Bristow vs. Latarjet Procedure: Understanding Shoulder Stabilization Surgeries

What is the difference between Bristow and Latarjet procedure?

While both the Bristow and Latarjet procedures involve the transfer of the coracoid process to the anterior glenoid to stabilize the shoulder, the primary technical difference lies in the precise method of coracoid fixation and the management of the conjoint tendon relative to the subscapularis muscle, with the Latarjet being the more commonly performed and refined technique emphasizing a "triple-blocking" effect.

Introduction to Shoulder Instability

Shoulder instability, particularly anterior glenohumeral instability (dislocations or subluxations), is a common and debilitating condition, especially in athletes. While many cases can be managed with non-surgical approaches or soft tissue repairs (like the Bankart repair), some individuals require more robust bony reconstruction. This is often necessary in cases of recurrent instability, significant bone loss from the glenoid (the socket part of the shoulder joint), or a large Hill-Sachs lesion (an impaction fracture on the humeral head). When significant bone defects are present, traditional soft tissue repairs may fail, leading to the consideration of procedures involving bone transfer, such as the Bristow and Latarjet.

Understanding the Latarjet Procedure

The Latarjet procedure, first described by Michel Latarjet in 1954, is a well-established and highly effective surgical technique for managing anterior shoulder instability, particularly in cases with glenoid bone loss.

• Key Principles: The core of the Latarjet procedure involves the transfer of a portion of the coracoid process (a hook-like bony projection from the scapula) along with its attached conjoint tendon (formed by the short head of the biceps and coracobrachialis muscles) to the anterior-inferior aspect of the glenoid.
• Surgical Steps:
  • An incision is made, typically anteriorly.
  • The coracoid process is osteotomized (cut) at its base.
  • The detached coracoid fragment, with the conjoint tendon intact, is then rotated and fixed with screws to the anterior neck of the scapula, flush with the articular surface of the glenoid.
  • Often, an additional capsulolabral repair (Bankart repair) may be performed concurrently.
• Mechanism of Action (The "Triple Blocking Effect"): The Latarjet procedure achieves stability through three primary mechanisms:
  1. Bone Block Effect: The transferred coracoid bone fragment physically extends the anterior glenoid, preventing the humeral head from dislocating anteriorly.
  2. Sling Effect (Conjoint Tendon): When the arm is abducted and externally rotated (positions prone to dislocation), the conjoint tendon, now positioned anteriorly, acts as a dynamic sling, further reinforcing the anterior capsule and subscapularis muscle.
  3. Capsular Repair/Reattachment: The anterior capsule and labrum are often repaired and reattached over the transferred coracoid, enhancing soft tissue stability.
• Indications: The Latarjet procedure is primarily indicated for recurrent anterior shoulder instability with:
  • Significant glenoid bone loss (typically >20-25%).
  • Large, engaging Hill-Sachs lesions.
  • Failed previous soft tissue repairs (e.g., Bankart repair).
  • Patients involved in high-demand overhead activities or contact sports.
  • Hyperlaxity with recurrent dislocations.

Understanding the Bristow Procedure

The Bristow procedure, described by Arthur Bristow in 1917, precedes the Latarjet and shares many conceptual similarities but has distinct technical differences. It is often considered a precursor or a specific variation of the coracoid transfer.

• Key Principles: Like the Latarjet, the Bristow procedure involves transferring the tip of the coracoid process with the conjoint tendon to the anterior glenoid. The defining characteristic often lies in how the conjoint tendon is managed relative to the subscapularis muscle.
• Surgical Steps:
  • The coracoid tip, with the conjoint tendon attached, is osteotomized.
  • This coracoid fragment is then typically passed through a split in the subscapularis muscle and fixed to the anterior glenoid.
• Mechanism of Action: The Bristow procedure aims to stabilize the shoulder primarily through:
  1. Bone Block Effect: The transferred coracoid fragment provides a bony buttress, similar to the Latarjet.
  2. Sling Effect: The conjoint tendon, passed through the subscapularis, provides some dynamic stabilization, though perhaps less pronounced or differently oriented than in the Latarjet.
• Indications: Historically, the Bristow procedure was used for similar indications as the Latarjet – recurrent anterior shoulder instability, especially with bony defects. However, with the refinement and widespread adoption of the Latarjet, the classical Bristow procedure is less commonly performed today as a standalone procedure for primary instability, though its principles are foundational.

Key Differences Between Bristow and Latarjet

While both procedures involve coracoid transfer, the critical distinctions lie in their technical execution and the resulting biomechanical effects.

