Single - Versus Separate-Anchor Biceps Tenodesis in Rotator Cuff Repair: A Comparative Clinical Study

Single - Versus Separate-Anchor Biceps Tenodesis in Rotator Cuff Repair: A Comparative Clinical Study

Riad Fakih, M.D.¹, Hady Ezzeddine, M.D.², Fouad Assaf, M.D. ², Kassem El Houcheim, M.D. ², Muhieddine Hamie M.D. ², Salah Ballout, M.D.¹

1. Orthopaedic Surgery Division, Makassed General Hospital, Beirut Lebanon.
2. Department of Orthopaedic Surgery and Traumatology, University of Balamand, Beirut, Lebanon.

*Correspondence to: Riad Fakih, MD, Department of Orthopaedic Surgery, Clemenceau Medical Center (Dubai)/Makassed General Hospital(Lebanon), Dubai, UAE/Beirut, Lebanon

Copyright
© 2026 Riad Fakih, MD is an open access article distributed under the Creative Commons Attribution   License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 13 July 2026

Published: 01 August 2026
DOI: https://doi.org/10.5281/zenodo.21767516

Abstract 

Background: Long head of the biceps tendon (LHBT) pathology commonly accompanies rotator cuff tears. Standard arthroscopic treatment often requires separate anchors for cuff repair and biceps tenodesis, increasing implant use. A single-anchor technique incorporating LHBT tenodesis into the anterior cuff anchor may reduce implants without compromising outcomes.

Purpose: To compare clinical outcomes of single-anchor concomitant LHBT tenodesis and rotator cuff repair with separate-anchor fixation at 30-month follow-up.

Methods: This retrospective cohort study included 44 patients with repairable rotator cuff tears and LHBT pathology. Twenty-two patients underwent single-anchor fixation with LHBT tenodesis using a lasso-loop technique, and twenty-two underwent separate-anchor cuff repair and biceps tenodesis. Outcomes were assessed using Constant and UCLA scores. Between-group comparisons used independent t-tests, and within-group improvements were analyzed with paired t-tests.

Results: Both groups demonstrated significant postoperative improvement in Constant and UCLA scores (P < 0.001). Postoperative Constant scores were 83.27 ± 7.88 in the single-anchor group and 82.41 ± 7.84 in the separate-anchor group (P = 0.72). UCLA scores were 30.41 ± 2.56 and 30.23 ± 2.41, respectively (P = 0.81). Improvement magnitude did not differ significantly for Constant scores (P = 0.57). Although UCLA improvement was slightly greater in the single-anchor group (P = 0.03), the difference was not clinically meaningful.

Conclusion: Single-anchor LHBT tenodesis during rotator cuff repair provides comparable mid-term outcomes to separate-anchor fixation and may serve as an implant-sparing, cost-conscious alternative.

Level of evidence: III.

Keywords: Rotator cuff repair; Biceps tendon; Tenodesis; Arthroscopy.

Introduction

Rotator cuff tears are frequently associated with long head of the biceps tendon (LHBT) pathology, reported in 30–69% of cases [1]. Larger tears and subscapularis tears are more likely to have LHBT pathology.

LHBT lesions may contribute to shoulder pain through several mechanisms: associated lesions in the labral complex, tendinopathy or tenosynovitis, partial or complete tendon tears or instabilities (such as subluxation, dislocation, and the pulley effect) in the LHBT [2 - 4].

Treatment is either by biceps tenotomy or tenodesis. Tenotomy is an easy, time-saving procedure that reduces pain effectively but causes popeye deformity [5], reduction in supination strength [6], and is associated with muscle cramps. This may necessitate another operation to reattach the LHBT and regain its tension. Tenodesis on the other hand involves releasing the LHBT and reattaching it along the bicipital groove. Its advantage is preserving the muscle length tension relationship, thus preserving strength (forearm supination and elbow flexion strength), decreasing the rate of discomfort and muscle cramping, and providing better cosmesis (avoids popeye deformity) [7 - 9].

