Biceps tenotomy / tenodesis

Summary

This operation is performed for a condition called biceps tendinitis.  The aim of the operation is to move the inflamed part of the biceps tendon (long head) that sits in your shoulder joint out of the joint.  The operation is usually performed under a general anaesthetic using keyhole surgery.  Mostly, the long head of biceps tendon is cut and allowed to fasten to the humerus on its own outside the shoulder joint.  This is known as a biceps tenotomy.  Sometimes an operation is performed to surgically fasten the long head of biceps tendon to the humerus, known as a biceps tenodesis.

Factors to Consider

You have been diagnosed with a condition called biceps tendinitis.  This commonly causes a sharp pain over the front of the shoulder, which goes down the arm and occurs when doing simple activities such as lifting a kettle.

The pain is caused by inflammation in the long head of biceps, which is part of the biceps tendon that enters into the shoulder joint and attaches on the top of the glenoid (socket).  This is usually associated with other problems in the shoulder such as subacromial impingement or rotator cuff tears.  Your surgeon will discuss this with you if these are present.A biceps tenotomy/tenodesis moves the long head of biceps tendon out of the area where it was being irritated, allowing those symptoms to settle.

Description of Surgery

The operation can usually be performed as a daycase procedure but you will need to ensure that there is someone to drop you off and pick you up from the hospital.  You will also need to have a responsible adult at home with you on the night of the operation.

The operation is performed through 2 or 3 small (less than 1cm) cuts to your shoulder.  The surgeon is able to look at your shoulder joint to make sure nothing else is contributing to your symptoms.  The biceps tendon can then be cut from its attachment on the glenoid.

The operation itself takes between 15 and 30 minutes.

Tenotomy or tenodesis

A tenotomy is much simpler than a tenodesis and allows a quick recovery for the patient.  It is therefore the preferred option for most patients.  A tenodesis involves reattaching the tendon either through keyhole surgery or a small open incision.  The recovery is slower as the tendon has to be given time to heal.  You should not lift anything heavy for the first 3 months following a tenodesis.  Both surgeries are good at providing pain relief without any loss in strength or function.  The chance of developing a “popeye” sign is greater with a tenotomy than a tenodesis.  Generally, a tenotomy works well for most patients with a tenodesis reserved for more athletic patients.  Your surgeon can  discuss the pros and cons of both procedures with you.

It is possible that there are other problems that are contributing to your symptoms that your surgeon will have identified before your operation.  These could include acromioclavicular (AC) joint arthritis, subacromial impingement or a rotator cuff tear.  These can almost always be managed at the same time as your biceps tenotomy or tenodesis.  It is still very likely that the surgery will be performed as a daycase procedure.

Anaesthetic

The operation is performed under a general anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

It is common for you to be offered a nerve block to help with the pain.  The nerve block allows excellent pain relief immediately after the operation.  It is considered a safe method of providing pain relief with few complications (less than 1%).  You will wake up with a numb arm, similar to when you sleep on your arm awkwardly.  The block wears off within 12-24 hours and so it is important to take pain killers the night after the surgery even if you don’t have pain when you go to sleep.

The anaesthetist will talk more about the nerve block when they see you.  If you do not want a nerve block your pain can be well controlled with local anaesthetic given during the operation.

What are the risks?

All operations involve an element of risk.  The risks for this particular operation are small but it is important that you are aware of them.

The risk of infection is very small and is thought to be about 0.5%.  Most infections will settle simply with antibiotics.

Damage to nerves and blood vessels around the shoulder can occur but this is rare.

There is a small risk (less than 5%) of worse pain and stiffness around the shoulder in the form of a frozen shoulder.  This usually settles with physiotherapy but occasionally you will require an injection or further surgery to settle your symptoms.

There is a risk that you may develop crampy pains within the biceps muscle.  This is more common with a tenodesis than a tenotomy.

There is a risk of developing a “popeye” sign, in which the biceps muscle will look more prominent in the arm.  This is named after “Popeye the sailor man” and is more common with a tenotomy than a tenodesis.

After Surgery

Pain

Local anaesthetic or a nerve block will be used during the operation and so you will feel comfortable when you first wake up.  The nerve block can make your whole arm feel numb.  This can last up to 12 hours but the shoulder may be sore after it wears off.  You will be given a combination of pain killers to go home with.  It is important that you take regular pain relief so that you can start moving your arm early.  

You may also be given an icepack.  The nurses will show you how to place the icepack on your shoulder.  The icepack should be taken off after 15 minutes  and can be used every 2 hours.

Remember, the aim of the operation is to get your arm moving normally again and so good pain relief will help you achieve this faster.  

Sling

You will wake up with your arm in a sling.  The arm should be comfortable but it is important to let the nurses know if you have pain so that further pain killers can be given.  The sling is for comfort only and so you can take it on and off as you wish.  Most patients stop using the sling within the first week following surgery.  You don’t need to wear the sling to sleep.

Dressings

There will be dressings applied to the wounds following your operation.  These can occasionally come off and will need to be replaced during the first 2 weeks after surgery to protect the wound.  

The dressings are splash proof but not waterproof and so you should avoid getting them wet.

The wounds are closed using non-dissolvable stitches.  The stitches will need to be removed at 10-14 days following surgery.  The nurses will arrange this to be done at your local GP practice before you are discharged.

Physiotherapy

Physiotherapy is absolutely essential in ensuring that your shoulder fully recovers.  You will need to teach your muscles how to work properly again to prevent your symptoms coming back and to ensure you achieve a full range of movement and function.  

The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you within 3 weeks of the operation.  Physiotherapy can be arranged local to you.  

Driving

You can drive when you feel you are safe to drive.  This means that you feel confident that you have full control of your car and are able to swerve out of the way of something in the road.  This will vary between patients but normally takes about a week.  

Return to work

This depends on what your job is.  You should be able to return to a “desk job” within a few weeks of your surgery.  If you have a more manual job it can take up to 6 weeks before you feel ready to return to work.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable.  Most people will be able to get rid of the sling in the first week and be using their arm comfortably below shoulder height within the first 4 weeks.  Your symptoms should be improved/improving by 3 months with the majority fully recovered by 6 months.  It can, however, take up to a year for some patients to fully improve.