Pectoralis major muscle rupture repair: technique using unicortical buttons

Abstract

Over the past few decades, there has been increased awareness of pectoralis major muscle injuries necessitating further evaluation of management options and, in particular, surgical repair. Injury typically occurs when an eccentric load is applied to the muscle, such as with bench pressing, and failure usually occurs through the tendon. Although nonoperative management is sometimes appropriate, given the injury's propensity for young, active male patients, surgical intervention is often warranted. Because the injury typically occurs at the muscle-tendon interface, surgery focuses on repair of the avulsed tendon into its anatomic attachment site. We describe the use of a unicortical suture button to repair the ruptured tendon. This technique achieves the goals of strong fixation and anatomic repair of the tendon back into its native footprint.

Figure 1

Left shoulder with patient in beach-chair position with shoulder flexed and internally rotated. A distal deltopectoral incision is made over the medial proximal humerus. Dissection is carried down to the proximal humerus until the bicipital groove is visualized. The lateral lip of the bicipital groove is exposed (black arrow), with care taken to preserve the overlying biceps tendon (asterisk). The fibers of the clavicular head (gray arrow) may still be intact and can aid in identifying the anatomic insertion.

Figure 2

Left shoulder with patient in beach-chair position with shoulder flexed and internally rotated. The pectoralis major muscle–tendon unit has been identified and freed from surrounding soft tissue. Each head of the pectoralis major muscle and tendon is whip-stitched to provide an attachment for anchoring with a unicortical pectoralis button. Repair includes a high-strength suture tape to improving the strength of the repair by decreasing pull-through, given that the pectoralis has a very short tendon and repair must be advanced into the muscle belly.

Figure 3

The anterior proximal humerus has been exposed, and the bicipital groove is identified. Spade-tipped drill bits are used to drill unicortical holes in parallel at the proximal and distal extent of the site of the original pectoralis major tendon footprint (the drill bit is proximal and the arrow is distal). These are then removed after drilling each unicortical hole along the lateral lip of the bicipital groove before inserting the cortical button.

Figure 4

A close-up of the unicortical pectoralis button used for repair of the pectoralis major muscle, which is threaded onto the high-strength tape, and suture in each respective head of the pectoralis major muscle. The button is then inserted into a previously drilled hole at the pectoralis major insertion into the proximal humerus.

Figure 5

Left shoulder with patient in beach-chair position. The torn pectoralis major muscle has been exposed, and its 2 heads have been individually whip-stitched. In patients with both clavicular and sternal head tears, a 180° twist of the pectoralis major tendons brings the sternal head proximal and deep to the clavicular head and re-creates the native architecture at the repair site.

Figure 6

The pectoralis major tendon is anchored to the proximal humerus at its native insertion site with appropriate tensioning of the unicortical pectoralis buttons for fixation. The sutures are then secured with a knot and cut. This allows for appropriate contour and tension of the pectoralis major muscle.

Figure 7

A postoperative radiograph showing the unicortical buttons within the medullary canal of the humerus. Of note, this patient also had a biceps tenodesis through the same incision with unicortical button fixation.