August 2025

A Buttoned-Up Approach to Distal Biceps Repair: Safe and Secure


By: Daniel J. Cognetti, M.D.
AANA Communications and Technology Committee

 

In Don Freeman’s classic children’s book Corduroy, a little bear sits on a department store shelf day after day, waiting to be chosen. He is nearly perfect, except for one thing: He’s missing a button. After a risky nighttime adventure and with the help of a new friend, he eventually manages to find his missing button, and with it, a sense of completeness. The story is simple, but the message resonates: sometimes, it’s a small detail, such as an additional button, that transforms something good into something whole.

 

Orthopaedic surgery is full of similar moments as we are constantly refining something functional into something truly finished. One clear example of this is the evolving approach to distal biceps repair.

 

Distal biceps tendon ruptures often occur in active, middle-aged men following a sudden eccentric load on a flexed elbow. While nonoperative treatment may suffice for lower-demand individuals, repair is advocated for most patients to restore supination and flexion strength.

 

Over the past two decades, a variety of surgical approaches and fixation strategies have emerged, each aiming to improve repair strength while minimizing complications. The variety of available implants and techniques has fueled many debates during this time, and none are more fundamental than whether to go with a single-incision or two-incision approach.

 

Suffice it to say, that each approach has its merits and its baggage:

The two-incision approach provides direct access to the dorsal aspect of the radial tuberosity, making it easier to recreate the tendon’s anatomic insertion and restore the mechanical “cam effect” of the tuberosity on the tendon. It also enables a transosseous technique, eliminating the need for an implant and the associated cost. However, the approach requires more dissection, time for closure and has been reported to have a higher rate of posterior interosseous nerve (PIN) neuropraxia. It is also historically associated with higher rates of heterotopic ossification.

 

On the flip side, the single-incision approach spares the dorsal forearm dissection, but introduces its own set of considerations. Cadaveric studies have shown that it does not quite allow full access to the native footprint, making it harder to perfectly recreate the anatomic attachment. However, clinical studies have not demonstrated any meaningful differences in strength or outcomes when comparing the two approaches.

 

Single incision repairs also rely on implants, and these dictate the biomechanical integrity and risk profile of the repair. Suture anchors are easy to place and widely available, but their lower pull-out strength and stiffness, compared to other implants, raise concerns in high-demand patients. Interference screws provide a broad tendon-to-bone interface, but require a large socket in the radial tuberosity, increasing the risk of fracture. Their fixation strength in isolation, is also comparatively low. 

 

Cortical buttons, on the other hand, have emerged as a preferred implant for many surgeons and for good reason. Single bicortical buttons offer excellent biomechanical strength and a solid clinical track record. They are also sometimes paired with an interference screw to enhance construct stability and reduce early failure. However, bicortical buttons are not without risk. Drilling through the far cortex of the radius brings the guide pin dangerously close to the PIN. Even with careful technique, drilling through the far cortex invites risk. As does flipping the button near the nerve. And when the risk is a life-altering complication, mitigating the risk becomes a priority.

 

This is where dual intramedullary buttons offer a meaningful advance and provide the surgical equivalent of Corduroy’s second button.

 

This technique avoids the far cortex altogether, removing the risk of direct injury to the PIN and bringing peace of mind to even the most experienced surgeons. However, its appeal extends beyond safety. Cadaveric studies suggest that dual intramedullary fixation offers superior biomechanical performance compared to suture anchors and transosseous techniques and matches or exceeds the strength of single bicortical buttons. Additionally, the use of two independent implants facilitates broader footprint restoration and the small drill holes may allow for more optimal implant positioning on the radial tuberosity than can be achieved when a button needs to be flipped bicortically or a socket is required for an interference screw.

 

What makes this approach compelling isn’t just its safety profile, but the completeness of it. It offers excellent fixation, recreates the native insertion and eliminates one of the most feared complications, all through a single-incision approach. Like Corduroy’s second button, the addition may seem small, but its impact is potentially transformative, elevating a good solution into something that feels more buttoned up and complete.

 

References:

 

  1. Litowski, M.L., Purnell, J., Hildebrand, K.A., Bois, A.J. Surgical Outcomes and Complications Following Distal Biceps Tendon Reconstruction: A Systematic Review and Meta-Analysis. JSES International. 2021;5(1):24-30. doi:10.1016/j.jseint.2020.09.010
  2. Hasan, S.A., Cordell, C.L., Rauls, R.B., Bailey, M.S., Sahu, D., Suva, L.J. Two-Incision Versus One-Incision Repair for Distal Biceps Tendon Rupture: A Cadaveric Study. Journal of Shoulder and Elbow Surgery. 2012;21(7):935-941. doi:10.1016/j.jse.2011.04.027
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  4. Lynch, B., Duke, A., Komatsu, D., Wang, E. Risk of Posterior Interosseous Nerve Injury During Distal Biceps Tendon Repair Using a Cortical Button. Journal of Hand Surgery Globe Online. 2022;4(1):14-18. doi:10.1016/j.jhsg.2021.09.003
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  7. Forlenza, E.M., Lavoie-Gagne, O., Parvaresh, K.C., Berlinberg, E.J., Agarwalla, A., Forsythe, B. Two Intramedullary and One Extramedullary Cortical Button, With or Without Interference Screw, Show Biomechanical Properties Superior to Native Tendon in Repair of the Distal Biceps Tendon: A Systematic Review and Network Meta-analysis of Biomechanical Performance. Arthroscopy. Published online October 2022:S0749806322005801. doi:10.1016/j.arthro.2022.08.037
  8. Siebenlist, S., Lenich, A., Buchholz, A., Martetschläger, F., Eichhorn, S., Heinrich, P., Fingerle, A., Doebele, S., Sandmann, G.H., Millett, P.J., Stöckle, U., Elser, F. Biomechanical in Vitro Validation of Intramedullary Cortical Button Fixation for Distal Biceps Tendon Repair: A New Technique. American Journal of Sports Medicine. 2011;39(8):1762-1769. doi:10.1177/0363546511404139
  9. Siebenlist, S., Buchholz, A., Zapf, J., Sandmann, G.H., Braun, K.F., Martetschläger, F., Hapfelmeier, A., Kraus, T.M., Lenich, A., Biberthaler, P., Elser, F. Double Intramedullary Cortical Button Versus Suture Anchors For Distal Biceps Tendon Repair: A Biomechanical Comparison. Knee Surgery, Sports Traumatology, Arthroscopy. 2015;23(3):926-933. doi:10.1007/s00167-013-2590-0
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