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A Novel Arthroscopic Inside-Out Repair Technique for PASTA Lesions
A Novel Arthroscopic Inside-Out Repair Technique for PASTA Lesions Lindsey S. Caldwell, M.D., Anna R. Cooper, M.D., M.P.H., and John C. Elfar, M.D.
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 years1 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
From the Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A. The authors report the following potential conflict of interest or source of funding: J.C.E. receives support from Synthes and Arthrex Research Support Grant ($3,000). Unrestricted in use of grant monies. This work was supported by NIH grant number K08 AR060164-01A (J.C.E.). Received March 18, 2014; accepted June 11, 2014. Address correspondence to Anna R. Cooper, M.D., M.P.H., Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14226/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.009
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 of transtendinous repair techniques.10-13 As recently as 2010, there were no prospective studies and no randomized controlled trials that looked at the clinical outcomes of these different techniques for treatment of PASTA lesions,14 suggesting that much research remains to be performed in this area. Complete takedown of the rotator cuff at the level of the tear with subsequent rotator cuff repair has been
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Table 1. Summary of Learning Points Tips Perform a thorough diagnostic examination to verify pathology is a PASTA lesion and not a full-thickness tendon tear. Be prepared to convert to another means of fixation if the tear is more extensive than preoperative imaging suggested. Pearls 1. The partially torn articular surface supraspinatus tendon is not further disrupted by our novel inside-out repair. 2. Directly visualize the repair to gauge tension. Key points 1. The indication for this technique is an articular-sided tear involving >50% of the thickness of the rotator cuff. 2. A horizontal mattress stitch is created in an inside-out fashion. 3. Use 1 suture per 5 mm of rotator cuff tear. Contraindication Full-thickness rotator cuff tear Risks 1. Failure of fixation 2. Standard risks of shoulder arthroscopy Treatment algorithm 1. Perform a diagnostic arthroscopic examination to confirm the presence of an articular-sided supraspinatus tear. 2. Prepare an articular-sided suture. 3. Perform subacromial decompression. 4. Complete the repair by tensioning on the bursal side of the tendon and secure with suture anchor(s). 5. If a full-thickness tear is identified, use other fixation methods.
described and recommended for tears in which greater than 50% to 70% of the thickness of the rotator cuff is involved.5,11,15 Complete takedown has been found in 1 prospective randomized controlled trial to yield less pain and a quicker functional recovery than a transtendinous repair technique but with a higher incidence of complete failure of the repair.15 Other studies have supported the idea that transtendinous techniques result in a lower rate of failure while suggesting that the functional outcomes and patient satisfaction after transtendinous repair may be higher than previously thought.16,17 One study found 1 failure and good to excellent results in 93% of cases at 12 years’ follow-up of PASTA lesions repaired with a transtendinous technique.16 We developed a novel inside-out repair technique for partial articular surface supraspinatus tears. Although previous transtendon techniques have required passage of the suture anchor through the already partially torn tendon, our technique does not require further disruption of the tendon by passage of an anchor. This technique is currently being used to fix PASTA lesions that involve greater than 50% of the thickness of the rotator cuff (Video 1, Table 1).
Surgical Technique After administration of regional and general anesthesia, patients are positioned in the lateral decubitus position with the operative arm pointed toward the ceiling in a trapeze suspension system with 10 lb of traction. The trunk is secured in a standard pegboard. An axillary roll is placed, and all bony prominences are
Fig 1. Arthroscopic view of glenohumeral joint with probe pointed into partial articular-sided supraspinatus tendon tear.
