The Role of Concomitant Biceps Tenodesis in Shoulder Arthroplasty for Primary Osteoarthritis: Results of a Multicentric Study

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1 4edwards.qxd 4/6/04 3:53 PM Page 401 The Role of Concomitant Biceps Tenodesis in Shoulder Arthroplasty for Primary Osteoarthritis: Results of a Multicentric Study GIUSEPPE FAMA, MD*; T. BRADLEY EDWARDS, MD ; AZIZ BOULAHIA, MD*; JEAN-FRANÇOIS KEMPF, MD ; PASCAL BOILEAU, MD ; CHANTAL NÉMOZ, PHD*; GILLES WALCH, MD* abstract This study evaluated the effects of concomitant biceps tenodesis in patients undergoing shoulder arthroplasty for primary osteoarthritis. Six hundred eighty-eight shoulders that had undergone replacement for primary glenohumeral arthritis were reviewed at a mean 43 months postoperatively. One hundred twenty-one patients had undergone a biceps tenodesis at arthroplasty, while the remaining patients did not. Tenodesis was significantly better than no tenodesis in most outcome parameters. No difference was found between the groups in complication rate. Biceps tenodesis is a useful adjunct to shoulder arthroplasty in the treatment of primary osteoarthritis. Shoulder arthroplasty for primary glenohumeral osteoarthritis treatment as described by Neer provides good postoperative function and pain relief However, not all shoulder replacements result in a satisfactory outcome. Reasons for these suboptimal results are not always apparent. 3,4,11,13 It has been hypothesized, based initially on a large anecdotal experience of the senior author (G.W.), that biceps tendon pathology (fraying and hypertrophy) may contribute to pain in shoulder osteoarthritis. Consequently, failing to address the biceps tendon with tenotomy or tenodesis at arthroplasty may lead to a less satisfactory result. However, these anecdotal contentions have not been scientifically defended by examining results of a large series of patients. More recently, the biceps tendon has been reported as a potential cause of unsatisfactory results of shoulder arthroplasty by Dines and Hersch. 21 With the exception of this report, no other information specifically regarding the handling of the biceps tendon during shoulder arthroplasty is available in the literature. This study examined the effect of biceps tenodesis performed at shoulder arthroplasty for primary glenohumeral osteoarthritis on shoulder specific outcome parameters, radiographic results, and complication rate. MATERIALS AND METHODS This investigation is based on a series of 1542 primary shoulder arthroplasties performed from and reported as part of a multicentric study in Nice, France in September In an effort to obtain a pure series of primary osteoarthritis, shoulders with an inflammatory arthropathy (eg, rheumatoid arthritis, systemic lupus erythematosis, ankylosing spondylitis), osteochondromatosis, acromegaly, Paget s disease, postinfectious arthropathy, skeletal dysplasia, neurological problems (eg, Charcot arthropathy, Parkinson s disease), and osteonecrosis (post-traumatic, radiation induced, idiopathic) were excluded from this population. Additional exclusion criteria included any shoulder with a history of shoulder trauma (fracture or soft-tissue injury), instability (surgically or nonsurgically treated), or prior shoulder surgery. Lastly, shoulders with marked rotator cuff pathology as indicated by acromiohumer- From *Clinique Sainte Anne Lumière, Lyon, France; Fondren Orthopedic Group, Houston, Tex; Hôpital de Hautepierre, Strasburg, France; and Hopital de l Archet, Nice, France. This investigation was performed at the Clinique Sainte Anne Lumière, Lyon, France. Reprint requests: T. Bradley Edwards, MD, Fondren Orthopedic Group, 7401 S Main St, Houston, TX APRIL 2004 Volume 27 Number 4 401

