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