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Repair of Pectoralis major muscle using Arthrex Pec Buttons

    Overview

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    The pectoralis major muscle is a fan shaped muscle the sits on the anterior aspect of the chest wall. It arises from the anterior surface of the sternal half of the clavicle, the anterior half of the sternum to the costal cartilages of the first six ribs and the aponeurosis of the external oblique muscle. As the muscle fibres converge towards its insertion on the proximal humerus, they form two distinctive insertions. The clavicular head fibres run obliquely inferiorly and laterally and inserts superficially. The sternal head fibres run more horizontally, whereas the inferior fibres run obliquely superiorly and laterally. The more inferior fibres tend to twist up and insert deeper and more superiorly on the proximal humerus. The fibres end up in a flat tendon around 5cm in diameter and insert into the lateral lip of the bicipital groove of the humerus.
    The main muscle actions of pectoralis major include flexion, adduction, internal rotation and extension (from a flexed position) of the humerus. It also acts as a dynamic stabiliser of the shoulder.
    Pectoralis major ruptures occur when there is an excessive tension acting on a maximally eccentrically contracted muscle, such as during a bench press. Pectoralis major ruptures can either occur as a tendinous avulsion (most common), or rupture at the musculotendinous junction or within the muscle substance itself.
    Ruptures of pectoralis major are rare but largely effect athletic populations, particularly weight-lifters. It predominantly affects males due to larger tendon to muscle ratio, greater elasticity and less energetic injuries occurring in males. This can result in weakness, pain and cramping.
    A very useful implant for the fixation of these rare injuries, and my preference, is using the Arthrex Large Pec Button Kit. This consists of a 3.7mm drill pin, 3 large Pec buttons with inserters, 2mm Fibretape x3 and number 5 Fibrewire x3. I prefer to use a Krakow stitch using the Fibretape in the ruptured pectoralis major tendon as it has better pullout characteristics due to the larger surface area of the tape. Two or three Pec buttons provide a robust fixation spread over a large area and restore the anatomy of the insertion of pectoralis major.

