Arthroscopy - 2026-09-22 - Journal Article; Review
Knot-Dependent Constructs Show Narrowly Better Ultimate Failure Loads Than Knotless Constructs in Proximal Biceps Tenodesis: A Systematic Review and Meta-analysis.
Girardi KG, Ali IS, Lord KT, Kamen JL, Surucu S, Lee MS, Kamalaldin N, Vorbau J, Fong S, Hsu JC, Jimenez AE
Topics
Key Takeaway
Knot-dependent proximal biceps tenodesis constructs demonstrated significantly greater ultimate failure load than knotless constructs by a weighted mean difference of only 28.2 N (95% CI: 0.22–56.17 N, P=.05), while inlay vs. onlay, all-suture vs. other materials, and single vs. double-anchor configurations showed no significant differences across 245 cadaveric specimens.
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Summary
This PRISMA-compliant systematic review and meta-analysis queried three databases for cadaveric biomechanical studies published 2019 or later comparing proximal biceps tenodesis construct ultimate failure loads (UFLs). Four subanalyses compared all-suture vs. other constructs, inlay vs. onlay, knotless vs. knot-dependent, and single vs. double-anchor configurations. Mean UFLs ranged from 79 N (interference screw) to 588 N (all-suture Caspari-Weber); only the knot-dependent vs. knotless comparison reached statistical significance (WMD 28.2 N, P=.05), though heterogeneity was substantial across all subanalyses (I²=53–84%).
Key Limitation
All included specimens are cadaveric, precluding assessment of biologic healing, tendon-to-bone integration, or clinical failure modes that dominate real-world tenodesis outcomes.
Original Abstract
PURPOSE
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.