- Email: [email protected]
Case Report Acute Complex SLAP Lesion
Case Report
Acute Complex SLAP Lesion Giuseppe Porcellini, M.D., Fabrizio Campi, M.D., Paolo Paladini, M.D., and Mariano Piu, M.D.
Summary: The SLAP lesion is a frequently observed lesion of the shoulder involving the superior glenoid labrum and long head biceps tendon. It is caused by falls onto an outstretched arm, inferior traction pull, abduction-external rotation injuries, anterior traction, and upward traction. The authors describe a complex SLAP lesion: type IV associated with an anterior Bankart lesion, that underwent arthroscopic treatment a few days after trauma. At 1-year follow-up of the patient, clinical evaluation and magnetic resonance imaging showed good healing of the long head biceps tendon and of the glenoid labrum, superior and anterior. In similar cases where evaluation is difficult because of shooting pain, drug resistance, and functional limitations of movements, we recommend arthroscopic evaluation a few days after trauma for better accuracy of imaging in the evaluation of acute lesions. Key Words: SLAP lesion—Biceps lesion—Shoulder pathology.
I
njuries to the superior labrum of the shoulder extending from anterior to posterior were first described combined with the transmission of traction forces along the long head of the biceps tendon on the superior glenoid labrum by Andrews et al.1 They ascribed the instability symptoms exhibited by athletes in throwing action to the inability of the biceps to lower the humeral head and press it on the glenoid cavity during abduction movements. The acronym SLAP lesion was coined by Snyder et al.2 for the same injury pattern (a specific injury pattern to the superior labrum of the glenoid going from anterior to posterior). These authors classified SLAP lesions into 4 types: type I, marked degenerative fraying of the superior labrum, peripheral labral edge firmly attached to the glenoid, and intact attachment of the biceps From the Department of Orthopaedics, Hospital Morgagni, Forlı` (G.P., F.C.); the Department of Orthopaedics University of Ancona, Ancona (P.P.); and the Department of Orthopaedics University of Ferrara, Ferrara (M.P.), Italy. Address correspondence to Porcellini Giuseppe, M.D., Modulo di Chirurgia della Spalla, Reparto di Ortopedia, Ospedale ‘‘G. Morgagni,’’ Piazzale Solieri 1, 47100 Forlı`, Italy. E-mail: [email protected] r 1999 by the Arthroscopy Association of North America 1526-3231/99/1508-2368$3.00/0
tendon to the labrum; type II, fraying and degenerative changes similar to type I, and superior labrum and attached biceps tendon stripped off the underlying glenoid; type III, bucket-handle tear in the superior labrum, with the central portion of the tear displaceable into the joint and the peripheral portion of the labrum firmly attached to the underlying glenoid and to the intact biceps tendon; type IV, bucket-handle tears of the superior labrum similar to those of type III and tear extending into the biceps tendon. Maffet et al.3 described further types of SLAP lesions, associating the type II of Snyder et al. with other lesions of the glenoid labrum: type V, anterior-inferior Bankart lesion continued superiorly to include separation of the biceps tendon; type VI, unstable flap tear of the labrum in addition to biceps tendon separation; and type VII, superior labrum-biceps tendon separation extended anteriorly beneath the middle glenohumeral ligament. Ryu4 added SLAP lesions type VIII, posterior Bankart lesion associated with SLAP type II, and type IX, posterior and anterior Bankart lesion associated with SLAP type II. The most frequent mechanism of injury, according to Snyder et al. is a fall onto an outstretched arm.2 Additional mechanisms of injury observed by Maffet
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 8 (November-December), 1999: E3
