1. Bristow Procedure Candis, Micah, Amanda & AngieCandis, Micah, Amanda & Angie

2. What is a Bristow Procedure? Used as a treatment for anterior shoulder instability Used as a treatment for anterior shoulder instability Tip of coracoid process of the scapula is transferred to the anterior portion of the glenoid neck Tip of coracoid process of the scapula is transferred to the anterior portion of the glenoid neck May also be called a Latarjet or Latarjet-Bristow Procedure May also be called a Latarjet or Latarjet-Bristow Procedure

3. Who will Benefit from a Bristow Procedure? People who play contact sports, such as football or basketball People who play contact sports, such as football or basketball People who have a large bony bankart  lesion formed to due multiple anterior dislocation People who have a large bony bankart  lesion formed to due multiple anterior dislocation Poor soft tissue Poor soft tissue Multiple dislocations Multiple dislocations Anterior labrum very poor quality Anterior labrum very poor quality Revision surgery Revision surgery Failed arthroscopic or open soft tissue bankart Failed arthroscopic or open soft tissue bankart

4. Who won’t benefit? Procedure is less successful for patients with: Procedure is less successful for patients with: Uncontrolled Epilepsy Uncontrolled Epilepsy Instability caused by paresis of deltoid, rotator cuff, or scapular muscles Instability caused by paresis of deltoid, rotator cuff, or scapular muscles Instability in multiple directions Instability in multiple directions Voluntary instability Voluntary instability These patients should be treated non-operatively: These patients should be treated non-operatively: Patients unfit for surgery Patients unfit for surgery Elderly Elderly Low-demand patients Low-demand patients

5. Surgical Procedure 1-3 cm of the coracoid process is removed from the scapula along with muscular insertions 1-3 cm of the coracoid process is removed from the scapula along with muscular insertions The removed bone and muscle attachments are moved to the anterior-inferior portion of the glenoid neck The removed bone and muscle attachments are moved to the anterior-inferior portion of the glenoid neck The coracoid tip is then placed by 1 or 2 screws to the glenoid neck The coracoid tip is then placed by 1 or 2 screws to the glenoid neck The new bony prominence prevents the humerus from dislocating anteriorly providing increased stability to the shoulder The new bony prominence prevents the humerus from dislocating anteriorly providing increased stability to the shoulder

6. Video of Bristow-Latarjet Procedure Video clip rated G for GRAPHIC. If you have a queasy stomach please use viewer discretion!!! Video clip rated G for GRAPHIC. If you have a queasy stomach please use viewer discretion!!! https://www.youtube.com/watch?v=_T6nD0Ryr2s https://www.youtube.com/watch?v=_T6nD0Ryr2s https://www.youtube.com/watch?v=_T6nD0Ryr2s

7. Post-surgical Precautions NO elbow extention: passive or active NO elbow extention: passive or active Passive elbow flexion Passive elbow flexion First week pt in immobilized shoulder sling First week pt in immobilized shoulder sling After Week 1- pt in standard shoulder sling for 3-4 weeks After Week 1- pt in standard shoulder sling for 3-4 weeks Codman’s exercises begin between 3-6 weeks Codman’s exercises begin between 3-6 weeks After 6 weeks PROM and AROM of shoulder is initiated After 6 weeks PROM and AROM of shoulder is initiated

8. Rehab of a Bristow Procedure Phase I: Immediate Post Surgical Phase (Approximately 1-3 weeks) Phase I: Immediate Post Surgical Phase (Approximately 1-3 weeks) Precautions: Precautions: No AROM No AROM No excessive external rotation No excessive external rotation Remain in sling, only remove to shower Remain in sling, only remove to shower Activity: Activity: PROM only PROM only “Ball exercises” “Ball exercises” Educate patient on proper posture and protection of the surgical shoulder Educate patient on proper posture and protection of the surgical shoulder

