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Special
Article
Concept
of
healing
of
recurrent
shoulder
dislocation
夽
Donato
D’Angelo
a,b,†aServic¸odeOrtopedia,HospitalSantaTeresa,Petrópolis,RJ,Brazil
bFaculdadedeMedicinadePetrópolis,Petrópolis,RJ,Brazil
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Articlehistory:
Availableonline22July2014
Keywords:
Shoulderdislocation/surgery Shoulderjoint/surgery Jointinstability
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Thispaperpresentsthe mainsurgicaltechniquesappliedin thetreatment ofanterior recurrentshoulderdislocation,aimingtheachievementofthenormalityofarticulate move-ments.Thiswasobtainedbycombiningdistinctsurgicalprocedures,whichallowedthe recoveryofacompletefunctionalcapacityoftheshoulder,withoutjeopardizingthe nor-malityofmovement,somethingthathasnotbeenrecordedinthecaseofthetensesutures ofthesurgicalproceduresofPutti-Platt,Bankart,Latarjet,Dickson-O’Dellandothers.
Thecarefulreviewofthemethodsappliedsupportstheconclusionthatrecurrentshoulder dislocationcanbecured,sincecurehasbeenobtainedin97%ofthetreatedcases.However, somedegreeoflimitationintheshouldermovement hasbeenobservedinmostofthe treatedcases.
Ourmaingoalwastoachieveacompleteshoulderfunctionalrecovery,bytreating simul-taneouslyall ofthe anatomical–pathologicallesions,without considering the so-called essentiallesions.
Theperiodofpost-operatoryimmobilizationonlylastforthehealingofsoftparts;this takesplaceinapositionofneutralshoulderrotation,sincetheuseofvascularbonegraft eliminatestheneedforlongtimeimmobilization,duetotheshoulderstabilizationprovided byrigidfixationofthecoracoidattheglenoidedge,asintheLatarjet’stechnique.
Ourprocedure,usedsince1959,comprisestheassociationofseveraltechniques,which haspermittedshoulderhealingwithoutmovementlimitation.Thatwasbecauseofthe ten-sionreductioninthesuturesofthesubescapularis,capsule,andcoracobraquialismuscles. ©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Conceito
de
cura
da
luxac¸ão
recidivante
do
ombro
Palavras-chave:
Luxac¸ãodoombro/cirurgia Articulac¸ãodoombro/cirurgia Instabilidadearticular
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Opresentetrabalhoanalisaasprincipaistécnicascirúrgicasempregadasnotratamentoda luxac¸ãorecidivantedoombro(LRO),comoobjetivodeobteranormalidadedaamplitude dosmovimentosarticulareseassociardiferentestemposcirúrgicosnumúnico procedi-mentoparaobterumacapacidadefuncionalcompleta,semcomprometeranormalidade dosmovimentos,porcausadassuturastensasusadasnascirurgiasdePutti-Platt,Bankart, Latarjet,Dickson-O’Delleoutras.
夽
Pleasecitethisarticleas:D’AngeloD.Conceitodecuradaluxac¸ãorecidivantedoombro.RevBrasOrtop.2014;49:420–425.
† InMemoriam.
Apóscuidadosarevisãodessesmétodosemuso,chegamosàconclusãodequeaLROpode serconsideradaresolvidaquantoàporcentagemdecura(97%).Permanecem,noentanto, limitac¸õesdosmovimentosnagrandemaioriadoscasos,aceitasatécomonecessáriaspara evitarrecidivas.
Onossoobjetivocirúrgicovisaàobtenc¸ão deumarecuperac¸ãofuncional completa, atuarsimultaneamentesobreasváriaslesõesanatomopatológicaseabandonaraideiadas chamadas“lesõesessenciais”.
Aimobilizac¸ãodoombrooperadoseráfeitasomenteduranteacicatrizac¸ãodaspartes molesemrotac¸ãoneutra.Comousodeumenxertoósseopediculadodispensa-sequalquer tipodeimobilizac¸ãoprolongada,porcausadaestabilidadeobtidapelaosteossínteseda coracoidenorebordodaglenoide,comonatécnicadeLatarjet.