padded. Surface anatomy landmarks are marked. A standard posterolateral portal is established approximately 2 cm distal and 1 cm medial to the posterolateral aspect of the acromial edge. A blunt trocar is used to enter the glenohumeral joint. An initial diagnostic evaluation of the joint is performed; any labral, chondral, and tendon pathology or loose bodies are noted, and the presence of an articular-sided supraspinatus tendon tear is confirmed (Fig 1). Next, an anterior portal is established using an inside-out technique. An arthroscopic shaver is introduced into the anterior portal, and any necessary debridement is performed. Next, a spinal needle is inserted through a port-ofWilmington portal such that it is visualized intraarticularly as coming through the cuff 1 cm medial to the anterior border of the edge of the supraspinatus tear. A No. 1 PDS suture (Ethicon, Somerville, NJ), to be used as a shuttle, is passed through this spinal needle and retrieved so that 1 end exits the anterior portal. A nonabsorbable stitch (FiberWire; Arthrex, Naples, FL) is tied over this PDS suture and retrieved through the port of Wilmington. A second spinal needle is placed through a second port-of-Wilmington portal such that it enters the joint at the posterior edge of the tear (Fig 2). The PDS suture is passed through this second portal, and 1 end is again retrieved through the anterior portal. The end of the nonabsorbable suture is tied over the end of the shuttling suture, and the construct is then retrieved through the second port-of-Wilmington portal such that both port-of-Wilmington portals now have a single threaded horizontal mattress stitch through the rotator cuff and the loop remains outside the anterior portal. Next, the spinal needle is reinserted 5 mm lateral
NOVEL INSIDE-OUT PASTA REPAIR
Fig 2. The PDS suture has been retrieved through the anterior portal after being passed from the first port-of-Wilmington portal. The spinal needle is establishing the second port-of-Wilmington portal.
to and between the other 2 port-of-Wilmington portals to create a third port-of-Wilmington portal (Fig 3). The shuttling suture is passed through this third portal and retrieved through the anterior portal (Fig 4). It is tied over the looped nonabsorbable suture, and the loop of nonabsorbable suture is retrieved through the third port-of-Wilmington portal (Fig 5). At this point, both
Fig 3. A suture has been shuttled through the first 2 port-ofWilmington portals so that the loop is outside the anterior portal. The spinal needle is establishing the third port-ofWilmington portal.
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Fig 4. Shuttle suture after being passed through third port-ofWilmington portal and tied over loop of nonabsorbable suture outside anterior portal.
single ends and the loop of nonabsorbable suture are clamped outside the port-of-Wilmington portals. Attention is then turned to the subacromial space. The posterior cannula is redirected into the subacromial space, and a standard lateral portal is created approximately 3 cm distal to the lateral border of the acromion. A subacromial decompression is performed with care
Fig 5. View from inside joint after loop of nonabsorbable suture has been retrieved through third port-of-Wilmington portal.
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being taken to identify and avoid damage to the nonabsorbable sutures traversing the subacromial space (Fig 6). Once the sutures are identified, they are retrieved through the lateral portal and clamped. A thorough subacromial decompression is performed
including debridement down the lateral recess past the insertion of the supraspinatus. The entire bursal side of the supraspinatus is visualized to confirm that the tear is articular sided only. If spurs are noted on the undersurface of the anterior acromion, an arthroscopic burr is placed into the subacromial space to remove the osteophytes. Once the subacromial space is decompressed, the 2 single ends and the loop of nonabsorbable suture remain outside the lateral portal. The 2 single ends are passed twice through the loop, and the entire construct is seesawed down until the loop sits flush against the bursal side of the rotator cuff, providing what is, in effect, a locking stitch (Fig 7). Next, a knotless suture anchor is placed just lateral to the footprint of the supraspinatus (starred position in Fig 8) with the 2 free ends of nonabsorbable suture placed through the anchor (Figs 9 and 10). If the tear is not fully reduced with the initial suture, a second nonabsorbable suture can be introduced in a similar fashion with or without a second anchor such that there is 1 nonabsorbable suture per 5 mm of rotator cuff tear. Once adequate fixation is achieved, the subacromial and glenohumeral spaces are drained, the incisions are closed, a sterile dressing is placed, and a 30 abduction shoulder immobilizer is applied. Patients remain noneweight bearing in the shoulder immobilizer for 6 weeks. Physical therapy is initiated at the first
Fig 7. The 2 single ends of the white tiger-striped sutures in the foreground, viewed from the subacromial space, have been looped twice through the loop of suture outside the lateral portal and have been seesawed down snug against the bursal side of the rotator cuff. The blue sutures in the background represent a separate stitch. The free ends of the white tiger-striped stitch remain outside the lateral portal and will be passed through a knotless anchor.