• Coracoid Transfer and Fixation:
  • Latarjet: Typically involves a larger portion of the coracoid, which is rotated 90 degrees and fixed flush with the glenoid face using two screws. This ensures maximal bony buttress and proper orientation for the sling effect.
  • Bristow: Often involves a smaller tip of the coracoid. The exact orientation and fixation can vary, but it's typically fixed with a single screw to the anterior glenoid.
• Conjoint Tendon Management:
  • Latarjet: The conjoint tendon remains superficial to the subscapularis muscle or the subscapularis is split, allowing the conjoint tendon to lie directly over the muscle belly. This allows for a more direct dynamic sling effect upon external rotation.
  • Bristow: The transferred coracoid with the conjoint tendon is typically passed through a horizontal split in the subscapularis muscle. This difference in tendon routing is a key distinguishing feature.
• Biomechanics and "Triple Blocking Effect":
  • Latarjet: Explicitly designed to create the "triple blocking effect" – the bone block, the dynamic sling effect of the conjoint tendon over the subscapularis, and the capsular repair. This comprehensive approach is a hallmark of the Latarjet.
  • Bristow: Primarily relies on the bone block and some dynamic sling effect, but the "triple blocking" concept is more explicitly associated with the Latarjet's refined technique and orientation.
• Historical Context and Evolution:
  • Bristow: Described earlier, it laid the groundwork for coracoid transfer.
  • Latarjet: A refinement of the coracoid transfer concept, which has evolved into the more commonly practiced and extensively studied procedure for anterior glenoid bone loss. Many modern surgeons consider the Latarjet a more biomechanically sound and consistently effective procedure.

Advantages and Disadvantages

Choosing between these procedures (or opting for a different stabilization technique) depends on patient-specific factors, surgeon preference, and the nature of the instability.

• Latarjet Advantages:
  • Highly effective for significant glenoid bone loss.
  • Provides robust mechanical stability through the "triple blocking effect."
  • Lower recurrence rates compared to soft tissue repairs in appropriate cases.
  • Well-studied with extensive long-term follow-up.
• Latarjet Disadvantages:
  • More invasive than soft tissue repairs.
  • Potential for complications such as nerve injury, non-union of the coracoid, hardware-related issues, or pain.
  • May lead to some loss of external rotation.
• Bristow Advantages:
  • Historically important, and some surgeons may still employ variations.
  • Can be effective in reducing instability.
• Bristow Disadvantages:
  • Less commonly performed in its classical form than Latarjet.
  • Potentially less robust in terms of the dynamic sling effect compared to the Latarjet due to tendon routing.
  • May have higher rates of coracoid non-union or other complications if not executed with the precision of modern Latarjet techniques.

When is Each Procedure Indicated?

In modern orthopedic practice, the Latarjet procedure is the dominant choice for bony augmentation in cases of anterior shoulder instability. It is indicated when:

• There is significant anterior glenoid bone loss (e.g., >20-25% of the glenoid width).
• There is an engaging Hill-Sachs lesion.
• Previous arthroscopic soft tissue repairs (like Bankart) have failed.
• The patient is involved in high-risk sports or occupations.

The classical Bristow procedure is less frequently performed as a primary procedure today. However, its historical significance is immense, and some surgeons might employ modifications or refer to the principle of passing the conjoint tendon through the subscapularis in specific scenarios. For practical purposes, when discussing coracoid transfer for bone loss, the Latarjet procedure is almost universally implied.

Recovery and Rehabilitation

For both procedures, recovery involves a structured rehabilitation program.

• Immobilization: Typically involves a sling for 4-6 weeks to protect the surgical site and allow initial healing.
• Early Motion: Gradual passive and then active-assisted range of motion exercises begin after the initial immobilization period, focusing on restoring mobility without stressing the repair.
• Strengthening: Progressive strengthening exercises for the rotator cuff and periscapular muscles are introduced, typically starting around 8-12 weeks post-surgery.
• Return to Activity: Return to sport or heavy overhead activities is usually permitted around 6-9 months, depending on the individual's progress, the sport's demands, and the surgeon's clearance. Full recovery can take up to a year.

Conclusion and Clinical Considerations

While the Bristow procedure historically paved the way for bony shoulder stabilization, the Latarjet procedure has emerged as the gold standard for managing anterior shoulder instability with significant bone loss. The Latarjet offers a comprehensive "triple-blocking" mechanism that provides robust and reliable stability. Understanding the subtle yet critical technical differences, especially regarding coracoid fixation and conjoint tendon management, is essential for appreciating their distinct biomechanical contributions. For individuals facing recurrent shoulder dislocations, a thorough evaluation by an orthopedic surgeon specializing in shoulder care is crucial to determine the most appropriate surgical approach based on the specific pathology and patient needs.