
Outcomes and Factors Associated With
Success and Failure
CDR Matthew T. Provencher,*y MD, MC USN, LCDR Frank McCormick,z MD, MC USNR,
CDR Christopher Dewing,y MD, MC USN, LT Sean McIntire,y MD, MC USN,
and CDR Daniel Solomon,§ MD, MC USNR
Investigation performed at the Naval Medical Center San Diego, San Diego, California
Background: There is a paucity of type 2 superior labrum anterior and posterior (SLAP) surgical outcomes with prospective data.
Purpose: To prospectively analyze the clinical outcomes of the arthroscopic treatment of type 2 SLAP tears in a young, active
patient population, and to determine factors associated with treatment success and failure.
Study Design: Case-control study; Level of evidence, 3.
Methods: Over a 4-year period, 225 patients with a type 2 SLAP tear were prospectively enrolled. Two sports/shoulderfellowship-trained orthopaedic surgeons performed repairs with suture anchors and a vertical suture construct. Patients were
excluded if they underwent any additional repairs, including rotator cuff repair, labrum repair outside of the SLAP region, biceps
tenodesis or tenotomy, or distal clavicle excision. Dependent variables were preoperative and postoperative assessments with
the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability (WOSI) scores and independent physical examinations. A failure analysis was conducted to determine factors associated with failure: age, mechanism of injury, preoperative outcome scores, and smoking. Failure was defined as revision surgery,
mean ASES score below 70, or an inability to return to sports and work duties, which was assessed statistically with the Student
t test and stepwise logarithmic regression.
Results: There were 179 of 225 patients who completed the follow-up for the study (80%) at a mean of 40.4 months (range, 26-62
months). The mean preoperative scores (WOSI, 54%; SANE, 50%; ASES, 65) improved postoperatively (WOSI, 82%; SANE, 85%;
ASES, 88) (P \ .01). The mean postoperative range of motion was 159° of flexion, 151° of abduction, and 51° of external rotation at
the side, which was less than the mean preoperative range of motion (164° of flexion, 166° of abduction, and 56° of external rotation
at the side). Of the 179 patients, 66 patients (36.8%) met failure criteria. Fifty patients elected revision surgery. Advanced age within
the cohort (.36 years) was the only factor associated with a statistically significant increase in the incidence of failure. Those who
were deemed failed had a mean age of 39.2 years (range, 29-45 years) versus those who were deemed healed with a mean age of
29.7 years (range, 18-36 years) (P \ .001). The relative risk for failure for patients older than 36 years was 3.45 (95% CI, 2.0-4.9).
Conclusion: Arthroscopic SLAP repair provides a clinical and statistically significant improvement in shoulder outcomes. However, a reliable return to the previous activity level is limited; 37% of patients had failure, with a 28% revision rate. Age greater than
36 years was associated with a higher chance of failure. Additional work is necessary to determine the optimal diagnosis, indications, and surgical management for those with SLAP injuries.
Keywords: superior labrum anterior and posterior; biceps tenotomy; biceps tenodesis; arthroscopy; surgical outcomes
acceptable treatment.12 There is an increasing incidence
of surgically treated SLAP lesions.21 Snyder et al19 subclassified SLAP tears, with type 2 being the most common
and amenable to surgical repair. The patient satisfaction
after type 2 SLAP repairs ranges primarily from good to
excellent,3,5,6,10,13,16,23 but with an unsatisfactory returnto-play percentage.3,10,13,16 Nonoperative treatment may
also be effective and yield comparable results.8 Additionally, diagnosis of a SLAP tear at an older age (usually
With the development of shoulder arthroscopic surgery
and recognition of superior labrum anterior and posterior
(SLAP) tears,20 SLAP tears are recognized as a cause of
shoulder pain, and operative stabilization is deemed an
The American Journal of Sports Medicine, Vol. 41, No. 4
DOI: 10.1177/0363546513477363
Ó 2013 The Author(s)
880
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Vol. 41, No. 4, 2013
Prospective Analysis of 179 Type 2 SLAP Repairs
.50 years) has been associated with increased failures. In
this population, biceps tenodesis or tenotomy has been suggested as an alternative to repair.2 However, there is a paucity of surgical outcomes with prospective data
analysis2,3,10 with a sample size large enough to identify
failure rates or allow subgroup analysis of factors associated with failures.
