SLAP repair and bicep tenodesis: a comparison of utilization and revision rates for SLAP tears

Abstract

Hypothesis

The management of superior labrum anterior to posterior (SLAP) tears typically consists of either repair or biceps tenodesis (BT). While repair is more frequently recommended in younger patients, patients older than 40 years are often treated with BT. The purpose of this study is to determine whether there has been a change in utilization of these procedures over the past decade with respect to patient age as well as compare reoperation rates between the two procedures.

Methods

The Pearldiver database was queried to identify BT and SLAP repairs indicated for SLAP tears performed from 2010 to 2019. The primary outcome was utilization rate, stratified by age. A secondary outcome was 2-year shoulder reoperation rates. Trends were reported in terms of compounded annual growth rate. Outcome analysis was conducted using univariate and multivariable analysis.

Results

From 2010 to 2019, SLAP repair was the most common procedure performed for SLAP tears. Regardless of age, BT performed for SLAP tear had a significantly increased utilization rate; whereas, SLAP repair had a significantly decreased utilization rate. SLAP repair was more commonly performed in younger patients compared to BT. Following multivariable analysis, patients who underwent SLAP repair had significantly higher odds (odds ratio (OR): 1.453; 95% confidence interval (CI): 1.26-1.68; P < .001) of requiring an arthroscopic reoperation within 2 years when compared to those who underwent BT with no significant difference with respect to 2-year open reoperation.

Conclusion

Although SLAP repair is still more commonly used to treat SLAP tears than BT, especially for younger patients, the utilization of SLAP repair is decreasing while BT is increasing. The increased utilization of BT may be associated with lower rates of shoulder reoperation for problematic SLAP tears.

The glenoid labrum is a fibrocartilaginous ring of tissue that serves to stabilize the humeral head against the glenoid and serves as an anchor for the origin of the long head of the biceps.^4,20 Superior labrum anterior and posterior (SLAP) tears were first described by Andrews,¹ and subsequently classified by Snyder.¹⁶ While initial treatment is often nonoperative, when surgery is indicated, many options can be offered, including but not limited to the following: repair, labral débridement, biceps tenotomy, and biceps tenodesis (BT). In the younger patient population, generally 40 years or less, SLAP repair and biceps tenodesis are most indicated.

Prior studies have shown arthroscopic SLAP repair to be the most commonly performed procedure for SLAP tears.^6,11 However, the relative utilization of BT compared to SLAP repair has been increasing.^6,11,18 Neither option is without complications, and subsequent 3-year repeat or revision surgery rates have been reported to be as high as 11.5% for SLAP repairs and 13.0% for BT.¹² Revision surgery after SLAP repair is most commonly indicated for persistent mechanical symptoms; however, pain, hardware complications, and separate shoulder pathology are other indications.¹⁴ Revisions of BT have been performed for pain, biceps cramping, and physical deformity.⁹

In this study, we aimed to examine the trends of surgeon utilization as well as subsequent surgery for SLAP repairs and BT indicated for SLAP tears, both within the general population and subdivided by age. For subsequent surgery, we examined whether the patient underwent any subsequent revision shoulder surgery. Based on prior trends, we hypothesized that the utilization of BT is increasing in all age groups and that rates of subsequent shoulder surgery would be higher in the SLAP repair patient cohort compared to the BT cohort.

Methods

Data source and collection

Data was provided from the Mariner subset of a national all payer's claim database (PearlDiver Patient Records Database, Colorado Springs, CO, USA). The Mariner dataset was specifically used because it longitudinally tracks patients based upon a distinct patient identifier. The utilization of patient identifiers minimizes loss to follow-up from changes in insurance status, a common limitation of other databases. This dataset contains records for over 121 million patients from 2010 to 2019, describing physician and hospital billing records. Patients were identified using Current Procedural Terminology (CPT) codes to identify primary SLAP repair (CPT-29807) and BT (CPT-29828, CPT-23430). Patients with diagnosis of SLAP tear at time of SLAP repair and BT were then identified using ICD-9 and 10 diagnosis codes (Supplementary Appendix S1).