    Indications

    INDICATIONS
    Although the muscle is not essential for normal daily shoulder function, it is important for strenuous activity.
    Indications for surgery includes patients who have a significant demand for their shoulder function, or wish to return to sporting or manual activities.
    SYMPTOMS & EXAMINATION
    Patients classically present with a history of sudden severe pain in the arm and shoulder at the time of injury, with or without a snapping sensation with resisted adduction and internal rotation. Patients complain of painful limitation of motion and weakness.
    The patient may present with localised swelling and ecchymosis.
    Clinical examination may reveal loss or a palpable defect of the anterior axillary fold. This can be accentuated by asking the patient to tense the pectoralis muscle in the prayer position. There may be associated weakness on adduction and internal rotation.
    IMAGING
    Plain AP and axillary or scapular Y lateral radiographs of the shoulder joint are required to exclude any fractures in the context of trauma. However, diagnosis of pectoralis major injuries are largely clinical, and x-ray findings tend to be normal.
    To confirm the diagnosis, an ultrasound scan or MRI performed by a musculoskeletal radiologist should be sought. However, as these injuries are uncommon, the quality of the report is dependent on the experience of the operator.
    A ultrasound is a dynamic test and may confirm the diagnosis more easily. Again, this is operator dependent. It may also be easier and quicker to arrange. Tears are identified by uneven echogenicity and muscle thinning.
    An MRI will give more detail as the imaging can show where the rupture has occurred. It can assess the grade of injury, site, and the level of retraction in experienced hands. However, it may take longer to arrange.
    CLASSIFICATION
    Tietjen originally classified pectoralis major tears according to the severity (I – contusion or muscle strain, II – partial tear, III – complete tear) and location of the tear (IIIA – complete tear of the muscle origin, IIIB – complete tear of the muscle belly, IIIC – complete tear of the musculotendinous junction, IIID – complete tear at the tendinous insertion). This was modified by Bak to include IIIE – bony avulsion from insertion, and IIIF – complete tear of muscle tendon substance.
    ALTERNATIVE OPERATIVE TREATMENT
    The method of fixation is largely dependent on location of injury, timing of presentation and surgeon preference.
    Location of injury
    Different methods of surgical fixation have been described in the literature depending on the location of injury. For the most common ruptures at the insertion, the common techniques include transosseous sutures, suture anchor fixation or cortical button techniques (uni or bi-cortical).
    Overall, there seems to be little biomechanical advantage from one technique over the other (Sherman et al.)
    For ruptures at the musculotendinous junction, direct suture repairs have been described if there is sufficient viable tissue.
    Gupton M, Johnson JE. Surgical Treatment of Pectoralis Major Muscle Ruptures: A Systematic Review and Meta-analysis. Orthop J Sports Med. 2019 Feb 7;7(2):2325967118824551. doi: 10.1177/2325967118824551. eCollection 2019 Feb.
    Timing of presentation
    Acute injuries have been arbitrarily defined as occurring in less than 8 weeks. Those presenting acutely are more likely to undergo primary repair.
    If presentation is delayed, there may be concerns regarding the level of retraction, adhesions and mobility of the muscle which ultimately, affects the reducibility of the muscle tendon to its insertion point. If not repairable primarily, an autograft or allograft may be used to bridge the gap. Grafts including semitendinosus/gracilis tendon, Achilles tendon, tensor fascia lata, patella tendon and semitendinosus tendon techniques have been described to bridge the gap.
    As these remain rare injuries, the body of evidence remains small. However, the literature suggests that there is no significant difference in outcome between acute and chronic repairs.
    NON-OPERATIVE MANAGEMENT
    As mentioned before, an intact pectoralis major muscle is not essential for everyday function. Therefore, patients may opt for non-operative management if they do not wish to undergo the risks of surgery, or if they are of low demand.
    Conservative management is recommended for proximal tears and some partial tears, tears in the muscle or tear at the musculotendinous junction.
    Non-operative management involves initial sling immobilisation, rest and analgesics. This is usually followed by early shoulder mobilisation and stretching exercises, followed by strengthening exercises at 6-8 weeks.
    Conservative management of complete tears result in a cosmetic defect and a significant deficit in strength. Bak et al. showed that 88% of surgically managed pectoralis major repairs resulted in an excellent to good outcome vs. 27% in the conservatively managed group.
    OUTCOMES
    Bak graded the outcomes of pectoralis major repairs as:
    Excellent – Pain-free, full range of motion, no cosmetic complaints, symmetrical manual adduction strength or <10% isokinetic strength loss, return to previous activities without restrictions
    Good – Slight functional impairment with slight restrictions in movement or strength, no cosmetic complaints, symmetrical manual adduction strength or a <20% isokinetic deficit
    Fair – Impairment of function affecting return to the desired activity, due to pain or weakness on activity, or unsatisfactory cosmetic result
    Poor – Significant complications occurred, pain or restricted range of motion, or significant cosmetic complaints from scarring or inadequate repair
    CONTRAINDICATIONS
    Although there are no absolute contraindications, there would be significant reservations in patients with potentially complicating medical conditions, in the elderly age group and in cases where there are compromised soft tissues from trauma, or in a previous radiotherapy field.

    Setup

    The procedure is performed under general anaesthetic.
    The patient is set up on a shoulder table inclined at around 45 degrees. It is important to check that the head and neck are secure in the head clamps.
    A pre-surgical scrub of the shoulder and axilla may be performed prior to routine skin preparation. Flowtron intermittent calf compression may be used to reduce the risk of thromboembolic disease. Intravenous antibiotics are administered by the anaesthetist.
    The whole of the shoulder, arm and hand of is prepared with chlorhexidine spirit and draped to allow adequate exposure for the deltopectoral approach. Of particular note, draping should be up to the midline on the chest wall to maximise access to the pectoralis major muscle to aid retrieval of the retracted tendon.
    The operative arm is placed in a stockinette and set up in the Arthrex TRIMANO Limb Positioner as this allows optimal positioning of the upper limb during the procedure.

