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Superior Labrum Anterior- Posterior Lesions: Diagnosis with MR Arthrography of the Shoulder¹

¹ From the Department of Diagnostic Radiology, Long Island Jewish Medical Center, 270-05 76th Ave, New Hyde Park, NY 11040 (J.T.B.); the Department of Diagnostic Radiology, Maimonides Medical Center, Brooklyn, NY (J.B.); and the Departments of Diagnostic Radiology (Z.S.R., S.S., J.M., J.M.M.) and Orthopedic Surgery (A.R., J.Z., F.C., D.R.), Hospital for Joint Diseases–Orthopedic Institute, New York University Medical Center, NY. From the 1997 RSNA scientific assembly. Received September 29, 1998; revision requested November 4; revision received March 29, 1999; accepted April 26. Address reprint requests to J.T.B. (e-mail: bencardi@lij.edu).

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in the diagnosis of superior labrum anterior-posterior (SLAP) lesions of the shoulder.

MATERIALS AND METHODS: From January 1995 to June 1998, MR arthrography of the shoulder was performed in 159 patients with a history of chronic shoulder pain or instability. Fifty-two patients underwent arthroscopy or open surgery 12 days to 5 months after MR arthrography. Diagnostic criteria for SLAP lesion included marked fraying of the articular aspect of the labrum, biceps anchor avulsion, inferiorly displaced bucket handle fragment, and extension of the tear into the biceps tendon fibers. Surgical findings were correlated with those from MR arthrography.

RESULTS: SLAP injuries were diagnosed at surgery in 19 of the 52 patients (37%). Six of the 19 lesions (32%) were classified as type I, nine (47%) as type II, one (5%) as type III, and three (16%) as type IV. MR arthrography had a sensitivity of 89% (17 of 19 patients), a specificity of 91% (30 of 33 patients), and an accuracy of 90% (47 of 52 patients). The MR arthrographic classification showed correlation with the arthroscopic or surgical classification in 13 of 17 patients (76%) in whom SLAP lesions were diagnosed at MR arthrography.

CONCLUSION: MR arthrography is a useful and accurate technique in the diagnosis of SLAP lesions of the shoulder. MR arthrography provides pertinent preoperative information with regard to the exact location of tears and grade of involvement of the biceps tendon.

Index terms: Shoulder, abnormalities, 41.4819 • Shoulder, injuries, 41.4819 • Shoulder, MR, 41.121411, 41.121415, 41.121416, 41.122

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
A superior labral anterior-posterior (SLAP) tear was described by Snyder et al (1) in a series of 27 patients who presented with pain and/or associated clicking or popping about the shoulder. SLAP lesions were initially classified into four types on the basis of arthroscopic findings (1). In the study by Snyder et al (1), type I lesions (11%) were defined as marked fraying of the free edge of the superior labrum; type II (41%), avulsion of the labral-bicipital complex from the glenoid; type III (33%), displaced bucket handle tear of the superior labrum with an intact biceps anchor; and type IV (15%), bucket handle tear of the superior labrum, with extension into the fibers of the biceps tendon. Maffet et al (2) added three more types to this classification. Type V lesions consist of an anteroinferior Bankart lesion that extends upward to include separation of the biceps tendon, type VI lesions are defined as unstable radial or flap tears that are associated with separation of the biceps anchor, and type VII lesions are characterized by extension of the SLAP lesion beneath the middle glenohumeral ligament. The classification system proposed by Snyder et al (1) and Maffet et al (2) is based on arthroscopic observation and has no bearing on severity of symptoms or prognosis.

Physical examination is often an unreliable method for diagnosing SLAP lesions. Occasionally, if the lesion involves the biceps tendon insertion, stress maneuvers may reveal glenohumeral instability. Débridement procedures are performed in cases of marked fraying (type I lesions) or inferiorly displaced buckle handle fragments (type III lesions). Surgical treatment with reattachment of the superior labrum is indicated when there is avulsion of the biceps anchor (type II or IV lesions) (3). Therefore, special attention must be focused on determining the integrity of the biceps tendon for preoperative planning (3,4). The differential diagnosis of superior labral lesions from normal variants of the labral-bicipital complex is crucial to avoid unnecessary surgical procedures (5,6). Assessment of SLAP lesions with computed tomographic (CT) arthrography, magnetic resonance (MR) imaging, or MR arthrography has been previously reported in small retrospective series (7–11). To our knowledge, however, this is the first prospective study in which the findings at MR arthrography are correlated with those at arthroscopy or open surgery for the diagnosis and classification of SLAP lesions of the shoulder.

