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The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs
J Shoulder Elbow Surg (2012) 21, 728-731
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The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs Ikemefuna Onyekwelu, MD*, Omar Khatib, MD, Joseph D. Zuckerman, MD, Andrew S. Rokito, MD, Young W. Kwon, MD, PhD Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA Background: Superior labrum anterior-posterior (SLAP) lesions of the shoulder that require surgical repair are relatively uncommon. However, recent observations suggest that there may be a rise in the incidence of SLAP lesion repair. Materials and methods: The Statewide Planning and Research Cooperative Systems (SPARCS) database from the New York State Department of Health was used to acquire data for all outpatient ambulatory surgery procedures that were performed in New York State from 2002 to 2010. The data were reviewed and analyzed to compare the incidence of arthroscopic SLAP lesion repairs relative to other outpatient surgical procedures. Results: Within New York State, from 2002 to 2010, the number of all ambulatory surgical procedures increased 55%, from 1,411,633 to 2,189,991. Correspondingly, the number of ambulatory orthopedic procedures increased 135%, from 118,126 to 278,136. In comparison, the number of arthroscopic SLAP repairs increased 464%, from 765 to 4,313 (P < .0001). This represented a population-based incidence of 4.0/100,000 in 2002 and 22.3/100,000 in 2010. The mean age of patients undergoing arthroscopic SLAP repair in 2002 was 37 14 years. The mean age in 2010 was 40 14 years (P < .0001). Conclusions: The data suggest a substantial increase in the number of arthroscopic SLAP repairs that is significantly more rapid than the rising rate of outpatient orthopedic surgical procedures. In addition, there is a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs. Level of evidence: Level III, Cross Sectional Study, Epidemiology Study. Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: SLAP repair; superior labrum anterior posterior lesions; epidemic; shoulder; arthroscopy; CPT code
Lesions of the superior labrum anterior and posterior (SLAP) to the biceps tendon were first recognized by Andrews et al1 and later classified by Snyder et al13 into 4 This study was exempt from Investigational Review Board approval. *Reprint requests: Ikemefuna Onyekwelu, MD, NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 E 17th St, New York, NY 10003, USA. E-mail address: [email protected] (I. Onyekwelu).
types. Depending on the nature and the extent of the injury, treatment was recommended to address one or both components of the labrum-biceps complex. Among the 4 types of SLAP lesions described by Snyder et al,13 detachment of the labrum-biceps complex from the superior glenoid rim (type II) is believed to be most prevalent and can be treated arthroscopically.16 However, there is considerable controversy in the management of SLAP
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2012.02.001
Rising incidence of arthroscopic SLAP repairs
729
Table I Volume and population-based incidences (per 100,000) of ambulatory orthopedic surgeries, shoulder surgeries, and superior labrum anterior and posterior (SLAP) repairs from 2002 to 2010 Year 2002 2003 2004 2005 2006 2007 2008 2009 2010
Ambulatory orthopedic
Ambulatory shoulder
Arthroscopic SLAP repairs
(No. per 100,000)
(No. per 100,000)
(No. per 100,000)
118,126 164,172 196,212 212,456 226,828 237,324 272,599 288,444 278,136
616.5 853.7 1016.8 1099.0 1171.8 1221.9 1400.3 1476.1 1435.3
lesions because the current literature lacks a consensus on the recognition and treatment of these lesions.8,10 Isolated SLAP lesions are believed to be relatively uncommon. In addition, when they occur with other concurrent shoulder pathology, SLAP lesions are unlikely to be the primary cause of pain or dysfunction.5 Therefore, arthroscopic repair of SLAP lesions has been reported to comprise only 3% of any orthopedic shoulder practice.16 More recent studies, however, have reported that the prevalence of SLAP lesions might actually be higher,14 and several studies have demonstrated that the number of SLAP lesion repairs has been increasing.9,19,21 To quantify the incidence of arthroscopic SLAP lesion repairs, the Statewide Planning and Research Cooperative Systems (SPARCS) database of the New York State Department of Health was examined. We hypothesized that the overall incidence of arthroscopic SLAP repair has been increasing and that this relative increase is greater compared with other ambulatory orthopedic surgical procedures.
