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Appendix 1

Review of 14 Selected Studies

In 2009, Brockmeier et al. [2] from the Hospital of Special Surgery prospectively followed 47 patients with symptomatic Type II superior labral anterior-posterior (SLAP) tears. Of these patients, 28 were overhead athletes. The tears were repaired with anchors. The researchers allowed for patients to return to athletics 3 months postoperatively after a throwing program, for those who were throwing athletes. With an average followup of 2.7 years, the authors found 71% of the overhead athletes were able to return to previous level of play. In subset analysis, seven of 11 (64%) of baseball players were able to return to their previous level of play. Overall, the researchers found 87% great to excellent outcomes using the American Shoulder and Elbow Surgeons (ASES) score [15] and the L’Insalata score [11]. Of note, although the authors excluded patients with rotator cuff tears requiring repair or concomitant shoulder instability, some patients had clearly identifiable small rotator cuff tears. Inclusion of these patients or other coexisting pathology may affect athlete outcomes, particularly high-demand overhead athletes. In terms of limitations of the study, there was no prospective power analysis, and the operations were performed by multiple surgeons and with multiple forms of anchors, with a shift from more metal anchors early to more bioabsorbable anchors later.

Boileau et al. [1] performed a cohort study in France in 2009 to determine whether biceps tenodesis with an interference screw could be an effective alternative to suture anchor repair of Type II SLAP tears. They followed a group of 25 patients, 15 of whom were overhead athletes, who were divided into two groups: one group receiving suture anchor fixation and the other receiving only biceps tenodesis with a bioabsorbable interference screw. The authors used age as their primary determinant for separating the patients into two groups. Patients with any identifiable concomitant pathology (particularly rotator cuff tears, shoulder instability, or impingement) were excluded. The patients were allowed to return to sports approximately 4 to 6 months postoperatively. The researchers used return to play, pain on a VAS, and the Constant-Murley score [5]. The results showed 87% of the athletes in the tenodesis group had pain relief; in fact, four of the athletes who received the suture anchor repair went on to tenodesis as second operation for pain relief. Only 20% of the original SLAP repair athletes were able to return to previous level of play, and only 40% of the group had “good-to-excellent” results. Both of these results were the lowest values related to SLAP repair in all the studies we identified. The authors hypothesized the major pain generator in the SLAP repair group may be traction of the superior labrum in overhead athletes. The authors conceded the major weakness of the study was the lack of age-matched controls, as they selected the tenodesis group to be much older than the repair group.

Yung et al. [19] in a 2008 study from Hong Kong followed 16 patients, 13 of which were overhead athletes, with isolated Type II SLAP lesions treated with Mitek® suture anchors. The researchers allowed the patients to resume full throwing at 4 to 6 months postoperatively after a structured rehabilitation program. They compared preoperative and postoperative clinical examination and UCLA shoulder assessment scores [6]. The results were generally optimistic, with less positive Speed, Yergason, and O’Brien tests and improved UCLA shoulder scores. The overall “good-to-excellent” rate was 92% in this study. The authors noted the elite athletes in this small sample required longer to reach a return to preinjury activity level. Overall, the authors found great clinical and functional outcomes of suture anchor repair of Type II SLAP tears in a small sample of overhead athletes.

Another study from Hospital for Special Surgery by Coleman et al. [4] in 2007 retrospectively compared outcomes of Type II SLAP tears treated with tacks alone or in combination with arthroscopic acromioplasty. There were 33 athletes in the SLAP-only group compared to 12 athletes in the combined group. The patients were followed for an average of 3.4 years postoperatively and assessed with the ASES and L’Insalata scores. Overall, the authors found increased “good-to-excellent” grades in the combined group (81%) versus the SLAP-only group (65%), with similar ASES and L’Insalata scores between groups. Only three of the 45 athletes in total were unable to return to previous level of play. Also of note, seven of the 33 athletes in the SLAP-only group (21%) had clinical signs of impingement postoperatively, compared to zero patients in the combined group. Thus, the authors concluded combined SLAP repair with acromioplasty provides similar functional outcomes with the additional benefit of a decreased level of postoperative impingement for these athletes.

A retrospective study by Enad et al. [7] in 2007 focused on a military population with Type II SLAP tears repaired with bioabsorbable anchors. For these 30 patients, full participation in throwing sports was allowed after 6 months, following a structured strengthening program. Using ASES and UCLA scoring systems, the authors found the majority of patients had pain reduction and a 77% return to previous level of play. About 90% of patients reported “good-to-excellent” results. However, only 15 of the 30 patients were found to have an isolated SLAP tear, which could skew the results. Nevertheless, the authors found good clinical success with anchor fixation of Type II SLAP tears in a military population. To further elucidate whether concomitant pathology affects outcomes in SLAP tears, Enad and Kurtz [8] retrospectively looked at 36 military patients and divided them into age-matched groups based on isolated SLAP lesions or SLAP lesions with other pathology. The SLAP tears were repaired with suture anchors, and either a subacromial decompression or rotator cuff débridement was performed simultaneously in the combined group. Using ASES and UCLA scores, the authors found no difference in functional outcomes between the groups, other than increased pain scores for the isolated SLAP group. The “good-to-excellent” results were 89% for the isolated group compared to 94% in the combined group, and 17 of 18 patients in each group returned to full duty. The authors concluded treating concomitant pathology with SLAP tears appears to confer a similar outcome.

