Pectoralis Major Tear with Retracted Tendon: How to Fill the Gap? Reconstruction with Hamstring Autograft and Fixation with an Interference Screw

Background: The pectoralis major (PM) is made up of multilaminar muscle segments that form a complex insertion on the proximal humerus; it is composed of an anterior and a posterior tendon layer. The tear patterns and patient characteristics of operatively treated PM ruptures in the general population remain poorly understood. Purpose: To comprehensively report the demographic characteristics of patients who are clinically diagnosed with structurally significant PM ruptures and to describe PM tear patterns identified during surgery. Study Design: Case series; Level of evidence, 4. Methods: A retrospective analysis of surgically treated PM tears was performed for a single-surgeon case series between January 1, 2003, and November 1, 2017. Patient demographic characteristics, classification of tear pattern, and treatment (repair/reconstruction) were recorded. Results: A total of 104 surgical cases of PM tendon rupture were identified; 100 patients underwent primary repair and 4 underwent dermal allograft reconstruction. All patients were male, with a mean age of 36.5 ± 9.2 years. Chronic tears (>6 weeks old) accounted for 63.6% of surgical cases, and 96% (n = 100) of tears occurred at or between the musculotendinous junction and tendinous insertion. A partial-thickness, complete-width tear of the posterior tendon layer at this same location was the most common tear pattern identified. Conclusion: PM ruptures occurred almost exclusively at or between the musculotendinous junction and tendinous insertion, with predominant involvement of the posterior tendon layer. Chronic tears can be safely treated with primary repair in the vast majority of cases.

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“…We have also seen several new descriptions of surgical repair techniques for both acute and chronic ruptures. 3 , 6 , 7 , 22 …”

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confidence: 99%

Pectoralis Major Ruptures: Tear Patterns and Patient Demographic Characteristics

Kowalczuk

Rubinger

Elmaraghy

2020

Orthopaedic Journal of Sports Medicine

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“…Despite the numerous surgical techniques described for repair of acute tears of the PM tendon, 11 only a handful of techniques have been described with grafts to augment the repair of a chronically torn PM tendon or a torn PM tendon with poor tissue quality. 5 , 14 , 20 , 23 , 25 , 26 They include the use of a bone–patellar tendon autograft, hamstring autograft, Achilles tendon allograft, and fascia lata allograft. These are only case reports or small case series with limited objective outcomes.…”

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confidence: 99%

Outcomes After Dermal Allograft Reconstruction of Chronic or Subacute Pectoralis Major Tendon Ruptures

Neumann

Klein

Eck

et al. 2018

Orthopaedic Journal of Sports Medicine

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Background:Avoiding delay in the surgical management of pectoralis major (PM) ruptures optimizes outcomes. However, this is not always possible, and when a tear becomes chronic or when a subacute tear has poor tissue quality, a graft can facilitate reconstruction.Purpose:The primary aim was to evaluate the clinical outcomes of PM reconstruction with dermal allograft augmentation for chronic tears or for subacute tears with poor tissue quality. A second aim was to determine patient and surgical factors affecting outcome.Study Design:Case series; Level of evidence, 4.Methods:Nineteen consecutive patients (19 PM ruptures) with a mean ± SD age of 39.1 ± 8.4 years were retrospectively reviewed at 26.4 ± 16.0 months following PM tendon reconstruction with dermal allograft. Surgery was performed at 19.2 ± 41.2 months after injury (median, 7.6 months; range, 1.1-185.4 months). Several outcome scores were recorded pre- and postoperatively, including Disabilities of the Arm, Shoulder, and Hand (DASH), as well as visual analog scale (VAS) (range, 0-10; 0 = no pain) and Single Assessment Numeric Evaluation (SANE). Range of motion, Constant score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and complications/reoperations were recorded postoperatively.Results:Scores improved significantly for the DASH (preoperative, 34.9; postoperative, 8.0; P < .001) and VAS (preoperative, 5.0; postoperative, 1.5; P = .011). There was a trend toward improved SANE scores (preoperative, 15.0; postoperative, 80.0; P = .097), but the difference was not statistically significant, likely because of the small number of patients having preoperative SANE scores for review. Increased age was associated with higher VAS scores (r = 0.628, P = .016) and less forward flexion (r = –0.502, P = .048) and external rotation (r = –0.654, P = .006). Patients with workers’ compensation had lower scores for 3 measures: SANE (75.8 vs 88.4, P = .040), Constant (86.7 vs 93.4, P = .019), and ASES (81.9 vs 97.4, P = .016). Operating on the dominant extremity resulted in lower Constant scores (87.8 vs 95.4, P = .012). A 2-head tendon tear (107.5° vs 123.3°, P = .033) and the use of >1 graft (105.0° vs 121.3°, P = .040) resulted in decreased abduction.Conclusion:This was the first large series to observe patients with chronic or subacute PM tendon tears treated with dermal allograft reconstruction. PM tendon reconstruction with dermal allografts resulted in good objective and subjective patient-reported outcomes.

