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SLAP & PASTA Lesions                Alan M. Hirahara, M.D., FRCS(C)       Board Certified in Orthopaedic Surgery & Orthopa...
SLAP LESIONS
SLAP Lesions        • Superior (Top)        • Labral        • Anterior (Front)        • Posterior (Back)                  ...
MRI vs. MRAMRI – 50% Sensitivity; MRA – 93% Sensitivity                                   Rafii et al. Radiol Clin North A...
Beware the Buford Complex• 58 yo female with anterior shoulder pain since   8/08, without trauma. Surgeon took her to   su...
Beware the MGHL Band
SLAP Repair: PushLock
Enhancing SLAP repairs with        Fibrin-PRP Clots                             Alan M Hirahara, MD, FRCSC                ...
Study• Case-Control study design• 178 patients with SLAP repair with & without PRP• Study group had statistically signific...
Fixation Options
SLAP Repair: Suture Anchor
Knot Stacks
Knot Stacks
Knot Stacks              Courtesy of Dr. Neal ElAttrache
Labral Deficiency• 40 yo woman h/o superior  labral resection• c/o grinding with arm going  above shoulder with severe,  p...
Labral Sewing
Labral Reconstruction   Labral Sewing
PASTA LESIONS
PASTA Lesions
Determining PASTA Size         • Ellman et al – Normal cuff 10-12 mm thick         • Nottage et al                  – Expo...
Determining PASTA Size• “Shaver Method”• Ultrasound  – Smith et al. Clin Radiol. 2011 – Meta-analysis     •   62 studies /...
To Repair or Not To Repair?          • > or < 50% - Classic indication(1-4)          • Abrams: 25% - 50% - a questionable ...
Current Recommendation• Romeo et al. Arthroscopy. 2011   – Literature review – 16 studies   – Excellent outcomes 28.7% - 9...
Repair Options• Debridement• “Complete the Tear”• Trans-osseous suture arthroscopic repair (Tauber)• Trans-tendon repair (...
PASTA Repair: Trans-tendon
Traditional RC Techniques        Anchor depth         Distal-lateral        determines           fixation improves        ...
Rationale for a New Technique• Suture anchor technically challenging• Couldn’t address broad Anterior-Posterior lesions
PASTA Bridge• Combines a horizontal mattress & bridging style repair• Does NOT require ANY arthroscopic knot tying
PASTA Bridge• Combines a horizontal mattress & bridging style repair• Does NOT require ANY arthroscopic knot tying
Pasta Bridge Technique
PASTA Bridge - A New Technique in PASTA Repairs: A BiomechanicalEvaluation of Construct Strength vs.          Suture Ancho...
Study: Construct Strength• 12 cadaveric shoulders (6 matched pairs)• 50% thickness, 1 cm wide PASTA lesion created in each...
PASTA Bridge: Construct Strength      Comparison Study                            SutureTak and SwiveLock PASTA Repair    ...
PASTA Bridge – Methods of Failure
PASTA Bridge - A New   Technique in PASTA Repairs:       A Clinical Evaluation                            Alan M Hirahara,...
PASTA Bridge Clinical Study          Preliminary Results• Case-Control analysis of 76 patients    – 50 study patients – PA...
Results                     Pain Scores                                          ASES Scores8.0                           ...
Results - Failures                 Failures             4 4                               33.5 32.5 21.5 1          4/26  ...
Conclusion• No significant difference between groups• Will require a randomized controlled trial• Easy, percutaneous techn...
Extension Bridge
Increased Concentration of White Blood Cells in PRP Weakens Rotator Cuff Tendons When Used for PASTA                Repair...
Study Design• Case-Control study design• 3 Groups    – Group 1: 14 patients, PASTA repair without PRP    – Group 2: 72 pat...
WBC’s: Harmful to Healing          •        The inflammatory response can cause muscle damage                     –      N...
Study• No significant difference in improvement of ASES &  VAS scores• Significant difference in Modes of Failure   – Grou...
Study• Conclusion  – PRP aids healing of PASTA repairs  – PRP with concentrated WBC’s may create a    “Zone of Weakness”  ...
FlexiGraft DBM Sponge• Partially demineralized cancellous sponges  – Ground  – Cubes  – Strips• Demineralized cortical fib...
Literature• Re: Tendon-to-bone healing. “Increase in the strength of the  interface … [is] proportional to the amount of o...
Literature• DBM produced significantly more  fibrocartilage & mineralized fibrocartilage  at 12-week post-op, showing a mo...
Flexigraft – Clinical Effectiveness in          Rotator Cuff Repairs                               Alan M Hirahara, MD, FR...
Study Design - PASTABridgeStudy                               Control• 7 patients                        • 35 patients   –...
FlexiGraft – PASTA Bridge
PASTABridgeVAS             ASES7.0             80.06.0             70.0                60.05.0                50.04.0     ...
