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IC 205-2022: Shoulder Arthritis In Young Active Pa ...
Shoulder Arthritis In Young Active Patients - What ...
Shoulder Arthritis In Young Active Patients - What Are The Best Options? (5/5)
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off ball, and make sure we're all on the same page. So 49-year-old, very active guy, fit. He's got some limitations, particularly of rotation, and that's what we oftentimes see, is patients can maintain their range of motion. There's a lot of options that may be available, but when they lose the internal and external rotation, it really affects their daily life. They have trouble sleeping at night, and that gets to be a big problem for them. And maybe the CAM procedure is the right thing to do for some of these. So active works out. And his radiographs show these findings here. So for instance, Brandon's on the phone. It's a patient that has probably a very early B1, just because there's a slight amount of wear posterior, and they have some osteophytes, so they've lost the joint space, as you see best on the axillary lateral view. And they've exhausted all injections that don't seem to be working for them. So Matt, what do you think? 49-year-old, active guy, in Vail, Colorado. He still wants to rock climb. He still wants to ski. He still wants to do all the things that they do out there. He had a biceps tenodesis and an arthroscopy debridement, and that was done about four or five years ago, and now he's not getting better. Yeah, no, it's great. He already had the procedure. I would have recommended it for him, so you can see his biceps button. So Matt, the one thing that Brandon brought up, and I just want your thoughts on that, is the CAM procedure, one of the important parts that Peter brings up is to take off that inferior osteophyte and sometimes decompress the axillary nerve. I think a lot of people don't mind doing arthroscopic surgery and debridement, but that part they don't want to do because of the risk of hurting the axillary nerve. So what are your thoughts on it? Is that really essential to say you've done the CAM procedure? Yeah, so Peter would argue, yes, it's essential to get the osteophyte out. There's a quote-unquote mass effect, but the problem is, I mean, just like we know in the knee, if you go and trim up osteophytes, they come back and they can come back with a vengeance. It's not as bad in the shoulder. The timeline's a little bit longer in my experience, but Tony, you're right, the axillary nerve issue is real there and we use switching sticks and other things to really move that capsule away as you're debriding this osteophyte. How many of you have tried to take off the inferior osteophyte arthroscopically? How many of you use, do you use a retractor on the nerve or how do you make sure you don't get the nerve? Gus, what do you do? I use a C-arm to try to figure out how much because as I kind of get into debriding that osteophyte, I always think I'm doing a lot more than I actually am. Yeah. So I'm always shocked at that. Like I'll be leaving that osteophyte and think I'm going in the humeral head and then I realize I'm just limiting a little bit at it. So that's one thing. I think the switching stick to try to push everything away, also going from posterior, kind of like that seven o'clock portal, I think has really helped me a lot. Okay, great. The other thing, Gus, to follow on that is the area where that osteophyte is, it forms on very hard cortex and so you have a very nice interface and so using, Tony taught me this trick, you use a combination of elevator devices and so we use these spoon different elevators, you know, a curette, et cetera. You have a really nice interface and you're scraped super hard on that humerus. So I've been there and I'm like, oh, I took this whole thing off and then you get the post-op x-ray, like I didn't even touch the thing. So it is deceiving. Yeah, so if you're gonna buy into that operation, you gotta do that operation and theoretically, if you're using Peter's work, which is the work that's out there, you have to take off some of that inferior osteophyte. A lot of people don't do that and that may affect the results. One of the other things I would say is if you didn't do the operation, I think it's important to get a copy of the op note because yeah, his biceps has been taken care of so his biceps is not going to be the issue but if somebody stuck a scope in, did a little debridement, moved the biceps and got out, then you lost the whole advantage of the capsular release in order to get a little bit of joint distension. He's stiff again. So he's going towards arthroplasty here, Matt and total shoulder or hemi? Yeah, I think unfortunately, I would get some more work up obviously. This is MRI and CT in my hands, really understand exact angles, numbers for their shoulder. The posterior subluxation there is over 70, 75%. For me, this is a total shoulder just because it was confirmation. Total shoulder. Would anyone do a hemi arthroplasty in this 49-year-old guy or reman run? A reman run or just a hemi arthroplasty? Just a hemi. In my ears, they do better than I'm hearing. Yeah. So in your hands, it seems that you're still getting pretty good results with this. And then I change them to reverse and they hurt. They don't have a rotator cuff most of the time. Your backup plan. Yeah, so this is one where you may consider, depending on the patient, depending on how much pain they're having, non-smoker, smoker and other things, whether you would do a reman run but total shoulder arthroplasty. You know, Tony, to your comment, I