We performed this study to determine the accuracy of MR arthrography in the diagnosis of SLAP lesions of the shoulder.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
From January 1995 to June 1998, a 42-month period, 159 patients (123 men, 36 women; mean age, 33 years) with a history of chronic shoulder pain or instability were referred to undergo MR arthrography of the shoulder. The patients included in our series did not have clinical findings suggestive of rotator cuff abnormality. In 43 of the 159 patients (27%), MR findings were interpreted preoperatively as positive for SLAP lesions, and lesions were classified by using arthroscopic criteria available in the orthopedic literature (types I–IV). After undergoing MR arthrography, 52 patients (39 men, 13 women; age range, 20–55 years; mean age, 32 years) underwent arthroscopy or open surgery. The interval between MR arthrography and arthroscopic or open surgery varied from 12 days to 5 months. Surgical findings were then correlated with MR arthrographic diagnosis.

Shoulder arthrography was combined with MR imaging, as described in a previous report (12). Fluoroscopically monitored arthrography was performed. A 20–22-gauge needle was placed in the glenohumeral joint, and the needle position was verified with injection of 1–5 mL of 60% diatrizoate meglumine (Hypaque; Winthrop-Breon Laboratories, New York, NY). Next, 0.1 mL of gadopentetate dimeglumine (Magnevist; Berlex Laboratories, Wayne, NJ) diluted in 20 mL of normal saline was injected along with 0.3 mL of epinephrine 1:1,000 (Abbott Laboratories, North Chicago, Ill) to delay absorption of the contrast material solution.

MR arthrography of the shoulder was initiated within 30 minutes after the intraarticular injection and was performed with a 1.5-T magnet (Magnetom SP 4000; Siemens, Iselin, NJ). A dedicated shoulder surface coil was used, and patients were positioned with the shoulder in a neutral position or mild external rotation. T1-weighted (repetition time, 600–800 msec; echo time, 15–20 msec [600–800/15–20]) transverse and oblique sagittal images and intermediate-weighted and T2-weighted (1,800–2,000/20–100) oblique coronal images were obtained in the initial phase of the study. We also used T1-weighted (900/20) sequences with frequency-selective presaturation of the fat in the transverse, oblique coronal, and oblique sagittal planes. In addition, a single fast spin-echo T2-weighted (3,500/99) coronal sequence was performed. The section thickness was 3 mm with interleaved sections or 4 mm with a 1-mm gap. We used a 16–18-cm field of view; two signals were acquired. The matrix was 302–358 x 512 for fat-suppressed T1-weighted images and 198 x 256 for fast spin-echo T2-weighted images.

Approval for the intraarticular injection of gadopentetate dimeglumine was obtained from the institutional review board at the Hospital for Joint Diseases–Orthopedic Institute, New York University Medical Center. All patients signed an informed consent form before undergoing the procedure. There were no known complications related to iodinated contrast material or gadopentetate dimeglumine during or after the examination.

The MR images were reviewed prospectively by one musculoskeletal radiologist (J.B.). The superior labrum was described as normal, meniscoid, or torn. In addition, each labral tear was classified as type I–IV according to the system of Snyder et al (1). A tear was diagnosed when the labrum was detached and displaced from the glenoid rim or when a contrast material interface was seen interposed between the articular cartilage margin and the attachment of the labrum and biceps anchor. Linear regions of contrast material collections pointing laterally within the labrum were also considered diagnostic of tear.

Special care was taken to differentiate a labral tear from a normal sublabral recess or sublabral foramina. Diagnosis of a sublabral recess was made when a medially oriented deposit of contrast material was observed interposed between the superior glenoid rim and the anterior half of the superior labrum, with no posterior extension to the biceps tendon anchor (5,13). In the absence of associated abnormalities, focal contrast material collections at the anterosuperior labrum between the origins of the middle and inferior glenohumeral ligaments were interpreted as sublabral foramina (14,15).

