import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Enters coracobrachialis 5cm from coracoid**. CRITICAL: Limit medial dissection to less than 5cm from coracoid tip. Mark coracoid with suture as reminder. Palpate coracobrachialis before placing medial retractors. **Medial and deep to conjoint tendon**. Avoid aggressive medial or deep retraction. Stay anterior and lateral in surgical field. No dissection medial to conjoint tendon. **Anterior circumflex humeral artery at surgical neck**. Identify and ligate if encountered. No deep medial dissection. Apply direct pressure if massive bleeding, call for vascular backup. **Marks deltopectoral interval in 88% of cases**. Identify early and preserve. Usually retract laterally with deltoid. Can be ligated if injured - collateral drainage adequate. - Complete pectoralis major rupture at tendon insertion (Tietjen Type III/IV) in active patient - Acute tear less than 6 weeks old with good tissue quality - Sternal head avulsion with loss of anterior axillary fold - High-demand athlete or manual laborer requiring full strength - Young patient unwilling to accept cosmetic deformity **Exam Key**: "The classic surgical candidate is a young male weightlifter (95% occur during bench press) with acute complete rupture, loss of anterior axillary fold, and significant weakness. Surgery within 6 weeks while tissue quality is good gives best outcomes." - Partial tear greater than 50% of tendon width - Combined sternal and clavicular head tears - Chronic tear 6 weeks-3 months in motivated young patient (accept higher revision rate) - Significant cosmetic concern about axillary fold deformity **Absolute Contraindications:** - Muscle belly tears (Tietjen Type I) - manage non-operatively (no surgical repair possible) - Active infection or medical instability **Relative Contraindications:** - Partial tears less than 50% (especially isolated clavicular head - good outcomes non-op) - Chronic tears greater than 6 months with significant retraction and muscle atrophy - Low-demand elderly patient who accepts weakness - Medical comorbidities precluding anaesthesia Tears >6 months have poor tissue quality, muscle atrophy with fatty infiltration (visible on MRI), and significant retraction making direct repair impossible. These require allograft reconstruction (Achilles or fascia lata) with lower success rates (75-80% vs 95% for acute). **Origins:** - **Clavicular head (20%)**: Medial half of clavicle - **Sternal head (80%)**: Sternum, ribs 1-6, external oblique aponeurosis **Insertion:** - Lateral lip of bicipital groove - Footprint: 5cm long × 1cm wide - Lies LATERAL to biceps groove (subscapularis is MEDIAL) **CRITICAL: Bilaminar Tendon with 180° Twist:** - Inferior muscle fibers (sternal head) insert SUPERIORLY on bone - Superior muscle fibers (clavicular head) insert INFERIORLY - This twist is essential for normal function **Exam Key**: "The pectoralis major tendon has a 180° twist - inferior fibers insert superiorly. This creates the bilaminar insertion and is critical for function. During repair, I must restore this anatomic configuration." **Lateral Pectoral Nerve (C5-C7):** - From lateral cord of brachial plexus - Supplies clavicular head (primarily) - Pierces clavipectoral fascia **Medial Pectoral Nerve (C8-T1):** - From medial cord of brachial plexus - Supplies sternal head (primarily) - Passes through or around pectoralis minor **Musculocutaneous Nerve (CRITICAL):** - Arises from lateral cord - Enters coracobrachialis **5cm from coracoid tip** - Supplies biceps, brachialis, coracobrachialis - Sensory: Lateral antebrachial cutaneous nerve - **5CM RULE**: Never dissect >5cm medial to coracoid **Long Head of Biceps:** - Lies in bicipital groove - Marks MEDIAL boundary of pectoralis insertion - Do not injure during footprint preparation The musculocutaneous nerve enters coracobrachialis 5cm from coracoid tip. Mark coracoid with suture as reminder. Palpate coracobrachialis before placing medial retractors. Use BLUNT dissection only medially. If nerve damaged: weak elbow flexion, numbness lateral forearm. **Pathognomonic Signs:** - Loss of anterior axillary fold (92% sensitivity) - Ecchymosis over chest wall tracking to antecubital fossa - Palpable gap at insertion site **Weakness Pattern:** - Adduction (across body) - most affected - Internal rotation - Horizontal adduction (bench press motion) **Provocative Tests:** - Bear hug test: Weakness maintaining adducted position - Resisted adduction test: Compare to contralateral - Belly press test: Internal rotation weakness **Exam Key**: "Loss of the anterior axillary fold is PATHOGNOMONIC for pectoralis major rupture. Combined with ecchymosis tracking down the arm and