How Are Distal Biceps Tendon Tears Repaired? A Comprehensive Guide to Surgical Treatment

Distal biceps tendon tears represent a challenging orthopedic injury that primarily affects active middle-aged men. When this crucial tendon ruptures, surgical repair becomes essential for restoring optimal arm function, particularly for athletes and individuals who rely on forearm strength and supination. Understanding the various repair techniques and approaches helps patients make informed decisions about their treatment options.

Understanding Distal Biceps Tendon Anatomy and Function

The distal biceps tendon connects the biceps muscle to the radial tuberosity, a bony prominence on the radius bone near the elbow. This tendon serves two critical functions: elbow flexion and forearm supination (turning the palm upward). When torn, patients experience significant weakness in both movements, making everyday activities and athletic performance challenging.

The biceps muscle originates as two separate heads - the long head and short head - which converge into a single tendon before inserting on the radial tuberosity. The short head contributes more to flexion strength, while the long head provides greater supination force. This anatomical understanding guides surgical repair strategies.

Why Surgical Repair Is Necessary

Unlike some tendon injuries that may heal with conservative treatment, distal biceps tendon tears rarely recover without surgical intervention. Several factors contribute to this:

• Poor blood supply to the distal tendon region impairs natural healing
• Tendon retraction occurs rapidly after rupture, making delayed repair more challenging
• Significant functional deficit persists without repair, particularly in supination strength
• Progressive weakness develops over time when left untreated

Research consistently demonstrates that surgical repair produces superior outcomes compared to non-operative treatment, with patients regaining approximately 90% of their pre-injury strength when repair is performed promptly.

Surgical Approaches for Distal Biceps Tendon Repair

Single-Incision Technique

The single-incision approach utilizes one anterior incision in the antecubital fossa (elbow crease) to access and repair the torn tendon. This technique offers several advantages:

Benefits:

• Shorter operative time
• Single scar
• Less tissue dissection
• Reduced risk of posterior nerve injury

Limitations:

• Limited visualization of the radial tuberosity
• Difficulty achieving truly anatomic repair
• Potential risk to neurovascular structures in the antecubital fossa

The single-incision method typically employs non-anatomic repair, attaching the tendon near but not exactly at the native insertion site. Despite this limitation, functional outcomes remain excellent for most patients.

Double-Incision Technique (Boyd-Anderson Approach)

The double-incision technique uses both anterior and posterior incisions to achieve anatomic repair directly on the radial tuberosity. This method was developed to address the limitations of single-incision repair.

Advantages:

• Anatomic tendon reattachment
• Better visualization of repair site
• Reduced risk to anterior neurovascular structures
• Potentially superior strength restoration

Disadvantages:

• Longer operative time
• Two surgical scars
• Increased risk of posterior interosseous nerve injury
• More extensive tissue dissection

Studies suggest that anatomic repair achieved through the double-incision technique may provide slightly better flexion and supination strength compared to non-anatomic repair methods.

Endoscopic-Assisted Repair

Some surgeons employ endoscopic techniques to minimize tissue trauma while maintaining visualization of the repair site. This approach combines the benefits of minimally invasive surgery with direct tendon reattachment, though it requires specialized equipment and expertise.

Fixation Methods for Tendon Repair

Cortical Button Fixation

Cortical button systems use a small titanium button that flips and locks against the far cortex of the radius bone. A high-strength suture connects the button to the tendon, creating a secure fixation.

Advantages:

• Excellent pullout strength
• Minimally invasive insertion
• Allows for some tendon adjustment during healing

Considerations:

• Potential for button prominence
• Learning curve for proper insertion
• Cost considerations

Interference Screw Fixation

Interference screws secure the tendon within a bone tunnel by compressing it against the tunnel walls. This method provides immediate, rigid fixation.

Benefits:

• Strong initial fixation
• Bone-to-tendon healing interface
• Familiar technique for many surgeons

Limitations:

• Risk of tendon laceration during insertion
• Difficulty with revision if needed
• Potential for screw prominence

Suture Anchor Repair

Suture anchors are implanted directly into the radial tuberosity, with high-strength sutures used to reattach the tendon to bone.

Advantages:

• Direct bone-to-tendon repair
• Multiple anchor options available
• Good for salvage procedures

Considerations:

• Requires adequate bone quality
• Multiple drill holes in bone
• Variable pullout strength depending on bone quality

Bone Tunnel and Transosseous Repair

This traditional technique creates bone tunnels through the radius, with sutures passed through the tendon and tied over a bone bridge on the opposite cortex.