Essanossaconduta,empregadadesde1959,consiste,portanto,naassociac¸ãodasvárias técnicascomasquaisseobtêmacurasemlimitac¸ãodosmovimentos,porcausadareduc¸ão datensãonassuturasdacápsulaedosmúsculossubescapularecoracobraquialempregadas nastécnicasacima.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Asindicatedbythetitleofthisstudy,myintentionherewas todemonstrateourthinkingregardingtheconceptofcuring ofrecurrentshoulderdislocation(RSD),inthe lightof cur-rentknowledgeandpersonalexperience,morethansimply describingatreatmentmethodandanalyzingitsresults.Ialso aimedtoprovideanexplanationforthegeneraltendencyto accepthealingofRSDtobecessationofrecurrences,evenif jointfunctionhastobepartiallycompromisedtoachievethis. OurpositionistodefinetheconceptofcuringofRSDas heal-ingthatresultsnotonlyincessationofrecurrencesbutalso inrestitutionofnormalfunctioningoftheoperatedjoint.
Evolution
of
surgical
treatments
SurgicaltreatmentforRSDhasundergoneevolutionthatcan bedividedintofoursomewhatelasticperiods.
Thefirst,from1870to1910,wastheperiodduringwhich thefirstattemptstoimplementsurgicalsolutionsemerged. These attempts demonstrated that there was confusion regardingknowledgeofthispathologicalcondition,basedon erroneouspremises.Surgeons’attentionwasdirectedtoward thecapsule,anditslaxitywasinterpretedasthesolecauseof theinstability.Fromthisnotion,capsulorrhaphywas devel-oped,withitslackofsuccess.
The second period, from 1910 to 1940, was the era of descriptionofthetechniquesthatwouldmarkthepathtoward definitivecureofthe disease,which seemedtoleadtothe same objective: creation of an inelastic scar on the ante-riorfaceofthe shoulder.Thus,theoperativetechniquesof Hybbinette,1 Eden,2 Oudard,3 Putti-Platt,4 Gallie,5 Bankart,6
Nicola,7Magnuson,8etc.emerged.
The third period was between 1940 and 1950, when it became possible to gather together the worldwide experi-ence for judgment and analysis. This would confirm the successoftheabovetechniques,andshowthedistribution ofpreferencesaccordingtogeographicalzonesofinfluenceof languages,schoolsorascendance.
1950markedthestartoftheperiodinwhichsimplification ofthesurgerywassought.Thisgoalisacceptableasageneral principleofprogressinanyfield:resolutionofdifficultiesof atechnicalnature,presentationofimprovedresultsandeven simplificationofthesurgicalprocedure.
Overthe course oftime, there wasslow but sequential developmentofstudiesonRSD.Studieswereconductedand theirconclusionswerecompareduntilaproperlygrounded body ofknowledgehad beenattained. Adefinedbasiswas thusformed,fromwhichnewattemptswouldstart,with pro-cedures that were identified as valid contributions toward improvements, in relation to interpretation either of the events already observed or, especially, of details with the capacitytoimprovethefunctionalresultsfromthetreatment. Myparticipationinthissubjectdatesbacktothestartof myactivitieswithinthisspecialtyandwasmarkedby con-tact withthetechniqueofNicola,7 which atthat timewas
receivedwithgreatenthusiasm,sinceitseemedtoaddressa commonanxietyamongthespecialists.Thisanxietyseemsto ustobedefinedasthesearchforsimplicity,incontrastwith thetechniquesofBankart6andPutti-Platt,4whicharealso
effi-cientbutdemandgreaterdexterityamongsurgeons,giventhe complexityoftheseprocedures.Thiscomplexitycomesnot onlyfromtheirrequirementfortheoperationtobeoflonger duration,butalsofromrepercussionsoftherisksofprolonged generalanesthesia.
During the time that I was at the Rizzoli Institute, in Bologna,asabursary-holderin1948and1949,Ihadthe sat-isfaction ofassisting Professor Delitala9 around ten times,
to carryout histechnique. Asknown from its details,this was also introduced as an attempt to simplify Bankart’s technique,6comprisingfixationofthecapsuleontheglenoid
rim.
AftermyreturnfromtheRizzoliInstitute,myintentionwas toputintopracticetheexperiencewithDalitala’stechnique6
thatIhadacquired,althoughIcontinuedtofeelthatitwas complex,albeitlesssothanearliertechniques.Thus,itstill didnotreachourideal.
onknowledgeofthepathologicalanatomyofRSD,wewere ledtotheobservationthatratherthanconsistingofasingle essentiallesion,therewereseveralcoexistinglesions.
