a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
With the advent of arthroscopy of the shoulder, it is now possi-ble to diagnose types of labral lesion that was not diagnosed bymeans of radiographic methods. One type of lesion involvingthe upper area of the glenoid labrum, which begins posteri-orly and extends anteriorly to the glenoid cavity, is named theSLAP lesion (superior labrum anterior and posterior). This areaof the glenoid labrum is functionally important for the upperstability of the shoulder and also serves as an "anchor" for theinsertion of the long head of the tendon of the biceps brachiimuscle.
SLAP lesions were first described by Andrews et al.3in 1985and were subsequently classified into four subtypes by Snyderet al.1in 1990. In 1995, Maffet et al.4added type V to the clas-sification of Snyder et al.1This comprises lesions of the upperglenoid labrum that extends to the anteroinferior region. In1998, Morgan et al.5subdivided type II into three subtypesaccording to the location of the lesion in the upper glenoidlabrum: anterior, posterior or combined.
The exact etiology of SLAP lesions remains a matter of con-troversy. However, two possible causes have been described inthe literature: compression forces applied to the glenohumeraljoint consequent to a fall with the shoulder in a position ofabduction and flexion; or tension forces applied to the arm,caused by a traction mechanism applied to the upper limb as aresult of a throwing movement, which is particularly observedamong baseball players.
The objective of the present study was to evaluate the func-tional results from arthroscopic repair of SLAP lesions throughthe portal described by O'Brien.
Materials and methods
A retrospective evaluation was performed on 19 shoul-ders of 18 patients who underwent arthroscopic repair ofSLAP lesions through the O'Brien portal between Novem-ber 2007 and January 2012. The inclusion criterion was that the patients undergoing arthroscopic surgical treatment ofSLAP lesions had not responded clinically to conservativetreatment. Patients with histories of previous surgery or extra-articular diseases in the shoulder that was to be evaluatedwere excluded.
SLAP lesions were diagnosed when there was a positiveO'Brien test in association with magnetic resonance imagingof the knee suggestive of a lesion in the upper glenoid labrumand arthroscopic observation of the lesion.
The following were recorded: the time that elapsedbetween the start of symptoms of the lesion and the surgicaltreatment; and the patient's age, sex, occupation and returnto sport (activity level). Postoperative function was assessedusing the UCLA and ASES scales in the versions translatedand adapted to the Portuguese language.2,11-13Data were gath-ered by means of physical examination (O'Brien, Jobe andPatte tests) and a questionnaire that was applied to all thepatients.
The surgical procedures were performed by the same sur-gical team, with the patient under general anesthesia, withoutblockage of the brachial plexus. The patient was placed inthe "deckchair" position. A posterior portal was used to intro-duce the arthroscopic optical device, and this was located2 cm distally and 2 cm medially to the posterolateral angleof the acromion. The joint was investigated using the refer-ence point of the tendon of the long head of the biceps brachiimuscle and its upper labral origin. Following this, the ante-rior, inferior and posterior labra, joint surfaces, glenohumeralligaments, rotator cuff, capsule and joint recesses were eval-uated.
The following intraoperative diagnostic criteria for SLAPlesions were then used: a positive drive-through test (easypassage of the arthroscopic optical device through the gleno-humeral space); positive peel-back test (glenoid labrumopening greater than 1 cm during abduction and external rota-tion of the shoulder); and direct viewing of the degeneratedand fibrillated labral tissue with signs of avulsion14(Fig. 1).
A portal was constructed in the anterior region in orderto place the first 8.5 mm cannula (portal 1), while keeping tothe side of the coracoid process in order to minimize the risk
of neurovascular injuries. This cannula was placed above theupper border of the tendon of the subscapular muscle (anteriorrotator interval).
To construct the arthroscopic portal described by O'Brienet al.9(portal 2) (Fig. 2) and place the second 8.5 mm cannula, a
Jelco no. 14 needle was placed in the superolateral region of theshoulder, through the rotator cuff, in the direction of the pos-terosuperior region of the glenoid (Fig. 3). The location of theportal varied according to the anatomy of the patient's shoul-der and the location of the posterior labral deinsertion, withthe aim of facilitating access to the posterosuperior region ofglenoid and to the glenoid labrum.
After the portals had been constructed, the process ofopening up the upper glenoid rim (and the anterior rimwhen necessary) was started, using a 4 mm bone shavingblade (Fig. 4), in order to form a bloody bed that wouldfavor healing of the labrum-capsule complex that would bereinserted.
To reinsert the glenoid labrum, two absorbable polylacticacid anchors of size 2.7 m were placed using nonabsorbablethread, starting from the anterosuperior region. The anteriorportal (portal 1) was used as the main one and the O'Brienportal (portal 2) was used as an auxiliary. To reinsert thelabrum posteriorly to the tendon of the biceps, the O'Brienportal (portal 2) was used as the main one and the anteriorportal (portal 1) as an auxiliary. To pass the threads throughthe glenoid labrum, curved bird-beak instruments alone wereused (Fig. 5A-F).