don't mind the hemi in this case. It's like, I've revisited more and more, and especially in these 30s, 40s, maybe young 50s. And like you said, you come down and do the reverse, glenoid's pristine, might have some different wear pattern. Where are you from? Georgia. Yeah. So I think that there is a very strong understanding of the patient in front of you, and depending on who they are, certain parts of the community and demographics are gonna definitely do better. And one of the things that Dr. Mattson has the advantage of is that very active patient population up in Seattle, and people that are very active want to stay active and go to him. And so he's got a select patient population. Yes. Can you guys that do these total shoulders on the young people talk about when you revise them, how successful that revision is? Yeah, we'll get to that in just a minute. So I just wanna go through a stepwise fashion, begin at the chapter one, and then we go to chapter two. Chapter 30 will be coming up on the revisions. But we have a little bit of time. So this is a case here, and as Matt has already said, it's pretty straightforward. Native version and inclination. You know, again, it would be nice, the reason I presented this is because it'd be nice if there was a non-arthroplasty option. It's not that much deformity, and maybe going back and doing a CAM procedure would possibly work for this individual. That's not what most people would do. Most people are gonna do an arthroplasty. And the question is hemi versus total. As you've heard, the literature would suggest quite strongly that a total is a better outcome, but we know anecdotally a lot of people get excellent results. Tony, can you go back one second? This is a subtle but small point. All of these plans, you look at that humeral head diameter of 52, there's absolutely no way. It's probably a 46. So don't buy these humeral head diameters, and that's the number one issue with these patients not doing well, whether you're doing a hemi or a total, is these plans overestimate humeral head size big time. I think it's important if we're gonna do an anatomic shoulder replacement, we make it anatomic, and overstuffing the humeral head is a common problem that we see. And so I did a simple procedure here. I did a total shoulder arthroplasty in this individual. Sam, you didn't mention this, but I'm sure you're doing less and less metal, so either a short stem micro or stemless for a young patient. There's no indication for a longer stem in these younger patients, right? I mean, you can do it. I mean, I don't think that there, I don't have any problem with a longer stem. I wouldn't put something cemented in, but for me, I mean, almost all the time I'm using just a short stem. I still like a stem as opposed to the stemless, but that has less to do with anything other than the way that I repair my LTO that I can do with the stem that I can't do with stemless. How many people use a stemless or have used a stemless device? Okay. And so I think the key here is really less metal. I mean, a 78-year-old lady had a total shoulder in for the last 16 years, long stem, and by the time I have to split, it's a stem that it basically heals all the way to the very tip. It's 14 centimeters long. You have to go all the way down here to get it out. I mean, there's actually bone ingrowth at the very tip of the stem as you're taking a chisel or a high-speed burr to get off. So for those of us that have to do a third or more of our cases of revision, we appreciate it if you use less metal, if it's gonna work. If I could, just one comment about stemless in general. So one of the selling points is you take less bone, which is true at the incident operation, but not necessarily so at the revision operation. And I think that there are some real advantage to stemless in terms of humeral head positioning, et cetera. But I think it is a myth that you are taking less bone when it comes to thinking about revising these. And so when you do revise stemless, consider using an inlay on the humeral side so that you can still maintain your press fit. So, and what he's talking about is really the stemless devices that have primary metaphyseal fixation because that's gonna go all the way out. And so when you take that out, you've removed pretty much all the bone from inside. With a device like this, it's a little bit different. We do have little, there's slots along this so you can take this out. And typically when you're done, you just have lost the bone where the hollow screw is at on the revision cases. At least that's been my experience in dealing with patients that had infection or referred to me for malposition, is that we've been able to preserve the majority of the bone. But it is a potential risk. And also the other risk is that people are not as familiar and they have a tendency to put these more vertical. And that actually is the kiss of death for stemless. It needs that cow cart to be stable. So you have to make sure you don't do that. So it's just. Yeah, the other option, and it's somewhere out there, are convertible implants down the road, especially you have total hemi to reverse convertible. So you can keep and preserve a short stem. At this point, there's no stemless convertible option. They're coming. There's gonna be a lot of torque across that reverse at the end of the day. So that's what they're working on through the FDA. But convertible may be an option with some companies. They're getting better. We didn't used to have these a few years ago. Yeah, I think there's a lot of, there's some, for our younger patients, it's important to have the