Putti-Platt Procedure

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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]}

The Putti-Platt capsulorrhaphy was first published by Osmond-Clarke in February 1948. ^[5]  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. ^[5]  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. ^[6]  He also found its specific disadvantage to be the loss of external rotation. ^[6]  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 ^[7] :

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. 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. ^{[8, 9]}  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. ^[10]

Multiple papers have reported recurrence rates in the range of 1.2-20%. ^[8]  Kiss et al published their redislocation rate of 9% in 1998 after following 90 primary Putti-Platt procedures for an average of 9 years. ^[11]  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. ^{[8, 12]}  Zaffagnini also reported a correlation between the degree of arthrosis, range of motion limitation, and strength reduction. ^[13]  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. ^[14]  Zaffagnini et al saw limitations in function to be related to the presence of pain and arthrosis. ^[13]  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. ^[15]

Regan WD Jr, Webster-Bogaert S, Hawkins RJ, Fowler PJ. Comparative functional analysis of the Bristow, Magnuson-Stack, and Putti-Platt procedures for recurrent dislocation of the shoulder. Am J Sports Med. 1989 Jan-Feb. 17(1):42-8. [Medline].

Flatow EL, Miniaci A, Evans PJ, Simonian PT, Warren RF. Instability of the shoulder: complex problems and failed repairs: Part II. Failed repairs. Instr Course Lect. 1998. 47:113-25. [Medline].

Rowe CR. Acute and recurrent anterior dislocations of the shoulder. Orthop Clin North Am. 1980 Apr. 11(2):253-70. [Medline].

Levy DM, Cole BJ, Bach BR Jr. History of surgical intervention of anterior shoulder instability. J Shoulder Elbow Surg. 2016 Jun. 25 (6):e139-50. [Medline].

Osmond-Clarke H. Habitual dislocation of the shoulder; the Putti-Platt operation. J Bone Joint Surg Br. 1948 Feb. 30B(1):19-25. [Medline].

BRAV EA. An evaluation of the Putti-Platt reconstruction procedure for recurrent dislocation of the shoulder. J Bone Joint Surg Am. 1955 Jul. 37-A(4):731-41; passim. [Medline].

Symeonides PP. Reconsideration of the Putti-Platt procedure and its mode of action in recurrent traumatic anterior dislocation of the shoulder. Clin Orthop Relat Res. 1989 Sep. 8-15. [Medline].

Rokito AS, Namkoong S, Zuckerman JD, Gallagher MA. Open surgical treatment of anterior glenohumeral instability: an historical perspective and review of the literature. Part II. Am J Orthop (Belle Mead NJ). 1998 Dec. 27(12):784-90. [Medline].

Morrey BF, Janes JM. Recurrent anterior dislocation of the shoulder. Long-term follow-up of the Putti-Platt and Bankart procedures. J Bone Joint Surg Am. 1976 Mar. 58 (2):252-6. [Medline].

Salomonsson B, Abbaszadegan H, Revay S, Lillkrona U. The Bankart repair versus the Putti-Platt procedure: a randomized study with WOSI score at 10-year follow-up in 62 patients. Acta Orthop. 2009 Jun. 80 (3):351-6. [Medline]. [Full Text].

Kiss J, Mersich I, Perlaky GY, Szollas L. The results of the Putti-Platt operation with particular reference to arthritis, pain, and limitation of external rotation. J Shoulder Elbow Surg. 1998 Sep-Oct. 7 (5):495-500. [Medline].

Truchly G, Thompson WA. Simplified Putti-Platt procedure. JAMA. 1962 Mar 17. 179:859-62. [Medline].

Zaffagnini S, Marcacci M, Loreti I, Visani A, Vascellari A. Results of the original Putti-Platt procedure for shoulder instability: review of Putti’s scholar experience. Knee Surg Sports Traumatol Arthrosc. 2000. 8 (5):314-9. [Medline].

Leach RE, Corbett M, Schepsis A, Stockel J. Results of a modified Putti-Platt operation for recurrent shoulder dislocations and subluxations. Clin Orthop Relat Res. 1982 Apr. 20-5. [Medline].

Iordens GI, Van Lieshout EM, Van Es BC, Schep NW, Breederveld RS, Patka P, et al. Outcome after modified Putti-Platt procedure for recurrent traumatic anterior shoulder dislocations. Strategies Trauma Limb Reconstr. 2013 Nov. 8 (3):141-7. [Medline].

Zenni EJ Jr. An axillary approach for a Putti-Platt repair. Clin Orthop Relat Res. 1978 Oct. 157-9. [Medline].

Hawkins RJ, Angelo RL. Glenohumeral osteoarthrosis. A late complication of the Putti-Platt repair. J Bone Joint Surg Am. 1990 Sep. 72 (8):1193-7. [Medline].

van der Zwaag HM, Brand R, Obermann WR, Rozing PM. Glenohumeral osteoarthrosis after Putti-Platt repair. J Shoulder Elbow Surg. 1999 May-Jun. 8 (3):252-8. [Medline].

Samilson RL, Prieto V. Dislocation arthropathy of the shoulder. J Bone Joint Surg Am. 1983 Apr. 65(4):456-60. [Medline].

Richards RR, Hudson AR, Bertoia JT, Urbaniak JR, Waddell JP. Injury to the brachial plexus during Putti-Platt and Bristow procedures. A report of eight cases. Am J Sports Med. 1987 Jul-Aug. 15 (4):374-80. [Medline].

Kline DG, Judice DJ. Operative management of selected brachial plexus lesions. J Neurosurg. 1983 May. 58 (5):631-49. [Medline].

Ahmad CS, Wang VM, Sugalski MT, Levine WN, Bigliani LU. Biomechanics of shoulder capsulorrhaphy procedures. J Shoulder Elbow Surg. 2005 Jan-Feb. 14(1 Suppl S):12S-18S. [Medline].

Elizabeth Dulaney-Cripe, MD Resident Physician, Department of Orthopedic Surgery, Wright State University, Boonshoft School of Medicine

Disclosure: Nothing to disclose.

Michael A Herbenick, MD Assistant Professor of Orthopedic Surgery and Sports Medicine, Wright State University, Boonshoft School of Medicine; Residency Director, Department of Orthopedic Surgery, Miami Valley Hospital

Michael A Herbenick, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Putti-Platt Procedure

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