1. SLAP Tears Edwin E Spencer Jr MD Shoulder and Elbow Center
Knoxville Orthopaedic Clinic

2. Definition Andrews first described labral tears in 1985
Snyder coined the term SLAP (superior labral anterior posterior) tears in 1990 and classified 4 types
I – Degenerative fraying
II – Detachment of biceps origin
III – Bucket-handle tear
IV – Intrasubstance tear of the biceps with a bucket-handle tear

3. Type II SLAP Tears
The greatest controversy surrounds the treatment of Type II SLAP tears
Etiology?
Clinical exam?
Arthroscopic findings and definition
Treatment?

4. Etiology
Kim et al reviewed 544 arthroscopic cases and found the incidence of a SLAP tear to be 26%. Of these 21% were type II which is similar to other studies.
They found that those over 40 years of age were associated with RCT’s and those under 40 were associated with instability
Kim, TK et al. Clinical features of the different types of SLAP lesions. JBJS 2003

5. Etiology
Proposed mechanisms in the young patient with a type II tear include
Biceps traction in follow through phase of throwing (Andrews)
Internal impingement (Walch and Jobe)
“Peel-back” secondary to biceps traction in late cocking phase of throwing –abduction and external rotation (Burkhart and Morgan)
This “peel-back” has been demonstrated in cadaveric models (Kuhn)

6. Etiology
McMahon et al have demonstrated increased anterior and inferior translation of the glenohumeral joint in a cadaveric model after creating a SLAP tear.
This is consistent with several clinical studies which have found that type II SLAPs are associated with instability in the young patient
McMahon PJ, et al. Glenohumeral translations are increased after a type II SLAP lesion:
A cadaveric study of severity of passive stabilizer injury. JSES 2004

7. Definition
Defining a type II SLAP tear intraoperatively can be difficult
Differentiate from a sublabral foramen and Buford complex
Labrum might have more of a meniscal appearance
The labral origin might be more medial
The best definition of a detached labrum is where there is exposed bone or torn tissue medial to the articular cartilage of the superior glenoid

8. Treatment
Snyder and Altchek have reported unsuccessful outcomes with debridement alone for type II tears.
This prompted operative stabilization with various devises and with various methods including suture anchors, knotless anchors and the SureTac.

9. Treatment
Cohen et al looked at the results of SureTac fixation of 41 isolated type II SLAP tears
Found that nonthrowing athletes (71% satisfaction) had better results than throwing athletes (38% satisfaction)
The use of a transrotator cuff portal was associated with poor results with only 55% of the patients in this group having G/E results
Only 40% able to return to preinjury sport
Cohen DB et al Outcomes of isolated type II SLAP lesions treated with arthroscopic
Fixation using a bioabsorbable tack. Arthroscopy 2006

10. Treatment
Rhee et al found that 76% of their athletes were able to return to preinjury sport.
They evaluated 44 SLAP’s (mostly type II’s)
Fixed with SureTac and suture anchor and found no difference but switched to suture anchor fixation midway through the study secondary to a case of synovittis
86% G/E results via UCLA score
Rhee, YG et al. Unstable isolated SLAP lesion: Clinical presentation and outcome
of arthroscopic fixation. Arthroscopy 2005

11. Treatment
DiRaimondo et al compared suture anchor fixation to bioabsorbable tack fixation and found that the suture fixation was superior with regard to pullout strength and performed better under cyclic loads
DiRaimonodo CA, et al. A biomechanical comparison of repair techniques for type II
SLAP lesions. AJSM 2004

12. Treatment Unstable biceps anchor Prepared superior glenoid tubercle
Place anchor (3mm) through myotendinous junction of supraspinatus

13. Treatment
Pass suture through Neviaser portal with spinal needle

14. Treatment

15. Summary Make sure that the treatment is not worse than the disease
Fix lesion with as little collateral damage as possible
Avoid fixing degenerative lesions (I very rarely fix a SLAP in a patient>40yo)
I believe suture anchor fixation is better
Perform RCR and SLAP concomitantly with caution (increased chance of stiffness)