My name is Samer Hassan, I'm from Cincinnati, Ohio and I'll be moderating our late afternoon ICL on From Arthroscopy to Arthroplasty Treatment Strategies for the Young Patient with Glen and Rural Arthritis. Disclosures are on the Academy website and I'm joined by an esteemed panel, it really doesn't need any introduction, Joe Abboud from Rothman, Mike Amini from CORE and Rob Hartzer from San Antonio, all of whom are very active here at this meeting. And so just to give you sort of our game plan, we'll do a brief for didactics, maybe collective we'll take hopefully about half the time and then we've got a bunch of cases that we'd like to run through and we want this to be interactive so comments and questions are encouraged. So I'll lead off with just a couple of slides about non-operative because that's typically where we start and then turn it over to Rob to talk about arthroscopy, I'll spend a little time talking about anatomic and then some variants including the Riemann Run which I do perform, Mike Amini's going to talk about reverse and then Joe's going to bring it home with emerging tech and especially alternative bearings. So a little bit about non-operative treatment, you know, we are generally trying to avoid doing surgeries on young patients with arthritic shoulders and patients are also trying to stay away from it so we definitely start with non-operative treatment, sometimes it's really hard to get patients to moderate their activities but we make attempts to so if they get pain when they golf, two consecutive days we tell them maybe you should take a day off but certainly if they're a laborer or have other high demands, military, what have you, it's often very hard obviously. And just a couple of points about some of the treatments on this pyramid, you know, patients with advanced arthritis are not going to do well with a sleep or stretch but we're often amazed at patients who compensate very well with advanced arthritic changes radiographically. Conversely we see patients who have a lot of stiffness and mild arthritic changes, almost like a frozen shoulder but again with some cartilage loss and for those patients there may be a role for doing a little bit of physical therapy and that actually shows up on our clinical practice guidelines that it may be a benefit for select patients going to humoral osteoarthritis but certainly not for everyone. We are seeing some constraints obviously with insurance payers where they almost expect us to do a trial but how much of it you do is really up to you. Highly urinate injections, their mechanism is unknown, it's off-label in the shoulder although the last couple of years I'm starting to see some of the commercial Medicare plans approve it probably because they figure it's cheaper than an arthroplasty. Just some limited data to support its use, some systematic reviews but again and even if it works by a placebo effect, if it works for a patient that may be a way to get them and I've got patients who've had several series of them over two or three years. However when you look at the clinical practice guidelines there is no benefit and that's strong evidence again so you have to sort of make your own conclusions. Corticosteroid injections are still performed routinely although you really look at it's not a whole lot of data guiding us in the shoulder most of it's extrapolated by other joints. You got to be careful about diabetics particularly those with poor glycemic control and most importantly don't operate on them right after a cortisone injection, certainly not with arthroplasty because they increase revision risk and PJI risk. And PRP again similarly again this is something Ann is taking real leadership looking at biologics. A lot of that data is extrapolated from knee OA studies although there's some good emerging systematic reviews and studies that show a benefit at least in the knee and a smaller randomized control trial in the shoulder showed similar benefit with leukocyte poor PRP compared to highly urinate but again it's expensive and not for everyone. And again we look at the clinical practice guidelines that often regress to a low common or denominator. There is there's really no reliable evidence and therefore cannot be recommended the use of injectable biologics for glenohumeral OA. So I'll stop right there and I'm going to introduce Rob Hartzler to talk to us a little bit about arthroscopy and go from there Rob. Samer thanks for organizing us and intro and everything. I'm Rob Hartzler from San Antonio. This is I mean these patients are I think fun and a real challenge to treat and the stakes are high. So we have to be really thoughtful about what we do with them. OK so striker consulting disclosures. Another disclosure is I'm going to I'm not going to really hammer this operation home a little bit but I'm going to talk about dermal allograft resurfacing of the glenoid which is off label use of dermal allograft. So I was looking back I largely used a talk from a year ago to build this talk and this was one of my conclusions arthroscopy should be the first line approach in treating these patients. I'm not sure about that now a year later and I'll tell you why I've come to that conclusion but I think that Peter Millet's CAM procedure for these patients is a very viable option and glenoid resurfacing which I'm just going to touch on a little bit is out of favor for me and I may not do it anymore. So I'm going to talk to you about my approach to these patients and the arthroscopic options my CAM results my glenoid resurfacing results. As Samer said I think aggressive non-operative treatment is the key for many of these patients and really helping them to understand the situation that they if they have full-blown osteoarthritis of their shoulder at a young age just understanding the nature of that problem in the natural history is really important. Trying to individualize care as much as possible for them and especially if you're sort of a soup to nuts shoulder surgeon and especially if you're young like I am you know you're playing the long game with them you know you're responsible for the aftermath of operations that you choose to perform on them. So scope first maybe. Game changers recently for me subscap sparing approaches to shoulder arthroplasty. One of the reasons why I had previously in my mind thought you know we should really scope these people first is because you know typically that's subscap sparing operation and you really in my mind only get one crack at that when you take down their subscap but now that potentially patients can get an arthroplasty option with an intact subscap in my mind that's a game changer. I think pyrocarbons potentially a game changer for these young patients and just things like you know advanced technology for arthroplasty registry data you know we're understanding more and more I hope Mike talks about registry data for reverses in young patients. So the fun thing about shoulder surgery always evolving always changing. So kind of a basic treatment algorithm for me you know if you're Captain America with osteoarthritis you know you're getting a scope in general if you're Captain America's dad or we're doing some kind of prosthesis. So really kind of age activity level or is the first decision point and then can Peter Millett's CAM operation if generally there's less radiographic and clinical disease and glenoid resurfacing for advanced disease. So what is CAM complete arthroscopic management debridement including osteophyte removal and that's sort of the key for I think these arthroscopic approaches are you going to go after those osteophytes does that do anything does that help these patients a capsule release treatment of the biceps typically that's a subpectin adhesives and some sort of subacromial work if that's appropriate. So I got interest this patient really made a big difference in my thinking in clinical practice this is maybe like three or four years into clinical practice this guy came in and said my shoulder doesn't hurt very much but it's so stiff and I just really want to be able to like spike a volleyball. Can you help me and he had seen a couple other surgeons and you know it was like do I need to have the bone spur out. So I told him no you don't need to have the bone spur out that's what Dr. Burkhart taught me it's dangerous to go after the marginal osteophytes the goat's beard. So this is just a capsule release for this patient and you can see you know he's got great motion really improved it just releasing that intraoperatively this patient had zero clinical benefit from this operation you know months years down the road stiffness came right back and he was not happy about that. So I sort of started at that time to like you know entertain the notion of maybe I should go after the osteophytes maybe Millet is right about that. This is actually one of Dr. Burkhart's patients is one of our one of his former fellows who convinced him to go after some osteophytes so kind of he changed his mind a little bit about it and started doing that a little bit at the very end of his practice. So I kind of you know made a practice change and said let's go let's start to do Peter Millet's cam let's really see if removing these these the goat's beard helps these patients. So so this is how I do this now. So I'm working through two posterior portals the posterior superior viewing portal posterior inferior working portal or in lateral decubitus position there. It's actually I don't know if you can