1. Pectoralis Major Repair With Unicortical Button Fixation And Suture Tape 
Anthony Sanchez, B.S., Marcio B. Ferrari, M.D., Salvatore J. Frangiamore, M.D., George Sanchez, B.S., Bradley M. Kruckeberg, B.A., Matthew T. Provencher, M.D. 
Arthroscopy Techniques 
Volume 6, Issue 3, Pages e729-e735 (June 2017)
DOI: /j.eats
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
Pectoralis major repair performed in the right shoulder. The coracoid process (red arrow) is palpated and used as a reference. Using a surgical pen, the surgical approach is drawn based on the axillary fold (A). The incision starts 3 cm below the coracoid process and extends distally for 5 cm. The skin is retracted using Senn-Muller retractors (blue arrows) (B). Then, Metzenbaum scissors are used to expose the surgical field medially and laterally, and to create an interval between the deltoid and pectoralis major muscle. A defect between the clavicular (black arrow) and sternal (green arrow) heads of the pectoralis major is identified (C).
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
Humeral preparation for a pectoralis major repair in the right shoulder. Once the pectoralis tendon is visualized and all the adhesions are removed, the tendon is secured with a Kocher clamp, then mobilized and retracted (green arrow). A Kolbel or blunt Homan retractor is used to retract the deltoid muscle laterally, thereby exposing the humeral shaft (blue arrow) (A). The lateral biceps tendon must be identified (orange arrow) and retracted medially to prevent iatrogenic damage while preparing the humeral bone for fixation (B).
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
To safely expose the humeral shaft of the right shoulder, the deltoid muscle (green arrow) must be retracted laterally and the pectoralis major tendon (blue arrow) must be retracted medially with the long head of the biceps tendon. All soft tissue must be resected from the anterior humeral shaft using a curette, rongeur, or an acorn-tip burr to create a bleeding surface for repair of the pectoralis major tendon.
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
The pectoralis major tendon of the right shoulder is prepared for fixation. The pectoralis major tendon (green arrow) must be released from all adhesions, which can be significant in a setting of chronic cases. Once the tendon is completely mobilized, it is prepared for fixation by whipstitching a combination of No. 5 FiberWire and FiberTape (Arthrex).
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

6. Fig 5
Repair of the pectoralis major is performed in the right shoulder with Pec Buttons (Arthrex) (black arrow). Three equidistant holes are drilled using a 3.7-mm spade tip drill at the level of tendon insertion. Then, three 3.2-mm × 11-mm Pec Buttons are loaded (A) and inserted in the previously drilled holes in a unicortical fashion, from inferior to superior (blue arrow) (B). Of note, we recommend a slight abduction and external rotation of the arm while repairing the tendon to the humeral shaft.
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

7. Fig 6
After fixation of the pectoralis major tendon to the humeral insertion site of the right shoulder, a physical examination is performed to assess the tension of the fixation during range of motion. With the left hand placed at the interface between the tendon and humerus insertion site, the arm is gently externally (red arrow) (A) and internally (red arrow) (B) rotated while the tension of the repair construct is evaluated. After this, the shoulder is placed in slight forward flexion (red arrow) (C), and the tension is once again evaluated. Evaluation of the tension of the repair construct during range of motion guides the postoperative rehabilitation protocol.
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

8. Fig 7
Once the repair is complete and the tension of the repair construct has been evaluated during range of motion of the right shoulder, a Double Syringe System (Greyledge Technologies, Vail, CO) (red arrow) (A) is used to inject a combination of autologous conditioned plasma (ACP) and platelet-rich plasma (PRP) at the interface between the tendon and humerus insertion site (red arrow) (B) to maximize the healing potential.
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions

9. Fig 8
Once the procedure is complete, palpation of the repair construct (red arrow) (A) in the right shoulder ensures that the tendon is in close contact with the bleeding surface of the humeral shaft. Lastly, copious lavage is performed and the clavipectoral fascia is closed in a standard fashion (red arrow) (B).
Arthroscopy Techniques 2017 6, e729-e735DOI: ( /j.eats )
Copyright © 2017 Arthroscopy Association of North America Terms and Conditions