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Arthroscopic SLAP IIb Repair Using Knot-Tying Versus Knotless Suture Anchors: Is There a Difference?

December 3, 2018 | Surgery
S. Joseph de Groot, MD ; Justin W. Arner, MD ; Clair N. Smith, MS ; James P. Bradley, MD
Author and Disclosure Information

Dr. de Groot is an Orthopaedic Surgery Resident in the Department of Orthopaedic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, PA. Dr. Arner is an Orthopaedic Surgery Resident in the Department of Orthopaedic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, PA. Ms. Smith is a biostatistician in the Departments of Orthopaedic Surgery and Physical Therapy, University of Pittsburgh, Pittsburgh, PA. Dr. Bradley is a Clinical Professor at Burke and Bradley Orthopedics, University of Pittsburgh Medical Center, Pittsburgh, PA.

Authors’ Disclosure Statement: Dr. James P. Bradley receives royalties from Arthrex. His co-authors report no actual or potential conflict of interest in relation to this article.

Address correspondence to: James P. Bradley, MD, Burke and Bradley Orthopedics, University of Pittsburgh Medical Center. UPMC St. Margaret, 200 Medical Arts Building, Suite 4010, 200 Delafield Road, Pittsburgh, PA 15215 USA (tel, 412-784-5783; fax, 412-784-5748; email, bradleyjp@upmc.edu).

Am J Orthop. 2018;47(12). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

S. Joseph de Groot, MD Justin W. Arner, MD Clair N. Smith, MS James P. Bradley, MD . Arthroscopic SLAP IIb Repair Using Knot-Tying Versus Knotless Suture Anchors: Is There a Difference?. Am J Orthop. December 3, 2018

TAKE-HOME POINTS

  • SLAP IIb tears are common injuries in overhead athletes, yet surgical outcomes are variable, with throwers commonly having difficulty with return to play at the same level.
  • In this study, 92% of athletes returned to play post-operatively, yet only around 55% returned at the same level.
  • In overhead athletes, overall return to play was 85.7%, yet only 39.3% returned at the same level.
  • Knotless fixation required less revision surgery and had higher outcome scores and return to play when compared to knotted fixation; however, this did not reach statistical significance.
  • Knotless fixation should be considered in SLAP IIb repairs given their lower profile leading to less rotator cuff irritation, the ability to better provide more consistent tensioning, and decreased surgical time.

Injury of the anterosuperior labrum near the biceps origin was first described by Andrews and colleagues in 1985 in overhead athletes.1 The term SLAP, or a tear in the superior labrum anterior to posterior, was coined a few years later by Snyder and colleagues.2 They described an injury to the superior labrum beginning posteriorly and extending anteriorly, including the “anchor” of the biceps tendon to the labrum. Snyder further delineated SLAP lesions into 4 subtypes, the most common being type II, which he described as “degenerative fraying of the labrum with additional detachment of the superior labrum and biceps from the glenoid resulting in an unstable labral anchor.”2,3 Type II tears are of particular importance as they are the most common SLAP lesions, with an incidence of 55%, and comprise nearly 75% of SLAP repairs performed.2,4

Morgan and colleagues further delineated type II SLAP tears into IIa (anterior), IIb (posterior), and IIc (combined). Their group found that SLAP IIb tears were the most common type in overhead throwers, accounting for 47% of overhead athletes with type II tears.5 Further, type IIb tears can have a significant impact in throwers, in part due to greater shoulder instability as well as anterior pseudolaxity.5 SLAP injuries typically have been difficult to successfully treat nonoperatively in overhead athletes.6 A study by Edwards and colleagues6 examined 39 patients with all types of SLAP tears. Although, in their study, nonoperative management failed in 20 patients and they required surgery, 10 of the 15 overhead athletes in whom nonoperative treatment did not fail initially returned to sport at a level equal to or better than their pre-injury level, indicating that nonoperative treatment may play a role in some patients’ recovery.6

Surgical outcomes of SLAP IIb repairs have traditionally been less predictable than those of other shoulder injuries. Some believe that traditional knotted anchors may be partially to blame by abrading the rotator cuff, possibly leading to rotator cuff tears and pain. Further, knotted anchors are typically bulkier and require more experience with tying and tensioning and, therefore, may lead to less consistent results.7 The purpose of this study was to investigate if knotless anchors result in more favorable outcomes in repair of type IIb SLAP lesions when compared with traditional knotted anchors. It was hypothesized that knotless fixation will provide superior clinical outcomes, improved return to play (RTP), and lower revision rates as compared with traditional knotted fixation in the repair of SLAP IIb tears.

METHODS

PATIENT SELECTION

The authors retrospectively reviewed SLAP tears repaired by the senior author from June 2000 to September 2015. The inclusion criteria consisted of all athletes at any level who were diagnosed intraoperatively with a type IIb SLAP tear as defined by Morgan and colleagues5 with a minimum 2-year follow-up. The exclusion criteria were any patients with a previous shoulder surgery and the presence of any labral pathology aside from a SLAP IIb tear. Patients with rotator cuff or biceps pathologies were included. In all included patients, an initial course of preoperative physical therapy, including strengthening and stabilization of the scapulothoracic joint, had failed. Patient-directed surveys evaluated RTP, as well as the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, American Shoulder and Elbow Surgeons (ASES) score, stability, range of motion (ROM), strength, and pain scores, as previously described.8-10 Institutional Review Board and informed consent approval were acquired prior to initiation of the study.

PATIENT EVALUATION

An appropriate preoperative history was taken, and physical examinations were performed, including evaluation of the scapulothoracic joint, as well as tests to evaluate the presence of a SLAP tear, anterior instability, posterior instability, multi-directional instability, and rotator cuff tears, as previously described.11 Patients with a history and physical examination concerning SLAP pathology underwent an magnetic resonance imaging (MRI) arthrogram, which was used in conjunction with intraoperative findings to diagnose type IIb SLAP tears.

Continue to: SURGICAL TECHNIQUE

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