appreciate like there's a little bit of tension there you know and for me and my assistant because you know you're running these burrs and shavers like down in the inferior joint where the axillary nerve is nearby. So this this case I mean I've done many of these by this point but still a little bit of a stinker tightening moment you know when you start working down there. Also it's very difficult to make these radiographically pleasing. If you bring in fluoroscopy and you know work for a while work work work and go I did great and then take a fluoro shot you're like I did nothing. You know it's they're really frustrating cases if you care about what the x-rays look like. So I've gotten better over time doing that. One of the keys for safety I think is you know leave the capsule intact while you're doing the bone work which makes it more difficult. I've started doing a little bit of detachment on the humerus side of the capsule just to appreciate I think it helps you appreciate visually where the osteophytes are. So if you just give yourself like a little bit of a view there then you can bring you know the shaver in and just kind of get it's hard to know where to start on these a lot of the time. So that can be a little bit of a helpful hint. Millet says use these curved osteotomes to get the anterior osteophytes and you can just internally rotate it and that'll do the trick. It's really a nightmare to get all of them I mean it's it's these are hard. So and I don't actually know if it matters but I think it does. I think it does. So it's you know you're taking away a space occupying lesion in the joint. I think that that helps improve the range of motion especially if that's one of the clinical goals. It really gives you a very good view of the capsule so you can see on that arthroscopic image of the right. Once you take the bone out you can really really work on their inferior capsule and get a nice release down there. So Millet's data I'm going to skip this. You can read his paper. Risk factors for failure of the CAM approach are worse clinical disease worse radiographic disease especially in terms of deformity of the humeral head and glenoid. So this is a little bit. This is like a year old data I had done nine of these where this isn't just sort of debridement for arthritis. This is like where they really had significant osteophytes and I went after the osteophytes as part of the comprehensive management. So if you take away the SANE score you can see and the most important thing for me here is how what percent got to an acceptable symptomatic state. It depends a little bit on how you define the acceptable symptomatic state or pain but it's kind of like you know maybe half two thirds something like that. I basically tell these patients there's a 50 50 chance with this surgery that I'm going to make you better to the point where you would say Dr. Hartzler thanks so much for the surgery. I'm like a lot better. So I say kind of 50 50 and I think that's reasonable based on my results and Millet's survivorship is OK but survivorship is kind of like you know it's a little bit of maybe a misleading metric because some of those people are still miserable it's just everybody told them they were too young for a total shoulder and so they haven't had more surgery. So I think the patient reported clinical outcome measures are really important in understanding the results of these operations. So Dr. Burkhart taught me how to do this operation put a dermal allograft skin grafted glenoid. So is that a good idea. He and Joe DeBeer we put together this case series patients generally improved a fair amount. It actually was sort of like the pain relief of an anatomic total shoulder. If you compare the literature of this with young outcomes I'm basically going to skip this because I just really I'm not sure if this is a good operation. We don't really know very much about the structural outcomes of it. You know my patients have done fine clinically. Most people that have a big experience doing it kind of say like it's not a good it's not a good surgery. And you know one of the things about arthroscopy is you're tempted to say you know we're not burning any bridges doing these scope procedures on people but I think that that's actually really a very that's like a thought process that's bad because every operation compromises the next operation even if it's small and this kind of surgery where you know you put this dermis and all these anchors around the glenoid and stuff like that. You know if they have to have a reoperation you're concerned about bone loss and infection and things like that and it's sort of I think this thing is high risk high reward and for me I just I have stopped taking that leap mostly with my patients. If you want to look at a bunch of fun cases this is like kind of a case presentation from San Diego shoulder from a few years ago. There's some like pretty cool outcomes from it. I was very excited about it then but I'm sort of less excited about it now. So you know these crazy kind of cowboy arthroscopy surgeries you know are they risky are they futile is it just for our benefit as a compromise future operations. I think you've got to really think about that. So what's the future is it better prosthesis or better joint preservation options. I don't know. I don't know. That's it. Perfect. Robert you're getting older and more cynical and jaded just like the rest of us. So while we're getting the call this is the one with the F at the end. Thank you. Are you doing an axillary neurolysis like Peter describes consistently or are you just doing the release like you do for a capsule release and so I you know so I really I do a complete 360 degree release and I take a switching stick I manipulate them look back in the joint usually take a switching stick and kind of you know look around a little bit and see because I love seeing the nerve when I can see it but I think that in this situation and also in adhesive capsulitis I really see the nerve maybe about like 5 percent of the time or 10 percent. So you know neurolysis like he showed in his original pictures where you know you see the nerve arborizing and things like that. No. OK. Yeah that's right. And that's the branch of the Terry's minor. Right. Exactly. OK. All right. So when I shift gears and talk about anatomic shoulder arthroplasty I'll include the Riemann run as a variant that I've learned from my mentor Rick Madsen. So talk a little bit about total shoulder and Riemann run and hemi arthroplasty in passing because there's a number of studies have shown superiority or total shoulder arthroplasty versus neglecting the glenoid outright discuss the outcomes and then some of the limitations and concerns which have been touched upon by Rob as well. So the challenges of prosthetic shoulder arthroplasty is that any young patients that these patients often have the highest expectation regarding return to work or sport they often place great demands on their shoulders so there's potential for excessive excessive loading and they're also staring at the prospects of more than one revision because of their life expectancy and we know that with each revision the results are far less predictable. The other thing too is that the definition of a young patient is evolving. Some of the early reports on young patients looked at patients 50 and 55 and up to 60 but we know that patients much younger than that undergo shoulder arthroplasty and it's unclear if we can extrapolate to these much younger patients based on the available literature. Conversely we all come across patients that are older but are exceptionally active and may have the expectations and demands of someone much younger. And finally primary glenohumeral osteoarthritis in your younger patients is actually not not that common and we see a heterogeneous group of diagnoses including post-traumatic and dislocation arthropathy, capsular arthropathy, osteonecrosis, inflammatory arthritis although the severe arthritis mutilands from a generation ago is not as common because of demards and then at one point we saw this scourge of chondrolysis which was really devastating and implicated our factors including excessive thermal heat at the time when we didn't have good outflow, interarticular pain pumps delivering local anesthetics and also prominent anchors, particularly metal anchors. And I've seen cases of almost 40 and have published in arthroscopy on this previously. So talking a little bit about anatomic total shoulder, I'll still submit to you that it's the gold standard in these younger patients for end stage primary and secondary osteoarthritis. It requires an intact or functionally intact rotator cuff. It's a soft tissue procedure so you know how to do it and this is beyond the scope of this ICL. When you come across failures after this operation, typically with traditional subscambularis off approaches, early failure of that repair is the primary concern and Rob talked about that. Late failures tend to be because of glenoid problems, either glenoid loosening or progressive glenoid component wear and then of course attritional cuff failure which is a part of senescence. So here's a patient just in his early 70s, actually a retired accountant, now does maintenance for a golf course, plays a lot of golf and there's his arthroplasty I did just last year and he reminded me in his pre-op visit, you know, you don't remember but you fixed my other shoulder 21 years ago. I said, of course I don't remember but