Study Design - SutureBridgeStudy                               Control• 9 patients                        • 45 patients   ...
FlexiGraft – SutureBridge
SutureBridgeVAS              ASES9.0              80.08.0              70.07.0              60.06.0                 50.05....
Future Research•   Investigator: James Cook, DVM, PhD, University of Missouri•   Objective: To assess the effects of Flexi...
Thank You!
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SLAP & PASTA Lesions 01-2013

SLAP & PASTA lesions presentation at Results Physical Therapy Education Forum, Sacramento, CA January 2013

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SLAP & PASTA Lesions 01-2013

  1. 1. SLAP & PASTA Lesions Alan M. Hirahara, M.D., FRCS(C) Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine Specializing in arthroscopic shoulder surgery Medical Director Team Physician ConsultantSacramento State Athletics Sacramento River Cats Oakland A’s MiLB - AAA
  2. 2. SLAP LESIONS
  3. 3. SLAP Lesions • Superior (Top) • Labral • Anterior (Front) • Posterior (Back) Maffet et al., Am J Sports Med, 1995; 23:93-98
  4. 4. MRI vs. MRAMRI – 50% Sensitivity; MRA – 93% Sensitivity Rafii et al. Radiol Clin North Am 1998, 36: 609-633
  5. 5. Beware the Buford Complex• 58 yo female with anterior shoulder pain since 8/08, without trauma. Surgeon took her to surgery 2/2009 and performed “debridement of pRCT and Bankart repair.”• Presented 6/2010 with significantly increased pain and limited Abd-ER
  6. 6. Beware the MGHL Band
  7. 7. SLAP Repair: PushLock
  8. 8. Enhancing SLAP repairs with Fibrin-PRP Clots Alan M Hirahara, MD, FRCSC Kyle Yamashiro, PT Russ Dunning, MSPT*Presented @ AANA, AOSSM, COA, WOA 2009
  9. 9. Study• Case-Control study design• 178 patients with SLAP repair with & without PRP• Study group had statistically significant: – Improved pain scores from 3 months & on – Improved ASES scores from 1 month & on – Improved time to discharge by 91 days – Improved return to work by 59.4 days – Improved failure rate from 10.3% (Control) to 0.7% (Study)• Conclusion – PRP ensures the healing process is initiated properly where placed
  10. 10. Fixation Options
  11. 11. SLAP Repair: Suture Anchor
  12. 12. Knot Stacks
  13. 13. Knot Stacks
  14. 14. Knot Stacks Courtesy of Dr. Neal ElAttrache
  15. 15. Labral Deficiency• 40 yo woman h/o superior labral resection• c/o grinding with arm going above shoulder with severe, progressively worsening pain
  16. 16. Labral Sewing
  17. 17. Labral Reconstruction Labral Sewing
  18. 18. PASTA LESIONS
  19. 19. PASTA Lesions
  20. 20. Determining PASTA Size • Ellman et al – Normal cuff 10-12 mm thick • Nottage et al – Exposed bone between cuff / articular margin = 1.7 mm – If interval > 7 mm, then > 50% thickness tear • PASTA Depth Guide – Ian LoEllman H, Clin Orthop 254:64-74, 1990.Nottage W et al., AANA, Washington DC, 2002.
  21. 21. Determining PASTA Size• “Shaver Method”• Ultrasound – Smith et al. Clin Radiol. 2011 – Meta-analysis • 62 studies / 6066 shoulders • Partial RCT Sensitivity 0.84 / Specificity 0.89 • Full RCT Sensitivity 0.96 / Specificity 0.93 • Technician dependent
  22. 22. To Repair or Not To Repair? • > or < 50% - Classic indication(1-4) • Abrams: 25% - 50% - a questionable region? (5)Ellman. Clin Orthop 254:64-74, 1990.Gartsman et al. J Shoulder Elbow Surg 4:228-241. 1995.Nottage et al. AANA, Washington DC, 2002.Wright et al. J Shoulder Elbow Surg, 5:458-466, 1996.Abrams. AAOS ICL, 2002.
