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. 2023 Nov 28;50:29–35. doi: 10.1016/j.jor.2023.11.053

Surgical management of SLAP lesions: Which technique has better surgical outcomes?

Eslam Abourisha a, Mohamed Sakr b, Ananth Srinivasan a,∗, Harvinder P Singh a
PMCID: PMC10755497  PMID: 38162261

Abstract

Background

The gold-standard surgical management for superior labral anterior to posterior (SLAP) lesions is unclear. This meta-analysis compares the outcomes of different surgical SLAP lesion management techniques including labral repair, long head of biceps (LHB) tenodesis and LHB tenotomy with consideration to clinical scores, return to sports, re-operation, range-of-motion and patient satisfaction.

Methods

PRISMA guidelines were adhered. Web of Science, PubMed, Cochrane Central, Science direct and EMBASE were searched using relevant keywords. Eligible studies were screened, data extracted and synthesised using Review Manager (Version 5.4.1). Bayesian network meta-analysis (NMA) was conducted. Randomised control and clinical trials regarding SLAP lesion management in patients over 18 years old were included. Studies were excluded if patients had concomitant massive tears of the rotator cuff, Bankart lesions or instability of the shoulder.

Results

Patient satisfaction with LHB tenodesis was superior to superior labral repair. No difference was demonstrated with respect to ASES score, pain VAS score, return to sports and pre-injury activities, reoperation rate or range-of-motion. LHB tenodesis and LHB tenotomy show no difference in ASES score or post operative deformity in management of SLAP lesions.

Discussion

High-quality, standardised randomised control studies between the different surgical techniques is warranted.

Keywords: Superior labrum from anterior to posterior, SLAP lesion, Tenotomy, Tenodesis, Labral repair

Highlights

  • •

    Patient satisfaction was superior following LHB tenodesis in comparison to repair of the labrum.

  • •

    Significant heterogeneity present in patient demographics, presence of concurrent rotator cuff injury and measured outcomes.

1. Introduction

Tears of the superior labrum at the anchorage of long head of biceps (LHB) tendon occur as a result of repetitive overhead activity in sportspeople and fall related injuries in the elderly.1,2 Superior Labral Anterior to Posterior (SLAP) lesions pose significant challenges in the management of the disabled throwing shoulder and surgical management is often recommended to restore function.1

Such injuries to the glenoid labrum-LHB complex can substantially compromise shoulder joint stability. The terminology ‘SLAP’ was first introduced in 19853 and classified further into four subtypes in 1990 with type II lesions being the most prevalent.4 The natural progression of SLAP lesions and the efficacy of conservative management are poorly understood and have only been reported in limited case series.5

Current surgical interventions for SLAP type II lesions include repair of the superior labrum, LHB tenodesis or LHB tenotomy.6 Arthroscopic repair of SLAP type II lesions has demonstrated excellent outcomes for patients not involved in overhead activities or throwing sports.7,8 Published surgical outcomes demonstrate significant inconsistency, with variable and often suboptimal return-to-activity and -sports.9 Current treatment practices for SLAP lesions are controversial and this in part due to imprecise treatment.10

This network meta-analysis compares the clinical outcomes of surgical techniques established for the management of SLAP lesions including repair of the superior labrum, LHB tenodesis, LHB tenotomy, sham surgery and debridement. The meta-analysis will focus on clinical scores, satisfaction, return-to-sports, re-operation rate and range-of-motion as key outcome measures. By evaluating these parameters, the authors seek to determine on the most effective treatment for SLAP lesions.

2. Methods

Manuscript development adhered to PRISMA statement guidelines for systematic review and meta-analyses.

