I've got a 430 text from Romeo using his bathroom floor as his bed, so he can't be here. But I'll present his cases once we're done with this. So for mine, we're going to talk a little about shoulder arthritis in the young patient and how we sometimes manage this. My disclosure is, again, not relevant to this. So we're basically just going to walk through some cases. And this can certainly be interactive, so please feel free to chime in, ask us questions. We're going to talk amongst ourselves up here so you guys can hear. And then certainly, if things come up or you have cases that you want to talk about, stop us at any time. The whole point of this is to be interactive. So first case, I had a 37-year-old lady who came in, right shoulder pain, wasn't responding to PT, injections, et cetera, right? Complains of the usual dull, achy pain in the shoulder. She was an avid gardener. She was having a hard time gardening. She works on a farm. She's like from north of me, so I practice in the city. These guys, much more rural. But I sometimes get the rural people who come to my office as well. So exam-wise, actually a pretty good exam. I called her 175. She probably got up to about 170 of forward flexion and abduction, so really pretty good range of motion. A little bit of limitation on her external compared to her other side. Her other side, she can get out to almost 75, 80 degrees. On her right side, she was limited to 50 degrees. And then her internal rotation wasn't bad. She got up to kind of L1. A lot of tenderness over her AC joint, a lot of tenderness over her biceps. Good strength testing when we tested her cuff, so wasn't concerned about having a big, massive cuff tear. A lot of positive bicep steps, so O'Brien speeds, throwing test. For me, I do the O'Brien three-pack pretty consistently. So I do the active compression of the O'Brien's test, tenderness over the biceps, and then the throwing test where you bring them back here and have them push forward. You guys examine the biceps any differently? No, I use the same exam maneuvers. I may have peeked at the patient's x-ray, and if they had arthritis, I don't think I would be doing the throwing maneuver specifically, but certainly for most patients in the younger age range looking for slap bicep pathology, I think those are very helpful examination maneuvers. Yeah, I agree. I personally have found speeds maneuver to be not the most useful, but the throwing test, let me ask you this. So do you call that a dynamic labral shear? Do you think that's distinct from the dynamic shear? Are they useful in different circumstances? I think it's distinct. It's a dynamic labral shear. So when Pete's talking about using our throwing athletes, if we're trying to differentiate how much of their symptoms are coming from maybe a slap tear, that may extend a little posteriorly versus a biceps test. The throwing test, I really keep them here, and then I have them resist me, or I resist them as they go forward. The labral shear, I really bring them up and kind of back and over when I do it. So I'm really trying to load the top part of their labral when I do that. I don't think I'm doing that so much when I have them at 90-90, because I don't think I'm loading the top. So I think they're kind of separate. What's your-? I totally agree with what you just said. For me, the dynamic shear is you have to- it's loaded. So I usually have them pulling kind of into flexion and extension at the same- like elbow flexion and shoulder extension as they do it to try to load that posterior superior labrum. I think where they feel pain a lot of times, so forget the shoulder arthritis patient, but where they feel pain sometimes is actually pretty relevant, right? So are they feeling it anteriorly around their biceps? Are they feeling it kind of deep inside or even posterior and posterior superior? If it's posterior and superior, I think it's more coming from slap, usually if I'm doing a labral shear, if it's more anterior, I usually attribute it to the biceps. I don't know if that's how you guys feel as well. Completely agreed. Yeah. I agree. And then she had some crepitation as you'd expect. So take a look at her x-rays. So not bad, right? So she's 37. What do you guys think? Not horrible, right? Starting to get a little bit narrow, and it's not the best rotation. I'll be honest, I don't have the best x-ray techs all the time, so the rotation is sometimes a little bit off. But x-ray wise, what are you thinking? Yeah, I think that this patient, I would tell them they have mild to moderate arthritis. They don't have severe arthritis yet, and at their age, I would be certainly trying to talk them towards a trial of non-operative treatment before getting too aggressive with surgery in this setting. A lot of times, they like to see that it's not bone on bone or severe arthritis, and I think that can be helpful for them. And they can get better, especially if it's not too severe, with non-operative measures. PRP injections are very effective for some of these patients if they're willing to do the out-of-pocket payment. And so I've had good luck with that in the younger patient. That's interesting. So you're using PRP, are you using hyaluronic acid at