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J Shoulder Elbow Surg (2014) 23, e191-e197

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CASE REPORT

Distal biceps brachii tendon repair complicatedby a suture granuloma mimicking a soft-tissuesarcoma: a case report and review of theliterature

Arash J. Sayari, BSa, Juan Pretell-Mazzini, MDb,*, Jean Jose, MS, DOc,Sheila A. Conway, MDb

aUniversity of Miami Miller School of Medicine, Miami, FL, USAbMusculoskeletal Oncology Service, Department of Orthopaedics, University of Miami Miller School of Medicine,Miami, FL, USAcMusculoskeletal Radiology Service, Department of Radiology, University of Miami Hospital, University of Miami MillerSchool of Medicine, Miami, FL, USA

The incidence of distal biceps brachii rupture is 1.2 per100,000 persons per year; it most commonly occurs in thedominant elbow of men aged in their 40s.25 The repair,which includes several described techniques, is generallysuccessful in restoring elbow strength, allowing for an earlyresumption of daily activities.5,25

Foreign-body granulomas have been extensively re-ported in the literature, occurring in a wide variety of op-erations and anatomic locations.4,6,9,11,27 Different surgicalmaterials such as surgical sponges and silicone have beenassociated with the formation of this benign inflammatorylesion.9,14 Nonabsorbable sutures such as Ticron (Tyco,Waltham, MA, USA), FiberWire (Arthrex, Naples, FL,USA), and Ethibond (Ethicon, Somerville, NJ, USA), as inour case, used during tendon repairs can also elicit such aresponse.3,7,14,18,27 Though rare, these reactions can act asmalignant neoplasms.1,9,16,17 However, no cases of suturegranulomas after distal biceps brachii tendon repair pre-senting as a soft-tissue sarcoma (STS) have been reported.

t was exempted from IRB review as it was not considered

17 Research under 45 CFR 46 as per University of Miami

Research Office.

quests: Juan Pretell-Mazzini, MD, 4036 UMH, East

i, FL 33136, USA

ss: juanpretell@gmail.com (J. Pretell-Mazzini).

ee front matter � 2014 Journal of Shoulder and Elbow Surgery

/10.1016/j.jse.2014.05.004

To our knowledge, we report the first case of a patientwith a suture granuloma after a distal biceps brachii tendonrepair that mimicked the behavior of an STS, and wefurther review the natural history, approach, and manage-ment of this uncommon entity.

Case report

A 58-year-old man was evaluated for a slowly growing masslocated in the volar aspect of his proximal right forearm of severalyears’ duration. He had a history of a right distal biceps brachiitendon repair due to traumatic rupture 7 years prior. There was nohistory of fever, sweats, chills, or weight loss. The medical history,family history, social history, and complete review of systemswere noncontributory. The patient was seen at an outside facility,magnetic resonance imaging (MRI) showed an enhancing soft-tissue mass (STM) (Fig. 1) suggestive of sarcoma, and he wasreferred to our musculoskeletal oncology service for furtherevaluation and definitive treatment.

Physical examination showed a transverse scar located on thevolar aspect of the proximal right forearm consistent with thepatient’s previous operation. Deep and proximal to this incision,there was a 3.9 � 3.4–cm, fixed, nontender mass, with no over-lying changes in the skin. The right elbow range of motion wascomplete and painless. On the basis of the indeterminate MRIfindings, an ultrasound-guided core needle biopsy was performed

Board of Trustees.

Figure 1 Axial T2 fat-suppressed (A), axial T1 (B), axial T1 fat-suppressed post-contrast (C), and sagittal T1 fat-suppressed post-contrast (D) magnetic resonance images of right elbow at patient’s initial presentation. There is a large heterogeneous STM (straightarrows) arising from the biceps tendon (curved arrows). The lesion is hyperintense to skeletal muscle on T2 imaging, is isointense toslightly hyperintense to skeletal muscle on T1 imaging, and shows peripheral solid enhancement with a fluid center. There are subtlelow–signal intensity curvilinear lines within the tumor (chevrons), reflecting suture material.

Figure 2 Transverse grayscale ultrasound images (A, B) show a hypoechoic peripherally solid mass (calipers) with an internal fluidcenter (star) arising from the biceps tendon (curved arrows). There are subtle echogenic curvilinear lines within the tumor, reflecting suturematerial (chevrons). The lesion shows increased central and peripheral enhancement on power Doppler (C, D), showing ultrasound-guidedSTM biopsy tract.

e192 A.J. Sayari et al.