When tenodesis is performed, many different factors affect tendon repair, including tendon quality and strength of the stitch. For improving strength, Lafosse et al. (2006) introduced a new technique called the Lasso stitch, which showed superior biomechanical properties in overcoming load failure compared to compressive rivet and interference screw. Some authors also stated that the Lasso loop technique has less humeral fracture risk (theoretically associated with drilling) than interference screw [10]. The goal is to pass a loop through any tendon that is to be repaired and to pass a single free end through the loop for use as a lever arm mechanism [11]. Tenodesing the biceps to the supraspinatus theoretically creates opposing forces that help to depress the humeral head and restore some function of the biceps tendon as a dynamic stabilizer [12]. In this study, we compare clinical outcomes of single-anchor concomitant fixation, at the anteromedial border of the footprint, versus separate-anchor fixation in patients undergoing arthroscopic rotator cuff repair with LHBT tenodesis, using a lasso loop stitch.

The aim of this study was to compare the outcome and effectiveness of simultaneous integration of rotator cuff repair and LHBT with the same anchor using Lasso technique and repairing LHBT and rotator cuff separately at 30 months postoperatively. We hypothesized that simultaneous fixation would yield comparable clinical outcomes to separate fixation while reducing implant use.

In the current era of value-based healthcare, reducing implant utilization without compromising clinical outcomes has become increasingly relevant. Therefore, evaluating techniques that potentially decrease resource use while maintaining functional outcomes is of clinical importance.

Methods

This retrospective cohort study included patients treated between January 2010 and December 2021. Patients were followed up for 30 months after the operation. Forty-four patients were enrolled in this study and underwent arthroscopic rotator cuff repair with biceps tenodesis and were divided into two groups. In the first group, 22 patients underwent simultaneous rotator cuff repair and LHBT tenodesis using the same suture anchor, while in the second group 22 patients underwent separate repair of rotator cuff and LHBT using different suture anchors. The choice of fixation technique was based on surgeon preference and intraoperative findings; therefore, no randomization was performed. Exclusion criteria were isolated rotator cuff tear, isolated long head of biceps lesion, irreparable cuff tears, revision surgery, prior total shoulder arthroplasty, glenohumeral osteoarthritis, and malignant disease.

Demographics included age and gender. Physical examinations for suspected rotator cuff and long head biceps pathology were performed by a highly experienced surgeon in the field of arthroscopy and sport injuries.

The diagnosis of full thickness supraspinatus tears was done by MRI and confirmed by arthroscopy, whereas biceps tendon pathology was in most of the patients suspected by MRI and confirmed arthroscopically. LHBT pathology was defined as the presence of tendinopathy, partial tearing, instability, or pulley lesions identified on MRI and confirmed during arthroscopy. Measuring cuff defect was done using a graduated probe introduced through the posterior portal while viewing through the lateral portal. Tear size was classified intraoperatively as small, medium, or large according to standard rotator cuff classifications.

Patients were examined a few days before surgery and postoperatively by measuring forward flexion, lateral elevation, external rotation, and internal rotation. Clinical scores (Constant and University of California Los Angeles) were recorded at final follow-up (30 months). Range of motion was assessed at six months and at final follow-up.

This study was approved by the Institutional Review Board of our institution in accordance with institutional guidelines for retrospective studies with assigned approval number MGH-08-21022. Documentation is available and was submitted with the manuscript and the study adhered to the principles of the Declaration of Helsinki.

Operative Technique

The patient was placed in the lateral decubitus position with the arm in a longitudinal traction device weighing between 4.5 and 6 kg depending on the patient’s size and musculature. A standard 30° scope is used throughout the procedure. Posterior portal is made and diagnostic arthroscopy performed. Then the arthroscope is introduced through the posterior portal into the subacromial space, and a lateral portal is made at the junction of the anterior and middle third of the acromion.

After localizing and measuring the cuff tear, edges are debrided, the footprint is prepared and pathology of the LHBT is re-identified from the subacromial space. Posterolateral and anterolateral portals are then made. The lateral portal becomes the viewing portal and the latter two are used as working portals. Three 4.5 mm double loaded suture anchors are used. The distance of the first anchor from the biceps groove depends on the size of the anterosuperior cuff tear. It is placed in the antero-medial aspect of the footprint just posterior to the groove if the cuff tear is small. The anchor is placed more posteriorly in medium-sized or large tears.

