Abstract
Background:
Partial articular supraspinatus tendon avulsion (PASTA) lesions are a common cause of shoulder pain and dysfunction. Transtendinous repair is a surgical technique used to restore tendon integrity while preserving intact tendon and minimizing iatrogenic tendon damage.
Indications:
This technique is indicated in patients with symptomatic, partial-thickness rotator cuff tears who have failed conservative management.
Technique Description:
The PASTA transtendinous technique repair is performed in the beach-chair position. The articular-sided tear is visualized, debrided, and 2 suture anchors are placed percutaneously through the tendon into the rotator cuff footprint. The sutures are passed in a boxed mattress configuration, and knot-tying is performed arthroscopically on the bursal side of the cuff, securing the tendon back to its footprint and preserving intact tendon fibers.
Results:
This construct demonstrates stable fixation of the tendon to its native footprint, with preservation of tendon integrity. Postoperatively, patients undergo a structured rehabilitation protocol. Return to full activity/sport is expected at approximately 4 to 6 months.
Discussion/Conclusion:
Transtendinous repair of PASTA lesions provides a reliable method for restoring native tendon integrity, while preserving intact tendon fibers. This technique minimizes tendon trauma compared with traditional “take-down” rotator cuff repair techniques, maintains native anatomy, and facilitates anatomic healing with good functional recovery.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Keywords
Video Transcript
This video will discuss the treatment of a partial articular-sided supraspinatus tendon avulsion repair using a transtendinous technique, presented by Dr Brittany Ammerman, orthopaedic surgery resident at the Hospital for Special Surgery in New York City. The case being presented is that of Dr Karen Sutton, an attending orthopaedic sports medicine surgeon at the Hospital for Special Surgery.
Background and Indications
The patient is a 42-year-old, right-hand-dominant female who presented with right shoulder pain and weakness. The pain began after 6 weeks of increased paddle tennis. She endorsed pain with lifting, pain at night, and pain with reaching. The pain ranged from 3 to 5 out of 10. Her past medical history is significant for Crohn disease, and her surgical history is unremarkable.
On examination, she had a normal cervical examination, tenderness to palpation at the bicipital groove, 5-/5 supraspinatus strength, and positive Neer, Hawkins, and Speed tests.
Radiographs demonstrated a type 3 acromion, acromioclavicular joint arthritis, and were otherwise unremarkable.
Magnetic resonance imaging demonstrated multifocal rotator cuff tendinosis with partial-thickness tear of the supraspinatus and infraspinatus without a full-thickness defect. There was also mild tendinosis and fraying of the proximal biceps tendon without rupture.
Her initial clinical course of conservative management included an ultrasound-guided biceps injection, which provided minimal relief, physical therapy without improvement, and a subacromial injection without relief. She is unable to tolerate nonsteroidal anti-inflammatory drugs in the setting of the Crohn disease. After 4 months of conservative management, the decision was made to proceed with right shoulder arthroscopy to include subacromial decompression, biceps tenodesis, and transtendinous rotator cuff repair.
Technique Description
The patient was positioned in the beach-chair position with an arm holder (Figure 1). An examination was performed under anesthesia, which revealed full range of motion. The traditional landmarks were drawn out (Figure 2), and the standard posterior viewing portal was first established, followed by an anterior accessory portal under direct visualization. The steps that followed included a diagnostic arthroscopy, consideration of subacromial decompression if indicated and followed by the rotator cuff repair.
Patient beach-chair positioning. Reproduced from Ulrich MN, Meta F, Tagliero AJ, Camp CL. Basics of shoulder arthroscopy part II: diagnostic arthroscopy in the beach-chair position. Arthrosc Tech. 2024;13(10):103083. https://doi.org/10.1016/j.eats.2024.103083.
Arthroscopic anatomic landmarks. Reproduced from Ulrich MN, Meta F, Tagliero AJ, Camp CL. Basics of shoulder arthroscopy part II: diagnostic arthroscopy in the beach-chair position. Arthrosc Tech. 2024;13(10):103083. https://doi.org/10.1016/j.eats.2024.103083.
