1. Pitanje broj: #17064

    Prije 4 godine sam imao operaciju ramena. Op. zahvat je naveden kao "Bristow".
    Možete li mi pojasniti kakav je to zahvat.
    Unaprijed hvala.

    Odgovoreno: 18. 12. 2008.
    • Poštovani Saša,
      Operacija ima za cilj stabilizaciju ramena gde se pojedini mišići i tetive ramenog pojasa pripajaju za lopatičnu kost. Preporučujem Vam da pročitate detaljan opis operacije koji je dat u tekstu. Bristow-Helfet Procedure This procedure was developed, used, and reported by Arthur Helfet (Helfet, 1958) in 1958 and was named the Bristow operation after his former chief at St. Thomas Hospital, W. Rowley Bristow of South Africa. Helfet originally described detaching the tip of the coracoid process from the scapula just distal to the insertion of the pectoralis minor muscle, leaving the conjoined tendons (i.e., the short head of the biceps and the coracobrachialis) attached. Through a vertical slit in the subscapularis tendon, the joint is exposed and the anterior surface of the neck of the scapula is "rawed up." The coracoid process with its attached tendons is then passed through the slit in the subscapularis and kept in contact with the raw area on the scapula by suturing the conjoined tendon to the cut edges of the subscapularis tendon. Effectively, a subscapularis tenodesis is performed. In 1958, T. B. McMurray (son of T. P. McMurray of hip osteotomy fame) visited Dr. Newton Mead (Mead and Sweeney, 1964) of Chicago and described modifications of the Bristow operation that were being used in Capetown, Johannesburg, and Pretoria. Mead and Sweeney (Mead and Sweeney, 1964) reported the modifications in over 100 cases. The modifications consist of splitting the subscapularis muscle and tendon unit in line with its fibers to open the joint and firmly securing the coracoid process to the anterior glenoid rim with a screw. May (May, 1970) has modified the Bristow procedure further by vertically dividing the entire subscapularis tendon from the lesser tuberosity; after exploring the joint, he attaches the tip of the coracoid process with the conjoined tendon to the anterior glenoid with a screw. The subscapularis tendon is then split horizontally and reattached--half of the tendon above and half below the transferred conjoined tendon--to the site of its original insertion. Again, the net effect is a tenodesis of the subscapularis. Helfet (Helfet, 1958) reported that the procedure not only "reinforced" the defective part of the joint but also had a "bone block" effect. Mead, (Mead and Sweeney, 1964) however, does not regard the bone block as being a very important part of the procedure and believes that the transfer adds a muscle reinforcement at the lower anterior aspect of the shoulder joint that prevents the lower portion of the subscapularis muscle from displacing upward as the humerus is abducted. Bonnin (Bonnin, 1969; Bonnin, 1973) has modified the Bristow procedure in the following way: he does not shorten or split the subscapularis muscle tendon unit but for exposure he divides the subscapularis muscle at its muscle-tendon junction and, following the attachment of the coracoid process to the glenoid with a screw, he reattaches the subscapularis on top of the conjoined tendon. Results with this modification in 81 patients have been reported by Hummel and associates. (Hummel et al, 1982) Torg and coworkers (Torg et al, 1987) reported their experience with 212 cases of the Bristow procedure. In their modification the coracoid was passed over the superior border rather than through the subscapularis. Their postoperative instability rate was 8.5 per cent (3.8 per cent redislocation and 4.7 per cent subluxation). Ten patients required reoperation for screw-related problems; 34 per cent had residual shoulder pain and 8 per cent were unable to do overhead work. Only 16 per cent of athletes were able to return to their preinjury level of throwing. Carol and associates (Carol et al, 1985) reported on the results of the Bristow procedure performed for 32 recurrent dislocating shoulders and 15 "spontaneous" shoulder instabilities. At an average follow-up of 3.7 years, only one patient had recurrent instability and the average limitation of external rotation was 12 degrees. Banas et al (Banas et al, 1993) reported 4% recurrence with a 8.6 year followup; however, additional surgery was required in 14%. Wredmark et al (Wredmark et al, 1992) found only 2 out of 44 recurrent dislocations at an average followup of 6 years, but 28% percent of patients complained of