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IC 305-2023: Shoulder Arthritis In Young Active Pa ...
IC 305 - Shoulder Arthritis In Young Active Patien ...
IC 305 - Shoulder Arthritis In Young Active Patients - What Are The Best Options? (4/4)
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this morning on the management of shoulder arthritis in a young patient, and I'm supposed to do some cases, and we're gonna stay away from some of these crazy things. This is a 39-year-old gentleman who has synovial chondromatosis and has a little extra bone formation, and these get to be a little tricky sometimes. CAM procedure. Yeah, CAM procedure. Do that arthroscopically. And so, but it did turn out okay for him. You know about our speakers. All have great expertise in this area. Why are we having this ICL at the American Orthopedic Society for Sports Medicine? Well, because one out of four adults have arthritis, and one out of 10 have shoulder arthritis that can be symptomatic, and oftentimes it is in the younger, athletic patient population. So you may be doing an ACL on one of your 50-year-olds that hurt their knee skiing and say, oh, by the way, can you take a look at my shoulder? And they have a B2 glenoid with osteoarthritis and would like to have your advice on that. We see the incidence for shoulder arthroplasty going up very steadily, just like it is for other arthroplasties, and reverse arthroplasty is now more common than anatomic, and that's not surprising considering the challenges we've had with the soft tissues around the shoulder. Shoulder arthritis comes in a variety of different, basically, patterns, and that's what we really have to think about, and when our younger patients have shoulder arthritis, you have to really ask them carefully about their history because oftentimes it's not osteoarthritis, it's some other form of arthritis, whether it's capsulography arthritis or arthritis related to other conditions that you have to be careful to extrapolate the information that you're hearing. So here's a 44-year-old male with shoulder pain. He's an arborist, he takes care of trees. He has a very stiff, painful shoulder, and what are you gonna do for this guy to try to help him out? Here's another patient in their 40s that had a stabilization procedure and now has this problem. What are you gonna do? And we have a lot of unique and exciting new tools available to us to try to treat each person with precise or direct care, so that's what we're trying to do at this ICL, is help give you some guidance on what's best for the patients in front of you. And another important driving factor in all of this is that many of these cases are being done more and more often in Outpatient Inventory Surgery Center, which has really been the world of the sports medicine physician, not the arthroplasty physician, although it's becoming that way. They're becoming part of that. So you all have an opportunity to care for these patients in your own little backcourt, and that's nice to have the ability to manage these people. So just simply, when we think about the things that were talked about today, 52-year-old guy comes in, he has this kind of arthritis, early B2. He's got this CT scan. You're gonna plan him or not plan him. We didn't hear anything about planning, but do we talk about that? Or what kind of stem are you gonna use? What kind of glenoid are you gonna use? So then you heard the presentations that we have. So let's go over some cases and see if we can put this together. So Brandon, this is a 36-year-old guy that comes in. He's got joint space narrowing. He's got a very stiff shoulder. He's got a large inferior osteophyte. His rotator cuff is normal. He's a very physical guy. He's about 6'4", about 260. And this is, and he has arthritis. So we're gonna offer him the CAM procedure. Is that a reasonable option for a 36-year-old? If it looks like this, do we tell him that, you know, listen, we did what we could, but you're probably gonna need an arthroplasty? Once you see this, where there's no humeral articular cartilage left, what are you gonna tell them? Yeah, so that would make me a little nervous. And I guess to your point of, you know, the imaging that you had beforehand, we kind of touched on a little bit, but you know, on a bunch of our slides, you saw that, you know, joint space less than two millimeters was a really important predictor of whether or not all the things that we're gonna try are gonna work or whether or not we need to go with what Sam told you about. And so I guess, you know, if it looked okay on the x-ray when you went in, I think it's a reasonable thing to try. When you get in there, sometimes you can get surprised like this. And so I would have a very long discussion with a matador and say, hey, listen, we cleaned up as best we could. We took care of everything that we planned to take care of, but