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Chronic bilateral pectoralis major ruptures and reconstruction with allograft
Injury Extra 40 (2009) 267–269
Contents lists available at ScienceDirect
Injury Extra journal homepage: www.elsevier.com/locate/inext
Case report
Chronic bilateral pectoralis major ruptures and reconstruction with allograft Nasir M. Naderi, Lennard Funk * Upper Limb Unit, Wrightington Hospital, Appley Bridge, Wigan WN6 9EP, United Kingdom
A R T I C L E I N F O
Article history: Accepted 25 August 2009
1. Introduction Pectorals major muscle is a powerful adductor and to a lesser extent flexor and internal rotator of humerus.9,15 It has a broad origin from sternum and clavicle and inserts to inertubercular humeral groove just lateral to biceps.15 Rupture of pectoralis major is an uncommon injury and most reported cases were in professional athletes at the insertion of tendon to the humerus.3 Although conservative treatment is an accepted treatment in nonathletic older patients, surgical repair provides better results in the athlete.15,4,13,1 Bilateral injuries are even more uncommon and there are only two previous cases reported in the literature. No previous studies report bilateral repairs and allograft reconstruction in bilateral ruptures. We report a rare case of simultaneous bilateral pectoralis major rupture in a young man, which presented late requiring repair on one side and allograft reconstruction on the other side. 2. Case report A 28-year-old scaffolder and amateur bodybuilder fell from high scaffolding. To break his fall he extended both arms out to the side in full extension and abduction. He felt a ripping pain in both sides of his chest and sustained bilateral pectoralis major tendon injuries. He sustained no other injuries. Nonoperative management was undertaken locally. He presented to the senior author 14 months after the injury, as he was still unable to return to full heavy manual work or weight training due to both weakness and cramping in his pectoralis major muscles. He did not have any history of anabolic steroid or creatine usage. Clinically he had a significantly retracted tear of the right pectoralis major and a less retracted tear on the left side (Fig. 1). Magnetic resonance scans of both pectoralis muscles revealed
* Corresponding author. Tel.: +44 0161 2270027; fax: +44 0161 2270028. E-mail address: [email protected] (L. Funk). 1572-3461/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.08.028
probable musculotendinous or tendon tears with retraction. There was minimal fatty infiltration of the muscles. Exploration and repair of the left side was undertaken first. This confirmed a musculotendinous tear. After adequate mobilization of the medially retracted muscle repair was performed with 2 Orthocord sutures using a double-breasting technique (similar to that used for hernia repairs). The patient made an excellent recovery from this repair and exploration of the right side was undertaken 3 months later. This rupture was a tendon pull-off from the bone and had retracted significantly. Despite extensive mobilization (with protection of the medial and lateral pectoral neurovascular bundles) it was impossible to return the retracted tendon to the humerus. The tendon edges were tagged for possible later reconstruction (Fig. 2). After much discussion, the patient was keen to proceed to a further reconstruction of the right side. Tendo-Achilles allograft reconstruction was performed 2 months after the previous exploration. An irradiated, frozen tendo-Achilles allograft was used. This was of standard dimensions. The allograft was ‘interwoven’ to the retracted pectoralis major using No. 2 high strength sutures (Fig. 3) (Orthocord, Mitek-DePuy, Boston, USA) and a modified whip-stitch suture technique. This was fixed to a broad footprint area on the humerus using three large rotator cuff titanium suture anchors (Fastin anchors, Mitek-DePuy, Boston, USA), as previously described by the senior author.6 Tension was determined with the arm in neutral abduction and rotation. Rehabilitation after each surgery involved active-assisted mobilization in a safe zone for 3–6 weeks and then a progressive resistance program.5 The patient made an excellent recovery following the second surgery (Fig. 4). He returned to work as a scaffolder 8 months after the injury and his pre-injury bench press weights at 12 months. 3. Discussion Pectoralis major tears were previously considered a rare injury, but with the increased popularity of strength sports and weight training the incidence of this injury has risen.7 In the past most authors preferred to treat this injury nonoperatively, but surgical treatment has been shown to give excellent results even in chronic cases.7,11,14 The preferred technique for surgical repair is direct repair of tendon to bone or remaining tendon via modified deltopectoral approach.14 Despite a delay in diagnosis and treatment of pectoralis major ruptures, most patients usually have a successful repair and tendon
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Fig. 1. Significantly retracted tear of the right pectoralis major and a less retracted tear on the left side.