all in your practice for this kind of patient? What about you? If they're okay paying for it. So the problem is, I think if they're both considered together, PRP is probably better than hyaluronic acid, and if you're doing hyaluronic acid as three shots, the cost oftentimes is the same as PRP. So for me in those settings, I'll use leukocyte for PRP for arthritis patients because you're putting it into articular rather than doing the gel shots. If there's any chance that insurance will pay for it or things like that, then I'll do this go first before I start to move to PRP. Mostly a cost thing for me. You called this mild to moderate. I think this is always an interesting discussion with patients because when the patient here is moderate, they feel like I'm one step away from severe. And I've had difficulty with this. If you use the traditional Samuelson-Pareto classification, it's judged solely on the size of the humeral osteophyte, which is relatively small in this patient, although she does have peripheral osteophytes all the way around. You can see them anteriorly and posteriorly on the axillary. You can't really see one up by the cuff, but you can definitely see one inferiorly on your grachi. We've got to teach your x-ray techs to do more external rotation with your grachis. But definitely there's substantial joint space narrowing on your grachi view. There should be about four millimeters of space between those two bones and, well, I don't have a ruler, and that looks to be one to two millimeters. So she's lost a lot of cartilage. And that's, if you look at the more RSI classifications, that's taken into account. So she would be more moderate. While she's probably only mild on Samuelson-Pareto, she's more moderate on the, so it depends on how you classify it. I think those words matter sometimes in how you use them for patients. Because if you say mild, patients are like, okay, well, I'm a long way away from doing anything. Whereas if you say moderate, they're like, I'm one step away, you know? I usually tell them you don't have bone-on-bone arthritis is what I usually say. And they like hearing that. Because if you tell them that, then it's like game over for them. So we've got some advanced imaging on her. So here's her axial cuts. You can start to see some edema within the humeral head, right? You can start to see some of the osteophytes you talked about, Pete, as we get a little further down here. A good amount of fluid over the biceps. You put a lot of stock into the fluid around the biceps? If they have bicep symptoms and a lot of fluid there, I think that kind of corroborates, but I don't specifically care about what the MRI shows on the biceps fluid. One other question on the x-ray, if they had, they don't in this case, but if they had more of a posterior subluxation, some early posterior wear, does that change how you counsel them about their future arthritis progression? Very different conversation for me. If they're starting to lose, if they're no longer concentric, because we know that some of the studies show that if they're starting to form a B2 glenoid, they're going to continue to progress to be a worse B2 down the road. If they're relatively well-centered as an A, they may not progress over time, but if they're starting to sublux posteriorly, I think that's a problem. And you mean specifically progress in terms of their osteosquare, not necessarily progress in terms of worsening of the underlying? Yes. More arthritis. Can you scroll through those one more time? I can. Just, yeah, in the middle maybe somewhere. A little bit more. So it's really interesting if you look at this view. I mean, on her x-ray, she looks pretty well-centered, and on this view, there's not a lot of subluxation, but there's definitely pretty substantial retroversion. What are your thoughts? Do you guys think that contributes to the underlying risk for arthritis? Do you think that that's neither here nor there? Do you think that's wear-related? I don't know what to think. I think that's more just her baseline anatomy, because I think that that becomes relevant when they're a little bit more progressed than this, and maybe I just don't get enough early arthritis MRIs to see that, probably. But to me, on this, that wasn't concerning to me, but I don't know. Are you thinking about it more? No, I mean, you just wonder. I mean, she's 37. She's so young, you know? Yeah. Yeah. The other thing I think is... I think you see some patients with this retroverted pattern that contributes to posterior labral pathology, and some patients, even in their 20s and 30s, starting to get some early arthritis. I would expect, X-ray-wise, to be more apparent in terms of posterior subluxation, but I think you do see that pattern occasionally, and I'm not sure that's the case here. We don't have an MRI from 10 years ago, but I think that you can see that. I'm not sure there's anything you can do to prevent the progression, so you perhaps tell people that heavy weightlifting, 400 pounds, is not in their best interest long-term, but at the same time, patients are going to do what they want to do, so I'm not too keen on telling them what they should and shouldn't do if they have that