Putti-Platt Procedure

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] :

• Shortening of the stretched subscapularis
• Creation of a double layer of muscle and capsule in front of the joint, forming a firm fibrous buttress
• 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

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.

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.

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.

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]

Anesthesia

General anesthesia is used for this procedure.

Positioning

The patient is positioned supine in a beach-chair position. The room should be arranged so as to allow the arm to be fully abducted and externally rotated throughout the procedure.

The technical description below is directly based on the original Osmond-Clarke paper.[6] In general, the subscapularis is approached through a deltopectoral interval. The subscapularis is divided at the musculotendinous junction. The distal portion is attached to the glenoid margin and the proximal portion is attached to the medial aspect of the bicipital groove.

Anterior approach

Approach anteriorly from the outer one third of the clavicle, extending downward for 9 cm.

Open the groove between the deltoid and pectoralis major muscle widely. Divide the clavicular portion of the deltoid muscle 1 cm distal to the bone (not subperiosteally). Ligate the cephalic vein. Identify and tie troublesome vessels in the subacromial region that cross the upper limit of the deltopectoral groove.

Expose the coracoid process, and free the conjoint tendon of the coracobrachialis and the short head of the biceps. Divide the upper 2.5 cm of the margin of the pectoralis major tendon. Open the interval between the conjoint tendon and the pectoralis minor, taking care to avoid damage to the musculocutaneous nerve, its branches, or the main axillary neurovascular bundle (see the image below).

Retract the conjoint tendon downward by a stitch, but not too vigorously (see the image below).

Divide the tendon of the subscapularis. Its upper and lower margins are readily identified by rotating the arm outwards. The lower margin is conspicuous because three veins that accompany the anterior humeral circumflex artery run below it. Divide and ligate these vessels (see the image below).

Pass a blunt spike beneath the tendon from above or below, and divide the tendon 2.5 cm from its insertion. The capsule, which is usually adherent to the deep surface of the tendon near its insertion, is frequently opened.

Retract the subscapularis medially by 3 or 4 stitches inserted through it. Deliberately open the capsule if it has not already been opened. Examine the glenoid margin and the humeral head for defects.

The distal stump of the subscapularis tendon is attached to the most convenient soft-tissue structure along the anterior rim of the glenoid cavity, which may be the labrum itself. It may also be placed to the deep surface of the stripped capsule and the subscapularis muscle (see the image below).

Raw the anterior surface of the neck of the scapula so that the sutured tendon-capsule adheres to it. Insert and tie four sutures while the thumb is internally rotated. Draw the medial portion of the capsule outward to overlap the tendon of the subscapularis, giving a “double-breasted coat” effect. Provide an "overcoat” by suturing the muscle belly of the subscapularis to the scarified tendinous cuff, which overlies the greater tuberosity, or the bicipital groove (see the image below).

Rotating the arm outward to the neutral position should still be possible.

Reattach the conjoint tendon to the coracoid and the deltoid to the clavicle and pectoralis major; then close the wound.

After treatment, bandage the arm to the trunk with the forearm across the chest and the fingers to the opposite shoulder. Maintain this internal rotation for 3-4 weeks.

Axillary approach

An additional approach has been described by Zenni.[17]  It is an axillary approach with the advantages of an adequate exposure with minimal blood loss and a more desirable scar. The steps are as follows:

• Place the patient supine with a sandbag or towel under the scapula
• Place the arm in 90º and adducted to the side
• Extend the skin incision anteriorly 2.5 cm above the axillary crease and 10 cm posteroinferiorly
• With the arm fully abducted, undermine the skin edges and identify the pectoralis major
• Use a Kelly clamp to pass beneath the pectoralis major and identify the cephalic vein
• Cut the tendon of the pectoralis major at its musculotendinous portion, and retract it into the edges of the wound.
• Partially remove the coracobrachialis from its attachment at the coracoid process
• Identify the subscapularis; identify and ligate one artery and two veins inferiorly
• Cut a 4-cm flap of the subscapularis at the humeral attachment, and raise this lateral flap to expose the shoulder joint
• Attach the lateral subscapularis flap to the glenoid labrum
• Imbricate the medial portion of the subscapularis flap over the lateral flap
• Repair the coracobrachialis and the pectoralis major

Surgery should immediately be followed by immobilization in adduction and internal rotation.[6, 1]  Immobilization time ranges from 3 to 6 weeks.[6, 3]  After immobilization, rehabilitation is necessary and progresses with gradual voluntary exercises to increase range of motion and strength over the next 2 months.[13]  Rowe noted that by 1 year after the procedure, most patients have regained functional range of motion and a strong shoulder.[3]

In 1976, Morrey and Janes cited the following four reasons for surgical failure[10] :

• Inappropriate surgical procedure
• Technical inadequacy
• Insufficient duration of postoperative immobilization
• Overly intense athletic activity following the repair

They also identified four patient characteristics that predosposed to surgical failure[10] :

• Youth
• Bilaterality of symptoms
• Positive family history
• Posterior instability

Hawkins and Angelo noted the following as complications[18] :

• Persistent pain
• Recurrent subluxation or dislocation
• Residual weakness of the shoulder
• Paresthesias of the musculocutaneous nerve
• Infection

In 1988, one study reported that patients present again with pain an average of 13.2 years after having undergone the Putti-Platt procedure.[9] This agrees with the finding by Hawkins and Hawkins that patients develop pain at an average of 13 years after the Putti-Platt procedure.[9]

Kiss et al also noted an incidence of osteoarthritis following the Putti-Platt procedure, with the external rotation at the side of the body being the best predictor of osteoarthritis.[12] Rozing and van der Zwaag found the best predictors of osteoarthritis to be duration of follow-up, range of motion, and pain score.[19] Samilson and Prieto supported that the limitation of external rotation could be correlated with the severity of the arthrosis.[20]

Richards et al reported five cases of brachial plexus palsy following a Putti-Platt repair and identified structural damage to the plexus in each case that was explored.[21] Two cases of brachial plexus injury following a Putti-Platt procedure were reported by Kline and Judice as well.[22]

Ahmad et al addressed that an anterior repair such as the Putti-Platt procedure would alter the loading of the glenohumeral joint.[23] This alteration in loading increases the loading along the posterior aspect of the joint, with the potential to create an abnormal posteroinferior humeral head subluxation. This results in increased wear along the posterior aspect of the glenoid, likely leading to secondary osteoarthritis. This was identified in multiple long-term follow-up studies.[12, 19, 20]

Kiss et al recommended that if the Putti-Platt repair is to be done, the patient should have at least 30º of external rotation at the completion of the surgical repair.[12]