9. Rehab Phase II: Intermediate Phase/ROM (approximately 4-9 weeks) Phase II: Intermediate Phase/ROM (approximately 4-9 weeks) Precautions Precautions No active movement of shoulder No active movement of shoulder No lifting with affected upper extremity No lifting with affected upper extremity Do not perform activities or strengthening exercises Do not perform activities or strengthening exercises Activities Activities Progress shoulder PROM Progress shoulder PROM Abduction in the scapular plane Abduction in the scapular plane Glenohumeral and scapulothoracic joint mobilization Glenohumeral and scapulothoracic joint mobilization Continue AROM elbow, wrist, and hand Continue AROM elbow, wrist, and hand Strengthen scapular retractors and upward rotators Strengthen scapular retractors and upward rotators

10. Rehab Phase III: Strengthening Phase (Week 10 – week 15) Phase III: Strengthening Phase (Week 10 – week 15) Precautions: Precautions: Avoid contact sports/activities Avoid contact sports/activities Do not overstress anterior capsule with overhead activities Do not overstress anterior capsule with overhead activities Patient education regarding a gradual increase to shoulder activities Patient education regarding a gradual increase to shoulder activities Actvities Actvities Continue AROM/PROM as needed Continue AROM/PROM as needed Progress subscapularis strengthening Progress subscapularis strengthening Progressive strengthening of pectoralis major minor Progressive strengthening of pectoralis major minor

11. Rehab Phase IV: Overhead Activities (Week 16 -20) Phase IV: Overhead Activities (Week 16 -20) Precaution Precaution Avoid excessive anterior capsule stress Avoid excessive anterior capsule stress Avoid tricep dips Avoid tricep dips Do not begin throwing or overhead athletic moves Do not begin throwing or overhead athletic moves Activities Activities Strengthening overhead ROM Strengthening overhead ROM Continue shoulder stretching and strengthening Continue shoulder stretching and strengthening More exercises and activities: http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/ph ysical%20therapy%20standards%20of%20care%20and%20protocols/shoulder%20- %20latarjet%20protocol.pdf More exercises and activities: http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/ph ysical%20therapy%20standards%20of%20care%20and%20protocols/shoulder%20- %20latarjet%20protocol.pdf http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/ph ysical%20therapy%20standards%20of%20care%20and%20protocols/shoulder%20- %20latarjet%20protocol.pdf http://www.brighamandwomens.org/patients_visitors/pcs/rehabilitationservices/ph ysical%20therapy%20standards%20of%20care%20and%20protocols/shoulder%20- %20latarjet%20protocol.pdf Pages 5-10 Pages 5-10

12. Informational Sources http://www.boneschool.com/upper- limb/shoulder/instability/anterior/open-surgical-options/bristow- laterjet Vourazeris, Jason D., Herbenick, Michael A. “Bristow Procedure.” Medscape. 10/28/2014. http://emedicine.medscape.com/article/1894367-overview Vourazeris, Jason D., Herbenick, Michael A. “Bristow Procedure.” Medscape. 10/28/2014. http://emedicine.medscape.com/article/1894367-overview http://emedicine.medscape.com/article/1894367-overview http://emedicine.medscape.com/article/1894367-overview#a30 http://www.brighamandwomens.org/patients_visitors/pcs/rehabil itationservices/physical%20therapy%20standards%20of%20care%20a nd%20protocols/shoulder%20-%20latarjet%20protocol.pdf

13. Media Sources http://www.rocmd.com/conditions-treated/shoulder- anatomy/shoulder-dislocation/ http://www.rocmd.com/conditions-treated/shoulder- anatomy/shoulder-dislocation/ http://www.rocmd.com/conditions-treated/shoulder- anatomy/shoulder-dislocation/ http://www.rocmd.com/conditions-treated/shoulder- anatomy/shoulder-dislocation/ https://www.youtube.com/watch?v=_T6nD0Ryr2s https://www.youtube.com/watch?v=_T6nD0Ryr2s https://www.youtube.com/watch?v=_T6nD0Ryr2s