(Fig. 2). Pathologic evaluation showed reactive fibrous tissuewith acute and chronic inflammation, associated with reactiveconnective tissue and blood vessels, consistent with the diagnosis

of a foreign-body granuloma (Fig. 3). After a discussion regardinghis treatment options, the patient chose observation because themass was not symptomatic. Seven months later, he returned to our

Figure 3 Fibro-connective tissue with multinucleated giantcells, with haphazardly arranged nuclei. These giant cells arefused macrophages. There are also some acute and chronic in-flammatory cells. (Hematoxylin-eosin stain, original magnifica-tion �4).

Biceps tendon granuloma mimicking sarcoma e193

office with a tender STM and interval changes in size in com-parison with the last examination. Repeat MRI (Fig. 4) showed anenlarging STM with more heterogeneity and a more aggressiveappearance. A week later, the STM ulcerated and began to bleedthrough the skin (Fig. 5). Because of these findings, the patientwas scheduled to undergo core needle biopsy and excision of theSTM. Findings from frozen-section analysis of the tissue obtainedfrom the biopsy were consistent with a foreign-body granuloma.Once this benign condition was confirmed, excision of the STMwas completed. The STM was located between the brachioradialisand the flexor carpi radialis muscles, arising deeply from the bi-ceps brachii tendon insertion. Inside the STM, a clear, nonpurulentfluid was encountered with a free-floating Ethibond suture at thecenter of the mass (Fig. 6). Final pathologic review of the massconfirmed the diagnosis of a suture granuloma with no evidence ofneoplasm.

At 8 weeks’ follow-up, the patient was doing well; the surgicalwound was completely healed; the elbow range of motion wasrestored with no biceps weakness; and he had a Mayo ElbowPerformance Score of 100 and Disabilities of the Arm, Shoulderand Hand score of 0.

Discussion

Distal biceps brachii tendon repair is a procedure per-formed by upper-extremity surgeons and general ortho-paedists.25 Sutures used in these repairs can trigger theformation of a suture foreign-body granuloma, which in-volves an acute reaction of the tissues to the passage of theneedle, as well as a chronic response to the suture materialused.20 Inflammatory reactions can occur in response toboth endogenous and exogenous substances and result inthe release of interferon g, colony-stimulating factors, andleukotrienes.27 Macrophages, unable to degrade nonab-sorbable sutures, will accumulate into epithelioid macro-phages, and a fibroblastic granuloma can be formed in as

little as 24 hours.16,17 CD68 immunohistochemical stainingwill show multinucleated giant cells, and the foreign-bodyreaction may or may not form a sinus tract to the skin,which can explain the ulceration that presented in ourcase.14

The incidence of foreign-body granulomas after ortho-paedic surgeries has been described to be 0.61%, and thesehave been reported as isolated cases.1,2,9,10,13-19,23,27 Fewarticles have reported on suture foreign-body granulomas inthe orthopaedic literature (Tables I and II).14-16,18,27 Mor-imoto et al16 reported a 2-year history of a left buttock massthat rapidly grew over a period of 2 months after nonab-sorbable nylon suture was used to surgically repair a hipdislocation 20 years earlier. Marcus et al15 reported 2 casesof suture granulomas in the shoulder presenting as in-fections: 1 patient had symptoms of an STM afterMagnuson-Stack repair 9 years earlier, and another patienthad shoulder pain and a nontender STM for 10 months aftera Putti-Platt shoulder repair 8 years earlier. A Ticron suturegranuloma has been described after inferior capsular shiftof the shoulder, presenting as a shoulder abscess 4 yearsafter the original operation, as well as after flexor digitorumprofundus tendon repair 4 months earlier.18,27 Mack et al14

reported a series of patients who had foreign-body reactionsand sinus tract formation due to FiberWire suture that arosebetween 5 and 16 months after lower-extremity amputa-tions. Interestingly, this was the only series in which suturegranulomas formed sinus tracts to the skin, and this ispresentation is similar to the skin ulceration observed inour case.

