Name: My Approach to Superior Labral Tears
Uploaded: 2014-07-23T00:00:00Z
Channel: Arthrex

<p>Neal S. ElAttrache, MD, (LosAngeles, CA) presents his experience on superior labrum and complex bicepsinjuries. He discusses the controversies surrounding the treatmentoptions, anatomy of the biceps labral complex and superior labrum and thedistinct functional difference of these structures. Dr. ElAttrache shows commonpathologies, patient examination tests, diagnostic imaging and treatmentoptions. Dr. ElAttrache demonstrates several case examples and hissurgical decision making algorithm including when and where to do a bicepstenodesis versus a SLAP repair. His patient case videos includeprofessional baseball players, a professional climber, two Olympic water polo players,a college volleyball player and the typical causes of poor surgicaloutcomes.</p>

Not Hidden

English  - en

video

VPT1-00113-EN | A | My Approach to Superior Labral Tears

Neal ElAttrache

Human

A video of a live presentation reviewing Arthrex products or techniques.

Video einer Live-Präsentation, die Arthrex Produkte oder Techniken überprüft.

Präsentationsvideos

Presentation Videos

Vídeo de apresentação ao vivo analisando produtos ou técnicas da Arthrex.

Apresentação vídeos

Video de presentación en vivo que revisa los productos o técnicas de Arthrex.