ability to do the revision. And so we wanna be able to have a plan for that, as it's been said. So whether you have a platform system or you have a device that you use that's easily convertible to the next device, it's just something to keep in mind for our younger patients. So here's a next case, a little bit more in line with some of the things we're talking about. Here's a guy in 2008. This is his surgery that he had in 2008. And so he had a CAM procedure. So there's that inferior osteophyte. And that's debrided. We like to use a retractor to hold this out here. We know where the nerve is at. But you wanna get a good exposure. That whole area there is gonna need to be removed. And as Gus said, it's helpful if you're not sure to take a C-arm and just take a look at that and make sure you're clear with your osteophyte. And you can see the way the joint space looks on this here. So he's got a relatively congruent joint, not too much subluxation. And the guy did amazingly well. I mean, he came back 12 years later. So that's a win. That's a big win. Because he's 32. And he got this. Now this guy is a six foot four, 260 pound, relatively thin guy. He's very athletic. He's an arborist. An arborist is people that takes care of the trees. And he does a couple of the cities. And he's up there climbing trees and everything. And he finally gets to the point where he says, I just can't move my arm like I used to. And so I thought I'd have you take a look at it. And you know, it's 12 years later. And that's his x-rays. So Matt, have you seen with the CAM procedure that some of these patients come back almost as if you've denervated their joint? I mean, the amount of deformity, compression of the humeral head, osteophyte seems to be even greater than you would normally expect. Have you seen that? Or is that just kind of a unique situation here? No, I think what you're presenting is actually not uncommon. This is Charcot-ish, if you will. The classic boards questions, there's something wrong with your spinal cord or central portion of the cord or some other things. You've lost that proprioception and other sensory modalities back to the joint, to the central brain. So this is some, I don't think we understand fully. But what we do know is that this is a significant wear pattern here with significant loss of conformity of the humeral head, a flattened, rectangularish humeral head, as I call it. And then this is what we were talking about, these osteophytes coming back with a vengeance, just like they do in the knee if you take them out. It just usually takes a little longer in the shoulder. So massive posterior wear, it's almost a C-type glenoid at this point. I totally agree with you, Tony. I think you lose a little bit of that feedback and that proprioception. And you've actually taught all of us that there are some people that we're dealing with in their 20s and 30s, which is akin to this, that they are on the bench press all day long, and they continue to go on the bench press all day long, and take supplements to get there, and they just grind through the pain. And this is the type of patient you would see. So they almost have a self-inflicted Charcot joint, which is another similar presentation. So Sam, you know, obviously, shoulder, you're not gonna go back and do an arthroscopic procedure. So this patient lives with it, which he's been doing now for 12 years. So he's got a very good result, considering what we think is a value, you know, 10 years or more, I think is worth it in a young patient. Some may argue with that, but now we've got this. You're gonna have a shoulder arthroplasty. When would you think, I might even have to do a reverse on this individual. Would you ever consider that for this patient, who at least clinically seems that their subscapularis is normal, and their cuff appears to be functioning well? It's just arthritis. When would you say, I have so much bony deformity, I need to think about a reverse in this patient? Now, but I mean, it's in my toolbox. I mean, this patient, I mean, obviously, I'd like to see what the CT scan looks like and that kind of stuff, but that actually, that CT worries me even a little less actually than the x-ray, which is good, but he's gonna have all kinds of stretched out posterior whatever capsules left, even though he had capsule release. This one goes in as a anatomic possible reverse. These are ones where I will, I'll prepare like I'm gonna do an anatomic. I'll actually put a glenoid trial in before I cement anything, and then trial it, and if the head just flops out the back, then this is a reverse, even though he's 44. And are you using these augments that are available? Pretty much every system now has both polyethylene augments as well as in the reverse augments. These are taken into consideration for this glenoid deformity? In this guy? So, yeah. So this guy, let's take a- I think that's an option. In this guy, I would probably think a little bit differently with a convertible metal-backed base plate that I can bone graft behind it and then convert to a reverse in, you know, hopefully 20 years, but I can convert more easily on the glenoid side while protecting whatever glenoid bone stock that I have currently. So another variable, a metalback glenoid in a young patient with a bone loss, and so that's something we can discuss. So here's some of the planning so we can think about this a little bit more visually here. So his native inclination was about 7 degrees, so that's an acceptable number, somewhere around 5 degrees or less. His version is 29 degrees. So does that change your thought process on this, Matt? Yeah, you