Great, his is working just fine. So Dr. Erickson is gonna present to us on the arthroscopic management of shoulder arthritis in the young patient. All right, well thank you Dr. Romeo and good morning to you everybody. So I've been tasked kind of with the non-arthroplasty, non-biologic treatment of young patients with shoulder arthritis and I'll show you some things and a lot of it's come out of actually where Dr. Preventer is, not necessarily his work but his partner's work. We'll talk a little about what we can do and what our options are and what the results are. So I have no relevant disclosures. All right, so first talk a little bit about our arthroscopic options. I'll kind of discuss with you, is there a best option? And I don't know that we necessarily have a best option with this and then we'll talk a little bit about the current evidence. So this is the issue when you have a patient who's in their 40s and they come in and they're starting to have arthritis and you get an MRI and they have a lot more arthritis in their MRI than it even looks like. On their x-rays, they're starting to get that inferior humeral osteophyte and it's kind of a trigger for you to know that their arthritis may be a little bit worse than what you can see on the x-rays when you start to see that little inferior osteophyte there. And so what are the treatments for this person? Well certainly, we've seen a lot in the knee literature with things like joint lavage, not even a meniscectomy, not doing anything else, just doing a joint lavage. I don't personally do that because I don't think that's gonna give you great success but it's certainly an option to just go in, wash out the joint, see if they get better. What I think is probably one of the best options is to take care of the biceps because I do think the biceps is a pain generator in these patients. And so we talk about just doing an isolated biceps, tenotomy or tenodesis. I think this will address some but not all of their pain and it kind of comes down to what their complaints are before surgery. So are they complaining to you of anterior shoulder pain right in the region of the bicipital tunnel and the bicipital groove? Are they complaining of pain that's at night so that's waking them up at night or when they sit down, they feel like they get stiff and they have to move it? If they're having a lot of those biceps symptoms preoperatively. An isolated biceps procedure is a very good option for this. And I take a lot of actually what I do with the biceps from what Sam and Dr. O'Brien have done in their three-pack exam for the biceps. So I'll usually do palpation over the bicipital groove. I'll have them do a throwing test. I'll have them do a modified, an O'Brien's test, excuse me. And then sometimes if you're really curious about it, you can always do an isolated biceps tenon sheath injection to see if you're getting into the right spot. And so that's an option to determine how much pain is coming from that biceps. If they get great relief with that, then you can say, okay, if I treat your biceps arthroscopically or open, you'll probably have a good result from it. They get no relief from that, then it's probably not the best idea. And so you can treat the biceps in different ways. This is a patient, this is actually the patient from that first slide that had mostly bicep symptoms in addition to some arthritis symptoms, but refused to have any type of shoulder arthroplasty. So you can see the glenoid there is pretty bare when you go in. It's not the best view of what you want to see arthroscopically, but we had this discussion beforehand. So we knew what we were getting ourselves into. And so I usually do the biceps in a sub-pectoral way. I just took a picture of it so you can see what it looks like here, the way it's whip stitched with a fiber loop suture. You can see here when you take the biceps out, and this is actually one of Dr. Romeo's patients, that you can see how much inflammation is around that biceps tendon there. And you can imagine if you take care of that issue in some of these patients, you can get them some pretty good results with this. And the only thing I'll mention to you, biceps tenodesis, you can do this however you like, whatever is good for you. You can do it super-pectoral, you can do it sub-pectoral, you can do it arthroscopic, you can do it open. We look at a lot of studies and I don't necessarily think that it matters. I'm a believer in kind of groove pain and I think the biceps tenode can cause some pain. So I do all of mine open sub-pectoral. And the way I do it is with just a small button. You can use an interference screw, you can use a suture anchor. It doesn't matter how you do it as long as you're putting it at the right spot. And when I say putting it at the right spot, this is just to show you where the different spots are. Here it is with some arrows then I'll show you on the next slide here how we kind of measure the length tension relationship. Because I think it's important if you're gonna take care of this to make sure you restore the biceps function for these patients. So for me, I always try to re-approximate the muscle tendon junction of the biceps with the inferior border of the pec. And so when I try to expose this, I usually actually put a home and retractor through the pec tendon and I'll spin it around the humerus so I can retract everything out of the way. And then I'll have a blunt Chandler usually immediately to avoid anything bad. And then if I have an extra assistant, I'll have an Army Navy pulling a proximal to make sure I'm at the right spot. And then I'll pretty much hold the biceps up to where I think it needs to go and just see where the inferior border of the pec is, see where the muscle tendon junction is, make sure it's at the right spot. And then I'll put my drill hole accordingly. And as I said, the way I do it is with a button. So this is what you see on your post-operative film. So you guys have to tell them, they'll have a little metal on their body unless you do it a different way. This is what I like. There's a tension slide. It brings the biceps down nicely. So anything I'll tell you when you're dealing with the biceps and we're talking about patients with shoulder arthritis, you don't necessarily want to over constrain the joint, but I do think having an upper border subscapularis tear can sometimes contribute to their symptoms as well. So if you have a lot of biceps issues, a lot of times you'll see some of these patients as we heard in some of the talks yesterday in the ballroom, they do have these upper border subscapularis tears. And I do think this is a pain generator. And if you can reestablish basically this rotator cuff cable, which I think the upper border of the subscapularis plays a lot role into, this will help these patients as well. So I usually do this with a couple of fibrillate sutures and I put it into a swivel lock anchor. If it's just an upper border tear, then you can see that you nicely re-approximate the upper border of the subscapularis there. So this patient obviously does not have significant arthritis, but I do want you to just be mindful of if you're taking care of the biceps to make sure you don't forget about the upper border of the subscapularis. Now, there's some other options too. Of course, we can just take out loose bodies, right? Some of these patients are gonna form loose bodies. Sometimes they get stuck in the subscapularis recess, they cause them a lot of pain. So that can be another option for you arthroscopically. And then probably the procedure that's seen the most in the way of literature and results is the CAM procedure. So this comprehensive arthroscopic management procedure that was described by Dr. Millet. And basically it involves a series of a few things. Sorry. So you do a glenohumeral chondroplasty, okay? You take out any loose bodies that are in there, okay? You will take out an osteophyte, that kind of inferior beard osteophyte from the back. You'll do a capsular release to improve their motion. So anterior, inferior and posterior. You also do a subacromial decompression. And then if you have the guts to do it, you can do an axillary nerve neurolysis. I generally do not do this, but this is how they describe it. And then you can also do a biceps tenodesis with this. So this is just one of the patients that I did this on. Again, you can see the inflammation on the biceps tendon as you pull it into the joint, being a pain generator. I just wanted to show you here. You can see that as you're looking from the back and there are some videos online that Dr. Millett has, but just to show you an idea of how you get around the back. And after you've done your release, your capsule, you can see what you're doing. You can get your shaver in there and take down that osteophyte. Now, if you kept going inferior here, you'll start to see the axillary nerve come around. So you can gently with an ablator or with the shaver, not with any suction, you can expose the axillary nerve and make sure that's freely moving. Again, like I said, I don't generally do that with this just because I'm not as comfortable exposing the axillary nerve there. You can see you go up top, do a subacromial decompression. And then we do our biceps tenodesis portion of this. And so to the point of, is there a best option for this? The literature regarding arthroscopic management of blunt hemoarthritis is very much one-sided. It's pretty much all for the arthroscopic CAMP procedure. There's not a lot on isolated biceps tenodesis in patients with arthritis. There's not a lot on joint lavage or loose body removal. So I'll show you here, the studies surrounding this are really on that CAMP procedure. And so if you ask me, what's the best option, that's probably the best option because it's what has the most data behind it. And if you look at some of the results of these studies, and I'll go through them with you, they're actually pretty good in the right patient. Every patient is not a candidate for this procedure. And the reason I think that Dr. Millick gets such good results is because he's very selective in the patients that he chooses for this. It's not every young patient that comes in with arthritis that's getting a CAMP procedure. Specific patients, specific complaints, and they have to be willing to understand that they're probably gonna have a low level of discomfort in their shoulder long-term because they still have their arthritic pain. So if you look here, this is their first study that they published back in 2013, and they basically reported the results of 29 patients that underwent this arthroscopic CAMP procedure. You can see the demographics of the patients there. Majority were men in their early 50s. And what they found was that about two years, six of their 30, so 20%, progressed to a shoulder arthroplasty. They did well after the shoulder arthroplasty, but 20% went on to a shoulder arthroplasty. And what they found was patients that had less joint space, as you'd imagine, were more likely to progress on to a shoulder arthroplasty. Now you can see the kind of copathologies and concomitant procedures that they did with these patients here. So again, doing the debridement, capsular release, that happened in everybody. And then going down the list of loose body removal, synovectomy, some people they did a microfracture on, which isn't really part of that procedure, but they did it in some patients. And then they also did the axillary nerve release only seven times, so they don't do this quite as frequently. And then again, the decompression, the biceps tenodesis. And what they found was that in the 24 patients that did not progress to shoulder arthritis at 2.6 years, they found significant improvements in all of their clinical outcome scores, as well as their range of motion, as well as their satisfaction. So they were pretty happy with the results of this study. And again, this is short-term results, but in the short-term, this seemed like it was a very good idea. And you can see here the change in their motion from preoperative to postoperative, and then taken out to two years. And you can see what a dramatic increase it was. These were patients that had a huge loss of motion, and they gained a ton of motion, which was significant in both elevation and rotation, both postoperatively, and then again at two years. These are just to show you the scores that improved from the clinical outcome scores, the ASES scores. And then when they asked their, basically questions of how much their pain was limiting their life, you can see that all of those scores improved as well. So then they took this out to 10 years, because you want to see, okay, we don't want to just give somebody a year of pain relief. That's silly, it's not