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Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database Brendan M. Patterson, R. Alexander Creighton, Jeffrey T. Spang, James R. Roberson and Ganesh V. Kamath Am J Sports Med 2014 42: 1904 originally published online June 2, 2014 DOI: 10.1177/0363546514534939 The online version of this article can be found at: http://ajs.sagepub.com/content/42/8/1904
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Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database Brendan M. Patterson,*y MD, MPH, R. Alexander Creighton,y MD, Jeffrey T. Spang,y MD, James R. Roberson,z MD, and Ganesh V. Kamath,y MD Investigation performed at the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Background: After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions. Hypotheses: For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy. Results: From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P \ .0001), while biceps tenodesis increased from 1.9% to 18.8% (P \ .0001), and biceps tenotomy increased from 0.4% to 1.7% (P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% (P \ .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% (P \ .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P \ .0001). Conclusion: Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. Keywords: SLAP; biceps tenotomy; biceps tenodesis; rotator cuff tear
treatments of SLAP tears.5,8 The documented success rate for SLAP repairs in the setting of isolated SLAP tears ranges from 74% to 94%.3,9 Similar success rates have also been reported for biceps tenodesis as an alternative treatment in the setting of isolated SLAP tears.2 Although there is no clear consensus on the optimal treatment of isolated SLAP tears, it is well understood that patient age and prior level of function play important roles in guiding surgical management.12 Similarly, there is conflicting evidence for SLAP repair versus biceps tenodesis or biceps tenotomy for patients
Interest in the diagnosis and treatment of superior labrum anterior and posterior (SLAP) lesions has grown in recent years. According to a recent study by Weber et al,20 the rate of SLAP repairs has increased in recent years. Despite this increased rate of SLAP repairs, there is evidence in the literature to support both operative and nonoperative
The American Journal of Sports Medicine, Vol. 42, No. 8 DOI: 10.1177/0363546514534939 Ó 2014 The Author(s)
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over 50 years of age with rotator cuff tears. Franceschi et al7 investigated the optimal treatment for patients with rotator cuff tears and SLAP lesions undergoing arthroscopic rotator cuff repair. They found that patients had improved outcomes with rotator cuff repair and biceps tenotomy compared with those undergoing combined rotator cuff and SLAP repair. Similar outcomes have been noted for patients with SLAP tears and large rotator cuff tears.10 There is additional evidence to support debridement of SLAP tears in place of SLAP repair for patients with combined rotator cuff and SLAP tears.1 Despite these recent published series, there is also evidence to support SLAP repair in this patient population. Multiple studies have shown improved results for patients undergoing SLAP repair with concomitant rotator cuff repair.6,19 Forsythe el al6 demonstrated that for patients with SLAP and rotator cuff tears, those undergoing repair of both tears had improved outcomes compared with patients undergoing rotator cuff repair alone. Accurate reporting of practice trends in orthopaedic surgery has been enhanced by the development of the American Board of Orthopaedic Surgery (ABOS) database. Koval et al11 were the first to query the ABOS database to determine the trends in fracture treatment among candidates applying for orthopaedic board certification between 1999 and 2008. They found that candidate surgeons were treating fractures at similar rates over the 10-year study period. Owens et al14 utilized the ABOS database to determine the rates of arthroscopic and open Bankart repair from 2003 to 2008. Although tenodesis and tenotomy of the long head of the biceps have become more accepted procedures among orthopaedic surgeons and patients, there has not yet been a study describing the trends of these procedures over the past decade.4
MATERIALS AND METHODS When designing this study to examine the ABOS database from 2002 to 2011, it was our hypothesis that (1) for patients with SLAP lesions, the frequency of SLAP repair has decreased while the frequency of biceps tenodesis and tenotomy has increased; and (2) patients with SLAP lesions undergoing rotator cuff repair more frequently undergo concomitant biceps tenodesis or tenotomy rather than SLAP repair. To determine the rate of SLAP repair, biceps tenodesis, and biceps tenotomy for the treatment of isolated SLAP tears, and for patients undergoing rotator cuff repair from 2002 to 2011, a query of the ABOS database was performed. The ABOS database is securely maintained and contains information submitted voluntarily from orthopaedic surgeons sitting for part II of the orthopaedic board
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examination. These data are collected over a 6-month period. Candidates submitting case information to the ABOS database must have already passed part I of the orthopaedic board examination and must have been in practice for 22 months. A detailed description of the ABOS database and the information contained within has been published previously.20 A query of the ABOS database was performed from 2002 to 2011. The database was searched for patients with SLAP lesions, based on International Classification of Diseases–9th Revision (ICD-9) code 840-7, undergoing SLAP repair (Current Procedural Terminology [CPT] code 29807), open biceps tenodesis (CPT code 23430), arthroscopic biceps tenodesis (CPT code 29828), or biceps tenotomy (CPT code 23405). The database was then queried for patients with SLAP tears undergoing arthroscopic rotator cuff repair (CPT code 29827) with the accompanying ICD-9 code for a SLAP tear. Surgical logs were noted for either concurrent SLAP repair, biceps tenodesis (open or arthroscopic), or biceps tenotomy. Surgical cases were categorized by year and by surgeon and patient variables. Specific variables pertaining to each candidate surgeon were extracted from the database including declared subspecialty fellowship training. The following subspecialty fellowship training categories were included in the analysis: sports medicine, hand and upper extremity, shoulder and elbow, and general orthopaedics. Patient-specific variables included patient age, sex, and surgical complication.
Statistical Analysis Routine descriptive statistics were calculated for continuous variables including means 6 standard deviations. Frequencies were obtained for categorical variables. The x2 test was used for analysis of contingency tables. Analysis of variance (ANOVA) was used for comparison of multiple group means together with the Tukey-Kramer post hoc test. The a level for statistical significance was set at \.05.
