The term PASTA lesion (partial articular supraspinatus tendon avulsion) was first described by Snyder1 in 2003, and the management of these lesions remains controversial.2,3 Various factors contribute to PASTA tears.4 Intrinsic factors include reduced vascular supply and age-related changes to the tendon.5 Contributing extrinsic factors include subacromial impingement,6,7 instability,8 internal impingement,9–13 and traumatic events.4,5,14,15 The clinical diagnosis can be challenging,5,16 and some radiologic signs, such as a notch or cyst in the greater tuberosity, can indicate partial-thickness tears.5,17 Ultrasonography has a limited role in identifying these lesions,4,5 and magnetic resonance arthrography is more accurate, with mean sensitivity of 85.9% and specificity of 96.0%.4,18 Arthroscopy is the gold standard in delineating the extent of the tear and the quality of the tissue.4 Ellman19 described a classification system that relies on arthroscopic assessment of the dimension of the disrupted tendon from medial to lateral. The tears are categorized as grade 1 (<3 mm), grade 2 (3–6 mm), and grade 3 (>6 mm). A grade 3 tear is defined as injury of more than 50% of the tendon.15
Despite the debate on the management of PASTA lesions, there is a consensus that grade 3 tears require operative intervention.20 Treatment options include completing a full-thickness tear, followed by repair, and performing transtendon repair. The principle of transtendon repair is to maintain the fibers of the lateral aspect of the cuff.3 Because of the limited understanding of the optimal method to manage this injury and the potential advantages of the HEALIX TRANSTEND Implant System (DePuy Synthes, Raynham, Massachusetts), the authors elected to use this system.
Materials and Methods
This study included a retrospective consecutive case series of 64 patients who had grade 3 PASTA lesions during a 4-year period from January 2013 to January 2017. The patients were treated by 2 senior shoulder surgeons (C.A.P., B.W.M.) from 2 centers with the same repair technique and implant system. One of the senior surgeons (C.A.P.) later became more interested in elbows and therefore had significantly fewer patients who met the inclusion criteria.
Inclusion and Exclusion Criteria
Indications for surgical repair included confirmed PASTA lesions on magnetic resonance imaging that involved more than 50% of the tendon when assessed intraoperatively. The authors assessed the lesion by comparing the width of the torn portion with that of the footprint of the entire tendon to determine a ratio. This method was preferred to measuring the lesion in millimeters because the width of the footprint varied significantly from 6.9 to 21 mm.21–23 Patients who required other procedures concomitantly, such as biceps tenotomy/tenodesis or acromioclavicular joint (ACJ) excision, were excluded. Similarly, patients who had concomitant bursal-sided tears along with impingement lesions requiring subacromial decompression were excluded. These patients were excluded to ensure that any clinical improvement observed postoperatively would be attributed to the tendon repair itself rather than to decompression.
All procedures were performed under general anesthesia with the patient in the beach chair position. The repair technique involved 2 medial single-loaded anchors (HEALIX TRANSTEND, 2.9-mm titanium; DePuy Synthes) inserted through a dilator protecting the tendon. The sutures from the medial single-loaded anchors were secured to a third lateral anchor (VERSALOK PEEK knotless anchor system; DePuy Synthes), creating a double-row repair. The tear was visualized and assessed through the glenohumeral joint posterolateral viewing portal (Figure 1). The footprint was prepared through an anterior portal in the rotator interval. A guidewire (1.1 mm) was then inserted medial to the tear through a lateral portal, followed by a dilator (4 mm), and the 2.9-mm anchor (single loaded with ORTHO-CORD; DePuy Synthes) was placed at the desired position medially (Figure 2). The same procedure was repeated for the second medial anchor (Figure 3). The anchor guides were left in situ to protect the sutures during bursal clearance, which was performed only for visualization. No bony acromioplasty was performed. Sutures were passed through the intact tendon medially in a horizontal mattress fashion (Figure 4) and were retrieved from the subacromial space through a cannula inserted in the lateral portal (Figure 5). The sutures were then secured laterally into a third anchor (VERSALOK PEEK knotless anchor system) to complete the double-row repair (Figure 6).
Posterolateral arthroscopic view of the glenohumeral joint showing a grade 3 partial articular supraspinatus tendon avulsion lesion.
Posterolateral arthroscopic view of the glenohumeral joint showing transtendon placement of a medial 2.9-mm, single-loaded titanium anchor via an anchor guide.
Posterolateral arthroscopic view of the glenohumeral joint showing transtendon placement of second medial 2.9-mm, single-loaded titanium anchor via an anchor guide.
Posterolateral arthroscopic view of the glenohumeral joint showing ORTHOCORD (DePuy Synthes, Warsaw, Indiana) sutures passed through the intact tendon medially in a horizontal mattress fashion.
Posterolateral arthroscopic view of the subacromial space showing the retrieved sutures through a cannula inserted in the lateral portal.
Lateral arthroscopic view of the subacromial space showing the complete double row repair.
All patients underwent functional assessment preoperatively with the Oxford Shoulder Score (OSS). In the immediate postoperative period, all patients had standardized rehabilitation with physiotherapists. Patients were followed for a mean of 28 months (range, 14–50 months). At the final review, patients were assessed with the OSS and asked whether they were satisfied or dissatisfied with the procedure. Student's paired t test was performed to determine statistical significance. SPSS Statistics for Windows version 21.0 software (IBM Corp, Armonk, New York), was used for all analyses.