the reality is, and you showed them the pictures when you're doing this, your shoulder does not have any cartilage left. You are going to have pain with this. If the pain becomes a big issue, likely at some point, you're going to need a shoulder replacement because that's pretty far gone. Sam, this is not something you offer your patients occasionally or? No, it is. How aggressive should we be against that inferior osteophyte? That's really where, I mean, most people can release the capsule and do a debride and release the biceps. The Waterloo is down there at the bottom at six o'clock. How aggressive do we need to take care of that osteophyte? I was actually going to ask you the same question. The, no, I mean, I think that can be tricky and I'm a beach chair person, which makes actually getting that inferior osteophyte. But so is Peter Millett. And he does that, you know, he's the one that sort of talked about this operation. He developed this in the beach chair position. So I agree with you. That, to me, that seemed to be harder, but he's the one that designed it. So I'm watching this video. I'm like, man, that would be much easier. Yeah, this is a lateral position. This way I would do it. No, I mean, I don't tend to get extremely aggressive with it and that may be because of my own access issues with the beach chair. And Matt, what do you think? Yeah, great points. I do this lateral and you can get it pretty well. You're showing the scariness though. It's right there, the nerves right there. And if you get into some bleeding or a little bit of bruising and you're getting frustrated, yeah, it's a really nice view of it. It's right there crossing transversely across your screen. In this view right here, I just want to point out, Matt, that this view, here's the glenoid here. The nerve is up here. It's right here. That's the nerve right there. So that's, if you're wondering where it's at, that's what that's showing you is where the nerve's at. Right behind those subscap fibers. So one of the things, just as a point, you may create a third portal and put a Wissinger rod in there and use it as a retractor. That would be, if you're not comfortable doing this, then be a little safer and put a small rod on that and pull back on it before you try to treat that. Wissinger rod, a probe, a couple of different cannulas, percutaneous portals, posterolateral portal. That's why the lateral for me works really nicely. You know what's amazing here is I've gone back on these and having done these, and that very nice aggressive release that you did, the capsule comes back. It's crazy. It's unbelievable to me. It's almost like you never did anything. Well, hold on to that thought because not only does the capsule come back, but this is the guy eight years later. You've done something to his pain fibers and his sensation of discomfort, and look at the osteophytes that developed. When you cut the capsule and release that and he goes on, this is the guy I showed just a few minutes ago, the arborist, very physically demanding guy. He says, Doc, I've been going for as long as I can. He told me just to stick it out, but I just can't do it anymore. I have to cut these trees and I can't get my arm above shoulder level, and even though I'm tall, it's making it so I can't do my job, so. Do you, I have a question. When you guys are doing these arthroscopic cams, how do you manage them in the post-op period? Do you hit them with a steroid injection early in order to help reduce inflammation? Do you consider any other biologic stuff? Is there anything that you do differently? I don't. I tend to, if they're hurting and not getting their motion early, I will hit them with a steroid, but is there anything else different that you guys do for these people that you may do for another type of an arthroscopic procedure? I kind of treat them like, and he's a capsulitis patient afterwards, so I treat them like frozen shoulder that we have to operate on. So I generally start them in therapy the next day, as best I can. I do them three times a week. I have a low threshold for putting them on a medjool dose pack early on, but I try to get them into therapy immediately because to Matt's point, the capsule is going to regrow. Same thing in a frozen shoulder. It's gonna start to regrow, and if you don't get them early motion, it will stiffen back up again. Matt? Yeah, the other thing we've added in, and we've done some research and veil on this, and I don't know, that might be a little bit of voodoo, but we've also added in doxycycline for its anti-scar extraneous properties, 100 milligrams twice a day, and also lasartan, which is a blood pressure medication taken in low dose, 12.5 milligrams twice a day. Off-label for scar minimization, so I use lasartan as well, doxycycline. I do like a medjool dose pack. I usually wait on the injections until they come back in three to six