  23. 23. Current Recommendation• Romeo et al. Arthroscopy. 2011 – Literature review – 16 studies – Excellent outcomes 28.7% - 93% – Debridement of pRCT < 50% -> Good/Excellent outcomes • Associated progression to fRCT = 6.5 – 34.6% – > 50% -> Excellent results • Using takedown, trans-tendon, or trans-osseous repairs
  24. 24. Repair Options• Debridement• “Complete the Tear”• Trans-osseous suture arthroscopic repair (Tauber)• Trans-tendon repair (Burkhart, Romeo, Snyder)
  25. 25. PASTA Repair: Trans-tendon
  26. 26. Traditional RC Techniques Anchor depth Distal-lateral determines fixation improves compression compressionSuture anchor Transosseous
  27. 27. Rationale for a New Technique• Suture anchor technically challenging• Couldn’t address broad Anterior-Posterior lesions
  28. 28. PASTA Bridge• Combines a horizontal mattress & bridging style repair• Does NOT require ANY arthroscopic knot tying
  29. 29. PASTA Bridge• Combines a horizontal mattress & bridging style repair• Does NOT require ANY arthroscopic knot tying
  30. 30. Pasta Bridge Technique
  31. 31. PASTA Bridge - A New Technique in PASTA Repairs: A BiomechanicalEvaluation of Construct Strength vs. Suture Anchors Alan M Hirahara, MD, FRCSC*Presented @ AANA, COA, WOA, WSTC-EFOST 2012
  32. 32. Study: Construct Strength• 12 cadaveric shoulders (6 matched pairs)• 50% thickness, 1 cm wide PASTA lesion created in each shoulder• For each pair: – Titanium corkscrew anchor with single horizontal mattress repair – PASTA bridge repair – 2 – 2.4 BC ST & 1 – 4.5 VSL• Load to Failure & Mode of Failure
  33. 33. PASTA Bridge: Construct Strength Comparison Study SutureTak and SwiveLock PASTA Repair Ultimate Load Donor # Gender Age Mode of Failure (N) 10-09064 M 62 1637 humeral head broke 10-08024 M 27 1499 tendon tore mid-substance 10-11021 F 53 811 tendon tore at repair 10-09062 F 52 899 humeral head broke 11-01032 M 46 402 muscle body tore from tendon 10-10068 F 53 810 muscle body tore from tendon Average 49 1010 Standard Deviation 12 468 Titanium Corkscrew PASTA Repair Ultimate Load Donor # Gender Age Mode of Failure (N) 10-09064 M 62 1398 muscle body tore from tendon 10-08024 M 27 1642 tendon tore at repair 10-11021 F 53 922 humeral head broke 10-09062 F 52 969 tendon tore at repair 11-01032 M 46 1003 muscle body tore from tendon 10-10068 F 53 575 tendon tore at repair Average 49 1085 Standard Deviation 12 378
  34. 34. PASTA Bridge – Methods of Failure
  35. 35. PASTA Bridge - A New Technique in PASTA Repairs: A Clinical Evaluation Alan M Hirahara, MD, FRCSC*Presented @ AANA, COA, WOA, WSTC-EFOST 2012
  36. 36. PASTA Bridge Clinical Study Preliminary Results• Case-Control analysis of 76 patients – 50 study patients – PASTA Bridge repair – 26 control patients – Trans-tendon repair• Inclusions: All PASTA repairs, > 25% thickness• Exclusions: Any post-op trauma or non-compliance• Failure to heal: Evaluated any symptoms 4-6 months post-op with repeat MRA or surgery
  37. 37. Results Pain Scores ASES Scores8.0 80.07.0 70.06.0 60.05.0 50.04.0 40.03.0 30.02.0 20.01.0 10.00.0 0.0 Pre-op 1 2 3 4 5 6 Pre-op 1 2 3 4 5 6 Month Month Month Month Month Month Month Month Month Month Month Month  Control Group: n = 26  Study Group: n = 50
  38. 38. Results - Failures Failures 4 4 33.5 32.5 21.5 1 4/26 3/500.5 0 Control Group Study Group
  39. 39. Conclusion• No significant difference between groups• Will require a randomized controlled trial• Easy, percutaneous technique• Minimal risk of damaging shoulder during surgery• Proven biomechanical strength
  40. 40. Extension Bridge
  41. 41. Increased Concentration of White Blood Cells in PRP Weakens Rotator Cuff Tendons When Used for PASTA Repairs Alan M Hirahara, MD, FRCSC*Presented @ WOA 2011 & WSTC-EFOST 2012 / Accepted for Presentation @ AANA 2013
  42. 42. Study Design• Case-Control study design• 3 Groups – Group 1: 14 patients, PASTA repair without PRP – Group 2: 72 patients, PASTA repair with PRP with concentrated WBC’s – Group 3: 29 patients, PASTA repair with PRP with reduced WBC’s• MRA or surgery was performed for people having persistent pain or complaints at four to six months post-operatively to evaluate healing
  43. 43. WBC’s: Harmful to Healing • The inflammatory response can cause muscle damage – Neutrophils can delay regenerative healing capacity1 – Neutrophils cause cytotoxic destruction of muscle2 • WBCs can suppress bone formation and bone healing – Neutropenic mice—higher bending moment at fracture callus site3 – Immunosuppressed rats; implanted DBM had enhanced bone formation4 • Concentrated WBCs may be detrimental toward wound healing – Neutropenic mice had accelerated wound closure and healing5 – PU.1 null mice (lack neutrophils and macrophages) repair wounds in a scar-free manner, similar to embryonic healing6 – Oral mucosa wounds heal fast without scarring—have reduced influx of neutrophils and macrophages71. Toumi H et al. The inflammatory response: friend or enemy for muscle injury? Br J Sports Med 2003; 37(4): 284-6.2. Schneider BS et al. Neutrophil infiltration in exercise-injured skeletal muscle: how do we resolve the controversy? Sports Med 2007; 37(10): 837-56.3. Grogaard B et al. The polymorphonuclear leukocyte: has it a role in fracture healing? Arch Orthop Trauma Surg 1990; 109(5): 268-71.4. Voggenreiter G et al. Immunosuppression with FK506 increases bone induction in demineralized isogenic and xenogenic bone matrix in the rat. J Bone Miner Res 2000; 15(9): 1825-34.5. Dovi JV et al. Accelerated wound closure in neutrophil-depleted mice. J Leukoc Biol 2003; 73(4): 449-55.6. Martin P et al. Wound healing in the PU.1 null mouse—tissue repair is not dependent on inflammatory cells. Curr Biol 2003; 13(13): 1122-8.7. Szpaderka AM. Differential injury responses in oral mucosal and cutaneous wounds. J Dent Res 2003; 82(8): 621-6.
