APEX Shoulder Mastering Surgical Techniques for Clinical Success-Shoulder Session Q&A

Shoulder Session Q&A
Video Transcription
I thought those were really engaging discussions. Thanks everybody, panelists and moderators.  Thanks Dr. Field, good job on faculty selection there. We've got a chunk of time here before the wall goes up and we do our combined session with the elbow group  on the overhead throwing athlete. So we've got 20 minutes, questions, audience.  Yes, from the faculty.  Yeah, regarding the last presentation, I wanna ask if someone by chance has chosen to plate an acromion before a fracture, like a prophylactic plating on a high risk patient.  Describe, does that mean plating an impending fracture or plating from time zero of the reverse?  So I just had one this two weeks ago. I had a patient that was referred to me, failed to rotate a cuff, had a fall and had a scapular spine fracture.  We waited four months on CAT scan, he had a lot of callus around it, we still had some discomfort. He demanded a reverse for all four months  and we bounced it around, we prophylactically plated before putting the reverse in.  I've only, I've done it at time zero once. Similar story, cuff tear arthropathy fell, had an acromion fracture and I dual plated it first  but then did the reverse during the same surgery but fixed the acromion first to help tension it. And he did all right, but I've only done it once.  Rob, do you think you need to take out an overstuffed glenosphere to fix the acromial fracture or do you think you maintain the prosthesis and then just plate around it?  Phil, solve. I don't have enough experience fixing them to know. I fixed two and I did not change the components of those two. Both healed, one subsequently fractured lateral  to the plate and just horrible osteoporotic patient that had all kinds of fragility fractures and fracture surgery. So thoughts from any other faculty,  do the arthroplasty components ever need to be, does it need to be converted to? I've heard proposed convert to Hemi, fix fracture, back to reverse after fracture healed.  I don't think we know very much about this. Thoughts, anybody?  The only thing that I've done that I do use different is that I use a spider instead of a mechanical arm. So with a spider, you can actually lift the arm up  and release some tension from the anterior part. That makes it easier.  Beach chair surgery. I like doing these in lateral. Anybody else for lateral for Andrew?  Other issues, instability. Comment on just plating techniques is I've seen George Athwal, he'll take a recon plate and bend it into a hook plate.  And then he hooks it over the acromion and then fixes it to the scapular spine and then puts a two seven plate posterior. So I think 90 degree plating is important.  I think adding infuse and bone graft and throwing the kitchen sink at it is important. Crest. I haven't done crest. I go to the lumber yard for these, go to the crest.  Yeah, I mean, everything, right?  Right.  Makes sense. Tiger.  Hey, Tiger, can you use the mic?  Yeah, so can you hear me a little better now? Okay, so I use a clavicle plate. If you use a contralateral plate for the acromion fractures, it works really well.  And if you have a non-union of these plates, you bring it up, two K wires in the acromion, bring it up, put the K wires through. It's good to somewhat reduce.  Put the clavicle plate. The clavicle plate works perfectly for these. You can get different lengths and you put the distal end of clavicle plate on the scapular spine.  On the scapular spine, you get screws anywhere between 35 to 40. It gets you closer to the coracoid. And you get further away, it's a little bit harder,  but you can get two or three screws between 35, 40. Just put your hand on the spine, the spine, fixation. And then distally, you have all the little locking holes.  You can put 10 or 12 millimeter screws onto the acromion. And they do really well. I don't do night-night plating on these. I just do that. And, well, for these acromion fractures.  I 3D printed both of mine also. Anybody else have a 3D printer? Institution have it? Arner does, yeah. It's not easy to learn how to 3D print,  but it's pretty handy, right?  Institution, yeah. When you're working in weird air, like, you know, we're not used to fixing the scapula that often. So weird bone equals, that's a lot of valuable information.  You can order them, too.  Order 3D prints. Hey, Rob. Yeah. I'm curious to know how many people use a seven o'clock anchor for their shoulder stabilizations routinely? Can you see?  Yeah, that's a good, that's a great question.  Yeah, I'd be moaned am I not going inferior enough on a couple of those cases, but yeah.  Fixing posterior to where there's any obvious pathology just for capsular imbrication. Or, hey, Brian, what do you, do you, let's say that your tear goes to, you know, 5.30.  Do you mobilize the labrum past so that you can kind of do capsular labral imbrication, or do you just put an anchor back there where it's normal and then bring up capsule?  I think whenever it starts to medialize, that's where I stop. So I usually go to the margin of healthy tissue, and then if it's in situ, then I would just leave it,  leave it be and just imbricate around it. Just imbricate it, yeah. Dave, you are nodding your head. Any pearls on that? Do you always put a seven o'clock anchor  for anterior instability post your anchor? I think the most important thing with regards to instability reconstructions is the actual capsular and labral shift.  