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ORIGINAL ARTICLE

Pectoralis Major Tendon Ruptures: Repair Using Absorbable Anchor Sutures

 Ramzi Moucharafieh

Address for Correspondence:

Ramzi Moucharafieh MD FACS
Email: ramzi@hhclebanon.com

 

Abstract:

Pectoralis major tendon ruptures are uncommon injuries and most physicians have little experience with the surgical treatment of this injury. The purpose of this article is to describe a new method of fixation of the ruptured tendon that facilitates the surgical procedure without altering the postoperative care, rehabilitation, and complication rate.

Keywords:

Pectoralis Major, Rupture, Absorbable Anchor Sutures.

J.Orthopaedics 2007;4(4)e9
 index.htm

Introduction:

Pectoralis major tendon ruptures is a relatively uncommon injury, with only about 200 reported cases in the literature. The injury was originally described by Patissier in 1822.1 Recently, the reported incidence has been increasing which may be related to the increasingly active population.

The injury has been commonly associated with athletic competition and weight-lifting. The mechanism is usually indirect, and classically described as occurring when the muscle transitions from an eccentric load to a concentric contraction. Blunt force and traction injuries have also been described. 2, 3

The past treatment of pectoralis major ruptures have been controversial, however recently most authors advocate early repair.3, 4  Several studies have demonstrated significant strength deficits with persistent weakness, as well as associated cosmetic deformity in the conservatively treated injuries.4, 5, 6 Conversely the outcome of surgical repair has been very encouraging with return to normal or near normal strength postoperatively.7, 8, 9 Elderly or low demand patients with pectoralis ruptures can be treated conservatively with acceptable results.10

Surgical repair must re-establish the tendon end into apposition to the bony insertion site. Passing sutures pulled through bone tunnels with needles that match the curve of the drill holes is cumbersome. We present our experience with the use of absorbable anchor sutures (Duet anchor suture Bionx-Linvatec)

 

Material and Methods :

Over a period of 2 years seven patients with eight complete ruptures of the pectoralis major underwent surgical repair within one week of injury. They were all athlete males who sustained their injuries during heavy weight lifting. The age range was 24-36 years. Four patients were receiving anabolic steroids and all were on high protein intake.

A careful physical examination provided the necessary information to make the clinical diagnosis (Fig 1). In three patients the diagnosis was confirmed by MRI.

 

Fig 1: Ecchymoses and asymmetry of the pectoral axillary fold.

All paients had a standard delto-pectoral approach in the beach-chair position. A 5-8 cm incision, at the distal end of the delto-pectoral interval, was utilized for exposure. The avulsed pectoralis tendon was easily identified. (Fig 2)

Fig 2: The avulsed Sternal and Clavicular heads

The insertion site of the tendon lateral to the bicipital groove was cleaned of any tendon remnants and roughened to create a bone trough. Three absorbable anchor sutures (Duet anchor suture Bionx-Linvatec) were used to fix the avulsed pectoralis tendon. The absorbable anchors are inserted into the humeral bone at the intended fixation site. Two anchor sutures were used to bring the sternal head deep and proximal to the clavicular head muscle which was repaired with one suture. (Fig 3)

Fig 3: Suture arms through the Sternal and Clavicular heads.

The arm is slightly adducted and internally rotated, and traction placed on the sutures arms brings the tendon down to the bone, tying the suture over the bone trough. (Fig 4)

Fig 4: Following repair, reestablishment of the delto-pectoral groove.

The wound is irrigated, and closed with subcutaneous absorbable sutures. (Fig 5)

Fig 5: Symmetry of the pectoral axillary fold restored postoperatively.

Postoperatively, the operated shoulder was immobilized for four weeks in adduction and internal rotation using an arm sling. Patients were requested to avoid abduction, external rotation, and resisted internal rotation. They were otherwise allowed passive motion within these parameters. Range-of-motion exercises except for abduction and external rotation were started at four weeks. Six weeks post operatively, the sling was discontinued, and abduction and external rotation were initiated. Isometric exercises were started at two months. Light resistance training was started at three months and heavy training at four months, with a return to unrestricted activity at six months.

Results :

At an average follow-up of fourteen months post repair (twelve to eighteen months), all patients were satisfied. They had restoration of the axillary folds with full active range of motion. There was return to full strength in adduction and internal rotation. All patients went back to weight lifting and body building sports activities.

There were no immediate surgical postoperative complications and no re-ruptures during the follow up period.