a history of bench press injury, clinical diagnosis is often possible without imaging." **Plain Radiographs:** - Usually normal - May show bony avulsion fragment (rare) - Rule out other pathology **MRI (Gold Standard):** - Confirms complete vs partial tear - Location: tendon (most common), MTJ, muscle belly - Degree of retraction - Muscle quality - fatty infiltration = chronic/poor prognosis - Both heads involvement **Classification (Tietjen):** | Grade | Description | Location | Management | |-------|-------------|----------|------------| | I | Contusion/strain | Muscle | Non-operative | | II | Partial tear | Any | Non-op if <50% | | III | Complete muscle tear | MTJ | Surgical if active | | IV | Tendon avulsion | Insertion | Surgical | - **Smoking cessation**: Minimum 4 weeks pre-op - **Anabolic steroids**: Cease if used (weakens tendon) - **Patient counselling**: 6 months no bench press - critical compliance discussion - **Photography**: Document pre-op for comparison - **Timing**: Ideally within 3-6 weeks for best tissue quality Many bodybuilders use anabolic steroids which weaken tendon quality and increase rupture risk. Steroids impair healing. Ask directly about usage (often not disclosed), counsel about cessation, and consider this in prognosis discussion. **Common (>5%):** - Re-rupture: 5-12% (higher with non-compliance) - Stiffness: 5-15% - Persistent weakness: 5-15% (usually achieves 85-95% strength) - Cosmetic asymmetry despite repair **Uncommon (1-5%):** - Musculocutaneous nerve injury: 1-3% - Infection: 1-3% - Hematoma requiring drainage **Rare (<1%):** - Humerus fracture through tunnel/anchor sites - Brachial plexus injury - Axillary vessel injury **Activity Restrictions (CRITICAL):** - NO bench press for 6 months (most common cause of re-rupture) - NO push-ups for 4-6 months - NO heavy lifting for 4-6 months - Return to full sport 6-9 months **Expected Outcomes:** - 85-95% strength recovery (may never achieve 100%) - May have persistent cosmetic asymmetry - Excellent return to sport rate if compliant (>90%) **Cosmetic Concerns:** - Young athletic males often very concerned about appearance - Discuss axillary crease incision (hidden scar) - Some asymmetry may persist despite repair **Exam Key**: "When consenting, I emphasize: 1) NO bench press for 6 months - this is non-negotiable, 2) Expected 85-95% strength recovery, 3) Some cosmetic asymmetry may persist, 4) Re-rupture risk 5-12% especially with non-compliance. I offer axillary crease incision for better cosmesis." - **Non-operative**: Accept weakness and cosmetic deformity (reasonable for low-demand patients) - **Delayed surgery**: Beyond 6 weeks outcomes diminish; beyond 6 months need allograft - **Allograft reconstruction**: For chronic tears with retraction - Achilles or fascia lata **Systematic Reviews (Sanchez 2021, ElMaraghy 2012):** - Surgical repair: 88-100% good/excellent outcomes - Non-operative: 56-68% good/excellent outcomes - Surgical patients return to sport at higher level - Significant strength advantage with surgical repair **Timing of Surgery:** - Acute (<3 weeks): Best outcomes - Early chronic (3-6 weeks): Good outcomes - Late chronic (>6 weeks): Diminishing results - Very late (>6 months): Often need allograft reconstruction **Exam Key**: "Evidence clearly supports surgical repair for complete ruptures in active patients. Acute repair within 6 weeks achieves 90%+ strength recovery vs 60% non-operative. The key is early surgery while tissue quality is good." **Suture Anchors vs Bone Tunnels:** - Biomechanical studies: Equivalent strength (Shepard 2019) - Both achieve >900N ultimate failure load (exceeds physiologic demand) - Suture anchors: Technically easier, lower profile - Bone tunnels: Lower cost, more traditional **Number of Fixation Points:** - 3-4 anchors or tunnels recommended - Single anchor/tunnel: Insufficient for complete tear - Spaced 1.5-2cm along 5cm footprint **Timeline:** - Return to light gym: 4-5 months - Return to bench press: 6 months minimum - Return to competition: 6-9 months - Full activity without restriction: 9-12 months **Return to Sport Rates:** - Overall return: 85-95% - Return to pre-injury level: 70-80% - Professional athletes: Higher compliance, better outcomes **Predictors of Good Outcome:** - Acute repair (<6 weeks) - Compliance with restrictions - Good tissue quality - Anatomic repair with adequate fixation - Motivated patient with good rehabilitation **Standard Equipment:** - Basic shoulder tray (self-retaining retractor, Fukuda retractor, Army-Navy) - Cephalic vein retractors - Power drill with 3.2mm drill bit (for bone tunnels) - Suture passer or looped wire **Fixation Options:** - **Suture Anchors**: 3-4 × 5.5mm