    Operation – 1

    MRI – T1 weighted axial
    This image shows the haematoma in the potential space after the tendon has ruptured and retracted medially.
    Note, chronic injuries are best seen on T1 weighted images.

    MRI – T2 weighted axial
    This image shows the rupture more clearly on the background of haematoma formation.
    T2 weighted images may more useful in diagnosing acute and subacute tears as T1 weighted images may not allow differentiation from haemorrhage/haematoma from muscle.

    MRI – Fat saturated axial
    This image also helps to highlight the haematoma(1) formed and the retracted end of the pectoralis major tendon(2).

    MRI – Fat saturated coronal
    This image shows the haematoma(1) in the coronal profile.
    Just lateral to this, you can appreciate the fibres of the clavicular head of pectoralis major(2).
    The distorted fibres of the sternal head of pectoralis major are noted (3)

    MRI – Fat saturated coronal
    The clavicular head of pectoralis major (2) is more convincingly intact in the image.

    The patient is set up on a shoulder table inclined at around 30-40 degrees.

    The location of the palpable defect in the defect anterior axillary fold is identified prior to draping.A stockinette is applied after Chlorhexidine prep is applied.
    As the arm is abducted, the loss of the anterior axillary fold becomes more apparent, confirming that there is a rupture of the pectoralis major tendon.

    Application of Arthrex Trimano Limb PositionerThe Trimano is set up by first applying it to the rail of the shoulder table using the Trimano clamp. It is important to apply the clamp towards the head end of the rail, rather than the foot end. This is to avoid the Trimano getting in the way when positioned in the ‘axilla’ side of the arm when operating.
    A sterile adapter is applied to the Trimano arm and the disposable drapes and armrest are applied. The upper limb is secured to the armrest using the long stretch strap.
    It is important to apply this strap with enough tension to ensure that when the arm position is adjusted, the arm sits securely in the armrest.

    The incision is marked out using the coracoid as the reference point for a modified deltopectoral approach.The approach is through a deltopectoral incision.
    The landmark for this is the coracoid (1).
    The approach for a pectoralis major repair means the incision is sited distal to the coracoid. The standard incision runs from the coracoid to the insertion of deltoid (2), aiming to avoid the axilla.
    However, the distal aspect of the approach is aligned more medially (3) to allow adequate exposure of the retracted pectoralis major tendon. This aids retrieval of the tendon which sits medially.
    Note, even though the incision is more medial. I tend to align the distal aspect of the incision lateral to the axilla (3).
    The deltopectoral approach is an extensile approach utilising the interval between deltoid (supplied by axillary nerve) and pectoralis major (medial and lateral pectoral nerves). Note as pectoralis major may be deficient, it is important to identify the deltopectoral interval. This can be identified by locating the cephalic vein as it lies in a layer of fat in the interval.

    The standard incision runs from the coracoid to the insertion of deltoid, aiming to avoid the axilla.The skin and fat are incised and the soft tissues are spread using a West retractor in the orientation of the incision.
    The aim is to incise down to the fascial layer to locate the deltopectoral interval.

    When exposing the deltopectoral interval, blunt dissection is performedHaemostasis is achieved using cautery for the superficial vessels in the skin.
    As the upper limb is highly vascularised, there can be significant bleeding if these vessels are not addressed.
    When exposing the deltopectoral interval, blunt dissection down to the fascial layer is performed using Mcindoe scissors to avoid injury to the cephalic vein.

