CLINICAL RESEARCH
Results
of Anatomical Repair of the Distal Biceps via an Implant-Free Anterior Approach
Ignacio Seré,
Santiago Llumipanta, Juan Carrizo, Natalia Villa,
Marcos Deimundo, Enrique Gobbi
Orthopedics and Traumatology Service,
Hospital Universitario CEMIC, Autonomous City of
Buenos Aires, Argentina
ABSTRACT
Introduction: There
are numerous approaches for treating distal biceps injuries, each with varying
success rates and associated complications. We describe an implant-free
technique for anatomical reinsertion of the distal biceps through an anterior
incision and report the clinical and functional outcomes. Materials and Methods: A
retrospective review was conducted of 11 patients who underwent this surgical
technique for the repair of their distal biceps injuries. The mean age was 43.8
years, and all patients were male. Demographic data were collected, as well as
clinical and functional outcomes more than one year after surgery. Results: At
the final assessment, no mobility deficits were found. All patients returned to
their pre-injury work and sports activities. The mean residual pain score on
the Visual Analog Scale was 0.22. The average QuickDASH
score one year after surgery was 6.38. There were 3 cases with complications: 2
transient neuropraxias of the lateral antebrachial
cutaneous nerve and one surgical wound infection. Conclusions: Our results with
this technique for repairing distal biceps injuries are comparable to those
obtained using implant-based techniques. Recovery was satisfactory in all
cases, with a low complication rate. This technique may represent a viable
alternative to other, more complex surgical approaches.
Keywords: Distal
biceps injury; anterior approach; transosseous
suture.
Level of Evidence: IV
Reparación anatómica del bíceps distal por
un abordaje anterior sin el uso de implantes: resultados clínicos y funcionales
RESUMEN
Introducción: Existen múltiples enfoques quirúrgicos para abordar las
lesiones del bíceps distal, con diferentes tasas de éxito y complicaciones
asociadas. En este artículo, se describe una técnica quirúrgica sin implantes
para la reinserción anatómica del bíceps distal a través de una incisión
anterior, y se comunican los resultados clínicos y funcionales. Materiales y
Métodos: Se evaluó retrospectivamente a 11 pacientes sometidos a
esta técnica quirúrgica para la reparación de lesiones de bíceps distal. Todos
eran hombres y la edad promedio era de 43.8 años. Se recopilaron parámetros
demográficos, los resultados clínicos y funcionales a más de un año de la
cirugía. Resultados:
En la evaluación final, no se observaron déficits de movilidad.
Todos los pacientes reanudaron sus tareas laborales y deportivas como antes de
la lesión. El puntaje promedio de dolor residual en actividad, según la escala
analógica visual, fue de 0,22. El puntaje de QuickDASH
promedio después de un año de la operación fue de 6,38. Se produjeron 3
complicaciones: 2 neuropraxias transitorias del antebraquial cutáneo externo y una infección de la herida
quirúrgica. Conclusiones:
Nuestros resultados con esta técnica quirúrgica para la reparación
de lesiones de bíceps distal son comparables con los obtenidos usando técnicas
con implantes. La recuperación fue satisfactoria en todos los casos, con una
tasa de complicaciones aceptable. Esta técnica podría representar una
alternativa viable a otros enfoques quirúrgicos más complejos.
Palabras clave: Lesión; bíceps distal; abordaje anterior; sutura transósea.
Nivel
de Evidencia: IV
INTRODUCTION
Avulsion
of the distal biceps tendon from its insertion on the radial tuberosity of the
proximal radius is uncommon (1.2–2.5 cases per 100,000 persons per year); it
typically occurs when resisting a sudden load with the forearm in flexion and
supination, as during weightlifting or when attempting to arrest the fall of a
heavy object. Nonoperative treatment results in a
22-50% loss of supination strength and a 12-40% loss of flexion strength.1,2
Although
there remains some controversy regarding the need for repair of acute distal
biceps avulsion, surgical repair has been associated with better outcomes in
terms of strength, endurance, and cosmesis compared
with nonoperative management.1,2
Currently,
numerous surgical techniques are available for reattachment of the distal
biceps brachii tendon, including fixation to the
radial tuberosity using Endobutton® systems (cortical
fixation with a titanium button), specifically designed interference screws,
suture anchors, or transosseous sutures. The most
commonly used method is the Endobutton® system
combined with an interference screw. An important aspect of the native distal
biceps tendon insertion is its ulnar and posterior position on the radial
tuberosity, which enables effective forearm supination through contraction by
exploiting the cam effect of the radial tuberosity. As the
radial tuberosity projects eccentrically from the central axis of the radius,
it increases the distance between the biceps tendon and the axis of rotation,
thereby enhancing its moment arm.3,4 Classically, the anterior approach allows
fixation of the tendon on the anterior surface of the radial tuberosity, as
with Endobutton® systems or suture anchors, which may
reduce supination strength. In contrast, the Boyd two-incision approach
allows for posterior reinsertion, but may interfere with pronation and also
fails to fully exploit the cam effect, as it has been shown that, with a
posterior insertion, the tendon migrates proximally on the tuberosity during
contraction, thereby diminishing the cam effect.3-5
The transosseous suture technique through a single anterior
approach used in this series allows replication of the native biceps insertion,
maximizing the contact surface between the tendon and the radius and restoring
the cam function of the radial tuberosity (Figure 1).