Fig 8. Shoulder model showing location of anchor site (star).
Fig 6. The sutures are identified in the subacromial space. Subacromial decompression is performed, with care taken not to disrupt the sutures. The free ends of the sutures and loop are retrieved through the lateral portal.
NOVEL INSIDE-OUT PASTA REPAIR
Fig 9. Placement of knotless anchor with free ends of suture through it.
postoperative visit and consists of 4 weeks in a sling with elbow range of motion only, followed by progression to shoulder range of motion and strengthening.
Discussion The described technique represents a novel technique for repair of PASTA lesions developed at our institution. The potential benefits of this technique include the following: (1) the repair does not further disrupt the already partially torn tendon by passing an anchor through it, (2) tension on the bursal side of the repair is able to be visually gauged and adjusted before final fixation, and (3) the anchor is not within the joint or exposed to intra-articular fluid. The remainder of the techniques for PASTA repair described to date have required either completion of the tear or passage of an anchor through the intact bursal surface of the cuff. Our technique attempts to maintain the integrity of any intact portions of the cuff while still repairing the torn portion. Second, over-tensioning of the bursal side of the cuff in PASTA repairs has been postulated to be a contributing factor to the postoperative stiffness encountered with these repairs.12 The described technique allows the surgeon to visualize the bursal side of the cuff while adjusting the tension on the sutures through the knotless suture anchor before final insertion of the anchor. The ability to visually gauge the tension on the bursal side of the cuff allows us to avoid overtensioning of this surface and may contribute to less postoperative stiffness. Third, the anchor in our technique is placed through the subacromial space and thus is not within the joint or directly exposed to intra-articular fluid. Several studies
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have quantified the presence of inflammatory cytokines and matrix metalloproteinases (MMPs) in the synovial fluid and subacromial bursa in the presence of rotator cuff pathology.18-20 These studies have shown higher levels of interleukin (IL) 1, IL-6, tumor necrosis factor a, MMP-2, and MMP-13 in patients with rotator cuff pathology, as well as statistically significantly higher levels of inflammatory cytokines and MMPs in the synovium of full-thickness rotator cuff tears versus PTRCTs.18-20 In addition, higher levels of IL-6, IL-1, and tumor necrosis factor a have been shown in the subacromial bursa in patients with full-thickness rotator cuff tears.19 This research suggests that creating a fullthickness defect by passage of an anchor through the intact bursal side of a partial-thickness tear may correspond with a higher level of inflammatory cytokines both within the joint and within the subacromial bursa. By placing the anchor in the subacromial space, it may be possible to avoid exposing both the anchor and the patient to the increase in inflammatory markers that occurs particularly within the glenohumeral synovial fluid (but also within the subacromial bursa) associated with the creation of a full-thickness rotator cuff defect. The major risks with our technique are similar to those of other arthroscopic rotator cuff repairs: failure of the repair, stiffness, and infection. There are no additional risks posed by this technique as compared with other arthroscopic means of repair. Anecdotally, our cohort of over 50 patients has had no short-term complications requiring return to the operating room or repeat imaging to evaluate the repair. In summary, the presented novel inside-out technique for PASTA repair has several potential advantages over previously described techniques, including preservation of the intact tendon; avoidance of fullthickness tear creation and its inflammatory sequelae;
Fig 10. View from bursal side after placement of knotless anchor.
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and a lower likelihood of over-tensioning of the bursal surface, which may decrease the likelihood of postoperative stiffness. We present this novel technique for further evaluation and as an avenue for future study.