To facilitate the correlation between the MR arthrographic and surgical findings, the lesions were defined in relationship to the biceps tendon and to the hours of the analog clock. Four orthopedic surgeons (A.R., J.Z., F.C., D.R.) specially trained in the diagnosis and treatment of shoulder disorders performed 46 of the 52 procedures in these patients. Surgical criteria for diagnosing a SLAP lesion included marked fraying of the superior labrum, complete detachment or avulsion of the biceps anchor, inferiorly displaced bucket handle fragment, and extension of tear within the fibers of the long head of the biceps tendon.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
SLAP lesions were surgically diagnosed in 19 of the 52 patients (37%) who underwent arthroscopy or open surgery after shoulder MR arthrography. At surgery, six of the 19 lesions (32%) were classified as type I (Fig 1), nine (47%) as type II (Fig 2), one (5%) as type III (Fig 3), and three (16%) as type IV (Fig 4). SLAP lesions were associated with partial tear of the rotator cuff tendon in eight of the 19 (42%) patients. Other associated lesions included frayed or lax inferior glenohumeral ligament (five patients [26%]), Bankart lesion (three patients [16%]) (Fig 5), Hill-Sachs lesion (three patients [16%]), chondral lesions (three patients [16%]), loose bodies (two patients [10%]), complete rotator cuff tear (one patient [5%]), and posterior labral tear (one patient [5%]). Rotator cuff tears were distributed among the different subtypes of SLAP injuries (type I, three lesions; type II, three lesions; type III, one lesion; type IV, two lesions). Six of the eight glenohumeral ligament abnormalities and anterior labral tears (75%) occurred in patients with type II or IV SLAP lesions.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Type I SLAP injury. Oblique coronal, fat-suppressed, T1-weighted MR image (900/20) shows irregularity and pooling of contrast material (arrow) within the labrum, without evidence of complete extension of the lesion throughout the superior labral substance.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Type II SLAP lesion. (a) Oblique coronal, fat-suppressed, T1-weighted image (900/20) shows complete separation (arrow) of the bicipital-labral complex from the superior glenoid rim. (b) Arthroscopic view obtained from a posterior portal confirms the presence of a type II SLAP tear (arrows). B = biceps tendon.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Type II SLAP lesion. (a) Oblique coronal, fat-suppressed, T1-weighted image (900/20) shows complete separation (arrow) of the bicipital-labral complex from the superior glenoid rim. (b) Arthroscopic view obtained from a posterior portal confirms the presence of a type II SLAP tear (arrows). B = biceps tendon.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 3a. Type III SLAP lesion. (a) Oblique sagittal and (b) oblique coronal T1-weighted MR images (600/20) show detachment and inferior displacement of the superior labrum (arrows in a, arrow in b), which is consistent with a bucket handle tear. The biceps tendon insertion (*) is preserved.

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 3b. Type III SLAP lesion. (a) Oblique sagittal and (b) oblique coronal T1-weighted MR images (600/20) show detachment and inferior displacement of the superior labrum (arrows in a, arrow in b), which is consistent with a bucket handle tear. The biceps tendon insertion (*) is preserved.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 4. Type IV SLAP lesion. Oblique sagittal T1-weighted MR image (650/20) shows contrast material (arrow) dissecting into the fibers of the long head of the biceps tendon. A = acromion, C = coracoid, Cl = clavicle.

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 5a. Type II SLAP lesion associated with Bankart lesion. (a) Oblique sagittal, fat-suppressed, T1-weighted MR image (900/20) shows a large anteroinferior Bankart lesion (solid arrows) with superior extension into the labral-bicipital complex (open arrow). (b) Coronal, fat-suppressed, T1-weighted MR image (900/20) shows complete separation of the superior labrum (arrow) from the glenoid.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 5b. Type II SLAP lesion associated with Bankart lesion. (a) Oblique sagittal, fat-suppressed, T1-weighted MR image (900/20) shows a large anteroinferior Bankart lesion (solid arrows) with superior extension into the labral-bicipital complex (open arrow). (b) Coronal, fat-suppressed, T1-weighted MR image (900/20) shows complete separation of the superior labrum (arrow) from the glenoid.

Of the 17 SLAP lesions identified at MR arthrography, 13 (76%) were correctly graded with MR arthrography (two as type I, nine as type II, and two as type IV). Of the four incorrectly classified lesions, two were overestimated at MR arthrography as bicipital anchor type II tears. At surgery, only fraying of the free edge of the superior labrum (type I lesion) was demonstrated. One lesion classified as type III injury at MR arthrography had changes consistent with type I tear at surgery. Finally, one lesion with previous postsurgical changes related to repair of a SLAP type II tear was misclassified as a type II retear. Surgical evaluation revealed compromise of the substance of the biceps tendon, and the lesion was reclassified as a type IV tear.

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
The lesions of the superior glenolabral junction have gained considerable attention since Snyder et al (1) described them in 1990. On the basis of arthroscopic findings, SLAP lesions were initially classified into four types (1). Recently, Maffet et al (2) added three more grades to the classification. Two mechanisms of injury have been proposed: (a) compression force to the shoulder, usually after a fall onto an outstretched arm; and (b) traction on the arm, either as a result of a sudden pull on the arm or secondary to repetitive overhead use, as occurs in baseball pitchers, swimmers, and tennis and volleyball players. Urban and Caborn (3) postulated that different mechanisms of injury would result in different types of SLAP lesions. Athletes who use repetitive overhead arm motions are prone to develop type I or II lesions, whereas patients who present after a fall onto an outstretched arm are more likely to have type III, IV, or VI lesions. Type V and VII lesions seem to be more frequent in patients with instability from an acute trauma.