Materials and methods The SPARCS outpatient database of the New York State Department of Health was established in 1979 under the legislation and regulations of the Public Health Law to record inpatient data. However, ambulatory procedures and emergency department admission information were also recorded. SPARCS has streamlined the process of this data collection according to the Universal Data Set specifications, allowing for a single-format database. Although not without certain limitations, the SPARCS database has been used to collect epidemiologic and biostatistics information for various diseases in previously peer reviewed and published articles.11,15 The American Medical Association introduced the Current Procedural Terminology (CPT) code 29807 for ‘‘arthroscopic repair of a superior labrum anterior/posterior lesion’’ in 2002. Therefore, the SPARCS ambulatory surgery registry was queried for cases of arthroscopic SLAP lesion repairs using the CPT code 29807 from 2002 to 2010. From the ambulatory surgery registry, the number of orthopedic procedures was calculated by identifying all musculoskeletal CPT codes within the range of 20100 to 29999. Similarly, ambulatory shoulder procedures, open and
15,607 22,957 27,659 30,601 33,426 35,234 38,844 43,000 42,033
96.7 142.1 170.2 186.9 202.9 213.3 232.7 256.0 252.1
765 2,153 2,424 3,069 3,754 3,908 4,556 4,763 4,313
4.0 11.2 12.6 15.9 19.4 20.1 23.4 24.4 22.3
Figure 1 The change is shown in the incidence of ambulatory orthopedic, ambulatory shoulder, and arthroscopic superior labrum anterior and posterior (SLAP) repairs in New York State from 2002 to 2010. arthroscopic, were calculated by identifying cases with CPT codes from 29805 to 29828 and from 23000 to 23929. The obtained data were adjusted for differences in population size according to the New York State Census database. SAS 9.1 software (SAS Institute Inc, Cary, NC, USA) was used for all data processing and statistical analyses. Descriptive statistics were reported on demographic variables, including age and sex. A nonpaired Student t test was used to compare the data from 2002 and 2010, and the c2 test was used to assess the proportional differences between 2002 and 2010. Statistical significance was deemed at P < .05.
Results During 2002 and 2010, 1,411,633 and 2,189,991 ambulatory surgical procedures were performed in the State of New York, respectively, which is an increase of 55%. Similarly, the number of all ambulatory orthopedic procedures increased 135%, from 118,126 in 2002 to 278,136 in 2010. On the basis of the population of New York State, this represented an incidence of 616.5/100,000 in 2002 and 1435.3/100,000 in 2010, which is an increase of 133%. For ambulatory shoulder procedures, the incidence was 81.5/ 100,000 in 2002 and 216.9/100,000 in 2010, which is an increase of 166% (Table I and Fig. 1).
730 Table II Year
I. Onyekwelu et al. Demographic data of patients undergoing superior labrum anterior and posterior (SLAP) repairs from 2002 to 2010 Mean age) Range M/F Mean age (years) Age 50 years (years)
2002 2003 2004 2005 2006 2007 2008 2009 2010
37.4 38.6 39.2 39.8 39.8 39.5 39.5 40.0 39.9
14.0 13.9 13.9 13.8 13.9 13.8 13.9 14.0 14.2
(years)
(%)
M
F
(%)
(13-83) (12-82) (13-85) (13-85) (12-86) (12-86) (11-83) (13-86) (13-87)
75:25 76:24 74:26 77:23 75:25 75:25 75:25 76:24 75:25
35.7 37.2 38.0 38.7 38.6 38.2 38.1 38.8 38.5
42.5 42.8 42.8 43.3 43.3 43.5 43.8 44.0 44.1
20.0 22.5 23.7 24.9 25.4 24.2 24.5 26.0 26.3
F, female; M, male. ) Mean data for all patients are presented with the standard deviation.
