Abstract
Background: Lesions of the long head of the biceps tendon are often
associated with massive rotator cuff tears and may be responsible for shoulder
pain and dysfunction. The purpose of this study was to evaluate the clinical
and radiographic outcomes of isolated arthroscopic biceps tenotomy or
tenodesis as treatment for persistent shoulder pain and dysfunction due to an
irreparable rotator cuff tear associated with a biceps lesion.
Methods: We conducted a retrospective study of sixty-eight
consecutive patients (mean age [and standard deviation], 68 ± 6 years)
in whom a total of seventy-two irreparable rotator cuff tears had been treated
arthroscopically with biceps tenotomy or tenodesis. A simple tenotomy was
performed in thirty-nine cases, and a tenodesis was performed in thirty-three.
No associated acromioplasty was performed. All patients were evaluated
clinically and radiographically by an independent observer at a mean of
thirty-five months postoperatively.
Results: Fifty-three patients (78%) were satisfied with the result.
The mean Constant score improved from 46.3 ± 11.9 points preoperatively
to 66.5 ± 16.3 points postoperatively (p < 0.001). A
healthy-appearing teres minor on preoperative imaging was associated with
significantly increased postoperative external rotation (40.4° ±
19.8° compared with 18.1° ± 18.4°) and a significantly
higher Constant score (p < 0.05 for both) compared with the values for the
patients with an absent or atrophic teres minor preoperatively. Three patients
with pseudoparalysis of the shoulder did not benefit from the procedure and
did not regain active elevation above the horizontal level. In contrast, the
fifteen patients with painful loss of active elevation recovered active
elevation. The acromiohumeral distance decreased 1.1 ± 1.9 mm on the
average, and glenohumeral osteoarthritis developed in only one patient. The
results did not differ between the tenotomy and tenodesis groups (mean
Constant score, 61.2 ± 18 points and 72.8 ± 12 points,
respectively). The "Popeye" sign was clinically apparent in
twenty-four (62%) of the shoulders that had been treated with a tenotomy; of
the sixteen patients who noticed it, none were bothered by it.
Conclusions: Both arthroscopic biceps tenotomy and arthroscopic
biceps tenodesis can effectively treat severe pain or dysfunction caused by an
irreparable rotator cuff tear associated with a biceps lesion. Shoulder
function is significantly inferior if the teres minor is atrophic or absent.
Pseudoparalysis of the shoulder and severe rotator cuff arthropathy are
contraindications to this procedure.
Level of Evidence: Therapeutic Level III. See
Instructions to Authors for a complete description of levels of evidence.
Massive, degenerative rotator cuff tears in elderly patients can be
disabling because of severe pain, weakness, and/or debilitating
pseudoparalysis of the shoulder. A patient with severe rotator cuff deficiency
often has severe daily pain, poor sleep quality, and a decreased ability to
independently perform activities of daily
living1-2.
Radiographic analysis usually shows a reduction of the acromiohumeral
distance, while magnetic resonance imaging or computed tomography with
arthrography often demonstrates severe muscle atrophy with fatty infiltration
of the rotator cuff
muscles3-6.
Treatment options depend on patient age, comorbidities, activity level, and
extent of the
disability7.
Conservative treatment is initially attempted, with modalities such as
nonsteroidal anti-inflammatory medications, corticosteroid injections, gentle
physical therapy with strengthening of the intact components of the rotator
cuff and deltoid, and periods of
rest8-10.
Persistence of symptoms despite adequate conservative therapy may warrant
operative treatment. Many palliative interventions have been proposed for
patients in whom rotator cuff repair is not feasible as a result of advanced
fatty infiltration of the rotator cuff muscles, definitive loss of tendons,
and proximal humeral migration. Open treatments such as simple
débridement and acromioplasty have been adapted to be performed
arthroscopically11-18.
More invasive interventions such as partial rotator cuff
repair19,20,
musculotendinous
transfers21-23,
hemiarthroplasty24-27,
and constrained prosthetic
replacement28-30
have also been proposed.
Lesions of the long head of the biceps tendon are often associated with
massive rotator cuff tears and may be responsible for shoulder pain and
dysfunction31-40.
