Abstract
Background
Single-incision and double-incision techniques are widely used for distal biceps tendon repair, yet debate continues over which yields better outcomes.
Methods
A literature search was conducted across PubMed, Scopus, Cochrane Library, and Google Scholar through May 2025. Nineteen studies involving 2833 adult patients met inclusion criteria. Assessed endpoints included visual analog scale for pain, disabilities of the arm, shoulder and hand (DASH) scores, elbow ROM assessments, isometric flexion strength, heterotopic ossification, radioulnar synostosis, nerve injuries including lateral antebrachial cutaneous nerve (LACN), posterior interosseous nerve (PIN), and superficial radial nerve (SRN). Additionally, rerupture rates and other complication rates were evaluated.
Results
Compared with the double-incision approach, the single-incision technique was associated with improved DASH scores (MD: −1.08, p = .01), greater elbow flexion (MD: 8.18°, p < .001), higher isometric flexion strength (MD: 6%, p = .02), and greater pronation (MD: 4.29°, p = .03). It was also associated with a lower incidence of heterotopic ossification (risk ratio (RR): 0.51, p = .02) and radioulnar synostosis (RR: 0.07, p < .001). Conversely, the double-incision technique was associated with lower rates of LACN and SRN injuries (RR: 4.45, p < .001; and RR: 2.74, p = .005, respectively) but remained susceptible to PIN injury (RR: 0.48, p = .02). Infection, rerupture, reoperation, stiffness, delayed wound healing, and persistent pain rates were comparable between techniques (p > .05).
Conclusions
The single-incision technique appears to be associated with more favorable objective functional outcomes and fewer structural complications, whereas the double-incision approach may reduce the risk of certain sensory nerve injuries. Further high-quality randomized trials are required to confirm these associations.
Keywords: Distal biceps tendon rupture, distal biceps avulsion, single-incision technique, double-incision technique, functional recovery, complication rates
Introduction
Distal biceps tendon ruptures, also known as distal biceps avulsions, are injuries that occur at the radial tuberosity insertion of the biceps tendon. These ruptures are typically caused by a sudden, excessive eccentric contraction of the biceps brachii during activities involving heavy lifting or forceful extension against resistance. 1 The condition predominantly affects the dominant elbow of middle-aged men, with the highest incidence occurring in their 40s. This injury leads to significant impairment of forearm strength, elbow strength, and range of motion (ROM), impacting both daily activities and occupational tasks. 2
Management of distal biceps tendon rupture involves both nonoperative and operative options, depending on the patient's age, activity level, and functional demands. Nonoperative management typically includes supportive treatment followed by physical therapy and is mainly reserved for older, low-demand, or sedentary patients willing to accept some loss of function, which is the main complication of this treatment option.3,4 In contrast, operative management is recommended for young, healthy patients who wish to restore full function, as well as for partial tears unresponsive to conservative therapy and subacute/chronic ruptures.5,6
The surgical repair of distal biceps tendon ruptures can be performed using two main approaches: the single-incision technique and the double-incision technique. The single-incision approach involves, developed by Dobbie, an anterior exposure at the antecubital fossa, allowing direct access to the radial tuberosity for tendon reattachment. 7 This method is typically associated with the use of suture anchors, interference screws, intraosseous screws, or suspensory cortical buttons for tendon fixation.8,9 In contrast, the double-incision technique, popularized by Boyd and Anderson, employs a second posterolateral incision for better visualization of the radial tuberosity. 10 This method often employs bone tunnels to secure the tendon, creating a strong anatomical repair with less soft tissue disruption. 11
Despite the effectiveness of both techniques in restoring function, each carries a specific set of complications. The single-incision technique is associated with a higher incidence of nerve injuries, such as the lateral antebrachial cutaneous nerve (LACN), the posterior interosseous nerve (PIN), and the superficial radial nerve (SRN). In contrast, the double-incision technique shows a higher prevalence of heterotopic ossification and radioulnar synostosis, which can significantly limit forearm rotation. Furthermore, improper dissection between the radius and ulna during the double-incision approach increases the risk of bone bridging, leading to functional impairment. Both techniques, however, share common risks of wound healing complications, stiffness, and, less frequently, infections.12–14
Given the variability in outcomes and complication rates between the single-incision and double-incision techniques, there is ongoing debate regarding the optimal surgical approach for distal biceps tendon ruptures. The purpose of this meta-analysis is to compare the clinical and functional outcomes, and the complication rates between the two techniques, with the goal of identifying the approach that best optimizes recovery while minimizing risks.
Materials and methods
Search strategy
This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO, ID: CRD420251161821). A systematic literature search was conducted across electronic databases including PubMed, Scopus, Cochrane Library, and Google Scholar, through 19 May 2025. The search strategy utilized a combination of Medical Subject Headings and free-text terms, focusing on concepts related to distal biceps tendon rupture and its surgical repair techniques. The primary search terms included anatomical and injury-related terms such as “Distal Biceps,” “Biceps Tendon Rupture,” “Biceps Tendon Repair,” “Distal Biceps Reconstruction,” and surgical intervention techniques like “Single-Incision” and “Double-Incision.” Boolean operators “AND” and “OR” were applied to optimize the search for both sensitivity and specificity. In addition, the reference lists of all included articles and relevant systematic reviews were manually screened to identify any additional eligible studies.
