A new anatomic technique for type II SLAP lesions repair

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Knee Surgery, Sports Traumatology,Arthroscopy ISSN 0942-2056 Knee Surg Sports Traumatol ArthroscDOI 10.1007/s00167-014-3440-4

A new anatomic technique for type II SLAPlesions repair

Alessandro Castagna, Silvana De Giorgi,Raffaele Garofalo, Silvio Tafuri, MarcoConti & Biagio Moretti

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Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-014-3440-4

SHOULDER

A new anatomic technique for type II SLAP lesions repair

Alessandro Castagna · Silvana De Giorgi ·

Raffaele Garofalo · Silvio Tafuri ·

Marco Conti · Biagio Moretti

Received: 11 July 2014 / Accepted: 11 November 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014

to return to their preinjury level. No complications were

observed in the present study.

Conclusion In our technique, the anatomy is respected

leaving the articular aspect of the superior labrum loose

and reinforcing the medial side. The clinical relevance of

this work is that probably this technique could improve

clinical results, giving a better mobility of the shoulder and

a return to the same preoperative level in overhead athletes.

Keywords SLAP lesion · Arthroscopic SLAP repair ·

Shoulder

Introduction

Superior glenoid lesions or SLAP lesions are infrequent but

important causes of shoulder pain and disability [19, 29].

Extremely variable presentations with non-specific clini-

cal and radiographic findings make preoperative diagnosis

of superior glenoid lesions difficult [9, 15, 22], therefore it

is a controversial topic for treatment and outcomes [1, 12].

Generally SLAP lesions present with shoulder pain and

mechanical symptoms such as clicking, catching or pop-

ping. These lesions can usually be diagnosed and managed

arthroscopically after careful assessment of the SLAP com-

plex. The standard arthroscopic repair of a SLAP II lesion

may result in a residual pain and stiffness of the shoulder

in overhead athletes [5, 6, 13, 26], and the return to elite

throwing sports particularly at the same preoperative level

remains challenging [11, 21]. The restoration of the real

anatomy can probably improve clinical outcomes and sport

performances, even if the reported literature about this

topic is lacking.

The superior and middle gleno-humeral ligaments usu-

ally attach to the anterior–superior labrum, which is loosely

Abstract

Purpose A new and more anatomical technique for SLAP

II lesions repair is described. It consists in the reattachment

of the medial aspect of the biceps anchor to the superior

glenoid neck with a mattress stitch posterior and medial to

the biceps anchor and a simple stitch placed anteriorly to

the biceps.

Methods From 2011 to 2012, 14 patients matching the

inclusion criteria were selected for the study. A visual ana-

logic scale, ROWE, UCLA, ASES and Constant scores

were used to make evaluation. The passive ROM before

surgery, at final follow-up, and the resumption of sports

activities were analysed.

Results The Constant, ASES, UCLA and ROWE scores

passed from 64.6 (SD 13.9), 76.9 (SD 22.4), 28.4 (SD 23.8)

and 53.6 (SD 20.6) to, respectively, 92.6 (SD 11.8), 108.3

(SD 8.5), 33.6 (SD 2.7) and 96.5 (SD 7.2) at final follow-

up. Of the four patients who had participated in agonistic

overhead athletics preoperatively, all of them were able

A. Castagna · M. Conti Shoulder and Elbow Unit, IRCCS Humanitas Institute, Rozzano, Milan, Italy

S. De Giorgi (*) · B. Moretti Department of Basic Medical Sciences, Neurosciences and Sensory Organs, University of Bari, Piazza G. Cesare 11, 70124 Bari, Italye-mail: [email protected]; [email protected]

R. Garofalo Shoulder Service, Miulli Hospital, Acquaviva delle Fonti, Bari, Italy

S. Tafuri Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy

Author's personal copy


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attached to the glenoid. The biceps anchor inserts for 40–

60 % of its fibres on the supra-glenoid tubercle of the scap-

ula, 5 mm medially to the joint rim and for the rest on the

glenoid labrum [30].

Therefore, during surgery for SLAP repair, the mobil-

ity of the labrum must be preserved, because if it is firmly

fixed to the glenoid, the risk of severe loss of rotation could

be high. Nevertheless, the stability of the LHB anchor must

be restored, thus stabilizing also the insertions of the SGHL

and MGHL [25], to reestablish the stabilizing effect of the

biceps tendon for the shoulder joint. Traditional techniques

of SLAP lesions repair often strangle the LHB giving a

high rigidity to the labrum which looses its mobility. Thus,

a certain stiffness of the shoulder often occurs.

