HABITUAL

DISLOCATION
The
H.

Paper

Habitual
The

Society

read

in

opening

of

the

of

Broca

of

and
been

Tavernier

the

dislocation

(1929)

and

importance

for

its

1890,

illustrates

deformation
added
to this

reattachment

the

Annual

joint

was

by

bone

of the

Hippocrates

to

of the

knowledge

Bankart

for
This

first

operation

of

of gleno-labrial

(1923)

the

Paul

Anatomical

sixty years ago (Fig.

reviewed
in masterly

advocated
glenoid.

and

Bulletins

the

than
been

(1942).

and

margin

to
from

was

Eyre-Brook

of the

1947

known
taken

comprehensive

detachment

Meeting

October

Hartmann,

how

recently

labrial

to

the

of the humeral
head more
knowledge,
though
it has

more

of the

at

ENGLAND

Association,

shoulder

SHOULDER

Operation

a Symposium

and

THE

LoNDoN,

Orthopaedic

ifiustration

of Paris

detachments
has since

Puttl.-Platt

OSMOND-CLARKE,

British

Aegina.

OF

1). Little
style
by

re-emphasised

time
became

an

operation

the

standard

.6

p.

FIG.

#{149}

Broca
showing

and

scapula,

the

head

c-capsule;

Hartmanns
illustration
(1890)
of horizontal
section
through
shoulder
forward
dislocation,
detachment
of labrum
and
periosteum
of neck
and
the anterior
margin
of the glenoid
engaged
in the posterior
defect
of the humerus.
G-glenoid;
o-neck
and body
of scapula;
p-periosteum;
t-lesser
tuberosity;
B-bicipital
groove;
T-greater
tuberosity;

b-posterior

British
of less
there

technical
is not

always

communication:
ing out the

constant

scapularis

tendon
to

appeared
of

was

the

VOL.

at
practice

NO.

1,

FEBRUARY

head

Hospital,

since

Putti
1923,

1948

of the

and

end

Manchester,
described

Platt

by

distal

under
of

of

the
the

by

Platt
same

This

the

by

his

provided

November
Valtancoli

It then
the

was

The

pupil

sub-

a primary

to
This

of

divided

subscapularis.

tendon.

type

procedure.

of the

subscapularis

on

in a personal

a standard

end

capsulorraphy.

the

says

few experiences
of carryI soon found
there
was no

margin.

inwards

Putti-Platt

performing
being

the

glenoid

shortening
the

As
first

repaired

stitching

divided
and

called

of being

by

forwards

proximal

overlap

I saw

capable

sure
remains

I have

Ancoats
later

margin.

make

the
an

which

years

standard
30B,

stitch

gleno-labrial

to

lesion

me

producing

performed

of the

present
technique
after
the
as described
by him originally.

of the
to

labrum.

my

cartilaginous

redislocation

operation

Some
his

to

to the

logical

capsule-thus

lesion

Bankartian

occurred

of

of

ten years,
until
the Nicola
procedure
seemed
to offer a method
During
these
ten years,
however,
some
surgeons
realised
that

evolved
procedure

Bankart

and
therefore

barrier

a gross
I

single

It

for the next

difficulty.

practice

attachment

of

13,

operation

the

first

genesis
operation

1925.
which

in

anterior

1925

had

been

and

more
19

20

H.

comprehensively
Scaglietti,
another
first

by

Codivilla,

literature.

the

title
the

complex

teacher

Putti

the

it
For

Putti-Platt
described

been

the

layers

are

divided

coraco-brachialis

to reach

layer,

and

is used,
the skin wound
then
extending
downwards

the

the

sake

Platt
Platt

me

justifiable

of

euphony,

adopted.
Swiss surgeon

was

the

OPERATIVE

Four

like

since
to

the

by

and

seemed

has

who

it,

operation.

combination

inquiries
within
the past
few months
from
the operation
may well have been performed

predecessor,

performed

independently,
for

procedure

and

certainly

procedure

eponymous

precedence,

in 1938.
Personal
pupils,
reveal
that

Puttis

Since

performed
an

by Boicev
of Puttis

OSMOND-CLARKE

never

described

certainly

thought

out

their

names

to

link

rather

than

A substantially
Matti
(1936).