know, Tony, these are the ones, no matter what age, to get a solid outcome in total shoulder, even though you can make it look good, put the augment in, everything. These are the ones that fail early on the total shoulder world, and this for me, when you're beyond 20 degrees, I am certainly thinking about reverse primarily, because they're just going to do better. It's going to be more predictable. Their revision situation is real for this patient, and the revision situation is very real within months to years time frame, not like a couple years. It is pretty dramatic, the presentation of these patients. How many of you would consider a reverse for this individual, a 44-year-old guy who's an arborist. He takes care of three of the suburb cities and all the trees in that area and has to climb up and down in the basket and cuts down limbs and all that stuff. Very physically demanding job. What would you do? I'd do reverse. Do a reverse? Look at your job options. And give him job options? Is that what you said? Yeah. Okay. Anyone else? How many of you would like to try to do an anatomic shoulder replacement of some sort? Okay. How many of you would use a metal back glenoid for that purpose or consider that? Okay. How many of you would use a polyaugmented glenoid for that indication? Okay. So that's the challenge we have. There's a lot of variability. There's a lot of smart people in the room, and I'm not sure we know the perfect answer. This individual was fit for a 25-degree augmented poly, as you see here. Some of that anterior bone that you see that's a little deforming is osteophyte, so if you kind of take that out of the picture, and that can help you out a little bit. Like Sam said, on the one CT scan, maybe the version is not as bad as we think, but the computer did pick it up correctly, so we need to correct it. And the other thing is, we don't need to correct it down to zero. When you're correcting version, and you've got these larger deformities, what's your target number? Is it 10 degrees? Yeah. 10 or less. 5 to 10, I try to aim for. Sam? It's nice to get down to zero. I mean, if we're in a reverse situation, I try to get down to zero because we know our internal is going to be a little bit better with that. So the natural version is about 7 degrees of retroversion, so there's no reason on an anatomic to try to aim for zero. In fact, if you get pretty close to 10, that's very helpful, and the difference between 10 and zero is a lot. It's usually 2 millimeters of bone or more, and so it's something to keep in mind when you're making these plans correctly. So that's what we did. We sort of thought this one out, and this is what it looks like on the difference of how much bone you have to remove to get this into the position that you'd like. We did have to remove a little bit of bone anteriorly, but when you look at the lower view and you brought that out correctly, it was pretty nice. And this is what he had, and it's exactly what Sam said. Everything was great and lined up well, anatomic reconstruction, and then put his arm, and Dr. Mattson's rules are the 40, 50, 60 rule, so 40 degrees of external rotation, they're stable, no problem. 50% of posterior translation with good bounce back, 100% translation with no bounce back. So now you've got a shoulder that as easy as drops out the back, and you know, you could have guessed that because of the size of his osteophytes, he had a big capsule release and things like that. We tried to adjust this. It actually is a head size larger than I would normally do in a normal patient, but for this guy I thought it was the right thing to do, and then he had good, you know, good internal rotation, 60 degrees. So we had very good motion, but now he's loose. Matt, what do you think? So Tony, this brings back a lot of great memories from a long time ago when I was your fellow, and this... I haven't learned much in 20 years, so I keep doing the same mistakes. But no, I remember these cases quite well. We get in there and I, you know, I always use the 40, 50, 60 rule, and I'm, okay, where are we at at 50% bounce back? We had a couple cases where, boom, I mean, it just totally dislocated with just breathing on it. Okay, we're going to get stitches. Give me some Vicryls, give me some Ethabonds, and start stitching over the back caps. We did all these crazy things that probably didn't work. It made sense at the time. It actually... It made you feel good at day zero. That's amazing. It actually works. Yeah. For a while. Yeah. is predicted based on the pre-op plan why I've been there I've been there 20 years ago it was a fellow and they just they just don't do well if they have that much bone loss posterior they're just gonna be happier you know and he's young but he's gonna be happier and more predictable with the reverse to start with on this sandwich which do I mean and he's just he just drops out and sits there so I mean I would probably move to a reverse I mean I would have the same stage yeah now there's a difference in my mind between he goes out the back and just sits out the back and you know 70% with some partial bounce back like that that type of a situation instead of just kind of plication stitches in the back I've taken stitches around the pegs before I actually put it down so you almost have like a suture anchor type construct you mentioned something about upsizing the head and when when you go into a situation like this whatever implant system you're using sometimes they need to bring in some some heads that they don't normally carry on the shelf the the bigger ones and so making sure that you have those available because