Incidence of Heterotopic Ossification Following Double-Incision Technique for Distal Biceps Tendon Repair

Background Heterotopic ossification (HO) is a postoperative finding that may occur after distal biceps tendon repair using the double-incision technique; however, its incidence, temporal evolution, and clinical relevance remain incompletely defined. Objectives The objectives of this study are to determine the incidence and temporal evolution of heterotopic ossification (HO), evaluate variables associated with its development, and assess clinical outcomes following double-incision distal biceps tendon repair performed under a standardized postoperative protocol including non-steroidal anti-inflammatory drug (NSAID) prophylaxis. Methods A retrospective cohort study was performed including 94 patients with complete distal biceps tendon rupture treated surgically with a double-incision technique between January 2018 and July 2023. All patients had a minimum follow-up of 24 weeks and underwent serial radiographic evaluation at two, four, eight, 12, and 24 weeks postoperatively. HO was identified radiographically, and patients were grouped according to its presence. Functional outcomes were assessed using the Mayo Elbow Performance Score (MEPS). Clinical outcomes, need for additional surgery, and associated risk factors were analyzed. Results HO developed in 11 patients (11.7%), with spontaneous resorption observed in 54.5% of cases. Patients without HO achieved a mean MEPS of 97.8±2.5, whereas those with spontaneous HO resorption achieved a mean MEPS of 94.2±2.0. Persistent HO treated nonoperatively demonstrated a mean MEPS of 83.3±2.9, while surgically treated patients achieved a postoperative mean MEPS of 90.0±0. Only two patients (2.1%) required surgical excision. Anabolic steroid use and a delay greater than 10 days between injury and surgery were significantly associated with HO development (p<0.001). Conclusion The double-incision technique is associated with the development of HO; however, most cases follow a favorable and self-limited course with frequent spontaneous resorption and preservation of functional outcomes. Persistent symptomatic HO may result in functional limitation and occasionally require surgical intervention.