Transcript Video Primary Anatomic [AP-014230A] Dr Dave Shukla presents anatomic shoulder arthroplasty to an esteemed panel on Wright’s “Tough Case Tuesday “ webinar presentation. SKU: 014230A so we're very pleased to introduce Dr Dave Shula as our special guest tonight. Doctor Shukla specializes in complex conditions of the shoulder and elbow, with emphasis on degenerative sports related and traumatic disorders of the upper extremity, with the primary focus on complex shoulder. Arthur Plasticky is orthopedic. Surgical training began at the Mayo Clinic, where he completed a surgical internship followed by a two year dedicated research fellowship on traumatic elbow injuries. Following this, he completed an orthopedic surgery residency at Mount Sinai Medical Center in New York and then returned to the Mayo Clinic for a one year fellowship and shoulder and elbow surgery. Dr. Shukla has conducted prolific research in Orthopedics and is an author of over 50 publications and serves as a consultant editorial reviewer for three prominent orthopedic journals. Dr. Supola currently practices with a Newport Orthopedic Institute and Hoag Orthopedic Institute in Orange County, California Also with us tonight is our esteemed faculty panel, Dr George After Wall, Dr J. Keener and Dr Robert Tashjian, doctor at the Wall, is a professor of surgery at the University of Western Ontario. Hand in upper limb center ST Joseph Health Care Dr. After Wall is also a condition. Scientists at Los and Health Research Institute Program of Advanced Surgical Technologies. Dr. Keener is a professor and chief of orthopedics and fellowship director for the shoulder and elbow service at Washington University Department of Orthopedic Surgery in ST Louis, Missouri. Dr. Tagine is a professor of orthopedics vice chairman for research that is equal, or a donkey and junior presidential endowed professor at the University of Utah School of Medicine in Salt Lake City, Utah. In addition to their busy practices of these three leaders and shoulder our capacity have joined together to create the Advanced Shoulder Society meeting, also known as ASAP, with a mission to be the ultimate international shoulder. Arthur Plastic course. Educating surgeons on all aspects of Shoulder Arthur Classy from the simple to the most complex. And finally, we extremely honored to have a special guest Panelists with us tonight. I would like to turn it over to the panel for the introduction of Dr William Levine. Great. Thanks, Tim. I'll get started. So how we're gonna set up the format is that we're gonna have Dr. Shukla is going to present some tough cases and then we have the panel are gonna go through them and then each year, each week Sorry. We're gonna have a really special guest on the special. Guest is gonna be a thought leader in shoulder surgery. Someone that we, uh, respect someone. That was opinion we value. And today we're really, really special for the inaugural event. We have actually the top shoulder doc in the U. S. A. We have the president, the SCS. We have Dr Bill Levin. So, Bill, thank you so much for joining us on this, uh, inaugural tough case Tuesday. Thanks, guys. It's fun to be here, so I thought I'd just talk a little bit about the genesis of this idea. And really, a lot of credit goes to the medical education team. Tim Avery, actually, uh, don for putting this all together. But really, I think Jake here it was Jay's idea. Probably about a month or two ago. Thio do something for the summer and he chatted with Bob and I, and as we always do, we always do things together. And James the great idea. So J thanks for a great idea. And on that note, I think we're gonna hand it over to Dr Shukla and use your All right, let's get let's get some tough cases going. All right? So she should share my screen. Or you, uh, controlling that? You can go ahead and sure yours. All right. Perfect. So, uh, I really appreciate the introduction. It's a huge honor to be able to present in front of such esteemed group of surgeons thes air, all surgeons. You know, we look up Thio students and learned a lot from have shaped our thinking and how we do things right now. Um, so that will just jump in. Um, first case is a 64 year old males left hand dominant. Um, he's been having professor pain and impairment. Um, he has undergone multiple joint joint sparing procedures by outside sports group. Probably 11. Um, I think none of them did anything. Um, and he's like one of those biker very muscular, um, martial artist boxer, you know, extremely active. And so when he comes in complaining of pain, that's at the end. It z pretty serious. One of the prior procedures included a opened dermal Allah grafting of Illinois that was eventually kind of eroded away. He's had injections of every type is you could see he had four elevation of 90 degrees and extra rotation, too. 10 degrees with scapular motion. Beyond that, uh, definitely no gliding of the ball on the socket. Here, you can see his X ray. Um, there's, you know, hypertrophic osteo five production. Uh, it's kind of strange here because it does not seem to be superior migration and almost looks like there's in fear migration, which not really used to seeing. But you can almost just barely see the line here. Extra Austin fights very sharp, aggressive spur on top. More