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,
athletic population. Most dislocations occur in the ante-
roinferior direction, causing injury to the anteroinferior
*Reprint requests: Thay Q. Lee, PhD, Orthopaedic Biomechanics
Laboratory, VA Long Beach Healthcare System (09/151), 5901 E 7th St,
Long Beach, CA 90822, USA.
E-mail address: tqlee@med.va.gov (T.Q. Lee).
labroligamentous complex.3,34 Avulsion of the anteroinferior
glenoid rim is associated with recurrent instability4 and oc-
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
glenoid bone loss and/or engaging Hill-Sachs lesions yield
failure rates that are unacceptably high (67%)7 when glenoid
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
Even though stability in these difficult cases can be
restored with coracoid transfer, the procedure is not benign.
Many complications such as screw breakage, nerve injury
from bicortical screw fixation, and nonunion of the bony
fragment have been described.1,15,17,33 Other complications
can result from incorrect placement of the transferred
coracoid process in relation to the articular surface.1,16
Finally, revision of a failed Bristow or Latarjet procedure
can be difficult, and non-local structural bone grafting may
be necessary to provide stability.32
Many of the complications of the modified Bristow
procedure are related to the bone block. The importance of
the bone block and the soft-tissue sling have been described
in the past.16,26 Emerging evidence is showing the impor-
tance of the soft-tissue sling.12,42 A recent biomechanical
article by Thomas et al35 suggests that the bone block may
be unnecessary in the setting of a normal glenoid. However,
a conjoined tendon–only transfer has not been evaluated
in the presence of bone loss. Potential disadvantages of
conjoined tendon transfer are recurrent instability by not
addressing the bone loss or a change in glenohumeral ki-
nematics by placing the tendon on the glenoid face. In the
presence of bone transfer, the tendon sits 1 cm anterior to
the glenoid.
This study was designed to determine the effect of the
modified Bristow procedure, with and without a bone
block, on glenohumeral range of motion, stability, and
humeral head kinematics after creation of a bony Bankart
lesion. To determine whether the bone block is necessary
for stability, we compared the amount of translation ante-
riorly and inferiorly in a modified Bristow reconstruction
versus a soft tissue–only conjoined tendon transfer placed
through a split in the subscapularis tendon.
Materials and methods
Eight cadaveric shoulders (4 left and 4 right shoulders from 6 male
and 2 female cadavers with a mean age of 60 years) were prepared
by removing the clavicle and major shoulder muscles, leaving the
rotator cuff, capsule, coracoacromial ligament, and conjoined
tendon intact. Three small reference screws were placed on the
Figure 1 Custom testing system, showing a left shoulder
mounted in 60
of glenohumeral abduction with 30
of scapular
abduction, in coronal plane.
anterolateral edge of the acromion and the proximal humerus for
measuring glenohumeral kinematics.
The scapula was secured to a mounting bracket, and the hu-
merus was secured to an intramedullary rod for mounting. The
scapula plate was mounted on the custom testing system with 20

of anterior tilt to simulate average in vivo positioning (Fig. 1).20
The humeral rod was inserted through a hollow–shaft angle
potentiometer (Novotechnik US, Southborough, MA, USA) for
measuring humeral rotation. The potentiometer was attached to an
arc with a custom device that allows for compression/distraction
and anterior/posterior and medial/lateral glenohumeral translation
while fixing abduction and the plane of abduction.
The rotator cuff and conjoined tendons were loaded based on
physiological cross-sectional area ratios with multiple lines of
pull.37 Specifically, 2 lines of pull were used for the supraspinatus,
3 for the subscapularis, 2 for the infraspinatus, and 1 for the teres
minor. Five newtons was loaded on each line of pull, for a total of
40 N. The conjoined tendon was sutured in Krackow fashion and
loaded with 10 N.
Humeral rotation was defined as 90
of external rotation when
the bicipital groove was aligned with the anterolateral aspect of
the acromion.24,36 A string was attached to the humerus at the
proximal pectoralis major insertion for the application of an
anteroinferior translation force. The string passed through a pulley
positioned perpendicular to the humerus anteriorly and 20
infe-
rior to the humerus. Three anteroinferior loads were applied, 20,
30, and 40 N, and glenohumeral translation was measured with a
MicroScribe 3DLX (Revware, Raleigh, NC, USA).
