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Bristow Procedure

  • Author: Jason D Vourazeris, MD; Chief Editor: Erik D Schraga, MD  more...
 
Updated: Dec 21, 2015
 

Background

In the Bristow procedure and its variants, the coracoid process is transferred through the subscapularis tendon as a method of treating recurrent anterior instability of the shoulder. The coracoid tip is transferred to the anteroinferior glenoid neck and likely serves as a bone block in front of the humeral head. The transferred short head of the biceps and coracobrachialis are placed so as to produce a strong dynamic buttress across the anterior and inferior aspects of the joint when the shoulder is in the vulnerable abducted and externally rotated position.[1]

Helfet first described the Bristow procedure in 1958 and named it after his late mentor.[2] He described a procedure in which the terminal 1 cm of the coracoid and the conjoined tendon were transferred through a horizontal slit in the subscapularis onto the neck of the scapula. The transfer was held in place by sutures through the conjoined tendon and subscapularis.

Latarjet described a similar procedure in 1954, in which he transferred the tip of the coracoid along with the conjoined tendon through a horizontal slit in the subscapularis and fixed it with a screw.[3] Many other surgeons have described variations of the procedure; however, the common aspect of most current techniques is fixation of the transferred coracoid to the scapular neck with a screw.

Boileau et al found bony glenoid lesions in 49% of their patients with recurrent instability.[4] Loss of glenoid bone can disrupt the glenoid concavity, thereby reducing the effectiveness of the concavity-compression mechanism in stabilizing the shoulder against anterior translation.[5] Therefore, patients with recurrent anterior instability and glenoid bone loss may not achieve favorable outcomes with soft-tissue procedures alone. Soft-tissue procedures do not restore the firm glenoid socket that normally resists anterior translation.

Patients are likely to suffer bony involvement at the time of initial dislocation. In the case of acute recurrent instability, identifiable fracture fragments are frequently reported.[6] In contrast to acute recurrent instability, patients studied at a mean of 15 months after initial dislocation exhibited erosive bone loss without an identifiable fracture fragment.[7] This pattern of bone loss demonstrates a progressive loss of bone over time.

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Indications

Indications for open surgical intervention include recurrent anterior shoulder instability after failure of a course of nonsurgical management. If glenoid bone loss is judged to be greater than 25-30%, restoration of bone loss must be considered as an option in order to prevent recurrent instability.[8] If a bony fragment is available, open or arthroscopic stabilization with bone fragment reduction and fixation might be performed. However, if no bony fragment is available, glenoid augmentation becomes a viable option. This can be done with bone graft augmentation or with coracoid transfer augmentation, such as the Bristow procedure.[9]

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Contraindications

Coracoid transfer augmentation for bony glenoid defects is less likely to be successful in patients who have the following:

  • Uncontrolled epilepsy
  • Iinstability associated with paresis of the deltoid, rotator cuff, and/or periscapular musculature
  • Multidirectional instability associated with generalized ligament laxity
  • Voluntary instability.

Continued nonoperative management should also be considered in patients who are medically unfit for surgery, elderly patients, and low-demand patients.[5]

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Outcomes

In a retrospective study of the modified Bristow technique for anterior shoulder instability, nearly 70% of 52 shoulders in 49 Naval Academy midshipmen achieved a good-to-excellent outcome.[10] The mean follow-up was 26.4 years; the longest outcome study of this technique in the literature. Recurrent dislocations were seen in 9.6% in this series, and recurrent subluxations were subjectively described in 5.8%. The reported incidence of recurrent instability following the Bristow procedure is in the range of 0-14%.

Torg et al reported the outcomes of the modified Bristow procedure in 207 patients (212 shoulders) at an average follow-up of 3.9 years.[11] They found a 3.8% redislocation rate and a subjective subluxation rate of 4.7%. A high percentage (96.2%) of the patients was happy with the procedure and noted that they would have the surgery again.

Hovelius et al reported on 112 shoulders with recurrent anterior dislocation treated with the modified Bristow technique at a mean follow-up of 30 months.[12] The incidence of redislocation was 6%, with a 7% subluxation rate.

