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Delayed repair of a pectoralis major tendon rupture with allograft: A case report
Delayed repair of a pectoralis major tendon rupture with allograft: A case report Thomas A. Joseph, MD, Michael J. DeFranco, MD, and Garron G. Weiker, MD, Cleveland, Ohio
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uptures of the pectoralis major muscle and tendon have been considered rare injuries, occurring primarily in male weight lifters during the eccentric phase of the bench press. There have also been sporadic case reports of isolated injuries occurring in other events in which resisted forces are applied to the extendedabducted humerus.3,5-8,10,15,18,22 Many of these injuries are initially misdiagnosed by patients and firstline physicians as pulled muscles, delaying proper diagnosis and treatment. Despite delays, several authors have reported successful late surgical treatment of pectoralis major tendon ruptures months to years after the initial injury.2,4,11,18,21 We report a case in which adequate mobilization of the ruptured muscletendon unit was not possible 8 weeks from the time of injury. A successful surgical result was achieved with the use of an Achilles tendon allograft to augment the repair. To the best of our knowledge, this technique has not been previously reported in the English literature. CASE REPORT A 21-year-old, right hand– dominant college student was seen 6 weeks after an injury sustained during the eccentric phase of a 250-pound bench press. He described feeling a pop in the anterior aspect of his dominant shoulder as the weight was lowered to his chest. This was followed by the immediate onset of pain and extensive ecchymosis about the anterior chest and upper arm over the next 24 hours. He was subsequently evaluated by his primary care physician, and the diagnosis of a muscle strain was made. The patient was treated with a sling and 4 weeks of rest. His pain resolved, but he noticed profound weakness when he tried to return to weight lifting. He was also involved in a softball league and was having trouble swinging a bat forcefully. This prompted his visit to our office. Before this injury, he had been working out with weights regularly for just over a From the Section of Sports Medicine, Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio and the Orthopaedic Center, Canfield, Ohio. Reprint requests: Thomas A. Joseph, MD, The Orthopaedic Center, 6470 Tippecanoe Rd, Canfield, OH 44406. J Shoulder Elbow Surg 2003;12:101-104. Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 32/4/128200 doi:10.1067/mse.2003.128200
year. He denied any prodromal symptoms or the use of anabolic steroids. At the time of presentation (6 weeks after the injury), his ecchymosis had resolved; however, he had a visible and palpable defect within his right (dominant) axilla that was more pronounced with isometric contraction of the pectoralis muscle. There was a thin cordlike band inferiorly, and he had weakness and pain with resisted cross-body adduction. On the basis of his physical examination, a diagnosis of a pectoralis major tendon rupture was made and surgical repair was recommended. The patient’s preplanned vacation further delayed the operation, which was performed approximately 8 weeks from the time of injury. Through a standard axillary incision, a complete rupture of both tendinous heads of the pectoralis major was identified. There were extensive adhesions and fibrosis medial to the normal insertion site, and the tendon had avulsed completely from its insertion on the humerus and was retracted medially to the anterior chest wall. Despite circumferential mobilization of the muscle-tendon unit and the placement of traction sutures, we were unable to restore sufficient length to allow anatomic repair to the humerus with the arm at the side. An Achilles tendon allograft was tubularized and sewn into the stump circumferentially beginning at the musculotendinous junction to provide approximately 3 cm of additional length. A direct repair to the humerus was then performed with 3 metal suture anchors (Figure 1). Postoperatively, the patient was immobilized with a sling and swathe for 4 weeks, removing it only to bathe and to allow wrist and elbow range-of-motion exercises 3 times a day. At 4 weeks postoperatively, he began a supervised physical therapy program that incorporated shoulder range-of-motion exercises. Light strengthening was initiated at 6 weeks, and at 12 weeks, he returned to weight lifting. At 5 months postoperatively, he began playing softball and water skiing without restriction. At the latest follow-up (18 months), he was satisfied with the cosmetic appearance of his surgical site and noted no functional limitations. He continues to play recreational sports and to lift weights but has chosen to avoid heavy bench-press exercises. Preoperative and postoperative (18 month follow-up) photographs are shown in Figure 2.