Exclusion/inclusion criteria

Patients were excluded if they were younger than 18 years or had undergone a prior shoulder procedure. For accurate revision surgery estimates, patients were also excluded if they did not have 2-year follow-up or if they had undergone the procedure prior to 2015. The database can ensure follow-up based on whether the patient has any records within a certain period following the index surgery. Patients with a concurrent and ipsilateral diagnosis of rotator cuff and bicep tendon pathology were excluded from this analysis (Supplementary Appendix S1). Since Pearldiver does not have CPT modifier codes to control for laterality, ICD-10 diagnosis codes for SLAP tear were paired with the procedure since they accounted for laterality. For trends analysis, revision surgery was not observed. Therefore, 2-year follow-up was not necessary, and trends were conducted from 2010 to 2019. Other exclusion criteria still applied in trends analysis.

Trends analysis

Our primary outcome was to observe the rate of utilization of SLAP repair and BT for SLAP tears from 2010 to 2019. The rate of change for surgical utilization was calculated using the compounded annual growth rate (CAGR), based on the following equation: $\mathrm{C}\mathrm{A}\mathrm{G}\mathrm{R}={(\mathrm{Y}2\mathrm{v}alue/\mathrm{Y}1\mathrm{v}alue)}^{1/(\mathrm{Y}2–\mathrm{Y}1)}–1$, where Y1 is the first year of the analysis and Y2 is the final year. The CAGR is a validated metric of annual change that is commonly used to analyze trends due to its ability to reduce the impact of short-term fluctuations on overall trends.^5,13 In addition to overall surgical utilization, we also assessed surgical utilization by age in years (18-24, 25-34, 35-44, 45-54, >55). Linear regression was also conducted comparing the variability of utilization, with a reported P value for trends significance. All analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria) provided within the PearlDiver database.

Demographics and outcomes

Our secondary outcome included a comparison of 2-year shoulder reoperation rates in patients who had undergone either SLAP repair or BT via univariate and multivariable analyses. Demographic characteristics included age, gender, and all individual comorbidities included in the Elixhauser index. Surgical outcomes included incidence of 2-year shoulder reoperation (arthroscopic and open procedures). Arthroscopic and open reoperations were defined using CPT codes found in Supplementary Appendix S1. To control for laterality and to observe that the surgery is a reoperation for a SLAP tear, we paired the CPT codes with the ICD-10 codes for SLAP tear. Data on patient demographics, comorbidities, and 2-year reoperations were initially analyzed with univariate analysis using R software provided by PearlDiver. Univariate analysis was conducted using Chi-squared and Student T-tests where appropriate. All 2-year surgical outcomes with P values less than .2 were included as dependent variables for separate multivariable analyses. To control for covariates and mitigate confounding variables, all demographic or comorbidities with P values less than .2 on univariate analysis were included as independent variables in each multivariable analysis. Multivariable analysis was performed using logistic regression run on R software provided by PearlDiver. Multivariable output was described using odds ratios (OR) and 95% confidence intervals (95% CI).

Results

Patient population

In total, we analyzed 131,221 patients who underwent SLAP repair (N = 92,220) and bicep tenodesis (N = 39,001).

Trends in surgical utilization

From 2010 to 2019, SLAP repair was the most performed surgical management for SLAP tear accounting for 70% of all procedures (Table I). However, BT had significantly increased utilization (14.96% to 49.07%; CAGR: +14.11). Conversely, SLAP repair has had a significantly decreased rate of utilization (85.04% to 50.93%; CAGR: −5.54%), Table I, Fig. 1).

Table I.

Trends in utilization of BT and SLAP repair for SLAP tear, 2010-2019.

