Rev. bras. ortop. vol.52 número1

rev bras ortop.2017;52(1):107–110

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

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Case

report

Simultaneous

bilateral

distal

biceps

tendon

repair:

case

report

夽

Thiago

Medeiros

Storti

_,

_Alexandre

_Firmino

_Paniago,

_Rafael

_Salomon

_Silva

_Faria

InstitutodoOmbrodeBrasília,Brasília,DF,Brazil

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Articlehistory:

Received11January2016 Accepted5February2016

Availableonline23December2016

Keywords: Rupture/diagnosis Rupture/etiology Rupture/surgery Tendoninjuries

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Simultaneousbilateralruptureofthedistalbicepstendonisarareclinicalentity,seldom reportedintheliteratureandwithuncleartherapeuticsetting.Theauthorsreportthecase ofa39-year-oldwhitemanwhosufferedasimultaneousbilateralrupturewhileworking out.Whenweightliftingwithelbowsat90◦_{offlexion,hesuddenlyfeltpainontheanterior} aspectofthearms,comingforevaluationaftertwodays.Hepresentedbulgingcontour ofthebicepsmusclebellyandecchymosisintheantecubitalfossa,extendingdistallyto themedialaspectoftheforearm,aswellasamarkeddecreaseofsupinationstrengthand paininactiveelbowflexion.MRIconfirmedtherupturewithretractionofthedistalbiceps bilaterally.Theauthorsoptedforperformingthetendonrepairssimultaneouslythroughthe doubleincisiontechniqueandfixationtothebicipitaltuberositywithanchors.Thepatient progressedquitewell,withfullreturntolaborandsportsactivities,beingsatisfiedwith theresultaftertwoyearsofsurgery.Intheliteraturesearch,fewreportsofsimultaneous bilateralruptureofthedistalbicepswereretrieved,withonlyonetreatedintheacutephase ofinjury.Therefore,theauthorsconsiderthisproceduretobeagoodoptiontosolvethis complexcondition.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Reparo

de

ruptura

bilateral

simultânea

do

bíceps

distal:

relato

de

caso

Palavras-chave: Rotura/diagnóstico Rotura/etiologia Rotura/cirurgia

Traumatismosdostendões

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Arupturabilateralsimultâneadostendõesdistaisdobícepséumaentidaderara,pouco relatadanaliteraturaecomdefinic¸ãoterapêuticapoucoclara.Relatamosocasodeum homem branco de 39 anos quesofreu rupturabilateral simultâneadurante treino de academiaemqueaopegarpesocomoscotovelosemflexãode90◦_{sentiudorsúbitana} faceanteriordosbrac¸osecompareceuparaavaliac¸ãoapósdoisdias.Apresentava abaula-mentodocontornodoventremusculardobícepsbraquialeequimosenaregiãodafossa antecubitalqueseestendiadistalmenteparaafacemedialdoantebrac¸o,alémdegrande

夽

StudyconductedattheHospitalOrtopédicoeMedicinaEspecializada(Home),Servic¸odeCirurgiadeOmbroeCotovelo,Brasilia,DF, Brazil.

∗ _{Correspondingauthor.}

E-mail:thiagostorti@hotmail.com(T.M.Storti). http://dx.doi.org/10.1016/j.rboe.2016.12.006

108

diminuic¸ãodaforc¸adesupinac¸ãoedoràflexãoativadocotovelo.Ressonâncianuclear mag-nética(RNM)confirmouarupturacomretrac¸ãodobícepsdistal,bilateralmente.Optou-se peloreparodaslesõessimultaneamentecomatécnicadeduplaincisãoefixac¸ãodotendão àtuberosidadebicipitalcomâncoras.Opacienteevoluiudeformabastantesatisfatória,com retornocompletoàsatividadeslaboraiseesportivas,estábastantesatisfeitocomo resul-tadoapósdoisanosdacirurgia.Napesquisadaliteratura,foramachadosmuitopoucos casosdescritosderupturabilateralsimultâneadobícepsdistal.Desses,somenteumfoi tratadonafaseagudadalesão.Portanto,osautoresconsideramoprocedimentodescrito comoumaboaopc¸ãoparaaresoluc¸ãodessacomplexacondic¸ão.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Simultaneous bilateral rupture ofthe distalbiceps tendon is an extremely rare entity with few reports in the litera-ture,whichcanleadtodevastatingfunctionaleffectsforthe patient.

