„„ Systematic Review

Single- versus double-­incision technique for

the treatment of distal biceps tendon rupture
a systematic review and meta-­a nalysis of comparative
studies

D. Castioni,
M. Mercurio, Aims
D. Fanelli, The aim of this systematic review and meta-­analysis is to evaluate differences in func-
O. Cosentino, tional outcomes and complications between single- (SI) and double-­incision (DI) tech-
G. Gasparini, niques for the treatment of distal biceps tendon rupture.
O. Galasso
Methods
From Department A comprehensive search on PubMed, MEDLINE, Scopus, and Cochrane Central databas-
of Orthopaedic and es was conducted to identify studies reporting comparative results of the SI versus the
Trauma Surgery, Magna DI approach. The Preferred Reporting Items for Systematic Reviews and Meta-­Analyses
Græcia University,
(PRISMA) statement was used for search strategy. Of 606 titles, 13 studies met the in-
Mater Domini
clusion criteria; methodological quality was assessed with the Newcastle-­Ottawa scale.
University Hospital,
Random- and fixed-­effects models were used to find differences in outcomes between
Catanzaro, Italy
the two surgical approaches. The range of motion (ROM) and the Disabilities of the Arm,
Shoulder and Hand (DASH) scores, as well as neurological and non-­neurological compli-
cations, were assessed.

Results
A total of 2,622 patients were identified. No significant differences in DASH score were
detected between the techniques. The SI approach showed significantly greater ROM in
flexion (standardized mean difference (SMD) -0.508; 95% confidence interval (CI) -0.904
to -0.112) and pronation (SMD -0.325, 95% CI -0.637 to -0.012). The DI technique was
associated with significantly less risk of lateral antebrachial cutaneous nerve damage
(odds ratio (OR) 4.239, 95% CI 2.171 to 8.278), but no differences were found for other
nerves evaluated. The SI group showed significantly fewer events of heterotopic ossifi-
cation (OR 0.430, 95% CI 0.226 to 0.816) and a lower reoperation rate (OR 0.503, 95% CI
0.317 to 0.798).

Conclusion
No significant differences in functional scores can be expected between the SI and DI
approaches after distal biceps tendon repair. The SI approach showed greater flexion
and pronation ROM and a lower risk of heterotopic ossification and reoperation. The DI
approach was favourable in terms of lower risk of neurological complications.

Cite this article: Bone Joint J 2020;102-B(12):1608–1617.

Introduction are risk factors for rupture.1 The use of anabolic

Correspondence should be
sent to M. Mercurio; email:
​mercuriomi@​gmail.​com
© 2020 The British Editorial
Society of Bone & Joint Surgery
doi:10.1302/0301-620X.102B12.
BJJ-2020-0822.R2 $2.00
Bone Joint J
2020;102-B(12):1608–1617.
1608
Distal biceps tendon ruptures predominantly
affect men aged between 30 and 59 years, usually
in the dominant arm, with a reported incidence
of 0.9 to 5.4 per 100,000 people per year.1 Typi-
cally, the injury results from an unexpected
extension of the actively flexed arm, or when the
biceps undergoes a forceful eccentric contrac-
tion. Demographic factors such as male sex,
elevated body mass index (BMI), and smoking
steroids and weightlifting might also result in
increased risk of sustaining this injury.2 Without
operative repair, considerable impairment can
be expected in terms of supination and flexion
strength and endurance.3 This is particularly
problematic for young and active patients, while
conservative management might be acceptable
for individuals with less physically demanding
lifestyles. Anatomical repair has become the
THE BONE & JOINT JOURNAL
 SINGLE- VERSUS DOUBLE-­INCISION TECHNIQUE FOR THE TREATMENT OF DISTAL BICEPS TENDON RUPTURE 1609

Records identified through

Additional records
database searching (n = 606):

Identification
identified through
PubMed/Medline (n = 385)
other sources
Scopus (n = 188)
(n = 0)
Cochrane Central (n = 33)

Records screened after Records excluded

duplicates removed (n = 435):
Screening

(n = 514)
Non-comparative studies (n = 308)
Nonoperative management (n = 46)
Technical articles (n = 38)
Cadaveric/Biomechanical studies (n = 30)
Case reports (n = 13)

Full-text articles assessed Full-text articles excluded, with reasons

for eligibility (n = 66):
Eligibility

(n = 79)
Non-English literature (n = 9)
Editorials (n = 9)
Technical articles (n = 5)
Studies included in Cadaveric/Biomechanical studies (n = 30)
qualitative synthesis Case reports (n = 11)
(n = 13) Nonoperative management (n = 2)
Included

Studies included in
quantitative synthesis
(meta-analysis)
(n = 13)

Fig. 1

Preferred Reporting Items for Systematic Reviews and Meta-­Analyses (PRISMA) flowchart for the search and identification of included studies.12

