A Novel Arthroscopic Inside-Out Repair Technique for PASTA Lesions

Abstract

There is no current consensus in the literature on the optimal technique for surgical treatment of partial articular-sided supraspinatus tendon avulsion (PASTA) lesions, although most techniques described to date require takedown of the partially torn tendon or passage of an anchor through the already damaged tendon. We describe a novel inside-out repair technique for partial articular surface supraspinatus tears that does not require further disruption of the partially torn tendon by passage of an anchor.P artial-thickness rotator cuff tears (PTRCTs) have long been recognized as distinct from full-thickness rotator cuff tears. They have been noted in as many as 26% of asymptomatic patients aged 40 to 60 years 1 but can present with a wide spectrum of symptoms including a higher level of reported pain than fullthickness tears. 2 They have also been noted to occur in the younger population, particularly overhead throwing athletes. 3 Only recently, however, has the literature recognized articular-sided PTRCTs as distinct from bursal-sided PTRCTs in both mechanism and potential treatment modalities. 4 Articular surface PTRCTs are reported 2 to 3 times more commonly than bursal-only PTRCTs in the literature. 5 More partial-thickness tears in older patients are articular-sided supraspinatus tears than bursal sided, and the most commonly reported tear in younger overhead throwing athletes is on the articular side at the supraspinatus-infraspinatus junction. 4 It has been noted that there is a relative hypovascularity of the articular surface of the supraspinatus tendon compared with the bursal surface, which may contribute to the higher incidence of degenerative tearing of the articular surface at the insertion of the supraspinatus. 6 The articular and bursal sides of the supraspinatus differ in their histology as well: The bursal side of the cuff contains mainly tendinous bundles, giving it a greater tensile strength, whereas the articular side is a more complex mixture of ligament, capsule, and tendon. 7 Although the initial treatment for most articular-sided PTRCTs is nonoperative and symptomatically oriented, the natural history of these lesions remains unclear. Cadaveric studies have shown an increase in strain on the remaining intact supraspinatus tendon during abduction when a 33% thickness partial articular-sided supraspinatus avulsion (PASTA) lesion is created, 8 and a serial arthrography study found that 27% of articular-sided tears progressed to full-thickness tears over a 1-year period whereas only 10% appeared to heal completely. 9 This finding suggests that even when nonoperative treatment is successful in resolving symptoms, it is unlikely that this represents healing of the tear. Failure of conservative management is considered an indication for surgical intervention.There is no consensus in the literature regarding the ideal technique for treatment of PASTA lesions, although many techniques have been described, including simple debridement, tear completion and complete repair, and a variety ...

All-Inside Arthroscopic Partial Articular-Sided Supraspinatus Tendon Avulsion (PASTA) Repair Without Bunching of the Bursal Side of the Tendon

“… 12 Many surgical techniques were reported to treat the PASTA lesion. 16 , 17 , 18 , 19 , 20 This PASTA repair technique differs from the previous technique in that it offers various advantages, including no tendon bunching on the bursal side or an overtensioned rotator cuff tendon, preservation of the intact tendon, superior biomechanical strength compared to tendon takedown and repair, and less articular cartilage injury due to the soft suture anchor. This procedure is performed on a beach chair with standard shoulder arthroscopy equipment and can also be performed in the lateral decubitus position, depending on the surgeon's preference.…”

Partial Articular Supraspinatus Tendon Avulsion Repair and Patch: A Technical Note for Augmenting the Supraspinatus Reinsertion with the Long Head of the Biceps Tendon

“…There are several techniques employed for repairing PASTA, most of them focusing on variations of debridement and anchor fixation 8–12 . However, the biceps tendon‐supraspinatus complex biomechanical relationship may influence the tear characteristics, especially in young and active patients with borderline sized lesions, that make choosing between repair or debridement with or without long head of the biceps tendon (LHBT) tenodesis not as straight‐forward, and currently there is little data on this matter 13–15 .…”

“…3 There are several techniques employed for repairing PASTA, most of them focusing on variations of debridement and anchor fixation. [8][9][10][11][12] However, the biceps tendonsupraspinatus complex biomechanical relationship may influence the tear characteristics, especially in young and active patients with borderline sized lesions, that make choosing between repair or debridement with or without long head of the biceps tendon (LHBT) tenodesis not as straight-forward, and currently there is little data on this matter. [13][14][15] Reports on medial rotator-cuff failure following repair of PASTA lesions, especially after transtendon repair, have noted that although clinical outcomes seem to improve following repair, there is still a high incidence of failure and progression towards full-thickness rotator-cuff defects.…”

The Fall Classic

“…C. Now, quickly, how many of the following arthroscopic and related techniques seem clinically relevant? Lateral patellotibial ligament reconstruction for medial patellar instability 4 ORIF of distal clavicle fracture with supplementary button coracoclavicular fixation 5 Arthroscopic decompression of central acetabular impingement with notchplasty 6 Transtendon, double-row, transosseous equivalent arthroscopic repair of partial-thickness, articular surface rotator cuff tears 7 Novel arthroscopic inside-out repair technique for pasta lesions 8 Arthroscopic treatment of subscapularis calcific tendonitis 9 ACL reconstruction with preservation of femoral ACL stump 10 Anatomic graft passage in remnant-preserving posterior cruciate ligament reconstruction 11 Anatomic reconstruction of chronic coracoclavicular ligaments tears: Arthroscopic-assisted approach with non-rigid mechanical fixation and graft augmentation 12 Medial patellofemoral ligament reconstruction: A technique with a "V" shaped patella tunnel 13 Arthroscopic anatomic reconstruction of the lateral ligaments of the ankle with gracilis autograft 14 Capsulotomy first: A novel concept for hip arthroscopy 15 What we find to be cool in this Fall Classic, as the Northern Hemisphere grows cool this time of year, is that the 12 techniques from the quiz represent the 12 PubMed Central cited Arthroscopy Techniques articles with videos published in September! [16][17][18][19] We have taken this quiz ourselves, because we wanted to judge the clinical relevance of Arthroscopy Techniques.…”