Bristow Procedure Technique

Updated: Dec 21, 2015
  • Author: Jason D Vourazeris, MD; Chief Editor: Erik D Schraga, MD  more...
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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. 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 first image below). The longitudinal split in the subscapularis is closed with interrupted sutures from the lateral edge of the transfer to the bicipital groove (see the second image below). Finally, the deltopectoral fascia, subcutaneous tissue, and skin are approximated appropriately.

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 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.
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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.

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Complications

Complications of the Bristow procedure and its variants include the following [16, 17] :

  • 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
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