I got an x-ray and this is his 21, first 20-year follow-up of any of my patients. He was by far and away the youngest that I did in my second year of practice. He was 51 and you can see, still looks pretty good. Tristem resorption, the glenoid component is all thinned out as you can imagine so this is the end of that, that's, you know, but he's still doing well, and I don't know for how much longer, but certainly a 20-year run's a good run. Subscapularis management, historically either tenotomy, peel, or lesser tuberosity osteotomy, the LTO popularized by Christian Gerber. Comparative studies have shown benefit of the LTO or no benefit, so you really can't make a strong recommendation one way or the other. Caveat that if you do an LTO and it fails, revising it, that's very hard. And this has obviously motivated the search for these subscapularis sparing options, and there's actually quite a bit, Joe actually has a review article on this with Massimo Hassan, but some of the options include preserving the top 1 1⁄2 or 2⁄3, that's kind of going through the bottom, so it's not truly subscapularis sparing, but sparing the tendinous portion, and there are a variety of techniques to that effect. There's a superior approach, which was really initially for the reverse, where you don't have for cuff-to-arthropathy, you don't have a whole lot of osteobites, and then Mike Rywe in Cincinnati working alongside of me has patented a posterior approach and has used this going through an infraspinatus-teres minor split, which is absolutely crazy, because you're in a lateral decubitus position, but I mean, he's written about it, and I've yet to see one of his failures, so we practice just a few miles apart. For all of these techniques, you really have a learning curve, you've got to practice in the lab, you need specialized instruments, and it's not for every patient, so it can be challenging for muscular-abuse patients or patients with masty of osteophytes, and most of my patients have one, if not all three of these problems. But this is one way of doing it, this is a little review article by a buddy of mine, Steve O'Brien, where you just detach, and you can rotate the arm to get access to the humeral head and then specialized retractors to approach the glenoid. When you look at the implants, we've gone through an evolution over 50 years with initially cemented monoblock implants and keeled glenoid implants, modularity, the anatomic shoulder arthroplasty with now the both combination of modularity and the availability of variable inclination or eccentric or offset heads. Keeled glenoids have been replaced by off-axis peg glenoids, which are superior, better biomechanically at least. But fast-forward to 2024, and some of the things that we're seeing are, again, shortening of our stems to stemless, particularly in our younger patients. We've got what we think is more durable polyethylene solutions, although only time will tell. You need 20-year follow-up or longer, it's just with my patient. And then cementless or minimally cemented glenoid fixation. There is an interest in convertibility. If patients have late cuff attrition and you need to do a reverse, there are convertible metal-backed glenoid implants. Concern is that these tend to overstuff. And on the humeral side, they're convertible implants. You can go back and forth between anatomic and reverse. But the question is, is that at the time of revision, do you miss or undertreat potentially occult PJI prosthetic joint infection? So, and then the other thing is, if you look at the growth in reverse shoulder arthroplasty, which has been exponential, anatomic hasn't been seeing that same amount of growth because we're tending to get isolated out to younger and younger patients, more and more active patients. Reverse shoulders are now commonly used for osteoarthritis with severe deformity. And so that's another thing, just to accept that as we, you know, where we are right now is, some of us are not doing as many anatomic shoulder arthroplasties than we were a few years ago. Just a comment about hemi arthroplasty, where you're just not doing anything to the glenoid. There's really good randomized control trials by late Sandra Kirkley and Gary Gartzman that show that total shoulder is much better in terms of outcomes, in terms of durability, so fewer early revisions. And then also John Sperling at the Mayo has looked at younger patients, long follow-up up to 20 years, showing that cohort that undergoes anatomic tends to have better survivorship compared to hemi arthroplasty because of painful glenoid erosion when you don't do anything to the glenoid side. And on occasion, posterior instability if you don't address posterior glenoid erosion. When we look at trends in humeral stem design, again, we've gone over this from long six-inch to four-inch to two-inch now to stemless implants. And the advantage of the stemless, I think the key ones are, there's no diaphyseal stress riser if you don't go into the diaphysis, and then ease of stem removal. And even smooth stems that are cementless can be hard to take out, depending on their design and the type of bone remodeling that takes place at the distal tip of the stem. And then you also are able to place your humeral head independent of the orthopedic axis of using a stemless. And even with short stem implants, we don't see us using offset or eccentric humeral heads very often. Again, the stemless history is 20 years in Europe. In 2015, at one point, there were four IDs running concurrently in the U.S., and these are just some of the early ones that came to market. There are more of those. And in Europe, this year, it's anticipated there'll be more stemless than stemmed anatomics, so over 50%, and we're seeing that in the U.S. as well. Glenoid implant options, just real briefly. Glenoid implant is a key long-term challenge. You saw, again, that your ability, it may last for 20 years, but at some point, it's gonna wear out. And so we're still trying to figure out the best glenoid option for our patients. Again, we said that PEG glenoids have sort of replaced Keel, but there are some minimally cemented options out there with metal posts or fluted central PEGs that don't have to be put in with cement and may allow for bone interdigitation. Convertibility, I already commented on this. And then while we historically have used standard or non-augmented glenoids, there are some augmented options out there. Stepped, which are the original ones, half-wedge, which are available now, multiple vendors, and full-wedge. Half-wedge may lend itself to the B2 glenoid. We've got a biconcavity for minimal bone removal and the B3 may lend itself best to a full-wedge option. And nevertheless, despite these augmented options, and despite the fact that biomechanical studies support the use of augmented in cases of greater retroversion, you still have surgeons publishing very good, short and long-term data with either putting it where it lies or doing partial correction aversion, or again, full restoration of the joint line with correction of the deformity. So we're gonna need a longer follow-up and large multi-center studies to really determine a superiority of one versus the other. Now, what about the glenoid? Why not just forget about a glenoid implant? And this kind of served as the, sort of the rationale for the Riemann run, which was developed by Rick Mattson. And this combines hemiarthroplasty with concentric glenoid reaming. For a slight radial mismatch, you're not putting a glenoid component. And you typically do just a little bit of version correction or just remove the little ridge, if you will, at the biconcavity. It was initially studied in the canine model, and then initial early studies started coming out as early as 2007. We did a review article where really the summary here is that the success of the Riemann run depends on careful patient selection. It's not for every patient. Preoperative education engagement's really important, particularly with a rehab, and you've gotta use careful surgical technique to get good balance or soft tissue balancing. The recovery tends to be a little bit longer. Patients are often young men, and they do tend to get stiff. Some of them have had multiple operations, so probably higher risk for PGI. And you have this gritty sort of surface on the glenoid side. So there tends to be higher levels of pain early on, although by two years, they tend to be very similar to an anatomic shoulder, total shoulder replacement with a glenoid component. Good outcomes have been reported in Seattle and also by others. Tony Romeo and Andy Green has also written about this. But again, there's a higher than typical incidence of early stiffness, and the amount of joint medialization or erosion is variable with the outliers actually eroding pretty quick, so we need to sort that out. I've looked at this on the lower half of this slide, just a select group. I'm very selective about this. The mean age in my series were 46, and you can see it in a blended follow-up for about three years. Pretty good results in only one reoperation. So what do we know about the outcomes? Well, the outcomes of shoulder arthroplasty in older young patients have been disappointing. In spite of objective improvements in range of motion and PROs, half of their patients rated their shoulders as they were dissatisfied with their shoulders. And again, it's hard for younger patients to wrap their head around the idea that they have a shoulder arthroplasty, and