I lost the ponytail, so I had to make it up somewhere. All right. Can we go back to presenting off the computer, and then please, panel come up, Michael Bryan, Tiger Lee, Brian Waterman. How many for the participants, how many were excited to see shoulder arthroplasty on an Anna course offering? Was that part of? Okay, good. All right. Excellent. Okay, good. We're going to be talking about anatomics here, and one of the big issues is, should we even be talking about anatomics? Case one, panel, are you doing anatomic shoulder arthroplasty in your practice, or all reverses, or so many reverses that is this a waste of time, Mike? You know, I would consider an anatomic in this person. So if he's got good passive motion, and his cuff is strong on exam, because I think that my best anatomic still outperforms my best reverse. So I don't have a hard age cutoff where I will not do an anatomic. I've done an anatomic in an 82-year-old woman, and she loved it. But I have concerns about cuff failure, so I don't know the right answer there. All right. Okay. So you're still doing them? Yeah. I probably do two-thirds reverse, one-third anatomic. How about for just OA? So in most of our practices, if you just look at all of your shoulder arthroplasties, it's way heavy for reverse, because you get massive cuff, and fractures, and stuff. But just primary OA, what do you think it is, anatomics versus reverses? Probably 50-50. 50-50? I think that's pretty much it. Especially when they're at 80. I look at the cuff. I look at the glomerophology. If there's any kind of posterior subluxation, or B2, or anything, I feel like they're going to may feel anatomic. I'm just going to go with the reverse. But I would say the anatomic do very well. If you do it well, and somebody who has cuff intact, and the head is well-centered, they're going to have better range of motion than reverse. Ryan? All reverses? Some anatomic? No, no, no. You like anatomics? Okay. Probably three months ago, I did an 83-year-old. He was a very fit guy, still refereed for college level, and I feel like you've got to take a good, long look at the exam, the cuff status, if you have advanced imaging, making some assessments about the risk profile. And then here, you can appreciate there's not a ton of medialization, right? There's some posterior retroversion, but it's kind of a deep dish, A2-ish variety. This guy was funny. I'll never forget, because he told me his volunteerism is helping old people. It's like a problem of the Western world, you know? That's great. He feels young. Yeah. I mean, there's really old people that need help from him as an 80-year-old. Okay, good. So standard practices on the cuff assessment part. That's the big concern, right? Subscap problems, secondary, posterior superior cuff failure. Mike, what are you doing? You get MRIs on these? You just looking at the CT exam? What do you do? Just looking at the CT. I get a CT on everyone for pre-op planning with your software of choice. If I'm thinking anatomic and I have concerns over the cuff, or if they've had previous cuff surgery, then I also get an MRI. If they've got good strength and I can see good muscle belly, like your cut right there, I'm happy with that. Anybody else? I hate MRIs, personally. I try not to look at it if they come in with one. I look at it if it's there, but it does scare you a little bit more. They all have partial, high-grade partial, articular, whatever. Okay, good. Any other thoughts on workup planning on your anatomics? Forget the 80-year-old guy, just in general anatomics. Guides, robots? What should people be doing? Let's say you do 20 total shoulder arthroplasties a year, 10 anatomics. I think you should be getting a CT scan on everyone. I think you should put everyone through pre-op planning software, because I think it better estimates your glenoid version and inclination that you might not catch just by X-ray alone, and then it's up to you if you decide if you want to use augments or not. I use a system that uses navigation the most, so I navigate most of my cases. Okay. Tiger? Guides? I don't do guides or navigation. I get a CT. I take a look at anatomy. If I have any concern, if there's a B2 or subluxation. If anybody has deformity, I get a CT and put a pre-op planning, but I say 80% of the time I don't need it. Brian, guides? Routine guides? No guides, no nav, but routine CT, pre-operative planning. Okay, good. All right, here's the CT. Back to the 80-year-old guy that likes to help old people. Still anatomic? How's his pre-op motion? It's good. Normal arthritic cuff. I do an anatomic. Any other special indications