An analysis of 140 injuries to the superior glenoid labrum

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1 ORIGINAL ARTICLES An analysis of 140 injuries to the superior glenoid labrum Stephen J. Snyder, MD, Michael P. Banas, MD, and Ronald P. Karzel, MD, Van Nuys, Calif. Between 1985 and injuries of the superior glenoid labrum were identified on arthroscopic evaluation and were recalled from a data bank of 2375 shoulder procedures performed during that time. The average patient age was 38 years, and 91% of the patients were men. The most common problem was pain, with 49% of all patients noting mechanical catching or grinding in their shoulders. No preoperative imaging modality consistently defined disease in the superior labral area. Fifty-five percent of all lesions were type II, 21% were type I, 10% were type IV, 9% were type III, and 5% were complex. Twenty-nine percent of lesions were associated with a partial-thickness tear of the rotator cuff, 11% with a full-thickness tear, and 22% with an anterior Bankart lesion. Twenty-eight percent of the superior labral lesions seen were isolated and did not have any associated rotator cuff or anterior labral disease. Type I lesions were debrided. Fifty-six percent of type II lesions were debrided in conjunction with an abrasion of the underlying glenoid rim. More recently suture anchors have been used to stabilize type II lesions. Treatment of type III and IV lesions depended on the extent of labral tissue disruption and involved either debridement or suture repair. Repeat arthroscopies were performed on 18 shoulders. Three of five type II lesions treated with debridement and glenoid abrasion were healed. Four of five type II lesions treated with an absorbable anchor were healed. Three type III and one type IV lesion treated with debridement had normal superior labrums. Two type IV injuries treated with suture repair had completely healed. Two complex type II and III iniuries treated with debridement and anchor fixation were healed. (J ShOULdER ELBOW SURe 1995;4: 243-8) Disease involving the superior labrum has become recognized as a primary source of shoulder pain. Shoulder arthroscopy has helped to delineate specific injury patterns of the superior labrum. Andrews et al. 1 initially described a lesion of the superior glenoid labrum in a study group of highlevel throwing athletes. Their report noted anterosuperior labral tissue that was detached, frayed, and sometimes accompanied by partial tearing of the biceps tendon. The postulated injury mecha- From the Southern California Orthopedic Institute. Reprint requests: Stephen J. Snyder, MD, Southern California Orthopedic Institute, 6815 Nobb Ave., Van Nuys, CA Copyright by Journal of Shoulder and Elbow Surgery Board of Trustees /95/$ /1/65525 nism in this patient population was traction to the involved labrum by the long head of the biceps tendon in the deceleration phase of throwing. Snyder et al. s recognized a similar type of injury to the superior glenoid labrum that was more global in character. They described a lesion involving the superior aspect of the glenoid labrum. It began posterior to the biceps tendon and extended anterior to the biceps tendon, stopping at or above the midglenoid notch. This area of the superior labrum is functionally important because it serves as the anchor for the insertion of the long head of the biceps tendon on the glenoid rim. This specific injury has been labeled a SLAP lesion (superior labrum anterior and posterior) and, although uncommon, represents a source of disability when present. 243

2 244 Snyder, Banas, and Karzel J. Shoulder Elbow Surg. July~August 1995 Figure 1 Type I SLAP lesion with frayed and degenerated superior labrum. Figure 3 Type III SLAP lesion with bucket-handle tearing of superior labrum. Remaining labral tissue remains anchored to glenoid rim. Figure 2 Type II SLAP lesion with detachment of superior labrum and biceps tendon from glenoid rim. Figure 4 Type IV SLAP lesion with extension of displaced bucket-handle labral tear into biceps tendon. SLAP lesions are classified into four distinct types. Type I lesions denote fraying and degeneration of the superior labrum with a normal biceps tendon anchor (Figure 1). Type II lesions may have fraying of the superior labrum, but their hallmark is a pathologic detachment of the labrum and biceps anchor from the superior glenoid (Figure 2). In type III SLAP lesions the superior labrum has a vertical tear analogous to a bucket-handle tear in the meniscus of the knee. The remaining rim of labral tissue is well anchored to the glenoid, and the biceps tendon anchor is intact (Figure 3). A type IV pattern involves a vertical tear of the superior labrum, but this superior labral tear extends to a variable extent up into the biceps tendon as well (Figure 4). The torn biceps tendon tends to displace with the labral flap into the joint, whereas the biceps anchor itself remains firmly attached to the superior glenoid. Last, a complex of two or more SLAP lesions may occur, with the most common presentation being a type II and a type IV lesion.

