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PEARLS & PITFALLS – SURGICAL TECHNIQUE

Discussion

Most authors in order to restore function and
full strength now recommend acute surgery when

complete tears occurs, especially in individuals
who want to resume their athletic upper extremity

activities. Conservative treatment, however, might
be satisfactory in elderly and inactive persons or in

intramuscular ruptures injury in the typical cases of
direct trauma.

Options for repair have varied widely. The way of

preparing the tendon usually makes use of Krakow
or Kessler sutures and the most common options for

fixation used are transosseous sutures and / or suture
anchors. However, others have been described in the
past, such as suturing the tendon to the periosteum,

the remaining tendon or the clavipectoral fascia,
screws with spiked plastic washers and even barbed 03

staples. Musculo-tendinous junction ruptures are Conclusion
better repaired using mattress sutures.
The previously described surgical technique attempts
The transosseous technique has demostrated good to combine the best of both options; knotless suture

long-term clinical outcomes and is considered the anchors allows the tendon end to be brought into the
“Gold Standard”, it allows for increased tendon to trough similar to the transosseous technique, yet has

bone surface healing. Suture anchors is becoming the strength inherent to the suture anchor technique.
a popular technique as biomechanical and By tying the pre-loaded sutures to themselves as

clinical studies, reported no significant differences well as the sutures in the tendon, we enhance the
comparing the transosseous option; however pros strength of the construct. Surgeons may want to add
and cons has been described with both repair
this technique to their repertoire as we believe this
constructs. The main disadvantage described with could lead to improved long-term outcomes.
transosseous technique is that sutures are tied over

two bone bridges, 1 cm lateral to the pectoralis
insertion area in a thinner bone with increased risk

of local fracture and fixation failure as well as greater
dissection and soft tissue stripping is required

compared to the suture anchor technique. Retracted
and/or chronic ruptures can be problematic as well

with transosseous technique as tendon length is
important to pass through the humerus.

Disadvantages of the suture anchor repair include
cost, local host reaction to metal or biodegradable

anchors, and decreased suture area contact of
tendon to bone. Also, metal anchors, if used, could

interfere with imaging.

01 Fig 1 Pectoralis major tendon hold with two number 2 ultra-
resistant Fiberwire © (Arthrex, Inc. Naples, FL) locked
sutures in a Krackow fashion. The humeral insertion

site was properly prepared, creating a trough with a
rounded burr at the anatomic insertion site, lateral to
the biceps tendon.

02 Fig 2 Insertion of one of the knotless Peek Swivelock© 5.5
anchor previously loaded with one of the #2 fiberwire©
(Arthrex, Inc. Naples, FL) sutures from the pectoralis
major tendon.

03 Fig 3 Final result of the pectoralis major repair. The anatomic
insertion site was respected, lateral to the bicipital
groove which is shown in the picture

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ISAKOS NEWSLETTER 2013: Volume II 41