The lesions vary in degree, from tendinitis, delamination, and subluxation on
the medial rim of the bicipital groove to frank dislocation or even joint
entrapment because of hypertrophy. In 1990, after observing the analgesic
effect of spontaneous rupture of the long head of the biceps tendon, Walch et
al. proposed arthroscopic biceps tenotomy as a palliative treatment to address
symptoms in patients with a massive irreparable rotator cuff
tear41. To reduce
the cosmetic deformity and associated muscle belly discomfort, the senior
author (P.B.) developed a technique of arthroscopic biceps
tenodesis42,43.
The purpose of the current study was to evaluate the clinical and radiographic
outcomes in a consecutive series of patients who had been treated with
isolated arthroscopic biceps tenotomy or tenodesis for persistent shoulder
pain and dysfunction due to an irreparable rotator cuff tear associated with a
biceps lesion.
Inclusion and Exclusion Criteria
The cases of patients who had presented with a symptomatic, massive, and
irreparable rotator cuff tear and had been treated with an isolated
arthroscopic tenotomy or tenodesis of the long head of the biceps tendon were
retrospectively reviewed at a minimum of two years postoperatively. Patients
who had a concomitant procedure (an attempted rotator cuff repair, an
acromioplasty, or any other surgical intervention) or had had previous surgery
were excluded from this investigation. The decision to perform arthroscopic
surgery was made only after the failure of conservative treatment with a
minimum six months of attempted rehabilitation.
The decision not to repair the rotator cuff was based on the presence of
one or more of the following criteria: substantial tendon retraction
precluding direct repair to the bone (grade
3)2,7,11,16,
advanced rotator cuff muscle atrophy or fatty infiltration (Goutallier stage 3
or
4)5,6,
proximal humeral migration with an acromiohumeral distance of <7 mm seen on
a true anteroposterior radiograph made in neutral
rotation3,4,
or a patient age of more than sixty years with poor motivation to comply with
the postoperative rehabilitation protocol following rotator cuff
repair44,45.
All patients had given written, informed consent before undergoing the
procedure and were aware that either a biceps tenotomy or a biceps tenodesis
could be performed at the time of surgery. The risks and benefits of both
procedures were explained to the patients, and they were aware that their data
could be used for research purposes. The patients were told that both
procedures would remove the pathological, intra-articular portion of the
biceps tendon and therefore should relieve the shoulder pain. The treatment
option was arbitrarily chosen by the surgeon who had developed the tenodesis
technique and depended mainly on the surgical conditions and possibilities as
well as the activity level and age of the patient. A biceps tenodesis was
preferentially performed in more active patients and in those under the age of
sixty-five. No specific randomization was performed for study purposes.
Patients
Between October 1999 and February 2002, seventy-eight consecutive patients
(eighty-two shoulders) with a massive, irreparable rotator cuff tear underwent
either an isolated arthroscopic biceps tenotomy or an isolated arthroscopic
biceps tenodesis. Seven patients were lost to follow-up, and three patients
died, leaving sixty-eight patients (seventy-two shoulders) for the present
retrospective study. The average age (and standard deviation) of the subjects
was 68 ± 6 years old (range, fifty-two to eighty-five years old) at the
time of the intervention and 71 ± 6 years old (range, fifty-five to
eighty-eight years old) at the time of the final review. There were forty-two
women (62%) and twenty-six men (38%). The dominant arm was affected in
sixty-three (88%) of the seventy-two cases. Ten (15%) of the sixty-eight
patients were employed, and fifty-eight (85%) were retired or had never
worked. The previous or present occupation of twenty-two patients (32%)
involved manual labor, and that of thirty-seven patients (54%) involved
sedentary work. Nine of the sixty-eight patients had never worked. At the time
of presentation, thirty-five shoulders (49%) were described by the patient as
having sustained antecedent trauma. Only one patient was treated as a result
of an injury at work.