Eligibility criteria and study selection
Studies were considered eligible based on the following criteria:
Comparative clinical studies including randomized controlled trials (RCTs), prospective cohort studies, or retrospective cohort studies that evaluated the use of single-incision versus double-incision techniques for the surgical repair of distal biceps tendon ruptures.
Adult patients (≥18 years) who underwent primary surgical intervention for distal biceps tendon ruptures.
Studies with clearly defined outcomes measured at specific follow-up periods.
Exclusion criteria included noncomparative studies (such as case series or case reports), studies involving pediatric populations, patients with nonsurgical management, studies focusing solely on revision surgeries, technical notes, abstracts without full text, and publications not available in English. Additionally, studies that did not provide sufficient data for analysis or lacked clear differentiation between single-incision and double-incision techniques were excluded.
Data extraction
Two independent investigators extracted data using a standardized electronic form. The extracted information included the following:
Study characteristics: first author, publication year, study design, sample size, and follow-up duration.
Patient demographics: mean age, sex distribution, cause of injury, and time from injury to surgery.
Surgical details: technique used (single-incision vs double-incision), specific surgical approach (e.g. Boyd-Anderson, anterior approach), and the type of fixation (e.g. suture anchors, Endobuttons, transosseous sutures, cortical screws).
- Outcomes measured:
- Pain scores: visual analog scale (VAS).
- Functional scores: disabilities of the arm, shoulder and hand (DASH).
- ROM: flexion, extension, pronation, and supination, in addition to isometric flexion strength.
- Nerve-related complications: LACN, PIN, and SRN injuries.
- Structural complications: proximal radioulnar synostosis, heterotopic ossification, infection, and distal biceps tendon rerupture.
- Other reported complications.
Discrepancies in data extraction were resolved through discussion between reviewers, with a third investigator consulted in cases of disagreement to ensure accuracy and completeness. Interrater agreement between the two primary reviewers was substantial, with κ = 0.88 at the title/abstract screening stage and κ = 0.92 at the full-text review stage.
Risk of bias assessment
The methodological quality of the included studies was evaluated using two well-established tools: the risk of bias in nonrandomized studies of interventions (ROBINS-I) for non-RCTs 15 and the Revised Cochrane Risk of Bias Tool (RoB 2.0) for RCTs. 16 The ROBINS-I tool assesses seven key domains, including confounding, participant selection, intervention classification, deviations from intended interventions, missing data, outcome measurement, and selection of reported outcomes. Each domain is rated as low, moderate, serious, or critical risk of bias. The RoB 2.0 tool evaluates RCTs across five domains: randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and selection of reported results. The overall risk of bias for each study was determined based on the highest level of risk identified in any single domain. Two independent reviewers performed the assessments, with any disagreements resolved through discussion and consensus or with the involvement of a third reviewer if necessary.
Publication bias and certainty methodological assessment
To evaluate potential publication bias, we performed Egger's regression tests for all outcomes with three or more contributing studies, and an intercept with a p-value less than .05 was considered statistically significant and indicative of small-study effects. A GRADE summary of evidence, certainty and findings was also conducted for outcomes that reached statistical significance between the two groups.
Statistical analysis
Statistical analysis was conducted using Review Manager (RevMan) version 5.4 (The Cochrane Collaboration, 2020). For continuous outcomes, mean differences were calculated. If different scales were used across studies, standardized mean differences were applied, both reported with 95% confidence intervals (CIs). For dichotomous outcomes, risk ratios (RR) with 95% CIs were used. Heterogeneity among studies was assessed using the Chi-square (Q) test and the I² statistic, with heterogeneity considered significant when p ≤ .10 or I² > 50%. A random-effects model was employed when heterogeneity was substantial, otherwise, a fixed-effect model was applied. A p-value < .05 was considered statistically significant.
For handling missing SDs and medians, when SDs were unavailable, they were derived from standard errors (SE) using the formula SD = SE × √n or from 95% CIs using SD = (CI width) × √n/(2 × 1.96). If only interquartile ranges (IQRs) were reported, SD ≈ IQR/1.35; if only ranges were provided, SD ≈ (max − min)/4, adjusted for small sample sizes. For studies reporting medians and IQRs instead of means and SDs, conversions were performed using the methods of Luo et al. and Wan et al., as implemented in our analysis code. Sensitivity analyses were conducted excluding converted data to verify robustness. A p-value < .05 was considered statistically significant.
For continuity corrections in zero-event data, binary outcomes were pooled using the inverse-variance random-effects method when no zero cells were present. For single-zero studies, the Mantel–Haenszel method with a treatment-arm continuity correction was used. Double-zero studies were excluded from the primary RR analysis and examined separately in sensitivity analyses using the Mantel–Haenszel risk difference and a binomial generalized linear mixed model. A p-value < .05 was considered statistically significant.
Results
Study selection
The systematic literature search identified a total of 587 records across the selected databases, including PubMed (n = 171), Scopus (n = 187), Cochrane Library (n = 11), and Google Scholar (n = 218). After removing duplicates, 227 records were screened by title and abstract. Of these, 110 were excluded. The remaining 117 full-text articles were assessed for eligibility, and 98 were excluded. Ultimately, 19 studies met all inclusion criteria and were included in the quantitative synthesis. The PRISMA flowchart (Figure 1) illustrates the study selection process.
Figure 1.
PRISMA flow diagram for study identification and selection.
