J Shoulder Elbow Surg (2014) -, 1-8

www.elsevier.com/locate/ymse

Biomechanical analysis of the modified Bristow

procedure for anterior shoulder instability: is the
bone block necessary?
Curtis J. Kephart, MDa, Michael H. Abdulian, MDa, Michelle H. McGarry, MSb,
James E. Tibone, MDa, Thay Q. Lee, PhDb,*

a
Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
b
Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare System, Long Beach, CA, USA

Background: Anterior shoulder instability with bone loss can be treated successfully with the modified
Bristow procedure. Opinions vary regarding the role of the soft-tissue sling created by the conjoined tendon
after transfer. Therefore, the aim of this study was to determine the effect of the modified Bristow proce-
dure and conjoined tendon transfer on glenohumeral translation and kinematics after creating anterior
instability.
Methods: Eight cadaveric shoulders were tested with a custom shoulder testing system. Range-of-motion,
translation, and kinematic testing was performed in 60
of glenohumeral abduction in the scapular and cor-
onal planes under the following conditions: intact joint, Bankart lesion with 20% glenoid bone loss, modi-
fied Bristow procedure, and soft tissue–only conjoined tendon transfer.
Results: A Bankart lesion with 20% bone loss resulted in significantly increased external rotation and
translation compared with the intact condition (P < .05), as well as an anterior shift of the humeral
head apex at all points of external rotation. Both the modified Bristow procedure and soft-tissue Bristow
procedure maintained the increase in external rotation but resulted in significantly decreased translation
(P < .05). There was no difference in translation between the 2 reconstructions.
Conclusions: The increase in external rotation suggests that the modified Bristow procedure does not
initially restrict joint motion. Translational stability can be restored in a 20% bone loss model without a
bone block, suggesting the importance of the soft-tissue sling.
Level of evidence: Basic Science, Biomechanics.
Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Shoulder; anterior instability; modified Bristow; conjoined tendon; glenoid bone loss

Shoulder instability is a common problem in the young, labroligamentous complex.3,34 Avulsion of the anteroinferior
athletic population. Most dislocations occur in the ante- glenoid rim is associated with recurrent instability4 and oc-
roinferior direction, causing injury to the anteroinferior curs up to 56% of the time.27 Repair of the Bankart lesion by
either open or arthroscopic techniques yields predictable
results.10,22,40 However, soft-tissue repairs in the setting of
*Reprint requests: Thay Q. Lee, PhD, Orthopaedic Biomechanics
Laboratory, VA Long Beach Healthcare System (09/151), 5901 E 7th St,
glenoid bone loss and/or engaging Hill-Sachs lesions yield
Long Beach, CA 90822, USA. failure rates that are unacceptably high (67%)7 when glenoid
E-mail address: tqlee@med.va.gov (T.Q. Lee). bone loss of 20% or greater is present.4,7,21,31,38

1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2014.03.003
2 C.J. Kephart et al.

Open nonanatomic stabilization techniques have had

success. Latarjet23 described his approach to this difficult
problem by transferring the coracoid process, after osteot-
omy at its base, to the anterior neck of the glenoid. This
provides stability by increasing the osseous diameter of the
glenoid, creating a sling with the lower portion of the
subscapularis tendon and reinforcing the inferior capsule
with a portion of the coracoacromial ligament.29 The
Bristow procedure, described by Helfet14 in 1958, involved
transferring just the tip of the coracoid process with the
conjoined tendon and suturing this to the anterior gleno-
humeral capsule and subscapularis. This was modified by
Mead and Sweeny28 in 1964 to include rigid internal fixa-
tion. Long-term results show high patient satisfaction
rates18 and relatively low redislocation rates.33 Figure 1 Custom testing system, showing a left shoulder
Even though stability in these difficult cases can be mounted in 60
of glenohumeral abduction with 30
of scapular
restored with coracoid transfer, the procedure is not benign. abduction, in coronal plane.
Many complications such as screw breakage, nerve injury
anterolateral edge of the acromion and the proximal humerus for
from bicortical screw fixation, and nonunion of the bony measuring glenohumeral kinematics.
fragment have been described.1,15,17,33 Other complications The scapula was secured to a mounting bracket, and the hu-
can result from incorrect placement of the transferred merus was secured to an intramedullary rod for mounting. The
coracoid process in relation to the articular surface.1,16 scapula plate was mounted on the custom testing system with 20

