All right, thank you, good to be here. I do work with DJO, so there's a conflict here. Guys, you're crazy, okay? This is the decision-making process that we're hearing here. These are called bad decisions, okay? I'm going to argue heavily in favor, obviously, on the shoulder arthroplasty side, with the understanding that many of the things that have been talked about, I do employ in my own practice in select situations, but for now, I ask you to unlearn what you have just been taught. Our actions do have consequences, okay? And despite the Peter Millett paper that Brandon presented here, there are numerous studies that have been shown, as Dr. Romeo mentioned, that do show negative impacts of prior arthroscopy. Higher re-operation rates, higher infection rates, lower outcomes from ultimate arthroplasty. This study from our institution, looking at a large database, here showing an odds ratio for infection after arthroplasty was nearly two. This is an actual picture that I did take during the height of COVID, an elderly couple who decided to go to Costco to pick up some flowers, okay? So this is, again, this is a bad decision. You need to kind of think about what the implications are of everything that you're going to do. And the bottom line here of what I'm going to talk about is that if you're not going to get 10 years out of a non-arthroplasty option, you're wasting their time and their quality of life and subjecting patients to potential complications down the road from the ultimate arthroplasty that's in their future. As has been mentioned, and I agree completely, that preoperative factors that negatively influence non-arthroplasty option are going to be severely narrowed joint space, limited range of motion, and particularly refractory night pain. Metal and plastic is a good but not perfect option. Even in the young patient does have a nearly 80% survival rate at 20 years, and we'll talk more about that. Hemiarthroplasty is inferior to total shoulder arthroplasty for return to sport and return to work, so that is a myth that if you're trying to get somebody back to sport, hemi. Our goal should be total shoulder. Don't compromise on your ability to perform the best operation first, and we'll take into consideration some of those things and set proper expectations. So obviously complex problem, many different things, and there are a number of history, physical, and imaging findings that I take into consideration when you think about kicking a can down the road. Moderate pain, plus or minus night pain, what kinds of things do they do, but particularly range of motion and external rotation. If somebody can get to 45 degrees and has reasonable forward elevation to 130 and some joint space that is present, I do think that a number of these options that have been talked about are reasonable, because you can kick that can down the road. But when you start to see severe limitations in range of motion, joint space, and then imaging findings that are portending alterations in what your ultimate arthroplasty will be, you realize that you're not really just kicking a can, you're kicking an oil drum. And so you have to think about how far down the road you're actually going to be able to kick this and implications of your decision making. So this is just a study here that looked at some non-arthroplasty options, PRP, VSCO, arthroscopy. And in their study, one of the biggest factors for the people that were going to fail these non-arthroplasty options and convert was external rotation restriction. So this is a patient of mine, he's 30 years old. Don't be scared to do the right operation and go down a whole slew of other non-arthroplasty routes because somebody is young. Do the best operation that you can first, and when that's an arthroplasty, you should do it. As Dr. Romeo talked about earlier, but just in general, the demand is increasing and we're going to continue to see some of these younger patients present more and more. Our arthroplasty options, the kind of hemi-arthroplasty, ream and run, total shoulder, and reverse. And I say avoid if possible, but the important part there is if possible. Like Dr. Romeo, I mean, the youngest reverse I've done was 26, and it is what it is when it is. We're going to go through a few things here. So ream and run is a great option. I don't know that it's a great option. I do think that it is an option, and my colleagues likely, I'm sure, have more experience with a ream and run as an option than I do. But Madsen and others, Dr. Romeo, have shown good results with a ream and run procedure, where really the concentric glenoid does better than an eccentric glenoid. And the rehab process for these is very intense and rigorous, and outcomes somewhat variable. But Madsen has shown that the survivorship of these, in terms of pain and function, can be quite good in the mid- to long-term. Let's get rid of that one for a sec. We'll skip this too. I'm not going to beat the horse. So what else do people sometimes say? Well, I'll do a HEMI now, and then I'll revise it to a total shoulder in the future. Not necessarily a great idea. So this was a study here looking at 16 HEMIs converted to total shoulders. The time to revision was three and a half years at a five-year follow-up. Really kind of mediocre results at best, with nearly half of patients ascribing a unsatisfactory result. And to what Dr. Preventer said earlier, subscap doesn't take a joke, and you only get so many shots at the title before that title is gone. It is important to note that in these HEMIs that more than half, so 64% of the cases, noted progressive posterior glenoid erosion. And so if you think you're going to go in to do a HEMI, and then you're going to go back and do a total shoulder, with new version changes, with now a B2 or significant posterior wear, you've now compromised your ability, not just through the subscap, but through the osseous morphology on the glenoid, from doing your best operation. So ultimately, they didn't feel here that a HEMI was great. While other people say, well, I'll do a HEMI so that they get back to sports, we're worried about the glenoid loosening over time, so I'll do a HEMI because they want to get back to sports. This is a paper out of our institution here showing that total shoulder has higher return to work and return to sport. Now, there are some limitations with regard to the type of work that they did. Total shoulder here, 97% returning to sports at six and a half months. Comparing HEMI to total shoulder, you can see higher VAS scores in the HEMI group, lower ASES scores, and lower return to sport for the HEMI arthroplasty than a total shoulder. So I'm not a fan of HEMI arthroplasty. I think there's a very limited role for it in today's world. Again, we're starting to kind of beat the horse here. But total shoulder, almost uniformly across the