often their expectations are not being met. The other concerning thing is higher risk of early revision. Dylan, using the Kaiser database, again, double the risk of early revision in patients younger than 59. When you look at the Australian registry, the population at 55 or younger had the highest rate of cumulative revision as compared to each successive decade, and that's sobering because these are patients we want the implant to last the longest. We looked at patients 40 years and younger. Again, heterogeneous groups, some chondrolysis patients, some AVN patients, and so forth. We included both resurfacings and anatomics. And again, it's sobering. Patients got better, but not anywhere near as well as you might think in an older population. The range of motion improvements, the outcome PROs were more modest improvements, and high revision rates. Joe Abboud's group and the Rush group have also presented on very young cohorts, again, showing the same thing. The revision rate tends to be highest in these very young patients. What about return to activity? This is a study at Tony Romeo looking at Riemann Run versus anatomic. A young group, again, in their early 50s. Return to sports high, fortunately, at 90%, and quite a few of them at the same or better level of intensity. What am I letting my patients do? Can we play the video? This is a guy who's the size of a small house. I've known him for about 20 years. He ran his course from a revision stabilization to arthroscopic debridement, and finally, sorry, can we just advance? Is this, yeah, thank you. So this is him at one year. He's not freaking me out by doing heavy weights. He's just doing his warmup weights. And this is him. He's, again, let's go to the next slide. Let's play the one on the left. Is it playing? Played earlier. So 350 pounds, and then he was doing his warmup bench. Let's go to the right. Can you see this? Pretty, I mean, listen, he's twice the size of me. He's gonna do whatever he feels like. So anyway, I'll stop right there. So in conclusion, I'll do the Riemann run for select very young patients. They have to be totally engaged and committed to the recovery, but the high frequency of revision surgery is concerning. So next, I'd like to bring up Mike Amini to talk about reverse shoulders. Yeah. All right, so let's talk about reverse shoulder arthroplasty in the young. There is still a place for it. We'll talk about where that may be. So I do have some relevant disclosures that you can find in the Academy website. So here's a case we'll start with. I get a phone call from a friend of mine who practices down the street. He says, I got a guy, I figured. 44-year-old, massive cuff tear, work comp, okay. He's already been repaired, okay. Failed, okay, fine. Did an SCR, okay. So I know he's calling me, right. Doesn't mean he's calling me to tell me how well it went. He's calling me for a reason. That failed. So now he needs a lower trapezius transfer, right. This is, I don't know, four years ago, let's say I had been doing tendon transfers and it was just starting to catch on in the community, but not a lot of people were doing it. So sends him to me for a lower trap transfer, but right, this history already, this is kind of the look on my face when I hang up that phone call thinking like, this is just, this isn't gonna go well. No matter what I see with this guy, I'm not really excited about it. So here's his X-ray. I won't even show you his MRI. So here's his X-ray. He's got a massive supra-infra. He's a little arthritic, not terrible. Still got some joint space, but he's got an osteophyte and he's, I think at this point, 46 maybe. And two prior operations. So let's frame the conversation with that guy in mind. So we ask WorkComp to cover a subacromial spacer for this guy. I thought maybe it's worth trying a balloon. He's already had two operations. He failed, he's already proven he can't heal biology. Although he was sent for tendon transfer, I thought that's probably not a good operation for a third operation. We didn't get a response. The guy disappears. And just as I start to really move on with my life, just like Jenny, he comes rolling back into my life. Two to three years later, shows back up, same pain, got a couple other opinions. Nobody really wanted to bite on anything. And now here's his X-ray. Osteophyte's bigger, cromial humeral space looks worse. Now he's pushing what used to be massive cuff tear and a little bit of arthritis now into cuff tear arthropathy, right? 48 at this point, I think. Cuff tear arthropathy, two prior surgeries. He's got a graft in there, or at least had a graft in there at one point. Still has preserved overhead motion on now chronic hydrocodone for his shoulder, BMI of 44. And oh, by the way, remember he's work comp too, right? He's been off work for like five years now. So like if I can describe a description of like the worst possible risk factors for outcomes after a reverse, that's like six of the seven I can think of off the top of my head. So here we are. So now let's talk about reverse for young patients. They have much worse PROs post-op, right? That is very abundantly clear in the literature. If we go into the registry data, this is just for you, Rob. New Zealand registry shows that their Oxford's, everybody's here for this. This is the moment you've been waiting for. Oxford's shoulder score is six points lower than the older cohorts, right? The MCID for the Oxford shoulder score is something around three. This is double the MCID difference between the young and old patients. How many studies do we see in orthopedics that have a double the MCID difference between cohorts? That is significant, right? Australian registry, similar findings. Way different WHO scores after their reverse in the young versus reverse in the old. So very, very big difference. RSA after prior cuff repairs, regardless of age, very clearly have inferior outcomes, worse pain, worse range of motion. Roughly a 20 point inferior ASES score post-op, roughly 20 degrees less elevation, couple of points higher on the pain scale. Reverse in preserved motion patients, regardless of age, also much lower satisfaction rate. Still satisfied, but much lower than if you take the people who are poor motion pre-op, right, so one of Rob's studies actually, satisfaction rate dips into the 80s and into the 70s if you have preserved motion before you reverse. How about revisions? So we've talked about PROs, we've talked about pain, we've talked about range of motion, but revisions, obviously, this is a big deal for this patient population. Reverse overall, 10 year survival, 6% revision rate. It's very, very good, right? It's pushing close to what a total hip and a total knee are. 45 to 50 year olds lifetime revision rate, however, is 30%, and I think that's actually almost an underestimate, to be honest. The reason is that if you think about how a survivorship curve and analysis is done, if you die with your implant, that implant survived forever, forever, forever, right? It's what we want, that's a good thing, but it does skew the data. So if we look at all comers for reverse, survivorship's so high, but it's because for a while we were doing them in only older patients. In the young patients, it's still better than maybe some of the other options, but it is not as good as it is for them, right? Younger you are, your survivorship automatically goes down, which kind of makes sense. Not kind of, totally makes sense. So despite the potentially acceptable revision rate though, lifetime revision rate of 30%, the magnitude of the complications is clearly way worse than any other alternative that you have for them, right? So I think that's, it's not just about the rate, it's about the magnitude of those things. Couple other things on revision, reverses have a higher early revision rate. So these are hemi for cuff tear arthropathy compared to reverse for cuff tear arthropathy. Reverses have a higher early revision rate, and a lot of that is owed to instability. Lower volume surgeons have even a higher early revision rate. And instability is definitely the most common reason, at least out of the registries for long-term revision, closely followed by loosening and infection. So instability is worth a little conversation here. Big risk factors, especially for first-time surgeries, right, revision by itself is a huge risk factor, but we'll forget them for a minute. Males, male gender is a huge risk factor. Young age is another big risk factor. Obesity is maybe one of the strongest, especially if you pair obesity and cuff deficiency, right? Big fat person, less tendons on the head, much more likely to dislocate their shoulder, right? There's more things pushing it out, less things keeping it in, which also makes sense. Our patient has every single one of those. So for stability, although these are maybe a little bit controversial, I'll at least say my thoughts on this. Certainly bigger sphere I think helps, bigger jump distance, we know that from the hip, mechanically it makes sense. A retentive liner I think for the most part can be helpful with one caveat. If you are going to worsen somebody's impingement on the scapular neck, right, because you have now a taller lip on the polyethylene, you might be actually causing more instability by impingement. As long as you're not causing more impingement, then yes, a deeper dish helps. I generally make this patient population much tighter than my little old cuff spherarthropathy, Caucasian females who