Archives of Orthopaedic and Trauma Surgery

, Volume 139, Issue 7, pp 981–990 | Cite as

Assessments of activities of daily living after arthroscopic SLAP repair with knot-tying versus knotless suture anchors

  • Y. Reinig
  • F. Welsch
  • R. Hoffmann
  • D. Müller
  • S. Gramlich
  • S. Fischer
  • K. F. Schüttler
  • E. Zimmermann
  • Thomas SteinEmail author
Arthroscopy and Sports Medicine



The clinical influence of knot-tying or knotless anchor systems for the arthroscopic repair of SLAP lesions (superior labrum lesion from anterior to posterior) remain unclear.

Materials and methods

In a retrospective cohort analysis, 61 of 78 (78.2%) patients with isolated symptomatic SLAP II lesions were examined with a minimum of 24 months after arthroscopic SLAP repair compared to a control group: 28 patients with knot-tying anchors (group I, G1; 28.95 ± 9.48 years, 23 male/5 female), 33 with knotless anchors (group II, G2; 31 ± 10.09 years, 26 male/7 female) and 140 healthy volunteers (group III, G3; 30.9 ± 8.9 years, 109 male/31 female). The clinical assessment included an examination and estimated parameters of ADL (activities of daily living), the CS (Constant score), ASES (American Shoulder and Elbow score), DASH (disability of arm-shoulder hand) and the RS (Rowe score).


The ROM analysis recorded no significant differences for the external rotation in 0° abduction (G1 63.75° ± 15.55° versus = vs G2 65.30° ± 18.15°; pERG1 vs G2 = 0.72). The clinical outcomes revealed significantly decreased pain status in G1 for the O’brien test and in G2 for the Palm-up test, whereas Yergason test showed similar pain levels (pO’brien = 0.03; ppalm up = 0.02; pyergason > 0.5). The pulley associated rotator cuff tests revealed a significantly inferior force status in G2 compared to G1 (plift-off = 0.005, pJobe = 0.02) whereas the further rotator cuff assessments were equal. In general, the intervention group showed increased pain level and functional deficits compared to the G3. The score analysis detected no significant differences with PCSG1 vs G2, PASESG1 vs G2, PDASHG1 vs G2 and PRSG1 vs G2 all > 0.05 and significant impairments compared to G3 in all scores pG1/G2 vs G3 < 0.05 (CSG1 = 88.28 ± 14.42, CSG2=92.73 ± 9.24, CSG3 = 96.2 ± 4.96; ASESG1 = 81.10 ± 21.69, ASESG2 = 85.35 ± 17.12, ASESG3 = 94.95 ± 10.39,; DASHG1= 35.75 ± 13.44, DASHG2 = 36.03 ± 17.55, DASHG3 = 27.13 ± 6.52; RSG1 = 90.71 ± 9.88, RSG2 = 88.33 ± 11.22, RSG3= 92.96 ± 11.27).


The clinical assessment revealed for both anchor systems similar outcomes but showed general underestimated impairments after the SLAP repair surgery compared to the healthy control. The clinical status only marginally differed between both techniques, wherefore the present assessment of ADL allowed no recommendation of one of these two specific surgery technique for SLAP repair.


SLAP lesion Arthroscopic SLAP-repair Suture anchor horizontal knot Knotless 



The authors appreciate the assistance of Dr. rer. med. Hanns Ackermann for collection and analyzing the data.


There existed no funding sources for this investigation.


