The "double pulley" technique for arthroscopic fixation of partial articular-side bony avulsion of the supraspinatus tendon: a rare case of "bony PASTA" lesion.

Introduction The ‘‘bony PASTA’’ lesion is a partial articular-side bony avulsion of the supraspinatus tendon. It was described only once up to date in literature in 2007 by Bathia et al. These authors presented an arthroscopic technique for fixation of the avulsed fragment using a single medial suture anchor with simple mattress sutures. We present the use of the double pulley technique for arthroscopical fixation of bony PASTA lesions. Materials and methods We report the case of a 22 years old man presenting with a bony PASTA lesion to the right shoulder followinga motorbike accident. The lesion was documented with X-rays and MRI exams. The surgical technique involved the use of a 30° and 70° arthroscope. Intraarticular observation documented a 15 long and 5 mm wide avulsion with two principal fragments. Subacromial observation documented the integrity of the lateral insertion of the supraspinatus tendon to the greater tuberosity. Two double-loaded suture anchors were implanted through the lateral intact aspect of the supraspinatus tendon with a transtendinous technique. The anchors were placed at the anterior and posterior extremities of the bony lesion respecting the tendon insertion to the avulsed fragment. Each of the 4 medial sutures was retrieved in the subacromial space through the intact supraspinatus tendon medial to the fracture. Reduction and fixation of the avulsed fragment was initially obtained with a simple suture for each anchor oriented from medial to lateral. The remaining suture wires were coupled in double pulley configuration generating two sutures oriented from anterior to posterior. Results At the end of the procedure adequacy of reduction was confirmed by intra-articular arthroscopic observation throughout complete range of joint motion. At 2 months from surgery the patients fully recovered daylife activities and X-rays and arthro-MRI imaging documented healing of the fracture. Discussion The advantage of the double-pulley configuration is the compression of the osteo-tendinous complex obtained along the whole anterior-posterior length of the lesion, unreachable with mediolateral oriented simple sutures. Moreover double pulley configuration creates a waterproof reduction of the fragment, protecting the fracture site from the negative effect of sinovial fluid on bone healing. Conclusions In our opinion the double pulley technique allows optimal reduction of bony fragments and reconstruction of normal footprint anatomy even in comminuted fractures.