»» All right, thank you very much. These are my disclosures. There are some relevant issues with these disclosures on this talk. Certainly with shoulder arthritis like other arthritic conditions, non-operative management is first-line treatment. Injections play a huge role I think at this day and age. I think using guidance, either ultrasound or in-office needle arthroscopy to ensure your success rate I think is imperative and critical. Studies show very low success rate doing these blindly. What about newer injections? Obviously VSCO supplementation has got a lot of need literature, very little literature in the shoulder world, not FDA approved. Systematic review of 15 studies, 1,000 patients did show improvement in VAS compared to PT and steroids. Biologics, again, not FDA approved. There have been some case reports with PRP. There's one study looking at BMAC, 115 shoulders, did show improvement in both the DASH and the VAS scores. Surgical options, arthroscopic debridement can have about 80% short-term success. Obviously the worse the arthritis, the less successful. This study of 56 patients, 32% went on to total shoulder by 11 years. The average about two years after surgery. Risk factors for poor outcome were less than 50% improvement, ASES and constant scores, and then not surprisingly work comp. The CAM procedure popularized by Peter Millett is basically an aggressive debridement with a combination of chondroplasty, capsular releases, microfracture, osteophyte resection, axillary nerve release, and bicep tenodesis and SAD. This is one of my patients, a very aggressive capsular release I think is critical down to the axillary nerve. I don't know you necessarily need to arborize it every single time, but seeing that with an aggressive release I think is important. Arthroscopic management looking at short-term outcomes have shown good success. This study of 100 shoulders, mean age of 52, found that 16% had a total shoulder by two years. Not surprisingly, the worse the arthritis, the worse they did. What about arthroplasty options in a younger patient? I think the debate has been settled that hemiarthroplasty is not as good as total shoulder. This systematic review found that in patients less than 60, a total shoulder performs much better than a hemiarthroplasty. The Mayo data looking at long-term follow-up in patients less than 50 found 72% of hemis had glenoid erosion, 76% of glenoids had loosening. Unsatisfactory results, 60% of hemis, 48% of total shoulders. The survival rate of a hemi was 75% at 20 years and the total shoulder 84% at 20 years. Again, this was published in 2004, so certainly using earlier arthroplasties. Is there an inflection point? There appears to be. This study of over 1,000 patients looked at where that inflection point is. They found that age less than 65 for a total shoulder had a three-fold increased risk of revision. And age less than 60 for a reverse had a five-fold increased risk of revision. We published our data looking at reverses, both primary and revisions in patients less than 65 and found similar improvements to older patients but lower functional scores. Part of that I think is their perception and their demands compared to older patients. Matson described the Ream and Run technique which is a hemiarthroplasty with a reaming of the glenoid to get some fibrocartilage. In this study of patients less than 55, 9 out of 65 required revision at two years. If you look at risk factors for failure, one of the biggest risk factors is an age less than 60. So again, not a great operation in younger patients. In this age-matched control study looking at Ream and Run versus a total shoulder, they found that total shoulder performed better both in the MCID and the ASES clinical benefit scores. I think that grafting, biologic resurfacing has kind of fallen out of favor. This review looking at all the data out there found 43% failures, 36% complication rate, and a 34% revision rate. Again, that's kind of fallen out of favor. So looking at other ways to preserve the glenoid, we know the glenoid is the weak link in the system. So looking at an inlay glenoid where you can get load sharing with a native glenoid I think is a viable option. Additional studies do show that load sharing compared to a lateralized onlay I think can be very important in showing decreased rate of loosening over time. You also see this sort of recorrection of the posterior subluxation if you can get an anatomic resurfacing with an elliptical humeral head in an inlay glenoid. The study looking at patients less than 60, 4-year follow-up, no loosening. The study of patients of 52 found a 75% return to sport, 50% at the same level. Again, no glenoid loosening. What about patients who have glenoid issues? I think correcting those version issues with metal or plastic as opposed to bone grafting and reaming I think can be very important for long-term follow-up. Using augments to correct version problems can really sustain long-term outcomes. We've been using these now for over 10 years. We published our first data about five years ago showing good long-term success or short-term success using augmented glenoids and further studies have said that as well. Biologic ingrowth I think is critical. We all know again that over time the poly tends to wear and get loose. I think using a bone cage you see here with this kind of bony ingrowth on the CT scan can improve the long-term outcomes. Another study out of San Diego looked at over 5,000 total shoulders and found that an all-poly osteointegrated center peg had decreased loosening rates compared to a cemented peg and a cemented keel glenoid. Again, improving your outcomes by getting biologic ingrowth I think is critical. I think if you do want to use stem, using modularity I think is important because they're likely going to need a revision down the road to being able to convert a total to a reverse. Without having to take a stem out I think is important. I think many of us have migrated to a stemless prosthesis to avoid that issue totally. In addition, being able to get a subscapularis repair using our arthroscopic type double row techniques around a stem I think in my hands has really improved the outcomes. If you put this all together, over 1,600 shoulders in patients less than 60, the highest revision rates are hemiarthroplasty with biologic resurfacing followed by hemi, then total, then reverse. So in conclusion, there are many options in younger patients. I think all in all a total shoulder is favored compared to a hemi, also a hemi with a biologic resurfacing. I think newer techniques, inlay, biologic ingrowth, vitamin E, lower wear patterns and even biologic resurfacing are the wave of the future. Thank you. Thank you. Applause

shoulder arthritis

non-operative management

injections

surgical options

total shoulder