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PASTA (partial articular supraspinatus tendon avulsion) lesions of greater than 50% thickness are usually repaired, whereas those of less than 50% thickness receive subacromial decompression and debridement. However, tears of greater than 25% thickness of the tendon result in increased strain of the adjacent, intact tendon fibers. Re-creating the tendon footprint at the greater tuberosity is the goal of a repair. Transtendon repairs have been considered the gold standard in repair but have shown varying outcomes and are technically difficult procedures. This report details the PASTA bridge—a technique for the arthroscopic, percutaneous repair of PASTA lesions. The PASTA bridge uses a spinal needle to ensure the repair includes the leading edge of the good tissue and is at the appropriate angle and area. Most procedures use a knife or trocar blindly to access the joint to place anchors, which has the potential to damage surrounding tissues and result in poor anchor and suture placement. The PASTA bridge is a safe, reliable procedure that is easily reproducible and appropriate for surgeons of all experience levels and should be strongly considered when repairing PASTA lesions.
See video under supplementary data.
Arthroscopic treatment of PASTA (partial articular supraspinatus tendon avulsion) lesions remains at the center of a great deal of debate among surgeons.
Two commonly used methods are the transtendon technique and the “takedown” procedure, in which a partial-thickness tear is completed with an ensuing full-thickness repair. Both have been shown to have comparable clinical outcomes,
found that approximately 50% were articular-sided tendon tears and that most of these lesions involved the anterior supraspinatus tendon. Studies have shown that restoration of the tendon footprint at the greater tuberosity is an important factor in the outcome of rotator cuff repairs.
The PASTA bridge sufficiently re-creates the footprint. We present our technique for the PASTA bridge—an arthroscopic, percutaneous method of repair for PASTA lesions.
Patient Setup and Preparation
The patient is brought to the operating room and placed in the beach-chair position under general anesthesia. A diagnostic arthroscopy is performed initially to determine tissue integrity and the presence of other pathologies. Before the repair, the exposed footprint at the greater tuberosity from the PASTA lesion should be debrided down to bleeding bone in preparation for the procedure (Fig 1).
Medial-Row Preparation and Anchor Placement
A 17-gauge spinal needle is used as a guide to determine anchor placement at the anterior aspect of the medial row while being viewed arthroscopically through a posterior portal (Video 1, Fig 2). Use of the spinal needle ensures the surgeon is using suitable tissue at its leading edge and the needle is at the appropriate entry area and angle. This safeguards against damaging the surrounding structures or the tendon itself because the spinal needle will cause minimal harm if passed blindly multiple times. When using the spinal needle to determine suture passage placement, the surgeon is advised to stay at least 1 cm away from the musculotendinous junction and away from the partially torn tendon (Table 1). For the supraspinatus, the anchors should be placed at the articular margin, but for the infraspinatus, the anchors should follow the normal attachment, leaving a bare spot. The first pass is usually for the anterior-most anchor. Once established, the inner trocar of the spinal needle is replaced with a nitinol wire (Fig 3). A No. 11 blade is used to make a small percutaneous incision. A 2.4-mm Portal Dilator (Arthrex, Naples, FL) is used to dilate the portal over the nitinol wire (Fig 4). The nitinol wire is removed. In this technique a half-pipe spear—as opposed to a full spear—replaces the dilator and is used to guide the punch for creation of the anchor sockets (Fig 5). The half-pipe spear is used so that a smaller hole is made through the rotator cuff. The spear can be moved as necessary to determine optimal anterior anchor placement, usually next to the bicipital groove at the articular margin. Because the greater tuberosity is made of soft, cancellous bone, a punch is used to create a socket (Fig 6). A 3.9-mm Knotless Corkscrew anchor (Arthrex) can be used in this technique (Fig 7). The anchor is placed into the socket.
Table 1Pearls and Pitfalls
Use cannulas to ensure there are no soft-tissue bridges when passing sutures.
Note that progressive dilation of the entry hole limits residual damage.
Place anchors at the articular margin for supraspinatus repair.
Make sure to pass the solid white portion of the TigerWire tail back onto itself for knotless anchors.
Stay away from the musculotendinous junction and tear site when placing the spinal needle.
Bear in mind that posterior anchor placements should follow anatomic attachment sites, not the articular margin, to avoid constraining the shoulder.
Note that the anchors must be tested after placement.
Be aware that the horizontal mattress configuration must be tensioned so that the tendon is abutted to the articular margin.
For placement of the anchor at the posterior aspect of the medial row, the procedure is the same as that of the anchor at the anterior aspect. A 17-gauge spinal needle is used to identify the correct location and leading edge of the appropriate tissue. A nitinol wire replaces the spinal needle. A No. 11 blade is used to make a small percutaneous incision at the nitinol wire. A dilator is exchanged for the wire and then removed when the half-pipe spear is introduced. The spear is adjusted as necessary to ensure optimal anchor placement; then, a punch is used to create a posterior socket. A 3.9-mm Knotless Corkscrew anchor is placed into the socket.
Medial-Row Mattress Fixation
With the medial-row anchors placed, the arthroscope is moved to the subacromial space. The attached TigerWire (Arthrex) from the posterior anchor (Fig 8) and the FiberLink (Arthrex), the looped passing suture, from the anterior anchor (Fig 9) are collected with a grasper and pulled through an 8 × 3–mm PassPort cannula (Arthrex). The TigerWire used in this technique has a white section and a black-and-white striped section (Fig 10). These areas denote changes in diameter, with the solid white area being a smaller diameter. The TigerWire is passed through the FiberLink almost back to the black-and-white striped section so that there is plenty of suture to shuttle through the knotless anchor (Fig 11). The suture end of the FiberLink is then pulled from the anterior anchor to pass the TigerWire until it is snug but not tensioned.
