All right, there's a couple of open, sorry it's a small room guys, there's a couple of open seats kind of over here on the second row if you guys want, you're starting to work on the stand. Sorry, there's not enough seats in the room. So we're gonna do a little talking about shoulder arthroplasty today. We have a really nice faculty who I've had the opportunity to know very well. Hopefully you guys will enjoy listening to. So first we're gonna start off with Brian Werner coming to us from University of Virginia and he's gonna give us a little talk on preoperative planning, right? How do we set ourselves up for success when we start the shoulder arthroplasty realm? Then Peter Chalmers is gonna talk to us about anatomic total shoulder arthroplasty, everything you need to know to do this effectively, how to execute a plan that you made based on what Brian taught you and he comes to us from the University of Utah. And then I'll talk to you a little bit about reverse shoulder arthroplasty again, how to set yourself up for success, how to do this effectively. And then Dr. Romeo is gonna talk to us a little bit about revision arthroplasty. So all the stuff that we don't wanna do that we send to him, he'll give us a story about that and then I'll also go over some cases at the end. And in between talks or when we finish talks, by all means, please stop us, ask us questions. This is the whole point of doing this. It's fine for us to just talk at you but it's much more beneficial, I think, if we're all on the same page and if all your questions get answered. So with that, I'll turn it over to Brian to start talking to us about preoperative planning. To get the clicker to work, click first on your slide to advance it. Let's see if that works. So I click once like that. All right, we'll see if I can get the clicker to work. Thanks everyone for coming this morning. You never know how a shoulder arthroplasty session is gonna be. I received a sports medicine meeting but I think this reflects that, you know, a lot of sports medicine surgeons are doing a fair amount of arthroplasty and that continues to grow. And so I did a sports medicine fellowship and actually was hired back at UVA to be a complex knee surgeon. And you can see how that ended up. But knee is probably 10 to 20% of my practice and I'm now 80% shoulder. So, you know, the job arrives and then the shoulder arthritis just keeps showing up and showing up. Another thing that's different between my training and my practice is I planned exactly zero cases in my fellowship. So I'm 10 years out of fellowship and I got a CT scan on exactly zero patients during my fellowship. And now I get a CT scan and preoperatively plan 100% of my patients. So obviously something changed in between fellowship and my practice and this talk will reflect a lot of that. So I have to click first, Brandon? Okay, I clicked once, perfect. So I really like this picture. This has nothing to do with preoperative planning but I saw this online and it kind of highlights a little bit why planning is important. The person who installed this bathroom has probably put thousands of bathrooms in and done a really good job at it. I mean, for whatever day they're just having a bad day or something about the dimensions of this bathroom were a little bit different and then the door doesn't open when they're done. And so these are the kind of things that you don't wanna have happen intraoperatively. You don't wanna find yourself halfway through a case and, you know, the glenosphere size is wrong or you don't have the correct implants or you needed an augment and it's not available in the operating room. And so it just really highlights a little bit why planning is important. It may not all be about differences in patient reported outcomes. It's about making the operating room day go well and doing a good job for your patients. So if this talk will talk about why we use preoperative planning, what preoperative planning is available and what it is, when it's helpful and then finally how to implement and how to use it in your practice. So we'll start first with why and I'm sure most of you have probably seen this paper. And if you have not, this is really what spoke to me when I first came out into practice. You know, I was trying to decide what implant systems I'm going to use, if I'm gonna plan my case or not. You have a lot of options. And this, I kind of got a hold of this paper by Ayanade and read it. And I was trying to develop a little bit of a shoulder arthroplasty practice. I also had to teach residents and fellows at the same time. And so these two graphs are really what spoke to me. And these are, you know, looking at three different scenarios. So looking at no planning at all, planning alone and then finally planning with transfer instrumentation. And so you can see the horizontal axis is version, the vertical axis is inclination. And so planning alone gets you more accurate, particularly with correction of version. But when you use some sort of transfer technology to transfer your plan, you can see that the majority of cases, these are saw bones, so a little bit artificial. We're really within a good prescribed area of correction of version and inclination. And so planning alone is gonna help you be more accurate, but certainly adding in some degree of transfer instrumentation is gonna be helpful. This is also the case for the location of the pin. It's the same three scenarios where you have no planning, planning alone, and then planning with transfer instrumentation. You can see the precision increases dramatically when you use planning, but then when you add some sort of transfer instrumentation, it's really gonna help you be more accurate. And so if you're nothing else, maybe it doesn't necessarily improve their patient reported outcomes. We probably need more data to prove that. It's going to make you more accurate with your pin placement, one less variable to worry about during surgery. And if you're an institution where you're teaching, much easier to teach people how to do shoulder arthroplasty when you plan and when you have transfer instrumentation. Ionati followed this up with another study, saying it's great that we can put the pin where we want it, but how does this translate to actually positioning a glenoid component? And so his conclusion from the follow-up study was that by looking at a 3D view of glenoid anatomy and then templating the implant, you're going to place the glenoid implant more frequently in the desired location. That kind of makes sense, but it's nice to have a study to prove that, that not only replacing the pin where we want, but we're also placing the glenoid implant where we want it. There's been several other follow-up studies to this. A few of these are mine. The first was a database study, and there's obviously limitations to those. What showed is the last decade for shoulder arthroplasty, a 530% increase in the use of preoperative CT scan. And there was a loose affiliation, I don't take much away from it, of a decreased revision rates with CT scans. What that shows, that if you're not getting preoperative CTs and planning your cases, you're falling behind your peers, and it's rapidly, and if not already, becoming the gold standard for shoulder arthroplasty. The following, the remaining two studies there show that preoperative planning and looking at 3D assessments of anatomy are in some percentage of your cases going to change your implant selection. In the other Dr. Werner study, it was 14% of the time. In the study we did out of the Arthrex Registry, we found that implant choice changed about in one third of cases. Again, an artificial scenario with kind of three-dimensional planning and virtual surgeries, not actually perform the surgeries. But certainly implant choice is going to change when you see a 3D assessment of glenoid anatomy. We've looked at this clinically out of our Arthroplasty Registry. We have two different studies. We wanted to see what the early patient-reported outcomes were when comparing patients with preoperative planning, patients without, and then patients with transfer instrumentation and without. For anatomic total shoulders, we found that the patients who had CT-based planning had better improvement in their ASCS scores next to rotation, but they were relatively small, and so while they were statistically significant, they weren't necessarily clinically significant. For reverse shoulder arthroplasty, we found similar patient-reported outcomes, whether you used transfer instrumentation or not, and found a loose affiliation with better strength that I didn't take much away from that. And so our conclusions from both these studies is that while insurance companies like to harp on the fact that two-year outcomes are what matters, I don't necessarily think that preoperative planning, we're not using that to improve a two-year patient-reported outcome or a measure of external rotation. It can be efficiency in the operating room, but also help us to identify deformity and position our implants better and be more comfortable in the operating room. The more and more that I talk about preoperative planning, this picture right here is a big reason why I use preoperative planning. This is my arthroplasty cart outside my operating room, and I operate in three different operating rooms, and my reps have to take all these implants around to different places. And then as we transition to an ambulatory surgical center where the lower number of implants is gonna be helpful, planning helps eliminate, it takes this to a tiny little basket that they bring in. And so for my reverse arthroplasty cases, I use a system that has a lot of different glenosphere diameters, base plates, base plate orientations. They can narrow that down to one or two glenospheres, one base plate, a couple of different screw lengths, one or two different stems, and have those ready for me. Certainly the cart's still out in the hallway, but it reduces the efficiency, or it kinda increases the efficiency in the operating room. It also helps me get all the staff, everyone in the operating room on the same page. And so I'm not doing discovery mode when I show up in the morning. I'm not trying to figure out what implant I'm gonna use, what size an implant's gonna be. I already have a plan. But then my circulator, my fellow, my resident, my PA, my scrub, my scrubs trainee, every single person knows the plan when we start that case. Small deviations are okay, but it makes it for a much more efficient day. And if you can save 10 to 15 minutes per arthroplasty case, and you're doing six or seven a day, that means you get to go home and have dinner that night and see your family. And so those type of efficiencies are very difficult to capture in a patient-reported outcome type of study, but they definitely are valuable to your practice. So we'll move on next to what. Obviously there's a lot of different systems from different vendors out there for preoperative planning. I think it's important whatever system you use to understand how that system works and make sure that you're good at doing it. Also recognize that each system translates a little different to each other. And so if there's a paper that talks about one system, that may not necessarily translate to a different system. And so if you're an Exact Tech GPS user, Arthrex VIP user, or a Blueprint user, understand how the scapula's registered. There's pros and cons to how each of those systems register the scapula. And so it's important for you to understand those and understand what their tendencies are. But in the end, they all allow you to do the basic functions of determining version and inclination, determining what type of implant you're gonna use, and how you wanna position that implant. The other part of preoperative planning is transfer instrumentation. And so every single vendor kind of handles this a little bit differently, but Ionati studies have shown us that there is some value to transfer instrumentation. And while it can be, depending on the system you use, somewhat annoying, there may be a little bit of setup, a minute or two where you have to register a tracker. You may have a week or two you need to wait for a particular guide to come across. But whatever system you use, transfer instrumentation can be pretty helpful, whether you're an early career surgeon, or whether you're a mid-career surgeon, or whether you're a late career surgeon. You'll see that probably everyone on this panel does a lot of preoperative planning for all their cases, and finds it to be valuable regardless of where they are. Again, for what, and this highlights a point I already made, this was a study that every single person on this panel did together, that's why I thought it'd be valuable to include it. But we compared all the different commercially available shoulder arthroplasty preoperative planning softwares, and planned a set of 81 CT scans within them. And so this was Blueprint, GPS, VIP, and Materialize, and compared version, inclination, and subluxation. And so it's a little bit of a busy slide that shows a bunch of different numbers. But in summary from these, what we found is that the preoperative planning software had limited agreement to measures of version, inclination, and subluxation, whereas the surgeons had very high inter-reliability between them. And so it's hard to know which is correct, but the surgeons were at least consistent between each other. But clearly the surgeons and the software are speaking a little bit of a different language. And so you just need to be cautious. It's not that any of these are relatively inaccurate, it's that you need to be cautious and understand what your particular system that you're using, how they register the scapula, where they have their errors, and understand how to handle those when you're