Outcome of repair of chronic tear of the pectoralis major using corkscrew suture anchors by box suture sliding technique

Optimizing pectoralis major tendon repair: a modified knotless suture anchor technique using high-strength suture and tape

Background

Rupture of the pectoralis major (PM) tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined.

Methods

We present a modified surgical technique utilizing knotless suture anchors for PM tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture.

Results

The utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques.

Conclusion

Our modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful PM tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care.

Pectoralis Major Tendon Tear: A Critical Analysis Review

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Pectoralis major (PM) tendon tears are predominantly seen in young men, and the majority of tears occur as tendon avulsions involving the sternal head. Weightlifting, specifically bench-pressing, and sporting activities with eccentric overloading of the PM tendon are the 2 most common activities that result in PM injury.

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Early surgical repair or reconstruction should be offered to younger, active patients with a complete PM tear; the majority of the patients undergoing surgical repair achieve good-to-excellent outcomes.

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Nonsurgical treatment of a complete PM tear is an option but will result in cosmetic deformity and a deficit in adduction strength of the arm. Outcomes after nonsurgical treatment of complete PM tears are less satisfactory than those obtained after surgical treatment.

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Currently, there is no consensus on the chronological definition of PM tears (acute versus chronic), the critical time limit for performing surgical repair, the ideal fixation device (cortical button, bone tunnel, or suture anchors), the indications for allograft use, and the ideal rehabilitation protocol after treatment of PM tears.

Direct repair of chronic pectoralis major tears in active duty military patients

Objective

To express the significance and report the clinical outcomes of active duty military patients who underwent direct pectoralis major repairs in a chronic setting.

Methods

Retrospective review of data collected on 16 active duty military patients who underwent direct repair of a chronic pectoralis major tear. Pre-operative and post-operative evaluations (minimum 2 year follow up; mean, 53.46 months; range, 24-88 months) included range of motion, Bak classification, visual analog scale (VAS), Single Assessment Numerical Evaluation (SANE) Score, Quick Disabilities of the Arm, Shoulder and Hand (DASH) Score, and American Shoulder and Elbow Surgeons (ASES) Shoulder Score.

Results

Using a Bak classification, 94% (15/16) of patients were reported with good or excellent results. Mean VAS score improved from 7.08 ± 1.66 to 0.54 ± 1.20 (p < 0.0001). Mean SANE score improved from 42.31 ± 19.96 to 94.62 ± 5.94 (p < 0.0001). The average Quick DASH score increased from 55.42 ± 15.34 to 7.30 ± 6.39 (p < 0.0001). The average ASES score increased from 48.71 ± 13.80 to 94.62 ± 7.63 (p < 0.0001). There was no loss of motion after surgery in forward flexion, external rotation or internal rotation. The average internal rotation muscle power increased from 4.15 ± 0.48 to 4.92 ± 0.28 (p < 0.0001).

Complications

6.25% (1/16) patients developed a keloid scar, tender to direct pressure post-operatively. 94% (15/16) of patients returned to their pre-operative level of recreational and military job activity.

Conclusion

Military patients who underwent direct repair of a chronic pectoralis major tear had excellent clinical outcomes, low risk of complications, and a high return to pre-operative level of recreational and military job activity.

Level of evidence

Case Series; IV.

Surgical Treatment of Pectoralis Major Muscle Ruptures: A Systematic Review and Meta-analysis

Background:

Pectoralis major muscle (PMM) tendon ruptures are becoming more common. Multiple techniques for fixation of the avulsed tendon to its humeral insertion have been described. None of these techniques has been reviewed to compare outcomes in efforts to establish a first-line surgical technique.

Purpose:

To systematically review and analyze the data available in the literature to establish a clinically superior surgical technique and time frame in which surgery should occur.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic literature review was conducted. Only studies reporting the surgical techniques and outcomes of PMM repair were included. Data including patient age, injury mechanism, type and extent of the rupture, time from injury to surgery, surgical technique, outcome including complications, steroid use, location and year of publication, and activity level were extracted from the included studies. Statistical and descriptive analyses were conducted on the available literature.

Results:

Of 259 cases from studies that provided the timing of repair, 72.6% (n = 188) were repaired acutely, while the remaining were repaired more than 8 weeks after the injury. There was no statistical difference found in the outcomes of these repairs. There were 265 cases included in the statistical analysis comparing the outcomes of surgical techniques. The odds of an excellent/good outcome were significantly better for the transosseous suture (TOS) compared with the unicortical button (UCB) technique (odds ratio [OR], 6.28 [95% CI, 1.37-28.75]; P = .018) and also for the suture anchor (SA) compared with the UCB technique (OR, 3.40 [95% CI, 1.06-10.85]; P = .039). The odds of an excellent/good outcome were not significantly different when comparing the TOS, SA, and TOS with trough techniques to one another. The probability of complications was highest with the TOS with trough technique (12.0%), although the odds of having a complication were not statistically significant for any single technique compared with the others.

Conclusion:

The low quality of evidence available limited this review. There were no significant differences observed in the outcomes of PMM repair based on the timing of repair. The TOS and SA techniques had statistically significantly greater odds of resulting in an excellent/good outcome compared with the UCB technique, but 1 study that contributed to this analysis may have statistically skewed the results for the UCB technique. Therefore, all 3 surgical techniques are accepted options, and the best technique is that with which the surgeon is most proficient and comfortable. Comparative research with a greater level of evidence is needed to determine a definitive first-line surgical technique.