The bony PASTA (partial articular surface tendon

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1 The Double-Pulley Technique for Arthroscopic Fixation of Partial Articular-Side Bony Avulsion of the Supraspinatus Tendon: A Rare Case of Bony PASTA Lesion Luigi Murena, M.D., Gianluca Canton, M.D., Daniele A. Falvo, M.D., Eugenio A. Genovese, M.D., Michele F. Surace, M.D., and Paolo Cherubino, M.D. Abstract: We report the use of the double-pulley technique for arthroscopic fixation of the bony PASTA (partial articular surface tendon avulsion) lesion. Arthroscopic examination documented a 15-mm-long and 8-mm-wide comminuted bony avulsion with 2 main fragments. Two double-loaded suture anchors were placed with a transtendinous technique at the anterior and posterior edges of the lesion respecting the tendon insertion to the avulsed fragment. The medial sutures were retrieved through the intact supraspinatus tendon medially to the fracture. The sutures were initially coupled in a double-pulley configuration generating 2 sutures oriented from anterior to posterior; then a simple suture for each anchor oriented from medial to lateral was obtained. At the end of the procedure, the adequacy of reduction and stability of the fragments were confirmed. At 2 months from surgery, radiographic healing of the fracture was noted and integrity of the supraspinatus tendon insertion to the footprint was confirmed by arthroemagnetic resonance imaging, with full recovery of daily activities and complete active range of motion confirmed at 6 and 12 months. The double-pulley technique allows optimal reduction of bony fragments and reconstruction of normal footprint anatomy even in comminuted fractures. Moreover, it creates a waterproof reduction of the fragments, protecting the fracture site from synovial fluid. The bony PASTA (partial articular surface tendon avulsion) is a rare lesion involving the rotator cuff. It was described for the first time in the literature by Bhatia et al. 1 in 2007 as a partial articular-side bony avulsion of the supraspinatus tendon. They noted that common surgical solutions were inappropriate for these lesions and presented an original arthroscopic technique for fixation of the avulsed fragment using a single medial anchor with mattress sutures. They obtained a stable anatomic reduction of the lesion in a case of single bony fragment avulsion. We present an From the Orthopaedics and Traumatology Section, Department of Biotechnologies and Life Sciences (L.M., G.C., D.A.F., M.F.S., P.C.), and Radiology Section, Department of Surgical and Morphological Sciences (E.A.G.), University of Insubria, Varese, Italy. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received August 7, 2012; accepted September 18, Address correspondence to Gianluca Canton, M.D., Orthopaedics and Traumatology Section, Department of Biotechnologies and Life Sciences, University of Insubria, Viale Luigi Borri 57, Varese, Italy. gcanton84@gmail.com Ó 2013 by the Arthroscopy Association of North America. Open access under CC BY-NC-ND license / alternative technique also suitable for comminuted and larger lesions. Surgical Technique and Case Report A 22-year-old male patient sustained an injury to the right dominant upper extremity in a car accident. In the emergency department, he reported isolated pain to the right forearm, and radiographic examination showed a displaced diaphyseal radial fracture. The patient was then immediately prepared for open reduction and plating of the radial fracture. An axillary brachial plexus block was obtained, and during patient positioning before surgery, the patient complained of omolateral shoulder pain. A shoulder radiograph was then taken, showing a displaced avulsion fracture of the greater tuberosity (Fig 1A). Magnetic resonance imaging (MRI) of the injured shoulder was obtained 2 days later. It documented a partial avulsion of the medial aspect of the greater tuberosity in the region of the supraspinatus tendon footprint, with an intact deep layer of supraspinatus fibers attached to the avulsed bony fragment and an intact superficial layer of supraspinatus fibers attached to the footprint, lateral to the fracture site. It also showed bone interstitial hematoma and bone marrow edema of the intact part of the greater Arthroscopy Techniques, Vol 2, No 1 (February), 2013: pp e9-e14 e9

$Preoperative imaging obtained after patient s complaint of right shoulder pain after a car accident: plain anteroposterior radiograph (A) showing partial articularside greater tuberosity fracture$