1
2
G. PORCELLINI ET AL.
et al.3 included inferior traction pull, abduction-external rotation injuries, anterior traction, and upward traction. The most useful diagnostic tests to identify SLAP lesions are the biceps tension test (resisted shoulder flexion with elbow extended and forearm supinated), the joint compression-rotation test,2 and the SLAP apprehension test.5 However, because of the absence of signs of instability and total functional impotence and shooting pain, none of these tests can diagnose an acute lesion with accuracy and certainty. Diagnosis is thus necessarily completed by imaging procedures, although computed tomographic arthrography and magnetic resonance (MR) arthrography are not sufficiently sensitive and specific to be the diagnostic procedure of choice for SLAP lesions.6-8 The treatment of a SLAP lesion is determined by its type: debridement for type I, debridement of the frayed labral tissue and fixation of the labrum and the long head of the biceps tendon for type II, excision of the bucket-handle tear for type III, and fixation of the labrum and excision of the bucket-handle tear if it involves less than 50%1,9 or 30%10 of the biceps, and tenodesis if it involves more than 50% of the tendon.2 Burkhart and Fox11 published a case report of a suture of the long head of the biceps tendon with a buckethandle tear greater than 60%. Associated pathologies have been described including cuff tears,2 osteolysis of the distal clavicle,12 and glenoid labral cyst entrapping the suprascapular nerve.13 The aim of the present report is to describe our experience in the treatment of an acute type IV SLAP lesion associated with a Bankart lesion. CASE REPORT In March 1998, a 38-year-old truck driver presented for a shoulder consultation. He had fallen on his outstretched arm, with the shoulder positioned in abduction and slightly forward flexion. He felt shooting pain to the anterior side of the arm going down along the biceps muscle; the pain was still present during the night and did not abate with drug therapy. Clinical examination showed limited active range of motion (abduction 30°, extrarotation 20°, and intrarotation 15°) with passive movements possible on all planes with pain. He performed the O’Brien, Jobe, and Neer tests with difficulty. The patient’s radiographs were negative. At ultrasound examination, the long head of the biceps tendon appeared surrounded by fluid with hypoechogenic imaging of the distal end of the supraspinatus, suggesting the possibility of a partial lesion. Ten days after the
FIGURE 1. Arthroscopic findings: hemorrhagic tear (red-on-red) of the long head of the biceps involves more than 50% of the tendon.
trauma, the patient had the same symptomatology and underwent arthroscopic surgery (Fig 1). Under general anesthesia, clicks were produced by extra- and intrarotation movements with the elbow flexed and the arm abducted to 90°. Diagnostic arthroscopy revealed a Bankart lesion and a type IV SLAP lesion with a longitudinal tear of the long head of the biceps tendon. The tear involved more than 50% of the tendon and was hemorrhagic (red-on-red) for its whole length. The biceps anchor was detached from the glenoid (Fig 2). The biceps anchor was repaired with a MiniRevo screw (Linvatec, Largo, FL), the long head of the biceps tendon was sutured with a mattress-knot (Ethibond No. 2; Ethicon, Somerville, NJ) on the nonarticular side (Fig 3) and the Bankart lesion was repaired with a MiniRevo screw (Fig 4). At the end of the surgical procedure, the anterior glenoid labrum and the
FIGURE 2. Arthroscopic findings: SLAP lesion type II. The probe lift off the biceps anchor.
ACUTE COMPLEX SLAP LESION
FIGURE 3. Suture of the tear of the long head of the biceps with a mattress knot on the nonarticular side using a crescent hook.
biceps anchor appeared stable. The patient was kept in a shoulder immobilizer for 3 weeks, then began passive and subsequently active mobilization in a pool with progressive loading starting from the 8th week. Four months after surgery the patient returned to his preinjury activity. One year after surgery the patient underwent follow-up clinical examination and MR imaging. He reported no painful catching or popping sensation, nor instability or subluxation. Clinical examination showed physiological range of motion. Passive and active mobilization were not painful. O’Brien, palm-up, and Jobe tests were completely negative; the isokinetic test showed similar strength in the 2 arms, confirming the clinical finding. The anterior glenoid
FIGURE 4. Postoperative axial radiograph showing the positioning of the 2 MiniRevo screws: (a) Anterior for the suture of the Bankart lesion, (b) superior for the suture of the biceps anchor.
