Real quick, two days ago I got a call from one of the professional baseball players. They said, hey Doc, this is so-and-so. It's been a long time, it's been eight years since you did my lat-terries and I've been doing great. I just got a recent MRI on my shoulder and I got a few opinions, I was wondering what you thought. And he's 32 now, and this is what his MRI says. Severe glenohumeral joint arthrosis, partial tearing of the supraspinatus, there's a loss of the joint space, there's diffuse labral tearing, osteophytes, acinivitis, and scattered loose bodies with capsulitis. He's 32. He told me, he says, it's really hard for me to get to 90 miles per hour when I throw now. And can you do something to help me get back? So these are the kind of patients we have today. So Matt's gonna tell us about some biological options that we may have for some of our patients, try to help them out. Thanks, Matt. Thanks, Tony. 90 miles an hour, pretty impressive. So there are many options for this biologic phenomenon. Tony, among others, have helped pioneer a lot of these. There's a lot of publications on this. A lot of these are case series because of just the relative infrequency, but when you put these all together, it's pretty interesting. There are a lot of different graphs. I gotta tell you, I've tried almost every single one of these, and I've got some of my favorites. So when we think about cartilage defects, the good news is we don't walk on our shoulders, and we get away with quite a bit. And so if you have a chondral defect, many times that can be incidental in the shoulder joint. We see it in the humerus. We could see it in the glenoid. And so what we've sort of broken these down to is these more palliative arthroscopic debridements, as Brandon showed you. Reconstructive is what I'm gonna talk about. And then for larger regions, you can do a reparative ACI, restorative bulk allografts, or other types of defects. But these are very tough, challenging problems. Many times these are post-surgical phenomenon. They have other concomitant pathology. There might have been other implicating factors, potentially. There could have been some anchors, or knots, or other things that are an issue, as was the case here. And you can see doing a arthroscopic capsular release, capsular debridement, as Brandon's shown, on top of biceps management, as well as any other rotator cuff issues, can work very well. What about when we're in the reconstructive realm? Say we've done the arthroscopic resurfacing, or say you're thinking about doing some arthroscopic work, but the joint space is very narrow. You've got a pretty limited joint space. We did have a phenomenon back in the day called chondrolysis of the shoulder. And you may remember that with the pain pump phenomenon. We published quite a bit on that. I almost wish I didn't, because the amount of attorneys that were calling my office for depositions and expert testimony was quite high. Fortunately, for the most part, the chondrolytic phenomenon has gone away. And the term chondrolysis, just so we know, was pioneered from our hip surgeons. Actually, in the pediatric world, it was SCIFI. And so basically, the word chondrolysis came to say this massive joint cartilage loss and destruction. We saw it in these pain pumps where interarticular pain pump was utilized, but it wasn't the whole issue or the whole factor. So the pain pump wasn't 100% implicated all the time. There were other factors that we just didn't know about, because there were a lot of pain pumps used back in the day and we didn't always get chondrolysis. Now, fortunately, for the most part, this has disappeared. Although even just last month, I saw a patient that had a pain pump put in about seven years prior. She was 27 years old and bone-on-bone arthritis. It's a much different type of phenomenon when you have this massive acute dissolution of cartilage. Tony and I have talked about this quite a bit. It's not the slow progression of arthritis, but it's a completely different phenomenon. So we have to be careful about throwing around a term chondrolysis, where it's really specific, related to this massive cartilage acute loss due to some type of insult. It doesn't even have to be our issue. It could be iatrogenic or otherwise. And so these were some of the things we had to pioneer because these patients, unfortunately, were so young during this phenomenon. A lot of this work came out of that chondrolytic phenomenon. And so when you look at this, this is a lateral meniscus allograft and hemolytic arthroplasty. And Mike Wirth was doing these very young patients. They were all age 15 or younger. Many of these were chondrolytics. And part of that issue with the chondrolysis, not to harp on it again, but it created such a massive synovial inflammation, a massive inflammation process in the shoulder. So you didn't have that longer runway of arthritic or osteophyte development where the shoulder can make these adaptive changes and the capsules sort of settle out. So it was really more a homeostasis issue of the joint is how I sort of thought about it. But even, you know, Mike Wirth showed a 30% reoperation. The scores were much better, but this was transplanting in with anchors, usually from an open approach. You can see here a bunch of anchors and suture knots around the periphery as we all did this. And the lateral meniscus was the graft of choice because it was really C-shaped. There was a lot of surface area coverage for it. What about dermal allograft? This is another one. 55 patients, Buzz Burkhead had hemiarthroplasty and then