Superior labral anterior posterior lesions of the shoulder: Current diagnostic and therapeutic standards

Abstract

Surgical treatment of superior labral anterior posterior (SLAP) lesion becomes more and more frequent which is the consequence of evolving progress in both, imaging and surgical technique as well as implants. The first classification of SLAP lesions was described in 1990, a subdivision in four types existed. The rising comprehension of pathology and pathophysiology in SLAP lesions contributed to increase the types in SLAP classification to ten. Concerning the causative mechanism of SLAP lesions, acute trauma has to be differed from chronic degeneration. Overhead athletes tend to develop a glenohumeral internal rotation deficit which forms the basis for two controversial discussed potential mechanisms of pathophysiology in SLAP lesions: Internal impingement and peel-back mechanism. Clinical examination often remains unspecific whereas soft tissue imaging such as direct or indirect magnetic resonance arthrography has technically improved and is regarded to be indispensable in detection of SLAP lesions. Concomitant pathologies as Bankart lesions, rotator cuff tears or perilabral cysts should be taken into consideration when planning a personalized therapeutic strategy. In addition, normal variants such as sublabral recess, sublabral hole, Buford complex and other less common variants have to be distinguished. The most frequent SLAP type II needs a sophisticated approach when surgical teatment comes into consideration. While SLAP repair is considered to be the standard operative option, overhead athletes benefit from a biceps tenodesis because improved patient-reported satisfaction and higher rate of return to pre-injury level of sports has been reported.

Keywords: Biceps tendon; Shoulder arthroscopy; Superior labral anterior posterior lesion; Superior labral anterior posterior repair; Tenodesis.

Figure 1

Superior labral anterior posterior classification. A: SLAP I lesion: Degenerative fraying of the superior labrum; B: SLAP II lesion: Detached labro-bicipital complex; C: SLAP III lesion: Bucket-handle tear; D: SLAP III lesion: Bucket-handle tear with extension to the biceps tendon. SLAP: Superior labrum anterior posterior.

Figure 2

Superior labral anterior posterior II lesion: Findings in direct magnetic resonance arthrography. A: The coronal oblique fat saturated image (cor pd tse fs) shows the detached labro-bicipital complex from the upper rim of the glenoid. The tear is marked by the arrow; B: The transverse fat saturated magnetic resonance arthrography-image (tra pd tse fs) reveals the slight runnel of contrast agent between superior labrum (arrowhead) and glenoid. A: Acromion; H: Humeral head; G: Glenoid.

Figure 3

Superior labral anterior posterior III lesion: Findings in direct magnetic resonance arthrography. The coronal T1-weighted (cor t1 tse fs) fat-saturated image shows the separated triangle (arrow) of the bucket-handle without instability of the labro-bicipital complex. A: Acromion; H: Humeral head; G: Glenoid.

Figure 4

Superior labral anterior posterior I lesion: Intraoperative findings in shoulder arthroscopy (posterior-anterior view from the posterior portal of a right shoulder). A: A degenerative fraying of the superior labrum could be detected by diagnostic arthroscopy; B: After debridement of the superior labrum, a sublabral recess appears. The presence of a type II SLAP lesion should be excluded; C: A more detailed demonstration of the sublabral recess (arrowhead) with smooth lining without instability of the labro-bicipital complex. LBC: Labro-bicipital complex; H: Humeral head; G: Glenoid; SLAP: Superior labrum anterior posterior.

Figure 5

Superior labral anterior posterior II lesion: Intraoperative findings in shoulder arthroscopy (posterior-anterior view from the posterior portal of a left shoulder). A: Intraoperative aspect of a non-displaced SLAP II lesion (arrowhead); B: Verifiction by inserting a probe; C: SLAP repair by a single stich posterior to the biceps tendon. LBC: Labro-bicipital complex; H: Humeral head; G: Glenoid; SLAP: Superior labrum anterior posterior.

Figure 6

Superior labral anterior posterior II lesion: Intraoperative findings in shoulder arthroscopy (posterior-anterior view from the posterior portal of a right shoulder). First step in mini-open tenodesis is an arthroscopic tenotomy of the biceps tendon (arrowhead) and reattachement of the superior labrum. H: Humeral head; G: Glenoid.

Figure 7

Mini-open biceps tenodesis: The red tagged part of the biceps tendon is resected. An extra-anatomical fixation is performed above the upper border of the tendon of the great pectoral muscle.