3
FIGURE 5. One year control MR: arrow shows the MiniRevo screw stabilizing biceps anchor and good and uniform condition of the long head.
labrum and the insertion of the long head of the biceps tendon on the biceps anchor were particularly well portrayed in MR oblique scans. The glenoid labrum appeared to have healed well, without degenerative changes and articular inflammatory fluid. MR scans showed the condition of the biceps tendon to be good and uniform, without reactive fluid around the synovial sheath (Figs 5 and 6). DISCUSSION When examining the effects of a fall onto an outstretched arm with the shoulder positioned in abduction and slight forward flexion, and when there is
FIGURE 6. One year control MR: arrow shows the biceps anchor and the synovial sheath of the tendon without inflammatory signs.
4
G. PORCELLINI ET AL.
clinical evidence of shoulder functional impotence, the clinician must expect not only a rotator cuff lesion, but also a SLAP lesion. This kind of lesion, if unrecognized, could determine a secondary impingement syndrome. In the presence of a type IV SLAP lesion, an urgent shoulder arthroscopy should be performed to avoid degenerative changes of the upper end of the long head biceps tendon and consequent debridement that could result in an unstable shoulder. The case described here has some unusual features because of the presence of a previously unreported complex lesion (type IV SLAP lesion associated with a Bankart lesion) and to the emergency treatment to which it was subjected. One case of urgently treated complex SLAP lesion (type IV plus Bankart) is hardly sufficient to establish a specific treatment procedure. The finding of a longitudinal lesion of the long head of the biceps tendon, hemorrhagic throughout its extent (red-on-red), prompted us to perform a suture as recommended by Burkhart and Fox11 for similar cases with red-on-white lesions, even though they exceed 60% of the tendon. This would be especially indicated in the case of a young patient with high functional demands. The satisfactory outcome of the urgent treatment of a red-on-red lesion not previously reported in the literature suggests that the elective treatment for this complex lesion is reconstructive, to achieve restoration of the integrity of the tendon and shoulder stability. Acknowledgment: The authors are grateful to Dr. Bazzocchi of the Radiology Department, Ospedale Morgagni Forlı`, for MR imaging.
REFERENCES 1. Andrews JR, Carson WJ, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sport Med 1985;13:337-341. 2. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279. 3. Maffet MW, Gartsman GM, Moseley B. Superior lambrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-98. 4. Ryu RKN. Classification and treatment of SLAP injuries. Presented at the 14th Annual Meeting, Arthroscopic Surgery of Shoulder, San Diego, CA, 1997;255-260. 5. Berg EE, Ciullo JV. A clinical test for superior glenoid labral or ‘SLAP’ lesions. Clin J Sports Med 1998;8:121-123. 6. Cartland JP, Crues JW, Stauffer A, Nottage W, Ryu RKN. MR imaging in the evaluation of SLAP injuries of the shoulder: Findings in 10 patients. AJR Am J Roentgenol 1992;159:787792. 7. Hunter JC, Blatz DJ, Escobedo EM. SLAP lesions of the glenoid labrum: CT arthrographic and arthroscopic correlation. Radiology 1992;184:513-518. 8. Smith AM, McCauley TR, Jokl P. SLAP lesions of the glenoid labrum diagnosed with MR imaging. Skeletal Radiol 1993;22: 507-510. 9. Rames RD, Karzel RP. Injuries to the glenoid labrum, including slap lesions. Orthop Clin North Am 1993;24:45-53. 10. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131. 11. Burkhart SS, Fox DL. Arthroscopic repair of a type IV SLAP lesion—The red on white lesion as a component of anterior instability. Arthroscopy 1993;9:488-492. 12. Berg EE, Ciullo JV. The SLAP lesion: A cause of failure after distal clavicle resection. Arthroscopy 1997;13:85-89. 13. Chochole MH, Senker W, Meznik C, Breitenseher MJ. Glenoid labral cyst entrapping suprascapular nerve: dissolution after arthroscopic debridement of an extended SLAP lesion. Arthroscopy 1997;13:753-755.