Specimens were tested in 60
of glenohumeral abduction in the
scapular plane and the coronal plane (30
posterior to the scapular
plane). Glenohumeral kinematics was measured throughout the
rotational range of motion at maximum internal rotation; 0
, 30
,
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
amount of rotation reached at 1.5 Nm with a torque wrench. This
torque was adequate to provide a consistent endpoint for measuring
humeral rotation while not resulting in soft-tissue damage. Ante-
roinferior translation was measured with the humerus locked in 60

of abduction and external rotation by adding 20-, 30-, and 40-N
loads incrementally through the pulley. Translation was measured in
the scapular and coronal planes. The 4 experimental conditions of
Is bone block necessary?
Table I Rotational range of motion for each condition and plane of testing
Mean  SD (
)
Intact condition Bony Bankart lesion
Scapular plane
External rotation 107.1  6.5 116.7  6.3)
Internal rotation 5.4  7.3 11.8  12.0)
Total rotation 112.4  10.1 128.5  13.4)
Coronal plane
External rotation 112.8  11.1 123.2  10.4)
Internal rotation 17.6  9.4 25.2  12.8)
Total rotation 130.5  9.2 148.4  12.3)
) P < .05 versus intact condition.
testing comprised (1) intact glenohumeral joint, (2) Bankart lesion
with 20% glenoid bone loss, (3) modified Bristow procedure, and (4)
conjoined soft-tissue transfer.
After intact testing, a Bankart lesion was created through a
split in the subscapularis. All tendons were unloaded temporarily
by removing the attached weights, and lateral traction was placed
on the proximal humerus to expose the glenoid face. The capsule
was split horizontally to the glenoid and then the labrum and
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
averaged. A mark was made on the face of the glenoid at the
calculated distance, and an osteotome was used to remove 20% of
the anterior glenoid in line with the longitudinal axis.30,32
The modified Bristow procedure was performed. The cor-
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
tip with the conjoined tendon attached. A 2.5-mm drill bit was used
to drill across the glenoid just below the equator (4-o’clock position)
to place a 3.5-mm bicortical screw and washer. Because the diam-
eter of the bone block when brought straight down and rotated 90

was approximately 1 cm across, the drill hole was made 6 mm from
the articular surface to ensure that the bone block was not too far
lateral. The bone block was secured to the glenoid through the split
in the subscapularis tendon with the screw and washer.
The conjoined soft-tissue transfer was the final condition. The
bone block was sharply removed from the tendon and placed back
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-
o’clock position was used for the top anchor, and a second screw hole
and anchor was placed 5 mm below this. Two single-loaded anchors
with needles were used. One limb was placed through the conjoined
tendon in a locking fashion. The other limb was passed once through
the tendon so that it could slide the tendon down to bone. The bottom
anchor was sutured to the conjoined tendon in the same fashion, and
both were secured with knots. This tendon was placed through the
same split in the subscapularis tendon to create a sling.
After testing, the specimen was disarticulated and the surface
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
apex position, defined as the highest point on the articular surface
of the humeral head relative to the plane of the articular margin,
was tracked relative to the geometric center of the glenoid. The
geometric center of the glenoid was defined as the point bisecting
3
Modified Bristow procedure Soft-tissue Bristow procedure
114.0  10.5) 115.6  8.6)
12.0  12.9) 12.3  11.2)
126.0  19.3) 127.9  16.6)
122.4  12.0) 125.9  12.2)
26.7  14.9) 27.6  13.9)
149.1  13.6) 153.5  14.5)
the superoinferior and anteroposterior axes of the glenoid at the
articular surface.25
All data were repeated for 2 trials, and if not repeatable within
1.0 mm for positioning, a third trial was repeated. The average
value for 2 trials was used for comparison. A repeated-measures
analysis of variance with a significance level of .05 was used. If a
significant difference was shown, a Tukey post hoc test was used
to determine the areas of significance.
Results
Rotational range of motion
After creation of a bony Bankart lesion, internal, external,
and total range of motion increased significantly from the
intact condition in both the scapular and coronal planes
(P < .005 for all comparisons) (Table I). The increase in
motion remained significantly increased from the intact
condition after modified and soft tissue–only Bristow pro-
cedures in both planes (P < .01). There was no significant
difference in range of motion between the modified and
soft-tissue Bristow groups.
