Does the surgical approach effect the rates of heterotrophic ossification in distal bicep tendon repair? A single centre study

Background: Acute rupture of the distal biceps tendon is an uncommon injury with an increasing incidence. Surgical repair is commonly performed to restore function; however, complications such as heterotopic ossification (HO) may occur. The effect of surgical approach and intraoperative factors HO formation remains unclear. Methods: This retrospective single-centre cohort study included patients who underwent primary surgical repair of acute distal biceps tendon between 2015 and 2023. Surgical approach, tourniquet use, and postoperative complications were recorded. The primary outcome was radiological HO. Secondary outcomes included neurological complications, range of motion restrictions, and patient-reported outcomes, as measured using the QuickDASH questionnaire. Results: A total of 259 patients were included, with a mean age of 43. A two-incision approach was used in 76 cases. HO was identified in six patients (2%). HO occurred more frequently following a two-incision approach compared with a single-incision approach (5.2% vs 1.1%), although this was not statistically significant (p = 0.063). Tourniquet use was significantly associated with HO formation, with five of six HO cases occurring in patients operated on under tourniquet control (p = 0.00029). Lateral cutaneous nerve palsy was more common following single-incision repair (15.8% vs 3.9%, p = 0.0067). Functional outcomes were generally favourable, with a mean QuickDASH score of 4.9, and no significant difference was observed between the surgical approaches. Conclusion: Distal biceps tendon repair provides favourable functional outcomes. HO is uncommon but appears more frequently associated with a two-incision approach and tourniquet use. Avoiding tourniquet use may reduce the risk of HO.