Baseline characteristics
The final analysis included 19 studies published between 1997 and 2023, comprising 18 retrospective studies and one RCT. Together, these studies involved a total of 2833 adult patients (1946 in the single-incision group and 887 in the double-incision group), with individual sample sizes ranging from four to 652 participants. The mean age of participants varied approximately from 36.3 to 53.61 years, and most studies included a predominantly male population. The majority of injuries were reported as work-related, typically resulting from eccentric loading of the flexed elbow during heavy lifting or pulling activities. The mean time from injury to surgery across all studies was calculated at 19.05 ± 5.69 days.
All included studies compared the two main surgical techniques for distal biceps tendon repair: single-incision and double-incision approaches. The single-incision technique was primarily performed using an anterior approach, with suture anchors (e.g. Mitek), Endobuttons, cortical screws, and tension-slide techniques as the main fixation methods. Some studies also utilized interference screws and transosseous suture methods in specific cases. In contrast, the double-incision technique was mostly executed with a Boyd-Anderson or Morrey modification, which allows for enhanced visualization of the radial tuberosity. The most common fixation methods for double-incision included bone tunnels with transosseous sutures, bony trough techniques, and Krackow suture configurations.
The follow-up periods varied across studies, ranging from four months to 4.3 years. A detailed overview of the baseline characteristics of the included studies is provided in Table 1.
Table 1.
Characteristics and methodological details of included studies.
| Author, year | Study design | Study population (n) | Intervention group 1 | Intervention group 2 | Group 1 follow-up duration (Mean ± SD or maximum) | Group 2 follow-up duration (Mean ± SD or maximum) | Measured outcomes | Mean age (years ± SD) group 1 | Mean age (years ± SD) group 2 |
|---|---|---|---|---|---|---|---|---|---|
| Martens et al., 1997 17 | Retrospective study | 18 | Single-incision (n = 12) |
Double-incision (n = 6) |
4 ± 0.5 months | Elbow ROM (flexion, extension,
supination, pronation) Motor or sensory nerve deficit Calcification at the tuberosity Return to work |
50 ± 7 | ||
| |||||||||
| El Hawary et al, 2003 18 | Prospective study | 19 | Single-incision (n = 9)
|
Double-incision (n = 10)
|
12 months | Patient rating scales SF36 PREE Elbow ROM (flexion, extension, pronation, supination) Elbow isometric and isokinetic strength (flexion and supination) |
47 ± 5.8 | 44 ± 7.8 | |
| Johnson et al, 2008 19 | Retrospective study | 26 | Single-incision (n = 12)
|
Double-incision (n = 14)
|
26 ± 14 months | 31 ± 21 months | Elbow isokinetic strength and endurance
(supination, flexion) Active and passive elbow ROM (flexion, extension, supination, pronation) Satisfaction Percentage of recovery Time until recovery Motor and sensory function of the upper extremity Heterotopic ossification and radioulnar synostosis |
49 ± 10 | 42 ± 7 |
| Citak et al, 2011 20 | Retrospective study | 54 | Single-incision (n = 39)
|
Double-incision (n = 15) Bone tunnels with transosseous sutures |
28.9 ± 18.6 months | 37 ± 18.6 months | Elbow ROM (flexion, extension,
pronation, supination) DASH score Duration of the surgery LOS Complications (neuropraxia, rerupture, wound healing disorder, stiffness) |
46.4 ± 8.5 | 48 ± 8.5 |
| Grewal et al, 2012 21 | RCT | 90 | Single-incision (n = 47) Anterior approach with 2 suture anchors (Mitek G4) |
Double-incision (n = 43)
|
24 months | ASES score (pain, function) Muscle strength Complication rates (Neuropraxia, rerupture, heterotopic ossification) DASH score PREE score Elbow ROM (flexion, extension, pronation, supination) Elbow isometric and isokinetic strength |
45.3 ± 7.4 | 44.9 ± 9.3 | |
| Shields et al, 2015 22 | Retrospective study | 41 | Single-incision (n = 20)
|
Double-incision (n = 21)
|
12 months | Elbow ROM (flexion, extension,
pronation, supination) Elbow strength measurements (flexion, supination) Complications (infection, radial nerve paresthesia, heterotopic ossification, weakness) DASH score VAS for pain Workers’ compensation status Patient satisfaction measures |
52 ± 9.5 | 43.7 ± 8.7 | |
| Cohen et al, 2016 23 | Retrospective study | 58 | Single-incision (n = 25)
|
Double-incision (n = 33)
|
24 months | DASH score (total, work, sports) Return to work Satisfaction Complications (rerupture, decrease pronation-supination, pain, numbness, cellulitis, cheloid lesions) |
52.6 ± 8.1 | 53.1 ± 8.2 | |
| Guglielmino et al, 2016 24 | Retrospective study | 20 | Single-incision (n = 13) |
Double-incision (n = 7) |
24 months | ESS score | 36.3 ± 7.25 | ||
| |||||||||
| Dunphy et al, 2017 25 | Retrospective study | 784 | Single-incision (n = 639)
|
Double-incision (n = 145)
|
49 ± 22.6 months | Elbow ROM Complications (infection, rerupture, reoperation, heterotopic ossification) Nerve complications (major nerve palsy, LACN palsy, SRN palsy, PIN palsy) |
48 ± 16 | ||
| Waterman et al, 2017 26 | Retrospective study | 284 | Single-incision (n = 214) |
Double-incision (n = 70) |
38.4 ± 24 months | Complications (infection,
rerupture, reoperation,
revision, malfunction,
heterotopic ossification) Nerve injury (LACN, SRN, Radial, MABCN, Median, PIN) |
38.9 ± 7.3 | ||
| |||||||||
| Ford et al, 2018 27 | Retrospective study | 970 | Single-incision (n = 652) |
