Rotation of the clavicular portion of the pectoralis major for soft-tissue coverage of the clavicle. An anatomical study and case report

Use of the clavicular part of the pectoralis major in treatment of failed revision osteosynthesis of the clavicle

BACKGROUND

Symptomatic atrophic nonunion after multiple clavicle osteosynthesis can be difficult to treat. The aim of this study was to evaluate the results of a transfer of the clavicular part of the pectoralis major muscle as augmentation of osteosynthesis of these nonunions.

MATERIALS AND METHODS

A retrospective study included all patients who were treated between 2001 and 2010 (minimum 2-year follow-up). The indications for primary surgery, the number of operations, and the indication for a pectoralis major transfer were evaluated. Time of radiologic consolidation and postoperative complications were assessed. Clinical evaluation was performed with preoperative and postoperative satisfaction ratings and Constant-Murley scores.

RESULTS

The study included 11 patients. The indications for a primary osteosynthesis were acute displaced fractures (7), delayed union (2), nonunion (1), and malunion (1). On average, 3.7 procedures were performed (range, 2-6) before the tendon transfer. At revision, there were 2 patients with infection and 9 without infection. Of the 11 clavicles, 10 showed radiologic consolidation after a mean time of 10 weeks (6-20 weeks). The mean follow-up was 62 months (24-132 months). The mean Constant-Murley score increased from 37 (24-55) preoperatively to 59 (43-98), and the satisfaction rating increased from 2 (1-3) to 7 (2-10). Complications included nonunion (1), hardware removal (2), hardware irritation (4), and donor site pain (1).

CONCLUSION

The use of the clavicular part of the pectoralis major transfer as an augmentation in revision for symptomatic atrophic nonunion after multiple clavicle osteosynthesis showed good radiologic and acceptable clinical results.

An assessment of the anatomical basis of the thoracoacromial artery perforator flap

BACKGROUND

Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap.

METHODS

A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels.

RESULTS

THE PERFORATORS THROUGH THE PM MUSCLE TO THE OVERLYING SKIN INCLUDED THREE REGIONAL GROUPS: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery.

DISCUSSION

The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.

[Pediculated deltoid muscle flap: an alternative for coverage of chronic radionecrotic lesions in the shoulder region]

Soft tissue lesions in the clavicular region may be the result of trauma, infections or oncological resection and necessitate plastic surgery coverage. A case of an 85-year-old woman is presented with non-union of the mid-portion of the left clavicle with an overlying skin defect and a brachial plexus lesion after radiation therapy for breast cancer. The left arm was functionless so after partial resection of the medial part of the clavicle coverage of the defect was conducted by a proximally pediculated anterior part of the deltoid muscle with a split thickness skin graft.