The active-duty military population has a proportionately
high number of SLAP injuries14 attributed to the demands
of a military occupation, specifically traction injuries while
lifting. While this is not a throwing population, the traction
injury has been well described as a SLAP injury mechanism, with ensuing pain and disability attributable to the
SLAP traction injury.20 In addition, the military population
has unique but very codified, highly physical demands of
push-ups, pull-ups, lifting activities, and combat readiness
that are difficult to omit from daily routine. This repetition
may also produce more of a degenerative SLAP-type injury,
but these factors remain difficult to quantify.11
To better understand the outcomes of a SLAP tear in
a young, active population, we performed a prospective outcome analysis using validated outcome measures and independent physical examinations of patients surgically
treated for isolated type 2 SLAP tears.22 Moreover, we sought
to identify factors associated with either successes or failures
of surgical treatment. Our null hypothesis was that there
would be no statistical difference between preoperative and
postoperative outcome scores after surgical repair and that
independent variables would be predictive of outcome.
MATERIALS AND METHODS
After institutional review board approval was obtained,
between 2005 and 2008, a total of 225 patients were
enrolled in a longitudinal prospective cohort study at a
tertiary care center under the care of 2 sports/shoulder
fellowship-trained surgeons (M.T.P., D.S.). Inclusion criteria included patients aged 18 to 50 years with both a clinical examination and magnetic resonance arthrogram
(MRA) evidence for a type 2 superior labral tear who failed
nonoperative measures (activity modification and physical
therapy). All patients who underwent surgery for a potential SLAP tear had an MRA before surgery. Exclusion criteria were defined as the presence of any other
concomitant lesion, including a full-thickness rotator cuff
tear, symptomatic acromioclavicular joint arthrosis, or
881
a labral tear requiring a repair outside the SLAP region
(10:30-1:30 clock position of the superior labrum). In addition,
patients were also excluded if they underwent any additional
repairs at the time of surgery, including rotator cuff repair,
labrum repair outside of the SLAP region, biceps tenodesis
or tenotomy, or distal clavicle procedures (Figure 1).
On initial evaluation and presentation to the clinic, the
diagnosis of a type 2 SLAP tear was made upon a comprehensive history assessment, physical examination, and MRA
confirmation. Patients were offered enrollment into the prospective study once they were thought to meet clinical preoperative criteria; however, they were instructed that the
diagnosis of a type 2 SLAP tear would be confirmed intraoperatively to continue with the prospective study enrollment. If at any time the patients were found not to have
a type 2 SLAP tear, they were removed from the study.
All patients underwent an initial period of nonoperative
care including physical therapy (mean, 10.5 weeks; range,
4-24 weeks) and activity modification. Those with failed
results were offered surgical intervention for clinical history, examination, and radiographic findings consistent
with a type 2 SLAP tear.19
Surgical Technique
After consenting for surgical treatment, the patients
underwent a comprehensive examination under anesthesia in the lateral decubitus position. A diagnostic arthroscopic procedure was performed using a posterior viewing
portal and a midglenoid portal in the midportion of the
rotator interval with a 5-mm smooth plastic cannula. A
type 2 SLAP lesion was confirmed if there was separation
of the bone-labrum junction, with erythema at the SLAP
anchor insertion, and a minimum of 5 mm of excursion utilizing the Snyder et al19 criteria for determination of a type
2 SLAP tear. Additional pathological lesions were fully
documented in a comprehensive diagnostic glenohumeral
arthroscopic procedure with an arthroscope from both posterior and anterior directions. Once an isolated type 2
SLAP tear was confirmed, an 8-mm cannula was then
inserted in the midglenoid portal through the rotator interval. An arthroscopic elevator and a 3.5-mm bone-cutting
shaver were utilized to prepare the bony glenoid and
supraglenoid tubercle for the superior labral repair. Once
a bleeding superior glenoid base was confirmed under
arthroscopic surgery, the bone preparation was finalized
with an arthroscopic rasp.