or contraindications? You know, on average, anatomics and reverses are about equal, right? So are you thinking about complications of one versus the other? Is it you're avoiding the complications of reverses? What's kind of the thought process on this kind of patient? I think the ceiling of function is much higher with an anatomic, and we'll talk about it. So if he tells you, like, this guy, he's really active, actually. He goes skiing every winter and stuff like that. Does that matter? I mean, let's say he says, I want to play pickleball. Does he fall while skiing? What about forehands? Racket sports forehands. Sometimes they get mad if their subscap doesn't work. Any special, I mean, just throwing it out there. Any other thoughts? Well, I mean, the only thought I have is that, you know, if you do a lot of reversing anatomics, and the only thing with a reverse, it's not predictable that you can get internal rotation. So if they're dumb and armed, they may not be able to wipe themselves. It's 50-50, and we don't know what the factors are to get those internal rotation done. It could have, you know, that's what Joe Walsh, when I was doing a fellowship, he was doing everybody neutral. He was telling me this 10 years ago, 12 years ago, that he put it in neutral because you get more internal rotation so they can wipe themselves. When it was JP and Larry, they were doing 20 retroversion. And now I do anatomic cuts, so it's about 30-40. I don't think we know the answer, but people try and put them maybe neutral to get better internal. I think the pre-op internal is probably the best, you know, predictive. But if you do a total on this patient, I'm not worried about wiping himself. I think he's going to be fine. But if you do a reverse and a dominant arm, I just worry that maybe he may not be able to wipe himself, especially in the indication of a cuff intact, everything looks good, the muscle quality looks perfect on this patient. It looks like the cuff is intact. I think anatomic is the way to go. But I would do a stem total for him. I wouldn't do a stemless just because I'm worried stemless someone like this may loosen or he's old. I'm not going to, most likely you're not going to come back for revision. I agree with everything you said. And I think that when I started, I was cutting reverses in neutral and now I cut him in 30 and I don't think it's changed my internal rotation one bit. And I think that's why the pre-op range of motion assessment I think is huge. And Jay Keener talks a lot about this. If he's got active elevation to 150 and internal rotation to T12 and you do a reverse, he's probably not going to get his hand that high and then he's going to be unhappy. I agree. That's one for me if they get really good pre-op motion. And if his pre-op motion is 90 and neutral, I'm going to do a reverse because he's so stiff I think his subscap is probably going to fail. So I think the pre-op range of motion assessment is huge. And also kind of dominant arm, what they want to do. If they can't get their hand past their back pocket, they're unhappy. I mean, I had a couple of patient complain that did the reverses. You never told me I can't wipe myself from a dominant arm. They were a year out and they had to switch. I mean, switch to the right hand and wipe the left hand. It's hard. I mean, if you try and wipe yourself. Did you add that to your surgical consent now? It could be hard to wipe with your dominant arm. Might have trouble wiping. But now I tell patients, hey, you know, it's 50-50 after this, your dominant arm, you can wipe yourself. You know, I tell them, hey, the internal rotation is not predictable. The motion is probably not going to be as good as what you have now. But that's why I know. And I've tried my best to make it better. But at the end of the day, it's hard to predict sometimes in these patients. You know, Michael Weider just had this study that came out in JBJS recently, looked at neutral versus 20, I think, degrees. And there was no difference in terms of functional, internal rotation, or any outcomes. So there's probably extraneous factors that are contributing to that. I can't explain it. How about the patient that's at higher risk for a chromeal fracture with a reverse? So woman, osteoporotic, maybe some inflammatory arthritis, high risk. Does that push you towards the anatomic at all? That actually— Because to me, I mean, it's sort of like reverse is great. You know, I'm super happy with all—and then you get in a chromeal fracture and you're like, you know, never doing a reverse again, right? I mean, that's the big problem with reversing everyone