standard care for patients wishing to achieve full return of
strength after distal biceps rupture. The specific surgical tech-
nique can vary, with bone tunnels, suture anchors, cortical
buttons, and interference screws all being employed with
satisfactory outcomes.4-7 With regard to the surgical approach,
repair can be performed with the use of either a single- (SI) or
a double-­incision (DI) technique.8 Initial concerns regarding
nerve injuries when using a SI technique, originally described
by Dobbie,9 led to the introduction of a DI technique that
allowed for anatomical reattachment of the biceps tendon to
the radial tuberosity.10 This approach, however, was found
to result in a marked risk of heterotopic ossification,11 thus
renewing interest in the SI technique. In the current literature,
there is no clear consensus regarding the optimal surgical
approach. The aim of this study was to evaluate differences
in functional outcomes and complications between SI and DI
techniques for the treatment of complete distal biceps tendon
rupture through the analysis of comparative studies arising
from databases.
Methods
Search strategy. A systematic review of the published liter-
ature was conducted and reported according to the Preferred
Reporting Items for Systematic Reviews and Meta-­Analyses
(PRISMA) statement (Figure 1).12 PubMed, MEDLINE,
VOL. 102-B, No. 12, DECEMBER 2020
Scopus, and Cochrane Central databases were searched in
January 2020. The terms “distal biceps”, “tendon rupture”,
“outcome”, “results”, “single”, “double”, and “incision” were
used in different combinations to retrieve relevant articles. Two
authors (DC, MM) independently conducted all the searches
and screened the titles and abstracts to identify relevant studies
published until the end of 2019. Differences were resolved by
consulting a third senior reviewer (OG). An additional search
was conducted by screening the reference list of each selected
article, as well as the available grey literature at our institution.
Inclusion criteria and study selection. During title, abstract,
and full-­text screenings, included studies had to: report compar-
ative outcomes and/or complications of SI versus DI approach;
include anatomical direct tendon repair without interposition
graft; report more than five cases treated for each approach; and
be written in English. Reviews, technical articles, case reports,
cadaveric/biomechanical studies, editorials, letters to the editor,
and expert opinions were excluded.
Data extraction and quality assessment. Two authors (DC,
MM) examined all the identified studies and extracted data.
The first author, journal name, year of publication, study de-
sign, surgical approach, fixation technique, and patient demo-
graphics were recorded for each article. Postoperative data con-
sidered for quantitative analysis consisted of the elbow range
of motion (ROM), the isometric elbow flexion/extension and
1610 D. CASTIONI, M. MERCURIO, D. FANELLI, O. COSENTINO, G. GASPARINI, O. GALASSO

Table I. Quality assessment of included studies according to the Results

Modified Newcastle-­Ottawa scale. Based on the total score, quality was
classified as “low” (0 to 3), “moderate” (4 to 6), and “high” (7 to 9).
Search results. A total of 606 relevant titles were identified
through the initial search. As shown in Figure 1, the abstracts of
Study author (year)* Criteria Total Quality
514 articles were screened, with the exclusion of 435 studies. A
1 2 3 4 5 6 7 8
total of 79 full-­text articles were then assessed for eligibility ac-
Citak et al18 (2011) 1 1 1 1 1 1 1 0 7 High
cording to inclusion criteria, leading to 13 comparative studies
Cohen et al19 (2016) 1 1 1 1 1 1 1 0 7 High
entering the meta-­analysis.18–30 Baseline characteristics of these
Dunphy et al20 (2017) 1 1 1 1 0 1 1 1 7 High
El-­Hawary et al21 (2003) 1 1 1 1 0 1 1 1 7 High
studies are summarized in Table II. A total of 2,622 cases were
Ford et al22 (2018) 1 1 1 1 2 1 1 0 8 High
included, of which 1,825 underwent SI repair and 797 DI repair.
Johnson et al23 (2008) 1 1 1 1 1 1 1 0 7 High Functional outcomes. Six studies compared elbow flexion
Lang et al24 (2018) 1 1 1 1 1 1 1 1 8 High ROM in a total of 1,036 patients: the SI technique showed sig-
Martens25 (1997) 0 0 1 1 0 0 1 1 4 Moderate nificantly greater flexion at follow-­up (mean 136° (SD 13°) and
Matzon et al26 (2019) 1 1 1 1 1 1 1 1 8 High mean 133° (SD 13°) for SI and DI, respectively; SMD -0.508,
Shields et al27 (2015) 1 1 1 1 1 1 1 0 7 High 95% confidence interval (CI) -0.904 to -0.112; I2 = 73.41;
Stockton et al28 (2019) 1 1 1 1 2 1 1 1 9 High Figure 2a). Five studies reported data for ROM in extension
Waterman et al29 (2017)1 1 1 1 1 1 1 1 8 High for a total of 989 patients: there was no significant difference
Criterion number: 1, representativeness of the exposed cohort; 2, between the two techniques (mean 2° (SD 5°) and mean 4° (SD
selection of the nonexposed cohort; 3, ascertainment of exposure; 6°) for SI and DI, respectively; SMD 0.032, 95% CI -0.320 to