Anatomic Lesions
The characteristics of the tendinous lesions were determined with
preoperative computed tomographic arthrography and direct arthroscopic
evaluation. The rotator cuff tear involved three tendons in fifty-four (75%)
of the seventy-two shoulders, two tendons in eleven (15%), and a single tendon
in seven (10%). The supraspinatus tendon was torn and retracted to the glenoid
(grade 3) in all shoulders. There was an associated infraspinatus tear in
fifty-nine (82%) of the seventy-two shoulders, a complete tear of the
subscapularis in two (3%), and a partial tear of the subscapularis (the
superior portion) in sixty-one (85%). There was a pathological lesion of the
long head of the biceps tendon in all cases, the details of which are given in
Table I.
Surgical Technique
All procedures were performed arthroscopically with the patient in the
beach-chair position and under general anesthesia with an interscalene block.
The procedure consisted of removal of the intra-articular portion of the
biceps tendon in all cases. A simple tenotomy was performed in thirty-nine
(54%) of the seventy-two shoulders, and a tenodesis was performed in
thirty-three (46%). Tenotomy involved division of the long head of the biceps
tendon at its proximal insertion at the supraglenoid tubercle and resection of
approximately 2 to 3 cm, representing the intra-articular portion; this
allowed the tendon to retract away from the joint into the bicipital groove.
Arthroscopic biceps tenodesis was performed with a previously described
technique: the tendon was brought out of the groove distal to the biceps
pulley, doubled over for a length of 2.5 cm, and then fixed into a bone socket
in the floor of the groove by means of a bioabsorbable (8.5-mm polylactic
acid) interference screw (Tenoscrew; Phusis, St. Ismier, France)
(Figs. 1-A and
1-B)42,43.
In neither protocol was an acromioplasty performed.
Postoperative Protocol
The inpatient stay was twenty-four hours. (We do not have an outpatient
surgical unit.) All patients wore a simple arm sling for two to three weeks
postoperatively. Pendulum exercises were started on the day following the
surgery, and they were performed for five minutes, five times per day.
Patients were encouraged to use the arm to eat, read, and write as soon as
doing so was comfortable. Self-mobilization in a pool was also recommended
once the surgical incisions were completely healed. The patients who had been
treated with the tenodesis were allowed to carry out activities of daily
living as tolerated after the second postoperative week because we thought
that the interference screw fixation was sufficient for these tasks. We did
not allow resistive exercises until at least six weeks had elapsed.
Functional Evaluation
All patients were examined preoperatively by the operating surgeon (P.B.)
and postoperatively by an independent reviewer (F.B.) at a minimum of two
years (average [and standard deviation], 35 ± 7 months; range,
twenty-four to seventy-six months). Both the Constant score and the range of
motion were measured during the preoperative and postoperatively clinical
examinations46,47.
The Constant score (0 to 100 points) comprises four sections: pain (0 to 15
points), activity level (0 to 20 points), active range of motion (0 to 40
points), and strength (0 to 25 points). With the patient seated upright,
strength was measured by means of a spring balance. The postoperative score
was adjusted for age and gender and used to define the result as excellent
(=100 points), good (86 to 99 points), fair (65 to 85 points), or poor
(<65
points)46,47.
At the time of follow-up, the patients were asked about discomfort and
cosmetic deformity of the biceps muscle. The examiner noted any tenderness in
the bicipital groove or the presence of a retracted biceps belly, the
so-called Popeye sign. Both active and passive forward elevation and external
rotation with the arm at the side were measured with a goniometer. Internal
rotation was determined by the highest vertebral level that could be reached
by the thumb. Subjective satisfaction was assessed by asking the patient if he
or she was very satisfied, satisfied, disappointed, or dissatisfied (unhappy)
with the result.
Radiographic Evaluation
An anteroposterior radiograph in neutral shoulder rotation with the patient
standing and a scapular lateral (outlet) radiograph were made preoperatively
and at the time of final follow-up. Acromial morphology was determined,
according to the criteria of Bigliani et
al.48, on the
preoperative scapular lateral radiograph. Eleven (15%) of the seventy-two
acromions were flat (type 1), forty-six (64%) were curved (type 2), and
fifteen (21%) were hooked (type 3). The subacromial space was evaluated
preoperatively and at the time of the last follow-up by measuring the distance
between the inferior acromial cortex and the superior pole of the humeral head
(the acromiohumeral distance) on the anteroposterior
radiograph4. The
preoperative acromiohumeral distance was <7 mm in sixty-three (88%) of the
seventy-two shoulders and =7 mm in nine (13%).
