Few topics in shoulder surgery generate as much casual debate as biceps tenodesis technique. Some surgeons prefer the familiarity and visualization of an arthroscopic suprapectoral approach. Others stick with the reliability of open subpectoral fixation.
But when it comes to outcomes, does the location of the tenodesis actually change much?
A large new systematic review suggests the answer may be: not as much as you might think.
A Tale of Two Techniques
Investigators reviewed 43 studies including more than 11,000 patients who underwent biceps tenodesis to treat symptomatic pathology of the long head of the biceps. The analysis compared two common techniques: arthroscopic suprapectoral biceps tenodesis (ASPBT) and open subpectoral biceps tenodesis (OSPBT).
Patients were followed for an average of about 24 months, with a mean age of 54 years. Roughly two-thirds were male, reflecting the demographics commonly seen in degenerative shoulder pathology.
The procedures were almost evenly split between the two approaches: 53.9% open subpectoral and 46.1% arthroscopic suprapectoral.
As expected, many patients were undergoing other shoulder procedures at the same time. Rotator cuff repair and subacromial decompression were the most common concomitant surgeries.
Everyone Gets Better
First, the good news: both techniques worked well.
Across studies, patients demonstrated meaningful improvements in patient-reported outcome measures regardless of the tenodesis location. Pain improved, function improved, and overall shoulder scores climbed.
For surgeons counseling patients, the takeaway is reassuring: either approach can deliver solid clinical outcomes.
Where the Differences Show Up
The real differences appeared not in overall success, but in complication patterns.
Overall complication rates were low, occurring in about 5.6% of patients across the entire dataset. But the types of complications differed between approaches.
Arthroscopic suprapectoral tenodesis showed: higher rates of postoperative stiffness (2.5% vs. 1.4%) and slightly higher reoperation rates (1.9% vs. 1.1%).
Meanwhile, open subpectoral tenodesis carried higher rates of: wound infections (1.1% vs. 0.5%) and nerve-related complications (1.1% vs. 0.2%).
Importantly, several complications surgeons worry about most showed no meaningful difference between techniques. Rates of: popeye deformity, implant failure, overall complications were essentially comparable.
Why the Patterns Make Sense
The complication profiles line up with the mechanics of each approach.
Arthroscopic suprapectoral procedures remain closer to the joint and the bicipital groove, where residual inflammation or scarring may contribute to stiffness or persistent symptoms that lead to revision.
Open subpectoral techniques move the fixation distal to the groove, which can reduce groove-related pain but introduces a small incision and deeper dissection, increasing the risk of wound issues or nerve irritation.
The differences likely reflect surgical anatomy more than surgical quality.
What This Means in Practice
For surgeons choosing between techniques, this review reinforces something many already suspect: the decision may come down more to preference, experience and patient factors than dramatic outcome differences.
Arthroscopic suprapectoral tenodesis offers a fully arthroscopic workflow, no additional incision and efficient treatment during shoulder arthroscopy.
Open subpectoral tenodesis offers reliable fixation distal to the groove, familiar exposure and potentially less residual groove pain.
Neither technique appears to hold a decisive advantage in overall outcomes.
The Bottom Line
In the long-running debate over where to fix the biceps, this large systematic review suggests the answer may simply be: wherever you’re most comfortable doing it well.
Both arthroscopic suprapectoral and open subpectoral tenodesis produce meaningful improvements for patients. The differences lie mainly in the types — not the rates — of complications.
For most surgeons, the take-home message may be reassuring: the best tenodesis technique might still be the one already in your hands.
Origin Study Title Link: Outcomes Following Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis at Short- to Midterm Follow-up: A Systematic Review
Authors: Tony Y. Lee, MD, Daniel C. Touhey, MD, Julia M. Perugini, BS, Robert H. Brophy, MD, Matthew J. Matava, MD, Matthew V. Smith, MD, Derrick M. Knapik, MD