4, demonstration that outcome of interest was not present at start
of study; 5, comparability of cohorts on the basis of the design or 0.385; I2 = 65.47; Supplementary Figure aa). The ROM in pro-
analysis; 6, assessment of outcome; 7, was follow-­up long enough for nation was reported in five studies and 252 patients, with the
outcomes to occur?; 8, adequacy of follow-­up of cohorts. Each study differences significantly in favour of the SI approach (mean 79°
was awarded a maximum of one or two points for each numbered item
within categories, based on the Modified Newcastle-­Ottawa scale rules.
(SD 10°) and mean 75° (SD 14°) for SI and DI, respectively;
*Grewal et al30 is not included in this assessment, as it was a SMD -0.325, 95% CI -0.637 to -0.012; I2 = 25.66; Figure 2b).
randomized controlled trial. This study was assessed with the RoB2 Data for ROM in supination was provided by six studies and
tool, recommended by the Cochrane Collaboration, and was scored 289 cases, with no significant differences (mean 73° (SD 14°)
“low risk”.
and mean 69° (SD 16°) for SI and DI, respectively; SMD -0.147,
95% CI -0.390 to 0.095; I2 < 0.001; Supplementary Figure ab).
A total of six studies with 308 patients evaluated the postoper-
forearm pronation/supination strength as a percentage of the
ative DASH score in the two techniques with no statistically
strength of the unaffected limb, the Disabilities of the Arm, significant differences (mean 6.5 (SD 11.6) and mean 6.7 (SD
Shoulder and Hand (DASH) score,13 the American Shoulder 12) for SI and DI, respectively; SMD 0.017, 95% CI -0.210 to
and Elbow Surgeons (ASES) score,14 the Patient-­Rated Elbow 0.244; I2 < 0.001; Figure 3). There was insufficient data to eval-
Evaluation (PREE) score,15 and the number and types of com- uate differences in strength, ASES, and PREE scores.
plications. The methodological quality of the included studies Neurological complications. Neurological complications
was assessed independently by three authors (DC, MM, DF); were found in 447 (24.5%) and 108 (13.4%) cases for the SI
cohort studies were assessed using the Modified Newcastle-­ and DI techniques, respectively, with significant difference in
Ottawa Quality Assessment Scale.16 Based on the total score, favour of DI (OR 2.570, 95% CI 1.410 to 4.682; I2 = 69.09;
quality was classified as “low” (0 to 3), “moderate” (4 to 6) Figure 4). When damage to specific nerves was evaluated, the
and “high” (7 to 9). Randomized controlled trials were assessed DI technique was associated with significantly less risk of lat-
with version 2 of the risk of bias tool (RoB2),17 recommended eral antebrachial cutaneous nerve (LACN) damage (OR 4.239,
by the Cochrane Collaboration. Discrepancies were resolved by 95% CI 2.171 to 8.278; I2 = 56.69; Figure 5), but no differences
consulting a senior reviewer (OG). Details of this quality as- were found for median nerve (MN), superficial branch of radi-
sessment are shown in Table I. al nerve (SBRN), or posterior interosseus nerve (PIN) damage
Data synthesis. Meta-­analysis of standardized mean differenc- (Supplementary Figure b). Across the studies, iatrogenic nerve
es (SMDs) and odds ratios (ORs) were used, respectively, to damage largely consisted of transient neurapraxia, presenting
with either numbness or paraesthesia of the respective area of
evaluate differences in functional outcomes and complications.
cutaneous innervation, or transient motor deficit. Persistent sen-
Generally, the choice of random- or fixed-­effects models was
sory/motor loss at follow-­up was noted in nine cases of LACN
based on the between-­trials heterogeneity as calculated by the I2
injury,22–24,26,30 of which one required neurolysis,22 in seven cases
statistics; when considerable heterogeneity was found, random-­
of SBRN injury,26,27,29 and in two cases of PIN palsy which re-
effects models were adopted. However, if the number of studies quired nerve exploration and repair.22 In total, permanent nerve
in a specific analysis was small and the between-­studies vari- palsy was therefore observed in 18 patients, representing 0.7%
ance (σ²) was judged to be poor, fixed-­effects models were con- of all cases and 3.2% of all neurological complications. In 21
sidered even with a significant I2. IBM SPSS v. 21.0.0.1 (IBM, cases, injured nerves were not otherwise specified.
Armonk, New York, USA) and Comprehensive Meta-­Analysis Other complications. Heterotopic ossification was seen in
version 3 (Biostat, Englewood, New Jersey, USA) were used 23 (2.0%) and 18 (3.8%) of the cases for the SI and DI tech-
for database construction and statistical analysis; a p-­value < niques, respectively, with significantly fewer events for the SI
0.05 was considered significant. group (OR 0.430, 95% CI 0.226 to 0.816; I2 < 0.001; Figure 6).
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 Table II. Characteristics of included studies.
Author Journal Year of Scientific Surgical Fixation Patient demographics
publication level 31 approach method