with your pre-op plan there even even with the with the augment you're medializing your media lies him significantly so you know right out of the gates even before anything else from a reversion standpoint that you're going to need a bigger head than you otherwise would so I very thoughtful about the medialization so I tried and I think you can see as great to Rossi's still lateral to his acromion I tried to minimize how much bone I took on the on the glenoid side and I gave him one size bigger on the head side my understanding has been when you're posteriorly unstable almost always it's because your glenoid version is off so my glenoid version as best I could tell was normal so in this situation for me it's a soft tissue problem so at the time of surgery I'm not going to convert them to a reverse Matt tells you what I've done in the past and remarkably it has been successful and that is that we it's a technique that I learned from dr. Mattson dr. Walsh has talked about it others but you take three absorbable sutures and you do a capsular plication posteriorly you can't actually fix it to the glenoid but I typically don't I go down one low at about the six o'clock one on a right shoulder one about the eight o'clock one about the ten o'clock position pass it through and then I bring one limb of that suture through the upper part of the subscap and the other limb through the rotator interval and we put the arm and in neutral position and we tie it at the end of the procedure and it's rock-solid and stable and we put them in a brace for three weeks in a neutral position and I'll be honest with you that's never failed me in the follow-up and we have about five-year follow-up on that what they you do see more than what's remarkable to me is not so much subluxation you actually see the glenoid start to rotate the glenoid actually surfs in the glenoid over a patient's lifetime it doesn't stay in exactly where you put it when you put it all polyethylene it actually will drift a little bit depending on the forces that you put in there so again if the head starts to go up you'll see the glenoid start to go like that if the head goes out the back you see the glenoid go like that over years and years of following this and I think it's one of the things that's a real serendipitous value of total shoulder arthroplasty is that the glenoids by all other arthroplasty would be considered loose but in fact they function very well within the bone and they drift a little bit depending on the forces that occur so that adapts over time which is kind of an interesting phenomenon so this guy has done very very well and his shoulders great he's a little about a year and a half out back to work and I'll keep a close eye on him but he did very well but this is definitely one where you would consider the possibility of a reverse shoulder arthroplasty but because of his work I did not do that we're out of time I want to know if any of you have any other questions I have lots more cases we can go through but yeah what would you like to know about the P acnes issue so you know I think that you know periprosthetic joint infections are a real problem in the shoulder the most common bacteria is the C acnes and we know that comes primarily from the patient I was fortunate to work with Serena Namduri and a couple years ago we published a paper on the evidence-based management of the bacterial load for shoulder arthroplasty so published paper my name and Serena's on it and it goes through the various steps and so our protocol is that we use a benzoyl peroxide type treatment two days before on the day of surgery to reduce the amount of C acnes okay none of this completely eliminates it but it does reduce the load which we think is important on the day of surgery the patients receive IV antibiotics we don't change it if it's ANSEF if they're penicillin resistant if they're penicillin allergic then they get clinomycin or vancomycin and then we make an incision with our knife and because the P acnes lives in the sebaceous glands below the level of skin we make the incision in that knife plate is thrown away and we usually some people will at that point do a little wash or put some vancomycin powder in there we don't we don't do that we go through our surgical procedure when we're done with the implantation we use a diluted betadine solution which has to sit there for two to three minutes to get the full effect of a bactericidal effect of the bacteria we wash that out and we sprinkle in a gram of vancomycin not very good evidence that that makes a difference but a lot of us still do that and we sprinkle in vancomycin then we close the wound and that seems to have ability to keep that infection rate below 0.5% or half of 1% and so typically in most centers it's about 0.3% for shoulder arthroplasty using that type of management for these patients if you have a patient where they've had prior surgery no matter what that surgery is we use what Matson calls a yellow protocol we don't think they're infected but we don't know and that is at the time as we do everything we just said but we put them on PO antibiotics for 21 days and we take five cultures during the surgery and if two or more of those cultures come back positive they're sent to ID for six weeks of IV antibiotics and then PO antibiotics for six more weeks and then we see how they do and usually that protects them from having a revision surgery so that's kind of the best evidence we have some of it has good evidence some of it's a little bit more we kind of all agree on these things but that's what many of us are doing you guys have any other suggestions