The impact of biceps tenotomy/tenodesis on Popeye sign incidence and functional outcome

Background

Literature reports varied incidences and clinical relevance of Popeye’s sign in patients who underwent biceps tenotomy or tenodesis. There is no consensus according to indication and outcome. We aimed to evaluate the frequency of the Popeye sign in a large cohort of patients concomitantly treated with an arthroscopic rotator cuff repair (ARCR). We assessed the effect on the clinical outcome based on biceps tendon treatment and Popeye sign.

Methods

A cohort of 973 primary ARCR patients from different Swiss and German orthopedic clinics was prospectively documented for up to 24 months postoperatively. All patients who received biceps tendon treatment were included in this study. We assessed Popeye sign occurrence across groups treated either with tenodesis or tenotomy. Additionally, we compared clinical and radiological outcome between Popeye/non-Popeye and tenotomy/tenodesis groups.

Results

Eight hundred patients were evaluated, of which 55% (n = 442) underwent tenodesis and 45% (n = 358) received tenotomy of the long head of the biceps tendon. Mean age of the tenodesis group was significantly lower than that of the tenotomy group (55 ± 9 and 61 ± 8 years, P < .001). The other demographics were comparable. Among the patients with tenotomy, 20% (n = 63) developed a Popeye sign, compared to only 6.3% (n = 25) in the tenodesis group (age-adjusted relative risk 3, 95% confidence interval 1.9-4.8; P < .001). There were no significant differences in shoulder function. The subjective shoulder value was lower in the Popeye group (82 ± 19% vs. 86 ± 15%, P = .010).

Conclusion

Patients with tenotomy of the biceps tendon are 3 times more likely to develop a Popeye sign compared to tenodesis. Popeye sign after ARCR seems to have no relevant effect on the clinical outcome and pain even though the subjective shoulder value was lower in patients with Popeye sign.