This will follow Bill's talk and Rosa's talk, it kind of ties in pretty nicely. A little bit of it is redundant. So we know that osteoarthritis is cartilage damage and loss of motion. We just showed you a couple of talks ago about how to get all that motion back with releases. The pain is with movement, not at rest, and then this is a significant impairment of activities of daily living. Traditionally, we were taught, we'll inject you a few times and then do a total shoulder. And as younger, active patients have these problems, as Russ showed so eloquently, we have to come up with different ideas. And so under 60, arthroscopic debridement of itself has very mixed results, but does correlate with outer bridge classification. So when you get past that one and two level, we have a problem. And Evan has looked at this and several others, Driscoll and Millett have published on this. And what we were looking for is something consistent that will give us good results. And so under 60 with replacements, I've had the same experience Bill had, where you get in there and someone's had a prior shoulder replacement, they're 40 years old and their subscap is dysfunctional and that's a disaster. You don't want to do a total shoulder on a 40-year-old and so now you're left with latissimus and pec transfers. So we're trying to do something and total shoulder arthroplasty in this under 50 population that's going to be so active does not work long term. So now they're getting reverse shoulders and that's even more of a disaster in terms of their activity level. So what about reverse shoulder? Well, these are some really good authors who looked at this in young patients and they said, well, maybe it's a possibility. And yet they had a 30% failure rate at two years and a 30% complication rate at two years. That's too high. That's two out of three that are going to do bad at two to three years follow up. That is not acceptable for these young patients. So why do they do worse? It's not fair comparison. These are not primary osteoarthritics. These are people that have problems and they're post-traumatic, their etiology is different and their expectations are different. At my age, I'm old, I just want to sit down and not have pain on a day-to-day basis. I'm not 30 years old and want to go kite surfing and lift weights and play baseball and all these things. So this is different and so we need more longevity and we need a higher activity level. And so younger solutions, think outside the box a little bit. This is a loose glenoid in a 30-year-old with severe synovitic reaction, both poly and infection, and that's a problem. Try to preserve your normal anatomy and reconstruct just the abnormal parts. And remember, you're buying time. If you get five years, it's better than none. But if they want a solution in a 30-year-old that's going to last the rest of their life, the only thing you have is an arthrodesis. Everything else will fail at some point. And that's a big jump in a young active individual. So can you modify activity? Sure. Do you think they'll listen to you? No, they will not. So you can talk about it and people can say, well, I'll put a total shoulder and expect activity modification. It's not going to happen. What about debridement? Well, we can do an arthroscopic debridement if we have a concentric joint, outer bridge one to three, we can do all the releases, take all the spurs off. You can see all the loose bodies in here. We take those out, trim back the spur a little bit, do all of our releases. This is a triathlete. He's 45 years old. He had to get back to swimming. We operated on him when he couldn't. And just with a simple debridement, it's pretty good. I mean, he was able to get back to that. This is his next operation. Resurfacing, we use patches. With respect to Bill, lateral meniscus is never going to work. It's a force concentrator. So you might get good peripheral healing, but you concentrate the force in the center. Think on your instability patients. You have a glenoid track. It's a figure of eight. It moves around there. It doesn't stay in the middle. And if you do something that's big on the sides and weak in the center, you don't restore that. You just pivot, and it's going to fail eventually. So you need something flat. So his comment about it being not uniform thickness is 100% correct. Humeral side, surface replacements versus humeral head. And then you saw a great talk by Bill Pennington using allografts, which I think is terrific. So commercial patches are not indicated for this, but it's a buying time and activity option. And so this is what you kind of look like. This is a patient that had multiple reconstructions, 30 years old. You can see all the anchor holes. These were not all placed in the wrong spot because you have wear. And so they're placed at an angle, but yet when the wear happens on the glenoid, they sort of erupt into the surface. And so we've got to measure it. We've got to take all these out. We've got to microfracture and get all these cysts out and create a good healing surface. And you can do that with the microfracture all, but get all that debris out. You do not want that under your patch. Once you get all of that stuff out and we continue working on that, we want to create a good bed. We'll keep working and working, working until we have this just about all the way done. And then once we really have this, then you're kind of ready to do stuff. Do you chondroplasty on the humeral head at the same time? Most of these have a little bit of hypertrophy of the posterior labrum, and we just shuttle the graft in. And I've gone completely to dermal patches. It's worked very well for me, even though our first series, just from blind luck, didn't have any complications. And this is what it looks like. It's a nice, smooth surface, uniform thickness throughout. And we'll let this happen, this movement happen back and forth and put things together. So with this kind of thing, let's move on. We keep them in an abduction sling for four weeks, start range of motion, a lot of distraction and stretching. This is also not one you just send to therapy and say, oh, do what you usually do. Therapists are taught to compress and then shift. And in these patients, you have to distract and shift. So it's a little bit different instructions, and then advance to rehab. In our initial paper, 19 out of 20 were pretty satisfied with pain relief at two years. 15 out of 20 at six years, three of them I should not have done. They had square humeral heads. It's like Bill said, you have to have a concentric humeral head to do this. But at six years, and now at actually 15 years out, none of these have had to be redone. They've actually maintained. They're playing golf. They're doing things. They've gotten through college, and they're doing well. This is long-lasting. Rob Hartzer just presented Steve Burkhart and Joe DeBeers' long-term results with a minimum 10-year follow-up, and 70% of them have not had to have future operations. So in these young patients, you can buy 10 to 15 years, which gets you into total shoulder category if necessary. This is one of our guys. He had a few surgeries. He's a welder. He is actually that. He's about 5'2 and about 400 pounds, so it was not easy to do. He's actually that. Somebody asked me one time, your video is not concentric. That's the way he looks, and so it wasn't easy. But we did a resurfacing. He's gone back to work offshore and doing really well with that. So we've had activity levels. People get back to college, football, softball, water skiers, lots of golfers, powerlifters, and then all the jobs you can think about. With a non-concentric humeral head, this is not an option unless you do both sides. And so for those, we usually do a resurfacing, as you see here. This is an eight-year follow-up of a powerlifter who's still lifting 325 pounds. So management of arthritis in our young patients is not for the faint of heart. Think outside the box a little bit. There are other options besides total shoulder. Try not to wear one hat. Look at the entire spectrum and tailor your operation for the patient, and they'll do well. Thank you.

osteoarthritis

younger patients

active patients

treatment challenges

alternative solutions