for me. I think in that one, I worry about her subscap failure. You know, her bone's going to be garbage, so you probably plan to do a standard stem and be ready to cement it. And I think in her, I would lean towards a reverse, but I would probably tailor my system that I'm going to use to probably use an inlay humeral stem and not try to distillize as much to decrease those risk factors. Okay. All right. Beaten to death. That's what I did. Stemmed, anatomic. This was in a tenotomy era for me. Did great. Criticisms? A little thin on the head. It looks great. No, it looks great. I bet he loves it. I was criticizing myself for using—in this system, you get a bunch of different head sizes and I almost always just use the thinnest one and I don't get any intraoperative imaging, so I was like, eh, it looks a little thin. Any questions on decision making or thoughts from the panel? I think one thing you can look at on your post-op, so you're starting out, you did a good job because if you look at the way that around the head is, if you make a perfect circle, it should encompass the greater tuberosity in the back. If it's an oval, if you do that, then it becomes overstuffed. So it looks like it's a perfect circle here. Maybe the head could have gone— It's under—I think it's almost under. Yeah, you could have gone a little bit up and centrally up top because there's a little bit of tuberosity. If you typically want like five to six millimeters of tuberosity to head height ratio, but it's a good, nice circle, so I think it's not overstuffed, it looks good and everything. And then the marker, I don't see an implant, there's no marker of a center, but it looks like the center part looks pretty well centered on the glenoid side. And your head size on the axillary looks great because if you look medial to lateral, you're like perfect there. Not bad. And so I think that's intraop, that's always important to make, so when you put your head up on the cut surface of the humerus, you want to look medial to lateral and make sure that fits. You don't want to judge it from superior to inferior because it's oval and then you'll overstuff it. So I think on your axillary lateral, it looks great. I'd rather have it be too small than too big. I agree. Okay. Let's talk B2s. 62-year-old woman, active, healthy, no surprises on exam, B2 on x-rays. Everybody agree? Yes. All right. So corrective reaming to neutral version, play it where it lies, augmented components. Those are pretty much our realistic options now. Anybody bone grafting this? Nobody's bone grafting anatomic? No bone graft. Nobody's bone grafting anatomic. Okay, good. All right. Here's two 3D plans. This one is corrective reaming. I need readers now, unfortunately. 17 degrees retroversion, 2.5 millimeters medialized. Not much reaming to get it pretty seeded though. I think it's almost 100%, 96%. Here's another plan. Nine degrees retroversion. Now you're at nine. With an augment. With an augmented, I think 25 degree, must be 20. Maybe that's a 15 degree. Yeah, 15. That works out better. 15. 15 degree, augmented component. What does everybody like? Corrective reaming, augmented component? Both. Yes. Does it matter? Tiger? You can probably correct up to 15% of retroversion. If you go more than 15% biomechanically, you're going to ream out the back. So if you're like 15%, 16%, you can essentially ream or you can do augment. If you're more than that, like 20 retroversion, then you might have to think about something more like reverse or something else to correct that version. And we actually did a study on JBJS and B2 glenoid using augmented total versus reverse. Interesting enough, there's no difference in outcome. And the only studies out there with a series on B2 and reverse is Joe Welsh's series. There's nobody else that has any other series out there on looking at B2. Because Joe talked about he had the B2, he had the retroversion, 27 degrees or so, and then they failed and he went to a total and then the total failed and then went to a reverse and they did much better with the cuff intact. But he's the only one that published a series on that. I think the augmented wasn't available back then. So I think the augmented up to 15, 20, maybe 18 degrees will be okay. Ryan, a cannulated reaming system, that guidewire, there's a certain limit to how much retroversion you can, you know, how much schwang you can put on that thing. Do you think 17 is too much for planning corrective reaming with a cannulated reaming system? You know, the old way, like, you know, the old way is pilot hole. You're talking about high-sided reaming? Yeah. I'll tell