This is achieved using transosseous sutures without
implants or anchors, with minimal impact on the structural integrity of the
radial tuberosity.6,7
The objectives
of this study were to describe the surgical technique and to evaluate clinical
and functional outcomes at more than one year postoperatively.
MATERIALS AND METHODS
We
retrospectively reviewed the medical records of 14 patients who underwent distal
biceps tendon repair between February 2021 and August 2024 and had a minimum
postoperative follow-up of 12 months. Three patients were lost to follow-up and
were excluded. The final study cohort consisted of 11 patients. All were men,
with a mean age of 43.8 years (range 21-60; standard deviation [SD] 10.4). Four
patients smoked more than 10 cigarettes per day, and two reported the use of creatine supplements to increase muscle mass. In eight
cases, the injury involved the dominant limb. The mechanism of injury was
consistently a sudden eccentric load against resistance, with the elbow in
flexion and supination: weightlifting (6 patients), lifting heavy objects (3
patients), and use of tools (2 patients). The mean time from injury to surgery
was 15 days (range 6-55; SD 14.4). Mean follow-up was
35.5
months (range 12-53; SD 13.4).
All
procedures were performed by the same surgeon with Level III experience
according to the Tang classification (defined as a surgeon with substantial
experience in the relevant techniques and more than 5 years of specialist
practice).8
Surgical Technique
A
standard Henry approach to the radial tuberosity of the proximal radius was
used. The skin incision was made longitudinally under fluoroscopic guidance.
Three surgical planes were identified:
-
Subcutaneous
plane, containing the major superficial veins, the lacertus
fibrosus, and the lateral antebrachial cutaneous
nerve;
-
Muscular
plane, defined superficially by the flexor carpi radialis
and brachioradialis, and deeply by the pronator teres and supinator muscles. This plane contains the radial
artery and its branches, the deep venae comitantes,
and the terminal branches of the radial nerve (superficial sensory branch and
posterior interosseous nerve); and
-
Osseous
plane, at the level of the radial tuberosity.
Immediately
beneath the dermis lies the superficial venous system, composed, from medial to
lateral, of the basilic vein, the median antebrachial
vein, the cephalic vein, and the accessory cephalic vein. The median
antebrachial vein divides into a lateral branch, the median cephalic vein, and
a medial branch, the median basilic vein, which join
their respective veins at the elbow (Figure 2).9
Deep
to the cephalic vein lies the lateral antebrachial cutaneous nerve, a terminal
branch of the musculocutaneous nerve, which enters the lateral bicipital groove
of the elbow from the interval between the biceps brachii
and brachialis muscles. It continues along the anterolateral aspect of the
forearm, providing cutaneous innervation as far as the wrist (Figure 3).1 The lacertus
fibrosus originates from the musculotendinous
junction of the distal biceps, extends over the flexor muscles of the forearm,
blends with their superficial fascia, and inserts into the subcutaneous border
of the ulna. It acts as a stabilizer of the distal biceps tendon (Figure 3).1
The
muscular planes (Figure 3) can be easily and safely separated by blunt dissection with
the index finger. Although arterial variations are not uncommon, in
approximately 47% of patients, the brachial artery (before bifurcating into the
ulnar and radial arteries) gives rise to an accessory dorsal radial recurrent
branch posterior to the biceps tendon (Figure 4).