Finally, revision of a failed Bristow or Latarjet procedure of anterior tilt to simulate average in vivo positioning (Fig. 1).20
can be difficult, and non-local structural bone grafting may The humeral rod was inserted through a hollow–shaft angle
be necessary to provide stability.32 potentiometer (Novotechnik US, Southborough, MA, USA) for
Many of the complications of the modified Bristow measuring humeral rotation. The potentiometer was attached to an
procedure are related to the bone block. The importance of arc with a custom device that allows for compression/distraction
and anterior/posterior and medial/lateral glenohumeral translation
the bone block and the soft-tissue sling have been described
while fixing abduction and the plane of abduction.
in the past.16,26 Emerging evidence is showing the impor- The rotator cuff and conjoined tendons were loaded based on
tance of the soft-tissue sling.12,42 A recent biomechanical physiological cross-sectional area ratios with multiple lines of
article by Thomas et al35 suggests that the bone block may pull.37 Specifically, 2 lines of pull were used for the supraspinatus,
be unnecessary in the setting of a normal glenoid. However, 3 for the subscapularis, 2 for the infraspinatus, and 1 for the teres
a conjoined tendon–only transfer has not been evaluated minor. Five newtons was loaded on each line of pull, for a total of
in the presence of bone loss. Potential disadvantages of 40 N. The conjoined tendon was sutured in Krackow fashion and
conjoined tendon transfer are recurrent instability by not loaded with 10 N.
addressing the bone loss or a change in glenohumeral ki- Humeral rotation was defined as 90
of external rotation when
nematics by placing the tendon on the glenoid face. In the the bicipital groove was aligned with the anterolateral aspect of
presence of bone transfer, the tendon sits 1 cm anterior to the acromion.24,36 A string was attached to the humerus at the
proximal pectoralis major insertion for the application of an
the glenoid.
anteroinferior translation force. The string passed through a pulley
This study was designed to determine the effect of the
positioned perpendicular to the humerus anteriorly and 20
infe-
modified Bristow procedure, with and without a bone rior to the humerus. Three anteroinferior loads were applied, 20,
block, on glenohumeral range of motion, stability, and 30, and 40 N, and glenohumeral translation was measured with a
humeral head kinematics after creation of a bony Bankart MicroScribe 3DLX (Revware, Raleigh, NC, USA).
lesion. To determine whether the bone block is necessary Specimens were tested in 60
of glenohumeral abduction in the
for stability, we compared the amount of translation ante- scapular plane and the coronal plane (30
posterior to the scapular
riorly and inferiorly in a modified Bristow reconstruction plane). Glenohumeral kinematics was measured throughout the
versus a soft tissue–only conjoined tendon transfer placed rotational range of motion at maximum internal rotation; 0
, 30
,
through a split in the subscapularis tendon. 60
, and 90
of external rotation; and maximum external rotation by
digitizing the 3 reference screws on the acromion and the humerus at
each position with the MicroScribe. Maximum was defined as the
Materials and methods amount of rotation reached at 1.5 Nm with a torque wrench. This
torque was adequate to provide a consistent endpoint for measuring
Eight cadaveric shoulders (4 left and 4 right shoulders from 6 male humeral rotation while not resulting in soft-tissue damage. Ante-
and 2 female cadavers with a mean age of 60 years) were prepared roinferior translation was measured with the humerus locked in 60

by removing the clavicle and major shoulder muscles, leaving the of abduction and external rotation by adding 20-, 30-, and 40-N
rotator cuff, capsule, coracoacromial ligament, and conjoined loads incrementally through the pulley. Translation was measured in
tendon intact. Three small reference screws were placed on the the scapular and coronal planes. The 4 experimental conditions of
Is bone block necessary? 3