    As the deeper dissection is taken proximally, the deltopectoral interval is found medially.
    If there is difficulty locating the deltopectoral interval, palpation of the coracoid and dissection from proximal to distal helps.
    This is because the deltoid lies lateral to the coracoid and the clavicular head of the pectoralis major lies medial to it.
    The fibres of deltoid and pectoralis major also diverge more proximally, making locating the inteval easier.

    The fat stripe in the deltopectoral interval aids in localising the cephalic vein
    The cephalic vein (1) is located in the fat stripe is marked by the forceps in this image.
    2 – Clavicular head of pectoralis major
    3 – Deltoid

    Once the fat stripe is bluntly dissected, the cephalic vein is exposed and is usually taken laterally along with the deltoid to avoid injury to the deltoid tributaries.This is mobilised up to the proximal extent of the incision.
    The cephalic vein is marked out by the forceps.
    Note it usually lies more medial than expected, particularly in muscular individuals.

    The medial limb of the West retractor remains retracting the soft tissues. The clavicular head of pectoralis major lies under this (1). The West retractor is adjusted from retracting the soft tissue to the deeper layer of muscle.
    The lateral limb of the West retractor is placed under the anterior edge of deltoid (2) and cephalic vein. Care is taken to ensure that the teeth of the retractor are under the anterior edge of deltoid to minimise the risk of damage to the cephalic vein (and deltoid).
    As the cephalic vein has been mobilised proximally, there is usually enough laxity to allow retraction.
    If the cephalic vein is damaged, it is better to ligate the cephalic vein before proceeding to minimise any bleeding during the operation. Risks of complications from this are negligible.
    Note, if pectoralis major is intact, the muscle would have to be retracted medially to expose the deeper layer.
    Once retracted, the deeper layers are exposed.
    The forceps marks the conjoint tendon (3). Note, the short head of biceps and coracobrachialis form the muscle of the conjoint tendon. Due to the muscle bulk, the muscle fibres are seen lateral to the tendon itself.

    Once the conjoint tendon has been identified, the West retractors are removed. This is to aid blunt dissection superficial to the conjoint tendon. This is to allow location of the retracted pectoralis major tendon.
    Using the finger as a blunt dissector it is possible to palpate the retracted pec major tendon. From here, it is important to bluntly dissect superficially and deep to the pectoralis major muscle to free it up from adhesions.
    This is to maximise the excursion and lateral mobilisation of the pectoralis major tendon.
    The potential risks of aggressive dissection include injury to the medial and lateral pectoral nerves and the pectoral branch of the thoracoacromial artery.
    The pectoral nerves (derived from the lateral and medial cords) enter the muscle on its
    deep medial aspect. The lateral pectoral nerve supplies the clavicular head and medial pectoral nerve, the sternal head.
    The pectoral branch of the thoracoacromial artery is the main blood supply of the muscle and enters the deep surface of pectoralis major.
    Therefore care must be taken to when dissecting the scar tissue on the deep surface of pectoralis major.

    Once the pectoralis major tendon is mobilised, it is retrieved and held using Kocher clamps.The muscle lateral to this is the deltoid muscle (1).

    The retrieved Pectoralis major tendon is inspected.The scarred remnants of the tendon stump becomes more obvious as it is brought into view.

    Once the tendon is identified, the Arthrex Large pec button disposable repair kit can be opened.
    The kit consists of 3x 2mm Fibretape (and number 5 Fibrewire) sutures, 3 large pec buttons on button inserters.

    Arthrex 2mm Fibretape on curved needle is prepared.The kit allows repair of the pec major tendon using number 2 Fibrewire or 2mm Fibretape.
    The author has a preference for Fibretape as the larger surface area minimises the risk of cut-out from the tendon.

