slaplesions-Bankart-Labral-tears
-
Upload
kirk-andrew -
Category
Documents
-
view
214 -
download
0
description
Transcript of slaplesions-Bankart-Labral-tears
Labral Tears: SLAP and Bankart Lesions
by Vic Goradia, MD, Knee, Shoulder & Sports Medicine Specialist
Basic Anatomy of Shoulder
The shoulder is a ball and socket joint. It consists of three bones: the upper arm bone (humerus), wing bone (scapula) and collarbone (clavicle). The ball (humeral head) fits into the small socket (glenoid). The glenoid is surrounded by a soft cartilage lip (labrum), which deepens the socket. The upper part of the wing bone (acromion) projects over the shoulder joint. One end of the collarbone is joined to the acromion by ligaments to form the acromioclavicular (AC) joint.
Labral Tears
The shoulder ligaments attach the humeral
head to the glenoid. These ligaments attach
to the labrum which is firmly attached to the
glenoid.
The labrum is the cartilage “lip” that lines
the shoulder socket or glenoid. This lip
helps to deepen the socket so the shoulder
ball will stay in the socket.
When the labrum tears away from the
glenoid, patients experience pain, catching,
clicking and/or locking. Depending on which
part of the labrum tears, it has different
names.
Go Orthopedics | 281 East Hundred Road, Chester VA 23836 | 804.452.1635 | GoOrtho.net | Copyright © 2009
2
For example, tears on the top part are known as Superior Labral Anterior Posterior (SLAP)
lesions. Since this is a mouthful it is much easier to refer to them simply as SLAP lesions.
Tears in the front part of the labrum that extend to the bottom are known as Bankart Lesions.
SLAP Lesions
The term SLAP lesion was first developed by Dr. Steve Snyder from Los Angeles in the early
1990’s. However the actual lesion was described in 1985 by Dr. James Andrews. Prior to this
time many patients suffered from shoulder pain that could not be easily diagnosed or treated.
Today most sports medicine and shoulder specialist are able to diagnose and treat SLAP
lesions. Unfortunately, there are situations in which these
tears are actually over-diagnosed. In other words,
patients are sometimes treated for SLAP lesions that do
not actually exist. It is therefore important to see a
surgeon that treats a large number of SLAP lesions and
other shoulder problems.
SLAP tears can occur when falling on the arm/shoulder,
having the arm suddenly pulled, a lifting injury or
repetitive overhead activity with the arm. Most commonly
they occur during work injuries in which the arm is
suddenly “yanked” or in overhead athletes.
In this latter situation, the tears are a result of repetitive
overuse more often than a sudden injury. It is very
common to hear of baseball pitchers having SLAP
lesions. With repetitive throwing or other similar activities,
the biceps can slowly pull the labrum away from the
socket. As you will recall from above, the biceps tendon
from the arm attaches onto the Superior Labrum. In other
cases, the Superior Labrum repetitively pinches between
the glenoid (socket) and rotator cuff causing the labrum to
gradually tear.
Regardless of the cause of a SLAP tear, the labrum will
not heal back to the bone. In those individuals that have
to use their arm repetitively, surgery is needed to treat the
SLAP lesion. Fortunately, the condition can be treated
with arthroscopic surgery.
Go Orthopedics | 281 East Hundred Road, Chester VA 23836 | 804.452.1635 | GoOrtho.net | Copyright © 2009
3
Bankart Lesions
Bankart lesions are another type of labral tear. They occur as a result of a shoulder dislocation
or multiple dislocations. When the ball (humeral head) dislocates out of the socket (glenoid),
the ligaments that normally hold these two structures together will either stretch or tear.
When they tear it is called a Bankart Lesion. In this case the inferior (i.e. lower) glenohumeral
ligament pulls the inferior labrum away from the glenoid. Less commonly the ligament will pull
the labrum with a piece of bone—this is known as a bony Bankart lesion.
Most shoulder dislocations have to be forcefully relocated (i.e., put back in place) by a doctor,
sometimes with sedation. Next, the patient is placed in a sling for immobilization that allows
some scarring and healing of the damaged ligament, labrum and /or bone. In many cases,
however, these structures do not heal in the correctly.
Studies have shown variable results with non-surgical treatment. Many published studies have
noted re-dislocation rates of 75-90% in patients under the age of 25 with a first time
dislocation. This risk is greatest for dominant arms of active individuals.
Surgical Treatment of SLAP and Bankart Lesions
Fortunately, if surgery is required it can be performed completely arthroscopically through
small skin punctures with use of a fiber optic camera. When arthroscopic surgical techniques
were first developed in the 1980’s and 1990’s, the outcomes were less favorable than
traditional open surgical procedures.
