Introduction

Superior labrum anterior to posterior (SLAP) tears occur when there is a tear in the superior portion of the glenoid labrum that begins posteriorly and extends anteriorly, compromising the long head of the biceps, which is necessary for stability at the glenohumeral joint.1 Although this injury was first described by Andrews et al. in 1985,2,3 Snyder et al.1 coined the term “SLAP lesion” in 1990 because of the location and extension pattern of the tear. They also developed a four-subtype classification system,1,3 with subtype II, characterized by superior labrum and biceps anchor tear,1 being the most common.4-6

It has been reported that SLAP tears are observed in 26% of shoulder arthroscopies,2,4 in association with arthroscopic signs of glenohumeral instability and increased humeral head translation.2 Moreover, several studies have demonstrated that superior labrum tears generate greater humeral head translation than isolated biceps tenotomy, suggesting that the superior labrum plays a critical role in glenohumeral stability, regardless of the biceps tendon.2,7,8

These injuries are more frequent among active individuals who perform sports activities with their arm above their head, in abduction, and externally rotated, such as baseball, tennis, and volleyball.3,5,9 It should be noted that SLAP lesions often occur concomitantly with shoulder conditions, such as rotator cuff or long head of the biceps tendon tears,1.2 or glenohumeral instability secondary to repetitive external rotation movements in abduction;10 in fact, it has been reported that only 26% of SLAP lesions are isolated.11

SLAP lesions can cause shoulder pain and disability;1,2,4,9 however, there is increasing evidence that these lesions are often asymptomatic and can be identified through nuclear magnetic resonance imaging (MRI).3 The vast majority of symptomatic tears are treated conservatively (modification of sports activity, rest, anti-inflammatory drugs, cryotherapy, and physical therapy).3,12 If conservative treatment fails, surgical management should be considered depending on the patient’s age, presence of concomitant conditions, functional requirements, work demands, and specific sports goals.3 While several surgical techniques are available, including debridement, labrum repair, biceps tenodesis, and biceps tenotomy,12,13 the choice of technique depends on the tear pattern and the presence or absence of associated shoulder conditions.3

Given the wide range of options available, the choice of the surgical technique for the management of these lesions remains a matter of debate. According to the literature, biceps tenodesis is the technique of choice in older patients with less athletic demand, whereas labrum repair is preferred in young, active individuals.13,14

Even though arthroscopic labrum repair has traditionally been the most commonly employed procedure, the use of tenodesis has increased by 20% in SLAP lesions treated surgically.15 Furthermore, in a 2018 systematic review and meta-analysis, Hurley et al.17 reported that biceps tenodesis is associated with higher rates of patient satisfaction and return to sports compared with labrum repair, although age difference between groups may have influenced these findings.17 In contrast, a recent meta-analysis concluded that there is no significant difference between biceps tenodesis and SLAP repair in young patients (<40 years) in terms of return-to-sport (RTS) rates, functional outcomes, and requirement for revision surgery.17

Even though multiple studies have compared both surgical techniques, as shown in the systematic reviews and meta-analysis by Hurley et al.,16,17 it has not yet been possible to establish the superiority of either technique, especially when the patient’s age is taken into account.

In view of the above, the objective of the present study was to compare the efficacy and safety of biceps tenodesis and labrum repair in the treatment of SLAP lesions.

Methodology

Study type

This systematic review and meta-analysis was conducted following the PRISMA 2020 statement guidelines.18

Information sources and search strategy

In December 2024, systematic searches of Medline (PubMed), Web of Science, Embase, and Cochrane were conducted using the following search strategy: (“shoulder injuries” OR “shoulder injury” OR “SLAP tear” OR “SLAP lesion” OR “Superior Labrum from Anterior to Posterior Injuries”) AND (“SLAP repair” OR “tenodesis” OR “biceps tenodesis”). The searches were performed independently by two authors (SE and IC).

Inclusion and exclusion criteria

The inclusion and exclusion criteria are described below:

Inclusion

• Randomized clinical trials and prospective or retrospective observational studies.
• Objective: studies comparing clinical and functional outcomes of arthroscopic labrum repair and biceps tenodesis in SLAP lesions.
• Studies in patients with a confirmed diagnosis of SLAP tear and in whom conservative treatment has failed.
• Studies published between January 2014 and December 2024.

Exclusion

• Studies with a low level of scientific evidence such as case series, expert opinions, or biomechanical studies.
• Systematic reviews and meta-analyses.
• Studies performed in patients with previous labrum repairs and/or underlying shoulder problems (biceps tendinopathy or glenohumeral arthritis).
• Studies published prior to 2014.
• Studies published in a language other than English, Spanish, or French.