DISCUSSION Injuries to the pectoralis major muscle have been well described. There is considerable variability in the types of injuries that occur and in their respective treatment. Ruptures may be complete or partial and may occur at the level of the muscle belly, at the
101
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J Shoulder Elbow Surg January/February 2003
Figure 1 Medical illustration demonstrating circumferential tubularization technique for allograft musculotendinous anastomosis.
musculotendinous junction, or at the distal tendinous insertion onto the humerus. Less common proximal injuries have been described at various sites of the muscle.22 Tears of the muscle belly, as well as myotendinous and tendinous ruptures, in elderly or lowdemand individuals can be effectively treated nonoperatively.21,23,24 Selective surgical repair is recommended for athletically inclined individuals sustaining complete ruptures, as improved clinical and functional outcomes have been demonstrated in comparative studies.19,21,23,24 For patients participating in sports that require upper body strength (football, wrestling, water skiing, etc), surgical repair has predictably resulted in normal or near-normal strength and return to sporting activities.6,11,21,23,24 Cosmesis is an additional concern within the bodybuilding population, and axillary contour may be reliably improved with surgical treatment as well.20 A working knowledge of the complex anatomy of this muscle is important in understanding the subtleties of surgical treatment. The complex insertional anatomy seems to predispose patients to partial rupture in select regions. In a biomechanical study, Wolfe et al23 characterized pectoralis major ruptures in cadaveric specimens subjected to eccentric loading. They showed disproportionate lengthening of the short sternal fibers during the terminal 30° of humeral extension with a simulated bench press. Pectoralis major tears were postulated to occur in a predictable anatomic sequence. The lower sternal abdominal fibers are the first to rupture, followed by the remaining sternal head, and finally the clavicular head. These findings are consistent with multiple clinical observa-
tions of an intact clavicular head found at the time of surgical exploration.2,5,12,15,21,23 In a comprehensive review of the literature supporting successful delayed repair of pectoralis ruptures, a common theme recurs: the presence of an intact portion of the tendon that prevents medial retraction.2,12,21 Under these conditions, the remaining intact fibers of the clavicular head act as a checkrein and serve as a scaffold to which the avulsed sternocostal fibers may adhere. The ruptured tendinous stump is found just medial to its anatomic insertion, and without shortening of the muscle-tendon unit or accompanying fibrosis, mobilization to the humerus is frequently possible. Our case was unique in that there was complete disruption of the entire insertion site, including both the sternal and clavicular fibers. Without any tethering structures, the tendon retracted medially into its thick muscle belly, much like the head of a turtle, and was encased in fibrous adhesions. Several traction sutures were placed, and the muscle was circumferentially mobilized. Despite these efforts, anatomic reinsertion on the humerus was not possible without creating undue tension on the repair. We chose to augment the repair with Achilles allograft in order to gain length. Although this technique has not been described specifically in relation to pectoralis repair, allograft has been used successfully in multiple cases of chronic disruptions of the knee extensor mechanism and Achilles tendon.9,14,16,17 Other authors have reported similar difficulty in achieving a direct repair in cases of chronic pectoralis major ruptures.1,13 Alho1 encountered difficulty at 3 months from the time of injury in a 28-year-old
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Figure 2 A, Preoperative photograph taken 6 weeks after injury. There was chest wall asymmetry and webbing of the axilla with abduction. B, Postoperative photograph taken 18 months after surgical repair, demonstrating improved axillary contour.