Table I Rotational range of motion for each condition and plane of testing
Mean  SD (
)
Intact condition Bony Bankart lesion Modified Bristow procedure Soft-tissue Bristow procedure
Scapular plane
External rotation 107.1  6.5 116.7  6.3) 114.0  10.5) 115.6  8.6)
Internal rotation 5.4  7.3 11.8  12.0) 12.0  12.9) 12.3  11.2)
Total rotation 112.4  10.1 128.5  13.4) 126.0  19.3) 127.9  16.6)
Coronal plane
External rotation 112.8  11.1 123.2  10.4) 122.4  12.0) 125.9  12.2)
Internal rotation 17.6  9.4 25.2  12.8) 26.7  14.9) 27.6  13.9)
Total rotation 130.5  9.2 148.4  12.3) 149.1  13.6) 153.5  14.5)
) P < .05 versus intact condition.

testing comprised (1) intact glenohumeral joint, (2) Bankart lesion the superoinferior and anteroposterior axes of the glenoid at the
with 20% glenoid bone loss, (3) modified Bristow procedure, and (4) articular surface.25
conjoined soft-tissue transfer. All data were repeated for 2 trials, and if not repeatable within
After intact testing, a Bankart lesion was created through a 1.0 mm for positioning, a third trial was repeated. The average
split in the subscapularis. All tendons were unloaded temporarily value for 2 trials was used for comparison. A repeated-measures
by removing the attached weights, and lateral traction was placed analysis of variance with a significance level of .05 was used. If a
on the proximal humerus to expose the glenoid face. The capsule significant difference was shown, a Tukey post hoc test was used
was split horizontally to the glenoid and then the labrum and to determine the areas of significance.
capsule were released from the anterior glenoid from the 12- to 6-
o’clock position. Next, 20% bone loss was created. The widest
part of the glenoid was measured twice with a depth gauge and Results
averaged. A mark was made on the face of the glenoid at the
calculated distance, and an osteotome was used to remove 20% of Rotational range of motion
the anterior glenoid in line with the longitudinal axis.30,32
The modified Bristow procedure was performed. The cor-
After creation of a bony Bankart lesion, internal, external,
acoacromial ligament was released to expose 1 cm of the coracoid
tip. A reciprocating saw was used to sharply cut 1 cm of the coracoid and total range of motion increased significantly from the
tip with the conjoined tendon attached. A 2.5-mm drill bit was used intact condition in both the scapular and coronal planes
to drill across the glenoid just below the equator (4-o’clock position) (P < .005 for all comparisons) (Table I). The increase in
to place a 3.5-mm bicortical screw and washer. Because the diam- motion remained significantly increased from the intact
eter of the bone block when brought straight down and rotated 90
condition after modified and soft tissue–only Bristow pro-
was approximately 1 cm across, the drill hole was made 6 mm from cedures in both planes (P < .01). There was no significant
the articular surface to ensure that the bone block was not too far difference in range of motion between the modified and
lateral. The bone block was secured to the glenoid through the split soft-tissue Bristow groups.
in the subscapularis tendon with the screw and washer.
The conjoined soft-tissue transfer was the final condition. The
Glenohumeral translation in scapular plane
bone block was sharply removed from the tendon and placed back
After creation of a bony Bankart lesion, anterior translation
anatomically with a screw. Two 5.5-mm Bio-Corkscrews (Arthrex,
Naples, FL, USA) were used for the repair. The screw hole at the 4- in the scapular plane significantly increased from the intact
o’clock position was used for the top anchor, and a second screw hole condition by 2.9 mm (SD, 1.8 mm), 7.3 mm (SD, 6.7 mm),
and anchor was placed 5 mm below this. Two single-loaded anchors and 7.7 mm (SD, 6.2 mm) for the 20-, 30-, and 40-N loads,
with needles were used. One limb was placed through the conjoined respectively (P ¼ .0003, P ¼ .002, and P ¼ .002, respec-
tendon in a locking fashion. The other limb was passed once through tively) (Fig. 2). Inferior translation also increased by
the tendon so that it could slide the tendon down to bone. The bottom 1.8 mm (SD, 1.0 mm), 8.4 mm (SD, 9.0 mm), and 9.5 mm
anchor was sutured to the conjoined tendon in the same fashion, and (SD, 8.3 mm), respectively, from the intact condition
both were secured with knots. This tendon was placed through the (P ¼ .0002, P ¼ .004, and P ¼ .0007, respectively) (Fig. 3).
same split in the subscapularis tendon to create a sling. Both the modified Bristow procedure and soft-tissue
After testing, the specimen was disarticulated and the surface
transfer restored translation to the intact condition.
geometry of the glenoid and humeral head was digitized by use of
the MicroScribe 3DLX relative to the 3 reference screws on each
bone. By use of these geometric relationships, the humeral head Glenohumeral translation in coronal plane
apex position, defined as the highest point on the articular surface After creation of a bony Bankart lesion, anterior translation
of the humeral head relative to the plane of the articular margin, in the scapular plane significantly increased from the intact
was tracked relative to the geometric center of the glenoid. The condition by 1.4 mm (SD, 1.0 mm), 3.7 mm (SD, 3.8 mm),
geometric center of the glenoid was defined as the point bisecting and 6.9 mm (SD, 2.9 mm) for the 20-, 30-, and 40-N loads,
4 C.J. Kephart et al.

