SUPERIOR LABRAL TEARS: Fact or Fiction?

Transcription

1 SUPERIOR LABRAL TEARS: Michael G. Ciccotti, MD The Everett J. and Marian Gordon Professor of Orthopaedics Chief, Division of Sports Medicine Rothman Institute Head Team Physician, Philadelphia Phillies Faculty Disclosure Consultant Stryker Endoscopy Consultant Venture MD Research Support Arthrex Board/Committee Membership Orthopaedic Learning Center BOD MLB Medical Advisory Committee MLB Elbow Research Study Group AOSSM Fellowship Match Committee AJSM Medical Publishing Board of Trustees What is that? 1

2 Normal Superior Labrum Anatomy Fibrocartilage Periosteal/Capsular vascularity Biceps attachment Normal Superior Labrum Biomechanics Biceps attachment site Deepens glenoid Distributes contact pressure between humerus & glenoid Washer Effect Attachment site for glenohumeral ligaments & capsule Pressure sensor for proprioception Superior Labrum is Important for the Overhead Athlete! Harryman, 1992 Pagnani, 1995 Lee, 2005 Veeger, 2007 Lee, 2008 Kibler, 2011 Predictable Series of Events in Throwers Progressive Osseous changes Scapular and Cuff weakness Post. Soft Tissue contracture Post-sup. Instability in ABD and EXT ROT. Peel-back mechanism occurs SLAP injury occurs with post-sup cuff injury General population is not routinely exposed to this cascade of events... but throwers are! 2

3 GENERAL POPULATION vs. THROWERS What s the Evidence? Research Data Epidemiologic Biomechanical Imaging Clinical Epidemiologic Evidence Incidence Studies General Population (Snyder et al, AJSM 1990) Throwing Athlete (Andrews et al, AJSM 1996) Throwers & Non-throwers (Burkhart et al, Arthroscopy 2000)... epidemiologic data document SLAP tears occur in overhead throwing athletes 3

4 Biomechanical Evidence Biomechanical Studies Traction vs. peel-back (Kuhn et al, Arthroscopy 2003) Peel-back mechanism (Andrews et al, AJSM 2004) Post-superior shift of humeral head with tight post-capsule (Tibone et al, AJSM 2008)... biomechanical evidence that overhead throwing generates SLAP tears Imaging Evidence Imaging Studies MRA correlated with operative findings: sensitivity 89%; specificity 88%; accuracy 89% Direct MR arthrography is optimal protocol; indirect MR arthrography an alternative Diagnosis can be made without contrast, and at low field strengths... imaging studies document SLAP pathology Richetti, Arthroscopy 2013 Kooima, Radiology 2003 Popovic, IJSM 2001 Chandnani, AJR 1995 Clinical Studies Retrospective and Prospective Studies documenting a range of outcomes after SLAP repair... clinical evidence documents varying % of return to play after treatment of SLAP tears in overhead athletes Snyder, AJSM 2003 Burkhart, CSM 2003 Cohen, SH 2008 Friel, JSES 2010 Forsythe, JBJS 2011 Neuman, AJSM 2011 Sayde, CORR 2012 Schroder, Arthroscopy 2012 Fedoriw, AJSM 2014 Rossy, SH 2016 Chalmers, KSSTA

5 Look more closely... Nonoperative Treatment of Superior Labrum Anterior Posterior Tears Edwards, Ahmad, Levine et al, AJSM, patients with clinically documented SLAP retrospectively reviewed Minimum 1 yr follow-up with Validated Scores Nonoperative Pt Group all with improvements in pain, function and quality of life Return to Play in Nonop Group 71% of all athletes; 66% of overhead athletes A trial of nonoperative treatment should be considered in patients with a SLAP tear Return to Play After Treatment of Superior Labral Tears in Pro Baseball Players Fedoriw, Ramkumar, Lintner et al, AJSM, players with clinically documented SLAP retrospectively reviewed Return to Play (RTP) vs Return to Prior Performance (RPP) 21 pitchers successful nonop: 40% RTP; 22% RPP 27 pitchers required operative tx: 48% RTP; 7% RPP 5

6 Return to Play After Type II SLAP Lesion Repairs in Athletes Sayde, Cohen, Ciccotti et al, CORR, 2012 Systematic Review 1950 to patients with Type II SLAP Repair 83% G/E subjectively 63% overhead athletes return to prior level Tremendous variation in operative technique and postop rehabilitation Results of Arthroscopic Repair of Type II SLAP Lesions in Overhead Athletes Return to Preinjury Playing Level Brian Neuman MD, Brittany Boisvert MD, Brian Reiter MD, Kevin Lawson BS, Michael Ciccotti MD, Steven CohenMD 30 overhead athletes with isolated Type II SLAP Avg ASES Score(0-100): 87.1 Avg KJOC Score(0-100): 71.6 ASES focuses on ADL s and may give a falsely elevated success rate The KJOC score better examines the demands of elite overhead athletes The outcome measures that we use impact our perception of success AJSM, 2011 SLAP Tear in the Older Patient Be cautious of SLAP repair in patients over age 50 yrs, especially with concomitant rotator cuff pathology Franceschi et al, AJSM 2008 Weber et al, Sports Med, 2010 Weber et al, AJSM,

