Partial Thickness Rotator Cuff Tears: All-Inside Repair of PASTA Lesions in Athletes

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Lambert Blankenship
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1 Partial Thickness Rotator Cuff Tears: All-Inside Repair of PASTA Lesions in Athletes Thomas M. DeBerardino, MD Associate Professor, UConn Health Center Team Physician, Orthopaedic Consultant UConn Huskie Athletics 5 mayo 2011

2 Background Incidence of PTRCT ranges from 13% to 37% Reilly reported an incidence of PTRCT of 18.5% in 2553 cadaveric shoulders Articular surface tears are 2 3 times more common than bursal-side tears Most PTRCTs involve supraspinatus tendon Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

3 Etiology Reilly, et al. observed tear propagation from joint to bursal sides during abduction Tendon failure occurred at the insertion site of the tendon Nakajima, et al. noted an increased incidence of articular-side tears after a traumatic event Bursal side of the tendon was able to undergo greater deformation and had a greater tensile strength than the articular side

4 Historical Classifications McConville and Iannotti (1999): cuff tears should be descriptive regarding location, size, and cause Codman (1934): PTRCT in undersurface of supraspinatus tendon adjacent to articular surface Neer (1983): 3 progressive stages of impingement- Stage III included PTRCT/FTRCT Ellman (1990) and Snyder (2003): differentiated PTRCTa from PTRCTb

5 Snyder Classification Classified size of defect by its superficial extension Grade I: Synovial irritation or capsular fraying < 1 cm Grade II: Fraying and some fiber failure < 2 cm Grade III: Fragmentation of the tendon fibers < 3 cm Grade IV: Sizable flap > 3 cm PASTA lesion (partial articular supraspinatus tendon avulsion): A special form of type A III or A IV (no mention of extension or exact location of PTRCT)

6 Reliability Multicenter study using standardized arthroscopic videos of different rotator cuff tears Kuhn, et al. found high interobserver agreement among experienced surgeons in distinguishing between FTRCT and PTRCT, and high agreement on side of involvement BUT no agreement classifying depth of PTRCT Kuhn, et al. MOON Shoulder Group. Interobserver agreement in the classification of rotator cuff tears. AJSM 2007;35:

7 56 patients (26 M 30 W), mean age of 54 w/ PTRCTa (clinically and MRI) Standardized arthroscopy prospectively documented (intraop documentation sheet) 26 (46.4%) reported a traumatic history Mean duration of symptoms was 24.6 months (range, 1 week to 25 years) Overhead sports activity by 29% (16 patients) Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

8 Exam Findings 59% w/ ++ full-can test 63% w/ ++ empty-can test 14% had ++ painful arc, 6% had a ++ liftoff test 81% of the patients had ++ O Brien test 59% had ++ palm-up test 58% had ++ impingement sign (Hawkins) 45% had ++ impingement sign (Neer) None with drop-arm sign, and all w/ FAROM Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

9 Habermeyer Subclassification Type 1 - small tear within transition zone from cartilage to bone Type 2 - tear up to center of footprint Type 3 - extends up to greater tuberosity Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

Sagittal Extension in the Transverse Plane Type A: tear of CHL continuing into medial border of supraspinatus tendon Type B: isolated tear within

10 Sagittal Extension in the Transverse Plane Type A: tear of CHL continuing into medial border of supraspinatus tendon Type B: isolated tear within crescent zone Type C: lateral border of pulley system to crescent zone of supraspinatus tendon Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

11 Sagittal Extension in the Transverse Plane Type A: tear of CHL continuing into medial border of supraspinatus tendon Type B: isolated tear within crescent zone Type C: lateral border of pulley system to crescent zone of supraspinatus tendon Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

12 Sagittal Extension in the Transverse Plane Type A: tear of CHL continuing into medial border of supraspinatus tendon Type B: isolated tear within crescent zone Type C: lateral border of pulley system to crescent zone of supraspinatus tendon Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

13 Sagittal Extension in the Transverse Plane Type A: tear of CHL continuing into medial border of supraspinatus tendon Type B: isolated tear within crescent zone Type C: lateral border of pulley system to crescent zone of supraspinatus tendon Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

14 Results Most PASTA tears were type 1 C or type 2 C Wider than deep Sagittal Longitudinal Tear Type A Type B Type C Type Type Type Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

15 Supraspinatus Footprint Mean superior-to-inferior tendon thickness was: 11.6 mm at rotator interval 12.1 mm at midtendon 12 mm at posterior edge Distance from the articular cartilage margin to the bony tendon insertion was 1.5 to 1.9 mm Tears with > 7 mm of exposed bone lateral to articular margin are 50% of tendon substance A P Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

16 Recommendation Arthroscopic measurement of exposed bone between articular margin and supraspinatus tendon insertion (footprint) represents an accurate way to estimate tear depth Provides rational, reproducible guideline for treatment by determining amount of tendon involvement Habermeyer, et al. J Shoulder Elbow Surg 2008;17:

17 My Preference Beach Chair with Spider Arm Holder Posterior then Anterior portal ASP portal through lateral interval at leading edge of PASTA lesion All-inside Knotless Repair

18 PushLock 3.5mm PushLock 4.5 mm PushLock

19 PushLock 3.5 mm Bio-PushLock (AR-1926B) 4.5 mm Bio-PushLock (AR-1922B) Bio-PushLock Major Diameter Minor Diameter Length 3.5 mm 3.5 mm 3.0 mm 14 mm 4.5 mm 4.5 mm 3.0 mm 18.5 mm

20 Goal is Anatomic Appearance

21 20 y/o RHD Pitcher Right Shoulder, Type 2 C

22 ASP Through Lateral Interval

23 Lasso Passing Suture Via ASP Retrieve via Anterior Portal Stab into apex between intact and torn cuff layers

24 #2 FiberWire Sutures

25 2 nd Suture and PushLock Repair

26 Thank You

Disclosure 11/14/2016. Partial Thickness Rotator Cuff Tears in the Throwing Athlete. Partial Thickness Rotator Cuff Tears. Neal S. ElAttrache, M.D.

Disclosure 11/14/2016. Partial Thickness Rotator Cuff Tears in the Throwing Athlete. Partial Thickness Rotator Cuff Tears. Neal S. ElAttrache, M.D. Partial Thickness Rotator Cuff Tears in the Throwing Athlete Neal S. ElAttrache, M.D. Disclosure I, Neal ElAttrache, or a family member(s), have relevant financial relationships to be discussed, directly