months with some pain, but I don't have any problem with that. So those are the things we've added into any of these tough arthrofibrosis or scarring or motion things, and we've actually had some reasonable results, and there's some early literature coming out with that. All right, some good ideas. So Sam, here's that patient. So you kind of look at this. He's got 29 degrees of retroversion. He's got at least 50%, probably more subluxation. Inclination's not bad. Anatomic or reverse? I mean, so. Cuff is intact. Yeah, I mean, when you go back and you look at that, that glenoid doesn't scare me as much as some others because I think that there's probably a little bit of some C-type to begin with, and it's kind of where he was living more than an acquired deformity entirely, but it's something that I would go in in this person with them being consented for an anatomic possible reverse, and I see if I can balance it, and if I can balance it great, and if I can't, then they get a reverse. What's balancing for you? Is that an augmented glenoid? Is that reaming down the high side? What would your approach be typically for this individual? In this one here, it would probably be an augment, but more commonly for me, it's a high side ream, but when, I think that this is too much, you way over medialize this if you high side ream, so I would probably, I would attempt an augment and bail if I couldn't balance it. Okay, would you ever look at this as an augment and say, you know, that's not enough, I'm gonna take his humeral head and put a bone graft with a metal back glenoid like you showed in one of your cases? Yeah, and if I'm going to bone graft on an anatomic, it's behind metal, it's not behind plastic. All right, Matt or Brendan, anything else on this? No, I definitely would use an augment like you did. I try to get them to about 10 degrees of retroversion when I'm planning, so if you can get them within 10 degrees of inclination, 10 degrees of retroversion, you should be okay from a stability perspective as long as you do the balancing properly. To Sam's point, you don't want to over medialize it with the augment, you can kind of limit the amount of medialization you have to do, and I would accept 10 degrees, so I would probably use different, companies have different systems, the system has a 10 and a 20 degree augment. I have used a couple of 20 degree augments, and then I've gotten a little scared with using the 20 degree, so I backed it down and used about a 10 degree augment, but just know that when you're planning it, a 10 degree augment doesn't correct 10 degrees of retroversion. A 10 degree augment corrects about five degrees of retroversion, a 20 degree augment would correct about 10 degrees, it's about half, same thing with reverses, so I would try to ream a little bit and then put a 10 degree augment in. One of the things that, you know, Joe Walsh always talked about, that these posterior sublux heads, regardless of what you do with an anatomic, they want to find their way back to where they started, and I hadn't entirely found that, in that I've mostly found that if I could balance it intra-op, then it could maintain that. That said, I have one of those metal back that I have both beautiful bone graft and a late 40s guy, and our fellows were running the research clinic for the kind of mid to long-term follow-up of these metal back glenoid things, and I get a text message with this head just sitting way out the back. But the guy's doing amazing, and now I have to call him back and say, hey, you know, we should probably do something. Yeah, you know, Tony, this is a bad actor. Any way you slice it, anything, I start to get nervous these days beyond. He's only 44. You're still gonna try an anatomic, though, right? Yeah, yeah, I think I'm still gonna try an anatomic, although, I don't know. The pendulum's swinging a little bit, and if you want one operation, it's a reverse, and the reverse is gonna do better, in this case, every day and twice a Sunday. And you don't worry about this big physical guy using that reverse like that all the time? No, no, I don't. I don't limit them. They can do whatever they want. I don't love them going back to lifting, but Sam already covered that. So, you know, this is a bad actor in any way you slice it, but I would probably do stemless, total shoulder, and then probably a metal back with some either reconstruction of the glenoid posteriorly. So, I elect to do stemless. We don't have enough time to go into the length options, but obviously, this has become more popular, and I did, this is a 15 and a 25 degree augment that reversed on the assistance, the 10 and the 20, and this is the 25 degree augment, and it looks good, but he was loose out the back because he had so much bone. So, now what do you do? Reverse. This sucks. Interrupt. At the time of surgery? Yes. So, I mean, I don't know if it's