From 2002 to 2010, 29,705 arthroscopic SLAP repairs were identified using the CPT code 29807. In 2002, 765 arthroscopic SLAP repairs were recorded. In 2010, there was a statistically significant increase in the number SLAP repairs to 4313 (P < .0001). Similarly, the incidence of arthroscopic SLAP repairs increased 458% from 4.0/ 100,000 in 2002 to 22.3/100,000 in 2010 (P < .0001; Table I and Fig. 1). Compared with ambulatory orthopedic and ambulatory shoulder procedures, this increase in the incidence of arthroscopic SLAP repairs was statistically significant (P < .0001). Patients treated with arthroscopic SLAP repair in 2002 were at a mean age of 37 14 years (range, 13-83 years). Correspondingly, patients treated with arthroscopic SLAP repairs in 2010 had a mean age of 40 14 years (range, 1387 years). This increase in age was statistically significant (P < .0001). Males accounted for approximately 75% of these patients, and this ratio remained relatively constant from 2002 to 2010 (Table II). A logistic regression model showed patients aged younger than 40 years were 2.8 times more likely to receive an arthroscopic SLAP repair compared with other orthopedic shoulder surgeries. Similarly, males were 1.9 times more likely than females to have an arthroscopic SLAP repair.
Discussion The data from this study demonstrates a steady increase in the incidence of all ambulatory, all ambulatory orthopedic, and all ambulatory shoulder procedures. These rising incidences of ambulatory procedures may be due to the advancements in imaging technologies2 and surgical techniques. Various patient-related and surgeon-related factors are also likely to have contributed to these trends.6,17,20 Even with this rise in the incidence of ambulatory procedures, however, the increase in the incidence of arthroscopic SLAP repairs from 2002 to 2010 in New York State was significantly more pronounced: the number of arthroscopic SLAP repairs rose by more than 450%
during this period. The cause for this dramatic increase in the incidence of arthroscopic SLAP repairs is also likely multifactorial and may include greater awareness of the pathology, ease of billing with the newly introduced CPT code, and financial motivations for added procedures. A previous study reported that up to 88% of patients with SLAP lesions demonstrated other concomitant shoulder pathology.9 In addition, only 36% of the patients who were treated with arthroscopic SLAP repairs in 2010 had superior glenoid labrum lesion (International Classification of Diseases, 9th Clinical Modification code of 840.7) as the primary diagnosis. More commonly, these patients were given the primary diagnoses of articular cartilage disorders and rotator cuff disorders, and superior glenoid labrum lesion was listed as a secondary or even tertiary diagnosis in most of the cases. This suggests that in some patients, SLAP lesions may have been incidental intraoperative findings that were then repaired. Previous studies have suggested that patients with rotator cuff tears, in the context of SLAP lesions, demonstrate improved outcomes with isolated repairs of the rotator cuff alone.7,12 Therefore, it may be more appropriate to treat certain pre-existing SLAP lesions with biceps tenotomy, a tenodesis, or a simple debridement, especially in the presence of concurrent shoulder pathology. In addition to the rising incidence of arthroscopic SLAP repairs, the age of these patients undergoing surgery has also steadily increased during this period. Repair of the superior labrum is generally reserved for the younger, more active individual, and in many cases, the overhand-throwing athlete. Although a specific age limit has not been identified, arthroscopic SLAP lesion repair is not associated with significant improvements in outcomes in the older patient groups.7,12 Our data showed that more than 26% of patients who were treated with arthroscopic SLAP repairs in 2010 were at least 50 years old. Even more alarming is that many patients aged older than 80 years were treated with arthroscopic SLAP repairs. Because arthroscopic SLAP repair can be associated with significant adverse effects and poor
Rising incidence of arthroscopic SLAP repairs patient outcomes,3,4,18,21 further education in identifying appropriate candidates for this procedure may be necessary. A limitation of this study is that the presented data only represents New York State. Therefore, broad extrapolations to other regions may not be possible. However, reports using the American Board of Orthopaedic Surgery national database have described a similar rising incidence of arthroscopic SLAP lesion repairs.22 Another limitation of this study is the lack of associated clinical data. Thus, we could not determine if the increased incidence of SLAP repairs was associated with improved outcomes or increased return to preinjury function. Although the accuracy of the SPARCS database has been validated,15 there is a possibility that coding errors and inaccuracies during the reporting process could have affected our results; for example, other unlisted or unspecified codes could have been used to describe arthroscopic SLAP repair or an arthroscopic debridement of a SLAP lesion could have been miscoded as an arthroscopic repair. Studies of this type rely on accurate data reporting and collection; this process could not be validated.