Acute Complex SLAP Lesion Giuseppe Porcellini, M.D., Fabrizio Campi, M.D., Paolo Paladini, M.D., and Mariano Piu, M.D.
Summary: The SLAP lesion is a frequently observed lesion of the shoulder involving the superior glenoid labrum and long head biceps tendon. It is caused by falls onto an outstretched arm, inferior traction pull, abduction-external rotation injuries, anterior traction, and upward traction. The authors describe a complex SLAP lesion: type IV associated with an anterior Bankart lesion, that underwent arthroscopic treatment a few days after trauma. At 1-year follow-up of the patient, clinical evaluation and magnetic resonance imaging showed good healing of the long head biceps tendon and of the glenoid labrum, superior and anterior. In similar cases where evaluation is difficult because of shooting pain, drug resistance, and functional limitations of movements, we recommend arthroscopic evaluation a few days after trauma for better accuracy of imaging in the evaluation of acute lesions. Key Words: SLAP lesion—Biceps lesion—Shoulder pathology.
I
njuries to the superior labrum of the shoulder extending from anterior to posterior were first described combined with the transmission of traction forces along the long head of the biceps tendon on the superior glenoid labrum by Andrews et al.1 They ascribed the instability symptoms exhibited by athletes in throwing action to the inability of the biceps to lower the humeral head and press it on the glenoid cavity during abduction movements. The acronym SLAP lesion was coined by Snyder et al.2 for the same injury pattern (a specific injury pattern to the superior labrum of the glenoid going from anterior to posterior). These authors classified SLAP lesions into 4 types: type I, marked degenerative fraying of the superior labrum, peripheral labral edge firmly attached to the glenoid, and intact attachment of the biceps From the Department of Orthopaedics, Hospital Morgagni, Forlı` (G.P., F.C.); the Department of Orthopaedics University of Ancona, Ancona (P.P.); and the Department of Orthopaedics University of Ferrara, Ferrara (M.P.), Italy. Address correspondence to Porcellini Giuseppe, M.D., Modulo di Chirurgia della Spalla, Reparto di Ortopedia, Ospedale ‘‘G. Morgagni,’’ Piazzale Solieri 1, 47100 Forlı`, Italy. E-mail: [email protected] r 1999 by the Arthroscopy Association of North America 1526-3231/99/1508-2368$3.00/0
tendon to the labrum; type II, fraying and degenerative changes similar to type I, and superior labrum and attached biceps tendon stripped off the underlying glenoid; type III, bucket-handle tear in the superior labrum, with the central portion of the tear displaceable into the joint and the peripheral portion of the labrum firmly attached to the underlying glenoid and to the intact biceps tendon; type IV, bucket-handle tears of the superior labrum similar to those of type III and tear extending into the biceps tendon. Maffet et al.3 described further types of SLAP lesions, associating the type II of Snyder et al. with other lesions of the glenoid labrum: type V, anterior-inferior Bankart lesion continued superiorly to include separation of the biceps tendon; type VI, unstable flap tear of the labrum in addition to biceps tendon separation; and type VII, superior labrum-biceps tendon separation extended anteriorly beneath the middle glenohumeral ligament. Ryu4 added SLAP lesions type VIII, posterior Bankart lesion associated with SLAP type II, and type IX, posterior and anterior Bankart lesion associated with SLAP type II. The most frequent mechanism of injury, according to Snyder et al. is a fall onto an outstretched arm.2 Additional mechanisms of injury observed by Maffet
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 8 (November-December), 1999: E3