References 1. Sher JS, Unbe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77:10-15. 2. Fukuda H. Partial-thickness rotator cuff tears: A modern view on Codman’s classic. J Shoulder Elbow Surg 2000;9: 163-168. 3. Andrews JR, Broussard TS, Carson WG. Arthroscopy of the shoulder in the management of partial tears of the rotator cuff: A preliminary report. Arthroscopy 1985;1:117122. 4. Wolff AB, Sethi P, Sutton KM, Covey AS, Magit DP, Medvecky M. Partial-thickness rotator cuff tears. J Am Acad Orthop Surg 2006;14:715-725. 5. McConville OR, Iannotti JP. Partial-thickness rotator cuff tears: Evaluation and management. J Am Acad Orthop Surg 1999;7:32-43. 6. Lohr JF, Uhthoff HK. The microvascular pattern of the supraspinatus tendon. Clin Orthop Relat Res 1990;254: 35-38. 7. Nakajima T, Rokuuma N, Hamada K, Tomatsu T, Fukuda H. Histologic and biomechanical characteristics of the supraspinatus tendon: Reference to rotator cuff tearing. J Shoulder Elbow Surg 1994;3:79-87. 8. Bey MJ, Ramsey ML, Soslowsky LJ. Intratendinous strain fields of the supraspinatus tendon: Effect of a surgically created articular-surface rotator cuff tear. J Shoulder Elbow Surg 2002;11:562-569. 9. Yamanaka K, Matsumoto T. The joint side tear of the rotator cuff: A followup study by arthrography. Clin Orthop Relat Res 1994;304:68-73. 10. Gartsman GM, Milne JC. Articular surface partial-thickness rotator cuff tears. J Shoulder Elbow Surg 1995;4:409-415.
11. Waibl B, Buess E. Partial-thickness articular surface supraspinatus tears: A new transtendon suture technique. Arthroscopy 2005;21:376-381. 12. Spencer EE. Partial thickness articular surface rotator cuff tears: An all-inside repair technique. Clin Orthop Relat Res 2010;468:1514-1520. 13. Seo YJ, Yoo YS, Kim DY, Noh KC, Shetty NS, Lee JH. Trans tendon arthroscopic repair for partial thickness articular side tears of the rotator cuff. Knee Surg Sports Traumatol Arthrosc 2011;19:1755-1759. 14. Bollier M, Shea K. Systematic review: What surgical technique provides the best outcome for symptomatic partial articular sided rotator cuff tears? Iowa Orthop J 2010;32:165-172. 15. Shin SJ. A comparison of 2 repair techniques for partialthickness articular-sided rotator cuff tears. Arthroscopy 2012;28:25-33. 16. Stuart KD, Karzel RP, Ganjianpour M, Snyder SJ. Longterm outcome for arthroscopic repair of partial articularsided supraspinatus tendon avulsion. Arthroscopy 2013;29: 818-823. 17. Castagna A, Delle RG, Conti M, Snyder SJ, Borroni M, Garofalo R. Predictive factors of subtle residual shoulder symptoms after transtendinous arthroscopic cuff repair: A clinical study. Am J Sports Med 2009;37: 103-108. 18. Gotoh M, Hamada K, Yamakawa H, et al. Perforation of rotator cuff increases interleukin 1beta production in the synovium of glenohumeral joint in rotator cuff diseases. J Rheumatol 2000;27:2886-2892. 19. Voloshin I, Gelinas J, Maloney MD, O’Keefe RJ, Bigliani LU, Blaine TA. Proinflammatory cytokines and metalloproteases are expressed in the subacromial bursa in patients with rotator cuff disease. Arthroscopy:1076.e11076.e9. Available at www.arthroscopyjournal.org. 20. Osawa T, Shinozaki T, Takagishi K. Multivariate analysis of biochemical markers in synovial fluid from the shoulder joint for diagnosis of rotator cuff tears. Rheumatol Int 2005;25:436-441.