boxer. He described a technique of fascial release through a separate incision that permitted a direct repair of the tendon to its humeral insertion. By advancing the tendon to overcome a 2-cm defect, immobilization in an adducted position was avoided and early mobility and return to activity were achieved. It has been our experience that although delayed surgical repair may be technically feasible, early repair (within 2 weeks) is preferred. In this case report, the use of fascial allograft to augment the repair and avoid undue tension on the retracted tendon did not compromise the final result. We present this technique as a means of increasing the awareness of surgeons dealing with chronic ruptures and as an alternative to
performing a repair under tension or to the use of fascial detachment and advancement techniques. REFERENCES
1. Alho A. Ruptured pectoralis major tendon. A case report on delayed repair with muscle advancement. Acta Orthop Scand 1994;65:652-3. 2. Anbari A, Kelly JD, Moyer RA. Delayed repair of a ruptured pectoralis major muscle. Am J Sports Med 2000;28:254-6. 3. Arciero RA, Cruser DL. Pectoralis major rupture with simultaneous anterior dislocation of the shoulder. J Shoulder Elbow Surg 1997; 6:318-20. 4. Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major. A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-9.
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5. Berson BL. Surgical repair of pectoralis major rupture in an athlete. Case report of an unusual injury in a wrestler. Am J Sports Med 1979;7:348-50. 6. Carek PJ, Hawkins A. Rupture of pectoralis major during parallel bar dips. A case report and review. Med Sci Sports Exerc 1998;30: 335-8. 7. Delport HP, Piper MS. Pectoralis major rupture in athletes. Arch Orthop Traumat Surg 1982;100:135-7. 8. Dunkelman NR, Collier F, Rook JL, et al. Pectoralis major rupture in windsurfing. Arch Phys Med Rehabil 1994;75:819-21. 9. Falconiero RP, Pallis MP. Case report: chronic rupture of a patellar tendon. A technique for reconstruction with Achilles allograft. Arthroscopy 1996;12:623-6. 10. Kawashima M, Sato M, Toriso T, et al. Rupture of the pectoralis major. Report of two cases. Clin Orthop 1975;109:115-9. 11. Kretzler HH, Richardson AB. Rupture of the pectoralis major muscle. Am J Sports Med 1989;17:453-8. 12. Lindenbaum BL. Delayed repair of a ruptured pectoralis major muscle. Clin Orthop 1975;109:120-1. 13. McEntire JE, Hess WE, Coleman SS. Rupture of the pectoralis major muscle. A report of eleven injuries and review of fifty-six. J Bone Joint Surg Am 1972;54:1040-6. 14. McNally PD, Marcelli EA. Achilles allograft reconstruction of a chronic patellar tendon rupture. Arthroscopy 1998;14:340-4.
J Shoulder Elbow Surg January/February 2003
15. Miller MD, Johnson DL, Fu FH, et al. Rupture of the pectoralis major muscle in a collegiate football player. Use of magnetic resonance imaging in early diagnosis. Am J Sports Med 1993;21:475-7. 16. Nazarian DG, Booth RE Jr. Extensor mechanism allografts in total knee arthroplasty. Clin Orthop 1999;367:123-9. 17. Nellas ZJ, Loder BG, Weirtheimer SJ. Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft. J Foot Surg 1996;35:144-8. 18. Orava S, Sorasto A, Aalto K, et al. Total rupture of pectoralis major muscle in athletes. Int J Sports Med 1984;5:272-4. 19. Park JY, Espiniella JL. Rupture of pectoralis major muscle. A case report and review of literature. J Bone Joint Surg Am 1970;52:577-81. 20. Rijnberg WJ, Linge BV. Rupture of the pectoralis major muscle in body-builders. Arch Orthop Trauma Surg 1993;112:104-5. 21. Schepsis AA, Grafe MW, Jones HP, et al. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15. 22. Tietjen R. Closed injuries of the pectoralis major muscle. J Trauma 1980;20:262-3. 23. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle. An anatomic and clinical analysis. Am J Sports Med 1992;20:587-93. 24. Zeman SC, Rosenfeld RT, Lipscomb PR. Tears of the pectoralis major muscle. Am J Sports Med 1979;7:343-7.