a dermal matrix. The thought that, listen, we don't wanna go to the glenoid. The glenoid is our issue. It's our enemy in terms of a total shoulder, especially in a young patient. We don't want early polyethylene. And so what he did was a hemiarthroplasty. Let's do the ball. That's fine. That seemed to work out really well in the hemi, but the literature again and again showed that hemiarthroplasty just doesn't give you the adequate pain relief. And total shoulder remained the gold standard for patients with bipolar arthritis. But Buzz Burkhead said, we'll put these PRP, we'll put the acellular dermal allograft in. And you can see that the scores actually improved quite a bit. The average joint space was pre-op. It went up maybe a millimeter post-operatively. So maybe the graft was helping that. And then 81% of patients were satisfied. What about a full systematic review? These are 268 shoulders in the literature. This is in 2020. So when you summarize all of these biologic options, we're trying to put together evidence that we just probably don't know exactly what to do best. But you can see these are the grafts that were chosen. Lateral meniscus, acellular dermal matrix, Achilles tendon, joint capsules, and fascia lata. And I would say my workhorse would usually be the lateral meniscus and the human acellular dermal matrix. And then the problem was at least a third went on to revision. So doing these, you're gonna have to really counsel your patients. I say, what I generally tell my patients are, you are going to need tune-ups on your shoulder going forward. There's no question. If we can get you some time at age 20 to 30 to 32, as Tony showed, to 40, that is a huge victory. And then we can go on to your total shoulder replacement down the road. These biologic resurfacing, here's another one with very good results, but unsatisfactory outcomes if you had other problems. Many of these patients are multiply operated on. And we always have the enemy in there of P. acnes or other things. So a lot of times we do biopsies when we're doing these cases because they've been operated on multiple times. And that's always a double-edged sword. You'd go in and do the biopsy first, then come back two weeks later after you have enough adequate tissue. Or do you do it, roll the dice, and say, listen, there's a variant, cross your fingers, Sam, and put all these graphs in and put everything in. And all of a sudden the cultures come back and you got positive P. acnes. What do you do with that? And we can talk about that in the panel. I think it's an interesting way on how we handle our multiply operated on shoulder patient. And Tony, when he was ASES president, was really instrumental in putting together a task force that helped us understand how to better manage shoulder infections and diagnoses. So here's some small lesions here you can see. This is almost a GLAD lesion, but it's in the posterior side. GLAD is a glenoid labrum articular disruption. Here you can see I'm doing a microfracture in the back of the glenoid here. But you already know this patient is going down a path. Why? Number one area in arthritis for the shoulder joint, posterior inferior. That's exactly where this is. So this patient's going down a bad path. This patient was very young in their 20s, but you can see the beat up labrum, the cartilage. And you can also see corresponding bipolar lesions on the shoulder. So a pretty tough problem. Sometimes we'll stabilize a labrum or bring up the labrum to cover this with anchors or other situations. The other thing we have here is microfracture marrow stimulation. Here you can see it really nice. You turn the pump down, you always get the good video when the marrow comes in. But microfracture of the humeral head, I found to actually be quite effective. Now what's interesting is the cartilage of the humeral head is quite different. A study was done out of rush that looked at the thickness of the humeral head cartilage. And guess what? It's only about 1.1 to 1.6 millimeters. It's very thin. And it probably has different biologic characteristics as well than other areas such as in the knee or the patella where the cartilage is much thicker. Here you can see the massive inflammation that can happen when you have these early lesions. And you probably say this is a symptomatic lesion. Why? It's a lot of synovitis, a lot of capsule irritation. And you can see the symptomatic lesion on the humeral head when you're trying to decide whether or not this is true. I also differentiate symptomatic lesion. Why? Because the first thing you lose is internal rotation. Now you gotta make sure you stabilize the scapula. It's missed all the time. My fellows are like, okay, yeah, normal internal rotation. Then I go in there and I put my arm on the scapula and stabilize it. And they have about five degrees of internal rotation. Why? Because they've learned to compensate very well. So test internal rotation abduction first. That'll help you find this out. I'm now gonna talk about some allograft options we've done. And again, these are in selective patients that we think have these lesions that are contained. Sometimes they're unipolar, but sometimes they're bipolar. Our best results have been in unipolar lesions, just like in the knee, if you don't have the tibia side. And so these are some of the graft options we've done from a cylindrical graft for, and we open up the shoulder for these focal lesions on the humeral head. This is from John Lee, who'd had 19 patients for OCA of large hill sacks. And so kind of extrapolating this, they had good