worthwhile. So what are the results at 10 years? So again, they had a few more patients at this, and they had 38 patients that they did the CAM procedure on. Again, the minimum follow-up was 10 years, went out to 14 years total. Again, patient age about the same, around 53. And what they found was that the survivorship for this at five years was about 75%, and it was a little over 60% at 10 years. That's pretty darn good in patients that have a lot of arthritis in their shoulder. So this is actually a very good option. To get somebody an extra 10 years for prolonging them to having a shoulder arthroplasty, that's excellent. So this procedure actually is doing very well long-term. So what you can see here is, these are some of the patients, they kind of broke it down to patients that were able to survive their CAM procedure and didn't have to have an arthroplasty versus those that did have to have an arthroplasty. And when you look at a lot of the things here, basically what they found was that if the humeral head was not congruous, so it was basically subluxating a little bit out the back, those patients did worse. That was one of the only factors that they found as a risk for failure with these patients. And so when we take a look, you can see here some of the survivors and failures. There weren't a lot of significant differences for what they did intraoperatively. So there wasn't something that they should have improved on from a surgical technique perspective. And when you take a look here, these are just the outcomes based on five and 10 years for the clinical outcome scores. You can see the significant improvements that they saw. So, and they tried to figure out which patients are gonna fail, right? Because you wanna try to avoid this in patients, it's not gonna do well. And so what they did was, they tried to aim to define factors that would predispose patients to having an early failure. So then, again, they had 107 shoulders. You can see the number of patients is getting higher and higher in all of these studies, starting in 2013 and coming out to 2017. Again, mostly men. And what they found was that 17 of the shoulders, so about 10%, progressed to a total at about two years after surgery. And so they kind of, you can see here the decision tree of things that they had. And some of the patients that didn't progress onto an orthoplasty had to have a revision procedure, whether it was a loose body removal or manipulation again. And what they found was that, as you'd intuitively think, less preoperative joint space. So potentially more significant arthritis was a risk factor for patients failing. Older patients, actually older than the age of 50 was a risk factor for them failing. And then starting to have some glenoid deformities. So getting that B2 glenoid, starting to posterior subluxate, or having a type C glenoid were risk for failures in this group when they took it out to 10 years. And you can see here the successful versus the failed CAMs. And again, that joint space, depending on, didn't matter where it was, superior, inferior, et cetera, was a risk factor for these patients failing. You can see here, as far as patient demographics, the only issue is really the age. So age over 50 was the only thing that really predisposed patients to failure. Otherwise, none of the treatments that they did, none of these demographic factors made a difference in whether or not they were gonna fail. And so this is their decision tree in patients that come in with glenohumeral arthritis on whether or not you should proceed to an orthoplasty or whether or not you should consider having the CAM procedure done. And lastly, I tell you, the thing you wanna make sure when you do these procedures is we're trying to push people off from having a shoulder orthoplasty, similar to what we do in the knee by giving them different types of injections and things. Are we negatively impacting our total shoulder that these patients are probably inevitably gonna have down the road by doing this procedure? And so again, Dr. Millett's group looked at this. And basically the bottom line is no, you're not. So the surgical time wasn't any worse. There wasn't any difference in the total shoulder outcomes. So this procedure did not negatively impact the next procedure. And I think that's really important because if you're gonna do something to somebody, you don't wanna set yourself up for failure on the next procedure that you know you're going to have to do. And based on the results of their study here, basically you can see that there were no issues post-operatively for the patients that had a prior CAM procedure and then those that did not. So you can see here the ACS scores were the same. Quick death scores were the same. There were no difference in any of these scores. So it's probably worthwhile to try this procedure in the right patient. And so just kind of wrap it up. We know shoulder arthritis in young patients is a difficult problem. There are some arthroscopic solutions for this. And I would probably tell you that based on what the data says, the CAM procedure in the right patient is probably a good option for these patients who really wanna push their arthroplasty out five, possibly 10 years. Do you have any other questions about some bicep stuff? A lot of the people in this room, some of the authors here, helped contribute to this book, which is out now. And there's also an interesting app that's coming out. It's kind of like an Instagram for surgeons that I've been starting to mess around with. So it's called Surgeon. We'll see if it is worth anything, but it's coming out. So it might be worthwhile to take a look at. Thanks. Thanks Brandon. I think that the arthroscopic surgery is a great option for some of our patients, but you really have to make sure you have the right patient. It's kind of like we'll maybe talk a little bit about the Riemann run, but you can see that it's not perfect. It does work well, but you may have to go back and do another surgery. You may have to do a manipulation, and as long as you have the right patient, they want to keep working towards that. I think that's potentially a good option. I'm just going to back up just for a minute so you understand our program for this morning. I apologize for this being out of order. We did check it before 7 a.m., and it was working, but unfortunately we had a technical glitch there. I apologize for that. Our learning objectives are in the program. We really want to know about the non-operative and operative management and understand where those thresholds occur. As you heard from Brandon, an A1, 2, or possibly a B1 may be a very good candidate for arthroscopic surgery, but applying that to a B2 or a C or a D, you're not going to get the same results. The faculty were selected by their experience, by the amount of research they've done, and really looked into these different topics. Each of them have a tremendous amount of background. Brandon is at the Rothman Institute in New York after his HSS sports and shoulder fellowship. He trained with us at Rush University in his residency. He was an undergrad at Notre Dame and has done a lot to publish about these things. Matt has already a household name in orthopedics and sports medicine and shoulder out at the Stedman Clinic. He was the chief of sports at Mass General, took care of the New England Patriots, and was a fellow with us at Rush after he had already been in charge of the sports and shoulder section at the Navy Medical Center in San Diego. He had tremendous experience with these young, athletic people in the military that had arthritis, and they want to continue to do what they do, and how do you make that happen? Sam also has had a great career. He's currently at HSS in the Department of Sports Medicine and Shoulder, and he's the team physician for the New York Giants. He's done a lot of research and interesting work in this area. His undergrad was at Harvard, where he was a wide receiver. I thought he was a tight end, but he says he was a wide receiver. He's done a tremendous amount of work on shoulder arthroplasty and the things they're doing there. I've been doing this for a little while, almost 30 years involved in these things. My conflict of interest is I have designed and developed arthroplasty products for arthrics for a long time. We try our best to stay focused on principles and not specifically any kind of industry ideas. These are really about the principles of managing these different kinds of conditions. What's the scope of this problem? As you can see here, the number of shoulder replacement procedures is going up dramatically. You'll see in the literature published oftentimes numbers that are only like one-third of this. That's because they're just using Medicare data. If you get the industry data, this is the real numbers. You can see right now this year we'll do 170,000 shoulder arthroplasties and just recently more reverses than anatomic. That's rightfully so because of the complexity of the problems we see in the shoulder. What a great device that has been for us. These numbers are going up just like you see in hips and knees. It's going up dramatically. We're going to have more and more of these patients we're going to have to try to figure out how to manage. We've talked about this. Glenohumeral arthritis in a young patient, what can you do arthroscopically? Brandon gave you some ideas about microfracture. We're pretty limited on that, just one side, not both sides typically can be helpful. The CAM procedure and looking for other sources of pain whether it's AC or biceps. One out of four adults in the United States have arthritis, one out of ten the shoulder, and there's about 330 million people. That's a lot of people with shoulder arthritis that are coming to us. Uniquely in the population that we're talking about this morning is really defined by what Dr. Mattson did when he looked up the cases that came to his office. Over age 50 it's mostly osteoarthritis. There's some very specific principles of osteoarthritis that don't apply entirely to our under 50. We just have to keep that in mind. Some of these cases are very challenging and unique and different. When we say the patients we'll hear wait as long as possible because it's only going to last five to ten years, it's really not fair. If they have osteoarthritis it should be 90% lasting at least 10 years and at least 70% or more 15 years. The problem is under age 50 not that many people have just plain osteoarthritis. That's why it doesn't last as long, it's tougher problems. We've struggled to figure out how to make that work. Capsular or arthropathy like this you've got a patient who's got a very stiff joint, they've got no external rotation, they've retroverted their glenoid, they've got hardware in place. This is not osteoarthritis. You're not going to get the same result in these patients and this could be a 35 year old. We just have to keep that in mind when we're offering our patients some things that we can do for them. With the recent advances in both anatomic and reverse you have to also keep in mind the many, many different options that are available. A reverse shoulder arthroplasty in a 30 year old seems crazy but may be exactly the right operation for some of these complex situations. We certainly favor anatomic because of its range of motion and because we think we're doing a really good job in getting these patients to last a long time too. Then other advances like outpatient surgery really helped us along. This is just an example of a patient preoperative plan, capsule release, stemless device, all poly glenoid, subscap repair. Outpatient procedure went home a couple hours after surgery. She's a 50 year old lady. She had her right shoulder went straight up to the air. That was replaced about three years ago. She came in, she's about two, two and a half months out from her left shoulder. She's going to show us here and these are the kind of results. She's back to doing her yoga, two and a half months, has no pain. Her range of motion is not equal to her right side, which really has full range of motion, but she's going to get there. We have learned how to create arthroplasties to match up. This is her, again, less than three months and you can see her subscap is functioning perfectly fine with the types of repairs we have and making sure that the humeral head size is correct and they can do remarkably well. So Brandon just gave you the presentation on arthroscopic management and certainly there's a patient population we want to keep in mind and now we're gonna have Matt talk to us about the biological options for shoulder O8. Matt, thank you. Great overview Tony. I find this a particularly challenging topic in terms of how we manage our patients that really for