2 4edwards.qxd 4/6/04 3:53 PM Page 402 TABLE 1 Preoperative Patient Evaluation Constant Score Active Forward Active External Patient Group Pain Activity Mobility Strength Total Adjusted (%) Flexion ( ) Rotation ( ) Hemiarthroplasty Concomitant tenodesis (n=13) No tenodesis (n=86) Total shoulder arthroplasty Concomitant tenodesis (n=108) No tenodesis (n=481) al arthritis, a massive rotator cuff tear, or a rotator cuff tear involving the infraspinatus (only 6 cases were excluded for an infraspinatus tear despite a suspected diagnosis of primary glenohumeral osteoarthritis) as displayed on imaging or at surgery were excluded, as it could not be concluded that the etiology of shoulder disease was primary glenohumeral osteoarthritis. Of the remaining arthroplasties, 766 shoulders in 725 patients underwent replacement for primary osteoarthritis as described by Neer. 15 Twenty patients died of problems unrelated to arthroplasty and 28 patients were lost to follow-up before a minimum of 2 years. Additionally, 12 patients experienced a biceps tendon rupture prior to arthroplasty and were therefore excluded from the study population, leaving 688 shoulders available for evaluation. Fifty-five surgeons from 9 countries contributed cases to this series of osteoarthritic patients. Average patient age at surgery was 68 years (range: years). Seventy-five percent of patients were female, and 59% of the prostheses were implanted in right shoulders. The dominant shoulder was involved in 60% of cases. All patients in this series underwent primary shoulder arthroplasty using the Aequalis prosthesis (Tornier, Mont Bonnot, France), which is an adaptable device with an adjustable stem diameter, head diameter, neck inclination, and head offset. Ninetynine shoulders underwent hemiarthroplasty, and 589 shoulders underwent total shoulder arthroplasty. The indication for hemiarthroplasty was based on surgeon preference. Most surgeons in this series performed hemiarthroplasty for young patients (aged 55 years) or patients without significant glenoid disease. One hundred twenty-one shoulders had a biceps tenodesis at arthroplasty. Five hundred sixty-seven shoulders underwent no additional biceps procedure at arthroplasty. Initially, the indication for biceps tenodesis was an abnormal appearing biceps tendon; however, during the final 3 years of this study, the senior author (G.W.) began systematically performing a biceps tenodesis during shoulder arthroplasty. The technique for tenodesis was standardized between surgeons. The most proximal 5 cm of biceps tendon was resected, and the remaining tendon stump was sutured to the pectoralis major tendon at its humeral insertion using multiple #2 braided nonabsorbable sutures. Postoperatively, patients were placed in a sling, which was gradually discontinued over 4 weeks. All patients underwent postoperative rehabilitation with an outpatient physiotherapist or in an inpatient rehabilitation facility (if transportation was unavailable for daily therapy). Physical therapy consisted of early (within postoperative week 1) active and passive mobility exercises. The only limitation placed on patients was that passive external rotation with the arm at the side beyond neutral was not allowed for 4 weeks and resisted internal rotation was not allowed for 6 weeks postoperatively. Daily therapy was continued as deemed appropriate by the physical therapist (average: 19 days) and then progressively weaned. All patients in this series were evaluated preoperatively with a Constant score, consisting of 4 individual scores for pain (15 points), activity (20 points), active mobility (40 points), and strength (kilograms of downward directed force the patient is able to resist with the shoulder in 90 elevation in the plane of the scapula as measured with a dynamometer and multiplied by 2). 22 The Constant score was adjusted for age and sex and reported as a percentage of normal (adjusted Constant score). 23 Additionally, active and passive preoperative mobility for forward flexion in the plane of the scapula and external rotation with the arm at the side were recorded (Table 1). Postoperative evaluation consisted of the Constant score, the adjusted Constant score, measurement of the same mobility parameters evaluated preoperatively, and a subjective patient result graded as excellent, good, fair, or poor. Radiographic evaluation, consisting of anteroposterior views in neutral, internal, and external humeral rotation and an axillary view, at latest follow-up was performed, specifically evaluating for humeral or glenoid periprosthetic radiolucencies or component loosening and proximal migration of the humerus. Glenoid radiolucencies were scored according to the system of Molé et al 24 (0 points for no radiolucency to 18 points for radiolucencies 2 mm in ORTHOPEDICS