    Krakow stitch to pectoralis major tendon stumpThe pec major tendon is broad at it’s insertion and is usually around 5 cm in width.
    Once the tendon is retrieved it is important to orientate muscle fibres appropriately and to plan were the 3 pairs of sutures will go in relation to the width of the pectoralis major tendon.
    The width of the pectoralis major tendon is divided into thirds. The pectoralis major tendon is prepared using a Krakow stitch utilising the Fibretape sutures.
    The Krakow stitch involves 4-5 locking loops in the ascending limb spaced 6-8mm apart. This is passed through the full width of the tendon before 4-5 locking loops are passed in the descending limb.
    The author prefers using the broader Fibretape sutures to minimise the risk of cut-out from what can be friable tendon stump.

    The reducibility of the tendon is assessed following placement of the KrakowOnce passed, there should be 3 pairs of Fibretape sutures across the width of the tendon as shown in the picture.
    Each pair of sutures should be pulled taut and tested to take out any residual slack.
    It is also checked to ensure that the ruptured tendon is reducible.
    If it is not reducible, manoeuvres to reduce the gap, including adducting the humerus, can be employed.
    If this is not successful, the use of grafts has to be taken into consideration.

    In this case, the clavicular head or the superficial portion of the pectoralis major tendon is noted to be intact (1).
    Although this is an uncommon injury, it has been sporadically recognised in the literature.
    Connell et al. noted that in a cohort of 15 pectoralis major tears undergoing MRI evaluation, 3 isolated sternal head tears, 2 isolated clavicular head tears and 10 complete ruptures involving both heads.
    Cordasco et al. more recently reported a higher rate of isolated sternal head ruptures (23/40 patients) in a consecutive series of surgically managed patients, compared with 17/40 complete ruptures of sternal and clavicular heads.
    With respect to pectoralis major tendon anatomy, as the muscle fibres converge, they form two distinctive insertions. The clavicular head fibres run obliquely inferiorly and laterally and inserts superficially (1). The sternal head fibres run more horizontally, with the inferior fibres run obliquely superiorly and laterally.
    The more inferior fibres tend to twist up and insert deeper and more superiorly on the proximal humerus. The fibres end up in a flat tendon around 5cm in diameter and insert into the lateral lip of the bicipital groove of the humerus.
    2 – deltoid

    The clavicular head of pectoralis major is isolated and put under tension.
    By passing the McIndoe scissors under the clavicular head and lifting it to put it under tension, it becomes clear that the distal insertion of the clavicular head (1) is intact on the proximal humerus.
    Care has to be taken not the injure the cephalic vein as the tip of the scissors enters the deltopectoral interval.
    The conjoint tendon lies deep to this so there should be no significant structures at risk.
    The decision was made to preserve the clavicular head.
    However, this made the reattachment of the sternal head a little more technically challenging as its insertion on the humerus obscures the insertion of the deep head.

    The West retractor is adjusted to lie inferior and medial to the clavicular head.
    The exposure was readjusted to allow approach the sternal head of the pectoralis major by retracting the clavicular head of pectoralis major (1) laterally.
    The sternal head sits inferior and medial to the clavicular head.
    This allows appropriate reattachment of the sternal head deep to the insertion of the clavicular head of pectoralis major.
    In this image you can see the scarred bed of the pectoralis major muscle and tendon medially (2).

    Operation – 2

    It is important to retrieve the limbs of the fibre-tape sutures from superior to the clavicular head of the pectoralis major tendon and bring them out inferior to the clavicular head.
    This is so that when approaching the insertion for the sternal head on the humerus, the clavicular head can be retracted laterally to visualise and access the whole footprint for the deep head.
    The footprint begins at the base of the bicipital groove and runs 3-5 cm, lateral to the long head of biceps tendon.

    The artery forceps are passed underneath the clavicular head of the pectoralis major tendon to retrieve the Fibretapes.

    The fibretapes are brought out inferior to the clavicular head of the pectoralis major tendon.
    Care is taken to ensure that the needles attached to the fibretapes are passed safely.

    The sternal head of the pectoralis major tendon( inferior to the clavicular head) is brought out and taken laterally.
    The slide shows that there is very little residual tendon stump attached to the muscle on the sternal head of the pectoralis major muscle (1).

