This document provides information about PASTA (Partial Articular Supraspinatus Tendon Avulsion) lesions and repair techniques. It discusses methods for determining the size of PASTA lesions, current recommendations for repair vs. debridement, and repair options. It then describes a new PASTA repair technique called the "PASTA Bridge", which does not require knot tying. Preliminary results of a clinical study comparing the PASTA Bridge technique to trans-tendon repair show no significant differences in pain or function scores between the groups, and a lower failure rate for the PASTA Bridge. The PASTA Bridge is proposed as an easy, percutaneous alternative to other PASTA repair methods.

1. PASTA Repair
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
Medical Director Team Physician Consultant
Sacramento State Athletics Sacramento River Cats Oakland A’s
MiLB - AAA

2. PASTA Lesions

3. Determining PASTA Size
• Ellman et al – Normal cuff 10-12 mm thick
• Nottage et al
– Exposed bone between cuff / articular margin = 1.7 mm
– If interval > 7 mm, then > 50% thickness tear
• PASTA Depth Guide – Ian Lo
Ellman H, Clin Orthop 254:64-74, 1990.
Nottage W et al., AANA, Washington DC, 2002.

4. Determining PASTA Size
• “Shaver Method”
• Ultrasound
– Smith et al. Clin Radiol. 2011 – Meta-analysis
• 62 studies / 6066 shoulders
• Partial RCT Sensitivity 0.84 / Specificity 0.89
• Full RCT Sensitivity 0.96 / Specificity 0.93
• Technician dependent

5. To Repair or Not To Repair?
• > or < 50% - Classic indication(1-4)
• Abrams: 25% - 50% - a questionable region? (5)
Ellman. Clin Orthop 254:64-74, 1990.
Gartsman et al. J Shoulder Elbow Surg 4:228-241. 1995.
Nottage et al. AANA, Washington DC, 2002.
Wright et al. J Shoulder Elbow Surg, 5:458-466, 1996.
Abrams. AAOS ICL, 2002.

6. Current Recommendation
• Romeo et al. Arthroscopy. 2011
– Literature review – 16 studies
– Excellent outcomes 28.7% - 93%
– Debridement of pRCT < 50% -> Good/Excellent outcomes
• Associated progression to fRCT = 6.5 – 34.6%
– > 50% -> Excellent results
• Using takedown, trans-tendon, or trans-osseous repairs

7. Repair Options
• Debridement
• “Complete the Tear”
• Trans-osseous suture arthroscopic repair (Tauber)
• Trans-tendon repair (Burkhart, Romeo, Snyder)

8. PASTA Repair: Trans-tendon

9. Rationale for a New Technique
• Suture anchor technically challenging
• Couldn’t address broad Anterior-Posterior lesions

10. PASTA Bridge
• Combines a horizontal mattress & bridging style repair
• Does NOT require ANY arthroscopic knot tying

11. PASTA Bridge
• Combines a horizontal mattress & bridging style repair
• Does NOT require ANY arthroscopic knot tying

12. Pasta Bridge Technique

13. PASTA Bridge - A New Technique in
PASTA Repairs: A Biomechanical
Evaluation of Construct Strength vs
Suture Anchors
Alan M Hirahara, MD, FRCSC
*Accepted for presentation @ AANA, COA, WOA 2012

14. Study: Construct Strength
• 12 cadaveric shoulders (6 matched pairs)
• 50% thickness, 1 cm wide PASTA lesion created in each
shoulder
• For each pair:
– Titanium corkscrew anchor with single horizontal mattress
repair
– PASTA bridge repair – 2 – 2.4 BC ST & 1 – 4.5 VSL
• Load to Failure & Mode of Failure

15. PASTA Bridge: Construct Strength
Comparison Study
SutureTak and SwiveLock PASTA Repair
Ultimate Load
Donor # Gender Age Mode of Failure
(N)
10-09064 M 62 1637 humeral head broke
10-08024 M 27 1499 tendon tore mid-substance
10-11021 F 53 811 tendon tore at repair
10-09062 F 52 899 humeral head broke
11-01032 M 46 402 muscle body tore from tendon
10-10068 F 53 810 muscle body tore from tendon
Average 49 1010
Standard Deviation 12 468
Titanium Corkscrew PASTA Repair
Ultimate Load
Donor # Gender Age Mode of Failure
(N)
10-09064 M 62 1398 muscle body tore from tendon
10-08024 M 27 1642 tendon tore at repair
10-11021 F 53 922 humeral head broke
10-09062 F 52 969 tendon tore at repair
11-01032 M 46 1003 muscle body tore from tendon
10-10068 F 53 575 tendon tore at repair
Average 49 1085
Standard Deviation 12 378

16. PASTA Bridge – Methods of Failure

17. PASTA Bridge - A New
Technique in PASTA Repairs:
A Clinical Evaluation
Alan M Hirahara, MD, FRCSC
*Accepted for Presentation AANA, COA, WOA 2012

18. PASTA Bridge Clinical Study
Preliminary Results
• Case-Control analysis of 62 patients
– 35 study patients – PASTA Bridge repair
– 26 control patients – Trans-tendon repair
• Inclusions: All PASTA repairs, > 25% thickness
• Exclusions: Any post-op trauma or non-compliance
• Failure to heal: Evaluated any symptoms 4-6 months post-op with repeat
MRA or surgery

19. Results
Pain Scores ASES Scores
8.0 80.0
7.0 70.0
6.0 60.0
5.0 50.0
4.0 40.0
3.0 30.0
2.0 20.0
1.0 10.0
0.0 0.0
Pre-op 1 2 3 4 5 6 Pre-op 1 2 3 4 5 6
Month Month Month Month Month Month Month Month Month Month Month Month
 Control Group: n = 26
 Study Group: n = 35

20. Results - Failures
4
3.5
3
4/26
2.5
2
1.5
1
1/35
0.5
0
Control Group Study Group

21. Conclusion
• No significant difference between groups
• Will require a randomized controlled trial
• Easy, percutaneous technique
• Minimal risk of damaging shoulder during surgery
• Proven biomechanical strength

22. Infraspinatous Repairs

23. Delamination Tears

24. Extension Bridge

25. THANK YOU