Study screening and selection

After removing duplicate records, the titles and abstracts of the studies were read to exclude those that were not relevant to the objective of the review. The remaining articles were then read in full to assess their eligibility based on the established inclusion and exclusion criteria. The references of each included study were also reviewed in search of additional articles that met the inclusion criteria (snowball search method). The screening and study selection process was performed independently by two reviewers (SE and JR); discrepancies were resolved by a third reviewer (IC).

Data extraction

Data were extracted independently by two authors (SE and IC) using a standardized template created in Microsoft Excel, in which they were also organized systematically. The following information was extracted from each of the studies included in the review: first author, year of publication, study design, sample size, demographic characteristics of the patients (age, sex), follow-up time, variables related to the surgical intervention analyzed, and main findings. Discrepancies between the two reviewers were resolved by consensus, thus obtaining a final matrix of extracted data.

Assessment of risk of bias

Since none of the included studies were randomized, risk of bias was assessed using the Newcastle-Ottawa Scale (NOS),19 which allows for the evaluation of three domains: selection of study groups, comparability of groups, and ascertainment of exposure or outcome of interest, with a maximum of 9 points. In the present systematic review, the quality of the studies was classified as very good (7-9), good (5-6), satisfactory (4), and not satisfactory (0-3). The assessment was carried out by one of the authors (SEFV); any doubts about risk assessment on any item were resolved by the other two authors.

Variables to study

Efficacy was assessed using the data reported in the included studies for the following variables: visual analog scale score (VAS score), ASES - Shoulder and Elbow Surgeons Score (ASES score), and return to sports activity. In turn, safety assessment of both techniques was based on complication rates, particularly the need for reoperation.

Statistical analysis

In order to summarize and integrate the results of the studies included in the review, a quantitative analysis was performed using the RevMan statistical software (version 5.4.1).20

Heterogeneity was assessed using the I2 statistic and the Cochrane’s Q test, considering a value <0.05 for Cochrane’s Q and an I2 >50% as statistically heterogeneous. Depending on this evaluation, a fixed-effect or a random-effects model was used.

Dichotomous variables were grouped using the Mantel-Haenszel method and are presented as relative risks (RR) with their respective 95% confidence interval (95%CI). The mean difference with its respective 95%CI was calculated for continuous variables. A statistical significance level of p<0.05 was considered.

The meta-analysis results are presented as numerical data and by means of forest plots. In addition, a funnel plot (Annex 1) was used to look for possible publication biases.

Results

Study search, screening, and selection

A total of 725 records were retrieved from the initial searches of the electronic databases. After removing duplicates (n=598), 127 records were screened by reading titles and abstracts, excluding 109 because they were not relevant to the objective of the review. Of the 18 studies that were read in full to assess their eligibility based on the established inclusion and exclusion criteria, 10 were finally included in the review for analysis. The study search, screening, and selection process is presented in the PRISMA flowchart (Figure 1).

Figure 1. PRISMA flowchart of the study identification, screening, and selection process.

Study characteristics

The 10 included studies were published between 2015 and 2023.2,10,21-28 Most were conducted in the United States (n=7; 70%) and all were published in English (n=10; 100%). Regarding study design, all were retrospective cohort studies (level of evidence III). Aggregate sample size was 538 patients, with individual samples ranging from 35 to 83 participants. However, seven studies compared only arthroscopic repair and tenodesis, while the remaining three included a third group (conservative treatment10 or repair + tenodesis2,24), so 59 patients were not considered for analysis, resulting in a final sample of 479 individuals: 251 (52.4%) in the arthroscopic repair group and 228 (47.6%) in the tenodesis group, with a clear predominance of the male sex and the frequency of men being >50% in all studies.

A noteworthy aspect is the mean age of the participants, with a clear distinction between those aged 40 and over and those under that age: the mean age of both groups was <40 years in 6 studies10,23-26,28 and ≥40 years in 3 studies;21,22,27 the mean age in the remaining study was <40 years in the labrum repair group and ≥40 years in the tenodesis group.2 The main study characteristics are presented in Table 1.

Table 1. Main characteristics of the included studies (n=10).

