Thank you, and I'd like to thank John and others for inviting me. I have no relevant disclosures to this talk, and it is listed on the Academy's website. So I'm going to briefly make an argument for the indications for metal resurfacing. So that would be hemiarthroplasty or resurfacing arthroplasty without full resurfacing of the glenoid. I had to look up Blarney because that was the name of my talk. Thanks, John. So it's to persuade using charm and pleasant flattery, and I'm not going to try that. I do want to talk about success, though, and how we measure it as surgeons. And there are different ways to approach these patients. What we're talking about is very young patients in whom we don't want to do too much, but who need good functional outcomes. So success for me is pain reduction, functional improvement, and then a reproducible surgery that I can do each time and that I can also teach to others. So there's some external validity to it, so I don't have to be a wizard to do it like some of the other speakers are today, technically. And then for the patient, they just want to forget about their problem. They want to move on with their life and not really think about the issue. And I'll subject to you that the current way that we look at arthroplasty patients, particularly young active patients, is inadequate. So the outcomes measures that we have are quantitative numbers, but there's a ceiling effect with young patients. We've seen that with both generalized and joint-specific outcomes. The median value in our cohort of athletes was a dash of zero. The normative values were over 20 in the same cohort in the published literature. And that's even in the setting of upper extremity injury. So you're not going to really have them report the outcomes that you want, and we're not going to be able to follow it just simply through the standard outcomes measures. So for me, this was a success. This is a patient from our children's hospital who is an ALL survivor. He's had chemotherapy, high-dose corticosteroids, and bilateral avascular necrosis with collapse. This is six years later. He's a machinist. He has no pain. I have to call him to come in every several years because he doesn't think about his shoulders at all. So it's a success for both of us. So the problem is in these patients, end-stage degenerative conditions in young active patients is relatively uncommon. It's not something that any of us make our living off of. There's a variety of treatments, and then the levels of evidence to support each treatment is still fairly low. I picked this time period to show the volume of anatomic shoulder replacements in the United States. This is two years prior to the FDA approval of reverse shoulder arthroplasty in this country. And after that, there's been about a 15% year-over-year increase or growth in shoulder replacements in this country. However, if you look at anatomic replacements, they really have not increased in frequency, and they're very uncommon in those under 40. So the etiologies that we look at are idiopathic or mostly iatrogenic, chondrolysis, dislocation arthropathy, AVN, post-traumatic, and then primary OA in those under 40 is actually quite uncommon outside of severe glenoid dysplasia. So fortunately, we stopped using intra-articular pain pumps. We're more careful with intra-articular thermal devices, and we're seeing much less of this. But this was an intercollegiate athlete who transferred to Penn. She had been in the West Coast and had had a simple labral treatment and gone on to have a 100% cartilage loss on both the humeral head and the glenoid with severe chondrolysis. So a simple procedure with a lifetime impact on her that was negative. Dislocation arthropathy is well documented by Havalius and others in showing that the number of dislocations and the time from dislocation results in eventual arthritic changes radiographically. This is one of our patients with post-traumatic arthritis, so treated by the trauma service at our institution. Had a fractured dislocation. She's 23. She has hardware that's penetrating the joint and glenoid as well as humeral damage. This is a sickle cell patient. In addition to the children's hospital patients that I see with AVN, these also tend to be younger patients. I won't talk about non-operative treatment. We've had excellent talks on arthroscopic treatment and we'll have others. Interposition arthroplasty, I think Buddy's going to talk about a little bit more. Partial resurfacing and hemi-arthroplasty are more what I'm talking about, and then total shoulder arthroplasty will be touched on later. In this post-traumatic case, I simply did a capsular release of the CHL, everything both subacromially and intra-articulately, despite severe collapse in the subchondral bone. She's had about three years of decent function and relief. She's about ready for subsequent surgery, but that's one of my first go-to treatments and we've published and presented data on that previously. Interposition, if one has the skill to do it, and I'm marginally skilled to do that arthroscopically, I've done these cases, but I haven't been as satisfied. I've done them more open in the setting of hemi-arthroplasty or resurfacing arthroplasty with good success. My results have been much better than some of the published literature. We did a series of 13 patients who have over six-year follow-up now, and three have gone on to conversion total shoulder. This is a patient of mine who sends me patients who had this done with structural bone grafting, interposition of a cellular dermal graft and a stem implant. We and others have reported, though, that sometimes you can get cutobacterium infections with dermal grafts as well as giant cell foreign body reactivity. This is a patient sent to me after undergoing an interposition arthroplasty arthroscopically. She had decreased motion, increased pain, decreased joint space, and had done worse with the interposition. After a total shoulder replacement, she's back on track and doing well. In my hands, this is not a very reproducible technique. Some of the newer retrograde reamers and things are better, and I haven't used those. I always had a difficult time matching the subchondral surface up and felt that long-term the wear patterns would not be as good, although I could line up the articular surface. Total shoulder replacement for primary osteoarthritis is certainly the gold standard, but there's limited data in young patients. This is a marginal patient with a total shoulder replacement, and he starts doing crawls and other plyometrics that he's been doing against my advice, but that's what patients do. My concern is this is going to be ultimately what he's going to be facing 10, 15 years down the road with limited options. How do we reproducibly get good results? I think resurfacing and hemiarthroplasty in the very young, active patients is the way to go. On the right side, this is nine years out. On the left side, six years out. This is a lymphoma survivor from our children's hospital with chemo. When we do resurfacing arthroplasty, I think a biceps tenodesis is imperative. I like Buddy's technique of going under the subscapularis. In my hands, I'm more consistent preserving the subscap with an osteotomy and then repairing it as anatomically as possible. Do adequate soft tissue releases. Avoid any varus placement of your implant. Other size. We're just replacing the articular surface, so it looks funny when you do it, but if you're reaming on top of everything, you're going to overstuff the joint and not do a good job. And then in cases where I leave the head on to get to the glenoid, sometimes I'll release a little bit of the upper portion of the latissimus. Not all patients can undergo minimally invasive procedures, including this patient who has juvenile rheumatoid arthritis, is about four years out from me doing bilateral elbows. She's had bilateral hip and knee replacements previously. So in summary, how do we get good results? This is our gymnast. She took a red shirt year. I did a replacement on her with a dermal graft, and this is her a year out. She's subsequently gone on to the Peace Corps, gone to graduate school, and has no complaints of shoulder pain. So I think in the very young patients with end-stage disease, we can be successful, reproducible. We need to use different tools, but in my hands, metal replacements are the most successful. Thank you.

metal resurfacing

young patients

end-stage degenerative conditions

outcomes measures

arthroplasty