hard. Yeah. So, I would suggest no, don't do that. This is obviously a shoulder that's been stretched out by the osteophytes, and so what we've learned over the years is that we can put plication stitches, and there's a couple different ways to do that. I use PDS, but I put three plication stitches in the back capsule, so I'll take the head off. I'll put three plication stitches in the back capsule from inferiorly to superiorly. I pass one limb of the suture through the upper edge of the subscap, so we'll pull them out the rotator interval. We'll close the subscap. We'll pull it out the rotator interval. One limb goes through the subscapularis, one limb over the top, and you tie it, and you put the arm in a neutral rotation brace for three weeks, and I can tell you, over 30 years, I've probably done that about 10 times. It was more common with second generation, and we've never had to go back and redo it immediately in that situation. If it's a patient that has a history of posterior instability, and you don't restore their glenoid version, then yeah, then you're in trouble. The key here is glenoid version, and his glenoid version was restored under 10 degrees, so it's a soft tissue problem. I've done that. He's about two to three years out and doing fine, and their soft tissue does contract and come back, so just as an option to consider instead of bailing on it and going to reverse, that's an option. I think he'll do fine for a very long time. As Sam said, will I get 10 years out of it? Yeah, I think so. I think we'll get at least 10 years out of it. You know, Tony, it's a great, you taught me that trick a very long, probably 20 plus years ago, and I pulled it out. Well, the reverse has almost eliminated that, so it's really rare. You got no options. I mean, I was kind of facetious about trading out the reverse, which obviously you're not gonna do unless it's consented, but these are the ones, I'm like, hey, if this is not balancing, as Sam pointed out, this is how you might wake up with a reverse, but I don't like doing that. It's really not good for the patient, and the other thing is internal brace concepts are becoming more and more ubiquitous for the soft tissue balancing, so tensioning anteriorly, tying to the implant, the soft tissue, a little bit better, the subscap, the rotator interval tissue to the capsule, and tying that actually into the implant, putting sutures under the stemless implant, et cetera. There's a bunch of other things you can augment with. Is 61 appropriate for this ICL? Is that old? Or is that a young? I'm not gonna answer that question. That's really young. Okay. Depends on your own age, right? So this is a young, active guy. Both shoulders are very stiff. It's joint replacements. He's having trouble doing it because his arms hurt so much. Does he bench press? He still does it, but he doesn't have a range of motion. He can't bring it all the way down to his chest. It just hurts too much, and so the big question here is what are you gonna do on the humeral side? Do you have to do a stem device? Sam, you showed an example on the glenoid side where you bone grafted it. What about on the humeral side? Can you get away with bone grafting this one and getting away a stemless device, or are you going to automatically go to a stem device? I mean, I tend to use a short stem prosthesis. So that's gonna go a little bit below this. Yeah, you're showing huge cyst in that proximal humeral. Yeah, yeah. On a number of occasions, I've used the inlay reverse with a hemi adapter in order to still get bony perches two or three times on a humeri that looked like that and in an effort to avoid using either a longer stem bone graft or cement. So we'll think about that, and then, Brandon, we talk a lot about version, but we don't talk, we have started to talk more about inclination. What is a good inclination for you? His cuff's intact, but his inclination is higher than what we'd like it to be in terms of normal, and Christian Gerber and others have suggested this may be putting the cuff at risk. Do we do something to correct that? I do, I usually try to correct them down to 10. So you're gonna ream that down? I ream it down. Because we don't really have augments that have a basically three-dimensional posterior and superior of that. Right, so in our reverses, you're putting in a circle so you can spin the augment wherever you'd like, but in the anatomics, we don't have that luxury and pretty much all the implants on the market, the augment sits, I mean, you can have them anterior too, but most of them sit posteriorly. They don't sit superior and inferior. So I'll ream, you're only showing, you know, correcting like six degrees or so. So I'm usually okay reaming that down. I usually correct maybe 10 degrees unless there's an issue with glenoid bone stock, but any young, healthy guy like me should do it. Tony, Frank has