Authors and year of publication	Country/Language	Objective	Level of evidence	Study type	Biceps tenodesis			Arthroscopic repair			Follow-up time (months)	Variables related to efficacy and safety of the procedure	Main findings
					n	Sex (M/F)	Age (years)	n	Sex (M/F)	Age (years)
Denard et al., 201421	United States/English	To compare biceps tenodesis with biceps repair for the treatment of isolated type II SLAP lesions	III	Retrospective cohort	15	12/3	52.0± 8.0	22	14/6	45.2±5.5	52.1 (24-60) Tenodesis: 41.1 ± 19.8 Repair: 63.2 ± 14.5	ASES score, UCLA score, VAS, SANE evaluation, degree of satisfaction, return to normal activity and sports, complications	No significant differences between groups were found in any of the variables analyzed
Chalmers et al., 20152	United States/English	To compare the clinical outcomes of using combined tenodesis + labrum repair vs. tenodesis alone or labrum repair for the treatment of SLAP lesions	III	Retrospective cohort	23	14/9	45±13	45	30/15	35±13	38.4 (12-58.8) Tenodesis: 27.6 ± 10.8 Repair: 49.2 ± 22.8	Range of motion (active forward elevation, adduction with external rotation, abduction with internal rotation, abduction), return to activity (sports and work), ASES score, VAS, simple shoulder test (SST)	No significant differences between the tenodesis and labrum repair subgroups were found in ASES score, SST score, and VAS
Lim et al., 201922	Korea/English	To compare the clinical and imaging outcomes of labrum repair or tenodesis (both combined with arthroscopic rotator cuff repair) for the treatment of SLAP lesions	III	Retrospective cohort	18	10/8	54.8±7.9	17	11/6	54.9±6.5	29.4 ± 11.4 (24-84)	VAS, ASES score, UCLA score, Constant score, range of motion.	No significant differences were observed between groups in the variables analyzed. A significant improvement in VAS, functional scores, and range of motion was observed in both groups after intervention (last follow-up)
Dunne et al., 202023	United States/English	To compare the outcomes of tenodesis and labrum repair in the treatment of type II SLAP lesions in an active young population (15-40 years of age)	III	Retrospective cohort	20	13/7	26.9±5.9	33	26/7	30.4±7.4	41 (24-78) Tenodesis: 32.3 ± 10.3 Repair: 45.8±18.5	ASES score, DASH-sport score, VAS, level of satisfaction, return to sporting activity	No significant differences were found between groups in any of the outcomes analyzed
Ridley et al., 202124	United States/English	To compare biceps tenodesis, labrum repair, or combination of both techniques for treatment of isolated SLAP type II-IV lesions.	III	Retrospective cohort	38	-	29.7±9.6	13	-	36.5±7.3	49.2 (24-96) Tenodesis: 43.2 (range 24-96) Repair: 55.2 (range 12-96)	ASES score, SANE score, QuickDASH score, SF-12 questionnaire (physical component), level of satisfaction, return to sporting activity, complications	Significant differences in favor of tenodesis were found in the SANE score. No significant differences were found in the other outcomes evaluated.
Parnes et al., 202125	United States/English	To compare the outcomes of biceps tenodesis with the outcomes of arthroscopic biceps repair in the treatment of SLAP II type lesions in military patients under 35 years of age.	III	Retrospective cohort	23	18/5	28.9±4	25	24/1	27.8±4.3	83 months Tenodesis: 79.8±22.2 Repair: 86.6±18.8	ASES score, SANE score, VAS score, complications	Five years after surgery, pain intensity (VAS) was lower, while SANE and ASES scores were higher in the tenodesis group, with the difference being statistically significant in the SANE score (84.0 vs. 63.3, p=0.0001). Moreover, the failure rate was higher in the repair group than in the tenodesis group, although the difference was not significant (20.0% vs. 0.0%; p=0234).
Lacheta et al., 202226	United States/English	To compare the efficacy of labrum repair and labrum tenodesis in terms of clinical outcomes and return to sporting activity in athletes with symptomatic SLAP type II lesion	III	Retrospective cohort	16	12/4	28.6±6.1	28	24/4	24.4±5.7	39.3 months (24-71.9)	ASES score, SANE score, QuickDASH score, SF-12 questionnaire (physical component), level of satisfaction, return to sporting activity, complications	No significant differences were found between groups in any of the outcomes measured
Song et al., 202227	China/English	To compare the clinical outcomes and postoperative efficacy of arthroscopic modified double-row biceps tenodesis versus labrum repair in isolated type II SLAP lesions	III	Retrospective cohort	26	15/11	40.9±10.2	30	17/13	42.8±10.6	24.7 months Tenodesis: 23.6±3.8 meses (17-31) Repair: 25.8±5.3 meses (13-34)	ASES score, VAS, UCLA score, level of satisfaction, time required to return to previous activities, workers’ compensation status, postoperative complications	At 2-year follow-up, significant differences were observed in favor of biceps tenodesis in VAS (1.5 vs. 1.8; p=0.008), level of patient satisfaction (92.3% vs. 46.7%; p<0.001, p<0.001) and time required to return to previous activities (6.8 ± 1.8 vs. 8.1 ± 1.5, p=0.007)
Rothermich et al., 202228	United States/English	To compare the efficacy of biceps tenodesis versus arthroscopic biceps repair for the treatment of SLAP lesions in fast-pitch softball players	III	Retrospective cohort	29	29/0	17.4±2.0	18	18/0	17.4±2.2	55.2±43.2 months Tenodesis: 38.4±22.8 Repair: 81.6±54	ASES score, ACS score, KJOC score, and return to sporting activity	No significant differences were found between groups in any of the outcomes reported by the patients evaluated
Goncharov et al., 202310	Italy/ English	To compare the efficacy of biceps tenodesis, arthroscopic labrum repair, and conservative management in the treatment of SLAP lesions in adults <40 years of age	III	Retrospective cohort	20	-	27.5 (19-35)	20	-	27.5 (19-35)	24.1 (19-24) meses Tenodesis: 24.2 (range 21-24) Repair: 24.0 (range 19-24)	ASES score, UCLA, Constant-Murley and Oxford instability score, VAS score, range of motion (both in forward flexion and abduction)	No significant differences were found between tenodesis and arthroscopic repair in terms of pain reduction and functional improvement, although biceps tenodesis showed greater efficacy