Video presentaciones

My Approach to Superior Labral Tears

I'm going to talk a little bit about superior labrum biceps complex injuries. And you know, there's always this ongoing debate on what to do with with the biceps in this injury. Should you just treat the lesion by cutting the bicep. And what should you do with the labrum. A lot of it does depend on your patient population, but I hope that with this lecture we can talk a little bit about what is the combined function of the biceps and labrum in in a very active population, patients that use their arm at the extremes of motion and with extremes of exertion and, and give you some instances where, where I may do a biceps tenodesis on those and maybe we can talk a little bit more about it in the, in the discussion. So the biceps labral complex does act in concert and they but they also have independent functions. You have to consider function and pathology of the biceps and the superior labrum independently, as well as how they work together to gain complete understanding of these structures and conceive rational treatment plans for these injuries. The superior labrum in the superior hemisphere is often discoid. It's occasionally thin and absent in the superior quadrant to the glenoid sulcus so that anterior-superior area. Sometimes there is not much labral tissue there. The majority of the biceps has a has a shared origin. The posterosuperior labrum makes up the bulk of the origin. The supraglenoid tubercle also has a lot of the medial fibers of the biceps. The anterior-superior quadrant involves the attachment points for the superior glenohumeral ligament, the middle glenohumeral ligament, and the vertically oriented inferior glenohumeral ligament, but there are very few biceps fibers that extend into the anterior superior labrum. Therefore, the major area of concern for biceps labral attachments is posterosuperior. The major area of concern for ligamentous attachments is anterior-superior. So it's important when you're deciding on on the significance of a biceps cleft or I'm sorry, a labral cleft to look and see the morphology. Where are the ligaments attaching and how far does that labral tear extend posteriorly? If the if the labral tear extends at least a centimeter anterior and a centimeter posterior to the biceps. This biomechanically showed us significant translations and rotational abnormalities in the lab. So that's that's a general guideline. That size you get significant increases in AP translation and in rotation with that instability depends on anterior-superior ligament morphology, and instability markedly increases as the tear involves the posterosuperior quadrant down to the equator. These abnormal translations allow edge loading of the humeral head on the glenoid, and so therefore you get pain at the extremes of motion as the head perches or comes close to the rim, either anteriorly or posteriorly. And the patients can have sometimes symptoms of instability. Now let's talk about the biceps. The biceps is held stable in its groove by the coracohumeral ligament, which splits to invaginate the biceps. It also uses the capsule, the subscapularis, and the supraspinatus fibers to stabilize it in this aperture in the groove. What it's depicting is how the biceps moves with the humeral head. The humeral head glides up and down on the tendon of the long head of the biceps, and the biceps rotates with the humeral head from an anterior superior oblique position in internal rotation to a posterior superior oblique position at about 120 degrees of rotation in external rotation with extreme rotation and abduction. The intra-articular length of the biceps becomes its shortest and the tension is the highest. Therefore it Therefore it increases the concavity compression of the glenohumeral joint, assuming you have an intact labrum. What's the effect of the long head of the biceps? I was talking to Brian, who also did a study with this. And and our data is in agreement. The biceps has tethering effect on the glenohumeral rotation and all directions of translation, which is most marked at the extremes of rotation. Dynamic loading of the biceps shifts the humeral head center of rotation more toward the center of the glenoid. Therefore, the biceps tendon acts as a dynamized ligament at the extremes of motion. For the biceps to have its effect, the superior labrum has to be stable and well attached to the glenoid. If the superior labrum is avulsed, you lose the attachment for the superior glenohumeral ligament, the middle glenohumeral ligament, and occasionally a vertically oriented inferior glenohumeral ligament, as well as the secondary stabilizing role of the bicep. So it's based on on this knowledge and these studies that we try to elucidate what to do with these labral tears in these overhead athletes. So our patient selection, let's let's make sure we know who we're talking about here. It's the active patient overhead or contact sports. Also people that may be involved in heavy lifting heavy pushing heavy pulling for instance rock climbers, heavy laborers and they can have traumatic or repetitive microtrauma events that cause these lesions. And you can have a traumatic event superimposed on microtrauma as well. And the traumatic events where you have a sudden avulsion of the superior labrum has been shown to have better results and better outcomes when you do surgical treatment for them. These patients present with shoulder pain that is usually both anterior and posterior, depending on the position you put the shoulder in. At the extremes of motion. They have minimal or no pain. At rest they have minimal or no pain with functional range of motion. So if you're seeing functional range of motion pain when on the exam, you have to be thinking at least the person has developed some secondary rotator cuff tendinitis subacromial bursitis, AC joint arthritis, glenohumeral joint JD don't forget that too. But there's something else causing pain. If they're if they're complaining of pain during their functional range of motion, they generally have full range of motion. But a lot of throwers can be tight in internal rotation. Some of them will prevent with mechanical symptoms and may, may or may not have symptoms of instability on exam. Again, they have no pain. With this active range of motion within their functional limits, the pain is usually only at the extremes of motion pain with edge loading and what the the exam maneuvers that cause edge loading are the O'Briens test, relocation and abduction. External