are getting a reverse. Subscap repair, although admittedly, it matters more in certain constructs. So with a Grumont-style design with a valgus neck shaft angle, medialized glenoid, medialized humerus, subscap repair is very, very important for stability. Depending on how you then change that makes subscap less significant. So I think it's still relevant, but relatively speaking. Lateralized glenoid helps to decrease impingement, improve soft tissue tension. A lateralizer and onlay humerus also helps, and just generally making them tighter. So the other issue is the survivorship and revision rates and registry data doesn't really do a great job of capturing the non-revision bad outcomes. The big one, of course, is acromial stress fracture. Depending on how you want to spin this data, minimum 2%, at least maybe up to four or five is actually a pretty reasonable number to quote to yourself, to your patients. Certain populations that very quickly gets up to 10% and 15%. So osteopenic females getting a reverse for copter arthropathy, that's into the teens for sure. So keep that in mind. Doesn't lead to revision, right? We've been leaving these alone. We're starting to fix more of them, but that's not technically an implant revision even if we're capturing those surgeries. But it does lead to pretty poor outcomes, especially certain subsets of these. Very high non-union rates. Fixation still doesn't work so well. And the location, more medial locations, very bad outcomes. The other thing that we've maybe started to delve into a little bit is there's a subset of patients who just never really gets good pain relief, even if they don't have some of these risk factors like prior cuff repairs, young age. There's just a couple outliers here and there that just don't have great pain relief, and we don't really have reasons. We put them through an infection workup, implants are stable, infection workup's negative, tissue biopsies are negative, and they just have pain after a reverse. There are some of those out there, and we've all seen them in our practice. People have started to postulate maybe some of that is conjoined tendon-related pain. People are doing lengthenings or tenotomies there. But there is that group of patients that no data, you know, large data is ever gonna really capture. So here's this patient. So despite all the bad things I just told you about him, I'm still gonna do a reverse for him. But I'm gonna set the expectations down here, right? Because I think it's really easy for those patients to come in thinking, well, if I need that arthroplasty eventually, I might as well do it now. I wanna be fixed, right? And then I say that is absolutely the wrong thing to think about, right? This is the best of your bad options. On the other hand, right, this patient, I see tons of inflammatory patients who now are just refusing to take their biologics. So we're seeing this wave of uncontrolled inflammatory disease come rolling back in. You know, I see an X-ray like this in a 45-year-old not infrequently, right? There's no other option than a reverse for me. So it is what it is. You just have to make sure that the patient is prepared and frankly that you are prepared for kind of what may be ahead. So the outcomes are definitely inferior for older patients, sorry, compared to older patients who are getting first-time surgery. It's still the best option in certain circumstances. I think appropriate expectations for everyone are important and appropriate attention to try to minimize complications is also very important. Thanks. Thank you. All right, Joe, bring it home. All right, I'm not sure what I'm gonna do at this point. All right, so thank you again for organizing this, Samer. So I get to be the last talk for the second day at 5.50. So it's gonna be riveting on alternative bearings. So did anyone watch the Tom Brady special? Okay, so I got your attention, that's good. It's pretty entertaining. I can't mention any parts of it, but it's pretty darn entertaining. It has nothing to do with alternative bearings, but it's alternative lifestyles, I'll tell you that. All right, so pyrocarbon. I'm gonna primarily talk about pyrocarbon because that's primarily the alternative bearing that's approved in the United States at this point. But there are other alternative bearings that are approved, OUS, I'll touch on. So I'm not directly conflicted with this prosthesis that I'm gonna be talking about, but it is the only one that's available on the market at this point. So straight to a total, issuing younger patients, we've all talked about this already, so I'm not gonna belabor this point. Pyrocarbon to the rescue. When I first was exposed to pyrocarbon, it was 2006. There was a company in Texas, Austin, actually, called Ascension that was then acquired by Integra that was then acquired by Smith & Nephew that had a pyrocarbon that they were trying to get on the market. They actually got it off in Australia as resurfacing pyrocarbon by Mark Ross, but it never got an IDE in the United States. And so, long story short, Wright, Tournier, then Stryker, and then finally approved this past year, so pyrocarbon's available. And what's the interesting thing about pyrocarbon? It's got a long history of use to medical device in heart valves, in PIP, in small joint replacements. It's got a long history of use. It's elastic modulus is close to bone. It decreases, potentially, wear. Coefficient of friction is low, but it is brittle. So you can't, that's part of the problem with the current design that's out there. The only one in the US is there's this platform you gotta hit on, and that causes potential for overstuffing. So it's been studied for long periods of time. Structural properties tend to lend themselves to cartilage preservation. So if you're doing an AVN HEMI, it might be a good thing, but I don't necessarily think that the wear on cartilage is necessarily the same as the wear on bone. So if you have a B2 glenoid, it's gonna still potentially erode that, but if you have an AVN situation, it may be a better potential option. So most of the literature comes from the hand, and how many people here are hand surgeons? Okay, so I don't wanna make any jokes about hand surgeons. All right, so, you know, compare the outcomes to the pyrocarbon versus metal implants. This is looking at Mark Ross and Phil Duke's data. So at six years, the metal HEMI had almost a double rate of revision versus the pyrocarbon HEMI. This is a resurfacing HEMI that they used. So it was statistically significant, and no pyrocarbon was revised for glenoid erosion, but you may say sometimes people are living with problems, not necessarily going to surgery. So as this was starting to come out in the United States, obviously Pascal, I think, is conflicted with this. So some of his data has been coming out. So I believe him, he's an honest researcher, but I do also acknowledge the fact that he's financially conflicted with some of this. So you just gotta be cognizant that there's no real good long-term data at this point. But survival rate, very high, 92%. Revision rates at five out of these 64 patients. So that's pretty good, a significant increase in clinical scores. Another study, again, looking at this, 16 patients, high survival rates. So a lot of the data is promising, and I would say that don't be an early adopter, a quick adopter of new technology just to try it. I mean, I think you wanna make sure you've been involved, read the data. The one thing that concerns me a little bit is the IDE in the United States has not been published yet. And I was involved in that IDE. I haven't been necessarily showing the data myself, but when you have an IDE that's done in the United States by the FDA regulations, it usually is published in a top-tier journal. And I believe it was rejected by JBJS, so I'm not entirely sure why. So that concerns me a little bit about the data. It was a comparative study compared to the historical cohort of HEMIs with a head. It was not a randomized study. So it was a comparative study compared to the previous right medical registry. This is the current FDA-approved pyrocarbon hemiarthroplasty. So it's a stemmed implant, it's not a stemless. It's got that neck there for impacting of the pyrocarbon because of the way it has to be manufactured is a bit difficult. So it doesn't have a role in my practice. I've actually did seven of these in the IDE. I have not used it yet since it was released by the FDA, primarily because of my VAC committee. I just don't want to go through the VAC process, to be honest. But I do think it has a role, particularly in unipolar lesions, AVN. You are seeing some IDEs now with alternative bearing surfaces. So this company has an IDE where the surfaces for a stemless reverse are inverted, so polyglanosphere, the metal tray. And ceramic on poly is available in OUS. It's intriguing possibility. Obviously we've been using it in the hip for decades, but obviously not approved in the United States. So for me, pyrocarbon is an intriguing technology. I'm gonna wait to see more literature on it, particularly from non-conflicted authors. It may limit cartilage deterioration, but that doesn't necessarily mean it limits bony glandular erosion. I do have a case that hopefully we'll get to that shows my seven-year outcome on one of my patients. And he's done well, but you can see there's progressive glandular erosion. And it is now FDA approved. So goodbye, HEMI. I don't think so. We're bringing the HEMI back, but with