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Single-Portal SLAP Lesion Repair
Technical Note
Single-Portal SLAP Lesion Repair Daniel J. Daluga, M.D., and Andrew T. Daluga
Abstract: SLAP lesions are increasingly being recognized as a common cause of shoulder pain. Because an intact superior labral complex is required for peak performance of the shoulder, it is critical that all arthroscopic surgeons are able to recognize and repair these injuries. The most common method of repair involves at least 2 additional portals. The area of repair can become quite crowded, and the method can be challenging at times. A simple and highly reproducible technique is described. This technique requires only an anterior portal for suture management and no special instrumentation. A 5-mm anterior portal is established along with a standard posterior portal. A spinal needle is inserted from the anterior-lateral aspect of the acromion to identify the most desirable location for the suture anchor. After placement of the suture anchor, a second spinal needle is placed in the area of the subclavian portal. This needle is passed through the base of the biceps origin. PDS suture (Ethicon, Somerville, NJ) is placed through the needle and captured with a standard grasper. Before the needle is removed, a loop grasper or crochet hook is used to locate the needle. This prevents the suture from getting caught in hypertrophic tissue. A standard switching technique is then performed, and both sutures are brought out of the anterior portal and tied. This technique is simple and reproducible and requires no special instrumentation. Key Words: SLAP lesion—Single portal.
F
irst described by Andrews et al.1 in 1985 in a group of overhead-throwing athletes and subsequently categorized by Snyder et al. in 1990,2 the SLAP lesion is now well recognized. SLAP lesions occur through a variety of mechanisms that are classified primarily into 2 groups: compression injuries and traction injuries.3 Most are the result of traction injuries that occur in routine daily life, as well as in overhead throwing.4,5 Some may even arise without any known associated injury.6 Numerous biomechanical studies have confirmed the importance of the su-
From the Arnett Clinic, Indiana University, Lafayette, Indiana, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to Daniel J. Daluga, M.D., Lafayette Orthopaedic Clinic, 1411 Creasy Ln, Lafayette, IN 47904, U.S.A. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Daluga DJ, Daluga AT. Single-portal SLAP lesion repair. Arthroscopy 2007;23:321.e1-321.e4 [doi: 10.1016/j.arthro.2006.05.033]. 0749-8063/07/2303-5297$32.00/0 doi:10.1016/j.arthro.2006.05.033
perior labrum– biceps complex in the stability and function of the shoulder.7,8 Therefore the current recommendation is to anatomically repair the detached complex. A multitude of arthroscopic repair techniques have been described with a variety of suture passage devices, multiple portals, and a number of fixation devices.9 The most common technique, which often involves the placement of 2 anterior portals, can be challenging, especially in small shoulders. A recently described technique uses the subclavian portal but requires 4 to 5 portals and special instrumentation.10,11 In this report a simple technique for repair of the SLAP lesion with the use of 1 small anterior portal and no special instrumentation is described.
SURGICAL TECHNIQUE After induction of general anesthesia, the patient is placed in the beach-chair position. Diagnostic arthroscopy is performed through a standard posterior portal via a standard 30° arthroscope. After a thorough eval-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 3 (March), 2007: pp 321.e1-321.e4
321.e1
321.e2
FIGURE 1.
D. J. DALUGA AND A. T. DALUGA
A spinal needle is used to help locate the precise location for the suture anchor (A), which is placed through a stab wound (B).
uation of the articular surfaces, rotator cuff, and biceps tendon, an anterior portal is established with assistance from a spinal needle. A 5-mm anterior portal is
FIGURE 2. One arm is pulled through the anterior portal, and a spinal needle is passed through the modified Neviaser portal or the subclavian portal into the labral defect.
established, and the SLAP lesion is evaluated. By use of a 4.5-mm shaver, the base of the lesion is prepared in standard fashion. Once the base is adequately prepared, a spinal needle is inserted from the anteriorlateral aspect of the acromion (Fig 1A). The needle
FIGURE 3.
No. 1 PDS suture is then passed through the needle.
SINGLE-PORTAL SLAP REPAIR
321.e3
identifies the most desirable spot for the suture anchor. A stab wound is made adjacent to the spinal needle, and the suture anchor is placed in the previously prepared bone bed of the superior glenoid (Fig 1B). One of the limbs of the suture anchor is pulled out of the anterior portal (Fig 2). A new spinal needle is then inserted directly above and slightly medial to the coracoid (i.e., the subclavian portal). The spinal needle is easily and precisely placed in the base of the bicipital attachment. No. 1 PDS suture (Ethicon, Somerville, NJ) is threaded through the spinal needle, captured with a standard grasper, and pulled out of the anterior portal (Fig 3). Before the needle is pulled out, the needle’s shaft is located between the rotator cuff and the SLAP lesion by use of a loop grasper or crochet hook (Fig 4). This makes for much simpler suture retrieval and prevents the suture from getting caught up in hypertrophic tissue.
