PURPOSE: Subpectoral biceps tenodesis is a widely used surgical technique to relieve pain and restore function in the shoulder by securing the long head of the biceps tendon. This study aimed to evaluate the mechanical performance of three fixation techniques using cortical button, interference screw and keyhole methods by assessing their strength, durability and strain distribution, incorporating the novel application of digital image correlation (DIC). METHODS: Thirty fresh porcine bone-tendon specimens were allocated evenly among the fixation techniques. Biomechanical testing involved cyclic axial loading (10-100 N) for 500 cycles, followed by load-to-failure testing using a universal testing machine. DIC analysis assessed strain distribution around the bone drill site. Statistical comparisons of displacement, load-to-failure and strain patterns were performed. RESULTS: Cortical button fixation demonstrated the highest average load-to-failure at 353 ± 45 N, with all specimens completing 500 cycles and showing the least variability. In comparison, interference screw fixation had the lowest average load-to-failure (271 ± 71 N) with two failures occurring before 500 cycles, and the keyhole technique showed intermediate performance at 319 ± 45 N, also with two early failures. Cyclic displacement after 500 cycles was lowest for the interference screw (3.16 ± 0.52 mm), followed by the keyhole (11.51 ± 2.08 mm), and highest for the cortical button (13.84 ± 1.90 mm). Displacement range after 500 cycles was also lowest in the interference screw group (0.62 ± 0.05 mm), compared to the cortical button (0.88 ± 0.07 mm) and keyhole (0.91 ± 0.23 mm). DIC revealed the highest maximum first principal strain around cortical button fixation (0.21%), followed by interference screw (0.16%) and keyhole (0.13%). CONCLUSION: Cortical button fixation demonstrated the highest load-to-failure and the lowest variability, indicating mechanical reliability. The interference screw and keyhole techniques showed comparable load-to-failure values and cyclic displacement but exhibited greater variability. DIC analysis revealed higher localized strain around the cortical button fixation, whereas the interference screw and keyhole techniques displayed more evenly distributed strain. LEVEL OF EVIDENCE: Level V.

1st Department of Orthopaedic Surgery St Anne's University Hospital and Faculty of Medicine Masaryk University Brno Czechia

Institute of Solid Mechanics Mechatronics and Biomechanics Faculty of Mechanical Engineering University of Technology Brno Czechia

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Aflatooni JO, Meeks BD, Froehle AW, Bonner KF. Biceps tenotomy versus tenodesis: patient‐reported outcomes and satisfaction. J Orthop Surg. 2020;15(1):56. PubMed PMC

Apostolopoulos V, Boháč P, Marcián P, Nachtnebl L, Mahdal M, Pazourek L, et al. Biomechanical comparison of all‐polyethylene total knee replacement and its metal‐backed equivalent on periprosthetic tibia using the finite element method. J Orthop Surg. 2024;19(1):153. PubMed PMC

Arora AS, Singh A, Koonce RC. Biomechanical evaluation of a unicortical button versus interference screw for subpectoral biceps tenodesis. Arthroscopy. 2013;29(4):638–644. PubMed

Arthrex Inc . Subpectoral biceps tenodesis using cortical buttons [Internet]. Naples, FL: Arthrex; [cited 2025 Jan 9]. Available from: https://www.arthrex.com/de/weiterfuehrende-informationen/LT1-0591-EN/subpectoral-biceps-tenodesis-using-cortical-buttons.

Arthrex Inc . The BioComposite Tenodesis Screw surgical technique. Arthrex. n.d. Available from: https://www.arthrex.com.

Buchholz A, Martetschläger F, Siebenlist S, Sandmann GH, Hapfelmeier A, Lenich A, et al. Biomechanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy. 2013;29(5):845–853. PubMed

Colantonio DF, Tucker CJ, Murphy TP, Mescher PK, Le AH, Putko RM, et al. All‐suture suspensory button has similar biomechanical performance to metal suspensory button for onlay subpectoral biceps tenodesis. Arthrosc Sports Med Rehabil. 2022;4(6):e2051–e2058. PubMed PMC

DeAngelis JP, Chen A, Wexler M, Hertz B, Grimaldi Bournissaint L, Nazarian A, et al. Biomechanical characterization of unicortical button fixation: a novel technique for proximal subpectoral biceps tenodesis. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1434–1441. PubMed

Elser F, Braun S, Dewing CB, Giphart JE, Millett PJ. Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy. 2011;27(4):581–592. PubMed

Friedel R, Markgraf E, Schmidt I, Dönicke T. Die proximale Humerusschaftfraktur als Komplikation nach der Schlüssellochplastik: ein fallbericht. Unfallchirurgie. 1995;21(4):198–201. PubMed

Froimson AI, O I. Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop Relat Res. 1975;112:245–249. PubMed

Frost HM. Skeletal structural adaptations to mechanical usage (SATMU): 2. Redefining Wolff's Law: the remodeling problem. Anat Rec. 1990;226(4):414–422. PubMed

Frost HM. Skeletal structural adaptations to mechanical usage (SATMU): 1. Redefining Wolff's Law: the bone modeling problem. Anat Rec. 1990;226(4):403–413. PubMed

ISO 9513:2012. Metallic materials: calibration of extensometer systems used in uniaxial testing. Geneva: International Organization for Standardization; 2022.