*Address correspondence to CDR Matthew T. Provencher, MD, MC USN, Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800
Bob Wilson Dr. Ste 112, San Diego, CA 92134 (e-mail: matthew.provencher@med.navy.mil).
y
Sports Medicine Division, Department of Orthopedic Surgery, Naval Medical Center San Diego, San Diego, California.
z
Rush Orthopedic Sports Medicine Fellowship Program, Midwest Orthopedics at Rush, Chicago, Illinois.
§
Marin Orthopedics and Sports Medicine, Novato, California.
Presented at the 37th annual meeting of the AOSSM, San Diego, California, July 2011.
The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of
Defense, or the United States Government.
One or more of the authors has declared the following potential conflict of interest or source of funding: Dr Provencher is affiliated with the following:
AOSSM (board of directors, research), SOMOS (past president), AAOS (publications), BOS (research), ISAKOS (upper extremity), and AANA (program/
education). He also received the following research support: AOSSM Young Investigators grant (2005), AANA research grant (2008, 2006), and OREF grant
(2002, 2004, 2011). Moreover, he is involved with the following: Elsevier (deputy editor, Arthroscopy), JSES, JBJS, JAAOS, Slack (orthopedics, JKS), and
SAGE (AJSM). Dr Solomon participates in the following: Arthroscopy (editorial board) and AOSSM (board of directors). He has also received honoraria from
Arthrex and Pacific Medical for educational presentations within the past 5 years.
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882
Provencher et al
The American Journal of Sports Medicine
TABLE 1
Respondent Cohort Demographics of 179 Patients
Who Completed Follow-upa
Demographics
Age, mean (range), y
Sex, n (%)
Male
Female
Follow-up, mean (range), mo
Injury origin, n (%)
Traumatic
Atraumatic
Injury to dominant extremity, n (%)
No. of anchors required for repair, mean (range)
31.6 (18-45)
144 (80)
35 (20)
40.4 (26-62)
85
94
101
1.6
(47)
(53)
(56.4)
(1-2)
a
Consists of more than 80% of the total operative cohort.
Figure 1. Flow diagram of patient identification, enrollment
criteria, and study completion requirements. AC, acromioclavicular; PRCT, partial rotator cuff tear; RCT, rotator cuff tear.
The first anchor was then inserted at the posterior aspect
of the SLAP region near the posterior extent of the tear
(11-o’clock position). A 3.0-mm anchor (Bio-SutureTak;
Arthrex, Naples, Florida) was inserted in a percutaneous
fashion through a small 3-mm skin incision just off the lateral edge of the anterior acromion once the correct trajectory was finalized with an 18-gauge spinal needle. With
use of a sharp anchor inserter and drill guide, the guide
was passed through the muscle-tendon junction of the rotator cuff and then inserted in the 11-o’clock position (right
shoulder; 1-o’clock position for a left shoulder) of the glenoid,
just at the posterior base of the SLAP attachment. The
anchor was placed, and the suture left out through the percutaneous skin incision. From the anterior portal, an arthroscopic labral repair hook was used (Spectrum II; Linvatec,
Largo, Florida), just anterior to the biceps tendon and passed
around the biceps-labrum junction just posterior to the
biceps. A No. 1 polydioxanone (PDS) suture was brought
out the cannula and the No. 2 suture from the anchor shuttled for a simple vertical repair stitch. This was the post
suture, and the glenoid side suture was retrieved out of the
cannula. The sutures were shuttled on the superior aspect
of the biceps between the biceps and the capsule and then
tied with a sliding-locking knot (modified Roeder) with 3
alternating half-hitches. In cases with a labral injury and
clear superior labral tear that extended anteriorly to the 1o’clock position (n = 49), 1 additional anchor was placed anterior to the biceps-labrum junction in a similar fashion.
