Review articleDermal allograft reconstruction of a chronic pectoralis major tear
Section snippets
Case report
A 30-year-old male entertainment wrestler sustained an injury to his nondominant right shoulder while trying to break a fall. He was initially treated in a conservative manner, but presented to the senior author (A.E.) 2 years later with complaints of ongoing pain and weakness, as well as a bothersome deformity of his chest. Because of the injury, he could no longer perform as an entertainment wrestler or participate in recreational sports involving the upper extremity. The patient also
Operative technique
The patient was placed under general anesthetic in a beach chair position with the right shoulder and arm prepped and draped free. Examination under anesthesia demonstrated a deficient anterior axillary fold. A standard axillary incision was performed over the distal aspect of the deltopectoral interval. We identified a chronic tear (timing), “at or within” the musculotendinous junction of the pectoralis major (location), which was full-thickness and complete width (extent), thus leading to its
Postoperative care and rehabilitation
Postoperatively, the arm was immobilized in a sling for 6 weeks. Passive closed chain pendulum exercises, restricted to an arc of 45°, were initiated immediately after the operation. Active range of motion and stretching exercises were initiated after postoperative week 4. Dynamic strengthening was delayed until postoperative week 12. Standard gym exercises and light weight training were initiated after 4 months, but return to contact sports or heavy weight training was not allowed until after
Results
The QuickDASH, a valid and reliable outcome measure, was used to measure pain and function.5 A maximum score of 100 on the QuickDASH indicates severe disability and pain, whereas a score of 0 indicates healthy pain-free unrestricted use of the upper extremity. Visual analog scales (VAS) were used to measure both pain and cosmetic satisfaction. Strength was measured by dynamometer. Outcome measurements were recorded preoperatively and postoperatively at eleven and seventeen months after surgery.
Discussion
Several studies have demonstrated superior outcomes with operative compared to conservative treatment in acute pectoralis major ruptures.3, 13, 18 However, it is common for this injury to be missed during initial presentation, leading to delayed diagnosis and referral for appropriate treatment, which may include surgical repair or reconstruction. Less is known about the results of operative management in the presence of a chronic tear. Several surgical treatment approaches for chronic tears
Conclusion
We believe that our reconstruction technique using a human extracellular matrix scaffold can be expected to yield a strong repair and successful outcomes following surgery. The use of the dermal graft avoids donor site morbidity, as well as the long graft preparation time that can be associated with using tubular or unprepared graft sources to reconstruct the defect in the pectoralis major, a normally flat tendon. Dermal allografts likely have negligible infection/rejection risk and adequate
Acknowledgment
The authors thank Valerie Oxorn for her illustrative contributions to this article.
Disclaimer
None of the authors, their immediate family, nor any research foundation with which they are affiliated received any financial payments or other benefits from any commercial entity related to the subject of this article.
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IRB approval for this study was granted by the St. Joseph's Health Centre Research Ethics Board: #2012-030.