Conclusions Since the introduction of CPT code 29807 in 2002, there has been an alarming increase in the incidence of arthroscopic SLAP repair in New York State. In addition, the mean age of patients undergoing this procedure has also increased, with a larger population of older patients undergoing SLAP repairs now. As such, too many SLAP repairs are being performed in elderly patients, despite evidence questioning its use in this patient population. The causes behind these trends are not clear and are likely to be multifactorial. Nevertheless, it may be necessary to refine and redefine treatment algorithms for this procedure.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 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: 337-41. 2. Bencardino JT, Beltran J, Rosenberg ZS, Rokito A, Schmahmann S, Mota J, et al. Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-71.
731 3. Byram IR, Dunn WR, Kuhn JE. Humeral head abrasion: an association with failed superior labrum anterior posterior repairs. J Shoulder Elbow Surg 2011;20:92-7. doi:10.1016/j.jse.2010.05.013 4. Chan H, Beaupre LA, Bouliane MJ. Injury of the suprascapular nerve during arthroscopic repair of superior labral tears: an anatomic study. J Shoulder Elbow Surg 2010;19:709-15. doi:10.1016/j.jse. 2009.12.007 5. Cooper DE, Arnoczky SP, O’Brien SJ, Warren RF, DiCarlo E, Allen AA. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg Am 1992;74:46-52. 6. Dunn WR, Schackman BR, Walsh C, Lyman S, Jones EC, Warren RF, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am 2005;87:197884. doi:10.2106/JBJS.D.02944 7. Forsythe B, Guss D, Anthony SG, Martin SD. Concomitant arthroscopic SLAP and rotator cuff repair. J Bone Joint Surg Am 2010;92: 1362-9. doi:10.2106/JBJS.H.01632 8. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg 2009;17: 627-37. 9. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am 2003;85:66-71. 10. Li X, Lin TJ, Jager M, Price MD, Deangelis NA, Busconi BD, et al. Management of type II superior labrum anterior posterior lesions: a review of the literature. Orthop Rev (Pavia) 2010;2:e6. doi:10.4081/ or.2010.e6 11. Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 2009;91:2321-8. doi:10.2106/JBJS.H.00539 12. Maffulli N, Franceschi F, Longo UG, Ruzzini L, Rizzello G, Denaro V. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50. Am J Sports Med 2008;36:247-53. doi:10.1177/ 0363546507308194 13. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-31. 14. Patzer T, Kircher J, Lichtenberg S, Sauter M, Magosch P, Habermeyer P. Is there an association between SLAP lesions and biceps pulley lesions? Arthroscopy 2011;27:611-8. doi:10.1016/ j.arthro.2011.01.005 15. Quan JM. SPARCS: the New York State health care data system. J Clin Comput 1980;8:255-63. 16. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 1995;4:243-8. 17. Sperling JW, Smith AM, Cofield RH, Barnes S. Patient perceptions of open and arthroscopic shoulder surgery. Arthroscopy 2007;23:361-6. doi:10.1016/j.arthro.2006.12.006 18. Takase K. Risk of motion loss with combined Bankart and SLAP repairs. Orthopedics 2009:32. doi:10.3928/01477447-20090624-05 19. Vitale MA, Arons RR, Hurwitz S, Ahmad CS, Levine WN. The rising incidence of acromioplasty. J Bone Joint Surg Am 2010;92:1842-50. doi:10.2106/JBJS.I.01003 20. Vitale MG, Krant JJ, Gelijns AC, Heitjan DF, Arons RR, Bigliani LU, et al. Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair. J Bone Joint Surg Am 1999; 81:763-72. 21. Weber SC. Surgical management of the failed SLAP Repair. Sports Med Arthrosc 2010;18:162-6. doi:10.1097/JSA.0b013e3181 eaf4ef 22. Weber SC, Payandi S, Martin DF. SLAP lesions of the shoulder: incidence rates, complications, and outcomes as reported by ABOS II Candidates. Amercian Shoulder and Elbow Surgeons, 2010 Annual Meeting (Closed). October 22, 2010 (Paper #19):57.