bioabsorbable anchors loaded with #2 FiberWire - **Bone Tunnels**: 3.2mm drill, suture passers, optional cortical button **Suture Material:** - #2 FiberWire or Ethibond for tendon fixation - Krackow stitch or baseball whipstitch configuration **Optional:** - C-arm fluoroscopy for anchor/tunnel position - Dermal allograft for augmentation (chronic/revision cases) - Closed suction drain (10Fr Blake) **Patient Position**: Beach chair 30-45° upright or supine. Arm free-draped on armboard allowing full ROM - must be able to adduct across chest (relaxes pectoralis for mobilization) and extend/externally rotate (tensions repair for testing). **Surgical Approach**: Deltopectoral approach via traditional vertical incision or axillary crease incision (preferred for cosmesis). **Anaesthesia**: General anaesthesia with interscalene or supraclavicular block for post-operative analgesia. **Incision Options:** | Approach | Length | Advantages | Disadvantages | |----------|--------|------------|---------------| | Axillary crease | 8-12cm | Hidden scar, Langer's lines | Less extensile | | Deltopectoral | 8-10cm | Extensile, familiar anatomy | More visible scar | ### Step 1: Surgical Setup and Incision Perform WHO surgical safety checklist. Position patient beach chair 30-45° with arm free-draped. Mark incision - axillary crease preferred for cosmesis in young males. Prep widely including chest wall to clavicle. Make 8-12cm transverse incision in anterior axillary fold or vertical incision from coracoid to deltoid insertion. **Axillary Crease Advantage**: Hidden in natural fold, follows Langer's lines, less visible especially in men with chest hair. Increasingly preferred for primary acute repairs in young patients concerned about cosmesis. ### Step 2: Deltopectoral Interval Development Incise skin and Scarpa's fascia sharply. Identify cephalic vein marking deltopectoral interval in 88% of cases. Preserve vein and retract laterally with deltoid. Develop interval by blunt and sharp dissection. Divide clavipectoral fascia vertically. Evacuate hematoma in acute tears to improve visualization. Identify early - marks the interval. Preserve if possible (better drainage) but can ligate if injured. Thermal injury with cautery causes thrombosis - use bipolar carefully near vein. ### Step 3: Identification of Ruptured Tendon Identify torn pectoralis major tendon - typically torn at or near insertion on lateral lip of bicipital groove in acute tears. Tendon usually retracted 3-5cm medially with surrounding hematoma. Grasp stump with Allis or Kocher clamp. **Key Anatomy - Bilaminar Tendon with 180° Twist:** - Clavicular head (20%) inserts more proximally via anterior lamina - Sternal head (80%) inserts more distally via posterior lamina - Inferior muscle fibers insert superiorly on bone - this twist is critical for function **Most Common Tear Pattern**: Sternal head avulsion from lateral lip of bicipital groove (60-70%). Clavicular head often intact in partial tears. Complete tears involve both heads. ### Step 4: Tendon Mobilization Mobilize tendon by dissecting from surrounding hematoma, scar tissue, and chest wall adhesions. Work medially to gain adequate length for tension-free repair. Remove devitalized tendon edges but preserve maximum length. Adduct shoulder to relax muscle-tendon unit during mobilization. CRITICAL: Limit medial dissection to less than 5cm from coracoid tip. Mark coracoid with suture to remind team. Palpate coracobrachialis before placing medial retractors - can feel nerve within muscle. Use only blunt dissection medially. ### Step 5: Tendon Preparation Place 2-4 heavy braided non-absorbable sutures (#2 FiberWire or Ethibond) through tendon before reduction using Krackow locking stitch or baseball whipstitch pattern. This is easier before repair when access is good. ### Step 6: Footprint Preparation Retract tendon medially to expose lateral lip of bicipital groove (insertion footprint). Identify long head of biceps in groove as medial landmark. Use periosteal elevator to clear soft tissue and scar from lateral lip. Create clean bony surface for healing. Footprint is approximately 5cm long × 1cm wide. **Anatomic Landmark**: Pectoralis major inserts lateral to biceps groove. Subscapularis inserts medial to groove. Biceps tendon is your medial boundary - stay lateral to it. ### Step 7A: Suture Anchor Fixation (Preferred Technique) Place 3-4 suture anchors (5.5mm bioabsorbable) along lateral lip of bicipital groove: - Space anchors 1.5-2cm apart along 5cm footprint - Use drill guide to create pilot holes perpendicular to cortex - Confirm solid purchase by tugging suture limbs - Multiple anchors provide combined strength of 900-1200N **Advantages of Anchors:** - Technical