    Further mobilisation of the transferred Pec Major head by dissection of soft tissue adhesions is required if it doesnt mobilise adequately.Any residual adhesions of the pectoralis major muscle to the subcutaneous tissues are freed up using the Mcindoe scissors.
    This is performed using a combination of blunt and sharp dissection.
    Care is taken not to ‘buttonhole’ through the skin by staying on the muscle layer.
    There are no major neurovascular structures at risk although care is required to diathermy any bleeding vessels to the skin.

    Once the pectoralis major is mobilised, attention is turned to its insertion of on the proximal humerus.
    The arm is abducted and externally rotated to expose the humeral insertion of pectoralis major.
    The slide shows the relation of the clavicular head (1) and the scarred bed of the sternal head (2).

    Repositioning in abduction and external rotation using Trimano to aid identification of the pec major on the proximal humerus.Repositioning of the arm into abduction and relative external rotation is made easier using the Trimano.
    Flexion can also be applied if needed.
    Once locked, the position is maintained. This reduces the tension of the deltoid muscle (and in this case the clavicular head of the pectoralis major).
    Again, note the loss of the anterior axillary fold.

    A Hohmann’s retractor is placed under deltoid and the clavicular head of pectoralis major and retracted laterally to aid exposure of the insertion of the pectoralis majors’ footprint.
    This slide shows the bony footprint of the pectoralis major insertion in the lateral lip of the bicipital groove (1).
    The long head of biceps tendon is marked by the forceps.

    The area of humerus receiving the pectoralis major tendon is marked out using diathermy, just lateral to the long head of biceps.
    Anatomically, the insertion of the pectoralis major tendon usually starts distal to the bicipital groove and spans 4-5 cms distal to this.

    Once the footprint has been exposed using diathermy, a small high speed spherical burr is used to freshen up the cortical bone to stimulate bone to tendon healing.

    Once the footprint has been lightly decorticated three unicortical drill holes are made using a 3.7mm drill pin (enclosed in the kit).

    It is important to space the drill holes far enough apart to minimise the risk of stress risers and propagation of a potential fracture.

    Space the unicortical drill holes each approximately 2cm apart
    It helps to stagger the drill holes from medial to lateral so that the footprint forms a shallow base triangle, with the apex lateral.
    This maximises the distance between the drill holes.
    This slide shows the drill holes adjacent to the insertion of the clavicular head of pectoralis major.

    Once the pectoralis major tendon and footprint have been prepared, the Fibretapes are loaded onto the Arthrex large pec buttons.
    The first limb of the Fibretape is passed through the proximal eyelet of the pec button (as shown).

    When orientating the pec button for loading with the Fibretape, it is important to note that the pec button is chamfered.
    The aim is to ensure that the suture exits the distal eyelet on the long edge of the pec button.

    The Fibretape is then passed through the second eyelet in the opposite direction.
    The free end of the limb can be held on an artery clip to minimise the risk of the suture slipping back through and unloading.
    It also marks the limb of suture to be pulled taut once the button is unloaded from the holder.
    The Fibretape is loaded in a fashion so that the free end of Fibretape exits the distal eyelet on the long edge of the pec button as shown in the image. This is so that when it is unloaded from the holder, and the free limb of Fibretape is pulled taut, it encourages the button to flip in the intramedullary canal and lock into place.

    The second limb of the suture is threaded through the distal eyelet in the opposite direction to the first suture limb.

    Once passed through it is fed back through the proximal eyelet so that all 4 limbs of the suture exit the eyelet in the same direction.
    At this stage it is important to mark or note the free limb of Fibretape that is exiting the distal eyelet of the pec button.

    Once the sutures are all taut and appropriately located, they should exit in the same direction on the pec button.

    This more clearly demonstrates all the sutures exit in the same direction.