planning cases. And also if you see a paper published with exact text outcomes, that doesn't necessarily translate to Blueprint outcomes. You need to understand the difference in how those systems work a little bit differently. So when is preoperative planning helpful? So when I went into practice, like I said, I did zero cases with preoperative planning in my fellowship. But going into practice, they were just starting to come out with all polyaugments for anatomic arthroplasty. I said, you know what, for all anatomic total shoulders, I think I'm gonna do preoperative planning. I think it's gonna be really helpful. I'm not the best at measuring on x-rays, so I'm gonna get CT scans for these and I'm gonna plan them. Then I said, gosh, if I see any kind of preoperative deformity on the glenoid, I think I really wanna get an x-ray. So, and then move on CT scan and do more. And so any amount of glenoid deformity, I think I'll plan it. Then I had the patients where I was kind of in between. Their exam was a little bit in between. Their deformity was a little bit in between. And so I found preoperative planning would be really helpful, at least from an anatomy standpoint of determining who I could do an anatomic arthroplasty and who was probably better served with a reverse. Then I started getting them on all my reverses also. And then I found out it was just easier for my clinic staff, for patients, just to get a CT scan on everyone. Instead of having my clinic staff or my PA asking, do you want a CT scan on this patient? Do you wanna plan this case? The answer is just yes for everybody. And patients began to accept it. And so then I started doing it for all my reverses. And I actually now find it to be almost more beneficial for my reverses than I do for my anatomics. There's just a lot of different sizing variables, position variables, screw, rotation, humeral planning, range of motion, other things that we can do with reverses. And they don't necessarily do when you plan anatomic. And I find the reverse cases be more beneficial. I found it to be very beneficial as a beginning surgeon. It made me more comfortable. And as you're first starting in practice, eliminating any variable in the operating room is going to be helpful and make your day a little bit easier. As a more experienced surgeon, and certainly there's surgeons with more experience who'll be speaking today as well, I still find to be incredibly valuable. It increases efficiency in the operating room. And I'm always surprised. There's at least one case every week where I get the preoperative plan back, like holy smokes, that's a lot more version or inclination than I thought it was gonna be. And now I'm using a 20 degree augment as opposed to a standard type of case. And so it still changes my plan for a lot of patients by planning them. And so when is it helpful? I would argue that it's helpful for every single case. And so I certainly have some patients that sneak through the woodwork or get a CT scan that doesn't get accepted by the vendor and I'll go ahead and do it without it. But as much as I can, probably 99% of my patients, ideally 100% of my patients, I preoperatively plan. So how do you implement it in your practice? I think the easiest thing that I found was I personally discuss it with every patient. I do not spend long. I spend about 30 seconds mentioning it to them. But if they understand why I find it's valuable and how it's important to their care, they're much more likely to actually follow through and get the CT scan. And so when I was just having my nurses hand them a sheet and say, go get your CT scan, little less likely to actually follow through with it. But at UVA, we have patients coming from three, four hours away to get shoulder arthroplasty, and they have to come back to get their CT scans because most of the imaging centers in the outskirts won't follow the protocol quite as well. And so if they understand why it's valuable to me and them, they'll do it. You need to get the CT scan, obviously. You need to get it to your industry partner. And so we're fortunate enough that we can directly download or upload our DICOMs to a website and do it. But it could be a CD, you can have your rep help you, whatever it is, and you get it to your industry partner and then you plan it. And I would argue that planning it yourself is probably one of the most valuable exercises. I let my fellows plan, but they're never allowed to finalize a plan. They just have to hit save and they can't execute the plan because I still like to go through and plan every single case. It's kind of like doing the surgery beforehand. And then I'm familiar with the case when I get in there. It does not take long to plan a case. Even with every six months, there's some new bell and whistle to all these preoperative planning softwares. And so, you know, even with all these new bells and whistles it really takes three to four minutes per case to plan it unless there's a lot of extreme deformity. So it does not add a lot and certainly saves you easily that much time in the operating room. And so I use Arthrex VIP. There's obviously a lot of different systems you can use but this just shows that software, most of the software is gonna have very similar type of features, but you have native version and native inclination. Recognize that every software is probably gonna calculate those a little differently depending on how they register it based on the paper we showed earlier. There's just a lot of things you can do and you can plan it. I like to size the Glenisphere based on axial but I certainly plan that out beforehand. It is one of the most common things that I'll change. You can measure out your central post or central screw fixation, whatever your system uses. I really like planning reverses for determining screw trajectory and determining length of screws. And so I can dial in the orientation, the rotation of the base plates that I get the longest column of bones to do that. Humeral planning has been a really nice addition. I would argue that it's not necessarily perfect. If I plan a nine millimeter humerus, I don't necessarily think that that's exactly what I'm gonna use. But humeral plan has been very helpful for me is to identify outliers. So significant humeral deformity, very small humeri where I need a different type of implant. It's nice now that we have this osteophyte removal tool that I'm showing where, particularly for anatomic arthroplasty, I've been more accurate with my humeral head sizing because I'm actually able to resect the osteophytes. I can look and experiment between the different stem diameters, but also different stem lengths like I'm showing there as well. And so there's a lot of different things you can do in the planning software. There's torsion, inclination, different things you can look at. And then most of the softwares now offer some assessment of range of motion. There's been some literature come out recently to say that maybe this doesn't necessarily translate to a clinical range of motion, but we're certainly actively studying that in our research group to look at range of motion and see how that will translate clinically. And if there's improvements we can make to determining scapular position or other things to help determine and make the range of motion that's planned more accurate to what actually happens. So I've just one case I'll show you to finish. This is a 48-year-old left-hand dominant male. He's two years after a left conversion of a failed anatomic to reverse. I did not do his anatomic, but the reason for failure was very early glenoid loosening. His glenoids started loosening at nine months. And so he'd failed injections and PT. He's very wary of an anatomic total shoulder just because of his experience on the other side. But he's certainly open to discussion in my recommendations. So he had a B2 glenoid, but some degree of retroversion on there. It was a little difficult to tell on X-ray, but a fair amount of posterior humeral subluxation. It's the reason why I like to show this case. It certainly surprised me. And so 27 degrees of retroversion. I think what likely happened on his other side after revising his other side is that the surgeon had the same surprise I did except he didn't plan the case. And so probably had a lot of retroversion that he didn't necessarily correct well. And his entire implant on the other side were revised. It was not seated in the backside. So he probably had about 40% backside seating on the other side. And a 48-year-old, I still like to do an anatomic if I can. But particularly with that degree of retroversion combined with 19 degrees of inclination, knowing that he's done really well with the reverse and that's what he wants anyway, I was worried about an anatomic. So the nice thing about planning is you can do the case beforehand. And so with this particular system, they have a 25-degree half wedge, all polyglenoid. And so I put that in there and tried to kind of accept a little more retroversion than I otherwise would, but still found that I was reaming a pretty sizable amount of bone and eight millimeters of depth of bone to really get even reasonable amount of backside seating with a 25-degree augment. And this is one of these cases where I had him posted for shoulder arthroplasty. I didn't necessarily, I hadn't decided on anatomic versus reverse. That doesn't happen very frequently for me. But I really wanted to do an anatomic and just based on this, I didn't think that I could. And so I called him and said, hey, you know what? I think a reverse is gonna be a better option. He was excited anyway. It's what he wanted to hear. But even with a reverse, I was using a 20-degree full wedge augment to get an adequate correction for him. And so these are the decisions I don't wanna make in the operating room for a 48-year-old patient. So planning this out in advance is really helpful. And of course, we only show cases that do well. And so he's a year and a half post-op. He's great range of motion. What he does have is limited internal rotation. And as we know, that can be pretty variable after a reverse arthroplasty. And so he's a little bit difficult time reaching behind his back on that side. The other side, actually, the revision ended up getting better internal rotation for whatever reason, go figure. But pretty happy with his outcome. And so I think that's gonna give him a durable outcome and not needing a revision nine months later. One final study to show you, then I'll stop talking. This was a Keith Baumgarten study looking at cases that had interoperative deviations from their plan, which is something that I'll do not infrequently. And so it's hard to know why this finding occurred. But what he found is that patients without any deviation from their preoperative plan had better functional outcomes at two years. And so you have to really dig into the data to understand why that's the case. But certainly there is something to preoperative planning and sticking to your plan. And I think the more interesting thing from this paper is looking at the types of changes that we make, particularly as we transition to ambulatory surgery centers. More and more, we wanna be able to predict what we're doing to help our industry partners bring less implants, have less kind of inventory sitting around, and help our ASCs have less inventory sitting around as well. So thank you very much. Thank you. Okay, so I'm Peter Chalmers from the University of Utah, it's obviously a huge honor to be here. That was a phenomenal talk by Brian and Priya Planting, kudos to you, I mean that was really a nice demonstration of everything. So obviously this is the main reason that we're doing our anatomic shoulder orthoplasties is glenohumeral osteoarthritis and I wanted to just very briefly review kind of the basics of the implant because I think it's helpful to understand where we've been and where we're going to, to understand your options when you actually go to perform this case. So this is Near's original orthoplasty, it came in three sizes, head attached to the stem monoblock. First iteration, remove fixation from the head so that we can separately size our fixation and our articular surface replacement. Next problem of course is the difference in offset between center rotation of the head and the canal, which as you can see here there's a posterior and medial offset, which is the reason why we have this eccentricity within our heads, which allows you to put the stem where you want it to go and still get the articular surface to get the restoration that you need. So this is, if you're going to use a stemmed orthoplasty, a really critical thing for you to understand is that you want to rotate the eccentricity to where you're going to go and obviously there's always going to be patients where you're going to want to use a stemmed implant, even though we're all moving towards stemless, which I'm going to get to in a second. The next thing of course to talk about is we've moved towards platform components and there's really one really important thing to talk about with this that I want everyone to understand, which is that as we've moved towards more and more and more develops on the humeral side, we've moved our fixation up the humerus, right? So full stemmed implants, we did not like to have fixation because then you get stress shielding. So one of the consequences of platform components is that the best platform components are on lay reverse components because otherwise you end up with a design like this. And the challenge with this is you get diaphysial fixation so that you can get an inlay component on the humeral side and then you have to have some modular interconnection. And I will tell you, if you ever want to remove this component, good luck because you have to get all the way down to the diaphysis to get