Cases available, n Sex, % Mean age, yrs Dominant arm WCP, % Mean follow-­up, mths
(SD, range)* injured, % (SD, range)*

Initial At follow-­up M F

Citak et al18 Knee Surg 2011 III SI SA 39 39 97.4 2.6 46.4 (8.5, 31 to 65) 48.4 N/A 28.9 (18.6, N/A)

VOL. 102-B, No. 12, DECEMBER 2020

Sports Traumatol
Arthrosc
DI T 15 15 100 0 48 (8.5, 31 to 65) 40 N/A 37 (18.6, N/A)
Cohen et al19 Phys Sportsmed 2016 III SI CB 25 20 92 8 52.6 (8.1, N/A) 52 28 > 24 (N/A, N/A)
DI T 33 26 100 0 53.1 (8.2, N/A) 54.5 30.3 > 24 (N/A, N/A)
Dunphy et al20 Am J Sports Med 2017 III SI CB/IS/SA 639 639 98.5 1.5 48 (16, 20 to 83) 52 N/A 49 (22.6, 6.6 to 96.9)
DI T 145 145 98.5 1.5 48 (16, 20 to 83) 52 N/A 49 (22.6, 6.6 to 96.9)
El-­Hawary et al21 J Hand Surg Am 2003 II SI SA 9 9 N/A N/A 47 (5.8, 37 to 60) 66.7 33.3 > 12 (N/A, N/A)
DI T 10 10 N/A N/A 44 (7.8, 29 to 60) 60 0 > 12 (N/A, N/A)
Ford et al22 J Shoulder 2018 III SI N/A 652 652 97.6 2.4 49 (N/A, N/A) N/A N/A 3.8 (0.9, 2 to 5.6)
Elbow Surg
DI N/A 318 318 97.6 2.4 49 (N/A, N/A) N/A N/A 3.8 (0.9, 2 to 5.6)
Grewal et al30 J Bone Joint 2012 I SI SA 47 44 100 0 45.3 (7.4, N/A) 68 32 > 24 (N/A, N/A)
Surg Am
DI T 43 40 100 0 44.9 (9.3, N/A) 59 23 > 24 (N/A, N/A)
Johnson et al23 HSS J 2008 III SI SA 12 12 83.3 17 49 (10, N/A) 83.7 N/A 26 (14, 13 to 75)
DI T 14 14 100 0 42 (7, N/A) 71.4 N/A 31 (21, 13 to 75)
Lang et al24 Orthop 2018 III SI CB/SA 30 30 100 0 47.1 (8.9, N/A) 70 N/A 10.7 (2.8, N/A)
Traumatol Surg
Res
DI T 17 17 100 0 43.9 (8.9, N/A) 76.5 N/A 11.1 (3.3, N/A)
Martens25 Acta Orthop Belg 1997 III SI N/A 12 12 100 0 50 (7, 37 to 65) 61.1 N/A > 4 (0.5, 4 to 6)
DI N/A 6 6 100 0 50 (7, 37 to 65) 61.1 N/A > 4 (0.5, 4 to 6)
Matzon et al26 J Hand Surg Am 2019 III SI CB/SA 112 112 98.1 1.9 48.7 (12, 27 to 75) 47.6 N/A 4.1 (4, N/A)
DI T 100 100 98.1 1.9 48.7 (12, 27 to 75) 47.6 N/A 4.1 (4, N/A)
Shields et al27 Am J Sports Med 2015 III SI IS/CB 20 20 100 0 52 (9.5, 32 to 66) 30 20 > 12 (N/A, N/A)
DI T 21 21 100 0 43.7 (8.7, 31 to 61) 38 33 > 12 (N/A, N/A)
Stockton et al28 J Shoulder 2019 III SI CB 22 22 100 0 47.8 (2.6, 42.7 to 53) 55 9.1 29.6 (N/A, 19.5 to 36.4)
Elbow Surg
DI T 15 15 100 0 46.5 (1.9, 42.4 to 50) 53 26.7 19.5 (N/A, 13.8 to 39.4)
Waterman et al29 Arthroscopy 2017 III SI N/A 214 214 100 0 38.9 (7.3, 20 to 61) 69 N/A 38.4 (24, 24 to 120)
DI N/A 70 70 100 0 38.9 (7.3, 20 to 61) 69 N/A 38.4 (24, 24 to 120)
SINGLE- VERSUS DOUBLE-­INCISION TECHNIQUE FOR THE TREATMENT OF DISTAL BICEPS TENDON RUPTURE

Total SI 1,825 98.8 1.2 47.3 (8.1, 32 to 66) 58.4 24.9 23.4 (10.5, 19.5 to 36.4)
DI 797 100 0 46.1 (8.9, 29 to 61) 56.1 25 24.1 (17.4, 13.8 to 39.4)
*When not specified, SDs were calculated from the ranges (max range to min range/4).
CB, cortical button; DI, double incision; IS, interference screw; N/A, not applicable; SA, suture anchor; SI, single incision; T, bone tunnel; WCP, workers’ compensation patients.
1611
1612 D. CASTIONI, M. MERCURIO, D. FANELLI, O. COSENTINO, G. GASPARINI, O. GALASSO

Fig. 2

a) Comparison of elbow flexion between single- and double-­incision techniques: forest plot of effect sizes. b) Comparison of elbow pronation
between single- and double-­incision techniques: forest plot of effect sizes. CI, confidence interval; Std diff, standardized difference.

No differences were found between the two techniques in
terms of superficial (OR 2.365, 95% CI 0.525 to 10.661; I2 <
0.001; Figure 7) or deep infections (OR 0.580, 95% CI 0.162
to 2.074; I2 = 6.86; Supplementary Figure c). With the limita-
tion of large CIs, no differences between SI and DI procedures
were found for wound healing problems (OR 3.227, 95% CI
0.521 to 20.000; I2 < 0.001; Supplementary Figure d). Tendon
re-­rupture affected 27 (2.3%) and seven (1.5%) patients in the
SI and DI groups, respectively, but this difference was not sta-
tistically significant (OR 1.473, 95% CI 0.721 to 3.007; I2 <
0.001; Figure 8). Proximal radioulnar synostosis was seen in
one and ten of the cases for the SI and DI techniques, respec-
tively.22 Radial neck fracture occurred in one patient of the SI
group,20 whose tendon was repaired using a cortical button plus
interference screw fixation. Flexion contracture and stiffness of
the elbow occurred in three patients in the SI group;18,21 they
were treated with physiotherapy and open arthrolysis. Finally,
comparisons of reoperation rates were reported in three studies;
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a significant difference was found in favour of the SI group (OR
0.503, 95% CI 0.317 to 0.798; I2 = 55.56; Figure 9).
Discussion
The most important findings of this study were that patients
undergoing distal biceps tendon repair with the SI approach can
expect greater ROM in elbow flexion and pronation, a lower
risk of HO postoperatively, and a reduced overall risk of reoper-
ation. However, a higher risk of LACN damage was observed in
the SI group compared with the DI group. Deficits in ROM for
extension and supination, as well as the postoperative DASH
score, were similar with the two approaches. The incidence of
surgical site infections, wound healing disorders, and tendon
re-­rupture was also comparable.
In previous meta-­analyses, functional endpoints such as
ROM and DASH were either not the focus of these studies32,33
or were not analyzed as continuous variables34 or, again, were
not quantitatively analyzed because of lack of data.8,35 Kodde
THE BONE & JOINT JOURNAL
 SINGLE- VERSUS DOUBLE-­INCISION TECHNIQUE FOR THE TREATMENT OF DISTAL BICEPS TENDON RUPTURE 1613

Study name Statistics for each study Std diff in means and 95% CI
Std diff Lower Upper
in means limit limit p-value

Citak et al (2011)18 -0.525 -1.129 0.079 0.088

Cohen et al (2016) 19
-0.023 -0.543 0.497 0.931
Grewal et al (2012)30 0.186 -0.243 0.615 0.396
Lang et al (2018) 24
-0.177 -0.781 0.427 0.566
Shields et al (2015)27 -0.194 -0.808 0.420 0.536
Stockton et al (2019) 28
0.862 0.177 1.548 0.014
0.017 -0.210 0.244 0.887

-2.00 -1.00 0.00 1.00 2.00

Favour single incision Favour double incision

Fig. 3

Comparison of DASH score between single- and double-­incision techniques: forest plot of effect sizes. CI, confidence interval; DASH, Disabilities of
the Arm, Shoulder and Hand; Std diff, standardized difference.