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The rising incidence of arthroscopic superior labrum anterior and posterior (SLAP) repairs Ikemefuna Onyekwelu, MD*, Omar Khatib, MD, Joseph D. Zuckerman, MD, Andrew S. Rokito, MD, Young W. Kwon, MD, PhD Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY, USA Background: Superior labrum anterior-posterior (SLAP) lesions of the shoulder that require surgical repair are relatively uncommon. However, recent observations suggest that there may be a rise in the incidence of SLAP lesion repair. Materials and methods: The Statewide Planning and Research Cooperative Systems (SPARCS) database from the New York State Department of Health was used to acquire data for all outpatient ambulatory surgery procedures that were performed in New York State from 2002 to 2010. The data were reviewed and analyzed to compare the incidence of arthroscopic SLAP lesion repairs relative to other outpatient surgical procedures. Results: Within New York State, from 2002 to 2010, the number of all ambulatory surgical procedures increased 55%, from 1,411,633 to 2,189,991. Correspondingly, the number of ambulatory orthopedic procedures increased 135%, from 118,126 to 278,136. In comparison, the number of arthroscopic SLAP repairs increased 464%, from 765 to 4,313 (P < .0001). This represented a population-based incidence of 4.0/100,000 in 2002 and 22.3/100,000 in 2010. The mean age of patients undergoing arthroscopic SLAP repair in 2002 was 37 14 years. The mean age in 2010 was 40 14 years (P < .0001). Conclusions: The data suggest a substantial increase in the number of arthroscopic SLAP repairs that is significantly more rapid than the rising rate of outpatient orthopedic surgical procedures. In addition, there is a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs. Level of evidence: Level III, Cross Sectional Study, Epidemiology Study. Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: SLAP repair; superior labrum anterior posterior lesions; epidemic; shoulder; arthroscopy; CPT code
Lesions of the superior labrum anterior and posterior (SLAP) to the biceps tendon were first recognized by Andrews et al1 and later classified by Snyder et al13 into 4 This study was exempt from Investigational Review Board approval. *Reprint requests: Ikemefuna Onyekwelu, MD, NYU Hospital for Joint Diseases, Department of Orthopaedic Surgery, 301 E 17th St, New York, NY 10003, USA. E-mail address: [email protected] (I. Onyekwelu).
types. Depending on the nature and the extent of the injury, treatment was recommended to address one or both components of the labrum-biceps complex. Among the 4 types of SLAP lesions described by Snyder et al,13 detachment of the labrum-biceps complex from the superior glenoid rim (type II) is believed to be most prevalent and can be treated arthroscopically.16 However, there is considerable controversy in the management of SLAP
1058-2746/$ - see front matter Ó 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2012.02.001
Rising incidence of arthroscopic SLAP repairs
729
Table I Volume and population-based incidences (per 100,000) of ambulatory orthopedic surgeries, shoulder surgeries, and superior labrum anterior and posterior (SLAP) repairs from 2002 to 2010 Year 2002 2003 2004 2005 2006 2007 2008 2009 2010
Ambulatory orthopedic
Ambulatory shoulder
Arthroscopic SLAP repairs
(No. per 100,000)
(No. per 100,000)
(No. per 100,000)
118,126 164,172 196,212 212,456 226,828 237,324 272,599 288,444 278,136
616.5 853.7 1016.8 1099.0 1171.8 1221.9 1400.3 1476.1 1435.3
lesions because the current literature lacks a consensus on the recognition and treatment of these lesions.8,10 Isolated SLAP lesions are believed to be relatively uncommon. In addition, when they occur with other concurrent shoulder pathology, SLAP lesions are unlikely to be the primary cause of pain or dysfunction.5 Therefore, arthroscopic repair of SLAP lesions has been reported to comprise only 3% of any orthopedic shoulder practice.16 More recent studies, however, have reported that the prevalence of SLAP lesions might actually be higher,14 and several studies have demonstrated that the number of SLAP lesion repairs has been increasing.9,19,21 To quantify the incidence of arthroscopic SLAP lesion repairs, the Statewide Planning and Research Cooperative Systems (SPARCS) database of the New York State Department of Health was examined. We hypothesized that the overall incidence of arthroscopic SLAP repair has been increasing and that this relative increase is greater compared with other ambulatory orthopedic surgical procedures.