Glenohumeral translation in scapular plane
After creation of a bony Bankart lesion, anterior translation
in the scapular plane significantly increased from the intact
condition by 2.9 mm (SD, 1.8 mm), 7.3 mm (SD, 6.7 mm),
and 7.7 mm (SD, 6.2 mm) for the 20-, 30-, and 40-N loads,
respectively (P ¼ .0003, P ¼ .002, and P ¼ .002, respec-
tively) (Fig. 2). Inferior translation also increased by
1.8 mm (SD, 1.0 mm), 8.4 mm (SD, 9.0 mm), and 9.5 mm
(SD, 8.3 mm), respectively, from the intact condition
(P ¼ .0002, P ¼ .004, and P ¼ .0007, respectively) (Fig. 3).
Both the modified Bristow procedure and soft-tissue
transfer restored translation to the intact condition.
Glenohumeral translation in coronal plane
After creation of a bony Bankart lesion, anterior translation
in the scapular plane significantly increased from the intact
condition by 1.4 mm (SD, 1.0 mm), 3.7 mm (SD, 3.8 mm),
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-
tively) (Fig. 4). Inferior translation also increased by
1.0 mm (SD, 0.7 mm), 4.5 mm (SD, 6.5 mm), and 11.5 mm
(SD, 5.8 mm), respectively, from the intact condition
(P ¼ .0005, P ¼ .06, and P ¼ .0002, respectively) (Fig. 5).
The modified Bristow procedure restored translation to the
intact condition for the 20- and 40-N translational loads,
whereas the soft-tissue transfer restored translation to the
intact condition for all translational loads applied.
Humeral head apex position
The humeral head apex shifted posteriorly at all points of
external rotation compared with the Bankart lesion and
intact condition after we performed both the modified
Bristow procedure and soft-tissue Bristow procedure
(P < .05) (Figs. 6 and 7). There was no statistical difference
in humeral head apex position between the 2 reconstruction
groups. There were no significant differences in super-
oinferior or mediolateral humeral head apex position.
Discussion
In this biomechanical model, a Bankart lesion with 20%
glenoid bone loss resulted in a significant increase in
external rotation and overall range of motion. The modified
Bristow procedure resulted in motion that was not statisti-
cally different from the intact condition in the scapular
plane but was significantly increased in the modified
Bristow condition in the coronal plane. The soft-tissue
transfer condition resulted in significantly increased
external rotation and total range of motion compared with
the intact shoulder in both planes. This indicated that, at
time 0, the modified Bristow procedure resulted in range of
motion more similar to the intact shoulder than soft-tissue
transfer.
Clinical studies consistently have documented a loss of
external rotation after open nonanatomic reconstruc-
tion.2,15,19 This has been shown to be important especially
in overhead athletes. Throwing athletes returned to
throwing but over half had a loss of velocity possibly
because of the loss of external rotation, which is an adap-
tive finding in overhead throwing athletes.8,9 At time 0 in
our biomechanical study, the soft-tissue transfer had
increased external rotation of 13
compared with the intact
shoulder. Because external rotation was higher than that in
the intact condition with the soft-tissue Bristow procedure,
after healing, this procedure might result in motion more
similar to the intact shoulder and mitigate the loss of
Is bone block necessary?
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,
which has been well documented in the literature.
An interesting study for comparison involved an
arthroscopic soft-tissue Bristow procedure.5 The authors
performed a tenodesis of the coraco-biceps tendon above
the subscapularis tendon on the glenoid neck, creating a
soft-tissue sling with no bone block. In 36 patients, they
found a mean deficit of 15
in external rotation in abduc-
tion. This might indicate that loss of motion clinically
might be similar with the soft-tissue transfer and modified
Bristow procedure. One confounding variable is that the
authors also performed a Bankart repair and capsular
plication,5 which we did not.
The translational part of our study was of great impor-
tance to show biomechanically whether the bone block is
necessary to restore stability. Thomas et al35 performed the
first biomechanical study to show improved stability with a
soft-tissue transfer. They recommended further study in a
model with significant bony defects. They also noted that
stability might have been enhanced if they had left the
subscapularis intact. This provided the basis of our
5
experimental design in which we loaded the rotator cuff to
simulate the compressive stabilizing force and created a
bone loss model for testing.