3 J. Shoulder Elbow Surg. Volume 4, Number 4 Snyder, Banas, and Karzel 245 The purpose of this article is to present the cumulative data involving superior labral injuries recorded at the Southern California Orthopedic Institute from 1985 through MATERIAL AND METHODS A retrospective review was conducted of 2375 shoulder arthroscopies that were performed at the Southern California Orthopedic Institute between January 1985 and December From this population a computerized data bank identified all patients with intraoperative confirmation of a superior labral injury. One hundred forty patients had documented superior labral injuries; this group represented our study population. A single author (S. J. S.) performed or supervised 84% of the total number of shoulder arthroscopies and classified 125 of the reported superior labral injuries. Each patient's chart was then reviewed to record his or her age, occupation, and dominant shoulder. The presenting symptoms and the exact mechanism of initial injury were examined. All positive preoperative physical examination findings and shoulder range of too'lion were recorded. Results of all diagnostic studies performed and the length of time elapsed from time of initial injury to operative intervention were noted. An analysis of the intraoperative findings was then performed. SLAP lesion type and the presence of any other disease involving the glenohumeral or acromioclavicular joints were recorded. Isolated, superior labral lesions were identified as those not accompanied by any other labral or rotator cuff disease. Treatment rendered to both the labral injury and any associated disease was noted. Lastly, the postoperative course of the patient was tracked until discharge from the clinic. Reports of any reoperations were reviewed; special attention was given to the previously seen superior labral injury. RESULTS There were 2375 shoulder arthroscopies performed at our institution between January 1985 and December From this group 140 superior labral injuries were identified, which represented 6% of all shoulder arthroscopies performed. There were 128 male patients and 12 female patients; the average patient age was 38 years (range 16 to 73 years). Ninety right and 50 left shoulders were involved; 98 were dominant extremities, and 42 were nondominant extremities. Forty-three (31%) of the patients were heavy labor- ers, 25 (18%)business personnel, 21 (15%)sedentary workers, 15 (11%) professionals, 11 (8%) students, three (2%) professional athletes, and 22 (15%) other occupations. All patients presented with shoulder pain. Sixtynine (49%) patients had mechanical symptoms such as locking, catching, popping, or snapping in their shoulder. The most common mechanism of injury involved 43 (31%) patients who had fallen or had received a direct blow to their shoulder. Twenty-seven (19%) patients had an episode of glenohumeral subluxation or dislocation, 23 (16%) noted initial pain while lifting a heavy object, 19 (14%) had an insidious onset of pain, eight (6%) incurred symptoms while participating in' overhead racquet sports, and eight (6%) had pain while throwing. No statistical correlation was seen between the type of superior labral injury noted and the mechanism of injury (Table I). Physical examination findings varied according to the associated disease and did not correlate significantly with the type of labral lesion recognized. Sixty-six (47%) patients had positive impingement tests, 54 (39%) had rotator cuff signs, 21 (15%) had acromiodavicular joint pain with adduction-compression testing, and 23 (16%) had clinical anterior glenohumeral instability. When clinical evaluation of the superior tabrum was attempted, 48 (34%) patients had a positive biceps tension test, and 31 (22%) patients had crepitus on range of motion or compression-rotation testing. Preoperative radiographs were not helpful in suggesting superior labral disease. Seventy-three magnetic resonance imaging studies obtained from multiple centers were available for preoperative evaluation. In this group 19 (26%) magnetic resonance image scans suggested an injury to the superior glenoid labrum. Nine preoperative glenohumeral arthrograms and three computed tomography arthrograms failed to show disease involving the superior glenoid labrum. Twenty-nine (21%) lesions were type I, 77 (55%) were type II, 13 (9%) were type Ill, 14 (10%} were type IV, and 7 (5%) were complex. Of the complex lesions three were type II and III, and four were combined types II and IV. Forty (29%) patients had associated partial tearing of the rotator cuff, and 15 (11%) patients had full-thickness tears. Anterior Bankart labral detachments were present in 31 (22%) shoulders, acromioclavicular joint spurring or degeneration was present in 22 (16%) shoulders, and glenohumeral chondromalacia was present in 14 (10%) (Table II). Forty superior labral lesions were solo and iso-