taught us that the problem is, I try to get this down to three to five degrees of inclination because that's the normal. On an anatomic? That's a normal anatomic inclination on the glenoid. Do you do the same on a reverse or you go to zero on reverse? I go to zero on reverse or even just a little below that. That's a different story. Two to five degrees of superior inclination is native, but the problem is Frank has shown us that if you get down to that subchondral bone, we're compromising our plastic fixation. He's got some really good work on that and finite element analysis, and the bone is just not good stock to be able to hold and support that plastic as soon as you get through the cortex. So, you know, to Brandon's point, like we don't really know what that number is. I'm trying to bring it down to anatomic, but I'm also trying just to preserve as much cortex as possible, especially as young patients. Yeah, I agree. I think that's a good principle. And so I did what Sam did on the glenoid. I took the humeral head and crunched it up as much as I could and filled it in. And obviously if the fixation didn't work, I would have converted it to a stemmed or short stemmed device in this situation. But we were able to get good fixation. Range of motion was improved. And I just want to show you here, this is him about three to four months after his surgery. He's just doing his exercises here. But you'll notice here that it looks like there's a gap up here, but this is because I did what Brandon said. I actually reamed inferiorly and I put in a 15 degree augment on him in the back. And so we have what looks like a gap, but it's actually a pretty good position for him. And he came back a year later and had his other one done. He's done pretty well with his shoulders. He was, in terms of orthopedic surgeon going back to work, he does have good support. And he said he could have gone back at two weeks, but he was being nice and he went back at four weeks after his surgery, which is a little early for subscap healing, but he had someone help him with the more strenuous things. The cyst to me with the stem cell implant, I mean, I use the same implant you use. I've never had a problem with getting fixation with that implant. Like I know we talk about the, you know, pushing on the bone, seeing if it'll, you know, if you get a little bounce test and if you just kind of thumb falls and maybe convert, but I haven't had a problem. And even in the two patients that I've put that in where I was like, gosh, the screw isn't perfect. It's not biting as hard as it usually does. They've been fine. Like there's been no issue. So I don't know that we get, we see that and we get scared. I don't know that that's a problem once you put the bone graft around it, if you try to do that. You gotta know your implant. You know, some systems are all metaphyseal bone and they may have more difficulty being fixed in that. So you've got to know your implants, but you should address it. Even if you put in a stem implant, you should feel that defect. I think that's really in the best interest. In fact, for every case where we use this device that has a hollow screw, I pack the hollow screw with bone, even if I've already packed the humerus because I think it's very important to get that bone through the small holes. It's really what I learned from Dr. Mattson 30 years ago. It's impaction grafting. It's just a different style to the implant. So here's another case. This is a 58 year old guy who's got a B2 glenoid you see up here. And we know how these wear. We've talked about it a little bit. So it could be a 48 year old person. It's fine. So this is what we have here. Sam, what are your thoughts? 25 degrees. It's bothersome, but doesn't scare you, right? You're going to still do an anatomic on this guy. Yeah, and this person I'm talking to about anatomic and reverse. I mean, if I can balance it, they get an anatomic. And if I'm not happy, then they're getting a reverse. You're likely putting an anatomic in this one. I am likely going to get an anatomic in this, yes. The posterior subluxation worries me more than sometimes the glenoid morphology. Well, that's another story, too, because we have two different ways of measuring posterior subluxation, and yet we group them all together in how we actually describe it. I mean, is it posterior subluxation with respect to the plane of the scapula? Or is it posterior subluxation with respect to the face of the glenoid? Here, there's actually very little posterior subluxation with regards to the face of the glenoid, but they're significant with regards to the scapula. So, if you love reverses, you use the scapular plane because that's a higher level of subluxation. But the truth is, we don't really know the answer yet. So, we're still learning. And this is what I wanted to bring out in terms of the glenoid. You know, restore the