R
uptures of the pectoralis major muscle and tendon have been considered rare injuries, occurring primarily in male weight lifters during the eccentric phase of the bench press. There have also been sporadic case reports of isolated injuries occurring in other events in which resisted forces are applied to the extendedabducted humerus.3,5-8,10,15,18,22 Many of these injuries are initially misdiagnosed by patients and firstline physicians as pulled muscles, delaying proper diagnosis and treatment. Despite delays, several authors have reported successful late surgical treatment of pectoralis major tendon ruptures months to years after the initial injury.2,4,11,18,21 We report a case in which adequate mobilization of the ruptured muscletendon unit was not possible 8 weeks from the time of injury. A successful surgical result was achieved with the use of an Achilles tendon allograft to augment the repair. To the best of our knowledge, this technique has not been previously reported in the English literature. CASE REPORT A 21-year-old, right hand– dominant college student was seen 6 weeks after an injury sustained during the eccentric phase of a 250-pound bench press. He described feeling a pop in the anterior aspect of his dominant shoulder as the weight was lowered to his chest. This was followed by the immediate onset of pain and extensive ecchymosis about the anterior chest and upper arm over the next 24 hours. He was subsequently evaluated by his primary care physician, and the diagnosis of a muscle strain was made. The patient was treated with a sling and 4 weeks of rest. His pain resolved, but he noticed profound weakness when he tried to return to weight lifting. He was also involved in a softball league and was having trouble swinging a bat forcefully. This prompted his visit to our office. Before this injury, he had been working out with weights regularly for just over a From the Section of Sports Medicine, Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio and the Orthopaedic Center, Canfield, Ohio. Reprint requests: Thomas A. Joseph, MD, The Orthopaedic Center, 6470 Tippecanoe Rd, Canfield, OH 44406. J Shoulder Elbow Surg 2003;12:101-104. Copyright © 2003 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2003/$35.00 ⫹ 0 32/4/128200 doi:10.1067/mse.2003.128200
year. He denied any prodromal symptoms or the use of anabolic steroids. At the time of presentation (6 weeks after the injury), his ecchymosis had resolved; however, he had a visible and palpable defect within his right (dominant) axilla that was more pronounced with isometric contraction of the pectoralis muscle. There was a thin cordlike band inferiorly, and he had weakness and pain with resisted cross-body adduction. On the basis of his physical examination, a diagnosis of a pectoralis major tendon rupture was made and surgical repair was recommended. The patient’s preplanned vacation further delayed the operation, which was performed approximately 8 weeks from the time of injury. Through a standard axillary incision, a complete rupture of both tendinous heads of the pectoralis major was identified. There were extensive adhesions and fibrosis medial to the normal insertion site, and the tendon had avulsed completely from its insertion on the humerus and was retracted medially to the anterior chest wall. Despite circumferential mobilization of the muscle-tendon unit and the placement of traction sutures, we were unable to restore sufficient length to allow anatomic repair to the humerus with the arm at the side. An Achilles tendon allograft was tubularized and sewn into the stump circumferentially beginning at the musculotendinous junction to provide approximately 3 cm of additional length. A direct repair to the humerus was then performed with 3 metal suture anchors (Figure 1). Postoperatively, the patient was immobilized with a sling and swathe for 4 weeks, removing it only to bathe and to allow wrist and elbow range-of-motion exercises 3 times a day. At 4 weeks postoperatively, he began a supervised physical therapy program that incorporated shoulder range-of-motion exercises. Light strengthening was initiated at 6 weeks, and at 12 weeks, he returned to weight lifting. At 5 months postoperatively, he began playing softball and water skiing without restriction. At the latest follow-up (18 months), he was satisfied with the cosmetic appearance of his surgical site and noted no functional limitations. He continues to play recreational sports and to lift weights but has chosen to avoid heavy bench-press exercises. Preoperative and postoperative (18 month follow-up) photographs are shown in Figure 2.