Figure 2 Anterior glenohumeral translation in scapular plane for 20-, 30-, and 40-N anteroinferior translational loads.

Figure 3 Inferior glenohumeral translation in scapular plane for 20-, 30-, and 40-N anteroinferior translational loads.

respectively (P ¼ .01, P ¼ .0002, and P ¼ .0005, respec- external rotation and overall range of motion. The modified
tively) (Fig. 4). Inferior translation also increased by Bristow procedure resulted in motion that was not statisti-
1.0 mm (SD, 0.7 mm), 4.5 mm (SD, 6.5 mm), and 11.5 mm cally different from the intact condition in the scapular
(SD, 5.8 mm), respectively, from the intact condition plane but was significantly increased in the modified
(P ¼ .0005, P ¼ .06, and P ¼ .0002, respectively) (Fig. 5). Bristow condition in the coronal plane. The soft-tissue
The modified Bristow procedure restored translation to the transfer condition resulted in significantly increased
intact condition for the 20- and 40-N translational loads, external rotation and total range of motion compared with
whereas the soft-tissue transfer restored translation to the the intact shoulder in both planes. This indicated that, at
intact condition for all translational loads applied. time 0, the modified Bristow procedure resulted in range of
motion more similar to the intact shoulder than soft-tissue
Humeral head apex position transfer.
The humeral head apex shifted posteriorly at all points of Clinical studies consistently have documented a loss of
external rotation compared with the Bankart lesion and external rotation after open nonanatomic reconstruc-
intact condition after we performed both the modified tion.2,15,19 This has been shown to be important especially
Bristow procedure and soft-tissue Bristow procedure in overhead athletes. Throwing athletes returned to
(P < .05) (Figs. 6 and 7). There was no statistical difference throwing but over half had a loss of velocity possibly
in humeral head apex position between the 2 reconstruction because of the loss of external rotation, which is an adap-
groups. There were no significant differences in super- tive finding in overhead throwing athletes.8,9 At time 0 in
oinferior or mediolateral humeral head apex position. our biomechanical study, the soft-tissue transfer had
increased external rotation of 13
compared with the intact
Discussion shoulder. Because external rotation was higher than that in
the intact condition with the soft-tissue Bristow procedure,
In this biomechanical model, a Bankart lesion with 20% after healing, this procedure might result in motion more
glenoid bone loss resulted in a significant increase in similar to the intact shoulder and mitigate the loss of
Is bone block necessary? 5

Figure 4 Anterior glenohumeral translation in coronal plane for 20-, 30-, and 40-N anteroinferior translational loads.

