Arthroscopic Inlay Suprapectoral versus Mini-Open Onlay Subpectoral Biceps Tenodesis: A Prospective, Randomized Analysis of Clinical Outcomes and Ultrasound-Assessed Structural Integrity.

Background: Surgical techniques for biceps tenodesis vary in approach, fixation strategy, and anatomic location without clear superior technique for this common procedure.

Hypothesis/purpose: The purpose of this study was to prospectively evaluate a randomized cohort of patients undergoing arthroscopic suprapectoral (ASBT) with interference screw fixation using an inlay technique versus mini-open subpectoral (MOBT) with a unicortical button implant using an onlay technique with regards to 1) clinical outcome measures and 2) structural healing as evaluated by ultrasound.

Methods: From May 2017 to April 2021, patients undergoing biceps tenodesis were preoperatively randomized to either ASBT or MOBT. American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) scores were recorded at baseline, three months, and two years postoperatively. The integrity of the biceps tendon at the tenodesis site was independently examined via ultrasound by a musculoskeletal trained radiologist at three months and two years postoperatively. T-tests were performed for continuous variables, while Chi squared tests were performed for categorical variables.

Results: A total of 52 patients (24 ASBT, 28 MOBT) were randomized and completed follow-up. At baseline, three months, and two years postoperatively, the mean ASES, SANE and VAS scores were not statistically different between ASBT and MOBT. At the three-month postoperative ultrasound, 23/24 (96%) of the ASBT patients and 26/28 (93%) of the MOBT patients were noted to have a clearly intact biceps tenodesis. At two years, all biceps tenodesis regardless of group were noted to be intact and healed, including all three shoulders whose ultrasound noted a questionably intact repair without significant retraction of the tendon at prior three-month ultrasound evaluation.

Conclusion: This study demonstrates similar clinical outcomes at two year follow-up between ASBT and MOBT. Both groups demonstrated improvement that exceeded the reported patient acceptable symptom state (PASS) and minimal clinically important difference (MCID). Ultrasound showed excellent structural healing rates for both inlay and onlay biceps tenodesis techniques.

Level of evidence: Level II; Randomized Controlled Trial; Treatment Study.