Careful diagnosis and appropriate treatment are needed
There are good reasons not to surgically repair everything that looks like a superior labral anterior posterior (SLAP) tear,” said Stephen C. Weber, MD, of Sacramento (Calif.) Knee & Sports Medicine, during the 2012 Arthroscopy Association of North America Specialty Day Program.
One reason is that accurate diagnosis can be challenging. According to Dr. Weber, separating normal plicae variants from pathologic conditions can be difficult. Another reason to exercise caution with SLAP repair, he said, is that the surgical procedure can lead to complications and poor outcomes.
During his presentation, Dr. Weber explored these issues and outlined his strategies for diagnosing and treating SLAP tears.
A difficult diagnosis
Ever since SLAP tears were first described (Fig. 1), said Dr. Weber, much controversy has existed about their diagnosis.
“Shortly after SLAP lesions were initially identified as possible pathologic lesions in the shoulder, other surgeons emphasized that many labral variants were not pathologic,” he noted. “Some very gifted foreign surgeons have described SLAP lesions as the ‘American disease,’ and others as the ‘plica of the shoulder.’”
Accurately diagnosing a SLAP lesion is difficult, noted Dr. Weber, because no single physical examination for identifying SLAP lesions currently exists.
“Many different tests are described in the literature, the efficacy of which is almost always difficult for subsequent reviewers to validate,” he said. “Even if more than one test is used, the results are not always clinically useful.”
Plain arthrograms and computed tomography (CT) scans are not helpful in diagnosing SLAP lesions, said Dr. Weber, adding that “while gadolinium-enhanced magnetic resonance imaging (MRI) is the gold standard, according to the literature, radiologists often believe they diagnose these lesions better than surgeons do.
“Recent studies have shown that even when fellowship-trained surgeons view the same surgical pathology, little agreement exists among them as to what constitutes a SLAP tear,” he added.
“Another problem is that it has been very difficult to prove that repairing SLAP tears helps,” said Dr. Weber.
Isolated SLAP lesions are uncommon, said Dr. Weber, and are the focus of only a few studies. Patient outcomes, he said, also vary.
“Surgical outcomes being reported today are not as good as those we expected 10 years ago,” he said. “Although patients can achieve good American Shoulder and Elbow Surgeons scores, failure rates are high when you consider those who do not return to sport.”
A review article published in 2010 found that outcomes varied widely, with return to previous level of play rates ranging from 20 percent to 94 percent.
“So, the question is, if we can’t diagnose this clinically, can’t always see it on imaging studies, can’t agree on what the pathology is, and may not be able to prove that surgery helps, why would we repair any of these?” he asked.
The answer, he said, is that although SLAP tears are rare, they do exist.
“Look at your own cases,” he told the audience. “If you are performing SLAP repairs in more than 10 percent of your surgical cases, you may be performing surgery on more plicae—normal variants—than on real pathology.”
There are reasons not to operate on normal variants, he said, because complications such as arthritis and synovitis can result.
“SLAP repair is not a universally benign procedure,” asserted Dr. Weber. “Stiffness, tack synovitis, cysts, and arthritis can occur.”
Dr. Weber’s first rule related to SLAP repair is to avoid performing the repair based solely on an MRI report, because a radiologist may misread an MRI as being positive for a SLAP lesion.
“In addition,” he said, “I never repair SLAP lesions that have significant articular cartilage damage, because these are degenerative SLAP lesions and do not require surgery. SLAP repair would result in stiffness in these patients.”
Dr. Weber also takes the patient’s age into account.
“Patients who are older than 40 years rarely have true SLAP lesions,” he said. “Their lesions are usually degenerative. These patients are usually better served with some type of biceps procedure.”
Another contraindication for surgery, said Dr. Weber, relates to multiple pathologies.
“If the patient has multiple pathologies, consider leaving the SLAP tear alone,” he recommended. “These patients could develop stiffness following SLAP repair. The exception to this rule, however, involves instability. A SLAP tear associated with instability needs to be repaired, even when a patient has multiple pathologies.
“Finally,” he added, “remember that although SLAP repair is a relatively simple procedure to perform, it is not always universally successful, can lead to complications, and requires 12 months of recovery time.”
Disclosure: Dr. Weber reports ties to DePuy, A Johnson & Johnson Company; Sport Medicine and Arthroscopy Review; Journal of Shoulder and Elbow Surgery; Techniques in Shoulder and Elbow Surgery.
Jennie McKee is a staff writer for AAOS Now. She can be reached at email@example.com
- Gorantla K, Gill C, and Wright RW: The Outcome of Type II SLAP Repair: A Systematic Review. Arthroscopy 2010 Apr; 26(4):537-45. Epub 2010 Jan 25.
- Diagnosing true SLAP lesions can be difficult, because no single physical examination exists for identifying them, and MRI and CT scans can yield false positive results.
- Because most studies of SLAP repair involve at least one other procedure, determining whether the SLAP repair is relevant to clinical improvement is difficult.
- Dr. Weber identified the following contraindications for SLAP repair: patients with articular cartilage damage; patients older than 40 years; and patients with multiple pathologies. If a patient with multiple pathologies has a SLAP tear as well as instability, however, he noted that the SLAP tear should be repaired.
June 2012 Issue
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