What is the recommended limit of retraction for recurrent bicep tendon tear repair?

Limit of Retraction for Recurrent Bicep Tendon Tear Repair

Primary repair without graft augmentation can be safely performed when the retracted distal biceps tendon can be reapproximated with the elbow flexed to 90° or less, with optimal results achieved when repair requires less than 60° of flexion.

Flexion Angle Thresholds for Primary Repair

The degree of elbow flexion required to reapproximate the retracted tendon to its anatomic insertion serves as the key surgical decision point:

Standard Threshold (≤60° flexion)

• Repairs requiring ≤60° of elbow flexion demonstrate excellent outcomes without graft augmentation, with Mayo Elbow Performance Scores of 100, full range of motion (3° to 138°), and high patient satisfaction in both acute and chronic cases 1
• This represents the ideal scenario where tendon retraction is minimal and primary repair is straightforward 1

Extended Threshold (60-90° flexion)

• Contracted tendons requiring up to 90° of elbow flexion can be reliably reattached to their anatomic insertion without reconstruction, based on a case series of 23 patients with high-flexion repairs 1
• Only 1 of 23 patients required graft augmentation due to poor tendon quality, demonstrating that the flexion angle itself does not mandate grafting 1
• Outcomes matched control patients repaired at lower flexion angles, with no statistically significant differences in function 1

Critical Cutoff (>90° flexion)

• When tendon reapproximation is not possible at 45° to 90° of elbow flexion, reconstruction with allograft or autograft should be considered rather than primary repair under excessive tension 2
• Repairs requiring extreme flexion beyond 90° risk excessive tension on the repair, though the specific upper limit is not definitively established in the literature 2

Chronic vs. Acute Tear Considerations

Chronic Tears (>6 weeks)

• Primary repair remains viable for chronic tears (average 71 days post-injury) requiring an average of 64° of flexion, achieving excellent patient-reported outcomes (QuickDASH 6.6, PREE 7.8) 3
• However, complication rates are higher (47%) in chronic repairs compared to acute repairs, including increased risk of neuropraxias (12 cases), re-rupture (2 cases), and heterotopic ossification 3
• Advanced MRI imaging is crucial in chronic cases to assess the level of biceps tendon retraction and determine reparability before surgery 2

Surgical Decision Algorithm

When evaluating a retracted biceps tendon intraoperatively:

1. Attempt primary repair if the tendon reaches its anatomic insertion with ≤60° of elbow flexion - this represents the optimal scenario with minimal complications 1

2. Consider primary repair if reapproximation requires 60-90° of flexion - outcomes remain excellent, though carefully assess tendon quality 1

3. Plan for reconstruction with graft if >90° flexion is required - excessive tension increases failure risk 2

4. Use graft augmentation selectively based on tendon quality rather than flexion angle alone, as poor tissue quality may necessitate grafting even at lower flexion angles 1

Critical Pitfalls to Avoid

• Do not assume chronic retracted tears automatically require grafting - primary repair succeeds even in tears >6 weeks old if the flexion threshold is met 3
• Do not delay surgery unnecessarily - complication rates increase with delayed intervention, particularly for heterotopic ossification and nerve complications 4, 3
• Do not rely solely on clinical examination to assess retraction - MRI without contrast (86.4% accuracy) is essential for surgical planning in chronic cases to visualize tendon position and quality 5, 6
• Do not use the two-incision technique when single anterior incision suffices - the two-incision approach carries greater risk of heterotopic bone formation limiting forearm rotation 4, 7