it out. All right. The other thing we've gone towards is shorter and shorter stems. And I will say this experience has been overall good, but not universally good. Some of the problems have been people have undersized them and then they need to loosen them or people have oversized them and you have to get to end up with even more stress shielding than if you used a long stem component. And then this is what we move towards for most of our arthroplasty at this point is a stemless component. And there's pluses and minuses to this. So the plus to a stemless component is fewer concerns about stress shielding. Although I will say the evidence is somewhat mixed and there are some stemless components that have even more stress shielding than long stem components. So you want to know your component and what you're using because you can have more problems with that than you'd think. And then problem number two is that this component places much more burden on you as the surgeon to place it. So this is what I mean by this. And this is always true in technology. With technology, whenever you have a new tool, you must both make sure that the tool is accomplishing the job you need to accomplish and that the tool is functioning properly. With the stemless component, your head cut is everything as is your center pin. Whereas with the stem component, you have the stem to guide you as to where the stem, the component is going. So much easier to malposition a stemless component in varus or valgus than it is a stem component for that reason. So again, I think this has overall been a positive development. No evidence of difference in outcomes, but you have to be aware of that challenge with it. And then currently on the market right now in the United States, there are no platform stemless components that are approved by the FDA. There are components that will allow you to make that change, but that is an off-label FDA change as of right now. Okay. So let's talk about the glenic component. There's been a lot of variation in the glenic component. So first variation is circular, oval, semi-rectangular. So the advantage of a circular component is you can use an inset component. And the advantage of an inset component is it gives you kind of some of that, you know, manhole on a manhole cover fixation where you get a corner for fixation. The disadvantage is that you don't get good coverage. The glenod is not a circle, so you cannot completely cover it with a circular component. The second thing that's come is we've moved towards more metal fixation parts on the backside of the component. And there's been a lot of iterations in this. So originally we went with keels and then with pegs, and you can see a couple of different variations of pegs. And then there was this anchor peg concept. And we've moved towards these metal or hybrid. And I just want to comment real briefly on this because it's pretty clear with the evidence right now that hybrid fixation on the backside reduces the incidence of radiolucent lines. We don't know in the long term if that reduces revision rates, but generally better lucent lines lead to loosening, leads to revision. So if you just follow that along, I would say that metal or hybrid components seem to be the future in this regard. But there's one quick important aspect of this, which is that you want your metal components to be separated. You don't want one complete metal plate on the backside. The reason then is you have this big stiffness mismatch between the poly and the metal. And that leads to all of the problems we've had traditionally with metal back components. So when I talk about fixation, I'm not talking about a complete metal plate. I'm talking about separate little metal pegs, like you can see here with that Regenerix poster, like you've seen with other metal components. Okay. The other thing is variations in the curvature on the backside. Originally these were all flat. Clearly the glenar is not flat. So we've all moved towards curved components. And then there's one component on the market with this grid. And the thought is that you would put cement interdigitated into the grid. And it's a little bit unclear how well that works, but there's a biomechanical study showing good results with it. And then augments, which you've heard about a little bit already. Certainly there are a lot of variations in this. Originally these were these step cut augments that were actually very, very challenging technically to put in. So people have all moved towards half wedge or full wedge, which are much easier to put in because then you can ream them as you traditionally would just off access. Okay. So doing the operation, generally this is a beach chair operation that's performed through a delta pectoral approach. Usually the way I'll do this is if you find the coracoid, put a pen down, the pen will find the groove for you. This is a trick I learned from my mentor, Tony Romeo. And then from there, you find the vein and you can take it meteor or laterally. I prefer laterally, but I think both can work well. And then you get down to the humerus. And from here you have to decide what to do with the subscap. And we'll talk about the subscap in a little bit. Whether you do a tenotomy or a peel or an osteotomy, you will always have to fixate it at the end and then protect it. And if it fails, then you can have issues. So we'll chat about that a little bit, but there are variations in that. Remove your osteophytes and then make your cut. And for making your cut, this is a really critical part of the operation. An accurate head cut is really critical for getting a good reconstruction. I think if you're using a stemless, if you're planning a stemless component, you should use a guide. This is a paper that we published showing, this is a comparison of my partner's patients where he was using an IM guide, even though he was using a stemless component, to another institution where they were just making freehand cuts. And you can see that there's a better likelihood you will get a more accurate reconstruction of the center of rotation with your component, with a stemless component, if you use a guide to make your cut. So if you're going to use a stem component, I don't think it matters. But if you're going to use a stemless component, I think you should strongly consider using an intramedullary or extramedullary guide when you make your cut, because you'll get a more accurate reconstruction. Then you need to be careful of the axillary nerve once you've made your cut. So the axillary nerve is wrapped around the humerus like a snake. It is always going to be in your way when you're doing your capsulotomy, when you're doing your releases of your subscapularis. So clearly, if you're going to do this arthroplasty, that is, the axillary nerve is the most important structure that you're going to encounter, for the most part, during that arthroplasty. So if you don't protect that, the patient's outcome will be bad, and it becomes very difficult to recover from that. So that's critical. And then you have to expose the glenoid. And this is traditionally the thing that people struggle with. So for me, some of the tips to glenoid exposure, I think your cut is really critical. Your retractors are important. I think it's really helpful to clip the front retractor to the drapes, as I've shown here, because then you don't have to have another assistant in front of you managing that. Once you've got your glenoid component in, you place your humeral component, and then you've got to get the head right. I will say that getting the head right perfect, perfect, perfect doesn't seem to matter so much. We actually did a study comparing, you know, during constructions, these were all done with stems, and looking at how much distance there was between the perfect center of rotation and the projected center of rotation with the implant. And as long as it's within four millimeters, it doesn't really seem to affect the patient's outcome. But if there's a big outlier, it clearly does. So you want to expend some effort at that point of the operation to get that right, with the understanding that you may want to use the head to correct for some of the imbalance you have with glenoid retroversion. So this is an example of a reverse offset head. We've published outcomes of that. And that can work quite well if you're struggling with a really retroverted or posteriorly subluxated shoulder. And then you've got to repair the subscap. And failure is a problem, whether you use sutures or wires. And even if it heals, there's muscle atrophy and weakness. The data on the top is from a study my partner did of his own LTO, where he had all of them heal, but there's still weakness that you can see in the patient's strength. And then the data on the bottom is from George Athewall's study, looking at CT fatty infiltration. Again, even though all of them healed, there is fatty infiltration. And the reason why this matters is because rotator cuff muscle volume imbalance does associate with instability. We published this. And also because the subscapularis pulls down on the humerus. So if you don't have as much subscapularis strength, you can end up with proximal migration. And if you have proximal migration, then you end up with more rocking horse glenoid and then glenoid loosening. And that's actually been shown in multiple studies. So obviously, the problem is, if it fails, you'll see this. You'll see proximal migration or anterior subluxation in the humeral component. And you can try and repair it again, but my personal experience has not been great with that. So if it fails, I would strongly consider just going straight to converting it to a reverse. Generally, total shoulder hypoplasty works quite well. So these are three published studies that we published, as well as my own personal outcomes. Generally, this gets you a B-plus shoulder, and over 90% of your patients will be significantly improved if you do this operation with the right indications. And the symptom improvement occurs quite early. So this is outcomes data from 700 patients at the University of Utah, where we looked at their ASES scores. And you can see that even by 30 to 60 days, two-thirds of patients said their shoulder was better than it was before the operation. So generally, in the short term, patients are quite happy with this operation. The problems occur in the long term, so especially in young patients. And I totally respect what Brian said, that in young patients, he prefers to do an anatomic. But if you look at the long-term outcomes in young patients doing anatomics, they are not good. There's this paper that Denard published, who I know is in your guys' group, 63% loosening at 10 years. God, that's not great. Don't love to see that, given that that patient in 10 years is going to be 58 and then going to need what at that point becomes a more complicated revision. Certainly that's related to subscapularis healing. So my personal thought is that the future of total shoulder hypoplasty is subscapularis-on approaches. This is one that I did with a subscap-on. This is the patient at six weeks, and you can see his subscap strength is nearly equivalent side to side. And these are our two-year results thus far. So this is the thing that I'm pushing towards right now, and I think the thing to pay attention to for the future of anatomic shoulder arthroplasty. Subscapularis may definitely be the future for anatomic. It is technically very challenging. So we have a ways to go on making things a little bit easier to get that done. So let me skip past Brian's bald head. And OK. So we'll talk a little bit about, we'll flip over to reverse now, OK? So we had great talks on planning. We had great talks on anatomic. Let's move on to reverse. So from an outline perspective, we'll talk a little bit about how the reverse functions, what are my indications for this, what are the goals when we do this? So Brian told you how we preoperatively plan. Let me tell you how you want to plan a reverse and then execute that plan. Some pearls. And then there's been some complications with reverses in the past, and we've had some implant designs that have changed over time to try to mitigate the risk of those complications. So I'll talk to you about that a little bit. So this is the person that, for me, is a reverse every time. He's 79. He's a B2 glenoid. He's starting to sublux out the back a little bit. And so this is the guy that we wanna get a good outcome for because he's really active and wants to do really well, but he's not really an anatomic candidate. So how does the reverse work? So from a biomechanical perspective, right? You have your center of rotation, which is your point that's fixed in a bone when there's motion that's being done. So it has zero velocity when you're moving. And in your native shoulders, you can see on that slide on the left, it's actually within the humeral head, a little bit below where you're gonna cut the head, it's that black circle. And then in your reverse, it's actually moved to being within the glenoid. And this is the old designs with the medial center of rotation. Now we've started to move the center of rotation a little bit more lateral to try to increase the effectiveness of the deltoid, increase its efficiency. But you can still see even in our lateralized designs of reverses that that center of rotation is still medial to where it is in a native shoulder. So just something to keep in the back of your head. And then you have to remember from a reverse perspective, this is a constrained implant. So in Peter's anatomics, they're not constrained. They have the same mobility as your regular shoulder. In an anatomic, you're trading some amount of motion for the stability that you get with the implant. And so it's important as Brian showed you with one of his patients that had a hard time