joint line, I think we've learned that that's more important than a lot of us were doing. We just used to ream down the high side on these things and go for it. And with a second generation stem, if you put in a bigger head, they were stable. But their functional results were not what we were able to achieve with the third generation anatomic reconstruction. So, we're trying to restore the joint line much better. And we can do that now with a number of implant options available with a augmented device. Some people have talked about limiting the correction. So, you hear about inlay glenoids and a 20 to 25 degree. Some of the proponents of that just leave it right where it's at and put an inlay glenoid and have reported good results out to three to five years. So, we'll see if that's the right answer. And some talk about a partial correction, and the other way is to put a bone graft in some of these when it's 25 degrees. And, you know, we know if you ream, this is the study that was done by our French group, it really, really makes a big difference in terms of the overall outcome if you follow these patients. So, if you want glenoid survivorship to be best, you wanna make sure you ream as little as possible and preserve as much of the peripheral bone. And this is a paper that I wrote with Pat Denard recently just to kind of give you a strategy before these cases. So, this is in this category here for this patient we have under the age of 65. Age is, you know, relative, of course, but we're gonna think about an augmented poly, but maybe a reverse, as Sam said, if there's some soft tissue problem. Bone grafting is the big question. And Matt or Sam, or you guys, Sam already mentioned, he's not gonna bone graft if he's putting in a polyglenoid. He's not gonna use a bone graft in cement, right, Sam? Correct. Tony, I don't use augments above 15 degrees. They've been associated with problems, issues, and higher failure, meaning a polyethylene augment. With that, and if I'm concerned, I'm gonna take cement out of the equation and use a metal back, meaning a screw-in convertible glenoid option. Yeah, so, you know, you could plan these. One of the nice things about preoperative planning, I have one system I'm showing you, but there's lots of other systems out there, so I don't, and each system is slightly different. Matt's published on that, and Brandon, too. So you have to, again, know your system to understand what its predictability is and what's going on in the operating room. And then you have to have a good strategy of how you deliver that plan into your operating room, whether it's with a device or whether it's with technology. But I find these things and these hard cases help me to be better and more efficient in my care. I don't have to figure things out as much in the operating room, so I really do like to plan these out. And so this is one where we did put an augment in place for this, and we thought that that would be a good option for them. And 15-degree augment, stemless device, and this is what it looked like when we were done. Corrected them down to 10, not from 25 to 10, so we were able to do probably, I think it was one or two millimeters of reaming in addition to that augment. But I think this is an acceptable final result, right, Sam? Would you agree with that? And it's centered on the glenoid, so that's good. It looks like it's centered in this direction here, so we could pick on the fact that maybe didn't get all the osteophyte in the back and stuff like that. Tony, the biggest thing there, it's not overstuffed. It's a beautiful fit. You look at both those sides. If that head sticks over the edge, especially anteriorly and or inferiorly, it's gonna cause massive soft tissue problems. It cuts into the subscap, has all other kinds of issues, the other things with the overstuffed situation. And I can just mention what you mentioned about all these planning systems. The planning system spits out one number, but we're not dealing with a one number version issue. It's 25 or 28 degrees, whatever you showed this one, at an average of one spot. So every system's kind of different, but there's a continuum of, could be five degrees of retroversion at the top and 28 at the bottom. So you have to be a little bit careful and kind of really still look at the patient. They're just spitting out one number. And so that's what the research, what we did looking at a bunch of different, and you helped me with that paper. Well, we call them guides. These are not robots. They're not just plugging in the numbers and cutting it. But I think they do help reduce the amount of questioning that can go on in the operating room on these complex cases, because you have some visual backup to what you planned preoperatively. And I think you could probably do most of this with a piece of paper, just old school, if you really wanted to. It's just easier