Lee HJ, Jeong JY, Kim CK, Kim YS. Surgical treatment of lesions of the long head of the biceps brachii tendon with rotator cuff tear: a prospective randomized clinical trial comparing the clinical results of tenotomy and tenodesis. J Shoulder Elbow Surg. 2016 Jul;25(7):1107-14.
In patients with reparable rotator cuff tears and symptomatic lesions of the long head of the biceps brachii tendon (LHBT), what is the comparative efficacy of tenotomy and tenodesis?
Randomized (allocation not concealed)*, blinded (patients and outcome assessors), controlled trial with follow-up at a mean of 20 or 25 months.
The Catholic University of Korea, Seoul, Republic of Korea.
137 patients (mean age, 63 years; 77% women) who needed surgical repair for small to medium-sized rotator cuff tears and had concomitant symptomatic partial tears of the LHBT (confirmed with magnetic resonance imaging) that had shown no improvement after ≥1 month of conservative treatment with medication or corticosteroid injections. The exclusion criteria were large or massive rotator cuff tears, previous shoulder surgery or trauma, glenohumeral arthritis, or labral tears. 93% of patients completed follow-up.
LHBT funnel-shaped tenotomy, performed by dividing the LHBT at its proximal origin at the labrum (n = 60), or LHBT tenodesis, performed inside the glenohumeral joint (n = 77). Both groups underwent rotator cuff repair, with a single-row repair used for small tears (<1 cm) and equivalent repair (suture-bridge technique) used for medium tears (1 to 3 cm). All procedures were performed by 1 senior shoulder specialist.
Main outcome measures:
The outcomes included function (American Shoulder and Elbow Surgeons [ASES]) score and Constant Shoulder Score [CSS]), pain (visual analog scale, with 0 indicating no pain and 10 indicating most severe pain), range of motion, Popeye deformity, and rotator cuff repair rate, all of which were evaluated at 3, 6, and 12 months and at the time of the final follow-up. In addition, elbow motor power (flexion, supination, and pronation) was evaluated at the time of the final follow-up.
The mean duration of follow-up was 25 months for the tenotomy group and 20 months for the tenodesis group. The groups did not differ in terms of function, pain, range of motion, or rotator cuff retear rates (Table I). Patients in the tenotomy group had lower elbow supination power and higher rates of Popeye deformity (Table I).
In patients with reparable rotator cuff tears and symptomatic lesions of the LHBT, tenotomy and tenodesis did not differ in terms of function or pain. Tenotomy was associated with lower elbow supination power and higher rates of Popeye deformity.
*Information provided by author.
Source of funding:
No external funding.
For correspondence: Dr. J.-S. Kim, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea. E-mail address: email@example.com.
The randomized controlled trial (RCT) by Lee and colleagues addresses an interesting and often debated topic: How should we treat the biceps tendon in patients with a full-thickness rotator cuff tear? There are 3 main strategies: (1) biceps tenotomy, (2) biceps tenodesis, and (3) no treatment. Usually, the decision is based on personal preference, with little use of evidence. A randomized controlled trial (RCT) is appropriate to evaluate the efficacy of the treatments.
In this RCT, 128 patients with small to medium-sized rotator cuff tears underwent repair surgery and were analyzed. The 2 groups were somewhat unequal: 56 patients had tenotomy, and 72 had tenodesis. This discrepancy was not well-explained: one would have expected the groups to be more or less equal in a block-randomized study. The outcomes, assessed after mean durations of follow-up of 20 and 25 months, were similar in both groups in terms of functional scores (ASES and CSS scores) and elbow strength. However, forearm supination power was greater in the tenodesis group.
The limitations of the trial included the different-sized study groups, the small sample size (although a sample-size calculation determined that 37 patients per group was enough to avoid a type-2 statistical error with 80% power, α = 0.05), and the relatively short follow-up period. A major concern is the lack of a no-treatment control group, particularly since it may be appropriate to leave the biceps tendon alone when performing a cuff repair. Also, the strength measurement was based on comparison with the contralateral side, but no information was reported about the health status on the other side. Despite these limitations, this study represents one of the largest trials comparing biceps tenodesis and tenotomy.
The authors did not state if they prefer one treatment over the other. The answer might be obvious: tenotomy is simpler, easier to perform, quicker, and less expensive. Thus, it is somewhat surprising that the authors do not draw this conclusion given that the final outcomes in terms of functional scores and strength were similar for both groups.
Disclosure: The author indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/A14).