Allograft Reconstruction Literature and Technique Overview
Chronic pectoralis major tendon tears represent a technically demanding subset of shoulder girdle injuries, often complicated by tendon retraction, poor tissue quality, muscle atrophy, and loss of the native humeral footprint. These challenges are magnified in ultra‑chronic tears—injuries presenting years after the index event—where profound musculotendinous shortening, fatty infiltration, and complete absence of repairable tendon are common. Historically, such cases were frequently deemed irreparable, and patients were counseled toward nonoperative management despite persistent pain, weakness, and cosmetic deformity. Advances in allograft reconstruction techniques have challenged this paradigm, demonstrating that even super‑chronic tears may be amenable to surgical reconstruction when appropriate length–tension relationships and fixation strategies are restored.
Ultra‑Chronic Tear Considerations
Ultra‑chronic pectoralis major tendon tears—typically defined as injuries presenting more than two to three years after rupture—represent the most severe end of the chronic spectrum. In these cases, primary repair is rarely possible due to extreme tendon retraction, loss of viable tendon substance, and irreversible remodeling of the musculotendinous unit. The principal determinant of successful reconstruction in this setting is not the chronicity itself, but rather the ability to restore appropriate length–tension mechanics while distributing load across a stable reconstructed footprint. Contemporary outcome studies using Achilles tendon and acellular dermal allografts have demonstrated meaningful functional recovery, high patient satisfaction, and return to activity even in markedly delayed cases, supporting surgical intervention for select ultra‑chronic tears.
PecFlexFix™ Grafting Technique for Ultra‑Chronic Tears
The PecFlexFix™ grafting technique was developed specifically to address the biomechanical and biological challenges associated with ultra‑chronic pectoralis major tendon tears. This technique employs a double–double Achilles tendon allograft construct, providing increased graft length, thickness, and redundancy necessary to bridge large defects and accommodate severe tendon retraction. A three‑point fixation strategy is utilized to restore the native footprint geometry, enhance rotational control, and improve resistance to cyclic loading. By distributing forces across multiple fixation points and allowing controlled tensioning of the shortened musculotendinous unit, the PecFlexFix™ technique minimizes stress concentration at the graft–bone interface. This approach facilitates restoration of chest wall contour, improves functional strength, and expands surgical options for patients with super‑chronic pectoralis major ruptures previously considered unsalvageable.
Summary of Key Allograft Literature
- Neumann et al., OJSM 2018 – Dermal allograft; mean delay ~10 months; significant improvement in DASH and pain scores.
- Zacchilli et al., JSOA 2013 – Achilles allograft; mean delay 22.2 months; good to excellent outcomes.
- Gouk et al., Ochsner Journal 2021 – Dermal allograft; delays 12 and 18 months; preserved strength and cosmesis.
- Mardani‑Kivi et al., J Orthop Sci 2023 – Achilles allograft; mean delay 37 months (range up to 182 months); high return to sport.
- Rivera et al., Arthroscopy Techniques 2023 – Achilles allograft; technical note.
- Hachem et al., JSES RRT 2025 – Achilles allograft; mean delay ~20 months; full ROM and symmetric strength.
Mora MD
The PecTear MD
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