	Total	BT	SLAP repair
	N	N (%)	N (%)
Total	131,221	39,001 (29.72)	92,220 (70.28)
2010	15,544	2326 (14.96)	13,218 (85.04)
2011	14,858	2548 (17.15)	12,310 (82.85)
2012	14,632	3094 (21.15)	11,538 (78.85)
2013	14,867	3808 (25.61)	11,059 (74.39)
2014	14,335	4214 (29.40)	10,121 (70.60)
2015	13,259	4213 (31.77)	9046 (68.23)
2016	11,185	4073 (36.41)	7112 (63.59)
2017	10,623	4378 (41.21)	6245 (58.79)
2018	10,108	4552 (45.03)	5556 (54.97)
2019	11,810	5795 (49.07)	6015 (50.93)
CAGR	-	- (14.11)	- (−5.54)
P value	-	<.001	<.001

BT, Bicep tenodesis; CAGR, Compound annual growth rate.

Significance level = 0.05 (bolded).

Figure 1.

Trends in utilization of BT and SLAP repair for SLAP tear 2010-2019.

Trends in utilization by patient age

For the categorized age ranges, most patients who underwent a surgical operation for SLAP tear were older than 55 (32%), followed by 45-54 (26%), 35-45 (19%), 18-24 (13%), and 25-34 (10%). BT was associated with a significantly increased rate of utilization for all age ranges, with a greater rate of increase in utilization in younger patients (CAGR: +11.59% to +19.87%, Table II, Figure 2, Figure 3, Figure 4, Figure 5). Conversely, SLAP repair was associated with a decreased rate of utilization for all age ranges, with a more prominent decrease in utilization in older patients: (CAGR: −0.61% to −8.84% Table II, Figure 2, Figure 3, Figure 4, Figure 5).

Table II.

Trends in age of patients who underwent BT and SLAP repair for SLAP tear, 2010-2019.

Age group	Bicep tenodesis					SLAP repair
	18-24	25-34	35-44	45-54	>55	18-24	25-34	35-44	45-54	>55
2010	1.29%	4.68%	17.76%	17.63%	25.13%	98.71%	94.90%	89.74%	82.37%	74.87%
2011	2.32%	4.49%	17.66%	20.54%	29.11%	97.68%	94.72%	88.52%	79.46%	70.89%
2012	2.60%	7.38%	25.39%	23.94%	34.52%	97.40%	91.50%	83.64%	76.06%	65.48%
2013	2.44%	8.37%	29.52%	30.54%	39.43%	97.56%	89.85%	80.13%	69.46%	60.57%
2014	3.51%	10.01%	34.86%	35.71%	44.19%	96.49%	87.48%	76.29%	64.29%	55.81%
2015	3.77%	11.84%	38.36%	38.98%	47.19%	96.23%	85.67%	73.77%	61.02%	52.81%
2016	3.94%	13.19%	45.47%	44.66%	53.46%	96.06%	83.72%	67.43%	55.34%	46.54%
2017	4.72%	12.18%	48.10%	51.02%	58.61%	95.28%	83.02%	64.87%	48.98%	41.39%
2018	4.71%	15.29%	50.12%	54.89%	63.89%	95.29%	80.14%	63.35%	45.11%	36.11%
2019	6.60%	15.20%	53.85%	57.61%	67.45%	93.40%	78.38%	59.89%	42.39%	32.55%
CAGR	+19.87%	+13.98%	+13.12%	+14.06%	11.59%	−0.61%	−2.10%	−4.39%	−7.12%	−8.84%
P value	<.001	<.001	<.001	<.001	<.001	<.001	<.001	<.001	<.001	<.001

BT, Bicep tenodesis; CAGR, Compound annual growth rate.

Significance level = 0.05 (bolded).

Figure 2.

Trends in utilization of BT and SLAP repair for SLAP tear 2010-2019 in those less than 25 years of age.

Figure 3.