2.1. Inclusion and exclusion criteria

The study included parallel randomized controlled trials and non-randomized clinical trials investigating different surgical modalities for SLAP lesion management in patients aged 18 years and above. The selected studies reported outcomes using various measures: American Shoulder and Elbow Surgeon (ASES) score, University of California-Los Angeles (UCLA) shoulder scale, Pain Visual Analogue Scale (VAS), reported satisfaction, re-operation rate and range-of-motion. To ensure data reliability, the authors excluded case-series, case-reports, non-English studies, theses, conference abstracts and studies with unreliable data extraction. Additionally, studies involving patients with associated massive rotator cuff tears, Bankart lesions, or shoulder instability were excluded as the authors felt that major concomitant shoulder pathology would confound reported outcomes. The prevalence of small rotator cuff tears in asymptomatic patients is high and hence patients with concomitant small rotator cuff tears were included in the meta-analysis.

2.2. Search strategy

PubMed, Cochrane Central, Web of Science, Science Direct and EMBASE databases were searched to identify articles. Literature search sensitivity was improved with a further MESH database search using ‘SLAP*’ OR ‘Superior Labrum from Anterior to Posterior Injuries’ terminology. Titles and abstract screening was independently performed by two authors with any discrepancies resolved by the senior authors. Eligible full-text articles were retrieved and further assessed for potential inclusion in the meta-analysis.

2.3. Quality assessment

Quality of eligible studies was evaluated following the guidelines stipulated by the Cochrane Handbook for Systematic Reviews of Interventions 5.1.0 (2011). The Cochrane risk-of-bias assessment tool was utilized to stratify the risk-of-bias: judgments were categorized as 'Low', 'High' or 'Unclear’ risk-of-bias.

2.4. Data synthesis

ASES score, UCLA score, pain VAS, patient satisfaction, range-of-motion and re-operation rate were extracted from selected studies and data was pooled for meta-analysis. RevMan (version 5.4.1 for Windows) was used to conduct the meta-analysis. Bayesian network meta-analysis (NMA) was performed using the MetaInsight V3 tool.

2.5. Heterogeneity assessment

Heterogeneity was assessed through forest plots inspection and quantitative analysis using I-square and Chi-Square tests. In cases of significant heterogeneity, we applied the random-effects model, while a fixed-effect model was used when heterogeneity was not significant.

3. Results

3.1. Search results

713 articles were retrieved following the literature search. 197 of the abstract titles were appropriate for full-text screening. Twelve studies were eligible for the systematic review and nine were included in the meta-analysis (Fig. 1. PRISMA flow diagram). Study and population characteristics are summarised in Table 1.

Fig. 1.

Fig. 1

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Prisma flow diagram.

Table 1.

Characteristics of included trials.

Study ID Group Sample size Age Mean (SD) Gender-Male/%
Schrøder 201711 Labral repair 40 42 (22–57) 63
RCT Biceps tenodesis-mini open 39 40 (18–64) 62
Sham surgery 39 40 (23–60) 58
Denard 201412 Labral repair 22 45.2 ± 5.5 64
Retrospective study Biceps tenodesis-Arthroscopic 15 52.0 ± 8.0 80
Boileau 200913 Labral repair 10 37 (19–57) 100
Cohort Biceps tenodesis-Arthroscopic 15 52 (28–64) 60
Ek ETH 20146 Labral repair 10 31 (21–43)
Retrospective study Biceps tenodesis-open 15 47 (30–59)
Abbot 200914 Labral repair 18 52.6 (47–60)
Cohort Sham surgery 20 51.2 (45–60)
Franceschi 200815 Labral repair 31 61.8 (51–79) 58
RCT Biceps tenotomy-open 32 64.7 (53–81) 47
Kanatli 201116 Labral repair 15 58 ± 7.5 (46–72) 56
Cohort Labral repair + Rotator cuff repair 16 56.8 ± 6.7 (47–70)
Joo Han Oh 201617 Simple debridement 28 58.98(39–76) 32
RCT Biceps tenotomy 27 59.61(39–76) 33
Biceps tenodesis 31 56.61(42–76) 68
Hufeland 201818 Tenodesis 9 51.5 ± 9.5(37–63) 78
RCT Biceps tenotomy 11 52.8 ± 8.0(36–62) 36
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3.2. Quality of included studies

Study quality ranged from ‘moderate’ to ‘high’. The Newcastle Ottawa Score (NOS) was used to assess non-randomised clinical trials (Fig. 2, Fig. 3 and Table 2).