4 246 Snyder, Banas, and Karzel J. Shoulder Elbow Surg. July~August 1995 Table I Superior labral lesion and mechanism of injury Fall/collision Lifting Insidious Overhead to shoulder weight Dislocation/subluxation onset sports Throwing Other Type I Type II Type III Type IV Complex Total 43 (31%) 23 (16%) 27 (19%) 19 (14%) 8 (6%) 8 (6%) 12 (8%) Table II Superior labral lesion and associated intraarticular disease Bankart Rotator cuff, Rotator cuff, Glenohumeral lesion partial tear full tear chondromalacia Type I Type II Type III Type IV Complex Total 31 (22%) 40 (29%) 15 (11%) 14 (10%) lated from any associated injury to the rotator cuff or remaining labrum. This population represented 28% of all superior labral lesions seen in this series. Two (5%) type I solo injuries, 31 (77%) type II, two (5%) type III, and three (8%) type IV were seen. Two solo injuries were complex; both were types II and III. All patients in this group noted pain, whereas 28 (70%) patients with isolated superior labral tears reported mechanical symptoms. The most common mechanism of injury among the isolated labral injuries involved 16 (40%) patients who had fallen or had received a direct blow to the shoulder. Seven (18%) patients incurred injuries lifting heavy objects, five (12%) noted insidious onset of pain, four (10%) had symptoms caused by throwing sports, and two (5%) had symptoms from overhead racket sports. Physical findings in this group included impingement findings in 24 (60%) patients, rotator cuff symptoms in 12 (30%) shoulders, and a positive anterior apprehension sign in 11 (27%) patients. Sixteen patients had a positive biceps tension test (40%), and 11 (27%) had crepitus with range of motion or compression-rotation testing. The average time from injury to arthroscopy for all SLAP lesions was 20 months. Solo lesions on average were surgically evaluated at 13 months after injury. Treatment modalities for all lesions are recorded in Table III. No significant postoperative complications occurred. Repeat arthroscopies were performed on 18 patients. Five reoperations were necessary to remove loose portions of bioabsorbable tacks, four were necessary to further treat anterior instability, and three were necessary to remove metal fixation used in previous anterior capsular-labral reconstructions. Five reoperations were necessary to evaluate persistent shoulder pain, and one was necessary to perform an arthroscopic-assisted biceps tenodesis. Of the five type II lesions treated with debridement and superior glenoid rim abrasion, three were healed, and no had loose biceps anchor attachments. Of five other type II lesions treated with absorbable tack fixation, four were healed, and one patient with persistent pain had a foramen at the biceps anchor attachment. Three type III lesions and one type IV lesion that were initially debrided had normal remaining superior labrums. Two type IV lesions treated with suture repair had healed on reevaluation. Two complex type II and III lesions initially treated with debridement and suture anchor fixation also had healed on reinspection. DISCUSSION Injuries to the superior glenoid labrum are relatively uncommon. In this report they represented only 6% of a large group of symptomatic shoulders evaluated with arthroscopy. Several authors have noted considerable variation in the attachment of the superior labrum to the glenoid rim. 2' 3 Cooper et a17 reported anatomic dissection, which identified hyaline articular cartilage extending over the glenoid rim at the 12 o'clock position. This creates a synovial recess variable in size beneath the biceps tendon and superior labrum. They also

5 J. Shoulder Elbow Surg. Volume 4, Number 4 Snyder, Banas, and Karzel 247 Table In Summary of treatment modalities for superior labral tears SLAP Debride with Debride with Debride with type Debride glenoid abrasion anchor/tack suture repair Total I h 29 II III IV II and III II and IV reported the anterosuperior labrum to occasionally attach onto the middle or inferior glenohumeral ligament rather than the glenoid margin. This creates a communication with the subscapularis recess beneath the labrum at the 2 o'clock position. Both normal variants can create a loosely attached superior labrum that should not be considered pathologic unless definite tearing is identified. Inability to recognize such variations will lead to an overdiagnosis of superior labral lesions. Men constituted 91% of the patients seen in our group. As previously noted the most common mechanism of injury involved a fall onto the involved shoulder or a direct collision to the joint itself. 5 Approximately one half of the patient population had painful "catching" or "popping" in their shoulder, consistent with other reports." 