  1. 1.
    Andrews JR, Carson WG Jr, McLeod WD (1985) Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 13(5):337–341CrossRefGoogle Scholar
  2. 2.
    Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ (1990) SLAP lesions of the shoulder. Arthroscopy 6(4):274–279CrossRefGoogle Scholar
  3. 3.
    Snyder SJ, Banas MP, Karzel RP (1995) An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg 4(4):243–248CrossRefGoogle Scholar
  4. 4.
    Burkhart SS, Morgan CD, Kibler WB (2003) The disabled throwing shoulder: spectrum of pathology. Part II: evaluation and treatment of SLAP lesions in throwers. Arthroscopy 19(5):531–539CrossRefGoogle Scholar
  5. 5.
    Morgan CD, Burkhart SS, Palmeri M, Gillespie M (1998) Type II SLAP lesions: three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 14(6):553–565CrossRefGoogle Scholar
  6. 6.
    Burkart A, Debski R, Musahl V, McMahon P, Woo SL (2003) Biomechanical tests for type II SLAP lesions of the shoulder joint before and after arthroscopic repair. Der Orthopade 32(7):600–607. CrossRefGoogle Scholar
  7. 7.
    Zhang AL, Kreulen C, Ngo SS, Hame SL, Wang JC, Gamradt SC (2012) Demographic trends in arthroscopic SLAP repair in the United States. Am J Sports Med 40(5):1144–1147. CrossRefGoogle Scholar
  8. 8.
    Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ (2014) Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: repair versus biceps tenodesis. J Shoulder Elbow Surg 23(7):1059–1065. CrossRefGoogle Scholar
  9. 9.
    McCormick F, Bhatia S, Chalmers P, Gupta A, Verma N, Romeo AA (2014) The management of type II superior labral anterior to posterior injuries. Orthop Clin N Am 45(1):121–128. CrossRefGoogle Scholar
  10. 10.
    Erickson J, Lavery K, Monica J, Gatt C, Dhawan A (2015) Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med 43(5):1274–1282. CrossRefGoogle Scholar
  11. 11.
    Friel NA, Karas V, Slabaugh MA, Cole BJ (2010) Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: prospective evaluation at a minimum two-year follow-up. J Shoulder Elbow Surg 19(6):859–867. CrossRefGoogle Scholar
  12. 12.
    Dines JS, Elattrache NS (2008) Horizontal mattress with a knotless anchor to better recreate the normal superior labrum anatomy. Arthroscopy 24(12):1422–1425. CrossRefGoogle Scholar
  13. 13.
    Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R (2009) Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med 37(5):929–936. CrossRefGoogle Scholar
  14. 14.
    Yang HJ, Yoon K, Jin H, Song HS (2016) Clinical outcome of arthroscopic SLAP repair: conventional vertical knot versus knotless horizontal mattress sutures. Knee Surg Sports Traumatol Arthrosc 24(2):464–469. CrossRefGoogle Scholar
  15. 15.
    Stein T, Buckup J, Efe T, von Eisenhart-Rothe R, Hoffmann R, Zimmermann E, Welsch F (2015) Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique. Arch Orthop Trauma Surg 135(3):369–382. CrossRefGoogle Scholar
  16. 16.
    Vangsness CT Jr, Jorgenson SS, Watson T, Johnson DL (1994) The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders. J Bone Jt Surg Br 76(6):951–954CrossRefGoogle Scholar
  17. 17.
    Chokshi BV, Kubiak EN, Jazrawi LM, Ticker JB, Zheng N, Kummer FJ, Rokito AS (2006) The effect of arthroscopic suture passing instruments on rotator cuff damage and repair strength. Bull Hosp Jt Dis 63(3–4):123–125Google Scholar
  18. 18.
    Hu D (1971) Gelenkmessung (Neutral-0-Methode), Längenmessung, Umfangmessung. Bulletin des Offiziellen Organs der Arbeitsgemeinschaft für Osteosynthesefragen, BernGoogle Scholar
  19. 19.
    Lo IK, Nonweiler B, Woolfrey M, Litchfield R, Kirkley A (2004) An evaluation of the apprehension, relocation, and surprise tests for anterior shoulder instability. Am J Sports Med 32(2):301–307. CrossRefGoogle Scholar
  20. 20.
    Magosch P, Lichtenberg S, Loew M, Tauber M, Habermeyer P (2013) Die Klinische Untersuchung der Schulter. Sportmed 64:372–379. (Jahrgang 64, Nr. 12) Google Scholar
  21. 21.
    Altchek DW, Warren RF, Skyhar MJ, Ortiz G (1991) T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Jt Surg Am 73(1):105–112CrossRefGoogle Scholar
  22. 22.
    Gagey OJGN (2000) The hyperabduction test: an assessment of the laxity of the inferior Glenohumeral ligament. J Bone Jt Surg Br 82:69–74Google Scholar
  23. 23.
    Hegedus EJGA, Campbell S et al (2008) Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med 42:80–92CrossRefGoogle Scholar
  24. 24.
    Scheibel M, Habermeyer P (2005) Current procedures for clinical evaluation of the shoulder. Der Orthopade 34(3):267–283. CrossRefGoogle Scholar
  25. 25.
    Gerber C, Sebesta A (2000) Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: a preliminary report. J Shoulder Elbow Surg 9(6):483–490. CrossRefGoogle Scholar
  26. 26.
    Hawkins RJBD (1990) Clinical evaluation of shoulder problems. In: Rockwood CA, Matsen FA III (eds) The shoulder, vol 1. Saunders, Philadelphia. pp 149–177Google Scholar
  27. 27.
    O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB (1998) The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality. Am J Sports Med 26(5):610–613CrossRefGoogle Scholar
  28. 28.
    Holtby R, Razmjou H (2004) Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy 20(3):231–236. CrossRefGoogle Scholar
  29. 29.
    Oh JH, Kim JY, Kim WS, Gong HS, Lee JH (2008) The evaluation of various physical examinations for the diagnosis of type II superior labrum anterior and posterior lesion. Am J Sports Med 36(2):353–359. CrossRefGoogle Scholar
  30. 30.
    AM E-S (2014) Intensive care unit-acquired weakness. Ain-Shams J Anaesthesiol 7:81–87. CrossRefGoogle Scholar
  31. 31.
    Gerber C, Krushell RJ (1991) Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. J Bone Jt Surg Br 73(3):389–394CrossRefGoogle Scholar
  32. 32.
    Barth JR, Burkhart SS, De Beer JF (2006) The bear-hug test: a new and sensitive test for diagnosing a subscapularis tear. Arthroscopy 22(10):1076–1084. CrossRefGoogle Scholar
  33. 33.
    Hertel R, Ballmer FT, Lombert SM, Gerber C (1996) Lag signs in the diagnosis of rotator cuff rupture. J Shoulder Elbow Surg 5(4):307–313CrossRefGoogle Scholar
  34. 34.
    Jobe FW, Jobe CM (1983) Painful athletic injuries of the shoulder. Clin Orthop Relat Res 173:117–124Google Scholar
  35. 35.
    Castoldi F, Blonna D, Hertel R (2009) External rotation lag sign revisited: accuracy for diagnosis of full thickness supraspinatus tear. J Shoulder Elbow Surg 18(4):529–534. CrossRefGoogle Scholar
  36. 36.
    Itoi E, Kido T, Sano A, Urayama M, Sato K (1999) Which is more useful, the “full can test” or the “empty can test,” in detecting the torn supraspinatus tendon? Am J Sports Med 27(1):65–68. CrossRefGoogle Scholar
  37. 37.
    Kelly BT, Kadrmas WR, Speer KP (1996) The manual muscle examination for rotator cuff strength. An electromyographic investigation. Am J Sports Med 24(5):581–588. CrossRefGoogle Scholar
  38. 38.
    Walch G, Boulahia A, Calderone S, Robinson AH (1998) The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears. J Bone Jt Surg Br 80(4):624–628CrossRefGoogle Scholar
  39. 39.
    Hurschler C, Wulker N, Windhagen H, Hellmers N, Plumhoff P (2004) Evaluation of the lag sign tests for external rotator function of the shoulder. J Shoulder Elbow Surg 13(3):298–304. CrossRefGoogle Scholar
  40. 40.
    Burrus C, Deriaz O, Luthi F, Konzelmann M (2017) Role of pain in measuring shoulder strength abduction and flexion with the Constant-Murley score. Ann Phys Rehabil Med 60(4):258–262. CrossRefGoogle Scholar
  41. 41.
    Michener LA, McClure PW, Sennett BJ (2002) American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg 11(6):587–594. CrossRefGoogle Scholar
  42. 42.
    Hudak PL, Amadio PC, Bombardier C (1996) Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 29 (6):602–608.;2-L CrossRefGoogle Scholar
  43. 43.
