Sports Medicine Research: In the Lab & In the Field: Long Head of the Biceps Issues– Cut it or Move it? (Sports Med Res)
Tuesday, March 27, 2012

Long Head of the Biceps Issues– Cut it or Move it?

Biceps Tenotomy Versus Tenodesis: Clinical Outcomes

Slenker NR, Lawson K, Ciccotti MG, Dodson CC, Cohen SB. Arthroscopy. 2012 Jan 25. [Epub ahead of print]

Chronic inflammation of the long head of the biceps brachii (LHB) tendon can be a stubborn and complex condition.  As with most chronic inflammatory conditions a course of rest, activity modification, nonsteroidal anti-inflammatory drugs (NSAIDs), rehabilitation, and even corticosteroid injection may be indicated.  However, if conservative treatment fails there are two surgical interventions, biceps tenotomy (complete detachment of the LHB) or tenodesis (detachment with anchoring of the LHB in the bicipital groove). Slenker et al. conducted a systematic review to determine the clinical effectiveness of both surgical treatments.  They conducted a systematic review of PubMed and were able to identify 16 studies with a total of 699 tenotomy procedures and 433 tenodesis procedures. Subjects ranged in age from 15 to 83 years of age and there was no mean age difference between the 2 treatment groups.  Tenodesis resulted in a good to excellent outcome in 74% of the cases and yielded a cosmetic deformity (the Popeye sign) 8% of the time. After LHB tenotomy, 77% of the patients reported good to excellent outcomes, but cosmetic deformity was present in 43% of the cases. There was also less bicipital pain experienced post-op in the tenotomy group (19%) as compared to the tenodesis group (24%).  The authors did analyze a subgroup of patients having either tenotomy or tenodesis performed along with concomitant rotator cuff pathology.  The tenotomy subjects stated good to excellent outcomes 72 to 85% of the time.  The subjects treated by tenodesis reported good to excellent outcomes 63 to 93% of the time.  The Popeye sign was noted 27 to 62% and 0 to 9% respectively for tenotomy versus tenodesis. 
                                                         
The data collected shows that biceps tenotomy and tenodesis have very similar success rates, whether there is rotator cuff involvement or not. The authors state that procedure selection should be based on a multitude of factors, including age and activity level.  Biceps tenotomy has a much shorter recovery period due to the procedure being much less invasive than the tenodesis. However, the tenotomy treatment experiences greater incidence of cosmetic deformity.  The tenodesis procedure typically takes longer to perform and recover from, and there is greater associated post-operative pain but less chance of cosmetic deformity.  Prevailing thought dictates that for older and/or more sedentary patients, biceps tenotomy might be more appropriately indicated.  Younger and/or more active (athletic/labor intensive careers) individuals might benefit more from biceps tenodesis.  One item that remains unclear is if there is any true strength loss after either procedure. Some studies have shown as much as a 20% decrease in elbow flexion and supination strength after tenotomy, while others haven’t demonstrated any decreases. The authors set out to determine which procedure is clinically more effective; however, both procedures had similar clinical outcomes.  As with any treatment or surgical procedure, the main factor to consider is the patient’s quality of life and function.  Future studies are going to need to be conducted in an effort to clarify this topic, especially involving individuals that participate in vigorous overhead activity. What are your experiences with LHB surgical options?  Should we consider either option at all, based upon the LHB's role as shoulder dynamic stabilizer? Aside from the cosmetic differences, can you say whether one procedure has worked better than the other for your patients?  

Written by:  Mark Rice
Slenker NR, Lawson K, Ciccotti MG, Dodson CC, & Cohen SB (2012). Biceps Tenotomy Versus Tenodesis: Clinical Outcomes. Arthroscopy PMID: 22284407

4 comments:

Kellie Bliven said...

Good post... interesting results. I think we do need to identify more clinical outcomes to compare these procedures - such as strength, ROM, function, and impact on surrounding musculature (ie RC) following the procedures to make a more informed decision.

Mark A. Rice said...

Thanks for reading and commenting, Kellie. I couldn't agree more. This seems to be an area where a lot more research could be done.

Kyle Kosik said...

This is a great post, and I find the results and procedures intriguing. With this study showing that the removal of the LHB being fairly common, it makes me wonder what exactly function of the LHB really is? If we can surgical remove the LHB and still be function, then the LHB has to play a small roll in the shoulder. If this is true, it also make me wonder what is it, that is causing so much pain in the shoulder? I think it would also be interesting to see if the patients that received either the tentomy or the tendonesis surgery experienced any rotator cuff pain or impingement symptoms down the road.

More research definitely needs to be done looking at the function of the LHB and what is causing the pain.

Stephen J. Thomas, PhD, ATC said...

Kyle you bring up many great questions. The role of the biceps at the shoulder remains highly debated. Some feel it plays a large role to joint function and stability while others feel its role is minimal. In this study there were a subset of patients that received the tentomy or tenonesis in conjunction with a rotator cuff repair but I agree examining the patients with an isolated biceps transaction 5 or 10 years post-op would be interesting to see if any joint damage has occurred.

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