SLAP & PASTA lesions presentation at Results Physical Therapy Education Forum, Sacramento, CA January 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 A’s
MiLB - AAA

2. SLAP LESIONS

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 – 50% Sensitivity; MRA – 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 “debridement
of pRCT and Bankart repair.”
• Presented 6/2010 with significantly increased
pain and limited Abd-ER

6. Beware the MGHL Band

7. SLAP Repair: PushLock

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:
– 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. Fixation Options

11. SLAP Repair: Suture Anchor

12. Knot Stacks

13. Knot Stacks

14. Knot Stacks
Courtesy of Dr. Neal ElAttrache

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. Labral Sewing

17. Labral Reconstruction
Labral Sewing

18. PASTA LESIONS

19. PASTA Lesions

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 Lo
Ellman H, Clin Orthop 254:64-74, 1990.
Nottage W et al., AANA, Washington DC, 2002.

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. 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. 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. Repair Options
• Debridement
• “Complete the Tear”
• Trans-osseous suture arthroscopic repair (Tauber)
• Trans-tendon repair (Burkhart, Romeo, Snyder)

25. PASTA Repair: Trans-tendon

26. Traditional RC Techniques
Anchor depth Distal-lateral
determines fixation improves
compression compression
Suture anchor Transosseous

27. Rationale for a New Technique
• Suture anchor technically challenging
• Couldn’t address broad Anterior-Posterior lesions

28. PASTA Bridge
• Combines a horizontal mattress & bridging style repair
• Does NOT require ANY arthroscopic knot tying

29. PASTA Bridge
• Combines a horizontal mattress & bridging style repair
• Does NOT require ANY arthroscopic knot tying

30. Pasta Bridge Technique

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:
– 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. 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. PASTA Bridge – Methods of Failure

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
– 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. Results
Pain Scores ASES Scores
8.0 80.0
7.0 70.0
6.0 60.0
5.0 50.0
4.0 40.0
3.0 30.0
2.0 20.0
1.0 10.0
0.0 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. 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

40. Extension Bridge

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
– 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. 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 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 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. 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. Study
• Conclusion
– PRP aids healing of PASTA repairs
– PRP with concentrated WBC’s may create a
“Zone of Weakness”
– Neutrophils most likely culprit

46. FlexiGraft DBM Sponge
• Partially demineralized cancellous sponges
– Ground
– Cubes
– Strips
• Demineralized cortical fibers

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. 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. Flexigraft – 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
– 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. FlexiGraft – PASTA Bridge

52. PASTABridge
VAS ASES
7.0 80.0
6.0 70.0
60.0
5.0
50.0
4.0
40.0
3.0
30.0
2.0
20.0
1.0 10.0
0.0 0.0
 Study Group
 Control Group

53. Study Design - SutureBridge
Study 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. FlexiGraft – SutureBridge

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
 Study Group
 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:
– 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. Thank You!