you, I virtually never do that. Never do it. And here's the reason why. I think you should aim to try to restore the pre-morbid joint line. And very often, you're getting into a conversation more about stability than you are trying to correct to neutral. Because you could probably get it anywhere between zero and 10 degrees of retroversion, you'd be fine. But oftentimes, you do high-sided reaming, then you're going more medial, more spongy bone, more potential for subsidence, maybe potential for some mismatch in post-year slop. So I kind of like the small augmented glenoid. I think that works well. Final answer, Mike, small augment. I totally agree. I like augments as well. Joe and I already showed in a study that kind of the average retroversion pre-morbid is about five degrees of retroversion for the general population. So I don't think we need to get them back to zero. So a little bit of corrective reaming with an augment to try and get to less than 10 degrees of retroversion, and I'm happy. I almost never do corrective reaming except this one I actually did. This was an exception because of, this was a subscap sparing approach, and I wasn't confident that I could get the reamers in for the augmented components, so. Is that a keeled glenoid? A keeled glenoid, yep, yep. So subscap sparing, we'll just put on hold on the discussion, but teaser for the lab, we'll have some subscap sparing stuff to show you if anybody wants to look at that tomorrow afternoon. Take some guts to go after that large humoral osteophyte with a subscap sparing. Yeah, I know, that's, yeah. There's a, I'm still in the learning curve, Brian. Thank you for pointing that out. Further along than I am. Okay, so B2 glenoid exposure. You expose this thing and it's a monoconcavity, right? It's not biconcave until you, dung, dung, dung, take off the cartilage that's still on the high side. So I think that's just an important technical factor, pearl for these cases, especially if you have a guide. You don't wanna be trying to put the feet of the guide on cartilage because that was planned from bone from the CT scan. Comments? Any other thoughts on B2s? What is everyone's upper limit of a B2 that you'll try and correct with an augment before you just say I'm doing a reverse? Do you have an upper limit number in your head? So wait, let's define the downside real quick. So radiolucent line, right? Potential for loosening and then residual pain. What do you think? Is there anything else that's really proven if you say did 25, 35 degrees? Well, yeah, I mean- For me, it's all about, for me, it's all on the pre-op planning, but then intraoperatively, I'm not buying that glenoid until I trial it because sometimes you'll just get, the soft tissue envelope does not accommodate an anatomic. In that case, you just don't, in my opinion, you do not wanna force that in 2024. I think that's- Revert that to a reverse. I think that is a great point, and I say that to patients, which I heard John Sperling say, he consents everyone for an arthroplasty and says you might wake up with an anatomic, you might wake up with a reverse. I'm gonna put in whatever I think is best for you at the time, and that way, you avoid those uncomfortable discussions where they're expecting an anatomic and they wake up with a reverse. So I think it's important to consent your patients for both. If you cement a glenoid, if you cement that augmented glenoid in, and then you can't repair their subscap or they're falling out the back, that's a bad day. Okay, good, all right, B2s, good discussion. Let's just talk about subscap. 70-year-old woman, inflammatory arthritis, was scoped, didn't seem to have had a cuff repair during the scope at some point. Let's say she was 55. Has had a bunch of injections over the years. I forgot to put her physical exam. No surprises there. Can you go back one sec? If you look at that X-ray on her axillary, she's anterior just a little bit, which makes you worry about- You think it's a D-glenoid? No, no, I think that might be a sign of some subscapularis weakness. I think she's subluxated anterior. Came in with an MRI. It says cuff intact. A lot of artifact there from, I think she actually had an open acromioplasty is why she has like deltoid sutures. Here's her 3D plan. How are we doing on time here? Okay, good. No big surprises there. Seven degrees, retroverted. I think that's acceptable. Immediate post-op, one week. Any thoughts on those? That's good. That's good. Reasonable? Yeah, that's good. Okay. She says she didn't understand that she was supposed to be wearing a sling. So it comes in six weeks. Not horrible. Two