I think the problem with my talk is that I don't know how to teach you how to do this arthroscopically. Otherwise, I think you would all agree with my answer because that's really what the evidence would show for us. My disclosure updated regularly at the American Academy of Orthopedic Surgery website. Here where arthroscopists and arthritis may not seem to be a key component but realize shoulder arthritis is a critical part of our healthcare dollars with more than 50 billion dollars a year dedicated towards managing this condition. It's not the same as hip and knee. It's not a weight bearing joint. Handedness plays a role. It's unclear if even weight loss makes a difference and we always start with non-operative management. In fact, Peter Millett put together a nice algorithm and where are we looking at for the non-surgical treatment? Here are these patients who have the deformity on the glenoid, those that have less than 2mm of glenohumeral joint space, they have bipolar disease, less than 50 may be part of it and severe arthritis and what we're concerned about are these are all factors that some of the arthroscopic surgeries have been shown not to work very well with and even with the graphs, we struggle with that. We're really talking about the mild to moderate arthritis. We agree that if it's relatively, excuse me, the moderate to severe, if it's relatively mild we'll try other options. If you do a mark off analysis to try to figure out where it's truly valuable in terms of quality of life as Dr. Millett's team did, what you'll see is below 47 arthroscopic treatment wins out, above 66 shoulder arthroplasty so we're sort of discussing this in between group what's really the best options for these individuals from about 45 to 65 and as others have already mentioned when we look at these individuals, their arthritis pattern is not osteoarthritis as a group. It's much more diverse and we have to make sure we keep that in mind. We do recognize that this group is a relatively small aspect of all shoulder arthroplasty. In fact, when you look at the Mayo Clinic series, it's about 5% of all their shoulder arthroplasties are age 55 or younger and so in their hands, it's rarely indicated as a higher revision rate and in their long-term studies, total shoulder always wins out over hemiorthoplasty for pain relief, motion, and patient satisfaction and if you look at this, another systematic review looking at studies that have longer-term follow-up under age 65, what you can kind of summarize is that at about 10 years of follow-up, the complication rate is just under 10% and the revision rate is about 17% so keep that in mind when you're comparing that to other options. If you look specifically at the Mayo Clinic series for the longest follow-up with 20-year follow-up in the U.S., what you can see is total shoulder arthroplasty wins the day over hemiorthoplasty and it's particularly valuable in patients with rheumatoid arthritis versus post-traumatic and if you tried to draw a survival curve for these different implants 20 years ago when the implants were not as anatomic, were not as clear as where to put our glenoid, what you saw is the results with total shoulder arthroplasty at 15 years out in hemi. Where do all the soft tissue operations, all these different resurfacings of different types of tissue, whether it's skin or meniscus or fascia lata, none of them even come close to this type of long-term outcome that we see with shoulder arthroplasty so again, keep this in mind for your patients you're talking about trying to avoid two surgeries but you're guaranteeing them at least two if not three surgeries with some of these other treatments. We've talked about glenohumeral arthritis in young patients and certainly for the little lesions we do all the things that you've heard about, microfracture, sometimes we can recover that area but for the more advanced arthritis, arthroplasty is the way to go. We looked at all the biological resurfacing and although you heard about this small series that was presented that worked out pretty well, the long-term follow-ups in this area no matter how you look at it, the results were terrible. Ours were 50% failure at four years out and in Serena Namduri looked at this again, 26% recovery operation at four years, remember what shoulder arthroplasty is. Here's another one by experts in arthroscopy, arthroscopic joint preservation using interpositional humo-dermal allograft, 25% less than five years follow-up. So why don't we just get rid of the glenoid and just put a hemi-arthroplasty on like this guy who came in to see me and said, well my doctor passed away so I haven't seen anyone in like 10 years so I thought I'd just come in, it's my 25-year anniversary and have you check me out and make sure I'm okay. And I said, well what did he do, he says, well he just replaced the ball and I've been using my arms for the rest of my life and I swim and everything and this is what his results are and this is his radiographs, it's unbelievable, this guy has no pain, he uses arms for all the activities and wouldn't that be great if we could do that every single time and