related to biologic resurfacing. I like to forget those and look forward to what we can do in the future. So this is a 55 year old. So first issue is, is he young? I guess the older I get, the younger this gets. But he's a power lifter and he's unwilling to stop. So he's a gym guy, he's sought out PRP on his own, he's had corticosteroid injections, and now his shoulder pain is debilitating and he cannot bench press or shoulder press. Here's his examination, limited elevation, external rotation, and internal rotation. His strength is excellent and he's got glenohumeral crepitation, joint line tenderness, typical of these radiographs. So here we have a true AP, graph review, your scapula Y and your axillary view. So I'll ask the panel, let me go on to his MRI first. So here's his x-rays, here's his MRI. So his cuff is largely intact, he's got some intrinsic degeneration of his cuff. He does have a fair amount of retroversion of his glenoid. And he's got some posterior subluxation of his humeral head. So, here's our options, I'll go down to panel. Maybe we'll start with Glenn since you're first, in line here. Yeah, I take care of a huge number of these guys. And what you don't have listed here is, really the first is a great sit down talk with them, discussing their shoulder and discussing the prognosis. I'm big into modifying the lifting technique, but you gotta make it straightforward. I think the bench press, which we all did as kids and bragged about, is probably one of the more destructive elements to articular cartilage ever invented. So you try and get them into maybe as they're aging, pulling, not pushing, working different aspects, possibly starting with an injection biologic along those lines. And for me, it's gonna be a total shoulder, likely a stemless with a augmented glenoid, but I'm not gonna jump right into that. It's gonna be a little bit of a dance and a little education so that when the time comes, maybe they're at a stage where they'd modify some of their endeavors. So let's assume all that's been done. And I've talked to him blue in the face in the office, and they're unwilling to stop a lot of these lifters. So Paul, what do you say? I mean, what's the next step? The challenge here for me, it's gonna be between a Riemann run and a total shoulder. We all know that a total shoulder is gonna get him a better result in terms of our inferred range of motion and scores. But it's really reading into him and what he believes. I find that those people, even though I've done the HEMIs on them, they still modify their activity. They're just happier. They're more sort of bought in. So to me, after the appropriate discussions, it's gonna be what does he really want or she really want for themselves. And I think choosing that operation that they want's gonna do better. Total will do the best. HEMI will do well if they have the right buy-in. Okay. All right, so here's the procedure I chose. Controversial. So a Riemann run and some technical aspects. I do use a lesser tuberosity osteotomy. I did not correct his glenoid version. I was worried about reaming down his anterior bone. In this case, I did use a two millimeter reamer mismatch. And I preserved his labrum. And then used an anatomic humerus. In some of the original papers from Seattle, used a 56 millimeter humeral head. But I prefer an anatomic reconstruction. So typical post-operative course, perfectus subscapularis. He did have a muscular cutaneous neuropraxia. And this looks to the challenge of these patients when you're doing the arthroplasty. Their size, their pectoralis size, their deltoid, their retraction. And it's not an easy case. He did return to the gym at three months. He had no shoulder pain originally. Although about a year later, he has mild two out of 10 pain. Interesting enough, he went on to tear his triceps about nine to 10 months after his operation. So here is post-operative x-rays. He's a stemless implant. This is the tournier simplicity. No affiliation. His head is relatively centered. Although he did not make any attempt to correct it. And my reaming goal, this is a B2 glenoid. But I try to remove as little bone as possible when I do the reaming run. Mainly for preservation purposes for later. Partial glenoid correction, but not complete correction. And this is a study out of Jefferson from my partner Charlie Getz, Mark Lazarus, Jerry Williams. This is B2 glenoids with a 25% failure rate. And they found that the failure rate was highest in the patients that were corrected to neutral as opposed to those patients that were left slightly posterior subluxed. So, and this is my main concern with the reaming run. The durability, the late wear, the conversion to a shoulder arthroplasty. What degree of retroversion did you put the humerus in? The humerus I put in native, I didn't. Native? Yeah. With that device, it would be hard to. You really can't correct the version with that implant. Well, with that implant, it'd be difficult to. And if you look at the anatomic literature on with B glenoids, posterior subluxated glenoids, the humerus is antiverted relative to normal, which is 35 degrees or so. But with a stemmed implant, obviously it would be much easier to correct the version. And also, out of Seattle, they anterior rostrate the humeral head when they do the reaming run. So, there's no single cure, and this is an individualized operation. So we have to be careful. You need to be familiar with multiple techniques. Matt, that last slide, that was his revision? Like, that was his conversion to total? That was conversion to total. Okay. So, my current algorithm, unipolar defects, reconstructive, mild to moderate OA with greater than two millimeter joint space. I'll debride arthroscopically, a CAM procedure. Severe OA depends on their activity level. If they're high activity level and they're centered, I'll do a hemiarthroplasty, again, with the known limitations. If they have, they're eccentric, I'll do a reaming run. And if they're low activity level, I will do a total shoulder arthroplasty. And noticeably absent here is the mild to moderate OA with the subluxed humerus. So, it's a big question mark there. Thank you. That actually brings us right to five o'clock at the end of this session. So I wanna thank the panelists for being here and helping, and thank you for your attention.

powerlifter

shoulder pain

treatment options

surgical options

post-operative follow-up