The same process is repeated for the posterior anchor. The FiberLink from the posterior anchor and the TigerWire from the anterior anchor are gathered and pulled with a grasper through the 8 × 3–mm PassPort cannula. The TigerWire is passed through the FiberLink. The suture end at the posterior anchor is pulled to pass the TigerWire through the knotless anchor. The 2 suture ends can then be pulled alternately to tension the horizontal mattress (Fig 12). Visualization with the arthroscope can help to ensure the rotator cuff tissue is abutted and tensioned to the articular margin appropriately. The construct can be tested and re-tensioned as necessary. This completes the medial-row anchor construct.
Lateral Anchor Fixation
The remaining sutures are gathered and pulled through the lateral portal (Fig 13). A Vented SwiveLock (Arthrex) is then attached to the suture. A standard punch is used to create a lateral socket. The SwiveLock is introduced and fixed into position at the lateral aspect of the construct (Fig 14). The remaining suture can be cut (Fig 15), completing the repair (Fig 16).
The initial phase of rehabilitation after the PASTA bridge begins within 1 week of surgery to commence early passive range of motion. A sling is a requirement for the first 3 to 4 weeks for protection of the repair and for comfort. By 6 weeks, full active range of motion should be achieved, and light rotator cuff and scapular strengthening can begin. By 12 weeks, the patient can begin moderate lifting, weight training, and plyometrics. Return to play and participation in a throwing program begin at 5 months. Return to non-throwing sports occurs at approximately 8 months. Overhead athletes can return to play between 9 and 12 months.
Partial-thickness rotator cuff tears are a prevalent injury, yet there is no consensus on the optimal repair technique. Although many procedures have been developed, 2 traditional methods are transtendon repair and the takedown method of propagating a partial tear to completion with a subsequent full-thickness repair. The transtendon repair is technically very difficult and could result in damage to the surrounding tissues while trying to introduce the anchor into the joint blindly or trying to create a blind hole in the tendon with a scalpel or trocar. Furthermore, the takedown method takes a partial tear into a full tear. If the repair fails, the patient is left with a full-thickness tear that could be more debilitating and painful. Repaired partial cuff tears also exhibit significantly improved biomechanical properties when compared with full-thickness repairs.
Some surgeons have been reluctant to perform these surgical procedures because of the risks and technical difficulty inherent to the procedures. Although reports on the 2 aforementioned procedures have produced adequate outcomes,
Re-creating the rotator cuff footprint at the greater tuberosity is the primary goal of arthroscopic rotator cuff repair. Providing greater contact at this important site has the potential to improve healing.
The PASTA bridge re-establishes this tendon-bone interface in a similar manner. Placing anchors laterally in conjunction with a medial row has led to superior outcomes resulting from an increase in the repair site contact area.
The PASTA bridge uses a lateral anchor to take all the stress off the construct being pulled medially and only using the medial anchors as pivot points. Double-row techniques have been argued to be superior to single-row procedures by increasing the number of fixation points.
Anchor placement during the PASTA bridge is performed with a spinal needle. The spinal needle allows the surgeon to choose his or her site of entry and can be placed or moved intraoperatively without damaging surrounding tissue. This is in contrast to other techniques that use a scalpel or spear as their method of entry, which could cause iatrogenic damage to surrounding tissues. For this reason, many surgeons have historically been hesitant to repair partial cuff tears of less than 50% thickness. This technique makes smaller tears more amenable to repair.
For repairs that require multiple anchors, placement is difficult and cumbersome in traditional methods. The PASTA bridge's percutaneous technique is safe and reliable for single- or multiple-anchor repairs. The angle of anchor placement varies by patient and can be optimized by using the spinal needle. Because of its unobtrusive nature, the PASTA bridge can be used for tears of virtually any size or thickness. Ideally, the leading edge of the good tissue should be used. If the anchors are placed too medially near the musculotendinous margin, tear through may occur. If the anchors are placed into the PASTA defect, the tissue may not hold. If a delamination tear is present, the PASTA bridge can reliably incorporate this tissue into the repair. Although this procedure is aimed toward PASTA lesions, the technique can be used in a variety of settings, including supraspinatus tears, infraspinatus tears, subscapularis tears, and remplissage. The PASTA bridge is a reliable procedure that is appropriate for surgeons of all experience levels. Given its technical ease and percutaneous nature, the PASTA bridge should be considered when treating PASTA lesions.
The patient is placed in the beach-chair position. The arthroscope is placed through the posterior portal in the left shoulder, and the exposed footprint from the PASTA (partial articular supraspinatus tendon avulsion) lesion is prepared. A 17-gauge spinal needle is inserted through the leading edge of the good rotator cuff tissue to determine appropriate entry. A punch is used to create a socket for anchor placement. A Knotless Corkscrew anchor is placed into the socket. A second anchor is placed anterior to the first. With the anchors fixed, the subacromial space is viewed through an anterolateral portal. The TigerWire suture from the posterior anchor and the FiberLink passing suture from the anterior anchor are gathered and pulled extra-articularly. The TigerWire is looped through the FiberLink back onto itself and shuttled through the anterior anchor. The same steps are performed for the opposing anchor. With the medial-row horizontal mattress completed, the remaining TigerWire sutures are gathered and pulled extra-articularly. The TigerWire sutures are attached to a Vented SwiveLock. After a punch is used to create a lateral socket, the Vented SwiveLock is fixed into position laterally. The remaining sutures are cut, completing the repair.
The authors report the following potential conflict of interest or source of funding: A.M.H. receives support from Arthrex. Consultant, research support. Clarius Mobile Health. Medical advisor. Full ICMJE author disclosure forms are available for this article online, as supplementary material.