Editorial Manager(tm) for Techniques in Shoulder and Elbow Surgery Manuscript Draft Manuscript Number: Title: Pectoralis major rupture in athletes; Footprint technique and results. Article Type: Technique Keywords: Pectoralis major rupture, Surgical technique, Suture Anchors, Double row, Results, Athletes, Foot print Corresponding Author: Mr L Funk, FRCS (T&O), FFSEM (UK) Corresponding Author's Institution: Wrightington Hospital First Author: NH Shah, MSc, FRCS (T&O) Order of Authors: NH Shah, MSc, FRCS (T&O); R Badge , MRCS; S Talwalkar , FRCS (T&O); L Funk, FRCS (T&O), FFSEM (UK) Manuscript Region of Origin: UNITED KINGDOM Abstract: Over a two year period, ten male athletes underwent repair of the pectoralis major tendon using a double row surgical technique employing three bone anchors to produce a foot print repair of the pectoralis major tendon. The mean patient age was 33.9 years (23-46 years). The mean time between surgery and the original injury was 11.6 weeks (1- 48 weeks). Outcome measures included patient satisfaction, bench press strength, pain and cosmesis. The average follow up was 20.3 months (12-39). Eight patients had pain prior to surgery and all patients were not satisfied with the appearance of their chest. The average loss of bench press strength was 75% preoperatively. At the final follow up, none of the patients complained of any pain while one patient reported mild pain. Nine were satisfied with the appearance. The average improvement in bench press strength was 90%. One patient developed a deep infection requiring a further washout and antibiotics. No re-rupture was seen amongst any of our patients. There was no difference in outcomes between the early and late repairs in all the criteria. In conclusion, satisfactory results can be achieved with a suture-anchor footprint repair technique of the pectoralis major strength athletes with return to previous sports and strength.

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TITLE

Pectoralis major rupture in athletes; Footprint technique and results.

AUTHORS

Shah NH; MSc, FRCS (T&O), Upper Limb Fellow

Badge R; MRCS, Clinical Research Fellow

Talwalkar S; FRCS (T&O), Upper Limb Fellow

Funk L; FRCS (T&O), FFSEM (UK), Consultant Shoulder & Upper Limb Surgeon

INSTITUTION

Upper Limb Unit, Wrightington Hospital

Hall Lane, Appley Bridge, Lancashire, England, WN6 9EP

CORRESPONDING ADDRESS

Lennard Funk, 120 Princess Road, Manchester, M15 5AT, UK

Tel: +44 161 227 0027

Email: lenfunk@shoulderdoc.co.uk

SHORT TITLE

Footprint technique for pectoralis major repair

DISCLOSURE OF FUNDING AND CONFLICT OF INTEREST

We declare no conflict of interest neither we received any funding from any organization.

Manuscript (All Manuscript Text Pages, including Title Page, References and Figure Legends)

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ABSTRACT

Over a two year period, ten male athletes underwent repair of the pectoralis major tendon

using a double row surgical technique employing three bone anchors to produce a foot

print repair of the pectoralis major tendon.

The mean patient age was 33.9 years (23-46 years). The mean time between surgery and

the original injury was 11.6 weeks (1- 48 weeks). Outcome measures included patient

satisfaction, bench press strength, pain and cosmesis. The average follow up was 20.3

months (12-39).

Eight patients had pain prior to surgery and all patients were not satisfied with the

appearance of their chest. The average loss of bench press strength was 75%

preoperatively. At the final follow up, none of the patients complained of any pain while

one patient reported mild pain. Nine were satisfied with the appearance. The average

improvement in bench press strength was 90%. One patient developed a deep infection

requiring a further washout and antibiotics. No re-rupture was seen amongst any of our

patients. There was no difference in outcomes between the early and late repairs in all the

criteria.

In conclusion, satisfactory results can be achieved with a suture-anchor footprint repair

technique of the pectoralis major strength athletes with return to previous sports and

strength.

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INTRODUCTION

Muscle injury may vary from minor strains to a complete disruption of fibres. These

injuries involve different locations within the musculotendinous unit; including the site of

origin, within the muscle belly itself, at the musculotendinous junction and complete

tendinous avulsion from the bone. Tendon avulsion from the bony insertion usually

occurs when a maximally contracted muscle is subjected to an overwhelming force [1].