2 e10 L. MURENA ET AL. Fig 1. Preoperative imaging obtained after patient s complaint of right shoulder pain after a car accident: plain anteroposterior radiograph (A) showing partial articularside greater tuberosity fracture (oval) and MRI coronal (B, C) and sagittal (D) views showing displaced bony fragment with medial supraspinatus tendon insertion attached. The lateral tendon insertion to the footprint is intact. Greater tuberosity bone edema suggests an acute lesion. tuberosity, confirming the recent traumatic pathogenesis of the lesion. On sagittal and axial sequences, a comminution of the fracture with 2 principal fragments was shown (Fig 1B-D). Surgical intervention (Video 1) was performed 3 days after trauma, with the patient in the beach-chair position under general anesthesia. Arthroscopic examination was performed by use of a 30 arthroscope through a standard posterior portal and an arthroscopic pump maintaining pressure at 50 mm Hg. A comminuted avulsion fracture with 2 main bone fragments was confirmed (Fig 2A). The fragments were avulsed from the medial aspect of the supraspinatus footprint beginning 5 mm posterior to the rotator interval. An anterior portal was created with an outside-in technique, and a probe was inserted to determine the dimensions of bony avulsion and assess the reducibility of the displaced fragments (Fig 2B). The bony avulsion measured 15 mm from anterior to posterior and 8 mm from medial to lateral, and it was easily reducible. Supraspinatus tendon attachments to the avulsed bone fragment and to the lateral footprint region were confirmed to be intact. A Monoplus suture (polydioxanone long-term absorbable monofilament suture; B. Braun Medical Ltd, Sheffield, England) was inserted at the level of the lesion through a spinal needle with an outside-in technique to mark the fracture area on the bursal side. After subacromial bursectomy, the integrity of the bursal side of the supraspinatus insertion was then confirmed (Fig 2C). The fracture surfaces were prepared with an arthroscopic shaver introduced from the anterior portal. Two double-loaded suture anchors (TwinFix Ultra Ti 5.5-mm suture anchor, nonabsorbable No. 2 braided polyethylene; Smith & Nephew Endoscopy, Andover, MA) were implanted at an optimal 45 dead-man angle through 2 accessory para-acromial portals created with an outside-in technique. The anchors were implanted through the lateral intact aspect of the supraspinatus tendon with a transtendinous technique at the anterior and posterior margins of the lesion, with preservation of the tendon attachment to the detached fragment and the lateral retained supraspinatus insertion (Fig 2D). The 2 medial limbs of both suture anchors were retrieved through the anterior portal. At the level of each anchor, a spinal needle was inserted from the para-acromial portals and passed through the intact superficial and deep supraspinatus tendon fibers, above and medial to the bone fragments. A Monoplus transport suture was inserted in an outside-in manner through the needle and retrieved through the anterior portal. The 2 medial limb pairs of sutures were then passed through the supraspinatus tendon in a retrograde fashion by means of the transport sutures. The lateral limbs position was already satisfactory as obtained with a transtendon technique of anchor placement. An anterolateral portal was created, and a cannula was inserted to allow suture tightening. One suture for each anchor was chosen to be coupled in a doublepulley configuration. Once the double pulley was completed, the fracture fragments were correctly reduced by the 2 sutures oriented from anterior to posterior. Fixation of the avulsed fragment was then completed with tightening of non-sliding knots on the remaining sutures of each anchor in a simple configuration from medial to lateral (Fig 2E). At the end of the procedure, the adequacy of reduction was confirmed by intra-articular arthroscopic observation throughout the complete range of joint motion and the stability of fracture fragments was assessed with a probe (Fig 2F). The surgical steps are listed in Table 1.