it in the

to

and
as

indicate

similar

but

more

DETAILS

shoulder

: the

skin,

the

subscapularis-capsular

curving
inwards
for about
six

along
inches.

delto-pectoral

layer.

muscle

An

the outer
one-third
It is important
that

anterior

layer,

approach

of the
clavicle
and
the incision
should

skirt
the medial
edge
and
pectoralis
major
retraction
is required,

of the tip of the coracoid

process.
The groove
between
the deltoid
muscle
is widely
opened
(Fig. 2).
This
is made
easier,
and
less
if the clavicular
portion
of the deltoid
muscle
is almost
completely

divided

of

three-eighths

if division
In opening

an

inch

is made
through
the delto-pectoral

distal

to

the muscle
groove
the

the

bone

: subsequent

than
if the
cephalic
vein

troublesome
vessels
in the subacromial
region
cross
groove
and are worth
while identifying
and tying.
The next
step is to expose
the coracoid
process
coraco-brachialis
the

upper

and

inch

of the

short

head

margin

of the

of the

biceps.

pectoralis

expansion
of it which
runs upwards
under
which
gives
the appearance
of thickened
tendon
and the pectoralis
minor
is opened
cutaneous

nerve,

its branches,

or the

(Fig. 3). The tendon

is freed
a sufficient
stump
to facilitate
Morestin-Bazy
is retracted
freed

technique
downwards

too extensively
The next step

by

main

on all aspects
subsequent

of division
a stitch,

To
major

the

upper

and

free

limit
the

is much

adequately

tendon,

and

of the

tendon

particularly

the

of the
to

divide

attenuated

the deltoid
to reach
the capsule
of the joint,
and
deep
fascia.
The interval
between
the conjoint
with care in order to avoid
damage
to the musculoaxillary

neuro-vascular

bundle

which

and divided
close to the coracoid
repair.
I find this to be more

or below,
and
which
is usually

is close

process,
simple

and repair
of the coracoid
process.
The
but to avoid
damage
to its nerve
supply

from above
the capsule,

but

delto-pectoral

it is wise

along
its medial
border,
nor pulled
on too vigorously.
is to divide
the tendon
of the subscapularis
muscle.
Its

the tendon
In this step

easier

subperiosteally.
Several
small

conjoined

do this

margins
are readily
identified
by rotating
the arm outwards.
because
three
veins
which
accompany
the anterior
humeral
(Fig. 4).
These
vessels
are divided
between
artery
forceps
passed
beneath
its insertion.

resuture

muscle
is detached
is usually
ligated.

by

leaving
than
the

conjoint
it should
upper

tendon
not be

and

lower

The lower margin

is conspicuous
circumflex
artery
run below
and ligated.
A blunt
spike

the tendon
adherent

is divided
to the deep

it
is

one inch from

surface
of the

tendon
near
its insertion,
is frequently
opened
(Fig.
5).
The
subscapularis
is retracted
medially
by three
or four stitches
inserted
through
it.
If the capsule
has not already
been incised,
it is deliberately
opened.
The glenoid
margin
and the humeral
heard
are examined
for defects.
It is common
to find a tear of greater
or
less magnitude
in the gleno-labrial
attachment,
a defect
in the head
of the humerus,
and a
remarkably
voluminous
anterior
capsule.
Definitive
repair-The
distal
stump
most

convenient

soft

times

this

labrum

is the

tissue

structure
itself.

along
In

other

of

the

subscapularis

the

anterior

cases,

when

stripped
not only from the glenoid
margin
but also
the suture
is made to the deep surface
of the stripped

rim
the

from the
capsule
THE

tendon
of the
capsule

is attached

glenoid
and

to

cavity.
labrum

have

front of the neck of the

and subscapular
muscle

JOURNAL

OF

BONE

AND

JOINT

the

Somebeen

scapula,
(Fig. 7).
SURGERY

HABITUAL

DISLOCATION

OF

THE

21

SHOULI)ER

I
/

F.