The radial artery courses just medial to the biceps tendon and gives rise to
the radial recurrent artery, which runs anterior to the tendon, transversely
across the forearm axis, approximately 4 mm proximal to the most proximal
aspect of the radial tuberosity (Figure 5). This artery anastomoses with the anterior radial collateral artery
(a branch of the profunda brachii
artery), forming the so-called Henry vascular leash (Figure
4).9 The deep venous system accompanies the arterial
system in a more anterior plane as venae comitantes,
with multiple anastomoses forming a venous plexus that communicates with the
superficial venous system through perforating veins.9 If the
radial recurrent artery or its venae comitantes
interfere with visualization or limit adequate exposure of the radial
tuberosity, they may be ligated.1,2,6,7,9
The
radial nerve divides into its superficial (sensory) branch and its deep motor
branch (posterior interosseous nerve) proximal to the arcade of the supinator
muscle (arcade of Frohse).10 The
superficial sensory branch travels along the medial aspect of the brachioradialis muscle, accompanies the radial artery, and
continues toward the wrist and hand. The deep motor branch, corresponding to
the posterior interosseous nerve, continues distally in close contact with the
lateral aspect of the radial neck, making it particularly vulnerable to injury
when using Hohmann retractors at the lateral border
of the radial neck. Forearm supination is recommended, as it moves the nerve
into a more posterior and lateral position (whereas pronation shifts it
anteriorly and medially),10 along with a triangular retractor configuration
to access the radial tuberosity, using two long-blade Farabeuf
retractors laterally and a medial Hohmann retractor (Figure 5).11
Dissection
of the aforementioned anatomical structures allows access to the anterior
surface of the radial tuberosity, whose apex, as a reference point, is oriented
opposite to the radial styloid process.4 The residual distal
biceps tendon is detached from the tuberosity using a rongeur
or curette. The tuberosity bed is then prepared on its posteromedial surface
using a curette or rasp, which corresponds to the native insertion footprint.
With
the forearm in 45° of supination, two holes are drilled using a 2-mm drill bit,
approximately 1 cm apart. The drill is directed from the anterior aspect of the
radial tuberosity at a 30° medial angle toward the dorsoulnar
cortex of the radius (Figure 6A). The use of
a soft-tissue protector facilitates the procedure. The 45° supination position
and the ulnar direction of the drill holes facilitate suture passage and
maximize the distance between the drill bit and the posterior interosseous
nerve.6,7,10
A
strong monofilament suture (Prolene, PDS, or 0 nylon)
is then passed through the radius to serve as a shuttle suture, as follows: a
standard right-angle clamp is introduced from the medial side to the posterior
aspect of the radius, aligned with one of the drill holes (Figure 6B). An 18G spinal needle is inserted
through the drill hole from anterior to posterior until the surgeon feels
contact with the tip of the clamp. The clamp is slightly opened, the needle is
advanced a few millimeters, and the clamp is then gently closed to grasp the
needle. The stylet is removed, and the monofilament suture is passed through
the needle lumen. The assistant advances the suture as far as possible; the
clamp is then gently opened, and the needle is withdrawn a few millimeters
while maintaining tension on the suture to prevent it from backing out. The
clamp is then closed to grasp the suture, which is retrieved through the
interval between the radius and ulna. The same procedure is
repeated for the second drill hole, resulting in a monofilament shuttle
suture in each hole, passing from the anterior cortex of the radius and exiting
posteriorly into the radioulnar space (Figure 6C).
The
avulsed distal biceps tendon is identified by digital
proximal dissection, with the elbow flexed to bring the incision closer to the
retracted tendon stump. Typically, a smooth anterior surface and a posterior
surface can be distinguished, the latter often showing a lateral bundle (long
head) and a medial bundle (short head). The tendon is secured using two Krackow locking sutures placed in a running fashion along
each border, using high-strength flat braided nonabsorbable
suture (No. 1.5 or 2), with the sutures overlapping so that the four free ends
exit posteriorly 2–3 mm from the distal end of the tendon. This configuration
provides a compressive effect, seating the tendon against its bony insertion site
(Figure 7B). For a more anatomic repair, the
external rotation of the tendon at its insertion must be considered: the long
head inserts more proximally (superiorly) on the radial tuberosity, whereas the
short head inserts more distally (inferiorly). Accordingly, the medial Krackow suture should be passed through the distal drill
hole, and the lateral suture through the proximal drill hole, ensuring
restoration of the tendon’s native external rotation.3,4 Intermediate sutures are passed one through each
hole.