ASC: Andrews Carson Score, ASES: American Shoulder and Elbow Surgeons; KJOC: Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow; M/F: male/female; NOS: Newcastle-Ottawa Scale; QuickDASH: Quick Disabilities of the Arm, Shoulder and Hand Score; SANE: Single Assessment Numeric Evaluation; SF-12: General Health Short Form-12; UCLA: University of California, Los Angeles; VAS: Visual Analog Scale.

Source: Own elaboration.

Risk of bias assessment

Although none of the included studies achieved the maximum NOS score, 9 (90%) obtained a score of 8 and 1 (10%) received a score of 7, indicating that they all have a very good methodological quality. The results of the individual evaluation of the studies with the NOS are presented in Table 2.

Table 2. Risk of bias assessment of the studies included in the review. Newcastle-Ottawa Scale.

Author	Year	Selection			Comparability			Exposure			Total score
		Case definition is adequate with independent validation	Consecutive or clearly representative series of cases	Community controls	Controls without history of disease (endpoint)	Age-matched cases and controls	Cases and controls comparable on other factors.	Ascertainment of exposure using secure records or structured interviews with blinded status	Ascertainment of exposure using the same method for cases and controls.	Ascertainment of exposure with similar non-response rates for both groups
Denard et al., 201421	2014	*	*		*	*	*	*	*	*	8
Chalmers et al., 20152	2015	*	*		*	*	*	*	*	*	8
Lim et al., 201922	2019	*	*		*	*	*	*	*	*	8
Dunne et al., 202023	2020	*	*		*	*	*	*	*	*	8
Ridley et al., 202124	2021	*	*		*		*	*	*	*	7
Parnes et al., 202125	2021	*	*		*	*	*	*	*	*	8
Lacheta et al., 202226	2022	*	*		*	*	*	*	*	*	8
Song et al., 202227	2022	*	*		*	*	*	*	*	*	8
Rothermich et al., 202228	2022	*	*		*	*	*	*	*	*	8
Goncharov et al., 202310	2023	*	*		*	*	*	*	*	*	8

Source: Own elaboration.

ASES score

The ASES score was measured preoperatively in 8 studies2,10,21-23,25-27 and postoperatively in all 10 studies.2,10,21-28 The mean preoperative and postoperative ASES scores were 51.84 and 87.25 and 51.76 and 85.62 in the tenodesis group and in the labrum repair group, respectively. There was no statistically significant difference between both surgical techniques in preoperative ASES score (MD: -0.75, 95%CI: -2.67 to 1.17, p=0.44) (Figure 2a) or postoperative ASES score (MD: 0.72, 95%CI: -1.61 to 3.05, p=0.54) (Figure 2b).

Figure 2A. Forest plot of preoperative ASES score between tenodesis and labrum repair in SLAP lesions. Figure 2B. Forest plot of the postoperative ASES score between tenodesis and labrum repair in SLAP lesions.

IV: Inverse variance.

Source: Own elaboration.

Visual Analog Scale

Pain was assessed before and after surgery in 7 articles,2,10,21-23,25,27 all using the VAS. The mean preoperative VAS score in patients who were to be treated with tenodesis was 6.37 and 6.21 in the repair group. The mean postoperative VAS score in patients who underwent tenodesis was 1.65 versus 1.92 in those treated with arthroscopic repair. Although no statistically significant differences were found between groups in preoperative VAS scores (Figure 3A), there were statistically significant differences in postoperative pain in favor of biceps tenodesis (MD: -0.29, 95%CI: -0.50 to -0.07, p=0.010) (Figure 3B).

Figure 3A. Forest plot of preoperative VAS scores between tenodesis and labrum repair for the treatment of SLAP lesions. Figure 3B. Forest plot of postoperative VAS scores between tenodesis and labrum repair for the treatment of SLAP lesions.

IV: Inverse variance.

Source: Own elaboration.