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.
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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 years1 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
From the Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, Rochester, New York, U.S.A. The authors report the following potential conflict of interest or source of funding: J.C.E. receives support from Synthes and Arthrex Research Support Grant ($3,000). Unrestricted in use of grant monies. This work was supported by NIH grant number K08 AR060164-01A (J.C.E.). Received March 18, 2014; accepted June 11, 2014. Address correspondence to Anna R. Cooper, M.D., M.P.H., Department of Orthopaedic Surgery and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/14226/$36.00 http://dx.doi.org/10.1016/j.eats.2014.06.009
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 of transtendinous repair techniques.10-13 As recently as 2010, there were no prospective studies and no randomized controlled trials that looked at the clinical outcomes of these different techniques for treatment of PASTA lesions,14 suggesting that much research remains to be performed in this area. Complete takedown of the rotator cuff at the level of the tear with subsequent rotator cuff repair has been
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Table 1. Summary of Learning Points Tips Perform a thorough diagnostic examination to verify pathology is a PASTA lesion and not a full-thickness tendon tear. Be prepared to convert to another means of fixation if the tear is more extensive than preoperative imaging suggested. Pearls 1. The partially torn articular surface supraspinatus tendon is not further disrupted by our novel inside-out repair. 2. Directly visualize the repair to gauge tension. Key points 1. The indication for this technique is an articular-sided tear involving >50% of the thickness of the rotator cuff. 2. A horizontal mattress stitch is created in an inside-out fashion. 3. Use 1 suture per 5 mm of rotator cuff tear. Contraindication Full-thickness rotator cuff tear Risks 1. Failure of fixation 2. Standard risks of shoulder arthroscopy Treatment algorithm 1. Perform a diagnostic arthroscopic examination to confirm the presence of an articular-sided supraspinatus tear. 2. Prepare an articular-sided suture. 3. Perform subacromial decompression. 4. Complete the repair by tensioning on the bursal side of the tendon and secure with suture anchor(s). 5. If a full-thickness tear is identified, use other fixation methods.
described and recommended for tears in which greater than 50% to 70% of the thickness of the rotator cuff is involved.5,11,15 Complete takedown has been found in 1 prospective randomized controlled trial to yield less pain and a quicker functional recovery than a transtendinous repair technique but with a higher incidence of complete failure of the repair.15 Other studies have supported the idea that transtendinous techniques result in a lower rate of failure while suggesting that the functional outcomes and patient satisfaction after transtendinous repair may be higher than previously thought.16,17 One study found 1 failure and good to excellent results in 93% of cases at 12 years’ follow-up of PASTA lesions repaired with a transtendinous technique.16 We developed a novel inside-out repair technique for partial articular surface supraspinatus tears. Although previous transtendon techniques have required passage of the suture anchor through the already partially torn tendon, our technique does not require further disruption of the tendon by passage of an anchor. This technique is currently being used to fix PASTA lesions that involve greater than 50% of the thickness of the rotator cuff (Video 1, Table 1).
Surgical Technique After administration of regional and general anesthesia, patients are positioned in the lateral decubitus position with the operative arm pointed toward the ceiling in a trapeze suspension system with 10 lb of traction. The trunk is secured in a standard pegboard. An axillary roll is placed, and all bony prominences are
Fig 1. Arthroscopic view of glenohumeral joint with probe pointed into partial articular-sided supraspinatus tendon tear.