So when you were, you know, like putting, when you were getting after yourself for that anchor placement in the case earlier,  I didn't think there was a significant problem with that, as long as you took a bite of tissue distal to that, yeah. So if you did that, then you shifted it.  So really, we're just using the anchors to have the soft tissues heal back to the glenoid. So it really, anchor placement is important, but tissue purchase is way more important.  Another thing we didn't talk about in instability is return to play testing. So Albert Lin really convinced me about doing that. And I think that it's a no brainer  to just get a return to play testing protocol and make your athletes pass it before you let them return, particularly to collision sports. And it's a little bit of a pain  because, you know, they have to do another PT appointment and the therapists sometimes aren't used to doing the testing. But once they get used to it,  it's just helpful to know whether they're ready because there's strength testing as a part of the protocol, there's proprioception testing. And in Albert's series,  it was four times recurrence rate improvement with making them pass testing. So that's totally free for the patient. I mean, in terms of like the things that we worry about,  surgical morbidity, you know, just to make them do one more office visit and tell them they need more rehab time. Anybody else return to play testing? Yeah.  I do it just in my athletes that have access to Biodex and Advanced Physio, usually.  Is it like ACL? Are we sending people back too soon with shoulder instability surgery? Rosano's nodding his head.  Maybe we shouldn't even be telling them they can go back to collision sports for like, what, eight to 12 months, something like that, I don't know. Yeah, I don't know.  Some of our European colleagues might say, are we doing the right operation? That's true. A lot of the folks across the pond that do a lot more Latter Jays would say,  well, why are you guys spending six months trying to get people back when we can do the same operation with really high stability rates and return them at like three months? Yeah.  Yeah.  Well, we talked about a lot of stuff. Cuff.  I have one comment on the ROWI score. Maybe I don't use it so much to make a surgical decision, but it's very important for me to talk about it  with the patient so you can fix expectations. And you can tell them, okay, this is with data, the data we have. So you have a really high risk of failure.  So you can lower them a little bit. So just put them on reality.  Are you talking to them about structural failure or clinical failure?  Both.  When I talk to people about structural failure, it's because I'm about to sell them some biologic products. I hate to be crass about it, but otherwise, why mention it to them?  Because most people, most cuff repairs that structurally fail are clinically basically okay.  I mean, just from a practical clinical practice standpoint. Yeah. You know what I mean? We don't have in Mexico like biological products. So we use biceps.  So it's mostly just to manage their expectations.  What do you tell people? Do you tell people a structural failure rate for a rotator cuff repair?  Let's say the average 58-year-old guy with a cheese ball, two centimeter non-retractable. I will do it if it's like over expectations or their expectations are way too high.  I'll say, okay, let's talk about reality. This is the data we have. You need to just keep in mind that we're going to do the best we can. If you want to quote them a real number,  you should probably say like 20% or something like that. Something outrageous where a normal person,  if you were signing up for surgery and they had half a brain, they would say, wait, come again? You know, one in five chance that the surgery you did  that I spent six to 12 months rehabbing is not going to structurally work. I mean.  All right, good.  Good question. Anybody want to, who didn't, who does a lot of instability work that wasn't on an instability panel? Rosano? Do you do a lot of bone loss instability?  We do DSMAP bone loss instability. Okay. Do you have a bunch of bone options in your toolkit? Like, are you thinking DTA  versus Latter-J versus crest versus distal clavicle versus scapular spine? Or do you kind of have like a couple of hit?  