Download pasta repair technique

PASTA REPAIR TECHNIQUE
William B. Stetson, MD
Stetson Powell Orthopaedics and Sports Medicine
Associate Clinical Professor
University of Southern California Keck School of Medicine
Repair of a Partial Articular-Side Rotator Cuff Tear Using a Trans-Tendon Suture Technique
(The PASTA Repair)
1. Complete Diagnostic Exam of the Glenohumeral Joint
View from the posterior portal
View from the anterior superior portal
Special attention to the articular side of the suprpaspinatus tendon and the footprint
(Figure 1)
Figure 1 – The normal supraspinauts footprint
2. Debride all frayed portions of the rotator cuff near the footprint on the humeral neck adjacent
to thearticular cartilage with a shaver through the anterior superior portal
This provides a clean bony surface for tendon healing (Figure 2).
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Figure 2 – A partial tear of the supraspinatus tendon. The degree of tearing can be
measured from the edge of the articular surface to the tendon. Assuming that the average
tendon is between 9-12 mm thick, greater than 6 mm of distance indicates a tear greater
than 50%.
3. Place a PDS marker suture through the tear with the use of a spinal needle
4. Change position of the arm to enter into the subacromial space and perform a diagnostic
bursoscopy
Evaluate for impingement and the bursal surface of the cuff, especially in the area of the
marker suture
With a PASTA tear, the subacromial space is usually normal with no evidence of
impingement
There is usually no need to perform a subacromial decompression
Debride the posterior bursal curtain and any lateral bursal tissue
This will help facilitate locating and tying sutures later
5. Return the arm to 70 degrees of abduction and reinsert the arthroscope into the glenohumeral
joint via the posterior portal. Place a clear, Crystal cannula (Arthrex) with a ring into the anterior
superior portal. The ring prevents the cannula from being pushed or pulled out and maintains the
portal.
6. Insert a spinal needle percutaneously into the joint adjacent to the edge of the articular
surface. This will establish the ideal position for the first anchor (Figure 3). The arm must
sometimes be in adduction to facilitate proper angle of insertion and to prevent shallow insertion
of the anchor and possible early pull-out.
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Figure 3 Pass a percutaneous spinal needle lateral to the edge of the acromion. This
needle will traverse through the substance of the remaining attached rotator cuff into the
exposed footprint. This will serve as a guide for anchor insertion.
7. Using the spinal needle to establish the ideal angle for the anchor insertion, make a small stab
incision and insert the anchor adjacent to the articular surface into the humerus. Examples of an
anchor include a 5 mm Corkscrew anchor (Arthrex) or a 4 mm Revo or Super Revo anchor
(Linvatec) or any comparable anchor. I prefer metal anchors but many surgeons use absorbable
anchors with similar results. Take care not to damage the articular surface or skive off the bone
(Figure 4). Usually these anchors are double loaded with 2 sutures.
Figure 4 – The anchor is placed into the anatomic footprint adjacent to the articular
surface. Make sure the anchor is well seated into the humerus.
8. Remove the driver and test the sutures for security by pulling on them to make sure the
anchor is well seated. There will be four limbs of the sutures which are color coded to help
differentiate the limbs of each (Figure 5).
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Figure 5 – The anchor is well embedded into the humeral head with four limbs of suture.
9. Take one limb of the suture and pull it out the anterior superior portal with a crochet hook
through the Crystal cannula. Insert the spinal needle about 5 mm anterior to the anchor insertion
through the cuff about 5 mm medial to the edge of the flap tear. Pass a shuttle relay or a PDS
suture down the needle and grasp it with a grasper through the anterior superior portal, remove
the needle and bring the shuttle out this cannula.
10. Load the shuttle outside the anterior superior portal and pull the shuttle from the other end
and it will take the limb of the suture through the cannula, into the joint, through the articular
side of the rotator cuff into the subacromial space and out the skin percutaneously (Figure 6).
Figure 6 – The bottom arrow points to the shuttle relay suture (striped suture) as it is tied
around one limb of the suture (top arrow) and is brought out from the cannula, into the
joint, through the articular side of the rotator cuff, into the subacromial space and out the
skin
11. With a crochet hook through the anterior superior portal, take the second limb of the suture
out the anterior superior portal. Insert the spinal needle about 5 mm posterior to the previous
suture, pass the shuttle relay into the joint and grasp it from the anterior superior portal and bring
it out this cannula. Load the shuttle outside the cannula and again pull the other end into the
joint through the articular side of the rotator cuff and through the subacromial space and out the
skin percutaneously.
12. Repeat the steps for the second suture. One or more anchors may be needed to completely
close the tear.
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13. The arm is then again placed into the bursal position by adjusting the suspension device and
the arthroscope reinserted into the subacromial space. Insert the Crystal cannula (Arthex) or
similar cannula into the subacromial space via the lateral portal and locate the first set of suture
limbs. Pull them out through the lateral portal with a crochet hook. If they slide easily, a sliding
knot may be used. If not, a modified Revo knot (alternating half-hitches) must be used (Figure
7). I prefer the alternating half-hitch knot because of better security.
Figure 7 – Color coded sutures help identify which suture limbs go together. They are tied
using a lateral portal
14. The arthroscope is reintroduced into the glenohumeral space and the edge of the partial tear
should be contiguous with the articular margin, completely effacing the previously exposed
footprint (Figure 8). The shoulder is then taken through a range of motion to evaluate the quality
of the repair, to make sure undue tension is not present, and to make sure a near anatomic repair
has been performed
Figure 8 – The anatomic footprint (large arrows) has been reestablished
Special thanks to Dr. Richard Ryu and Dr. Stephen Snyder for their help with the technique
and diagrams for this presentation.
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