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit p-value

Citak et al (2011) 18
2.059 0.220 19.251 0.527
Cohen et al (2016)19 1.364 0.251 7.407 0.719
Dunphy et al (2017) 20
3.489 2.021 6.025 0.000
El-Hawary et al (2003)21 4.500 0.374 54.155 0.236
Ford et al (2018) 22
1.059 0.755 1.486 0.739
Grewal et al (2012)30 12.333 3.306 46.014 0.000
Johnson et al (2008) 23
3.783 0.141 101.826 0.428
Lang et al (2018)24 0.073 0.004 1.504 0.090
Martens (1997) 25
1.000 0.072 13.868 1.000
Matzon et al (2018)26 5.824 2.736 12.395 0.000
Shields et al (2015) 27
5.000 0.507 49.266 0.168
Stockton et al (2019)28 2.769 0.603 12.714 0.190
Waterman et al (2017) 29
2.120 0.789 5.693 0.136
2.570 1.410 4.682 0.002

0.01 0.1 1 10 100

Favour single incision Favour double incision

Fig. 4

Comparison of neurological complications between single- and double-­incision techniques: forest plot of effect sizes. CI, confidence interval.

et al,34 for example, evaluated the ROM in a dichotomous way,
satisfactory or unsatisfactory (ROM deficit lower or higher than
30°, respectively), failing to find differences based on surgical
approach or technique. By considering ROM as a continuous
variable, we could report a more precise difference between SI
and DI techniques. In contrast with most comparative cohort
studies,18,20,24,30 our meta-­analysis showed in fact that ROM in
flexion and pronation was significantly higher after SI; this
is consistent with the works of El-­Hawary et al18 and Shields
VOL. 102-B, No. 12, DECEMBER 2020
et al.27 No differences in extension and supination ROMs
were detected across the studies.18,21,24,27,30 It should be noted
that between-­study differences in ROM might be the result
of different postoperative rehabilitation protocols, as well as
patient adherence to recommended treatment.
Differences in DASH score between SI and DI techniques
were evaluated in six studies, with the two approaches consis-
tently showing similarly satisfactory results; these data were
confirmed in our analysis. The total complication rate in patients
1614 D. CASTIONI, M. MERCURIO, D. FANELLI, O. COSENTINO, G. GASPARINI, O. GALASSO

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit p-value

Dunphy et al (2017)20 7.482 3.240 17.279 0.000

El-Hawary et al (2003) 21
11.308 0.499 256.198 0.128
Ford et al (2018)22 3.831 2.226 6.593 0.000
Grewal et al (2012) 30
12.333 3.306 46.014 0.000
Johnson et al (2008)23 3.783 0.141 101.826 0.428
Lang et al (2018) 24
0.073 0.004 1.504 0.090
Matzon et al (2018)26 11.297 3.321 38.429 0.000
Stockton et al (2019) 28
2.769 0.603 12.714 0.190
Waterman et al (2017)29 1.333 0.430 4.130 0.618
4.239 2.171 8.278 0.000

0.01 0.1 1 10 100

Favour single incision Favour double incision

Fig. 5

Comparison of lateral antebrachial cutaneous nerve damage between single- and double-­incision techniques: forest plot of effect sizes. CI,
confidence interval.

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit p-value

Dunphy et al (2017) 20
0.333 0.152 0.727 0.006
El-Hawary et al (2003)21 3.706 0.133 103.114 0.440
Grewal et al (2012) 30
0.907 0.055 14.997 0.946
Johnson et al (2008)23 0.333 0.030 3.721 0.372
Lang et al (2018) 24
3.302 0.149 72.988 0.450
Matzon et al (2018)26 0.295 0.012 7.320 0.456
Shields et al (2015) 27
0.190 0.009 4.219 0.294
Waterman et al (2017)29 0.991 0.040 24.594 0.995
0.430 0.226 0.816 0.010

0.01 0.1 1 10 100

Favour single incision Favour double incision

Fig. 6

Comparison of heterotopic ossification between single- and double-­incision techniques: forest plot of effect sizes. CI, confidence interval.

