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 bone-block procedure and the arthroscopic Bankart repair while eliminating the potential disadvantages of each. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Delayed diagnosis of inferior cervical spine injury]. / Délai diagnostique dans les lésions traumatiques du rachis cervical inférieur.

PURPOSE OF THE STUDY: According to data in the literature, traumatic injury of the inferior cervical spine is not recognized in 4.5 to 33% of victims. The purpose of our study was to evaluate the rate of delayed diagnosis, search for causes, and propose a diagnostic approach. MATERIAL AND METHODS: This prospective study included 284 patients recruited by eleven referral centers between November 1999 and March 2001. Each participating center completed a data chart and classified lesions. Exclusion criteria were whiplash without neurological disorder and without imaging anomaly, spinal ankylosis, and trauma more than three weeks before the first examination. RESULTS: Among the 284 patients included, 240 had a unique lesion of the inferior cervical spine, 44 had multiple injuries. In all, 338 spinal lesions were recorded. There were 35 patients with multiple trauma injuries and 95 patients with spinal cord injuries. Time to diagnosis was less than 24 hours for 211 patients (74%), one day to one week for 38 patients (14%), and more than one week for 35 patients (12%). Defective management was noted in 13% of the cases. Late diagnosis was considered to have had a prejudicial effect in nine patients (3%). There was no correlation between time to diagnosis and type of lesion, level of lesion, or presence of multiple injuries. DISCUSSION: Late diagnosis of inferior cervical spine injury can be an inevitable result of the context. This is particularly true for patients with multiple injuries or patients with purely discal or ligament injuries whose first manifestations occur late after the trauma. Beyond these specific situations, there is no logical explanation for late diagnosis other than insufficient diagnostic management. Spinal injury should always be suspected in trauma victims and the initial neurological status must be noted. If the subject is conscious, plain x-rays should be obtained in the event of pain in the cervical spine. A computed tomography is the exploration of choice. Dynamic views should be performed in all cases to search for pure ligament injury. The correct time for such explorations can only be determined on an individual basis. If the patient is unconscious, standard procedure includes x-ray of the cervical spine, and computed tomography of the skull-spine junction and the cervico-thoracic spine. Widespread systematic use of spiral and multiple array computed tomography should limit the number of late diagnoses. CONCLUSION: Late diagnosis of inferior cervical spine injury is probably not uncommon. Improved management can be achieved through better medical awareness, better knowledge of cervical spine injuries, and routine imaging in application of the rule of prudence.