We used the radiographic classification developed by Hamada et al. to
characterize the massive rotator cuff tears on the preoperative and final
radiographs49.
Preoperative so-called acetabularization of the acromion (stage 3) was noted
in eleven shoulders and glenohumeral arthritis was noted in one (stage 4).
There were no cases of necrosis of the humeral head (stage 5).
All patients underwent computed tomographic arthrography preoperatively to
evaluate the quality of the remaining rotator cuff muscles. Fatty infiltration
of the infraspinatus and subscapularis was classified according to the
criteria of Goutallier et
al.5 (see Appendix).
Finally, the status of the teres minor was evaluated with computed tomography
according to the criteria of Walch et
al.45. The teres
minor was atrophic or absent in twelve (17%) of the seventy-two shoulders, and
it was normal or hypertrophic in sixty (83%).
Statistical Analysis
Univariate analysis was performed with the Fisher exact test, Student t
test, and Student paired t test for parallel series. For continuous variables,
we created a linear regression model and included in the model variables
associated with treatment (to a significance level of 15%). We compared the
demographic data between the two treatment groups (tenotomy and tenodesis).
For discrete variables, we created a regression model that included the same
variables and criteria. The significance level for all tests was considered to
be p < 0.05.
Subjective Results
The patients were very satisfied after thirty-three (46%) of the
seventy-two procedures, satisfied after twenty-three (32%), disappointed after
eleven (15%), and dissatisfied after five (7%).
Functional Results
The functional results are summarized in
Table II.
With the exception of strength, all Constant subscores (for pain, activity,
and active range of motion) were significantly improved (p < 0.001) at the
time of final follow-up. The improvement in the range-of-motion score was
secondary to improvement in active elevation, to an average of 155°
(change of +23° from the preoperative average of 132°); active
rotation was unaffected. When adjusted for age and gender, the Constant score
was excellent for thirty-seven shoulders (51%), good for ten (14%), fair for
seventeen (24%), and poor for eight (11%).
Results According to Initial Clinical Presentation
There were three types of initial presentation: isolated chronic pain
(fifty-four [75%] of the seventy-two cases); painful loss of
elevation—e.g., chronic pain and patient complaints of weakness and a
reduced range of active motion (fifteen [21%]); and pseudoparalysis of the
shoulder—i.e., almost no active elevation or abduction, with any attempt
to elevate or abduct the arm resulting in an ineffective shrug because of
anterosuperior subluxation of the humeral head (three [4%]). The three
patients who had exhibited pseudoparalysis preoperatively had persistent
pseudoparalysis at the time of final follow-up. In contrast, all fifteen
patients who presented with a painful loss of active elevation recovered
active elevation.
Radiographic Results
The mean acromiohumeral distance decreased from 5.6 ± 2 mm (range, 2
to 10 mm) preoperatively to 4.5 ± 2 mm (range, 0 to 10 mm) at the time
of the final review. This difference (1.1 ± 1.9 mm) was not
significant.
According to the radiographic classification system of Hamada et
al.49, eleven
shoulders had a deterioration of one stage and one had a deterioration of two
stages (Table III).
Acetabularization of the acromion (stage 3) developed in eight shoulders, but
the presence of acetabularization on the preoperative or final radiographs did
not appear to be related to the final Constant score or Constant pain subscore
(Figs. 2-A and 2-B).
Two patients had glenohumeral arthritis (Hamada stage 4) at the time of the
last review (Table III), but
true glenohumeral arthritis developed in only one patient after the surgery.
In retrospect, we found that osteoarthritis had been present in one patient
before the procedure, but the diagnosis had been missed. The other patient was
the only true example of deterioration seen radiographically in the series.
Necrosis of the humeral head (Hamada stage 5) did not develop in any
patient.
Results According to the Initial Status of the Rotator Cuff
With the numbers studied, neither the number of torn tendons nor the
extension of the tear (anteriorly into the subscapularis or posteriorly into
the infraspinatus) significantly influenced the functional result.
