What are the management options for a patient with squeaking hardware after a SLAP (Superior Labrum Anterior to Posterior) tear repair?

Management of Squeaking Hardware After SLAP Tear Repair

For patients with squeaking hardware after SLAP tear repair, hardware removal with possible biceps tenodesis is recommended as the most effective treatment option.

Diagnostic Approach

• Initial evaluation should include magnetic resonance imaging (MRI), MR arthrography, or ultrasonography to identify the exact position of hardware and assess for associated pathology 1
• CT arthrography may be considered if MRI is contraindicated, as it can effectively evaluate both bony lesions and soft-tissue injuries 1
• Physical examination should focus on identifying mechanical symptoms, range of motion limitations, and pain patterns associated with specific movements 1

Understanding the Problem

• Squeaking hardware after SLAP repair represents a mechanical complication that can significantly impact quality of life and function 2
• Failed SLAP repairs are multifactorial and may be due to:
  • Hardware prominence or loosening
  • Improper anchor placement
  • Overtensioning of the labral repair
  • Biological failure to heal 2, 3
• Patients typically present with pain, decreased range of motion, and mechanical symptoms including audible squeaking with shoulder movement 4

Management Algorithm

Step 1: Conservative Management (First-Line Approach)

• Physical therapy focusing on rotator cuff and periscapular strengthening exercises 5
• Activity modification to avoid positions that provoke symptoms 3
• Corticosteroid injection may provide temporary relief but has limited long-term efficacy in cases with mechanical symptoms from hardware 5
• Note: Conservative treatment has a high failure rate (71%) in patients with poor outcomes after SLAP repair, particularly when mechanical symptoms like squeaking are present 4

Step 2: Surgical Management (For Failed Conservative Treatment)

• Hardware removal is the primary intervention for symptomatic hardware causing mechanical symptoms like squeaking 2
• Surgical options include:
  1. Hardware removal alone: For cases with well-healed labrum and no other pathology 2
  2. Hardware removal with biceps tenodesis: Preferred for patients over 30 years old or those with concomitant pathology 3
  3. Hardware removal with revision SLAP repair: Generally reserved for younger (<30 years) overhead athletes 3

Factors Affecting Treatment Decision

• Age: Patients over 30 years have better outcomes with biceps tenodesis rather than revision SLAP repair 3
• Activity level: Overhead athletes may benefit from revision repair, while non-overhead athletes typically do better with biceps tenodesis 3
• Associated pathology: Presence of rotator cuff tears or glenohumeral arthritis may influence treatment choice 1

Expected Outcomes

• Approximately 62% of patients report satisfaction after revision surgery for failed SLAP repairs 4
• Even with appropriate surgical intervention, 32% of patients may continue to have suboptimal results 4
• Return to pre-injury level of function is more likely in non-overhead athletes and recreational athletes compared to elite overhead athletes 6

Post-Surgical Rehabilitation

• Early mobilization is recommended to prevent stiffness 1
• Supervised physical therapy focusing on rotator cuff strengthening, scapular stabilization, and gradual return to activity 1
• Return to sports should be based on functional testing rather than arbitrary time points 1

Common Pitfalls to Avoid

• Delaying surgical intervention when mechanical symptoms are present, as conservative management is less likely to be successful 4
• Attempting revision SLAP repair in older patients (>30 years), as biceps tenodesis typically provides better outcomes 3
• Failing to address concomitant pathology during revision surgery 2