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° in external rotation with the arm at the side, a mean deficit of 15° 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 bone-block procedure and the arthroscopic Bankart repair while eliminating the potential disadvantages of each. Level of Evidence: Level IV, therapeutic case series.