Authors’ Disclosure Statement: Dr. Romeo reports that he receives royalties from Arthrex and Elsevier; is a consultant for Arthrex; receives research support from Arthrex, Smith & Nephew, Össur, MioMed Orthopaedics, DJO Global, ConMed Linvatec, and Athletico; is on the editorial board of Orthopedics Today, Journal of Shoulder and Elbow Surgery, Techniques in Shoulder and Elbow Surgery, Operative Techniques in Sports Medicine, Sports Health, and Orthopedics; and receives publisher support from Elsevier and Orthopedics Today. The other authors report no actual or potential conflict of interest in relation to this article.
In each case, we perform glenohumeral arthroscopy to evaluate the BLC and identify any other pathology. For overhead athletes who are younger than 30 years and lack bicipital groove pain or signs of gross tendinopathy, we favor arthroscopic SLAP tear repair. Repair is usually performed through an anterior working portal for suture passage and a Wilmington portal for anchor placement. We use knotless technology to achieve stable fixation and stay posterior to the biceps anchor insertion.
For the prevention of any potential pain from the bicipital groove in carefully selected patients—recreational overhead athletes and patients who want a less involved surgical recovery—we favor open subpectoral biceps tenodesis rather than arthroscopic tenodesis. The outcomes of biceps tenodesis are consistent, according to the literature.47,57,64 Moreover, the open approach is favored for the incidence of postoperative stiffness in the arthroscopic population.65 Tendons can be fixed with multiple procedures, including soft-tissue tenodesis, interference screw fixation, and surface anchors. We favor using a tenodesis screw in the subpectoral location, as outlined by Mazzocca and colleagues.64Our algorithm for SLAP lesions is evolving with our understanding of this complex disease process. For young overhead throwers with type II SLAP lesions, we favor arthroscopic SLAP tear repair with knotless technology. For older recreational overhead athletes, we favor biceps tenodesis in the subpectoral region after diagnostic arthroscopy plus biceps tenotomy with or without additional SLAP tear fixation, depending on the stability of the biceps anchor (Figures 4A, 4B).
In this procedure, a unicortical hole is drilled in the center of the bicipital groove, with careful attention given to restoring the anatomical length–tension relationship.66 For revision of SLAP tear repair, we recommend revision to a biceps tenodesis using our published technique.57,67 Postoperative rehabilitation is crucial, as failure to return to play may stem from poor throwing mechanics rather than from the surgical fixation technique used.
Conclusion
Overhead athletes who present with symptomatic SLAP lesions often provide a treatment dilemma. Although SLAP tear repair historically has been standard treatment, biceps tenodesis represents a consistent surgical option with low complication rates and low revision rates. It is likely that, as additional data on glenohumeral kinematics and outcomes in young athletes become available, improved decision-making algorithms will follow.
Am J Orthop. 2017;46(1):E71-E78. Copyright Frontline Medical Communications Inc. 2016. All rights reserved.
