Putti-Platt Procedure Technique

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]