Anterior and inferior translation was significantly
increased from the intact condition after creation of a Bankart
lesion with 20% glenoid bone loss. The modified Bristow
procedure restored stability similar to the intact shoulder. In
the same fashion, the soft-tissue transfer restored stability
with translation similar to the intact condition. There was a
trend toward less translation in both planes with the soft-
tissue transfer compared with the modified Bristow proce-
dure, but this was not statistically different. Without the
coracoid tip bringing the tendon more anteriorly off the
glenoid, the soft-tissue transfer placed the tendon directly on
the glenoid, and therefore, the humeral head was abutting the
soft tissue directly, leading to less translation.
The stability conferred in soft-tissue transfer can only be
explained by the sling effect. We chose to load the tendon with
10 N of force because prior studies have shown improved
biomechanical properties and substantial effects on joint sta-
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
size defects have been investigated. Yamamoto et al41 recently
reported that a glenoid defect larger than 19% remains un-
stable after soft-tissue Bankart repair. Other studies have used
30% bone loss because this is a larger-sized defect that would
typically undergo bone grafting.6,11 Provencher et al,32 in a
review paper, explained that the questionable area is between
15% and 30% bone loss. Our 20% bone loss model provides
relevant information for cases in which it is questionable
whether a bony procedure is needed.
The modified Bristow procedure and soft-tissue transfer
both shifted the humeral head apex posterior to the intact
shoulder. Interestingly, the soft-tissue transfer shifted the
apex more posteriorly than the modified Bristow procedure.
This could be a result of the tendon being placed directly on
the glenoid neck, abutting the humeral head before it would
in the modified Bristow procedure, where it sits 1 to 1.5 cm
anterior to the glenoid neck. The clinical manifestations of
this effect are unknown.
One proposed benefit of a soft-tissue transfer is that it may
be more tolerated when it contacts the articular surface of the
humeral head. The clinical manifestations of improper bone
block placement are well documented.1,16 Boileau et al5 re-
ported on an arthroscopic soft-tissue Bristow technique. Their
technique involved placing the bone block into the glenoid
through a tunnel and achieving fixation with an interference
screw. This would effectively place the conjoined tendon
directly against the humeral head as in our study.
Many of the limitations of this study are inherent to a
cadaveric study. The donor specimens, with a mean age of
60 years, are not similar to a younger patient population
that presents with instability. Our results can only be
determined at time 0. When patients return to activities and
sports, the effects may not be the same in terms of soft-
Is bone block necessary?
tissue healing, scarring, and contracture after surgery, as
well as adaptations made by patients during rehabilitation.
In addition, we performed both surgical reconstructions on
the same specimen, and sequential testing could have
affected the results. However, the fact that soft-tissue
transfer conferred stability after testing of the modified
Bristow procedure’s stability only strengthens the argument
that the bone block is not necessary. There was no
randomization in the testing sequence. The same sequence
of reconstructions and testing was performed in the same
order on all specimens. The results of this study are only
applicable to 20% glenoid bone loss. It is possible that there
is a limit to how much bone loss can be stabilized with a
soft-tissue transfer, and further study in 25% and 30% bone
loss models is needed. For this procedure to be effective, it
would require healing of tendon to bone. We did not
observe any failures of our suture anchor technique during
testing, but evaluation of different fixation methods to
secure the conjoined tendon would be beneficial.
Conclusions
The increase in external rotation observed in our insta-
bility model remained significantly increased from the
intact condition in each repair condition. This suggests
that nonanatomic reconstruction does not initially
restrict joint motion. The data also show that trans-
lational stability can be restored in a 20% bone loss
model without a bone block, suggesting the importance
of the soft-tissue sling created by the conjoined tendon
and subscapularis in the position of abduction and
external rotation. An all–soft tissue procedure lends it-
self to arthroscopic techniques. Suture anchors might be
technically easier to use than a bone tunnel for tenodesis
or using a screw with a bone block. An all–soft tissue
procedure would also mitigate many of the complica-
tions associated with the modified Bristow procedure,
such as screw breakage, nerve injury, nonunion, and
arthritis with malposition. Potential disadvantages of
conjoined tendon transfer are recurrent instability by not
addressing the bone loss or a change in glenohumeral
kinematics by placing the tendon on the glenoid face.
Disclaimer
Partial funding was provided by VA Rehabilitation
Research and Development Merit Review and the John
C. Griswold Foundation. The funding source did not
play a role in the investigation.
The authors, their immediate families, and any
research foundations with which they are affiliated have
not received any financial payments or other benefits from
any commercial entity related to the subject of this article.
7
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