rotation with hyper A perambulation load and shift tests. So? So if you try to perch that head on the glenoid, especially posteriorly. I actually had a patient that had was found to have a big posterior labral tear involving the superior labrum that put her put the patient in the O'Briens position and sublux the shoulder on exam. So that definitely puts the humeral head back on the posterior rim. The best objective test that we have short of arthroscopy, is MRI arthrogram. And the treatment options for these typically are initially non-operative with rest, anti-inflammatories, physical therapy, then return to throwing and working on their throwing mechanics. And this can be effective in about half the patients that will present with a symptomatic throwing related superior labral tear. A history of acute slap event, however, is more frequently a non-responder to therapy and does better with surgery. This is what we call the internal impingement continuum. And if therapy is going to work, you want to get to it before they start to develop mechanical and and anatomic detachments of their tissue. Oftentimes that's not possible. But that's where therapy has a tendency to be most effective. So let's talk about the surgery. This is a diagnostic arthroscopy. And we see these the concomitant injuries to the posterosuperior rotator cuff and posterosuperior labrum. In general we we tend to breed type one and small and stable flaps. Then we test for the, the labral stability after that and we take a look at the at the ligament morphology, because that's going to determine the location of fixation. We try to stay away from the base of the bicep to allow the biceps to continue to have its excursion. So once again, we do breed type one. We stabilize the biceps anchor in type two. In type three we excise and possibly repair bucket handle tears in type four. We do what we do in the type three plus stabilize the biceps anchor, possibly a tenodesis if the biceps is badly damaged. Avoid repairs when you have this in the face of significant glenohumeral fascia, especially with subchondral bone deformity on the posterior margin. So as the posterior margin becomes sclerotic, you lose articular cartilage there. If you do a superior labral repair in those, you you oftentimes will make that patient worse. Be careful in adhesive capsulitis. Be careful in the older patient with coexisting pathology, treating the other things generally works better than tightening the joint. And be careful with rotator cuff repairs with superior labral repair as well. If you're in doubt as to the significance of a labral tear, look for other reasonable causes of pain. Look in the subacromial space. The AC joint rotator cuff. Don't forget articular damage. And then pull the biceps into the joint. Look for for biceps pathology with regard to the peel back. Steve and Craig Morgan really added a lot to our understanding of what's happening inside the shoulder in the throwing position. And they saw this torquing and twisting of the biceps, which causes the labrum to become mobile. And this is an adaptive developmental change in these throwers. And my current thinking that that this is a normal adaptation to throwing to have a normal mobile label labral segment. And I don't repair it if it's just mobile, if it develops a true separation and it starts to sublux off the back of the of the glenoid, which when when Steve gives his talk of this, he shows a truly a peel back lesion. Be careful with the ones that are just hypermobile where guys are going in and chiseling off this mobile, but still attached labrum and then perching it rigidly back up onto the rim. All that's going to do is cause earlier contact whenever you get into that throwing position. So the so the the ones that Steve shows are truly pathologic peel backs. Those are the ones that have separated and are subluxated down off the rim. So I do a let's talk. When I do do Bio-Tenodesis I do it with. If you have biceps luxation, sometimes it's tempting to go in and tighten up the rotator cuff interval. And you can you can get the stitches in. You guys are some of the more talented arthroscopic surgeons, and I think that you can do this technically. However it's unpredictable how that's going to scar in. So oftentimes you'll scar and tether the bicep and lower down in the groove. The biceps may still not sit quite well in the groove at the extremes of rotation, so I tend to do a biceps. Tenodesis. If you have biceps luxation in these patients, I do it. The if the the patients that have grooved. Pain with deformed frayed by pathologic biceps I'll do it in those recurrent slaps presents a problem because the healing potential of of a slap that's already been operated on is probably a bit less. So I tend if you've got a symptomatic slap in those, I, I would probably do it, do a biceps tenodesis rather than repair the slap. But I'd also hang a lot of crape ahead of time and tell the throwing athlete that that they may this may not work. May also need to repair the labrum even if you do the tenodesis. So you have to take a look at the labrum where it's at, what's attaching to it, and decide if you have to fix it. This is a good looking bicep whenever you first look at it as it sits in the joint, but if you pull it in, the biceps can be badly damaged in the groove. So don't forget to do this. Flex the elbow. Relax the biceps. Put a probe on it and pull it into the joint. So I generally surgically will try to anatomically restore the labral attachment. I'll debride these small bucket handle or small flaps, repair large bucket handle and biceps delaminations, which do heal very well if it's at the base of the bicep. If the biceps is severely damaged, then I'll do a tenodesis and then I'll treat the labrum depending on the stability and ligament morphology. Let's look at a few cases. I've gone in the superior hemisphere of the glenoid, and especially posteriorly I've gone to Nautilus. And this eliminates suture, suture abrasion on the control surfaces, the synovium and cuff. And it restores the anatomic position of the labrum on the glenoid cannulated anchors also, as we see, provides extra channel for marrow elements to come and help healing. So this is an example on the lower left of how I used to do it with mattress sutures with knots. And this is how I do it now on the on the upper right. I do mine in the lateral decubitus position. I stay medial with my superior portal's medial to the rotator cuff cable. Therefore I'm in the muscular portion of the rotator