Double-incision (n = 318) |
5.6 ± 0.9 months | Reoperation Major complications (rerupture, infection, PIN palsy, heterotopic ossification with reoperation, loss of ROM with reoperation, proximal radioulnar synostosis, complex regional pain syndrome, brachial artery laceration, fascial dehiscence with reoperation) Minor complications (LACN neuritis or numbness, SRN neuritis or numbness, cubital tunnel syndrome, lateral epicondylitis, symptomatic heterotopic ossification, superficial infection |
49 | ||
| |||||||||
| Lang et al, 2018 28 | Retrospective study | 47 | Single-incision (n = 30)
|
Double-incision (n = 17)
|
46.3 ± 13.8 weeks | DASH score Strength measurements (flexion, supination and pronation) Complications (re-rupture, heterotopic ossifications, nerve paresthesia, superficial infection) Elbow ROM (flexion, supination, pronation) |
47.1 ± 8.9 | 43.9 ± 8.9 | |
| Matzon et al, 2019 29 | Retrospective study | 212 | Single-incision (n = 112) Tension-slide technique with suture button (105) Suture anchors (9) |
Double-incision (n = 100) Modified Boyd-Anderson technique |
17.6 ± 2 weeks | Complications (infection, wound dehiscence, sensory nerve injury, motor nerve injury, heterotopic ossification, rerupture, olecranon bursitis, LACN and SRN sensory neurapraxias) | 48.7 ± 12 | ||
| Stockton et al, 2019 30 | Retrospective study | 37 | Single-incision (n = 22)
|
Double-incision (n = 15)
|
28.1 ± 14.6 | Peak supination torque
strength of supination in
neutral, 45°, 60° supination Peak supination torque strength of pronation in 45° Elbow ROM Flexion-extension arc (% of unaffected side) Supination and supination range and arc (% of unaffected side) Grip strength (% of unaffected side) ASES score (pain, function) SF-12 (PCS, MCS) DASH (total, work, sports/arts) VAS (pain, function) Complications (heterotopic ossification, LACN and PIN nerve injury) |
47.8 ± 2.6 | 46.5 ± 1.9 | |
| Grewal et al, 2021 31 | Retrospective case series | 277 (8 included in first repair analysis) | Single-incision (n = 4) Most with interference screw + cortical button |
Double-incision (n = 4) All with transosseous suture repair |
8.7 months | SF-12 Quick-DASH |
47.5 ± 9 | ||
| Di Stefano et al, 2021 32 | Retrospective study | 54 | Single-incision (n = 29)
|
Double-incision (n = 25)
|
26.1 ± 11.85 months | DASH score Mayo Score Elbow ROM (flexion, extension, pronation, supination) Complications (infections, heterotopic ossification, LACN palsy, synostosis) Radiographic outcomes |
48.85 ± 6.62 | ||
| Kapicioglu et al, 2022 33 | Retrospective study | 17 | Single-incision (n = 9) Anterior approach with cortical suspension system + tenodesis screw |
Double-incision (n = 8) Posterolateral double-incision bone tunnel technique |
33 ± 10.5 months | MEPS Elbow ROM (flexion, extension, pronation, supination) Complications (fracture, wound problem, infection, stiff elbow, heterotopic ossification, synostosis, LACN palsy, PIN palsy, re-rupture, hematoma) |
45.6 ± 6.4 | ||
| Hogea et al, 2023 34 | Retrospective study | 69 | Single-incision (n = 45) Endobutton + screw |
Double-incision (n = 24) Morrey-modified approach, Krackow sutures, drill holes |
24 months | Elbow ROM (flexion, extension,
pronation, supination) Elbow isometric strength Pain levels Satisfaction Major complications (proximal radio-ulnar synostosis, PIN palsy, re-rupture) Minor complications (intermittent pain, ROM deficiency, isometric strength deficiency, LACN injury, infection) |
N/A | ||
| Micheloni et al, 2023 35 | Retrospective study | 25 | Single-incision (n = 13) Anterior approach, BicepsButton + interference screw |
Double-incision (n = 12) Boyd-Anderson style, Krackow sutures, transosseous fixation |
4.31 ± 0.5 years | Elbow ROM (extension, flexion, supination
and pronation with and without resistance) Complications (Neuropraxia and heterotopic ossification) |
47 ± 7.5 | ||
Note. ASES: American Shoulder and Elbow Surgeons; DASH: disability of the arm, shoulder, and hand; ESS: Epworth Sleepiness Scale; LACN: lateral antebrachial cutaneous nerve; LOS: length of stay; MABCN: medial antebrachial cutaneous nerve; MEPS: Mayo Elbow Performance Score; PIN: posterior interosseous nerve; PREE: patient-rated elbow evaluation; RCT: randomized controlled trial; ROM: range of motion; SF-12: 12-Item Short Form Survey; SF-36: 36-Item Short Form Survey; SRN: superficial branch of radial nerve; VAS: Visual Analog Scale
Methodological quality assessment
The nonrandomized studies (n = 18) were assessed using the ROBINS-I tool, with all studies rated as having an overall moderate risk of bias. In Domain 1 (confounding) and Domain 7 (selection of the reported result), the majority of studies showed a moderate risk of bias, reflecting the inherent limitations of retrospective designs in controlling for external variables and ensuring unbiased outcome selection. Domain 3 (classification of interventions) was consistently rated as low risk across all studies, suggesting that the interventions were well-defined and consistently applied. The remaining domains (D2, D4, D5, and D6), which include participant selection, deviations from intended interventions, missing outcome data, and measurement of outcomes, demonstrated variable risk levels ranging from low to moderate across different studies. This variability likely reflects differences in follow-up consistency, data completeness, and accuracy in measurement methods among the included studies.