The clinical presentation of foreign-body granulomasvaries. In general, they present as an STM that can appearas early as 1 week after the initial surgical procedure and upto 20 years later. This STM may or may not be painful andgrow slowly over a period of a few months to years. As inour case, the diagnosis of STS is often considered given thisnonspecific clinical presentation (Table I).1,9,16,17,23 Insome cases, sinus tracts can develop, and surgical resectionis the treatment of choice.14 In most of the cases in whichoutcomes were reported, the patients did well (Tables I andII).10,13-16,23,27

STSs are uncommon malignancies, with approxi-mately 50% of the cases located in the extremities.24 Aslowly growing mass warrants high suspicion for thisdiagnosis, particularly for masses larger than 5 cm, thoselocated deep to the deep fascia, and those associated withrapid growth, progressive symptoms of pain, or ulcera-tion.8,26 Patients generally do not present with systemicsymptoms such as fever or weight loss. Although, in ourcase, there was a history of distal biceps brachii tendonrepair with Ethibond and granuloma formation wasconsidered in the differential diagnosis, the size anddepth, progressive symptoms, and ulceration were con-cerning for STS.

Nonspecific findings on imaging make differentiationbetween an STS and foreign-body granuloma difficult.12

Figure 4 Axial T2 fat-suppressed (A), axial T1 (B), axial T1 fat-suppressed post-contrast (C), and sagittal T1 fat-suppressed post-contrast (D) magnetic resonance images of right elbow 7 months after patient’s presentation. An increase in size has occurred, with internalfluid of the large heterogeneous STM (straight arrows) arising from the biceps tendon (curved arrows). There are subtle low–signal in-tensity curvilinear lines within the tumor (chevrons), reflecting suture material. There is surrounding peritumoral soft-tissue edema andenhancement.

Figure 5 Clinical picture of volar aspect of right proximalforearm. An STM overlying skin changes associated with ulcer-ation can be observed.

Figure 6 Ethibond suture that was inside STM. This was totallyuntethered from the biceps brachii tendon.

e194 A.J. Sayari et al.

Ultrasound is a useful tool, and as in our case, it mayshow hypoechoic lesions and hyperechogenic lines, sug-gestive of suture granulomas.6,22 MRI typically shows thenonspecific features of T1-weighted hypointensity andheterogeneous intensity on T2-weighted imaging.

Therefore, a histologic evaluation is often needed fordefinitive diagnosis.12,16 In this case, ultrasound imagingand needle biopsy results were compatible with foreign-body granuloma. However, the progressive symptoms,growth, and subsequent ulceration led us to suspect amore aggressive lesion, and for this reason, the biopsy

Table I Cases reported in orthopaedic literature dealing with formation of foreign-body granuloma in which diagnosis of STS wasconsidered

Author Year PatientSex, Age(y)

History Preoperative diagnosis Intraoperative findings Follow-up

Current study 2014 M, 58 Several-year history ofSTM in forearm thatprogressively grewand eventuallyulcerated

STS Inflammatorysubstance andEthibond suture

3 mo, uneventful

Morimoto et al16 2012 M, 80 STM in left buttockexpanding over2-mo period aftersurgical reduction ofdislocated hip

High-grade sarcoma Encapsulated masswith previoushemorrhage andmicroscopicnonabsorbablenylon suture

1 y, hip pain (likelyosteoarthritis)

Ando et al1 2009 F, 9 Mass and pain in leftfoot for 1 y aftertrauma caused bywood 2 y earlier

Hematoma, coldabscess, STS

Two wooden foreignbodies

Unknown

F, 56 Growing mass in leftposterior thigh 4 yafter blunt trauma

Unknown Tile inside cystic tumorlined withgranulation tissue

Unknown

F, 3 Painful mass in rightproximal lower legfor 1 wk afterpenetrating traumaby toothpick

Unknown 3-cm toothpick tip Unknown

Iwase et al9 2007 F, 72 10-y history of STMafter hiphemiarthroplasty forfracture 12 y earlier

False aneurysm,hematoma, STS

Granuloma filled withsurgical sponge

Unknown

Mouhsine et al17 2006 M, 58 Painless massenlarging over18-mo period 3 yafter varicose veinstripping

Tumor of mesenchymalorigin

Surgical gauze Unknown

Sakayama et al23 2005 M, 61 5-y history of leftthigh swelling 35 yafter externalfixation surgery

Soft-tissue malignancy Elastic mass, rich invessels, withretained surgicalsponge

2 y, uneventful

F, female; M, male.

Biceps tendon granuloma mimicking sarcoma e195

was repeated at the time of resection to confirm thebenign nature of the STM before we proceeded withmarginal excision.