    Germann G, Wind G, Harth A (1999) The DASH (Disability of Arm-Shoulder-Hand) Questionnaire—a new instrument for evaluating upper extremity treatment outcome. Handchir Mikrochir Plast Chir 31(3):149–152. CrossRefGoogle Scholar
  44. 44.
    Jensen KU, Bongaerts G, Bruhn R, Schneider S (2009) Not all Rowe scores are the same! Which Rowe score do you use? J Shoulder Elbow Surg 18(4):511–514. CrossRefGoogle Scholar
  45. 45.
    Morgan RJ, Kuremsky MA, Peindl RD, Fleischli JE (2008) A biomechanical comparison of two suture anchor configurations for the repair of type II SLAP lesions subjected to a peel-back mechanism of failure. Arthroscopy 24(4):383–388. CrossRefGoogle Scholar
  46. 46.
    Uggen C, Wei A, Glousman RE, ElAttrache N, Tibone JE, McGarry MH, Lee TQ (2009) Biomechanical comparison of knotless anchor repair versus simple suture repair for type II SLAP lesions. Arthroscopy 25(10):1085–1092. CrossRefGoogle Scholar
  47. 47.
    Sileo MJ, Lee SJ, Kremenic IJ, Orishimo K, Ben-Avi S, McHugh M, Nicholas SJ (2009) Biomechanical comparison of a knotless suture anchor with standard suture anchor in the repair of type II SLAP tears. Arthroscopy 25(4):348–354. CrossRefGoogle Scholar
  48. 48.
    Rhee YG, Ha JH (2006) Knot-induced glenoid erosion after arthroscopic fixation for unstable superior labrum anterior-posterior lesion: case report. J Shoulder Elbow Surg 15(3):391–393. CrossRefGoogle Scholar
  49. 49.
    Boesmueller S, Mayerhofer S, Huf W, Fialka C (2012) Short-term clinical results after arthroscopic type II SLAP repair. Wien Klin Wochenschr 124(11–12):370–376. CrossRefGoogle Scholar
  50. 50.
    Katz LM, Hsu S, Miller SL, Richmond JC, Khetia E, Kohli N, Curtis AS (2009) Poor outcomes after SLAP repair: descriptive analysis and prognosis. Arthroscopy 25(8):849–855. CrossRefGoogle Scholar
  51. 51.
    Ebinger N, Magosch P, Lichtenberg S, Habermeyer P (2008) A new SLAP test: the supine flexion resistance test. Arthroscopy 24(5):500–505. CrossRefGoogle Scholar
  52. 52.
    Braun S, Horan MP, Elser F, Millett PJ (2011) Lesions of the biceps pulley. Am J Sports Med 39(4):790–795. CrossRefGoogle Scholar
  53. 53.
    Martetschlager F, Tauber M, Habermeyer P (2016) Injuries to the Biceps Pulley. Clin Sports Med 35(1):19–27. CrossRefGoogle Scholar
  54. 54.
    Kurji HM, Ono Y, Nelson AA, More KD, Wong B, Dyke C, Boorman RS, Thornton GM, Lo IK (2015) Magnetic resonance imaging arthrography following type II superior labrum from anterior to posterior repair: interobserver and intraobserver reliability. Open Access J Sports Med 6:329–335. Google Scholar
  55. 55.
    Yang HJ, Yoon K, Jin H, Song HS (2014) Clinical outcome of arthroscopic SLAP repair: conventional vertical knot versus knotless horizontal mattress sutures. Knee Surg Sports Traumatol Arthrosc. Google Scholar
  56. 56.
    Gorantla K, Gill C, Wright RW (2010) The outcome of type II SLAP repair: a systematic review. Arthroscopy 26(4):537–545. CrossRefGoogle Scholar
  57. 57.
    Slenker NR, Lawson K, Ciccotti MG, Dodson CC, Cohen SB (2012) Biceps tenotomy versus tenodesis: clinical outcomes. Arthroscopy 28(4):576–582. CrossRefGoogle Scholar
  58. 58.
    Frost A, Zafar MS, Maffulli N (2009) Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med 37(4):828–833. CrossRefGoogle Scholar
  59. 59.
    Schroder CP, Skare O, Reikeras O, Mowinckel P, Brox JI (2017) Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. Br J Sports Med. Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Sporttraumatology-Knee- and Shoulder-SurgeryBerufsgenossenschaftliche Unfallklinik Frankfurt am MainFrankfurt am MainGermany
  2. 2.Department of Trauma and Orthopedic SurgeryBerufsgenossenschaftliche Unfallklinik Frankfurt am MainFrankfurt am MainGermany
  3. 3.Department of Sports ScienceUniversity of BielefeldBielefeldGermany
  4. 4.Department of Orthopaedics and RheumatologyUniversity Hospital MarburgMarburgGermany
  5. 5.Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital Frankfurt am MainFrankfurt am MainGermany

Personalised recommendations