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SLAP & PASTA Lesions 01-2013
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 Consultant
Sacramento State Athletics Sacramento River Cats Oakland Aâs
MiLB - AAA
3. SLAP Lesions
⢠Superior (Top)
⢠Labral
⢠Anterior (Front)
⢠Posterior (Back)
Maffet et al., Am J Sports Med, 1995; 23:93-98
4. MRI vs. MRA
MRI â 50% Sensitivity; MRA â 93% Sensitivity
Rafii et al. Radiol Clin North Am 1998, 36: 609-633
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 âdebridement
of pRCT and Bankart repair.â
⢠Presented 6/2010 with significantly increased
pain and limited Abd-ER
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. Study
⢠Case-Control study design
⢠178 patients with SLAP repair with & without PRP
⢠Study group had statistically significant:
â Improved pain scores from 3 months & on
â Improved ASES scores from 1 month & on
â Improved time to discharge by 91 days
â Improved return to work by 59.4 days
â Improved failure rate from 10.3% (Control) to 0.7% (Study)
⢠Conclusion
â PRP ensures the healing process is initiated properly where placed
15. Labral Deficiency
⢠40 yo woman h/o superior
labral resection
⢠c/o grinding with arm going
above shoulder with severe,
progressively worsening pain
20. Determining PASTA Size
⢠Ellman et al â Normal cuff 10-12 mm thick
⢠Nottage et al
â Exposed bone between cuff / articular margin = 1.7 mm
â If interval > 7 mm, then > 50% thickness tear
⢠PASTA Depth Guide â Ian Lo
Ellman H, Clin Orthop 254:64-74, 1990.
Nottage W et al., AANA, Washington DC, 2002.
31. PASTA Bridge - A New Technique in
PASTA Repairs: A Biomechanical
Evaluation of Construct Strength vs.
Suture Anchors
Alan M Hirahara, MD, FRCSC
*Presented @ AANA, COA, WOA, WSTC-EFOST 2012
32. Study: Construct Strength
⢠12 cadaveric shoulders (6 matched pairs)
⢠50% thickness, 1 cm wide PASTA lesion created in each
shoulder
⢠For each pair:
â Titanium corkscrew anchor with single horizontal mattress
repair
â PASTA bridge repair â 2 â 2.4 BC ST & 1 â 4.5 VSL
⢠Load to Failure & Mode of Failure
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
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. PASTA Bridge Clinical Study
Preliminary Results
⢠Case-Control analysis of 76 patients
â 50 study patients â PASTA Bridge repair
â 26 control patients â 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
38. Results - Failures
Failures
4
4
3
3.5
3
2.5
2
1.5
1
4/26 3/50
0.5
0
Control Group Study Group
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
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. Study Design
⢠Case-Control study design
⢠3 Groups
â Group 1: 14 patients, PASTA repair without PRP
â Group 2: 72 patients, PASTA repair with PRP with concentrated WBCâs
â Group 3: 29 patients, PASTA repair with PRP with reduced WBCâs
⢠MRA or surgery was performed for people having persistent pain or
complaints at four to six months post-operatively to evaluate healing
43. WBCâs: Harmful to Healing
⢠The inflammatory response can cause muscle damage
â Neutrophils can delay regenerative healing capacity1
â Neutrophils cause cytotoxic destruction of muscle2
⢠WBCs can suppress bone formation and bone healing
â Neutropenic miceâhigher bending moment at fracture callus site3
â Immunosuppressed rats; implanted DBM had enhanced bone formation4
⢠Concentrated WBCs may be detrimental toward wound healing
â Neutropenic mice had accelerated wound closure and healing5
â PU.1 null mice (lack neutrophils and macrophages) repair wounds in a scar-free manner, similar to
embryonic healing6
â Oral mucosa wounds heal fast without scarringâhave reduced influx of neutrophils and macrophages7
1. 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 mouseâtissue 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. Study
⢠No significant difference in improvement of ASES &
VAS scores
⢠Significant difference in Modes of Failure
â Group 1: 2 (14%) fail by non-healing of primary lesion
â Group 2: 10 (14%) fail by cut-through from sutures
⢠2 (3.5%) fail by non-healing of primary lesion
â Group 3: 1 (3.5%) fail by different, new delamination tear
45. Study
⢠Conclusion
â PRP aids healing of PASTA repairs
â PRP with concentrated WBCâs may create a
âZone of Weaknessâ
â Neutrophils most likely culprit
47. Literature
⢠Re: Tendon-to-bone healing. âIncrease in the strength of the
interface ⌠[is] proportional to the amount of osseous ingrowth.â
⢠Rodeo, Arnoczky et al., JBJS(A) 1993;75: 1795â1803
⢠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. Literature
⢠DBM produced significantly more
fibrocartilage & mineralized fibrocartilage
at 12-week post-op, showing a more
mature, organized tendon-bone interface
â Sundar et al.
⢠J Biomed Mater Res. 2009; 88B: 115-122
⢠J Bone Joint Surg Br. 2009;91;(9)1257-62
49. Flexigraft â Clinical Effectiveness in
Rotator Cuff Repairs
Alan M Hirahara, MD, FRCSC
*Presented @ North American Faculty Forum 2013
50. Study Design - PASTABridge
Study Control
⢠7 patients ⢠35 patients
â 6 male / 1 female â 15 male / 20 female
â Age mean: 45.11 (27 â 67 yo) â Age mean: 52.07 (22 â 80 yo)
⢠2 revisions ⢠3 revisions
55. SutureBridge
VAS ASES
9.0 80.0
8.0 70.0
7.0 60.0
6.0
50.0
5.0
40.0
4.0
30.0
3.0
2.0 20.0
1.0 10.0
0.0 0.0
ď Study Group
ď Control Group
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:
â Chronic Infraspinatus canine model (n=10 dogs), bilateral shoulders (release tendon, wait 4
weeks)
â FlexiGraft+ACP vs. Direct Repair (n=10 shoulders per group)
â SpeedFix Repair â SwiveLock and FiberTape
â @ 12 weeks post-op
⢠MRI (n=10 dogs, 20 shoulders)
⢠Biomech testing (destructive, n=5 each group)
⢠Histo (n=5 each group)