1
2
G. PORCELLINI ET AL.
et al.3 included inferior traction pull, abduction-external rotation injuries, anterior traction, and upward traction. The most useful diagnostic tests to identify SLAP lesions are the biceps tension test (resisted shoulder flexion with elbow extended and forearm supinated), the joint compression-rotation test,2 and the SLAP apprehension test.5 However, because of the absence of signs of instability and total functional impotence and shooting pain, none of these tests can diagnose an acute lesion with accuracy and certainty. Diagnosis is thus necessarily completed by imaging procedures, although computed tomographic arthrography and magnetic resonance (MR) arthrography are not sufficiently sensitive and specific to be the diagnostic procedure of choice for SLAP lesions.6-8 The treatment of a SLAP lesion is determined by its type: debridement for type I, debridement of the frayed labral tissue and fixation of the labrum and the long head of the biceps tendon for type II, excision of the bucket-handle tear for type III, and fixation of the labrum and excision of the bucket-handle tear if it involves less than 50%1,9 or 30%10 of the biceps, and tenodesis if it involves more than 50% of the tendon.2 Burkhart and Fox11 published a case report of a suture of the long head of the biceps tendon with a buckethandle tear greater than 60%. Associated pathologies have been described including cuff tears,2 osteolysis of the distal clavicle,12 and glenoid labral cyst entrapping the suprascapular nerve.13 The aim of the present report is to describe our experience in the treatment of an acute type IV SLAP lesion associated with a Bankart lesion. CASE REPORT In March 1998, a 38-year-old truck driver presented for a shoulder consultation. He had fallen on his outstretched arm, with the shoulder positioned in abduction and slightly forward flexion. He felt shooting pain to the anterior side of the arm going down along the biceps muscle; the pain was still present during the night and did not abate with drug therapy. Clinical examination showed limited active range of motion (abduction 30°, extrarotation 20°, and intrarotation 15°) with passive movements possible on all planes with pain. He performed the O’Brien, Jobe, and Neer tests with difficulty. The patient’s radiographs were negative. At ultrasound examination, the long head of the biceps tendon appeared surrounded by fluid with hypoechogenic imaging of the distal end of the supraspinatus, suggesting the possibility of a partial lesion. Ten days after the
FIGURE 1. Arthroscopic findings: hemorrhagic tear (red-on-red) of the long head of the biceps involves more than 50% of the tendon.
trauma, the patient had the same symptomatology and underwent arthroscopic surgery (Fig 1). Under general anesthesia, clicks were produced by extra- and intrarotation movements with the elbow flexed and the arm abducted to 90°. Diagnostic arthroscopy revealed a Bankart lesion and a type IV SLAP lesion with a longitudinal tear of the long head of the biceps tendon. The tear involved more than 50% of the tendon and was hemorrhagic (red-on-red) for its whole length. The biceps anchor was detached from the glenoid (Fig 2). The biceps anchor was repaired with a MiniRevo screw (Linvatec, Largo, FL), the long head of the biceps tendon was sutured with a mattress-knot (Ethibond No. 2; Ethicon, Somerville, NJ) on the nonarticular side (Fig 3) and the Bankart lesion was repaired with a MiniRevo screw (Fig 4). At the end of the surgical procedure, the anterior glenoid labrum and the
FIGURE 2. Arthroscopic findings: SLAP lesion type II. The probe lift off the biceps anchor.
ACUTE COMPLEX SLAP LESION
FIGURE 3. Suture of the tear of the long head of the biceps with a mattress knot on the nonarticular side using a crescent hook.
biceps anchor appeared stable. The patient was kept in a shoulder immobilizer for 3 weeks, then began passive and subsequently active mobilization in a pool with progressive loading starting from the 8th week. Four months after surgery the patient returned to his preinjury activity. One year after surgery the patient underwent follow-up clinical examination and MR imaging. He reported no painful catching or popping sensation, nor instability or subluxation. Clinical examination showed physiological range of motion. Passive and active mobilization were not painful. O’Brien, palm-up, and Jobe tests were completely negative; the isokinetic test showed similar strength in the 2 arms, confirming the clinical finding. The anterior glenoid
FIGURE 4. Postoperative axial radiograph showing the positioning of the 2 MiniRevo screws: (a) Anterior for the suture of the Bankart lesion, (b) superior for the suture of the biceps anchor.