In total, 66 consecutive patients were reviewed (44 from the first center and 22 from the second center). The outcome measures for all but 2 patients were available for review (64 patients). Patient demographics are summarized in Table 1. A significant improvement in mean OSS was noted, from 19.2 (SD, 7.5) preoperatively to 39.8 (SD, 7.8) postoperatively (P=.0001). One patient had a recurrent tear that required revision arthroscopy. Intraoperatively, the failure was noted at the tendon-suture interface, with a full-thickness tear. Of the patients, 58 (88%) were satisfied with the procedure and 8 (12%) were dissatisfied. All 58 patients who were satisfied regained excellent range of movement and strength comparable to the contralateral side at final follow-up. Of the 8 patients who were dissatisfied, at final review, 4 still showed improvement of at least 5 points on the OSS. The cause of dissatisfaction was attributed to postoperative stiffness and pain. For 2 patients, these symptoms resolved by 6 months with physiotherapy alone. The other 2 patients underwent arthroscopic arthrolysis at 9 and 11 months after tendon repair.
The remaining 4 patients who were dissatisfied showed a decrease on the OSS. Of these 4 patients, 1 had evidence of supraspinatus tendinopathy on magnetic resonance imaging without evidence of a re-tear. This patient was successfully treated with further steroid injections and physiotherapy. Two patients had ongoing pain as a result of ACJ that was treated with arthroscopic ACJ excision at 14 and 22 months postoperatively. The remaining patient had stiffness that required arthroscopic release.
The overall rate of reoperation was 9.3% in this series (6 patients). However, an indication for revision supraspinatus repair was seen for only 1 patient (1.6%). For the remaining patients, re-operation included capsular release for stiffness for 3 patients (4.6%) and ACJ excision for 2 patients (3.1%). For these 5 patients, during the secondary procedure, the supraspinatus tendon was completely intact.
In a cadaveric study, Gonzalez-Lomas et al15 compared the biomechanical advantages of transtendon repair with surgical completion and repair of PASTA lesions. Their study showed that transtendon repair offers less gap formation and a significantly higher load before ultimate failure of the tendon. Although the transtendon technique preserves the lateral tendinous attachment, it potentially causes iatrogenic injury by passing a relatively bulky anchor through intact tendon. A specific benefit of the HEALIX TRANS-TEND system used in this study is the narrow diameter of the anchors compared with alternative techniques.24 However, in prospective randomized studies,25–27 both procedures showed improved clinical outcomes. In addition, multiple case series (most of which included grade 3 lesions) reported excellent clinical outcomes after tear completion and repair28,29 as well as after transtendon repair.30–32
For debridement alone, favorable clinical outcomes were limited to PASTA lesions of less than 50% and of varying grades, more commonly grades 1 and 2.33–37 The current authors reported clinical outcomes of transtendon repair for patients who had lesions involving 50% or more of the tendon. The current results were based purely on patient reports of functional outcomes and satisfaction with the procedure. The current authors did not use magnetic resonance imaging for routine assessment of postoperative healing of the tendon, in contrast to previous studies26,27 (transtendon repair vs tear completion and repair). Interestingly, the healing rate was comparable in both groups and exceeded 90%. In addition, even patients whose tendon did not heal had satisfactory clinical outcomes. Instead, the authors used magnetic resonance imaging only for patients who had clinical suspicion of a re-tear (1 patient in this series). The authors believe that arthroscopy is the gold standard for assessing the integrity and healing of the tendon. However, this assessment was not possible for all patients because some did not have indications for repeat arthroscopy. For the 5 patients who required further arthroscopic treatment for stiffness (3 patients) and ACJ pain (2 patients), the integrity of the repair was assessed, and it was intact in all cases.
The current results were consistent with previous reports of transtendon repair.30–32 However, these studies included patients with grade 2 lesions30,32 and patients who underwent additional procedures at the same time as transtendon repair.31 Although the current study was limited to level IV evidence, it was strengthened by including a larger case series of consecutive patients. In addition, the study included only patients who had PASTA lesions of 50% or more and excluded those who had concomitant procedures. These criteria help to focus clinical decision making and highlight the benefits for this patient group.
Although the best treatment for PASTA lesions is debatable, the evidence suggests that both transtendon repair and tear completion and repair are beneficial.38,39 No studies have compared surgical repair of any kind with debridement alone. Previous reports on debridement alone were limited to grade 1 and 2 lesions and were generally favorable.33–37,40 The current study reported debridement for 12 patients with grade 3 lesions, but no functional outcome measures were reported.34 The authors believe that a randomized controlled trial comparing debridement alone with surgical repair for the treatment of PASTA lesions of 50% or more would provide valuable guidance on the treatment of these lesions and potentially could justify the time and resources needed for tendon repair.
Based on the significant improvements in OSS and the high satisfaction rates reported after transtendon repair, the authors believe that surgical repair of PASTA lesions of 50% or more is beneficial. There is still debate about the best surgical tactic (transtendon repair vs tear completion and repair). The authors recommend the transtendon approach because they believe that preserving the lateral fibers improves the biologic and mechanical characteristics of the supraspinatus tendon. Further high-quality randomized controlled trials are needed to compare the benefit of repair vs debridement alone for grade 3 PASTA lesions.
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|Age, mean (range), y||55 (26–71)|
|Side, right/left, No.||39/25|
|Sex, male/female, No.||37/27|
|Follow-up, mean (range), mo||28 (14–50)|