After evaluating the May modification of the Bristow-Latarjet procedure in 319 shoulders, Hovelius et al concluded that the procedure yields good results, with bony fusion of the coracoid in 83% of cases.[13]

In a study of 38 rugby players (40 shoulders) in whom traumatic anterior instability of the shoulder was treated with arthroscopic Bankart repair followed by a Bristow procedure with preservation of the repaired capsular ligaments, Tasaki et al found that the combined surgical procedure effectively prevented recurrent dislocation, though some of the players complained of insufficiency in the quality of their play.[14]

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Contributor Information and Disclosures
Author

Jason D Vourazeris, MD Resident Physician, Department of Orthopedic Surgery, Sports Medicine, and Rehabilitation, Wright State University, Boonshoft School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Michael A Herbenick, MD Assistant Professor of Orthopedic Surgery and Sports Medicine, Wright State University, Boonshoft School of Medicine; Residency Director, Department of Orthopedic Surgery, Miami Valley Hospital

Michael A Herbenick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References
  1. Phillips BB. Recurrent Dislocations. Canale ST, Beaty JH. Campbell's Operative Orthopaedics. 11. Mosby; 2008. 3: 2700-02.

  2. Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br. 1958 May. 40-B(2):198-202. [Medline].

  3. Latarjet M. [Surgical Technics in the Treatment of Recurrent Dislocation of the Shoulder (Antero-internal)]. Lyon Chir. 1965 Mar. 61:313-8. [Medline].

  4. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006 Aug. 88(8):1755-63. [Medline].

  5. Lynch JR, Clinton JM, Dewing CB, Warme WJ, Matsen FA 3rd. Treatment of osseous defects associated with anterior shoulder instability. J Shoulder Elbow Surg. 2009 Mar-Apr. 18(2):317-28. [Medline].

  6. Sugaya H, Kon Y, Tsuchiya A. Arthroscopic repair of glenoid fractures using suture anchors. Arthroscopy. 2005 May. 21(5):635. [Medline].

  7. Mologne TS, Provencher MT, Menzel KA, Vachon TA, Dewing CB. Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid. Am J Sports Med. 2007 Aug. 35(8):1276-83. [Medline].

  8. Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009 Aug. 17(8):482-93. [Medline].

  9. Streubel PN, Krych AJ, Simone JP, Dahm DL, Sperling JW, Steinmann SP, et al. Anterior glenohumeral instability: a pathology-based surgical treatment strategy. J Am Acad Orthop Surg. 2014 May. 22 (5):283-94. [Medline].

  10. Schroder DT, Provencher MT, Mologne TS, Muldoon MP, Cox JS. The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen. Am J Sports Med. 2006 May. 34(5):778-86. [Medline].

  11. Torg JS, Balduini FC, Bonci C, Lehman RC, Gregg JR, Esterhai JL, et al. A modified Bristow-Helfet-May procedure for recurrent dislocation and subluxation of the shoulder. Report of two hundred and twelve cases. J Bone Joint Surg Am. 1987 Jul. 69(6):904-13. [Medline].

  12. Hovelius L, Körner L, Lundberg B, Akermark C, Herberts P, Wredmark T. The coracoid transfer for recurrent dislocation of the shoulder. Technical aspects of the Bristow-Latarjet procedure. J Bone Joint Surg Am. 1983 Sep. 65(7):926-34. [Medline].

  13. Hovelius L, Sandström B, Olofsson A, Svensson O, Rahme H. The effect of capsular repair, bone block healing, and position on the results of the Bristow-Latarjet procedure (study III): long-term follow-up in 319 shoulders. J Shoulder Elbow Surg. 2012 May. 21(5):647-60. [Medline].

  14. Tasaki A, Morita W, Yamakawa A, Nozaki T, Kuroda E, Hoshikawa Y, et al. Combined Arthroscopic Bankart Repair and Coracoid Process Transfer to Anterior Glenoid for Shoulder Dislocation in Rugby Players: Evaluation Based on Ability to Perform Sport-Specific Movements Effectively. Arthroscopy. 2015 Sep. 31 (9):1693-701. [Medline].

  15. Mitchell EI, Murphy FL, Wyche MQ, Torg JS. Interscalene brachial plexus block anesthesia for the modified Bristow procedure. Am J Sports Med. 1982 Mar-Apr. 10(2):79-82. [Medline].

  16. Young DC, Rockwood CA Jr. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am. 1991 Aug. 73(7):969-81. [Medline].

  17. Griesser MJ, Harris JD, McCoy BW, Hussain WM, Jones MH, Bishop JY, et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg. 2013 Feb. 22(2):286-92. [Medline].

 
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The coracoid process (C) and the conjoined tendon (CT) after osteotomy.
The glenoid (G), humeral head (H), and the scapular neck (N) after division of the subscapularis and capsule.
The musculocutaneous nerve (M) is identified near the conjoined tendon (CT) in order to ensure it is not under undue tension.
The coracoid tip has been secured to the scapular neck, and the capsule and subscapularis have been repaired.
 
 
 
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