predisposition. Yeah. I generally don't try... I explain that to them, but I never tell them to stop doing what they're doing, because they're going to do it anyway, and then you're going to make them miserable, and they're going to come home and say, the doctor told me I can't do this, and then other things will happen. I generally don't do that. And so, if you look at her coronal slices here, cuff, pretty good, right? You probably see some edema where the cuff attaches, but you have some also edema in the humeral head. Yeah. I think the biggest issue here you see occasionally is somebody sees this MRI, doesn't really recognize the arthritis, and starts addressing partial cuff tear. Maybe they complete the partial cuff tear, or they do other procedures for partial cuff tear, and then this patient is no better, and they're actually far worse, especially if it doesn't heal. So that's the biggest issue that can arise with you. If you have this MRI, you don't really have good x-rays, et cetera. Totally agree. I base a lot of how I treat them intra-op on their preoperative exam, so if they had no pain and their strength is completely normal, and her symptoms were not, for me, cuff, I would just gently debride that. I would not repair that back down. Totally agree. Yeah. Would not over-treat. So, what are you guys doing? So she's had injections, had steroids, not working. We go, this go PRP like we talked about. She didn't really want to pay for that. You know, she's a little north of the city, $1,000 for a PRP injection is a lot of money for her, and she didn't want to try it. So, medically-wise, are you thinking arthroscopic treatment, going to move to an arthroplasty, hemi, total? What are your thoughts? Yeah, so as I mentioned, I think non-operative treatment would be my first recommendation. You don't have severe arthritis. PRP, I think, can be very helpful, but if the cost is an issue, they're going to end up with a lot of cost undergoing a surgical intervention based on deductibles and so forth. However, I would discuss with them both of the options listed in this case. Arthroscopic debridement, biceps tenidesis, a lot of biceps signs on that examination and on the symptoms, and I tell them that that won't fix the arthritis, and there's some patients that this is tremendously successful, some patients that this is not, and it's probably about 60-40 in my experience in terms of really substantially better symptomatology with the arthroscopic procedure. And some studies suggest it's higher than that, but there will be progression in the future, and the most important thing is don't touch the cuff. And then in terms of TSA, I would counsel them about that with the risk of loosening long-term need for revision, but it is going to be a more successful option for pain relief for that patient. Same. I think there's a couple of other, I totally agree with what you say about the 60-40 for arthroscopic. I think there's a, just to stay on that for one second, I think that the disease of osteoarthritis is a heterogeneous disease. There are patients in whom there's a substantial amount of loose bodies that are created as part of the process, and if part of the patient's complaint is locking and catching, or if there's a large loose body that's wedged someplace that can cause pain, for instance if there's a large loose body in the subcortical recess, I have had substantial success with just removing those. She doesn't have a lot of that, so that definitely makes me less bullish on the arthroscopic option. I think if you can give someone a bicep sheath injection, and they have substantial relief, you can have more confidence that a bicep stenosis is going to provide some relief. The other point I wanted to make is for non-operative treatment. So we, I also think that her range of motion is pretty good. If her range of motion is severely limited, then you can have some more luck with an arthroscopic debridement and capsule release concomitantly to at least get her some better flexibility, although I think that's probably likely temporary in the long term. The final thing is about whether or not there's any role for physical therapy in this patient. So often these patients come and their primary care doctor has already sent them to physical therapy. What are your thoughts, Greg? Would you take a patient with early arthritis and send them to therapy, or would you not send them to therapy? I have to say that I am not very confident that physical therapy is effective here. I think typical physical therapy regimen works on stretching, flexibility, strengthening, rotator cuff, and I think sometimes it flares up the underlying arthritis. That said, there are patients who they really want to give that a try, and as long as I communicate with the physical therapist that they can work on these things, but there may be certain range of motion limitations that you just can't surpass given the underlying osteophytes, not as much in this case. And overdoing it with heavy strengthening might flare up the underlying arthritis. I think that whether it's placebo effect or what, the patients can often have some benefit from it, so I do discuss that as an option here. I tell them if it's not working, then