In patients with subacromial symptoms (n = 22), a bursal debridement was performed with the arthroscope in the
posterior portal and a combination of shaver and radiofrequency wand placed from the lateral portal. Only anterior
osteophytes of the anterior acromion were removed and
only performed in a minority of cases (n = 4); in the remainder (n = 18), a subacromial debridement was performed
with a complete anterior and anterolateral bursectomy.
All patients underwent the identical printed rehabilitation protocol with supervised physical therapy. Patients
used a sling for a total of 4 weeks with scapular mobility
and gentle passive range of motion, followed by progressive
full range of motion that started at 4 to 6 weeks postoperatively. Scapular exercises were started by 1 week, and
rotator cuff strengthening was instituted between 4 to 6
weeks postoperatively. At 3 months, patients were allowed
to return to light (nonthrowing/nonlifting) sports and
a work-specific strengthening regimen, with resumption
of full activities between 4 to 5 months. At 5 months, overhead lifting and sporting activities were allowed.
Surgical Outcomes
Patients were evaluated in the clinic preoperatively and postoperatively with a comprehensive history evaluation, independent physical examination, and assessment with
a battery of outcome scores that included the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric
Evaluation (SANE),7 and Western Ontario Shoulder Instability (WOSI) scores.17 The physical examination was performed
by an unblinded independent examiner and consisted of evaluation of a full range of motion in the supine position with
a goniometer, including flexion, abduction, abduction external
rotation (ABER), and abduction internal rotation (ABIR). The
examiners were not associated with the study, were aware of
the procedure but not patient details, and serially evaluated
the patients until final follow-up.
Subgroup Failure Analysis
A subgroup analysis was performed to identify factors
associated with surgical failure. Surgical failure was
defined as revision surgery or an ASES score of less than
70. In addition, patients were also evaluated to see if
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Prospective Analysis of 179 Type 2 SLAP Repairs
883
TABLE 2
Preoperative and Postoperative
Outcome Scores and ROMa
Preoperative,
Mean 6 SD
Outcome score
ASES
64.3 6 4.1
WOSI
980/2100b 6 32.1
SANE
50 6 5.4
ROM, deg
Flexion
164 6 7.2
Abduction
166 6 8.1
ER at side
56 6 3.9
ABER
86 6 6.6
ABIR
77 6 8.1
Postoperative,
Mean 6 SD
P Value
88.2 6 5.3
380/2100c 6 26.4
85 6 6.1
.01d
.01d
.001d
159
151
51
83
60
6
6
6
6
6
5.5
6.1
4.1
5.9
8.4
.042d
.039d
.38
.44
.29
a
There was a statistically significant improvement across each
patient-reported outcome measure. However, there was a statistically significant mean decrease in range of motion in forward flexion and abduction. ROM, range of motion; ASES, American
Shoulder and Elbow Surgeons; WOSI, Western Ontario Shoulder
Instability; SANE, Single Assessment Numeric Evaluation; ER,
external rotation; ABER, abduction external rotation; ABIR,
abduction internal rotation.
b
Converts to 54% of normal.
c
Converts to 82% of normal.
d
Statistical significance at P \ .05.