In 2006, Cohen et al. [3] retrospectively looked at 41 patients with isolated Type II SLAP tears treated with tacks. They excluded concomitant pathology in these patients. Using the ASES and L’Insalata scores, the researchers found high marks after tack repair. However, patient satisfaction was only 71%. Of the 29 athletes in the study, only 14 were able to return to previous of play, and only three of eight throwers were able to do the same. The throwers also had lower L’Insalata scores and their patient satisfaction was only 38%. The majority of patient complaints appeared to be related to night pain, which the authors believed may have been due to a transrotator cuff approach for some of the repairs. In a subgroup analysis, the authors found improved outcomes in patients with a rotator interval approach, and all the patients with night pain were found to have been fixed via a transrotator cuff approach. As is the case with most of the current research, the authors could only hypothesize as to why the throwing athletes consistently had poorer outcomes compared to their nonthrowing counterparts.

In a 2005 study from Japan, Ide et al. [9] focused specifically on overhead throwing athletes. They prospectively divided the 40 athletes into an overuse group and a trauma group of SLAP tears. The tears were repaired with suture anchors, and their results were graded on a modified Rowe score, which is based on pain, function, and physical examination [16]. Overall, 30 of the 40 athletes were able to return to previous level of play. However, only 12 of the 19 baseball players were able to attain that feat. The overall “good-to-excellent” score rate was 90%. Of note, there was a higher percentage of baseball players in the overuse group. The authors hypothesized the baseball players may have had inferior results compared to the other overhead athletes due to repetitive stress on supporting structures of the shoulder, such as the capsule, specifically the inferior glenohumeral ligament.

In 2002, O’Brien et al. [13] retrospectively analyzed 31 patients with Type II SLAP tears repaired with arthroscopic tacks. The authors excluded patients with instability or full-thickness rotator cuff tears. The patients were evaluated with the ASES and L’Insalata scores. The overall “good-to-excellent” score was 74%, but only 16 of the 31 patients were able to return to previous level of play. The authors hypothesized possible concomitant postoperative impingement as one possible reason for the relatively low return to play rate. Of note, all 31 patients were repaired using the transrotator cuff approach, which was addressed as a possible issue in the 2006 study by Cohen et al. [3].

In a study from Korea in 2002, Kim et al. [10] retrospectively looked at 34 isolated Type II SLAP lesions treated with suture anchors. Of these patients, 30 were athletes and 18 were overhead athletes. The results were positive on the whole, with 94% “good-to-excellent” results on the UCLA shoulder scores. However, the overhead athletes had lower functional scores and return to previous level of play compared to the other athletes in the study, with only four of the 18 overhead athletes returning with no impairment. The authors did not hypothesize why the overhead athletes did poorer than their nonoverhead counterparts.

In 2001, Samani et al. [17] looked at a case series of 25 athletes with Type II SLAP tears repaired with bioabsorbable tacks. The athletes’ shoulder functions were assessed with the UCLA and ASES scoring systems. The results were the most successful of the 14 studies reviewed. Their “good-to-excellent” rating was 88%. Of the 25 athletes, 23 were able to return to their previous level of play, and these athletes included some elite throwing athletes. The UCLA and ASES scores were both improved across the board as well. The authors noted they had a substantial percentage of patients with concomitant pathology upon arthroscopy, most commonly rotator cuff pathology (76%) and subacromial pathology (56%).

Morgan et al. [12] in 1998 focused on subclassifying the Type II SLAP tear by anatomic location: anterior, posterior, and combined anterior and posterior. The authors believed the posterior and combined are frequently observed in the overhead athlete, which may contribute to the glaring discrepancy in patient outcome and return to sports. To elucidate this difference, they separated patients into an overhead athlete group of 53 patients and a nonoverhead traumatic group of 49 patients. The SLAP tears were repaired with suture anchors, and rotator cuff tears found intraoperatively were repaired or débrided based on their size. Light throwing was permitted at 4 months for overhead athletes, with mound throwing permitted at 6 months and all restrictions lifted at 7 months, which is a slightly slower progression than most studies reviewed. The researchers found the posterior subtype was three times more common in the overhead throwers. In the overhead group, 87% had “good-to-excellent” results, including 84% “good-to-excellent” for baseball players. Also, 31% of the patients were noted to have rotator cuff tears that were repaired or débrided. It was hypothesized these superior results in overhead athletes may be in part due to the subclassification of the Type II SLAP tear, as the posterior subtype was repaired in a unique manner as described in this study.

In 1995, Pagnani et al. [14] published a study looking at the use of bioabsorbable tacks to treat Type II SLAP tears. Thirteen of the 22 patients studied were overhead athletes. The patients were allowed to resume light throwing at 4 months and unrestricted throwing at 6 months postoperatively. The ASES scores improved for the majority of the patients, and 86% had “good-to-excellent” results. Twelve of the 13 overhead athletes returned to previous level of play, included all six elite overhead athletes. The few dissatisfied patients underwent subacromial decompression at the same time, which led the authors to postulate repairing concomitant pathology needed further study, as was seen in the other studies we reviewed.

Yoneda et al. [18] in a 1991 study from Japan reviewed a case series of 10 patients who underwent arthroscopic stapling for SLAP tears. All of the patients were overhead athletes and seven were baseball players. The rehabilitation included graduated throwing at 3 to 4 months and full throwing at 6 months postoperatively. Unlike other studies, the authors performed second-look arthroscopies (average 3.9 months postoperatively) to retrieve the nonabsorbable tacks, with no visualized failed repairs. Eight of the 10 patients had “good-to-excellent” functional scores (mainly pain scores) and were active in athletics, though only five of 10 returned to their previous level of play. The authors concluded bioabsorbable fixation devices that were being introduced at the same time were more practical and negated the need for second-look arthroscopy and implant removal.


References

1.  Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated Type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009;37:929-936.

2.  Brockmeier SF, Voos JE, Williams RJ 3rd, Altchek DW, Cordasco FA, Allen AA. Outcomes after arthroscopic repair of Type-II SLAP lesions. J Bone Joint Surg Am. 2009;91:1595-1603.