RESULTS There were a total of 8963 cases reported for the treatment of an isolated SLAP lesion from 2002 to 2011 and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. While the CPT codes for SLAP repair and open biceps tenodesis were available beginning in 2002, the CPT codes for biceps tenotomy and arthroscopic biceps tenodesis were not available from the ABOS database until 2003 and 2007, respectively. Trends in each of the surgical procedures for SLAP lesions were therefore compared with the first year in which they were available from the ABOS database. For the treatment
*Address correspondence to Brendan M. Patterson, MD, MPH, Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, CB #7055, Chapel Hill, NC 27599, USA (e-mail: [email protected]). y Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. z Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA. Presented as a poster at the annual meeting of the AOSSM, Seattle, Washington, July 2014. One or more of the authors has declared the following potential conflict of interest or source of funding: This study was paid for by the University of North Carolina at Chapel Hill, Department of Orthopaedic Surgery, Sports Medicine Research Fund.
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TABLE 1 Isolated SLAP Tear Cases Reported and Surgical Treatments From 2002 to 2011a
Year
Isolated SLAP Tear Cases, n
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
678 717 760 862 932 1189 1038 942 908 937
Isolated SLAP Tears Treated With Repair 470 483 533 593 670 794 654 483 433 420
(69.3) (67.4) (70.1) (68.8) (71.9) (66.8) (63.0) (51.3) (47.7) (44.8)
Isolated SLAP Tears Treated With Open Biceps Tenodesis 13 16 11 19 35 63 35 70 102 89
Isolated SLAP Tears Treated With Arthroscopic Biceps Tenodesis
(1.9) (2.2) (1.4) (2.2) (3.8) (5.3) (3.4) (7.4) (11.2) (9.5)
0 0 0 0 0 2 35 47 54 87
(0.0) (0.0) (0.0) (0.0) (0.0) (0.2) (3.4) (5.0) (5.9) (9.3)
Isolated SLAP Tears Treated With Biceps Tenotomy 0 3 1 4 4 7 2 16 36 16
(0.0) (0.4) (0.1) (0.5) (0.4) (0.6) (0.2) (1.7) (4.0) (1.7)
a
Data are presented as n (%) unless otherwise indicated. SLAP, superior labrum anterior and posterior.
70%
80% 70%
60%
60%
Percentage
Percentage
50% 50% 40% 30% 20%
40% 30% 20%
10%
10%
0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year SLAP Repair
Biceps Tenodesis
Biceps Tenotomy
Figure 1. Treatment of isolated superior labrum anterior and posterior (SLAP) lesions from 2002 to 2011. of SLAP lesions from 2002 to 2011, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P \ .0001), while the proportion of biceps tenodesis increased from 1.9% to 18.8% for open and arthroscopic biceps tenodesis (P \ .0001) from 2002 to 2011, and the proportion of biceps tenotomy increased from 0.4% to 1.7% (P = .018) from 2003 to 2011 (Figure 1 and Table 1). When comparing arthroscopic and open biceps tenodesis, the data indicate that both procedures increased over the study period. From 2002 to 2011, open biceps tenodesis increased from 1.9% to 9.5%, and arthroscopic biceps tenodesis increased from 0.2% to 9.3% from 2007 to 2011 (Table 1). For patients with SLAP lesions undergoing arthroscopic rotator cuff repair, similar trends were observed, as the proportion of SLAP repairs decreased from 60.2% to 15.3% (P \ .0001) from 2003 to 2011, while the proportion of those undergoing biceps tenodesis or tenotomy
0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year SLAP Repair
Biceps Tenodesis/Tenotomy
Figure 2. Treatment of superior labrum anterior and posterior (SLAP) lesions with concomitant rotator cuff repair from 2003 to 2011. increased from 6.0% to 28.0% (P \ .0001) from 2003 to 2011 (Figure 2). Of the 8963 cases logged for the treatment of isolated SLAP lesions from 2002 to 2011, 75.2% were for male patients (n = 6744), and 24.8% were for female patients (n = 2219). The mean age for all patients reported was 40.7 years. There was a significant difference in the mean age of patients with SLAP tears undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P \ .0001) (Figure 3). This pattern persisted for patients with SLAP tears undergoing rotator cuff repair, as the mean age for patients undergoing SLAP repair was 48.1 years, while the mean age of patients undergoing biceps tenodesis or tenotomy was 53.3 years (P \ .0001) (Figure 4).
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70
70%
60
60%
50
30 20
55.7 47.2 37.1
40% 30% 20%
10
10%
0 SLAP Repair
Biceps Tenodesis
Biceps Tenotomy
0%
Surgical Procedure
Figure 3. Mean patient age and surgical treatment for patients with isolated superior labrum anterior and posterior (SLAP) lesions.
Shoulder and General Elbow Orthopaedics
70
Hand and Upper Extremity
Sports Medicine
Subspecialty Biceps Tenodesis
SLAP Repair
Figure 5. Treatment of isolated superior labrum anterior and posterior (SLAP) lesions as a function of subspecialty declaration.
60 50 40
60%
30 20
53.3
48.1
10 0 SLAP Repair
Biceps Tenodesis/Tenotomy Surgical Procedure
Figure 4. Mean patient age and surgical treatment for patients with superior labrum anterior and posterior (SLAP) tears undergoing concomitant rotator cuff repair.
