All right, so we're going to talk about arthroplasty here. Relevant, do work with, ANOVUS, DJO, and we're going to talk about shoulder arthroplasty. Won't belabor this too much, this is obviously what Brandon was just talking about. But I just kind of point to, and this comes from what Tony was just saying in terms of what our expectations can be. Even when the 10-year survival rate of a procedure is 63%, it raises some concerns. And so maybe this is the conversation my colleagues want to have with their patients, is that 60% of the time it works every time, but that's not really for me. And so if you believe that, I'm happy to sell you guys a tour of the Titanic. Too soon? Maybe. Okay. Okay. No billionaires in the audience, that's a problem. Our actions do have consequences. And despite some of the things that Brandon was showing earlier, there are numerous studies suggesting that non-arthroplasty surgery prior to arthroplasty does lead to lower outcomes, higher re-operation rates, and higher infection rates when it comes down to shoulder arthroplasty. So over the next 10 minutes or so, these are the things I'm going to tell you. Your goal should be to get, with any of these things and these young people, if you're looking to avoid an arthroplasty, you should really be aiming to get 10 years plus. Because if you can't do that, then you have impacted what would otherwise be your best operation for this patient, which I would argue is an arthroplasty. That poor range of motion, particularly external rotation, extremely narrow joint space and refractory night pain really push me down the arthroplasty track. Metal and plastic is good, but not perfect. It certainly has higher survival rates at the 20-year than some of these other non-arthroplasty options. And for the most part, hemiarthroplasty has largely gone by the wayside. My goal generally is total shoulder. Don't compromise your best operation because you're too scared because the person may be on the young side. So it's obviously a very difficult and challenging problem, and there are a lot of different options. Anytime I'm considering a patient and what the heck do we do for this 30-year-old patient, these are some of the history and physical things and imaging findings that are important to me. And so I'm kind of asking myself, can I kick this can down the road? And for me, the non-arthroplasty options that my colleagues have talked about are certainly viable in this patient with decent range of motion, greater than 2 millimeters of joint space present, neutrally centered glenohumeral joint, and more of like an A-type glenomorphology. But when these things change, it's not so much a can you're kicking, but more of an oil drum. And so meaning that you're very unlikely to get 10 years of kicking the can down the road once you start to get completely obliterated joint space, you start to see the posterior subluxation, the changes in the B-type glenoids which tend to progress. And so these are the situations where kind of regardless of age, I'm really much more down an arthroplasty path. In this study kind of looking at delaying things to arthroplasty, you can see that on average some of the injection options as well as the arthroscopic options yielded about a three to five year delay into arthroplasty. And in this study they found that external rotation restriction was the most negative predictive factor for survival of a non-arthroplasty option. And so I implore you, don't be scared to do the right operation for the patient, even in the young patient. Give people the best chance that you can. And as Matt mentioned before, the subscap, it doesn't take a joke and you only get so many shots at that subscap. And so to go in and try and put a fascial autograft and take down your subscap so you can buy somebody five years when they're 35, what have you really accomplished? I mean I would argue that if anything you've done, you've done a detriment to that patient because you've made the arthroplasty, which is the more, will give you more longitudinal success or less reliable. So obviously we've all seen that arthroplasty, the explosion of shoulder arthroplasty, certainly how reverse has come into the picture as well, even frankly for some of these young people. The demand for shoulder arthroplasty is only increasing and will only decrease the age with which people start seeking this out. In general, I find hemiarthroplasty have extremely limited role, almost reserved for AVN with intact glenoid cartilage in the young patient and a subset of proximal humerus fractures. Dream and run, at least in my hands, has a very limited role. Total shoulder's my goal. And when I was reviewing these slides last year, I had avoid if possible in red, but I've kind of upgraded that to yellow this year because it kind of, again, goes back to doing your best operation first. And so for the same reasons that I may not want to do a non-arthroplasty option because it's only going to get somebody five to seven years, I'm becoming less willing to push the limit