information, I think, will be clean from the C T scans. Usually the actual views, um, more prominent in the back. I would we will see the value soon, but I would say he's He's very, very a posterior early. Um, sub looks pretty much probably over 80 90. Re subject stated. Um, because retro version um, waas called his 10 degrees measures 10 degrees. Um um inclination was eight degrees on the superior officers post. Your civilization was 67%. Again, I don't necessarily agree with that. I think it's much higher than that. Well, how about we coming to chat about those extras were pretty interesting. No, I don't know. Uh, a Bob. What do you think? Like you go back a couple of slides. Just looking at the A p. Or how about how about you go back to the history? All right? Oh, yeah. So 64 he's, um you know, totally. You know, he's not super young, but obviously, from an activity standpoint, he clearly is not 64 going on 84. So, you know, I think that considered I would consider this person a young person in the grand scheme of treating him on do things, I guess that I think about he's had multiple surgeries, and that obviously makes me a little bit worried about infection. Especially with having, um, kind of progressive erosion, worsening of symptoms. So that would be in the back of my mind. Um, a potentially, um, least making sure that after any of his surgeries, he doesn't have wound healing problems. Andi even might potentially getting a said rate CRP on bond. Um, uh, and an aspiration. Potentially even in someone with this many surgeries. And Bob Bob Thio out onto that, he had a dead piece of skin put into his short, and then Dave, can you share with us? When was his most recent injection relative to you seeing him? Do you recall? Yeah, it waas about a year before he came to see me. Okay, Three other thing that might be relevant here, Dave, is if the open dermal Allah graft was done with the sub's cap take down, that's gonna influence. Obviously your concern about the subs, cap integrity and health If you're considering an an atomic replacement and this guy, which I'm probably leaning towards just because of this activity level eso again a lot of different features Thio consider just from the history alone. Did you did you do any type of infection work up on him? We did a full work up with two cultures. Also intra operatively on. They were held for 21 days. Um, he had a head rate, um, and, uh, CRP, which was the normal limits. Normal white blood cell count. And it was unfortunate because exactly what you said, they had to have gone through the subject of artists and prepared it. But his del toward was so large that I think it was overcompensating for any deficiency he had. And I really didn't know the extent of how afraid his rotator cuff was until I was inside his shoulder. Okay, Another. Another thing that considering a guy like this is that many patients in this category sometimes, especially with this history, they can be on, you know, hormonal replacements. So testosterone. And it's something that I have become very alert to of in the history. Um, the guys up, a University of Washington, Jason and Dr Mattson just recently published a paper that looked at factors that were associated with positive cultures at the time of revision and and testosterone supplementation came back as a significant finding. And so it's just something to think about that maybe it might, uh, kind of, uh, boosting those. You know, hair follicles, thio be worrisome that you might actually be entering a P acne situation. So it's just another another thing to think about. Bob, you have to have hair to give your hair follicles boosted just just throwing that out there, Dave. And I know what that's like, but you don't know the rest of my body. That's a low blow. Hey, that this is a this is a G rated webinar eyes one of the one of the thing. I just wanna say Dave to the young surgeons who might be watching tonight. And you know, my partner, Chris Ahmad gets our fellows and residents and all the faculty to start doing mental rehearsal about cases before you're in the case and to think about what the problems were going to be before you're there. So one of those things is that this guy is 65 and he's muscular, and he has 67% give or take. You want to same or post your subluxation, so you should be thinking already about that big, huge deltoid. You should be thinking about how I'm going to get paralysis and get my exposure to do a Glenwood, whether it's an atomic or or reverse way ahead of time. If you happen to be in a place like Colombia, where we do 95% regional Onley anesthesia, this is not the one that I want regional only anesthesia. I want general, I want to be able to paralyze the the shoulder, and I want to be able to subluxation and get exposure to the Glenwood so just a couple of thoughts and you're preoperative planning, forgetting about all the cool three D print a three D software we're gonna look at. But there's some other fundamental principles of surgery that will help get you or keep you out of trouble. Hopefully, do you use paralysis on the majority of your case is what you say, because I don't think I've ever used it. I don't I don't. In fact, I do about 90% of my our shoulder Arthur Plastics with a regional only. But this is the case where I will, you