Two-year delayed reconstruction of chronic distal biceps tendon rupture with allograft: a case report

Abstract Chronic distal biceps tendon ruptures present significant reconstructive challenges due to tendon retraction, scarring, and muscle atrophy. Allograft-based reconstruction is a viable option for delayed presentations, particularly in high-demand individuals. We report the case of a 33-year-old male bodybuilder who presented 2 years after sustaining a distal biceps rupture. Examination revealed a reverse Popeye deformity, marked weakness, and magnetic resonance imaging evidence of complete tendon rupture with substantial retraction and muscle atrophy. Surgical reconstruction was performed using an Achilles tendon allograft secured proximally with a Pulvertaft weave and distally with a cortical button fixation device (EndoButton™, Smith & Nephew, Memphis, TN, USA) following preparation and tensioning of the graft. Rehabilitation progressed from immobilization to full return to lifting by 6 months. Preoperatively, the patient reported a QuickDASH score of 54.54, indicating substantial upper-extremity disability. At 7 months postoperatively, the patient demonstrated full, pain-free elbow motion; symmetric flexion and supination strength; and restored biceps contour. The QuickDASH improved to 25.0, and the Oxford Elbow Score reached 48/48, reflecting marked functional recovery. Radiographs confirmed absence of heterotopic ossification or fixation-related complications. This case highlights the feasibility and favorable short-term functional outcomes of Achilles allograft reconstruction for chronic distal biceps ruptures, even in patients presenting more than a year after injury. These findings support Achilles allograft reconstruction as a viable option in selected high-demand individuals with neglected injuries.