SLAP with Spinoglenoid Cyst

SLAP with Spinoglenoid Cyst by
Joo Han, Oh M.D., Ph.D.

Seoul National University Bundang Hospital
Republic of Korea

■ Patient information
This patient was 34-year-old firefighter and had right shoulder pain for 5 years. He had a trauma 5 years ago, falls on outstretched hand injury during skiing.
He had gotten the steroid injection more than 10 times. The physical examinations (PE) of SLAP lesion were checked, and compression rotation test, O’Brien test, apprehension test, Whipple test, and biceps load II test were positive. However, for the biceps tendon, biceps groove tenderness, Speed test, and Yergason test were negative.
In the CT arthrography (CTA) and MRI, type 2 SLAP lesion from 9 to 1 o'clock direction with 2.8 cm-sized paralabral cyst at 10 o'clock position, extending to the spinoglenoid notch was noted. EMG showed no abnormal finding on the peripheral nervous system of the arm.
Problem list of the patient is as follows.
- PEs of SLAP lesion (+)
- Biceps groove tenderness and Biceps-related PE (-)
- SLAP lesion with ganglion cyst in the spinoglenoid notch on CTA and MRI
- Consistent pain after steroid injection (more than 10 times)

The patient has the SLAP lesion on the CT arthrography and MRI with ganglion cyst at the spinoglenoid notch. His physical examinations for SLAP lesion were positive, but biceps tenderness and other biceps PEs were negative. He had persistent pain even though several steroid injections. Therefore, we decided to do arthroscopic repair of SLAP lesion with spinoglenoid notch cyst decompression.

■ Operative procedure
The patient underwent surgery in the lateral decubitus position under general anesthesia. Diagnostic arthroscopy was performed with a standard posterior viewing portal and anterior working portal. The superior labrum complex was palpated with a probe to determine the presence and the type of SLAP lesion. Detached superior labrum with posterior extension was observed, and the lesion was diagnosed as a type VI SLAP lesion.
The spinogleniod ganglion cyst was decompressed through the SLAP lesion using the sharp and blunt elevators through the anterior portal. After sufficient decompression, trans-rotator cuff portal (TRCP) was made for the SLAP repair.
To make the TRCP, a spinal needle was inserted from just lateral or slight posterolateral aspect of the lateral acromion. To avoid violation of the supraspinatus tendon, the entry point of TRCP was created through the muscle-tendon junction of supraspinatus that is directed to the superior glenoid rim. Then an 8 mm cannula was introduced into the joint through the TRCP. After the release of adhesion between the superior portion of the labrum and the capsule, the subchondral bone of the supraglenoid tubercle was exposed with a high-speed bur through the TRCP or anterior portal. Two holes were drilled through the TRCP at the 10-o’clok and 12-o’clock position. A suture hook loaded with No. 2 polydioxanone (PDS, Ethicon, Somerville, NJ) was introduced through the TRCP and pierced the posterosuperior labrum at the base of the biceps tendon. Then, a strand of the PDS (blue strand) was retrieved through the anterior portal. A FiberWire was passed into loop of PDS, and then PDS was retrieved through the TRCP with the shuttle relay technique. Bioabsorbable knotless suture anchor (PushLock Knotless anchor system 2.9 mm; Arthrex) with the FiberWire was inserted into the drilled hole through the TRCP. Additional second (anterior) bioabsorbable knotless suture anchor fixation was performed with the same technique. After finishing the repair, we checked for firm reattachment of the labrum to the glenoid with a probe. To prevent postoperative stiffness, superior capsule release from the superior labrum was performed.

■ After operation
The patient should start passive range of motion exercise immediately after the operation. The gaining of full range of motion was encouraged until 2 months after the operation. Then muscle-strengthening exercises were started with the resistance band (TheraBand, How-Medical, Korea) at 2 months after the operation. Sports activity was allowed 5 to 6 months after the operation

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