Furthermore, neither fatty infiltration of the subscapularis or infraspinatus
nor the acromiohumeral distance had a measurable effect on the final result
with the numbers available. In contrast, absence or atrophy of the teres minor
on preoperative imaging was associated with severe fatty infiltration of the
infraspinatus and with significant decreases in both postoperative external
rotation and the postoperative Constant score compared with the values for the
patients with a healthy-appearing teres minor preoperatively
(Fig. 3).
Complications and Reoperations
Eight (12%) of the sixty-eight patients had an adjusted Constant score of
<65 points and were considered to have had a failure of the surgery; these
patients included the three with pseudoparalysis of the shoulder and the two
with glenohumeral osteoarthritis. In addition, the shoulder of one patient
remained stiff postoperatively, and the patient was subsequently diagnosed as
having reflex sympathetic dystrophy. Finally, two patients continued to have
pain, but no clear explanation for the persistent pain was found; both
patients declined to have additional surgery.
Three of the sixty-eight patients underwent additional operations. One
patient was treated with immediate arthroscopic irrigation and antibiotic
therapy for an acute postoperative infection, which was successfully
eradicated. The latest Constant score for this patient was 73 points after
twenty-six months of follow-up, and the patient continued to be free of
infection. One of the patients who had persistent pseudoparalysis of the
shoulder and the patient with a missed preoperative diagnosis of
osteoarthritis underwent a subsequent reverse shoulder arthroplasty procedure,
three years after the index procedure. They both had a good final functional
result with a Constant score of 71 points and 65 points, respectively.
Results of Tenotomy and Tenodesis
Epidemiologically, the tenotomy and tenodesis groups were not equivalent:
there were more men and the mean age was younger in the tenodesis group (see
Appendix). Linear regression modeling, with the preoperative Constant score,
gender, age at surgery, and time to follow-up included in the model
(Table IV), was used to
separately compare the results between the two groups.
With the numbers studied, there was no difference in the Constant score at
the time of follow-up between the patients who had been treated with a
tenotomy and those who had been treated with a tenodesis. As expected, the
prevalence of muscle belly retraction (the Popeye sign) was significantly
higher in the tenotomy group (62% compared with 3%, p < 0.001). However,
this deformity had been noticed by only sixteen of the twenty-four affected
patients and was not a concern for any of them. Muscle cramps in the biceps
were more frequent after tenotomy, although the difference was not
significant. There was a trend for increased muscular ache and tenderness in
the bicipital groove in the tenotomy group, but these differences were also
not significant.
Lesions of the long head of the biceps tendon are often associated with
massive rotator cuff tears and may be responsible for shoulder pain and
dysfunction30-39.
Arthroscopic biceps tenotomy or tenodesis has been proposed as a method with
which to relieve the pain and restore shoulder function in patients with a
massive, irreparable rotator cuff tear and a lesion of the biceps
tendon40-43.
However, all patients who have symptoms related to a massive, irreparable
rotator cuff tear do not present with the same clinical features: some
patients only have pain, whereas others have pain and loss of active anterior
elevation of the shoulder.
In the present study, we found that it is crucial to differentiate between
patients with true pseudoparalysis of the shoulder and those with painful loss
of elevation. The primary difference is that a shoulder with true
pseudoparalysis is nonfunctional, exhibiting an ineffective shrug with
attempted elevation of the arm, whereas a shoulder with painful loss of
elevation is functional but active elevation is limited because of pain. In
our series, the fifteen patients with painful loss of elevation had
substantial improvement and regained nearly symmetrical active elevation after
arthroscopic biceps tenotomy or tenodesis. In contrast, the three patients
with a misdiagnosed pseudoparalysis of the shoulder did not benefit from the
procedure and did not regain active shoulder elevation above the horizontal
level.
It is not always easy to differentiate between painful loss of elevation
and true pseudoparalysis of the shoulder. The examiner must look for
anterosuperior subluxation of the humeral head between the acromion and the
coracoid when a patient tries to elevate or abduct the
arm30,50
(Fig. 4). However, this
clinical sign is not always easy to observe, and, in our series, the diagnosis
of pseudoparalysis of the shoulder was missed in three patients. This clinical
experience has led us to perform the following test on our patients. The
examiner slowly brings the patient's arm just above the horizontal level
(between 90° and 120°) and asks the patient to actively maintain this
position. A patient with true pseudoparalysis of the shoulder will not be able
to do so; the arm will fall down despite his or her efforts (the landing
test). The descent of the arm is related to muscle weakness and not to pain
(Figs. 5-A and 5-B).