3 DOUBLE-PULLEY TECHNIQUE IN BONY PASTA LESION e11 Fig 2. Arthroscopic reduction and fixation of bony PASTA lesion: surgical technique in a right shoulder, with the patient in the beach-chair position, by use of a 30 arthroscope. (A) Identifying bony avulsion on the greater tuberosity (articular side, posterior viewing portal). The asterisks indicate the 2 main bony fragments with the medial articular tendon insertion still attached. (B) Measurement of lesion (articular side, posterior viewing portal, probe in anterior portal). (C) Intact rotator cuff on bursal side (bursal side, lateral viewing portal). The arrow indicates the site of lesion on the articular side marked with a Monoplus suture. (D) Position of posterior (A1) and anterior (A2) suture anchors (articular side, posterior viewing portal, probe in anterior portal). (E) Final rectangle configuration of sutures and knots (bursal side, lateral viewing portal). The black dotted line indicates the double pulley, and the blue dotted line indicates the simple stitches. (F) Assessment of stability of avulsed fragment after repair (articular side, posterior viewing portal, probe in anterior portal) showed restoration of anatomic supraspinatus tendon insertion with good stability. (HH, humeral head; SS, supraspinatus.) Radiographic postoperative images confirmed reduction of the fracture and correct placement of suture anchors. The postoperative protocol consisted of abduction/ external rotation sling immobilization for 4 weeks, and passive motion exercises were allowed from the first day after surgery. Active motion exercises were allowed at 1 month after surgery, and full recovery of daily activities was reached at 2 months (Fig 3). At 2 months after surgery, a radiographic evaluation confirmed that fracture reduction had been maintained, and the integrity of the supraspinatus tendon with watertight insertion to the footprint was confirmed by arthroemri (Fig 4). Discussion The PASTA lesion was first described by Snyder et al. 2 as a lesion affecting both young active (especially throwers) and more aged patients, where the great pulling forces act on a suffering tendon surface due to Table 1. Sequence of Steps for Double-Pulley Technique for Arthroscopic Reduction and Fixation of Bony PASTA Lesions Identify, define, and measure the fracture on the articular side. Debride the fracture site. Mark the fracture site with a suture through a spinal needle. Make certain of the integrity of the supraspinatus tendon on the bursal side. Place the suture anchors with a transtendon technique at the anterior and posterior edges of the fracture respecting the medial tendon insertion to the avulsed bony fragments. Assess the reducibility of the fracture by means of 2 spinal needles inserted in a para-acromial manner through the supraspinatus tendon above and medial to the fracture: the position of these needles allowing the correct reduction of the fracture will correspond to the position of the medial suture limbs. Use the spinal needles in the correct position as shuttling instruments to retrieve the medial suture limbs in the subacromial space. Tie a medial pair of suture limbs with the double-pulley technique and then tie the corresponding lateral limbs. Tie the remaining sutures using simple stitches. Assess the stability and correct reduction of the fracture on the articular side.

e12 L. MURENA ET AL. Fig 3. Clinical range of motion at 2 months follow-up after arthroscopic repair of bony PASTA lesion showing mild deficit of elevation and internal rotation.

$The first description of partial avulsion greater tuberosity fracture was given by Bhatia et al. 1 in 2007, who recognized it as a rare variant of the PASTA lesion.$

4 e12 L. MURENA ET AL. Fig 3. Clinical range of motion at 2 months follow-up after arthroscopic repair of bony PASTA lesion showing mild deficit of elevation and internal rotation. overuse (young) or degenerative changes (aged). 3 Anyway, this lesion usually leaves the bony footprint area intact. The first description of partial avulsion greater tuberosity fracture was given by Bhatia et al. 1 in 2007, who recognized it as a rare variant of the PASTA lesion. According to them, a shearing mechanism limited to a part of the tuberosity, eccentric contraction of the deeper fibers of the supraspinatus, and healthy status of the tendon-bone interface resulted in a partial avulsion of the bony footprint without disruption of the tendon fibers. 1-4 This consideration would lead to the conclusion that a strong, resistant, intact tendon would be the necessary substratum for this rare lesion to occur. 1 The young ages of the patients in whom this lesion has been described (17 years in the work of Bhatia et al. and 22 years in our study) seem to support this statement. We believe that the real incidence of this lesion could be underestimated, mainly because of the possible misinterpretation of radiographic examinations in which the bony fragment could resemble supraspinatus calcifying tendonitis. Anyway, the sharp margins of the displaced fragment and its cortical density on radiographs, together with the history of recent trauma, should suggest the traumatic etiology. Furthermore, MRI examination showing bone marrow edema and interstitial hematoma clarifies any doubt. Arthroscopic techniques described for repair of partial-thickness articular-side tears of the supraspinatus involve debridement and completion of the tear to full thickness, followed by repair, side-to-side intertendinous sutures, and transtendon suture techniques. 2,3,5 Arthroscopic techniques for treatment of Fig 4. Postoperative imaging after arthroscopic reduction and fixation of a bony PASTA lesion with 2 suture anchors in double-pulley configuration. (A) Anteroposterior radiograph showing correct position of suture anchors and reduction of bony fragments. (B-D) Arthro-MRI coronal views at 2 months showing watertight repair of rotator cuff and reconstruction of supraspinatus footprint.

