The Popeye sign: beyond the bulge-a proposal for a standardized definition and classification.

Popeye sign: Frequency and functional impact.

Although tenotomy and tenodesis are frequently used for long head of the biceps tendon lesions, controversies remain as to which technique is superior regarding pain, functionality, complications, and cosmetic appearance. (1) For long head of biceps tendon lesions, does tenotomy or tenodesis result in greater improvements in VAS score for pain? (2) Which approach has superior results when evaluating function outcome (Constant) scores? (3) Does tenotomy or tenodesis have fewer complications? (4) Does tenotomy or tenodesis result in better cosmesis (Popeye sign)? A systematic review was performed in the Cochrane Library, Embase, PubMed, and Literatura Latino Americana e do Caribe em Ciências da Saúde (LILACS) using the keywords "long head of the biceps tendon," "biceps tenodesis," and "tenotomy." We completed the search in June 2020. The inclusion criteria were randomized controlled trials and quasirandomized controlled trials that investigated tenodesis and tenotomy with no language restriction and evaluation of adult patients who presented with a long head of the biceps tendon lesion, associated with other lesions or not, without previous shoulder surgeries and who had no response to nonoperative treatment. The initial search yielded 239 studies, 40 of which were duplicates. We assessed the titles and abstracts of 199 articles and excluded all studies that were not randomized controlled trials (literature reviews) or that compared different techniques. We assessed the full text of 14 articles and excluded the ones that were protocols and cohort studies. We evaluated the risk of bias using the Cochrane Collaboration tool. We included eight studies in this systematic review and meta-analysis, with a total of 615 participants, 306 of whom were treated with tenotomy and 309 with tenodesis. The median duration of follow-up was 2 years. Overall, the included studies had a low risk of bias. The complications evaluated were adhesive capsulitis, biceps brachii tear, cramps, and a subsequent second surgical procedure. We used a random model in this meta-analysis so that we could generalize the results beyond the included studies. In this study, we only reported differences between the groups if they were both statistically valid and larger than the minimum clinically important difference (MCID). Comparing tenotomy and tenodesis, we observed no difference between the groups regarding pain in the long term (mean difference 0.25 [95% confidence interval -0.29 to 0.80]; p = 0.36). There was no difference in Constant score in the long-term (mean difference -1.45 [95% CI -2.96 to 0.06]; p = 0.06). There were no differences when evaluating for major complications (odds ratio 1.37 [95% CI 0.29 to 6.56]; p = 0.70). There were not enough papers evaluating adhesive capsulitis, cramping, and risk of revision surgery. Popeye sign was more frequent in the tenotomy group than in the tenodesis group (OR 4.70 [95% CI 2.71 to 8.17]; p < 0.001). This systematic review demonstrated that tenotomy and tenodesis offer satisfactory treatment for long head of the biceps tendon lesions. In terms of pain improvement and Constant score, there was no difference between the techniques, but patients undergoing tenotomy have worse cosmetic results. Therefore, surgeons should choose the technique based on their skills and the patient's expectations of surgery, such as cosmesis and time to recovery. More studies are needed to evaluate complications such as adhesive capsulitis and cramping, as well as to compare duration of surgery and recovery time for each technique. Level I, therapeutic study.

Background Treatment of chronic, refractory biceps tendinitis remains controversial. The authors sought to evaluate clinical and functional outcomes of arthroscopic release of the long head of the biceps tendon. Hypothesis In specific cases of refractory biceps tendinitis, site-specific release of the long head of the biceps tendon may yield relief of pain and symptoms. Study Design Case series; Level of evidence, 4. Methods Fifty-four patients diagnosed with biceps tendinitis underwent arthroscopic release of the long head of the biceps tendon as an isolated procedure or as part of a concomitant shoulder procedure over a 2-year period. Patients were not excluded for concomitant shoulder abnormality, including degenerative joint disease, rotator cuff tears, Bankart lesions, or instability. Nine of 40 patients had an isolated arthroscopic release of the biceps tendon. At a minimum of 2 years, the American Shoulder and Elbow Surgeons; the University of California, Los Angeles; and the L'Insalata shoulder questionnaires as well as ipsilateral and contralateral metrics were used for evaluation. Results The L'Insalata; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 77.6, 27.6, and 75.6, respectively. Seventy percent had a Popeye sign at rest or during active elbow flexion; 82.7% of men and 36.5% of women had a positive Popeye sign (P <. 05); 68% were rated as good, very good, or excellent. No patient reported arm pain at rest distally or proximally; 38% of patients complained of fatigue discomfort (soreness) isolated to the biceps muscle after resisted elbow flexion. Conclusion Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. Cosmetic deformity presenting as a positive Popeye sign and fatigue discomfort were the primary complaints. Clinical Relevance Although tenotomy is not the ideal intervention for patients of all ages with various shoulder abnormalities, data suggest that it may be an acceptable surgical intervention for a specifically selected cohort of individuals.

