Bristow Procedure 

Updated: Apr 19, 2018
Author: Jason D Vourazeris, MD; Chief Editor: Erik D Schraga, MD 

Overview

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.

Indications

Indications for open surgical intervention include recurrent anterior shoulder instability after failure of a course of nonsurgical management.[8] 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.[9]

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.[10]

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]

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.[11] 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.[12] 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.[13] 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.[14]

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.[15]

 

Periprocedural Care

Patient Preparation

Anesthesia

The choice of anesthesia should be based on the following:

  • Comorbidities present
  • Preference of the patient
  • Preference of the surgeon
  • Skills of the anesthesiologist

The options for anesthesia include general anesthesia, interscalene block with light sedation, and interscalene block with general anesthesia. Interscalene block has been shown to be a viable alternative to general anesthesia for the Bristow procedure. It has been shown that interscalene block results in a shorter hospital stay, significantly less blood loss, and presumably imparts the advantages of local anesthesia.[16]

Positioning

The patient is placed in a supine position on a standard operating table with a bump placed underneath the medial border of the scapula. The patient can alternatively be positioned supine in a beach-chair position.

 

Technique

Bristow Procedure

The procedure was originally described by Latarjet in 1954 and subsequently modified by Helfet in 1958.[2, 3] The initial descriptions of the procedure have since been modified many times.[17, 18] Although the technique used now is slightly different than the one originally described, it is still based on the transfer of a portion of the tip of the coracoid along with the attached conjoined muscle attachments. The technique described below is derived from Campbell’s Operative Orthopaedics.[1]

Deltopectoral approach

First, an incision is made, starting from the coracoid process and running along the deltopectoral groove toward the deltoid insertion. The deltopectoral groove is then located by identifying the course of the cephalic vein. The cephalic vein should be protected during dissection in order to reduce postoperative edema. The cephalic vein is retracted laterally or medially, and an opening is made along the groove. The deltoid is retracted laterally and the pectoralis major medially.

Coracoid osteotomy

Next, the coracoid process is exposed along with its conjoined muscle attachments. The insertions of the coracoacromial ligament and the pectoralis minor are reflected from the superior surface of the coracoid. The coracoid process is then osteotomized with an osteotome or cut with angled rib cutters. A 1- to 3-cm portion of bone is removed along with the attached muscles.

The coracoid tip is mobilized distally with its attached short head of the biceps and coracobrachialis (see the image below). The musculocutaneous nerve penetrates the coracobrachialis a few centimeters below the coracoid tip; therefore, care must be taken to protect the nerve during dissection. The nerve can be located by palpating with the gloved finger or by noting fatty areolar tissue along its course.

The coracoid process (C) and the conjoined tendon The coracoid process (C) and the conjoined tendon (CT) after osteotomy.

Exposure of scapular neck

The upper and lower limits of the subscapularis are identified. The plexus of the anterior humeral circumflex vessels identifies the lower border of the muscle; the interval between the subscapularis and the supraspinatus marks the upper border. The subscapularis is then split in line with its fibers from lateral to medial at approximately the middle to lower third of the muscles.

At this point, a periosteal elevator can be used to reflect the subscapularis from the outer surface of the shoulder capsule. The anterior capsule is then split in much the same fashion as the subscapularis was. Medial exposure of the anterior scapular neck is necessary for proper placement of the transferred coracoid (see the image below).

The glenoid (G), humeral head (H), and the scapula The glenoid (G), humeral head (H), and the scapular neck (N) after division of the subscapularis and capsule.

Subperiosteal dissection helps expose the scapular neck. The transfer site should be inferior to the equator of the glenoid and less than 5 mm from its rim. A 3.2-mm hole should be drilled through the posterior scapular neck at the position on the anteroinferior portion of the scapular neck. A similar hole is drilled in the coracoid tip. The scapular neck is roughened, and care is taken to ensure that all soft tissues have been removed. The transferred coracoid tip, with its muscle attachments, is positioned through the horizontal slit in the subscapularis onto the neck of the scapula.

Securing of coracoid

Next, the capsule is approximated with interrupted sutures. A Swiss malleolar screw of appropriate length is used to fix the coracoid tip to the scapular neck. When the screw and bone block are in place, care is taken to ensure that no overhang beyond the anterior rim of the glenoid exists. Now, the musculocutaneous nerve should be inspected to ensure that it is not under tension (see the image below).

The musculocutaneous nerve (M) is identified near The musculocutaneous nerve (M) is identified near the conjoined tendon (CT) in order to ensure it is not under undue tension.

The longitudinal split in the subscapularis is closed with interrupted sutures from the lateral edge of the transfer to the bicipital groove (see the image below). Finally, the deltopectoral fascia, subcutaneous tissue, and skin are approximated appropriately.

The coracoid tip has been secured to the scapular The coracoid tip has been secured to the scapular neck, and the capsule and subscapularis have been repaired.

Postoperative Care

Postoperatively, the patient should be placed in a shoulder immobilizer for approximately 1 week. At 1 week, the patient is transferred to a standard shoulder sling for 3-4 weeks. Active or passive elbow extension should not be allowed, but passive flexion is encouraged. Pendulum exercises can begin between 3 and 6 weeks. After 6 weeks, passive and active range of motion of the shoulder can be initiated.

Postoperative radiographs should be obtained periodically in order to confirm stable placement of both the transferred coracoid and the screw.

Complications

Complications of the Bristow procedure and its variants include the following[19, 20] :

  • Recurrent anterior instability of the shoulder
  • Loss of external rotation
  • Nonunion of the coracoid transfer
  • Screw-related problems
  • Neurovascular injury
  • Posterior instability of the shoulder