Double bucket handle tears of the superior labrum

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1 Case Report pissn X eissn Double bucket handle tears of the superior labrum Dong-Soo Kim, Kyoung-Jin Park, Yong-Min Kim, Eui-Sung Choi, Hyun-Chul Shon, Byung-Ki Cho, Ji-Kang Park, Sang-Wook Keum, Seung-Myung Choi Department of Orthopaedic Surgery, Chungbuk National University College of Medicine, Cheongju, Korea Bucket handle tears of the superior aspect of the labrum, classified by morphologic features as type III and type IV superior labrum anterior-posterior lesions, have been rarely reported. Especially, there has been no previous report of a double bucket handle tear of the superior labrum. Here, we report two cases of arthroscopically-confirmed double bucket handle tears of the superior labrum accompanying a Bankart lesion in patients with multidirectional shoulder instability and recurrent shoulder dislocation along with a review of the literature. Keywords: Superior labrum; Superior labrum anterior-posterior lesions; Double bucket handle tears INTRODUCTION The two major mechanisms of injury for superior labrum anterior-posterior (SLAP) lesions are (1) application of a compression force on the outstretched arm with the shoulder in abduction or forward flexion, resulting in direct impaction of the humeral head against the long head of the biceps tendon-superior labrum complex and (2) traction of the biceps tendon, resulting in detachment of the labrum from the glenoid. A SLAP lesion can also occur when the biceps tendon-superior labrum complex is detached medially due to repetitive and abnormal increases of the peel-back force in the posterosuperior labrum. In this report, we present two cases of arthroscopically-confirmed double bucket handle tears of the superior labrum that appeared to have resulted from the above-described mechanisms of injury. CASE REPORTS Case 1 A 25-year-old man visited our clinic with a major complaint of right shoulder pain. The patient sustained a dislocation of the right shoulder after falling on his hand with the elbow joint extended while skiing about 2 years ago and reduced the dislocation by himself. Afterwards, the dislocation recurred 5 times and the most recent episode occurred one month before the visit. Physical examination revealed no limitation in the range of motion (anterior elevation, 180 o ; external rotation, 80 o ; internal rotation, T10; and abduction, 180 o ). Pain was elicited by external rotation, generalized ligamentous laxity was present, and apprehension test and sulcus sign were positive. Generalized ligamentous laxity was assessed with passive apposition of the thumb to the anterior aspect of the forearm and 10 o of hyperextension of the elbow. Stress test showed anterior-posterior and inferior subluxation of the shoulder. A Hill-Sachs lesion was observed in the right shoulder on the plain radiograph (Fig. 1A) and subluxation of the humeral head was noted in the weight bearing view. Subsequently, magnetic resonance arthrography was performed, which revealed a double bucket handle tear of the superior labrum that extends to the long head of the biceps tendon, a type IV SLAP lesion (Fig. 1B). Based on the findings, surgical intervention was Received August 22, 2013; Revised August 29, 2013; Accepted August 29, 2013 Correspondence to: Kyoung-Jin Park, Department of Orthopaedic Surgery, Chungbuk National University Hospital, Sunhwan-ro, Heungdeok-gu, Cheongju , Korea. Tel: , Fax: , oslion@chungbuk.ac.kr Copyright 2014 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( AOSM by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Arthrosc Orthop Sports Med 2014;1(1):