  44. 44. Study• No significant difference in improvement of ASES & VAS scores• Significant difference in Modes of Failure – Group 1: 2 (14%) fail by non-healing of primary lesion – Group 2: 10 (14%) fail by cut-through from sutures • 2 (3.5%) fail by non-healing of primary lesion – Group 3: 1 (3.5%) fail by different, new delamination tear
  45. 45. Study• Conclusion – PRP aids healing of PASTA repairs – PRP with concentrated WBC’s may create a “Zone of Weakness” – Neutrophils most likely culprit
  46. 46. FlexiGraft DBM Sponge• Partially demineralized cancellous sponges – Ground – Cubes – Strips• Demineralized cortical fibers
  47. 47. Literature• Re: Tendon-to-bone healing. “Increase in the strength of the interface … [is] proportional to the amount of osseous ingrowth.” • Rodeo, Arnoczky et al., JBJS(A) 1993;75: 1795–1803• Improving the osteoconductive/inductive environment improves tendon-bone healing • Shen H, et al. Int Orthop. 2010;34;(6)917-24. • Hioki S, et al. Am J Sports Med. 2012;40;(8)1772-80. • Kadonishi Y, et al. JBJS(B). 2012;94;(2)205-9.
  48. 48. Literature• DBM produced significantly more fibrocartilage & mineralized fibrocartilage at 12-week post-op, showing a more mature, organized tendon-bone interface – Sundar et al. • J Biomed Mater Res. 2009; 88B: 115-122 • J Bone Joint Surg Br. 2009;91;(9)1257-62
  49. 49. Flexigraft – Clinical Effectiveness in Rotator Cuff Repairs Alan M Hirahara, MD, FRCSC*Presented @ North American Faculty Forum 2013
  50. 50. Study Design - PASTABridgeStudy Control• 7 patients • 35 patients – 6 male / 1 female – 15 male / 20 female – Age mean: 45.11 (27 – 67 yo) – Age mean: 52.07 (22 – 80 yo)• 2 revisions • 3 revisions
  51. 51. FlexiGraft – PASTA Bridge
  52. 52. PASTABridgeVAS ASES7.0 80.06.0 70.0 60.05.0 50.04.0 40.03.0 30.02.0 20.01.0 10.00.0 0.0  Study Group  Control Group
  53. 53. Study Design - SutureBridgeStudy Control• 9 patients • 45 patients – 5 male / 4 female – 25 male / 20 female – Age mean: 61.61 (55 – 68 yo) – Age mean: 56.64 (34 – 78 yo)• 2 revisions • 9 revisions
  54. 54. FlexiGraft – SutureBridge
  55. 55. SutureBridgeVAS ASES9.0 80.08.0 70.07.0 60.06.0 50.05.0 40.04.0 30.03.02.0 20.01.0 10.00.0 0.0  Study Group  Control Group
  56. 56. Future Research• Investigator: James Cook, DVM, PhD, University of Missouri• Objective: To assess the effects of FlexiGraft for rotator cuff tendon-to-bone healing in a canine model of a chronic rotator cuff tear using MRI, biomechanical testing and histology.• Experimental design: – Chronic Infraspinatus canine model (n=10 dogs), bilateral shoulders (release tendon, wait 4 weeks) – FlexiGraft+ACP vs. Direct Repair (n=10 shoulders per group) – SpeedFix Repair – SwiveLock and FiberTape – @ 12 weeks post-op • MRI (n=10 dogs, 20 shoulders) • Biomech testing (destructive, n=5 each group) • Histo (n=5 each group)
  57. 57. Thank You!

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