Figure 2. At a mean follow-up of 40.4 months (range, 26-62
months) after primary surgery of the 179-patient cohort, there
was a statistically significant improvement in overall outcome
parameters (P \ .01). The mean preoperative scores (WOSI,
54% 6 32.1%; SANE, 50% 6 5.4%; ASES, 65 6 4.1)
improved postoperatively (WOSI, 82% 6 26.4%; SANE,
85% 6 6.1%; ASES, 88 6 5.3). *Statistically significant
improvement (P \ .01). ASES, American Shoulder and Elbow
Surgeons; SANE, Single Assessment Numeric Evaluation;
WOSI, Western Ontario Shoulder Instability.
they could return to full military duty as well as their
desired sport. Variables that were assessed to be potential
predictors of surgical failure were tear origin (traumatic,
or a defined day of injury, vs atraumatic), smoker or nonsmoker, preoperative outcome scores, and age. Because
all of the patients treated for type 2 SLAP tears and
enrolled in the study had to perform overhead-lifting tasks
as part of their military duties, overhead athlete subcategorization was not included as a subgroup analysis.
Statistical Analysis
Statistical analysis included a stepwise linear regression
on the aforementioned preoperative variables to determine
overall success or failure. In addition, preoperative and
postoperative outcome scores and shoulder ranges of
motion were compared utilizing Student t tests, with a statistical significance set at P \ .05 utilizing XLSTAT-Pro
software package (Addinsoft, New York, New York). We
performed a prestudy power analysis based upon finding
a difference in a preoperative versus postoperative ASES
score of 20 points comparing failure versus success, with
a standard deviation of 7.4, which identified that a total
of 44 patients needed to be enrolled in the study.4
Figure 3. The mean postoperative range of motion,
assessed by an independent observer, was 159° 6 5.5° of
flexion (Flex), 151° 6 6.1° of abduction (Abd), and 51° 6
4.1° of external rotation (ER) at the side, which was less
than the mean preoperative range of motion. *Statistically
significant improvement (P \ .01). ABER, abduction external
rotation; ABIR, abduction internal rotation.
were 144 men and 35 women, with a mean age of 31.6 years
(range, 18-45 years). Approximately half (n = 85, 47.4%)
described a traumatic event to their shoulder, of which
almost all (97%) were traction injuries due to lifting heavy
objects. The remainder (n = 94, 52.6%) could not identify
an isolated event for their shoulder injury. There were 101
(56.4%) with the dominant extremity injured, and 130 were
right-hand dominant. A mean of 1.6 anchors were utilized
for repair (range, 1-2) of the type 2 SLAP injuries (Table 1).
RESULTS
Demographics
Surgical Outcomes
At a mean follow-up of 40.4 months (range, 26-62 months),
a total of 179 of 225 patients completed the study (mean
follow-up of 80%) (Figure 1). Of the 179 patients, there
There was a statistically significant improvement in overall outcome parameters and range of motion (P \ .01)
(Table 2 and Figures 2 and 3).
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884
Provencher et al
The American Journal of Sports Medicine
TABLE 3
Stepwise Logistical Regression Results of Independent
Factors Associated With Likelihood for Failure
Age .36 y at time of surgery
Smoking
Traumatic origin
Relative Risk for
Failure (95% CI)
P Value
3.45 (2.0-4.9)
1.10 (0.45-1.75)
1.25 (0.42-1.98)
.012a
.422
.355
a
Statistical significance at P \ .05.
TABLE 4
Characteristics of Success and Failure Subgroupsa
Age, y
ASES
WOSI
SANE
Failed Cases,
Mean 6 SD
Successful Cases,
Mean 6 SD
P Value
39.2
83.0 6 8.9
672/2100b 6 39
74 6 6.1
27.9
93.4 6 9.2
105/2100c 6 9
96 6 7.4
.01d
.021d
.01d
.001d
a
Figure 4. Flow diagram of surgical outcome analysis. A total
of 66 patients (66/179, 36.8%) met the failure criteria, and
28% underwent revision surgery, with biceps tenodesis
being the most common revision procedure. ASES, American Shoulder and Elbow Surgeons.