The aim of this retrospective study was to verify the

preliminary results of arthroscopic repair of type II SLAP

lesions using a new and more anatomical repair tech-

nique. Our hypothesis was that arthroscopic repair of type

II SLAP tears with this technique could lead to better out-

comes than traditional repair.

Materials and methods

A retrospective case series study about the results of a

new technique for anatomical SLAP II lesions repair with

a short-term follow-up was performed. A SLAP II lesion

was considered to be a complete detachment of the supe-

rior labrum and biceps anchor from the superior glenoid

tubercle, besides certain fraying of the edge of the labrum

[29, 31]. It could be possible to observe a chondral dam-

age, chronic or acute changes to the undersurface of

the labrum. Nine males (64.3 %) and five females aged

28.4 ± 6.6 years were included in this study. The mean

follow-up was 12.7 ± 7.4 months (range 5–24). The domi-

nant arm was involved in ten cases (71.4 %), while the

right arm was involved in 78.6 % of the cases. The surgery

was carried out by the same senior surgeon. Every single

patient was assessed before and after surgery by the passive

ROM and using the Constant score (1987), the ASES score

[24], the UCLA and the ROWE score. The O’Brien and the

painful apprehension tests were used for clinical diagnosis

[14]. All the patients underwent an arthro-MRI for imaging

confirmation before surgery. The load and shift and drawer

tests were performed on all the patients. No ganglion cyst

of the spino-glenoid notch was present in the arthro-MRI

and during surgery [17].

For each enroled patient, a standardized form reporting

demographic data (age, sex), time of follow-up, dominant

arm (right/left), affected shoulder, passive ROM, Constant

score, ASES score, UCLA, ROWE score, O’Brien test, at

the time of the surgery (time zero) and at the time of fol-

low-up (6 months and final follow-up) was completed.

All the patients were surgically treated for pain or inability

to perform sports, after a period of at least 6 months of failed

conservative management (physiotherapy, rest, drugs, etc.).

Fig. 1 Using a probe, the SLAP type II lesion was confirmed accord-ing to the existence of a complete detachment of the biceps anchor from the superior glenoid tubercle, besides certain fraying of the edge of the labrum

Fig. 2 Using the anterior portal, a bioabsorbable anchor loaded with two sutures (Lupine Depuy Mitek) was inserted into a predrilled hole in the glenoid rim just below the biceps anchor, 2–3 mm medial to the articular surface (12 o’clock position)



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Description of the technique used

All patients were operated by the same senior surgeon

(A. C). In our daily practice, an arthroscopic surgery under

interscalene block anaesthesia with the patients in the lat-

eral decubitus position is usually performed. A standard

posterior viewing portal and an accessory antero-superior

working portal, high in the rotator interval region, using

the inside-out technique were created. An evaluation of the

rest of the intraarticular structures of the shoulder (cuff,

biceps tendon, articular surface), apart from the superior

labrum, was carried out in order to confirm the presence

of concurrent pathologies. Then, using a probe, the SLAP

type II lesion was confirmed (Fig. 1) according to the exist-

ence of a complete detachment of the biceps anchor from

the superior glenoid tubercle, besides certain fraying of

the edge of the labrum [29]. A 4.5 mm shaver was used in

order to regularize the edge of the superior labrum when

necessary and debride to bleeding bone, the superior part

of the glenoid neck. Using the anterior portal, a bioabsorb-

able anchor loaded with two sutures (Lupine Depuy Mitek)

was inserted into a predrilled hole in the glenoid rim just

below the biceps anchor, 2–3 mm medial to the articular

surface (12 o’clock position; Fig. 2). With the help of a

suture passer, a free non-reabsorbable monofilament suture

was passed through the posteromedial aspect of the biceps

anchor, from superior and medial to inferior and lateral,

emerging just under the posterior aspect of the superior

labrum (Fig. 3). The intraarticular end of this monofilament

suture was retrieved through the antero-superior portal, in

order to shuttle one of the limbs of the sutures in the anchor

through the labrum (Fig. 4). The other limb was passed

through the labrum adjacent to the biceps, a few millime-

tres anterior to the first one, thus creating a mattress stitch

(Figs. 5, 6, 7). The horizontal mattress suture should not

crossover point “A” (anterior edge of LHB on the labrum)

because no LHB fibre was sent anterior to the anterior edge

of the supraglenoid tubercle [2, 25]. Using the same suture

passer technique, one of the limbs of the second suture of

the anchor was passed through the superior labrum at the

level of the insertion of the MGHL and the SGHL, creating

a simple stitch (Figs. 8, 9, 10, 11). Finally, the biceps and

labral stability were tested with a probe.

