Journal ClubSurgical treatment of isolated type II SLAP

lesions: repair versus biceps tenodesis. J Shoulder Elbow Surg. 2014 Jul;23(7):1059-65. Ek ET,

Shi LL, Tompson JD, Freehill MY & Warner JP

Abbas Rashid FRCS (Tr&Orth) Wrightington Upper Limb Fellow

Introduction• Optimal treatment for Type 2 SLAP in non-elite athlete • Classified by Snyder (1990): type 2 most common (detachment of labrum &biceps

anchor) • Outcomes: age, level of activity, concomitant pathology

• Options: SLAP repair vs. biceps tenodesis • controversies: 1. Outcomes of SLAP repair - Boileau (2009): patient satisfaction 40%(SR) vs. 80%(BT), return to sports 20%(SR) vs 87% (BT) - Snyder (2003), O’Brien (2007), Kim (2008): 97% good to excellent in SR

2. Does age affect outcome? - Alpert (2010): patients satisfaction lower >40 years -Denard (2012): age>40 years = worse outcome (P>0.05) - Provencher (2013): RR failure=3/45>36 years - Schroder (2012): patient satisfaction same but more stiffness if>40years

• Aim: indications for repair and tenodesis, compare clinical outcomes ➔ Hypothesis: both give good results in appropriately selected patients

Methods• Retrospective • single surgeon (JP Warner) • type 2 SLAPs treated between Jan 2008-March 2011 • Inclusions: clinical & radiological evidence of SLAP, minimum 24 month f/u • Exclusions: other types of SLAP, concomitant pathology

SLAP repair Biceps tenodesisN

Loss to f/u 18 3

13 3 Mean age at surgery

(years)31 47

Mean f/u (months) 35 31

SLAP repair vs. Biceps tenodesis• Decision: age, activity level & status of labrum • Surgical technique: - Beach chair, diagnostic scope, ‘peelback’

- labrum: degenerate or normal (based on fraying, thickness, elasticity)

- BT: tenotomy, open subpec tenodesis in groove with 2.9mm Bioraptor anchor - SR: transcuff portal, 2.9mm Bioraptor anchor below/pos to biceps anchor

• Rehab: - SR 4/52 sling, ROM, strength, full activity/sports 6/12

- BT 2/52 sling, AROM, resistance after 4 weeks, full activity 10 weeks

• Assessment: - preop SSV and VAS

- postop VAS, groove pain, ASES, return to work/sports, SSV, patient satisfaction

• Stats: student t test comparison p<0.05

Results SLAP repair Biceps Tenodesis

Labrum Degenerate = 0/10 Normal = 10/10

Degenerate = 13/15 Normal = 2/15 (both>55years)

Age 3/10>years 13/15>35years

Other procedures • 2 PL cyst decompression • 1SSc nerve release • 2 ASAD

• 11 ASAD • 1 ACJ excision

Complications 2 stiffness (?age) tx PT 1 Popeye sign (asymptomatic)

Sport 10/10 65% RTS at 8.2months

15/15 73% RTS at 6.8months

SSV 51% → 84% 44% → 85%

Pain score 6/5 → 0.8 6.2 → 0.9

ASES 93.5 93.0

Satisfaction 90% satisfied or very satisfied

93% satisfied or very satisfied

Discussion• Importance of Study: - No. of SLAP repairs performed in US increasing

- role in stability: increase AP translation →? Does repair improve stability - No consensus in non-athletes

• Boileau (2009) Am J Sports Med: - SLAP repair (10) vs. Biceps Tenodesis (15)

- BT group>30years and less active → better patient satisfaction & return to sport

• Both treatments: improvements in function, pain, patients satisfaction • No difference: outcome scores RTS

• No difference between groups (cf. Boileau et al) - ? Better quality labrum therefore likely to heal - Less chance of stiffness in older age group

• Limitations: retrospective, non-randomised, small sample size, rare condition in isolation

Analysis: IntroductionIs there a clear description of the problem ✓

Is the study useful ✓

What type of study was done? Retrospective cohort study

Type of research? Primary

Was the study ethical? No mention of ethics/audit

Is there a review of the literature ✓

Is the writing style easily understood ✓

Is the paper was well laid out and easy to follow ✓

Analysis: MethodsThe design of the study is consistent with the aims ✓

Who is the study about? Non-elite athletes with T2 SLAP

The sample of the study is representative of the population as a whole

✓

How were subjects recruited? database

Who was included in and who was excluded from the study? Isolated pathology

Were the subjects studied in “real life” circumstances? ✓

Details of the study such as numbers, time intervals, statistical test used are clear and appropriate

✓

Were the groups comparable in all important aspects except for the variable being studied?

✗

What outcome(s) were measured and how? SSV, VAS, RTS

Was assessment of outcome “blind”? ✗

Are there sources of bias in the setting of the subjects ✓

Have confounding influences and multiple influences been removed ✗

Was the study continued for long enough, and was follow up complete enough, to make the results credible?

✓

Analysis: StatisticsWhat sort of data have they got and have they used appropriate statistical tests? parametric

Have the appropriate tests been used ✓

Were paired tests performed on paired data? ✓

Were outliers analysed with common sense and appropriate statistical adjustments?

✓

Probability and confidence and degree of significance been interpreted correctly ✓

Have P values been calculated and interpreted appropriately? ✓

Have confidence intervals been calculated and do the authors’ conclusions reflect them?

✓

Analysis: ResultsMissing data such as drop outs, non-responders are accounted for ✗

Details of the results such as the numbers , statistics, are accurate and clear ✓

If statistics are appropriate to the study, then they were well used ✓

The sample size is of a significant amount ✗

Are the results clearly presented ✓

Have they used bar charts, tables appropriately used ✓

Analysis: DiscussionThe study is discussed critically ✓

The results are discussed with reference to other important literature ✓

The discussion does not speculate too far beyond what has been shown in the study

✓

Summary of Analysis• Prof Funk, Mr Walton & Fellows

• No mention of history (eg. Wrenching injury with fall or overhead sport) therefore surgeons treating pathology rather than patient

• No mention of clinical an radiological parameters used to make diagnosis • ? Non-operative tx tried • No description of biceps pathology at arthroscopy • Many patients had secondary procedure (eg. ASAD) therefore significant confounding • Not a matched cohort study therefore difficult to make direct comparisons between

groups • Limitations of retrospective study • Adds nothing to decision making process