caution. Thanks very much. Great job. So before we get to the cases, just maybe a good pause. If anyone has any questions regarding sort of the didactic portion, yes. I have a question and probably comes to the case you are presenting. And what about C. acnes infection in this kind of patients? You know, the patient that has a prior surgery and you are just willing to put the reverse, but how much are we willing to go directly to the reverse or probably in the camp? We're gonna do a camp for or something like that. If there is not a total destroy of the bone, but what about the infection with C. acnes? Yeah, so, you know, people who have a reverse, I'm sorry, people who had a prior cuff repair, there's now a couple of studies that have suggested that there's a very high rate of C. acnes colonization, seemingly higher than just the normal rate that you would pick up on a virgin shoulder surgery, which is still high, right? I mean, it's five to 20 something percent depending on what study you read, but it seems to be a little bit higher with prior cuff repair, even arthroscopic. So if I ever do that, if I do a reverse on somebody who's had a cuff repair within the last two years or so, I culture them, my personal culture rate, positivity rate, multiple culture positivity, not one or two, like three out of five or more is pushing 50%, so it's significant. Every other study I think would say it's at least 28, 35, 40%, there's a couple of those out there. So it's likely that there's some colonization. I don't know if that's the reason their infection rate's higher or just having had prior surgery changes the kind of soft tissue lymphatic environment, but their infection rate's higher, like their actual clinical infection rate post-op is higher. So I culture them, I hit them with sort of every tool in my tool bag to try to decrease their infection rate, but it's a concern. So just to, so, but you know, it's the same with arthroplasty, though. For example, if you have a failed arthroplasty, this is sort of akin to doing a single-stage revision. So we're getting the cultures, we're gonna put them on bridge antibiotics, but we're still gonna do the operation we set out to do. And I think my experience has been in failed soft tissue procedures is I can do a fluoroscopic-guided, ultrasound-guided tap, half the time it's negative, serologies are negative, so unless I scope all of them one more time, and even the scope biopsies are not as good, so for me, I wind up not wasting, I'm thinking about it, I'm gonna get my five cultures, but I'm still gonna do the operation I set out to do and treat the problem on the back end, and just do all the other things in terms of, you know, irrigating, doing some of the other things that people are doing, whether it's bank powder or just extra irrigation or some other solutions, to try and perhaps prevent this from becoming a problem after the arthroplasty. And I think that was exactly the question, because one of my partners, he's very, very intense in that. He goes for the CAM and do all the cultures and all that stuff before going, or thinking of going to the reverse. In my mind, I go, take the cultures, do the reverse, and treat it if that's the case. But I'm not sure, and there is no literature to actually tell you which one is better, to do the CAM and wait for cultures or go directly to the reverse if you have that kind of patient. I think another consideration there is I actually spend, so I don't think the concern is as significant for somebody who's had a cup repair 10 years ago. It's really the ones in the last one or two years where my culture rate, because I was doing it on everybody who had a prior cup repair, that 10-year-old cup repair was never positive. It was always the one or two-year-old. So in that sense, I do a little bit more tissue debridement, capsular resection, synovectomy. I actually go take the time to get the anchors out, even if they're not actually in the way of the stem, get all the sutures out that I can find without destroying everything. So it's a different process interoperatively. Thank you. Thank you. Joe, why don't you go ahead and start and present your case, and then we'll just go from there. Thanks. So, can we go back to my talk, please? So that was the last slide there. I'm Joe Abboud. Yep, there you go. Thanks. So I'm gonna, whoops. Yeah, go to the last slide again. All right, so I'll start this off with this gentleman. Oh, go there, that's good. All right, 24-year-old male. This was tail end of the pain pump experience. I had a labral repair seven years prior to presentation. And I would say that back to kind of etiology of young OA, I think a lot of it is us doing unindicated surgery on bases with slap tears that I can tell you is the biggest portion of my practice that's growing, like unindicated arthroscopy by us. So we are causing the epidemic of 40 or younger. You occasionally have the weight lifter, et cetera, but a lot of it is iatrogenic. So developed chondrolysis, 24. This is his x-rays. Not a good looking 24-year-old shoulder. I know Mike's gonna put a reverse in him. Tried a cortisone shot, no improvement. The HEMI trial was underway. Took a while to get his insurers to approve it because they were concerned that he was gonna have something that was un-FDA approved and then they'd have to deal with this 24-year-old for years to come with this process. But finally, they did approve it and I did it. And I would say I'd give myself maybe a B on the AP. You can see he's still subluxed posteriorly. I overstuffed him based on, again, that concern with the imprant. He doesn't see it as well, so you gotta actually core out some of that proximal bone, which I've learned and this is, I think, the first patient I actually did. This is progressively one year, two years, three years. You can see some erosion superiorly and calcar absorption. He centers kind of on the glenoid. Five years, six years, seven years. And this is looking at him progressively. So you can see there's some erosion. It kind of slows down, but it happens, right? And so the debate has been, would you rather revise an eroded glenoid or a polyethylene disease glenoid? Probably I would probably take the eroded glenoid, which is sclerotic bone, right? So I think there's that positivity of it. But then I also look at him and I must say that I wouldn't say that he's the average result, but he's pretty damn good at seven years. I mean, for a 24-year-old, I mean, it's hard for me to tell which side, other than the fact that the x-rays are the right side. So that's my end of seven I did, but that's probably my best one. But I would say for the IDE, I picked the worst of the worst, like patients with sickle cell, with AVN, that were morbidly obese, that were 34. So I think it's a somewhat of a skewed core, for me at least, and I would say it was comparable to how my HEMIs have done, maybe a little bit better than my typical HEMIs, but I still think that the gold standard still for me is an anatomic glenoid, whether you use a inset or onlay glenoid component, I'm not sure about that, but so that's the case I was gonna present, any questions? I, in that time period, I would take a drill and I would perforate the glenoid, so kind of decompress the subchondral bone there. So I would create a bleeding surface, but I did not ream the glenoid, and I would do a capsular resection. I did not, no, but I do know some people that did, but I did not. Yeah, I think you're also just touching upon the point of recentering, and even the Integra implant, the resurfacing that's available in Australia and New Zealand, they commented on that too. So this recentering that you see is real, I mean, and I think that that may be, to your question, a reason why you don't have to do as much on the glenoid side with a pyrocarbon. Yeah, you see, like, here at seven years, it looks like I actually did something to his glenoid. Well, maybe it's because you did something to the erosion, but you didn't concrete it. Yeah, yeah, no, I. Joe, so my understanding of Pascal's data with regard to this issue is that it didn't prevent erosion, but the erosion was less painful in patients that it happened to. Is that your understanding of kind of his published research on this? I mean, he's, yeah, I would agree with it. I would say he does show erosion. Right, they should. But his revision rate is lower, and his satisfaction rate's higher, so. Yeah, and the rate of erosion per year is still a little bit less. It's not nothing, right, it's not a non-erosive implant, it's not something that's gonna replace the total shoulder, which is kind of what it seems like you're hinting at, right, that it's not equivalent to a total shoulder without a plastic, just without a plastic component, right? It is, probably seems to be a better HEMI than a cobalt chrome HEMI, but it's something in the middle between the existing options. Yep. Sam, can I ask you a question on Riemann run? Sure, sure. So if you're, so standard cobalt chrome HEMI in a young patient, if it's an A glenoid, is there a point to doing anything on the glenoid side with a Riemann? B, I understand the rationale, you know, creating a monoconcavity. No, I mean. A glenoid, do you touch it, do you do anything? A glenoid or very general B1, I'm leaving alone. But I am doing releases, so excision, intercapsule, and then A, I'm also releasing the circumferentially, essentially. Leave the labrum. Leave the labrum, so extra, absolutely. And in fact, even when we do a Riemann