Several surgical procedures for anatomical repair of the distal biceps tendon have evolved during the last decade. The purpose of this study is to compare functional outcomes and complication rate between inlay and onlay distal biceps tendon repair with the Tension Slide Technique.

Previous articles demonstrated already no significant difference in bone-to-tendon healing between cortical and cancellous bone. The cortical button has shown superiority in many biomechanical studies. Efforts to simplify the surgical technique can help to minimize most common surgical complications. The need for a bone tunnel to guarantee good functional outcomes is questioned. A retrospective comparative case-control study was used to compare the onlay (study) and inlay (control) distal biceps repair (DBR). Strength measurements were noted as a percentage of the unaffected contralateral side. Functional outcomes were recorded using a Visual Analog Scale (VAS), the Mayo Elbow Performance Score (MEPS), the short version of the Disabilities of the Arm, Shoulder and Hand score (QUICK DASH) and the Patient-Rated Elbow Evaluation (PREE). All questionaries, including Satisfaction and Return to work/play, were completed at the final follow-up.

We selected 259 out of 270 patients. The study and control cohort consisted of 90 and 169 patients, respectively. At short term (4.7±3 months) the inlay cohort has significant higher supination strength (74.90% vs 80.52%, p=0.023). The functional outcomes in terms of MEPS, Quick DASH and PREE were not statistically different (p=0.551, p=0.292 and p=0.378, respectively). The overall complication rate was in favour of the onlay cohort, although statistically not different (p=0.056). The inlay cohort had significantly more heterotopic ossifications (p=0.003). At long term (FU 35.6±22 months), the functional outcomes remains similar. The Subjective elbow force evaluation was slightly higher in the inlay cohort (87.56% vs 90.70%, p=0.081). No differences in overall satisfaction (p=0.834). Onlay distal biceps repairs delivered earlier ‘Return to play’ (p=0.041).

The inlay and only distal biceps repair, have similar functional outcomes and overall complication rate. At short term, the supination strength is in favour of the inlay repair, although we saw significantly more heterotopic ossification with the bone tunnel. The results present both techniques as reliable, reproducible and overall safe.