Post-operatively, the patients were protected in a sling

in neutral rotation and 20° of abduction for 3 weeks. They

were limited to early pendular shoulder exercises with a

gradual progression of forward flexion from 90° to 150°

over 6 weeks. Strengthening exercises begun 6 weeks after

the operation in a progressive strengthening programme.

The patients were advised to avoid vigorous sports activi-

ties for 6 months after the operation.

This study was approved by the Institutional Review

Board of our Institute (IRCCS Humanitas Institute,

Rozzano, Milan, Italy). Prior to enroling in the study, all

patients were informed of the details of the operation tech-

nique, and they gave their consent to participate in the

study.

Fig. 3 With the help of a suture passer, a free non-reabsorbable monofilament suture was passed through the posteromedial aspect of the biceps anchor from superior and medial to inferior and lateral, emerging just under the posterior aspect of the superior labrum

Fig. 4 The intraarticular end of this monofilament suture was retrieved through the antero-superior portal in order to shuttle one of the limbs of the sutures in the anchor through the labrum



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Statistical analysis

All information collected for each patient was reported in a

standardized form. Completed forms were computerized in

a database created by File Maker Pro. Data were analysed

by STATA MP11 software.

Sample size calculation, carried out on the basis of pre-

liminary data on the trend of visual analogic scale (VAS)

mean values in the times of follow-up and considering a

Fig. 5 The other limb was passed through the medial aspect of the biceps a few millimetres anterior, thus creating a mattress stitch



Fig. 8 Using the same suture passer technique, one of the limbs of the second suture of the anchor was passed through the superior labrum at the level of the insertion of the MGHL and the SGHL, cre-ating a simple stitch. All the knots were tied behind the biceps anchor and medial to the labral tissue to avoid prominence of the knot adja-cent to articular cartilage. Finally, the biceps and labral stability were tested with a probe



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margin of error of 5 % and a confidence level of 95 %, con-

firmed a minimum sample of ten.

Qualitative variables were expressed as proportions

using the Chi-square test for the comparison. Quantitative

variables were expressed as a mean with a standard devia-

tion. For the comparison of the means at different times,

a Student’s t test for paired samples was used. A multiple

logistic regression model to evaluate a relationship with

age, sex, sport of the examined parameters was performed.

The level of significance was set at p < 0.05.

Results

Of the 14 patients operated with this technique from 2011

to 2012, all the patients had isolated SLAP II lesions.

The number and proportion of patients with positive

O’Brien sign was 12 (85.7 %) at time zero and 1 (7.1 %) at

6 months and at final follow-up (Table 1).

Means of Constant, ASES, ROWE, SST scores and VAS

(Visual Analogue Scale for pain evaluation) statistically

improved from time zero to 6 months and from 6 months to

final follow-up (Table 2).

The number and proportion of patients who referred to

practice sports was 12 (85.7 %) at time zero, 10 (71.4 %) at

6 months follow-up and 10 (71.4 %) at final follow-up. Of

the four patients who had participated in overhead agonistic

athletics preoperatively (volleyball and tennis), all the four

were able to return to their preinjury level.

The mean value of passive abduction (ABD), external

rotation with arm at side (ER1) and external rotation with

90° of abduction of the arm (ER2) did not differ in the

three times of evaluation (n.s.). Anterior flexion of the arm

(AF) and internal rotation of the arm (IR) was increased

from 6 months to final follow-up (Table 3).

The Apprehension and relocation tests were positive in

eight patients before surgery and negative in all the cases after

surgery. No complications were observed in the present study.

Clinical scores were better in male patients, if the domi-

nant arm was involved, and in older patients (low signifi-

cance). Passive ROM was not reduced by surgery (Table 3).

Discussion

The most important finding of the present study was that

all throwing athletes returned to their preinjury level sport.

Therefore, a meticulous respect of the real anatomy in the

surgical procedure is promising in clinical outcomes.





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Repair of the type II SLAP lesions has been shown to be

a successful procedure in the young overhead athlete; nev-

ertheless, recent literature reported that the ability to return

to preinjury level of sports remains a concern [20, 21].

Promising results are published for both biceps tenodesis

and labral repair [18, 28].

Several techniques of SLAP II lesions repair are

described, differing in the portals and numbers of anchors

[23], but they are all related to the labral stability without

understanding the anatomy we are aiming to restore. As a

matter of fact, over-tensioning the biceps anchor and the

superior labrum may lead to residual stiffness and clinical

symptoms.