padded. Surface anatomy landmarks are marked. A standard posterolateral portal is established approximately 2 cm distal and 1 cm medial to the posterolateral aspect of the acromial edge. A blunt trocar is used to enter the glenohumeral joint. An initial diagnostic evaluation of the joint is performed; any labral, chondral, and tendon pathology or loose bodies are noted, and the presence of an articular-sided supraspinatus tendon tear is confirmed (Fig 1). Next, an anterior portal is established using an inside-out technique. An arthroscopic shaver is introduced into the anterior portal, and any necessary debridement is performed. Next, a spinal needle is inserted through a port-ofWilmington portal such that it is visualized intraarticularly as coming through the cuff 1 cm medial to the anterior border of the edge of the supraspinatus tear. A No. 1 PDS suture (Ethicon, Somerville, NJ), to be used as a shuttle, is passed through this spinal needle and retrieved so that 1 end exits the anterior portal. A nonabsorbable stitch (FiberWire; Arthrex, Naples, FL) is tied over this PDS suture and retrieved through the port of Wilmington. A second spinal needle is placed through a second port-of-Wilmington portal such that it enters the joint at the posterior edge of the tear (Fig 2). The PDS suture is passed through this second portal, and 1 end is again retrieved through the anterior portal. The end of the nonabsorbable suture is tied over the end of the shuttling suture, and the construct is then retrieved through the second port-of-Wilmington portal such that both port-of-Wilmington portals now have a single threaded horizontal mattress stitch through the rotator cuff and the loop remains outside the anterior portal. Next, the spinal needle is reinserted 5 mm lateral
NOVEL INSIDE-OUT PASTA REPAIR
Fig 2. The PDS suture has been retrieved through the anterior portal after being passed from the first port-of-Wilmington portal. The spinal needle is establishing the second port-of-Wilmington portal.
to and between the other 2 port-of-Wilmington portals to create a third port-of-Wilmington portal (Fig 3). The shuttling suture is passed through this third portal and retrieved through the anterior portal (Fig 4). It is tied over the looped nonabsorbable suture, and the loop of nonabsorbable suture is retrieved through the third port-of-Wilmington portal (Fig 5). At this point, both
Fig 3. A suture has been shuttled through the first 2 port-ofWilmington portals so that the loop is outside the anterior portal. The spinal needle is establishing the third port-ofWilmington portal.
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Fig 4. Shuttle suture after being passed through third port-ofWilmington portal and tied over loop of nonabsorbable suture outside anterior portal.
single ends and the loop of nonabsorbable suture are clamped outside the port-of-Wilmington portals. Attention is then turned to the subacromial space. The posterior cannula is redirected into the subacromial space, and a standard lateral portal is created approximately 3 cm distal to the lateral border of the acromion. A subacromial decompression is performed with care
Fig 5. View from inside joint after loop of nonabsorbable suture has been retrieved through third port-of-Wilmington portal.
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being taken to identify and avoid damage to the nonabsorbable sutures traversing the subacromial space (Fig 6). Once the sutures are identified, they are retrieved through the lateral portal and clamped. A thorough subacromial decompression is performed
including debridement down the lateral recess past the insertion of the supraspinatus. The entire bursal side of the supraspinatus is visualized to confirm that the tear is articular sided only. If spurs are noted on the undersurface of the anterior acromion, an arthroscopic burr is placed into the subacromial space to remove the osteophytes. Once the subacromial space is decompressed, the 2 single ends and the loop of nonabsorbable suture remain outside the lateral portal. The 2 single ends are passed twice through the loop, and the entire construct is seesawed down until the loop sits flush against the bursal side of the rotator cuff, providing what is, in effect, a locking stitch (Fig 7). Next, a knotless suture anchor is placed just lateral to the footprint of the supraspinatus (starred position in Fig 8) with the 2 free ends of nonabsorbable suture placed through the anchor (Figs 9 and 10). If the tear is not fully reduced with the initial suture, a second nonabsorbable suture can be introduced in a similar fashion with or without a second anchor such that there is 1 nonabsorbable suture per 5 mm of rotator cuff tear. Once adequate fixation is achieved, the subacromial and glenohumeral spaces are drained, the incisions are closed, a sterile dressing is placed, and a 30 abduction shoulder immobilizer is applied. Patients remain noneweight bearing in the shoulder immobilizer for 6 weeks. Physical therapy is initiated at the first
Fig 7. The 2 single ends of the white tiger-striped sutures in the foreground, viewed from the subacromial space, have been looped twice through the loop of suture outside the lateral portal and have been seesawed down snug against the bursal side of the rotator cuff. The blue sutures in the background represent a separate stitch. The free ends of the white tiger-striped stitch remain outside the lateral portal and will be passed through a knotless anchor.