Figure 5 Inferior glenohumeral translation in coronal plane for 20-, 30-, and 40-N anteroinferior translational loads.

external rotation after the modified Bristow procedure, experimental design in which we loaded the rotator cuff to
which has been well documented in the literature. simulate the compressive stabilizing force and created a
An interesting study for comparison involved an bone loss model for testing.
arthroscopic soft-tissue Bristow procedure.5 The authors Anterior and inferior translation was significantly
performed a tenodesis of the coraco-biceps tendon above increased from the intact condition after creation of a Bankart
the subscapularis tendon on the glenoid neck, creating a lesion with 20% glenoid bone loss. The modified Bristow
soft-tissue sling with no bone block. In 36 patients, they procedure restored stability similar to the intact shoulder. In
found a mean deficit of 15
in external rotation in abduc- the same fashion, the soft-tissue transfer restored stability
tion. This might indicate that loss of motion clinically with translation similar to the intact condition. There was a
might be similar with the soft-tissue transfer and modified trend toward less translation in both planes with the soft-
Bristow procedure. One confounding variable is that the tissue transfer compared with the modified Bristow proce-
authors also performed a Bankart repair and capsular dure, but this was not statistically different. Without the
plication,5 which we did not. coracoid tip bringing the tendon more anteriorly off the
The translational part of our study was of great impor- glenoid, the soft-tissue transfer placed the tendon directly on
tance to show biomechanically whether the bone block is the glenoid, and therefore, the humeral head was abutting the
necessary to restore stability. Thomas et al35 performed the soft tissue directly, leading to less translation.
first biomechanical study to show improved stability with a The stability conferred in soft-tissue transfer can only be
soft-tissue transfer. They recommended further study in a explained by the sling effect. We chose to load the tendon with
model with significant bony defects. They also noted that 10 N of force because prior studies have shown improved
stability might have been enhanced if they had left the biomechanical properties and substantial effects on joint sta-
subscapularis intact. This provided the basis of our bility without influencing humeral head translation.13,39
6 C.J. Kephart et al.

Figure 6 Change in anteroposterior (AP) humeral head apex position in scapular plane compared with intact position throughout
rotational range of motion from maximum internal rotation (Max IR) to maximum external rotation (Max ER). 0ER, 0
of external rotation;
30ER, 30
of external rotation; 60ER, 60
of external rotation; 90ER, 90
of external rotation.

Figure 7 Change in anteroposterior (AP) humeral head apex position in coronal plane compared with intact position throughout rota-
tional range of motion from maximum internal rotation (Max IR) to maximum external rotation (Max ER). 0ER, 0
of external rotation;
30ER, 30
of external rotation; 60ER, 60
of external rotation; 90ER, 90
of external rotation.

Glenoid bone loss is seen in recurrent instability, and various anterior to the glenoid neck. The clinical manifestations of
size defects have been investigated. Yamamoto et al41 recently this effect are unknown.
reported that a glenoid defect larger than 19% remains un- One proposed benefit of a soft-tissue transfer is that it may
stable after soft-tissue Bankart repair. Other studies have used be more tolerated when it contacts the articular surface of the
30% bone loss because this is a larger-sized defect that would humeral head. The clinical manifestations of improper bone
typically undergo bone grafting.6,11 Provencher et al,32 in a block placement are well documented.1,16 Boileau et al5 re-
review paper, explained that the questionable area is between ported on an arthroscopic soft-tissue Bristow technique. Their
15% and 30% bone loss. Our 20% bone loss model provides technique involved placing the bone block into the glenoid
relevant information for cases in which it is questionable through a tunnel and achieving fixation with an interference
whether a bony procedure is needed. screw. This would effectively place the conjoined tendon
The modified Bristow procedure and soft-tissue transfer directly against the humeral head as in our study.
both shifted the humeral head apex posterior to the intact Many of the limitations of this study are inherent to a
shoulder. Interestingly, the soft-tissue transfer shifted the cadaveric study. The donor specimens, with a mean age of
apex more posteriorly than the modified Bristow procedure. 60 years, are not similar to a younger patient population
This could be a result of the tendon being placed directly on that presents with instability. Our results can only be
the glenoid neck, abutting the humeral head before it would determined at time 0. When patients return to activities and
in the modified Bristow procedure, where it sits 1 to 1.5 cm sports, the effects may not be the same in terms of soft-
Is bone block necessary? 7

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