whatever reason, genetics, post-surgery, post-injury, PTOA, post-traumatic osteoarthritis, which by the way from the NIH and DOD is in general the number one funded line for us in orthopedics, so it's a big problem. So many of these times are just post-traumatic and they're young, they're 20s, they're 30s, they're 40s and many times just don't have great options. And so I'm going to talk about this, the injections I've left off for the most part, but we can talk about that on the panel in terms of what we would do and how we would increase some longevity in the injections or other options or even injections into the humeral head, into the glenoid we've entertained and done. So there are some options with that, but again these are more investigational. They are a challenge to get paid from a CPT code as well as these are a little bit of a challenge to get paid, but usually you can get some of this through especially with our evidence in terms of what we're doing. So I've sort of broken this down to more palliative and we talked about that, to reconstructive, and then small and large lesions when you're thinking about these chondral defects. And first of all, guess what, we don't walk on our shoulders, so many times we can get away with not having, you got this on MRI, you've got this on arthroscopy, but it may not be an issue. But when you're getting something like this, it's a big problem. And so these arthroscopic debridements and as Brandon showed, even just a capsule release, biceps tenodesis, and this is me doing a capsule release. It's very similar to the way Dr. Romeo does it, where I use a basket all the way around 360. So it's really a capsulectomy where I'm taking about two to three millimeters of tissue. You can certainly use a heat stick or a wand and do that, but you have to be careful in the axillary nerve. There are reports of axillary dysesthesia, even a burning sensation in the deltoid, and case reports using RF down inferiorly in that power. So you have to be really careful. When we then look at these reconstructive options that I'm going to try to focus on, and these are the young patients, ones that just may not have a great option, and they're in their 20s, their 30s, their 40s, and we're just not entertaining a HEMI or a Riemann run or some of these other options. And we're talking about these biologic resurfacing. When you look at this, you had 30 patients aged 15 years or younger. The problem was 30% reoperation rate. And so I always tell these patients, you are going to need a tune-up on your shoulder, and you're going to need more things down the road. And it might be five years, seven years, nine years, but we may be able to give you substantial benefit. It's not going to be perfect. We may be able to give you a substantial benefit for this short term, but we're dealing with a very challenging problem. And these biologic resurfacing using all types of grafts have been very good, and you can improve ASES pretty significantly, but when you're looking at a 72 ASES score, it's not that great. And that's what this study showed. They did improve from the 30s and 40s, so there was certainly a 30 or 40 delta in their ASES score. So we are improving something in which patients are very debilitated. Why? Because they're young and they're demanding, and that's the balance we have to maintain in terms of trying to provide longevity and improvement of their shoulder. But these are the types of things I talk to my patients about when they come in with some of these very challenging problems. So here's a review of this, a systematic review. This was just published this past year. 268 shoulders of biologic resurfacing. There's not a ton of evidence out there, but we're getting better. We're figuring out what might work better. Most of this was lateral meniscus transplant, lateral meniscus allograft. Why lateral meniscus? As you know from the knee, the meniscus on the lateral side covers much more of the tibial plateau, and so it's got a much wider surface area. We know that if we lose lateral meniscus in the knee, that's a very bad problem. That's why the meniscus is so big, and that's really been the workhorse. Now we're getting into the acellular dermal matrices, and that's really been one of my workhorses for these on the glenoid. Achilles tendon allografts have actually worked quite well. Shoulder joint capsules, fascia latae autograft. I'd probably stay away from that, but then usually those are overseas studies out of Japan where you don't have allograft options. We've really stuck with the allograft for the workhorse of these reconstructive options on the glenoid. Here's another study looking at biologic resurfacing. Achieved satisfactory results in rheumatoid, but unsatisfactory outcome in some of these others. Rheumatoid is a very challenging problem. Many times we're thinking about, okay, do we do a hemi or do you go right to the reverse? A total shoulder does not work well in a rheumatoid or any type of inflammatory arthritis, and that's another patient we will see, another population that has these early arthritic shoulder problems we have to be very careful of. But the discussion really, depending on their age, is when's your eventual reverse going to be? Because that's just the absolute best option for someone with some level of inflammatory arthropathy. When we're looking at microfraction, we uncovered a little bit of this. This is one way to do this, a lot of different probes. I actually use something that's actually very small. I use a small K wire. I put it through a cannula or even just like we're doing anchor drill. A lot of times we have these knotless and all suture type of anchors. I'll actually open up an anchor drill, and that works quite well. One of these very small ones, a 1.1 millimeter drill or even smaller, or you can put a K wire, a long K wire down these cannulas with the anchor guides. You can come down and do a very nice job. Many people advocate advancing labrum tissue over this glenoid. Now, is this really a symptomatic lesion? Maybe. It's a GLAD lesion. There's some injury, but a lot of times you have these bipolar problems. Obviously, here's the picture we all like to see, and everyone shows it after you turn the water off. You get this very nice marrow response, but how much is too much? A lot of times when I see this, and if I feel it's symptomatic, or if they have this thick capsule or other associated conditions that's going on in the shoulder, bad biceps, very thick capsule, inflamed, thickened, why is that happening? It's because the cartilage is not there, and so I will usually treat that or do something, and then our mind trying to separate out, okay, is this cartilage lesion real or not real for the patient? I think that's the one of the biggest decisions to make, but I do microfracture, and it actually, with second looks, guess why? Because we're in there again for tune-ups, second looks, this actually looks pretty good. Now, let's talk about some of the allograft. This has been more of a workhorse for me, and again, the patient selection is absolutely critical. A lot of times, these are high-demand, isolated focal defects, such as humeral head focal defect is really good. Here's just looking at large heel sacs. When we looked at this, and this article was 19 patients with large heel sacs. This was a frozen graft from overseas, and so they did have some resorption in this. We use fresh allograft, and whether it's for the humerus or the glenoid, we're mostly using ankle products at this point because they're just much easier to get from our graft companies, and I'll talk about that in a second. When we're looking at some of the midterm results, there's 20 patients, significant improvement in VAS. You're getting down from a six. Again, the six pain score is pretty bad on the VAS, and going down to 1.5, we're liking that, but again, ASES is still a little sobering at 76. This is not perfect, but it's a lot better, but you're going from the 30s to the 70s. It's pretty impactful. I can tell you the patients are pretty happy, but they don't last forever, and the osteochondral allograft is a pretty good viable option, but we have to be careful about that. Why? Many times, we're taking down partial subscap, top of the subscap. Many times, I'll try to sneak it in if we can through a subscap split or an inferior subscap peel. Again, why? We're going to be going back to that shoulder, and the subscap is of critical importance. So here's a case, a 24-year-old male, sorry, Navy parachuter, one and a half years after an instability repair, and we've seen this case and pain and mechanical symptoms. So my plea to you is if you have a patient after instability repair, and again, our anchors are getting better, our techniques are getting better, we don't know if the anchor was left proud or was pulled proud or it pulled out. Those are very tough decisions to make from imaging and or your arthroscopic findings, and I get asked about that all the time, especially in the medical legal, and I'm always saying, listen, you don't know where that anchor was at the end of the day, and this thing could have pulled out. So it's a very, very tricky scenario, and sometimes we get what's called anchor arthropathy, and this is exactly what's going on here. And so you're seeing a significant deformity in a 24-year-old of this humerus. It's flat. It's not round. You can see the inferior osteophytes, but this presented over a 1.5-year time frame. So my plea to you, and this patient was referred to me, but I was like, well, when did your clicking and catching mechanical symptoms start? Well, it started like from week one, and I just couldn't get it, and my therapist was grinding on me and pushing, and I felt crunching and clicking. I'm like, it's really hard to see on imaging. Obviously, get the MRI if they're not doing well, but here you can see what I call linear stripe wear in the humeral head, and what we have is a anchor that came out at some point. We don't know when that was, but you can see the linear stripe wear. That's not a Hill-Sachs lesion. That was not there before, and on that humeral head, you can see now the osteophytes developed, and right there above to the left is that linear stripe wear of the shoulder moving around in what we call anchor arthropathy. And so with this, in this linear stripe fashion, here it is. You can actually see the path that the shoulder takes with a fixed point on the glenoid where the anchor was rubbing. It's pretty interesting. You can see that almost v-shaped line of where the anchor was in a trajectory for the shoulder. It's like all these mapping studies you do in a bio-motion lab. It was pretty interesting. Did two osteochondral plugs. Took down about the top two-thirds of the humerus. This one, I was able to get a fresh humeral head, but most of these now, I am doing a fresh talus. The reason is a fresh humeral head is very challenging to get from our graft companies. It can take three to six months, and it can be on the list. I've had some that are on the list for one and a half, two years, but what we found is since the tibia fits the glenoid very well, the talus will fit the humerus very nicely, and it's a very nice radius of curvature match. It's very dense bone. The cartilage match is very close. We published on this a bunch, and it doesn't give you everything though, and up to about 35-38 millimeters in diameter, so I can get two plugs almost like this similarly from one fresh talus bone, and these are put up for the foot and ankle surgeons all the time, and so they're available readily. I can get it in like a week. It's unbelievable, and usually, especially with some of the evidence now, we can get that through insurance pretty reasonably, sometimes a little bit back and forth fight, but you know, these cases don't come along that often, so I always think it's worth the fight, and here is what you're seeing at nine months, sorry, you see it at nine months post-op. You see this young guy. You can see the integration of that fresh allograft, and I think the fresh allografts we've shown to be much better, whether it's a fresh distal tibia or the fresh humerus or the fresh talus, those have healed much better with less resorption than some of our colleagues overseas were using frozen, prily processed bone and other things, femoral head, etc. Proximal tibia has been utilized in the glenoid, so there's a lot of things out there, but that resorption rate's been much higher than what we've seen, and here you can see after nine months, you get pretty reasonable function, but again, this is not going to last forever, but he's 24. Case two, it's a 35-year-old right-hand dominant female. It's another interesting case, but I just bring this up for something to think about. When you