Injury to the pectoralis major muscle is usually caused by a sudden forceful overload of

the maximally contracted muscle, which usually involves the application of an

overwhelming extension force to the maximally contracted pectoralis major muscle.

Hence, this eccentric contraction of the muscle with the arm in the adducted and extended

position leads to a complete avulsion from the bone [2, 3].

Rupture of the pectoralis major is a relatively uncommon injury first being reported in

1822 [4]. Since then more than 200 cases have been reported in literature so far, however

most of these cases have been described in the last 25 years due to the increasing

popularity and involvement in competitive sports. The most common mechanism of

injury tends to be weight lifting [2]. Most of these injuries occurred in men during their

third and fourth decades [3]. The single most common mechanism for pectoralis major

rupture has been the bench press exercise [5, 6, 7, 8].

There are many published repair techniques including bony tunnels [2, 6, 8, 9, 10, 11,

12], pull out wires [13], staples [14], cancellous screw [15] and suture anchors [3, 11, 16,

17]. All have had satisfactory results.We used a new double row surgical technique using

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three bone anchors to produce a large foot print of the pectoralis major tendon on the

humeral shaft. Here, we present the result of our new surgical technique for the repair of

the pectoralis tendon rupture in strength athletes.

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MATERIAL AND METHODS

Between June 2005 and September 2007, senior author (LF) performed surgical repair of

the distal end of the pectoralis major tendon in ten male athletes. Six patients had seen

other surgeons previously and had been advised non-operative treatment. One had had an

exploration and attempted repair before presenting to us.

Patients were assessed subjectively for pain, appearance and strength. We used the same

outcome criteria as previously described [2]. Appearance of the chest was assessed by a

visual analogue scale ranging from 0 (completely unsatisfied with the appearance of the

chest in the mirror) to 10 (complete satisfaction with the appearance of the chest). Pain

was also measured on a visual analogue scale ranging from 0 (no pain) to 10 (severe

pain). Shoulder strength was determined by asking the patients to estimate the percentage

of normal shoulder strength which they had prior to injury.

We used the Tietjen classification [18] for the management of the pectoralis major tears.

All patients had type 3-D (complete tears at the tendon level), which was confirmed intra-

operatively. Diagnosis was made with history and clinical examination. Magnetic

resonance imaging (MRI) scans were obtained for five of the patients, but the diagnosis

was predominantly a clinical diagnosis and therefore not required.

Operative Details

Surgery was performed under general anaesthetic with an interscalene block and

additional local anaesthesia for the axillary incision. Patients were placed in a supine

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position with their arm on a short arm table. After preparing the whole upper limb and

ipsilateral anterior chest wall, isolation draping was performed to allow the free

movement of the arm and full exposure of the affected anterior chest wall. In some cases

the opposite chest wall was also prepared and exposed to ensure good cosmetic symmetry

post-repair.

A 6 centimeter low longitudinal anterior axillary incision is made through the skin and

subcutaneous tissue, with the arm in the adducted position, utilizing the natural axillary

fold (Figure 1). The medial edge of the deltoid was then identified, along with the

cephalic vein. The retracted musculotendinous unit of the pectoralis major was identified

by finding the fascial sheath and tunneling medially. There was often a clear zone of

injury in both acute and chronic injuries which could be identified, providing the correct

plane of dissection. Once the lateral end of the pectoralis major muscle was identified,

traction sutures were placed superiorly and inferiorly. The pectoralis major muscle was

mobilized and released both subcutaneously and deeply. In chronic cases this release

involved mobilization down to the sternum and clavicle both deep and superficial to the

muscle. Care was taken to avoid damage to the lateral and medial pectoral neurovascular

bundles and to ensure reattachment to the humerus with minimal tension. Once full

mobilisation of the muscle was achieved the humeral insertion point was prepared. Three

centimeters of the humerus is cleared of the soft tissues and then prepared with petalling

and roughening of the cortical surface using osteotomes to allow endosteal bleeding.

