CASE REPORT

Delayed Repair of Rupture of the BicepsFemoris Tendon · A Case Report

K L Pan, FRCS*, F Ting, FRCS**, *Faculty ofMedicine and Health Sciences, Universiti Malaysiasarawak, **Department of Orthopaedics, Sarawak General Hospital, Kuching, Sarawak

Introduction

Spontaneous rupture or avulsions of the biceps femoristendon is rare. The first case was reported in 1990' .Subsequently, four other cases have been described',3. Allthe patients were seen and treated in the acute phase. Onlyone patient was treated conservatively with a plaster castbecause he refused surgeryJ. Our patient is the first case ofdelayed presentation and surgical repair to be described.

Case Report

InJune 1997, the patient, a 33 year-old male was playingsoccer, when, in attempting to kick the ball withconsiderable force, he missed the ball completely. As theknee straightened into a stretch, he heard a dull "pop"and felt a sudden sharp pain at the posterolateral aspectof the right knee. He had to stop playing immediately.There was no swelling and the pain gradually subsided.He only sought traditional treatment initially.

Four months later, he tried to resume playing football butwas unable to do so due to pain and a subjective feeling ofweakness. He also had difficulty in standing up from asitting position; controlling the brakes and accelerator ofa car; going down the stairs and carrying heavy weights.It was then that he was first seen in the orthopaedic clinic.

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Clinical examination revealed an essentially normal kneejoint. The range of movement was full (0 - 130 degrees).There was an absence of the posterolateral skin foldnormally produced by the underlying tendon of thebiceps femoris and the tendon was also deficient onpalpation. There was no longer any tenderness. X-rays ofthe knee showed no abnormalities.

Surgical repair of the tendon was carried out. The bicepstendon was found to be completely avulsed from thefibular head and was retracted 7em proximally. Themuscle was mobilised. The tendon was then repaired byplicating it with non-absorbable sutures (nylon 2.0) andfixing it to the fibula head through drill holes. This wasdone with difficulty after a period of sustained tractionon the muscle and was only possible with the knee at 80degrees of flexion. Fractional lengthening was also doneby using two incomplete incisions over the tendon at themusculo-tendinous junction. (Figure 1)

Postoperatively the knee was immobi:lised with aposterior plaster splint at 80 degrees flexion. After two.weeks this was gradually extended with cast changesuntil 15 degrees of flexion was achieved at six weeks atwhich point unrestricted knee range of motion exerciseswere started. A persistent discharging sinus wasexplored at two months. The scar was not adherent to

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DELAYED REPAIR OF RUPTURE OF THE BICEPS FEMORIS TENDON

Fig. 1. Intraoperative photograph of theruptured biceps femoris tendon(forceps) with two fractional cutsdone. The common peroneal nerve isseen emerging below the tendon.

Fig. 2. Clinical photograph 6 months later.

the surgical repair. No evidence of infection was foundand after closure, the wound subsequently healed withno further discharge.

At six months (Figure 2), full tange of movement of theknee had been achieved and although the patient hadnot returned to sporting activities, there was no longerany difficulty in getting up from a sitting position,driving a car or negotiating the staitcase.

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Discussion

The mechanism of injury in this patient is similar to thatdescribed by Y. Fortems in one ofhis patients3• In missingthe attempted kick on the soccer ball, our patient hadfotcibly flexed his hip and inadvertently extended hisknee to a gteater degree than intended. This hadstretched the hamstrings while they were in contraction.It is also a fact that the biceps femoris straddles two jointsand is therefore more prone to rupture. In hurdlers(athletes), there are avulsions of the hamstrings origin atthe ischial tuberosity but in this patient, the avulsion wasat the distal insertion. A possible reason for the differencecould be that in hurdlers, the greatest stretch of thehamstrings comes at the extreme of hip flexion in goingover the hurdles. In this patient, the maximal stretch wasat the extreme of knee extension when he missed theattempted kick on the ball.

The patient lived in a small village SOkm away from thehospital. As medical treatment was not easy to come by,the injury had initially seemed too innocuous to him towarrant a visit to the hospital. After the acute symptomshad subsided, he continued to have significantfunctional problems of daily living which brought himto our hospital.

Reported biomechanical studies show loss of flexion forceafter use of the biceps femoris tendon for reconstructionof the quadriceps tendon2

• The main clinical signs onpresentation were an absence of the posterolateral skinfold overlying the biceps femoris tendon as well as adeficiency of the tendon on palpation. This must bespecifically sought fot in making a diagnosis.

We have shown that it is possible to bridge a gap of7cm. by using incomplete cuts of the tendon at themusculo-tendinous junction and by flexing the kneeacutely. It should be stressed though, that after twoweeks, the knee should be gradually straightened out toprevent a flexion contracture. The patient developed apersistent seroma over the operative site. This couldhave been due to extensive undermining of tissue planesfor exposure together with the laxity of the skinoverlying the region when the knee was immobilised at80 degrees. This complication might have beenprevented by leaving the suction drain in situ for alonget period.

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CASE REPORT

1. McGoldrick F, Colville ]. Spontaneous rupture of thebiceps femoris. Arch Orchop Trauma Surg 1990: 109: 234.

2. David A, Buchholz], Muhr G. Tear of the biceps femoristendon. Arch Orthop Trauma Surg 1994; 113:.351-52.

3. Fortems Y, Viccor ], Dauwe D, et at. Isolated completerupture ofbiceps femoris tendon. Injury 1995; 26(4): 275-76.

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