Thus,thetechniquetobeusedintreatingashoulderthat repeatedly dislocates should be one that reconstitutes the mainlesionsobserved,toasgreatanextentaspossible.This wouldtheoreticallypreventthedislocationfromrecurring.
Currentknowledgeshowsthatcapsule-ligamentlesions, bonelesions at the glenoid rim and muscle lesions mani-festedmainlybyatrophyanddistensionofthesubscapularis existconcomitantly.Thus,atechniquethatcouldbecalled idealwouldbeonethataimedtocorrectalloftheseinjured elements.
Sincethemajorityofauthorshadbasedtheirworkonthe notionthat there was oneessential lesion and hence had proposeddifferenttechniquesdirectedtowardtreatingthese lesions,theidealaidoutabovenecessarilyledtoward combin-ingthesedifferentapproachesandcreatingasingleoperation fortreatingalmostallthelesions.Thisdifferedfromthefew combinedtechniquesthathadalreadybeenputforward,given thatthesewerealllimitedtobringinginonlyoneadditional approach,tojointogetherwiththemainapproach.Our rea-soningwasbasedontwomainprinciples:
1. Knowledgeoftheanatomopathologicallesionsand there-foreofthephysiopathologyoftherecurrences,whichmade it possible to conceive of treatment for them that had theaimofachievingtrue“anatomicalrestitution”,which wouldconsequentlybefunctional.
2. Use ofcertain technical details and general orthopedic principlesthatcouldcontributesignificantlytowardthis completefunctionalrecovery.
Withregardtothefirstprinciple,thehistoricalevolutionof knowledgeofthepathologicalanatomyandphysiopathology ofRSDcoincidedwiththeappearanceofaseriesoftechniques thatbecamethemainonesamongthe200orsothatwere alreadyknown.Thesetechniquesbecameconsolidatedand establishedthrough years ofexperience around theworld, withtheinterestingfactthateachofthemformedthebasis fortreatingone oftheanatomopathologicallesions,which theauthorofthattechniqueconsideredtobethe“essential lesion”forexplainingtherecurrenceofthedislocation.
Theterm“essentiallesion”firstappearedinthestudyby Bankart,6whodescribedthisasdeinsertionofthelabrumof
therim oftheglenoid bone,which formedacleftthrough whichthehumeralheadwouldstarttodislocateagain.This termbecamegeneralizedafteritsauthorthoughtthathehad clarifiedthewhilecomplexityoftheproblem.
Capsulelesions had already been described, and hence capsulorrhaphywasthefirsttechniquefortreatingRSDtobe published.
Bone lesions of the glenoid rim had likewise been described.From this,pre-glenoidbonegraftingemerged, as seeninthetechniquesofEden2andHybbinette.1
Followingthis,musclelesionsweredescribed,particularly thoseofthesubscapularismuscle,asshownbyMagnuson.8
Thisauthor’stechniqueisstillused.
Posteriorexternaldepressionofthehumeralhead,whichis presentinalmostallcasesofRSD,wasalsotakentomeritthe
nameofprincipallesion,asdescribedbyPalmerandWiden.10
Thiswasbasedonhowthisdepressionfittedintotheanterior rimoftheglenoid.
Throughphylogeneticandontogeneticanalyses,Dickson andO’Dell11wereevenledtoproposeRSDtreatmentbymeans
ofrestitutionoftheinternalrotatorfunctionofthepectoralis minor, which had been lost through the evolution of the species,withconsequentlyunbalancingofthejointsuchthat theexternalrotatorswerefavored.
Summarizing the points laid out above, the following injuries were described asessential or principal lesionsby theirdiscoverers,andaspecifictechniquewasproposedfor treatingeachofthem:
1. Capsule-ligamentinjury,withlabrallesion. 2. Injurytotherimoftheglenoidbone.
3. Impaction injury of the posterior external part of the humeralhead.
4. Injurytothesubscapularismuscle.
5. Factorsthatpredisposedtowardjointinstability,ofa phylo-geneticorontogeneticnature,duetothepectoralisminor.
Nonetheless, withthe current knowledge regarding the pathologicalanatomyofRSD,amultiplicityoflesionsis recog-nized.Foreachofthese,asolutionhasbeenproposed,which hasbeenacceptedandconsolidatedthroughlongexperience. Implementationofatreatmentmethodaimedtoward cor-rectingonlyoneofthemultiplelesionspresentwouldrequire thismethodtoberesponsibleforsuppressingtheother recur-rencefactors,probablyatthecostofreducingjointmobility. Thislimitationwouldbecomeaformof“stabilizingfactor”, whichwouldavoiddislocationbypreventingaseriesof func-tionaldeficitsfrombeingtriggered,whichwouldhavebeen consequencesofthemultipleanatomopathologicallesions.