Return to sports activities

Return to sports activity was analyzed in 7 studies.2,21,22,25-28 The proportion of patients who returned to sports activities was 82.2% in the tenodesis group and 74% in the arthroscopic repair group, with no statistically significant differences (RR: 1.08, 95%CI: 0.97 to 1.21, p=0.15) (Figure 4).

Figure 4. Forest plot of return to sports activity between tenodesis and labrum repair for the treatment of SLAP lesions.

M-H: Mantel-Haenszel.

Complications

According to the 8 studies that reported information on complications,2,21-27 the reoperation rate was 2.23% (n=4) and 8.46% (n=18) in patients taken to biceps tenodesis and arthroscopic labrum repair, respectively. No statistically significant differences were found between groups (RR: 0.41, 95% CI: 0.17 to 1.01, p=0.05) (Figure 5).

Source: Own elaboration.

Figure 5. Forest plot of reoperation rate between tenodesis and labrum repair in SLAP lesion repair.

M-H: Mantel-Haenszel.

Source: Own elaboration.

Finally, other minor complications that did not require reoperation were reported: one case of superficial infection23 and one case of stiffness27 in the tenodesis group, as well as one case of neurological involvement,23 two cases of persistent nocturnal pain, and three cases of postoperative stiffness27 in the labrum repair group.

Discussion

For several years, biceps tenodesis was the surgical approach of choice for the management of SLAP lesions in older patients with lower functional demand due to the presence of a more degenerated and frayed labrum, while arthroscopic labrum repair was preferred in younger individuals with high functional demand due to the presence of healthy labrum tissue.13,14 Recent studies have mostly focused on older and younger patients, failing to analyze the differences between the two age groups. However, a randomized clinical trial published in 2017 evaluating patients undergoing upper labrum repairs for isolated type II SLAP lesions with long-term follow-up found no significant differences between patients <40 years and those ≥40 years in terms of overall level of satisfaction and functional scale scores.29

The present systematic review included 6 studies in which the mean age in both groups was <40 years,10,23-26,28 3 in which the mean age was ≥40 years,21,22,27 and 1 study in which the mean age was <40 years in the labrum repair group and ≥40 in the tenodesis group.2 Regardless of this factor, we found that although there were no significant differences between the two surgical techniques in terms of patient’s subjective perception of daily activities, return to sports activity, and need for reoperation, postoperative pain intensity was significantly lower in the tenodesis group.

Functional scores

Although the included studies report data for different functional scores, the ASES (American Shoulder and Elbow Surgeons) score was the most commonly used (10 studies). This instrument allows measuring the quality of life of patients with shoulder conditions by assessing pain and functionality in this joint when performing activities of daily living, such as grooming, reaching high shelves, or usual work. These results are compared between the operated arm and the contralateral arm, with functional limitation determined by the patient.30,31

While significant differences between preoperative and postoperative ASES scores in both techniques were observed in all studies included in this systematic review, the results of the meta-analysis showed that there are no significant differences between biceps tenodesis and labrum repair in preoperative and postoperative ASES scores (7 and 10 studies, respectively). Furthermore, when analyzed individually, none of the 10 studies reported significant differences in postoperative scores in favor of either technique.

These results are in line with those reported in the meta-analysis published in 2024 by Hurley et al.17 (5 studies), in which they found that although the postoperative ASES score was higher in patients treated with biceps tenodesis than in those undergoing labrum repair, the difference was not statistically significant (87.2 vs. 86.2; I2=27%, p=0.27; 4 studies). However, they differ from those described in the meta-analysis published by Ren et al.15 in 2019, in which a statistically significant difference was found in favor of tenodesis (MD = −6.32, 95%CI= −10.08 a −2.55, p= 0.001; 3 studies, 83 patients: 37 in the tenodesis group and 46 in the arthroscopic repair group). One possible explanation for the discrepancy between our finding and that of the meta-analysis by Ren et al.14 is the number of studies evaluated for this outcome (10 vs. 3). The foregoing demonstrates the need for further studies to evaluate the differences in this score between the two techniques in order to confirm these results.

On the other hand, the VAS was the most frequently used instrument in the studies to assess pain (n=7).2,10,21-23,25,27 In all cases, significant differences were reported between preoperative and postoperative pain in both surgical techniques. In addition, we found a statistically significant difference in postoperative pain in favor of biceps tenodesis, a group in which the mean VAS score was 1.65 compared to 1.92 in patients undergoing labrum repair (p=0.010).

Return to sports activities

Return to sports activity is one of the variables of greatest interest in this systematic review due to the differences observed among the 7 studies that reported data for this outcome. Our results show that 82.2% of patients undergoing tenodesis and 74% of those treated with arthroscopic repair returned to their pre-injury level of physical activity, with no statistically significant differences between groups. At an individual level, for example, the study by Chalmers et al.,2 which analyzed the return to full duty at work and return to pre-injury level of play in workers and athletes with SLAP lesions, respectively, reported that 64% of athletes returned to their pre-injury level of play in the repair group and 88% of workers fully returned to their duties, while these results were reported in 75% and 75% of workers in the tenodesis group, with no statistically significant differences between techniques.