Fig. 2.

Fig. 2

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Risk of bias figure for included studies.

Fig. 3.

Fig. 3

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Risk of bias summary for included studies.

Table 2.

Newcastle Ottawa Score: authors' judgements about each risk of bias item for each included study.

Study and year Selection Comparability Outcome
Denard 201412 *** * ***
Boileau 200913 **** * ***
Ek ETH 20136 *** * ***
Abbot 200914 **** ** ***
Kanatli 201116 *** * ***
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3.3. Outcome analysis

  • 1.
    Labral repair vs Tenodesis vs Tenotomy
    • •
      ASES score

A network meta-analysis demonstrated no difference between LHB tenodesis and LHB tenotomy groups when compared with the labral repair group, mean differences were −0.594 (−10.9, 11.4) and −5.00 (−22.2, 8.25) respectively (Fig. 4). SUCRA value was 83.5 % for the LHB tenotomy group, 36.6 % for the LHB tenodesis group and 29.9 % for the labral repair group (Fig. 5).

  • 2.
    Labral repair versus Tenodesis
    • •
      ASES score

Fig. 4.

Fig. 4

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The Bayesian random effect model forest plot comparing labral repair with tenodesis and tenotomy.

Fig. 5.

Fig. 5

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Study rankings.

Overall mean difference between labral repair and tenodesis did not favour either group with a mean difference of −0.73 (−6.77, 5.30; P = 0.81) (Chi-square P = 0.68, I-square = 0 %) (Fig. 6).

  • •

    Patient satisfaction

Fig. 6.

Fig. 6

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Forest plot comparing labral repair with tenodesis on ASES score.

Overall risk ratio between labral repair and tenodesis favoured the tenodesis group with a relative risk of 0.85 (0.75, 0.98; P = 0.02) (Chi-square P = 0.16, I-square = 42 %) (Fig. 7).

  • •

    Return to sports and pre-injury activity level

Fig. 7.

Fig. 7

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Forest plot comparing labral repair with tenodesis on patient satisfaction.

Overall risk ratio between labral repair and tenodesis did not favour either group, relative risk was 0.68 (0.41, 1.14; P = 0.14) (Chi-square P = 0.07, I-square = 62 %) (Fig. 8).

  • •

    Re-operation rate

Fig. 8.

Fig. 8

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Forest plot comparing labral repair with tenodesis on return to pre-injury sports and activities.

Overall risk ratio between labral repair and tenodesis did not favour either group, relative risk was 1.60 (0.67, 3.85; P = 0.29) (Chi-square P = 0.10, I-square = 7 %) (Fig. 9).

  • •

    Pain VAS

Fig. 9.

Fig. 9

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Forest plot comparing labral repair with tenodesis on re-operation rate.

Overall mean difference between labral repair and tenodesis did not favour either group, mean difference was 0.20 (−0.42, 0.82; P = 0.53) (Chi-square P = 0.65, I-square = 0 %) (Fig. 10).

  • •

    Range-of-Movement – shoulder forward flexion

Fig. 10.

Fig. 10

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Forest plot comparing labral repair with Tenodesis on pain VAS score.

Overall mean difference between labral repair and tenodesis did not favour either group, mean difference was 13.45 (−42.40, 15.51; P = 0.360) (Chi-square P < 0.00001, I-square = 97 %) (Fig. 11).

  • •

    Range-of-Motion - external rotation

Fig. 11.

Fig. 11

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Forest plot comparing labral repair with Tenodesis on forward flexion.