see these, she was mountain biking in Vail as a very aggressive 35-year-old, and they take the gondola up and go down at about 50 miles an hour on their mountain bike, so it's a level one trauma to the shoulder, either going 50 miles an hour and don't have a seat belt on, but they have a mountain bike accident taken to the ER, and we've seen this many times, and just FYI, I know we all know this out here, but this is the number one closed claim from a medical legal standpoint from an emergency department presentation of the shoulder. Number one. Why? Because they're comfortable in a sling in internal rotation, you don't get an axillary view, and you miss this type of dislocation, so she was actually sent to the CT scanner in the ER. I usually like to get the CT after it's reduced, but sometimes these are hard and have to go to the operating room because they're so notched in, and this is a reverse hill sax. I particularly don't like the term reverse hill sax because it's very different than a hill sax. The reverse hill sax is all cartilage, and that's a big problem. The regular hill sax only becomes cartilage after it gets pretty big, so this is all cartilage. Usually when we looked at these and looked at our posterior dislocations, it's about a 35 to 45 degree arc loss on average when you have these large hill sax. So here's what we use, the fresh talus. We get this, and I take down the top two thirds, trying to preserve as much subscap as possible, but it's right there. You sort of have to get through this, and it's always in an orange slice or a lemon wedge type of configuration. The bone is very compacted, very sclerotic. There are some case reports out there of people percutaneously tamping these up, pushing it out. I have tried that. I have not had much success with that because the bone is very fragmented, but I would put it on the table for certain patients. You can tamp it up. You can put some bone graft from the back, and under fluoroscopic imaging in the OR, that may be an option, but what I've done is just sort of use this as an opportunity to reconstruct this. So here's the talus. You have to do wood shop class 401, and it's back and forth and back and forth. I actually bring the sagittal saw. I have a cordless one, so I bring it up to the back table. I'm sorry, the mayo stand right next to the shoulder, so I can go back and forth. The other thing I'm doing a lot is three-dimensional printing, and so I will actually three-dimensionally print it. They will sterilize it for you and stare at it, and it's actually pretty nice, and in your towns, you can actually find a 3D printer if you don't have one. I have one in my office, but if you don't have one, you can send it to a 3D printing commercial company, and even some of the companies and our vendors are doing this now, where you can actually three-dimensionally print this, and you can use a wax mold, so you get some bone wax and do a reverse wax mold for this, and you can actually put it in really nicely and plan really well from a reverse wax molding, and so here's what we do. We wood shop it up. We get it in place. What we're really looking here for a match is the radius of curvature. We're looking for how this fits in. I fix it with headless compression screws, and you can see this is the type of repair we get with a big reverse heel sax that was five months, and here's what we're getting at the end of the day, and this patient does very well. We repair the subscap in usual open fashion, your choice, and these patients do very well, and you can see the humeral head well centered, and she went on to a great outcome. One more case, a 36-year-old female, two-year history of persistent posterior instability at a previous left shoulder arthroscopy, chondroplasty, microfracture, et cetera. Posterior symptoms resolved, now has pain with loading and other problems. The x-rays, you can see a small inferior osteophyte, and then when we get to this, you can see some of the humeral head changes anteriorly, and you can see where this story is likely going, and here's our interop findings of this wear and tear type of lesion. It was all pain. She also had associated stiffness, which always goes along with this. Loss of internal rotation is almost always the first thing you find. A loss of external rotation at the side, and here I am actually using an oval graph. This is actually a knee type of product that actually fits really well, and so she had a pretty significant bipolar lesion due to anchor arthropathy, and so there's a fresh distal tibia, a cylindrical graph in the glenoid, and a bio-uni knee application that I applied to the shoulder and put this humeral head graph from the talus, so I had to get two graphs. Fortunately, each of these graphs are almost cumulative. The two graphs are about as expensive as a femoral hemicondyle that we get, so it's definitely not cheap, but you can get two graphs out of this. That's about an 18 millimeter diameter on the glenoid, and that's a kind of a hub cap that I put in. I put two small 2.5 millimeter headless compression screws, titanium. I love using titanium for this. I love using headless compression screws. It just gives me the best compression. There are other products out there that have the plastic type screws or PLA screws. Those are okay, but I've also had issues with those where the head has broken off those screws fixing these lesions, so they're not perfect, and the way it's designed, there are some issues with it, but you can see there's some other unique options for her, so in summary, you get these in young patients. It's a big problem. We don't have all the evidence, but we're certainly pushing the envelope. I acknowledge that. We have to be very careful talking to your patient and tell them where these are going to get. They're going to get in the 70s, 80s, maybe high 80s, maybe low 90s if it's a home run, but many of these patients are starting in the 30s. Keep that in mind. They're miserable. They're young. They're active, but guess what? They're young and active. They're going to chew this up, and so then we're going to need our next talk to help them out down the road. Thank you. One question, Matt. Can you just clarify? There's a lot of talk about that. You keep saying fresh graft, but there's a lot of offerings of the frozen graft as being equal in terms of its biology and having the same amount of cartilage and everything else. Come right here. Just one quick question, and then we'll have Sam come up, but I think it's an important thing because a lot of people are asking about that. In general, I trained in San Diego. We had a very robust, fresh allograft program. You look at people like David Amil and Bill Bugbee and others. It's really one of the places that had fresh osteochondral allografts first on the roadmaps. We've been doing this for 25 years from a fresh allograft standpoint, and so that's why I've used it, because we just had such great experience in the knee, great experience in the elbow with dissecans, very good experience now in the shoulder with these healing very reliably. Now, that being said, my good friend Ivan Wong and others overseas, Ivan is in Canada. It's very challenging for him to get fresh grafts, so he actually has a frozen bank up in Halifax, Nova Scotia. Go figure. He's got a frozen place up in Halifax, but he's got a frozen bank that the hospital runs, so he's using frozen distal tibias and frozen talus for the shoulder, and he showed very good results, Tony, in terms of less resorption, and clearly that would be the way to go. I've been too scared to do it yet, but Ivan's been paving the way, but he's been showing very good results with minimal resorption. Our resorption rates overall, the whole graft, have been anywhere from 8%, 9%. It's not these 40, 50, 80% we've been seeing in the past, so that's why I've stuck with it, but I think we'd be really enviable to have these frozen grafts. Why? Available, probably off the shelf, maybe in your freezer, and much less expensive. Thanks, Matt. So we'll move on, and Sam's going to talk to us about our arthroplasty options, particularly for these younger patients, so we have to really put our thinking cap on, on how to manage that. And then we'll go over some cases to try to pull a lot of these thoughts together. Thanks, Sam. Thanks guys. It's good to be back in person. I've learned a lot at this conference. One thing I have learned, having worn scrubs for the last year and a half and trying to fit into my suit is that I've put on some weight during COVID. All right, so we're gonna talk about arthroplasty as the option. It is the best option. That's the end of my talk. Thank you very much. Have a great day. I don't know how to advance this. Nothing. You can advance for me if you want. There we go. I do consulting work for DJO and do receive royalties. So it's a conflict of interest. So in general guys, like let's make some better decisions here. So, I mean, listening to some of these talks in these people, this is kind of the way that I envision you guys having a beer pool party here. So let's try and make some better decisions. So now you've heard everything. We're gonna take the immortal words of Yoda. You must now unlearn everything that you have learned. Remember that our actions have consequences, okay? So things that we do, just like what these guys were talking about, have implications. And what we've just heard is that at the end of the day, these people are getting a replacement. And so anything that you're gonna do to them beforehand, you gotta think down the road, how is that gonna affect what your ultimate outcomes are? So prior non-arthroplasty surgery results in lower outcomes at arthroplasty and higher reoperation rates. Prior arthroscopy literally doubles the infection rates for arthroplasty. I took this picture at Costco in the absolute height of the pandemic in New York of an elderly couple wearing no mask at Costco. And if you look what's in their basket, they went to get a flower pot, okay? So like question your decisions, okay guys? The bottom line here is that if you aren't gonna get 10 years or so out of non-arthroplasty options, then you're wasting the patient's time and their quality of life. For me, poor range of motion, obliterated joint space, like what Brandon was talking about, less than two millimeters and refractory night pain tend to push me towards arthroplasty as an option. Metal and plastic is a good but not perfect solution. And as Tony said, about 76% retention at 20 years from a Mayo study in people under the age of 50. Hemiarthroplasty is inferior to total shoulder for return to sport and work. And our goal should be total shoulder arthroplasty. Don't compromise your ability to perform the best operation first for whatever reason. And think about what imaging things may push you towards pulling the trigger earlier. And then as Matt was saying, it's always important to set proper expectations. I tell my patients that if I'm doing an arthroplasty in a 30 year old, you are going to get a revision in your lifetime, at least one, okay? So this is a complex problem and I'm not gonna be a hammer that only just pounds nails in with shoulder arthroplasty. I'm gonna do all of the things that these guys talk about, but we're gonna focus on arthroplasty. So I think about many different things in history, exam and imaging findings. And when we think about how we're gonna kick the can down the road, because that's essentially what we're doing with non-arthroplasty options. I think about pain scale less than six, plus or minus night pain. You know, have they failed non-surgical? All of the usual suspects, you know, do they still have reasonable range of motion? Do they have joint space of two millimeters? And then imaging wise, you know, like what does the glenoid look like? This is a huge thing for me, a huge thing for me. And their posterior subluxation. Because when you start talking about people that have pain scores greater than six, tons of night pain, start to really lose motion and have B-type glenoids, large intraosseous cysts and posterior subluxation, you're not just kicking a can down the road, you're trying to kick an oil drum down the road. So don't do that. So don't be scared to do the correct operation in your patient, regardless of how old they are. So I'm gonna go through kind of a number of things here. So this is Surin and Amdari, again, kind of projecting out where we're going, essentially looking at a 300 plus increase over the next, you know, 15 years or so in shoulder arthroplasty for people under the age of five. So this problem isn't going away, it's only going to expand in its magnitude dramatically. What are our options? Hemiarthroplasty, for me, very limited role, primarily for like humeral head AVN, person's