No clinical difference in outcomes between inlay and onlay arthroscopic biceps tenodesis techniques during rotator cuff repair

Background: Both inlay and onlay arthroscopic biceps tenodesis (ABT) are common procedures performed during rotator cuff repair. The inlay method involves creating a bone socket in the bicipital groove to secure the long head of the biceps tendon using an interference screw. The onlay method utilizes a suture anchor to secure the long head of the biceps tendon on the surface of the bicipital groove. Little is known on the long-term differences in patient-reported outcomes between these 2 techniques. The primary purpose of this study was to compare patient-reported outcomes of inlay vs. onlay ABT with a minimum follow-up of 2 years. Secondary aims were to evaluate the impact of rotator cuff tear size on outcomes and compare rates of complications between the 2 techniques. Methods: A retrospective chart review was performed to identify patients who had an ABT during a full-thickness rotator cuff repair. Any symptom specific to the biceps were noted, including pain and cramping, Popeye deformity, or revision surgery. Complication rates were compared between groups. The visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Veteran's RAND -12 score (VR-12) scores were compared at 2 years. The impact of rotator cuff tear size was analyzed by categorizing into small/medium or large/massive based on operative reports and arthroscopic images. Results: There were 165 patients identified (106 in the inlay group and 59 in the onlay group). No revision surgeries were performed secondary to the biceps tendon in either group. Eleven patients (10%) in the inlay group complained of biceps pain or cramping compared to 2 patients (3%) in the onlay group ( P = .11). One Popeye deformity was noted in each group ( P = .67). No significant differences were found between groups for visual analog scale ( P = .41), ASES functional ( P = .61), ASES index ( P = .91), Single Assessment Numeric Evaluation ( P = .09), VR-12 Physical Component Score ( P = .77), or VR-12 Mental Component Score ( P = .09). Rotator cuff tear size within the groups also did not demonstrate statistical significance. Conclusion: No clinical differences or complications were found at minimum 2 -year follow-up between inlay and onlay ABT in patients undergoing rotator cuff repair when controlling for tear size. The clinical relevance suggests either technique is effective and can be based on surgeon preference. Level of evidence: Level III; Retrospective Cohort Comparison; Treatment Study (c) 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.