Prospective outcome analysis following tenodesis of the long head of the biceps tendon along with locking plate osteosynthesis for proximal humerus fractures

The Impact of Biceps Tenotomy/Tenodesis on Popeye Sign Incidence and Functional Outcome

The Elongation of Biceps Muscle Tendon Unit After Rerouting of the Long Head of Biceps Tendon as Superior Capsular Augmentation: A Quantitative Measurement

Paper #107 Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results

Objectives:Evaluation of the mid-term clinical and functional outcome in a cohort of patients who underwent transfer of the long head of the biceps tendon (LHBT).Methods:Patients diagnosed with biceps instability or related pathology that underwent arthroscopic assisted or all arthroscopic transfer of the long head of the biceps tendon to the conjoint tendon were considered. The procedure was performed either as an isolated procedure on in conjunction with another procedure by the senior author. Outcome surveys were collected for 157 patients with a subset of 43 patients available for clinical examination at 2-10 years postop time point. Outcome measures were based on American Society of Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA), and L’Insalata questionnaires. Ipsilateral and contralateral metrics were also evaluated.Results:157 patients (25 female, 132 male; average age 50 years; average postop 4.9 years) were evaluated with L’Insalata, UCLA, and ASES questionnaires, scoring 84.78, 29.77, and 83.4, respectively. In the 33 patients who had an isolated LHBT transfer, the L’Insalata, UCLA, and ASES scores were 79.52, 27.6, and 83.95, respectively. 43 shoulders (7 female, 36 male; average age 50 years; average postop 5.1 years) were available for clinical examination by a physician other than the treating surgeon. There was no statistically significant side-to- side strength difference using a 10-pound weight. All of the patients reported no arm pain at rest with regard to the biceps. 81% of patients reported no biceps tenderness upon palpation of the bicipital groove and 85.8% had a negative throwing test. 95.2% of patients had a negative active compression test. Speed’s and Yergason’s tests were negative in 90.5% and 95.2% of patients respectively. One patient (3%) complained of fatigue discomfort (soreness) isolated to the biceps muscle following resisted elbow flexion. Five patients (12.0%) had a Popeye sign and one patient (3%) exhibited biceps subsidence. 86% of patients were self-rated as good to excellent, with the remaining 14% reporting fair or poor results.Conclusion:Arthroscopic subdeltoid transfer of the LHBT to the conjoint tendon is an appropriate and reliable intervention for active patients with chronic, refractory biceps pathology. There was no loss of strength for biceps curls. All patients reported no pain isolated to biceps muscle at rest. Ninety-seven percent of patients had resolution of their preoperative biceps symptoms.

Arthroscopic Transfer of the Long Head of the Biceps Tendon: Functional Outcome and Clinical Results

Editorial Commentary: Failure Following Biceps Long Head Tenodesis Includes Popeye Sign, Cramping, and Tendon Migration