gotta have good glenoid cartilage. Riemann run, I mean, there's not much of a role for it in my practice, people have had reasonable results in the correct patient. My goal is total shoulder. And if you can avoid a reverse, avoid a reverse, but don't do a bad operation because you're scared to do a reverse. I mean, I've got a couple of reverses in people in their 20s. And when it's the only option you got, it's the only option you got. So let's talk about a few different things here. So things that I hear people say, so Riemann run is a great option, okay? In deference to Dr. Mattson and others, I would say Riemann run is an option. And so Mattson's looked at this and shown pretty good overall results. But one of the things here that they showed is that their best results were in their A2 glenoids. So a well-centered humeral head relative to the glenoid. They did show durable results out 10 plus years, which is good. Tony's got a couple of studies here looking at return to sport and return to work, showing overall pretty good results again. And I think he'll stress in the correct patient. So I would say Riemann run is not a great option, but Riemann run is an option. What do we got? Skip forward. Here's another one. I'll do a HEMI now, and then I'll revise it to a total shoulder in the future. Bullshit, okay. So when we look at that, so this is a study, an older study out of Columbia, looking at conversions of HEMIs to total shoulders, the average time to revision was three and a half years. You didn't buy them anything. You bought them nothing. And not only did you buy them nothing, but almost half of these patients were dissatisfied with their results. And a significant portion of these patients, 64% of these patients showed progressive posterior glenoid erosion, which is going to challenge you further. Not only that, the subscap doesn't take a joke. So the more times you go through a subscap, the less good results you're ultimately going to be. And so they said, you know, on the basis of the complexity, unsatisfactory rate, et cetera, et cetera, this is a salvage procedure, probably not as good as a primary. So what else do we get? So I'll do a HEMI so they can get back to sports, right? So you got the guy who's a pretty active person, and you're a little bit nervous about your glenoid, and you're going to do it so they can get back to sports. Well, not entirely agreed. There's a series that's from our institution where we looked at a number of these things, and total shoulders have an extremely high return to work and return to satisfaction. So 100% of total shoulders got back to sedentary to moderate level of work, less so with the heavy work. 97% returned to sport, where you can see 93% golf, 88 tennis, 78 swimming. So pretty good results for total shoulder replacement. When we look at comparing HEMI to total, you can clearly see a significant difference in that despite your best intentions of getting somebody back to sport by putting in a HEMI, only 2 3rds of patients are getting back to sports with a HEMI versus 97% with a total shoulder. So I'm not a fan, as you can tell here. So yet another study kind of looking at the same thing, and then a meta-analysis looking at almost 1,000 shoulders showing very similar kind of return to sporting activities of 93 versus 71%. So this is what it's like doing a HEMI arthroplasty. I didn't know if that slide would get me in trouble, so don't tell anybody. All right, so do your best operation first, guys. All right, and for me, I think that it's an anatomic total shoulder with a glenoid. So what do patients ask? What do we ask? So how long is this gonna last? Well, so this was the study I referred to before from Mayo looking at kind of the HEMI arthroplasty survival versus total shoulder survival. I'm gonna focus more on the total shoulder survival that they had, which was 76% in age under 50 at 20-year follow-up. The reason I'm gonna kind of skip on the HEMI side is that this whole population was prior to reverse, so you didn't have a great secondary revision option. And so that may affect what more modern results would show. But overall, I would tell people, just like what Tony was saying before, somewhere between 70 and 80% retention likely at 20 years. It's important to also think about the technology of the time. So this study was based on the old near prosthesis where you're cementing everything in place. Materials were different than the things that we're doing now with in-growth and some of the vitamin E poly, et cetera. And so at least we don't know, but our hopes would be that the durability of more modern day prostheses may be better. So I always tell patients, metal and plastic is not as good as what God gave you, and you wore that out. So it's important that you really think about how you're gonna conduct your lifestyle post-operatively. And so that goes to patient selection. So it's very important, just like if you're gonna select the right patient for a Riemann run, you gotta understand that you're adopting this patient for the duration of your career when you're gonna do an arthroplasty operation on somebody who's in their 20s, 30s, 40s. And so it's important to have appropriate indications. So this patient here, who's got a zipper tattoo around this skin graft is a total meathead who got neck fash from injecting cocaine into his deltoid. So probably not the greatest patient to put a total shoulder in. Appropriate indications are people, they're miserable. They can't sleep, they can't take care of their kids, they can't function in their ADLs. And then also, as I'll go into in a second, where waiting on them may affect your ability to do what I would consider the gold standard being an anatomic total shoulder. Appropriate indication is not so that I can get back to bench pressing. Like I said, you're adopting them forever. So it's important to choose the right patient and also get patient buy-in so that they understand what they're getting themselves into. So when to pull the trigger. So I'm gonna kind of skip on the history and examine folks a little bit more on the imaging because it's pretty objective and there's pretty good data, at least in my mind, to support the rationale for pulling a trigger on total shoulder arthroplasty in a 30-year-old. And in particular, it's gonna be your B-type glenoids or some type of a large cyst that may impact your ability to get your glenoid fixation, humeral heads that start to sublux. This was a really good study out of the Cleveland Clinic, Eric Orchetti's group. They looked at a bunch of CT scans and the important takeaway point there was that if somebody was well-centered on a CAT scan, and so this study looked at, basically a time zero CT and then one that was at least 24 months, but on average is about five years apart, that your A-type glenoids stayed A-type, largely. And that's a super important factor when you're thinking about these things. Yet almost 90% of your B-type glenoids progress. So I look at that and that's a really scary slide. And I'm sure some of you guys have had patients that are young patients, they come in, they've got a B1, they kind of disappear for five years and they show back up with 30 degree B2 and you're like, oh shit, now what do I do with this? Where if you'd pulled the trigger earlier, maybe you could have at least changed the natural history a bit of the way that the shoulder would progress. All right, so I'm just gonna go through a few patients imaging to kind of talk a little bit about how I think about this. So this is a 33-year-old retired NFL lineman. So you can see his x-rays, 2015 and then 2020, 15 was when he was still playing. Significant arthrosis on the right there, but looks pretty well centered on the axillary. Has a few injections over the years. The axillary in 2020 starts to look like he's subluxing a bit. And the take home message there is that with these young people, I like to follow them with an annual x-ray, with an annual axillary, just so that I can check for that as they start to progress. And in a situation like this, where that axillary looks like he's starting to poke out the back, I wanna get a CAT scan to see where they are. And actually his CAT scan was reasonably well-centered. It was a rotational issue with the axillary. And so this guy, he remained well-centered. He's got moderate symptoms, managing reasonably well with non-surgical stuff. And so we continue non-surgical care for him. And that was something he was happy with, and I think is very reasonable based upon these imaging. This is a 55-year-old with a big old cyst in the glenoid. And so, I mean, he's a little bit posteriorly sublux, but in this situation, I've got concern about how I'm gonna get my glenoid fixation if that cyst starts to get a whole lot bigger, and I don't really wanna get put in a position where my hand is forced into doing a reverse in an otherwise reasonably well-centered joint and an intact cuff. And so we actually used a biomet prosthesis that had an ingrowth post, and allowed me to bone graft and get some hybrid fixation there. So we pulled the trigger there somewhat early, even though he had a reasonable range of motion and was there. So what about this one? So this is a 40-year-old with pretty good motion. I mean, overall 150, 50 of ER, quite a bit of pain, but he's got, you can see this kind of early B2, 17 degrees of retroversion, starting to posteriorly sublux. And so when I start seeing this, this is one of the few situations in my practice where I will coerce somebody into an operation that they may not be emotionally ready for, because not doing so potentially changes their outcome in the future. So when this guy comes back in three years and it's now 25 degrees of retroversion, and now he's ready, you know, he's in an emotional place where he's ready to actually move forward, my option may not be as good as what my option is now. So we're able to correct this with some eccentric reaming in an all poly glenoid here. This one is another kind of a B1, 19 degrees of retroversion, fair amount of subluxation, very similar story, you're kind of hearing my theme here, that we know from Eric Ricchetti's work that we know where this is going to go. And so I want to push this person to get them what I perceive to be the best operation for them. Then you start to get into this, you know, you're 50 something year old, 24 degrees of retroversion, otherwise intact cuff. Problem is that a guy like, you know, this one I would start to really think about reverse potentially as an option here, but his motion's so good. And so we kind of did kind of a bio total shoulder, we're using a metal back glenoid and packing bone graph behind it in order to center him better. So you got to have a number of tools in your toolbox. And then finally, this is a 30 year old, he had two prior posterior stabilizations. He's totally miserable. He's done everything that he possibly can. He can't hold his kid, he can't sleep. His CT scan, you can see not really no glenoid deformity, but he's kind of perched on the back there. And so this is one where he was more than happy to move forward with a total shoulder here. And so this is him about six months post-op, he's back fly fishing during the pandemic and he's a happy guy now, he has no pain, says he wants me to replace his other shoulder. I don't even know if there's anything wrong with it, but. So anyway, at the end of the day, you know, kind of back to what I was saying before, it's a tough problem when these people walk into your office and there's a lot of different options like we heard about. And it's all right to kick a can down the road, but make sure it's a can you're kicking and it's not an oil drum that you're trying to kick down the road. And if you can buy somebody 10 years, that's great. But if you think you're gonna go do something so you can buy somebody three years, you're not saving them a revision arthroplasty because you bought them three years with something else. Remember that our actions have consequences and the subscap doesn't take a joke. You only get so many shots at the subscap. So while some of the stuff that Dr. Preventer was talking about, it's very sexy, it just gives me a bit of anxiety to think about how I'm gonna go through a subscap a second time in somebody who's gonna be 40 years old and throw in an anatomic. Poor range of motion, no joint space, refractory pain, as well as all of the imaging things that I talked about are the situations where I'll try and push somebody to do something sooner than they may even be ready for. 76% retention at 20 years, total shoulders the goal and set the most appropriate expectations and ultimately make good decisions. Thank you. Thanks Sam. So if we can have our speakers up here. Are there any questions, burning