The results of our meta-analysis differ from those described in other meta-analyses and systematic reviews.16,32-34 For example, the meta-analysis by Hurley et al.17 found significant differences in favor of tenodesis in the rate of return to sports activity compared to labrum repair (81.3% vs. 64.3%, p=0.02). Similarly, in a recent systematic review, Sandler et al.32 found that the rate of return to sports activities was higher in the tenodesis group than in the labrum repair group in all included studies (63%-85% vs 50%-76%; 4 studies). However, it is important to keep in mind that, unlike our study, the review by Sandler et al.32 only included young adult population.

Complications

Complications were measured in terms of the need for reoperation. The cause of reoperation in the tenodesis group was the presence of residual pain, whereas post-surgical stiffness was the cause of reoperation in patients treated with labrum repair. The reoperation rate was lower in the tenodesis group (2.23% vs. 8.46%), with no significant differences between techniques both in the meta-analysis and in the individual studies that reported information on this outcome (n=8).

In this regard, the meta-analysis published in 2018 by Hurley et al.16 (5 studies) reported that although there was no statistically significant difference between labrum repair and biceps tenodesis, there was a trend toward a higher reoperation rate in patients taken to SLAP repair (14.2% vs 6.5%; RR: 0.50, 95%CI: 0.22-1.12; I2= 48%, p=0.22; 5 studies). This same scenario was observed in the presence of postoperative stiffness (5.8% vs. 12.5%; RR: 0.51, 95%CI: 0.18-1.40; I2= 0%, p=0.19; 3 studies). These results were confirmed in the meta-analysis published by Hurley et al.17 in 2024, in which, again, a trend toward a higher reoperation rate was found in the SLAP repair group (2.9% vs. 10.7%) but the difference was not statistically significant (MD: -2.66, 95%CI: -7.40 to 2.09, I2: 27%, p=0.27; 3 studies). In any case, it should be noted that the meta-analysis by Hurley et al.17 only included studies performed in patients under 35 years of age with high functional demand (mean ages between 24.3±4 and 27.8±4.3 years in the three studies considered in the meta-analysis of this variable).

Finally, although none of the studies included in our systematic review reported complications related to mechanical symptoms or shoulder instability, several minor complications were described, including Popeye sign21 or superficial infection23 in the tenodesis group, and neurological involvement23 and residual nocturnal pain27 in patients treated with labrum repair.

Limitations

This systematic review has several limitations. First, the level of scientific evidence is low, as only retrospective observational studies were included, which reduces the scientific quality of the review. Second, although the number of studies included is acceptable, not all the articles analyze the same variables, thus adding a certain heterogeneity to the objectives analyzed. Third, according to the funnel plot (Annex 1), there is a possible publication bias, given that the number of studies analyzed for each variable is less than ten. Lastly, each study uses a different rehabilitation protocol, which may have an effect on clinical and functional outcomes and patient perception of the efficacy of the surgical techniques evaluated.

Conclusions

The present systematic review found that, regardless of age, there are no significant differences between biceps tenodesis and labrum repair in the treatment of SLAP lesions in terms of subjective patient perception on functional scores, return-to-sports rate, and reoperation rate. However, there was a statistically significant difference in postoperative pain, which was lower in patients who underwent tenodesis.

More studies with a higher level of scientific evidence comparing the efficacy and safety of these surgical techniques in the long term are required to confirm the findings reported herein and to reach clear conclusions as to whether one technique is superior to the other or not.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

None stated by the authors.

References

1.Snyder SJ, Karzel RP, Pizzo W Del, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990;6(4):274-9. doi: 10.1016/0749-8063(90)90056-j. PMID: 2264894.

2.Chalmers PN, Monson B, Frank RM, Mascarenhas R, Nicholson GP, Bach BR, et al. Combined SLAP repair and biceps tenodesis for superior labral anterior–posterior tears. Knee Surg Sports Traumatol Arthrosc. 2016;24(12):3870-6. doi: 10.1007/s00167-015-3774-6. PMID: 26328801.

3.Varacallo MA, Tapscott DC, Mair SD. Superior Labrum Anterior Posterior Lesions. 2023. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. PMID: 30855868.

4.Li X, Lin TJ, Jager M, Price MD, Deangelis NA, et al. Management of type II superior labrum anterior posterior lesions: a review of the literature. Orthop Rev (Pavia). 2010;2(1):e6. doi: 10.4081/or.2010.e6. PMID: 21808701; PMCID: PMC3143955.