getting behind their back that they may lose a little bit of motion when they have a reverse. So who gets a reverse in my practice from an age perspective? Well, for me, there's really no age minimum or maximum for a reverse. I've done reverses on people as early as 30 some odd, and I'll show you that a little bit later in some cases, up to almost 90 years old depending on their functional status. So I don't think that age necessarily matters for a reverse. I also don't have a cutoff where I say, okay, you're over 70, 75, you're gonna get a reverse. I just try to do the operation that's right for that patient. From a diagnosis perspective, there's a lot of diagnosis that reverses treat, and this is why we've seen so many more reverses done over time than anatomics. Anatomics have a pretty limited indication. Reverses can be used to treat a lot of things, cuff tear, arthropathy, arthritis with deformity, even though it's off label to do this for arthritis with an intact cuff, and then certainly proximal humerus fractures are a really nice treatment option for reverses. From a range of motion perspective, it doesn't matter to me what the range of motion is beforehand, but the thing you have to make sure is that their deltoid is functioning right. If you do not have a functioning deltoid, you cannot get a reverse shoulder replacement. They will dislocate, they will not be able to move their arm. You are 100% relying on that deltoid to power your implant, so if they have any issues with their deltoid, get a preoperative EMG, make sure things are firing properly, because sometimes it can be hard to examine the deltoid in these pseudo-paralytic patients, but you have to make sure that their deltoid's firing because you don't want to put an implant in those patients. So this is our patient that I showed you before. So this is showing you the B2 glenoid, but then it's also showing you some inclination on the glenoid side, right? And Brian talked to you a little bit about measuring your glenoid inclination and looking at the different preoperative planning softwares. I will tell you most preoperative planning softwares measure the glenoid inclination from the bottom of the glenoid to the top of the glenoid. That's fine, but that's not relevant for where you're putting your reverse shoulder implant, right? When we put this glenoid base plate in place, it's not sitting on the top of the glenoid, it's sitting below that. So you actually need to measure this reverse shoulder arthroplasty angle, which is basically looking at where you're going to put your implant and see what the inclination is based off that. And this was a study that was done by Pascal Ballot, basically talking about the reverse shoulder arthroplasty angle and the different types of glenoids that you can see. So my point in saying this is just when you're planning these cases and when you're looking at these patients, don't forget to take into account where your implant's going to sit. Don't just look at what your planning software gives you because it may underestimate the amount of inclination that's there by quite a bit, and you may have to correct it down the road. So it's just something to think about. This is just showing you different types of measurements. This is the Favard classification, just looking at the different types of inclination here. And you can see as you get more medialized, you get a little bit more higher in the classification. So you just want to make sure that you don't miss this when you're planning. So from a goals perspective, from a reverse, where do you want to put the implant? So Brian showed you how to plan it, but what parameter should you use when you're planning this? So for me, from a version perspective, I usually try to shoot from zero to 10 degrees. I'll accept a little bit more in somebody who has a ridiculous amount of retroversion, and I don't want to start to add bone posteriorly to build that back up, but I usually try to get it within zero to 10 degrees. From an inclination perspective, we usually try to be flat to slightly inferiorly inclined. We know that if you start to put a base plate in that has a lot of superior inclination to it, it's probably going to loosen over time because as you start to lift up on the deltoid, you start to lift that base plate up, and so your risk of loosening is much higher. So ideally, you want to be neutral. I usually try to shoot for five degrees down, but at the same time, you don't want to take too much bone off of the glenoid. So if you get to zero or one or two degrees of inferior inclination, that's fine. You just don't want to be superiorly inclined. From a base plate coverage perspective, this certainly varies with the different implants that you're going to use. Ideally, you want to get 100% as you do in an anatomic, but the reality is with a reverse, sometimes you're doing this in such deformed cases that you can certainly accept 75% or less, and the reality is you can probably accept 50% with some of the implants that are there. I really try not to do that, but most of these implants are going to be stable with 50% coverage. Don't shoot for that, but it's just there if you need it in some of these very deformed cases. And then from a reaming perspective, with the addition of augments that have come out, the amount of reaming we've had to do to put the base plate in the position that we want has gone down significantly, and that's what you want to see. You really want to minimize the amount of reaming that you have to do in case you have to come back for a revision. You want to leave as much bone stock as possible, and so with the addition of the augmented base plates, you've really had to ream significantly less. So from a Pearl's perspective, Peter kind of went over this a little bit. A couple of the things that I think are relevant. Every patient gets CXA that has a total shoulder arthroplasty with me. I think this has really helped decrease the amount of blood loss. From the setup, Peter kind of went over this a little bit. I don't clip the front drape to the bed. I use the pouch that you put the instruments in, so the instrument pouch, to hold my anterior retractor. So it depends on who you have helping you, and they are, I have one PA helping me. Sometimes you have multiple people. If you have multiple people, it doesn't matter. Somebody can hold that. But if you just have one person helping you, ideally, to see the glenoid really well, you want to have a retractor that's posterior inferior, and then posterior superior. So after you get your glenoid completely released around, because in reverses, you'd like to do a 360 degree release. Anatomic, sometimes you don't release the back portion as much, but in a reverse, it's okay to release the whole thing around. It'll give you better exposure. It really helps to have that instrument pouch hold that anterior retractor, so you can get a better exposure of that posterior superior glenoid with that pointed homin that's there. And then Peter kind of mentioned subscapularis management, and I think this is actually really relevant also in reverses. Certainly in anatomics, it's critical. Some people don't repair the subscapularis in reverses. I tend to, because I think it helps with stability. I think it helps decrease dislocation risk. I actually think it helps with strength and range of motion. If you look at some of the data that's out there, if you take a look at this study looking at reverse shoulder replacements where they didn't repair the subscapularis, you'll see that the amount of internal rotation that patients had when you fixed the subscap was significantly better. And then if you take a look at this systematic review here, what they found was that there was a lower dislocation rate when the subscap was repaired. Now this doesn't look at subscapularis healing. So to Peter's point, sometimes you can repair the subscap and it doesn't necessarily heal, but I think there's probably some scar tissue that forms there that gives you a little bit of anterior stability. So I think it's worthwhile to repair the subscap if you can. And Peter kind of went over this. And so what I like to do for this is make sure you have really good subscap mobility. You don't want to constrain your implant too much. So if you can't mobilize your subscap enough or if there's no tissue there, it is what it is. But if you can repair the subscap, you'd ideally like to. So for me, when you're doing your initial release, what you want to do is get the capsule off the back of the subscap. And you can usually take your mets and dissect the plane in between the capsule and subscap, heading from superior to inferior. You don't want to cut going that way, obviously, because you don't want to cut towards the axillary nerve. So then you can dissect the plane going from lateral to medial in between the capsule and the subscap. And usually what we hear people say is what's white is white and what's red is red. So you want to leave the subscap tissue alone, take the white capsule off, and then you can take that all the way back to the glonate. So now you've released it completely and you'll see a significant increase in the subscap mobility with that. The other thing is make sure you run a mets along the top portion of the subscap. That'll help release some of the adhesions that can happen there too. And almost always I can get the subscap repaired here. And you could do as a stem-based repair. You can do it as a suture anchor repair. You can transosseous tunnels, whatever you'd like to do. There's no one better technique than any other ones. Sometimes it depends on your implant design. Sometimes it depends on how you'd like to do it. But for me, I usually use transosseous tunnels just with high tensile suture that goes through it. And then make sure when you're doing it, you have the arm in 30 or 40 degrees of external rotation if you can. And if you look at some of the outcomes with our lateralized implants and repairing the subscap, basically what we found was that subscapularis repair, even when you lateralize, these patients do pretty well. So if you think about it, you're trying to push the implant lateral, so you're worried about overtightening the subscap. You don't have to be. They did pretty well with this. And so let's move on to complications, right? So we know that reverses can have a lot of complications. And when they do, it's really challenging to take care of some of these. Some of these are really devastating. One of the most devastating ones is an acromial fracture. So you obviously know the anatomy of the deltoid muscle, but it puts it at risk for hurting the acromion as you start to distalize the implant. So we started to see over time that if you shift that center of rotation distal, right? So if you have an implant that's an onlay design or you're really building up to move the humerus down, you wind up having a significantly higher risk of having a scapular spine or acromial fracture. So if you look at this study that was done, you can see that the amount of scapular spine fractures that happened in an onlay group with the implants that's on top of the humerus versus an inlay group where you put the implant within the humerus, it was significantly less. That just is basically a factor of how much you're distalizing the humerus. And you can see that when they measured the acromio-humeral distance, so taking the distance from the acromion to the bottom part of the humerus, which is basically a measure of distalization, a higher amount or a bigger acromio-humeral distance was a risk factor for having an acromial fracture. Scapular notching is something that we saw a lot in the past, and we started to see less of with new implant designs, and I'll go over this with you. And basically what it is is as you adduct the arm, the implant abuts the inferior portion of the glenoid and can start to erode the bone away. And older studies kind of cited this between 50 and almost 100%. We weren't always sure what the clinical relevance of this was. It was one of the radiologic findings, but we didn't see a ton of base plate loosening with this. But you certainly can as you start to erode that bone because you can destabilize your implant and certainly can lead to polyethylene wear and inflammation around the joint. And you can see here like the numbers for scapular notching previously were pretty significantly high in 10, 15 years ago. And so how do we change the design of these implants? So what are we gonna use now to help mitigate this risk? So from an acromial fracture perspective, we try to lateralize more on the glenoid base plate side, the glenosphere side, to try to mitigate the risk of having an acromial fracture. So you're not distalizing the center of rotation as much, but are still increasing the moment arm of the deltoid and increasing the tension on the deltoid. From a scapular notching perspective, a lot of the old implants were at the 155 range and you had a medialized center of rotation. So as you lateralize more and use an implant that's a little bit steeper, it's very hard for the implant to now abut the inferior portion of the glenoid. So your scapular notching has gone down with the 135 degree inlay components. And then from a range of motion perspective, we think that as we start to increase lateralization, this tends to help with a range of motion perspective. And so these are some of the designs of implants that can help with this. Certainly some of the augments to help decrease the amount of reaming that you have to do, but also provide some lateralization. And then oftentimes different companies will have different amounts of lateralization you can do on the glenosphere side as well. The company that I particularly use, just you can go from zero to eight millimeters of lateralization. I almost never do zero. I'm usually