What is the treatment approach for biceps tenodesis?

Biceps Tenodesis Treatment Approach

There is insufficient evidence to recommend for or against biceps tenotomy or tenodesis when performing shoulder arthroplasty in patients with glenohumeral osteoarthritis, as current practice habits are either anecdotal or based on experience rather than high-quality evidence. 1

Current Evidence and Recommendations

• The American Academy of Orthopaedic Surgeons (AAOS) guidelines indicate that due to the paucity of literature and variety of techniques used to address the biceps tendon during shoulder arthroplasty, neither routine biceps tenotomy nor tenodesis can be supported 1
• Some surgeons routinely sacrifice the biceps tendon during arthroplasty while others preserve it, but these practices are based on experience rather than evidence 1
• When biceps tenodesis is performed, appropriate tensioning is critical to establish a patient-specific, anatomic length-tension relationship to avoid undesirable outcomes such as cramping or cosmetic deformity 2

Comparison of Tenodesis vs. Tenotomy

• A high-quality randomized controlled trial comparing biceps tenodesis versus tenotomy found that both procedures result in good subjective outcomes with similar improvements in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Rotator Cuff Index (WORC) scores 3
• The relative risk of cosmetic deformity (Popeye deformity) in the tenotomy group compared to the tenodesis group was 3.5 times higher (33% vs 10%) 3
• No significant differences were found between tenodesis and tenotomy groups in terms of pain improvement, cramping, elbow flexion strength, or supination strength 3
• Surgeon preference is likely more influential in choosing between tenotomy and tenodesis due to similar functional outcomes 4

Technical Considerations for Biceps Tenodesis

• Various techniques have been described for biceps tenodesis, including arthroscopic versus open and suprapectoral versus subpectoral approaches 4
• The subpectoral approach provides excellent versatility when performing revision tenodesis by removing the tendon completely from the groove while preserving biceps function 5
• Anatomic tensioning during tenodesis is important to limit undesirable outcomes such as cramping or cosmetic deformity 2

Management of Failed Biceps Procedures

• Failed biceps tenotomy generally results from inadequate preoperative discussion of potential outcomes rather than technical problems 5
• Patients with unsatisfactory results after tenotomy can be treated with conversion to biceps tenodesis 5
• Failed biceps tenodesis is usually recognized by persistent pain in the bicipital groove area, often caused by mechanical failure of the tenodesis or unaddressed associated shoulder pathology 5
• Treatment options for failed tenodesis include revision tenodesis or biceps tenotomy 5

Common Pitfalls and Considerations

• Failure to address underlying biomechanical issues may lead to recurrence of biceps tendon pathology 6
• Misdiagnosing biceps tendinopathy as an inflammatory condition rather than a degenerative condition can lead to inappropriate treatment focus 6
• Premature return to aggravating activities before adequate healing can lead to recurrence 7
• Delayed referral for surgical consultation when conservative measures have failed after 3-6 months can lead to prolonged recovery 7

Despite the lack of clear guidelines specifically for biceps tenodesis, the available evidence suggests that both tenodesis and tenotomy can provide good functional outcomes, with tenodesis offering a lower risk of cosmetic deformity but potentially involving more complex surgical techniques.