73.1 Goals of Procedure

Rupture of the pectoralis major (PM) can lead to significant functional deficits, especially during labor-intensive actions and athletic activities. ^{1 – 5} The objective of the anatomical repair is to restore the function of the PM as a potent adductor, internal rotator, and dynamic stabilizer of the glenohumeral joint. ^{6 – 8}

73.2 Advantages

In the elderly and the low-demand patient, nonoperative treatment can result in good functional outcomes during activities of daily living. ^{1 , 2 , 9 – 12} However, athletes and laborers treated nonoperatively are unable to return to their preinjury level of activity. ^{1 , 2 , 4 , 5} Several studies have demonstrated surgical treatment provides the ability to return to a preinjury level of activity with great patient satisfaction and enhanced cosmesis. ^{2 – 5 , 7 – 10 , 13 – 21}

73.3 Indications

Injuries proximal to the muscle–tendon junction, muscle contusions and strains, partial tears, and complete tears (Tietjen’s classification ²² types I, II, IIIA, and IIIB) in the low-demand patient are treated without surgery. ² Tendon ruptures at the insertion site or intrasubstance in the athletes (Tietjen’s classification types IIIC and IIID, and Bak et al’s modification types IIIE and IIIF), workers, and patients with cosmetic deformity of axillary fold are indicated for surgical repair. ^{13 , 22} Surgical treatment of chronic injuries can lead to satisfactory outcomes, and should not prohibit surgical treatment. ^{5 , 7 , 16}

73.4 Contraindications

Complete tears in patients with multiple comorbidities and low-demand (elderly, nonworker, and sedentary) patients are contraindicated for surgical repair.

73.5 Preoperative Preparation

A detailed history and focused physical examination is of paramount importance. Patients usually recall the injury and are able to describe the mechanism of injury. They complain of weakness, swelling, ecchymosis, asymmetry, and pain in the axilla and chest wall. In acute injuries, the amount of swelling, pain, and ecchymosis may confound the clinical scenario particularly if presented in the emergency department or primary care setting. ^{2 , 20 , 23 – 27} Advanced imaging is extremely helpful, especially during the acute presentation, to provide for further clarity of the clinical picture and facilitate an accurate and timely diagnosis. ^{2 , 20 , 23 – 27}

MRI is the favored imaging technique. Imaging can differentiate between partial and complete tears, whether the tear involves both the clavicular head (CH) and sternocostal heads (SH) or often in the context of weight training, an isolated SH tear. ^{20 , 27 – 29} MRI can also facilitate the distinction between acute and chronic PM tendon injuries. ²⁶ At our institution, an axial fast-spin echo (FSE) MRI is obtained first, then the oblique coronal images are determined and acquired based upon the orientation of the axial images in parallel to the long axis of the PM tendon complex. Additionally, a coronal inversion recovery sequence is acquired in a comparable mode.

73.5.1 Positioning

Following combined regional and general anesthesia, the patient is placed in the beach-chair position with the operative arm in a positioner ( Fig. 73.1 ). The operative area is covered and sealed using an Ioban drape (3M, St. Paul, MN).

73.6 Operative Technique

The distal part of the deltopectoral approach is used for surgical exposure ( Fig. 73.2 ). In cases of CH and SH tears, the torn and retracted tendon is identified on the deep, posterior aspect of the muscle, released from adhesions, and mobilized. When an isolated SH tear is present, the deltopectoral interval will be intact. Cordasco et al have reported that isolated SH tears occur in the majority of weight training injuries (described as indirect injuries) compared to injuries that involve both the CH and SH, which have occurred with trauma, so-called direct injuries. ²⁰ The approach will not, in general, require a deltopectoral interval takedown, as it is important to leave the CH insertion intact. By developing a plane inferior to the CH, the SH stump can be identified and repaired without compromising the CH insertion. The tendon edges are then debrided of mechanically incompetent tissue. In general, two sets of locking no. 2 FiberWire sutures (Arthrex, Naples, FL) are applied to each torn head, using a modified Krackow suture arrangement with four suture limbs for each head ( Figs. 73.3, 73.4 ). These stiches are deployed to the superior and inferior areas of each ruptured tendon.

To identify the PM footprint, lateral to the bicipital groove, a retractor is placed along the lateral side of the humerus to retract the anterior deltoid. The humeral insertion site is debrided, while protecting the long head of the biceps. Electrocautery is utilized to mark the site of implant placement. A 3.2-mm guide pin (Arthrex) is utilized to establish four unicortical drill holes. These are placed in a staggered fashion, leaving a sufficient bone bridge to avoid increasing the risk of fracture. To gain intramedullary (IM) length to flip the cortical buttons, the drill holes are angled. The titanium buttons are preloaded with two no. 2 FiberWire (high-strength nonabsorbable) sutures ( Fig. 73.5 ). The button is deployed into the IM canal and the tendon reduction is performed by tensioning the suture limbs to the footprint. ^{1 , 30} The anatomic reduction and fixation are performed with the arm in adduction and neutral position. The SH is reduced first, given that the footprint is more posterior and more proximal than the CH ( Fig. 73.6 ). Sutures in the SH are tensioned first, then the CH, and then secured by standard knots.

Generally, a total of four buttons (two per head) are used for complete ruptures. Fluoroscopy is then used to confirm correct button position ( Fig. 73.7 ). Following wound irrigation, a layered closure is performed and the arm is then placed in a sling in an adducted position.