Hi, everyone. My name is Hafeez Kassam, and I'm going to be taking a couple of minutes today to talk about slap tears and some of my tips and tricks for success to try and help treat your patients a little bit better. So the first tip I have is really know the nuances of what the injury is. I think it's very important to understand what slap tears are, what the natural history is, what the nuances of treatment are, to not only help you clinically going forward treating your patients, but specifically to have really informed conversations with them about what their injury is. There's a lot of information out there. There's a lot of nuanced information out there. And having a really informed conversation with your patients about what slap injuries are can help mitigate expectations going forward during the treatment process. So slap tears generally occur as a result of overuse injuries, particularly in overhead athletes that can be the result of traumatic falls or traction injuries. There's really no single physical sign that's patho-mnemonic at first slap tears. It's more so a collection, I think, or a collection of signs or kind of an impression. There's provocative tests that can be helpful to indicate presence of an injury. So positive O'Brien's, positive Speed's, positive Kim test, positive Yergeson's, and that can help you direct where the diagnosis is going, particularly with a positive history. A diagnosis generally includes an MRI now. I think an arthrogram is probably more so the gold standard. But if your practice is anything like mine, a lot of people show up with an MRI and then sending them back for another arthrogram can be difficult. So understanding what the subtle signs can be on a regular MRI can be helpful. And treatment really depends on the patient, right? It depends on their age, their activity level, the severity of their symptoms, if there's any associated injuries such as instability or rotator cuff tears. Knowing the classification can be helpful, particularly to help divide in your mind what the treatment options are for particular types of tears. Snyder's original classification of one to four is probably the most commonly used. With our advent of arthroscopy, we've subsequently developed subclassifications, I think, all the way to 10 at this point. But really understanding what the first four are can be very helpful. And knowing that the type two tear with a detached biceps anchors is probably the most common, probably accounting for about 40% of slap tear injuries. The second tip I have is that if you've diagnosed the tear, try to avoid surgery. And this is because non-op treatment is largely successful. I think there's a lot of studies out there showing this with some showing anywhere from 50% to about 85% success with non-op treatment, including, you know, the very simple things like rest, activity modification, anti-inflammatories, physical therapy. I think it's helpful if physical therapy really focuses on addressing concurrent issues as well. So any internal rotation deficit for throwers, scapular stabilization exercises, rotator cuff strengthening. I think there's a role for injections. Steroid injections can be helpful on a limited basis. I think multiple injections, as with most things we're learning, multiple injections can be harmful and can perhaps, you know, worsen the situation. But a single injection can help reduce pain so people can do more therapy, which is a good option for them. Biologic injections such as PRP, I think might be growing in use and popularity, but I would caution its use right now because there's not a host of strong evidence. And I would say it's rather limited for its use in isolated slap tears, but I think it's an option and something that will probably be more explored in the future. My third tip is that if non-op treatment, it doesn't work and you're going to do surgery, then knowing what the surgery, what surgery to do and when to do it. And that's why kind of having a classification system in your mind help figure out these pathways can be helpful. So a simple debridement is very helpful for type one tears or even type three bucket handle tears where the biceps anchor is still attached because you can debride the labrum that's causing the mechanical impingement. Doing a repair is probably the most controversial aspect of all of this. We generally do this for type two tears that have a detached anchor in patients who have failed non-operative treatment and are relatively young. The age cutoff is again, another controversial subject. Most people are probably settling on the 35 to 40 year old age mark, particularly because if you do repairs in patients older than that, there's some concern about developing stiffness, particularly in external rotation. I've kind of moved that cutoff for me to the younger side on 35 because of the success that a tenotomy and a tinnitus can have, particularly in non- competitive athletes. Doing a tenotomy or tinnitus in isolation can be helpful, particularly with type four tears where there's a large bucket handle and the anchor is detached, doing a tinnitus to really prevent mechanical blocks into the joint can be helpful. Doing it also for type two tears in older patients, and this has been shown to be very successful. I also