Additionally, infiltration of the shoulder with lidocaine may help to
differentiate the two clinical presentations by relieving the shoulder pain
and allowing active elevation. An isolated biceps tenotomy or tenodesis is
contraindicated for patients with a massive, irreparable rotator cuff tear who
present with true pseudoparalysis of the shoulder despite rehabilitation, and
we now perform a reverse shoulder arthroplasty for those
patients28,29,51.
This study confirmed that both arthroscopic biceps tenotomy and
arthroscopic biceps tenodesis are effective palliative treatmentsfor a
symptomatic, irreparable rotator cuff tear associated with a biceps lesion in
an elderly patient without pseudoparalysis of the shoulder. It should be noted
that, in this series, biceps tenotomy or tenodesis was performed as an
isolated procedure, without any attempt at rotator cuff repair and without an
associated acromioplasty. Fifty-three (78%) of the sixty-eight patients were
satisfied or very satisfied with the result at an average of thirty-five
months postoperatively. Improvements in function, range of motion, and
activity level were secondary to pain reduction. The Constant score increased
by an average of 20 points, with an average final score of 66.5 ± 16.3
points, a result that parallels those in the
literature44,45,52-54.
Walch et al. recently reported the long-term results of 307 biceps tenotomies,
110 of which were performed with a concomitant acromioplasty, as palliative
treatment for rotator cuff
tears45. At an
average of fifty-seven months postoperatively, 87% of the patients were
satisfied or very satisfied and the mean Constant score had improved to 67.6
points, compared with 48 points preoperatively.
As expected, active external rotation was not improved after the surgery.
Like Walch et
al.45, we found
that an absent or atrophic teres minor on preoperative imaging was associated
with severe fatty infiltration of the infraspinatus, a decrease in
postoperative external rotation, and a lower postoperative Constant score. The
result of a tenotomy or tenodesis is, therefore, improved if the infraspinatus
or teres minor can provide active external
rotation44,54.
Preoperative knowledge of the status of the remaining rotator cuff can help
the surgeon and patient to arrive at the best treatment option. When a patient
has a severe external rotation deficit (a Hornblower sign and dropping sign)
and a teres minor that is torn or has fatty infiltration, and the goals are
more than just palliation, we now perform an additional latissimus dorsi and
teres major tendon transfer in order to improve this
function23,50.
At an average of three years postoperatively, glenohumeral arthritis had
developed in only one patient. The average reduction in the acromiohumeral
distance was 1.1 mm, which is commensurate with the natural history of massive
rotator cuff tears or biceps
tenotomy3,24,49.
In the study by Walch et al., biceps tenotomy led to an average 1.3-mm
decrease in the acromiohumeral space at an average of fifty-seven months
postoperatively45.
Moreover, the acromiohumeral narrowing observed in our study is equivalent to
that seen after simple débridement and less than that seen after
acromioplasty14-16.
Our clinical observation confirms the findings of the biomechanical studies by
Yamaguchi et al.51
and Levy et al.55
but is in contrast with those of others, who found that the long head of the
biceps is unlikely to be an active humeral head depressor, even in patients
with a massive rotator cuff
tear56-59.
We found no association between humeral migration or even acetabularization
of the acromion and the Constant score or pain. Therefore, acetabularization
(Hamada stage 3) does not appear to be a contraindication to a biceps tenotomy
or tenodesis, nor should it be an indication for reverse shoulder arthroplasty
in the absence of pseudoparalysis of the shoulder. Acromial acetabularization
represents a functional adaptation to a chronic massive rotator cuff tear: as
long as the coracoacromial ligament is intact, the deltoid and the remaining
rotator cuff can compensate for loss of the superior portion of the rotator
cuff
24,45,49.
In this situation, there is a risk that an acromioplasty will destabilize the
shoulder, converting a painful functional shoulder into a painful
nonfunctional one with loss of active
elevation60-62.
