E-mail this article to a friend  Download this article in PDF format

A “worrisome” trend in SLAP repair

By Peter Pollack

Young surgeons have high rates of surgery

American Board of Orthopaedic Surgery (ABOS) Part II candidates may be performing superior labral tear anterior to posterior (SLAP) repairs at greater rates than they should, leading to poor outcomes and increased complication rates, according to data presented by Stephen C. Weber, MD, at the annual meeting of the Arthroscopy Association of North America.

“SLAP lesions are rare injuries,” explained Dr. Weber. “Stephen J. Snyder, MD, has reported that SLAP lesions were found in about 3 percent of patients referred to a large tertiary care facility. In a previous study, we found that SLAP lesions accounted for about 1.1 percent of our practice during a 10-year period.”

Dr. Weber noted that magnetic resonance imaging (MRI) scans often produce false positives and that SLAP lesions are difficult to diagnose clinically. Numerous studies suggest that even experts disagree on how to define a type II SLAP tear.

“Furthermore, repairing SLAPs is not a benign process, and caring for failed SLAPs can be very difficult,” said Dr. Weber. “Complications include stiffness, persistent rotator cuff tears next to the portals, and damage to the articular cartilage.”

Coronal T1-weighted magnetic resonance angiography study with fat suppression, showing a type II SLAP tear. The area shown is just posterior to the bicipitolabral complex (arrow).

Repair rates on the rise
The authors searched the ABOS Part II database for all International Classification of Diseases codes corresponding to SLAP lesions and SLAP repairs from 2003 to 2008. They analyzed the incidence of cases by geographic region, complication rates and outcomes, and applicant’s orthopaedic specialty declaration.

Overall, they found 4,975 SLAP repairs (78.4 percent in male patients), representing 9.4 percent of all shoulder cases reported in the database during the study period. Dr. Weber found that the rate of repair increased over time to peak at 10.1 percent in the final year of the study. Sports medicine specialists performed SLAP repairs at the highest rate—12.4 percent—compared to a rate of 9.2 percent among general orthopaedists.

At mean follow-up of 8.9 weeks, 26.3 percent of patients responded that they were pain-free, and only 13.1 percent reported that they were functionally normal. ABOS applicants reported that their patients had “excellent results” 40.1 percent of the time. The applicants’ self-reported complication rate was 4.4 percent.

“The follow-up is short,” Dr. Weber admitted. “Having said that, patients usually start getting significantly better by 3 months, and they might actually get worse with longer follow-up.”

Too old for SLAP repair?
In addition, the mean age of male patients was 36.4 years (standard deviation [SD] = 13.0), with a maximum age of 85 years. The mean age of female patients was 40.9 years (SD = 14.0), with a maximum of 88 years.

“Patients in their 80s wouldn’t be considered candidates for repair by virtually any specialist,” explained Dr. Weber, “and several studies have shown that patients older than age 40 probably would do better with biceps tenodesis or tenotomy than repair.

“The ABOS candidates are performing SLAP repairs at a rate three times what the literature would suggest,” said Dr. Weber. “Even among general orthopaedists, the rate is higher than for a tertiary care orthopaedic group.”

Dr. Weber expressed concern about the number of older patients receiving SLAP tear repairs, because of the potential for a significant number of complications and poor outcomes.

He suggested that educating young orthopaedists to distinguish between pathologic SLAP lesions and incidental degeneration of the labrum might help to reduce the rates of SLAP repair and improve outcomes.

“I think we need to do a better job of defining labral pathology for the patients who truly have symptomatic SLAP lesions,” he said.

Dr. Weber’s coauthors included Soheil Payvandi, DO; David F. Martin, MD; and John J. Harrast, MS.

Disclosure information: Dr. Weber—DePuy Orthopaedics. Drs. Payvandi and Martin, and Mr. Harrast—no conflicts.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Bottom line

• Candidate physicians preparing to take the ABOS Part II exam perform SLAP repairs at rates three times greater than the literature suggests.

• Some of these repairs may be on patients who are not ideal candidates for repairs.

• Better training is needed to reduce the rates of SLAP repairs and improve outcomes.

AAOS Now
August 2010 Issue
http://www.aaos.org/news/aaosnow/aug10/clinical2.asp