Putti Procedure: History, Technique, Limitations, and Modern Alternatives for Shoulder Instability

What is the Putti procedure?

The Putti procedure is an older, open surgical technique primarily used to address recurrent anterior shoulder instability, particularly dislocations, by tightening the anterior capsule and subscapularis muscle to prevent the humerus from slipping forward out of the glenoid.

Understanding Shoulder Instability

The shoulder joint, or glenohumeral joint, is a highly mobile ball-and-socket joint, allowing for a vast range of motion. This mobility, however, comes at the cost of inherent stability. The joint relies heavily on a complex interplay of static stabilizers (like the glenoid labrum, joint capsule, and ligaments) and dynamic stabilizers (the rotator cuff muscles and deltoid).

Shoulder instability occurs when these stabilizing structures are compromised, leading to the humeral head moving excessively or completely dislocating from the glenoid fossa. This can result from:

• Traumatic injury: Often a forceful external rotation and abduction of the arm.
• Repetitive microtrauma: Common in overhead athletes.
• Ligamentous laxity: General looseness in the connective tissues.

When conservative treatments such as physical therapy fail to restore stability, surgical intervention may be considered to prevent recurrent dislocations or subluxations, which can damage cartilage, bone, and nerves over time.

The Putti Procedure: A Historical Perspective

Named after Italian orthopedic surgeon Vittorio Putti (1886–1940), the Putti procedure, also known as the Putti-Platt procedure (with modifications by Sir Harry Platt), emerged in the early to mid-20th century as a prominent surgical solution for recurrent anterior shoulder dislocations. At a time when understanding of shoulder biomechanics and advanced surgical techniques was still evolving, this procedure offered a direct approach to addressing the perceived laxity in the front of the shoulder.

Core Principle: The fundamental idea behind the Putti procedure was to reinforce the anterior aspect of the shoulder joint by shortening and tightening the subscapularis muscle and the anterior joint capsule. This was believed to create a strong barrier that would physically block the humeral head from dislocating forward.

How the Putti Procedure Was Performed

The Putti procedure was an open surgical technique, meaning it involved a significant incision to directly visualize the shoulder joint. The key steps typically included:

• Incision: An anterior incision was made, often along the deltopectoral groove, to expose the structures at the front of the shoulder.
• Subscapularis Division: The subscapularis muscle, one of the four rotator cuff muscles, was carefully identified and often divided or detached from its insertion point on the humerus.
• Capsular Plication/Overlap: The anterior joint capsule, which often becomes stretched or torn in recurrent dislocations, was then imbricated or overlapped. This involved folding the capsule and stitching it onto itself to shorten and tighten it.
• Subscapularis Reattachment/Shortening: The subscapularis muscle was then reattached or re-sutured in a shortened position, often overlapping itself (plication) or attaching to the adjacent capsule and glenoid rim. This created a strong, taut barrier across the front of the joint.
• Closure: The overlying tissues and skin were then closed.

The intention was that the tightened subscapularis and capsule would act as a checkrein, preventing the excessive external rotation and abduction that often leads to anterior dislocation.

Indications for the Putti Procedure

Historically, the Putti procedure was indicated primarily for:

• Recurrent Anterior Shoulder Dislocations: Patients experiencing repeated episodes of the humeral head dislocating forward.
• Failed Conservative Management: When non-surgical approaches, such as physical therapy and activity modification, did not prevent further dislocations.
• Absence of Significant Bone Loss: The procedure was less effective in cases where there was substantial bone loss from the glenoid (Bankart lesion bone defect) or humeral head (Hill-Sachs lesion).

Limitations and Complications

While effective in reducing dislocation rates for many patients, the Putti procedure had notable limitations and potential complications that led to its eventual decline in popularity:

• Significant Loss of External Rotation: This was the most common and limiting complication. By shortening and tightening the subscapularis muscle (an internal rotator), the procedure inherently restricted the shoulder's ability to externally rotate and abduct. This could severely impact daily activities, sports performance (especially throwing sports), and personal care.
• Risk of Subscapularis Dysfunction: Altering the length and tension of the subscapularis could lead to weakness, impingement, or even rupture of the muscle.
• High Recurrence Rate: Although initially effective, over the long term, the recurrence rate could still be substantial, especially compared to more anatomically precise modern techniques.
• Open Surgery Risks: As an open procedure, it carried the general risks associated with any major surgery, including infection, nerve damage, significant scarring, and longer recovery times.
• Arthritic Changes: The altered biomechanics could, in some cases, lead to premature degenerative changes within the joint.

Rehabilitation Post-Putti Procedure

Post-operative rehabilitation following a Putti procedure typically involved a period of immobilization, followed by a structured physical therapy program. However, due to the intentional tightening of the anterior structures, the emphasis was often on achieving stability at the expense of full range of motion, particularly external rotation.

General Rehabilitation Phases:

• Phase 1: Immobilization and Protection: Protecting the surgical repair, often with a sling for several weeks.
• Phase 2: Gradual Range of Motion: Carefully introducing passive and then active-assisted range of motion, with a cautious approach to external rotation.
• Phase 3: Strengthening: Progressive strengthening of the rotator cuff and deltoid muscles, avoiding positions that stress the repair.
• Phase 4: Return to Activity: Gradual return to functional activities, with the understanding that certain overhead or high-external rotation movements might be permanently limited.

Modern Alternatives and Evolution of Shoulder Surgery

With advancements in surgical techniques, imaging, and understanding of shoulder biomechanics, the Putti procedure has largely been replaced by more effective and less restrictive alternatives. Modern approaches aim to restore anatomical structures more precisely and preserve range of motion.

Key modern procedures include:

• Arthroscopic Bankart Repair: This is the most common procedure for traumatic anterior instability. It involves reattaching the torn labrum (Bankart lesion) to the glenoid bone using anchors, often performed arthroscopically (minimally invasive) to preserve surrounding tissues and facilitate a faster recovery with better range of motion.
• Latarjet Procedure: For cases involving significant glenoid bone loss or failed previous surgeries, the Latarjet procedure involves transferring a piece of bone (the coracoid process) with its attached muscles and ligaments to the front of the glenoid. This creates a bony block and a "sling" effect to prevent dislocation.
• Capsular Shift/Plication: For multi-directional instability or generalized ligamentous laxity, the joint capsule can be tightened and re-tensioned, often arthroscopically.
• Rotator Interval Closure: A less common technique that tightens the space between the supraspinatus and subscapularis tendons to improve anterior-inferior stability.

These modern techniques offer superior outcomes in terms of both stability and preservation of functional range of motion, making them the preferred options in contemporary orthopedic practice.

Conclusion

The Putti procedure represents an important chapter in the history of shoulder surgery, providing a foundational approach to addressing shoulder instability when other options were limited. While it offered a solution for recurrent dislocations for many patients, its inherent limitations, particularly the restriction of external rotation and the advent of more anatomically precise and less invasive techniques, have rendered it largely historical. Today, orthopedic surgeons utilize a range of sophisticated procedures, primarily arthroscopic, that offer superior long-term stability with minimal compromise to the shoulder's natural range of motion, allowing patients to return to their desired activities with greater confidence and function. For anyone experiencing shoulder instability, consulting with a qualified orthopedic surgeon is crucial to determine the most appropriate and evidence-based treatment plan.