/
Fi;.
Incision
below
outer
the
interval
between

third
the

of
two

Note
the
axillary
neuro-vascular
coraco-brachialis.
The
lateral
lateral
head
of the
median
liable
to he injured

In these
so that

circumstances
the sutured

chromic

catgut,

the

suitable
30B,

VOL.

BI

it is advisable
tendo-capsule

NO.

1,

FEBRUARY

cord
nerve,
by

to

will

of
1948

an

assistant,

and
which

Iio.
bundle
of the
gives
vigorous

needle-holder,

powerful

manipulations

clavicle
muscles

raw

over
delto-pect
is (leepened

3
lying
brachial
off the
traction

tile

a(Ihere
an(l
are

groove,
the

third

to
the
medial
aspect
Plexus,
before
continuing
musculo-cutaneous
nerve
or free
mobilisation.

it.

adequate
all

show

deep

anterior
to

ral
to

the

surface
A

small

of the
Mayo

retraction
special

of

of
as
which

neck
cutting
tile

instruments

t.XpSflg
layer.

of

the
the
is

the

scapula

needle,
humeral

stout
head

required.

by
It

.)9

H.

()SMON1)-CLARKE

11G.

lhie

coraco-brachiahis

has

been
Note

(lownwards.

divided
the
line

close
to
(1 division

JIG.

the

coracoid

of the

sul)scapularis
has
been
divided
an(I
the
proximal
inwards
(the
lower
margin
of
division
being
identified
the
anterior
humeral
circumflex
artery,
which
are
adherent
capsule
is incised
in the
course
of muscle

be

awkward
There

consunlillg.

or

the

rotated

articular

(Fig.

to

insert

is no

risk

cartilage.
8).

The

the
Four

medial

sutures

of causing
portion

but
further

sutures
of the

are

an(l

retracted

part
of
by three

lhie

may

process

subscapularis.

the
damage
inserted

capsule

ligated).
division,

the
muscle
retracted
veins,
accompanying

or

The
underlying
deliberately

embarrassment

is

to the
and
is drawn
THE

anterior

tied

while

outwards
JOURNAL

OF

no

more

margin
the

limb

to

overlap

BONE

AN!)

and
opened.

than
of the

time-

glenoid

is internally
the
JOINT

tendon
SURGERY

HABITUAL

DISLOCATION

OF

capsule

is
torn

retracted
off

the

inwards
gienoid

and

margin

the

and

of the
overcoat
tendinous
causes
VOL.

tissues

subscapularis,
-is
cuff

NO.

front
are

which
of
I,

of the
stitched

giving
by

provided

shortening
30B,

in

FEBRUARY

overhes
the

neck
of the
to the
distal

suturing
the

subscapularis
1948

the
greater

(labrum,

exposed.
from

T he
neck.

the

coat
belly

tuberositv,
however,

periosteum.
subscapularis.

the

of

muscle

which,

stripped

labruni

is

scapula
stump

double-breast

lesion

Bankart
capsule

the

lio.
ike

23

SHOULI)ER

11G.

The

THE

effect.

of

the

or the
must

capsule)

deej)

overlapping-

further

subscapularis
l)icipital
not

to

groove
be

overdone.

tile

(Fig.

an
scarified
9).

At

the

This
end

24

H.

OSMOND-CLARKE

/
11G.

The

four

or

live

sutulres

which

have

been

Internal

inserte(l
(

are

tied

while

the

limb

is

held

in

tation.

...-

FIG.

lhe

muscle

stitched
conjoint

of

the

wards

to tissues
tendon
of

reefing

to the

and

neutral

contracture

may

the

to

deltoid

belly

the

subscapularis

in tile
region
coraco-brachiahis

position;
clavicle

for

greater

the
and

some

tile

muscle
time.

pectoralis

double-breasted
tuherosity

pectorahis

operation

if
and

15

of

muscle-shortening
Persist

the

of

The
major,

minor

it

is still

and

conjoint
and

tile

bicipital

is reattached

be

sllould

more

over

possible

shortened
tendon

capsule,
and
groove.
The
to the
coracoid.

to

a stubborn
is

the

wound

THE

JOURNAL

reattached

rotate

the
internal
to

the

arm

out-

rotation
coracoid,

is closed.
OF

BONE

AND

JOINT

SURGERY

HABITUAL

After-treatment-The
and

the

by
is

fingers

Two

arm

on the

strapping,

then

opposite

maintain

this

redeveloped,
weeks

and

later

DISLOCATION

is bandaged

degree

THE

to the

shoulder.

