To the Editor:

I commend Rob Powers, PA-C, ATC, for his article on SLAP lesions in the March 2011 issue of JAAPA (“SLAP lesions: How to recognize and treat this debilitating shoulder injury”). However, I caution readers that SLAP lesions are quite rare. At large subspecialty/tertiary surgical referral practices, SLAP lesions represent only 1% to 3% of all shoulder cases. At my practice, we have done less than a dozen isolated SLAP repairs over the past 10 years.

According to Stephen Snyder, MD, an active member in the Association of Shoulder and Elbow Surgeons (ASES), there is a worrisome trend toward young surgeons who are candidates for board certification doing too many SLAP repairs. To investigate, Weber and colleagues searched the American Board of Orthopedic Surgery Part II database for all SLAP lesions and SLAP repairs done between 2003 and 2008. The investigators found 4,975 SLAP repairs (9.4% of all shoulder cases) and noted that the rate of repair increased to 10.1% by 2008. Alarmingly, this included patients as old as 88 years in women and 85 years in men (mean age, 36.4 years). During 8.9 weeks of self-reported follow-up, the complication rate was 4.4%, and only 26% of the patients were pain-free while 13% were functionally normal.1 They concluded that the candidates for board certification performed SLAP repairs three times more often than the literature recommended. Young orthopedists need to distinguish between truly pathologic SLAP lesions and incidental degeneration of the labrum with aging to help reduce the rates of SLAP repairs and improve outcomes.

In addition, there are numerous advantages to using new nonabsorbable, inert plastic anchors over those made of metal or absorbable material that Mr. Powers discussed. Metal anchors, especially Poly-L-lactide anchors, interfere with MRI imaging and can cause articular chondral damage. Research has shown that metal anchors do not absorb; much of the polymer is still present after 3 years, although in isolated fragments, and there is absence of its replacement by bone.2 Furthermore, if the absorbable anchor fails and leaks occur inside the joint, tack synovitis and significant chondrolysis can occur.3,4,5 Patients with anchor-related complications generally present with pain and/or stiffness, and the surgeon/PA team should have a high index of suspicion if a patient does not progress as expected. Glenohumeral synovitis, glenoid osteolysis, loose bodies, and chondral injury with full thickness chondral loss are some of the notable complications that have been reported. Some dispute this finding, but the end result can be devastating nonetheless in young patients with end-stage arthropathy.

Vinh Dang, MPAS, PA-C

Sports and Orthopaedic Specialists, PA

Minneapolis, MN

REFERENCES

1. Weber SC, Payvandi S, Martin DF, Harrast JJ. SLAP lesions of the shoulder: incidence rates, complications, and outcomes as reported by ABOS part II candidates (SS-19). Arthroscopy. 2010;26(6)(suppl):e9-e10.

2. Walton M, Cotton NJ. Long-term in vivo degradation of poly-L-lactide (PLLA) in bone. J Biomater Appl. 2007;21(4):395-411.

3. Freehill MQ, Harms DJ, Huber SM, et al. Poly-L-lactic acid tack synovitis after arthroscopic stabilization of the shoulder. Am J Sports Med. 2003;31(5):643-647.

4. Athwal GS, Shridharani SM, O'Driscoll SW. Osteolysis and arthropathy of the shoulder after use of bioabsorbable knotless suture anchors. A report of four cases. J Bone Joint Surg Am. 2006;88(8):1840-1845.

5. Glueck D, Wilson TC, Johnson DL. Extensive osteolysis after rotator cuff repair with a bioabsorbable suture anchor: a case report. Am J Sports Med. 2005;33(5):742-744.