Subgroup Analysis of Surgical Failures
A total of 66 patients (66/179, 36.8%) were deemed to have
failures based on the aforementioned criteria (Figure 4). In
those with failures (n = 66), the mean time to failure was
11.8 months (range, 6-22 months), and mean postoperative
outcome scores of those with failures were much less than
those with successful outcomes. All patients with failures
had ASES outcome scores of less than 70 and a significantly
diminished range of motion versus those who were deemed
a success. A total of 16 of 66 patients were medically separated from the military, and the remaining 50 patients underwent revision shoulder surgery at a mean time of 12.9 months
(range, 8-26 months) after the index procedure. Those with
failed results had a mean age of 39.2 years (range, 29-45
years) versus those who were deemed healed with a mean
age of 29.7 years (range, 18-36 years) (P \ .001).
The group that underwent revision surgery (n = 44) had
a biceps tenodesis (n = 42), tenotomy (n = 4), or intra-articular
debridement (n = 4). Twenty of these patients also had subacromial debridement (no bony excision was performed).
The only factor associated with failure on regression
analysis was age (age .36 years; P \ .01) (Table 3). The relative risk for failure for patients older than 36 years was
3.45 (95% confidence interval, 2.0-4.9). A total of 51 patients
(51/66, 77%) with failures were over the age of 36 years, and
15 patients (15/66, 23%) were under the age of 36 years. The
remainder of the variables in the logistical regression were
When the cohort is separated into success and failure subgroups, the above characteristics of each group demonstrate
a bimodal distribution, which is clinically and statistically significant between the 2 groups. ASES, American Shoulder and Elbow
Surgeons; WOSI, Western Ontario Shoulder Instability; SANE,
Single Assessment Numeric Evaluation.
b
Converts to 68% of normal.
c
Converts to 95% of normal.
d
Statistical significance at P \ .05.
not associated with either success or failure, and origin of
injury (traumatic vs atraumatic), smoking history, and individual preoperative scores were not associated with success
or failure (P . .55 for all variables). Outcome scores
between successes and failures are listed in Table 4.
DISCUSSION
In this study, we sought to prospectively determine the shortterm and midterm clinical results in a large, young, and
active population with isolated type 2 SLAP tears. The principal findings of our study demonstrate that type 2 SLAP
tear repairs have a clinical and statistically significant
improvement using validated outcome scores. Thus, we reject
our null hypothesis. However, there is a large group (38%) of
patients who did not fare well after the surgery, with many
in the original primary repair cohort who met failure criteria
and eventually had revision surgery (28% of the cohort).
The overall outcome scores were improved across all
variables, demonstrating that the type 2 SLAP repair
does work, likely in the correctly selected patient. Our
data demonstrate a statistical and clinical improvement
across all validated outcome measures with moderate/
high correlation between outcome scores. This is in accordance with previously published short-term surgical
results in athletes and active patients for isolated SLAP
lesions: Friel et al10 reported good to excellent results in
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Vol. 41, No. 4, 2013
Prospective Analysis of 179 Type 2 SLAP Repairs
79% of 48 patients, with 89% patient satisfaction and an
8% reoperation rate; Cohen et al5 reported 69% good to
excellent results in 39 patients, with 71% patient satisfaction; Ide et al13 investigated overhead athletes and demonstrated 90% good to excellent outcome scores; Enad et al9
showed 88% good to excellent outcome scores; and Yung
et al23 reported on 12 young patients with good results.
However, our patients demonstrated an unexpectedly
high failure rate of 38%, with 28% of patients requiring revision. As previously mentioned, our cohort has a high athletic
activity requirement to remain on active duty. Our data are
not dissimilar to those of other authors who have published
difficulty with returning patients to their previous level of
activity after SLAP repair, especially with overhead athletes.
Of 2 prospective studies, Friel et al10 reported that 62% of
patients returned to play, 59% of overhead athletes, comparable with Brockmeier et al,3 who described that 74%
returned to play, with 71% returning to play as overhead athletes. A previous retrospective analysis by Ide et al13 showed
that 75% returned to play as overhead athletes; Kim et al16
showed that 63% returned to play but only 20% returned
to play as overhead athletes. Our findings are in contrast
to those of Enad et al,9 who demonstrated that 90% returned
to active military duty. Our failure rate is likely a comparable
measure of return-to-play rates.