To
pass the high-strength sutures through the radial drill holes, one end of each
braided suture is tied to the posteromedial end of the monofilament shuttle
suture previously passed through the radius (Figure
6D). Then, traction is applied to the monofilament from the anterior
aspect, allowing the high-strength sutures to be shuttled from posterior to
anterior. This process is repeated for the second hole. With the forearm in
full supination and approximately 70° of flexion, an assistant applies traction
to one pair of sutures, reducing the tendon onto the posteroulnar
aspect of the radial tuberosity (Figure 7A).
This reduction suture is maintained under tension while the surgeon ties the
second high-strength suture over the anterior cortical bone bridge between the
drill holes. The remaining suture is then tied over the same cortical bridge,
completing the repair. After thorough irrigation and meticulous hemostasis, the
wound is closed in layers, with skin closure only.
The
mean operative time from skin incision to sling placement was 105.5 minutes
(range 75-175; SD 32.12).
Postoperative Protocol
A
sling is applied with a short arm cast, with the elbow at 90° of flexion and
the forearm in neutral rotation, for 10 days to reduce pain and edema. Passive
range of motion is then initiated as tolerated, with limits of 30° of elbow
extension and 30° of forearm rotation, while maintaining continuous sling use
(removed only for exercises) until 4 weeks postoperatively. After this period,
the sling is used only when going out and during sleep for an additional 2
weeks. At 6 weeks, the sling is discontinued and active range of motion is
allowed, without resistance. Gradual and progressive strengthening is initiated
at 12 weeks, and unrestricted use of the arm, according to tolerance, is
permitted after 6 months.12
We
reviewed the medical records of patients with at least 12 months of follow-up.
Patients were evaluated using the QuickDASH score,13 the visual analog scale (VAS) for pain,14 and were asked whether they had returned to
their pre-injury level of activity. The contralateral limb served as a control
for assessing range of motion and subjective weakness. Patients were also asked
whether their decision to undergo surgery was driven by functional or aesthetic
concerns.
RESULTS
Eleven
patients with postoperative follow-up >12 months were included. Eight
reported undergoing surgery for both functional and aesthetic reasons, and
three for functional reasons only. Eight of the repairs were performed on the
dominant side. The mean follow-up was 35.5 months (range 12-53).
No
differences were observed in pronation-supination or flexion-extension arcs
compared with the contralateral side. Mean values were 138° of flexion, 3° of
extension, 76° of pronation, and 75° of supination.
The
mean QuickDASH score was 6.38 (range 2.7-13.6). The
mean VAS score during exertion was 0.22/10 (range 0-2). Eight patients reported
no postoperative symptoms. All patients returned to their usual work and sports
activities, and were allowed to resume exertional activities 6 months after
surgery.
The
complications observed were as follows: two patients developed lateral
antebrachial cutaneous nerve neuropraxia with
transient symptoms that resolved after 4 months; and one patient developed a
wound infection requiring surgical debridement and antibiotic therapy. This
patient, who was also involved in a labor dispute, had the worst outcomes on
the QuickDASH (13.6) and VAS (2/10 with exertion),
and reported persistent subjective weakness.
In one
patient with symptoms unrelated to the biceps tendon, postoperative magnetic
resonance imaging of the elbow was performed. The images confirmed reinsertion
of the tendon onto the posterior ulnar aspect of the radial tuberosity (Figure 8).
DISCUSSION
The
key to successful distal biceps tendon repair lies in a thorough understanding
of regional anatomy. On the one hand, surgical exposure in the deep aspect of
the elbow requires careful anticipation of the neurovascular structures
encountered, allowing the surgeon to perform a safe and effective repair of the
distal biceps tendon. On the other hand, accurate restoration of the native
insertion footprint of the distal biceps tendon enables patients to achieve
functional outcomes as close to normal as possible.
