The Bony Partial Articular Surface Tendon Avulsion Lesion: An Arthroscopic Technique for Fixation of the Partially Avulsed Greater Tuberosity Fracture

Abstract The partial articular surface tendon avulsion (PASTA) is a common lesion that involves the supraspinatus tendon in most cases. We present an arthroscopic fixation technique for a previously undescribed lesion that may be considered a variant of the PASTA. The lesion involves a partial avulsion of the greater tuberosity with an intact deep insertion of the supraspinatus tendon into the fractured bone fragment and an intact superficial insertion of the supraspinatus into the unavulsed lateral aspect of the greater tuberosity: a “bony PASTA” lesion. The surgical technique involves the use of a 70° arthroscope to provide an “end-on” view of the pathology. A superior-medial transmuscular portal is used for anchor insertion and suture management; the portal avoids damage to the intact tendinous insertion of the supraspinatus, which can occur during transtendon anchor/screw insertion. Abduction of the arm to 50°, after creation of the portal and passage of the cannula, permits an optimal “deadman” angle of anchor placement. An angled suture grasper is used to retrieve the 4 suture strands from the double-loaded suture anchor through the intact superficial and deep supraspinatus tendon fibers along the length of the fracture; these are tied as 2 mattress sutures over the tendon fibers in the subacromial space by use of sliding-locking knots. Adequacy of reduction is confirmed by intra-articular arthroscopic observation during movement of the extremity through its complete range of motion.