think doing a tenotomy and a tinnitus is a good option for patients who have concurrent issues in their shoulders. So if you have a concurrent rotator cuff tear, or there's a lot of arthritis, doing a tenotomy or tinnitus right away rather than a slap repair or seeing if the repair works down the line is probably your best bet at a single operation. And also knowing that doing a repair and a tenotomy is reasonable. I think the indications for this are a little bit more select. So the classic example is a type four tear where you do the tenotomy, you debride the labrum that's come into the joint, but it's just not enough. And it's still probably causing some mechanical issues into the joint itself. So putting an anchor into the glenoid to tack it back and keep it out of the joint is an entirely reasonable approach and something you should keep in mind for those situations. My fourth tip is have a system. So I think if you're going to do a slap repair, understanding what your approach is and really having a reproducible method for success can be very helpful. Positioning is very important. You can do this either lateral or beach chair. For me, I do all my labor work lateral, but I do pretty much everything else beach chair. So if I'm really doing what I think is an isolated slap injury, or labor work, I'll put them lateral. But if there's any concurrent pathology, I'll change that. I think both have good success. You just have to be pretty confident in your approach to it. Having reproducible portals, landmarking them so that you can get where you want in the shoulder is very important. In the video that's going to be coming up, I'll show you my approach to that. Always debride the glenoid labral interface to ensure that there's a good environment for biologic healing. I think this may be a step that some people skip, I should say. And I think it's a very simple thing to do to really improve your outcomes. And the final thing is pick your tools. So there's obviously a lot of arthroscopy companies out there with a lot of different tools available. There's some emerging evidence for whether we should be doing hard body anchors, all suture anchors, knots, knotless. For me, I choose to use a hard body anchor with a knotless approach and using labral tape. And I find that that helps quite a bit. I also think percutaneous instrumentation, which is available from some companies, is very helpful. And it helps provide an inline approach to the labral tear, which I'm going to show in a video right now, which outlines my approach and preference to a slap repair. So in this video, we're going to be showing a knotless slap repair with an inline percutaneous technique. We're showing some equipment, but I'm not a consultant. This is a 19-year-old non-throwing football player who's out of season. He has positive findings and he's failed extensive non-operative treatment. For the sake of this video, the patient's placed in the lateral position. We've performed diagnostic arthroscopy and we've found that he has an isolated type 2 slap lesion with no other concurrent issues. I landmark my portals off the lateral edge of the acromion. So my viewing portal is 2cm distal and my working portal is 1cm distal and 1cm anterior. Once you get into the joint, I establish a standard anterior portal in the rotator interval, utilize a probe to inspect the tear, make sure I know what's going on. Then I debride that glenoid labral interface, usually with an elevator and then a subsequent shaver. Then I establish my working portal. I found that these percutaneous sets are very helpful to get an inline approach to the lesion that you're trying to address. So I place my spinal needle into the working portal, make sure that I have an approach that I want. You can place your guide wire in the joint. I bring it across the joint to avoid injury to the cartilage and then place the guide rod down the wire. And you can then place the cannula and guide, drill guide together over the rod, place it into the joint. You can use the drill guide to drag the labrum out of the way to get a good grip onto the glenoid interface and then drill your pilot hole. I utilize a straight curved tip suture passer through the working portal. I place it through the working cannula, test that the deployment device will work, go behind the labrum and then get right adjacent to the cartilage, being as careful as possible not to injure the cartilage itself. Then pull it out the anterior portal and then we'll pass my labral tape, which has a luggage tag mechanism on it. I find that this is very helpful to get good tension with the labrum itself. You cinch down the luggage tag, place the anchor down the working portal and with appropriate tension, place it into the pilot hole. Once you remove the inserter, you can then use your knotless cutter, cut it flush to the glenoid and then place your probe to check your work and make sure that you have good stability. And that entire process takes about three to four minutes overall. So it's a very simplified, quick, easy way reproducible system to fix slab tear. Thank you all for your time. I appreciate it and please don't hesitate to reach out if you have any questions.

slap tears

treating patients

overhead athletes

treatment options

knotless slap repair