years, definitely had secondary cuff. Well, either her subscap never healed, this was a tenotomy, or secondary rotator cuff tearing. Pretty happy though. Like, you know, a little bit weak, but it has full range of motion. Are you glad you did it? Yeah, it feels better than before. This happens a lot, right? Yes, let it ride. She's happy. All right. Do you mention the- What's everybody doing for their subscap? So I have a bunch of pictures of subscap management. Was this the tenotomy's fault that I, you know? What do you guys do? Primary subscapularis management. LTO, appeal, tenotomy, subscap sparing. Just go down the line. Mike? LTO. LTO, Tiger? I started LTO for the first three, four years, and then I moved to appeal, because I feel LTO sometimes is a little bit hard to get the two, you know, to line up perfectly. So I do appeal now. All right. Ryan? Tenotomy. Tenotomy, interesting. That's awesome, all three. Yeah, good. Okay. Final answer, it doesn't matter. Yeah, one, yeah. There's pros and cons. Okay. Who said appeal? Tiger, do you take the appeal with a knife? No, Bovee. Bovee? Steve Snyder says, don't burn things you want to heal back. I burn every time. Okay, he burns every time. It heals. Okay. Final answer, doesn't matter. Doesn't matter. Okay, good. Tenotomy, Waterman. I just can't believe it worked out this way. Larry, good job. Now, tenotomy's not gonna be very unforgiving. Do you cut the tenotomy? Do you have the residents cut the tenotomy? No. You do it? Maybe if Nicole, she's a month into her fellowship, we'll get her to it. But the residents, no. Do you? Sorry, Nicole. How are you doing it? Do you see the musculatinous junction and the groove and kind of go in the middle? Do you measure it from the groove? Do you put something in the joint to kind of feel? How do you, where do you cut the tenotomy? Yeah, so I mimic Greg Nicholson. And so you identify the superior old border, the subscap, with your scissors. You take that transversely across and then you do almost like a Zorro, Z-shaped tenotomy, which is pretty consistent with the shape of the tuberosity. Okay. It's pretty lateral, so we kind of call it a tenotopeal. Can you stand up and do the Z, right shoulder? Where's your subscap? There's your most, your most, yeah. Yeah, so scissors here, right on. That's the interval. Yeah, scissors right underneath the coracoid. You get the rush of fluid. And then you can get a Dara right behind there if you need to, to tension it. Then you come over, down, and then feather back here. And oftentimes I'll take it down and just take a little bit of the latissimus with that. Okay. Yeah, I get it. And then we place transosseous sutures and side-to-side soft tissue as well, so. Good. Okay, and then Mike, LTO. Osteotome, saw, how do you do it technically? I use an osteotome. I put a Metz in the interval so I can see the articular attachment of the subscap. And I start with an osteotome and drop my hand. So I try and take a very thin wafer. Okay. I'm a little bit more stemless on the humerus and I don't want to take a huge LTO and get into the humeral head. So I use an osteotome. The bigger you take, the better your exposure is on the glenoid side. Correct, so if it's a male with a really tight shoulder, I do a bigger LTO because I know they're going to be tighter. Okay. All right, good. All right, here's some LTO. If we want to do repair techniques, we can do them in the lab. Do a good repair. Whatever you do, do a good repair. There's pros and cons, not big differences in the literature. Okay, we've got three minutes. Glenoid exposure. So this isn't case-based. This is just throwing up pictures, sorry. These are all cases. So that's a fun day, a better day, right, than if you're struggling. So how do we get that routinely? Honestly, the humerus is the most important. So this is a subscap sparing glenoid exposure. This is the subscap right here. It's still attached to the humerus. So you can get a really, if you remove enough head, you can get a good view at the glenoid. So here, I'll prove it to you. There's the subscap, never been cut, externally rotating it like crazy. So- With relaxation? With, yes. Those were two different shoulders, weren't they? Same shoulder, same shoulder. So glenoid exposure starts on the humerus, good releases and aggressive cuts. You want to see a big old chunk of bone like that. Don't cut the cuff, obviously. That's usually not the problem. Usually under a section. If it looks like a heart like that after you've taken all the osteophytes away, you know for sure that you've cut enough. Narrows down like that. Okay, now I'm going to show