In the evaluation of an STM, a biopsy is recommendedbefore surgical excision if the history, physical exami-nation, and advanced imaging findings suggest that STSis included in the differential diagnosis. The preferredbiopsy for an STM occurs under the direction of a sur-geon with specialization in sarcoma management and in asarcoma center with a multidisciplinary sarcoma team. Ofthe cases reported in which an STS was a concern (TableI), only 2 of 7 underwent a biopsy before surgical

treatment.9,23 Given the dramatically different surgicalmanagement of STS and the frequent need for neo-adjuvant management, biopsy should be completedbefore surgical excision when STS is included in thedifferential diagnosis. We recommend confirmation of thehistologic diagnosis before proceeding with surgicalexcision because an unplanned excision of an STScan dramatically change the prognosis of the patient andoften requires additional aggressive surgical proceduresfor adequate local control.21 As found in the reportedcases (Tables I and II), surgery provides definitivetreatment.

Table II Cases reported in orthopaedic literature dealing with formation of foreign-body granuloma in which diagnosis of STS was notsuspected

Author Year Patient Sex,

Age (y)

History Preoperative

diagnosis

Intraoperative

findings

Follow-up

Pabari et al18 2011 M, 30 Cystic swelling 4 moafter flexor digitorum

profundus tendonrepair

Abscess Ticron suture attachedto flexor digitorum

profundus tendon

Uneventful

Bergquist et al2 2010 M, 23 1.5-y history of ankleswelling after

stepping onhorseshoe crab

15 y earlier

Foreign-bodypseudotumor,

myositis ossificans

Pseudocapsule withpurulent fluid and tail

of horseshoe crab

Swelling andPseudomonas growth

at 1 mo (treated withvancomycin and

Zosyn); 2 mo afteroriginal treatment,

episode of swellingand repeat operation

Mack et al14 2009 M, 22; M, 46;

M, 23; M, 41;M, 29

Draining sinus tract

over suture line 5to 16 mo after

lower-extremityamputation

Unknown Suture surrounded by

soft and amorphoustissue

All returned to walking

in prostheses

Patel et al19 2007 M, 29 Asymptomatic swellingof distal fibula 2 y

after Ilizarov andfibular plate repair,

as well as openreduction and plating

Unknown Gauze surrounded byfibrous tissue

Unknown

Warme et al27 2004 F, 22 Tender axillary mass4 mo after inferior

capsular shift

Shoulder abscess Two ‘‘balls’’ of Ticronsuture

Returned to normalactivity within 1 mo

Kulkarni et al13 2003 M, 60 Briskly growing, tender

right volar wrist mass45 y after being

stabbed in wrist bya pencil

Foreign-body graphite

fragments

Biopsy-confirmed pencil

lead; patient declinedfurther surgery

Asymptomatic

Kalbermattenet al10

2001 M, 41 Left thigh swelling 20 yafter open reduction

and fixation offemoral

fracture that rapidlygrew over next 5 y

Myositis ossificans Encapsulated mass withcotton sponge

4 wk, uneventful

Marcus et al15 1997 M, 27 4-wk history ofnontender

STM of left shoulderafter Magnuson-Stack

repair 9 y earlier

Tuberculous arthritis,necrobiotic palisading

suture granuloma

Black suture material ininflammatory mass

12 y, uneventful

M, 35 10-mo history of

progressive rightshoulder pain and

4-mo history of

shoulder stiffnessafter Putti-Platt

repair 8 y earlier forrecurrent subluxation

and dislocation

Necrobiotic palisading

suture granuloma

Unknown 9 mo, joint stiffness;

otherwise uneventful

F, female; M, male.

e196 A.J. Sayari et al.

Biceps tendon granuloma mimicking sarcoma e197

Conclusion

Foreign-body granuloma is a well-described complica-tion after various forms of surgery; however, it has notbeen previously described after distal biceps brachiitendon repair. In our case, the mass began to rapidlygrow and mimicked the behavior of an STS, but histo-logic findings were compatible with a suture foreign-body granuloma. Although granulomas can remainasymptomatic for many years, they may also behavevery aggressively and mimic an STS clinically andradiologically.13 In these cases, a thorough radiologicand pathologic evaluation is warranted to ensure theappropriate surgical intervention and to avoid the un-planned excision of an STS.

Disclaimer

The authors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of thisarticle.

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