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
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;17:909-913.
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
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
Snyder Classification
 Classified size of defect by its superficial
extension
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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)
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;35:437-41.
 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;17:909-913.
Exam Findings
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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;17:909-913.
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;17:909-913.
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;17:909-913.
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;17:909-913.
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;17:909-913.
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;17:909-913.
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 1
8
6
13
Type 2
5
5
11
Type 3
2
2
4
Habermeyer, et al. J Shoulder Elbow Surg 2008;17:909-913.
Supraspinatus Footprint
 Mean superior-to-inferior tendon thickness was:
 11.6 mm at rotator interval
 12.1 mm at midtendon
A
P
 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
Habermeyer, et al. J Shoulder Elbow Surg 2008;17:909-913.
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;17:909-913.
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
PushLock
 3.5mm PushLock
 4.5 mm PushLock
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
Goal is Anatomic Appearance
20 y/o RHD Pitcher
Right Shoulder, Type 2 C
ASP Through Lateral Interval
Lasso Passing Suture
Via ASP
Stab into apex between
intact and torn cuff layers
Retrieve via Anterior Portal
#2 FiberWire Sutures
2nd Suture and PushLock Repair
Thank You