Radioulnar Heterotopic Ossification
After Distal Biceps Tendon Repair:
Results Following Surgical Resection
Robert W. Wysocki, MD, Mark S. Cohen, MD
From the Rush University Medical Center, Department of Orthopaedic Surgery, Chicago, IL.
Purpose: The purpose of this study is to evaluate the clinical outcome of patients who had
excision of a radioulnar heterotopic ossification (HO) as a complication of a distal biceps
tendon repair. The hypothesis is that there are no measurable clinical losses that persist after
Methods: Eight consecutive patients were identified between 1996 and 2005. All were
treated with HO excision using a standard surgical technique and rehabilitation protocol.
These individuals were studied and compared to a matched cohort of 8 patients who had a
distal biceps tendon repair with a similar surgical technique that was uncomplicated. All
study patients were evaluated at a minimum 1-year follow-up with physical examination,
isokinetic dynamometry, and outcome measures. Comparisons were made both between
groups as well as side-to-side within groups.
Results: At follow-up examination, the mean arc of forearm rotation in the HO group
measured 151°. The mean arc of forearm rotation in the control group measured 165°. With
the numbers available, no measurable differences in arc of motion were identified between
groups (p ? .05). When compared to the normal, uninvolved side, patients who developed
HO lost an average of 9° of forearm pronation (p ? .01). No differences were identified
between the HO and control groups with respect to isokinetic torque, endurance strength, or
Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire (American Academy of
Orthopaedic Surgeons, Rosemont, IL) scores (p ? .05).
Conclusions: When patients develop motion-limiting HO after distal biceps tendon repair,
surgical resection can lead to a functional recovery of elbow and forearm motion. Biceps
strength can be maintained with no measurable differences in clinical outcome when
compared to individuals who do not suffer this complication following distal biceps repair.
(J Hand Surg 2007;32A:1230–1236. Copyright © 2007 by the American Society for Surgery
of the Hand.)
Type of study/level of evidence: Therapeutic III.
Key words: Distal biceps, heterotopic ossification, isokinetic dynamometry, radioulnar syn-
ostosis, 2-incision technique.
cidence of 1.2 per 100,000 persons per year.1,2Direct
repair of the biceps tendon to the radial tuberosity has
been demonstrated to improve strength and func-
tion.3,4The procedure is not without potential com-
plications, however, with one of the most devastating
being the development of motion-limiting hetero-
topic ossification (HO) between the radius and the
ulna. This complication was initially attributed to the
raumatic rupture of the distal biceps tendon is
a rare injury, comprising approximately 3% of
all ruptures of the biceps with an overall in-
surgical approach in a 2-incision technique in which
both the radius and ulna were exposed.5,6The devel-
opment of radioulnar HO and synostosis, however,
has also been reported in muscle-splitting 2-incision
exposures of the tuberosity and much less frequently
when a single anterior exposure is used for re-
Once motion-limiting heterotopic bone forms, sur-
gical resection can improve clinical outcome.16,19–22
This procedure, however, carries the risk of neuro-
vascular injury and can lead to disruption of the
The Journal of Hand Surgery
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The Journal of Hand Surgery / Vol. 32A No. 8 October 2007