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Three 5 mm FastinRC

(Depuy Mitek, Raynham, MA) anchors with double loaded

Orthocord ™

or 5mm Twinfix

(Smith and Nephew, Memphis, TN) anchors with double

loaded Ultrabraid ™

were inserted in a step wise fashion longitudinally with the superior

and inferior anchors being placed laterally whilst the middle anchor was placed medially

(Figure 2). The most superior and the most inferior sutures are passed in a modified

whip-stitch suture technique, while the rest of the suture strands (one each from the

superior and inferior anchors) were passed through the pectoralis major tendon at about

1-2 cm from the tendon edge. These later sutures were passed from the undersurface to

the superficial surface. These created the lateral end of the foot print of the tendon. Then

the sutures from the middle anchor were passed more medially from the deep to the

superficial surface, through the pectoralis major tendon, resulting in the foot print of the

tendon (Figure 3).

The arm was then held in the adducted position and in neutral rotation. The two suture

limbs of the superior anchors were tied together after checking the correct tension in the

tendon. Sequentially, the corresponding suture limbs of the inferior anchor were tied

sliding the tendon down to the bone. Finally, the two suture limbs of the middle anchor

were tied (Figure 4).

The final repair was checked, assessing the comfortable range of abduction and external

rotation under direct vision. This was documented. Post-operatively, the arm was placed

in a standard arm immobilizer sling. The sling is worn for comfort only for the first three

weeks. Physiotherapy commenced immediately post-operatively. This comprised active

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assisted mobilisation within the safe zone (as dictated by the range post-repair and patient

tolerance) under the direct supervision of a physiotherapist. During this time forced

external rotation, abduction and resisted adduction of the shoulder was not performed.

The sling was weaned by three weeks. After three weeks, active movements were

introduced and were progressed to increase the range of movement in all directions, as

tolerated by the patient and under strict supervision. Exercises which combined

isometrics, closed chain exercises, proprioceptive and core stability exercises were an

essential part of the rehabilitation from early post-operatively, using the senior author’s

guidelines [19]. Sports specific props were encouraged early in the regimen. This

progressed to open chain exercises from approximately three to six weeks and then light

active resistance activities.

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RESULTS

All ten patients were male athletes with a mean age of 33.9 years (23-46 years). The

average follow up was 20.3 months (12-39). The mean time between surgery and original

injury was 11.6 weeks (1- 48 weeks). Four patients claimed that they were using anabolic

steroids. None of the patients were lost in follow-up. Five patients had incurred the injury

on the dominant side while another five patients sustained the injury on the non-dominant

side. Mean time between injury and surgery was 11.6 weeks (1- 48 weeks). Details of the

sports involved and the mechanism of injury are presented in table 1 & 2. One patient had

previously undergone an exploration and attempted repair a few months prior to

presentation to us.

Pain

Pre-operatively two patients complained of severe pain, five reported moderate pain and

one experienced mild pain while another two did not complain of pain either at rest or

with activity. After the surgical repair and at their last follow up, nine patients did not

complain of any pain while one patient experienced mild pain on moving their arm across

the body. None of the patients reported any pain on pushing weights away from the body.

Appearance

Pre-operatively all ten patients were unsatisfied with the cosmetic appearance of their

chest. Two patients were totally unsatisfied. Average pre-operative score was 4.1 for the

appearance (0-7 range). However, after the surgical repair eight patients were completely

satisfied with the appearance of their chest (Figure 5 & 6); one patient was unsatisfied

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while one patient was moderately satisfied. Average post op score was 6.8 (1-10 range), a

40% improvement.

Strength

Prior to the surgical repair, average loss of strength was 75% (range 50-100%). However,

after the repair average post-op strength was 90% of normal for that patient.

Re-ruptures

No clinical re-ruptures were seen at their final follow up visit. Four of the patients had

follow-up magnetic resonance imaging (MRI) scans. One patient had a scan report that

was equivocal, but clinically appeared intact.

There was no difference in outcomes between the early and late repairs in all the criteria.

Complications

One patient, who had undergone previous exploration and repair of the pectoralis major

tendon, developed a deep wound infection which required a wound washout and a course

of antibiotics. He made a full recovery.