cuff. Take a look at the video of this. This is a right shoulder. Looking at it from posterior. The entire superior lateral segment is avulsed from equator to equator. So we have our cannula through the muscular portion of the rotator cuff medial to the cable passing our suture with this is a standard sized lasso. We now have smaller lassos. You'll see in subsequent video that very accurately put these sutures through through the labrum. And generally to do this you have to have two passes through the labrum. So the smaller lassos that work very nicely. You can see that what I've done is I've brought both free ends of the suture underneath the labrum so that I can hide the the suture into the bony socket. And all you see is the little belt loop of suture that goes across the top of the labrum. Since this video has been done, there's now a material called LabralTape that gives you a little bit broader, a little flatter type of repair. And you can do the same things with the LabralTape that you can with this round. Fiberwire. So you can see I'm not putting any, any anchors or sutures at the base of the biceps or lassoing the bicep at all. And I like the fact that when you take it into rotation, you'll see the labrum have its normal role and excursion, but it won't pull off of the off of it. And here's how the marrow elements bleed up through the cannula. So take a look at another one. This is a professional climber. Once again creating this. I like how you use the curettes here. I'm going to start using the Curettes to breed that. I use rasp and shavers, but the Curette does a nice job here. Again we're. This is actually LabralTape. And so you hide the suture material quite nicely from the articular surfaces and from the from the posterosuperior synovium. You don't get the clumps of synovitis that we sometimes see with, with with that, whenever the knots are in the cleft behind the labial edge and the glenoid rim. And these are 2.9mm PushLock. So water polo player that was complaining of pain and instability. Biceps looks good. She had a big, very prominent middle glenohumeral ligament. So in her the instability was coming not only from the the extent of the labral tear down to the posterior equator, but also the attachment site for the middle glenohumeral ligament was gone. So it's important to get good fixation where that ligament is trying to attach anterior-superior. So I put two anchors with two sutures, one one more medial on the rim and one more lateral near the articular margin. And those are luggage tag type configuration. Again no knots. Anterior-superior. This is a baseball player with batter's shoulder. That's a posterolateral avulsion. And you can see the difference in in the knots. The very very far posterior inferior. I used one technique that had a knot because I wanted to gather more of the posterior inferior capsule. But then as I came superiorly, I used a used knotless tape type of technique. And there you see the bleeding that comes from the cannulated anchors that are the second and third anchors up, but no bleeding that comes from the solid anchor down below. This is another Olympic water polo player that had a horrible looking labrum. If I would have sacrificed that bucket handle tear, I would have lost the whole middle glenohumeral ligament, as you can see in the upper right hand corner. So I repaired the bucket back and repaired the base of the bicep as you see there in the lower right. She had AC joint symptoms about a year later, so I had a chance to get a second look. The lower the lower slides, there are the healed labrum and healed bucket handle and healed base of the bicep. And she actually was a Canadian Olympic water polo player that was going to school at Berkeley. And she went back and competed in London for the Canadian team. The causes of failure. Poor patient selection. Technical. We've over constrained the biceps. In the past we've have have had prominent implants. Suture abrasion can't be underestimated. What problems that that causes failure to treat coexisting pathology and failure to correct predisposing mechanics. This is a this is a college volleyball player who had had a labor repair done with the typical technique. And look what's happening there. This patient the her her preoperative I'm sorry her the the photographs that her initial index operation she brought in with her showed a pristine rotator cuff. And so when they get up into the abducted, externally rotated position, these the suture we put in there is not always innocuous. So out comes summary. With this type of treatment strategy, we can expect about 80% return to the same competitive level after slap repair. There's no data on return of elite overhead athletes after biceps tenodesis. We know that tenodesis does not restore stability to the joint. You still have to pay attention to the labrum. We do a tenodesis to do a tenodesis of a structurally normal biceps. You either must think that the biceps is vestigial and has no function, or completely disregard the biomechanical data that we have to date. So the etiology is multifactorial. Rehab may involve extensive stretching and attention to scapulothoracic mechanics. Anatomic surgery repair if is necessary. If non-operative treatment fails, determine all potential sources of pain and determine if the tear causes disruption of stability independent of the bicep. Minimize technical causes of failure, especially over constraint. Improved mechanics that got you there in the first place. So I would fix what you see on the left. And I would not cut a normal biceps, as you see on the right. Thanks.

My Approach to Superior Labral Tears

Related Pages

Shoulder

FASTak^®/FASTak^® II/Bio-FASTak^® Technique

Procedure

Shoulder

PushLock^® Anchor Instability Technique

Procedure

Shoulder

SLAP Rasp

Product

Shoulder

SwiveLock^® Instability Technique

Procedure

Shoulder

SutureTak^® Technique

Procedure

Shoulder

Tension-Slide Technique

Procedure

Elbow

Tension-Slide Technique

Procedure

My Approach to Superior Labral Tears

Related Pages

Shoulder

FASTak®/FASTak® II/Bio-FASTak® Technique

Procedure

Shoulder

PushLock® Anchor Instability Technique

Procedure

Shoulder

SLAP Rasp

Product

Shoulder

SwiveLock® Instability Technique

Procedure

Shoulder

SutureTak® Technique

Procedure

Shoulder

Tension-Slide Technique

Procedure

Elbow

Tension-Slide Technique

Procedure

FASTak^®/FASTak^® II/Bio-FASTak^® Technique

PushLock^® Anchor Instability Technique

SwiveLock^® Instability Technique

SutureTak^® Technique