2 Fig. 1. (A) The X-ray shows a Hill-Sachs lesion (arrow). (B) A coronal magnetic resonance angiography shows a type IV superior labrum anterior-posterior lesion (arrow). Fig. 2. (A) Arthroscopic finding shows a displaced inferior bucket handle tear of the superior labrum (arrow). (B) Arthroscopic finding shows superior and inferior lesions of the double bucket handle tear of the superior labrum (arrow). (C) The superior lesion of the double bucket handle tear of the superior labrum was repaired successfully. considered necessary for recurrent shoulder dislocation and multidirectional instability. The surgery was performed under general anesthesia in the beach chair position. The intraoperative arthrosopic findings included (1) anterior subluxation of shoulder joint and a Bankart lesion and (2) a tear of the superior labrum into an upper band and a lower band (double bucket handle tear) (Fig. 2A, B). The lower band was debrided and the upper band was repaired. Then, the anterior Bankart lesion was sutured and capsular plication was performed in the inferior and posterior aspects of the glenoid (Fig. 2C). For six postoperative weeks, an abduction orthosis was applied and pendulum exercises and stretching exercises were performed for restoration of range of motion. Excessive adduction, internal rotation, external rotation, and resistive exercises were not allowed to prevent suture failure for 10 postoperative weeks. At the 6th postoperative month, no side-to-side difference was noted in the range of motion, there was no evidence of pain, joint instability, and posterior shift, and patient satisfaction was high. Case 2 A 17-year-old male patient visited our clinic with a major complaint of right shoulder instability. He was a baseball player and experienced a dislocation of the right shoulder during pitching 3 years ago. Although he reduced the dislocation by himself, it recurred on an average of once every other month when engaged in pitching movements. Physical examination revealed no limitation in the range of motion (anterior elevation, 180 o ; external rotation, 60 o ; internal rotation, T12; and abduction, 180 o ). Pain was elicited by external rotation, generalized ligamentous laxity was present, and apprehension test and sulcus sign were positive. A bony Bankart lesion was observed in the right shoulder with plain radiography (Fig. 3A), Stress test revealed subluxation of the humeral head. MR arthrography showed a double bucket handle tear of the superior labrum without extension into the long head of the biceps tendon, a type III SLAP lesion (Fig. 3B). Based on the findings, surgical intervention was 60

3 Fig. 3. (A) The X-ray shows a bony Bankart lesion (arrow). (B) A coronal magnetic resonance angiography shows a type III superior labrum anterior-posterior lesion (arrow). Fig. 4. (A, B) Arthroscopic finding shows superior and inferior bucket handle tears of the superior labrum (arrow). (C) Double bucket handle tears of the superior labrum were debrided. considered necessary for recurrent shoulder dislocation and multidirectional instability. The surgery was performed under general anesthesia in the beach chair position. The intraoperative arthroscopic findings included (1) anterior subluxation of shoulder joint and a bony bankart lesion and (2) a tear of the superior labrum into an upper band and a lower band (double bucket handle tear) (Fig. 4A, B). The upper and lower bands were debrided, and the long head of the biceps tendon was firmly anchored to the superior glenoid. The anterior bony Bankart lesion was repaired and capsular plication was performed in the inferior and posterior aspects of the glenoid (Fig. 4C). For six postoperative weeks, an abduction orthosis was applied and pendulum exercises and stretching exercises were performed for restoration of the range of motion. Excessive adduction, internal rotation, external rotation, and resistive exercises were not allowed to avoid the risk of suture failure for 10 postoperative weeks. At the 6th postoperative month, no side-to-side difference was observed in the range of motion, there was no evidence of pain, joint instability, and posterior shift, and patient satisfaction was high. DISCUSSION SLAP lesions in patients with shoulder pain have been reported with growing frequency. This can be attributed largely to the increasing interest among orthopedic surgeons since Snyder et al. [1] proposed a classification system for SLAP lesions and the advances in MR arthrography and shoulder arthroscopy. Snyder et al. [1] classified SLAP lesions into four types: type 1, fraying and degeneration of the superior labrum without detachment; type 2, fraying and detachment of the superior labrum; type 3, a bucket handle tear of the superior labrum and intact biceps tendon; type 4, a bucket handle tear of the superior labrum that extends into the biceps tendon. Maffet et al. [2] added three more 61

