Background
The Putti-Platt procedure is a historically significant nonanatomic procedure for shoulder instability with promising initial outcomes but disappointing long-term follow-up. The procedure is based on the concept of tightening the anterior capsule and subscapularis with a subsequent accepted loss of external rotation in order to increase the stability of the shoulder. It has been described as a "vest over pants" approach and a "double-breasted" technique. [1, 2, 3, 4, 5]
The Putti-Platt capsulorrhaphy was first published by Osmond-Clarke in February 1948. [6] Platt first performed this operation in Ancoats Hospital on November 13, 1925. He divided the subscapularis tendon, attaching the distal end to the glenoid margin and the proximal end to the anterior capsule. [6] Putti performed this same operation, independently from Platt, since 1923, and the technique was likely also performed by Putti’s teacher Codivilla.
Brav found the specific advantages of the procedure to be its technical simplicity and applicability regardless of the etiology of instability. [7] He also found its specific disadvantage to be the loss of external rotation. [7] This loss of external rotation and subsequent surgical scarring of the anterior capsule constitute the mechanism of increased stability for the anterior shoulder.
Symeonides described the following three reasons for the effectiveness of the procedure [8] :
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Shortening of the stretched subscapularis
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Creation of a double layer of muscle and capsule in front of the joint, forming a firm fibrous buttress
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The medial part of the subscapularis is sutured over the lateral one, allowing the wider part of the subscapularis to prevent anterior dislocation of the humeral head in abduction and lateral rotation
Indications
This procedure was originally indicated for patients with unidirectional anterior instability of the shoulder. Evaluation of outcomes and biomechanics suggests that this procedure is rarely indicated.
Contraindications
It is important to exclude voluntary, posterior, and multidirectional instability as diagnoses prior to this procedure. A Putti-Platt repair addresses only anterior instability. [5] Glenohumeral arthritis is also a contraindication. Any restriction in external rotation preoperatively is exacerbated following this type of repair.
Technical Considerations
Because of the loss of external rotation, the applicability of the procedure is limited. Athletes and laborers requiring a normal range of motion in external rotation are limited with this procedure. This procedure also limits use for throwers and overhead athletes.
Adequate padding is imperative in prevention of intraoperative complications. Also, identification of the neurovascular structures is essential in the approach to the subscapularis.
Outcomes
Following surgical stabilization of the anterior shoulder, the main outcomes measured would be a recurrence of instability and the significance of the loss of external rotation.
In 1976, Morrey and Janes reported an 11% recurrence of dislocation following surgical repair. [9, 10] A 10-year follow-up was completed by Salomonsson et al and determined that of the 30 patients who returned the questionnaire, 15 had had an episode of instability, defined either as a redislocation or a subluxation. [11]
Multiple papers have reported recurrence rates in the range of 1.2-20%. [9] Kiss et al published their redislocation rate of 9% in 1998 after following 90 primary Putti-Platt procedures for an average of 9 years. [12] They also noted an impact of age on their outcomes with a redislocation rate of 12% in patients younger than 30 years and a 6% incidence in patients older than 30 years at the time of surgery.
In the evaluation of the loss of external rotation, the range reported is 6-29º. [9, 13] Zaffagnini also reported a correlation between the degree of arthrosis, range of motion limitation, and strength reduction. [14] A spectrum of loss of function was reported in relation to the loss of external rotation, from no limitations in any activity including overhead and throwing athletes to difficulties with activities of daily living.
Leach et al noted that the loss of external rotation is insignificant in relation to the stability gained and therefore no major disadvantage to limiting external rotation exists. [15] Zaffagnini et al saw limitations in function to be related to the presence of pain and arthrosis. [14] After studying the results of this procedure in 51 patients, Iordens et al reported high patient satisfaction and excellent results, with only limited range of motion restrictions. [16]
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Division of pectoralis major.
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Retraction of conjoint tendon.
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Division of subscapularis.
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Attachment of distal portion of subscapularis to glenoid rim.
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Attachment of proximal subscapularis to medial bicipital groove.
