The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy versus tenodesis and evaluate risk factors and subjective and objective outcomes.
Data for this study were collected as part of a randomized clinical trial in which patients 18 years of age or older undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24-months post-operative as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10 cm visual analog scale (VAS), rated their pain and cramping, and completed the American Shoulder and Elbow Score (ASES) and Western Ontario Rotator Cuff score (WORC). Isometric elbow flexion and supination strength were also measured. Cohen’s kappa was calculated to measure interrater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence/absence of a Popeye deformity.
One hundred and fourteen patients were randomly assigned to two groups of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical assessment, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (p=0.018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity with male gender trending towards significance (OR = 7.33, 95% CI 0.867-61.906, p=0.067). Mean (SD) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r=0.640; p=0.025) but there was no association with gender (r=-0.155; p=0.527) or BMI (r=-0.221, p=0.057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed.
The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician assessment. Male gender was trending towards being predictive of having a deformity. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.