Biceps Tenotomy vs. Tenodesis: Editorial

J Shoulder Elbow Surg (2021) 30, 949–950
www.elsevier.com/locate/ymse
EDITORIAL
Biceps tenotomy vs. tenodesis

We begin this issue with 2 unusual articles for science. Level I systematic reviews and meta-analyses are
JSESdsystematic reviews and meta-analyses on the same the highest-level evidence we can muster, and both found
topic.1,3 Further, both of these are Level I systematic re- the same thing, mainly that there were no differences in
views, meaning that they looked only at Level I studies on overall outcomes from the 2 procedures. Further, although
this topic, which was a comparison of outcomes of biceps both reviews found that the Popeye deformity was more
tenotomy vs. biceps tenodesis. In addition, we follow these common after a tenotomy, it still occurs in tenodesis cases,
reviews with an original article on the Popeye deformity in and the Dutch study showed that this may be more
proximal biceps surgery and how much of a problem that noticeable to the doctors than to the patients, who in many
was for the patients. cases did not care about the cosmetic problem.
Level I studies in orthopedic surgery are somewhat rare, Unfortunately, we know that this is not always the case,
as they are in any surgical specialty, because it is difficult to and it is too simplistic to just state that it does not matter
do blinded studies of invasive procedures, and to obtain which procedure one performs. In my surgical career, I had
enough patients willing to be submitted to a randomized 2 patients unhappy with the appearance of their arm after a
study of those invasive procedures. Systematic reviews of tenotomy. One had me revise that to a tenodesis, and the
Level I studies are even rarer in the surgical specialties other scheduled to do so but did not show updprobably
because it is difficult to find enough Level I studies on the going elsewhere. I also had 2 patients with continued pain
same topic to actually do such a systematic review. after a tenodesis, who eventually came to a revision
The 2 review articles were done by Eric McCarty’s group tenotomy that relieved their pain.
at the University of Colorado1 and Moin Khan’s group at On one of the patients unhappy with the tenotomy, he
McMaster University in Hamilton, Ontario.3 Both came to was a young guy with a fairly muscular build, and in
essentially the same conclusionsdthat there were no sig- retrospect, it was probably the wrong decision not to do a
nificant differences in outcomes between proximal biceps tenodesis. On one of the patients with continued pain after
tenotomy and proximal biceps tenodesis. Both also showed tenodesis, who was in his mid-60s, an initial tenotomy
that a Popeye deformity was more common after biceps probably would have served him better. As is often the case
tenotomy, as expected, occurring about 7% of the time after with medicine and surgery, listen to the patientdthey will
tenodesis and about 23% of the time after tenotomy. often tell you the diagnosis, or the surgery needed.
However, the presence or absence of this deformity did not So despite these 3 excellent studies, it behooves all of us
affect the overall patient outcomes. The numbers are very to continue to listen to the patients and treat each of them
similar as they studied the same group of Level I studies. individually, taking into account their age, their builds, their
Finally, the third article, on the Popeye deformity, came activity levels, their chief complaints, and what they hope
from a Dutch group led by Derek van Deursen in Amster- to get out of any surgery on their proximal biceps. There
dam and Utrecht.2 They showed that the Popeye deformity, are certainly cases where tenodesis will be the proper
in many cases, was more of a problem noted by the doctor procedure, where the patient may be more cognizant of the
than by the patient. Only 2 of 97 patients felt that they had a cosmetic appearance of the arm. And in many patients,
cosmetic deformity, although the doctors found that 32 often older, who may have lesser demands on their arms,
cases had the Popeye deformity, 19 after tenotomy and 13 and less concern about cosmesis, tenotomy will likely be a
after tenodesis, and the 2 groups only agreed on 1 case. sufficient procedure to achieve the patient’s goals.
So, in a sense, you could say that these articles, espe- At any rate, the patients should always be informed of
cially the systematic reviews, make this somewhat settled the best evidence as to the expected outcomes of either
procedure, which are likely very similar, and to the possi-
Reprint requests: William J. Mallon, MD. bility of a cosmetic deformity, which is more common after
1058-2746/$ - see front matter Ó 2021 Published by Elsevier Inc. on behalf of Journal of Shoulder and Elbow Surgery Board of Trustees.
https://dx.doi.org/10.1016/j.jse.2021.03.131
950 Editorial
tenotomy, but by no means occurring in all such cases, and References

in many cases, not a problem to the patient.
Thus, we would like to say that this is settled science, 1. Belk JW, Kraeutler MJ, Houck DA, Chrisman AN, Scillia AJ,
McCarty EC. Biceps tenodesis versus tenotomy: a systematic review
but it is never that easy in medicine or surgery. We applaud
and meta-analysis of level I randomized controlled trials. J Shoulder
all 3 groups for these excellent studies, which we know will Elbow Surg 2021;30:951-60. https://doi.org/10.1016/j.jse.2020.11.012
help our readers make more informed decisions in treating 2. van Deurzen DFP, Garssen FL, Wessel RN, Kerkhoffs GMM, van den
patients with proximal biceps pathology. Bekerom MPJ, van Wier MF. The Popeye sign: a doctor’s and not a
patient’s problem. J Shoulder Elbow Surg 2021;30:969-76. https://
doi.org/10.1016/j.jse.2020.10.040
William J. Mallon, MD
3. Xi MZ, Leroux T, Ben-David E, Dennis B, Gohal C, Kirsch JM, et al. A
Editor-in-Chief meta-analysis of level I evidence comparing tenotomy vs tenodesis in
Journal of Shoulder and Elbow Surgery the management of long head of biceps pathology. J Shoulder Elbow
E-mail: [email protected] Surg 2021;30:961-8. https://doi.org/10.1016/j.jse.2021.02.002

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J Shoulder Elbow Surg (2021) 30, 949–950

Biceps tenotomy vs. tenodesis

tenotomy, but by no means occurring in all such cases, and References

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