5 No clinical examination was specific for a superior labral injury, and only one third of the patients had a positive biceps tension test. No preoperative imaging modality consistently defined disease of the superior labral area. Therefore a high clinical suspicion of a superior labral injury is necessary to make the diagnosis. The average time from injury to arthroscopic evaluation was 20 months; this time represents a notable improvement since our last report. 5 Andrews et al.' reported an average of 12 months of symptoms before surgical evaluation. However, this group consisted of high-level throwing athletes who would be referred to a shoulder specialist more quickly than the general population. Type II lesions represented 55% of all superior labral tears seen. Partial- or full-thickness tearing of the rotator cuff accompanied 40% of all lesions, and anterior labral injuries were seen in 22% of the cases. Twenty-eight percent of the superior labral injuries were considered isolated and not accompanied by other injuries to the rotator cuff or remaining labrum. Type II lesions represented 77% of these solo lesions, and isolated tears of types I, III, and IV were also identified. Our treatment protocol involves debridement of all type I lesions. Type II lesions initially were treated with debridement and glenoid abrasion. However, a more aggressive approach to arthroscopic fixation of the biceps anchor to the glenoid rim has been developed to allow early postoperative range of motion. Yoneda et al. r reported 10 athletes with type II superior labral lesions who were treated with abrasion and arthroscopic staple fixation. They performed repeat arthroscopy at 3 to 6 months, and all labral lesions were firmly healed to the glenoid rim. At an average follow-up time of 9 months, we reinspected five type II and two complex type II and III lesions via arthroscopy. All seven of the lesions were initially reattached to the glenoid rim with a suture anchor or bioabsorbable tack, and at the second evaluation six of the seven were firmly attached to bone. Of note, five of the repeat reoperations were necessary to remove loose fragments of bioabsorbable tacks. Because of this finding we no longer recommend the absorbable tack device and currently use a removable screw-in suture anchor (Revo, Linvatec Corp., Largo, Fla.) for fixation of the superior labrum to the glenoid with a nonabsorbable braided no. 2 suture (Figures 5 to 7). This anchor is screwed into the superior glenoid and the sutures are passed through the base of the biceps in a mattress stitch with a Shuttle Relay (Linvatec Corp.)." For type III lesions we excise the bucket-handle portion of the labral tear. Type IV lesions can be treated with excision of the torn labral tissue and biceps tear versus arthroscopic suturing of the split biceps tendon and labrum. If the biceps tendon split involves more than 50% of the tendon, and particularly if the patient has symptoms referable to the biceps tendon, biceps tenodesis is performed. Two type IV lesions treated with suture repair had healed at an average rearthroscopic evaluation time of 14 months. In summary, superior glenoid labral injuries are relatively uncommon, representing only 6% of shoulder arthroscopies performed during an 8-year period. The lesion is predominantly seen in

6 248 J. Shoulder Elbow Surg. July~August 1995 Snyder, Banas, and Karzel Figure 5 Revo suture anchor screw is inserted below detached biceps-jabral anchor. Figure 7 Braided No. 2 nonabsorbable suture is passed through )abrum and tied with mattress stitch anterior on base of biceps tendon. 40% of all injuries having affiliated rotator cuff injuries. However, 28% of superior labral lesions are isolated from any associated rotator cuff or other labral disease. Suture anchor fixation of type II lesions can reliably reconstruct the normal anatomic attachment of the superior labrum to the glenoid. Also, suture repair of the split biceps tendon and superior labrum in type IV lesions can create their normal appearance. REFERENCES Figure 6 Suture passing needle is inserted through biceps to pass Shuttle Relay device, which aflows passage of braided suture, males with nonspecific clinical and radiographic findings. In a patient with pain and mechanical "catching," a high suspicion for labral disease is necessary. Type II lesions are most common, with 1. Andrews JR, Carson WG, Jr, McLeod WD. GJenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985; 13: Cooper DE, Arnoczky SP, O'Brien SJ, eta). Anatomy, histology and vascularity of the glenoid lahrum, j Bone joint Surg Am 1992;74A: De~risac DA, Johnson LL. Arthroscopic shoulder anatomy: pathological and surgical impjications~thorofare, New Jersey: Slack, Snyder S]. Shodder arthroscopy. New "York: McGraw-Hill, Snyder SJ, Karzel RP, Dd Pizza W, Ferkel RID, Friedman MJ. SLAPlesions of the shoulder/lesions of the superior Jabrum both anterior and posterior). Orthop Trans 1990~14: Yonda M, Hirooka A, Saito S, et ak Arthroscopic stapling for detached superior glenoid }abrum. J Bone Joint Surg Br 1991 ; 73B: