Analysis of young, military population shows high failure rate for SLAP 2 repairs

Issue: Issue 5 2012

SAN FRANCISCO — Researchers at the U.S. Naval Medical Center in San Diego found a 37% failure rate for surgical repair of type 2 SLAP lesions among military patients and discovered an association between patient age and failure.

“Successful outcome after repair of SLAP 2 lesions still remains a challenge,” CDR Matthew T. Provencher, MD, MC, USN, said. “Our cohort, and specific to our population, had a 37% revision rate with overall good response to revision with biceps tenodesis. Age of greater than 36 [years] was our best factor that was predictive of failure. We need to do additional work to define who is going to benefit from a SLAP 2 repair.”

Provencher, who is an Orthopedics Today Editorial Board member, presented the results of the prospective analysis of 225 patients followed for a mean of 38 months postoperatively with SLAP 2 tears at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting.

Surgical technique, study group

Matthew T. Provencher

The study included patients between the ages of 18 years and 50 years who had clinical magnetic resonance arthrogram diagnoses of SLAP 2 lesions and failed nonoperative treatment, Provencher said. Exclusion criteria were other repairs including rotator cuff, labral, distal clavicle, biceps tenotomy and tenodesis. Outcome scores included American Shoulder and Elbow Surgeons (ASES), Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores, and range of motion. Two surgeons performed the repairs, and an independent researcher evaluated the results. Mean follow-up was 40 months.

“We started the study in 2005 using a similar surgical technique with a mean of 1.6 suture anchors,” Provencher said. “Most always, it was a percutaneous-type anchor approach through the muscle-tendon junction of the rotator cuff. We tied anteriorly through a rotator interval, 8-mm cannula, and the knots were tied on the superior aspect of the biceps.”

The standard rehabilitation protocol was 3 weeks to 4 weeks of immobilization. The researchers deemed the procedure successful if patients had ASES scores greater than 75, no revision surgeries and returned to military duties, according to Provencher.

Of the 179 patients available for follow-up, the researchers found that 113 had successful procedures. Of the failures, 66 patients had ASES scores lower than 75, and 50 of these had revision surgery including tenodesis, tenotomy or surgical debridement.

“Clearly, there were patients who truly benefited from the procedure; however, a number were not able to demonstrate an improvement from their preoperative function,” Provencher said.

Overall, all outcome scores improved preoperatively to postoperatively with WOSI scores increasing from 54% to 82%, SANE scores from 50% to 85% and ASES score improving from 65 to 88 points. The investigators also found significant improvements in range of motion. However, those that were deemed failures (66 out of 179 patients or 37%) had no statistical improvement in their scores, as well as little improvement in range of motion.

Arthroscopic image in a 26-year-old man who had previous SLAP 2 repair

Arthroscopic image in a 26-year-old man who had a previous SLAP 2 repair 8 months prior. The sutures are loose (black arrow) and the biceps is inflamed, torn from the base with extension into the biceps tendon. He was treated with an intra-articular debridement, removal of suture and debris and biceps tenodesis.

Arthroscopic image of a 32-year-old man who had previous SLAP 2 repair

Arthroscopic image in a 32-year-old man who had a previous SLAP 2 repair 10 months prior. This demonstrates an incompetent SLAP anchor, loose sutures (black arrows), inflammation and detachment of the superior labrum from the glenoid. He was treated with an intra-articular debridement and biceps tenodesis.

Images: Provencher MT

Results of revision

“We looked at that final cohort of 50 that we revised,” Provencher said. “Scores overall statistically improved with revision. Most of the revisions had a tenodesis procedure. The [ASES scores] scores in the 60s ended up in the mid 80s. Range of motion also improved with revision surgery, specifically in flexion and abduction.”

The researchers also found that greater age was associated with failure.

“We identified a relatively high failure with SLAP 2 surgical repair in this young, but military population,” Provencher said. “We did not have anyone over the age of 45 that we repaired. Our mean age was 31 [years]. But with revision surgery, we were able to improve their range of motion and outcomes scores. But certainly, it was not perfect. I am not sure why the age of 36 had a high risk of failure, likely [this is] multi-factorial from biological or other reasons.”

The researchers identified the strict failure criteria and a limited throwing population as study limitations.

“But this [study], represents a good working and lifting population I deal with in the military,” Provencher said. He also noted that two surgeons performed the procedures, which contributed to the external validity. – by Renee Blisard Buddle

Reference:

Provencher MT, McCormick F, Dewing CB, Solomon DJ. Revision rates and outcomes of superior labrum anterior posterior 2 repairs: A prospective analysis of 225 patients. Paper #208. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-11. San Francisco.

For more information:

CDR Matthew T. Provencher, MD, MC, USN, can be reached at the U.S. Naval Medical Center, San Diego, Department of Orthopaedic Surgery, 34800 Bob Wilson Dr., San Diego, CA 92134; email: matthew.provencher@med.navy.mil.
Disclosure: Provencher is deputy editor for Arthroscopy; is on the Board of Directors for the Amercian Orthopaedic Society for Sports Medicine; and has committee memberships of the American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, Society of Military Orthopaedic Surgeons and American Academy of Orthopaedic Surgeons.