Fig. 2. The tagged pectoralis major muscle, which was not able to mobilize sufficiently for a direct repair.
graft is rarely necessary.2,3,14 In some chronic injuries, retraction of muscle belly may prevent direct repair. Joseph et al. reported a rare case of chronic rupture of pectoralis major that after 8 weeks of injury mobilization of muscle was not possible. The authors used an Achilles tendon allograft for augmentation of repair.8 Schachter et al. reported revision reconstruction of pectoralis major after two previous failed repair. The authors reconstructed the tendon by using of a gracilis-semitendinosus autograft.12
There is only one previous report of bilateral pectoralis major ruptures in the literature. Potter et al. reported a 40-year-old man with simultaneous bilateral ruptures of pectoralis major following performing dips on wide-grip parallel bars. The patient underwent delayed repair in a staged fashion with satisfactory result, similar to our case.10 However, in our case the muscle belly in right side was too far retracted and direct repair was impossible, so we performed an allograft reconstruction.
Fig. 3. (a) Interweaving suture of the allograft tendon to the muscle. (b and c) The final repair of the allograft, as seen on the muscle and humeral sides.
N.M. Naderi, L. Funk / Injury Extra 40 (2009) 267–269
Fig. 4. Appearance of the repair and scar at 6 months after surgery.
In conclusion, tendo-Achilles allograft reconstruction is a suitable treatment for selected cases with a symptomatic chronically retracted pectoralis major tendon rupture. References 1. Aarimaa V, Rantanen J, Heikkila J, Helttula I, Orava S. Rupture of the pectoralis major muscle. Am J Sports Med 2004;32(July–August (5)):1256–62.
269
2. Anbari A, Kelly JD, Moyer RA. Delayed repair of a ruptured pectoralis major muscle. Am J Sports Med 2000;28:254–6. 3. Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major: a metaanalysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8(2):113–9. 4. Beloosesky Y, Grinblat J, Weiss A, Rosenberg PH, Weisbort M, Hendel D. Pectoralis major rupture in elderly patients: a clinical study of 13 patients. Clin Orthop Relat Res 2003;413(August):164–9. 5. Funk L, Tatlow K. http://www.shoulderdoc.co.uk [page updated November 2008]. 6. Funk L, Shah N, Talwalker S, Badge R. Pectoralis major rupture in athletes—a new surgical technique and results. Presented at the British Orthopaedic Association conference, September 15–18, 2009. 7. Hanna CM, Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202–6. 8. Joseph TA, DeFranco MJ, Weiker GG. Delayed repair of a pectoralis major tendon rupture with allograft: a case report. J Shoulder Elbow Surg 2003;12:101–4. 9. Marmor L, Bechtol CO, Hall CB. Pectoralis major muscle: function of sternal portion and mechanism of rupture of normal muscle: case reports. J Bone Joint Surg Am 1961;43:81–7. 10. Potter BK, Lehman RA, Doukas WC. Simultaneous bilateral rupture of the pectoralis major tendon. A case report. J Bone Joint Surg Am 2004;86-A(July (7)):1519–21. 11. Quinlan JF, Molloy M, Hurson BJ. Pectoralis major tendon ruptures: when to operate. Br J Sports Med 2002;36(June):226–8. 12. Schachter AK, White BJ, Namkoong S, Sherman O. Revision reconstruction of a pectoralis major tendon rupture using hamstring autograft: a case report. Am J Sports Med 2006;34:295–8. 13. 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. 14. Shubinstein B, Potter HG, Wickiewicz TL. Repair of chronic pectoralis major ruptures. Tech Shoulder Elbow Surg 2002;3(3):174–9. 15. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle: an anatomic and clinical analysis. Am J Sports Med 1992;20:587.