questions from the audience? All pretty straight, yes, Samer. You want to start, Matt? 100% agree. The amount... This is probably one of my biggest learning curves, is not all arthritis is the same. Just take away inflammatory, take away rheumatoid, but not all arthritis is the same. But sometimes you're dealing with this. Chondrolysis was an issue. We published a lot on this, and I almost wish I didn't. Samra knows all about that. You know, and you've done it well. We probably both don't want that. But it was a significant challenge with some pain, pump, implication, and other issues. And for whatever reason, not everyone got it. But that was a massive, very acute, quick destruction of the joint, which led to massive inflammation. It was almost an inflammatory, massive response. And that patient is clearly different. Or the early anchor arthropathy or post-instability arthropathy, the early one, not the one that was presented earlier, 10 years or 15 years, but some of the ones I showed, those patients don't do as well with biologics at the end of the day. And that was a very big learning curve for me. And I would keep pushing the envelope because they were young, they were in the demographic, but not all arthritis is created equal. And I probably share the same experience, I imagine. So on some of those, if they have this acute finding, I'm doing more leaning to what Sam Taylor was talking about getting earlier on the arthroplasty. So traumatic and osteoarthritis, early arthritis gives you some of these other options. But once it becomes inflammatory or there's external factors involved, the biologic treatments are unpredictable. Yeah, I totally agree. My biologics, those have been the lesser outcomes for sure. But those are the ones we push in. And the literature reflects that, although it's not well delineated. A lot of that lateral meniscus, a lot of that dermal patches, is stuff in patients that were super inflamed very quickly, massive capsulitis, et cetera, from an acute type of process, not a long-term development of arthritis. Go ahead, Sam. I was going to say, is this on? Yeah. Sam, it's an awesome question. I wish you didn't ask it because it's really hard to answer. But, you know, I think that your point is that the pathogenesis of the destruction also plays a big role in how you think about the problem. And so when I think about something like what Matt was showing before with the kind of anchor arthropathy, you know, I think that in general that's a very different beast than the kind of globally arthritic shoulder. And so that some of the options like he was showing are very reasonable because you're addressing the inciting issue. The ones that start to get really tricky, in my mind, are the kind of post-latter-ge arthropathies and post-open stabilization arthropathies, where the literature is really starting to delineate more clearly that actually reverse does a better job in improving people's function. And so that's tough when you start to get into that group with the 40-year-old who's 10 years out from a latter-ge that the shoulder's totally jacked up and, you know, you really want to do an anatomic. But, I mean, I would say that, you know, in those situations, I don't know about you guys, but my experience in the handful of those that I've done anatomics on, I mean, they haven't done as well. Yeah, if there's any compromise of the anterior soft tissues, you're going to be in trouble. It's going to be very tricky. I think we're going to work through some of these cases, and we'll go pretty quickly through a few so we can get some of these points driven home. So Brandon, 54-year-old guy, right-hand dominant, still very active. His range of motion is not that bad, but he's been treated for Lyme disease, but he's had injections, he's had therapies, everything, and his shoulder just is not getting any better. And he's like, I'm tired of this. What would you do? His range of motion is good. And I think one of the things in the arthroscopy papers that you talked about, if you have good range of motion, doing a capsule release is probably not going to be very effective, right? Totally agree. Yeah, so it's really good for the younger patient who's really stiff and their arthritis is not that bad. That's the ideal patient you're looking for, and they're centered. But this guy, what do you think? He's literally the opposite of what we were talking about, right? He has less than 2 millimeters of joint space. He's not well-centered. He's starting to come out the back. He's posterior subluxated. Can you speak into the mic a little bit? It's hard to hear you. Sorry. Good. Okay. So to the point before, he has less than 2 millimeters of joint space. He's starting to subluxate out the back. His motion is good, like you said. So I don't think there's a role, at least for me, for that CAM procedure in this patient, if they refuse an arthroplasty and, you know, they had a lot of bicep symptoms. Sure, you could consider it. But, again, to Sam's point, he's going to be – He already had one. Listen here. See, I look at that X-ray, and I'm like, shit, somebody already took away my other option. Obviously, if this guy walked in for the first time, you're going to try a little bit of physical therapy, some medication, some injections. Are you going to use any HA? Are you going to try that? It's very hard to get approved to the point before. It's not approved. It cannot get approved. The patient has to pay for it. It's expensive for that. I don't know that I would tell them that HA is any more beneficial than a PRP. What about PRP or stem cells? Why not? If I was going to pick one of those, I'd pick PRP to do because I think the benefit from that and HA is similar. For me, I think PRP is probably a better option. Leukocyte, poor PRP. In the knee? No, in the shoulder. I think they do okay. I missed that publication. There's no publication. Oh, I'm sorry. Just anecdotally. I think that's an option, but it is expensive. So I always tell them, listen, this is an option, but I can't tell you you're going to get better from that. Because short of that, you're talking about some type of surgical intervention. I agree, an arthroscopic procedure for him is probably not the best idea. So you're looking at somebody who's probably going to benefit from a total at the age of 54. Yeah, and many of the major metropolitan areas, certainly on the two coastlines, people are coming and asking for the biologic treatment. They're willing to pay for it. They don't care. And so we don't have a predictability about how well it works. So we're extrapolating information from the knee. So I don't mind doing it if that's what a patient wants, but I'm not going to sell it as being a cure-all. But if that's what you'd like to do to get some more time, we'll give it a try and see what happens. The placebo effect is a real thing. Yeah. So we've got a CT scan. Do you want any more than this? Any more? Well, I mean, you'd like to probably get an MRI on him just to see what was going on with his rotator cuff. But just to your slices here. Sam was normal for his cough. He had good cough function. Would you get an MRI anyways? I mean, some people do. But Sam, would you get an MRI? I do. I don't. I mean, unless I'm unless from a- He's got good strength. I mean, on exam, that's not his problem. It's his hurts. I would see. So, I mean, I like imaging. Hollis Potter, if I said I didn't want an MRI, I'm kind of like looking around. Is she going to come out? So, no, I like MRs. But I would say a couple of things. So, one, this guy had a prior operation. So he had a biceps tenodesis. I'll just take a look at the op note. They'll tell me whether his cuff's intact or not. And that suffices. Two, from a clinical standpoint, I would say that largely in glenohumeral arthritis is a cuff-preserving pathology. And I'd say, you know, one in 200 times a year I'm surprised when somebody's got a cuff tear. But no. So, Matt, get a CT scan so you can do some preoperative planning. You can see here as native version is only minus four. His inclination is 3.7. Not too bad, right? Pretty straightforward. Yeah, pretty straightforward. What are you going to do? A little surprising. Actually, when you put this through the 3D, it all depends how that 2D is protocoled. And if you're in the plane from 12 to 6 o'clock. But it's not too bad. But definitely his posterior is subluxed. Tony, can you go back? Sure. I personally, I actually get an MRI because the stakes are high. And the reason is I've found issues. The problem is patients like this, they've been grinding their shoulders. And the supraspinatus will many times have partial issues in it and partial tears. And you can manage that as part of the arthroplasty. And if you go in there and look at it from a gross specimen standpoint when you're opening it up, you don't see it. And there are times I will actually look at some of these partial under surface tears and actually repair those at the same time. So the stakes are high for this person. I get an MRI. I want the data. So that's just my take on it. We should probably have to learn more about that. This is a guy who had 150 degrees of elevation. So you can actually do a reasonable supraspinatus test and it seems to be functionally intact. And the world's literature would suggest that a small rotator cuff tear of the supraspinatus doesn't change outcome. Whether you repair it or don't repair it at the time of surgery, it actually does change outcome. They don't necessarily get the same level of strength back or overhead activity. But if you repair it or don't repair it, the world's literature suggests there's not a difference in outcome. So it may be an area where if we pay more attention to it, we might be able to improve that. Sam, you wanted to make a point about the 2D? Yeah. So this is one of my pet peeves is that when we look at just the regular reformats that the radiologists give you, oftentimes with that axial, you're getting like an oblique axial. It's not a true axial. And so at least on our PACS, we've got an MPR, a multi-planar reconstruction option that allows you to do your own coronal, sagittal, and axial reformats. And if you go to the next slide, you see how in here, you've oriented your glenoid and the way that you're going to be looking at the glenoid and thinking about it in three dimensions. And you can do the same thing in 2D with the MPR function. But you can be surprised. Your version can change by about 10 degrees as you rotate your axis. Yeah. We published on this in 2016 in Shoulder and Elbow. And the average off-axis there is about 38 degrees. And it can fool you on these 2Ds quite a bit. So for me, the solution is… We've reset it. You go to a 3D. 3D is absolutely true. The solution is if you want to reformat, you can do that. Or you get a CT scan with 3D, and you send it out to whichever company that you're working with. And so you have the reconstruction, and you can plan your procedure out. And now you have a much better idea of exactly what's going on over the whole three dimensions, which is, for me, the next step. So if someone comes in with the 2D, I still send them out to get the CT scan that I need to be able to plug it into whatever system I'm using to do my preoperative planning. And I really believe firmly that preoperative planning is a very valuable part, especially in these younger patients because, as Sam said, you want this thing to last a long time. You better get it right the first time because you don't want to be doing a revision in three to five years. It really changes that patient's lifetime outcome. And so you want to do the best you can the very first time, just like any surgery. But, again, the stakes are higher because you know they're going to be living with the shoulder. On average, a 50-year-old is going to live at least another 20 years or more. So we have to be aware of that. Tony, another comment on this plan. So the implant size, so your implant type, large or whatever on the glenoid, that's pretty true. You can fit that. But you've got a 52 humeral head. I guarantee you it's not a 52-millimeter humeral head. So you want to talk about that. It's at least four, maybe five, six millimeters down from whatever comes here. And the rep will pull out a 52, is what the plan shows. This system is not accurate for humeral head sizing. It will be much more accurate at the academy. So there's been a big change in the system that will come out very soon. Some of the other systems are more accurate with regards to humeral head. And the reality is, and just an overall principle, is in terms of the patient's function, the humeral head size being correct is how you get the patient's function. The glenoid being in the right spot and secure is how you get the long-term