undergoing repair of distal biceps tendon rupture is estimated to
be between 15% and 35%.36 In our analysis, neurological and
non-­neurological complications were identified as endpoints.
The most frequently affected nerve is the LACN, with rates
reported in the literature from 5% to 57%.36 This nerve is
particularly vulnerable during a single anterior approach, when
it must be retracted for preparation of the bicipital tuberosity.
In agreement with our findings, the two largest cohort studies
included in our analysis, consisting of 970 and 780 repairs,
reported a remarkable difference in risk of injury to this nerve
between the SI and DI approaches (24.4% vs 4.1% and 16.9%
vs 5%, respectively).20,22 A limited anterior SI33 or a posterior
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single approach27 are two other strategies that have been advo-
cated as possible solutions to reduce the risk of damaging this
nerve. Apart from the LACN, no other nerve seems to be at
greater risk of injury based on the specific surgical approach.
While Dunphy et al20 reported a higher risk of PIN palsy in
the DI group (3.4% vs 0.8%, p = 0.010), other studies chal-
lenged this finding.22,29 Regarding SBRN paraesthesia, most
comparative studies reported a trend towards higher rates with
the DI technique,20,26,27,29 while the largest cohort by Ford et al22
demonstrated the opposite. The authors explained this apparent
contradiction by pointing out that, in their study, experienced
shoulder and elbow surgeons with lower overall complication
THE BONE & JOINT JOURNAL
 SINGLE- VERSUS DOUBLE-­INCISION TECHNIQUE FOR THE TREATMENT OF DISTAL BICEPS TENDON RUPTURE 1615

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit p-value

Cohen et al (2016)19 7.128 0.327 155.370 0.212

Lang et al (2018) 24
0.593 0.035 10.142 0.718
Shields et al (2015)27 5.811 0.262 128.901 0.266
Waterman et al (2017) 29
1.659 0.079 34.967 0.745
2.365 0.525 10.661 0.263

0.01 0.1 1 10 100

Favour single incision Favour double incision

Fig. 7

Comparison of superficial infections between single- and double-­incision technique: forest plot of effect sizes. CI, confidence interval.

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit p-value

Citak et al (2011) 18
2.973 0.145 61.045 0.480
Cohen et al (2016)19 0.425 0.017 10.873 0.605
Dunphy et al (2017) 20
0.560 0.173 1.813 0.334
Ford et al (2018)22 3.214 0.721 14.331 0.126
Grewal et al (2012) 30
2.854 0.285 28.612 0.373
Lang et al (2018)24 3.302 0.149 72.988 0.450
Matzon et al (2018) 26
1.800 0.161 20.157 0.633
Waterman et al (2017)29 5.096 0.287 90.375 0.267
1.473 0.721 3.007 0.288

0.01 0.1 1 10 100

Favour single incision Favour double incision

Fig. 8

Comparison of tendon re-­rupture between single- and double-­incision techniques: forest plot of effect sizes. CI, confidence interval.

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit p-value

Dunphy et al (2017)20 0.266 0.122 0.582 0.001

Ford et al (2018)22 0.669 0.371 1.206 0.181
Matzon et al (2018) 26
1.800 0.161 20.157 0.633
0.503 0.317 0.798 0.004

0.01 0.1 1 10 100

Favour single incision Favour double incision

Fig. 9

Comparison of reoperation rate between single- and double-­incision techniques: forest plot of effect sizes. CI, confidence interval.