In the cases in which the patient presented anterior gleno-humeral instability with an anteroinferior lesion of the glenoid
labrum (Bankart lesion), labral reinsertion was always startedin an anticlockwise direction, from the anteroinferior regionto the posterior region, using another two anchors (total offour). After labral reinsertion, dermal suturing of the portalswas performed and the operated limb was then immobilizedusing a Velpeau sling.
Results
Nineteen shoulders were evaluated, in 18 patients: 16 males(84.2%) and three females (15.7%). The minimum postopera-tive follow-up was seven months and the maximum was56 months (mean of 33.9). The patients' ages ranged from27 to 40 years (mean of 34.3). There were 12 patients (63.1%)with a lesion in the right shoulder, six cases (31.5%) in the leftshoulder and one case (5.2%) of bilateral lesions. In relationto dominance, 13 patients (68.4%) presented the lesion in thedominant limb and five (26.3%) in the non-dominant limb.
From the evaluations on these 19 shoulders, we observedthat nine cases (47.3%) had SLAP lesions alone, 10 cases (52.6%)were related to glenohumeral instability and a single case(5.2%) presented recurrence of glenohumeral dislocation. Thispatient decided not to undergo a new surgical intervention(Table 1).
In relation to sports activity, nine patients were practicinga variety of sports before the injury (volleyball, swimming andtennis) and nine were not. After the surgical treatment, eightof the nine patients returned to the sports that they had beendoing before the treatment. One patient did not return to thesports activity that he had practiced, but he did not correlatethis with the surgical result.
According to the UCLA scale, as adapted to the Portugueselanguage, 10 patients (52.6%) obtained results that were con-sidered to be excellent, seven (36.8%) presented good results,a single patient (5.2%) obtained a fair result and these were nopoor results2,13(Fig. 6).
In relation to the ASES scale, as adapted to the Portugueselanguage, 58% of the patients obtained scores of 100%, 17%obtained 95%, 21% obtained 90% and 4% obtained 70% (Fig. 7).
All the 18 patients, who all completed the study follow-up,presented negative Jobe and Patte tests in the physical exami-nation conducted at the time of the functional evaluation. Themean time taken for release from the outpatient follow-up wassix months.
Discussion
In our sample, we found epidemiological agreement withthe literature consulted, with predominance of SLAP lesionsin males (84.2%) and higher frequency of lesions affectingthe dominant limb (68.4%).1,6,8,10,11The mean age among ourpatients was 34.3 years, which was similar to the age found
in the study by Miyazaki et al.,6but greater than that of otherstudies.
The treatment for SLAP lesions varies from conservative toarthroscopic surgery. In arthroscopic procedures, an anterosu-perior and/or anteroinferior portal is used in most cases, witha route through the rotator interval to reach the labral lesionsof the upper and lower glenoid. These portals limit access tothe posterior and superior region of the glenoid for placementof an anchor and reinsertion of the posterior labrum.
Accessory portals for attempting to facilitate posterosupe-rior access have been described, such as the Neviaser portaland transacromial portals. However, there is a risk of injury tothe suprascapular nerve and fractures of the acromion.
More recently, Warner et al.17described the use of ananterolateral portal for accessing the posterosuperior regionof the glenoid labrum. However, this portal would require awide incision in the tendon of the rotator cuff.
O'Brien et al.9developed a portal for accessing upper labrallesions that would enable access to the anterior and postero-superior regions of the glenoid labrum. This was described as areliable technique that was easily reproducible, using a needleto locate the most appropriate region for accessing the poste-rior labral lesions. The potential risk of injury to the rotatorcuff was minimized by using cannulae of smaller diameters,which only gave rise to divulsion of the fibers at the muscle-tendon junction of the supraspinatus muscle.
In the study by O'Brien et al.,9arthroscopic repair of SLAPlesions was performed in 31 patients using a portal passingthrough the rotator cuff. No injuries to the rotator cuff con-firmed by magnetic resonance imaging were observed. Ohet al.18obtained excellent postoperative results from arthro-scopic repairs to SLAP lesions using a portal passing throughthe rotator cuff in 58 shoulders, thus confirming the safety andefficiency of this portal. In our sample, no evidence of weak-ness of the rotator cuff, as assessed through the Jobe and Pattetests, was observed. Nor was there any diminution of the rangeof motion of the operated shoulder.
In our series of 19 shoulders, in 18 patients who weretreated for SLAP lesions with a mean postoperative follow-upof 33.9 months, good clinical results were found through eval-uations using the ASES and UCLA scales, as translated andadapted to the Portuguese language. It was found that 96% ofthe results were excellent or good, similar to the findings fromother studies.
Conclusion
The present study demonstrated that accessing SLAP lesionsfrom portals passing through the rotator cuff, as describedby O'Brien et al., was easily reproducible, with a high rate ofexcellent and good results and a low complication rate.
Conflicts of interest
The authors declare no conflicts of interest.
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