run, we try to leave the labrum, but as you can imagine with a large spherical Riemann, you're removing most of the central labrum, but there still can be some peripherally left. Why don't we go ahead and do another case. You wanna get up there and present your case, and then we'll kind of work our way backwards. This would be in my section up top, Hartzler. All right, so 53-year-old gentleman, you know, one of the questions is, is this young? You know, there's some debate about that. To me, I considered him young. He was a very active guy, maintenance worker, moderate laborer, but, and a former heavyweight lifter. This was not surgeon iatrogenesis. This was, you know, overuse as a heavyweight lifter, but still very active hiker biker. He was the kind of patient who came in, like, you know, he would have come in for an injection every month, you know, if you'd injected him that often, but, you know, so did it a few times per year for years, now lost its effectiveness. Preserve range of motion. These are his PROs, so you can see he's got moderate pain. He says, I'm 70% normal, you know, night pain's a big problem, difficult to do most of his daily activities, so I thought a reasonable patient for surgery. Most of these patients that I'm considering arthroscopic treatment for, I do get MRIs to make sure that they have an intact rotator cuff and that I understand, make sure that they have a good subscap C. I think it's helpful to know how much biceps disease they have, if they have really bad biceps, kinesinovitis, and other things like that, then I think you can justify a little bit more doing arthroscopic treatment on them. So I already showed that. This is, that's actually that patient. I love the fact that that guy's trashing the arm the entire time for you. He would beat my ass in Philly for that. So, controversial, you know, had an anterior supraspinatus tear, I fixed it. I mean, it makes sense with that big infusion he had in subocclavial space, you know? Yeah, and the chronic cystic changes and the tuberosity, so that's an angry stuff. Yep. So, okay, preoperative imaging, immediate post-op, so, you know, Joe, what did you give yourself for that, for your, what grade did you give yourself? I think I gave myself a B, but I was a generous grader. I think this is a B, you know, maybe B+, definitely got it. You did the scan procedure, the surgical, comprehensive, arthroscopic, management, I'm sorry, it's the CAM, I'm sorry, you just, put the names for it, SHAN, SCAN, CAM. All right, so here's, okay. Rob, question for you. So I've done a couple, and I can get along the backside with osteophytes, I can get inferiorly, I can get kind of anterior superior, but that like mid-subscap region. Yeah, it's impossible. Like, I don't understand how you can get that. Yeah, so. And it always looks, it always makes the x-ray, it shows up kind of anterior inferior on the x-ray. It does, it totally does, yeah. There's a, if you go, if you are a podcast aficionado, Millet and I did a podcast on this, and I asked him that, you know, how do you get those, and, you know, he was like, I tried everything, all kinds of different portals and different ways of doing it, and basically he was like, the only thing you can do is try to maximally internally rotate them, and whatever comes into your view, you know, get with those curved curettes. So you can only do so much. Okay, so, interestingly, he, I, so I continued to treat him for his other shoulder, which sucks, so I can't remember if my PA got these x-rays or if I did for interest here, but two year post-op, you can see his disease has continued to progress there, it's, you know, concentrically worn, and he's very, but he's very happy with his shoulder, so he rates his pain at zero to two on the right side that had the CAM, that had the SCAM, what did you call it, Joe, SCAM, zero to two, zero to two, no further injections, he comes in for injections on the other side all the time, he doesn't want any more injections on the right side, so his left shoulder sucks there, I don't know what we're going to do with that, but anyway. Yeah, so would you do a CAM on that? I don't know. Beyond that point? I don't want to think about it, honestly. Okay. So, I'm not thinking about it. Excellent. Yeah. That's good, thank you. I mean, for me, I'm interested in pyrocarbon right now for this kind of patient. If he, yeah, I'll advanced image and decide, you know, when it's time, but I think I'm more interested for this disease severity because of Millett's data, you know, I mean, his right shoulder was bad, but the left shoulder, you know, there's deformity of the humeral head, I think I would do an arthroplasty on him now at this point. All right. Thank you. Mike, why don't you bring us home with your case? All right. So that's on the top section, Amini Casey on the young OA. Thanks. Thank you. All right. 35-year-old patient. So, this guy, 35-year-old, he had recurrent shoulder instability for eight years. I'll save you the instability side of this conversation, 25% glenoid bone loss, 24% Hill-Sax interval. So, I did a La Roger and I did a rump massage. I actually add a rump massage fairly liberally to my bone blocks, but nonetheless, here's what we did. Doing well three months post-op, stable, good motion. I said, you know, wait till six months before you get back to like unrestricted activity, but I'll just see you at a year. I want to see everybody a year. Let's see how things look. You know, I don't know the grafts are really healed. People say grafts heal really quick. I don't know that they're really healed at three months, but it comes back at a year with this. Stable, but painful. Still has good motion, but very painful. I've had this happen a couple times, and I went back and looked at my post-op x-rays to see if I left the graft overhanging. It's pretty close to being where it should be, maybe a millimeter. I don't know. I don't have a post-op CT to know that for sure, and axillary x-rays are kind of what they are. But it's nothing egregious, but yet here we are at a year. I have a couple others that had reasonably looking positioned grafts that have looked like this at a year. It's not an unanticipated thing. So the question is why, right? Is it because of the graft? Is it because he's infected? Are you going to put him through an infection workup? What kind of infection workup? And then ultimately, what treatment, right? So I'm kind of curious what you guys would say. Joe, infection workup, what kind? What does that mean to you? He's painless. Painful. He has pain. Stable, painful. I would get a CT scan. Probably get an MRI as well. And yes, I've seen, I mean, I've obviously seen infections in this situation. I think if I'm concerned about that, I would do a scope biopsy. I don't do too many aspirations in the office or ultrasound guided aspirations. ESR, CRP are pretty useless. Yeah. Rob? Joe, when you said MRI and CT, what are you looking for there? Let's say you can see, so I can see on his x-ray, graft is healed. If it's prominent, is there really anything to do about it at this point? Kind of cats out of the bag, right? Well, it could get worse, right? Yeah, that's true. And you can still remove the screws, shave down if it's prominent. And I think that. Just to be thorough, young kid, Rob? With regard to the infection part of this question, I would do, I mean, my approach has been basically what Samer said, plan my next operation, do the best I can to work it out preoperatively, but if everything's negative, which you anticipate it to be, because it usually is, then take tissue samples at the time of the next surgery and treat it on the back end. How many tissue samples? Five. How long do you hold them for? 14 days. 14 days. Do you send them home with antibiotics while those are cooking? Yeah, Doxy. Doxy for 14 days? Mm-hmm. Okay. Samer? Yeah, pretty much the same thing, although it really does worry me how rapid this arthrosis, and so certainly, this almost meets the criteria, chondrolysis, rapid, fulminant destruction of the cartilage, right? And infection is in that differential as well, so maybe this is one where I would veer from what I just told Rob to say, and I might go ahead and aspirate fluoroscopic, I might go ahead and biopsy, because if it turns back infected, this one might be one that I would consider staging, meaning do a- What makes you say that? Well, because I'm just a little worried about just how deep-seated this may be. Yeah, this question, it just depends on how committed you are to single-stage treatment. I'm pretty committed. Yeah. And of course, I would say that the biggest challenge I would have with, let's say, doing an arthrotomy, resecting, putting a spacer, taking out the screws, is I don't wanna do a reverse on him as a second operation, so now you've violated the subscap twice, so if you're saying there's no way I'm gonna do that, then you kind of revert back to what Rob just said, which is I'm just gonna do it once because there's no way I'm going through that subscap twice, and this would not be a good candidate for any subscap spearing because these guys are gonna be so incredibly stiff when they have this concentric wear so rapidly. Okay. All right. I don't know if we have, we can probably do one more. I know it's 6.15, but. What was the conclusion? Yeah. I need help. I'm seeing, I saw him like last week. That's just hanging there. Oh my gosh. Come back next year. We'll do this again next year, I'll tell you. Okay. That was his last