sustainability of the implant. And so it really is important on both sides for both of those reasons. So, Brandon, what do you think here? Any polyethylene, glenoid, cemented, metal back? And on the humeral side, are you going to do stemless, short stem, or long stem? Yep. So I would go all poly on the glenoid side. I'd go stemless on the humeral side. One of the points just to make about your pre-op planning, we did a study looking at pre-op planning to make sure that the plans that the systems were giving you are relatively accurate to what you would get if you corrected, to Sam's point, to being in the plane of the scapula. And we found that they were pretty accurate. So you can, for the most part, unless the deformity is really great, trust that plan. You just have to make sure that you get the correct CT scan where you include the medial border of the scapula, have one millimeter slices, things like that. So I would do exactly what you did. I used the same implant that you do. So I would probably do a subscapularis peel with this. I've migrated to that recently rather than a tenotomy. I used to do a tenotomy, and now with a new implant design that comes out, to be able to repair the subscap here with a few medial row and then two lateral row. Do any of you do a subscap sparing approach like Mark Mile and some others have been promoting recently? Yes. Yes. So I do it a la Latter-day type of procedure where we have the interval through the rotator interval and also a subscap split. So it's a little more challenging. It's a lot more challenging. It's waiting on some more instrumentation, but I've been able to use a sling for a few days or maybe just let the incision calm down with a true subscap splitting for this exact construct. This construct lends itself well to a subscap sparing technique, but stay tuned. You need to practice this. Yes, stay tuned. It's coming. Yes, you need to practice it in a lab. That's my standard. As long as they're not humongous. I was going to say the easiest ones to practice on is your little old ladies, not the big 50-pound guy that lifts weights. Don't try to do your first subscap sparing approach on that. You're going to hate yourself because those are just really hard to do. There are some new ways coming up with that, but it's not as consistent as we'd like it to be. Some people are doing a good job with it, but it's just something to keep in mind. So let's move on. Here's a 51-year-old orthopedic surgeon who played college football and was a very talented guy. Just to point out a couple of things. Obviously, he's got narrowing of his glenohumeral joint space. He knows not to have this done until he really just can't stand it anymore and he's just really having problems. Tony, are you talking about you? No, me. That's not me. It looks worse than that, but not my shoulder. I almost put your images in my talk. My shoulders are so far okay. Of course, the way I know they're okay is I don't take an X-ray, and so that way. Dr. Andrews taught me that a long time ago. If you're not really sure about your operation and you want good long-term follow-up, just don't take an X-ray and you'll be fine. That's how he did such great results with his AC joint reconstructions for so many years. The problem here, a couple of things. One, you see he's got a huge cyst in his humeral head. His glenoid pretty much is an A2, but you get the CT scan and it's like, holy crap, what am I going to do? On the humeral side, that's just right underneath the cortex. Am I going to have to use a stem prosthesis or what do I need to worry about here? Sam, what do you think? It's an A2 glenoid, but he's got this big humeral cyst. What do you want to tell your buddy? On the humeral side, I have a very similar case to this, except the cyst was more on the medial calcar eroding out. Actually, the way that I addressed it was using an inlay reverse prosthesis with a hemi adapter on the humeral side so that I could actually get a press fit without having to cement. Do you understand what he said? There's implants now that are convertible, so he's using the stem as if it's a reverse, but it has an adapter to put the normal head on there. Essentially, he's filling that bone void with metal in this environment. Where you get your ingrowth around there. In a situation like this, you should be able to get at least 270 degrees of press fit metal contact. It actually worked out really well, even though when I first saw that image, I puckered up pretty. Matt, would you tell your buddy to do anything other than an all poly glenoid? Would you do a metal back? Would you do a Riemann run? There's a resurgence of metal back technology, early outcomes. We have to be a little bit careful, but I may consider a metal back on this one. Just based on some of the numbers, you're at 15, 16, just looking at the subluxation inversion. I was worried not only the inclination, but he was pretty medialized. It was a solid A2, and I was just worried about whether I'd even get the poly in there. The planning actually helped me show, but it's close. It made me a little nervous about what I might have to do. I did plan it out for a metal back glenoid, and I presented it to him. He says, Tony, I know the literature on implants. Metal back glenoids suck. Don't do that to me. I said, okay, we won't do the metal back then. That's exactly what he said. You look at that, you're getting nearly 90% with the metal back, even positioned neutral-neutral. At the end of the day, it's probably a better option. It's still a little early in the new metal back resurgence, but the technology is much better. The fixation is much better, and we basically extrapolated this type of product, which has been used traditionally for a reverse fixation that we know stands the test of time and there's zero cement on the glenoid. So, stand by again, but I think this is a very nice construct for some of these younger patients or ones that you know will be converted down the road and they talk you into not doing the reverse, which is a whole nother discussion. So all the world's registries show that metal backs have a higher revision rate in the Mayo Clinic series from a long time ago and the argument is, well, those designs are older designs. And so we are seeing some newer designs because of all the success of the reverse and just to get away from cement on the glenoid side. So I think we'll continue to see more and more as Sam showed you an example of that in some of our younger patients, but we have to be critical of that. And so it's not the metal to bone, usually that heals, it's the polyethylene to metal junction that's the issue for us, especially if that humeral head, which is 75% out the back when you started and then two, three, four years later is going back to that position, what's gonna happen to the poly? So it's a big question, but it's something to consider. So this is what- The other thing, Tony, everyone asks about, okay, let's put the 10 or 15 degree plastic wedge in for someone like this that's got 15 degrees. Brandon, you've written on this and looked at some of these outcomes and when you're beyond 15 degree wedge, the outcomes are much less better, they're not good. You guys want to comment on that additionally? I mean, it's been a problem with these bigger wedges and we have to be careful. The sweet spot is about 10 degrees of correction. When you start going beyond that, it gets a little tricky on anatomics and reverse is not the same. Reverse, you can go bigger than that. The reverse actually, the number is probably about 25 degrees and then you're into trouble where even if you have a 25 degree wedge of metal and you're still losing bone, you've got to do something on the bone side in most cases. But on the anatomics, the sweet spot is 10 degrees of correction or less and if you can get it within 10 degrees of retroversion, most of the world's literature would suggest that's a pretty good reconstruction and you don't have to get too fancy with it by when you start getting above that. Sam, what's been your experience? Similar. Yeah, so I told him I'm not sure how this is all gonna turn out yet. I told him exactly what our plan is. We planned it out together. He's an orthopedic surgeon. I said, is that what you're doing? He goes, yeah, I think that's great. So I cut off his humeral head. I took off, there was really no cartilage left and I just ground it down as best as I could and I filled that entire cyst with his humeral head and that's what it looked like to start with and so, Brandon, would you trust that for a stemless device? How did it feel when you put your thumb into it? I mean, you know, this is your friend. He is for now anyways. So I would say this. I would at least prep it for a stemless device. I'd probably try to put that cage screw in. I use the same implant that you use. So if it got a good bite and it felt stable, I would leave it. If I put it in and there was any question about it, then I would switch. Yeah, I think if you're using a metaphyseal-only fixation on a stemless device, I would be a little nervous. This is, as hard as you can compact that, it'd still make me nervous. If you're using a device that has both metaphyseal and diapsial cortical fixation, then you might be able to get away with it. And then you really, really wanna work hard on the subscapularis repair. We'll just talk about that here. Here's an example of one of the newer subscap repairs. It's a double row transosseous equivalent type repair. Sam, what do you routinely do for your subscap repairs to get that thing to heal and do as best as possible? So I may be different than you guys, but so my first three years in practice, I was doing a tenotomy with suture repair, and then I switched over to an LTO, and I will never go back. Like, I love my LTO repair. Do you let your fellows cut the LTO? So Brandon was actually the first fellow that I let cut an LTO in practice. And that one gave me anxiety. It was a couple years after that before I let it. Just for those of you that do the LTO, and if you happen to have people that you're training, it is a big issue because you can change the operation by the LTO. So done well, it's a very nice operation, and it can work very well. So I do an LTO almost exclusively unless I'm doing a total shoulder. I've kind of gone back and forth on the LTOs and the 80 plus women, just because the people I work for. And what do you do to fix the LTO? So I use the DJO stem that has fins with holes in it, and so I'll actually pass doubled over fiber wires, and because they can slide, I can do it as a racking half hitch, and I get three great racking halves through it. And I've had, in the last four years, I've had zero atraumatic subscap failures, and I've had three traumatics. And Matt, what do you do for your subscap? This is really important in this age group. It's massively important, as we talked about. I've done them all. There is no difference in the literature in terms of outcome, and they all work in your hands, as long as you do it well. I really, I do LTO and peel just depending on the patient type, and as Sam said, an older patient, I won't do an LTO. I'll usually just do a peel. Double row type of repair. I also use, I take advantage of the biceps groove and use unicortical buttons, metal buttons, and I found that to be very nice. Sometimes in these all suture anchors, especially in a cystic, lesser tuberosity, there can be some fixation concerns, and I've had those pull out. So you have to be careful. You have to have some backup fixation options. But this is something I do not skimp or compromise on. So just from a practical point of view, the tenotomy has fallen by the wayside just because if you don't do this as routinely, you can be inconsistent with exactly where you make that incision, and people are not that excited about just side-to-side repair, but actually with stemless devices, their literature suggests it works very well. So it is an option. Most people, go ahead, Sam. I was gonna say, just the other part, kind of a negative on tenotomy is that in general, these people have contracted subscaps with external rotation loss, and just by nature of doing a tenotomy and then doing a repair, your repair shortens your subscap. And so you're, I mean, I would tend to go with when you really have to make sure your head size is exactly correct. So most people do a peel, and then some people, not as many, will do this sliver osteotomy. And then on the fixation side, there's a variety of different techniques, but really critical. And we're running out of time, so I just kind of want to run through a couple more principles. So this is what he got. He got the Eclipse. I thought that for sure he had excellent fixation. This is his post-operative views. You can