Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Treatment Options

The past treatment of pectoralis major ruptures has been controversial. There have been studies advocating conservative treatment, some operative repair , and several have included both in their descriptions . More recently, most authors advocate early repair of these injuries . The pectoralis major functions to adduct, forward flex, and internally rotate the shoulder.

Several studies have demonstrated significant strength deficits in conservatively treated injuries, with return to near or normal strength after surgical repair. Young, athletic patients will generally not tolerate this persistent weakness, as well as the associated cosmetic deformity; however, elderly or low-demand patients with pectoralis ruptures can be treated conservatively with success.

The actual surgical repair technique has varied widely. There have been reports using barbed staples, screws and washer , suture anchors , bone trough and tunnels , and Achilles tendon allograft augmentation. The primary goal of surgical repair should be solid tendon apposition to bone.

Although staples and screws do accomplish this, the residual hardware can raise some concerns. Sutures anchors offer an easy fixation solution, but only provide point fixation of tissue to bone. It is difficult to use anything other than simple or horizontal suture patterns with anchor fixation.

Stronger, grasping suture patterns such as a Mason-Allen are much harder to accomplish with suture anchors. Our preferred surgical technique has been previously described, and advocates a method of direct suture repair to bone through drill holes.

The patient is placed in a supine position, with the arm supported on a hand table. We have not found the beach-chair position to be necessary. The entire upper extremity in addition to most of the thorax on the affected side is draped free. A 3–4 cm incision, at the distal end of the delto-pectoral interval, is more than adequate for exposure and repair.

For sternal head ruptures, the dissection is carried medially around the intact clavicular head, not into the interval with the deltoid. With complete ruptures, no delto-pectoral interval will be present. In acute injuries, a large hematoma is frequently encountered, and the avulsed tendon easily identified. Even if retracted, minimal mobilization is needed. In more chronic injuries, a synovial tract is often present, leading medially to the retracted tendon end.

The tendon is usually shortened and encased in scar. Aggressive scar release and mobilization is required to allow the tendon to reach the humeral insertion. Typically, the fibers of the sternal head of the pectoralis have an inferior-medial to superior-lateral obliquity. The clavicular fibers always have a superior-medial to inferior-lateral obliquity.

We have seen chronic injuries that can be adequately mobilized more than 10 years after injury. It is important to feel the inferior-lateral border of the muscle when pulling tension on the tendon. A fullness and firm edge should return to the anterior axillary fold. We use 1 mm cottony Dacron (Deknatel, Fall River, MA 02720) suture in the tendon end, placing three to four sutures in a Modified Mason-Allen fashion.

These sutures can be placed in the end of the muscle, for a myotendinous injury, and re-enforced as needed with soft tissue grafts or extra-cellular matrix grafts such as the Restore (DePuy, Johnson & Johnson) swine intestine submucosal graft. The insertion site of the pectoralis tendon is lateral to the bicipital groove.

For sternal head injuries, the clavicular head of the muscle will have its intact insertion distal to the proposed repair site. The sternal head is brought deep and proximal to the clavicular head muscle when repaired to the insertion site. The insertion site is cleaned of any tendon remnants, and can be roughened with a curette. We have not found it necessary to create a bone trough.

A Curvetek drill (Arthrotek, Ontario, CA 91761) is used to create bone tunnels at the repair site. Passing sutures are then pulled through the bone tunnels with a specific needle that matches the curve of the drill. The deep arm of each suture is passed through the bone tunnel. The arm is slightly adducted and internally rotated, and traction placed on the deep sutures.

This pulls the tendon down to the bone, and the superficial sutures are tied to deep sutures. This creates a broad area of contact between the tendon and bone, with the security of tying the suture over a bone bridge. The wound is irrigated, subcutaneous tissue closed with absorbable suture, and the skin closed with running prolene suture.

Postoperatively, the arm was placed in a sling. Patients were encouraged to perform limited activities of daily living as tolerated. Gentle range of motion (ROM) exercises were begun immediately, avoiding early passive external rotation or abduction. Light resistance exercises are started at six weeks, subsequent progression of strengthening, and resumption of full activity at four to six months.

It has been our experience that all patients with acutely repaired tendon ruptures, less than eight weeks, have returned to full activity. The majority of patients with repairs of chronically torn pectoralis tendons have had good pain relief, cosmetic appearance, and excellent return of strength . In contrast, high-demand athletes, particularly elite weight lifters, with chronically repaired tendon ruptures have shown significant improvement, but have frequently not been able to return to pre-injury weight training levels.

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