Biomechanical Evaluation of Unicortical Stress Risers of the Proximal Humerus Associated With Pectoralis Major Repair

No difference in load to failure or stiffness between transosseous tunnels, suture anchors, and cortical buttons for pectoralis major tendon repair: a systematic review & meta-analysis

PURPOSE

Surgical options for pectoralis major tendon tears include primary repair, though there is no consensus as to which constructs are biomechanically superior for repair.

METHODS

A systematic review was performed by searching PubMed, the Cochrane library, and Embase using PRISMA guidelines to identify studies that analyzed the biomechanical properties of bone tunnels (BT), cortical buttons (CB) and suture anchors (SA) techniques for pectoralis major tendon repair. The search phrase implemented was 'pectoralis major tendon repair biomechanics'. Studies that did not evaluate biomechanical outcome data, evaluated partial pectoralis major tendon tears, and non-English articles were excluded. Evaluated outcomes included ultimate load to failure (N) and stiffness (N/mm).

RESULTS

Six studies met inclusion criteria, including a total of 124 cadaveric specimens, for pectoralis major tendon repair comparing BT with SA and CB. Pooled analysis from four studies reporting on ultimate load to failure between BT and SA failed to reveal a difference between BT and SA (p = 0.489). Pooled analysis from two studies reporting on stiffness failed to reveal a difference in favor of BT compared to SA (p = 0.705). Pooled analysis from four studies reporting on ultimate load to failure between BT and CB failed to reveal a difference between BT and CB (p = 0.567). Pooled analysis from two studies reporting on stiffness failed to reveal a difference in favor of BT compared to CB (p = 0.701).

CONCLUSIONS

There was no difference in load to failure or stiffness when using BT, CB, or SA in pectoralis major tendon repairs. This review reveals that clinical outcomes may better inform which fixation construct to implement in pectoralis major tendon repairs.

LEVEL OF EVIDENCE

I.

Anatomic Pectoralis Major Repair With Intramedullary Anchor Fixation

Although previously described as a rare injury, pectoralis major tendon rupture has shown increased reports in recent years. This injury can be managed conservatively; however, given the propensity for young, physically active male individuals, surgical repair is often preferred. Definitive surgical repair can be performed through various techniques such as bone trough, transosseous fixation, suture anchor, and cortical button techniques. This technique guide describes surgical repair through intramedullary anchor fixation with a unique pull-through method using taped suture to secure the tendon repair to its anatomic footprint. We believe this method is biomechanically advantageous, reduces bone loss that may lead to postoperative fractures, and re-creates the anatomic footprint of the torn tendon.

Outcomes and Return to Sport After Pectoralis Major Tendon Repair: A Systematic Review

CONTEXT:

Pectoralis major tendon ruptures are becoming increasingly common due to the growing prevalence of active lifestyles. Studies investigating the efficacy of pectoralis major tendon repair have limited sample sizes and offer mixed results, while existing reviews do not explore postoperative activity outcomes for patients.

OBJECTIVE:

To summarize and synthesize the clinical outcomes and rate of return to activity after isolated pectoralis major tendon repair.

DATA SOURCES:

Four databases (MEDLINE, EMBASE, PubMed, and CINAHL) were searched from database inception through March 7, 2018.

STUDY SELECTION:

Studies reporting outcomes of isolated pectoralis major tendon repair for pectoralis major tendon rupture were included.

STUDY DESIGN:

Systematic review.

LEVEL OF EVIDENCE:

Level 4.

DATA EXTRACTION:

Data including patient demographics, intervention details, and clinical outcomes were extracted. The methodological quality of included studies was evaluated.

RESULTS:

Of 2332 retrieved articles, 18 studies were included, with a total of 536 patients. A majority (90%; 134/149) of patients undergoing pectoralis major tendon repair successfully returned to sport at a mean 6.1 ± 1.7 months postsurgery, of which 74% (95/128) successfully returned to their preinjury level of sport. The majority (95%; 269/284) of patients returned to work at a mean 6.9 ± 1 months. Postsurgically, 81% (83/102) of patients experienced complete pain relief after the surgery, and 19% (21/109) had cosmetic complaints after pectoralis major repair. Of the 10 studies that reported complications, 18% (75/423) of patients had postoperative complications, including reruptures and wound infections; 7% (30/423) of patients required reoperation for their complications.

CONCLUSION:

Pectoralis major tendon repair is an effective treatment that results in a high rate of return to sport and work, pain relief, and improved cosmetic appearance, albeit with a significant rate of complication. The evidence supporting all outcomes was limited by the rarity of the injury, the variable surgical techniques, and outcome assessment criteria.