    Once all 3 pairs of suture tape sutures have been orientated and loaded on to the pec buttons, they are placed on the drapes and secured using a artery clip.
    This helps to co-ordinate the pairs of sutures to be deployed in the superior, middle and inferior drill holes.

    Before the pec buttons are deployed in the humerus, a short aside to explain the mechanism…
    The image shows the pec button inserter (1) with pec button pre-loaded on the inserter (2)
    The central screw-in mechanism (3), screws into the pec button to capture it and hold it in place.

    By unscrewing the central mechanism (1), this disengages the pec button from the inserter.

    With the sutures loaded on the pec button, it is important to isolate the free limb of suture exiting the distal eyelet (1)

    With the suture isolated (1), the pec button is passed through the cortical drill hole.

    Operation – 3

    This coffee station mock up shows the view of the pec button as it sits in the intramedullary canal.
    Note, the suture (1) remains isolated from the remaining sutures.

    As the central mechanism is unscrewed, the pec button is released from the inserter and becomes free.

    By keeping the inserter in the drill hole and pulling on suture 1, this allows the pec button to flip and engage against the inner cortex with no risk of the pec button backing out of the drill hole.

    This view demonstrates how the inserter prevents the pec button from backing out when pulling on suture 1

    Once flipped, the inserter is removed and the 2 free limbs are sequentially pulled and tightened.

    This ‘intramedullary’ view shows the the button engaged flush against the inner cortex as the suture limbs are pulled tight.

    The pec button for the most inferior hole is brought towards the drill hole and the excess slack is taken out of the fibre-tape.

    The first and inferior Pec button is inserted into the drill hole.There is tactile feedback when the button passes through the drill hole into the intramedullary canal.

    Unscrew the Pec buttons central mechanismWith the Fibretape that exits the distal eyelet of the button isolated, the tension in this suture is maintained whilst the central mechanism is unscrewed.

    Removing the Pec buttons central mechanismThe central mechanism is removed from the button inserter handle.
    It is important to ensure that the pec button inserter remains held within the drill hole.
    Suture 1 is isolated as previously described.

    The limb of Fibretape (1) passing through the distal eyelet is pulled to flip the pec button within the canal.
    By maintaining the inserter in the drill hole, this prevents the pec button from being pulled out from the bone and ensures that it engages against the cortical bone.

    Once the button has flipped and engaged the pec button inserter can be removed and the two limbs of sutures (1&2) are pulled taut alternately to take out any excess slack.
    This is to reduce the pectoralis major tendon down towards the prepared footprint on the humerus
    The internal friction from the Fibretapes prevents the tapes from backing out.

    This image shows the second button being inserted into the middle drill hole.

    Following insertion of 3 Pec buttons, the Trimano is repositioned with the arm back in adduction to reduce the distance of travel of the retracted pectoralis major tendon to its insertion.

    Final tensioning of the Fibretapes occurs after repositioning of the arm.As the Fibretapes are still able to slide after deployment into the drill holes, each pair of Fibretapes are sequentially tightened and repeated to take out any excess slack and to ensure that the tendon is reduced onto its footprint.

    Once satisfied that the pectoralis major tendon has been fully reduced onto the footprint and the excess slack removed, the needles can be cut from the tape.

    By maintaining the tension, the Fibretapes can be finally tied and secured.

    This picture shows the reduced sternal head of the pectoralis major tendon (1) reattached at its bony insertion on the proximal humerus.
    The clavicular head (2) has been retracted lateral by the Hohmanns’ retractor.
    The deltoid muscle (3) lies lateral to this
    The tails of the suture (4) lie attached to the buttons at the footprint of pectoralis major.

    The fibretapes are secured using four throws of a knot and then cut.

    This slide shows the final result.
    Deltoid (1)
    Clavicular head of pectoralis major (2)
    Sternal head of pectoralis major (3)

    Deltopectoral interval closureOnce satisfied that an adequate repair has been performed, the soft tissues can be closed in layers.
    The deltopectoral layer can be reapproximated using 1 vicryl interrupted sutures.