Benefits:

• No implant required
• Strong fixation when properly executed
• Lower cost

Limitations:

• Technically demanding
• Risk of radius fracture
• Longer healing time

Factors Influencing Surgical Approach Selection

Patient-Specific Considerations

Age and Activity Level: Younger, more active patients may benefit from anatomic repair to maximize strength restoration, while older patients might be candidates for simpler single-incision techniques.

Timing of Repair: Acute repairs (within 2-3 weeks) allow for easier anatomic reattachment, while chronic tears may require reconstruction with grafts.

Bone Quality: Patients with osteoporotic bone may be better candidates for cortical button fixation rather than interference screws or anchors.

Surgeon Experience: The complexity of double-incision repair requires specific training and experience for optimal outcomes.

Injury-Specific Factors

Tendon Quality: Well-preserved tendon tissue favors direct repair, while degenerative tendons may require augmentation or reconstruction.

Degree of Retraction: Minimal retraction allows for easier anatomic repair, while significant retraction may necessitate tendon mobilization or grafting.

Associated Injuries: Concurrent elbow pathology may influence the choice of surgical approach and fixation method.

Postoperative Recovery and Rehabilitation

Immediate Postoperative Period (0-2 Weeks)

Following surgery, patients typically wear a sling or brace to protect the repair. Pain management and wound care are priorities during this phase.

Early Mobilization Phase (2-6 Weeks)

Gentle passive range of motion exercises begin, with strict limitations on active flexion and supination to protect the healing tendon. Physical therapy focuses on maintaining shoulder and wrist mobility.

Progressive Strengthening Phase (6-12 Weeks)

Active range of motion gradually increases, with light strengthening exercises introduced around 8-10 weeks postoperatively. The repair site gains strength as biological healing progresses.

Return to Full Activity (3-6 Months)

Most patients achieve near-normal strength by 3-4 months, with full return to sports typically occurring at 4-6 months. Heavy lifting and contact sports require clearance from the surgical team.

Expected Outcomes and Success Rates

Functional Recovery

Research demonstrates excellent functional outcomes following distal biceps tendon repair:

• 95% of athletes return to sports following surgical repair
• 82% return to their pre-injury competition level
• Average return to sports timeline: 40 weeks
• 90% strength restoration compared to the uninjured arm

Complications and Risks

While generally successful, distal biceps tendon repair carries potential complications:

Nerve Injury (2-5%): Posterior interosseous nerve palsy is the most concerning complication, though most cases resolve spontaneously.

Heterotopic Ossification (5-10%): Abnormal bone formation around the repair site can limit motion but rarely requires treatment.

Re-rupture (<2%): Modern fixation techniques have significantly reduced re-rupture rates compared to historical methods.

Infection (<1%): Superficial or deep infection requiring antibiotic treatment or surgical drainage.

Stiffness (5-15%): Some patients experience persistent elbow stiffness, particularly with immobilization protocols.

Comparison of Repair Techniques

Single vs. Double-Incision Outcomes

Studies comparing single and double-incision techniques show:

• Functional outcomes: Both approaches yield excellent results with minimal clinically significant differences
• Complication rates: Similar overall complication rates, with different risk profiles
• Strength restoration: Double-incision may provide slightly better supination strength
• Patient satisfaction: High satisfaction rates with both approaches

Fixation Method Comparison

Biomechanical studies suggest that cortical button and interference screw fixation provide superior pullout strength compared to suture anchors or transosseous repair. However, clinical outcomes remain excellent across all fixation methods when properly executed.

Future Developments in Distal Biceps Repair

Biological Augmentation

Research into growth factors, platelet-rich plasma, and stem cell therapy may enhance tendon healing and reduce recovery time in the future.

Minimally Invasive Techniques

Continued development of arthroscopic and endoscopic repair methods aims to reduce surgical trauma while maintaining repair quality.

Advanced Fixation Systems

New implant designs focus on optimizing the strength-to-size ratio while minimizing complications and improving ease of insertion.

Conclusion

Distal biceps tendon repair has evolved significantly over the past decades, with multiple effective surgical approaches and fixation methods available. The choice between single and double-incision techniques, along with various fixation options, should be individualized based on patient factors, surgeon experience, and injury characteristics. With proper surgical technique and rehabilitation, patients can expect excellent functional outcomes and return to their desired activity level.

Modern distal biceps tendon repair achieves high success rates, with 95% of athletes returning to sports and most patients regaining near-normal strength. While complications exist, they remain relatively uncommon with experienced surgeons using current techniques. The key to optimal outcomes lies in prompt recognition of the injury, appropriate surgical planning, and adherence to structured rehabilitation protocols.