The outcome of treatment of type II SLAP repairs

depends on several factors. These include associated

shoulder pathology, mechanism of injury, patient expec-

tations and the age of the patient. Recent clinical studies

have started to show that a certain population of patients

may, in fact, do better with biceps tenodesis, tenotomy or

debridement [5]. Better function, pain relief and larger

ROM were observed in patients undergoing debridement of

type II SLAP lesions when compared with repair of type

II SLAP lesion [1]. Biceps tenodesis is an option, alterna-

tive to labrum reinsertion using suture anchors for repair of

unstable isolated type II SLAP lesions, even for overhead

athletes [5]. RTC repair and biceps tenotomy leads to bet-

ter clinical outcome based on UCLA score and ROM when

compared with repair of both the RTC tear and type II

SLAP lesion in patients over 50 [12]. The utility of repair-

ing type II SLAP tears in the older patient population has

been recently questioned [1, 3].

Kim et al. [16] reported 90 % association with other

lesions, i.e. rotator cuff tear and Bankart lesion. Rota-

tor cuff lesions were more common in patients older than

40 years old, whereas Bankart lesions were more com-

monly seen in patients aged <40 years old [7]. In this


Table 1 Detailed list of the enroled patients including sports, func-tion and symptoms before surgery

Enroled patients

Elite throw-ing sport performed

Constant score preopera-tive ± SD

O’Brien sign

Apprehen-sion and relocation test

14 4 64.6 ± 13.9 12 8

Table 2 Mean values and standard deviations with statistical analysis of Constant, ASES, ROWE scores, VAS and SST at time zero, 6 months follow-up and at final follow-up

Scores Time zero ± SD Follow-up 6 months ± SD Time zero versus 6 months Final follow-up ± SD 6 versus 12 months

Constant 64.6 ± 13.9 80.7 ± 25.1 t = 1.9P = 0.04

926 ± 11.8 t = 6.5P < 0.0001

ASES 76.9 ± 22.4 100.6 ± 7.5 t = 3.8P = 0.001

108.3 ± 8.5 t = 5.0P = 0.001

ROWE 53.6 ± 20.6 88.6 ± 10.1 t = 7.4P < 0.0001

96.5 ± 7.2 t = 7.8P < 0.0001

VAS 5.7 ± 3.4 2.1 ± 1.5 t = 6.4P < 0.0001

0.57 ± 0.93 t = 5.7P < 0.0001

SST 6.9 ± 2.1 8.5 ± 0.6 t = 2.5P = 0.013

9.1 ± 0.9. t = 3.1P = 0.0039



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paper, only the patients without concomitant lesions were

included, to avoid any bias.

In the reported technique, a single anchor with two

sutures and a mattress suture configuration to attach the

medial insertion of the LHB origin to the glenoid rim was

used, according to the biomechanical findings of Domb

et al. [10] and Baldini et al. [4] who proved this configura-

tion to be the strongest one, avoiding to strangle the biceps

and alter the normal labral looseness on the articular rim. A

portal through the rotator cuff was not used because it may

be associated with poorer outcomes [8], while the repair of

an isolated type II SLAP lesion through a single anterior

portal is clinically and functionally beneficial to patients

regardless of the suture configuration [27], even if a small

cuff perforation for a drill guide and small anchors have not

been identified as a risk issue.

The main difference with a standard repair is that in the

reported technique, a mattress stitch to reinsert the medial

supratubercle origin of the biceps fibres at the medial side

of the biceps anchor and a simple stitch anteriorly through

the superior labrum at the level of the insertion of the

MGHL and the SGHL are applied, thus stabilizing those

ligaments. In the standard repair, two simple stitches are

applied anteriorly and posteriorly to the biceps, and this

can strangle it and can create pain with a loss of mobility

of the joint.

In the reported technique, the anatomy is respected:

the articular aspect of the superior labrum is loose and

the medial side reinforced. Thus, the clinical relevance

of this work is that a meticulous respect of the original

anatomy in the surgical procedure can improve outcomes

and resumption of sports activities, above all in overhead

athletes.

The weak points are that the follow-up is short, the sam-

ple is not large but it is homogeneous, because patients

with associated lesions were excluded. Another weak point

is that there was no control group, and that this paper has

a retrospective design. The clinical relevance of this work

is that an anatomical surgical procedure could give better

outcomes and prevent stiffness of the shoulder in overhead

athletes. Prospective studies with longer follow-up and

more patients in the sample are necessary to definitively

establish the superiority of this technique.

Conclusion

An anatomic surgical technique for a SLAP II lesion repair,

such as the one described in the present paper, can improve

clinical outcomes, avoiding stiffness and allowing resump-

tion of the throwing activities.

Acknowledgments Many thanks to Chiementin Tiziana and Paolini Donata for their kind contribution to the figures included in this paper.

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A new anatomic technique for type II SLAP lesions repair

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