What are the risks of recurrent repair of distal bicep tendon in a middle-aged male patient with a history of distal bicep tendon rupture and previous repair?

Risks of Recurrent Distal Bicep Tendon Repair

Recurrent repair of distal bicep tendon carries significantly elevated complication risks compared to primary repair, with major complications occurring in 7.5% of cases overall, and these risks increase substantially when repair is delayed beyond 28 days from initial injury. 1, 2

Major Complications

The most serious complications following distal bicep tendon repair include:

• Tendon re-rupture: Occurs in 1.6% of cases, representing a critical failure of the repair that necessitates revision surgery 2
• Posterior interosseous nerve (PIN) palsy: Affects 1.9-4% of patients, causing weakness in finger and thumb extension 1, 2
• Proximal radioulnar synostosis: Develops in 1.0% overall, but dramatically increases to 2.8% with two-incision techniques (19-fold increased risk compared to single-incision approach) 2
• Heterotopic ossification requiring reoperation: Occurs in 0.9% of cases, with higher rates after two-incision techniques, potentially limiting forearm rotation 2, 3
• Deep infection: Affects 0.5% of patients, requiring aggressive antibiotic therapy and possible surgical debridement 2
• Complex regional pain syndrome (CRPS): Develops in 0.6% of cases, causing chronic pain and functional impairment 2

Minor Complications

While less severe, minor complications are substantially more common:

• Lateral antebrachial cutaneous nerve paresthesia: Most frequent complication at 26%, more common with single-incision approaches, though typically resolves with time 1, 2
• Radial sensory nerve paresthesia: Affects 6% of patients, also more frequent with single-incision techniques 1, 2
• Superficial wound infection: Occurs in 2% of cases 1

Overall Complication Profile

• Total major complication rate: 7.5% 2
• Reoperation rate: 4.5% 2
• Any complication rate: 36% when including minor complications 1

Critical Risk Factors for Recurrent Repair

Timing is the most critical modifiable risk factor: Complications are significantly more common when repair is performed more than 28 days after the initial rupture 1. In chronic cases, proximal retraction and scarring of the muscle belly make tendon mobilization difficult, and inadequate distal tendon length may necessitate tendon augmentation with grafts (using semitendinosus, fascia lata, hamstring, Achilles, or flexor carpi radialis) 4, 5.

Surgical Approach Considerations

The choice between single-incision and two-incision techniques involves distinct risk profiles:

• Two-incision technique: Carries a 19-fold increased risk of radioulnar synostosis but markedly diminishes PIN injury risk 2, 3
• Single-incision technique: Higher rates of lateral antebrachial cutaneous and radial sensory nerve complications, but minimal heterotopic ossification risk 2, 3

Specific Concerns for Recurrent Repair

In the context of a recurrent repair (revision surgery after failed primary repair), additional considerations include:

• Poor tissue quality from previous surgery and scarring increases technical difficulty 4
• Tendon retraction may be more severe, potentially requiring graft augmentation 4, 5
• The risk of all complications increases with delayed intervention, making early revision critical if indicated 1, 3
• Serial resections generally lead to deteriorating outcomes with increased morbidity risk 6

Functional Outcomes Despite Complications

Most patients regain near-normal upper extremity motion and function and can return to preinjury activities, though small measurable deficits in power, endurance, and terminal forearm rotation may persist 3. When motion-limiting heterotopic ossification occurs, surgical resection can restore functional forearm motion once the process matures on plain radiographs 3.