50%
Percentage
Paent age (years)
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50%
40
Percentage
Paent age (years)
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40% 30% 20% 10% 0%
Candidates with a declared subspecialty in shoulder and elbow surgery performed biceps tenodesis for 25% of isolated SLAP tears, whereas candidates with a declared subspecialty in the hand and upper extremity, sports medicine, and general orthopaedics utilized biceps tenodesis in 11%, 8%, and 7% of cases, respectively (Figure 5). The difference in the proportion of biceps tenodesis performed by those with a declared subspecialty in shoulder and elbow surgery was significantly higher when compared with candidates declaring a subspecialty in the hand and upper extremity, sports medicine, or general orthopaedics (P \ .05). Candidates specializing in shoulder and elbow surgery were also noted to perform less SLAP repairs (30%) than surgeons specializing in the hand and upper extremity (65%), sports medicine (64%), or general orthopaedics (62%) for isolated SLAP tears; however, this trend did not reach statistical significance (Figure 5). Similar trends were seen for the treatment of patients with SLAP tears undergoing concomitant rotator cuff repair. Candidates with a declared subspecialty in
Shoulder and General Elbow Orthopaedics
Hand and Upper Extremity
Sports Medicine
Subspecialty SLAP Repair
Biceps Tenodesis/Tenotomy
Figure 6. Treatment of superior labrum anterior and posterior (SLAP) lesions in patients undergoing concomitant rotator cuff repair as a function of subspecialty declaration. shoulder and elbow surgery performed SLAP repair in this patient population in 5% of cases compared with candidates declaring subspecialties in the hand and upper extremity, sports medicine, or general orthopaedics, where SLAP repair was utilized in 49%, 38%, and 39% of cases, respectively (Figure 6). Surgeons specializing in the shoulder and elbow performed biceps tenodesis or tenotomy for 35% of SLAP tears in patients undergoing concomitant rotator cuff repair, whereas surgeons specializing in the hand and upper extremity, sports medicine, and general
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orthopaedics utilized these procedures in 14%, 12%, and 16% of cases, respectively (Figure 6). In the treatment of SLAP tears with concomitant rotator cuff repair, these differences between subspecialty-trained surgeons did not reach statistical significance.
DISCUSSION Our current study reveals interesting trends in the treatment of SLAP tears over the past decade. This query of the ABOS database indicates that among part II applicants, the rate of SLAP repairs has decreased, while the rate of biceps tenotomy and tenodesis has increased for the treatment of SLAP tears. These same trends are exhibited among patients with SLAP tears undergoing rotator cuff repair. This decreasing rate of SLAP repairs is in contrast to previously published literature from the ABOS database that described an increased rate of SLAP repairs as a function of total shoulder cases among part II applicants.20 This previously published literature by Weber et al20 examined the rate of SLAP repairs as a function of all shoulder cases reported in the ABOS database from 2003 to 2008. While these data by Weber et al20 provide a useful measure of the incidence of SLAP repairs over the past decade, it does not allow for an in-depth appreciation of the surgical trends in the treatment of SLAP tears. By limiting our query to include only those patients with SLAP tears, we were able to determine the proportion of SLAP repair, biceps tenodesis, and biceps tenotomy in the treatment of SLAP tears. We also expanded our query to include cases reported through 2011 so as to highlight the most recent trends in the surgical treatment of SLAP lesions. It is our belief that the current data represent the beginnings of a paradigm shift in the treatment of SLAP tears over approximately the past 5 years. Formal SLAP repair is being performed more infrequently on an annual basis. Although this decrease is not accompanied by an exact corresponding increase in biceps tenodesis or tenotomy, it is clear that alternative treatments of SLAP tears are being pursued, with the increasing use of either biceps tenodesis or tenotomy as a surgical option. The results from this study also highlight the relationship between patient age and the surgical management of SLAP tears. The mean patient age increased for patients undergoing SLAP repair, biceps tenodesis, and biceps tenotomy. Provencher et al16 recently reported on 179 patients undergoing SLAP repair and found that patients older than 36 years of age were at an increased risk of failure. We may continue to see surgeons electing to not perform SLAP repair in older patients with SLAP tears, given the higher rate of failure and decreased patient outcomes seen in this patient population with and without concomitant rotator cuff repair.7,16 Regarding the treatment of isolated SLAP tears, improved patient outcomes can be seen for patients undergoing both SLAP repair and biceps tenodesis. Kim et al9 demonstrated successful results in 94% of patients treated with SLAP repair, with improved outcomes reported in patients not involved in overhead sports compared with
patients participating in overhead activity. For high-level overhead athletes with SLAP tears, it has also been demonstrated that improved clinical outcome scores do not necessarily correlate with return to play. Park et al15 found that although overhead athletes with SLAP tears showed significant improvements in terms of pain and function, only 50% of these athletes were able to return to play after SLAP repair. Given the lack of conclusive evidence supporting SLAP repair for isolated SLAP tears, Boileau et al2 investigated the outcomes of SLAP repair versus arthroscopic biceps tenodesis in patients with isolated type II SLAP tears. They reported that arthroscopic biceps tenodesis was a good alternative to SLAP repair, as patients had improved function and satisfaction after biceps tenodesis. In their retrospective cohort, they also found that patients undergoing biceps tenodesis were older than those patients undergoing repair, at 52 and 37 years of age, respectively. This is the same trend found in our analysis of the ABOS database when looking at patient age and the treatment of SLAP tears. The abovementioned studies may represent a shift in the current understanding of the optimal treatment of isolated SLAP tears. This change in the surgical management of isolated SLAP tears is illustrated by the trends exhibited in our current study. When considering the optimal treatment of SLAP tears combined with rotator cuff tears, the literature shows evidence to support SLAP repair, biceps tenodesis, and biceps tenotomy. Voos et al19 found that patients with rotator cuff and SLAP tears treated with concomitant repair of both tears had improved postoperative