These deductions are based on the high percentage of shouldermovementlimitationsfoundinthedetailed statis-ticsonthemethodsmostused.
Some authors(such as Magnuson,8 DePalma,12
Watson-Jones13 andseveralothers) concededthattheselimitations
werenecessaryinordertopromotethecure.Othersadmitted thattheydecidednottocountlimitationsoflessthan20◦in
analyzingtheircases,ifthepatientsdidnotcomplainabout thisdegreeoflimitation.Inthismanner,aconceptofcureat thecostofpartiallossofjointmobilitywasestablished.
Taking into consideration the high percentage of such injuriesamongathletesandtheiryoungage,varyingdegrees oflimitationsinexternalrotationandabductionmovements would definitivelyprevent athletesfrom doing their sports activities.
technique brings together known methods, chosen from amongthosethatfavorrecoveryasearlyaspossible,suchas bydoingawaywithprolongedimmobilization.Moreover,we believethatpostoperativemeasuresrelatingtothetype, posi-tionandduration ofimmobilizationmaygiverisetobetter results.
Wewillnowmoreobjectivelyanalyzetheimportantdetails ofthereasoningpresented.Mostofthesurgicaltechniques usedfortreatingRSDare basedoncorrectionofoneofthe multipleanatomopathologicallesionsthatmakeuptheset ofcausesofrecurrences.Whereasthesetechniquespresent favorableresultsinrelationtorecurrences, fullrecoveryof joint movements is incomplete in a significant number of cases,inallthestatistics,tothepointthatthishasbecome ageneralconcern.Since1960,ourpreferencehasbeen for usingatechniquethatsought,inasingleprocedure,tocorrect multipleanatomopathologicallesionsandactsimultaneously oncapsule,muscleandbonelesions.Tothesedetailsofthe surgicalprocedures,othersarecombinedsoastoenableas short a duration of immobilization as possible, in a func-tionalposition,inthesamewayasdoneinrelationtoother jointsingeneral,therebyfacilitatingrecoveryofthese move-mentswithoutcompromisingthestabilizingactiondesired. Theprinciplethatwestartfromisthateachstructuretreated allowsproximalexternalrotationtothemidpointbetweenthe tworotations,sothatitcanbethusmobilized,withtheaim thattherecoveryphaseimmediatelyafterremovalofthe plas-tercastalreadystartswithhalfofthegaininrotaryexcursion. Wewillexaminetheinjuredanatomicalelementsandthe waysofrestoringthemandwillidentifythefactorsthatlimit function.
Injuriestothesubscapularis,whichisanimportantmuscle forstabilizingthejoint,aremanifestedmainlyintheexternal rotationandabductionpositions.Whenthismuscleisplaced undertension,theseinjuriesaretransformedinto dynamic blockingofthepassageofthehumeralhead.However, heal-ing ofinjuriesto the musclefibers, toformfibrous tissue, graduallycauses lossof elasticity and contractilecapacity, whichresultsinatrophyandconsequentlossofthedynamic containment role. Thetechnique aimed atrecovering this functioninvolvesreimplantationofthehumeralinsertionof thismuscle, withredirection ofits obliquepositioning toa horizontalposition.Thisdetailresultsinincreasedstabilizing function.Inourview,thistransferoftheinsertionofthe sub-scapularisfrominsidetooutsidethebicipitaltracknotonly advantageouslydirectsitsfibers,butalsoincreasesitsangleof insertioninthehumeralneck.Inturn,thisincreasesthe inter-nalrotationpowerofthismuscle.Thisbenefitsthedynamics oftheshoulder,sincetheincreaseininternalrotationstrength partiallyrebalancesthecomparisonwiththeexternalrotary forces,whichareanatomicallyfavoredbythegreater inser-tionanglesoftheirmuscles. Thisfunctional role,which in ourviewisimportant,hasnotpreviouslybeenattributedto thesubscapularisatitsnewinsertion.Itisimportantnever tosurgicallyinterruptthecontinuityofitsfibersand trans-ferthismuscle,whichhasbeenstretchedthroughcreation ofafibroperiosticflap,whendissectingitstartingatits inser-tioninthelessertuberosity.Alltheknowntechniquesthatare basedsolelyontransferringtheinsertionofthesubscapularis externallytothebicipitaltracksdeliberatelyaimtoreducethe
externalrotation oftheshoulderby20◦ to50◦
(Magnuson-Stack,8 DePalma,12 Palumbo and Quirin,14 McLaughlin and
Cavallaro15).