Therefore, in this series, no patient was treated with an acromioplasty.
The only patient in our series with true (but misdiagnosed) glenohumeral
cuff arthropathy (Hamada stage 4) did not benefit from a biceps tenotomy. We
think that the radiographic classification of massive rotator cuff tears
developed by Hamada et
al.49 helps to
clarify the indications for an arthroscopic biceps tenotomy or a reverse
shoulder arthroplasty: only patients who have a functional shoulder without
glenohumeral osteoarthritis (Hamada stage 1, 2, or 3) are candidates for an
arthroscopic biceps tenotomy or tenodesis. Patients with a nonfunctional
shoulder (pseudoparalysis) and/or glenohumeral osteoarthritis or humeral head
necrosis (Hamada stage 4 or 5) are candidates for a reverse shoulder
arthroplasty28-30,60.
Our study confirmed that distal retraction of the muscle belly is not the
rule after biceps tenotomy (it was seen in 62% of the shoulders in our series
and 50% in the study by Walch et
al.45) and that
cosmetic deformity of the arm that is bothersome to the patient is uncommon.
Although the results of the comparison of tenotomy and tenodesis in this
retrospective study must be interpreted with caution, the high rate of patient
acceptance of the cosmetic deformity seen following the tenotomy may be
explained by the age of the patients at the time of follow-up (mean, 71
± 6 years) and by their lack of pain. We observed a trend for a higher
prevalence of muscle belly discomfort in the tenotomy group (21% compared with
9%); however, as was the case in the study by Osbahr et
al.44, this was not
significant. Finally, in the present study, we did not measure the loss of
strength of flexion after biceps tenotomy or tenodesis. It has been reported
in the literature that 20% of forearm supination strength and 8% to 20% of
elbow flexion strength are lost following spontaneous proximal biceps
rupture63,64.
Recently, Maynou et al. found that, after biceps tenotomy in patients with a
massive, irreparable cuff tear, muscle force for elbow flexion-supination was
decreased by 40% compared with that in an age, gender, and dominance-matched
control
group53.
On the basis of our findings in this series, we concluded that isolated
arthroscopic biceps tenotomy or tenodesis is a valuable option for the
treatment of irreparable and degenerative rotator cuff tears in elderly
patients with a lesion of the biceps tendon. Although it does not improve
shoulder strength, biceps tenotomy or tenodesis reduces pain and improves the
functional range of motion. The preservation of some of the posterior part of
the rotator cuff, particularly the teres minor, results in improved external
rotation and therefore a better functional result. Superior humeral migration,
even with acetabularization of the acromion (Hamada stage 3), is not a
contraindication to a biceps tenotomy or tenodesis. Patients with a painful
loss of shoulder elevation benefit from the procedure. However, the operation
should not be performed either in patients with pseudoparalysis of the
shoulder or in those with preoperative radiographic signs of glenohumeral
arthritis or humeral head necrosis (Hamada stage 4 or 5).
While a prospective randomized trial would be needed to evaluate the
respective places of tenotomy and tenodesis in the treatment of degenerative
rotator cuff tears, we preferentially perform a biceps tenodesis in younger
patients (less than sixty years old) and in active patients who play sports or
whose daily activities involve repetitive forceful supination of the forearm
(gardeners, carpenters, woodworkers, automobile mechanics, and so on). Very
thin patients may prefer a tenodesis for cosmetic reasons. However, given the
increased surgical difficulty, time, and cost of a tenodesis procedure, a
simple tenotomy is probably sufficient for most elderly patients.
Tables showing the stages of fatty infiltration according to the criteria
of Goutallier et
al.5 and a detailed
comparison between the two study groups are available with the electronic
versions of this article, on our web site at
(go to
the article citation and click on "Supplementary Material") and on
our quarterly CD-ROM (call our subscription department, at 781-449-9780, to
order the CD-ROM). ?
Iannotti JP, Bernot MP, Kuhlman JR,
Kelley MJ, Williams GR. Postoperative assessment of shoulder function: a
prospective study of full-thickness rotator cuff tears. J Shoulder
Elbow Surg. 1996;5:
449-57.5449
1996
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