7 The Experts MLB Team Physician s Survey 12 Question Survey on SLAP Injury 26/30 Team Physicians responded 26/26 SLAP as true, identifiable pathology, but more often symptomatic in thrower than nonthrowers Rothman Institute, 2014 MLB Team Physician s Survey 26/26 felt SLAP injuries may not heal in throwers when treated nonoperatively, but may become clinically asymptomatic 26/26 felt pitchers most often required operative treatment Rothman Institute,

8 SLAP Tear in the Overhead Athlete MLB Shoulder Study Group GENERAL POPULATION vs. THROWERS The evidence indicates it is real IS IT WHAT WE THINK? SLAP Tear in the Overhead Athlete... Diagnostic Precision? 8

9 Clinical Evaluation Physical Exam No single test or series of tests reliably predicts a SLAP tear (McFarland, AJSM 2002; Stetson, AJSM 2002; Parentis, AJSM 2006) Imaging Asymptomatic changes exist in the superior labrum with age and in certain populations like overhead athletes (Richetti, JSES 2013;Connolly, JBJS 2013) Arthroscopy Meniscoid/Hypermobile/Peel-Back Variants (Davidson, JSES 2004: Burkhart, JSES, 2006) ARE THERE IS IT REALLY ANY ABNORMAL? CLUES? Physical Exam Pearls Clinical Utility of Traditional and New Tests in the Diagnosis of Biceps Tendon Injuries and SLAP Lesions 325 consecutive patients with shoulder pain underwent standardized clinical evaluation (6 traditional and 2 new tests) Clinical exam correlated with surgical findings Sensitivity, specificity, accuracy, +/- predictive value, and +/- likelihood ratio were calculated Kibler, Sciascia, Hester et al,

10 Physical Exam Pearls Superior Labrum Modified DLS Modified DLS Test was most accurate (0.84) and highest + likelihood ratio (31.57) Modified DLS & O Brien s together provided best prediction Kibler, Sciascia, Hester et al, 2009 Imaging Pearls Contrast undercutting the superior labrum at and/or posterior to the biceps root >2mm Detachment of superior labrum from glenoid Irregular borders of sublabral recess anterior to biceps anchor Peri-labral cyst formation Arthroscopy Pearls Need to Assess: Labral-Glenoid interface Tissue quality Presence of exposed nonarticular glenoid Mobility of labrum 10

11 Arthroscopy Pearls Hemorrhage Granulation tissue Lift off >3-5mm Peel-back in overhead athlete Exposed nonarticular glenoid The Mystery of the SLAP General Population Maybe But less frequently symptomatic 11

12 Overhand Athlete Yes... And often symptomatic High level overhead/throwing athlete Clinically straightforward Traumatic/repetitive microtraumatic history Positive exam findings Imaging illustrating superior labral detachment... Repair it! Arthroscopic findings consistent with abnormalities... but this may very well be a small percentage of SLAP tears overall! 12

13 Older patient/non-athlete/nonthrowing recreational athlete History inconsistent with SLAP Physical Exam ambiguous without any clear cut + SLAP tests Imaging without superior labral detachment Arthroscopic findings consistent with normal variants... Leave it alone! Optimize results by... Diagnostic Precision Specific Indications Nonconstraining Surgical Techniques Broad Postop Rehab Precise Outcome Assessment continued research THANK YOU. 13

14 MLB Team Physician s Survey 12 Question Survey on SLAP Injury 12/26(46%) no single test ideal 14/26(54%) O Brien s Test most precise 26/26 MRI with Gad best imaging study Rothman Institute, 2014 Nonoperative Treatment of Superior Labrum Anterior Posterior Tears Edwards, Ahmad, Levine et al, AJSM, patients with clinically documented SLAP retrospectively reviewed Minimum 1 yr follow-up Patient-derived Validated Scores: SF-36, VAS, ASES, SST, EuroQol 20 pts (51%) initial/delayed operative tx 19 pts (49%) successfully completed nonop tx 14

15 Nonoperative Treatment of Superior Labrum Anterior Posterior Tears Edwards, Ahmad, Levine et al, AJSM, 2010 Nonoperative Pt Group all with improvements in pain, function and quality of life Return to Play in Nonop Group 71% of all athletes; 66% of overhead athletes A trial of nonoperative treatment should be considered in patients with a SLAP tear 15