between six and eight millimeters, depending on the size of the patient. The one thing you have to be cautious of is if you're doing this in somebody that has approximately humerus fracture, you do not want to lateralize too much. They did not have an arthritis problem before this. You do not need to lateralize them too much. You will overtighten them. Your tuberosities won't heal properly. The range of motion will stink afterwards. So actually in these patients, these are the ones I usually am a two to four millimeter lateralization on, because if you push it too much, you're gonna have a problem with range of motion afterwards and that can increase your risk of scapular spine fractures. But certainly the more lateralization we have, as you can see in Brian's study, when they got out to eight millimeters of lateralization, this is in larger patients. So larger male patients usually get eight millimeters of lateralization. They found a significant increase in the internal rotation. Similar if you compared the six millimeter of lateralization group to zero two or four millimeters of lateralization. So more versus less, more lateralization, better internal rotation is the take home point from this study. And then if you look at the different humeral head inclination, because some people thought that maybe by changing the neck shaft angle, that you potentially have an increased risk of dislocation. We used to think that 155 degree implants were a little bit more stable than 135. But when we did a systematic review on this, looking at this, there really wasn't a difference in the amount of dislocations per group. So there really wasn't any issue with this. And we saw much less scapula notching in the 135 group. You can see there are less than 3% versus the 155 group, which gets close to 17%. So as Brian said, we show cases that do well. So this is our initial patient that we show. We used a pretty big augment on him, lateralized him quite a bit. And you can see we have pretty good base plate coverage and didn't have to do much reaming to get there. You can see the implant is a little bit inferiorly tilted. Don't just look at the base plate, look at where the glendosphere is sitting. And then you have to measure this off the scapular spine, obviously. So making sure you pick the right patient for reverse is obviously key. We want to correct our version and inclination as best we can. We know there can be problems more so with inclination being above zero or five degrees than necessarily version. So you can accept a little bit more retroversion. I think the complications that we saw in the past have gone down significantly since we've changed our implant designs a little bit. Most companies have done this. And I think the more lateralization you do, the better off you are. Thank you. Good morning everyone. It's interesting to see a full crowd in a small room for shoulder arthroplasty at a sports medicine meeting and I think that reflects our current practice of orthopedics and that is that we have pretty much owned the ambulatory surgery center for a couple of decades and now that we can do shoulder arthroplasty in this environment many of you are becoming better and better at this surgery. I'm going to go over the more complex things and one of the most important things to do is to plan your procedures in a way so you can avoid these revisions or complications because they are challenging. As Peter said, we haven't thrown away anatomic shoulder arthroplasty, but the patients that come to us are coming with more and more complex problems that we did not have a good solution for and when you look at the spectrum of shoulder arthritis with variable rotator cuff disease, we're now at a point where many of us that have shoulder arthritis practices and do a hundred or more or two hundred more shoulder arthroplasties a year, 75% or more of the cases we're doing are reverse arthroplasty. We know it's a very reliable procedure and as Peter said, it has good stability over a long period of time, but the reality is we're dealing with a certain problem that this is the best option for them. In my practice, only 20% of my cases are anatomic and that's because of the patients that are referred to me or come to me. This has been the most important advancement in the management of shoulder conditions in the last 20 years. Without a doubt. And so reverse shoulder arthroplasty is the reason that we're able to do so well and is really the focus for revision shoulder arthroplasty because of its reliability. If you look at what's going on in our country, which sort of sets the stage for many others, although some competition from Europe, you see that the reverse is now used more commonly throughout the country and that number keeps going up and we're now over 200,000 arthroplasties a year. Compared to about 6 to 700,000 hips and about 800,000 knees. And there's been a number of advances over the last 10 years that have allowed us to treat our patients much better. And if we do this well, we hope to get longevity will avoid revision surgery. You've heard a number of ideas related to how to manage this. But you know, if there's all these different types of models out there, we still don't have a perfect answer for all of them. And so it's important to stay focused on the principles and then whatever system you use, make sure you understand how it works and how you're trying to apply it to your patient. I had my hip replaced nine weeks ago. My surgeon said, you have 30 year result. You have a ceramic head, titanium stem and we've got a couple of screws in your acetabulum. You have your chance or you have a 30 year result. Do we have that in shoulder arthroplasty? I don't think so. So we've got a ways to go. But if we look at reverse shoulder arthroplasty, what we can see is it's pretty remarkable. We are out to 80% or more at 20 years. The revision rate though has gradually stayed around 6 to 8%. And so we're seeing more and more of these revision cases and the Australian registry is the best in the world because if you do a shoulder implant or any implant in Australia, it has to go into the government system. So they capture all of them. Unlike what we do here, it works amazingly well for cuff tear orthopathy. And as we've all learned, it works really well for osteoarthritis to our patients over 70 where we can't predict what's going on with the cuff. The reverse has been fantastic and it doesn't seem to be really disturbed by gliding morphology. As Brian showed you, if you plan it out appropriately, use the right device, you get very good results even with the deformities that we used to really worry about. And it takes a little bit of time. But within six weeks, these patients feel dramatically better. Some of them, it's just absolutely remarkable. By three months, they're back to the regular activities. And by six months, the vast majority are going back to all the things that they used to do and even some of the things they want to do. But we're not able to do that. I will point out to you in slight difference to what Peter said. If you look at last year's results with stemless anatomic shoulder arthroplasty, the revision rate at 10 years is the same as reverse 5%. Why would taking the stem out of the picture make a difference? It's because we're doing much better about putting the human head in the right spot. So when you look at all the glenly longevity studies, very, very few of them say anything about what's happening on the human side. And that's probably the primary determinant of how long the glen is gonna work. So I think if we use stemless devices, which most systems have now, we get the human head in the right spot, our glen is gonna last much longer. When we start to think about these complex cases, we have to know what options we have available. On the glenoid side, where we focus a lot, we have to look at this. And Brian talked to you about some of the aims and Brandon did too. So if we have an arthritic shoulder with a rotator cuff disease that is about 15 to 20 degrees, we're thinking an anatomic. When we start to get a little bit older and more deformity, we might go to reverse. And with more deformity, a reverse is a more reliable long term procedure. Although we have figured out some things for some complex cases using bone graft and other things. And I do think in some of our younger patients, as we've learned from reverse, these hybrids that Peter talked about and even metal back glenoids will come back to give some options to our patients under the age of 60 that have arthritis with good cuff disease, but severe glenoid deformity. Now, with the reverse again, we have a variety of ways of looking at this, but you can predict ahead of time what the deformity is. You can plan it out and you can either use metal or bone to fix the problem. The humoral side has not been talked about as much. Peter wrote this really nice paper and made this classification called the Pharos System Proximal Humoral Arthroplasty Revision Osseous Insufficiency. If nothing else to kind of classify this so that we talk to each other about this, we understand what we're trying to deal with and is helpful. And basically above the tuberosities, we have lots of options and below the tuberosities gives more challenging and below the deltoid, it's a pain in the butt and you hardly ever get a great result there. But this is a helpful way to look at things so that when we look at our revision cases, we really know where we're making progress in this area. So this is important paper to understand. And again, really, it's divided into those two, those three main areas. Why is that important? Because when you look at revision arthroplasty, which is currently mostly revision reverse arthroplasty for either an anatomic, a hemi arthroplasty or a failed reverse, we have a high complication rate and our overall results in our patients are not that great. We're getting slowly better with better technology and better preoperative planning, but it's really challenging. One of the things I think many of us fail to recognize until you take care of these patients over and over and over again is managing the comorbidities. If you have a patient who's malnourished, who smokes, who's diabetic, and you're gonna do a revision case, you're in trouble from the very beginning. You've got to do everything you can to maximize that patient's health to try to get a good result in these people. And if you're trying to rely on bone healing and things like that, again, these things are really going to affect your results. And every time we approach these revision cases, we just had our minds have to think of this principle, and that is the way the shoulder normally works is the rotator cuff holds the ball into a curve socket, the concavity compression mechanism. And when that's disrupted, either because there's no concavity or because there's no compression, then we have to have a stable universal joint on the scapula and rotate around it and rely on our deltoid to work. So when you have patients that have soft tissue deficiencies, there's absolutely no reason to do three or four different type of soft tissue procedures or rotator cuff surgeries. You're wasting your time. And not only that, you're making her result of her reverse basically nothing more than pain relief if you're lucky. It was mentioned the deltoid and how important it is. It really drives a lot of what we do. Fortunately, in most cases it is intact and it works well, but we oftentimes see patients who've had prior surgery that their anterior deltoid is not working right. And so they get good internal external rotation, maybe some abduction, but they can't raise their arm up. And it's very frustrating to them. It's usually iatrogenic. It's because of the surgical approach that was used by the surgeon before. And so just keep in mind that dissection that Peter showed you to make sure that you keep that anterior deltoid in place because that's very important for the long term result. If the deltoid is not working, it doesn't mean that you can't do a reverse. You may have to if they have no cuff, they've got arthritis. You can do a pain relieving operation, but you have to share with the patient. The outcomes are far less predictable. Some people, if they have some cuff, but their deltoid is out, we'll figure out how to make this work. So that's another option. But again, this can be a reasonable pain relieving operation. It's just not quite the same as if we had the deltoid working for us. So let's talk a little bit about the glenoid side. And you already heard about some of these issues from all the speakers in terms of understanding what that deformity is. And for me, I really, you know, we use radiographs. There's no doubt about it. That helps us to identify there's a problem there, as Brandon said. And then we have to do preoperative planning to figure this out. And until recently, the last five years, maybe a little bit longer, many of the systems could not do preoperative planning for us when there was metal in place. And that made it very challenging. But now a number of the companies have the ability to preoperatively plan even if there's metal. And that is very helpful, very helpful. And so we look at this and we want to make sure we know the failure of the glenoid is most commonly when we cannot get that in a neutral position of inclination. In fact, the original description of doing this operation is that you wanted to create what they call the source seal sign, or the smile, so that you reamed it so that the bottom inferior third was a cancellous bone. Then you knew you had a relatively zero inclinations before preoperative planning. But that's what we did 25 years ago. And it worked really well. And you put the glenoid a little bit lower. Now we can put it in a more anatomic position with better bone, but we