not put a glenoid in. So there is a way to do that for some patients, this is a Riemann Run patient, this guy is a state police officer, he is also involved in some of their tactical combatant activities so he has to fight, he has to lift weights and he would have to retire if he had any other type of surgery so he's got a Riemann Run procedure bilaterally and this is what he looks like. You can see bilaterally, not only does he have a nice anatomic alignment and good range of motion but you see there's space created there between the humerus and the glenoid and at four years out he's doing great, not having any problems, throwing baseball practice and still working full time as a police officer. And when we looked at the outcomes of our Riemann Run patients, that very select group that we did that were these very heavy physical demand people, we did see that they were able to get back to this heavy workload. So we don't care if they go back to lifting weights, we don't care if they go back to combatant activities if we don't put a glenoid in and some people do that. Now you have to be careful, here's a guy where we tried a biologic glenoid on his right side first and I was never happy with his result and neither was he and he always complained about a little bit of pain so when we came back for the other side, we did a total shoulder which one would you want? It's pretty straightforward, you want the total shoulder and he's very happy about that and both of them are probably going to be revised at the same time, the biologic one may be sooner and we've seen that in the rate of hemiarthroplasty unfortunately in our younger patients there is a higher revision rate and we have to be ready for that so when you think about what's the best choice, for me it's still metal on the humeral side and a glenoid works very well no matter what systematic review you look at and meta-analysis the larger the numbers the more that it favors total shoulder arthroplasty in these younger patients. A lot of us still think in our mind that we're doing total shoulder arthroplasty for this guy but we're not, we have people like this who had three arthroscopic surgeries, two of them because of a slap lesion that probably wasn't there and the third one to try to resurface it with some kind of graft and she did horribly and so I did a total shoulder on her and she's back doing triathlons. So our results and our expectations for our patients are much different now, we have better implants better procedures we can do that and to achieve these goals you have to plan ahead of time, know exactly where you're putting your implant, use patient specific instrumentation which will make you a better surgeon, make sure you have the right instruments to do the operation correctly, make sure that you know how to manage the subscap as Buddy said if that subscap fails you're in big trouble so you've got to make sure that you have a good plan and we can get that number well under five percent. The biggest priority is getting the right size head in the right spot and keeping there the stem is no longer an issue it can be as small as possible and just taking the head off and making sure we get the right head size in place is really the key to this operation. You don't have to worry about convertible stems or platforms, these shorter stems and stemless devices are easy to revise if you need to do that in our younger patients. In these types of operations these are the results that we're expecting for shoulder arthroplasty far different than what we saw 10-15 years ago and as the stems get shorter the revision rate gets easier and you can do these as an outpatient very very effectively in our younger patients so that's the next step is that we can do these outpatient operations in an hour, an hour and a half and they're home by noon or sooner and do very well. Finally restrictions after shoulder arthroplasty that's not the patient that's all of you saying I don't think you should do this and that's not really right our perspective should be we should allow them to get back to the activities that they want so what are our patients doing let's ask them in terms of sports total shoulder arthroplasty 93% are getting back to the sports that they were doing before especially tennis, golf and fitness activities. They're going to go back as Buddy said and we should be doing operations that allows them to get back not telling them we're going to do this operation but you have to change your life that's not the right approach. What about getting back to work we now get more than two-thirds of our patients back to the same level of work even heavy physical demand with shoulder arthroplasty so remember shoulder arthritis is different than hip and knee arthritis the patients compensate for it very very well so we're not going to do an arthroplasty until all the things have not worked non-operative treatment is effective we haven't figured out biologics at all and total shoulder arthroplasty is the way to go if you want the most definitive outcome with the most predictable results thank you.

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