The diagnostic arthroscopy demonstrated an intact labrum, with synovitis, and fraying of the biceps tendon. The biceps tenotomy was performed first using ArthroCare for later tenodesis. The arthroscope was then placed in the subacromial space, and using a lateral portal, a subacromial decompression was performed. The rotator cuff tear was then viewed from the bursal side and subsequently from the articular side.
Attention was then turned to the rotator cuff repair. With the arthroscope in the posterior viewing portal, the articular side of the rotator cuff tear was inspected, and the tear was appreciated. Through the anterior portal, using a shaver, the articular side of the rotator cuff was debrided. The guidepin was then percutaneously introduced to confirm the trajectory for the first anchor. Once satisfied with the guidepin placement, the cannula system was placed over the guidepin, and the guidepin was removed. This is designed to longitudinally split the cuff, causing minimal damage to the tendon. The tap was then placed through the cannula, followed by the anchor, which was then made flush with the cortical bone. The anchor inserter and cannula were removed, and the first anchor is now in place. One blue suture remains passed through the tendon, while the remaining 3 sutures are passed through the anterior portal cannula via a looped grasper. A spinal needle was then introduced anterior to the lateral portal, and a chia suture passer was introduced via the spinal needle. A grasper pulled the chia suture passer through the anterior cannula, and the blue matching suture anchor limb was loaded into the suture passer outside the shoulder. The chia suture passer was then pulled back through its percutaneous anterolateral entry site, passing the second limb of suture through the tendon.
The guide pin was then percutaneously introduced again to place the second anchor posterior to the first, just off the articular margin. The tap was then placed, the anchor seated and flush to cortical bone, and the inserter and cannula were again removed. Three suture limbs are again pulled through the anterior portal cannula, and 1 suture limb is left passed through the tendon. The chia suture passer is again introduced, pulled through the anterior portal cannula, the corresponding blue suture limb is loaded into the suture passer, and the chia suture passer is pulled back through the tendon and out its lateral percutaneous entry site. At this point, 2 suture limbs from each anchor have been passed through the tendon in a box configuration pattern.
The camera is then placed into the subacromial space to view the tear and suture repair from the bursal side. One suture from each anchor is subsequently pulled through the lateral portal with a looped grasper. These 2 sutures are then tied down with an arthroscopic knot-tying device on the bursal side of the rotator cuff. The suture limbs are cut to the knot. The remaining 2 sutures, 1 from each anchor, are then subsequently pulled out through the lateral portal with a looped grasper and tied down with an arthroscopic knot-tying device on the bursal side of the rotator cuff. The suture limbs are cut to the knot. This completes the boxed mattress configuration (Figure 3).
Suture box mattress configuration.
The camera was then brought back to the glenohumeral joint, and the articular side of the rotator cuff was viewed. The tendon was pulled back to the greater tuberosity footprint, and adequate fixation was achieved.
Results
The patient is placed in a sling with an abduction pillow at 30° to 45° in neutral rotation, to be worn at all times. No shoulder active or assisted active range of motion is allowed in the initial rehabilitation phase. Formal physical therapy is started on postoperative day 3, with passive range of motion in external rotation <20° and forward elevation <90° allowed. Distal upper extremity range of motion is maintained, except for only passive range of motion at the elbow with concomitant biceps tenotomy or tenodesis. The surgeon follows the Mass General Brigham Rehabilitation protocol for rotator cuff repair—small to medium-sized tears 1 following this technique.
Return to full activities or sports typically takes 4 to 6 months after repair. An individualized, shared decision-making approach is used, and this timeline may vary.
Discussion/Conclusion
Advantages of the transtendinous repair include attachment of a partially torn rotator cuff, retaining the attached tendon; minimizing tendon trauma; preserving natural anatomy; and avoiding the sacrifice of a healthy, intact tendon via the traditional take-down repair.
We would like to thank The Forum for the invitation to provide this technique video article.