Trends in utilization of BT and SLAP repair for SLAP tear 2010-2019 in those aged 25-34 years.

Figure 4.

Trends in utilization of BT and SLAP repair for SLAP tear 2010-2019 in those aged 35-44 years.

Figure 5.

Trends in utilization of BT and SLAP repair for SLAP tear 2010-2019 in those aged 45-54 years.

Univariate demographic, comorbidity, and reoperation analyses

Patients who underwent BT were significantly older (P < .001) and more likely to be female (P < .001). This patient group also had higher comorbidity (arrhythmias (P = .036), hypertension (P = .041), liver disease (P = .005), and psychosis (P = .032)) when compared to those who underwent SLAP repair (Table III). Patients who underwent SLAP repair were associated with a significantly higher incidence rate of arthroscopic shoulder reoperation within 2 years of index procedure when compared to those who underwent BT (2.57% versus 1.56%; P < .001) (Table IV). Patients who underwent a primary SLAP repair had a 0.57% incidence rate of BT conversion within 2-years (Table IV).

Table III.

Univariate analysis of BT and SLAP repair: demographics and comorbidities.

	Total	BT	SLAP repair	P value
	N	N (%)	N (%)	N
Total	131,221	37,836 (-)	15,779 (-)	-
Demographics	-	-	-	-
Average age	-	53.94 (-)	42.12 (-)	<.001∗
Gender	-	-	-	-
Male	33,132	23,038 (60.89)	10094 (63.97)	<.001∗
Female	20,483	14,798 (39.11)	5685 (36.03)	<.001∗
Comorbidities	-	-	-	-
CHF	-	25 (0.07)	<11 (0.03)	.125∗
Arrhythmias	80	65 (0.17)	15 (0.10)	.036
Valvular disease	53	42 (0.11)	11 (0.07)	.166∗
Pulm circ disorders	-	17 (0.04)	<11 (0.01)	.071∗
PVD	65	49 (0.13)	16 (0.10)	.394
HTN	178	138 (0.36)	40 (0.25)	.041∗
Paralysis	-	<11 (0.01)	<11 (0.01)	.846
Other neuro disorders	-	19 (0.05)	<11 (0.03)	.355
CPD	102	71 (0.19)	31 (0.20)	.831
Diabetes mellitus	80	62 (0.16)	18 (0.11)	.173∗
Hypothyroidism	58	47 (0.12)	11 (0.07)	.080∗
CKD	-	26 (0.07)	<11 (0.04)	.185
Liver disease	-	46 (0.12)	<11 (0.04)	.005∗
PUD	-	<11 (0.01)	<11 (0.02)	.436
Rheumatoid arthritis and CVD	-	36 (0.10)	<11 (0.06)	.165∗
Coagulopathy	-	<11 (0.01)	<11 (0.01)	.834
Fluid and electrolyte disorders	70	52 (0.14)	18 (0.11)	.495
Blood loss anemia	-	<11 (0.01)	<11 (0.02)	.616
Deficiency anemia	-	26 (0.07)	<11 (0.05)	.450
Drug abuse	40	28 (0.07)	12 (0.08)	.937
Psychoses	-	11 (0.03)	<11 (0.00)	.032∗
Depression	125	85 (0.22)	40 (0.25)	.528
Obesity	85	63 (0.17)	22 (0.14)	.473
Smoking	78	55 (0.15)	23 (0.15)	.991

BT, Bicep tenodesis; CHF, Congested heart failure; HTN, Hypertension; PVD, Peripheral vascular disease; CPD, Chronic pulmonary disease; CKD, Chronic kidney disease; PUD, Peptic ulcer disease; CVD, Collagen vascular disease.

^∗P < .2 was run on multivariable analysis; Significance level = 0.05 (bolded).

Table IV.

Univariate analysis of BT and SLAP repair: 2-year reoperations outcomes.

