Paper in Focus

Pulcinelli FM, Caterini A, Rovere G, D’Ambrosio M, Minnetti GM, Farsetti P, De Maio F.
Anatomical Reconstruction of Chronic Distal Biceps Tendon Ruptures Using a Tripled Semitendinosus Auto-Graft, Tension-Slide Technique and Interference Screw: Description of a New Surgical Technique and Preliminary Results.
Journal of Clinical Medicine. 2025;14:7948.
DOI: 10.3390/jcm14227948
PMID: 41302984
PMCID: PMC12653424

Opening Editorial: Editor’s Perspective

Chronic distal biceps tendon ruptures represent a challenging injury pattern in orthopaedic surgery. While acute ruptures may often be treated with primary repair, delayed presentation introduces a more complex problem. Tendon retraction, muscle shortening, scar formation, and tissue degeneration can make direct anatomic reinsertion difficult or even impossible.

In this issue of Conversations in Orthopaedics, we examine a 2025 article by Pulcinelli and colleagues describing a surgical technique for chronic distal biceps tendon rupture using a tripled autologous semitendinosus graft, fixed with a tension-slide technique and interference screw. The article is valuable not only because it presents preliminary clinical outcomes, but because it reflects an important principle in reconstructive orthopaedics: when native anatomy cannot be restored directly, reconstruction must aim to recreate length, strength, and function as closely as possible.

Why This Paper Matters

The distal biceps tendon plays a critical role in elbow flexion and, even more importantly, forearm supination. When this injury is missed or treatment is delayed, patients may experience persistent weakness, functional limitation, and difficulty returning to work, sport, or daily activity.

The authors highlight that chronic distal biceps ruptures are typically defined as injuries persisting beyond 3 to 6 weeksafter trauma. In these cases, direct repair may be limited by tendon retraction and tissue atrophy. Because of this, reconstruction with graft tissue becomes an important option.

This paper matters because it addresses a difficult clinical scenario:
how to restore function when the original tendon can no longer be repaired under acceptable tension.

The Surgical Concept

Pulcinelli et al. describe reconstruction using an autologous semitendinosus tendon graft harvested from the patient. The graft is tripled to increase mechanical resistance and then anchored to the residual distal biceps tendon beginning near the myotendinous junction.

The reconstructed tendon is then passed distally and reinserted anatomically at the radial tuberosity using a Biceps Button tension-slide technique with additional fixation from an interference screw.

The figures in the article help demonstrate the stepwise nature of the technique. On page 3, the authors show the two-incision approach, with one incision used to locate the proximal tendon stump and the other centered near the radial tuberosity. On page 4, the intraoperative images show the semitendinosus graft being secured to the residual tendon and the final appearance of the tripled graft construct.

The goal of this technique is straightforward but technically demanding: restore tendon length, secure the graft anatomically, and allow healing at the radial tuberosity while minimizing the risks associated with excessive tension.

Study Design and Patient Group

This was a retrospective study of 13 patients with chronic distal biceps brachii tendon rupture. The cohort included 11 males and 2 females, with a mean age of 46 years. All patients underwent reconstruction using the tripled semitendinosus autograft technique with fixation at the bicipital tuberosity.

Outcomes were assessed at a mean follow-up of 35 months using the DASH score, Mayo Elbow Performance Score, radiographs, and tensiomyography to evaluate muscle contractile function.

Key Findings

At final follow-up, the authors reported generally favorable outcomes:

The mean DASH score was approximately 11 points, suggesting low residual disability.

The mean Mayo Elbow Performance Score was approximately 87 points, consistent with good overall elbow function.

Six patients achieved excellent results, while seven achieved good results.

No patient experienced tendon re-rupture.

No peripheral neurological deficits were reported.

No symptomatic heterotopic ossification or radioulnar synostosis was observed.

All patients returned to their previous daily and sporting activities.

Some patients did have mild residual deficits. Seven had mild elbow motion limitation, six had mild limitation in forearm pronation-supination, and five demonstrated mild flexion or supination strength deficits on tensiomyography. However, these deficits were relatively limited and did not prevent return to activity.

Timing Still Matters

One of the most interesting findings in this study was the relationship between surgical timing and outcome.

Patients treated within six weeks had better functional outcomes than those treated later. The early surgery group had lower DASH scores and higher MEPS values compared with patients treated after seven weeks.

This reinforces an important clinical principle: even within the category of “chronic” injury, earlier recognition and intervention may still influence recovery. The longer the tendon remains retracted, the more difficult it may become to restore anatomy, tension, and muscle function.

Clinical Relevance

For orthopaedic surgeons and trainees, this paper highlights several important points.

First, chronic distal biceps ruptures require careful evaluation. While the diagnosis may be relatively straightforward in acute injuries, chronic cases may be more subtle and often require imaging, especially MRI, to understand tendon retraction and tissue quality.

Second, reconstruction should aim for anatomic reinsertion when possible. Tenodesis to the brachialis may improve elbow flexion, but it does not fully restore supination strength. Since supination is one of the key functional roles of the distal biceps, anatomic reconstruction remains important.

Third, graft choice matters. The semitendinosus autograft offers length, strength, and avoidance of allograft-related risks. In this technique, tripling the graft may provide additional mechanical resistance, while button and screw fixation may improve initial stability.

Finally, rehabilitation must respect biology. The authors immobilized patients initially, then gradually progressed passive motion, active motion, strengthening, and return to activity over several months. This staged approach reflects the balance between protecting the reconstruction and preventing stiffness.

Strengths of the Article

A major strength of this article is that it focuses on a difficult and relatively uncommon injury pattern. Chronic distal biceps rupture does not have one universally accepted surgical solution, and additional technical descriptions can help expand the reconstructive options available to surgeons.

Another strength is the use of both clinical outcome scores and tensiomyography. Many studies rely mainly on subjective or physical examination outcomes, but the addition of an instrumental assessment of muscle function provides another layer of evaluation.

The follow-up period, averaging nearly three years, also gives more meaningful insight than a very short postoperative assessment.

Limitations and Questions Raised

The authors appropriately acknowledge several limitations. The study was retrospective, included only 13 patients, and did not have a control group. Because of this, the results should be interpreted as preliminary rather than definitive.

Important questions remain:

Would this technique outperform other graft choices such as Achilles allograft, tibialis anterior allograft, or fascia lata autograft?

How much donor site morbidity occurs with semitendinosus harvest in larger cohorts?

Would outcomes remain favorable in older, lower-demand, or medically complex patients?

What is the long-term durability of this reconstruction beyond three to five years?

These questions will require larger comparative studies with standardized strength testing and longer follow-up.

Final Thoughts

This article offers a thoughtful approach to a challenging reconstructive problem. Chronic distal biceps tendon ruptures are difficult because the surgeon is no longer simply repairing a tendon; they are reconstructing a functional muscle-tendon unit. The technique described by Pulcinelli and colleagues emphasizes anatomic restoration, stable fixation, and biologically paced rehabilitation.

For Conversations in Orthopaedics, this paper fits well because it demonstrates how surgical innovation often develops in response to complex clinical problems. When standard repair is no longer possible, successful reconstruction depends on understanding anatomy, biomechanics, fixation strategy, and patient function.

The broader lesson is clear: in orthopaedics, restoring anatomy is important, but restoring meaningful function is the true goal.