Materials and methods The SPARCS outpatient database of the New York State Department of Health was established in 1979 under the legislation and regulations of the Public Health Law to record inpatient data. However, ambulatory procedures and emergency department admission information were also recorded. SPARCS has streamlined the process of this data collection according to the Universal Data Set specifications, allowing for a single-format database. Although not without certain limitations, the SPARCS database has been used to collect epidemiologic and biostatistics information for various diseases in previously peer reviewed and published articles.11,15 The American Medical Association introduced the Current Procedural Terminology (CPT) code 29807 for ‘‘arthroscopic repair of a superior labrum anterior/posterior lesion’’ in 2002. Therefore, the SPARCS ambulatory surgery registry was queried for cases of arthroscopic SLAP lesion repairs using the CPT code 29807 from 2002 to 2010. From the ambulatory surgery registry, the number of orthopedic procedures was calculated by identifying all musculoskeletal CPT codes within the range of 20100 to 29999. Similarly, ambulatory shoulder procedures, open and
15,607 22,957 27,659 30,601 33,426 35,234 38,844 43,000 42,033
96.7 142.1 170.2 186.9 202.9 213.3 232.7 256.0 252.1
765 2,153 2,424 3,069 3,754 3,908 4,556 4,763 4,313
4.0 11.2 12.6 15.9 19.4 20.1 23.4 24.4 22.3
Figure 1 The change is shown in the incidence of ambulatory orthopedic, ambulatory shoulder, and arthroscopic superior labrum anterior and posterior (SLAP) repairs in New York State from 2002 to 2010. arthroscopic, were calculated by identifying cases with CPT codes from 29805 to 29828 and from 23000 to 23929. The obtained data were adjusted for differences in population size according to the New York State Census database. SAS 9.1 software (SAS Institute Inc, Cary, NC, USA) was used for all data processing and statistical analyses. Descriptive statistics were reported on demographic variables, including age and sex. A nonpaired Student t test was used to compare the data from 2002 and 2010, and the c2 test was used to assess the proportional differences between 2002 and 2010. Statistical significance was deemed at P < .05.
Results During 2002 and 2010, 1,411,633 and 2,189,991 ambulatory surgical procedures were performed in the State of New York, respectively, which is an increase of 55%. Similarly, the number of all ambulatory orthopedic procedures increased 135%, from 118,126 in 2002 to 278,136 in 2010. On the basis of the population of New York State, this represented an incidence of 616.5/100,000 in 2002 and 1435.3/100,000 in 2010, which is an increase of 133%. For ambulatory shoulder procedures, the incidence was 81.5/ 100,000 in 2002 and 216.9/100,000 in 2010, which is an increase of 166% (Table I and Fig. 1).
730 Table II Year
I. Onyekwelu et al. Demographic data of patients undergoing superior labrum anterior and posterior (SLAP) repairs from 2002 to 2010 Mean age) Range M/F Mean age (years) Age 50 years (years)
2002 2003 2004 2005 2006 2007 2008 2009 2010
37.4 38.6 39.2 39.8 39.8 39.5 39.5 40.0 39.9
14.0 13.9 13.9 13.8 13.9 13.8 13.9 14.0 14.2
(years)
(%)
M
F
(%)
(13-83) (12-82) (13-85) (13-85) (12-86) (12-86) (11-83) (13-86) (13-87)
75:25 76:24 74:26 77:23 75:25 75:25 75:25 76:24 75:25
35.7 37.2 38.0 38.7 38.6 38.2 38.1 38.8 38.5
42.5 42.8 42.8 43.3 43.3 43.5 43.8 44.0 44.1
20.0 22.5 23.7 24.9 25.4 24.2 24.5 26.0 26.3
F, female; M, male. ) Mean data for all patients are presented with the standard deviation.
From 2002 to 2010, 29,705 arthroscopic SLAP repairs were identified using the CPT code 29807. In 2002, 765 arthroscopic SLAP repairs were recorded. In 2010, there was a statistically significant increase in the number SLAP repairs to 4313 (P < .0001). Similarly, the incidence of arthroscopic SLAP repairs increased 458% from 4.0/ 100,000 in 2002 to 22.3/100,000 in 2010 (P < .0001; Table I and Fig. 1). Compared with ambulatory orthopedic and ambulatory shoulder procedures, this increase in the incidence of arthroscopic SLAP repairs was statistically significant (P < .0001). Patients treated with arthroscopic SLAP repair in 2002 were at a mean age of 37 14 years (range, 13-83 years). Correspondingly, patients treated with arthroscopic SLAP repairs in 2010 had a mean age of 40 14 years (range, 1387 years). This increase in age was statistically significant (P < .0001). Males accounted for approximately 75% of these patients, and this ratio remained relatively constant from 2002 to 2010 (Table II). A logistic regression model showed patients aged younger than 40 years were 2.8 times more likely to receive an arthroscopic SLAP repair compared with other orthopedic shoulder surgeries. Similarly, males were 1.9 times more likely than females to have an arthroscopic SLAP repair.