range of motion and overall clinical outcomes, with 90% of patients reporting a good to excellent result at a minimum of 2 years’ follow-up. Forsythe et al6 investigated middle-aged patients with rotator cuff and SLAP tears undergoing rotator cuff repair alone or concomitant rotator cuff and SLAP repair. They found that patients undergoing simultaneous repair of both tears had improved Constant scores compared with patients undergoing rotator cuff repair alone. Before this study, Franceschi et al7 had performed a randomized trial comparing SLAP repair to biceps tenotomy in patients older than 50 years of age with rotator cuff and SLAP tears. In this study, patients undergoing biceps tenotomy with rotator cuff repair had superior outcomes as measured by functional outcome scores, range of motion, and patient satisfaction compared with patients randomized to receive concomitant SLAP and rotator cuff repair. Kim et al10 recently investigated patients with SLAP tears with associated large to massive rotator cuff tears and found that patients undergoing biceps tenotomy had significant improvements in functional outcomes and postoperative forward flexion compared with those undergoing SLAP and rotator cuff repair. In regards to applicant subspecialty, our data show that part II applicants with shoulder and elbow–specific fellowship training performed less SLAP repairs than those applicants with general orthopaedic training. One might expect surgeons who were fellowship trained specifically in shoulder and elbow surgery to be performing a higher proportion of SLAP repairs; however, this was not found
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to be the case in this study. This in part may be because of the evolution in our understanding of the optimal treatment strategies for both isolated SLAP tears and combined SLAP and rotator cuff tears. As described previously, the most recent literature on the treatment of SLAP tears showed improved outcomes after biceps tenodesis and tenotomy compared with SLAP repair in certain subsets of patients.2,7,10 We hypothesize that surgeons trained specifically in shoulder and elbow surgery may be more aware of the current trends in the treatment of SLAP tears and are thus performing less SLAP repairs compared with surgeons trained in other subspecialties. This study has some limitations. It would have been optimal to provide a subgroup analysis for the treatment of each type of SLAP lesion. However, given the nature of the ABOS certification database, it is not possible to provide such a subgroup analysis. More importantly, the current study involves over 8000 cases taken from populations across the entire United States and in all likelihood represents a standard distribution of type I to IV SLAP tears as previously described by Snyder et al.17,18 Another limitation of this study is the lack of availability of CPT codes for biceps tenodesis and tenotomy for the entire study period. While the CPT codes for SLAP repair and open biceps tenodesis were available beginning in 2002, the CPT codes for biceps tenotomy and arthroscopic biceps tenodesis were not available from the ABOS database until 2003 and 2007, respectively. As there was no CPT code available for arthroscopic biceps tenodesis until 2007, we hypothesize that many arthroscopic biceps tenodesis cases may have been coded as open biceps tenodesis before 2007. As such, it is difficult to make a direct comparison between the rates of open versus arthroscopic biceps tenodesis for the treatment of SLAP tears. We were unable to include data on arthroscopic biceps tenotomy because a specific CPT code for this procedure does not currently exist, but we believe that the CPT code for open biceps tenotomy of 23405 is often used as a substitute. In some cases, it is possible that the unlisted CPT code of 29999 is used for arthroscopic biceps tenotomy, but because it is an unspecified code pertaining to other procedures used during shoulder arthroscopic surgery, it could not be incorporated into our analysis. Furthermore, it is unlikely that these aforementioned limitations solely account for the dramatic decrease in SLAP repairs from 2002 to 2011. As biceps tenodesis and SLAP repair are intrinsically separate procedures, we think it is unlikely that a biceps tenodesis procedure could have been coded as a SLAP repair because the tenodesis procedure would not meet the appropriate requirements to qualify for the aforementioned CPT code of 29807 (SLAP repair). Although the ABOS database maintains surgical data for a large group of orthopaedic surgeons, it does so only for candidate surgeons sitting for part II of the orthopaedic board examination. These candidates are, on average, younger surgeons who have only recently finished their orthopaedic training. The trends noted in this article are therefore not the practice trends of every practicing orthopaedic surgeon. Despite this limitation, previous studies utilizing the ABOS
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database have argued that the practice trends detailed in this database provide value, as they represent the trends of the most recently trained orthopaedic surgeons.13 A final limitation is that we were not able to obtain the clinical outcomes of the surgeries; therefore, we cannot comment as to whether the changes in the procedures performed have been accompanied by any change in the quality of the surgical outcomes. This study provides insight into the current practice trends of recent orthopaedic training graduates in the treatment of SLAP tears with and without a concomitant rotator cuff injury. We have shown that over the study period in question, the rate of SLAP repairs decreased, while the rate of biceps tenodesis and tenotomy increased for the treatment of SLAP tears with and without rotator cuff repair.
ACKNOWLEDGMENT The authors acknowledge John Harrast for his assistance with data analysis.
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13. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2012;94(16):1492-1499. 14. Owens BD, Harrast JJ, Hurwitz SR, Thompson TL, Wolf JM. Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination. Am J Sports Med. 2011;39(9):1865-1869. 15. Park JY, Chung SW, Jeon SH, Lee JG, Oh KS. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. Am J Sports Med. 2013;41(6):13721379. 16. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and
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posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med. 2013;41(4):880-886. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4(4):243-248. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274-279. Voos JE, Pearle AD, Mattern CJ, Cordasco FA, Allen AA, Warren RF. Outcomes of combined arthroscopic rotator cuff and labral repair. Am J Sports Med. 2007;35(7):1174-1179. Weber SC, Martin DF, Seiler JG 3rd, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med. 2012;40(7):1538-1543.