5 DOUBLE-PULLEY TECHNIQUE IN BONY PASTA LESION e13 Table 2. Advantages and Disadvantages of Double-Pulley Technique for Bony PASTA Lesions Advantages Suitable for large (>1 cm) and comminuted lesions Anatomic reduction with homogeneous compression of bony fragments and control of both coronal and sagittal dislocating forces (fence configuration) Watertight repair of lesion: ideal biological environment for fracture healing Allows transtendon technique of anchor insertion respecting intact tendon attachment to bony fragments Disadvantages Not applicable for small lesions Longer procedure with higher costs when compared with singleanchor repair Risk of intact supraspinatus tendon lesion if transtendon technique is not performed correctly greater tuberosity fractures have used both screws 6 and, more recently, single- or double-row suture anchors for fixation of the bony fragments. 7,8 Bhatia et al. 1 commented on the latter techniques, considering them to be inappropriate for bony PASTA lesions. Therefore Bhatia et al. chose to fix the fracture with a doubleloaded suture anchor placed medially to the lesion with 2 single mattress sutures oriented from medial to lateral, inserted from a transmuscular superomedial portal to respect the integrity of the involved rotator cuff. In our study we could not achieve reduction and fixation of the fracture using a single anchor, mainly because of the dimension and comminution of the displaced fragments. Indeed, Bhatia et al. 1 reported an 8-mm-long and 5-mm-wide single fragment, whereas in our case the bony lesion was comminuted and almost double the size. Therefore the use of 2 suture anchors was necessary, and comminution precluded the use of simple stitches oriented in a medial-to-lateral direction. In our opinion, the double-pulley technique could represent a good technical solution to manage the described lesion (Table 2). The double-pulley technique was described for the first time by Arrigoni et al. 9 for rotator cuff lesions as a method to provide continuous tendon-to-bone contact without spot welds. 10,11 They reported how this technique reconstructs the native rotator cuff footprint while evenly distributing the compressive forces among 2 double loops of sutures, providing a broad area of tissue compression against the native greater tuberosity bone bed. In our case the goal was to achieve stable anatomic reduction of fragments to the greater tuberosity, as well as their compression to the bony bed, together with waterproof sealing to synovial fluid, to guarantee an optimal biological environment for fracture healing. The double pulley allowed an anatomic reduction with homogeneous compression of bony fragments, which resulted in watertight repair of the lesion as shown by arthro-mri. Moreover, the presence of a medial anterior-posterior tightened suture discharges pulling forces of the supraspinatus tendon from bony fragments, decreasing the risk of loss of reduction and nonunion. The 2 medial-to-lateral simple stitches were tightened to eventually correct some degrees of coronal tilt of the fragments, potentially leading to suboptimal reduction. The resulting suture configuration could be described as a rectangle of sutures, distributing compression forces equally throughout the fragments surface (Fig 5). Finally, the fence configuration of repair was effective even in the presence of comminuted fragments. With regard to anchor stability and resistance to pullout, some concerns may arise when suture anchors are implanted in a fractured bone area. The absence of the cortical layer could compromise anchor strength to pullout. Furthermore, a traumatized bone bed could present with poor biomechanical features when compared with healthy cancellous bone. Indeed, the Fig 5. Bony PASTA lesion and surgical technique for its treatment. (A) Bony partial avulsion of greater tuberosity with medial tendon insertion still attached. (B) Position of suture anchors and suture limbs. (C) Final configuration of sutures on bursal side after repair, showing double pulley in blue and simple stitches in green (i.e., rectangle of sutures ).