I usually go Latter-J because I want to restore the bone but have a sling effect. Open? Open. I do them open. And then obviously if there's a failure of a Latter-J, that's why  I went to solid screws because we had a football player break his graft off and so we had to  do a DTA on that. And with the distal tibial allografts, we still try to, I do those open because I want to find the conjoint and I try to sew it onto one of the screw heads  or repair it somehow to try to get some type of sling effect. So usually it'll be Latter-J then distal tibial allograft. But if I do a distal tibial allograft, I'm trying to  biologic to a stem cell, bone graft, whatever I can because that front of the glenoids is a little beat up. And I think for instability, a lot of times going straight to Latter-J  I don't love because I do see a lot of reabsorption. It wants to create a pair again. So it is hard to, for me to jump straight to a bone block type procedure. And I think  the biggest thing for instability is, you know, it's not unidirectional, it's bidirectional and it does deal with the patient's, what they want to do athletically. You know, if  this is a football player, it is a Bankart in a stability stitch at seven o'clock. Or  if they have a small Hill Sachs, it is a Remplisage. So you're doing something to bring that dislocation  rate back down to a normal level. So I think the standard Bankart is kind of going away. Rob, I also think it's important to differentiate DTA from AAGR. Like I think that it's not  the same procedure and it needs to have different considerations when we're talking about this just to make sure that we're speaking the same language. So for me...  Because of graft costs? Well, just in terms of what you're actually doing. Like with an AAGR, you're using a frozen  graft versus a fresh graft. You're rendering it extra articular by preserving the anterior capsule ligamentous complex and rendering your graft extra articular versus a DTA. You  know, it's fresh graft and you want it to articulate with the native humeral head. So for me, because I'm doing the marthroscopic, the Latter-day or the AAGR both ways, I sort  of... And it's a frozen graft. So, you know, you can just put it back in the freezer if you decide not to use it. I'm relying on what the intraoperative tissue looks like. So if  I have them consented for an AAGR but their intraoperative anterior capsule is very deficient,  then in those cases, I think a Latter-day is more reliable. So that's one of the differentiating factors.  Okay, so good. So Bogdan has more multiple bone options in your toolkit, all scope, and you're deciding based on the soft tissue because of AAGR. Do you think that it really matters  the Bankart repair and making the graft extra articular? Do you think that that heals over that?  Well, I mean, I think if you look at Ivan Wong's data, you know, he seems to think very highly of it, obviously, and thinks that it heals over top. I do think that you're providing  sort of a capsular shift with it because when you perform your episiotomy of the superior labrum, just below the biceps attachment, you are shifting it up afterwards with your  repair. So I think it tensions the capsule as well.  All right. Are there Blastetopics? Yeah, Fernando. One more question. Three more minutes and then we'll take a five-minute break and then we'll...  To the faculty, how many of you on a Massey retracted cough, you go and release the suprascapular nerve? Almost never for me. Larry, how about you?  I haven't deviated from Dr. Burkhardt's protocols, which I inherited from him as his fellow,  which is massive and revision, things that you want to heal, reconstructions, six-week sling, wait until four months for strengthening or active overhead range of motion.  So he would have them do passive range of motion from six weeks to four months and tell them, don't use your hand above shoulder level. Very, very conservative.  And, of course, those patients don't have very much stiffness problems. They have healing problems. So it seems to work clinically.  I don't know about structural outcomes, but doing early passive motion for smaller cuff tears seems to prevent postoperative stiffness.  I think, Dave, have you changed anything from Steve's way of doing it? It seems to work to go slow. Big tears don't get stiff. Faculty, anybody else?  I just think, you know, I was taught to do a super scapular nerve in my fellowship. It's a release, JP released every time, you know, in Europe.  And I started doing it when I was in practice for a year and realized it's stupid. Like there's no reason to, so I stopped doing it.  Just one thing, I think, like a lot of times we're taught dogma and we're taught a lot of things in fellowship, this is the way you do it.  But when you go in real practice, you have your own experience. And I think a lot of things doesn't make sense. And you can change and see how it works.  But I think there's a lot of stuff. So one thing I'll say, have you guys, a lot of you guys do lower traps? Or have you learned lower trap?  That's a great, it's a great option, you know, to do for passive tears. It works. And, you know, I never seen it in fellowships. I graduated, you know, 10 years ago.  I saw videos, you know, I taught myself to do it about two years ago. And it works really well. So if you guys are here in lab, you want to learn how to do lower trap,  it's not that hard to do. It's very easy to do. And it works really well. It's a great thing to add to your tool belt for somebody who has a massive tear.  Yeah, I don't know if we have any whole body specimen. You have to have the whole thorax to learn the approach for the trap. So I don't know if we have that.  But, you know, you can get it arranged. And it is, once you kind of see what to do once, it's pretty straightforward. Just don't cheat yourself on your incision length.  That would be my recommendation for that. That's a big old incision. Okay, good.
Asset Caption
Moderators: Larry Field, M.D. and Robert Hartzler, M.D.