with the computers, to be honest with you. And now that we all get, many of us get 3DCT scans for our complex cases, that also helps us out quite a bit in these cases to be prepared for the complexity. So Brandon, now are we getting a little too far? This is a 52-year-old anesthesiologist. He's had two or three prior histories of posterior inferior stabilizations and loves to play golf. And he comes in and says, Tony, I've had it. My shoulder's not unstable anymore. It just hurts all the time. Do we immediately go to reverse on this one? So I got a couple of points. So one, the age thing here. So 52 to me is like young for the world, but 52 for me is totally reasonable to talk arthroplasty. Once they break 50 for me, that's kind of a switch in my head that goes off. Like, okay, arthroplasty to me, it's pretty reasonable. Wait till you're 50 years old. No, I'm just kidding, I'm just kidding. So, but this to me is, to our point that we were just discussing before, this is gonna be a bad actor from trying to balance this with anatomic. Prior stabilization surgery, pretty large osteophyte inferiorly, ton of posterior subluxation. I honestly would, and we'll see what the CT looks like. To me, this is a reverse. This isn't even a discussion. So I planned both anatomic and reverse. And this is interesting, Sam. I'm sure you have this in your patient population and Matt does too. The patient says, I've read the literature. I don't want a reverse. I'm way too active for a reverse. And you say, well, listen, reverse so you can play golf. No, I don't want a reverse. I want an anatomic. So what do you say in that environment? I would say, when you get on an airplane, do you tell the pilot how to fly? How well does that work for you in New York? That works great. They walk right down the hallway. Isn't there someone else in HSS to see? I don't want them as a patient. No, at the end of the day, I mean, I think that there are discussions where there can be shared decision making, but ultimately we are all responsible for making what we believe to be the best decision. And I think looking at least just what we saw here with the magnitude of subluxation, the inferior osteophyte, when you take the capsule down, that's gonna add to the redundancy of the posterior capsule, all of this. I can't do an anatomic with this. Tony, I started using the word non-negotiable more and more and it just simplified my life. You know, happy to say it, here's what you got. I'm a great negotiator with my patients, but I was like, listen, sorry, this is just non-negotiable for me. This is my solution for you. Yeah, so with him, I was at 30. I was able to get him down to 10 with a 25 degree augment and inclination from 15 to five and the implant looked like this. So there's that anterior spur. It looked good on the vertical inclination wise. And again, I went over with him and I guess I stayed with the shared decision making process but I said that we've got a lot to correct here. I'm just not sure that that's the right answer. We have good results with metal as opposed to poly, at least in the European literature, not in Australia, but in the European literature. And we were able to correct him a little bit better, especially his inclination. And we can add a bone graft where we don't have to cement. I think the old fashioned way of taking this graft and putting it in there and then cementing it in a polyethylene is done extremely rarely around the world at this time. There was some early literature that suggested that this worked pretty well, but nobody else has been able to reproduce these results. Most of them are more along this line here within three to five years. So nobody is putting in a bone graft, fixing it and then cementing in a poly. There are devices available to be more precise with making the bone graft if you like. You can actually ream that area and prepare it. And when you go in, you basically, before you cut the humeral head off, you surface it, resurface it as if you're gonna put a glenoid on top of that. You do this for reverse, but you can do this also for an anatomic if you're using a metal-backed device. Then you can core this out with the coring devices that are available. And you can put a bone graft on there. You can prepare your glenoid the same way. So the technology for doing these things has advanced a lot. I'm not saying that this is the best answer. You've already heard the opposition to doing this, but I'm saying if you're gonna do these things, you probably should do this as precisely and as well as possible to give your patient a good chance to get at least 10 years out of these things if that's gonna work. And there are tools to do that and prepare this. And so he got a metal-backed glenoid that got him down to seven degrees of retroversion and zero degrees of inclination. And his results are great for early follow-up, but we'll