6 e14 L. MURENA ET AL. Table 3. Diagnosis and Treatment of Bony PASTA Lesions: Tips and Tricks Consider a bony PASTA lesion in cases of radiographic evidence of bony fragments over the medial aspect of the greater tuberosity in association with a history of recent trauma. Use MRI to confirm diagnosis: bone marrow edema suggests the recent traumatic etiology of the lesion. Radiographic imaging can underestimate the size and severity of the lesion: comminution of the fracture is best assessed by direct arthroscopic visualization. The size and number of bony fragments determine the choice of surgical technique (single anchor v double pulley). During anchor placement, perform transtendon technique properly to avoid damage to the tendon insertion to the avulsed fragments and to the lateral intact aspect of the supraspinatus tendon. Spinal needles are used to assess fracture reduction and as shuttling instruments: percutaneously insert the needles beside the anterolateral edge of the acromion. The position of sutures through the tendon influences the reduction of the fracture: define it carefully. Tie the double pulley sutures first, starting with the medial limbs, to obtain reduction of fragments: the simple stitches refine the result on the coronal plane. use of 2 anchors yields sharing of mechanical loads, resulting in a more solid construct. Moreover, anchor placement at the margins of the lesion guarantees better bone quality for the implant. Some authors have suggested that a transtendon technique from the lateral acromial edge allows the anchor to be placed at an optimal dead-man angle into the medial margin of the supraspinatus footprint. 5 Anyway, Bhatia et al. 1 considered transtendon insertion techniques to be at risk for partial disruption of the intact tendon attachment to the bone fragment and to the unavulsed region of the greater tuberosity. Consequently, in their technique a superior-medial portal for anchor placement through the muscular part of the rotator cuff was used. They stated that abduction of the arm to 50 after creation of the superior-medial portal could allow an angle of anchor placement comparable to the ideal dead-man angle. 1 In our study the use of the double-pulley technique allowed us to insert 2 anchors at the anterior and posterior margins of the displaced fragments, minimally influencing the integrity of the ruptured tendon-bone complex as confirmed by arthro-mri evaluation at 2 months follow-up (Table 3). References 1. Bhatia DN, de Beer JF, van Rooyen KS. The bony partial articular surface tendon avulsion lesion: An arthroscopic technique for fixation of the partially avulsed greater tuberosity fracture. Arthroscopy 2007;23:786.e1-786.e6. 2. Snyder SJ, Pachelli AF, Del Pizzo W, Friedman MJ, Ferkel RD, Pattee G. Partial thickness rotator cuff tears: Results of arthroscopic treatment. Arthroscopy 1991;7: Strauss EJ, Salata MJ, Kercher J, et al. The arthroscopic management of partial-thickness rotator cuff tears: A systematic review of the literature. Arthroscopy 2011;27: Kaspar S, Mandel S. Acromial impression fracture of the greater tuberosity with rotator cuff avulsion due to hyperabduction injury of the shoulder. J Shoulder Elbow Surg 2004;13: Lo IKY, Burkhart SS. Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff. Arthroscopy 2004;20: Carrera EF, Matsumoto MH, Netto NA, Faloppa F. Fixation of greater tuberosity fractures. Arthroscopy 2004;20: e109-e Lee SU, Jeong C, Park IJ. Arthroscopic fixation of displaced greater tuberosity fracture of the proximal humerus. Knee Surg Sports Traumatol Arthrosc 2012;20: Ji JH, Shafi M, Song IS, Kim YY, McFarland EG, Moon CY. Arthroscopic fixation technique for comminuted, displaced greater tuberosity fracture. Arthroscopy 2010;26: Arrigoni P, Brady PS, Burkhart SS. The double-pulley technique for double-row rotator cuff repair. Arthroscopy 2007;23:675.e1-675.e Zhang J, Jiang C. A new double-pulley dual-row technique for arthroscopic fixation of bony Bankart lesion. Knee Surg Sports Traumatol Arthrosc 2011;19: Koo SS, Burkhart SS, Ochoa E. Arthroscopic doublepulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy 2009;25:

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

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