have to preoperatively plan to get that straight. So please keep in mind all the things that Brian said to you. And I also agree 100% of the cases. It makes me a better surgeon. It makes everybody in the room better help. It was really valuable teaching tool. An example of how we can put this together. This is a straightforward case. So 55 year old, bilateral pain, fails conservative measurement, has a complex deformity. And we put it in there. There's 16 degrees of inclination and 30 degrees of retroversion. He's only 58. That's a tough case. We really don't have a good anatomic solution for that. And if we plan this out either way, the right answer is a reverse. If you decided that, I don't know, I think I can make this work, and I put an anatomic, well this person is gonna get a revision in five to ten years. And so one of the best ways to manage revision surgery is not to have to do it. And that means doing the right thing the first time. 78 year old lady, there's something wrong with her glenoid. She has a lot of wear. CT scan makes you more aware of that. But with your preoperative planning and being able to look at these things, her version is getting close to 30, inclination is there, we can plan this out as Brian showed you and come up with an excellent result. It can get more difficult. This lady, her family brought her in. She didn't want to have anything done. She's active, she just doesn't use her arm. It's been bothering her for five years. And you look at this and you say, is there any way we could just live with this? And you try to figure out what's going on. You get the CT scan. She obviously had an anterior instability event of some sort and destroyed her anterior glenoid, and now she really doesn't have much of a pedestal sit on. So you try to preoperatively plan this, and it's really difficult. But again, if you don't sit there and think about this, this is gonna be an early revision. So you have a couple of options, metal, bone, or possibly custom. And you try to put this together. The good thing that we do have in this case is her humeral head is there. So we have some bone graft, not always reliable, but these are really tough cases. But taking her humeral head, using it as part of the fixation, getting it all lined up right, we're able to get a good result. She's three years out, has no pain, and is doing very well. You heard about achieving lateralization. I think this has been very important. There's two ways to do that, on the glenoid and the humeral side. And some companies do more on one versus the other. And there's a lot of reasons that they support that. And so just understand the implant system that you have, and how you're trying to do that. Even with the lateralization on the genosphere, we don't actually approach the perfect position for center of rotation. But it works out very, very well functionally. And we can do this in a variety of ways. One of them is filling the bone defect with bone graft. And there are some good systems available. We learned from our French colleagues with the Bio RSA, Pascal Boileau, that the bone that's there, especially in our primary cases, can be a very valuable graft, and can have tremendous longevity. So don't forget about those younger patients, instead of always using an augment. If you have a 40-something year old with a really horrible glenoid, you may consider a bone graft procedure to restore their scapula. Because who knows if it's gonna last 20 years or 30 years, but now they're in their 60s and 70s, it'd be nice to restore their scapula if you can. There are a variety of techniques out there, and tools that make this more specific. And actually you can refine this down, like we do a lot of things in sports medicine, down to the millimeter, which then makes us feel better that we're doing it more precise, and getting a better chance for it to work, and get solid backside coverage. And our goals in these cases, again, is to have these types of results that we have here. So when we lateralize, Brandon sort of talked about that, we'd like to get it out to six to eight millimeters. We'd be very careful not to overstuff, especially in our female patients. And we'd like to see that greater tuberosity beyond the lateral edge of the acromion. And you almost get a restoration, we were talking about an anatomic-looking reverse shoulder arthroplasty as our final goal for the results. Now, a little bit more about the revision stuff before we go into the cases. We all take care of fractures. It's a very common thing. And there's been a lot of talk about the fact that most of these patients can be treated nonoperatively, which I think is BS. Most of these patients treated nonoperatively, you've basically committed them to a crappy working shoulder for the rest of their life that won't go above shoulder level. And I realize that in some patients, that's the right answer. But here's a 73-year-old, very active lady who falls and has this injury. You could treat her nonoperatively. Her pain relief will probably be okay. She'll probably be able to tabletop activities. She's never raising her arm above her shoulder level again. I don't think that's a reasonable, acceptable thing to do in a 73-year-old. I know a lot of 73-year-old people who are super active. They're gonna live another 20 years. I don't think we should make that decision in a lot of our patients. We have to be careful not to over-lateralize these people because as Brandon said, they're not arthritic ahead of time. We have to be careful about the bone preparation. You guys know all of this. But what I wanted to talk about to avoid revision surgery is you've gotta get tuberosity healing. That's the key. If you're gonna do a fracture, if you're gonna review anything before you get in the OR, review the way you fix the tuberosities to your implant. It's not just the fixation, it's the position of the fixation. There are a few techniques out there that work really, really well. But just throwing some sutures in there on the outside is not gonna work. The patients are gonna get the same result or worse than if you just left them alone. This is a technique that Brandon wrote up. It's really developed with him and Evan and Letterman and Ruben Gabese. And I can just tell you that for me, this has really worked so nicely in terms of when we have these fractures. I don't think I can go any further on this, right? Yeah, this is too long of a video. But basically, when you pass these sutures where we know they're supposed to be at the bone tendon junction and set it up ahead of time and we fix it to the stem that's well-fixed either with or without cement. And believe me, I will use cement just like in femurs. We know some of our older patients, their humeri are not that great. You have to use cement. There's not a problem with that. But we get solid fixation of those tuberosities and bring it down to the right position on our stem. And these are the results we get. This is the same patient. She's gonna do great. This is gonna be an awesome result. In six weeks, she's gonna be back to all of her activities. In three months, she'll be able to do whatever she wants. That's better than non-operative treatment. But you gotta do the right operative treatment or you'll be revising it or have to do a tough reverse when it hasn't been done well. 160 degrees of elevation. And we get the tuberosities right. We do well. 58-year-old male. This is what he has. He comes in, you see that. This is not an issue with the implant, but there's something not right. So there's this erosion of the bone and something's not going well. And you get in there and unfortunately, it's infected. So we take everything out. And whenever you do these revision cases, do your best to figure out what system is in. There is something online from the American Shoulder and Elbow Society that helps identify. We don't always, some of them go back a long ways. We don't always have that. Find out what system is. Call that company's representative and ask them, how do you guys take your system out? Everybody has a different way of doing it. If you have their tools, it's gonna be by far the best way to do it, to get it out. And you're gonna have to do this in a revision case, whether it's an infection or an anatomic has a cuff tear. So use them. They're there for supporting you and you'll be much better being a revision surgeon. These things, even if they don't look loose, are not always that easy to get out and take a little bit of work. We try our best to preserve bone because that makes the reconstruction better. But sometimes, you know, we take out some. So here is a little bit of bone here, but on the glenoid side, we did well. And then we have to decide, is it a single stage or is it two stage? There's no doubt, more and more people are doing single stage revisions for infection. But with this case, it just felt better to put a cement spacer, young person, gonna get our highest chance of preserving this shoulder without infection if we do a two stage. But a single stage could have been argued by some. But that's a defect you have. And the nice thing is is now we can plan it. So there's a cement spacer in there, but we can look at this with CT scans. We can do planning on these things because the metal is not all the way into the joint. We can decide where we want our implants, where our bone defect is coming back. And I think in general, if you don't have a plan with your initial revision case, taking everything out and then planning, you're gonna get a better final result. If you get it planned out well with the implants in place, get everything out smoothly, don't lose any extra bone, you can get a very nice single stage re-implantation. But here we had some defects, some bone loss. We're able to preserve that. The nice thing about stemless, of course, is we really, if we're safe, the tuberosity stay in place, we have good function, and we can get a nice result. So even in a younger patient like this, we don't worry too much about having to convert to an anatomical reverse, because they're gonna be much better after this operation than they were with the other operation. Now, if the other operation worked, they would have done great, but this is what we need to do. So just keep in mind those things and be prepared for those bone defects, whether you're gonna use allograft and a non-infected shoulder or autograft, and then know your system's ability to change with regards to the glenoid. Here's an example, revision arthroplasty. Sometimes we can't fix the glenoid. The patient may be a little bit more sick, and we might have to use something like a cuffed-hair arthropathy head. But sometimes the deformity's bad, but we have now more and more options to do on the glenoid side. There's a variety of companies now that are offering us custom glenoids. So don't just give up on the patient. See what's out there. Here's an example where, if you get this all cleaned out, you can get a reasonable reconstruction. Here's one of your peers, someone you trained with, 70-year-old orthopedic surgeon, still does 700 cases a year. And he had an anatomic seven years ago, and now he's having more and more pain. Is it infected, is it loose? Hard to know. The glenoid clearly is loose. So you go to do a revision reverse. You plan it out. Four months after revision, he says, you know, it still hurts. I don't know, but it's still really bugging the crap out of me. And you can see the glenoid is not completely engaged with the scapula. And that's a little disappointing, but it's not terribly bad, so you wait. Now you get some humeral subsidence. The glenoid's not completely in place, and now we're very worried. And eight months after revision, you've gotta plan this out. So there are ways to do this, but we have to keep in mind, as Peter and others told us, that there's a high risk of infection when it's infection of C acnes. If you can plan it out well, you might do a single-stage re-implantation. But this was the defect that I had when I took everything out. I don't know any system that has off-the-shelf components to do a single-stage implantation with this. In fact, what I did is I put a femoral cement spacer in his humerus to fill that gap, because the humeral ones were just way too small. He went back to work in four weeks. And he worked for about six weeks, and I did forget, I did lose, I broke a screw and didn't realize it. So that was very frustrating for me. So here I am, and so about six months later, he said, my shoulder does hurt a lot, I can't do anything above shoulder level, I don't think I'm ready for it. And so we do this, and you can see he's got, basically the deformity's huge. You can look at different programs that are out there, and you can match the defect, and you can end up with something that works like this, get his humerus back in the right spot, get him well-fixed on the scapular side when it looks like there's no bone left to get that done. And this is what he has. And he's back 100% at about three months. So not perfect, but these are the kind of things we have to plan ahead of time. So one last little thing about the difficult humerus. I talked to you about the Pharaoh's classification. These cases come in and you just shake your head, just in the middle of your office days, patient's scheduled for 15 minutes, good luck with that. And their whole family's there with you, wanna know what happened, what happened. So we struggle to get it out, we put a spacer in there, and we come back and revise it, do everything right, and she fails at the distal end of her implant. This is a great implant for these tough cases, was designed for tumors, but can be used for these bad humoral problems. It really fixes well distally, but she really almost didn't have enough bone. We were worried about that, and sure enough, she just kind of failed at the