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Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder: Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database Brendan M. Patterson, R. Alexander Creighton, Jeffrey T. Spang, James R. Roberson and Ganesh V. Kamath Am J Sports Med 2014 42: 1904 originally published online June 2, 2014 DOI: 10.1177/0363546514534939 The online version of this article can be found at: http://ajs.sagepub.com/content/42/8/1904
Published by: http://www.sagepublications.com
On behalf of: American Orthopaedic Society for Sports Medicine
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Surgical Trends in the Treatment of Superior Labrum Anterior and Posterior Lesions of the Shoulder Analysis of Data From the American Board of Orthopaedic Surgery Certification Examination Database Brendan M. Patterson,*y MD, MPH, R. Alexander Creighton,y MD, Jeffrey T. Spang,y MD, James R. Roberson,z MD, and Ganesh V. Kamath,y MD Investigation performed at the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Background: After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions. Hypotheses: For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy. Results: From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P \ .0001), while biceps tenodesis increased from 1.9% to 18.8% (P \ .0001), and biceps tenotomy increased from 0.4% to 1.7% (P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% (P \ .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% (P \ .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P \ .0001). Conclusion: Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair. Keywords: SLAP; biceps tenotomy; biceps tenodesis; rotator cuff tear
treatments of SLAP tears.5,8 The documented success rate for SLAP repairs in the setting of isolated SLAP tears ranges from 74% to 94%.3,9 Similar success rates have also been reported for biceps tenodesis as an alternative treatment in the setting of isolated SLAP tears.2 Although there is no clear consensus on the optimal treatment of isolated SLAP tears, it is well understood that patient age and prior level of function play important roles in guiding surgical management.12 Similarly, there is conflicting evidence for SLAP repair versus biceps tenodesis or biceps tenotomy for patients
Interest in the diagnosis and treatment of superior labrum anterior and posterior (SLAP) lesions has grown in recent years. According to a recent study by Weber et al,20 the rate of SLAP repairs has increased in recent years. Despite this increased rate of SLAP repairs, there is evidence in the literature to support both operative and nonoperative
The American Journal of Sports Medicine, Vol. 42, No. 8 DOI: 10.1177/0363546514534939 Ó 2014 The Author(s)
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over 50 years of age with rotator cuff tears. Franceschi et al7 investigated the optimal treatment for patients with rotator cuff tears and SLAP lesions undergoing arthroscopic rotator cuff repair. They found that patients had improved outcomes with rotator cuff repair and biceps tenotomy compared with those undergoing combined rotator cuff and SLAP repair. Similar outcomes have been noted for patients with SLAP tears and large rotator cuff tears.10 There is additional evidence to support debridement of SLAP tears in place of SLAP repair for patients with combined rotator cuff and SLAP tears.1 Despite these recent published series, there is also evidence to support SLAP repair in this patient population. Multiple studies have shown improved results for patients undergoing SLAP repair with concomitant rotator cuff repair.6,19 Forsythe el al6 demonstrated that for patients with SLAP and rotator cuff tears, those undergoing repair of both tears had improved outcomes compared with patients undergoing rotator cuff repair alone. Accurate reporting of practice trends in orthopaedic surgery has been enhanced by the development of the American Board of Orthopaedic Surgery (ABOS) database. Koval et al11 were the first to query the ABOS database to determine the trends in fracture treatment among candidates applying for orthopaedic board certification between 1999 and 2008. They found that candidate surgeons were treating fractures at similar rates over the 10-year study period. Owens et al14 utilized the ABOS database to determine the rates of arthroscopic and open Bankart repair from 2003 to 2008. Although tenodesis and tenotomy of the long head of the biceps have become more accepted procedures among orthopaedic surgeons and patients, there has not yet been a study describing the trends of these procedures over the past decade.4
MATERIALS AND METHODS When designing this study to examine the ABOS database from 2002 to 2011, it was our hypothesis that (1) for patients with SLAP lesions, the frequency of SLAP repair has decreased while the frequency of biceps tenodesis and tenotomy has increased; and (2) patients with SLAP lesions undergoing rotator cuff repair more frequently undergo concomitant biceps tenodesis or tenotomy rather than SLAP repair. To determine the rate of SLAP repair, biceps tenodesis, and biceps tenotomy for the treatment of isolated SLAP tears, and for patients undergoing rotator cuff repair from 2002 to 2011, a query of the ABOS database was performed. The ABOS database is securely maintained and contains information submitted voluntarily from orthopaedic surgeons sitting for part II of the orthopaedic board
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examination. These data are collected over a 6-month period. Candidates submitting case information to the ABOS database must have already passed part I of the orthopaedic board examination and must have been in practice for 22 months. A detailed description of the ABOS database and the information contained within has been published previously.20 A query of the ABOS database was performed from 2002 to 2011. The database was searched for patients with SLAP lesions, based on International Classification of Diseases–9th Revision (ICD-9) code 840-7, undergoing SLAP repair (Current Procedural Terminology [CPT] code 29807), open biceps tenodesis (CPT code 23430), arthroscopic biceps tenodesis (CPT code 29828), or biceps tenotomy (CPT code 23405). The database was then queried for patients with SLAP tears undergoing arthroscopic rotator cuff repair (CPT code 29827) with the accompanying ICD-9 code for a SLAP tear. Surgical logs were noted for either concurrent SLAP repair, biceps tenodesis (open or arthroscopic), or biceps tenotomy. Surgical cases were categorized by year and by surgeon and patient variables. Specific variables pertaining to each candidate surgeon were extracted from the database including declared subspecialty fellowship training. The following subspecialty fellowship training categories were included in the analysis: sports medicine, hand and upper extremity, shoulder and elbow, and general orthopaedics. Patient-specific variables included patient age, sex, and surgical complication.
Statistical Analysis Routine descriptive statistics were calculated for continuous variables including means 6 standard deviations. Frequencies were obtained for categorical variables. The x2 test was used for analysis of contingency tables. Analysis of variance (ANOVA) was used for comparison of multiple group means together with the Tukey-Kramer post hoc test. The a level for statistical significance was set at \.05.
