Knot-Dependent Constructs Show Narrowly Better Ultimate Failure Loads Than Knotless Constructs in Proximal Biceps Tenodesis: A Systematic Review and Meta-analysis

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.

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.

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, I² = 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, I² = 74%), inlay versus onlay techniques (95% CI: [-75.3, 35.42], P = .48, I² = 84%), and 1-implant versus 2-implant constructs (95% CI: [-66.9, 12.5], P = .18, I² = 55%).

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.

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.