just stop the physical therapy and just go back, go about your life. What do you think? I think it's partly patient-dependent. You've got to get a read for your patient. Are they somebody who just is, what do they think? Do they think they're going to get better if you give them the list of non-operative treatment options, or do they not? So if they say, oh man, therapy, I think it's going to be a waste of time, then I don't really push it. If they come in kind of looking for it or asking for it, then I'll do it, and if it flares it up, it flares it up because we know the process and we know what it is, and they're probably going to wind up with surgery at some point. But sometimes they just need to feel like they've failed everything before you resign them to a surgery. And so I have no problem trying things like that. So one thing I will say that we've started recently, and the evidence I have to back this up is somewhat circumstantial, but we've done a bunch of work where we've looked at muscle volumes in association with various pathologies, and one of the things we found that surprised me is when you look at patients with arthritis and you compare them to age-matched normals, there is selective muscular atrophy in the rotator cuff. So the deltoid is the same size, the rotator cuff is more atrophied, and the atrophy is actually asymmetric dependent on the patient's retroversion in their subluxation. So in patients like this that are young, what I actually have been doing is doing some physical therapy, doing a very specific thing. So we're not stretching into the end ranges. What I'm specifically doing is band work alone in the mid-ranges, selective to the rotator cuff, with a preference towards whichever muscles are atrophied. So in a patient like this, it's hard to look, it's hard to see on the images you've shown, but I'd be willing to bet usually when there is retroversion and posterior subluxation, their selective atrophy of the subscapularis is compared to the infraspinatus and Terry's minor unit. So what we usually will do is some strengthening of the subscapularis with the hope that we can then overcome muscularly some of those muscular forces that are leading towards that deformity to begin with, because this patient's young enough that there's hope that if you strengthen those muscles and keep up with that regimen, that number one, it provides the patient with more stability and more strength to use the joint when they're at the low ranges. So for someone like this who's like, often I'm using my arms on my farm, you know, like in this position to throw my horse on my saddle, throw my saddle on my horse, or I'm milking cows, or I'm doing things that require a lot of strength but they're not at the end ranges, if you can give the patient more stability there, sometimes the arthritis is less symptomatic. The other question becomes, is there an instability, is there an instability component to arthritis to begin with? And that I think is something that we're still ferreting out, but there is some evidence for that. Certainly there's instability arthropathy and there's evidence of that from the knee too. So anyway. I think that's a good point. I didn't know about that. I think this probably makes total sense though. So you're not stretching it past where the joint wants to go and you strengthen the mid-range. I think that makes total sense. So I'll probably incorporate that now. So arthroscopics that we kind of talked about, you can just do a joint lavage, right? You can go and just lavage the joint. We don't usually do that. As Pete said, take out some loose bodies. We can do an isolated biceps procedure, or we can do a CAM procedure, which is kind of what we were talking about, a little bit of kind of a chondroplasty, taking loose bodies out, getting rid of an osteophyte if you have it, capsule released, get their motion back, take care of their biceps, etc. So the biceps tendon, I mean, I am very much a believer that the biceps tendon can cause pain. And while we don't want to sacrifice this on our overhead athletes at just, you know, our random will, in an older, not older, but over 30, 35 year old patient that's not an overhead athlete, I don't have a problem cutting the biceps. Do you guys have a problem taking the biceps? I knew that. We all trained at Rush, so we don't, they killed the biceps a lot there. So we don't have problems taking the biceps. But this is what it oftentimes looks like. And the problem is you can see, based on a lot of the work that Sam Taylor and Steve O'Brien have done, you don't always see what's going on inside the joint. So for me, I don't make my decision intraoperatively if I'm going to take the biceps. I've already made that decision beforehand. So I go in and the first thing I do is cut the biceps if I know I'm taking it based on what their preoperative exam was. And you can see in this person here how just thick their biceps tendon was. And I think that this really, truly helps a lot with pain, with alleviating pain in these patients. And then as far as, you know, we can discuss where to put the biceps, and I don't want to dwell on this a little bit. I do mine as a mini open sub-pack, and I use a unicortical