Paper 30: Comparative outcomes of distal biceps tendon repair in patients with and without testosterone therapy

Objectives: The use of testosterone replacement therapy (TRT) has risen significantly in the United States over the past several years. There is evidence that anabolic steroids and TRT increase risk of biceps tendinopathy and distal biceps tendon rupture; however, there is limited research investigating the association between TRT use and postoperative outcomes following distal biceps repair. This study aims to evaluate postoperative distal biceps tendon repair outcomes in patients with history of TRT versus those who have never used exogenous testosterone.
Methods: This retrospective cohort study queried the TriNetX US Collaborative database from August 2005 to August 2025 to identify adult males over age 18 who were diagnosed with distal biceps rupture and underwent surgical repair, with a TRT prescription present, at minimum 3 months prior. A control cohort excluded patients who ever had a TRT prescription. Distal biceps tendon injuries and postoperative outcomes following surgical repair were identified using ICD-10 and CPT codes (Figure 1). Patients with other injuries were excluded. Univariate analysis was performed to assess risk of the following outcomes of interest after distal biceps repair in TRT users versus non-users: secondary surgery, elbow stiffness, postoperative infection, cellulitis and neural injury at the forearm.
Results: 380 patients with TRT with distal biceps tendon rupture and underwent surgery were identified and 11,229 non-TRT users were identified. Between these two cohorts there was a statistically significant higher risk of reoperation and cellulitis at 6, 12, and 24 months in the TRT cohort compared to the non-TRT cohort (p < 0.05) (Table 1). Additionally, the TRT cohort demonstrated a significantly higher risk of postoperative infection and neural injury at the forearm at 3, 6, 12, and 24 months (p < 0.05). There was no significant difference between the cohorts in risk of reoperation or development of cellulitis within 3 months or experiencing elbow stiffness within 3, 6, 12, or 24 months.
Conclusions: These findings suggest that exogenous testosterone is a risk factor for increased postoperative complications following distal biceps tendon repair. Specifically, exogenous testosterone increases the risk for reoperation, postoperative infection, cellulitis, and neural injury at the forearm. Patients on testosterone therapy should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk. Further prospective studies are warranted to help establish the underlying mechanism associating TRT therapy and increased postoperative complications in patients undergoing distal biceps repair.