ease compared to bone tunnels - Lower profile - less irritation - Allows revision if needed - Equivalent biomechanics to tunnels ### Step 7B: Bone Tunnel Technique (Alternative) Create 3 unicortical bone tunnels with 3.2mm drill: - Space tunnels 1.5-2cm apart (minimum 1cm to prevent fracture) - Drill perpendicular to cortex, 15-20mm deep - UNICORTICAL ONLY - Pass suture passer or looped wire through each tunnel Penetrating far cortex risks radial nerve in spiral groove on posterior humerus. Unicortical only. ### Step 8: Tendon-to-Bone Fixation Position arm in 30-45° abduction, neutral rotation. Reduce tendon to footprint without gap. **For Suture Anchors**: Pass anchor sutures through tendon in mattress configuration. Tie with sliding knots locked with alternating half-hitches. Use all available suture limbs. **For Bone Tunnels**: Pass pre-placed Krackow sutures through tunnels. Tie over bone bridge or cortical button with appropriate tension. **Tensioning Principle**: Test at 30-45° abduction, neutral rotation - approximates resting muscle length. After repair, should achieve full passive adduction to neutral, IR to abdomen, and 140° forward elevation. If repair limits these motions, it is too tight. ### Step 9: Repair Assessment Test repair construct: 1. Visual inspection - tendon reduced to bone without gap 2. Palpation - solid tendon-bone interface 3. Passive ROM - full elevation, ER, IR, and adduction across chest 4. Gentle resisted activation - no gapping with gentle pec squeeze **If any concerns about security or tension, revise repair before closing.** ### Step 10: Closure and Immobilization Irrigate with 1-2L normal saline. Achieve meticulous hemostasis. Close in layers: - Clavipectoral fascia with 2-0 Vicryl if divided extensively - Deep subcutaneous with 2-0 Vicryl - Dermis with 3-0 Monocryl subcuticular - Skin with 4-0 Monocryl or skin glue **Immobilization**: Shoulder sling with arm in NEUTRAL ROTATION and slight ADDUCTION (opposite to Bankart which requires external rotation). Some surgeons use 30° abduction pillow to reduce tension on repair. **Drain Decision**: Consider 10Fr Blake drain if: extensive dead space, persistent oozing, patient on anticoagulation, revision surgery. Most primary acute repairs do not require drain if good hemostasis achieved. Remove at 24-48 hours. **Rehabilitation Timeline:** | Phase | Timeframe | Activities | |-------|-----------|------------| | Phase 1 | 0-4 weeks | Strict sling, NO shoulder motion (elbow/wrist/hand ROM only) | | Phase 2 | 4-6 weeks | Begin passive ROM (pendulums, assisted elevation to 90°, ER to 30°) | | Phase 3 | 6-12 weeks | Active-assisted → active ROM, light isometrics week 8 | | Phase 4 | 12-16 weeks | Progressive resistance, light bench press | | Phase 5 | 4-6 months | Gradual return to unrestricted activity | | Phase 6 | 6-9 months | Return to competitive sports and heavy lifting | **Critical Restrictions:** - **NO bench press for 6 months** (mechanism of injury in 70%) - NO push-ups for 4-6 months - Limit adduction across body for 3 months - Avoid resisted internal rotation for 4 months Early return to gym and bench press. Young athletic males eager to return to lifting have high non-compliance rate. Strict patient education about 6-month timeline is essential. ## References 1. Bodendorfer BM, et al. Pectoralis major tears: Epidemiology, outcomes, and surgical technique. J Am Acad Orthop Surg. 2020;28(13):532-541. 2. Sanchez A, et al. Pectoralis major ruptures: A systematic review. Am J Sports Med. 2021;49(4):1067-1076. 3. ElMaraghy A, Devereaux M. A systematic review and comprehensive classification of pectoralis major tears. J Shoulder Elbow Surg. 2012;21(3):412-422. 4. Bak K, et al. Surgical repair of pectoralis major ruptures in athletes. A review of the current state of management. Am J Sports Med. 2000;28(4):590-595. 5. de Castro Pochini A, et al. Complete rupture of the pectoralis major muscle in athletes: A prospective study. Am J Sports Med. 2010;38(1):92-98. 6. Cordasco FA, et al. Pectoralis major tendon ruptures: Functional outcome after repair. J Shoulder Elbow Surg. 2022;31(5):946-952. 7. Tietjen R. Closed injuries of the pectoralis major muscle. J Trauma. 1980;20(3):262-264. 8. Hanna CM, et al. Pectoralis major tears: Comparison of surgical techniques. Am J Sports Med. 2001;29(1):9-15. 9. Shepard NP, et al. Biomechanical comparison of suture anchor versus bone tunnel repair of pectoralis major tendon. J Shoulder Elbow Surg. 2019;28(11):2194-2199. 10. Provencher MT, et al. Surgical management of pectoralis major ruptures in athletes. JBJS Rev. 2018;6(2):e7.

Pectoralis Major Tendon Repair - Acute Rupture

Pectoralis Major Tendon Repair - Acute Rupture