Boileau et al2 suggested that biceps tenodesis is superior
to the repair of type 2 SLAP tears, especially in the older,
overhead-throwing athletic population. In a prospective
randomized study of 20 older overhead athletes, all patients
improved, with an equivocal outcome score between the 2
groups; 87% returned to play after tenodesis, whereas
only 20% returned to play after repair. Our study results
are in agreement. Based on our subgroup analysis, those
failing surgery were significantly older than those with
good outcomes. Although the terminal end point we defined
as ‘‘failure’’ may be debatable, it was decided to use rigorous,
yet realistic patient-derived criteria to provide meaningful
information regarding SLAP treatment. The age at which
we found one’s risk for failure with type 2 SLAP repair is
over 36 years. This is in contrast to the findings of Alpert
el al,1 who concluded that age was not a predictor of surgical
failure using outcome measurements based on a retrospective analysis of 52 patients divided into 2 groups (age \40
years and .40 years). However, this study was likely underpowered to find a difference, and it demonstrated a trend
toward worse outcomes in those over 40 years. Thus, in
older athletes with type 2 SLAP tears, the surgeon should
discuss the risks of type 2 SLAP repair versus biceps tenodesis at the initial surgery.15
Yet, with a young patient, our study demonstrates a clear
benefit to arthroscopically repairing the SLAP tear. The
young cohort had excellent outcomes and a desirable and reasonable return-to-duty percentage. The younger group (\36
years) had higher outcome scores and higher level of function
throughout versus those who were over the age of 36 years.
There may be some protective function of the biceps, especially as it relates to overhead activity and a secondary shoulder stabilizer.18 Thus, given our excellent outcome scores in
the younger subgroup, it may be wise to repair the biceps
lesion while leaving tenodesis as an option for revision.
885
The major strength of our study is its methodology. We
performed a prospective study with 80% follow-up at
a mean follow-up of 3.5 years and assessed patients with
multiple validated outcome measurements and an independent physical examination. Moreover, strict inclusion
and exclusion criteria were used, notably excluding concomitant pathological abnormalities. Finally, with our
large cohort, we were able to perform subgroup analysis
and identify factors associated with failures supported by
clinically meaningful statistical findings.
Our study of only an active military population creates
some external validity concerns that our results may not
be generalizable to other patient cohorts. However, this
study does encompass a working and lifting population
with documented isolated SLAP lesions and is certainly generalizable to some degree. Despite a limited overheadthrowing population, all patients are required to meet minimum standards of fitness, including push-ups and pull-ups,
and suitability for combat operations. The need for all military members to meet this minimum may be reflected in our
high failure rate despite a mean improvement in the shoulder outcome measurements. In addition, our failure definition parallels the return to athletic activity rate previously
published in the literature. Another concern is that all surgical repairs were performed by 2 surgeons who used an
identical repair technique. Repair security may have been
an issue with 1.6 anchors used per case and a simple suture
pattern. Also, as a response to the high failure rate and the
resultant diminished range of motion in those failures, our
rehabilitation protocols have since been modified. We now
are more aggressive in regaining range of motion. There is
also an element of selection bias by those who chose to enroll
in the study. Finally, there is a potential for response bias
from the 20% of patients who did not complete the study
and were not available for final evaluation.
CONCLUSION
Arthroscopic SLAP repair provides a clinical and statistically
significant improvement in shoulder outcomes. However,
a reliable return to the previous activity level is limited,
and within this population, 37% of patients failed, with
a 28% revision rate. Age greater than 36 years was associated with a higher chance of failure. Additional work is necessary to determine the optimal diagnosis, indications, and
surgical management for those with SLAP injuries.
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REFERENCES
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