end of this. And so I had to do a complete tumor replacement with a total elbow on this lady. And she's got, her hand works, she can crochet, she's so happy, she can crochet, she can write, but you know, she can barely touch her mouth, but she can, but she can't raise her arm up. These are tough cases. So keep in mind the defects that you have. If you're doing a revision of an arthroplasty, talk to the company that made that to help you get it out. Identify your bone defects and plan it out ahead of time, and you'll get a good result. And remember, unfortunately, revision cases have a high risk of infection, so we have to do all the infection protocols. And if you have to take it out and come back, that's not necessarily a loss, and sometimes that's the best thing to do for your patients. Thank you very much. Thank you. I definitely send you those that disaster at the end there. That's not that's not something I have any interest in So before we get going on cases questions, we can answer it all about anything. We've talked about so far By all means like ask whatever We're up here for you guys. So I Plan every reverse for fracture If yeah, I mean if there's some reason Medically, we have to get there sooner or which is unusual Usually I would plan for any case that I'm gonna put an art to plastia Pete burn Yeah, I will say at this point for reverse I'm planning and navigating every case All of the cases within two to three days, they can turn it around and then you can navigate it. So that, to me, has totally changed things. You can't do that with PSI, unfortunately. You can do that with some of the other systems that have a reusable guide, which I think your guy's system has. So that's, again, I think that if you become, if you look at the literature closely, it's pretty clear, I think, at this point, that it does make a difference. And mostly for avoidance of complications, which are really the problem with reverses. I don't know what your guys' thoughts are, but I think if you deal with reverses, shepherd the patient through not getting an appropriate fracture or dislocation. For the most part, those patients do quite well and there's great durability to the result. You know, when I was a resident and you went on the trauma service, if you didn't come into the room with your cutouts and your preoperative plan, you didn't get to do the case. And I just found that to be an incredibly valuable learning experience to prepare ahead of time and the cases just seemed to go so much easier. And then we get out of practice, we're busy, we don't have the time, but oh, I've seen this before. And then every once in a while you get in a case where this is, I should have thought about this a little bit more. Now the technology's there that really facilitates the ability to do that for your resident, your fellow, is the company's technology. And so, to me, surgery's an open book test. There's no reason why you can't use whatever you possibly can bring to the OR to help you do the best. You've got two hours to change this person's life for the better. Why not use all the information you can get? The acromial fracture thing, actually, we didn't really talk on treatment for that. Brian, any treatment pearls if somebody comes in with an acromial fracture after a reverse? I think the best treatment is trying to avoid it in the first place. Oh, yeah, right, so they have it. Continue researching it. Yeah, yeah. Not to happen, but still you'll see it, probably 5% of patients. A lot of them, if you catch them early, can be managed non-operatively relatively successfully. Obviously, the result's not ideal. I spend a lot of time coaching patients about what to look for. I really see a bimodal distribution of it. It's the old ladies with bad bone, and then it's the young males who are splitting wood and working on their farm at one week post-op. And they come in, and so by telling them, I catch a lot of them early. They'll call the day that they know something happens, and then we can get them in a sling and try to get them to heal. I probably plate maybe 20% of acromial fractures. I'm not into plating all of them, just because the outcome doesn't seem to be overwhelmingly better than when I don't plate them. I'm not saying that they do great. But the displaced ones, I'll plate. Yeah, I try to sling them as soon as possible. Try to sling them for somewhere between four and six weeks with an abduction pillow so they're a little bit out. One thing I will say, so there's, I think there is a lot of emerging evidence on that topic. The emerging evidence is there's a paper in press right now from JVGS by the ACS Multi-Center Group, written by Amy Jala, where it's quite clear that humeral lateralization reduces your risk, and that collateralization increases the risk. So I think not all lateralization is created equal in that regard, because I think you can reduce the rate below 5%. And then the last thing to say is there's, this also hasn't been published yet, but I think for type threes, where it's a very medial, more scapular spine fracture, there is evidence now from George Athwell that fixing them, you can make those patients better. But the more lateral type one, like very out on the acromion, I think those really should be treated non-operatively. It's very hard to fix those and actually get anything to work. Would you agree? Yeah, the scapular spine, totally different. All right, good, well, let's go through some cases. So this first one, this 20-year-old, very nice girl comes in, history of leukemia. She's had some chemo in the past. She's a college basketball player right now. Been having pain for a while, saw a couple other outside orthopedists, had some steroid injections. Nothing was doing well for her. She wants to play. She has two years left to play. So she comes in, we get these x-rays. Pete, what do you got? Yeah, I mean, these appear to be normal AP and axillary radiographs. You don't see a lot of abnormality. I think, yeah, subchondral. Yeah, so it's subtle, right? But just, yeah, so yeah, so she's got a little bit of subchondral stuff going on. So we think, okay, maybe she has some AVN, so we get some further testing on her. Get a catch. Just by the history alone, you're gonna be worried about that as her pain, so you're gonna want some type of imaging beyond radiographs. So we start to see maybe some bony change in the CT, but obviously she has no degenerative changes in her shoulder. And then we get an MRI on her, and you can see that she's starting to collapse a little bit. So she's 20. She's had some steroid shots. She wants to play basketball. Dr. Romeo, what are you doing here? Are you gonna do like a core decompression, or are you gonna keep giving her- How much pain is she having? Enough that she can't play basketball. She's a tough kid. You know, we've talked about this over the years, and it can be a reasonable pain relieving operation for a short period of time. It doesn't change the natural history at all. So she's really uncomfortable, and she's got good range of motion, but she's really uncomfortable. It's probably from interosseous hypertension, and then that collapse. So I would consider offering her a core decompression, but tell her that, listen, this is not always very predictable, but two out of three patients can get excellent pain relief. Most of them are not as active as you, and as you continue to do this, we're gonna finally get to the point where the geometry of the ball is gonna change, and we're gonna have to come up with a better option. Brandon, can you go back to the MRI? Yep. I can say I don't do a ton of core decompression, but I really worry about that coronal MRI on the left. I've done a lot of arthroplasties for these. It would only be for pain relief. The cartilage starts to delaminate really quickly, and so certainly if someone's gonna go and play basketball, you know she's gonna go play basketball and try to. And this patient, I actually would scope her first, looking at her cartilage, and there's a big flap, I'd debride it, and I'd do a core decompression, and you can get a year or two out of her just to get her through her college years in a good case, but it's unpredictable. So it's just an option, as opposed to going to an arthroplasty in a 20-year-old right from the very beginning. So one thing, I totally agree exactly what Tony just said. The one thing I would add is if you find a chondral flap and you wanna do a core decompression, get your ACL drill guide out, and that'll help you to drill exactly to where beneath where the flap is, because otherwise a core decompression is actually a relatively technically challenging operation. Once you get your floor spots, it can be hard to see where the area that you're trying to aim for is. It's not just up, it's usually slightly posterior from your plane, so you start right off the biceps, and as Peter said, you kinda have to really figure it out. So using a guide is very helpful. So- The cost of the axillary nerve ladder. Yep. So I talked to her about that. I actually talked to all three about this case like two years ago, and that wasn't the answer any of you gave me. So you can see the difference that when we go through these things. So what every one of them said resoundingly was do a HEMI, which is what I thought was probably the best option for her and so that's what we did. This is what she looked like intra-op. You can see the cartilage starting to compress down there, and so she has done great. She was back to playing basketball earlier than six months. Obviously, I told her that there's probably gonna be somewhere that happens on her glenoid down the road, and she managed to be converted to putting a glenoid component in, but for her, the timing of, if we do a core decompression and she doesn't get back, she'd miss her season, and so that was part of the thing that weighed into our decision because she really, this was like in a cancer patient who wants to play like her last two seasons of basketball, this is what we did. So we got lucky here and it worked out. This is a case where I would use pyrothermine. Yeah. Just because it's a little softer, yeah. Well. No, I didn't. I didn't, I used to, I do a peel when I do the subscap and I use for this particular implant, I use the all suture kind of, or the speed bridge repair kit. It's honestly done pretty well for me. She's done okay, so we'll see. Yeah, I'm not that good at this. I can't do a subscap sparing it. Yeah. But you can do what you want in this age group and the subscaps can do. Yeah. Yeah, and I think, you know, and Peter said, you know, he would use a different articulating surface, but I think that's because if you compare to what we've done in the past where the humeral head has not been in the right spot with a lot of those longitudinal studies, we have some emerging evidence that it may be a little bit nicer on the glenoid side over time, but I honestly, having done the stemless devices, getting the humeral head in the right spot, getting these people with their full range of motion back, we are not seeing much in the way of any articular cartilage wear or erosion, at least even five years out. So I would say that more importantly than the surface is going to still be getting the humeral head in the right spot. Now, if you don't do that right, everything else is not gonna work well. I would agree. The other thing I was nervous about, so obviously she had some bony changes in her deficial region, and so I told her I would try to do a stemless implant, but obviously I have a stem implant just in case, but she had great bony fixation there, so it wasn't an issue. Sorry, second case. 77-year-old guy falls at work, dislocates his shoulder two months out, works at a bakery, pretty active 77-year-old guy, has had multiple reduction attempts, and the shoulder keeps coming out, right? So then he comes into the office, he has some deformity, and he basically can't move his shoulder. We get some x-rays. Clearly, this is not what we want to see. Two months after his injury. So we get a CAT scan on him just to see, well, maybe we won't see. There we go. So we want to see kind of what his deformity looks like now, and you can see he has quite a large chunk of his humeral head that's missing, and part of his glenoid that he's knocked off as well. What do you guys think about trying to fix this, about trying to do a reverse on this? You see how much of his glenoid he's knocked off on the front there. What are your thoughts? your dislocations where they're three, four months out, probably a different answer. Yeah, so, you know, in the past, before the reverse, I'm the only one up here that remembers that time, I'm sure. And you know, if we, if the head looked okay, we're going to do an instability operation. But when they stay locked out on the front like that, these older patients, there's something wrong neuromuscular with their shoulder. And so it's a very high failure rate with adding a Latter Jay or putting an Iliac crest bone graft or any of those things. Even if you do an arthroplasty, so it was a really a tough problem for us. And we put the head in more retroversion, put a bone graft on the front, don't have a move. And we still had some of these people, they'd come back at three months and the humeral head is eroding through that front part of the glenoid. So for me, this is absolutely no doubt the reverse is the right answer for this patient. Even with an intact cuff? Should we try to do an anatomic? There's something we can't pick up on these patients that is, is, you know, I don't know if there's a seizure disorder, I know you say followed all that stuff, but I'm just telling you that the results of doing an instability operation on this patient are not going to be anywhere near as successful as doing a reverse. Well, that's what we did. So we did a reverse on him. You can