know, pre op debriefing with the anesthesiologist. I'll say, This guy's getting general, I'm gonna want you to paralyze him Most likely if I'm having any issue with exposure, Do you think that's protective against a break? You'll e o anecdotally ideo. I can't prove that scientifically, but it's certainly something that I'm worried about, and I see enough break your plex aapa thes referred and I've had to in my own practice in 21 years, and I don't ever want to see number three. Let me just tell you. Oh, I think this guy is still working out. Does this guy lift weights and workout. He is. He's willing to tone it down a bit, but not completely. That means he will not, David. All right. Anything else that we should talk about the history of to remove on? Uh, no, I would have one question is, you know, at what point would you considered just doing Ah, partial replacement If most of the deformities on the human side George departed from here? Well, I mean, let's go through the images, but certainly for me. Uh, the only thing I mean a little bit older at 64 But I've had a fair number of patients that I have about, I think what 10 or 11 professional body builders that I've done Henry are for classes, and they're the happiest patients. They just need to get their pain down so they could lift. Uh, this guy is gonna lift. And if he's 6465 and he's lifting, he's lifting two or three plates. He's not. He's not. He's not lifting £10 weights, right? He's putting a law. If he's bulky and his outsize, he's lifting a lot. So that's something to consider. Actually, I involved them in the discussion I talked to about Henry Arthur Plasticky Total shoulder after plasticky Reverse. I explain to them. I give them given the Ortho website. Asked me Look through it and we kind of come to a decision. Is a group okay? Okay. Mhm. Uh, move on. Thio What was done? Well, let's just look at your X rays for a sec because his X rays were pretty unique. He's got that. If you look right there on the image on the left, that AP scapular view, I must admit, when I see that I've seen that several times. That usually gets me a little nervous, Especially if there's in fear. Capsule redundancy. Things were hanging a little bit low. Um, I'm a little bit nervous if in older patients, I consider doing a reverse on patients that have this kind of in fear subluxation. But I can't really explain it and for him because he's got that. That's one more tick for me that's gonna lead me towards Henny versus an atomic total. Because if I put a total in and he still sags, I'm worried about listening. I was gonna That's just I mean, there's no paper published on this? I don't think. But it worries me. I have seen a couple of cases. I think George has a relevant point, especially if there's Ah history of a prior interposition on the Illinois. I've seen meniscal back when we did Henry Arthur classes with meniscal Allah graphs. If the graft, uh, loses its fixation and becomes displaced and wedged in the joint, it can cause mechanical symptoms and occasionally, some resting subluxation. I'm not sure how long ago the Dermagraft was, but sometimes you see those graphs just kind of balled up and sitting in the poster superior quadrant of the Glen oId. And it's kind of it's like having a rock in your shoe. Um, it just doesn't make for a very symmetric joint space narrowing. Um, is this Ah, a modified actually review, Dave, or it's just a poor view on a stiff shoulder. It's just a terrible actually view that they got in our office, and I don't know what it was supposed to be, but it was not great. I apologize. It was the best that I could get on him. Eso Dave. One of the fundamental questions is that our audience needs to know is kind of Are you selective about who you get C t scans on? If you're thinking about preoperative planning for an atomic or you do it selectively. If you had a great Axler of you here and the head was centered, for example, would you still get a CT scan? E gonna see these kind of every patient regardless. Bob. George, do you agree? I do. Dr. Levin? Yes, we dio we dio Hey, George. Uh, James Gregory is asking What about an inlaid Glenwood versus an on Lake Glenwood? Because builder E I mean, uh, I have not done in lays for bodybuilders just because But I have done for type Siegel annoyed. Um, surely that being indication, I would just be worried that it's such a small button that it may experience a lot of load, But because does anybody have experienced James, if you haven't experience, just, uh, type it in on the questions, we'll forward it onto the audience. I personally don't have experience within Like I have some experience. I think Bob probably has some Aziz. Well, I typically use it for heads that air well centered. I worry. I think there's theoretical and maybe some minor early empirical clinical data that shows better survivorship with the inlaid Glenn oId, certainly less rocking horse stress, etcetera. But if there's a significant subluxation in, in my opinion, I would like to cover the whole surface area of the Glenroy so I could get contact of my head against. I don't want any edge loading on the on my inlay. So I think in lays are you know, they're like everybody has people that use them. They all have differing indications. I know people that use in late for almost