Timing
The procedure is best performed within the first 2-3 weeks after the injury. Delaying treatment makes the surgery more challenging as the tendon shortens and gets stuck down by scar tissue. In some instances this may result in it not being possible to repair the tendon to its original attachment site on the bone and occasionally it may be necessary to use a tendon graft to bridge the gap.
How is the procedure performed?
The procedure is performed under a combination of general and regional anaesthesia. An incision is made on the front of the shoulder. The bone where the tendon normally attaches is exposed and freshened to aid healing. Sutures are placed in the tendon and the tendon is then advanced to the insertion site and fixed by passing the sutures through drill holes, with the aid of buttons or sometimes with suture anchors. In chronic cases a tendon graft may be required to bridge the gap. The graft may be prepared from the patient’s own tendon or from donor tissue.
Benefits
The main benefit of the procedure is to reattach the tendon and improve the function and strength of the muscle. More than 85% of patients achieve benefit from surgery.
Risks
The overall risk of complications is less than 10%.
Nerve injury - The nerves that supply the pectoralis major muscle may rarely be injured during surgery.
Bleeding and haematoma - This may manifest as bruising around the surgical site.
Tendon damage: Damage to the biceps tendon may occur.
Damage to the bone – A hairline fracture of the bone may occur at the site of insertion.
Rerupture or hardware failure – The tendon may fail to heal or the fixation device may work loose. The risk of rerupture is greater when the injury occurs at the muscle-tendon junction.
Heterotopic ossification – New bone may form at the insertion site and may be a source of pain.
Infection or wound breakdown – The risk of infection is about 1-2%. You will be given antibiotics as a precaution.
Numbness around the scar – This is possible but uncommon.
Aftercare
Following the procedure the skin incision will be closed with sutures and tape and covered with a shower-proof dressing, which should be left undisturbed until the sutures are removed at 12-14 days.
Rehabilitation: Prior to discharge from hospital a physiotherapist will provide instructions on looking after the arm.
0-4 weeks: The arm will be protected in a sling. The arm may be removed from the sling intermittently to move the elbow, hand and wrist.
5-8 weeks: Active and assisted movements of the shoulder are started in flexion and internal rotation. Care should be taken not to push the arm very hard into abduction or external rotation.
9-12 weeks: Light resistance exercise may be started. Lifting and carrying heavy objects should be avoided. >12 weeks: Weight training may be gradually resumed.
> 6 months: Full activities may be resumed.
Outpatient physiotherapy will be arranged.
Resuming activities
You may resume driving at approximately 4 weeks after surgery or when you have regained sufficient movements and control of the arm to drive safely. Return to work will depend on your occupation. Manual activities should be avoided for at least 3 months.
Follow-up
An appointment will be arranged for you to be seen at 2 weeks after the procedure. Follow-up is required for at least 6-12 months after surgery or until a satisfactory recovery is achieved.