rates were more likely to perform a SI than a DI technique. Only Heterotopic ossification is a well-­known complication of
two studies reported damage to the MN, with no significant distal biceps tendon repair, potentially leading to decreased
difference in the two groups.26,29 ROM at the elbow and radioulnar synostosis, although in the
VOL. 102-B, No. 12, DECEMBER 2020
1616 D. CASTIONI, M. MERCURIO, D. FANELLI, O. COSENTINO, G. GASPARINI, O. GALASSO
majority of cases it is an incidental finding.36 Heterotopic ossi-
fication was traditionally associated with the Boyd-­Anderson
technique,11,37 and its incidence was reduced by the subse-
quent modifications brought by Morrey et al,38 consisting of
a posterior exposure that spares the ulna from the surgical
site. In our analysis, rates of heterotopic ossification ranged
from 0.5% to 11% for the SI approach and from 1% to 21.4%
in the DI approach, with significant differences favouring the
SI technique.20,21,23,24,26,27,29,30 These findings could explain, at
least in part, the greater ROM in elbow flexion and pronation
in the SI group.
Infection is one of the most common wound complica-
tions after this surgery. While superficial infections are
often treated with a course of antibiotics and occasion-
ally debridement, deep infections can be devastating and
usually require hardware removal. Both superficial19,24,27,29
and deep infections18,29,39 were reported across the studies,
but we observed no specific trend in their occurrence based
on the surgical approach. Other wound healing disorders
were represented by cellulitis, keloid formation, rash, and
wound dehiscence, again with no differences between the
two approaches.18,19,30
Partial or full-­thickness tendon re-­rupture is reported to occur
in 1.4% of cases,32 and it usually occurs when a strenuous load
is applied to a flexed arm in the early postoperative period.36
For this reason, patients are usually instructed to limit physical
activity in the first three weeks following the operation.39 In
contrast with previous systematic reviews that reported a higher
incidence of re-­rupture with the SI approach,32,33 we found no
difference between the two techniques. This is perhaps due to
previous reviews which included a higher number of “historical
studies”, with a preference for the SI approach, as well as older
techniques and implants, as reported by Amarasooriya et al.32
Finally, another interesting finding of this review was that the
overall reoperation rate was higher in the DI approach and this
concurs with the findings from the large cohort by Dunphy et
al.20 Our systematic review is the first one to report this finding
and the result is not necessarily surprising considering that HO,
which occurs mostly in the DI group, is the main reason for
reoperation after tendon repair.32
We reported several new findings that are of interest to clini-
cians. We selected comparative studies only, allowing for pooling
of effect sizes. This minimized the bias coming from the aggrega-
tion of data of single-­arm heterogeneous trials, typical of previous
meta-­analyses, which gave rigour and credibility to our findings.
Some limitations of this review, however, must be considered.
First, we selected only literature in the English language, poten-
tially contributing to publication bias. Second, some heterogeneity
was still found across studies in terms of surgical technique and
follow-­up time, with implications for transferability of our find-
ings; in order to maintain sufficient power for the meta-­analysis,
we could not discriminate between bone tunnels, suture anchors,
cortical buttons, and interference screws, or between a limited
and extensile SI approach. Finally, surgeon experience is another
factor that could potentially impact the rate of complications20,36
and, therefore, clinicians should interpret these findings in light
of their experience and confidence with a specific approach when
counselling patients.
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In conclusion, this meta-­analysis revealed that, when SI and
DI approaches are compared after distal biceps tendon repair, no
significant differences for postoperative functional scores can be
noted. The SI demonstrated greater flexion and pronation ROMs,
a lower risk of HO and, with some possible interrelations, a lower
risk of reoperation. The DI approach, in contrast, was favourable
in terms of the lower risk of LACN damage, which is largely
represented by transient neurapraxia.
Take home message
-- The single-­incision (SI) technique results in greater elbow
flexion and pronation compared to the double-­incision (DI)
technique.
-- The risk of re-­operation for all causes is lower with the SI approach;
in part, this might be explained in part by the lower incidence of
heterotopic ossification.
-- The DI technique is associated with a lower risk of transient lateral
antebrachial cutaneous nerve palsy.
Supplementary material
‍ ‍Additional
information about differences in functional
outcomes and complications between single and double
incision techniques for the treatment of distal biceps
tendon ruptures.
References
1. Kelly MP, Perkinson SG, Ablove RH, Tueting JL. Distal biceps tendon ruptures:
an epidemiological analysis using a large population database. Am J Sports Med.
2015;43(8):2012–2017.
2. Ward JP, Shreve MC, Youm T, Strauss EJ. Ruptures of the distal biceps tendon.
Bull Hosp Jt Dis. 2014;2013(72):110–119.
3. Hetsroni I, Pilz-­Burstein R, Nyska M, et al. Avulsion of the distal biceps brachii
tendon in middle-­aged population: is surgical repair advisable? A comparative study
of 22 patients treated with either nonoperative management or early anatomical
repair. Injury. 2008;39(7):753–760.
4. John CK, Field LD, Weiss KS, Savoie FH. Single-­Incision repair of acute distal
biceps ruptures by use of suture anchors. J Shoulder Elbow Surg. 2007;16(1):78–83.
5. Olsen JR, Shields E, Williams RB, et al. A comparison of cortical button with
interference screw versus suture anchor techniques for distal biceps brachii tendon
repairs. J Shoulder Elbow Surg. 2014;23(11):1607–1611.
6. Peeters T, Ching-­Soon NG, Jansen N, et al. Functional outcome after repair of
distal biceps tendon ruptures using the endobutton technique. J Shoulder Elbow
Surg. 2009;18(2):283–287.
7. Stuby FM, Langenbeck JE, Eingartner C, Weise K, Rolauffs B. Bone tunnel
fixation versus suture anchor: mid- and long-­term results after distal biceps tendon
rupture. Sportverletz Sportschaden. 2007;21(2):88–92.(Article in German)
8. Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon:
a systematic review. Am J Sports Med. 2008;36(8):1618–1624.
9. Dobbie RP. Avulsion of the lower biceps brachii tendon: analysis of fifty-­one
previously unreported cases. Am J Surg Elsevier. 1941;51:662–683.
10. Boyd HB, Anderson LD. A method for reinsertion of the distal biceps brachii tendon.
J Bone Joint Surg Am. 1961;43-­A(7):1041–1043.
11. Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD. Proximal radioulnar