all an atomic Arthur plastics now, and they have not had concerns about EJ loading or instability. I use them for type sees and A ones, or start eight TEUs with the Glenwood vaults very shallow. And I want fixation because the pegs air shorter and you get a lot of rim fit fixation with the endless. Uh, but I would worry a little bit about so that's just the same concerns you had George about EJ loading and being able to control subluxation within in Les, but I think it's controversial, James answered. He said he's done some with positive results in a bodybuilder, but Ah, like not enough for a serious but had some good experience with it. Well, guys, this is called tough case Tuesday for a reason. So David's a great It's a great opening case because, you know, you have all these kind of either ors like you've got the inferior subluxation. So you're worried about what's going on there. You have the terrible pain and 11 failed surgeries. And that's what makes me so angst ridden George about doing a Hemi. Because if he still has pain after Operation 12 and you violated the subs cap or done something else, you're really hosing him. So it's a It's a tough situation and, you know, my bias is obviously that I know he's a bodybuilder, but I'd rather that we did an operation that's going to be the best for pain relief, and I think that would be in an atomic in this case, although you may have to change that plan, Inter operatively dependent upon the interrupt findings of your subs, capping your poster superior cuff. I think one thing soon as I get a guy over 6 ft tall or anybody over 6 ft tall actually measure the humor human head. Uh, I've been burned before where I've operate on a few basketball players and they have 58 59 millimeter human heads and no company makes anything that big. So something to consider him. If this guy's really 665 and he might have a 56. 58 millimeters in Berlin. So David, let's move on to the C T scan. So hey, George, while he's doing that e mean so for me, open prior approach equals Mariah's Well, because I wanna look to see if that subs Cap is completely filled with fat. And if he has ah, you know, fatty degenerative rotator cuff, Then I'm thinking of alternatives. Besides doing an atomic, I think with the physical exam of this patient with 90 degrees of Ford elevation 10 of external rotation, he's extremely stiff. I don't think there's any way that you can clinically evaluate his sub scapula rece on physical examination. Typically that usually the belly press. This is not usable, and he can't even get his hand behind his back to be able to look for a lift off. And so do you think there's any value in that to be able Thio. Look at the sub scat beforehand so that you know what what you want to do, Andi. Only other question. The point was, for me, for a Hemi. The only way that I would do it is if he was coming begging for a Hemi, because I think that the patient's expectations with regards to what they want hell, if he wants to go seek out a Hemi, that's the guy that's actually probably going to do well with the heavy Arthur blasting this. Agree? Agree completely. What do you think? What do you guys think about what you guys think about the new literature coming out? That the least seating where Henry Arthur Pass. It seems we have forming total shoulder of plastic patients under 50. I guess my interpretation of Lien Els data was not that that there was no statistically significant difference with regards to failure rates in terms of revision, even though that there was a difference with regards the survivorship by percentage that when they did the statistics, there was no different, and there was clear superiority with regards to pain relief and function in patients that are in an atomic total shoulder So I think to me my understanding of Paschal or that data was it's actually consistent with what we know from the Mayo Clinic, which is that total shoulder partner plastic outperforms hemming Arthur plasticky and then, at least from a statistical significance, there's no difference in terms of survivorship e. I think, uh, the paper when I read was that the niece presented to show that there was a higher revision rate with the Hemi than with started with the totals. And with him he's painfully for certainly better with the total's. But so that's why they're actually transitioning into pension, recommending him me for a younger, active patients now, but something to think about. So, um, do you think about memory? So for me, I think I start with a C T scan of the C T scan shows no fat infiltration. I don't go to the memory. Yeah, the other. The other clue here is you know, you can glean something from the subs cap muscle belly on the C T scan and the fact that the very fact that he's his tight easy is with external rotation kind of tells you indirectly that you know not only the interior capsule type of the subs caps probably intact. It's just not very functional. Um, so So, Dave, I noticed. Can you move to the next slide? Did you do you still manually measure to the images, or do you rely here? You've noticed you've kind of measured it yourself. Are are you? Is that for just kind of educational purposes, or do you rely on the blueprint? Um, do you trust the three D automated numbers? Um, no. And actually, you know, when we