Comparable and Improved Clinical Outcomes, Pain Relief, Return to Sport, and Low Popeye Deformity Rates in Inlay Versus Onlay Open Subpectoral Biceps Tenodesis: A Systematic Review.

Abstract

To directly compare clinical outcomes, including failure rates, incidence of Popeye deformity, and return to sport (RTS)/activity between inlay and onlay fixation techniques specifically for open subpectoral biceps tenodesis. A systematic search of PubMed, EMBASE, and Cochrane Library databases was conducted for studies published between 2014 and 2024. Inclusion criteria consisted of Level I to IV studies in English, reporting clinical outcomes for open subpectoral biceps tenodesis with at least a 2-year follow-up. Data on patient-reported outcome measures, RTS, Popeye deformity, and failure rates were extracted. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies criteria. Statistical analysis was performed to evaluate heterogeneity, and clinical outcomes between fixation techniques were compared using qualitative analysis and 95% confidence intervals. Fourteen studies with a total of 498 patients (347 in the inlay group, 151 in the onlay group) were included. Postoperative American Shoulder and Elbow Surgeons scores ranged from 78.6 to 95.8, visual analog scale pain scores from 0.25 to 2.6, and Constant-Murley scores from 26.7 to 91.8, with no differences noted between inlay and onlay techniques across these measures on qualitative assessment. RTS rates were similarly comparable, ranging from 62% to 93% across all studies. The incidence of Popeye deformity was low in both groups, ranging from 0% to 7.7% for inlay fixation and from 0% to 6.7% for onlay fixation, with no qualitative differences observed. Heterogeneity in outcomes was attributed to variations in study design and patient populations. Both inlay and onlay fixation for open subpectoral biceps tenodesis showed comparable clinical outcomes, similar pain relief, and low rates of Popeye deformity. RTS rates were consistently high across both techniques. The choice of fixation method did not significantly impact the overall results, suggesting that either technique can be used effectively based on surgeon and patient preferences. Level IV, systematic review of Level I to IV studies.