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Evolving Techniques in Posterior Instability of the Shoulder. Xavier A. Duralde, MD Atlanta, GA. Evolving Techniques in Posterior Instability of the Shoulder. Consultant: Smith + Nephew CORR: Board of Trustees. Evolving Technique. 21-Year-Old Offensive Lineman with Posterior Dislocation
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Evolving Techniques in Posterior Instability of the Shoulder Xavier A. Duralde, MD Atlanta, GA
Evolving Techniques in Posterior Instability of the Shoulder Consultant: Smith + Nephew CORR: Board of Trustees
Evolving Technique • 21-Year-Old Offensive Lineman with Posterior Dislocation • Wants Back in the Game 2 Weeks After Reduction on the Field • What Are My Rules for Fixing and Return to Sport • (7 min) – New York Plancher minutes
The Problem • Posterior instability more rare than anterior • Posterior structures less substantial • Non-operative techniques including bracing less successful
PathophysiologyPosterior Instability • Traumatic vs repetitive stress • Forceful axial loading in flexed/adducted position • Blocking, diving • Repetitive loading • Throwing, batting, swimming, golf
PathoanatomyPosterior Instability • Labral tear • Posterior glenoid rim fracture • Posterior capsular stretching • ? Circle concept • Anterior structures
Conservative TreatmentPosterior Instability • Unreliable • Atraumatic cases • Failure rates 20-100% • Challenges of Bracing • Position of instability • Flexed/adducted position
Conservative TreatmentResults • Atraumatic instability • Recurrence 6-23% • Burkhead ‘92, Kiss ‘01, Takwale ‘00 • Traumatic instability • Recurrence ~74% • Burkhead ‘92, Beall ‘87 • Surgery vs Non-op • Constant 87 v 78 • Rowe 88 v 64 • Walch Duplay • 82 v 65 • Cruz-Ferreira ‘17
Our CasePredicted Outcome of Early RTS • Unless he learns how to cheat better • He’s going to suck
Our CasePredicted Outcome of Early RTS • His quarterback is dead meat Maybe I should get my labrum fixed!!
Our CasePredicted Outcome of Early RTS • He may incur additional pathology
Surgical OptionsPosterior Instability • Anchor repair more successful than soft tissue • Bone graft for defect > 15-20%
Surgical OptionsPosterior Instability • Fix what is torn or stretched • ? Anterior component
Surgical TreatmentResults • RTP > 90% • RTPP • Contact ~60-80% • Throwers ~50-60% • Bradley ‘08, ’13, ‘15, ’15, Savioe ‘08, Bottoni ‘05, Duralde, ‘18
Return to PlayPost –op Rehabilitation • First 6 weeks • Sling in neutral rotation • ROM mid-range AFE +ER immediately; avoid IR • 6-12 weeks • Isometrics • Regain full ROM • 12+ weeks • Resistive exercises • 12+ weeks • Proprioceptive • Light sport specific • 4 months • Advance sport specific • 6 months • Impact loads • Full Return to Sport
Conclusions • There is no reliable quick solution for traumatic posterior instability of the shoulder • Conservative Rx and Bracing ineffective • Success following surgery requires a prolonged rehabilitation period
Conclusions • Surgery has a high success rate • Use anchors • Fix labral tear • Imbricate as needed • Address associated anterior pathology • Bone graft for significant defect
Xavier A. Duralde, MD Peachtree Orthopaedic Clinic