4 variations to the classification by including a Bankart lesion, a flap tear, and a SLAP lesion that extends below the middle glenohumeral ligament. Moreover, depending on the stability of the insertion of the long head of the biceps tendon, they can be simply divided into stable and unstable lesions. The etiology or mechanisms of SLAP lesions have not been elucidated. However, most of the lesions are found in pitchers who are commonly engaged in abduction or external rotation of the shoulder for throwing motion or after trauma. A SLAP lesion present with various symptoms and physical signs and can occur isolated or combined with an anterior-inferior labral tear that extends superiorly in patients with recurrent dislocation of the shoulder [3-6]. Burkart and Morgan [7] suggested three most common traumatic mechanisms of injury in non-athletes: (1) excessive traction during contraction of the long head of the biceps tendon, (2) a sudden blow to the shoulder when the arm is abducted and externally rotated, and (3) a fall on an outstretched hand. Snyder et al. [8] documented that the mechanisms of injury for SLAP lesions include (1) a compression force applied on the outstretched arm with the shoulder in extension or forward flexion, resulting in direct impaction of the humeral head against the long head of the biceps tendon-superior labrum complex and (2) traction of the biceps tendon, resulting in detachment of the labrum from the glenoid. They reported that a slap lesion is attributable to a compression injury and a traction injury in 57% and 27% of the cases, respectively. The relationship between labral tears and multidirectional instability of the shoulder has been well known: the former can cause the latter and vice versa [9]. The two patients described in this report presented with multidirectional instability of the shoulder, recurrent shoulder dislocation, and a Bankart lesion that was combined with a type IV SLAP lesion in one and a type III SLAP lesion in the other patient. The mechanism of injury was trauma from a fall during skiing (type III according to Bukart and Morgan [7]) in the first case and shoulder dislocation during abduction and external rotation of the arm for throwing a baseball (type II according to Bukart and Morgan [7]) in the second case. In spite of the difference in the mechanism of injury, the patients commonly exhibited multidirectional shoulder instability, recurrent shoulder dislocation, and a double bucket handle tear of the superior labrum. If recurring pain is present in a patient with multidirectional shoulder dislocation, not only the presence of an anterior-inferior and posterior labral lesion but also a concomitant SLAP lesion should be suspected. Furthermore, further studies are necessary to establish a relationship between double bucket handle tears of the superior labrum and recurrent shoulder dislocation caused by multidirectional shoulder instability. Double bucket handle tears caused by strong and repetitive injury to the labrum may result in more extensive damage than do other SLAP lesions. Considering the influence of SLAP lesion repair on the stability of the glenohumeral joint and normalization of the load on the long head of the biceps tendon [10], utmost care should be taken in determining whether to perform debridement or suture repair for a double bucket handle tear of the superior labrum. In this report, we presented two rare cases of arthroscopically-confirmed double bucket handle tears of the superior labrum in patients with multidirectional instability and recurrent shoulder dislocation along with a review of the literature. CONFLICT OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 1995;4: Maffet MW, Gartsman GM, Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23: Pagnani MJ, Speer KP, Altchek DW, Warren RF, Dines DM. Arthroscopic fixation of superior labral lesions using a bio degradable implant: a preliminary report. Arthroscopy 1995;11: Craig EV. Shoulder arthroscopy in the throwing athlete. Clin Sports Med 1996;15: Handelberg F, Willems S, Shahabpour M, Huskin JP, Kuta J. SLAP lesions: a retrospective multicenter study. Arthroscopy 1998;14: Kim JS, Whang PS, Yoo JH. Type II SLAP lesion wirh the rotator 62

5 cuff tear. J Korean Shoulder Elbow Soc 1999;2: Burkart SS, Morgan C. SLAP lesions in the overhead athlete. Orthop Clin North Am 2001;32: Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6: Mallon WJ, Speer KP. Multidirectional instability: current concepts. J Shoulder Elbow Surg 1995;4: Patzer T, Habermeyer P, Hurschler C, et al. The influence of superior labrum anterior to posterior (SLAP) repair on restoring baseline glenohumeral translation and increased biceps loading after simulated SLAP tear and the effectiveness of SLAP repair after long head of biceps tenotomy. J Shoulder Elbow Surg 2012;21: