Anatomic Total Shoulder Replacement Indication Techniques and Outcome. This is my disclosures, none of it is really relevant to this talk. So next 10 minutes for 15 minutes we're going to go over history, indications, colon morphology and outcome, surgical technique, a summary of anatomic total shoulder replacement. To look at the shoulder replacement near one and near two, Dr. Neer is widely considered as the father of shoulder replacement. In 1951, he developed the first hemiorthoplasty was proximal humerus fracture, the near one non-conjuring prosthesis. The 12 patients were fractures and 10, 11 out of 12 were pain free. 1973, Dr. Neer came out the near two prosthesis. The only difference is that he added a glenoid component. 44 patients demonstrated, almost 40 had excellent to satisfactory results. When we look at the near prosthesis, this is a classic article published in CORE. There's only three sizes, a small, a medium, and a large. In some of the original cases that Dr. Neer did, this is published in CORE, and you can see this is one of the patients a little bit high, and the humeral side, this is a little bit low, it's not matched perfectly onto the humeral side. And there's really a need for modularity for anatomic total. You really got to create the offset, the head thickness, the tuberosity height, everything needs to be perfectly recreated to match that particular patient's anatomy. And Dr. Iannari said in JBJS in 1992 that re-establishing the normal going humeral anatomic ratio is just, is important for optimal results, right? Which I believe 100% is a correct statement. In the 1980s, modular humeral components were developed, somewhat less glenoid fixation using polyglenoid on a metal back glenoid was done. Dr. Finland was one widely considered father of this. The modern day glenoid, however, is all poly because metal back had similar failure rate. It's pegged versus keeled. Central press fit has done in certain designs as well as metal pegs. This is a Regener-X peg, a metal component in the back. You got trapecular metal, and then you have a truly metal back glenoid, the FH ortho design as well. When you look at the shoulder anatomy, it has the greatest range of motion of any joint. Minimal hair bony and stability relies all on soft tissue for stability, and there's really very little glenoid bone stock in the shoulder. Indication for total shoulder arthroplasty, the primary or the best indication is osteoarthritis, rotator cuff intact, the humeral head is well-centered, there's very minimal posterior subluxation, very minimal retroversion of glenoid. Rheumatoid arthritis, avascular necrosis, post-traumatic arthritis, prostate fracture are all relative indications. Everybody that comes to my clinic, the first thing you want to do is start with concern management. This includes activity modification, physical therapy, anti-inflammatory medications. I try to get them injections or at least offer them. I like to do an ultrasound guided injection for going humeral joint because a lot of these patients with osteoarthritis have very narrow joints, have a lot of wear. With cortisone, you can do a hyaluronic acid, although it's not typically approved by the FDA for that indication. I don't do that HAI, I just typically do cortisone. You can do in the clinic, you can see this is an anterior and posterior injection. The anterior is for going humeral joint, the posterior for subclonic space. In terms of radiographs, I get plane x-rays and everybody comes in, true AP, axillary, and then a grassy view, internal, external, neutral rotation, and a wide view. Most of the patients, almost 100% of patients get MRI as a primary imaging modality. I look at the rotator cuff. Most importantly, in the glenoid morphology, whether it's retroverted or there's a B2 concave glenoid, I do not get CTs on everybody. Probably 20% of my patients get CTs and those are the patients that I'm concerned about the retroversion of the glenoid stock or it's somebody that needs a custom glenoid based on MRI. That's the only patient I get in addition to CTs. I don't get CT, MRI on anybody. I just typically get MRI and then make my determination based on MRI. This is a really important diagram. You want to look at the glenoid retroversion, you look at subluxation and morphology. The first line you draw on this diagram is called the Freeman's line. It bisects the glenoid in line with the scapular spine. The second line is perpendicular to that and the third line is right on the glenoid surface. That's a glenoid retroversion. Typically, it's neutral to 70 degrees retroversion. You also want to look at subluxation. The way you measure subluxation is a ratio A to B times 100% and 45 to 50% The way you measure this is that you take a circle. After you draw the Freeman's line, this is the distance of B and this is the distance of A. A to B times 100% anything more than 55% is considered a posterior subluxated. You can't talk about anatomic total without talking about glenoid morphology. The wild classification is something everybody knows. It's classified A, B, C, recently D. The most important thing you want to know is that A glenoid is a centralized glenoid with less than 15% retroversion, subluxation less than 70%. A1 is very minimal wear and A2 is quite a bit of central wear. The B classification is retroversion more than 15 degrees, subluxation more than 70 degrees. The B1 just had the human approach on the posterior aspect of the glenoid without a symptom of wear and B2 is a biconcave glenoid. A C glenoid is this plastic more than 25 degrees retroversion and now there's a C2 and the D1 glenoid as well based on how much articulation there is and also D1 glenoid is the anterior subluxation. Looking at total anatomic shoulder, the outcome depends on the glenoid side. You really want to maximize what you do on the glenoid, especially make sure the component is seated well. You can have catastrophic failures like these. You can see posterior dislocation. Humeral head is a little bit too high and then you get a component down here which is a dislocated component. These are disaster patients that needs a revision and the revision often is very difficult to do and the patients just don't do as well at the second surgery. When you look at survivorship on the humeral side, it does not fail on the humeral side. Very rarely does it fail there. In the male clinic experience, almost 1,600 hemi total shoulder placement. The survivorship is about 90% 20 years and then when you take out the survivorship of the humeral side due to glenoid failure, so these are the patients that you had to take out the humeral side to do the glenoid, the survivorship is much higher it's about 95% and then they also find the cemented hemis 2.7% times better than press fit. Looking at survivorship of the total shoulder glenoid is one of the best studies out there 5, 10, and 15 years. In terms of revision as a survivorship data, the 15-year survivorship is about 80%. However, when you look at glenoid radiograph loosening or any loosened line and the survivorship simply drops to 34% at 15 years. So what it tells you is that a lot of these glenoid loosens over time but the patient don't opt for revision either because they don't want a second surgery or they're just living with the pain that they have or they have minimal pain but some quite a bit of loosening radiographically. So it's not a perfect science when you do these totals with a plastic cupola in the backside. Preventing glenoid loosening is really important. Radiographic catastrophically and how do you do that. It's important the type of component they use and how you see the glenoid with your techniques. So when you look at the components peg versus keel components really no difference in literature in the study in terms of radiographic loosening. The second study showed the peg component have a little bit better radiographic survivorship loosening at 15% compared to keel 46%. In the literature systematic review by Dr. Moeller also showed that peg component had lower revision risk and it's cost effective compared to keel component setting. So I use a peg component but if you really I think it's really important just to seat it well. You can use a peg or a keel. Dr. Walsh used a keel component. He had excellent outcomes you know for many years and widely considered one of the fathers of shoulder replacement. And when you look at glenoid morphology versus outcome this is a general study first came out in in 2012. We looked at 92 total shoulder replacement between 1991-2007 all B2 glenoid and found that 16% revision rate only loosing six posterior subluxation in five patients. When you have a neoglenoid retroversion more than 27 degrees there's a 44% complication rate in the humeral head subluxation more than 80% risk factor dislocation was 60%. These patients have bone grafting and if you do a bone grafting five out of seven patients fail. So secondary surgery is not good and patients don't do as well after the second surgery. So Dr. Walsh the second study looked at 27 patients that osteoarthritis did not have a cuff tear. These are all B2 glenoids so he said why not just put a reverse in. In fact that when he did that these patients did very well. They're older patients average age 74. They did much better post-operatively than patient had classic rotator cuff tear. And there's only four complications in the study. In terms of revision when you look at the revision the patient that failed total shoulder replacement what happens to the revision patient? How do they do? This is one of the larger cohorts out there out of Mayo Clinic and they found that even when we revised them 25% underwent another surgery after the revision surgery. And then what happens when you revise a total to reverse 30% post-op complications 20% patient need this surgery or third revision surgery and 76% bone graft incorporated. So the big message here is that really you want to do it right the first time. That's your best chance for success after total shoulder replacement. And some of the disasters you can gone wrong. I just want a patient to refer to me to take care of the patient at total shoulder replacement. Humeral shaft fracture. They plated it. It fractured again. Developed non-union. Went to another hospital. They put a cement rod cement on the top to get a component. A couple of fracture screws distally and then he fractured over that region with this huge segmental defect on the midshaft. So for this particular patient what I did is a segmental allograft that you can reconstruct to put a reverse over that with plate fixation. And then distally I plated over the distal humerus provision. It's a tough case. Just to show you that if you do a total shoulder things can go wrong and can have really have disaster things on right all the time. So in summary total shoulder replacement 2004 indications primary osteoarthritis, rheumatoid arthritis, cuff and tag under 70. You want to look at the glenoid diversion, the morphology, humeral head subluxation, inclination. Patients older than 65 with B2, B3 or C glenoid more than 80% subluxation, cuff and tag. I'm going to reverse. I think that has the most predictable outcome with good survivorship. Under 60 with this morphology these are bone grafting, humeral head. You can use the crest. You can use the humeral head, essential reaming or module component for revision or augmented glenoid. These are younger patients. Between 60 and 65 is patient specific. On the humeral side is a press fit short stem anatomic head cut. I'll show you how to do the next following slides. Cement versus press fit. I like the press fit stem unless you have a really loose proximal bone that you can put a little bit of spend in there but majority of patients are press fit. Any kind of implant that you want to do. In terms of outcome revision total shoulder you want to look at the revision in terms of reverse and however no matter what you do the revision surgery just does not do as good as primary surgery. Addressing the B2 glenoid in 2024. These are biconcave glenoid and what do you do in the young patient. For me is a bone grafting, essential reaming, augmented poly. In terms of augmented poly component this has two to five years outcome data. Good to excellent results in most studies. In most studies poly glenoid will do well in the midterm. Really the big concern is early shifting of these glenoid. Nice CT study that show there is some early shifting between two to five years. We looked at literature system review and reverse for B2 glenoid meta-analysis and we found that really the complication is very similar. Total shoulder with essential reaming or augmented glenoid has similar outcomes as reverse shoulder osteoplasty. It's really dealer choice in how comfortable we are with the situation in a particular patient's morphology. In terms of technique in the next few slides, next few minutes is going total shoulder and how I like to do it. Surgical prep is important. You want to do a scrub brush shoulder, isopropyl alcohol prep with a coral prep three minutes to dry. I'll get everybody ANSEF one to two grams, Benco one gram for incision. I use beta solution throughout the case, BGI and more recently I've been using Intercept as well. You want to do an outband drape, a sandwich technique. The approach is Delta-PEC. I use a Bowie for dissection. I worry about PE agonies in the skin region. In terms of how you get to the shoulder, you can do Lesh tuberosity osteotomy, you can do subscap peel or tenotomy. I tend to favor subscap peel. I used to use tuberosity osteotomy, but I feel like it's sometimes a little bit harder to align the bone to bone. The peel has a very similar outcome to LTO, which Dr. Elthor shown in a prospective random study. In terms of humor, anatomic head cut, you can really just mark the humoral head and cut it anatomically. I use a press stem, fit short stem, and if you have osteoporotic bone, just put some cement in the humoral side. The glenal exposure is important. You want to release the inferior capsule around the glenoid, protect the axillary nerve with a retractor, release the top of the PEC major or top of the PEC latissimus dorsi, and I make sure the anesthesia paralyzes all the patients when I do the glenoid side. I think it makes a huge difference in exposure. In terms of what you use for glenoid side, I typically use a press-fitted central peg and that cement peripherally for the three pegs around it. So here's the exposure, and here's a component of one of my patients here in the retractor placement. In terms of the technoperol on the humoral side, you make an anatomic hug. I just basically mark where I need to make the cut. I make it freehand. You do not need a cutting guide or a jig for this, and then once you do that, whatever component you want to do, you broach the canal, you try to match the patient anatomy. That's the best way to have the best outcome for a patient with a total shoulder placement, and then here's just the stem going down. In terms of glenoid exposure, which is most important, what I like to do is here's a retractor in the anterior region, and then I just release the capsule labrum complex all the way out from the anterior to the inferior. You want to make sure 90 degrees perpendicular to the inferior aspect of the glenoid so that you're not hitting the axial nerve, and when you release that, you're going to get a very good exposure every time on these patients. Here's the glenoid side, whatever component you like to use. This is the component that matches the radial excursion in the back. You don't want to ream past the subcontral bone to cancel out this bone. You just want to ream very minimally and be able to see at least 80% of the glenoid backside to the glenoid. That's most important for outcome. So here's just the reamer coming in, and then I use a three-peg component for the glenoid side. So I draw the first superior anterior peg, put the peg holder in, and draw the backpack last. In terms of sizing and tuberosity and osteotomy, you can cut the tuberosity. In one of our earlier cases, you put the suture around. These are number five sutures. You know, tie the tuberosity, osteotomy, or subscap peel with these sutures. Here's the final repair. You can see, and then I tie the suture to itself after the repair, so that you get almost a double-roll repair on all these repairs. So here's the suture tying down to each other, and then residents just really holding it there. So this just gives you a little bit additional fixation of the tuberosity, osteotomy. And you can see there's a final repair. So glenoid prep, I use a non-candling system. I've been transitioning in the last five years into subscap peel. I think it has the same outcome. It's much easier to put back on. You don't really have to worry about lining up the bone to bone, and the patient has the same exact outcome, and it's very low failure rate. Three sutures. I use a suture tape now, two suture tapes, one on top, one on bottom, and number two fibro in the middle. And I do a secondary fibro on the humeral stem, and then these are horizontal mattress as a tag stitch on the medial side. Check the range of motion, external rotation, and interop to determine best post-op PT. Irrigate beta-isolation VGI intercept throughout the case. Change gloves for glenoid humeral component. Wound closure, 3-0 monocle, dumb bond. I use aqueous dressing so the patient can shower. No drain for these cases. This is the final post-op x-rays. One of my patients, how do you know you did a good job? With the way you measure this, you put a circle around the glenoid humeral component, and you want to make sure that circle matches posteriorly with the tuberosity. If you put the circle in there as elliptical, then you probably overstuffed the joint. The second thing you want to look at is when you're on this actual lateral, you want to see where the peg is. You draw a circle, and you want to make sure that circle is basically in the humeral head is in the middle of the triangle in that region. That's how you know you did a good job on this total shoulder. So the golden rule for total shoulder success and time of replacement, Dr. Joe Walsh proposes you must preserve subchondral bone. Glenoid component retroversion less than 10 degrees, inclination less than 10 degrees, superior inclination. That's where you want to correct to. Subluxation less than 80%, and you want a seating more than 80% on the glenoid, and the patient would do very well. So with that, thank you so much.

anatomic total shoulder replacement

NIR 1

NIR 2

shoulder arthroplasty

pre-operative management

surgical techniques

outcomes

indications

gleneoid morphology