DISCUSSION Injuries to the pectoralis major muscle have been well described. There is considerable variability in the types of injuries that occur and in their respective treatment. Ruptures may be complete or partial and may occur at the level of the muscle belly, at the
101
102
Joseph, DeFranco, and Weiker
J Shoulder Elbow Surg January/February 2003
Figure 1 Medical illustration demonstrating circumferential tubularization technique for allograft musculotendinous anastomosis.
musculotendinous junction, or at the distal tendinous insertion onto the humerus. Less common proximal injuries have been described at various sites of the muscle.22 Tears of the muscle belly, as well as myotendinous and tendinous ruptures, in elderly or lowdemand individuals can be effectively treated nonoperatively.21,23,24 Selective surgical repair is recommended for athletically inclined individuals sustaining complete ruptures, as improved clinical and functional outcomes have been demonstrated in comparative studies.19,21,23,24 For patients participating in sports that require upper body strength (football, wrestling, water skiing, etc), surgical repair has predictably resulted in normal or near-normal strength and return to sporting activities.6,11,21,23,24 Cosmesis is an additional concern within the bodybuilding population, and axillary contour may be reliably improved with surgical treatment as well.20 A working knowledge of the complex anatomy of this muscle is important in understanding the subtleties of surgical treatment. The complex insertional anatomy seems to predispose patients to partial rupture in select regions. In a biomechanical study, Wolfe et al23 characterized pectoralis major ruptures in cadaveric specimens subjected to eccentric loading. They showed disproportionate lengthening of the short sternal fibers during the terminal 30° of humeral extension with a simulated bench press. Pectoralis major tears were postulated to occur in a predictable anatomic sequence. The lower sternal abdominal fibers are the first to rupture, followed by the remaining sternal head, and finally the clavicular head. These findings are consistent with multiple clinical observa-
tions of an intact clavicular head found at the time of surgical exploration.2,5,12,15,21,23 In a comprehensive review of the literature supporting successful delayed repair of pectoralis ruptures, a common theme recurs: the presence of an intact portion of the tendon that prevents medial retraction.2,12,21 Under these conditions, the remaining intact fibers of the clavicular head act as a checkrein and serve as a scaffold to which the avulsed sternocostal fibers may adhere. The ruptured tendinous stump is found just medial to its anatomic insertion, and without shortening of the muscle-tendon unit or accompanying fibrosis, mobilization to the humerus is frequently possible. Our case was unique in that there was complete disruption of the entire insertion site, including both the sternal and clavicular fibers. Without any tethering structures, the tendon retracted medially into its thick muscle belly, much like the head of a turtle, and was encased in fibrous adhesions. Several traction sutures were placed, and the muscle was circumferentially mobilized. Despite these efforts, anatomic reinsertion on the humerus was not possible without creating undue tension on the repair. We chose to augment the repair with Achilles allograft in order to gain length. Although this technique has not been described specifically in relation to pectoralis repair, allograft has been used successfully in multiple cases of chronic disruptions of the knee extensor mechanism and Achilles tendon.9,14,16,17 Other authors have reported similar difficulty in achieving a direct repair in cases of chronic pectoralis major ruptures.1,13 Alho1 encountered difficulty at 3 months from the time of injury in a 28-year-old
Joseph, DeFranco, and Weiker
J Shoulder Elbow Surg Volume 12, Number 1
103
Figure 2 A, Preoperative photograph taken 6 weeks after injury. There was chest wall asymmetry and webbing of the axilla with abduction. B, Postoperative photograph taken 18 months after surgical repair, demonstrating improved axillary contour.