SLAP tears appear to begin posteriorly and extend anteriorly, terminating before or at the midglenoid notch. Difficulties in the diagnosis derived from the occurrence of normal foramina and synovial recesses in this region are widely recognized (6,16,17). In a recent study by Smith et al (5), MR arthrography proved to be more accurate than conventional MR imaging in the diagnosis of sublabral recesses of the superior glenoid labrum. In their study, MR arthrography demonstrated sublabral recess in 73% of cadavers. These results correlate with the anatomic and histologic findings described by Cooper et al (13), who found the superior labrum to be loosely attached in 45% and not attached at all in 36% of 23 specimens.

Snyder et al (1) believed that SLAP lesions, although uncommon, were a major source of disability that could be successfully managed with arthroscopic intervention. In our series, these lesions were found in 37% (n = 19) of 52 patients with a clinical history of instability or chronic shoulder pain. Increasing awareness of the condition by arthroscopists and radiologists may help explain the high prevalence of these lesions in our study population. Type I and II lesions were the most commonly encountered types, occurring in 79% (n = 15) of our 19 patients. The association of SLAP lesions of the shoulder with rotator cuff abnormality was also noticed by Snyder et al (1). In our study, partial or complete rotator cuff tears were seen in 47% (n = 9) of our 19 patients. The association found in our series between glenohumeral instability and SLAP lesions has also been reported in the orthopedic literature (3). This explains the concomitant occurrence of inferior glenohumeral ligament abnormalities, Hill-Sachs lesions, and Bankart lesions in our patients. Considering the additional three SLAP types described by Maffet et al (2), one of the type II lesions in our series was associated with a large Bankart lesion, which corresponds to a type V injury (Fig 5).

Three false-positive findings were identified in our series, all of which occurred early in our learning curve. At retrospective review, all were considered normal sublabral recesses. We found that the orientation of the contrast material deposit beneath the superior labrum is useful for differentiating this normal variant from an abnormality. Because the synovial recess is interposed between the hyaline cartilage of the superior glenoid rim and the superior labrum and bicipital anchor, the normal contrast material interface must point toward the glenoid (Fig 6). In our experience, the linear deposits of contrast material pointed laterally toward the long head of the biceps tendon in most cases with tear.

View larger version (156K): [in this window] [in a new window] [Download PPT slide]   Figure 6. Oblique coronal T1-weighted MR image (600/20) shows a prominent meniscoidlike superior labrum (*) associated with pooling of contrast material in the sublabral recess (arrow). This finding was misinterpreted as a type II SLAP lesion (false-positive finding). Note the medial orientation of the linear contrast material deposit, which is consistent with this normal anatomic variant.

View larger version (147K): [in this window] [in a new window] [Download PPT slide]   Figure 7a. Oblique coronal T1-weighted MR images (650/20) (b was obtained posterior to a) through the superior labrum show a linear deposit of contrast material (arrow), which was misdiagnosed as a normal sublabral recess (false-negative finding). Contrast material deposits posterior to the biceps tendon insertion (* in a) should be considered suggestive of a SLAP lesion.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 7b. Oblique coronal T1-weighted MR images (650/20) (b was obtained posterior to a) through the superior labrum show a linear deposit of contrast material (arrow), which was misdiagnosed as a normal sublabral recess (false-negative finding). Contrast material deposits posterior to the biceps tendon insertion (* in a) should be considered suggestive of a SLAP lesion.

Our study has some limitations. Because our cases were collected from a nonselected patient population with a history of chronic shoulder pain and instability, no specific images of the intraarticular portion of the biceps tendon were obtained. It is thought that imaging in a coronal plane parallel to the intracapsular portion of the long head of the biceps tendon allows better visualization of this structure and its anchor (7). Also, interobserver variation was not assessed in our study because all MR images were evaluated by only one musculoskeletal radiologist. On the basis of our results, we conclude that MR arthrography is a useful and accurate technique for diagnosing SLAP lesions of the shoulder. This technique also provides pertinent preoperative information such as the exact location of the labral tears and grade of involvement of the biceps tendon.

	Footnotes

 
Abbreviation: SLAP = superior labrum anterior posterior

Author contributions: Guarantors of integrity of entire study, J.B., J.T.B.; study concepts, J.T.B.; study design, J.B., J.T.B.; definition of intellectual content, J.T.B.; literature research, J.T.B.; clinical studies, D.R., A.R., J.Z., F.C.; data acquisition, S.S., J.M., J.M.M.; data analysis, J.T.B.; manuscript preparation, J.T.B.; manuscript editing, J.B.; manuscript review, J.B., Z.S.R.

	References

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 

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