Discussion The data from this study demonstrates a steady increase in the incidence of all ambulatory, all ambulatory orthopedic, and all ambulatory shoulder procedures. These rising incidences of ambulatory procedures may be due to the advancements in imaging technologies2 and surgical techniques. Various patient-related and surgeon-related factors are also likely to have contributed to these trends.6,17,20 Even with this rise in the incidence of ambulatory procedures, however, the increase in the incidence of arthroscopic SLAP repairs from 2002 to 2010 in New York State was significantly more pronounced: the number of arthroscopic SLAP repairs rose by more than 450%
during this period. The cause for this dramatic increase in the incidence of arthroscopic SLAP repairs is also likely multifactorial and may include greater awareness of the pathology, ease of billing with the newly introduced CPT code, and financial motivations for added procedures. A previous study reported that up to 88% of patients with SLAP lesions demonstrated other concomitant shoulder pathology.9 In addition, only 36% of the patients who were treated with arthroscopic SLAP repairs in 2010 had superior glenoid labrum lesion (International Classification of Diseases, 9th Clinical Modification code of 840.7) as the primary diagnosis. More commonly, these patients were given the primary diagnoses of articular cartilage disorders and rotator cuff disorders, and superior glenoid labrum lesion was listed as a secondary or even tertiary diagnosis in most of the cases. This suggests that in some patients, SLAP lesions may have been incidental intraoperative findings that were then repaired. Previous studies have suggested that patients with rotator cuff tears, in the context of SLAP lesions, demonstrate improved outcomes with isolated repairs of the rotator cuff alone.7,12 Therefore, it may be more appropriate to treat certain pre-existing SLAP lesions with biceps tenotomy, a tenodesis, or a simple debridement, especially in the presence of concurrent shoulder pathology. In addition to the rising incidence of arthroscopic SLAP repairs, the age of these patients undergoing surgery has also steadily increased during this period. Repair of the superior labrum is generally reserved for the younger, more active individual, and in many cases, the overhand-throwing athlete. Although a specific age limit has not been identified, arthroscopic SLAP lesion repair is not associated with significant improvements in outcomes in the older patient groups.7,12 Our data showed that more than 26% of patients who were treated with arthroscopic SLAP repairs in 2010 were at least 50 years old. Even more alarming is that many patients aged older than 80 years were treated with arthroscopic SLAP repairs. Because arthroscopic SLAP repair can be associated with significant adverse effects and poor
Rising incidence of arthroscopic SLAP repairs patient outcomes,3,4,18,21 further education in identifying appropriate candidates for this procedure may be necessary. A limitation of this study is that the presented data only represents New York State. Therefore, broad extrapolations to other regions may not be possible. However, reports using the American Board of Orthopaedic Surgery national database have described a similar rising incidence of arthroscopic SLAP lesion repairs.22 Another limitation of this study is the lack of associated clinical data. Thus, we could not determine if the increased incidence of SLAP repairs was associated with improved outcomes or increased return to preinjury function. Although the accuracy of the SPARCS database has been validated,15 there is a possibility that coding errors and inaccuracies during the reporting process could have affected our results; for example, other unlisted or unspecified codes could have been used to describe arthroscopic SLAP repair or an arthroscopic debridement of a SLAP lesion could have been miscoded as an arthroscopic repair. Studies of this type rely on accurate data reporting and collection; this process could not be validated.
Conclusions Since the introduction of CPT code 29807 in 2002, there has been an alarming increase in the incidence of arthroscopic SLAP repair in New York State. In addition, the mean age of patients undergoing this procedure has also increased, with a larger population of older patients undergoing SLAP repairs now. As such, too many SLAP repairs are being performed in elderly patients, despite evidence questioning its use in this patient population. The causes behind these trends are not clear and are likely to be multifactorial. Nevertheless, it may be necessary to refine and redefine treatment algorithms for this procedure.
Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
References 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: 337-41. 2. Bencardino JT, Beltran J, Rosenberg ZS, Rokito A, Schmahmann S, Mota J, et al. Superior labrum anterior-posterior lesions: diagnosis with MR arthrography of the shoulder. Radiology 2000;214:267-71.
731 3. Byram IR, Dunn WR, Kuhn JE. Humeral head abrasion: an association with failed superior labrum anterior posterior repairs. J Shoulder Elbow Surg 2011;20:92-7. doi:10.1016/j.jse.2010.05.013 4. Chan H, Beaupre LA, Bouliane MJ. Injury of the suprascapular nerve during arthroscopic repair of superior labral tears: an anatomic study. J Shoulder Elbow Surg 2010;19:709-15. doi:10.1016/j.jse. 2009.12.007 5. Cooper DE, Arnoczky SP, O’Brien SJ, Warren RF, DiCarlo E, Allen AA. Anatomy, histology, and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg Am 1992;74:46-52. 6. Dunn WR, Schackman BR, Walsh C, Lyman S, Jones EC, Warren RF, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am 2005;87:197884. doi:10.2106/JBJS.D.02944 7. Forsythe B, Guss D, Anthony SG, Martin SD. Concomitant arthroscopic SLAP and rotator cuff repair. J Bone Joint Surg Am 2010;92: 1362-9. doi:10.2106/JBJS.H.01632 8. Keener JD, Brophy RH. Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment. J Am Acad Orthop Surg 2009;17: 627-37. 9. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am 2003;85:66-71. 10. Li X, Lin TJ, Jager M, Price MD, Deangelis NA, Busconi BD, et al. Management of type II superior labrum anterior posterior lesions: a review of the literature. Orthop Rev (Pavia) 2010;2:e6. doi:10.4081/ or.2010.e6 11. Lyman S, Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology of anterior cruciate ligament reconstruction: trends, readmissions, and subsequent knee surgery. J Bone Joint Surg Am 2009;91:2321-8. doi:10.2106/JBJS.H.00539 12. Maffulli N, Franceschi F, Longo UG, Ruzzini L, Rizzello G, Denaro V. No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50. Am J Sports Med 2008;36:247-53. doi:10.1177/ 0363546507308194 13. Mileski RA, Snyder SJ. Superior labral lesions in the shoulder: pathoanatomy and surgical management. J Am Acad Orthop Surg 1998;6:121-31. 14. Patzer T, Kircher J, Lichtenberg S, Sauter M, Magosch P, Habermeyer P. Is there an association between SLAP lesions and biceps pulley lesions? Arthroscopy 2011;27:611-8. doi:10.1016/ j.arthro.2011.01.005 15. Quan JM. SPARCS: the New York State health care data system. J Clin Comput 1980;8:255-63. 16. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 1995;4:243-8. 17. Sperling JW, Smith AM, Cofield RH, Barnes S. Patient perceptions of open and arthroscopic shoulder surgery. Arthroscopy 2007;23:361-6. doi:10.1016/j.arthro.2006.12.006 18. Takase K. Risk of motion loss with combined Bankart and SLAP repairs. Orthopedics 2009:32. doi:10.3928/01477447-20090624-05 19. Vitale MA, Arons RR, Hurwitz S, Ahmad CS, Levine WN. The rising incidence of acromioplasty. J Bone Joint Surg Am 2010;92:1842-50. doi:10.2106/JBJS.I.01003 20. Vitale MG, Krant JJ, Gelijns AC, Heitjan DF, Arons RR, Bigliani LU, et al. Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair. J Bone Joint Surg Am 1999; 81:763-72. 21. Weber SC. Surgical management of the failed SLAP Repair. Sports Med Arthrosc 2010;18:162-6. doi:10.1097/JSA.0b013e3181 eaf4ef 22. Weber SC, Payandi S, Martin DF. SLAP lesions of the shoulder: incidence rates, complications, and outcomes as reported by ABOS II Candidates. Amercian Shoulder and Elbow Surgeons, 2010 Annual Meeting (Closed). October 22, 2010 (Paper #19):57.