RESULTS There were a total of 8963 cases reported for the treatment of an isolated SLAP lesion from 2002 to 2011 and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. While the CPT codes for SLAP repair and open biceps tenodesis were available beginning in 2002, the CPT codes for biceps tenotomy and arthroscopic biceps tenodesis were not available from the ABOS database until 2003 and 2007, respectively. Trends in each of the surgical procedures for SLAP lesions were therefore compared with the first year in which they were available from the ABOS database. For the treatment
*Address correspondence to Brendan M. Patterson, MD, MPH, Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, CB #7055, Chapel Hill, NC 27599, USA (e-mail: [email protected]). y Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA. z Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA. Presented as a poster at the annual meeting of the AOSSM, Seattle, Washington, July 2014. One or more of the authors has declared the following potential conflict of interest or source of funding: This study was paid for by the University of North Carolina at Chapel Hill, Department of Orthopaedic Surgery, Sports Medicine Research Fund.
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TABLE 1 Isolated SLAP Tear Cases Reported and Surgical Treatments From 2002 to 2011a
Year
Isolated SLAP Tear Cases, n
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
678 717 760 862 932 1189 1038 942 908 937
Isolated SLAP Tears Treated With Repair 470 483 533 593 670 794 654 483 433 420
(69.3) (67.4) (70.1) (68.8) (71.9) (66.8) (63.0) (51.3) (47.7) (44.8)
Isolated SLAP Tears Treated With Open Biceps Tenodesis 13 16 11 19 35 63 35 70 102 89
Isolated SLAP Tears Treated With Arthroscopic Biceps Tenodesis
(1.9) (2.2) (1.4) (2.2) (3.8) (5.3) (3.4) (7.4) (11.2) (9.5)
0 0 0 0 0 2 35 47 54 87
(0.0) (0.0) (0.0) (0.0) (0.0) (0.2) (3.4) (5.0) (5.9) (9.3)
Isolated SLAP Tears Treated With Biceps Tenotomy 0 3 1 4 4 7 2 16 36 16
(0.0) (0.4) (0.1) (0.5) (0.4) (0.6) (0.2) (1.7) (4.0) (1.7)
a
Data are presented as n (%) unless otherwise indicated. SLAP, superior labrum anterior and posterior.
70%
80% 70%
60%
60%
Percentage
Percentage
50% 50% 40% 30% 20%
40% 30% 20%
10%
10%
0% 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year SLAP Repair
Biceps Tenodesis
Biceps Tenotomy
Figure 1. Treatment of isolated superior labrum anterior and posterior (SLAP) lesions from 2002 to 2011. of SLAP lesions from 2002 to 2011, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P \ .0001), while the proportion of biceps tenodesis increased from 1.9% to 18.8% for open and arthroscopic biceps tenodesis (P \ .0001) from 2002 to 2011, and the proportion of biceps tenotomy increased from 0.4% to 1.7% (P = .018) from 2003 to 2011 (Figure 1 and Table 1). When comparing arthroscopic and open biceps tenodesis, the data indicate that both procedures increased over the study period. From 2002 to 2011, open biceps tenodesis increased from 1.9% to 9.5%, and arthroscopic biceps tenodesis increased from 0.2% to 9.3% from 2007 to 2011 (Table 1). For patients with SLAP lesions undergoing arthroscopic rotator cuff repair, similar trends were observed, as the proportion of SLAP repairs decreased from 60.2% to 15.3% (P \ .0001) from 2003 to 2011, while the proportion of those undergoing biceps tenodesis or tenotomy
0% 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year SLAP Repair
Biceps Tenodesis/Tenotomy
Figure 2. Treatment of superior labrum anterior and posterior (SLAP) lesions with concomitant rotator cuff repair from 2003 to 2011. increased from 6.0% to 28.0% (P \ .0001) from 2003 to 2011 (Figure 2). Of the 8963 cases logged for the treatment of isolated SLAP lesions from 2002 to 2011, 75.2% were for male patients (n = 6744), and 24.8% were for female patients (n = 2219). The mean age for all patients reported was 40.7 years. There was a significant difference in the mean age of patients with SLAP tears undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P \ .0001) (Figure 3). This pattern persisted for patients with SLAP tears undergoing rotator cuff repair, as the mean age for patients undergoing SLAP repair was 48.1 years, while the mean age of patients undergoing biceps tenodesis or tenotomy was 53.3 years (P \ .0001) (Figure 4).
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70
70%
60
60%
50
30 20
55.7 47.2 37.1
40% 30% 20%
10
10%
0 SLAP Repair
Biceps Tenodesis
Biceps Tenotomy
0%
Surgical Procedure
Figure 3. Mean patient age and surgical treatment for patients with isolated superior labrum anterior and posterior (SLAP) lesions.
Shoulder and General Elbow Orthopaedics
70
Hand and Upper Extremity
Sports Medicine
Subspecialty Biceps Tenodesis
SLAP Repair
Figure 5. Treatment of isolated superior labrum anterior and posterior (SLAP) lesions as a function of subspecialty declaration.
60 50 40
60%
30 20
53.3
48.1
10 0 SLAP Repair
Biceps Tenodesis/Tenotomy Surgical Procedure
Figure 4. Mean patient age and surgical treatment for patients with superior labrum anterior and posterior (SLAP) tears undergoing concomitant rotator cuff repair.