slide. We'll go ahead and do one more case, and then we can start a little early. I mean, we can start a little late, but I'm gonna close it up just in a couple minutes. Why don't we do a first case of my cases that's in the first block. All right, so here is a 36 year old male, played D1 baseball, had arthroscopic stabilization years earlier, shoulder never felt the same again, started having slowly progressive stiffness and pain. Actually my arthroplasty rep referred him to see me, so let's play the video on the, you're gonna see his motion still preserved. She had seen his x-rays, so he's got pretty good range of motion and sent to me to consider some type of arthroplasty, like a Riemann run perhaps. Now rotate to where you're facing the wall right there, bring both arms straight up overhead. He's still pretty good shape, he's got pretty good motion. He has pain and this kind of grinding in the back. See his range of motion behind his back, that's really what I want to get to. And now turn and face me, elbows at the side, swing your arms outward, okay, bring your arms down. Now one more time, go that way if you don't mind, and now straight in front of you one more time, all the way up, straight overhead, great. Bring your arms down, and now with your back towards me, behind your back, one arm then the other, all the way up the middle of your back. So that's your normal one, and now let me see the other side. So it's pretty limited. Thank you. All right, so his plane radiographs, again pretty large osteophyte, but his elevation was still pretty good. I know I could make his internal rotation better with an arthroplasty, that wasn't sure I was gonna make his elevation a whole lot better. So we got an MRI, or I think he may have had an MRI. Let's go ahead and play the top one, because he had been worked up out of town. So again, very large osteophyte. Joe, what are you thinking about here? Is this something you would do a CAM procedure? Are you thinking about some type of a... When you ask Aboud, you have to say scam. He doesn't hear CAM. No, I mean, I think he's got pretty advanced disease, unlikely to work, but 35 year old, you know, my mentor always used to say, they have no idea what they have, what they have coming at them with an arthroplasty. You know, Jerry Williams would say, they haven't gone through a divorce, bilateral knees, a cabbage, any of the crap that happens to you when you're 50 or 60. So this 35 year old is gonna think their arm is gonna be perfect, it's not going to be, and then you're gonna be owning them, versus you could consider, he had a previous, you know, arthroscopy, maybe something was left proud, there's something still grinding, you could do the CAM. You do burn a little bit of a bridge, but not as bad of a bridge as, you know, in your hands. Obviously an expert arthroplasty surgeon, yes, but I don't think I would recommend it to the general orthopedic surgeon that's not doing a lot of volume. So Rob, that's a pretty big osteophyte, at least as big as the one you showed. Are you doing CAM on this guy? I think this is a good patient for CAM, I think. He's, you know, he's actually got almost like a little bit of a D-wear pattern developing, you know, he's like wearing a little anteriorly, so I, you know, I think, I think this is, this is, well, how much pain was he in? There's a fair amount of pain, I mean he's, he's not catastrophizing, he's a straight shooter, an ex-jock, but he's hurting, I mean he's coming from the town next over to have an arthroplasty. I think you can, you can, you know, definitely do something mechanically to them by removing the osteophytes and doing a capsular release. So I think it's very likely that you can improve their range of motion and their pain somewhat. So this is the kind of person who I'd have a long conversation and tell them, you know, 50-50 that it's gonna make a big difference for you. Can we play the top video? So I agree with that, that exactly was my thinking. So again, pretty significant disease, large osteophyte front to back. However, I did not, so I basically tried to dissuade him from the procedure that he was sent up to see me, and I actually looked at this osteophyte and say, you know what, I do the CAM procedure, but this osteophyte was just beyond my comfort zone. And so I actually sent him to Peter Millett, I've done that three or four times, and Peter did the CAM procedure. Next one I'll send to you, Rob. Did a, did a good job, did a good job, and I talked to him that, that evening, but unfortunately he didn't do as well. And, and in fact, Peter was very upfront about this. He said that this is a pretty bad osteophyte, I'm gonna do my best, and you know, really we set them up, and I did as well, did not throw Peter under the bus, and he's actually taking care of a couple of my patients, one bilateral, excellent results, similar level. And so now he's coming back, eight months post op, his range of motion is tanking, he did well with a cortisone injection, but just temporarily. Mike, now what do you think? So he's had a CAM, but it hasn't turned out as well. What do you think? Are you thinking infection, are you thinking something else? No, I'm not necessarily worried about infection, I worry much more about that with a, you know, implantable operation. You know, somebody had anchors, etc., put in. It's still possible, but I don't even know. So we're headed towards an arthroplasty, right, at this point. I don't even know if I would bother biopsy him, because I don't, I don't want to keep asking myself what am I gonna do when he turns up one out of five positive. Yeah. Maybe two out of five positive, still could be contamination. So I would just plan on doing, at this age still, I would do a hemi arthroplasty. As of today, I prefer pyrocarbon over cobalt chrome. I do have a conflict related to that, but that, I think that's, registry data shows that the pyrocarbon at least has a lower revision rate than a cobalt chrome by about half in the same patient population. So I'm sticking with it. Rob, anything else? I mean, have any of yours, you've managed, you've done nine that you'd consider real camp, meaning big osteophytes, and all of yours have survived up to this date, right? I think so, but I have a couple of patients remote that potentially could have had other, well, they all could have had other surgery, but yeah, a couple that didn't, I thought, think bad enough to potentially have it. So, so anyways, I got a CT, I'm not gonna, we'll just run through this real quick. I mean, it did show just a progressive wear, even though the osteophyte, you can see the head is rounder, but it's not perfect. And so, so again, we talked about options, and I did a Riemann run for him, that's my bias. I thought, I felt that, and so again, this is, these are the post-op x-rays, and see it's kind of centered, you know, and the concern is, is this gonna wear, and how much is it gonna wear, and only time will tell. I have used pyrocarbon, I just did one last week, this was before the pyrocarbon became available. I'm not gonna, I'll just play this one, this is now at one year. I had to do a, give a talk on return to activity after this, and so he's pretty happy. He said he hadn't been able to do this since 20 years, 20 years, and to your point about infection, Mike, you know, even after the camp, he did well for a while, and so for me, I tend to worry more about infection if they just are, they never get out of the gates well. This guy did well, just didn't do well for very long, unfortunately. So what are you doing with the subscap on these? So I, I do, so, so I do a peel when I do anything but a resurfacing. I do resurfacing, it's hardly ever, but those I would just do suture anchors, double row transosseous. With these, I put multiple sutures. I tend to use six, not six, I tend to use eight to ten for a male, seven or eight for a woman, just to have, you know, load sharing, but that's pretty much it, and I do prepare the, you know, lesser tuberosity bed just to scuff it up. Basically Mattson's way, just different implants. Yeah, just, yeah, different implant. I do use high-strength sutures now. I worry about the, most of these stemless implants have, you know, something that's coated that, that will grab and cut sutures if you're not careful, so you just got to be careful with your suture, so I make certain that my sutures are away from whatever that fixation device. And you put the reamer on the glenoid. I do. You did the real deal. Did the real deal, did the real deal, but again, not trying to, you know, correct version. I didn't think that was a big issue here, but just trying to get a nice, try to get good register early on. And it's amazing, even though you're making that, you're, you're, you're, you're reaming through that glenoid, they still, when you do Mattson's rules and you look for 50%, they still spring back. So, you know, you've obviously, if you've tensioned things right, you can still get pretty good intraoperative range of motion or laxity testing. Well, listen, I appreciate all of your patience. Any questions at all from any of you about anything related to treatment of the young arthritic shoulder? So hearing none, we will adjourn. Enjoy your evening. Thank you again. Thanks to the panel.

shoulder arthritis

young patients

treatment strategies

non-operative treatments

arthroscopy

total shoulder arthroplasty

reverse shoulder arthroplasty

revision risks

stability factors

surgical options

patient selection