Jayamoorthy T, Field JR, Costi JJ, Martin DK, Stanley RM, Hearn TC. Biceps tenodesis: a biomechanical study of fixation methods. J Shoulder Elbow Surg. 2004;13(2):160–164. PubMed

Khan W, Agarwal M, Funk L. Repair of distal biceps tendon rupture with the Biotenodesis screw. Arch Orthop Trauma Surg. 2004;124(3):206–208. PubMed

Krackow KA. The Krackow suture: how, when, and why. Orthopedics. 2008;31(9):931–933. PubMed

Kusma M, Dienst M, Eckert J, Steimer O, Kohn D. Tenodesis of the long head of biceps brachii: cyclic testing of five methods of fixation in a porcine model. J Shoulder Elbow Surg. 2008;17(6):967–973. PubMed

Lacheta L, Rosenberg SI, Brady AW, Dornan GJ, Millett PJ. Biomechanical comparison of subpectoral biceps tenodesis onlay techniques. Orthop J Sports Med. 2019;7(10):2325967119876276. PubMed PMC

Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy. 2005;21(7):896. PubMed

Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005;21(11):1296–1306. PubMed

Millett PJ, Sanders B, Gobezie R, Braun S, Warner JJ. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord. 2008;9(1):121. PubMed PMC

Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg. 2010;19(5):764–768. PubMed

Otto A, Siebenlist S, Baldino JB, Murphy M, Muench LN, Mehl J, et al. All‐suture anchor and unicortical button show comparable biomechanical properties for onlay subpectoral biceps tenodesis. JSES International. 2020;4(4):833–837. PubMed PMC

Ozalay M, Akpinar S, Karaeminogullari O, Balcik C, Tasci A, Tandogan RN, et al. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy. 2005;21(8):992–998. PubMed

Palanca M, Tozzi G, Cristofolini L. The use of digital image correlation in the biomechanical area: a review. Int Biomech. 2016;3(1):1–21.

Patzer T, Santo G, Olender GD, Wellmann M, Hurschler C, Schofer MD. Suprapectoral or subpectoral position for biceps tenodesis: biomechanical comparison of four different techniques in both positions. J Shoulder Elbow Surg. 2012;21(1):116–125. PubMed

Reiff SN, Nho SJ, Romeo AA. Proximal humerus fracture after keyhole biceps tenodesis. Am J Orthop (Belle Mead NJ). 2010;39(7):61–63. PubMed

Rhee S‐M, Jeong HY, Ro K, Pancholi S, Rhee YG. Double on‐lay fixation using all suture‐type anchor for subpectoral biceps tenodesis has favorable functional outcomes and leads to less cosmetic deformities than single on‐lay fixation. Knee Surg Sports Traumatol Arthrosc. 2019;27(12):4005–4013. PubMed

Sakaguchi K, Tachibana Y, Oda H. Biomechanical properties of porcine flexor tendon fixation with varying throws and stitch methods. Am J Sports Med. 2012;40(7):1641–1645. PubMed

Sears BW, Spencer EE, Getz CL. Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients. J Shoulder Elbow Surg. 2011;20(6):e7–e11. PubMed

Šebek F, Salvet P, Boháč P, Adámek R, Věchet S, Návrat T, et al. Size effect on the ductile fracture of the aluminium alloy 2024‐T351. Exp Mech. 2024;64(9):1483–1495.

Sethi PM, Rajaram A, Beitzel K, Hackett TR, Chowaniec DM, Mazzocca AD. Biomechanical performance of subpectoral biceps tenodesis: a comparison of interference screw fixation, cortical button fixation, and interference screw diameter. J Shoulder Elbow Surg. 2013;22(4):451–457. PubMed

Slemenda CW, Hui SL, Williams CJ, Christian JC, Meaney FJ, Johnston CC. Bone mass and anthropometric measurements in adult females. Bone Miner. 1990;11(1):101–109. PubMed

Tatani I, Megas P, Panagopoulos A, Diamantakos I, Nanopoulos P, Pantelakis S. Comparative analysis of the biomechanical behavior of two different design metaphyseal‐fitting short stems using digital image correlation. Biomed Eng Online. 2020;19(1):65. PubMed PMC

Tyrovola JB, Odont X. The “Mechanostat Theory” of Frost and the OPG/RANKL/RANK system. J Cell Biochem. 2015;116(12):2724–2729. PubMed