see the cyst is completely filled with bone, and his colon is fine. He went back to work at six weeks. He could have gone back sooner, but he had taken the time off that way, so he went ahead and did that. And he called me and said, can you do my other side in December? And he doesn't have his biggest cyst on the other side. We don't really have a lot of time. This is, I was going to go over the inflammatory osteoarthritis patient. This is the one where we really have to be worried, as Matt said, about the rotator cuff. And you see the cysts that are there, and it makes you very, very nervous. This guy's 32 years old, and he's a scud. He's a muscular guy that works out. And I just like, I got the MRI thinking, well, I'm going to have to figure out what I'm going to do, and his cuff is intact. But you can see it's an angry-looking shoulder. His cuff looks okay. The glenoid's okay. I got the imaging studies. I did all the right things. We planned him out, and I did this. And he's done very, very well, but I get nervous about these patients, as Matt talked about. I did want to show you this one last case, and then I'll let you go, but this is a lady who's had four procedures, starting out with slap repair, then posterior repair, then bicep surgery. And she's never gotten better. That was all in her 30s. And they told her, you're just going to have to wait to get your shoulder replaced. And now she's, I think she's 42, 42 or 43. And this is what her shoulder looks like. And it's kind of what Matt talked about. It's not really osteoarthritis. It's post-traumatic, post-surgical arthritis. And then one of the things which you'll see is that, don't forget about, as Sam mentioned, her initial presenting diagnosis. And as you can see, she's sublux posteriorly, and this is where she's at. And so we get the preoperative planning here. And this is a challenge. Look at that. Her version is 23, and her inclination is 13, and she's 42. Sam, so this is the anatomic. And so I said, ooh, that doesn't look right. So I did the reverse, and I said, do I really want to do a reverse on this lady? Her cuff's intact. Her reverse looks better, though. And I don't have to do as much. I can use an augmented glenoid and get away with it. And she's 42. Maybe I'll figure this out. Maybe I'll do this here. What would you do? I mean, for me, this is one of the times where I would consider using that kind of convertible, kind of the Biomet metal back. Metal back glenoid? And bone graft behind it. Yep. And that way, I mean, there's a couple of, I don't know, I go back and forth on this one, but. That's why I brought it up. But it's potentially a good option. One of the things, just to think about, if you were to consider that implant, is that it sits more proud than your normal glenoid. You get more lateralization. Correct. And so you can overstuff it real quick. So you just have to be really careful about that. But with that, Sam, I don't lateralize it. With this metal back, Tony, I'm going down and getting this down to, it's pretty quick to get to 90%, and you medialize that metal back. Yeah. And that's what they've got. And I mean, you're taking bone, but you can get them down, and you're then bringing this down to something that's reasonable with a metal back. So you can't overstuff it. You've got, depending on what device, you've got about three or four millimeters of metal. And then you got anywhere from 2.5, 3.5 millimeters of plastics. That's a lot of lateralization, potentially. So you have to be really careful with that. And so you have to be comfortable medializing this on the glenoid more to not do that. But it also takes advantage of, you know, high-side reaming and correcting the inclination inversion. Yeah, so I went with exactly what Sam said. So Brandon, this is my post-operative films. And what I did is I took her humeral head. I used a flat glenoid, not an augmented glenoid, a flat one, but I put a significant piece of her humeral head posterior and superiorly to try to correct that. So I planned it out, got my guide pin in the right place, filled that with the bone graft. You can kind of see it up there. And her post-operative films, and this is what, so I maybe lateralized her a little bit. You see the greater tuberosity. Yeah, that's not bad. I mean, that's not bad. Brandon, what do you think? Is that okay? I think it's a tough problem. So, I mean, I have a, my question would be, would you not just, do you guys ever just put the humeral head on, fix it with a screw or two, and then treat it like that's your native glenoid, and then put an all-poly in with that instead of going with the metal back? Oh, put a metal, put a bone graft in, like Nicholson. So if you put, like Nicholson, so you put a bone graft in, you fix it with two screws that are recessed below the surface of it. Which you have to cement in. Yeah, the problem with that is there's a huge, make a resorption, there's a significant graft resorption issue in that setting, and now you've got an all-poly, and your graft, when your graft reabsorbs, now you've got nothing to support your backside. The whole thing falls apart. Greg Nicholson actually published some very, very good results, which were better than the previous literature, but since he published those results, I haven't seen anyone else publish similar results. So somehow, using the graft, he was able to get a less of an issue with this, but that's been the history, is that it will resorb that graft, and then you're loading that poly without much support, and you end up having the glenoid revisions at an earlier phase. That's the history, but it's an option, and Brandon trained with Dr. Nicholson, so maybe that would make him feel more comfortable. Yeah, I feel this, you can use a graft, and I think with plastic, it would be very, very hesitant to do it because of that issue. Now, Greg's got the results. The other thing you can do, Tony, is, and the literature's out there, but it may not be the best, is put it where it lies, inlay glenoid, or bring in a glenoid that's a little bit smaller, and taking advantage of more of the cortex around the periphery of the glenoid. Put it where it lies, and keep them at 23 degrees, and put your head on. Jerry Williams has shown some reasonable results in that, an inlay glenoid, and not perfect, but you're dealing with a tough problem in a young patient, so maybe an option inlay glenoid. So this lady came back in two months, no medications. This is the best my shoulders felt in a decade. Thank you so much, and we're gonna send her off for rehab to get more of a range of motion back and strengthening, and within a month, she said, I went to raise my arm up, and I got to about, just a little bit above this, and something happened, and I kept doing it. Now, I think it's stuck out the back. Dislocated posteriorly. Well, I mean, you look at the axle to be super critical, and you're like, okay, I'm gonna put this in, and you definitely have retroversion on it, but I've left it the same way. I mean, you've trained me that way. You definitely have retroversion on that initial axle, so that's one of the risks, and this is exactly. And this is what Sam was talking about, is that this lady was probably, if not a dislocator, which we didn't hear about, but a posterior subluxer, and a little bit of a loose joint, and I got her back, and I would've been better off lateralizing her more, and so I'm stuck with this. And so, you know, this is the kind of imaging you get. You get a CT scan, and it looks like crap. You know, obviously, Dr. Potter would never send this to your office. She would figure out what to do, but we don't have the same opportunity, but there are a lot of things that are available now, so you can ask for a CT scan with metal subtraction, or a MARS-type technique, and you can start to see it much better, and now they even have a technique where they can subtract the entire metal and outline the implant for you, so now you can really see the bone. So this is a beautiful representation of the problem, and when you measure, I have her in about 10 degrees of retroversion, so I, you know, having a history of, now, posterior instability, I should've put that no worse than neutral, or lateralized her, so I, you know, this is what happened. Sam, what are you gonna do now? This gets a reverse. I'm done. It's got a reverse. No, I mean, in all seriousness, now we're gonna do what? We're gonna go back through subscap, we're gonna try and upsize our head. Are you gonna try and revise that glenoid and destroy her bone? Yeah. You know, are you gonna try and put some posterior buttress allograft in there? I mean, this is like, just get like, unfortunately, she's got a bad problem. Brandon, what are you gonna do? No, I'm doing a reverse, but the only thing I'd mention about the reverse is if you go back to your initial CT plan, even though it measured the inclination at 25 degrees, it's probably actually more than that, because when these implants, when they measure that, they take that lip as it comes over the top into account, so if you look at your image on the left there, that's more than 25 degrees of inclination there, so I would be very careful with this. Yeah, that's the difference in the vault version versus the glenoid, I'm sorry, the vault inclination versus the glenoid inclination of where you put the implant, so that's very different. No question, it's reverse, Tony, and we've already, having had this same thing happen to me several times, if you're in that 20 plus range, my conversation is to steer you to reverse, otherwise, there's a very good chance you will not be happy. So, the CT scan for me said that she's about 10 degrees of retroversion, and that's completely acceptable for a reverse, so I didn't have to take out her metal as Sam talked about at all, I just took off the polyethylene, I did lateralize her, and because she has some soft tissue laxity to her, again, I wanted to get the proper tension of the reverse on the humeral side, so you can see there's a little bit of a humeral insert, I think she's got a plus six instead of a plus three, so just a little bit more, and she notices a big difference, she says, my shoulder actually feels a little tight, and I'm like, perfect, but she's doing very, very well, and literally within seven to 10 days, her pain was gone, she felt completely confident of her shoulder, and now at almost three months, she's using it for everything, so I think... Tony, it's amazing that when you look at this, the reverse versus total decision, at the end of the day, I mean, what do you tell your patients now? I mean, this outcome from a reverse is almost identical to a total, and it's getting better and better on the reverse side. This is so much better than she's been for a decade. Correct, and so the outcomes on this, from a motion standpoint, from a flexion, from this, okay, internal rotation, maybe a few other things external, but the outcomes of the reverse are closely approximating that of total, especially in a patient like this, that has these bad numbers to start with. My only concern, though, from a longevity standpoint, isn't the, it's not the fixation, it's not so much the poly, it's not the bone, it's the thing that I will have zero control over is if that deltoid tuckers out in 20 years. Yeah, yeah, we don't know. The recent literature from Christian Gerber's group, and now also the French group, is at 20 years, they're doing very well, but it's a different patient population, and so we don't know for sure if that is gonna happen in some of these patients. There was concerns about that with the reverse when it first came out, with the French design, which really displaced it inferiorly, that there was a certain amount of patients at seven to 10 years where their deltoid seemed to either act like it was overstretched or not working well, and they actually lost some of their abilities to raise, or we don't seem to see that information now, and the United States, as you know, we've had this just barely getting in 2003, so then 2014, so we're just looking at early 15-year results. We have a ways to go, so we're relying on our European colleagues. Well, I hope that that was helpful for all of you. These were some tough cases, but we went through the whole gamut of treating the young patient with osteoarthritis. We thank you very much for your attention. Please fill out your evaluations and let us know what we need to do better and what we did a good job with, and have a great rest of your meeting. Thank you. It's been a pleasure.

shoulder arthritis

treatment options

shoulder arthroplasty

joint space

pain levels

range of motion

surgical options

total shoulder arthroplasty

hemiarthroplasty

glenoid morphology

posterior subluxation

preoperative planning

implants