    The fat layer is closed using 3-0 vicryl
    The subcuticular layer is closed using 3-0 monocryl

    Additional half inch steri-strips help take the tension off any sutures and minimise stretching of the scar.

    A waterproof dressing is applied.

    A polysling without body strap is applied to ensure that the arm remains internally rotated.
    This is to take any tension off the pectoralis major repair.

    Operation – 4

    The radiograph shows the position of the buttons and confirms that the anatomical footprint of the pectoralis major tendon has been restored

    The images show that the buttons are aligned lateral to the bicipital groove.

    Post Operative

    <3 Weeks
    Polysling
    Elbow, wrist, hand and finger exercises
    Closed chain exercises as tolerated
    Passive/active assisted ROM in safe zone as tolerated
    Avoid forcing/stretching exercises
    Scapula setting exercises
    3-6 Weeks
    Gentle isometric exercises in neutral as pain allows
    Wean off sling
    Progress to open chain exercises in safe zone
    Avoid forcing/stretching exercises
    >6 Weeks
    Progress to open chain exercises in all ranges as tolerated
    Progressive resistance exercises
    Avoid hyperextending in bench press
    Avoid high weights with low reps and warm up slowly
    >3 Months
    Return to contact sports

    Recommended Reading

    Conservative vs. operative management of pectoralis major tendon tears.
    Hanna CM, Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med. 2001 Jun;35(3):202-6.
    Hanna et al. reported a series of 22 pectoralis major tears, comparing operative management with conservative management. Peak torque returned to 99% in the operative group compared to 56% in the conservatively managed group. This was independent of time to surgery.
    Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc. 2000;8(2):113-9.
    A meta-analysis of 112 cases of pectoralis major rupture, showed that patients who undergo surgical repair had less pain, a higher rate of pre-injury strength and return to activities, than patients managed conservatively.
    Outcome of pectoralis major repair.
    Cordasco FA, Mahony GT, Tsouris N, Degen RM. Pectoralis major tendon tears: functional outcomes and return to sport in a consecutive series of 40 athletes. J Shoulder Elbow Surg. 2017 Mar;26(3):458-463. doi: 10.1016/j.jse.2016.07.018. Epub 2016 Sep 30.
    Cordasco et al. reported high patient satisfaction scores, with patients returning to preinjury level of activities at an average of 5.5 months postoperatively. Of these, around 25% described mild or moderate difficulty with sport participation.
    Ten patients (25%) reported concerns about the cosmetic appearance of their surgical scar or mild chest asymmetry.
    Isokinetic evaluation of adduction strength revealed an average decrease of ≤9.9% compared with the contralateral side.
    Despite excellent patient satisfaction and functional outcomes, application of the Bak criteria revealed 37% excellent, 26% good, and 37% fair outcomes, with the majority of patients in the fair group reporting cosmetic concerns related to their incision or mild chest asymmetry (54%).
    With cosmesis removed, 46% of patients scored excellent, 37% good, and only 17% fair.
    Method of repair
    Sherman SL, Lin EC, Verma NN, Mather RC, Gregory JM, Dishkin J, Harwood DP, Wang VM, Shewman EF, Cole BJ, Romeo AA. Biomechanical analysis of the pectoralis major tendon and comparison of techniques for tendo-osseous repair. Am J Sports Med. 2012 Aug;40(8):1887-94. doi: 10.1177/0363546512452849. Epub 2012 Jul 9.
    Sherman et al. performed biomechanical testing on cadaveric specimens including cyclical loading and load to failure protocols. They showed that there was no difference between transosseous repair, suture anchors, and unicortical button repair.
    A meta-analysis of 112 cases of pectoralis major rupture, showed that patients who undergo surgical repair had less pain, a higher rate of pre-injury strength and return to activities, than patients managed conservatively.

    Reference

    • orthoracle.com

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