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Arthroscopic Repair of SLAP Lesions

  • Editor(s): Todd W Thomsen, MD, Gary S Setnik, MD, FACEP
  • Section Editor(s): Phillip M Harter, MD
  • Contributor(s): Carmie Chan, MD
PRE-PROCEDURE
INDICATIONS
  • Type I: debridement
  • Type II: debridement and attachment of biceps anchor
  • Type III: debridement of flaps with possible repair
  • Type IV: excision if tendon propagation less than one third; otherwise repair
  • A Bankart repair will be necessary for lesions that extend inferiorly.
  • A posterior capsule release may be required if GIRD is present.
CONTRAINDICATIONS
  • Patients with medical comorbidities that prevent surgery
  • Incidentally discovered lesions without symptoms
EQUIPMENT
  • Shoulder arthroscopy equipment
  • Suture anchors (e.g., Arthrex Bio-FASTak, Arthrex BioSutureTak) and associated equipment (e.g., Arthrex Spear Guide, Arthrex BirdBeak suture passers, Arthrex Surgeon's Sixth Finger)
ANATOMY
  • The labrum encircles the glenoid, increasing its depth around the humeral head, and thus provides increased stability.
    • Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally.
  • The labrum consists of dense fibrocartilaginous tissues and some elastic fibers.
    • It acts as a fibrocartilaginous anchor.
      • On the inner side, the labrum is continuous with the hyaline cartilage of the glenoid.
      • On the outer side, the labrum is continuous with the fibrous tissue of the capsule.
      • The capsule and ligaments of the shoulder, including the biceps tendon, are attached to and become part of the glenoid labrum, which in turn attaches to the glenoid.
  • The labrum is triangular in cross section and varies in size and thickness.
  • The glenoid labrum is supplied by branches of the suprascapular artery, the circumflex scapular artery, and the posterior humeral circumflex artery.
    • The vascular supply is typically limited to the outermost aspect, with the inner rim being relatively avascular.
      • This is akin to the menisci in the knee.

PROCEDURE
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Anterosuperior portal to access superior glenoid for suture anchor placement, suture passing, and knot tying. Portal is typically located 1 cm off anterolateral tip of acromion. Anterosuperior portal provides 45-degree angle of approach to corner of superior glenoid. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 3 :  Anterosuperior portal to access superior glenoid for suture anchor placement, suture passing, and knot tying. Portal is typically located 1 cm off anterolateral tip of acromion. Anterosuperior portal provides 45-degree angle of approach to corner of superior glenoid. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.

Type II SLAP lesion easily displaceable from glenoid rim. From Phillips BB: Arthroscopy of the upper extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
Figure 4 :  Type II SLAP lesion easily displaceable from glenoid rim. From Phillips BB: Arthroscopy of the upper extremity. In Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

Bone bed is prepared beneath superior labrum via anterior cannula using motorized shaver to debride down to bleeding bone bed. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 6 :  Bone bed is prepared beneath superior labrum via anterior cannula using motorized shaver to debride down to bleeding bone bed. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.

Arthroscopic suture anchor insertion. <B>A</B>, 3.5-mm Arthrex Spear delivery guide placed through anterosuperior portal beneath root of biceps. Angled opening of Spear guide allows retraction of biceps-superior labral complex by guide while viewing the instrumentation through the angled mouth. Pilot hole for suture anchor produced by 2-mm punch. <B>B</B>, 3-mm tap placed through delivery device to create threaded channel for suture anchor. <B>C, D</B>, 3-mm biodegradable BioFASTak suture anchor, placed through guide to prethreaded channel, may accommodate 1 or 2 sutures. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 7 :  Arthroscopic suture anchor insertion. A, 3.5-mm Arthrex Spear delivery guide placed through anterosuperior portal beneath root of biceps. Angled opening of Spear guide allows retraction of biceps-superior labral complex by guide while viewing the instrumentation through the angled mouth. Pilot hole for suture anchor produced by 2-mm punch. B, 3-mm tap placed through delivery device to create threaded channel for suture anchor. C, D, 3-mm biodegradable BioFASTak suture anchor, placed through guide to prethreaded channel, may accommodate 1 or 2 sutures. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.

Posterolateral portal (Port of Wilmington) used to place a suture anchor in posterosuperior quadrant of glenoid. <B>A</B>, Portal located 1 cm lateral and 1 cm anterior to posterior acromial angle. <B>B</B>, Intraarticular view of angle of approach to posterosuperior glenoid afforded by this portal (left shoulder, posterior viewing portal). From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 8 :  Posterolateral portal (Port of Wilmington) used to place a suture anchor in posterosuperior quadrant of glenoid. A, Portal located 1 cm lateral and 1 cm anterior to posterior acromial angle. B, Intraarticular view of angle of approach to posterosuperior glenoid afforded by this portal (left shoulder, posterior viewing portal). From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.

Arthroscopic suture passage. <B>A</B>, 45-degree suture passer (BirdBeak) penetrates the labrum from superior to inferior at the posterior root of the biceps. <B>B</B>, BirdBeak captures suture limb from anchor and is then withdrawn to pull suture limb out of anterosuperior cannula. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 9 :  Arthroscopic suture passage. A, 45-degree suture passer (BirdBeak) penetrates the labrum from superior to inferior at the posterior root of the biceps. B, BirdBeak captures suture limb from anchor and is then withdrawn to pull suture limb out of anterosuperior cannula. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.

<B>A</B>, Secure arthroscopic knots are tied using arthroscopic double-diameter knot pusher (Surgeon's Sixth Finger). <B>B</B>, Suture loop that provides labral fixation at posterior biceps root is most critical to resist peel-back forces. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 10 :  A, Secure arthroscopic knots are tied using arthroscopic double-diameter knot pusher (Surgeon's Sixth Finger). B, Suture loop that provides labral fixation at posterior biceps root is most critical to resist peel-back forces. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.

<B>A</B>, After repair with arm in neutral position. <B>B</B>, After repair with arm in abduction and external rotation. Biceps vector shifted posteriorly, but labrum does not shift medially because peel-back forces have been successfully neutralized by sutures. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.
Figure 11 :  A, After repair with arm in neutral position. B, After repair with arm in abduction and external rotation. Biceps vector shifted posteriorly, but labrum does not shift medially because peel-back forces have been successfully neutralized by sutures. From Burkhart SS, Morgan CD, Kibler B: The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 2003;19:531.


POST-PROCEDURE
CARE

The protocol was developed for patients after SLAP repair. Surgery and rehabilitation will differ depending on the type of lesion. Types I and III lesions usually are treated with debridement. The biceps tendon is stable, so postoperative rehabilitation can usually progress as tolerated. Types II and IV lesions indicate an unstable biceps tendon requiring repair. This protocol addresses range of motion (ROM) limitations and limited active biceps work necessary for the type II/IV repairs. This is a guideline and may be adjusted to the clinical presentation as well as the doctor's guidance.
COMPLICATIONS
  • As with any arthroscopic procedure in the shoulder, there is a risk of infection and brachial plexus neuropathy.
  • Persistent pain and nonhealing of the lesion
RESULT ANALYSIS
  • Occult instability may be associated with most labral tears, and debridement may be indicated for short-term relief in competitive athletes or in patients who are willing to decrease their overhead activities.
  • Initial debridement shows good to excellent results in 70% to 90% of patients at 1-year follow-up.
  • Long-term follow-up studies of labral debridement, however, have shown that results deteriorate over time.
  • Repair of type II lesions has a 95% success rate in young patients.
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