For the RCT assessed using the RoB-2 tool, the overall risk of bias was rated as some concerns. This judgment was driven by deviations from intended interventions (D2) and bias in the selection of reported results (D5), where minor discrepancies were noted in intervention application and selective reporting. However, the study showed low risk in randomization (D1), missing outcome data (D3), and measurement of the outcome (D4), reflecting strong methodological quality in these domains.
A detailed visual representation of the risk of bias assessment is provided in Figure 2.
Figure 2.
Risk of bias assessment for RCT (ROB2) and non-RCT studies (ROBINS-I).
Note: RCT: randomized controlled trial; ROBINS-I: risk of bias in nonrandomized studies of interventions.
Publication bias and certainty assessment
Egger's test showed no significant publication bias (p > .05), indicating low risk and supporting the robustness of the findings. The GRADE certainty assessment and summary of findings also demonstrated a high overall certainty of evidence for all outcomes (Table 2).
Table 2.
GRADE certainty assessment.
| Single-incision compared to double-incision in distal biceps tendon repair Bibliography: | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Certainty assessment | Summary of findings | ||||||||||
| Participants (studies) Follow-up |
Risk of bias | Inconsistency | Indirectness | Imprecision | Publication bias | Overall certainty of evidence | Study event rates (%) | Relative effect [95% CI] |
Anticipated absolute effects | ||
| With double-incision | With single-incision | Risk with double-incision | Risk difference with single-incision | ||||||||
| Postoperative VAS pain at 1.5 years | |||||||||||
| 78 (2 nonrandomized studies) |
Not serious | Serious a | Not serious | Not serious | Strong association all plausible residual confounding would reduce the demonstrated effect |
⨁⨁⨁◯ Moderatea |
36 | 42 | - | 36 | MD 0.14 lower (0.93 lower to 0.65 higher) |
| DASH score at 2 years | |||||||||||
| 232 (4 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Very strong association | ⨁⨁⨁⨁ High |
108 | 124 | - | 108 | MD 1.08 lower (1.94 lower to 0.22 lower) |
| Postoperative elbow extension range of motion (ROM) at 1.5 years | |||||||||||
| 230 (5 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Strong association | ⨁⨁⨁◯ Moderate |
103 | 127 | - | 103 | MD 0.73 higher (0.34 lower to 1.81 higher) |
| Postoperative elbow flexion ROM at 1 year | |||||||||||
| 114 (3 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Very strong association | ⨁⨁⨁⨁ High |
46 | 68 | - | 46 | MD 8.18 higher (5.14 higher to 11.23 higher) |
| Postoperative elbow pronation ROM at 2 years | |||||||||||
| 205 (5 nonrandomized studies) |
Not serious | Serious b | Not serious | Not serious | Very strong association | ⨁⨁⨁◯ Moderate b |
94 | 111 | - | 94 | MD 4.29 higher (0.47 higher to 8.11 higher) |
| Postoperative elbow supination ROM at 2 years | |||||||||||
| 242 (6 nonrandomized studies) |
Not serious | Serious c | Not serious | Not serious | Very strong association all plausible residual confounding would reduce the demonstrated effect |
⨁⨁⨁⨁ High c |
109 | 133 | - | 109 | MD 0.72 lower (3.14 lower to 1.71 higher) |
| Postoperative elbow isometric flexion strength at 1.5 years | |||||||||||
| 156 (3 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Strong association all plausible residual confounding would suggest spurious effect, while no effect was observed |
⨁⨁⨁⨁ High |
70 | 86 | - | 70 | MD 0.06 higher (0.01 higher to 0.11 higher) |
| Lateral antebrachial cutaneous nerve injury at 2 years | |||||||||||
| 1549 (10 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Very strong association all plausible residual confounding would suggest spurious effect, while no effect was observed |
⨁⨁⨁⨁ High |
16/434 (3.7%) | 222/1115 (19.9%) |
RR 4.45 (2.81 to 7.05) |
16/434 (3.7%) |
127 more per 1000 (from 67 more to 223 more) |
| Posterior interosseous nerve injury at 2 years | |||||||||||
| 2124 (6 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Strong association all plausible residual confounding would reduce the demonstrated effect |
⨁⨁⨁⨁ High |
16/565 (2.8%) | 19/1559 (1.2%) |
RR 0.48 (0.26 to 0.91) |
16/565 (2.8%) |
15 fewer per 1000 (from 21 fewer to 3 fewer) |
| Superficial radial nerve injury at 2 years | |||||||||||
| 1321 (4 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Strong association | ⨁⨁⨁◯ Moderate |
9/336 (2.7%) | 54/985 (5.5%) |
RR 2.74 (1.36 to 5.51) |
9/336 (2.7%) |
47 more per 1000 (from 10 more to 121 more) |
| Heterotopic ossification at 2 years | |||||||||||