5.Steinmetz RG, Guth JJ, Matava MJ, Brophy RH, Smith MV. Return to play following nonsurgical management of superior labrum anterior-posterior tears: a systematic review. J Shoulder Elbow Surg. 2022;31(6):1323-33. doi: 10.1016/j.jse.2021.12.022. PMID: 35063641.6.

6.Weick JW, Workman WB, Bush CJ, McCollum KA, Sugaya H, Freehill MT. Reported Technical Aspects of Type II SLAP Lesion Repairs in Athletes. Arthrosc Sports Med Rehabil. 2021;3(2):e289-e296. doi: 10.1016/j.asmr.2020.09.003. PMID: 34027434; PMCID: PMC8128993.

7.Patzer T, Habermeyer P, Hurschler C, Bobrowitsch E, Wellmann M, Kircher J, et al. The influence of superior labrum anterior to posterior (SLAP) repair on restoring baseline glenohumeral translation and increased biceps loading after simulated SLAP tear and the effectiveness of SLAP repair after long head of biceps tenotomy. J Shoulder Elbow Surg. 2012;21(11):1580-7. doi: 10.1016/j.jse.2011.11.005. Epub 2012 Feb 24. PMID: 22365557.

8.Strauss EJ, Salata MJ, Sershon RA, Garbis N, Provencher MT, Wang VM, et al. Role of the superior labrum after biceps tenodesis in glenohumeral stability. J Shoulder Elbow Surg. 2014;23(4):485-91.  doi: 10.1016/j.jse.2013.07.036. PMID: 24090980.

9.Rossy W, Sanchez G, Sanchez A, Provencher MT. Superior Labral Anterior-Posterior (SLAP) Tears in the Military. Sports Health: A Multidisciplinary Approach. 2016;8(6):503-6. doi: 10.1177/1941738116671693. PMID: 27765830; PMCID: PMC5089360.

10.Goncharov EN, Koval OA, Bezuglov EN, Vetoshkin AA, Goncharov NG, Ramirez MJE, et al. A Comparative Analysis Between Conservative Treatment, Arthroscopic Repair, and Biceps Tenodesis in Superior Labral Anterior-Posterior (SLAP) Lesions. Cureus. 2023;15(10):e47512. doi: 10.7759/cureus.47512. PMID: 38022173; PMCID: PMC10663969.

11.Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow Surg. 1995;4(4):243-8. doi: 10.1016/s1058-2746(05)80015-1. PMID: 8542365.

12.Aydin N, Sirin E, Arya A. Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management. World J Orthop. 2014;5(3):344-50. doi: 10.5312/wjo.v5.i3.344. PMID: 25035838; PMCID: PMC4095028.

13.LeVasseur MR, Mancini MR, Hawthorne BC, Romeo AA, Calvo E, Mazzocca AD. SLAP tears and return to sport and work: current concepts. J ISAKOS. 2021;6(4):204-11. doi: 10.1136/jisakos-2020-000537. PMID: 34272296.

14.Ren YM, Duan YH, Sun YB, Yang T, Hou WY, Tian MQ. Is arthroscopic repair superior to biceps tenotomy and tenodesis for type II SLAP lesions? A meta-analysis of RCTs and observational studies. J Orthop Surg Res. 2019;14(1):48. doi: 10.1186/s13018-019-1096-y. PMID: 30760293; PMCID: PMC6375148.

15.Erickson BJ, Jain A, Abrams GD, Nicholson GP, Cole BJ, Romeo AA, et al. SLAP Lesions: Trends in Treatment. Arthroscopy. 2016 Jun;32(6):976-81. doi: 10.1016/j.arthro.2015.11.044. PMID: 26907371.

16.Hurley ET, Fat DL, Duigenan CM, Miller JC, Mullett H, Moran CJ. Biceps tenodesis versus labral repair for superior labrum anterior-to-posterior tears: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2018;27(10):1913-9. doi: 10.1016/j.jse.2018.04.011. PMID: 29803502.

17.Hurley ET, Baker R, Danilkowicz RM, Levin JM, Klifto CS, Dickens JF, et al. Similar outcomes between biceps tenodesis and SLAP repair for SLAP tears in younger patients - A meta-analysis. J ISAKOS. 2024;9(1):79-83. doi: 10.1016/j.jisako.2023.09.007. PMID: 37797939.

18.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71. PMID: 33782057; PMCID: PMC8005924.

19.Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. 2021.

20.Review Manager (RevMan). Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration; 2014.

21.Denard PJ, Lädermann A, Parsley BK, Burkhart SS. Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years. Orthopedics. 2014;37(3):e292-7. doi: 10.3928/01477447-20140225-63. PMID: 24762158.

22.Lim S, Kim SK, Kim YS. Comparison between SLAP Repair and Biceps Tenodesis with Concomitant Rotator Cuff Repair in Patients Older than 45 Years: Minimum 2-Year Clinical and Imaging Outcomes. Clin Orthop Surg. 2020;12(3):364-370. doi: 10.4055/cios19157. PMID: 32904029; PMCID: PMC7449846.

