The Procedure
Pec major repair surgery is performed to treat pectoralis major tendon tear or rupture. The surgery involves reattaching the tendon to the humerus (upper arm bone) with sutures, anchors or screws. It helps to restore function and strength of the pec major muscle and the shoulder.
The surgery is performed either arthroscopically or open, and I book around two hours of time in the operating theatre.
Complications
General risks of surgery include:
- Bruising & haematoma: this will vary for each patient. Bruising is a normal side effect of surgery and usually resolves in a short time.
- Infection: infection is a possible risk and is usually treated with antibiotics.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here.
- Anaesthetic risks: general anaesthetic (GA) carries a number of risks, which will be discussed in detail with your anaesthetist prior to surgery. Fortunately, Australia is one of the safest places to undergo a GA. In Australia, the risk of mortality from GA is around 1 in 100,000. For context, the risk of death in a car accident in Queensland is around 1 in 10,000 per year.
- Wound issues: some superficial issues can develop in surgical wounds postoperatively, however most will require a small intervention to resolve the problem.
Specific risks of pec major repair surgery include:
- Nerve damage: injury to nearby nerves, including the axillary nerve, can cause numbness or weakness
- Stiffness or frozen shoulder
- Hardware issues
- Re-tear or rupture of the tendon, particularly during the early stages of recovery after surgery
Pre Op
Whilst you wait for your surgery date, there are a few things to do:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to my office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners, ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications, ring your anaesthetist and confirm whether you need to stop taking them before the operation.
- Confirm your admission details with my office one to two business days prior to surgery.
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be one night. You will be discharged usually around 10am. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
Following pec major repair surgery, the shoulder needs to be immobilised, which will require full time wearing of a sling for six weeks. Activities will need to be limited during the recovery, particularly in the first three months following surgery, to allow the tendon to fully heal, otherwise retear or rupture of the tendon can occur.
Once the sling is no longer required, physiotherapy can commence and aims to improve range of motion and build up strength.
A full recovery usually takes between six to 12 months, and physical activities need to be limited in the first six months.
Rehabilitation
Rehabilitation after pec major repair surgery focuses on restoring range of motion and improving strength in the shoulder. Early rehabilitation exercises aim to improve range of motion with limited strengthening exercises, while long term exercises focus on strengthening and returning to full activities.
Physiotherapy Guidelines
Day 1 Physiotherapy Guidelines
Reasonable healing of the Pec Major tendon takes at least 12 weeks, hence the caution during the first 3 months and need for care from day one.
The hospital physio will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling.
Day one (PHASE ONE – Early Healing Protective Phase)
- Education and precautions – “protective phase”
- New collagen network requires gentle stresses to positively affect fibre orientation – strict passive exercises only
- Immobilisation in sling at all times other than washing or doing exercises
- ADL (activities of daily living) advice – no active motion of shoulder, no external rotation/abduction motions, no load, light use of hand in sling only, no tucking in shirts or hand behind back, no weight bearing, pillow under elbow when sleeping if required
- Pain management advice – correct sling fit is paramount, ice
Patient seen day one in hospital:
- Education and precautions “protective phase”
- No activation of Pec Major muscle – no cross body motion, no push. No stretching of the Pec Major musculotendinous unit.
- Immobilised in a sling at all times except for washing and physio exercises
- Ensure good fit of sling, patient able to don/doff correctly
- Shoulder passive only movements to minimise chances of excessive GH (glenohumeral) stiffness
- Passive pendulum to 90°, do not do body swings
- Passive elevation of the shoulder to 90° with the arm held in internal rotation
- External rotation with arm by side to neutral.
- AA/AROM (active-assisted/active range of motion) Elbow Extension/flexion – 4 times a day
- Wrist/hand ROM (range of motion) – care no forceful grip
- C spine ROM (cervical spine range of motion)
- Gentle scapular neutral exercises/general posture
Follow up:
- See local physiotherapist week 2 to check good understanding of post op rehab guidelines and precautions. Therapist to check ROM (range of motion) goals being achieved and patient aware of precautions.
- No need to progress rehab or regular physio during this time. Rehab will be progressed once appropriate tendon healing after 6 weeks and review by Dr Cutbush.
Results After Surgery
Pec major repair surgery is typically successful, usually yielding long term improvement of pain and range of motion, and a return to normal activities. A small number of patients may experience a loss of strength, as well as residual pain, and some patients may require further surgery if a retear or rupture occurs. Adhering to recovery protocols and restrictions can influence results.