FIGURE 5. The needle is removed, and a standard handoff technique is used. The loop grasper is still in place holding the PDS suture.
A standard switching technique is then performed (Fig 5). The 2 suture limbs are brought out of the anterior portal and tied (Fig 6). A second suture can be added in a similar fashion if needed. Use of the spinal needle obviates the need for a second portal and reduces the risk of inadvertent damage to the biceps from multiple stabs from the penetrator. DISCUSSION
FIGURE 4. The PDS suture is retrieved through the anterior portal, but before the needle is removed, it is isolated and held with a loop grasper or crochet hook.
Arthroscopic SLAP repair is an excellent procedure with reproducible results. The clinical success rate for repairs via suture anchors has been reported by Morgan et al.5 to be 97%. This technique allows the procedure to be accomplished with the use of only 1 small anterior portal and no special instrumentation. Using a small spinal needle through the torn labrum improves the accuracy and minimizes the tissue damage that can occur with multiple passes of a tissue penetrator.
321.e4
D. J. DALUGA AND A. T. DALUGA CONCLUSIONS The simple modification described makes SLAP repair a very uncomplicated and easily reproducible procedure.
REFERENCES
FIGURE 6. The PDS suture is switched with the anterior arm of the suture anchor. The loop grasper is now holding the anterior arm of the suture anchor.
1. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-341. 2. Snyder SJ, Karzel RR, 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 labrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-98. 4. Burkhart SS, Morgan CD. The peel-back mechanism: Its role in producing and extending type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14:637-640. 5. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998;14:553-565. 6. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131. 7. Malicky DM, Soslowsky LJ, Blasier RB, Shyr Y. Anterior glenohumeral stabilization factors: Progressive effects in a biomechanical model. J Orthop Res 1996;14:282-288. 8. Pagnani MJ, Deng XH, Warren RF, Torzilla PA, Altchek DW. Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am 1995;77:1003-1010. 9. Yian E, Wang C, Millett PJ, Warner JJP. Arthroscopic repair of SLAP lesions with a bioknotless suture anchor. Arthroscopy 2004;20:547-551. 10. Nord KD, Mauck BM. The new subclavian portal and modified Neviaser portal for arthroscopic rotator cuff repair. Arthroscopy 2003;19:1030-1034. 11. Nord KD, Masterson JP, Mauck BM. Superior labrum anterior posterior repair using the Neviaser portal. Arthroscopy 2004; 20:129-133.
Single-Portal SLAP Lesion Repair Daniel J. Daluga, M.D., and Andrew T. Daluga
Abstract: SLAP lesions are increasingly being recognized as a common cause of shoulder pain. Because an intact superior labral complex is required for peak performance of the shoulder, it is critical that all arthroscopic surgeons are able to recognize and repair these injuries. The most common method of repair involves at least 2 additional portals. The area of repair can become quite crowded, and the method can be challenging at times. A simple and highly reproducible technique is described. This technique requires only an anterior portal for suture management and no special instrumentation. A 5-mm anterior portal is established along with a standard posterior portal. A spinal needle is inserted from the anterior-lateral aspect of the acromion to identify the most desirable location for the suture anchor. After placement of the suture anchor, a second spinal needle is placed in the area of the subclavian portal. This needle is passed through the base of the biceps origin. PDS suture (Ethicon, Somerville, NJ) is placed through the needle and captured with a standard grasper. Before the needle is removed, a loop grasper or crochet hook is used to locate the needle. This prevents the suture from getting caught in hypertrophic tissue. A standard switching technique is then performed, and both sutures are brought out of the anterior portal and tied. This technique is simple and reproducible and requires no special instrumentation. Key Words: SLAP lesion—Single portal.
F
irst described by Andrews et al.1 in 1985 in a group of overhead-throwing athletes and subsequently categorized by Snyder et al. in 1990,2 the SLAP lesion is now well recognized. SLAP lesions occur through a variety of mechanisms that are classified primarily into 2 groups: compression injuries and traction injuries.3 Most are the result of traction injuries that occur in routine daily life, as well as in overhead throwing.4,5 Some may even arise without any known associated injury.6 Numerous biomechanical studies have confirmed the importance of the su-
From the Arnett Clinic, Indiana University, Lafayette, Indiana, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to Daniel J. Daluga, M.D., Lafayette Orthopaedic Clinic, 1411 Creasy Ln, Lafayette, IN 47904, U.S.A. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Daluga DJ, Daluga AT. Single-portal SLAP lesion repair. Arthroscopy 2007;23:321.e1-321.e4 [doi: 10.1016/j.arthro.2006.05.033]. 0749-8063/07/2303-5297$32.00/0 doi:10.1016/j.arthro.2006.05.033
perior labrum– biceps complex in the stability and function of the shoulder.7,8 Therefore the current recommendation is to anatomically repair the detached complex. A multitude of arthroscopic repair techniques have been described with a variety of suture passage devices, multiple portals, and a number of fixation devices.9 The most common technique, which often involves the placement of 2 anterior portals, can be challenging, especially in small shoulders. A recently described technique uses the subclavian portal but requires 4 to 5 portals and special instrumentation.10,11 In this report a simple technique for repair of the SLAP lesion with the use of 1 small anterior portal and no special instrumentation is described.