boxer. He described a technique of fascial release through a separate incision that permitted a direct repair of the tendon to its humeral insertion. By advancing the tendon to overcome a 2-cm defect, immobilization in an adducted position was avoided and early mobility and return to activity were achieved. It has been our experience that although delayed surgical repair may be technically feasible, early repair (within 2 weeks) is preferred. In this case report, the use of fascial allograft to augment the repair and avoid undue tension on the retracted tendon did not compromise the final result. We present this technique as a means of increasing the awareness of surgeons dealing with chronic ruptures and as an alternative to
performing a repair under tension or to the use of fascial detachment and advancement techniques. REFERENCES
1. Alho A. Ruptured pectoralis major tendon. A case report on delayed repair with muscle advancement. Acta Orthop Scand 1994;65:652-3. 2. Anbari A, Kelly JD, Moyer RA. Delayed repair of a ruptured pectoralis major muscle. Am J Sports Med 2000;28:254-6. 3. Arciero RA, Cruser DL. Pectoralis major rupture with simultaneous anterior dislocation of the shoulder. J Shoulder Elbow Surg 1997; 6:318-20. 4. Bak K, Cameron EA, Henderson IJ. Rupture of the pectoralis major. A meta-analysis of 112 cases. Knee Surg Sports Traumatol Arthrosc 2000;8:113-9.
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Joseph, DeFranco, and Weiker
5. Berson BL. Surgical repair of pectoralis major rupture in an athlete. Case report of an unusual injury in a wrestler. Am J Sports Med 1979;7:348-50. 6. Carek PJ, Hawkins A. Rupture of pectoralis major during parallel bar dips. A case report and review. Med Sci Sports Exerc 1998;30: 335-8. 7. Delport HP, Piper MS. Pectoralis major rupture in athletes. Arch Orthop Traumat Surg 1982;100:135-7. 8. Dunkelman NR, Collier F, Rook JL, et al. Pectoralis major rupture in windsurfing. Arch Phys Med Rehabil 1994;75:819-21. 9. Falconiero RP, Pallis MP. Case report: chronic rupture of a patellar tendon. A technique for reconstruction with Achilles allograft. Arthroscopy 1996;12:623-6. 10. Kawashima M, Sato M, Toriso T, et al. Rupture of the pectoralis major. Report of two cases. Clin Orthop 1975;109:115-9. 11. Kretzler HH, Richardson AB. Rupture of the pectoralis major muscle. Am J Sports Med 1989;17:453-8. 12. Lindenbaum BL. Delayed repair of a ruptured pectoralis major muscle. Clin Orthop 1975;109:120-1. 13. McEntire JE, Hess WE, Coleman SS. Rupture of the pectoralis major muscle. A report of eleven injuries and review of fifty-six. J Bone Joint Surg Am 1972;54:1040-6. 14. McNally PD, Marcelli EA. Achilles allograft reconstruction of a chronic patellar tendon rupture. Arthroscopy 1998;14:340-4.
J Shoulder Elbow Surg January/February 2003
15. Miller MD, Johnson DL, Fu FH, et al. Rupture of the pectoralis major muscle in a collegiate football player. Use of magnetic resonance imaging in early diagnosis. Am J Sports Med 1993;21:475-7. 16. Nazarian DG, Booth RE Jr. Extensor mechanism allografts in total knee arthroplasty. Clin Orthop 1999;367:123-9. 17. Nellas ZJ, Loder BG, Weirtheimer SJ. Reconstruction of an Achilles tendon defect utilizing an Achilles tendon allograft. J Foot Surg 1996;35:144-8. 18. Orava S, Sorasto A, Aalto K, et al. Total rupture of pectoralis major muscle in athletes. Int J Sports Med 1984;5:272-4. 19. Park JY, Espiniella JL. Rupture of pectoralis major muscle. A case report and review of literature. J Bone Joint Surg Am 1970;52:577-81. 20. Rijnberg WJ, Linge BV. Rupture of the pectoralis major muscle in body-builders. Arch Orthop Trauma Surg 1993;112:104-5. 21. Schepsis AA, Grafe MW, Jones HP, et al. Rupture of the pectoralis major muscle. Outcome after repair of acute and chronic injuries. Am J Sports Med 2000;28:9-15. 22. Tietjen R. Closed injuries of the pectoralis major muscle. J Trauma 1980;20:262-3. 23. Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle. An anatomic and clinical analysis. Am J Sports Med 1992;20:587-93. 24. Zeman SC, Rosenfeld RT, Lipscomb PR. Tears of the pectoralis major muscle. Am J Sports Med 1979;7:343-7.