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DISCUSSION

After a pectoralis major tendon rupture some patients, especially the elderly or those with

low physical demands, are able to return to normal activities of daily living without

surgical repair. However strength athletes require full pectoralis major muscle strength

and bodybuilders require pectoralis major symmetry to continue their pre-injury sports.

Non-operative treatment has been shown to lead to a significant loss of strength of

adduction especially active people. Previous studies have shown that patients who have

had their pectoralis major muscle repaired have less pain, experience a subjective and

objective improvement in strength, and are happier with their outcome when compared

with similar patients who have not had a repair [2, 20, 21, 22, 23].

A meta-analysis by Bak et al [21] on pectoralis major muscle injuries revealed that 88%

of patients had excellent or good results after surgical repair compared with 27% for

patients treated non-operatively. Hanna et al [20] reported a series of 22 pectoralis major

ruptures, of which 10 underwent surgical repair while 12 were treated non-operatively.

They concluded that patients who had surgical repair had a better functional outcome as

99% strength recovery was seen among patients who had surgical repair while 56 %

strength recovery was seen among patients who had non-operative treatment. Petilon et al

[3] recommended surgical repair for all complete distal tears to regain full strength and

function and also to reduce cosmetic deformity. Kakwani et al [17] reported good to

excellent results in 92% patients after surgical treatment in their series of 13 athletes with

a complete pectoralis major rupture.

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All previous studies have used bone sutures or single row anchor techniques. Double row

techniques and very strong suture anchor and suture technology has led to much stronger

fixations in rotator cuff repairs. We have therefore adapted this for pectoralis major

repairs thus allowing more confidence in a faster rehabilitation and return to sports and

activities.

Our results are comparable to others and demonstrate that the surgical technique that we

have used in athletes is safe, reliable and can produce high patient satisfaction

accompanied with excellent pain relief and cosmetic results. The complication rate in our

study was low and we had no re- ruptures at a 20 month review.

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REFERENCES

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28(1):9-15.

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and management. J Am Acad Orthop Surg. 2005; 13(1):59-68.

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11. Aärimaa V, Rantanen J, Heikkilä J et al. Rupture of the pectoralis major muscle.

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review of literature. J Bone Joint Surg Am. 1970; 52(3):577-81.

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report of eleven injuries and review of fifty six. J Bone Joint Surg Am. 1972;

54(5):1040-6.

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using a barbed staple. Can J Surg.1987; 30(6):434-435.

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operate. Br J Sports Med. 2002; 36(3):226-8.

16. 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(3):475-7.

17. Kakwani RG, Matthews JJ, Kumar KM et al. Rupture of the pectoralis major

muscle: surgical treatment in athletes. Int Orthop. 2007; 31(2):159-63.

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264.

19. Funk L, Tatlow K, Leftley C et al. Shoulderdoc Shoulder Exercise Book.

Published by Shoulderdoc Ltd. 2008. ISBN: 978-0-9561396-0-3

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8(2):113-119.

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FIGURE LEGENDS

Fig 1. Low longitudinal anterior axillary incision

Fig 2. Three anchors placed in a step wise longitudinal pattern lateral to biceps

Fig 3. Sutures passed 1-2 cm from the edge of the tendon

Fig 4. Final position after suture tying

Fig 5. Final appearance

Fig 6. Final appearance

1

TABLE 1

Sports Number of patients

Body builder 4

Weight lifter 2

Professional rugby league player 2

Martial arts 1

Climber 1

TABLE 2

Mechanism of injury Number of patients

Bench press 5

Dumbbell flies 2

Fall 2

Direct impact 1

Table (NO Excel Files!  Submit as MS Word)

Fig 1. Low longitudinal anterior axillary

incision

Figure (TIF or EPS files. 300 ppi Images or 1200 ppi Line-Art)

Fig 2. Three anchors placed in a step

wise longitudinal pattern lateral to

biceps

Fig 3. Sutures passed 1-2 cm from the

edge of the tendon

Fig 4. Final position after suture tying

Fig 5. Final appearance

Fig 6. Final appearance