	Total	BT	SLAP repair	P value
	N	N (%)	N (%)	N
Total	131,221	37,836 (-)	15,779 (-)	-
Arthroscopic reoperation	995	590 (1.56)	405 (2.57)	<.001
Open reoperation	128	91 (0.24)	37 (0.23)	.896
Bicep tenodesis	90	0 (0.00)	90 (0.57)	-

BT, Bicep tenodesis.

Significance level = 0.05 (bolded).

Multivariable reoperation analysis

After controlling for patient comorbidities and demographics, patients who underwent SLAP repair were associated with a significantly higher odds of requiring an arthroscopic reoperation in the ipsilateral shoulder within 2 years of index procedure compared to those who underwent BT (OR: 1.453; 95% CI: 1.26-1.68; P < .001).

Discussion

The data shows increasing utilization of BT for SLAP tears across all age groups. For patients older than 55 years, the percent of patients undergoing BT increased from 25.13% in 2010 to 67.45% in 2019. This is in contrast to patients younger than 25, where BT was used in 1.29% of patients in 2010 and 6.60% of patients in 2019 (Table II).

In univariate analysis, subsequent arthroscopy rates were higher for SLAP repair than BT (2.57% versus 1.56%; P < .001). For those who underwent SLAP repair, 0.57% were converted to BT (Table IV). On multivariable analysis, the SLAP repair group was significantly more likely to undergo any subsequent arthroscopic surgery (OR: 1.453; 95% CI: 1.26-1.68; P < .001).

Several other studies have shown increasing utilization of BT to treat SLAP tears. Erickson et al reviewed records of 4 high-volume surgeons. In their cohort of 9765 patients undergoing common arthroscopic shoulder surgeries, the rate of SLAP repair decreased from over 10% to less than 4% between 2004 and 2014. The average age of patients undergoing SLAP repair also decreased from over 35 to just over 26 in that same period.⁶ Patterson et al corroborated these findings using the American Board of Orthopaedic Surgery Certification Examination Database. From 2002 to 2011, the proportion of isolated SLAP lesions treated with SLAP repair decreased from 69.3% to 44.8% (P < .001), while BT increased from 1.9% to 18.8% (P < .001). Patients undergoing SLAP repair were found to be significantly younger (37.1 years) compared to patients undergoing BT (47.2 years).¹¹ Hong et al observed this trend using the National Ambulatory Surgery Sample.¹¹ Their study also observed that the utilization of SLAP repair is decreasing from 2016 to 2018. Additionally, they confirm our results that SLAP repair was performed in younger patients; whereas bicep tenodesis was performed in older patients.

There are several clinical studies that help explain this shifting utilization. Foremost, SLAP tears are a difficult problem to treat and can be associated with other shoulder pathology, as 11.5% of SLAP repairs and 13.0% of BT patients will require reoperation or undergo subsequent shoulder surgery within 3 years.¹² The lower percentages reported in our study (2.80% for SLAP repair and 1.80% for BT) are likely due to the requirement that SLAP tear be listed as an indication for the subsequent surgery.

SLAP repair failure has been defined as “postoperative pain and/or stiffness (not associated with concomitant pathology) that does not resolve with nonsurgical measures”.¹⁹ Weber et al reported on 24 shoulders over a course of 7 years with pain after a SLAP repair. A true failure of the repair itself was diagnosed in 7 of 24 shoulders. Other causes of pain were chondral damage, stiffness, and implant irritation.¹⁷ Katz et al also reviewed 40 shoulders with pain after SLAP repair. While stiffness was the primary symptom in 75% of patients (n = 30), 21 patients underwent subsequent surgery. Five of 21 shoulders (24%) had continued SLAP pathology that was treated with revision SLAP repair (n = 1) or BT (n = 4). Other causes of SLAP repair failure may be due to implant selection.¹⁰ Park et al reviewed 348 patients who had a SLAP repair revision and failure of their index surgery was correlated with use of absorbable poly-L/D-lactic acid suture anchors.¹⁵

Unfortunately, patients who undergo BT can also experience complications, although at lower rates, with revision rates reported between 0.4%-1.9%.^2,8,10 Forsythe et al examined the PearlDiver database from 2008 to 2017 for both open and arthroscopic BT. In their study, 9274 patients underwent arthroscopic BT and 5983 patients underwent open BT with 171 (1.8%) and 111 (1.9%) patients requiring revision surgery from each group, respectively.⁸ Our data were consistent with this study, as we found an overall reoperation rate of 1.8%.