of total shoulder for fear, you know, in some of these posterior sublux people, for fear that I'm going to end up with a loose glenoid in five to seven years. All right. So we're going to go through some stuff. So people say reamer run is a great option. I would say that it is an option. I don't know that it's a great option. It's certainly not something that I have, I think I've, in nine years, I think I've done one reamer run. So I'm biased in that sense. That said, for the right patient, Mattson and others have shown some pretty positive results for this active patient. But it's not for everybody and certainly requires an extensive rehab effort and commitment on the patient's side. So it is an option. I won't kind of belabor some of these things here. All right. So this one, I love this one. So well, I'll just do a HEMI now and then I'll revise it to a total shoulder in the future. No. Okay. So there are many studies out there looking at the inferiority of HEMI arthroplasty when compared to a total shoulder, an anatomic total shoulder arthroplasty. In general, the time to conversion from HEMI to a secondary operation can be as low as three years or maybe 10 plus. But in general, results like this and 47% unsatisfaction are not what I'm aiming for in my practice. And I believe the previous slide had also showed that we do continue to see this erosion and wear patterns in the glenoid and that can have a huge impact on your ability to go back in and put a glenoid in. You've already hit the subscap once before. So you know what else is on the horizon in the United States? We don't have pyrocarbon, but elsewhere in the world other bearing surfaces do exist. This study was from Pascal Boulot in France and they noted at five years with a pyrocarbon in HEMI, a 10% conversion to a reverse and that they note in this study that the pyrocarbon did not protect against radiographic glenoid erosion. They also noted greater tuberosity erosion and stress fractures higher than you would see in more traditional techniques. So the thing that I would kind of pull from this when we talk about HEMI and the statement of I'll do a HEMI now and then I'll put in a total shoulder later is that it was a 10% revision rate to a reverse. And it's very uncommon that you end up able to revise a HEMI to an anatomic in the future. And so if you're going to go from an arthroplasty to a reverse, then give yourself the longest run that you can out of that anatomic before you're getting to the final procedure. I do a HEMI so they can get back to sports. Well, not true. Return to work and return to sport in numerous studies out of our institution and others have shown superiority for anatomic total shoulder compared to HEMI arthroplasty. Like I said here, so there's a return to work, there's a return to sport, again, significantly higher return to sport in the anatomic total shoulder. In general, I don't love a HEMI and it has a very limited role in my practice. So do your best operation first. What's the question? People will say, well, how long will this last? And the answer that I usually tell people is, well, I don't know. Because all of the longitudinal studies looking at survival of anatomic total shoulders are using implants from 20 or 30 years ago that we don't use anymore and a lot of the technology has changed. And so I remain hopeful that 20 years from now, whoever is giving this ICL will be able to report that the durability of these anatomic prosthesis is better than what we have to show you here. But in general, kind of what I'll tell people is there's about an 80% survival at 20 years for an anatomic. And so in that 30-year-old patient who's going to get an arthroplasty, just like what Matt and Brandon said, I'm telling you, this is probably not the last operation you'll have but I want to give you as long as you can. I want to kick that can as far as I can before reaching those next steps. So again, the difference is metal and plastic is good but it's not what God gave you and you wore that out. And so that's what I usually try and tell people. And if you're going to go into a shoulder arthroplasty in a young person, you really have to have buy-in from that person. The reality is that people, as they feel better, people are going to do what they want to do and your job is to basically counsel them on what the implications of going back to bench press are. I've got not a young guy but one of my high school buddies' dad, 70 years old, stonemason, salt of the earth, tough, tough guy. And I've replaced both his shoulders and my buddy will text me and say, hey, I just caught dad doing bench press down in the basement. So for the 70-year-old, I'm just thinking, all right, it's a race. It's going to last longer, mine or his. So patient selection is very important, appropriate indications, especially in the young person. People have got to be pretty miserable for me to take it to this level. And at least acknowledge and be willing to understand the implications of continued bench press and other higher level