50%
Percentage
Paent age (years)
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50%
40
Percentage
Paent age (years)
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40% 30% 20% 10% 0%
Candidates with a declared subspecialty in shoulder and elbow surgery performed biceps tenodesis for 25% of isolated SLAP tears, whereas candidates with a declared subspecialty in the hand and upper extremity, sports medicine, and general orthopaedics utilized biceps tenodesis in 11%, 8%, and 7% of cases, respectively (Figure 5). The difference in the proportion of biceps tenodesis performed by those with a declared subspecialty in shoulder and elbow surgery was significantly higher when compared with candidates declaring a subspecialty in the hand and upper extremity, sports medicine, or general orthopaedics (P \ .05). Candidates specializing in shoulder and elbow surgery were also noted to perform less SLAP repairs (30%) than surgeons specializing in the hand and upper extremity (65%), sports medicine (64%), or general orthopaedics (62%) for isolated SLAP tears; however, this trend did not reach statistical significance (Figure 5). Similar trends were seen for the treatment of patients with SLAP tears undergoing concomitant rotator cuff repair. Candidates with a declared subspecialty in
Shoulder and General Elbow Orthopaedics
Hand and Upper Extremity
Sports Medicine
Subspecialty SLAP Repair
Biceps Tenodesis/Tenotomy
Figure 6. Treatment of superior labrum anterior and posterior (SLAP) lesions in patients undergoing concomitant rotator cuff repair as a function of subspecialty declaration. shoulder and elbow surgery performed SLAP repair in this patient population in 5% of cases compared with candidates declaring subspecialties in the hand and upper extremity, sports medicine, or general orthopaedics, where SLAP repair was utilized in 49%, 38%, and 39% of cases, respectively (Figure 6). Surgeons specializing in the shoulder and elbow performed biceps tenodesis or tenotomy for 35% of SLAP tears in patients undergoing concomitant rotator cuff repair, whereas surgeons specializing in the hand and upper extremity, sports medicine, and general
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orthopaedics utilized these procedures in 14%, 12%, and 16% of cases, respectively (Figure 6). In the treatment of SLAP tears with concomitant rotator cuff repair, these differences between subspecialty-trained surgeons did not reach statistical significance.
DISCUSSION Our current study reveals interesting trends in the treatment of SLAP tears over the past decade. This query of the ABOS database indicates that among part II applicants, the rate of SLAP repairs has decreased, while the rate of biceps tenotomy and tenodesis has increased for the treatment of SLAP tears. These same trends are exhibited among patients with SLAP tears undergoing rotator cuff repair. This decreasing rate of SLAP repairs is in contrast to previously published literature from the ABOS database that described an increased rate of SLAP repairs as a function of total shoulder cases among part II applicants.20 This previously published literature by Weber et al20 examined the rate of SLAP repairs as a function of all shoulder cases reported in the ABOS database from 2003 to 2008. While these data by Weber et al20 provide a useful measure of the incidence of SLAP repairs over the past decade, it does not allow for an in-depth appreciation of the surgical trends in the treatment of SLAP tears. By limiting our query to include only those patients with SLAP tears, we were able to determine the proportion of SLAP repair, biceps tenodesis, and biceps tenotomy in the treatment of SLAP tears. We also expanded our query to include cases reported through 2011 so as to highlight the most recent trends in the surgical treatment of SLAP lesions. It is our belief that the current data represent the beginnings of a paradigm shift in the treatment of SLAP tears over approximately the past 5 years. Formal SLAP repair is being performed more infrequently on an annual basis. Although this decrease is not accompanied by an exact corresponding increase in biceps tenodesis or tenotomy, it is clear that alternative treatments of SLAP tears are being pursued, with the increasing use of either biceps tenodesis or tenotomy as a surgical option. The results from this study also highlight the relationship between patient age and the surgical management of SLAP tears. The mean patient age increased for patients undergoing SLAP repair, biceps tenodesis, and biceps tenotomy. Provencher et al16 recently reported on 179 patients undergoing SLAP repair and found that patients older than 36 years of age were at an increased risk of failure. We may continue to see surgeons electing to not perform SLAP repair in older patients with SLAP tears, given the higher rate of failure and decreased patient outcomes seen in this patient population with and without concomitant rotator cuff repair.7,16 Regarding the treatment of isolated SLAP tears, improved patient outcomes can be seen for patients undergoing both SLAP repair and biceps tenodesis. Kim et al9 demonstrated successful results in 94% of patients treated with SLAP repair, with improved outcomes reported in patients not involved in overhead sports compared with
patients participating in overhead activity. For high-level overhead athletes with SLAP tears, it has also been demonstrated that improved clinical outcome scores do not necessarily correlate with return to play. Park et al15 found that although overhead athletes with SLAP tears showed significant improvements in terms of pain and function, only 50% of these athletes were able to return to play after SLAP repair. Given the lack of conclusive evidence supporting SLAP repair for isolated SLAP tears, Boileau et al2 investigated the outcomes of SLAP repair versus arthroscopic biceps tenodesis in patients with isolated type II SLAP tears. They reported that arthroscopic biceps tenodesis was a good alternative to SLAP repair, as patients had improved function and satisfaction after biceps tenodesis. In their retrospective cohort, they also found that patients undergoing biceps tenodesis were older than those patients undergoing repair, at 52 and 37 years of age, respectively. This is the same trend found in our analysis of the ABOS database when looking at patient age and the treatment of SLAP tears. The abovementioned studies may represent a shift in the current understanding of the optimal treatment of isolated SLAP tears. This change in the surgical management of isolated SLAP tears is illustrated by the trends exhibited in our current study. When considering the optimal treatment of SLAP tears combined with rotator cuff tears, the literature shows evidence to support SLAP repair, biceps tenodesis, and biceps tenotomy. Voos et al19 found that patients with rotator cuff and SLAP tears treated with concomitant repair of both tears had improved postoperative range of motion and overall clinical outcomes, with 90% of patients reporting a good to excellent result at a minimum of 2 years’ follow-up. Forsythe et al6 investigated