improvement, but they also, these were frozen grafts. These were overseas. The graft options there are generally frozen or frozen, deep freeze type of grafts, and had high resorption rates. We have to be a little bit careful about that. In our allograft world, we found very little resorption, but we use a fresh allograft product. This is Tony's work where he had 20 patients looking at osteochondral allografts of the humeral head. And you can see here, generally fixed with headless compression screws. I love having a set like that that has a variety of two millimeter to four millimeter headless compression screws in a variety of sizes. So you can fit this and put this in. And these are really nice. You got to make sure they're recessed. And they actually do very well. And all of my allografts, the humeral head, I generally fix with these, even if it's a contained defect, just to get really good compressions. I don't want this thing to resort, but I want to give it the best chance to heal. But you can see, here's from Tony's work. You can see on the right side, at that large inferior humeral head osteophyte, significant loss of joint space, even loss of conformity and articular. The head's flattened. It just doesn't look good. And so you can see the nice look and the outcome you get after this procedure. But there is a shelf life to it. It looks great on x-ray on day one, but it definitely has a shelf life. So here's a case. This is a 24-year-old male. He's a Navy parachuter, three years after an instability repair, and had pain and mechanical symptoms. And you can see here, here is his imaging. Little bit of posterior glenoid bone loss, maybe a Walsh A plus-ish, if you will, maybe a B1. Excuse me. You can see the prior anchors. And then here on the right side, you can see that inferior humeral head osteophyte. This is the number one place you want to look for early wear and tear in your patient. It's right at the bottom of the humerus on a true AP view. And so you always get a true AP on your patients. In clinic, you can get, that's the gray-shaped view. You can get a couple other views, but this true AP is the most important one. So you can bring that humeral head out and it can really show you the inferior subtleties of this humeral head osteophyte. And so when you go into the arthroscopy, you can see really beat up degenerative labrum, posterior cartilage issues. And then almost what you have when we describe and written up is this linear stripe wear on the humeral head. And so you can see a stripe. And why is that? Because for whatever reason, the implant or not, or other things are causing issues on the humeral head. And you can see, you have good cartilage, bad cartilage. And look at the remodeling that's occurred on the left side of that after this issue. So implant arthropathy is the real deal. We have to be very careful how we comment on this, because you have no idea where that anchor was, bless you, where that anchor was, how it was put in. It could have settled. I said, I have no idea where this anchor settled down the road to the patient. What was it put in wrong? Was it done? No, it wasn't probably put in wrong. Everything was fine. It's just, this is where it settled and this is where the issue is. So I think we have to be very careful about commenting on where implants are for our colleagues out there, because you just have no idea. And so here's that same case. You can see the linear stripe wear, normal cartilage above. I take down, try to preserve the three sisters inferiorly. So we're just taking down the top two thirds of the subscapularis. Keep in mind, that's about a five centimeter attachment. So we're taking down about four centimeters of that subscap. And then we're putting two humeral head bone plugs in after sizing this, taking down osteophytes. And this is what we have here. This is from a fresh humeral head. These do take a little bit of time to obtain from the graft companies. They're not the easiest grafts to obtain. And largely I've switched to fresh tailor allograss, which I can get in about three to five days. And the radius of curvature is almost identical. I do male to male, female to female, nothing else matched. I don't worry about it. It's just male, male, female, female. And the fresh talus for this works very well. And so you can see some of the plugs put in and here he is at nine months post-op. Much better motion. It's not perfect, but it's not too bad. Good external. And you can see the issues with this are still having some problems with internal rotation at the end of the day. Here's a 35-year-old right-hand dominant female. It's a little bit different, but these do go on to arthritis and it's a big problem. This is something more common you might see. It's a classic fell off her mountain bike when she fell and landed on her arm, taking the OR for closed reduction following an accident. Now the problem is these patients can present to you in a sling. And so she has a posterior shoulder dislocation with a very large reverse heel sacs. Where's the seizure disorder? Where does the electrical shock come in? That's a classic boards question. And we certainly see that in seizure disorders. Still a pretty reasonable part of my practice. We have these very large bone lesions around the shoulder and generally they're in younger patients. And I generally treat these with bipolar grafts, distal tibia or iliac crest for the glenoid and then fresh talus for the humeral head. And so that's what we did here. She actually had a traumatic injury. There could be an argument to tamp this