Position the patient supine on the operating room table, use regional or general anesthesia, and place a sterile tourniquet on the upper arm.

Make an 8-cm longitudinal incision beginning at the flexion crease and extending distally following the medial aspect of the brachioradialis. Identify and protect the lateral antebrachial cutaneous nerve. If required for exposure, gently retract it laterally.

Identify the proximally retracted biceps tendon by elevating the proximal portion of the incision with a blunt retractor. Sweep the tendon down into the wound using your finger while milking the biceps muscle from above if necessary.

Debride the distal degenerated portion of the tendon.

The tendon should be oriented correctly during repair. The entire biceps complex externally rotates 90° from origin to insertion. The short-head portion of the distal biceps tendon attaches on the distal aspect of the bicipital tuberosity while the long-head portion attaches on the proximal aspect of the bicipital tuberosity. The short-head tendon can be identified by locating the origin of the lacertus fibrosus, which originates from the short-head tendon⁹.

Gently retract the brachioradialis laterally and the pronator teres medially.

Identify, ligate, and divide the recurrent leash of Henry in order to expose the bicipital tuberosity.

Scrape the tuberosity with a curet or, alternatively, create an intracortical facet with a high-speed burr to promote tendon healing.

Implant two suture anchors, each loaded with a single suture (e.g., a high-strength suture such as number-2 or 3 Ethibond [Ethicon, Somerville, New Jersey] or an alternative material such as another polyester braided suture, FiberWire [Arthrex, Naples, Florida], Hi-Fi [ConMed Linvatec, Largo, Florida), or ORTHOCORD (DePuy Synthes, Raynham, Massachusetts). Place the suture anchors approximately 1 cm apart, into the ulnar aspect of the bicipital tuberosity directed toward the intramedullary cavity. Check the position of the anchors using fluoroscopy.

Ensure that the tendon is oriented correctly while placing the sutures.

Place one end of the suture as a sliding stitch 1.5 cm up from the end of the tendon.

Using the other end of the suture, place three or four grasping stitches around the sliding stitch, making sure that it still slides.

Once both pairs of sutures have been passed, pull both the sliding ends to dock the end of the tendon to the bicipital tuberosity (Fig. 1).

Tension the sutures with the elbow in 45° to 60° of flexion and full supination and then tie. To augment the strength of the suture repair, particularly if the quality of the tendon is suboptimal, the ends of the tied sutures can be used to place additional locking sutures into the more proximal aspect of the tendon.

Use copious irrigation to remove all bone debris to lessen the risk of heterotopic ossification.

Release the tourniquet and ensure hemostasis prior to wound closure.

Make a 2-cm transverse incision in the antecubital crease.

Bluntly dissect in the deeper tissue planes, ensuring that the neurovascular structures are protected as described above.

Identify the distal stump of the biceps tendon and debride the distal degenerated portion (Fig. 2-A).

Pass two sutures (e.g., number-2 or 3 Ethibond or an alternative material such as FiberWire, Hi-Fi, or ORTHOCORD) through the distal tendon using the locking Krackow technique (Fig. 2-B).

Cut both arms of one suture shorter than the arms of the other pair. This will aid in identifying each suture arm later.

Palpate the biceps tuberosity with your index finger through the anterior incision and pass a curved clamp (carrying the four suture arms) ulnar to it. Direct the clamp through the interosseous space toward the dorsal aspect of the forearm, with the curved portion of the clamp facing laterally. Hold the forearm in maximal pronation to protect the posterior interosseous nerve while passing the clamp.

Maintain contact with the radius at all times and stay away from the ulna.

Advance the clamp through the common extensor musculature (Fig. 3), avoiding the subperiosteal ulnar interval. The clamp will be seen tenting the skin over the dorsal aspect of the proximal part of the forearm (Fig. 3).

Make a 3 to 4-cm incision directly over the clamp.

Expose the tuberosity with a muscle-splitting technique with the forearm maximally pronated.

Use a small round burr to create an oval trough in the ulnar aspect of the bicipital tuberosity that communicates with the intramedullary cavity (Fig. 4). The trough should be large enough to allow the tendon to be docked into the radius.

Maintain the forearm in maximal pronation throughout the procedure to allow for maximal exposure of the docking site and to protect the posterior interosseous nerve.

Drill three 2.0-mm drill holes anterior to the trough, ensuring that these holes are at least 5 mm apart and 2 mm away from the cortical edge.

Use caution to avoid breaking the bone bridges when passing and tying the sutures.

Using a suture retriever, pass the tendon sutures through the trough, exiting through the drill holes above.

Ensuring that the orientation of the tendon is correct, pass one long and one short suture through the middle hole and one in each of the proximal and distal holes (Fig. 5).

With the elbow in 90° flexion and the forearm in neutral rotation, pull the biceps tendon into the trough created in the bicipital tuberosity and tension the sutures.

Tie the long sutures to each other and the short sutures to each other over a different bone bridge.

Use copious irrigation to remove all bone debris to lessen the risk of heterotopic ossification.

Deflate the tourniquet and ensure hemostasis prior to wound closure.

Assess the range of elbow extension intraoperatively. If it is limited, take note of the angle beyond which the tendon is felt to be tight. Limit extension beyond this point in the early postoperative period to ensure that excessive tension is not placed across the repaired tendon.

Splint the elbow in 90° of flexion and full supination.

Consider prophylaxis against heterotopic ossification if no contraindications exist. We typically prescribe 25 mg of indomethacin (orally three times daily) along with a cytoprotective agent for three weeks.

Begin elbow mobilization two to three days postoperatively. During our study¹¹, patients were instructed to perform active extension, active pronation, passive flexion, and passive supination exercises. A removable splint was worn at all times, except when the patients performed the prescribed exercises. Nonadherence to active-use restrictions was the primary reason for rupture; thus, when making immobilization choices and precautions, consider indicators of a lack of adherence to the postoperative plan.

Limit extension if full elbow extension was not easily achieved intraoperatively, allowing a 10° increase per week until full extension is achieved.

At six weeks, discard the resting splint and begin unlimited active range-of-motion exercises. Strengthening can begin between ten and twelve weeks postoperatively. Unrestricted activity can begin between four and six months.

Acute distal biceps rupture (less than four weeks postinjury)

Patients whose recreational and vocational activities require optimal supination and flexion strength

Medical comorbidities that preclude surgery

Obtaining exposure of the operative site and maintaining correct forearm and elbow positioning require at least one dedicated assistant.

Single-incision technique: Care must be taken to avoid aggressive retraction of the lateral antebrachial cutaneous nerve.

Double-incision technique: To minimize the risk of developing heterotopic bone formation, care must be taken to avoid subperiosteal exposure of the ulna during tendon passage and to remove bone debris created by use of the burr.

Chronic distal biceps tendon ruptures may require additional considerations such as the use of autografts or allografts.