Contents lists available at ScienceDirect
Injury Extra journal homepage: www.elsevier.com/locate/inext
Case report
Chronic bilateral pectoralis major ruptures and reconstruction with allograft Nasir M. Naderi, Lennard Funk * Upper Limb Unit, Wrightington Hospital, Appley Bridge, Wigan WN6 9EP, United Kingdom
A R T I C L E I N F O
Article history: Accepted 25 August 2009
1. Introduction Pectorals major muscle is a powerful adductor and to a lesser extent flexor and internal rotator of humerus.9,15 It has a broad origin from sternum and clavicle and inserts to inertubercular humeral groove just lateral to biceps.15 Rupture of pectoralis major is an uncommon injury and most reported cases were in professional athletes at the insertion of tendon to the humerus.3 Although conservative treatment is an accepted treatment in nonathletic older patients, surgical repair provides better results in the athlete.15,4,13,1 Bilateral injuries are even more uncommon and there are only two previous cases reported in the literature. No previous studies report bilateral repairs and allograft reconstruction in bilateral ruptures. We report a rare case of simultaneous bilateral pectoralis major rupture in a young man, which presented late requiring repair on one side and allograft reconstruction on the other side. 2. Case report A 28-year-old scaffolder and amateur bodybuilder fell from high scaffolding. To break his fall he extended both arms out to the side in full extension and abduction. He felt a ripping pain in both sides of his chest and sustained bilateral pectoralis major tendon injuries. He sustained no other injuries. Nonoperative management was undertaken locally. He presented to the senior author 14 months after the injury, as he was still unable to return to full heavy manual work or weight training due to both weakness and cramping in his pectoralis major muscles. He did not have any history of anabolic steroid or creatine usage. Clinically he had a significantly retracted tear of the right pectoralis major and a less retracted tear on the left side (Fig. 1). Magnetic resonance scans of both pectoralis muscles revealed
* Corresponding author. Tel.: +44 0161 2270027; fax: +44 0161 2270028. E-mail address: [email protected] (L. Funk). 1572-3461/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2009.08.028
probable musculotendinous or tendon tears with retraction. There was minimal fatty infiltration of the muscles. Exploration and repair of the left side was undertaken first. This confirmed a musculotendinous tear. After adequate mobilization of the medially retracted muscle repair was performed with 2 Orthocord sutures using a double-breasting technique (similar to that used for hernia repairs). The patient made an excellent recovery from this repair and exploration of the right side was undertaken 3 months later. This rupture was a tendon pull-off from the bone and had retracted significantly. Despite extensive mobilization (with protection of the medial and lateral pectoral neurovascular bundles) it was impossible to return the retracted tendon to the humerus. The tendon edges were tagged for possible later reconstruction (Fig. 2). After much discussion, the patient was keen to proceed to a further reconstruction of the right side. Tendo-Achilles allograft reconstruction was performed 2 months after the previous exploration. An irradiated, frozen tendo-Achilles allograft was used. This was of standard dimensions. The allograft was ‘interwoven’ to the retracted pectoralis major using No. 2 high strength sutures (Fig. 3) (Orthocord, Mitek-DePuy, Boston, USA) and a modified whip-stitch suture technique. This was fixed to a broad footprint area on the humerus using three large rotator cuff titanium suture anchors (Fastin anchors, Mitek-DePuy, Boston, USA), as previously described by the senior author.6 Tension was determined with the arm in neutral abduction and rotation. Rehabilitation after each surgery involved active-assisted mobilization in a safe zone for 3–6 weeks and then a progressive resistance program.5 The patient made an excellent recovery following the second surgery (Fig. 4). He returned to work as a scaffolder 8 months after the injury and his pre-injury bench press weights at 12 months. 3. Discussion Pectoralis major tears were previously considered a rare injury, but with the increased popularity of strength sports and weight training the incidence of this injury has risen.7 In the past most authors preferred to treat this injury nonoperatively, but surgical treatment has been shown to give excellent results even in chronic cases.7,11,14 The preferred technique for surgical repair is direct repair of tendon to bone or remaining tendon via modified deltopectoral approach.14 Despite a delay in diagnosis and treatment of pectoralis major ruptures, most patients usually have a successful repair and tendon
268
N.M. Naderi, L. Funk / Injury Extra 40 (2009) 267–269
Fig. 1. Significantly retracted tear of the right pectoralis major and a less retracted tear on the left side.
