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Northern Territory Department of Health Library Services Historical Collection
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MODIFIED BRISTOW PROCEDURE
FOR RECURRENT ANTERIOR DISLOCATION OF THE SHOULDER
A review of 17 cases of the modified Bristow procedure in 16 patients with recurrent anterior dislocation or instability of the shoulder is presented. The average follow up period was 4 years 9 months.
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Although about 144 cases were done between 1982 - 1990, most patients did not respond to letters, presumably because they had either moved or left Darwin.
All operations presented in this review were done by the same surgeon (SB) .
The Bristow Procedure
Helfet in 1958 was the first to describe the Bristow Procedure which involves transplantation of the coracoid process with the attached conjoint tendon to the anterior surface of the glenoid. This produces a dynamic :µiusculo tendinous sling holding the humeral head posteriorly when the arm is abducted and externally rotated. Refer to diagram.
A deltopectoral incision was used, the coracoid was pre drilled, tapped, osteotomised and reflected.
The subscapularis was divided 1cm proximal to insertion and split longitudinally for 3 cm.
Joint examined.
Coracoid screwed to anterior glenoid between limbs of subscapularis with cancellous screw and washer ( = 35 mm).
Limbs of the subscapularis was plicated by 2 cm.
n,-,st operatively DL HIST
617.572 HUS 1991
sling for 1 month, then mobilization.
process
Osteotome
Corocobrachiolis
Fig. 52-27. Bristow procedure. Detachment of tip of -coracoid process.
Muscles attached to coracoid
Tip of coracoid process
Subscapularis
Fig. 52-29. Bristow procedure. Cross section through scapula at level of glenoid and humeral head.
wirh coracoid transfer Biceps brachii muscle-,
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RECURRENT DISLOCATIONS 2201
Fig. 52-28. Bristow procedure. Method of attachment of tip of coracoid to neck of scapula anteriorly.
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Fig. 52-30. Bristow procedure completed.
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MATERIAL AND METHODS
Follow up evaluation involved taking history and performing a physical examination.
History as regards nature of initial injury and of subsequent injuries causing dislocations, method of reduction and post operative result.
Physical examination included sensation, motor strength and active range of movement.
The range of movement was measured using a wall chart and· a hand held goniometer.
The shoulder was examined particubarly for stability, with the patient sitting and the arm at 90 of abduction and externally rotated - forward pressure was applied on the posterior aspect of the humeral head. Instability was diagnosed if there was apprehension or anterior excursion of the humeral head or both.
The results were rated as excellent, good;· fair or poor using Rowe's System, which takes into account stability (0 50 points), mobility (0 - 20 points) and function (0 - 30 points).
(Refer to Rowe's System on separate sheet)
EXAMINATION
STABILITY
so
No reoccurence sublu:xa tion or application
30
Apprehension when placing a rm in certain positions
10
Subluxation. Not requiring reduction
0
Recurrent disloca- tion
TOTAL UNITS
KEY
Excellent Good Fair Poor
ROWE'S SYSTEM FOR GRADING
o MOTION
20
100% of norma 1 exte rna 1, inte rna 1
rotation & eleva- tion
15
7 5% of norma 1 external rotation and normal eleva- ation and internal
rotation 5
50% of normal external rotation and 75% of normal elevation and internal rotation
0
50% of norma 1 elevation and internal rotation;
no external rotation
Loss of External Rotation
RATING
(100 - 90) ·,
=;·
( 89 - 75) ( 74 - 51)
50 or less)
FUNCTION 30
No limitation in work or sports: little or no discomfort
25
Mild limitation and minimum discomfort
10
Moderate limitation and discomfort
0
Marked limitation and pain
XRAYS
~
MALE
12
Football
5
Domestic violence
1
RESULTS
FEMALE (RT) (LT) DOMINENT NON DOMINENT
5 10 7 8 9
*
Average age at time of dislocation= 24 years (Range 13 - 39)*
At operation=
26 years (Range 16 - 39)Injuries causing initial dislocation
swimming Surfing Lifting Kung Fu Fall from
Fridge Ceiling
2 - 1 1 1 1
Motor Dog Fishing Habitual Epileptic Cycle Walking Dislocation Fit
1 1 1 1 1
_Results Cont'd
Method of Reduction
A & E OT Spontaneous/Other
1 - Fair
1 - Poor
8
14
1 1 1
1 8
GRADING of the 17 cases
Excellent Fair
Poor Failure
Average loss of External Rotation =
This patient had apprehension--±n certain positions- of the shoulder, pain and mild limitation of function, but no further dislocation.
This patient had shoulder girdle weakness prior to surgery (some form of neurological disorder at 15 months of age).
She had. habitual dislocation of the shoulder pre operatively.
On review she had apprehension, moderate limitation and discomfort, but no dislocation post operatively.
1 - Failure This gentleman lifted a heavy mattress by himself 8 months post operatively and dislocated his shoulder.
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DISCUSSION
All the patients in this series had significant shoulder instability following their initial dislocation. The shoulder dislocated easily in most cases during activities which involved abduction and external rotation. 3 had dislocations when turning in bed and 1 at times even on sneezing.
Thus they had marked limitation of daily activities and inability to swim or do other recreational sports.
14 of the 17 cases in this series had excellent result and the post operative stability of the shoulder allowed them to return to recreational sports and activities of daily living.
CONCLUSION
(1) The Bristow Procedure in this series has proved to be very effective for recurrent anterior dislocation of the shoulder.
The average loss of similar to that found countries)
external rotation in other series
of (ie
15 0 was in other
(2) The age of the patient at the primary dislocation has been demonstrated to be the most important and consistent determinant of whether the patient will have
recurrent dislocations. - - - -·
Rowe and Sakellarides noted 94% of their patients who were less than 20 years at initial dislocation developed recurrent dislocations.
In this series the average age at dislocation was 24 years.
(3) 8 of the patients had their first dislocations reduced in accident and Emergency Department. Only 1 had a general anaesthetic.
We suggest all first dislocations be reduced under general anaesthetic to minimise further damage and possible increased risk of recurrent dislocations.
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