This study showed that rotator cuff repair combined with biceps tenodesis increases both supination and elbow flexion strengths while decreases biceps groove pain compared to preoperative values at the early postoperative period. This was the main finding of our study.
Similar findings were reported by Hufeland et al. . Twenty-two patients included in their studywere randomized for tenodesis and tenotomy. They concluded that there was no significant difference in flexion and supination strength between tenodesis and tenotomy group after 12 months . Unlike our study, they did not perform additional rotator cuff repair and also performed the biceps tenodesis using the interference screw.
The addition of the repair of rotator cuff tear possibly contributed an increase to the strength in our study. The technique for biceps tenodesis was similar to the technique described by Levy JC. However, two simpler lasso loops were created and incorporated into lateral row anchors instead of Krackow technique, and also the tendon was not exteriorized . This might have resulted in an increase of BAD compared to preoperative levels due to some degree of distal migration of the biceps tendon. Nevertheless, it does not seem to be improved at the postoperative 3rd month period and reaches a plateau there after. Mazocca et al. reported higher ASES scores in patients who underwent subpectoral biceps tenodesis without rotator cuff lesion than the patients who had concomitant rotator cuff lesion. Boileau et al. conducted a retrospective study to evaluate the outcomes of arthroscopic biceps tenotomy or tenodesis who underwent surgery due to persistent shoulder pain. The rotator cuff muscles of the patients were irreparable. They conclude that both arthroscopic tenotomy and tenodesis can reduce pain .
In a study conducted by Checchia et al., 15 patients with rotator cuff tears and biceps tendon pathology were operated. The authors stated excellent results in 11 patients while reported satisfactory results as 93.4%. They evaluated the patients according to UCLA score and detected Popeye sign only in one patient. The mean follow-up period of the patients was 32.4 months . We use ASES and Constant score instead of UCLA to evaluate the patients. The mean follow-up period of the patients was 24 months in our study.
Another study with 114 participants was conducted by MacDonald et al. revealed good outcomes for both tenotomy and tenodesis groups. We did not compare the outcomes of tenodesis and tenotomy. Tenodesis was performed to all patients included in our study.
Gialanella et al. investigated the short-term effect of biceps surgery on rehabilitation and functional outcomes. They included 93 patients to the study. Twenty-five patients underwent rotator cuff surgery in addition to biceps tendon surgery and 68 of them underwent only cuff repair. They evaluated Constant score, ROM, pain, and UCLA at admission, the end of rehabilitation, and postoperative sixth month. The patients who underwent simultaneous biceps tendon surgery and rotator cuff repair showed poorer functional outcome in the postoperative sixth month . In our study, the elbow flexion and forearm supination values of the operated side were nearly 2-fold of preoperative values at postoperative 6th month.
One of the advantages of the technique we performed is providing a simple and low costing surgery by performing biceps tenodesis and double-row rotator cuff repair simultaneously.
In contrast to our study Yi et al. reported a higher degree of bicipital pain in the arthroscopic suprapectoral biceps tenodesis group compared to open subpectoral group at early period without a difference after 6 months. VAS scores of the arthroscopic group at postoperative 3rd month were similar to the present study (3 ± 1). Preoperative, postoperative ASES, CS scores were higher probably due to the inclusion of only small and medium-sized tears. More patients in the arthroscopy group had an increase of BAD .
Shang et al. conducted a meta-analysis to compare tenodesis and tenotomy groups combined with rotator cuff repairs. The results showed no significant differences in terms of ASES scores, elbow flexion strength index, forearm supination index, and range of motion. However, only few randomized controlled studies were included in this meta-analysis. We did not compare tenotomy and tenodesis patients, our study contained only one group of patients who underwent biceps tenodesis. This is one of the limitations of our study.
The disadvantages of LHB tenotomy are a higher risk for Popeye sign, the risk for loss of flexion and supination strength of elbow . It has been shown that tenodesis and tenotomy have resulted in a good or excellent result in 74% and 77% of cases, respectively. Besides, persistent pain related to tenodesis has reported in 24% of cases . In our study, the patients had almost halved pain at 3rd month. Also, we did not notice any popeye deformity at any patient.
Baumgarten et al. evaluated patients with a comparison between patients who underwent primary arthroscopic rotator cuff repair with and without biceps tenodesis. They stated no difference between groups and concluded that arthroscopic biceps tenodesis simultaneous rotator cuff repair is safe and effective. A study in 30 patients, 12 of whom had a rotator cuff tear underwent isolated biceps tenotomy was conducted by Gill et al. showed a significant improvement in function and reduction in pain. Although we performed tenodesis to our patients, we observed a decrease in pain and an increase in both forearm supination and elbow flexion.
In this study, the muscle strength measurements of the patients were compared with those of the contralateral side as a control group. When the measurements from the preoperative period to the postoperative 24th month were compared, it was found that the elbow flexion and forearm supination strength of the operated side reached a level similar to the contralateral side muscle strength from the postoperative 12th month (p > 0.05). As an unexpected situation, an increase in muscle strength was observed in the contralateral side in parallel with the increase in muscle strength on the operated side. The difference between the elbow flexion strength in the preoperative period and postoperative 24th-month muscle strength measurements on the contralateral side was 6.2 kg (p < 0.001) and the difference in forearm supination strength was 3.1 kg (P < 0.001). Among the reasons for this situation are; patients have been exposed to pain for approximately 1 year (mean preoperative pain duration: 11.2 ± 10.4 months) and thus, the development of avoidance of the extremity (decreased quality of life and daily activity level), the patients felt better in terms of psychology and muscle after the operation period. We think that there may be an increase in motivation, strength, and quality of life and daily activation level of patients with strength measurements. However, in this study, patients were not evaluated in terms of these parameters.
Various studies showed the effect of anxiety and depression on the outcomes of rotator cuff repair surgery [33–35]. Lau et al. aimed to evaluate the effect of anxiety or depression on the ASES score . They concluded that stronger feelings of anxiety or depression cause both lower preoperative and postoperative scores. However, it is correlated with better improvement from surgery. A systematic review conducted by Kennedy et al. to determine whether the patients with rotator cuff tear were affected by psychosocial factors . For this purpose, they identified 980 articles. This study stated that psychosocial factors significantly affect the level of disability and preoperative pain . Similarly, Cho et al suggested that the success of the rotator cuff surgery may improve health-related quality of life and psychological status .
Limitations of the present study include lack of a control group, short follow-up time, and the limited number of the patients. Control group consisting of rotator cuff repair with biceps tenotomy or consequences of patients with Popeye deformity remains to be clarified and both are the subject of future studies. Our hypothesis was proven as the increase of both supination and elbow flexion strengths were observed at an early follow-up as 3 months.