Distal Biceps Tendon Repair with Unicortical Button Via Single Anterior Approach: A Systematic Review of Biomechanical and Functional Aspects

Background

Distal biceps tendon ruptures are uncommon but functionally disabling injuries that frequently affect active adult males. Among the various surgical strategies available, repair using a unicortical button through a single anterior approach has gained popularity due to its minimally invasive nature and favorable biomechanical profile.

Objective

This systematic review aimed to evaluate biomechanical performance, functional outcomes, return-to-activity rates, and complications associated with distal biceps tendon repair using a unicortical button via a single anterior approach.

Methods

A comprehensive search of PubMed, Embase, Scopus, and Web of Science was conducted in May 2025 to identify studies published between January 2015 and May 2025. Eligible studies included adult patients undergoing distal biceps tendon repair with unicortical button fixation. Data were extracted on study design, surgical technique, biomechanical evaluation, functional outcomes, return to sport, and complications. Methodological quality was assessed according to the Oxford Centre for Evidence-Based Medicine 2011 guidelines.

Results

Thirty-six studies met the inclusion criteria. The majority were Level III or IV evidence, with only three studies rated as Level I. Unicortical button fixation demonstrated consistent biomechanical stability, high load-to-failure resistance, and minimal gap formation. Functional outcomes were predominantly excellent, with most patients recovering full range of motion and strength. Return-to-sport rates ranged from 84% to 95%, typically within 6 to 12 months. Complication rates were low and mostly transient, with few reports of nerve injury or heterotopic ossification.

Conclusion

The unicortical button technique via a single anterior approach is a safe, effective, and reproducible option for distal biceps tendon repair. It offers robust biomechanical performance and favorable clinical outcomes, even in high-demand populations. However, the predominance of lower-level evidence underscores the need for well-designed prospective studies.