Theliteraturedescribesseveral surgicaloptionsfor uni-lateral rupture of the distal biceps tendon, with different approaches,typesofsuture,andfixationmethods.For bilat-eralruptures,inturn,thereisnoconsensusonthesurgical technique, the most appropriate moment to perform the surgery,orrehabilitationprotocols.

Inaliteraturereview,itwasobservedthatthereareveryfew reportedcasesofsimultaneousbilateralruptureofthedistal biceps.Amongthem,thesurgicaltreatmenttookplaceduring theacutephaseinonlyonecase,butfixationwasperformed withasix-weekintervalbetweenprocedures.1

The authors report the case of a patient with bilateral simultaneous distal biceps tendon rupture during elbow-flexionresistanceexercise,whounderwentsurgicalrepairof bothsidesinonetime.

Case

report

A 39-years-old white male and right-handed patient pre-sentedtoourservicewithhistoryofsudden-onsetpainand deformityontheanterioraspectofbotharmsafterattempting toliftweightsinthegymwithelbowsflexedatabout90◦_two

daysbefore.

Hehadnosignificanthistoryofpreviousdiseaseorelbow pain. He practiced weightlifting onlyas a physicalactivity seekinghealthmaintenance;hedeniedseekingsubstantial musclehypertrophy.Hehadbeenonendocrinological treat-mentforhormonereplacementforsixmonths.

Upon physical examination, an obvious deformity was observed on the anterior aspect of the arm, with bulging contourofthebicepsmusclebellyandbruisingsonthe ante-cubitalfossaareaextendingdistallytothemedialaspectof theforearm.Thepatienthadpainonpalpationandabsence ofthebicepstendonontheanterioraspectofbothelbows.He alsopresentedgreatstrengthlossforandpainonflexingthe elbows.Neurologicalandvascularfunctionswerepreserved bilaterally.

The images obtained by magnetic resonance imaging disclosed complete rupture of the distal biceps tendons, with 5cm retraction on the right and 4.6cm on the left side.

Afterdiscussingthecasewiththepatientandfamily,the authorsoptedforimmediatesurgicaltreatmentandrepaired therupturesinbothlimbsduringthesameprocedure.

Thetechniqueusedforbothlimbswasthedoubleincision andtendonanchorfixation.

Surgical

technique

Thepatientwasplacedontheoperatingtableinsupine posi-tion,withouttourniquets. Thesurgerywasinitiatedonthe rightupperlimb.Atransverseincisionofapproximately3cm wasmadeabovethecubitalskinfold(Fig.1).Thebiceps ten-doniseasilycapturedwhentheskinisretractedproximally andawayfromthedeeptissues.Themostdistalportionof thedegeneratedtendonwasresected;thetendonwasrepaired usingBunnellsutureswithnonabsorbableNo.5threads.Then, theradialtuberositywaspalpatedandacurvedKellyforceps waspassedthroughthebicepstendontunnel,betweenthe ulnaandtheradius,anditwasadvanceduntilitstipcouldbe palpatedonthedorsalaspectoftheproximalforearm(Fig.2). Asecondincisionwasmadeovertheforceps;thetuberosity

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Fig.2–Intraoperativeimageshowingtheprominenceof

theKellyforcepspassedthroughthebicipitaltunnel.

wasexposedthroughmuscledivulsionwiththeforearmin maximalpronation(Fig.3).

Theradialtuberositywasscarifieduntilitpresented bleed-ing.Twobioabsorbable,double-loaded2.9-mmanchorswere positioned,andthebicepstendonwastransportedthrough itstunnelwiththerepairwire.Theanchorwireswerepassed throughthetendonforaU-suture.Thenotswereheldwith theforearmpronatedandtheelbowat90◦_{flexion.After}

test-ingthestabilityofthefixation,theskinwassuturedandboth limbswereimmobilizedwithslings.