A
crucial concept for understanding the supination function of the biceps is the
generation of supination torque as a function of tendon position throughout
forearm rotation. The native insertion of the distal biceps
tendon wraps around the apex of the radial tuberosity, which plays a key
biomechanical role by acting as a cam, displacing the line of pull away from
the center of rotation of the radius and thereby enhancing supination strength.3,7 Reinsertion of the distal biceps tendon is
classically performed using either a single anterior approach or a two-incision
technique.5 Traditional anterior repairs
(using suture anchors, interference screws, or cortical buttons), which fix the
tendon to the anterior surface of the tuberosity, restore less than 10% of the
native biceps footprint.4 Schmidt et al. demonstrated that, in some cases,
tendons repaired on the anterior surface of the radius may function as
pronators near terminal supination.3 Posterior repairs using the Boyd and Anderson
two-incision technique may limit pronation and do not reproduce the additional
cam effect of the radial tuberosity, as, during effective contraction, the
tendon translates proximally and exerts its pull above the tuberosity.4
Maximal
supination strength following both single-incision anterior and two-incision
repairs may reach more than 90% of the contralateral side when assessed in
mid-pronation; however, evaluation of supination strength throughout the full
arc of forearm rotation is not commonly reported. In a study
of anterior distal biceps repairs, a 33% deficit in supination strength was
observed compared with the contralateral side when measured at 60° of
supination.3,6,7 In the technique used in our study, the biceps
tendon is reattached to the posterior ulnar aspect of the radial tuberosity (Figure 6), thereby maximizing supination strength
throughout all positions of forearm rotation. From a clinical
standpoint, both short- and long-term follow-up show no differences in mean
outcome scores between the anterior approach and the two-incision technique.
However, significantly more (minor) complications were observed in the
single-incision group, primarily due to transient neuropraxias
of the lateral antebrachial cutaneous nerve. Conversely, a higher incidence of
significant loss of forearm rotation due to heterotopic ossification was
observed with the two-incision approach.5
Aesthetics
may play an important role, as many of our patients (8 of 11) acknowledged that
it influenced their decision to undergo surgery. However, aesthetic outcomes
are notably not included in commonly used instruments for evaluating elbow
function.
Biomechanical
studies evaluating various repair techniques have demonstrated the ability to
withstand loads of 200-400 N, including those using transosseous
tunnels similar to those employed in our technique.3,6,7 This has
encouraged us to initiate early active mobilization.
A
simple cost analysis comparing the use of sutures alone with commercially
available devices for distal biceps reinsertion reveals substantial cost
savings with this technique. Furthermore, the implants used in distal biceps
repair are not free from complications, such as osteolysis,
migration, or failure of fixation systems (Figure 9).
Complications
have been reported with all repair techniques, the most common being sensory
nerve disturbances. In our series of 11 patients, two cases of transient neuropraxia of the lateral antebrachial cutaneous nerve
were observed. Although the rate of re-tear remains unclear, such events have
been reported; however, no cases were observed in our series at the time of
study closure.
This
study has several limitations, including the small sample size, retrospective
design, absence of a control group, and reliance on subjective outcome measures.
Another limitation is the lack of objective assessment of supination strength.
In this regard, there is currently no consensus regarding the optimal method
for evaluating forearm supination strength following distal biceps repair.
Isotonic, isometric, and isokinetic methods have been
described, and even within these categories, different testing
parameters have been used.3 Current outcome scoring systems also appear to
have limitations and have not provided data that clearly differentiate between
repair techniques.
CONCLUSIONS
We
describe a distal biceps repair technique that restores native insertion
through an anterior approach. By reproducing the anatomical footprint, this
technique may maximize supination strength without compromising range of
motion. Additionally, by eliminating the need for anchors or specialized
implants, the procedure is cost-effective and may preserve the structural
integrity of the radius. However, further studies are required to evaluate the long-term
outcomes of this technique and to compare it with other established surgical
approaches.
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S. Llumipanta ORCID ID: https://orcid.org/0009-0009-4869-1158
J. Carrizo ORCID ID: https://orcid.org/0009-0004-5706-7131
N. Villa ORCID ID: https://orcid.org/0009-0007-2984-2235
M. Deimundo ORCID ID: https://orcid.org/0000-0002-2822-4394
E.
Gobbi ORCID ID: https://orcid.org/0000-0001-7310-6170
Received on December
12th, 2025. Accepted after evaluation on February 13th, 2026 • Dr. IGNACIO SERÉ • ignaciosere@gmail.com • https://orcid.org/0000-0002-3267-8073
How to cite this article:
Seré I, Llumipanta S, Carrizo J, Villa N, Deimundo M, Gobbi E. Results of
Anatomical Repair of the Distal Biceps via an Implant-Free Anterior Approach. Rev Asoc Argent Ortop Traumatol 2026;91(2):126-137. https://doi.org/10.15417/issn.1852-7434.2026.91.2.2270
Article Info
Identification: https://doi.org/10.15417/issn.1852-7434.2026.91.2.2270
Published: April, 2026
Conflict of interests:
The authors declare no conflicts of interest.
Copyright: © 2026, Revista de la Asociación Argentina de Ortopedia y Traumatología.
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