Partial rotator cuff repair: PASTA lesion repair.

Partial—thickness rotator cuff tear was described by Codmanl as ”rim rents” in i934; and classified by Ellrnai in i9‘?02 on the basis of arthroscopic findings and of location and depth of the tear. in i99i, 5n·yder2 introducei his classification based on the size of the defect by its superficial extension. Snyder also coined the acronym PAST: lesion (partial articular supraspinatus tendon avulsion) as a special form of partial articular side lesion, character ized by fragmentation of the tendon fibers and that may contain a sizable flap of 2-4 cmt. Recently, lrlabermayer introduced a new classification for articular side supraspinatus lesions based on the tear extension on sagittal ant coronal planes. The approach to the patient with a suspected partial-thickness rotator cuff tear should not differ from that i. any patient presenting with complaints of shoulder pain or dysfunction. Patients will often report pain and stiffnes of the affected shoulder. Nocturnal pain and pain exacerbated by overhead activity are common but not specifi for partial thickness tearing. The physical examination will often elicit a painful arc, positive impingernent signs and real or apparent weakness with rotator cuff strength testing. Partial tear natural history is still a motive for discussion. Fukuda et alé have shown, in histologic studies, thc partial—thickness tears have essentiafly no abiiity to heal themselves overtime. Yamanaka and Matsumoto? fo - lowed 40 articular-sided tears over 2 years with arthrography and showed 80% tear progression. Treatment is often initiated with conservative measures that include physical therapy, cuff stretching, nonstercl dal anti-infiammatory drugs and subacromial iniections2·B‘l3. When conservative treatment fails, partial tears wec surgically treated. Some authors recommend repair of tears involving 50% or more of the tendon thickness even it is always difficult to evaluate the depth of the tear. Ruotolo et allt had determined the average thickness of the rotator cuff footprint to be T4 mm. If the tear wa > 7 mm it was iudged to be > 50% thickness. On the basis of a multicenter study, using standardized arthroscopi videos of different rotator cuff tears, Kuhn et allf found high interobserver agreement among experienced surgeon in distinguishing between full—thickness and partial-thickness tears and high agreement on the side of involvemet of partial tears, but no agreement when classifying the depth of the partial—thickness tear. Many treatments were described to approach this pathology: it has been proposed to simply arthroscopicc debride the lesion relying on the healing properties of the tendon. However, recent studies do not recreate? excellent results found in initial studies of debridement alone, neither a spontaneous healing of the cuff after o bridement alone has been demonstratedl2·l6·'2. lt has also been suggested to transform this kind of lesion intc full thickness tear and then to treat it with the suture anchor techniaue'2#l8‘2P. This surgical option was criticized Lo and Burl<hart2l because completion of the tear potentially excises normal tissue; and because normal footpr and length-tension of the cuff may be alterated. These preconceptions were partially contradicted by Yamakad study 22 that found that over 90% of the macroscopically intact residual tendon tissue of the PASTA lesions shov· moderate histopathologic degeneration. Touber ond Reschm hove proposed o tronsosseous orthroscopic repoir thot, otter o relotively short tollow-up, _ bd potients to sotistqctory results. Recently, treotment ot these lesions hos been done with suture onchor vio o iunstendon opprocich without hoving to complete the teor2'*'2?. The oim ot this tronstendon technique is to preserve . {me loterol intoct bursol-side ond to restore the tootprint ot the rototor cutt, thus ovoiding completotion ot the teor _ {allowed by cult repoir2'·26·2B. Lo ond Burkhortgl did not recommend this technique only in rore coses where ct lorge cverhonging loterol ocromion moy prevent onchor insertion into the suprospinotus tootprint ot on oppropriote deod ¤¤n's ongle. In these coses the horizontol ongle ot opprooch couses the onchor to slip onto the orticulor surloce. Good results hove been published describing ull these techniques. However, only one prospective study hos ` [men corried out to evoluote the best treotment option". The Author observed thot cilthough repoir qtter con- version to o tull-thickness teqr showed less postoperotive morbidity, tendon integrity is ot primory concern otter spoir. Untortunotely, this study wos performed considering o smoll number ot potients; theretore its reliobility is 'q1estionoble. We corried out o similor prospective rondomized study, but on o higher number ot potients (74) ond ·• pored the clinicol ond subjective ditlerence between tronstendon repoir (Group A) or complete-repc1ir (Group in two homologous (tor oge ond onogrophic ospects) groups. All the potients were revolucited ot o minimum FU * · 2 yeors with Constont score (CS) ond Visuol Anologic Scole {VAS). Both groups showed stotisticolly signilicont rovement in the scores. There were no stotisticolly signiticont ditlerences reloting to the scores ond oge, sex '- • dominoncy ot the orm. CS improved by ci meon volue ot 25.l 5 (Group Al ond ot 29.02 (Group B); VAS score - - su eosed ot o meon volue ot 3.48 ond ot 3.67 respectively. The improvement wos higher in both groups tor the I ond in Group B the improvement in strength wos higher thon in Group A. A We concluded their repoir ot DPRCT provides good results in terms ot tunction und pqin regordless ot the I -• ir technique, but the completion ond repoir ot the teor provide better results in strength thon the tronsten- A ( • repoir opprooch. We connot exploin these results, but believe they could be reloted to the toct thot with the · -. endinous technique the superticiol loyers ot the suprospinotus ore kept mocroscopicolly intoct olbeit with o ' · ntiolly less tunctionol properly becouse ol on intrinsic degenerotion. Theretore, this technique moy leove less ` it ideel tendon, which theoreticolly increoses possibility ot re-ru pture. To mitigote these problems, Ji et ol3° hove ' . . sed o new orthroscopic tronstendon repoir technique with tenotomized iong heod biceps tendon ougmento- · for high grqde DPRCT with the gool ot providing increose tendon heoling ond minimize probability ot tciilure.