Knot‐Dependent Constructs Show Narrowly Better Ultimate Failure Loads Than Knotless Constructs in Proximal Biceps Tenodesis: A Systematic Review and Meta‐analysis
Kevin G. Girardi, Iyad S. Ali, Kevin T. Lord, Jordan L. Kamen, Serkan Surucu, Michael S. Lee, Nooraldin Kamalaldin, Jonas Vorbau, Scott Fong, Jim C. Hsu, Andrew E. JimenezPurpose
To provide an updated systematic review comparing the fixation strengths of proximal biceps tenodesis (BT) constructs in cadaveric biomechanical studies, including a meta‐analysis between all‐suture versus other constructs, knot‐dependent versus knotless constructs, inlay versus onlay techniques, and single‐ versus double‐anchor configurations.
Methods
A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Three separate databases were queried in April 2025 using relevant search terms for biomechanical studies published in 2019 or later that reported cadaveric BT load‐to‐failure results. Demographic factors, BT techniques, and ultimate failure loads (UFLs) were extracted. Four subanalyses were conducted by pooling studies with intrastudy comparisons of all‐suture versus other BT constructs, inlay versus onlay techniques, knotless versus knot‐dependent techniques, and 1‐implant versus 2‐implant constructs.
Results
A total of 245 cadaveric specimens across 12 studies were included for analysis. Mean UFL of BT constructs ranged from 79 N (interference screw) to 588 N (all‐suture Caspari‐Weber technique). Knot‐dependent techniques showed significantly greater UFL than knotless techniques, with weighted mean difference favoring knot‐dependent techniques by 28.2 N (95% confidence interval [CI]: [0.22, 56.17], P = .05, I 2 = 53%). There were no statistically significant differences in pooled UFL results between all‐suture constructs versus other construct material types (95% CI: [−19.9, 48.2], P = .42, I 2 = 74%), inlay versus onlay techniques (95% CI: [−75.3, 35.42], P = .48, I 2 = 84%), and 1‐implant versus 2‐implant constructs (95% CI: [−66.9, 12.5], P = .18, I 2 = 55%).
Conclusions
UFLs of proximal BT constructs showed substantial variability across techniques. No statistically significant differences were observed between inlay and onlay techniques, all‐suture and alternative constructs, or single‐ and double‐anchor configurations. Knot‐dependent constructs exhibited greater UFLs compared with knotless constructs; however, the difference was small and of uncertain clinical significance.
Clinical Relevance
Knot‐dependent constructs were narrowly stronger than knot‐independent constructs in this biomechanical analysis and may provide a minor amount of added strength in early rehabilitation. However, surgeon choice should be prioritized when considering a biceps tenodesis construct.