Discussion:

Most, if not all pectoralis major ruptures occur in males in their second to fourth decade of life. Most studies have demonstrated significant improvement in strength following acute repair of pectoralis major ruptures when compared with non-operatively treated injuries.2, 3, 11

Nearly two thirds of these ruptures occur at the tendinous insertion lateral to the bicipital groove.3

 

The advocated technique of tendinous repair is through the use of drill holes to create bone tunnels at the repair site. Passing sutures through the bone tunnels with a specific needle that matches the curve of the drill is somehow cumbersome.12 

In our study we have assessed the use of absorbable anchor sutures to overcome the above. Duet anchor suture Bionx-Linvatec is a bioabsorbale screw-in suture anchor that is preloaded on a disposable inserter device with two non-absorbable, braided, polyester #2 sutures. (Fig 6)

Fig 6: Duet Anchor Suture

It is manufactured from Self-Reinforced (96/4D) PLA Copolymer that retains 90% strength through 20 weeks and completely resorbs over a period of several years in vivo. The Self-Reinforced Copolymer provides high initial mechanical strength required for insertion and through the healing phase (20 weeks) with complete absorption occurring over several years. The absorption profile of the Copolymer allows the anchor to gradually loose strength as the collagen fibers of the repair form and gain strength. The Copolymer is inert, non-collagenous and non-pyrogenic through the absorption process.

The insertion is relatively simple, and provides an excellent pull out strength which is estimated at 217 N. The material strength eliminates bioabsorbable eyelet as a failure mode in repair construct, 406 N; 13

this was similar to our experience with use of these sutures at other sites (rotator cuff tears, vastus medialis ruptures).

Bal GK and Basamania CJ have expressed their concern with anchor suture repair not providing as much broad area of tendon-bone contact as it was with the routine bone tunnel sutures. This was not the case in our technique, which is basically due to the presence of a double suture line that can be utilized over a broader area of the repaired tendon.  We did not have any wound complications and no tendon repair re-ruptures.

Several studies have shown a possible correlation between prior steroid use and subsequent pectoralis major ruptures.2, 14 These patients should be cautioned concerning healing potential and overall risk of future medical problems or injuries.

Conclusion:

Pectoralis major tendon ruptures are uncommon injuries and most physicians have little experience with the surgical treatment of this injury. We have presented our experience with use of the absorbable anchor sutures in the acute repair of tendon ruptures. We feel that this technique simplifies a cumbersome step of the repair without altering the postoperative care, rehabilitation, and complication rate.

Reference :

1. Patissier P. Maladies des bouchers. Traite des maladies des artisans, 162-165, 1822.

2. Aarimaa V, Rantanen J, Heikkila J, Helttola I, Orava S. Rupture of the pectoralis major muscle. Am J Sports Med. 2004; 32:1256-1262.

3. Bak K, Cameron EA, Henderson IJ: Rupture of the pectoralis major: a meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc. 2000; 8:113-119.

4. Scott BW, Wallace WA, Barton MA. Diagnosis and assessment of the pectoralis major rupture by dynamometry. J Bone Joint Surg Br. 1992; 74:111-113.

5. McEntire JE, Hess WE, Coleman SS. Rupture of the pectoralis major muscle: a report of eleven injuries and review of fifty-six. J Bone Joint Surg Am. 1972; 54:1040-1046.

6. Roi GS, Respezzi S, Dworzak F. Partial rupture of the pectoralis major muscle in athletes. Int J Sports Med. 1990; 11:85-87.

7.Hanna CM, Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med. 2001;35:202-206.

8. Liu J, Wu JJ, Chang CY, Chou YH, Lo WH. Avulsion of the pectoralis major tendon. Am J Sports Med. 1992; 20:366-368.

9. Quinlan JF, Molloy M, Hurson B. J: Pectoralis major tendon ruptures, when to operate. Br J Sports Med. 2002; 36:226-228.

10. Beloosesky Y, Grinblat J, Weiss A, Rosenberg P, Weisbort M, Hendel D. Pectoralis major ruptures in the elderly. Clin Orthop. 2003; 413:164-169.

11. Schepsis AA, Grafe MW, Jones HP, Lemos MJ. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med. 2000; 28:9-15.

12. Bal GK, Basamania CJ. Pectoralis Major Tendon Ruptures: Diagnosis and Treatment (Technique). Techniques in Shoulder and Elbow Surgery. 2005; 6(3): 128-134.

13. Barber FA, Herbert MA, Richards DP. Sutures and suture anchors: update 2003. Arthroscopy. 2003; 19: 985-990.

14. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle. An anatomic and clinical analysis. Am J Sports Med. 1992; 20:587-593.

 

This is a peer reviewed paper 

Please cite as : Ramzi Moucharafieh : Pectoralis Major Tendon Ruptures: Repair Using Absorbable Anchor Sutures

J.Orthopaedics 2007;4(4)e9

URL: http://www.jortho.org/2007/4/4/e9

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