button to do it. But you can do it however you'd like, as long as you're basically restoring the length tension relationship to try to basically put the inferior border, or sorry, the muscle tendon junction of the biceps at the inferior border of the pec. However you decide to do that, totally fine. Super pectoral in the groove, whatever floats your boat is fine. I do the mini open sub-pack because I do believe in groove pain, and I don't want to have any issues of groove pain going down the road. These are just, again, the random, the different places you can fix the biceps. And this just goes to the length tension relationship. And this is kind of what the x-rays look like. I generally try to leave a little more tendon than some. So on my x-ray, the button winds up being a little bit higher than some, because I just think if, God forbid, that thing fails and you have to go in and revise it, you have some tendon to deal with. Whereas if you have a very short tendon stump and they fail for some reason, and you go back, you're trying to suture muscle, and it's not great. I haven't had to go back on one of these yet, but it's just my thought process going forward. So again, our patient, we kind of talked about it. So for me, obviously she's 37. I'm gonna try what I can and not resign her to a shoulder replacement yet. So we did kind of a CAM procedure. This is what her glenoid looked like when we were in there. So not great, right? That looks pretty terrible. So we went in, we did do a capsules. This is not her. This is just, you know, different ways to cut the biceps. I use a cautery device. Sometimes people will use a basket to cut it. And then you can get down low and take off whatever osteophytes you can see. So basically coming down here and just removing whatever osteophytes you find. She didn't have any loose bodies. You know, we do a subacromial decompression. And then we get them moving pretty quickly, because we're really just protecting the biceps tenodesis in these people. So range of motion of the shoulder, as long as you're doing it, you know, passively in physical therapy, starting at a week or two is totally fine. So you don't need to wait on them because they will stiffen up again. And if you look at the outcomes of CAM procedures, you know, some people think maybe it's a kind of coin flip. Is it going to work? Is it not going to work? You guys kind of talked about it 60-40 maybe. And most of the work on CAM procedures come out of Peter Millett and basically showing that, you know, at an average of 10 years, when we looked at 38 patients that had this, 75% of the patients at five years actually hadn't progressed to a shoulder arthroplasty in 60% of 10 years. So if you can buy somebody who's in their 30s or early 40s, five to seven to ten years before you have to resign them to an arthroplasty, I think it's probably worth it. Now the question is, you know, when you do this surgery, are you making them worse if you're gonna have to do a shoulder replacement on them? And which patients are going to fail and so you maybe shouldn't even bother with them? So they kind of looked at patients that they thought might fail from this. And basically what they found was that worse arthritis going into it, as you talked about, so less joint space, higher KL grades, and then older patients that you do this on are more likely to fail. And also B2 glenoids don't do as well. So to our point of if they're starting to come out the back a little bit, you're starting to erode the posterior glenoid, this may not be quite as successful. You can still try it, but you have to have a real conversation with your patients. If you have very little joint space, if they're starting to come out the back, they have a B2 glenoid, they may not do so hot from this. So you have to just make that known to them. These are just kind of showing you, you know, the difference in people who were successful versus failed. And again, statistically significant for what I was just kind of telling you about. So this was their kind of decision tree on who should have a CAM procedure versus who should have a total shoulder. So really, older patients, higher arthritis, go for a total shoulder. Younger patients, less arthritis, consider a CAM. And then to my point before, you know, you don't want to negatively impact your shoulder replacement. So if you buy somebody three years or four years from a CAM procedure, but your outcome after your shoulder replacement is not as good, then it probably doesn't make sense to do this. So they looked at this and luckily what they found was basically that doing a CAM procedure on these patients did not increase their risk for failure in having a shoulder replacement afterwards. So at least you're not burning any bridges by doing this. Sometimes we think about, we may talk about, you know, rotator cuff SCRs and progression to, you know, reverses later. And there may be some negative impact there. With this one, at least it doesn't seem if you're going to do a shoulder replacement on them, you're hosing yourself down the road. Any other thoughts on that case? Would you guys have done anything different? Looks great. No, I think it looks good. Do you do the