Rupturingofthecapsuleorextractionofitsglenoid inser-tionproducesaretraction,suchthatitssutureisplacedunder tension.Putti-Platt,4Brav16andMatti,17alongsidetheirgood
results,notedthatexternalrotationhadapermanent limi-tation.ColonnaandRalston18observedthata15◦reduction
in external rotation of the shoulder always remained and thoughtthatthegoodresultsmighthaveresultedfromthis partialblockageofmovements,sincethis wouldavoid slip-pageofthedeformedheadovertheglenoidrim,whichcauses thedislocation.
Inaseriesof49cases,Mackinnon19foundthat45hada
limitationof15◦ormoreintheirexternalrotationmovements.
Theonlythreecasesinwhichtherewasfullrecoveryof move-mentsweretheonesthatpresent recurrence.Inaseriesof 36cases,MerleD’Aubignéetal.20foundthateightpresented
a limitationofmorethan 30◦. Sandowand Jannes21 found
that100%oftheir90casesoperatedhadlimitationsof exter-nalrotation.Fromanalysisonthestatisticspublishedonthe techniqueofPutti-Platt,4therewasadefinitivelimitationof
atleast15◦inexternalrotationmovements.
Techniquesthatactonthecapsuleorinwhichitisopened arecarriedoutinadirectionparalleltotheanterioredgeof theglenoid.Itisknownthatthedurationoftheoperationfor suturingthecapsuleattheglenoidrimmaycausemovement limitations,particularlywithregardtoexternalrotation.
Weprefertoopenandsuturethecapsuleinahorizontal directionandtocorrectitslaxitywithoutshorteningits lon-gitudinalfibers,whichmaintainstheelasticityofthecapsule duringabductionandexternalrotation.Suturingthecapsule inahorizontalincision enablesclosureinthecraniocaudal direction,whichcorrectsitslaxitywithoutshorteningit.
Techniques thatactonbonelesions arebased onusing bonegraftstocorrectthe wearontheanteriorbonerimof the glenoid, so asto impede fitting ofthe posterior exter-naldepressionduetoexpansionofthewidthoftheglenoid cavity. Techniques that use a free bone graft compromise jointfunctionduetodelayedconsolidation.Introductionof thepedunculatedbonegraftofLatarjet,22fixedbymeansof
osteosynthesis,provided the possibilityof rapid consolida-tionanddidawaywithjointimmobilization,sinceitnotonly increasedtheareaoftheglenoidcavitybutalsoimpeded fit-tingoftheposteriorexternaldepression.
Webelievethatit isextremelyimportanttoreconstruct theglenoidbonerim,whichhasanundeniablerolein shoul-der instability. Pedunculate bone grafts not only have the mechanicalrequisitesfortheirintendedrole,butalso elim-inateproblemsofabiologicalnature,becauseoftherobust pedicle,whichishighlyvascularizedbythecoracobrachialis muscle,therebyprovidingassuredrapidconsolidation. Fixa-tionofthisgraft,whichispreparedanddoneusingaspongy screw,doesawaywithimmobilizationandallowsfunctional recoverytobestartedearlyon.
ContrarytoLatarjet,22weadoptedthepracticeofopening
rigidity and doaway with theuse ofexternal immobiliza-tion.