The Popeye sign: a doctor’s and not a patient’s problem

Background:Restoration of the long head of the biceps tendon (LHBT) length-tension relationship is critical in preserving muscle strength and efficiency when performing biceps tenodesis. While static anatomic landmarks such as the inferior border of the pectoralis major may be used intraoperatively to achieve this, shoulder position may affect the excursion of the biceps tendon and represents another variable to consider.Purpose/Hypothesis:The purpose of this study was to quantitatively evaluate the normal excursion of LHBT that occurs through a glenohumeral range of motion. We also sought to determine whether elbow position affects LHBT excursion. We hypothesized that LHBT excursion will be affected by glenohumeral flexion and extension, and elbow extension will result in increased excursion at each glenohumeral position compared with a neutral position.Study Design:Controlled laboratory study.Methods:A total of 10 fresh-frozen specimens underwent a standard approach for subpectoral biceps tenodesis. The LHBT was identified and tagged with a radiopaque marker within zone 3 of the bicipital tunnel. A total of 3 K-wires were then drilled into the osseous floor: one at the level of the marker in the LHBT, one at 1 cm proximal, and a third 1 cm distal. All 3 K-wires were then cut flush with the anterior humeral cortex. The specimens were next placed into 8 different positions, and the excursion of the LHBT was measured by referencing the K-wires using static fluoroscopic imaging. The results were analyzed using 1-way analysis of variance testing followed by Tukey honestly significant difference testing for pairwise comparison between each individual position and the reference position.Results:The average total LHBT excursion was 24.4 ± 5.2 mm between the neutral shoulder position and the other shoulder positions tested. The position of the LHBT was significantly different in the reference position compared with each of the other 7 shoulder positions (P < .001). Additionally, the 2 positions of shoulder extension had different LHBT excursions when compared with each position of shoulder flexion (P < .0001). For each shoulder position tested, the position of the LHBT was not significantly different in elbow flexion compared with extension.Conclusion:There is approximately 24 mm of LHBT excursion throughout the glenohumeral range of motion, with significantly different amounts of excursion in glenohumeral flexion and extension. Elbow position does not significantly affect LHBT excursion. Positioning the shoulder in extension during biceps tenodesis may overtension the biceps, while positioning the shoulder in flexion may undertension the biceps relative to the neutral position. Further research is needed to identify the optimal shoulder position for biceps tenodesis.Clinical Relevance:Shoulder positioning is an important consideration in establishing a normal length-tension relationship during biceps tenodesis. When compared with flexed shoulder positions, LHBT excursion significantly differs in positions of extension and in a neutral position.

Measurement of biceps tendon retraction after arthroscopic tenotomy

To compare the effectiveness of tenodesis and tenotomy in the treatment of long head of the biceps tendon (LHBT) lesions. The null hypothesis was that there is no difference in functional scores between the tenotomy and tenodesis groups. A total of 69 patients with a combined supraspinatus tear and LHBT lesion aged over 40years entered this prospective comparative study and were randomly assigned to the arthroscopic LHB tenotomy or tenodesis group. Fifty-five patients (31 in the tenotomy group and 24 in the tenodesis group) were available for the 6- and 24-month post-operative evaluations. There were no statistically significant differences in post-operative Constant and Murley score, quality of life, pain, and strengths between groups. Higher rates of Popeye's sign were noted 6 and 24months post-operatively in the tenotomy group compared to tenodesis. Although tenotomy is affected by a higher incidence of cosmetic deformity, there is no superiority of arthroscopic tenodesis over tenotomy in the treatment of LHBT lesion as a concomitant procedure to an arthroscopic repair of the supraspinatus tendon in terms of functional outcomes, quality of life, pain, and strength measured 6 and 24months post-operatively. I.

BackgroundThe best treatment for lesions of the long head of the biceps tendon (LHBT) with concomitant reparable rotator cuff tears is still controversial. The purpose of the meta-analysis was to compare clinical outcomes of biceps tenotomy and tenodesis for LHBT lesions.MethodsA literature retrieval was conducted in MEDLINE, Embase, and Cochrane Library from 1979 to March 2018. Comparative studies (level of evidence I or II) comparing tenotomy and tenodesis for LHBT lesions with concomitant reparable rotator cuff tears were included. Risk of bias for all included studies was assessed using the Cochrane Collaboration’s risk of bias tool. Clinical outcomes compared were Popeye sign, Constant score, VAS pain score, cramping pain, elbow flexion and forearm supination strength, and re-tear of the rotator cuff.ResultsTwo randomized controlled trials (RCTs) and five prospective cohort studies (PCS) with 288 biceps tenotomy patients and 303 biceps tenodesis patients were included in this review. Tenotomy resulted in significantly greater rates of Popeye sign (RR, 2.70 [95% CI, 1.80 to 4.04]; P < 0.01) and a less favorable Constant score (MD, − 1.09 [95% CI, − 1.90 to − 0.28]; P < 0.01) compared to tenodesis. No significant heterogeneity was found between the two groups across all parameters except forearm supination strength.ConclusionsThe current evidence indicates that biceps tenodesis for LHBT lesions with concomitant reparable rotator cuff tears results in decreased rate of Popeye sign and improved Constant score compared to biceps tenotomy.Trial registrationPROSPERO, CRD42018105504. Registered on 13 August 2018.