Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: The "belt-and-suspenders" operative technique and preliminary results

Purpose: We report the results of a new technique consisting of a combined arthroscopic Bankart repair associated with a transfer of the coraco-biceps tendon to reinforce the deficient anterior capsule by lowering the subscapularis. Methods: The procedure combines 2 parts: an arthroscopic Bankart repair, which recreates the glenoid concavity and retensions the inferior glenohumeral ligament (i.e., "the belt," or intra-articular ligamentoplasty), and an arthroscopic transfer of the conjoined tendon with a coracoid fragment, to reinforce the stretched or torn inferior glenohumeral ligament (i.e., "the suspenders," or extra-articular ligamentoplasty). The coracoid fragment is exteriorized, shaped, and calibrated, and a tenodesis of the coraco-biceps tendon is performed above the subscapularis tendon by fixing the coracoid fragment with a bioabsorbable interference screw in a glenoid socket in the scapular neck. Thirty-six patients were available for clinical and radiographic review with a minimum 1-year follow-up. Results: Of the patients, 28 (78%) were very satisfied, 5 (14%) were satisfied, and 3 (8%) were disappointed. In comparison to the contralateral shoulder, postoperative mobility revealed no loss of active anterior elevation, a mean deficit of 9 degrees in external rotation with the arm at the side, a mean deficit of 15 degrees in external rotation in abduction, and no loss of internal rotation. The mean Walch-Duplay score was 87 points. Failures occurred in 3 patients (8%) who presented with recurrent instability. Conclusions: This new intra- and extra-articular combined technique constitutes an alternative in the treatment of anterior shoulder instability in patients with deficient or stretched anterior capsule. It combines the theoretic advantages of the Bristow boneblock procedure and the arthroscopic Bankart repair while eliminating the potential disadvantages of each. Level of Evidence: Level IV, therapeutic case series.