However as our understanding of the anatomy and available instruments improved,
arthroscopic techniques have become the standard for most experienced shoulder surgeons.
Currently, surgeons have numerous different types of instruments, sutures and anchors
available to them for use in repair of labral tears.
The basic technique for labral repair requires the surgeon to
appropriately mobilize the labrum. This means they have to
free it from the surrounding scar tissue.
Next the glenoid bone has to be prepared so it bleeds and
allows the labrum to re-attach to it. Most surgeons use
dissolvable anchors. These are placed into the glenoid bone.
The sutures from these anchors are passed through the torn
labrum. At that point the surgeon can tie a knot or use a
knotless technique for final repair.
Go Orthopedics | 281 East Hundred Road, Chester VA 23836 | 804.452.1635 | GoOrtho.net | Copyright © 2009
4
My Preferred Treatments
>SLAP Lesions
The most important aspect of SLAP lesions is diagnosis. It is important for me to obtain
thorough historical information from the patient regarding their symptoms, any injuries and
response to previous treatment.
Next I will carefully examine the patient’s shoulders. At this point I will generally have a
suspicion about a SLAP and will order and MR arthrogram (MRA). With this test the radiologist
injects dye into the shoulder and then an MRI is performed. The MRA is much more sensitive
in diagnosing SLAP lesions than a regular MRI.
Once the tear is diagnosed, I will discuss the treatment options with the patient. Unfortunately
if they are having symptoms from the SLAP, the only definitive treatment is surgery. The only
other option is to modify or eliminate activities that produce pain. In my experience, most
patients do not want to eliminate activities and therefore usually select surgery.
>Bankart Lesions
If a patient has a first-time dislocation and is under the age of 25 years, I will discuss options of
immediate surgery vs. trying a period of immobilization. The latest research shows that
immobilization in external rotation (with the arm rotated out) is best if non-surgical treatment is
attempted. I carefully counsel the patient about the 75-90% risk of recurrent dislocations.
For individuals over 40 years of age that have a first-time dislocation, I base my
recommendations on the patients’ activity level and work requirements. Many patients can be
treated without surgery unless they have strenuous hobbies or work.
The middle group of patients, from 25-40 years of age, fall in a gray area. Again, it is important
to note their activity level, how loose their shoulder feels when I examine it and how large the
tear appears on the MRA.
Regardless of age, if patients have recurrent dislocations or are apprehensive about
participating in activities because of their shoulder, I will recommend and discuss surgery.
>My Surgical Technique for SLAP & Bankart Lesions
I currently use an all-arthroscopic technique with knotless, dissolvable anchors. The key to the
procedure is placing the anchors in the right place and appropriately mobilizing the labrum as I
noted above.
Go Orthopedics | 281 East Hundred Road, Chester VA 23836 | 804.452.1635 | GoOrtho.net | Copyright © 2009
5
>After Surgery
After arthroscopic repair of SLAP and Bankart tears, patients are generally given a sling or
immobilizer.
• Approximately one week after surgery, I send patients to physical therapy for protected
range of motion exercises.
• As the tear begins to heal over a period of 6-8 weeks, the therapist begins a
strengthening program.
• At 12 weeks most patients can begin heavier strengthening and light sports specific
training.
• Most patients resume non-contact sports by 4-6 months and contact sports by 6-9
months.
Baseball pitchers and other similar overhead athletes require a slightly modified rehabilitation
program that focuses strongly on throwing mechanics after the initial healing period. As with all
surgeries, I work closely with the physical therapist to develop a specific rehabilitation program
for every patient. For athletes we also include the athletic trainer(s) and coaches in our “team”
approach to treatment.
About Dr. Goradia
Although any general orthopedic surgeon can treat shoulder problems, the shoulder conditions
described here are treated more effectively by a surgeon with expertise and advanced training
in this type of diagnosis and treatment. There are a limited number of such specialists in most
large cities.
I have completed a 1-year, fully accredited fellowship in Sports Medicine, Arthroscopic Surgery
and Knee & Shoulder Reconstructive Surgery and am certified by the American Board of
Orthopedic Surgery. I was among the first in the U.S. to receive a Certificate of Added
Qualifications (CAQ) in Sports Medicine.
I also teach arthroscopic surgery to other orthopedic surgeons at national orthopedic
conferences and produce educational videos of my surgeries on the website of the
Arthroscopy Association of North America (AANA) for the purposes of educating other
surgeons.
I am nationally recognized in the field of arthroscopic surgery. For more information about my
qualifications please visit www.GoOrtho.net.