Overall mean difference between labral repair and tenodesis did not favour either group, mean difference was 37.05 (−34.77, 108.86; P = 0.31) (Chi-square P < 0.00001, I-square = 100 %) (Fig. 12).

  • 3.
    Tenotomy versus Tenodesis
    • •
      ASES score

Fig. 12.

Fig. 12

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Forest plot comparing labral repair with Tenodesis on external rotation.

Overall mean difference between tenotomy and tenodesis did not favour either group, mean difference was −8.52 (−24.82, 7.79; P = 0.31) (Chi-square P = 0.02, I-square = 81 %) (Fig. 13).

  • •

    Deformity

Fig. 13.

Fig. 13

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Forest plot comparing tenotomy with tenodesis on ASES score.

Overall risk ratio between tenotomy and tenodesis did not favour either group, risk ratio 1.57 (0.76, 3.24; P = 0.23) (Chi-square P = 0.63, I-square = 0 %) (Fig. 14).

Fig. 14.

Fig. 14

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Forest plot comparing Tenotomy with tenodesis on Deformity.

4. Discussion

This network meta-analysis demonstrates that LHB tenodesis confers superior patient satisfaction when compared to superior labral repair in the surgical management of SLAP lesions. There was no difference in the two techniques with respect to ASES score, pain VAS score, return to sports, pre-injury activities or range-of-motion. Furthermore, no difference in ASES score or post-operative deformity when comparing LHB tenodesis versus LHB tenotomy for SLAP lesions was demonstrated.

Schrøder et al. (2017) conducted a randomised control trial between sham surgery, superior labral repair and LHB tenodesis concluding that sham surgery had comparable outcomes to the former two techniques.11 This is one of the very few clinical trials in Trauma and Orthopaedics to include sham surgery in a treatment arm. Cools et al. (2017) question the validity of this study stating that sham procedures should only be considered where incisions are made and an arthroscopic evaluation not undertaken. The authors also advise further research into the peri-operative emotional and psychological response.19

Denard et al. (2014) reported on the outcome of arthroscopic LHB tenodesis versus labral repair for SLAP type II lesions in patients >35 years. The LHB tenodesis group had superior functional outcome with better satisfaction rate and return to activity and sports in comparison to the labral repair group.12 Franceschi et al. (2008) also suggested that LHB tenotomy is superior to labral repair when combined with rotator cuff repair in patients >50 years old.15 Kanatli et al. (2011) evaluated the effect of labral repair of SLAP type II lesions with concurrent rotator cuff tears and concluded that labral repair had a favorable outcome although it was negatively influenced by the torn rotator cuff.16 Hufeland et al. (2019) reported similar outcomes between LHB tenotomy and LHB tenodesis in a randomised clinical trial managing isolated SLAP lesions. Deformity was higher in the LHB tenotomy group but this was statistically insignificant.18

Oh et al. (2016) compared debridement, LHB tenotomy and LHB tenodesis in the management of SLAP lesions with concurrent rotator cuff repair. To our knowledge, this is one of two randomised clinical trials studying the effect of debridement. The authors concluded that all three studied techniques had a good outcome with respect to pain management and post-operative function. Simple debridement demonstrated the lowest risk of the deformity and preservation of forearm supination power.17 Abbot et al. also studied debridement in comparison to labral repair in patients with SLAP type II lesions associated with minimally retracted rotator cuff tears.14 Debridement in patients older >45 years with minimally retracted rotator cuff tears had a better outcome in terms of patient satisfaction, functional outcome, pain relief and range of motion.14

Boileau et al. (2009) concluded that arthroscopic LHB tenodesis was an effective alternative to superior labral repair in the management of isolated SLAP type II lesions.13 LHB tenodesis had superior rate of return to pre-injury levels of activity with lower re-operation rates. Furthermore, the authors suggest that LHB tenodesis provides a surgical solution for salvaging failed SLAP repairs.13 A limitation of this study was the difference in mean age between the study groups, where younger patients were preferentially treated with repair while patients 30 years and older were managed with LHB tenodesis.13 Ek et al. retrospectively studied the outcome of superior labral repair and LHB tenodesis in isolated SLAP type II lesions and found no significant difference.6 The authors suggest that LHB tenodesis should be considered over superior labral repair in managing patients >35 years in age while repair should be considered in the younger and more active patients.6