middle-aged patients with rotator cuff and SLAP tears undergoing rotator cuff repair alone or concomitant rotator cuff and SLAP repair. They found that patients undergoing simultaneous repair of both tears had improved Constant scores compared with patients undergoing rotator cuff repair alone. Before this study, Franceschi et al7 had performed a randomized trial comparing SLAP repair to biceps tenotomy in patients older than 50 years of age with rotator cuff and SLAP tears. In this study, patients undergoing biceps tenotomy with rotator cuff repair had superior outcomes as measured by functional outcome scores, range of motion, and patient satisfaction compared with patients randomized to receive concomitant SLAP and rotator cuff repair. Kim et al10 recently investigated patients with SLAP tears with associated large to massive rotator cuff tears and found that patients undergoing biceps tenotomy had significant improvements in functional outcomes and postoperative forward flexion compared with those undergoing SLAP and rotator cuff repair. In regards to applicant subspecialty, our data show that part II applicants with shoulder and elbow–specific fellowship training performed less SLAP repairs than those applicants with general orthopaedic training. One might expect surgeons who were fellowship trained specifically in shoulder and elbow surgery to be performing a higher proportion of SLAP repairs; however, this was not found
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to be the case in this study. This in part may be because of the evolution in our understanding of the optimal treatment strategies for both isolated SLAP tears and combined SLAP and rotator cuff tears. As described previously, the most recent literature on the treatment of SLAP tears showed improved outcomes after biceps tenodesis and tenotomy compared with SLAP repair in certain subsets of patients.2,7,10 We hypothesize that surgeons trained specifically in shoulder and elbow surgery may be more aware of the current trends in the treatment of SLAP tears and are thus performing less SLAP repairs compared with surgeons trained in other subspecialties. This study has some limitations. It would have been optimal to provide a subgroup analysis for the treatment of each type of SLAP lesion. However, given the nature of the ABOS certification database, it is not possible to provide such a subgroup analysis. More importantly, the current study involves over 8000 cases taken from populations across the entire United States and in all likelihood represents a standard distribution of type I to IV SLAP tears as previously described by Snyder et al.17,18 Another limitation of this study is the lack of availability of CPT codes for biceps tenodesis and tenotomy for the entire study period. While the CPT codes for SLAP repair and open biceps tenodesis were available beginning in 2002, the CPT codes for biceps tenotomy and arthroscopic biceps tenodesis were not available from the ABOS database until 2003 and 2007, respectively. As there was no CPT code available for arthroscopic biceps tenodesis until 2007, we hypothesize that many arthroscopic biceps tenodesis cases may have been coded as open biceps tenodesis before 2007. As such, it is difficult to make a direct comparison between the rates of open versus arthroscopic biceps tenodesis for the treatment of SLAP tears. We were unable to include data on arthroscopic biceps tenotomy because a specific CPT code for this procedure does not currently exist, but we believe that the CPT code for open biceps tenotomy of 23405 is often used as a substitute. In some cases, it is possible that the unlisted CPT code of 29999 is used for arthroscopic biceps tenotomy, but because it is an unspecified code pertaining to other procedures used during shoulder arthroscopic surgery, it could not be incorporated into our analysis. Furthermore, it is unlikely that these aforementioned limitations solely account for the dramatic decrease in SLAP repairs from 2002 to 2011. As biceps tenodesis and SLAP repair are intrinsically separate procedures, we think it is unlikely that a biceps tenodesis procedure could have been coded as a SLAP repair because the tenodesis procedure would not meet the appropriate requirements to qualify for the aforementioned CPT code of 29807 (SLAP repair). Although the ABOS database maintains surgical data for a large group of orthopaedic surgeons, it does so only for candidate surgeons sitting for part II of the orthopaedic board examination. These candidates are, on average, younger surgeons who have only recently finished their orthopaedic training. The trends noted in this article are therefore not the practice trends of every practicing orthopaedic surgeon. Despite this limitation, previous studies utilizing the ABOS
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database have argued that the practice trends detailed in this database provide value, as they represent the trends of the most recently trained orthopaedic surgeons.13 A final limitation is that we were not able to obtain the clinical outcomes of the surgeries; therefore, we cannot comment as to whether the changes in the procedures performed have been accompanied by any change in the quality of the surgical outcomes. This study provides insight into the current practice trends of recent orthopaedic training graduates in the treatment of SLAP tears with and without a concomitant rotator cuff injury. We have shown that over the study period in question, the rate of SLAP repairs decreased, while the rate of biceps tenodesis and tenotomy increased for the treatment of SLAP tears with and without rotator cuff repair.
ACKNOWLEDGMENT The authors acknowledge John Harrast for his assistance with data analysis.
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13. Mauro CS, Jordan SS, Irrgang JJ, Harner CD. Practice patterns for subacromial decompression and rotator cuff repair: an analysis of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2012;94(16):1492-1499. 14. Owens BD, Harrast JJ, Hurwitz SR, Thompson TL, Wolf JM. Surgical trends in Bankart repair: an analysis of data from the American Board of Orthopaedic Surgery certification examination. Am J Sports Med. 2011;39(9):1865-1869. 15. Park JY, Chung SW, Jeon SH, Lee JG, Oh KS. Clinical and radiological outcomes of type 2 superior labral anterior posterior repairs in elite overhead athletes. Am J Sports Med. 2013;41(6):13721379. 16. Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and
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posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med. 2013;41(4):880-886. Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4(4):243-248. Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274-279. Voos JE, Pearle AD, Mattern CJ, Cordasco FA, Allen AA, Warren RF. Outcomes of combined arthroscopic rotator cuff and labral repair. Am J Sports Med. 2007;35(7):1174-1179. Weber SC, Martin DF, Seiler JG 3rd, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. Am J Sports Med. 2012;40(7):1538-1543.
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