activities on how long this will last. You know, you're basically adopting this person for the duration of your practice. And so with the young people especially, I make them earn it. I am not offering a replacement the first time I meet you when you're in your 30s. This is somebody I want to see back several times. I want to get to know them a little bit, make sure that they're fully aware of what we are getting ourselves into. And so, you know, in general with shoulder arthroplasty, I try and tell people that I'm not going to push you to do something you're not ready for. However, there are situations in the young patient where I may start to push. And these would be some of the things that would kind of encourage me to encourage them to maybe do something before they're ready. And so these are things like emerging B2 glenoids, B1s with more significant retroversion, large atrocious cysts, and significant subluxation because I want to pull the trigger while I still can do an anatomic and not be in a position where I'm forced now to do a primary reverse in a 40-year-old. And so maybe these would be things that would push me. And Brandon mentioned this before, is that once you start to see this posterior subluxation, these B-type morphologies, the majority of them progress over time. So this is an example of a 33-year-old retired New York Giants lineman, and you can see what his shoulder looked like in 2015 and then the significant progression that we see there. And so when I'm following young people and I'm doing some of the other non-arthroplasty options, the injections and NSAIDs and CAMs and whatnot, I really like to follow these patients with an annual x-ray to watch for progression of that posterior subluxation. And on this guy, when we saw that, when in doubt, I will get a CT scan. And fortunately, that kind of turned out to be more of a rotational issue on that x-ray. Large introsteal cysts, I kind of fear a little bit that these will continue to progress and compromise the subchondral bone ultimately and preclude my ability to place an anatomic. So this may be something where I would push somebody to do something sooner than later on the CT here. This 40-year-old, pretty significant pain scores. Decent motion, but as I start to see that B2 morphology and significant posterior subluxation, I start to worry about what that's going to look like in a couple of years and my ability to do an anatomic, which I would believe to be this person's best operation, which was something we did almost done here. Another young person, again, pretty significant posterior subluxation. These are things that would push me to push them to do something maybe before they're ready. Other topics for a different, a whole other lecture, but kind of how to kind of manage these things. And this young person, we used one of these convertible base plates with bone graft behind it in an effort to do an anatomic and facilitate a future reverse if necessary. This is a 30-year-old who had two failed posterior stabilizations, gone on to arthritis, was miserable, couldn't even hold his kids. And these are the kinds of things that you can get out of it. See I had to, let's see if I can protect his face better than Matt's, but all right. But you can get results. This guy, and these can be some of your absolute happiest patients. He's now five years out, sends me pictures of him fly fishing in Colorado and holding his kids and stuff. And so you can have major effect. And then this kind of gets back to do the best operation that you can when you need to do it. And so this guy had a pretty significant glenoid morphology issue, 34 years old, terrible motion, miserable, had never had an operation. And we went in with the intent to do an augmented anatomic total shoulder. I couldn't balance the shoulder. And in years past, I may have started to do some posterior capsular plication and really upsizing the humeral head. And this is where I've gone from kind of red to yellow on that slide before. Because where we're at with a lot of the reverse stuff, I mean, this guy's three months post-op. And I know you can't see the smile behind his face, but he's smiling. And then there's roles for other arthroplasty options. This I got to do in about a month as a 14-year-old kid where the whole head is dead and we're going to end up having to do a hemi on him. So arthroplasty, ultimately, in my opinion, while it is a little scary to put in a fake joint in somebody who may be in their 20s, 30s, 40s, because you know it's unlikely that it will last them their lifetime, none of the stuff that these guys are talking about before me is going to last their lifetime. So all of these things that we're talking about in the 20, 30, 40-year-old patient, they're all bridging operations. And I think that an anatomic total shoulder has the highest probability of giving you the longest run and bang for your buck. That's all I got. Thanks, Sam.

arthroplasty

shoulder arthroplasty

10-year survival rate

patient expectations

non-arthroplasty surgeries