axillary nerve neuralysis that Millet describes? I don't quite have the gallstones for that, so I don't do that. I found the axillary many times arthroscopically. I just don't really think that axillary, I personally think axillary nerve entrapment is a big portion of the pain related to this disease, but I could be wrong. I generally don't go down to find the axillary nerve to be honest with you. So I will peel the capsule off arthroscopically down there and make sure I can see the osteophyte and be pretty protected when I take that inferior osteophyte off, but I don't go with the basket and the burner down there to find the axillary nerve. I think I can cause a problem. I don't want to cause a problem in a 37 year old. So how's the time? Because they don't have a timer up this year. They're not putting timers up. We're at 23 minutes. Okay. So I think we each probably spend 30 minutes. Yeah, so we'll go through this one a little bit faster. So this is a 43 year old guy, workers comp, came in, bilateral shoulder pain, really long history of both shoulders before he saw, before he came to our practice. So right side, labral repair, cuff repair, biceps, tenodesis, three separate procedures that he'd had before he saw us. Left side, cuff repair, biceps, tenodesis, two separate procedures before he'd seen us, and they also had an ACDF because he was having some neck stuff. He's actually a workers comp side. He's actually a reasonable dude, works hard. He's still working, so he's not out of work. He's not on disability. He's a heavy manual laborer, and he just is having a hard time with his shoulders. So we get this x-ray on his left side, which is the side he was coming in for. Again, you know, we won't dwell on it, but we can start to see some arthritic changes in the shoulder here, and he's really starting to subluxate a little bit out the back there, right? So to Peter's point before on these x-rays, he's not sitting well-centered anymore. This is a very different patient than that 37-year-old. This is somebody who is going down the road that is not great and has already had multiple failed arthroscopic procedures in his shoulder, and if we take a look at his CT scan here, you can start to see some relatively large osteophytes that are starting to form there. So I don't love seeing all this extra stuff here. That makes me a little bit nervous. You guys? Yeah, this is one where you wonder if he actually had a cuff tear in the first place, and they took it down, and they made a repair in his 30s because it's pretty unusual to have a full-thickness cuff tear then. They were probably treating arthritis all along, but you can't change that now, so you're kind of trying to do the best you can, so. But yeah, he's starting to sublux, wear the back a little bit, so definitely one that is concerning on multiple fronts because you're concerned about the cuff too. Yeah, I mean, so I could be wrong, but this is also one where I have a substantial discussion with the patient about, you're 43 years old, you're definitely young enough that we could, you know, like you've got another 22 years to retirement, depending on what your profession is, you're young enough that we could talk to workers comp about training you to do something else. I have had, I've had workers comp some success with that, so I've had definitely had patients, like I had an electrician that was electrocuted, and he had a substantial injury to both shoulders that did not allow him to return, and they trained him as a paralegal, and he's paralegal now. So they, um, that can happen, but you have to have the discussion with the adjuster to make sure that they're, and then they have a discussion, I don't know who discussed it, there's some discussion within workers comp to see, because for a guy like this they've already paid out a lot for this guy, you know. Yeah, and he's a, he's actually, I mean, he's a reasonable guy. Right. So you just kind of feel bad for him. And so, you know, we get an MRI, see some scatter from some of the metal stuff that was in there from his prior surgeries, but, you know, again, looking towards his, looking towards his cuff, you know, his cuff to me, even though he'd had a kind of cuff repair, I don't really see any. I don't see any anchors. Who knows if that was a little side-to-side repair or what they built for it, but his cuff to me looks, his cuff to me looks fine, I mean, not fine, but relatively okay, and I don't think that's his issue. And so, again, try to get him along with steroid injections. Let me ask you this, we talk a lot about injections, I know we want to talk about, you know, these surgical stuff, but sometimes we try to keep these people out of the OR. What's your threshold for steroid injections? How often will you give somebody with arthritis, but an intact cuff, a steroid shot? For me, it's inversely related to age and activity and everything. So in this guy, I would try to do one max, maybe two injections for cortisone and go from there. Eighty-year-old patient who doesn't want anything to do with surgery, there's no particular limit that I have in mind other than not too close together, three, four months apart. Yeah, completely agree. I mean that part of that