| 1563 (9 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | All plausible residual confounding would reduce the demonstrated effect | ⨁⨁⨁◯ Moderate |
20/447 (4.5%) | 25/1116 (2.2%) |
RR 0.51 (0.29 to 0.89) |
20/447 (4.5%) |
22 fewer per 1000 (from 32 fewer to 5 fewer) |
| Infections at 2 years | |||||||||||
| 1422 (6 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Strong association | ⨁⨁⨁◯ Moderate |
8/378 (2.1%) | 13/1044 (1.2%) |
RR 0.63 (0.28 to 1.42) |
8/378 (2.1%) |
8 fewer per 1000 (from 15 fewer to 9 more) |
| Distal biceps tendon rerupture at 2 years | |||||||||||
| 2499 (8 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Strong association all plausible residual confounding would reduce the demonstrated effect |
⨁⨁⨁⨁ High |
9/741 (1.2%) | 40/1758 (2.3%) |
RR 1.71 (0.88 to 3.30) |
9/741 (1.2%) |
9 more per 1000 (from 1 fewer to 28 more) |
| Synostosis at 1.5 years | |||||||||||
| 1093 (3 nonrandomized studies) |
Not serious | Not serious | Not serious | Not serious | Very strong association | ⨁⨁⨁⨁ High |
16/367 (4.4%) | 1/726 (0.1%) |
RR 0.07 (0.02 to 0.27) |
16/367 (4.4%) |
41 fewer per 1000 (from 43 fewer to 32 fewer) |
| Other postoperative complications | |||||||||||
| 2609 (10 nonrandomized studies) |
Not serious | Very serious d | Not serious | Not serious | Strong association all plausible residual confounding would suggest spurious effect, while no effect was observed |
⨁⨁◯◯ Low d |
102/786 (13.0%) | 222/1823 (12.2%) |
RR 1.38 (0.71 to 2.65) |
102/786 (13.0%) |
49 more per 1000 (from 38 fewer to 214 more) |
Note: CI: confidence interval; MD: mean difference; RR: risk ratio.
In the overall analysis, there is a substantial heterogeneity (I² = 53%) with a p-value of Cochran Q test at 0.15.
Although there is no overlap in the confidence interval, a substantial heterogeneity (I² = 69%) was observed with p-value of Cochran Q test at .01.
In the analysis, an overlap in the confidence interval of the mean difference was observed (95% CI [−3.14 to 1.71]), also a substantial heterogeneity (I² = 57%) with Cochran Q p-value = .04 were noted.
In the overall analysis, there is a considerable heterogeneity (I² = 79%) with an extremely low p-value of Cochran Q test (p < .00001).
Pain assessment
VAS for pain was reported in two studies (n = 78). The pooled random-effect model showed no significant difference (p = .73) at 1.5 years postsurgery between the single-incision and double-incision groups (Figure 3). There was moderate heterogeneity among the studies (I² = 53%, p = .15).
Figure 3.
Forest plot of postoperative VAS for pain at 1.5 years.
Note: VAS: visual analog scale.
Clinical and functional outcomes
DASH scores
DASH scores at two years postsurgery, where lower scores indicate better functional improvement, were reported in four studies, involving a total of 232 patients. The pooled fixed-effect analysis demonstrated a significant difference (p = .01) in favor of the single-incision technique compared to the double-incision approach (Figure 4), with a MD of −1.08 points (95% CI [−1.94 to −0.22]). There was no significant heterogeneity among the studies (I² = 0%, p = .62).
Figure 4.
Forest plot of postoperative DASH score at 2 years.
Note: DASH: disabilities of the arm, shoulder and hand.
Elbow flexion ROM
Elbow flexion ROM at one year postsurgery was reported in three studies, involving a total of 114 patients. The pooled fixed-effect analysis demonstrated a significant difference (p < .00001) in favor of the single-incision technique compared to the double-incision approach (Figure 5), with a MD of 8.18° (95% CI [5.14 to 11.23]). There was no significant heterogeneity among the studies (I² = 0%, p = .39).
Figure 5.
Forest plot of postoperative elbow flexion range of motion at 1 year (°).
Elbow isometric flexion strength
Elbow isometric flexion strength, measured as a percentage of the uninjured side during contraction without joint movement, was reported in three studies, involving a total of 156 patients at 1.5 years postsurgery (Figure 6). The pooled fixed-effect analysis showed a significant difference (p = .02) in favor of the single-incision technique, with a MD of 6% (95% CI [1 to 11]). There was low heterogeneity among the studies (I² = 20%, p = .29).
Figure 6.
Forest plot of postoperative elbow isometric flexion strength at 1.5 years (% of uninjured side).
Elbow extension ROM
Elbow extension ROM at 1.5 years postsurgery was reported in five studies and involved a total of 230 patients. Although the single-incision group demonstrated higher extension values on average, the pooled fixed-effect analysis showed no significant difference (p = .18) between the two surgical techniques (Figure 7). There was no significant heterogeneity among the studies (I² = 0%, p = .93).
Figure 7.