Fig 8. Shoulder model showing location of anchor site (star).
Fig 6. The sutures are identified in the subacromial space. Subacromial decompression is performed, with care taken not to disrupt the sutures. The free ends of the sutures and loop are retrieved through the lateral portal.
NOVEL INSIDE-OUT PASTA REPAIR
Fig 9. Placement of knotless anchor with free ends of suture through it.
postoperative visit and consists of 4 weeks in a sling with elbow range of motion only, followed by progression to shoulder range of motion and strengthening.
Discussion The described technique represents a novel technique for repair of PASTA lesions developed at our institution. The potential benefits of this technique include the following: (1) the repair does not further disrupt the already partially torn tendon by passing an anchor through it, (2) tension on the bursal side of the repair is able to be visually gauged and adjusted before final fixation, and (3) the anchor is not within the joint or exposed to intra-articular fluid. The remainder of the techniques for PASTA repair described to date have required either completion of the tear or passage of an anchor through the intact bursal surface of the cuff. Our technique attempts to maintain the integrity of any intact portions of the cuff while still repairing the torn portion. Second, over-tensioning of the bursal side of the cuff in PASTA repairs has been postulated to be a contributing factor to the postoperative stiffness encountered with these repairs.12 The described technique allows the surgeon to visualize the bursal side of the cuff while adjusting the tension on the sutures through the knotless suture anchor before final insertion of the anchor. The ability to visually gauge the tension on the bursal side of the cuff allows us to avoid overtensioning of this surface and may contribute to less postoperative stiffness. Third, the anchor in our technique is placed through the subacromial space and thus is not within the joint or directly exposed to intra-articular fluid. Several studies
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have quantified the presence of inflammatory cytokines and matrix metalloproteinases (MMPs) in the synovial fluid and subacromial bursa in the presence of rotator cuff pathology.18-20 These studies have shown higher levels of interleukin (IL) 1, IL-6, tumor necrosis factor a, MMP-2, and MMP-13 in patients with rotator cuff pathology, as well as statistically significantly higher levels of inflammatory cytokines and MMPs in the synovium of full-thickness rotator cuff tears versus PTRCTs.18-20 In addition, higher levels of IL-6, IL-1, and tumor necrosis factor a have been shown in the subacromial bursa in patients with full-thickness rotator cuff tears.19 This research suggests that creating a fullthickness defect by passage of an anchor through the intact bursal side of a partial-thickness tear may correspond with a higher level of inflammatory cytokines both within the joint and within the subacromial bursa. By placing the anchor in the subacromial space, it may be possible to avoid exposing both the anchor and the patient to the increase in inflammatory markers that occurs particularly within the glenohumeral synovial fluid (but also within the subacromial bursa) associated with the creation of a full-thickness rotator cuff defect. The major risks with our technique are similar to those of other arthroscopic rotator cuff repairs: failure of the repair, stiffness, and infection. There are no additional risks posed by this technique as compared with other arthroscopic means of repair. Anecdotally, our cohort of over 50 patients has had no short-term complications requiring return to the operating room or repeat imaging to evaluate the repair. In summary, the presented novel inside-out technique for PASTA repair has several potential advantages over previously described techniques, including preservation of the intact tendon; avoidance of fullthickness tear creation and its inflammatory sequelae;
Fig 10. View from bursal side after placement of knotless anchor.
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and a lower likelihood of over-tensioning of the bursal surface, which may decrease the likelihood of postoperative stiffness. We present this novel technique for further evaluation and as an avenue for future study.
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