SURGICAL TECHNIQUE After induction of general anesthesia, the patient is placed in the beach-chair position. Diagnostic arthroscopy is performed through a standard posterior portal via a standard 30° arthroscope. After a thorough eval-
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 3 (March), 2007: pp 321.e1-321.e4
321.e1
321.e2
FIGURE 1.
D. J. DALUGA AND A. T. DALUGA
A spinal needle is used to help locate the precise location for the suture anchor (A), which is placed through a stab wound (B).
uation of the articular surfaces, rotator cuff, and biceps tendon, an anterior portal is established with assistance from a spinal needle. A 5-mm anterior portal is
FIGURE 2. One arm is pulled through the anterior portal, and a spinal needle is passed through the modified Neviaser portal or the subclavian portal into the labral defect.
established, and the SLAP lesion is evaluated. By use of a 4.5-mm shaver, the base of the lesion is prepared in standard fashion. Once the base is adequately prepared, a spinal needle is inserted from the anteriorlateral aspect of the acromion (Fig 1A). The needle
FIGURE 3.
No. 1 PDS suture is then passed through the needle.
SINGLE-PORTAL SLAP REPAIR
321.e3
identifies the most desirable spot for the suture anchor. A stab wound is made adjacent to the spinal needle, and the suture anchor is placed in the previously prepared bone bed of the superior glenoid (Fig 1B). One of the limbs of the suture anchor is pulled out of the anterior portal (Fig 2). A new spinal needle is then inserted directly above and slightly medial to the coracoid (i.e., the subclavian portal). The spinal needle is easily and precisely placed in the base of the bicipital attachment. No. 1 PDS suture (Ethicon, Somerville, NJ) is threaded through the spinal needle, captured with a standard grasper, and pulled out of the anterior portal (Fig 3). Before the needle is pulled out, the needle’s shaft is located between the rotator cuff and the SLAP lesion by use of a loop grasper or crochet hook (Fig 4). This makes for much simpler suture retrieval and prevents the suture from getting caught up in hypertrophic tissue.
FIGURE 5. The needle is removed, and a standard handoff technique is used. The loop grasper is still in place holding the PDS suture.
A standard switching technique is then performed (Fig 5). The 2 suture limbs are brought out of the anterior portal and tied (Fig 6). A second suture can be added in a similar fashion if needed. Use of the spinal needle obviates the need for a second portal and reduces the risk of inadvertent damage to the biceps from multiple stabs from the penetrator. DISCUSSION
FIGURE 4. The PDS suture is retrieved through the anterior portal, but before the needle is removed, it is isolated and held with a loop grasper or crochet hook.
Arthroscopic SLAP repair is an excellent procedure with reproducible results. The clinical success rate for repairs via suture anchors has been reported by Morgan et al.5 to be 97%. This technique allows the procedure to be accomplished with the use of only 1 small anterior portal and no special instrumentation. Using a small spinal needle through the torn labrum improves the accuracy and minimizes the tissue damage that can occur with multiple passes of a tissue penetrator.
321.e4
D. J. DALUGA AND A. T. DALUGA CONCLUSIONS The simple modification described makes SLAP repair a very uncomplicated and easily reproducible procedure.
REFERENCES
FIGURE 6. The PDS suture is switched with the anterior arm of the suture anchor. The loop grasper is now holding the anterior arm of the suture anchor.
1. Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985;13:337-341. 2. Snyder SJ, Karzel RR, 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 labrumbiceps tendon complex lesions of the shoulder. Am J Sports Med 1995;23:93-98. 4. Burkhart SS, Morgan CD. The peel-back mechanism: Its role in producing and extending type II SLAP lesions and its effect on SLAP repair rehabilitation. Arthroscopy 1998;14:637-640. 5. Morgan CD, Burkhart SS, Palmeri M, Gillespie M. Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 1998;14:553-565. 6. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: Pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-131. 7. Malicky DM, Soslowsky LJ, Blasier RB, Shyr Y. Anterior glenohumeral stabilization factors: Progressive effects in a biomechanical model. J Orthop Res 1996;14:282-288. 8. Pagnani MJ, Deng XH, Warren RF, Torzilla PA, Altchek DW. Effect of lesions of the superior portion of the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am 1995;77:1003-1010. 9. Yian E, Wang C, Millett PJ, Warner JJP. Arthroscopic repair of SLAP lesions with a bioknotless suture anchor. Arthroscopy 2004;20:547-551. 10. Nord KD, Mauck BM. The new subclavian portal and modified Neviaser portal for arthroscopic rotator cuff repair. Arthroscopy 2003;19:1030-1034. 11. Nord KD, Masterson JP, Mauck BM. Superior labrum anterior posterior repair using the Neviaser portal. Arthroscopy 2004; 20:129-133.