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Evolving Techniques in Posterior Instability of the Shoulder

Explore the evolving techniques in treating posterior shoulder instability, including surgical options, rehabilitation protocols, and predicted outcomes. Learn about pathophysiology, pathoanatomy, conservative and surgical treatment results, and the importance of addressing associated anterior pathology.

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Evolving Techniques in Posterior Instability of the Shoulder

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  1. Evolving Techniques in Posterior Instability of the Shoulder Xavier A. Duralde, MD Atlanta, GA

  2. Evolving Techniques in Posterior Instability of the Shoulder Consultant: Smith + Nephew CORR: Board of Trustees

  3. 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

  4. The Problem • Posterior instability more rare than anterior • Posterior structures less substantial • Non-operative techniques including bracing less successful

  5. PathophysiologyPosterior Instability • Traumatic vs repetitive stress • Forceful axial loading in flexed/adducted position • Blocking, diving • Repetitive loading • Throwing, batting, swimming, golf

  6. PathoanatomyPosterior Instability • Labral tear • Posterior glenoid rim fracture • Posterior capsular stretching • ? Circle concept • Anterior structures

  7. Conservative TreatmentPosterior Instability • Unreliable • Atraumatic cases • Failure rates 20-100% • Challenges of Bracing • Position of instability • Flexed/adducted position

  8. 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

  9. Our CasePredicted Outcome of Early RTS • Unless he learns how to cheat better • He’s going to suck

  10. Our CasePredicted Outcome of Early RTS • His quarterback is dead meat Maybe I should get my labrum fixed!!

  11. Our CasePredicted Outcome of Early RTS • He may incur additional pathology

  12. Surgical OptionsPosterior Instability • Anchor repair more successful than soft tissue • Bone graft for defect > 15-20%

  13. Surgical OptionsPosterior Instability • Fix what is torn or stretched • ? Anterior component

  14. Surgical TreatmentResults • RTP > 90% • RTPP • Contact ~60-80% • Throwers ~50-60% • Bradley ‘08, ’13, ‘15, ’15, Savioe ‘08, Bottoni ‘05, Duralde, ‘18

  15. 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

  16. 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

  17. Conclusions • Surgery has a high success rate • Use anchors • Fix labral tear • Imbricate as needed • Address associated anterior pathology • Bone graft for significant defect

  18. Xavier A. Duralde, MD Peachtree Orthopaedic Clinic

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