23.Dunne KF, Knesek M, Tjong VK, Riederman BD, Cogan CJ, Baker HP, et al. Arthroscopic treatment of type II superior labral anterior to posterior (SLAP) lesions in a younger population: minimum 2-year outcomes are similar between SLAP repair and biceps tenodesis. Knee Surg Sports Traumatol Arthrosc. 2021;29(1):257-65. doi: 10.1007/s00167-020-05971-0. PMID: 32253479.

24.Ridley TJ, Horan MP, Nolte PC, Elrick BP, Millett PJ. Concomitant Biceps Tenodesis Improves Outcomes for SLAP Repair: Minimum 2-Year Clinical Outcomes after SLAP II-IV Repair Versus Tenodesis Versus Both. Arthrosc Sports Med Rehabil. 2021;3(6):e2007-14. doi: 10.1016/j.asmr.2021.10.007. PMID: 34977660; PMCID: PMC8689264.

25.Parnes N, Dunn JC, Czajkowski H, DeFranco MJ, Green CK, Scanaliato JP. Biceps Tenodesis as an Attractive Alternative to Superior Labral Anterior-Posterior (SLAP) Repair for Type II SLAP Lesions in Active-Duty Military Patients Younger Than 35 Years. Am J Sports Med. 2021;49(14):3945-51. doi: 10.1177/03635465211049373. PMID: 34672809.

26.Lacheta L, Horan MP, Nolte PC, Goldenberg BT, Dekker TJ, Millett PJ. SLAP Repair Versus Subpectoral Biceps Tenodesis for Isolated SLAP Type 2 Lesions in Overhead Athletes Younger Than 35 Years: Comparison of Minimum 2-Year Outcomes. Orthop J Sports Med. 2022;10(6):23259671221105239. doi: 10.1177/23259671221105239. PMID: 35757237; PMCID: PMC9218463.

27.Song Y, Wu Z, Wang M, Liu S, Cong R, Tao K. Arthroscopic Modified Double-Row Biceps Tenodesis versus Labral Repair for the Treatment of Isolated Type II SLAP Lesions in Non-Overhead Athletes. Orthop Surg. 2022;14(7):1340-49. doi: 10.1111/os.13229. PMID: 35633041; PMCID: PMC9251294.

28.Rothermich MA, Ryan MK, Fleisig GS, Layton BO, Mussell EA, Andrews JR, et al. Clinical outcomes and return to play in softball players following SLAP repair or biceps tenodesis. J Shoulder Elbow Surg. 2023;32(5):924-30. doi: 10.1016/j.jse.2022.10.025. PMID: 36442830.

29.Schrøder CP, Skare Ø, Reikerås O, Mowinckel P, Brox JI. 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. 2017;51(24):1759-66. doi: 10.1136/bjsports-2016-097098. PMID: 28495804; PMCID: PMC5754846.

30.Martínez-Cano JP, Llinás PJ, Escobar SS, López R, Caicedo Álvaro, Herrera G. Validación de la versión en español para Colombia de la escala ASES. RELART. 2022;29(01):22-27.

31.Ahmed R, Lanham NS, Peterson JR, Jobin CM, Levine WN. Characterization of ASES score pain and functional improvement after anatomic total shoulder arthroplasty: a patient-centered perspective. J Shoulder Elbow Surg. 2022;31(5):1042-1046. doi: 10.1016/j.jse.2021.10.031. PMID: 34808350.

32.Sandler AB, Scanaliato JP, Baird MD, Dunn JC, Parnes N. Lower Reoperation and Higher Return-to-Sport Rates After Biceps Tenodesis Versus SLAP Repair in Young Patients: A Systematic Review. Arthrosc Sports Med Rehabil. 2022;4(5):e1887-95. doi: 10.1016/j.asmr.2022.07.004. PMID: 36312714; PMCID: PMC9596896.

33.Civan O, Bilsel K, Kapicioglu M, Ozenci AM. Repair versus biceps tenodesis for the slap tears: A systematic review.  J Orthop Surg (Hong Kong). 2021;29(2):23094990211004794. doi: 10.1177/23094990211004794. PMID: 33882738.

34.de SA D, Arakgi ME, Lian J, Crum RJ, Lin A, Lesniak BP. Labral Repair Versus Biceps Tenodesis for Primary Surgical Management of Type II Superior Labrum Anterior to Posterior Tears: A Systematic Review. Arthroscopy. 2019;35(6):1927-38. doi: 10.1016/j.arthro.2018.12.015. PMID: 31053457.

Annex 1. Publication bias assessment using funnel plots for the different variables analyzed.

ASES score

VAS score

Return to sports activities

Reoperation rate