Pressure between the humeral head and the subscapularis tendon after the modified Boytchev procedure

Modified Boytchev procedure for recurrent anterior dislocation of shoulder

PURPOSE. To evaluate results of the modified Boytchev procedure for recurrent anterior dislocation of the shoulder in 60 patients. METHODS. Medical records of 45 men and 15 women aged 20 to 44 years who underwent the modified Boytchev procedure for recurrent anterior dislocation of the right (n=44) and left (n=16) shoulders were reviewed. The mean number of dislocations was 14. Outcome was evaluated using the Burkhead and Rockwood criteria. RESULTS. The mean follow-up period was 56 months. Outcome was excellent in 32 patients, good in 21, and fair in 7. None had poor outcome. The mean external rotation deficit at 0º and 90º of abduction improved from 14º to 7º (p=0.04) and 18º to 7º (p=0.03), respectively. Two patients had fragmentation of the coracoid process, which was fixed with non-absorbable suture. Two patients had traction injury to the musculocutaneous nerve, which recovered after 6 months. One patient had recurrent dislocation that ruled out the chance of revision surgery. CONCLUSION. The modified Boytchev procedure is a viable and simple treatment for recurrent anterior shoulder dislocation.

Recurrent shoulder dislocations secondary to coracoid process fracture: a case report

Coracoid process fracture is easily missed in recurrent anterior shoulder dislocation. We report one such case in a 48-year-old man. Radiology revealed the Bankart lesion and the Hill-Sachs lesion only; the coracoid process fracture was discovered intra-operatively. The anatomy of the shoulder was restored by fixing the fragment to its scapular remnant with a 4-mm cannulated cancellous screw. The tip and the proximal fragment were reamed before inserting the screw. This fragment was routed with attached short head of biceps and coracobrachialis through the lower one third of the subscapularis, before homing it and fixing it to the proximal coracoid fragment. This extraarticular repair resulted in less stiffness than any intra-articular procedure. At the 2-year follow-up, the patient had had no further shoulder dislocation.

Modified Boytchev procedure for treatment of recurrent anterior dislocation of shoulder

BACKGROUND

More than 200 different operations have been described for the treatment of recurrent anterior dislocation of shoulder. The Modified Boytchev procedure employs rerouting of the detached tip of coracoid process with its attached conjoined tendon (short head of biceps and coracobrachialis) deep to subscapularis and reattaches to its anatomical location. We conducted a study on evaluation of long-term effect of modified Boytchev procedure and to compare our results with other studies published in literature.

MATERIALS AND METHODS

Since June 2002, modified Boytchev procedure was performed on 48 patients, who presented with recurrent anterior dislocation. 45 were men and 3 were women and were in the age group of 18-40 years (mean 27.83±4.95 years). Forty patients were affected on the dominant side and rest on the non-dominant side. The mean number of dislocations in these patients was 18.22±12.08. The mean followup period was 58.13±19.06 months (range 18-96 months). The patients were evaluated by visual analogue score, modified American Shoulder and Elbow Surgeon's Score (ASES), and Single Assessment Numeric Evaluation (SANE) score at the last followup.

RESULTS

All the patients regained almost preoperative range of forward flexion at the last followup. In the preoperative period the mean external rotation deficit at 0° and at 90° of abduction was 13.22°±5.16° and 18.06°±6.50°, respectively. At the last followup, the mean external rotation deficit at 0° and at 90° of abduction was 8.06°±2.47° and 8.95°±2.07°, respectively. This improvement in external rotation deficit was statistically significant (P<.05). Preoperative scores were compared with the most recent followup scores for all variables with use of a paired t test. All patients had significant improvement in visual analogue score, modified American Shoulder and Elbow Surgeon's Score (ASES), and Single Assessment Numeric Evaluation (SANE) score at the last followup. Four of the patients developed superficial infection which got resolved after treating with antibiotics, and two of the patients developed transient musculocutaneous nerve paresis. There was no radiological evidence of loosening and migration of coracoid screw or any glenohumeral arthritis on subsequent followup of skiagrams in any of our patients.

CONCLUSION

Modified Boytchev procedure is an efficacious and technically simple procedure to treat recurrent anterior dislocation of shoulder.

Stabilizing effect of the transferred conjoined tendon on shoulder stability

The modified Boytchev procedure, i.e., rerouting of the coracoid process with its attached conjoined tendon (short head of biceps and coracobrachialis) deep to the subscapularis and reattachment to its anatomical location, has been advocated for recurrent anterior glenohumeral instability with controversial clinical outcomes. We aimed to investigate the dynamic contribution of the conjoined tendon in situ or transferred to the glenohumeral articulation in stable and unstable shoulders. Eight cadaveric shoulders were tested with the arm in 90 degrees abduction and 90 degrees external rotation. A constant 1.5 kg anterior translation force was applied to the proximal humerus, combined with 0, 1.5, 3.0 kg of load applied to the conjoined tendon sequentially. Anterior displacement of the humeral head relative to the scapula was recorded before and after an imitation Bankart lesion was created, and after treated with the modified Boytchev procedure for the Bankart lesion. Application of load to the conjoined tendon significantly reduced anterior displacement of the humeral head either with the capsule intact or with Bankart lesion simulated. The most significant decrease of the anterior displacement occurred when the conjoined tendon was transferred beneath the subscapularis. Our findings show that the conjoined tendon per se has a stabilizing effect on stable and unstable shoulders and therefore provide scientific support for the treatment of recurrent shoulder instability using the modified Boytchev procedure.