yeah I do I do the exact same thing especially around the periop which is very important I also use acrylic skin glue for everything absorbable suture monocryl our antibiotic PO of choice we've gone back and forth but in general and this has been worked out with our musculoskeletal infections there's actually MSSI's infection society to work closely with Sandra Nelson who was with me at Mass General she's was a former president so we we'd came up with kind of antibiotic cocktail she she feels sephirdoxal and rifampin are the best two for this type of antibiotic although there are several choices it's a sephirdoxal the third generation sephalosporin and then rifampin it's the one that can turn your tear ducts a little bit orange since you have orange tears but that's what I tell my patients about and we generally do that based on the same timeline and and so those antibiotics that you're gonna hear different I you've talked to people the Mayo Clinic they'll say there's no there's not enough evidence to change what we currently do but other places are trying to say well let's predictably see what we can prevent and then ultimately when you're doing in the surgery center you can't afford these antibiotics for all your patients so you just go back to the routine that I told you about so the routine I told you about may not be perfect but it's probably the most value-based care routine with the highest level of evidence but you can augment that as as Matt just suggested with a higher level of antibiotic particularly if you've noticed in your patient population or hospital a certain type of bacteria that happens more often Sam what do you guys do similar to everything that you said except I don't do the beta 9 wash at the end and I and I only use bank powder in revision settings but both of which do not have really strong scientific evidence that changes the outcome so you know Sam's what Sam saying is you know there's just not a lot of evidence that actually makes a difference we know if we extrapolate it from back surgery and from revision hip and knee surgery that the beta and wash seems to help but but the benzoyl peroxide is real yeah and and I mean the other other thing that I do that I have no evidence to support whatsoever is I go through the dermis with a bovie hopefully some the heat kills some of the bacteria in the sebaceous glands but yeah anyone else in the audience have any ideas Gus what what prayer do you say before every case so that's something Aaron Rosenberg told me he says well the most important thing is just share a prayer with your patient before every surgery and that that will help you that's perfect yeah the other thing is you know not all labs are created equal and you know ours is it's good but it can be all over the place and you're like okay we took eight tissue samples and one of eight are positive okay what do you do with that two of eight are positive or versus seven of eight are positive so there are gradations of this type of infection if you will we still don't know what to do with that we don't have the best evidence but I think you'd probably titrate treatment on some level with an informed discussion with your patient you can either you know go the full nuke if it's one out of eight cultures or one out of six versus six out of six cultures so you have to have that informed discussion with the patient that's generally what how I've approaches we don't really know what to do with that differential culture and there's there's a good paper grant Gary goose has that looks at how you interpret positive cultures so we need to be respectful to the rest of the meeting so thank you so much please make sure you fill out your evaluations we do value those and we use those to improve the course and provide the information you'd like to hear and thank you so much for spending your time with us this morning
Video Summary
The video transcript discusses the topic of shoulder arthroplasty and specifically focuses on cases involving patients with limitations in rotation and loss of internal and external rotation. The transcript includes discussions between various surgeons about different treatment options and considerations for these cases. The surgeons discuss the use of the CAM procedure, which involves removing an inferior osteophyte and decompressing the axillary nerve. They also discuss the challenges of preserving the axillary nerve during arthroscopic surgery and the potential need for a reverse shoulder arthroplasty in patients with significant bone deformity and instability.<br /><br />The surgeons also touch on the topic of periprosthetic joint infections, specifically the most common bacteria associated with these infections, Propionibacterium acnes (P. acnes). They discuss strategies for reducing the bacterial load during surgery, including the use of benzoyl peroxide, IV antibiotics, and making incisions in areas with fewer sebaceous glands. The surgeons also mention the use of antibiotics during the post-operative period and techniques for reducing the risk of infection in patients who have had prior surgeries.<br /><br />Overall, the video provides insights into the management of shoulder arthroplasty cases and the considerations involved in treating patients with specific limitations and challenges.
Asset Caption
Matthew Provencher, MD, MBA, MC USNR (Ret.); Brandon Erickson, MD; Anthony Romeo, MD; Samuel Taylor, MD
Keywords
shoulder arthroplasty
limitations in rotation
CAM procedure
axillary nerve
reverse shoulder arthroplasty
periprosthetic joint infections
bacterial load reduction
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