Yi-Ming Ren conducted a meta-analysis of randomised control trials and observational studies to investigate arthroscopic labral repair, LHB tenotomy and LHB tenodesis in managing SLAP type II lesions.20 The authors summarised that both had beneficial effects although LHB tenodesis and LHB tenotomy had higher ASES scores and patient satisfaction rate. Myung Ho Shin et al. conducted a meta-analysis to evaluate superior labral repair versus LHB tenodesis in overhead athletes21 and demonstrated that LHB tenodesis is a comparable technique to superior labral repair with higher ASES score and lower complication rates although this was statistically insignificant. Our study reports similar outcomes regarding patient satisfaction although differences in ASES score were statistically insignificant. The latter may be explained by our strict exclusion criteria of case series and clinical trials that recruited patients with large to massive rotator cuff tears and trials in languages other than English.20

A systematic review by Kibler et al. studying current surgical practice in the management of SLAP lesions concluded that current relevant literature is widely variable with respect to patient demographics, surgical management and measured outcomes.10 Most of the clinical trials included in our meta-analysis recruited patients with a wide age range (18–81 years) and we were unable to further sub-stratify age groups for meta-analysis. It would have been useful to review possible differences in outcomes between young and older patient groups. The rate of SLAP lesions with concurrent rotator cuff tears in literature ranges from 40 to 73 % (22, 23). In light of this, the authors agreed to include studies with patients identified to have concurrent small rotator cuff tears. Studies with patients suffering massive rotator cuff tears were excluded as the authors felt that this would significantly confound meta-analysis outcomes. This significant heterogeneity in patient demographics, presence of rotator cuff injury, management and various measured outcomes should be taken into consideration during future clinical trial design.10

5. Conclusion

This study analyses higher tier parallel randomised controlled trials and non-randomised clinical trials to investigate SLAP lesion surgical management. LHB tenotomy or LHB tenodesis is associated with significantly higher patient satisfaction compared to superior labral repair. The study failed to identify differences in ASES score, pain VAS score, return to activities/sport, re-operation or range-of-motion. Current literature in SLAP lesions is hindered by significant heterogeneity. Further high-quality randomised control studies with rigorous study design is necessary to identify the optimum surgical option.

Funding and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent

Not applicable.

Institutional Ethical Committee Approval

Not applicable.

Patients consent statement

This manuscript is a systematic review and meta-analysis and hence, did not require patient consent.

Ethical statement

‘The study is a systematic review and meta-analysis, hence did not require Institutional Ethical Committee Approval’.

CRediT authorship contribution statement

Eslam Abourisha: Conceptualization, Data curation, Formal analysis, Methodology, Writing – original draft. Mohamed Sakr: Data curation, Formal analysis, Methodology, Writing – original draft. Ananth Srinivasan: Formal analysis, Methodology, Visualization, Writing – review & editing. Harvinder P. Singh: Conceptualization, Supervision, management, Writing – review & editing.

Declaration of competing interest

All authors contributed equally to data collection and analysis, writing, and revising the manuscript.

The authors received no financial or material support for the research authorship and/or publication of this article.

All authors declare no conflict of interest.

Acknowledgements

None.

Contributor Information

Eslam Abourisha, Email: eslam.abourisha@nhs.net.

Mohamed Sakr, Email: mohamed.sakr1@nhs.net.

Ananth Srinivasan, Email: ananth.srinivasan@nhs.net.

Harvinder P. Singh, Email: harvinder.p.singh@uhl-tr.nhs.uk.

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