3 4edwards.qxd 4/6/04 3:53 PM Page 403 BICEPS TENODESIS & SHOULDER ARTHROPLASTY FAMA ET AL TABLE 2 Postoperative Patient Evaluation Constant Score Active Forward Active External Patient Group Pain Activity Mobility Strength Total Adjusted (%) Flexion ( ) Rotation ( ) Hemiarthroplasty Concomitant tenodesis (n=13) No tenodesis (n=86) Total shoulder arthroplasty Concomitant tenodesis (n=108) No tenodesis (n=481) zones). A score of 0-5 points is considered no loosening, 6-11 points is possible loosening, and points or component migration is definite loosening. The operating surgeon performed the radiographic interpretation. Complications or subsequent reoperations were noted. Additionally, to accommodate for preoperative differences between the groups, absolute gains were calculated for each parameter. Statistically, when evaluating quantitative values, analysis of variance was performed to determine significance. For qualitative values, a chi-square test was used. Significance was set at P.05. RESULTS Average follow-up was 43.4 months (range: months; 31 shoulders with 2-year follow-up because of early prosthetic revision or removal were included for analysis of early failures). Shoulders undergoing tenodesis had average 36- month follow-up (range: 5-84 months), whereas the remainder of shoulders had average 45-month follow-up (range: months) (P.0005). Average age of patients with shoulders undergoing tenodesis was 69 years (range: years), whereas the remainder of patients had an average age of 67 years (range: years) (P=.011). No other demographical differences were reported between the tenodesis group and nontenodesis group. The results of the postoperative evaluation in patients undergoing hemiarthroplasty and total shoulder arthroplasty are depicted in Table 2. Among the hemiarthroplasties, significant improvements over preoperative values were seen in every parameter evaluated for both the tenodesed and nontenodesed groups (P.0005 for all parameters). Hemiarthroplasty shoulders that had undergone a biceps tenodesis at surgery demonstrated a significantly higher average postoperative activity score (P=.020), mobility score (P=.030), and active anterior elevation (P=.010). When comparing the absolute gains in each parameter to minimize the effect of preoperative differences between the tenodesed and nontenodesed hemiarthroplasty shoulders, the findings were similar. The tenodesis group had significantly better gains in activity score (P=.001), mobility score (P=.002), overall Constant score (P=.015), and adjusted Constant score (P=.015). Subjectively, of the hemiarthroplasties undergoing concomitant biceps tenodesis, 11 (85%) shoulders had an excellent result, 2 (15%) shoulders had a good result, and no shoulder had a fair or poor result. Of the hemiarthroplasties undergoing no concomitant biceps surgery, 41 (48%) shoulders had an excellent result, 32 (37%) a good result, 8 (9%) a fair result, and 5 (6%) a poor result. Subjective results proved to be statistically better in hemiarthroplasties that had undergone concomitant biceps tenodesis (P=.020). Among the total shoulder arthroplasties, significant improvements over preoperative values were seen in every parameter evaluated for both the tenodesed and nontenodesed groups (P.0005 for all parameters). Total shoulders that had undergone a biceps tenodesis at surgery demonstrated a significantly higher average postoperative activity score (P=.047), mobility score (P=.005), overall Constant score (P=.034), adjusted Constant score (P=.005), active anterior elevation (P.0005), and active external rotation (P=.036). When comparing the absolute gains in each parameter to minimize the effect of preoperative differences between the tenodesed and nontenodesed total shoulders, the findings were similar. The tenodesis group had significantly better gains in activity score (P.0005), mobility score (P.0005), overall Constant score (P.0005), adjusted Constant score (P.0005), active anterior elevation (P=.043), and active external rotation (P=.009). Subjectively, of the total shoulders undergoing concomitant biceps tenodesis, 85 (79%) shoulders had an excellent result, 20 (18%) a good result, 3 (3%) a fair result, and no shoulder had a poor result. Of the total shoulders undergoing no concomitant biceps surgery, 344 (72%) shoulders had an excellent result, 105 (22%) a good result, 30 (6%) a fair result, and 2 (0.4%) a poor result. Radiographically, total shoulders without biceps tenodesis had a statistically higher incidence of radiolucent lines around the glenoid (61% versus 40%, P.0005) and humeral (15% versus 7%, P=.015) components. No difference existed between the groups in possible or definite glenoid loosening rates or humeral loosening rates. Humeral radiolucencies APRIL 2004 Volume 27 Number 4 403