3
FIGURE 5. One year control MR: arrow shows the MiniRevo screw stabilizing biceps anchor and good and uniform condition of the long head.
labrum and the insertion of the long head of the biceps tendon on the biceps anchor were particularly well portrayed in MR oblique scans. The glenoid labrum appeared to have healed well, without degenerative changes and articular inflammatory fluid. MR scans showed the condition of the biceps tendon to be good and uniform, without reactive fluid around the synovial sheath (Figs 5 and 6). DISCUSSION When examining the effects of a fall onto an outstretched arm with the shoulder positioned in abduction and slight forward flexion, and when there is
FIGURE 6. One year control MR: arrow shows the biceps anchor and the synovial sheath of the tendon without inflammatory signs.
4
G. PORCELLINI ET AL.
clinical evidence of shoulder functional impotence, the clinician must expect not only a rotator cuff lesion, but also a SLAP lesion. This kind of lesion, if unrecognized, could determine a secondary impingement syndrome. In the presence of a type IV SLAP lesion, an urgent shoulder arthroscopy should be performed to avoid degenerative changes of the upper end of the long head biceps tendon and consequent debridement that could result in an unstable shoulder. The case described here has some unusual features because of the presence of a previously unreported complex lesion (type IV SLAP lesion associated with a Bankart lesion) and to the emergency treatment to which it was subjected. One case of urgently treated complex SLAP lesion (type IV plus Bankart) is hardly sufficient to establish a specific treatment procedure. The finding of a longitudinal lesion of the long head of the biceps tendon, hemorrhagic throughout its extent (red-on-red), prompted us to perform a suture as recommended by Burkhart and Fox11 for similar cases with red-on-white lesions, even though they exceed 60% of the tendon. This would be especially indicated in the case of a young patient with high functional demands. The satisfactory outcome of the urgent treatment of a red-on-red lesion not previously reported in the literature suggests that the elective treatment for this complex lesion is reconstructive, to achieve restoration of the integrity of the tendon and shoulder stability. Acknowledgment: The authors are grateful to Dr. Bazzocchi of the Radiology Department, Ospedale Morgagni Forlı`, for MR imaging.
REFERENCES 1. Andrews JR, Carson WJ, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sport Med 1985;13:337-341. 2. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy 1990;6:274-279. 3. Maffet MW, Gartsman GM, Moseley B. Superior lambrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-98. 4. Ryu RKN. Classification and treatment of SLAP injuries. Presented at the 14th Annual Meeting, Arthroscopic Surgery of Shoulder, San Diego, CA, 1997;255-260. 5. Berg EE, Ciullo JV. A clinical test for superior glenoid labral or ‘SLAP’ lesions. Clin J Sports Med 1998;8:121-123. 6. Cartland JP, Crues JW, Stauffer A, Nottage W, Ryu RKN. MR imaging in the evaluation of SLAP injuries of the shoulder: Findings in 10 patients. AJR Am J Roentgenol 1992;159:787792. 7. Hunter JC, Blatz DJ, Escobedo EM. SLAP lesions of the glenoid labrum: CT arthrographic and arthroscopic correlation. Radiology 1992;184:513-518. 8. Smith AM, McCauley TR, Jokl P. SLAP lesions of the glenoid labrum diagnosed with MR imaging. Skeletal Radiol 1993;22: 507-510. 9. Rames RD, Karzel RP. Injuries to the glenoid labrum, including slap lesions. Orthop Clin North Am 1993;24:45-53. 10. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131. 11. Burkhart SS, Fox DL. Arthroscopic repair of a type IV SLAP lesion—The red on white lesion as a component of anterior instability. Arthroscopy 1993;9:488-492. 12. Berg EE, Ciullo JV. The SLAP lesion: A cause of failure after distal clavicle resection. Arthroscopy 1997;13:85-89. 13. Chochole MH, Senker W, Meznik C, Breitenseher MJ. Glenoid labral cyst entrapping suprascapular nerve: dissolution after arthroscopic debridement of an extended SLAP lesion. Arthroscopy 1997;13:753-755.