Given its infrequent occurrence, clinical data on patients who undergo revision BT are reported in only small case series. A systematic review by Civan et al showed that patients with bicep tenodesis had a higher return to preinjury sports level and patient satisfaction with lower reoperation rates when compared to patients who underwent SLAP repair all for SLAP tears.³ Euler et al examined 27 patients, 20 of whom had chronic long head of biceps ruptures and 7 who had undergone failed BT. Patients had less pain, cramping, and deformity after subsequent tenodesis. The SPBS, ASES, and SF-12 PCS scores significantly improved among this group of patients.⁷ Gregory et al also reported on a cohort of patients (n = 21) who underwent revision BT. The surgical indication was pain (n = 14) and ruptured biceps (n = 7). They improved in VAS, SANE, ASES, UCLA scores at mean follow-up of 33.4 months.⁹

Strengths and limitations

Our study has several strengths. Foremost, the use of a national data base allows for examination of large numbers of patients with increased generalizability to the greater orthopedic community. This large patient population helps facilitate studying rare pathology, such as revision BT surgery. Furthermore, patients can be tracked longitudinally and subsequent procedures can be captured even in the event the patients change insurance during that time. Additionally, our data show that SLAP tears are increasingly being treated with BT rather than SLAP repair. This is true across all age groups. Our data shed light on a potential driving force of this trend, as patients who underwent SLAP repair were more likely to need revision surgery compared to those who had BT.

Any study should be interpreted in view of its limitations. National database studies are limited by the data entry which can be subject to coding errors. The PearlDiver database does not track shoulder specific outcomes, such as functional scoring. Thus, we could not compare functional outcomes. Further, this study does not capture revision rates or subsequent shoulder surgery that may be tangentially but not directly related to their initial SLAP lesion. As this is a retrospective database analysis, this analysis was only able to show the trends but not explain why surgeons may be performing more of one surgery or why they are performing more in a certain population. Lastly, we can look at preoperative diagnoses based on ICD billing codes but cannot definitely observe that the surgery was only for that indication. Although we excluded bicep tendon and rotator cuff pathology. It is possible that the patient may have had the surgery for other indications.

Conclusion

This study shows that the percentage of BT procedures for the treatment of SLAP tears has been increasing when compared to SLAP repair, especially in older patients. This has important implications in clinical practice, decision making, and insurance reimbursement. Our study also shows that reoperation rates are higher for patients undergoing SLAP repair. This is a likely an important driver behind the increased utilization of BT.

Disclaimers

Funding: No funding was disclosed by the authors.

Conflicts of interest: Dr. Best reports other financial or material support from Arthrex, Inc: and Smith & Nephew. Dr. Srikumaran reports grants and personal fees from Arthrex, grants and personal fees from Depuy, personal fees from Fx Shoulder, personal fees from Orthofix, other from Quantum OPS, other from ROM3, grants from Smith and Nephew, other from Sonogen, personal fees from Stryker, personal fees from Thieme, personal fees and other from Tigon Medical, grants and personal fees from Wright Medical Technology, outside the submitted work; In addition, Dr. Srikumaran has a patent Conventus pending, a patent Fx Shoulder pending, and a patent Tigon Medical issued. The other authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. The authors received no financial support for the research, authorship, and/or publication of this article. The authors have no conflicts of interest with respect to the authorship and/or publication of this article. Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members.