4 4edwards.qxd 4/6/04 3:53 PM Page 404 TABLE 3 Complications Complications No. Early Intraoperative humerus fracture 11 Early infection 1 Hematoma 4 Early subscapularis detachment 2 Regressive axillary nerve palsy 11 Permanent axillary nerve palsy 4 Anterior dislocation 3 Posterior dislocation 5 Total 41 Late Humerus fracture 4 Infection 4 Rotator cuff tear 11 Subscapularis tear 4 Suspected subscapularis tear 6 Stiffness 3 Anterior dislocation 9 Posterior dislocation 8 Posterior subluxation 5 Polyethylene-metal dissociation 5 Excessive polyethylene wear 6 Superior migration of humeral head 3 Glenoid erosion 7 Glenoid loosening 14 Humeral loosening 1 Anterior subluxation 1 Total 91 and loosening were unaffected by biceps tenodesis in the hemiarthroplasty group. Additionally, biceps tenodesis did not influence proximal migration of the humerus in hemiarthroplasty or total shoulder arthroplasty. Complications are listed in Table 3. Forty-one early complications and 91 late complications occurred for an overall 19% complication rate. No statistical difference existed in the rate of complications or type of complications between the two groups. Sixty-eight shoulders were reoperated on for a problem related to the prosthesis, including 31 component revisions (12 for glenoid loosening, 11 for anterior or posterior prosthetic instability, and 8 for excessive polyethylene wear or polyethylene metal dissociation) and 9 component ablations (4 for sepsis and 5 for glenoid loosening or excessive wear with insufficient bone stock for glenoid revision). Additionally, 12 shoulders underwent soft-tissue procedures to address instability or subscapularis detachment, 6 shoulders initially treated with hemiarthroplasty underwent secondary glenoid resurfacing for persistent pain, 3 shoulders underwent open reduction internal fixation of late periprosthetic humeral fractures, 2 shoulders underwent biceps tenotomy for persistent pain believed to be related to the biceps tendon (these patients were kept in the no tenodesis group for data analysis), 2 shoulders underwent arthrolysis for persistent stiffness, 1 shoulder had the polyethylene portion of the metalbacked glenoid changed for excessive wear, 1 shoulder underwent irrigation and debridement of an early postoperative wound infection, and 1 shoulder underwent a glenoid bone graft for glenoid erosion following hemiarthroplasty. The rate or type of reoperation was not related to whether a concomitant biceps tenodesis was performed. DISCUSSION Results of this study demonstrate improved results of shoulder arthroplasty when concomitant biceps tenodesis is performed in shoulders with primary glenohumeral osteoarthritis. Most parameters of the Constant score were improved in patients who underwent biceps tenodesis at arthroplasty. Interestingly, tenodesis was not found to have a significant effect on the pain score, contradicting one of our hypotheses that the biceps was a source of pain in primary osteoarthritis. This is the first investigation specifically evaluating the role of concomitant biceps tenodesis in shoulder arthroplasty. Despite the predominantly good results of shoulder arthroplasty in primary osteoarthritis, a subset of patients exists that achieves a suboptimal outcome. Fair or poor outcomes have been reported in up to 25% of patients undergoing shoulder arthroplasty for primary osteoarthritis. 