Forest plot of postoperative elbow extension range of motion at 1.5 years (°).
Elbow pronation ROM
Elbow pronation ROM at two years postsurgery was reported in five studies, involving a total of 205 patients. The pooled random-effect analysis demonstrated significantly higher values (p = .03) in favor of the single-incision technique (Figure 8), with a MD of 4.29° (95% CI [0.47 to 8.11]). There was substantial heterogeneity among the studies (I² = 69%, p = .01).
Figure 8.
Forest plot of postoperative elbow pronation range of motion at 2 years (°).
Elbow supination ROM
Elbow supination ROM at two years postsurgery was reported in six studies and involved 242 patients. The pooled random-effect analysis demonstrated no significant difference (p = .56) between both surgical techniques (Figure 9). There was moderate heterogeneity among the studies (I² = 57%, p = .04).
Figure 9.
Forest plot of postoperative elbow supination range of motion at 2 years (°).
Nerve-Related complication rates
Lateral antebrachial cutaneous nerve
The rate of LACN injury at two years postsurgery, which provides sensation to the lateral forearm, was reported in nine studies (n = 1549). The pooled fixed-effect analysis demonstrated a significantly higher rate of LACN injury in the single-incision group (Figure 10(a)), with an RR of 4.45 (95% CI [2.81 to 7.05], p < .00001). There was no significant heterogeneity among the studies (I² = 0%, p = .45).
Figure 10.
Forest plot of postoperative nerve-related complication rates at 2 years. (a) LACN injury, (b) SRN injury, (c) PIN injury.
Note: LACN: lateral antebrachial cutaneous nerve; PIN: posterior interosseous nerve; SRN: superficial radial nerve
Superficial radial nerve
The rate of SRN injury, responsible for sensory innervation to the back of the hand, was reported in four studies at two years postsurgery, involving 1321 patients. The pooled random-effect analysis showed that single-incision group was associated with a higher incidence of SRN injury, with a pooled RR of 2.74 (95% CI [1.36–5.51], p = .005) (Figure 10(b)). There was no significant heterogeneity among the studies (I² = 0%, p = .94).
Posterior interosseous nerve
In contrast, the rate of PIN injury, which affects motor control in the posterior forearm muscles, was assessed in six studies, also at two years postsurgery (n = 2161). The pooled fixed-effect resulted in an RR of 0.48 (95% CI [0.26–0.91], p = .02), indicating a lower risk of PIN injury in the single-incision group (Figure 10(c)). There was moderate heterogeneity among the studies (I² = 35%, p = .19).
Structural complication rates
Proximal radioulnar synostosis
Radioulnar synostosis rates, a condition where abnormal bone growth leads to the fusion of the radius and ulna, limiting forearm rotation, was reported at two years postsurgery in five studies involving a total of 1136 patients. The pooled fixed-effect analysis demonstrated a significantly lower rate of synostosis in the single-incision group compared to the double-incision approach (Figure 11(a)), with a RR of 0.07 (95% CI [0.02 to 0.27], p = .0002). There was no significant heterogeneity among the studies (I² = 0%, p = .62).
Figure 11.
Forest plot of postoperative structural complication rates at 2 years. (a) Synostosis, (b) heterotopic ossification, (c) infection, (d) distal biceps tendon rerupture.
Heterotopic ossification
Heterotopic ossification rates, a condition characterized by the abnormal formation of bone in soft tissues, was reported at two years postsurgery in eight studies, with a total of 1563 patients. The pooled fixed-effect analysis resulted in a significantly lower rate of heterotopic ossification in the single-incision group compared to the double-incision approach (Figure 11(b)), with an RR of 0.51 (95% CI [0.29 to 0.89], p = .02). There was no significant heterogeneity among the studies (I² = 0%, p = .73).
Infection
Infection rates at two years postsurgery were reported in six studies, involving a total of 1422 patients. The pooled fixed-effect analysis showed no significant difference (p = .27) between the two surgical techniques (Figure 11(c)). There was no significant heterogeneity among the studies (I² = 0%, p = .62).
Distal biceps tendon rerupture
The rates of distal biceps tendon rerupture at two years postsurgery were reported in eight studies, involving a total of 2499 patients. The pooled fixed-effect analysis showed no significant difference (p = .11) between both techniques (Figure 11(d)). There was no significant heterogeneity among the studies (I² = 0%, p = .58).
Other complication rates
Remaining complications such as elbow stiffness, persistent pain, radial neck fracture, complex regional pain syndrome, delayed wound healing, and scar hypertrophy, were reported in ten studies, involving a total of 2609 patients. The pooled random-effect analysis showed no significant difference (p = .34) between the two surgical techniques (Figure 12). There was substantial heterogeneity among the studies (I² = 78%, p < .00001).
Figure 12.
Forest plot of postoperative other complication rates at 2 years.
Discussion
The management of distal biceps tendon ruptures remains a topic of considerable debate, particularly regarding the optimal surgical approach for restoring function and minimizing complications. This meta-analysis presents a comprehensive synthesis of evidence comparing the single-incision and double-incision techniques for the surgical repair of distal biceps tendon injuries. While previous meta-analyses36–38 have suggested potential differences in complication rates between the two approaches, our updated analysis, which integrates a consolidated evaluation of pain, functional outcomes, nerve-related injuries, structural complications, and other adverse events at specific follow-up periods, identifies several potential advantages and limitations associated with each of these techniques. This study incorporates a larger and more contemporary dataset (up to 2025) and applies strengthened methodology, including dual risk-of-bias tools (ROBINS-I for nonrandomized studies and RoB-2 for RCTs). Additionally, it standardizes outcome definitions and aligning results to specific timepoints for each variable, while introducing new quantitative assessments of isometric flexion strength and individual nerve subtypes (LACN, SRN, and PIN). These updates provide a more refined comparison of functional and structural outcomes, clarifying the balance between nerve safety and biomechanical recovery that earlier analyses addressed less completely.