pain. Hovelius and coworkers (Hovelius, Akermark and Albrektsson, 1983) reported follow-up on 111 shoulders treated with the Bristow procedure. At 2.5 years their postoperative instability rate was 13 per cent (6 per cent dislocation and 7 per cent subluxation). External rotation was limited an average of 20 degrees, and 6 per cent required reoperation because of screw-related complications. Muscle strength was 10 per cent less in the operated shoulder. Chen and colleagues (Chen et al, 1984) found that after the Bristow procedure, the reduced strength of the short head of the biceps was compensated for by increased activity in the long head.Other series of Bristow procedures have been reported, each of which emphasizes the potential risks. (Weaver and Derkash, 1994) Lamm and coworkers (Lamm et al, 1982) and Lemmens and de Waal Malefijt (Lemmens and de Waal Malefitj, 1984) have described four special x-ray projections to evaluate the position of the transplanted coracoid process: anteroposterior, lateral, oblique lateral, and modified axial. Lower and coworkers (Lower et al, 1985) used CT to demonstrate the impingement of a Bristow screw on the head of the humerus. Collins and Wilde (Collins and Wilde, 1973) and Nielsen and associates (Nielsen and Nielsen, 1982) reported that while they had minimal problems with recurrence of dislocation, they did encounter problems with screw breakage, migration, and nonunion of coracoid to scapula. Hovelius and colleagues (Hovelius, 1982; Hovelius et al, 1983) reported only a 50 per cent union rate of the coracoid to the scapula. Norris and associates (Norris et al, 1987) evaluated 24 patients with failed Bristow repairs; only two had union of the transferred coracoid. Causes of failure included (1) residual subluxation and (2) osteoarthritis from screw or bone impingement or overtight repair. They pointed to the difficulty of reconstructing a shoulder after a failed Bristow procedure. Singer et al (Singer et al, 1995) conducted a 20-year follow-up study of the Bristow-Latarjet procedure; in spite of an average Constant-Murley score of 80 points there was radiographic evidence of degenerative joint disease in 71%. Ferlic and DiGiovine (Ferlic and DeGiovine, 1988) reported on 51 patients treated with the Bristow procedure. They had a 10% incidence of redislocation or subluxation and a 14% incidence of complications related to the screw. An additional surgical procedure was required in 14% of the patients. In a long-term follow up study of 79 shoulders, Banas and colleagues (Banas, Dalldorf, Sebastianelli et al, 1993) also reported complications necessitating reoperation in 14% of patients. Seventy-three percent of reoperations were for hardware removal secondary to persistent shoulder pain. There also appears to be a significant problem with recurrent subluxation after the Bristow procedure. (Ferlic and DeGiovine, 1988; Hovelius, Eriksson, Fredin et al, 1983; Mackenzie, 1984; McFie, 1976; Norris, Bigliani and Harris, 1987) Hill and coworkers (Hill et al, 1981) and MacKenzie (Mackenzie, 1980) noted failures to manage subluxation with this procedure. Schauder and Tullos (Schauder and Tullow, 1992) reported 85% good or excellent results with a modified Bristow procedure in 20 shoulders with a minimum 3-year follow-up. Interestingly, the authors attributed the success to healing of the Bankart lesion, since there were many instances in which the position of the transferred coracoid precluded it from containing the humeral head. The authors suggested that the 15% fair or poor results were secondary to persistent or recurrent subluxation. In 1989, Rockwood and Young (Rockwood and Young, 1989; Young and Rockwood, 1991), reported on 40 patients who had previously been treated with the Bristow procedure. They commented on the danger and the technical difficulty of these repairs. Thirty-one underwent subsequent reconstructive procedures: 10 had a capsular shift reconstruction, four required capsular release, four had total shoulder arthroplasty, one had an arthrodesis, and six had various combined procedures. The authors concluded the Bristow procedure was nonphysiologic and was associated with too many serious complications and recommended that it not be performed for routine anterior reconstruction of the shoulder.
      ass dr med sc Dragan Milić

Komentari na pitanje: #17064

    • Dr Srdja Bulatovic 16. 02. 2011.

      Outstanding explanation of the bristow, , , , should be posted on wikipeia!!!!

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