3,4,11,13 Although some of these treatment failures can be explained by complications such as component failure or sepsis, some unsatisfactory results occur without obvious explanation. Recently, Dines and Hersch 21 reported eight shoulders in seven patients presenting with unsatisfactory outcomes following shoulder arthroplasty for a variety of etiologies. All patients underwent reoperation consisting of a biceps tenolysis, tenodesis, or tenotomy, as the biceps tendon was the suspected cause of the poor outcome. Postoperatively, two patients had excellent results, five patients achieved good results, and one patient improved from a poor to a fair result. The authors concluded that the biceps tendon should be considered as a possible source for unsatisfactory results following shoulder arthroplasty. This represents the only other investigation of the biceps tendon in shoulder arthroplasty. The results from our series demonstrated significant differences in most parameters evaluated between the biceps tenodesis group and nontenodesis group for hemiarthroplasty and total shoulder arthroplasty. Although the pain component of the Constant score was better in the tenodesis group, this could not be proven significant. The complication and reoperation rate in this series is similar to that reported by other investigators. 12,17,18 The rate and type of complication was not statistically related to performance of a concomitant biceps tenodesis. This attests that concomitant biceps tenodesis can be performed during shoulder arthroplasty for osteoarthritis without increased risk of postoperative problems. Surprisingly, the total shoulders not undergoing tenodesis demonstrated a higher incidence of humeral periprosthetic radiolucency and glenoid periprosthetic radiolucency than the tenodesis group. This finding could be a result of the significantly longer followup in patients not undergoing biceps tenodesis. This retrospective review has limitations imposed by study design. Surgical techniques are not completely standardized. 404 ORTHOPEDICS

5 4edwards.qxd 4/6/04 3:53 PM Page 405 BICEPS TENODESIS & SHOULDER ARTHROPLASTY FAMA ET AL What is already known on this topic No reports exist evaluating the role of biceps tenodesis in the treatment of shoulder osteoarthritis with shoulder arthroplasty. What this article adds Results of this study demonstrate improved results of shoulder arthroplasty when concomitant biceps tenodesis is performed in shoulders with primary glenohumeral osteoarthritis. Indications for variations in operative procedure provide further obstacles to interpretation of the results. Follow-up in this series averaged only 43 months, relatively shortterm for an arthroplasty study. Additionally, significantly different mean patient age and follow-up between groups further hinders interpretation of the results of this investigation. The use of the sex and age adjusted Constant score minimizes the influence of differing patient age (the tenodesis group outperformed the nontenodesis group for this parameter as well). The significantly longer mean follow-up in patients not undergoing a biceps tenodesis remains a concern. It is not clear whether the results of shoulder arthroplasty in the biceps tenodesis group will deteriorate with time to match that of the nontenodesis group. Another limitation of this study is that the preoperative state of the biceps tendon was not recorded, preventing any correlation between preoperative status of the biceps and outcome. Furthermore, the biceps tendon is difficult to clinically assess postoperatively in patients in this age group who usually lack defined muscle tone making identification of a postoperative biceps tendon rupture difficult. The unclear indications for biceps tenodesis in this investigation further limit the conclusions drawn. Finally, this investigation evaluated only biceps tenodesis. Simple biceps tenotomy may provide the same desired effect; however, we cannot conclude that from this study. Concomitant biceps tenodesis is a safe adjunct to shoulder arthroplasty for patients with primary osteoarthritis. Additionally, concomitant biceps tenodesis probably improves the results obtained in shoulder arthroplasty performed for primary osteoarthritis, although this cannot be definitively concluded because of the different mean follow-up between the two groups in this investigation. Hopefully, the results of this study will promote further investigation into the biceps tendon and arthroplasty, perhaps using patient matched or prospectively randomized study designs, which would allow more definitive conclusions. REFERENCES 1. Barrett WP, Franklin JL, Jackins SE, Wyss CR, Matsen FA III. Total shoulder arthroplasty. J Bone Joint Surg Am. 1987; 69: Bodey WN, Yeoman PM. Prosthetic arthroplasty of the shoulder. 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