Do we have time for questions? Yes? Okay, great. So that was a great session. You know, obviously I think we have the answer for older patients with osteoarthritis. A total TSA or reverse is probably the way to go, but it's that younger patient. And Tony gives some compelling evidence that obviously all, as Buddy alluded to, these are mostly bridging procedures. That total shoulder is a pretty big bridge. That 20-year result rate is pretty good, 83%. And then, of course, you could probably go to a reverse after that. But what about that younger patient, of course? And then to start off is the arthroscopic treatment, the capsular release. But so, Buddy, what's your KL grade that you'll go with for a capsular release in a 50-year-old patient? So 50 is a little bit different. 50 with concentric arthritis and out of reach 1 to 3, or hematoma 1 to 3, then I'll probably consider arthroscopy. But it's got to be concentric. If they're eccentric, they tend to do really badly with anything other than a total shoulder, either Riemann run or an augment glenoid. So concentric arthritis based on Bernoulli's view or a CT scan, then you can get by. Those will tend to do well, whether you just do a debridement or resurfacing. And I usually start with a debridement and release because there's no downtime with it and see how they do. And then depending on what their wishes are in activity levels, I may go biologic or I may go replacement. Any concern with the electrocardi or radiofrequency down below in the axillary pouch? So it's always interesting to listen to people talk about it and worry about the inferred capsule because they'll say, well, I released at 6 o'clock with a punch or something. And really, your risk areas are 5 and 7. So that's where it's tight. So it's always interesting. But if you stay right off the labrum, then you're going to be okay. If you do a beach chair, then the nerve is tucked in a little bit closer. Lateral cubitus has moved away about a centimeter. So for lateral guys, if you stay right off the labrum, you're going to be fine. For beach chair guys, I like doing the carotid because I know when I'm getting close to the nerve and I can stop and change it back a little bit, maybe take a snip or two and then go back to carotid. Any questions from the audience? Anyone? Merrick? One thing. What do you do before this? What's your plan on the first time they come in to you, arthritis of the shoulder, what do you guys do? Do you use viscosalpitation, steroid injections, and so forth? Oh, anybody? So initial line of treatment is the same in all arthritis. Obviously activity modification, anti-inflammatory medications for those patients that can tolerate it. If they have a stiffness to their joint, then a physical therapy program to help mobilize their shoulder. When we start talking about orthobiologics, we've really extrapolated from the knee and we don't have the same level of evidence in the shoulder. So most of the time, people start with a cortisone injection, which can give some temporary relief and sometimes it can last quite a long time. We know from the knee that PRP and maybe PRP plus HA may be a very good injection for the knee, but there hasn't been any studies in the shoulder to show whether that is giving any long-term benefit at this time. But some patients who have knee arthritis and have had that treatment and are convinced of it will come in and ask to have that treatment. Since it's not covered by insurance and you don't want to subsidize your patient's care, what we do is we write a prescription for the medicine, we give it to the patient, they go to the pharmacy, they pick up the medicine and they bring it back and we inject it into their shoulder for them so that we become the third party in that organization. And we haven't done anything in our practice either in Russia or Chicago with stem cells, so I can't speak to that. So mine's almost exactly like Tony's. It's basically shot medicine exercise. If you get four months, six months, a year out of the shot, then we'll just repeat that until it's no longer effective. I write the same prescription for the HA, tell them to bring it back and we'll put it in and we'll do it under ultrasound. And past that, Biologics, PRP, stem cell, it's a caveat emptor thing where we really don't have any evidence for it. And then after that, you move into the surgical realm. Mine's the same. I think that therapy for stretching the capsules is real important. I try to encourage my patients to get as good a motion that they can, have the therapist in line with that. As far as Biologics, my experiences and results are completely anecdotal and I haven't looked into them, but every Biologics shot I've given has been PRP and have done some HA and it's always been requested by the patient because they're convinced it's going to work. And I would say anecdotally, if that's the case, it usually does. Very similar. I think the patients with VSCO supplementation, if they have eccentricity of the joint or large marginal osteophytes with poor motion because of that, I tell them not to bother with VSCO supplementation, quite frankly. That would be the only difference. So a little controversy. How about the human dermal allograft versus the lateral meniscal graft for glenoid resurfacing? Bill, you seem to be a proponent of the meniscus and we've had some results that show that more increased failure rate with that. I think I kind of rushed through that part of the presentation. That was my initial experience back before we had really nice, thick dermal allografts. As I talked about, Buddy's first paper was using the thin porcine allograft and that's about the time that I was doing the meniscal stuff and I thought I could make the meniscal graft a little thicker. I didn't really like it. So you've really migrated away from that. I haven't put a meniscal allograft in since probably 2007. Once we started getting thicker dermal allografts in the right patient, to Tony's point, I don't do a lot of them. I'm very specific as far as their anatomy, geometry, et cetera, and activity. But I prefer the thicker acellular dermal allograft and I didn't show that on there. I do the same thing in glenoid preparation, I knew Buddy would be talking about it, but I do on my way out, I do aspirate some stem cells out of the proximal humerus, inject them underneath with PRP that I also soak the graft in as well for some magic formula in there as well. I don't know what it does, but it might help. And I'm lucky enough that we own our surgery center. I saw that yesterday and I'm like, wow, that's pretty cool, PRP into a human dermal allograft. That's not so bad, right? Why not try it? Yeah, I do it all. I own my surgery center and I own our, not I, we own our hospital and we own our surgery center and so I get kind of, I can do what I want and not have to charge a patient for it. As in New York, couldn't, they say, couldn't hoyt. Anyway, I think we're out of time, so thank you very much to the panel and to the presentations. Are you, I'm sorry, we have one question, yes? Just one question. In case of indication of glenoid arthritis, do you think that the best option is to surfacing biological with the dermal allograft, but you have stiffness. Do you perform first releases, you release in the same time or you do you stage the surgery? So for me, if they're still, if they're still stiff, when I go in to do the resurfacing, I'll release the capsule outside the labrum so that I get all of their motion back and then I put the patch on so that I can get all their motion back. You have to have full range of motion. Bill talked about that a little bit ago that you have to, one of the keys is to get normal motion back. So you have to have that for any of this to work. In terms of arthroscopic management of glenohumeral arthritis, the concentric glenoid with a stiff shoulder and a normal geometry to the humeral head is the ideal patient. A debridement capsule release will actually do very well for many years in some of those patients if you actually get that one in your office. And in this case, which is your post-op treatment? Do you put on a sling or you start to move progressively at the beginning? So for me, I have, the graph has to hold. So again, we'll start early passive motion, but, and even with a therapist, if I trust the therapist to distract and stretch and not go, not dislodge the graph, but the head on the graph actually holds it down pretty well. Same. I get it moving. Great. Thanks. We're out of time. And we're going to move on to the next session. Great job.

treating osteoarthritis

age groups

total shoulder arthroplasty

biologics

arthroscopic treatment