Thank you. Thank you for the invitation to talk about this. As Buddy alluded to, we're going to have some redundancy this afternoon. I'm making the argument for allograft resurfacing in the arthritic patient. I'll make the disclosure, well, first of all, my disclosures are on the website and are up to date and have really no conflicts with this talk. I'm going to talk about our present experience in biologic arthroplasty and why utilizing allograft joint resurfacing in young, active individuals with glenohumeral arthritis is the way to go. Obviously, some of my best patients are my arthroplasty patients. In a deformed humeral head and gross arthritis, sometimes we have no choice, but in the young active patient with lower grade arthritis where some may put joints in, I think there are some good biologic options. Buddy just talked about arthroscopic debridement with release. Certainly that was a great talk. Peter Millet's talked a lot lately and written about decompressing the axillary nerve from large goat's beard osteophytes, so that certainly can be beneficial. Biologic surfacing that I'm going to talk about today is involving both the humeral and glenoid side, sometimes individually. Then my preferred is usually both because it's very rare that you just have unipolar disease. Obviously, you can treat these patients with hemiarthroplasty or combined prosthetic or biologic approaches and ultimately a total shoulder. Why would we want to even think about this? This is a young patient who I had the pleasure of meeting who about a year ago had that total shoulder put in. It looks great until you do the axillary view and she has a failed subscap repair. She's 52 years old and has no choice really because the subscap is completely atrophic for revision into a reverse. How about this guy? This is a 52-year-old laborer. I met him after he had a reverse. He had five previous rotator cuff repairs. He's 52 years old, had that obvious arthritic shoulder with the maintenance of his humeral head and glenoid anatomy. He had a reverse put in, but then obviously he busted out with some P. acnes, so I got the ability to put in a spacer, treat him, and then actually I converted him back to a total with a superior capsule reconstruction. These are tough operations for these guys to go through and we don't know the longevity of them. So as long as we can keep them with their anatomy, the better. So I thought let's pick some cases that we could perhaps do instead of those arthroplasty procedures. So what are the advantages to biologic approaches? Well obviously if you do it arthroscopically, there's minimal invasion to the soft tissue envelope with no disruption of subscapularis or deltoid. That's important. You really have minimal restrictions on these patients and obviously if anything needs to be done in the future, there are no bridges burned due to minimal bony resection. It's also a safe procedure with less extensive complication profile than traditional arthroplasty. So what approaches do I use? Well we started a long time ago. I presented and wrote this up performing an arthroscopic lateral meniscal allograft. We tried to do that mostly on glenoid unipolar disease and if they had bipolar disease, they had to have a spherical humeral head. I also used this procedure arthroscopically in revision procedures for glenoid loosening and failed hemiarthroplasty. We wrote this up in arthroscopy and presented our two-year results back in the day. That was in 2005 and 2009 and we had a 93% satisfaction rate in two years for patients with just gross arthritic changes of the glenoid. Those were obviously pretty rare to find. 75% of patients overall were satisfied. Obviously isolated glenoid lesions fared better. Meniscal graft, I did not like it because it didn't have a uniform thickness. I wanted something more stout across the glenoid. So I really kind of abandoned that. When better procedures were discussed such as bloody, I'm not going to take away much of his thunder. This is from some of his original work that he wrote up about biologically resurfacing with a dermal allograft. This was a porcine allograft that he wrote up. This is from his article in arthroscopy in 2009. I'm sure he'll be talking about it. But I then evolved because in a lot of these arthritic patients, we had to have something to take care of both sides, the humerus and the glenoid. I was really happy to see Dr. Potzenberg giving his talk because this came from the work on the partial eclipse. That is a device that he talked about and we used the same instrumentation to perform these allograft procedures as he demonstrated in his videos in the talk earlier. So initially I performed these with a humeral head osteoarticular allograft for humeral head bone loss and then treated the tibia with a proximal tibial lateral plateau graft. So this is a picture where you basically get a humeral head allograft. This patient had a large central lesion. I'll show a video soon of the humeral head. You make an allograft that fits that defect and then you pass it in. Actually, I have to go back there and I think run this. This is her video. This is actually an interesting patient. She's a 35-year-old woman who had an immunization and I had scoped her already once and she had this. She had no infection. Everything was negative and she obviously had a lot of humeral cartilage chondrolysis. So this is a sizer as Dr. Potzenberg showed. I'm going in there basically to remove that central humerus. This is a transhumeral guide that you can place in the center of the defect and sides the defect and then retrograde ream through the humerus as he described in his talk for his prosthesis. Basically the reamer is a little bit more aggressive as we need to make a recipient socket for the allograft and you can see my thumb, my finger. This is the left shoulder. The glenoid is on the bottom. My finger is in the rotator interval. I help push this graft in. We put a suture knot through the graft and pull it into the joint and firmly fix it. You'll see the final product in a second after we impact and it looks pretty nice. So these are just some radiographs of that particular patient. She had a 25-millimeter graft put in. You can see that it covered the central area and this is five years post-op. The graft is still there. It's doing quite well. Here's another patient that was able to do it for a 35-millimeter graft as well. I'm going to try to run through this quickly. This is a humeral and tibial allograft for glenoid but I did not like the tibial because we had to snowman those and fixation was tough. So I'm just, as an alternative, we utilized glenoid resurfacing with dermal allografts. You can see you can use a glenoid guide and place a dermal allograft to get nice uniform replacement of the glenoid. And finally, for that arthritic patient who you have after multiple rotator cuff repairs, this is just another interesting case that I'm just going to put up for a final case of where I did actually an SCR with dermal allograft resurfacing of the glenoid. I get the dimensions of the glenoid and then what I need for the SCR. And basically, you can see here, I prepare the glenoid. This is a view from the mid-lateral portal. Maker holes in the glenoid and put in my graft fixation for the SCR. Resurfaced the glenoid on the bottom left and then the graft fixed to the humerus. And you can see this video here shows the SCR fixed, superior translatory forces resisted and the glenoid resurfaced. So these are her radiographs three years post-op. She's still doing well at labor and again, better than a reverse in a 52-year-old woman. So I'd like to use that as my argument for biologic resurfacing and I'm going to give the podium to the next speaker. Thank you very much for the invitation to talk about this.

allograft resurfacing

arthritic patients

biologic arthroplasty

glenohumeral arthritis

minimal invasion