see what it is at five to 10 years. And this is a person who's, this is the decision that we made in terms of taking care of that shoulder. The other thing I would note on that, so you had some metal anchors in the glenoid still? Yeah. So occasionally when you're placing your guide pin, things like that, those can kick you into a funny direction. So just be mindful of that when you're reaming and stuff. Because I've had a couple where they've been in, and as I've drilled my post hole, sometimes if you're not paying attention, it can kick your reamer a little bit. So just be mindful that they're there. So we need to wrap up because Sam is moderating the first session. I just wanted to also cause caution here. Here's a lady that also had the same procedure done. Glenoid version was recorrected. She had a posterior instability problem when she was younger, like 15, 20 years ago. So we corrected her version to under five degrees. She did great for three months. And she came back at six months, saying I was just lifting up my arm, and something happened. And she dislocated out the back. And so that was extremely disappointing. And really, the version had been corrected. So it's a soft tissue problem. She had it since she was a child. And this is what we have here on these metal subtraction CT scans to really understand and measure. Could we put the glenoid in a better spot? And basically, what we ended up doing for her is a converting it to a reverse. This is what we should have done in the first place. So any closing thoughts from the three of you so we get Sam off to the general session? You know, the other thing, the subscap doesn't take a joke. Many of these patients, even that one you probably showed, the ankle anchors had prior subscap open procedures, open Latter-Jay, open whatever, Bank Arts. The rotator cuff is a huge decision factor as well. And I know you had some of that in there, but it's not just about the version inclination. Yep, Sam? No, I learn a lot from you guys every time we get a chance to do this. So no, very, very complex topic, and a lot of different options. But any and all of the decisions that you make in these people, they're gonna have a huge impact on where they are five, 10, 20 years down the road. Brennan? I would say if you're gonna choose the arthroplasty option, a well-done anatomic still will outperform a well-done reverse. We've seen that in the literature. That being said, I think if you need a reverse, you put a reverse in. Yeah, and the last thing I would say is that I hope that I hear less and less from my patient sitting across from me who's told that I'm too young at 40, 42, and they said, wait until you're 50s to have a shoulder replacement. When they're miserable and they can't work, they can't sleep at night, that's not an acceptable answer. We have a very good answer for these people, and maybe the arthroplasty won't last them the rest of their life, but don't suggest that they should succumb to a decade of misery because we want our implants to last longer. Our job is to figure out the right answer so they will last longer and do these procedures better. As Sam said, we've done a lot of things over the last 10 years to try to make that happen. So we have good tools to take care of our patients, so we want to make sure to listen carefully and do that. So thanks everyone for your contribution, appreciate it. Thank you.
Video Summary
The video content is a discussion on the management of shoulder arthritis in young patients. The speakers discuss various cases and treatment options, including an arthroscopic CAM procedure, shoulder arthroplasty, and reverse arthroplasty. They emphasize that shoulder arthritis in young patients is often different from osteoarthritis and may require careful evaluation and consideration of different forms of arthritis. The speakers also note the increasing incidence of shoulder arthroplasty and the challenges associated with soft tissues around the shoulder joint. They discuss the importance of preoperative planning and using tools and technology to guide surgical decisions. The video highlights the need for individualized treatment plans based on each patient's specific diagnosis and condition. The speakers also discuss post-operative care, including early motion and potential use of steroid injections or other biologic treatments. Lastly, they mention the importance of patient education and decision-making, noting that sometimes a reverse arthroplasty may be the best option despite patient preferences. No credits were mentioned in the transcript.
Asset Caption
Matthew Provencher, MD, MBA, MC USNR (Ret.); Brandon Erickson, MD; Anthony Romeo, MD; Samuel Taylor, MD
Keywords
shoulder arthritis
young patients
management
arthroscopic CAM procedure
shoulder arthroplasty
reverse arthroplasty
preoperative planning
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