see how much bone he's lost on his humeral head. You can see how small his glenoid is, right? So that's the, that's the post that we drove for this particular reverse. And he doesn't have much bone left there. This is the smallest, smallest implant that I can put in. I put this picture up just to show you, there's actually a little bit of overhang anteriorly and posteriorly because of the bone that he's lost anteriorly. So it's okay to not have a hundred percent coverage. This guy's perfectly stable and you know, his initial post-operative radiographs were fine and obviously again, we show cases where people do well. So his range of motion was getting better at three months and then, you know, a year out he's doing well. But I think for fracture, again, this is a different type. This is not approximately humerus fracture, right? This is a fracture dislocation where the tuberosities were intact, so different animal. You can think about how much lateralization to put here. I didn't lateralize him as much as I sometimes would have with somebody that had some osteoarthritis. All right, this is a case that didn't do well. So let's go through this one. This is a 34 year old lady with Ehlers-Danlos, came in recurrent shoulder instability, multiple surgeries at an outside institution. She actually came to see Dr. Romeo when we practiced together and then he left and dumped this on me. So I had to deal with this. She had two scope stabilizations. They didn't work. A lot of stabilizations on the other side. She's 5'6". She weighs 265. She's a challenging lady. She's very nice, but she's very challenging. Her shoulder doesn't move very well. It seemed like, at least to me on exam, that she wasn't moving because she was scared that the shoulder was going to slide on her or pop out. Old incisions look fine. We get radiographs in the office. I don't think anything's super relevant initially. We get a CT scan on her initially just to take a look at what her bone looks like, see if she has any bone loss. You can see the old anchors from her repair seem to be in a reasonable position. I don't think trying to go in again and do the same operation again, whether or not you add in a remplissage or things like that, is probably going to get her to be stable. So I talked to her about that. So I thought, maybe Latter-J, maybe it's a tibial. Would you guys do anything different than a Latter-J for this patient? Tell me a little bit more about her instability pattern. Was it all three directions? Was it mostly anterior? What was your... I don't remember. It is impossible to examine her. So it's... I'm just being... In all honesty, it's impossible to examine her. She wears a sling around. So the problem with doing a focused anterior stabilization is they go out the back. You've got to resolve the inferior component of the instability. It's really important. Some of these people, if they have a primary anterior component to their instability, I will do a Latter-J, but I combine that with a graft from the posterior inferior part of their glenoid to create a deeper socket and a soft tissue. So it's both a soft tissue and a Latter-J. This is way different than what we do for our athletes without elaged analysis. We still don't have a great answer for this condition when it's really severe like this. They have a very high failure rate and oftentimes end up getting arthritic. And our treatment in the past has been a fusion, and nobody wants to do that anymore. So now we're starting to see some of these cases pop up and get a reverse, and that's not always the answer too. At this age, without arthritis, we're going to try to do some stabilization operation, but you can't make it unidirectional and it has to be the whole shoulder joint. So I do a Latter-J, I close the rotator interval, and I use usually a hamstring graft that I put in from the posterior aspect all the way around inferiorly, just like they do with hip surgery to reconstruct a bigger socket or bigger concavity, and even those will fail sometimes. Well, I did that minus the hamstring graft, right? And you pretty much laid out what's going to happen. So her initial radiograph, she does great. Six weeks, she's doing great. Start her in PT, so you're back at three months, no problems. Start a PT, doing fine, then feels like the shoulder starts to grind, comes back at five months, screws start to back out. So now you have the screws backing out, and so at this point, what do you do? Get a CT scan, right? See what the bone graft looks like? You probably have some resorption of the bone graft there. It doesn't look like much of it's healed. So do we take the hardware out? Do we revise her to a distal tibia allograft? Do we think about doing a reverse? Warner, what should I do here? I think we have the privilege of talking about this case, but you're getting down a rabbit hole. That's probably going to end with the bottom option, but I think you have to work your way in that direction. Does she still feel like she's unstable? Yep. Yeah, so we continued down this rabbit hole of, okay, so we did a distal halograft, and again, the same course happens. So she does fine, she has no problems, then she comes back and sees me, she started having shoulder pain again, felt like it was starting to slip again, x-rays show that her screws are starting to back out again. So we're in the same spot we were, we just pushed it down the road six months. And she's been asking me the whole time for a reverse, and I keep telling her no, because I don't want to do this, right, because I'm worried that I'm going to have problems. So again, we get to this point, we say, okay, maybe we just take the hardware out and see how you do, which is kind of what I did. So I took the hardware out arthroscopically like you recommended, but now you can see she's starting to get a little bit of arthritic changes in the shoulder, right, as Dr. Romeo predicted when we started this story. And so now you have somebody who's in their mid-30s, has Ehlers-Danlos, I've tried everything from a stabilization perspective, even with the arthritis, she still feels unstable and still has pain. And so I tried to give her as much time as I could, I gave her a steroid shot, nothing I could get her to a good place. So what else are we going to do? Obviously, we're talking arthroplasty options or fusion. I talked fusion with her, that was off the table in about 12 seconds. Then we talked about anatomic versus reverse. Obviously in somebody who's unstable, you don't want her to end anatomic, she's going to dislocate, right? So her option at this point becomes a reverse. And so the reason I thought this was relevant to talk about was because when you do the reverse in her, right, one, you want to make sure she's not infected, right, because she's had all these surgeries. So maybe I've been missing an infection the whole time. She wasn't infected, but we had, we got an aspiration done just to make sure. And when we did her case, when we picked our implants that go in, we wanted to leave ourself the most options to change things down the road. So when I planned her case out, I wanted to make sure that I lateralized as much on the base plate as I could, didn't lateralize the glenosphere and didn't distalize her as much as I had to, to get her stable. So when we did her case, we put in a lateralized base plate, didn't lateralize her glenosphere and only had to put in a plus three poly to get her to be rock solid stable. So that way, down the road, if I have to revise her, I don't have to take her base plate out. I can just start to lateralize her glenosphere. I can start to distalize her a little bit. I can upsize the glenosphere component that's in there. So I left myself some options down the road. Now she's two years out and she's doing great. She has no problems so far. I'm sure it's going to happen because she's not going anywhere and I'm not going anywhere. So it's going to be a problem down the road, but at least the two years, this is right. And so the question is, should we have just done this off the bat? Should I have done that off the bat? No. I didn't think so. We can get good results with some of these patients. And I think there's variable degrees of these collagen disorders and they're not, even though they may undergo this category, Ehlers-Danlos, there's a variety of different categories. And some of these patients will respond to what I would call our stabilization procedures with augmentation to the point that they'll do well. And so I think if there was any criticism, you know, maybe after the failure of the Lagerge, you could have gone to the reverse at that point. But I think it was not unreasonable to consider one more soft tissue with bony augmentation. These patients oftentimes will have four or five procedures before they actually end up going to an arthroplasty or in the past a fusion. And for those of you that have been not been doing this as long, there's a nice paper out of Toronto, patients that undergo a fusion for instability, 20 to 25% of them will complain of instability when there's radiographic evidence that it's fused. So there's something super-tentorial that's not completely correct in them. And so just by doing a fusion, you don't always solve the problems. I think, honestly, I've done a few of these now and they do actually work pretty well, but we don't have long-term follow-ups. So we'll see if they stretch out. I don't think they're going to because I think this is now you've put it into the muscle part of the cavity compression and you've taken care of the concavity part and it's the collagen and there probably is a very loose capsule and that doesn't heal well. But I think with the muscle and the stable universal joint, this will work. Maybe I can get away with this in Utah and you can't get away with this in New York, but the first visit I would have said, your arm is too heavy for the muscles in your shoulder and that's part of your problem. And so you either need to lose weight or we need to figure out a way to make your arm lighter. I've had multiple patients now where they've had very, very heavy arms and I've sent them to plastic surgery for like an arm paniculectomy and the plastic surgeons have removed, there was one patient where they told me they removed 30 pounds from one patient's arm and the fascinating thing is then the patient came back and they didn't have any symptoms anymore. So then they didn't want any more shoulder surgery because their shoulder didn't hurt. So I think that that plays a role in this patient and you have to address that with the patient to say, we are happy to help you, but you also want to help yourself. I think that's a great, I didn't even think about that. All right. Cool. We're getting close on time. So, I mean, questions, anybody before we wrap things up? Pete, you've probably done the most on this recently with some of your stuff. Do you want to hit that? Humeral version for humerus. Humeral version. I don't think it matters. There's a randomized clinical trial in this month's JVGS comparing zero and 30 degrees of humeral version on the reverse that makes more difference. For anatomic, I try and play it alive because I think you're trying to get the cuff to work as normally as possible. I would echo with the anatomic. I think the great advance of the stemless, no matter what company, is getting the humeral head in the right spot for that patient. And the soft tissue envelope around it is in the right spot when the humeral head's in the right spot. You know, I went through that transition where we had second generation's long stems and we had variable neck lengths to tension the shoulder before we closed the subscap because I was told by all the senior surgeons that this is a soft tissue operation. The metal part doesn't matter. Three years into my practice, I was able to join up with Gilles Walsh and Pascal Boileau, and the first time I did a truly anatomic shoulder with a ternary device, I was totally blown away. And by the time I'd done three, I said, I'll never go back to that old way of doing it again. Put the humeral head in the right spot, you're going to get the best result. So, anatomics, that's really the key to making that work. And there's people, like Peter said, like John Sperling does over 400 arthroplasties a year. John says, I don't want to create any problems. So, zero degrees of retroversion on the humerus, and we don't have to worry about it. Try to just prepare the glenoids so it's a zero, and prepare this to zero, and the patients do fine. So, you know, I don't know. I think we spend a lot more time trying to adapt or adjust back to what we think is the best anatomy on the reverses, and we'll find out that at some point how much we really had to do and how much we can accept. I don't know if we know that answer yet. I think the most important thing is you cannot fix your glenoid problems on the humeral side. So, if you put the glenoid component in anaversion, you can't fix that by retroverting the humeral component. So, the really most important thing about either the anatomic or the reverse is the version of the glenoid component. And the reverse, I think you can accept a fair amount of retroversion, and the anatomic, I think you really just cannot, unfortunately. Anybody else? This is your time. You got Dr. Romeo. Ask him what you want. What? I said this is their time. They got you. You're captive. Ask what you want. All right, great. Well, thank you guys all for coming. I really appreciate it. I'm going to send a picture to AOSSM to give us a bigger room next year.

shoulder arthroplasty

sports medicine

preoperative planning

CT scans

anatomic total shoulder arthroplasty

implant designs

subscapularis muscle

reverse shoulder arthroplasty

biomechanics

revision arthroplasty

glenoid deformities

patient comorbidities

surgical planning