Fig. 2. The tagged pectoralis major muscle, which was not able to mobilize sufficiently for a direct repair.
graft is rarely necessary.2,3,14 In some chronic injuries, retraction of muscle belly may prevent direct repair. Joseph et al. reported a rare case of chronic rupture of pectoralis major that after 8 weeks of injury mobilization of muscle was not possible. The authors used an Achilles tendon allograft for augmentation of repair.8 Schachter et al. reported revision reconstruction of pectoralis major after two previous failed repair. The authors reconstructed the tendon by using of a gracilis-semitendinosus autograft.12
There is only one previous report of bilateral pectoralis major ruptures in the literature. Potter et al. reported a 40-year-old man with simultaneous bilateral ruptures of pectoralis major following performing dips on wide-grip parallel bars. The patient underwent delayed repair in a staged fashion with satisfactory result, similar to our case.10 However, in our case the muscle belly in right side was too far retracted and direct repair was impossible, so we performed an allograft reconstruction.
Fig. 3. (a) Interweaving suture of the allograft tendon to the muscle. (b and c) The final repair of the allograft, as seen on the muscle and humeral sides.
N.M. Naderi, L. Funk / Injury Extra 40 (2009) 267–269
Fig. 4. Appearance of the repair and scar at 6 months after surgery.
In conclusion, tendo-Achilles allograft reconstruction is a suitable treatment for selected cases with a symptomatic chronically retracted pectoralis major tendon rupture. References 1. Aarimaa V, Rantanen J, Heikkila J, Helttula I, Orava S. Rupture of the pectoralis major muscle. Am J Sports Med 2004;32(July–August (5)):1256–62.
269
2. Anbari A, Kelly JD, Moyer RA. Delayed repair of a ruptured pectoralis major muscle. Am J Sports Med 2000;28:254–6. 3. Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major: a metaanalysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8(2):113–9. 4. Beloosesky Y, Grinblat J, Weiss A, Rosenberg PH, Weisbort M, Hendel D. Pectoralis major rupture in elderly patients: a clinical study of 13 patients. Clin Orthop Relat Res 2003;413(August):164–9. 5. Funk L, Tatlow K. http://www.shoulderdoc.co.uk [page updated November 2008]. 6. Funk L, Shah N, Talwalker S, Badge R. Pectoralis major rupture in athletes—a new surgical technique and results. Presented at the British Orthopaedic Association conference, September 15–18, 2009. 7. Hanna CM, Glenny AB, Stanley SN, Caughey MA. Pectoralis major tears: comparison of surgical and conservative treatment. Br J Sports Med 2001;35:202–6. 8. Joseph TA, DeFranco MJ, Weiker GG. Delayed repair of a pectoralis major tendon rupture with allograft: a case report. J Shoulder Elbow Surg 2003;12:101–4. 9. Marmor L, Bechtol CO, Hall CB. Pectoralis major muscle: function of sternal portion and mechanism of rupture of normal muscle: case reports. J Bone Joint Surg Am 1961;43:81–7. 10. Potter BK, Lehman RA, Doukas WC. Simultaneous bilateral rupture of the pectoralis major tendon. A case report. J Bone Joint Surg Am 2004;86-A(July (7)):1519–21. 11. Quinlan JF, Molloy M, Hurson BJ. Pectoralis major tendon ruptures: when to operate. Br J Sports Med 2002;36(June):226–8. 12. Schachter AK, White BJ, Namkoong S, Sherman O. Revision reconstruction of a pectoralis major tendon rupture using hamstring autograft: a case report. Am J Sports Med 2006;34:295–8. 13. 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. 14. Shubinstein B, Potter HG, Wickiewicz TL. Repair of chronic pectoralis major ruptures. Tech Shoulder Elbow Surg 2002;3(3):174–9. 15. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle: an anatomic and clinical analysis. Am J Sports Med 1992;20:587.