discussion I have the patient to is to say, if we're getting to two, if you're coming back asking for the third shot, it's not working, it's not a solution to your problem. Yeah, I totally agree. So two is the two is the max that I'll give them, and to Greg's point, I try to space them out at least five or six months on these guys, because you really don't want to deteriorate the cuff, because then you're really changing this from one problem to a very different problem in a 43-year-old person. So for me, he was gonna be somebody that had a total shoulder, so I didn't think it was worthwhile to mess around with arthroscopic treatment for him, I didn't think it was gonna work. So we generally, you know, plan our shoulders out, you know, we all do it a different way, I use this particular system basically to correct any type of version that he had. He didn't really have much in the way of any significant retroversion, even though he was starting to posterior subluxate a little bit, and generally we try to correct it to neutral if we can. You can tolerate a little more superior inclination with an anatomic than you can with the reverse, so with one degree it's totally fine, as long as you keep them within five to ten degrees of both retroversion and superior inclination, I think you're okay. So we put in a stemless arthroplasty in him, and he's actually done really well with this. Interestingly, before I operated on him, I had, you know, we were talking in the pre-op area, and he was also telling me, yeah, you know, I used to be able to just, or I can still sometimes when my daughter pulls my arm, it kind of subluxates a little bit, so it made me a little bit nervous intra-op, and so I put in a slightly bigger head than I usually do, so a thicker head, because I was worried about him coming out afterwards, even though he was arthritic, I was worried about his post-operative disability because he felt like the shoulders would dislocate sometimes. I think that was the right move, the wrong move? He's doing fine now, so I'm, it was okay, but it may have been fine with a smaller head. Would you guys have done that, or would you have just done your normal size, your normal thickness? Yeah, I wouldn't have adjusted for that particular complaint. I think that could easily be the arthritis. Again, it looks fine here. Maybe the head size could be one less, but I wouldn't adjust for that. I would potentially adjust the head offset or size if they were severely subluxated and continuing to subluxate out the back as the components go in, but not for that. I agree. So interestingly, I didn't tell you this before, but actually Romeo had done an anatomic on his other side three years before we got to this side, so he put it in his other side when he was 40. This is before the stemless was around, so I didn't tell you that piece of the story, but his right side already had an anatomic in it that he was happy with, so it was easy for me to decide to do an anatomic on his other side. And this is basically just looking at, you know, long-term clinical outcomes in total shoulders in patients under the age of 60, right, and basically just looking at kind of survivorship levels. And you can see kind of for shoulders it's actually pretty good. So at 10 years, about a 97 percent, 15 years drops to 85 percent, and 20 years about 80 percent. You can see kind of the Kappelmayr curve here does pretty well and then starts to go down over time, but it's not like they're failing at five to ten years after this, so it's not like if you put this in somebody who's 40, they have a 30 percent revision rate by the time they're 50 or 55. Now we know that over time they're gonna wear out at some point, but we always think that these are gonna fail relatively quickly, and we try to push them along an extra three to five years. But the point of this is to show that sometimes an arthroplasty is the best option, and when you should do an arthroplasty, go ahead and do it. Don't be afraid to try it. This is, again, just a different study looking at similar issues. So arthritis, very common problem, right? We try our best to avoid doing an arthroplasty in patients, but sometimes that's exactly what they need. We can try arthroscopic management depending on what their symptoms are, what the range of motion is like, and then obviously the goal is just to get them a functional shoulder. They may not be a hundred percent perfect after a shoulder. Arthroscopic surgery, especially in the CAM procedure we were talking about, I've had some patients where I've done this on, where they have had really poor motion going in, and you get them very good motion, and then they notice a lot more grinding and crepitation and clunking, and they're actually not always thrilled with that. I've had a couple that were like their motion is excellent, but they don't love all of the crepitation and grinding that they feel with that. I don't know if you guys have had that. Yeah, so can sometimes be an issue. Anyway, so these are a couple more books just for your reference, so thank you guys very much.

shoulder arthritis

young patients

conservative treatments

arthroscopic treatment

total shoulder arthroplasty

steroid injections