majority of studies, outperforms HEMI arthroplasty for return to sport. So like I said, do your best operation first. Don't be scared to do the best operation, but be prepared to have real conversations with people. I had a 30-year-old patient that Dr. Warren had referred to me for a total shoulder because he said, you know, I can do your total shoulder, but you have revisions in your future, and I'm not going to be there to do them. So I'd like for you to see one of my younger partners. And the question that patients ask or should ask is, well, how long is this going to last? And to what Brandon had said earlier, you know, on average about a one, one and a half percent failure rate with time. It's not a linear failure mode there. But you know, ultimately, I kind of tell my patients that about 80% of these will still be in and functioning at 20 years. Ultimately, the studies that look at long-term are kind of based on older implants, things that we're doing now. Materials are different, vitamin E, poly, different in-growth surfaces. Things have changed a lot. So ultimately, we don't know how long these things are going to last. But I do always tell patients that metal and plastic is not as good as what God gave you and you wore that out. And so you do have to have candid discussions with patients about activity modification so that they can hopefully avoid some of the posterior loading type activities that may lead to an earlier failure, particularly on the glenoid side. Patient selection is appropriate. This guy looks like he's not Nate's older, but looks like Nate's older. He's about six, nine, 300 pounds. He's got a zipper around his skin graft from injecting IM cocaine. So think about your patient selection. This guy's got a terrible shoulder, but I really don't want to operate on it. Appropriate indications, people are really, their quality of life is dramatically impacted. And then what I'm going to get into in a second is those who have morphologic changes, particularly on the glenoid side, that will, with time, alter your ability to perform your goal, which is a total shoulder. And I do tell people I don't want them bench pressing. I mean, obviously they can, but they shouldn't. And I'm curious to hear from you guys in a little bit, some of the restrictions that you tell your patients. But I also do try to tell people, I mean, you can't take everything away from somebody because if you take everything away, then they don't listen to anything you say and they do everything, right? So I at least try and tell them I don't want them bench pressing, but if you need to do some chest work, cable crosses, pec deck, at least put a little bit less stress posteriorly on implants. You know, you're buying this patient for the long run. This patient is going to be with you for likely the duration of your career. And these are people that you, in my opinion, shouldn't be offering anything, or certainly not a shoulder arthroplasty, to the first time that you meet them in the office. You know, in a lot of ways, they need some time to process it. You need some time to build a relationship and you kind of want them to earn the operation, if you will. So you know, when to pull the trigger, I mean, with shoulder arthroplasty, this is a quality of life issue and there often is no rush to do it. And I'm very reluctant to push somebody to do something that they're not ready for unless there's something about that patient that is going to change my ability, like I said, to perform a total shoulder. And from an imaging standpoint, that's largely glenoid morphology. So people with an early B2 or a B1 with starting to get more significant retroversion, large cysts that may impair as they progress my ability to get glenoid fixation or significant subluxation may push me to push them to try and get to the total shoulder before it becomes too late. This was out of the Cleveland Clinic. This is looking at the natural history of glenoid morphology changes and looking at a series of CT scans that are five years apart. And they basically found that if you're starting with a concentric glenoid, the majority of those stay concentric. And so I think that there is very little urgency in these patients, but I still do recommend following them annually. But if you have a B glenoid, almost 90% of them over five years are going to progress significantly from a B1 to a B2 almost 80% of the time, and 10% of them will even go to a B3. And these have significant implications on your ability to perform a total shoulder. This is an example. This is a retired Giants lineman, 2015. You can see the significant progression and you start to see that posterior subluxation and erosion of the glenoid. This is one that I was considering trying to push him in a direction. We got a CT scan and fortunately the x-ray had kind of overestimated what his subluxation and glenoid was. And so on a CT scan here, he was pretty concentric, not subluxed, and so we were able to continue with non-surgical management on him. I mentioned cysts. At some point, cysts oftentimes continue to get bigger with time and they can have implications on your glenoid fixation. This is kind of an early B2, 17 degrees of retroversion and subluxation. And so this is an example of somebody that despite pretty good function here, I'm going to encourage this person to move towards arthroplasty sooner than later here. Another one, again, this is kind of a B1, but again, you've got that posterior subluxation and this is going to portend more challenging technical issues in performing a total shoulder in the future. And just showing some other potential options with metal backs and bony augmentation. This was that patient that I mentioned earlier, 30 years old, two prior posterior scope stabilizations, arthritic and way subluxed. And so this was somebody that we went ahead and moved towards an anatomic total shoulder with some posterior capsule plication in order to, and you can see, upsize the humeral head a bit in order to gain stability. So again, back to the bottom line. It's okay to kick a can down the road, but make sure it's a can, not an oil drum and that you're going to get some real time out of it. If you can't buy somebody, you know, approaching 10 years, it's probably not worth the implications on potential infection, worse outcomes, hits to your subscap, progression of glenomorphology changes, et cetera. The things that are going to kind of push me more towards the arthroplasty option are going to be worse range of motion, particularly external rotation and obliteration of joint space. Metal and plastic, it's a very good but not perfect solution. Your goal should be total shoulder whenever possible. And that's about what I got.

shoulder arthroplasty

decision-making process

negative impacts

non-arthroplasty options

total shoulder arthroplasty