Two

of internal

movement
vigorous

a more

OF

trunk

or three
rotation

with

the

six-inch
for

restored
by active
regime
of gymnastics

25

SHOULDER

forearm

crepe

three

across

the

bandages,

or four

chest

reinforced

weeks.

Muscle

graduated
exercises
under
and games
is instituted.

power

instruction.

COMMENTS

one

\\ith

minor

years

ago.

cent.

of

cures.

the

Nicola

Bankart
various
\Ve

modifications

tells

In
procedure

the

me

that

early
would

this
he has

do not

claim

successes

that

the

block

that
with

the

bone.

The

of the
Putti-Platt

muscle

scapularis

movement.

Unless

in

most

these

offers
cases

can

under
price

success

in

be

tight
further

pay

forced

may
cure

the

for

Platt

are

those

their

operated

J.

full

on by
C. Adams.

produce

tissue,

or

scar

shortening

the

external

range,

and

have

it is clear

of
of

that
and

There

which

of fascia,

limitation

to

84 per

apparent
Putti-Platt

literature,

of

twenty-

claimed

operation.
the

safeguard

permanent

degree
of limitation
with full function.
elapse
before
full

anaesthesia

to

effective

capsule,

the

Harry
Putti

it became
life, the

reviewing

of

results

movements

dislocation
cannot
occur.
The usual
on examination,
does not interfere
cedure
is that
several
months
may
occasionally
manipulation
theless
it seems
a small

only
on

consistent

block

procedure

which

war when
of military

is the

most

front-a

by
and

The results
of a series
reviewed
by my colleague,

Nonetheless,
the

in

taught

a recurrence,

second
world
the strains

procedure

achieve
head

operation

had

as a routine.
have been

procedures.

which

exit

Force

Putti-Platt

many

operations

to

the

is the

never

years
of the
not withstand

procedures
were undertaken
surgeons
in the Royal
Air

been

of

personal
He

sub-

rotation

even

beyond,

following
operation,
though
apparent
The only valid
criticism
of the promovement
is regained,
and that
very

be required.
of one of the

This
most

is indeed
disabling

true.
Neverof afflictions.

habitual

dislocation

SUMMARY

1.
the

The

of the

genesis

of the

Putti-Platt

operation

shoulder
is outlined
so far as it is known.
2. The operation
is described
and briefly
commented
3. Since
there
is both
gleno-labrial
detachment

successful

and

history

depends
of external

treatment

ii) limitation

upon:
rotation

i) a block
movement.

to

for

upon.
and
defect

the

exit

of the

in

the

humeral

of

humeral
head

head
in front;

REFERENCES
BANKART,

A.

S.

BLUNDELL

(1923):

British

Medical

Journal,

BANKART,

A.

S. BLUNDELL

(1938):

British

Journal

of Surgery,

Boiczv,

B.

A.,

BROcA,

(1938):
and

Chirurgia
H.

HARTMAN,

EYRE-BROOK,

ARTHUR

degli

L.

MATTI,

H.

(1936):

Zentralblatt

PLATT,

H.

(1947):

Personal

0.

(1947):

Personal

L.

(1929):

Revue

VOL.

30B,

NO.

(1925):

di movimento,

Bulletins
British

1132.
26,

23,

de la Soci#{233}t#{233}
Anatomique
Journal

f#{252}rChirurgie,

of

63,

30,

Surgery,

3011.

communication.
dorthop#{233}die,

Chirurgia

I, FEBRUARY

1948

degli

23.

354.

communication.

SCAGLIETTI,

G.

(1890):

(1943):

TAVERNIER,
VALTANCOL!,

organi

2,

organi

16,

575.
movimento,

9,

131.

de Paris,
32.

5me

Serie,

Tome

IV,

312.