Shoulder Surgery

Arthroscopic SLAP repair

Arthroscopic SLAP repair

Arthroscopic SLAP repair is a minimally invasive keyhole procedure to repair the torn labrum at the top of the shoulder joint (biceps anchor). Patients wear a sling for six weeks and start therapy two weeks after surgery. Strengthening and training for your sport commences at 3 months; full unrestricted contact sport is possible at 4-6 months after surgery.

An arthroscopic SLAP repair is a surgical procedure where small keyhole incisions are used to access the shoulder using specialised instruments. For most patients who sustain shoulder injury and a SLAP tear that requires surgical repair, we are able to undertake this utilising an arthroscopic technique.

Using a minimally invasive approach means faster recovery time, minimal blood loss, and fewer complications from surgery. An arthroscopic SLAP repair is a common procedure and is done either as a day only case or with an overnight stay in hospital. The results are excellent and most patients return to their previous level of function.

Medical diagram showing arthroscopic SLAP repair

In most cases, the MRI scan will demonstrate whether this is an isolated SLAP tear or tear extension (either anterior and/or posterior). The MRI will also provide a guide as to the grade of the SLAP tear (ie the severity). It is also important to look at the quality of the biceps tendon and the rotator cuff on the MRI. All of these features will guide the best treatment around your SLAP tear and repair. 

The primary aim of a SLAP repair is to repair the superior labrum where the biceps tendon attaches to the glenoid (socket). At the time of surgery, if significant damage is found to the biceps tendon then it may be best to not complete a SLAP repair but instead re-anchor the biceps tendon out of the shoulder joint (this procedure is called a biceps tenodesis). 

If there is a labrum tear that extends anterior or posterior then this may also need to be repaired at the time of surgery. All of this can be performed by keyhole at the same time.

Medical diagram show a close up of the shoulder joint focusing on the Glenoid and Labrum SLAP tear

  • The procedure is under a General Anaesthetic where you will be positioned on your side and the affected arm secured in a special arm holder.
  • Small key-hole incisions (about 1cm) are made and the camera and surgical instruments are placed inside the shoulder. Usually, 3-4 small incisions are enough to carefully repair the SLAP tear
  • A thorough 15-point examination of the shoulder joint and SLAP tear is made via the arthroscopic camera and pictures are taken to document findings.
  • The SLAP tear is carefully prepared, scar tissue is cleaned up and stitches are placed around the tear which are in turn anchored back to the socket (2.9mm anchors). Usually, 2-3 anchors are needed to carefully re-attach the superior Labrum back to the top of the glenoid (socket).
  • Any other unexpected injuries/tears are noted and repaired via key-hole at the same time if needed. If the SLAP tear is too advanced then a biceps tenodesis may be recommended for some patients.
  • The key-hole incisions are closed with sutures, dressings applied and a custom sling used to position the arm correctly.
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Team Doctor/Physiotherapist to maximise your recovery.

Medical diagram showing a surgically repaired labral tear

Watch a surgical animation demonstrating how Dr Pant performs a Shoulder SLAP Repair. 

There are three essential components to a good outcome from surgery:

  • Your surgeon
  • You as a patient
  • Your physiotherapist

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement:

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling to protect your shoulder and allow the SLAP repair to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the SLAP repair begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post SLAP repair surgery.

Sling

  • A sling is required for the first 6 weeks after your surgery
  • The sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery)

The type of sling is selected specific to you and your shoulder surgery

  • SLAP repair +/- anterior labral repair – normal sling
  • SLAP repair + posterior labral repair – ER sling (with a triangular wedge at the front)

Cropped photo of 2 women showing the a normal sling and abduction sling used following SLAP repair surgery

When can I drive?

  • After shoulder surgery, you will be in a sling and you may be unable to drive for at least 6-8 weeks
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 2-4 weeks, and some may not be able to drive for the full 12 weeks. This will be discussed at your follow up appointments.

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection – Do not be concerned just yet; please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep.

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling
  • The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications.

The risk of complications after SLAP  repair surgery (shoulder and biceps stabilisation) are less than 1% in the Sydney Shoulder Unit experience. General risks include:

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to SLAP repair surgery (shoulder and biceps stabilisation)

Frozen shoulder (5% risk)

Improves over 3-6 months and will generally not affect your outcome or need further surgery.

Reoperation and failure of surgery

When performing a shoulder reconstruction, your surgeon is using your own tissue to repair what is damaged. The weakest point in the repair is your own tissue. The longer the history of damage and frequency of dislocations/instability prior to surgery, the more likely the tissue quality is poor.

There are three areas where your Labral repair (shoulder stabilisation) may fail:

Bone-Anchor interface

The anchors today are very high in quality and usually do not fail; sometimes if your bone is soft (older patients), the anchor may pull out of the bone.

Anchor-Suture interface

This area is typically very strong and not a source of common failure

Suture-Tissue interface

This is the weakest point and the most common reason for failure of surgery (usually due to poor tissue quality). There are special techniques in tissue management and suture choice to reduce failure rates.

Delays/Inability to return to previous level of sport

  • The published return to sport rate after shoulder stabilisation surgery (key-hole) is 70-90%. With stabilisation surgery, patients are 5-6 times more likely to return to play.
  • The risk of reinjury with overhead contact after soft tissue key-hole stabilisation is between 5-20% (depending on a number of factors)
    In some cases the biceps tendon causes pain down the track and there is a small chance you will need a second operation to re-anchor the biceps (biceps tenodesis).

Patients who smoke, use tobacco products, have diabetes, or elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing.

Most healthy patients, however, cope well with keyhole shoulder surgery and are unlikely to have complications.

SLAP repair surgery is a minimally invasive procedure that repairs the torn labrum at the top of the glenoid. It is a successful operation (>90% satisfaction) when undertaken for the correct indications. Younger patients, acute tears, higher grade SLAP tears and anterior/posterior tear extension are good indications for surgery and result in more reliable outcomes.

Patient results

SLAP Tear

This 19 year old tennis player sustained shoulder trauma with an instability episode. Over the following weeks, he was unable to play tennis and presented with night pain and difficulty undertaking overhead tasks.

His examination findings were consistent with a SLAP tear and this was confirmed to be a high-grade tear on MRI. Given his young age, functional demands, overhead sport, and high-grade SLAP tear surgery was the prefered option.

He underwent an Arthroscopy and SLAP repair. At the time of surgery anterior labral extension was noted and repaired at the same time. He used the JPL method for shoulder rehabilitation. At six weeks he had full range of motion and commenced strengthening at 3 months. He returned to playing tennis at five months pain-free with full shoulder function.

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