Synostosis after repair of distal biceps brachii rupture by the two-­incision technique.
Report of four cases. Clin Orthop Relat Res. 1990;253(253):133–136.
12. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting
items for systematic reviews and meta-­analyses: the PRISMA statement. BMJ.
2009;339:b2535.
13. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity
outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected].
The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602–608.
14. King GJ, Richards RR, Zuckerman JD, et al. A standardized method for
assessment of elbow function. Research Committee, American shoulder and elbow
surgeons. J Shoulder Elbow Surg. 1999;8:351–354.
15. MacDermid JC. Outcome evaluation in patients with elbow pathology: issues in
instrument development and evaluation. J Hand Ther. 2001;14(2):105–114.
16. Wells G, Shea B, O’Connell D. The Newcastle-­Ottawa Scale (NOS) for assessing
the quality of nonrandomised studies in meta-­ analyses. The Ottawa Hospital
THE BONE & JOINT JOURNAL
 SINGLE- VERSUS DOUBLE-­INCISION TECHNIQUE FOR THE TREATMENT OF DISTAL BICEPS TENDON RUPTURE
Research Institute. 2014. http://www.​ohri.​ca/​programs/​clinical_​epidemiology/​
oxford.​asp (date last accessed 24 September 2020).
17. Sterne JAC, Savović J, Page MJ, et al. Rob 2: a revised tool for assessing risk of
bias in randomised trials. BMJ. 2019;366:l4898.
18. Citak M, Backhaus M, Seybold D, et al. Surgical repair of the distal biceps brachii
tendon: a comparative study of three surgical fixation techniques. Knee Surg Sports
Traumatol Arthrosc. 2011;19(11):1936–1941.
19. Cohen SB, Buckley PS, Neuman B, et al. A functional analysis of distal biceps
tendon repair: single-­incision Endobutton technique vs. two-­incision modified Boyd-­
Anderson technique. Phys Sportsmed. 2016;44(1):59–62.
20. Dunphy TR, Hudson J, Batech M, Acevedo DC, Mirzayan R. Surgical treatment
of distal biceps tendon ruptures: an analysis of complications in 784 surgical repairs.
Am J Sports Med. 2017;45(13):3020–3029.
21. El-­Hawary R, Macdermid JC, Faber KJ, Patterson SD, King GJW. Distal
biceps tendon repair: comparison of surgical techniques. J Hand Surg Am.
2003;28(3):496–502.
22. Ford SE, Andersen JS, Macknet DM, et al. Major complications after distal
biceps tendon repairs: retrospective cohort analysis of 970 cases. J Shoulder Elbow
Surg. 2018;27(10):1898–1906.
23. Johnson TS, Johnson DC, Shindle MK, et al. One- versus two-­incision technique
for distal biceps tendon repair. HSS J. 2008;4(2):117–122.
24. Lang NW, Bukaty A, Sturz GD, Platzer P, Joestl J. Treatment of primary total
distal biceps tendon rupture using cortical button, transosseus fixation and suture
anchor: a single center experience. Orthop Traumatol Surg Res. 2018;104(6):859–863.
25. Martens C. Surgical treatment of distal biceps tendon ruptures results of a
multicentric BOTA-­study and review of the literature. Belgian Orthopedic Trauma
Association. Acta Orthop Belg. 1997;63(4):251–255.
26. Matzon JL, Graham JG, Penna S, et al. A prospective evaluation of early
postoperative complications after distal biceps tendon repairs. J Hand Surg Am.
2019;44(5):382–386.
27. Shields E, Olsen JR, Williams RB, et al. Distal biceps brachii tendon repairs: a
single-­incision technique using a cortical button with interference screw versus a
double-­incision technique using suture fixation through bone tunnels. Am J Sports
Med. 2015;43(5):1072–1076.
28. Stockton DJ, Tobias G, Pike JM, Daneshvar P, Goetz TJ. Supination torque
following single- versus double-­incision repair of acute distal biceps tendon ruptures.
J Shoulder Elbow Surg. 2019;28(12):2371–2378.
29. Waterman BR, Navarro-­Figueroa L, Owens BD. Primary repair of traumatic distal
biceps ruptures in a military population: clinical outcomes of single- versus 2-­incision
technique. Arthroscopy. 2017;33(9):1672–1678.
30. Grewal R, Athwal GS, MacDermid JC, et al. Single versus double-­incision
technique for the repair of acute distal biceps tendon ruptures: a randomized clinical
trial. J Bone Joint Surg Am. 2012;94-­A(13):1166–1174.
31. Howick J, Chalmers I, Glasziou P, et al. Explanation of the Oxford centre for
evidence-­ based medicine (OCEBM) levels of evidence (background document).
2011Oxford Centre for Evidence-­Based Medicine. https://www.​cebm.​ox.​ac.​uk/​
resources/​levels-​of-​evidence/​explanation-​of-​the-​2011-​ocebm-​levels-​of-​evidence
(date last accessed 14 October 2020).
VOL. 102-B, No. 12, DECEMBER 2020
1617
32. Amarasooriya M, Bain GI, Roper T, Bryant K, Iqbal K, Phadnis J. Complications
after distal biceps tendon repair: a systematic review. Am J Sports Med. 2020;48(12).
33. Amin NH, Volpi A, Lynch TS, et al. Complications of distal biceps tendon repair: a
meta-­analysis of single-­incision versus double-­incision surgical technique. Orthop J
Sports Med. 2016;4(10):2325967116668137.
34. Kodde IF, Baerveldt RC, Mulder PGH, Eygendaal D, van den Bekerom MPJ.
Refixation techniques and approaches for distal biceps tendon ruptures: a systematic
review of clinical studies. J Shoulder Elbow Surg. 2016;25(2):e29–e37.
35. Watson JN, Moretti VM, Schwindel L, Hutchinson MR. Repair techniques for
acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am.
2014;96-­A(24):2086–2090.
36. Garon MT, Greenberg JA. Complications of distal biceps repair. Orthop Clin North
Am. 2016;47(2):435–444.
37. Davison BL, Engber WD, Tigert LJ. Long term evaluation of repaired distal biceps
brachii tendon ruptures. Clin Orthop Relat Res. 1996;333:186–191.
38. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the
biceps brachii. A biomechanical study. J Bone Joint Surg Am. 1985;67-­A(3):418–421.
39. Hinchey JW, Aronowitz JG, Sanchez-­Sotelo J, Morrey BF. Re-­rupture
rate of primarily repaired distal biceps tendon injuries. J Shoulder Elbow Surg.
2014;23(6):850–854.
Author information:
D. Castioni, MD, Orthopaedic Resident
M. Mercurio, MD, Orthopaedic Resident
O. Cosentino, MD, Orthopaedic Resident
G. Gasparini, MD, Professor, Orthopaedic Surgeon
O. Galasso, MD, Professor, Orthopaedic Surgeon
Department of Orthopaedic and Trauma Surgery, "Magna Graecia"
University and “Mater Domini” University Hospital of Catanzaro, Catanzaro,
Italy.
D. Fanelli, MD, Clinical Development Fellow in Trauma and Orthopaedics,
Department of Rehabilitation Medicine, Woodend Hospital, Aberdeen, UK.
Author contributions:
D. Castioni: Designed the study, Acquired and interpreted the data,
Drafted, read, and approved the final manuscript.
M. Mercurio: Designed the study, Acquired and interpreted the data,
Drafted, read, and approved the final manuscript.
D. Fanelli: Performed the statistical analysis, Drafted, read and approved
the final manuscript.
O. Cosentino: Acquired the data, Read and approved the final manuscript.
G. Gasparini: Conceptualized the study, Read and approved the final
manuscript.
O. Galasso: Conceptualized and coordinated the study, Critically revised,
read, and approved the final manuscript.
Funding statement:
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article.
This article was primary edited by G. Scott.