Regarding postoperative immobilization, we adopted an intermediatepositionbetweeninternalandexternalrotation andfollowedaprinciplethatisusedforalljoints,soasto facil-itateitsrecoveryandthusavoidcapsuleandscarretractions andalsomuscleretraction.Whentheshoulderisimmobilized intheVelpeauposition,itiskeptininternalrotation,andthis becomestransformedintoafactorthatlimitsexternal rota-tionand requiressignificantlossoftimefromthe recovery phase.Theintermediatepositionbetweenthetwoextremes ofrotationmovementistestedduringthesurgicalprocedure beforestartingtoclosethewound.Thepatientisimmobilized inathoracobrachialbraceforashorttime,solelywiththeaim ofprotectingthesoft-tissuesutureswhiletheyare healing, whichtakes 12–14days. Afterthisperiod, the painful sen-sationwillhavediminishedandmovementcanberesumed immediatelyafterremovaloftheplastercast.
Sincewe soughtto obtain abone graft that wasas big aspossible,weperformosteotomy onthe coracoid apoph-ysisatits base,which would implylosing theinsertion of thepectoralisminorandabandoningitinthedeepplanesof theoperativewound.Inthiscase,weprefertomakeuseof itandrestoreitsprimitivefunction.Thetendonofthe pec-toralisminorisdissectedfromtheupperfaceofthecoracoid apophysisanditsfibroperiosticexpansion,extendingasfar asitslateraledge,isconserved.Itisusedtoprovide stretch-ingofthis muscle,therebyfacilitatingitsinsertionintothe greatertuberosityofthehumerusandthusavoidingpossible limitation ofexternalrotation. We use this surgical proce-dureproposedbyDicksonandO’Dell11inordertoaddfurther
internalrotaryforce,whichprotectsthejointagainstthe ten-dencytodislocateandpartiallyrestoresthebalanceofforces thatwaslostduringtheevolutionaryprocessthatthe shoul-derunderwent,asdescribedinwell-knownphylogeneticand ontogeneticstudies(Fig.1).
This transferof the pectoralis minor sometimesshows greatertensioninthetransferredmuscle,whichisobserved whenit issought totestplacement ofthe limbinneutral
Fig.1–OriginaltechniqueofDicksonandO’Dell(transfer ofthepectoralisminorfromthecoracoidprocesstothe greatertuberosity).
rotation for immobilization. In this case, we proceedwith stretching ofthe aponeurosisofthis muscle,bysectioning only the superficial inelasticfibrous parts and sparing the integrity of the elastic muscle fibers, which yield without breakage.
Conclusions
1. Apedunculatedbonegraft,whichisusedtoimprovejoint stability,expandsthesurfaceoftheglenoid,inaccordance with Latarjet’stechnique,and atthe same time creates an obstacle that impedes sliding of the humeral head, sinceitreconstitutesthebonerimoftheinjuredglenoid andexpandstheareaoftheglenoidcavity,whichmaybe anatomicallydeficientordeficientasaconsequenceofthe repeatedtraumaofdislocation.
2. TheBristowtechnique,whichistakeninEnglish-speaking countriestobesimilartoLatarjet’stechnique,isdifferent inourview.Thedifferenceliesinadetailthatwejudgeto beimportant:transfixationofthesubscapularmuscleby thecoracoid,whichcausesblockageofextensiveslidingof thismuscleandimpedescompleteexternalrotation.These featuresarenotseenwithLatarjet’stechnique.22
3. Useofcoracoidgraftsissuperiortousingcapsulorrhaphy, intermsofrecoveryofmobilityandrecurrences.The recur-rencerateis2.5%,versus11.5%fromBankart’soperation, accordingtoWalchetal.23
4. Latarjet’s technique presented a recurrence rate of 3% in Gazielly’s series24 of 89 cases, and no statistically
significant correlation wasfound betweenpostoperative arthrosis and age, orbetween arthrosis andthe typeof sportpracticed.
5. Inareviewseriesin2001,coveringmorethan15years, Hov-eliusetal.25confirmedthatthepresenceofabonegraftdid
notcausemorearthrosisthanseeninBankart’sprocedure. 6. In 1957, based on embryological and phylogenetic con-cepts, Dicksonand O’Dell11 publisheda technique
com-prisingtransferofthepectoralisminorfromitscoracoid insertiontothegreatertuberosityofthehumerus,which wealsobegantocombineinourcases.
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13.Watson-JonesR.Noteonrecurrentdislocationofthe shoulderjoint;superiorapproachcausingtheonlyfailurein 52operationsforrepairofthelabrumandcapsule.JBone JointSurgBr.1948;30(1):49–52.
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