you three ways of managing the anterior soft tissues. So this is my way. So this is a right shoulder, sutures in the subscap, retractors, making a little capsulotomy over the subscap muscle, kind of about five o'clock or so. Just tissue under tension there. If you get nervous, you can feel the nerve, but you're cutting onto the muscle of the inferior part of the subscap. That releases the anterior capsule from the inferior capsule. So you get kind of like a little bit of a T, another Zorro, actually, a Zorro cut. A little T-ing of the capsule there, then you can really work inferior. This is Andrew Rezano's video. He's one of our faculty members. He can show you this very violent way of doing it in the lab if you, where's Andrew? Yeah, finger, oh man, I missed. Okay, finger sweeping under the, between the axillary nerve and the subscap. Right there, big finger. Aggressive scissor releases, releasing at the capsule labral junction. Is that fair to say, Andrew? Yeah, good. Nicely released subscap there. Julie Bishop, Ohio State. Nice, sexy way. Feminine, a feminine touch here, dissecting in between the capsule and the inferior subscap. Kind of like my way, but except for with an instrument over there, so. All three of these methods have left the anterior capsule on the subscap, which I think is a nice way to manage that soft tissue. Peel, LTO, tenotomy. It's nice to have the capsule behind that for your repair. It reinforces that tissue instead of resecting fully the anterior capsule. Thoughts, guys? Anything to add on that, on glenoid exposure. How do you get good glenoid exposure? I agree with all that. I love it. Kind of like Julie Bishop does, and then go between the labrum and the subscap up, and then all the way around the bottom, around the back. But similar to you, I split it kind of at five o'clock, and then take it up and down and try and leave the capsule attached. Separate, instead of just having a big sling of anterior-inferior capsule, it's nice to have a little capsule. How to me to separate those two. Yep, I like it. Yeah. I think a easier way, you could just put a sharp homin at the inferior end of the glenoid, and then just take the bovie and just release from the front to the back, 90 degrees to the inferior aspect of the glenoid. Go all the way to the triceps, to the back. If you do that, you can get great exposure every time. If you do all the release in the front and the bottom, you can't see it, pull the humerus out, cut more on the humeral side, and go back and you'll see it every time. It's probably the humeral side you didn't cut enough. Yep, most important thing is if you're struggling on the glenoid side, go back to the humerus as fast as possible. You did not cut enough. If that still doesn't work, you can release the lat dorsi. I release the lat dorsi about a little bit, the top quarter is fine. You can get a little bit more. The lat dorsi, the pec, you can release that, get a little bit more if they're too tight. And the biggest thing is you want them to be paralyzed. The anesthesiologist has to paralyze the patient at that time when you do the glenoid exposure, so you can get more recharge. And I find large males, muscular males, are the ones that are hardest to do. Everybody else, it's not a big deal. Okay, we went over by two minutes. Larry, can you also just talk a little bit about arthroscopy visualization? Your videos are so beautiful. It's bloodless, it's clear. How are you getting that? Is that fluid management, anesthesia? Are you torturing anesthesia? What are you doing to get those beautiful images? Most of my patients have a lot of vascular compromise, and so they don't bleed very much. You know, I don't know. I take my time. I filmed a video yesterday on one of the rare true corcoid impingements with serious anterior subscapularis pathology, and it took us an extra probably 15 minutes of starting and stopping to get the videos we wanted. We didn't want to compromise the care of the patient, but you really have to be quite deliberate about things and video a lot and then go back and edit. So it's hard to say, but we just try to be thoughtful about it. And I'll say this, for every video I get like that, there are probably six or seven that I have to bail on before I really get a good one that can be educational. Okay, good. His answer is just be better, Robin. Just be better. All right, let's take a break. Thanks, everybody. Back in for AC Joint, moderated by Tiger at 410. 410 on the nose, people.

shoulder arthroplasty

clinical decision-making

pre-operative imaging

subscapularis management

glenoid exposure

patient assessment