One of the suture limbs is shuttled into the joint, the bird beak suture passer is used to penetrate LHBT medial to the cuff insertion and the suture limb is pulled through the tendon through the superior surface using suture passer to form a loop. Then, the suture passer is passed through the loop, and the free end of the same suture is pulled through the loop and tensioned. The same free limb is then loaded in a scorpion suture passer and passed through the rotator cuff and the other 2 limbs of the same anchor are passed through the rotator cuff at the same level. The other anchor is placed at the same level medially but more posterior. Biceps tenotomy is done at least 1 cm from the tenodesis site. The rest of the cuff repair is done in the usual technique.

When performing double row rotator cuff repair, the surgeon can use 1 or 2 anchors for the lateral row. Subacromial decompression was performed as indicated. In cases of a narrow subacromial space, the decompression is done before the repair to have a better working space for the tendon and the cuff. If the subacromial space is wide but a Bigliani type 3 acromion is present, the repair is done first followed by the subacromial decompression to avoid the risk of bleeding that will result from the decompression. The coracoacromial ligament is almost always preserved.

Post-Operative Rehabilitation

Shoulder immobilizer applied for 6 weeks postoperatively. First 2 weeks, no range of motion (ROM) is allowed at all. After that passive and gentle active assisted ROM (no external rotation) for short periods of time is started. After 6 weeks are completed, the immobilizer is discontinued and patients are started with active ROM exercises. At 12 weeks, resistance and strengthening exercises are begun with return to full activity at 6 months.

Statistical Analysis

Analysis was carried out using the Statistical Package for Social Sciences (SPSS version 24). The Chi square test was used for comparing categorical variables while the Student's t-test was used for comparing continuous ones. Categorical variables were presented as number and percent whereas continuous variables were presented as mean and standard deviation. Normality of continuous variables was assessed using the Shapiro–Wilk test. Paired t-tests were used to evaluate within-group pre- to postoperative changes, and independent t-tests were used for between-group comparisons. A P-value <0.05 was considered statistically significant.

Results

Patient Demographics

A total of 44 patients were included in this study with 22 patients in each group. In the simultaneous repair group, there were 14 (63.6%) males and 8 females (36.4%), their mean age was 65.00 ± 8.22. In the separate repair group, there were 15 males (68.2%) and 7 females (31.8%), their mean age was 62.55 ± 7.15. (Table 1)

Clinical Outcomes

Scores

Baseline demographics were comparable between groups with no significant differences in age or sex distribution (Table 1). The mean Constant score in the simultaneous repair group improved from 41.14 ±14.40 preoperatively to 83.27 ± 7.88 postoperatively with P < 0.0001, and in the separate repair group from 42.00 ± 14.83 preoperatively to 82.41 ± 7.84 postoperatively with P < 0.0001 (Table 2). There was no significant difference between groups in the magnitude of improvement in Constant score (42.14 ±10.25 vs 40.41 ±12.19, P =  0.57) (Table 3).

The mean UCLA score improved significantly in both groups. In the simultaneous repair group, scores increased from 11.77 ±4.60 to 30.41 ±2.56, while in the separate repair group they increased from 13.36 ±4.14 to 30.23 ±2.41. Both groups demonstrated statistically significant improvement (P < 0.001) (Table 2). Postoperative UCLA scores were comparable between groups. However, the magnitude of improvement was slightly greater in the simultaneous repair group (18.64 ±2.72 vs 16.86 ±2.51, P =  0.03) (Table 3)

Table 1. Patient’s demographics

P Value*: differences in postoperative scores between groups

Table 2. Clinical outcomes (scores)

Table 3. Difference in scores between pre- and post- operation in the two groups

Forward Flexion

In the simultaneous repair group, 19 (86.4%) patients had flexion between 61-120°. Only 2 (9%) patients reached flexion above 121° range. Postoperatively, all the patients (100%) had forward flexion above 121° with P < 0.0001 (Table 4).

In the separate repair group, 18 (82%) patients had flexion between 61-120° and postoperatively all patients (100%) ( had forward flexion above 121° with P < 0.0001 (Table 4).

No difference between the 2 groups postoperatively P* = 0.76.