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“…Repair augmentation with allograft and autograft tissues is recommended by some authors when the native tendon is too retracted at the time of surgery, a finding associated with chronic tears. 5,11,26 To our knowledge, there have been no large studies examining differences in chronic repair performed with or without graft augmentation. While our results support graft augmentation, certainly future studies with larger sample sizes are warranted to better examine these differences and establish which patients would benefit most from this adjunct to chronic repair.…”

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confidence: 99%

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods

et al. 2020

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Background: Repair of torn pectoralis major tendons is generally considered superior to nonoperative management, but there is a paucity of comparative data to demonstrate ideal repair timing and fixation methods. Purpose/Hypothesis: The purpose was to compare the outcomes between acute and chronic repair and among the various methods of fixation (transosseous tunnels, cortical buttons, suture anchors, screws with washers, and direct repair). It was hypothesized that acute repair would have superior outcomes and there would be similar outcomes among the various methods of fixation. Study Design: Meta-analysis. Methods: In accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review of the literature was completed through MEDLINE, SPORTDiscus, CINAHL, Cochrane, Embase, and Web of Science databases. English-language studies were included with a minimum of 6 months’ mean follow-up and 5 cases per study. MINORS (Methodological Index for Nonrandomized Studies) was utilized to assess the quality of the existing literature. Analysis of mechanisms of injury and meta-analysis of pooled outcomes were completed. Pooled effect sizes were calculated from random effects models. Continuous variables were assessed via mixed model analysis, with the individual study designated as a random effect and the desired treatment for comparison as a fixed effect. Bivariate frequency data were transformed through Freeman-Tukey log-linear transformation for variance stabilization and then assessed through a mixed model with a study-level random effect and subsequently back-transformed. Significance was set at P < .05. Results: Twenty articles with 384 injuries met the inclusion criteria for comparison. All patients were male, with 61.9% of injuries occurring during weight training, at a mean age of 31.53 years, and with a mean follow-up of 30.12 months. Included studies scored a mean (SD) 15.53 ± 4.26 (range, 7.0-23.3) by MINORS criteria. Acute repair was significantly superior to chronic repair, with a relative improvement of functional outcome by 0.85 ( P = .004) and satisfaction with cosmesis by 20.50% ( P = .003). There was a trend toward acute repair having a higher proportion of patients who were pain-free (34.47%, P = .064). There were no significant differences among the methods of fixation for repair. Conclusion: Acute repair of pectoralis major tendon tears resulted in significantly superior functional outcomes and cosmesis satisfaction with a trend toward a higher proportion of patients who were pain-free. There were no significant differences among the methods of fixation for repair.

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Pectoralis Major Tear with Retracted Tendon: How to Fill the Gap? Reconstruction with Hamstring Autograft and Fixation with an Interference Screw

Cited by 11 publications

References 47 publications

Pectoralis Major Ruptures: Tear Patterns and Patient Demographic Characteristics

Pectoralis Major Ruptures: Tear Patterns and Patient Demographic Characteristics

Outcomes After Dermal Allograft Reconstruction of Chronic or Subacute Pectoralis Major Tendon Ruptures

Treatment of Pectoralis Major Tendon Tears: A Systematic Review and Meta-analysis of Repair Timing and Fixation Methods

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