The single-incision technique is a widely adopted approach for the surgical repair of distal biceps tendon ruptures, involving a single anterior incision at the antecubital fossa. 39 This method provides direct access to the radial tuberosity for tendon reattachment while minimizing soft tissue disruption. During the procedure, dissection is performed between the brachioradialis and pronator teres, and the tendon is then reattached using various fixation methods, including suture anchors, cortical buttons, and interference screws.40,41 Our meta-analysis shows that the single-incision technique was associated with higher rates of LACN and SRN injuries (p < .01), though these injuries are typically transient and sensory in nature, rarely resulting in major functional impairment.
In contrast, the double-incision technique is a well-established approach for the surgical repair of distal biceps tendon ruptures, designed to improve visualization of the radial tuberosity while minimizing the need for extensive anterior dissection. This method utilizes a smaller anterior incision at the antecubital fossa combined with a second posterolateral incision.11,42 The anterior dissection is similar to the single-incision approach, exposing the tendon for retrieval. Posterior dissection is performed between the extensor carpi ulnaris and extensor digitorum communis, allowing access to the radial tuberosity for tendon reattachment10,43 This second incision provides enhanced access to the tuberosity, facilitating secure fixation while reducing the need for deep anterior dissection, which theoretically decreases the risk of nerve injury. The tendon is reattached using bone tunnels or transosseous sutures, which provide strong mechanical fixation but require more extensive bone preparation.44,45
However, this double-incision approach introduces distinct complications, particularly the increased risk of heterotopic ossification (p = .02) and radioulnar synostosis (p < .001), likely resulting from the exposure of the interosseous membrane and ulnar periosteum during the procedure. 46 Furthermore, although the DASH score favors the single-incision technique (p = .01), the MD (−1.08) remains well below the minimal clinically important difference of approximately 10 points, 47 indicating that the improvement, while statistically significant, may not translate into a perceptible functional advantage in daily life. However, differences in ROM, particularly elbow flexion (p < .001), isometric flexion strength (p = .02), and pronation (p = .03), appear more relevant from a biomechanical standpoint and may reflect tangible functional benefits in upper-limb performance following single-incision repair. This may be attributed to increased soft tissue disruption and greater periosteal exposure during the double-incision approach, which can impair tendon healing and contribute to scar tissue formation. 48 Additionally, the risk of PIN injury is notably higher, potentially resulting from the deeper dissection required for posterior access to the radial tuberosity.
Taken together, these findings indicate that neither approach is universally superior but rather suited to different clinical priorities. The single-incision technique may be preferred for active patients requiring maximal motion and strength, whereas the double-incision approach may be advantageous when minimizing sensory nerve injury risk is paramount. Both methods achieve comparable subjective functional outcomes, and the choice should ultimately be individualized, balancing nerve safety, tissue exposure, and functional goals rather than assuming one method's overall superiority.
Limitations
Several limitations of this meta-analysis should be acknowledged. First, variability in surgical techniques and fixation methods across the included studies may impact the comparability of outcomes. The choice of incision approach can also be linked with specific fixation methods, such as cortical buttons or interference screws for the single-incision technique and bone tunnels or transosseous sutures for the double-incision approach, which may influence biomechanical strength and clinical recovery. Moreover, differences in injury chronicity (acute vs chronic ruptures) and postoperative rehabilitation protocols are known to affect tendon healing, ROM, and complication rates. Because the available data did not permit subgroup analyses to control for these variables, their potential influence on pooled estimates cannot be excluded. Finally, the limited number of high-quality RCTs for certain outcomes, such as nerve injuries and structural complications, is also considered a limitation. Future research should prioritize well-designed, large-scale RCTs with standardized surgical protocols, consistent rehabilitation regimens, and stratification by fixation type and chronicity to improve the robustness and clinical applicability of the findings.
Conclusion
This meta-analysis provides an updated and comprehensive comparison of single-incision and double-incision techniques for distal biceps tendon repair. Both techniques remain effective and reliable, each offering distinct advantages. The single-incision approach tends to yield better objective recovery in ROM and strength, whereas the double-incision technique carries a lower risk of sensory nerve injury, particularly to the LACN and SRN.
Surgical selection should therefore be guided by patient characteristics and procedural priorities, favoring the single-incision approach for high-demand individuals seeking maximal motion and strength, and the double-incision approach when minimizing nerve injury risk is a primary consideration. Further high-quality randomized trials with standardized protocols are warranted to confirm these findings and refine surgical decision-making.
Footnotes
ORCID iDs: Guy Awad https://orcid.org/0009-0003-9902-7878
Marc Boutros https://orcid.org/0000-0003-1765-4222
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Availability of data: All data underlying this meta-analysis are publicly available from the cited primary studies. The data extraction sheets and analysis scripts are available from the corresponding author upon reasonable request.
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