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SLAP lesion

Introduction

  • Superior Labral Anterior to Posterior lesion
  • Usually following fall on out stretched hand or repetitive overhead activities
  • Young male
  • Pathophysiology is thought to be tightness of the posterior IGHL which shifts the glenohumeral contact point postero-superioly and increases the shear force on the superior labrum
  • Antero-superior labrum recieves poorest blood supply
  • May be associated with
    • Instability
    • Internal impingement
    • Rotator cuff tears
  • SLAP lesion increases the strain on the anterior part of the IGHL and compromises stability of shoulder

Anatomy

  • There is a normal variant consisting of a sublabral foramen below the anterosuperior labrum present in approximatley 12% of patients undergoing arthroscopy. Seventy five percent of these variants are associated with a cord-like middle glenohumeral ligament (MGHL) (~9% of patients undergoing arthroscopy) .
  • The Buford complex consists of a cord-like MGHL that inserts on the superior labrum at the base of the biceps tendon and crosses the subscapularis tendon to insert on the humerus. There is no anterior-superior labral tissue present between this attachment and the midglenoid notch .

Pathogenesis

Describe the biologic basis of the disorder or the mechanism of injury

Natural History

Describe the natural history,epidemiology and prognosis

Classification

  • G I : Degenerative fraying
  • G II : Detached superior labrum + biceps anchor
  • G III : Bucket handle superior labrum + intact biceps
  • G IV : Bucket handle superior labrum + biceps anchor
  • G V : SLAP extends to anterior labrum
  • G VI : SLAP extends as superior flap tear
  • G VII : SLAP extends to MGHL
  • G VIII : SLAP extends to posterior labrum
  • G IX : SLAP extends circumferentially

Patient History and Physical Findings

History:

  • Presents with deep shoulder pain, popping and clicking
  • May develop secondary ganglion cyst, which can cause suprascapular nerve pressure

Physical Findings:

  • Dynamic labral shear: Patient supine. Begin with shoulder in adduction, neutral rotation. Abduct the shoulder while axial loading. Positive exam with painful click or shift at roughly 90 degrees abduction.
  • Positive O'Brien's test
  • Positive Crank test
  • Positive Speed's test
  • Positive Yerguson's test
  • Bicipital groove tenderness

Imaging and Diagnostic Studies

Radiography:

  • For associated lesions
  • MRI
    • Can be diagnostic
    • Sensitivity and specificity increases with arthrogram
    • Shows associated ganglion cyst
  • Definitive diagnosis with arthroscopy

Differential Diagnosis

Treatment

Nonoperative treatment:

  • NSAIDs
  • Activity modification
  • Physiotherapy and muscle strengthening

Operative treatment:

  • Debridement and tenotomy +/- tenodesis
    • High-level basesball pitchers
    • Low demand patients and those over the age of 40 or 50 are best treated with debridement and tenotomy +/- tenodesis. There is minimal functional difference between tenotomy and tenodesis.
      • Consider tenodesis for:
        • laborers who frequently uses a screwdriver
        • patients concerned about cosmesis of biceps contour
        • body builders
  • SLAP repair
    • Consider SLAP repair for:
      • Young athlete with healthy biceps tendon and a clean SLAP tear

Pearls and Pitfalls

  • For repair candidates, consider the following guideline:
    • G I : Debridement
    • G II : Stabilization
    • G III : Debridement
    • G IV : Stabilization ± biceps tenodesis
    • G V : Stabilization
    • G VI : Debridement
    • G VII : Stabilization
    • G VIII : Stabilization
    • G IX : Stabilization

Tips and problems to avoid

Postoperative Care

Include immediate postoperative care and rehabilitation

Outcome

Include functional and prosthetic survivorship data as applicable

Complications

Include overview of complications

References

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