Theslingwasmaintainedforoneweek;thereafter, physi-caltherapywasinitiated.Initially,exercisesofpassiveflexion andactiveextensionwiththeforearminsupinationwere per-formed,aswellaspassivesupinationandactivepronationto 50◦_{. Thelimbswere immobilizedwiththeslingswhen not}

inphysiotherapy.Thisphaselasteduntiltheendofthethird week,whenexercisestoincreaseflexionandactive supina-tion withoutload were initiated;atthis phase, thepatient

Fig.3–Intraoperativeimageshowingtheexposedradial

tuberosity.

was instructed to interrupt the use of the slings. Muscle strengthening exerciseswere initiatedafterthesixthweek, progressivelyincreasingtheload.Threemonthsaftersurgery, the patienthadfullrangeofmotionwithoutpain,but still presenteddecreasedmusclestrength.Afterthefourthmonth, hewasallowedtoreturntothegymforprogressionof mus-clestrengthening.Atfivemonthspost-operative,thepatient had recovered full muscle strength and returned to daily activities.

Thelastassessmenttookplacetwoyearsafterthe proce-dure.Thepatientreportedhavingrecovered100%ofpre-injury function and havingmade a complete return tolabor and sportsactivities.

Discussion

Simultaneous rupture ofthe distalbiceps tendon isa rare diagnosis,andthemostsuitabletreatmentofsuchaninjury depends on numerous factors. Bayat et al.2 _{reported the} case of a 50-year-old mountain climber who had suffered asimultaneousbilateral ruptureduringpractice.He under-went reconstruction with fascia lata graft two years after injury, with a six-month interval between the two limbs. Belletal.3_{reported26casesofruptureofthedistalbiceps,} one of which was a simultaneous bilateral rupture. Those authorsdidnotreportthetypeandtimeofsurgeryforthis case.

RokitoandIofin4_{reportedthecaseofarecreational} body-builder,aged51years,whosufferedasimultaneousbilateral rupturewhenperformingaScottcurlwitha40kgload.He underwentprimaryrepairinonesidesevenweeksafterinjury, followedbyallograftreconstructionat13weekspost-injuryin thecontralaterallimb.

DaCambraetal.1_{describedtheonlycasefoundinthe} liter-aturereviewinwhichtheinjurywasrepairedbilaterallywhile stillinthe acutephase,but inastagedmanner. They pre-sented the caseofa43-year-oldpatient initiallysubmitted toacuterepairintherightlimb,andsixweeksafterinthe leftlimb,bothwithasingleanteriorapproachtechniquewith Endobuttonfixation.

Thecurrentliteraturedefinesasacuteinjuriesthosewith lessthansixweeksandaschronic,thoseoversixweeks.This six-weekcut-offisarbitrary,butitcreatesaguideline.After thisperiod,repairbecomesincreasinglydifficult.

Thepresentcasefeaturedacuteruptures,afewdaysfrom injury. To avoidthe risk oftendontransfer reconstruction, theauthorsdecidedtoaddressbothlimbsinthesame sur-gicaltime.Noneofthefewcasesdescribedintheliterature were treated in this way. The decision regarding whether to carry out the repair of both injuries in the same time or inastaged mannershouldbemadeafterassessing cer-tainpatientvariables,suchassocioeconomicstatus,thelevel of understanding,dominant limb, occupation, and general healthstatus.1

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site cancause difficulties forusing this technique.1 _Inthe present case, the authors opted for this approach due to thefamiliarityofthe surgeonswiththetechnique andthe fact that the injury had happened just a few days before surgery.

Conclusions

Thepresentpatientpresentedanexcellentfunctionalresult inthetwo-yearfollow-up,withcompletereturntolaborand sportsactivities;hereportedtohavefullyrecoveredthe pre-injuryfunction.Theauthorsbelievethatthisisthefirstcase describedintheliteratureofasimultaneousbilateralacute ruptureofthedistalbicepssuccessfullyrepairedinasingle surgicaltimeusingthedoubleincisiontechniqueandfixation anchors,whichrepresentsavalidoptionforthischallenging condition.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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3.BellRH,WileyWB,NobleJS,KuczynskiDJ.Repairofdistal bicepsbrachiitendonruptures.JShoulderElbowSurg. 2000;9(3):223–6.

4.RokitoAS,LofinI.Simultaneousbilateraldistalbicepstendon ruptureduringapreachercurlexercise:acasereport.Bull NYUHospJtDis.2008;66(1):68–71.

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