up. You can see the nice cortex there as it was acute. But the one thing I'll caution you of, these patients are very comfortable in internal rotation in a sling. And so this is the number one closed case for litigation in the emergency department for missed posterior shoulder dislocation. Because it's very easy to miss this. They got the CT in the ER while it was dislocated. But then the MRI they got actually in the ER after it was relocated and then the patient was sent to clinic. And so this is the tailor work we've done. And we found this very good fit to the humerus for the talus. You can see how this would be extrapolated for focal defects. I found this to be about in males about up to 40, 42 millimeters for the tailor block if you wanted to do that. These are in the shape of a lemon wedge or an orange slice for a reverse heel sacs. And the problem with reverse heel sacs is it's not a good name versus heel sacs because reverse heel sacs is totally different. It's all cartilage. It's 100% involves the joint. Whereas a heel sacs just depending on the size has to get really big until it starts to involve the cartilage. So we're sizing it and it's basically Woodshop class 401. A lot of these I 3D print ahead of time. You can do it with a commercial 3D printer. I even invoke some of our arthroplasty folks. I send it in and they'll actually print it for you and say, well, I'm not doing an arthroplasty but I'm doing this. I'll do the model for you. But I also send it to my 3D printers as well. And we get a nice model. Here's the talus. And you sort of just have to shape this in the lemon wedge. You got to do it angled to both flat surfaces. So you're doing an angle on the talus here and using a sad saw. There's the flat front anterior process of the talus there. I don't know. I forget a lot of the anatomy about the foot and ankle, I guess, but I just know there's the round. We just use the cartilage part of the talus. And then once we're able to Woodshop this and go back and forth, you can see this is an unmatched specimen. It's male to male, female to female for her. And you can see, I just took down a little bit laterally to be able to repair the subscapularis. And it's almost 100% conformity there. It's really nice, easy to get. And here you can see the x-rays post-operatively, the headless compression screws that we employ. And you can see the CT scan where we've reconstructed the joint here. So this is a nice workhorse for you around the shoulder joint from a graph standpoint. Here's another case, a 45-year-old female. Two-year history of posterior instability left shoulder. Previous arthroscopy, chondroplasty, microfracture of humeral head, biceps tenodesis. And certainly you can argue for what Sam's gonna talk to you about at this point. Her posterior symptoms resolved, but now has pain with loading activities of daily living. This is her shoulder, not too bad. You can see her prior tenodesis. Pretty reasonable joint space, but not perfect, probably in the one and a half to two millimeter interval. Her imaging shows a pretty symmetrical joint, maybe a little bit of posterior subluxation. And then cartilage wear on the humeral head. Cartilage MRI is very hard to see on the shoulder, depending on how your MRI protocol is. And you can see, here's our arthroscopy with, you can see almost a pretty extensive, but focal-ish humeral head defect. And you can see, here it is when it's open. And so this is another type of one we did where we did humeral head and glenoid. And so I actually did the talus as well as the distal tibia. And so the distal tibia, I did a round plug out of the distal tibia to the glenoid side. And then also on the humeral side, I'll go back one here. Also on the humeral side, did a osteochondral allograft. So she did quite well, but she's probably about five to six years into this, and I think she's going, she did quite well for those time. But now she's about 37, 38, and I think she needs her next tune-up here pretty soon. So we have to be realistic about this and honest, and I'm super transparent with my patients. So you might get five, seven, 10 years out of that, and that's gonna be a really good home run for you. So I think that conversation with them, these patients are ones I spend a lot of time with in clinic to make sure we have an understanding that, and I sort of put the decision on them as much as possible to take the stress, or we have enough stress in our lives and surgery and everything else, but I wanna put the decision on them to try to see what they wanna do in terms of their risk tolerance. The other thing is you only get so many chances at the subscapularis, and you have to be really careful about that. So that's another thing I talk to them about, and I think it's underappreciated. Tony's taught me that time and time again about the meticulousness of handling that subscap, and if you lose that, then you're down to that 30-year-old that might just be able to do the reverse, and that might be your only option, and that is a significant issue. So the evidence is still lacking. There's probably less than about 300 biologic patients in here from a biologic resurfacing. Arthrosphy still is the gold standard, but there are some hybrids, including HEMI, HEMI plus graft, HEMI and cartilage, and this continues to evolve down the road. It's challenging. Do it well the first time to avoid if possible, but we do certainly have some salvage options. Thank you very much. Thank you.

biological options

shoulder joint injuries

glenohumeral joint arthrosis

supraspinatus tearing

treatment options