were with when I was in my fellowship way, published the papers showing that there were significant differences in all three parameters between two D and three D measurements. Now, who knows which ones, right? Or if it's something in the middle. But I do all of mine to d andi. I don't. I sometimes will rely on the the blueprint provided measurements. Interesting. Okay, so, yeah, that we could probably spend 20 minutes discussing that There's, uh there's There's a lot of arguments, I think, towards moving towards three D imaging. At least for reliability standpoint, When you do your two D images, do you correct for the gantry? Correct the angle of the C T scan and all three planes on. Then go back and look at your actual views. Because if you don't correct that, you're gonna get inclination values that are way off and subluxation values that our office well, the the uncorrected axial slices in the mid Glenn oId on a two D images when the film's air uncorrected are actually very similar to the blueprint. But when you correct them, they're they're actually there tend to be a little bit less on the two D images that they are on blueprint. So we we've done a fair amount of work looking at that as well, so you definitely get different numbers. But I think there's something to be said about reliability and, uh, and having all kind of surgeons using somewhat similar technology to get to. So at least we're having a conversation that we're we recognize that the deformities that we're talking about are all very similar, because when you go on to the analysis and you're going uncorrected than corrected, you're speaking a different language sometimes. So, yeah. Okay. All right. Okay. Do you have any final thoughts, Dave? Do you think this is a How would you classify that? Glenn oId before you move on? And you think that's important? Yeah. So this was a little bit of difficult one. Um, I would call this probably a, uh, e. I don't see any bike on cavity. I mean, essentially eroded. Um, she's probably a A to Okay, what would you call it? J degrees? I'd call that a B three to me. I think that the, um it doesn't have quite as much deformities you typically see on the B three. That's close. You've published on That's closer to 15 degrees retro version in about 70% subluxation. But here you see Central and posterior aware Onda, um, I think that he's media lies the fair amount as well. Eh? So I wouldn't be surprised if this looked a little B two ish earlier, and it's now kind of centralized again to a B three, but I think a lot of people would call this an eight to, um, three other thing that the other clue is the density of the sub contra bones. Sometimes on a beat three is very dense in the central and post your aspect. I don't know what do you call it George? I must have you. Should I wait for the blueprint? Typically, I looked at the parameters here, but for patients that have had Prior Glenn, I'd work. I tend not to classify them. So he I would assume that he had some sort of reaming done or something to put the the Allah graft on. So e would probably wanna look at his X rays Before he had that procedure done, I suspected I'd like, kind of like a Riemann run. And then they put the patch on. Yeah, I'm looking at this. Uh, I mean, I would probably call it if it's truly if you're retro. Version was less than 10 degrees for me. This isn't a one. I think he's pretty. Well, medial ized eso you'd say a one versus 22. I have tow s. So I have to look at the base of the core coid so basic or could help you decide on also the enjoying the line. You know, if you draw the line from the front to the back, the head is going medial to the blue line so that it would classify the definition of a to here you go? Yeah. So here you go, Dave. Three experts quote unquote unquote experts arguing about the Glenwood Morphology. What is our guest Professors say, Well, I wouldn't call it in a one that, that's for sure. E called it a day to I just after the definition of the blue line there. Yeah. Yeah. I mean, you know, it doesn't It doesn't need the classic criteria for a B three. So J J is trying to push it into a B three because he knows it doesn't really look like in a two and feel and smell like in a to, um so. But by strict criteria, I would call it in A to It's not primary. So it's not a primary type of pattern because you had a prior surgery, so it's hard to classify. Okay, So what's your plan? What's your plan, Dave? At this point. So he needs a surgery. This is your deformity. You know what his motion is? His infection workups negative. What do you think? Yeah, so you know, generally, what I'm thinking is that he is probably going to do something to wear this out. Preferably not catastrophically. Um, in the next five or 10 years, and I had a very frank discussion with him about that. And I said that. You know, if you do that with the reverse stroller replacement in place than it's a much more challenging, uh, revision versus if you do within an atomic Children replacement, then as far as the Hemi side, I didn't consider the Hemi side because as we talked about other, he did have work done on that. And I mean, if there's I think if someone is going to go under anesthesia, I'd like to do my best to leaving the pain free as possible. So, you know, I've heard in the path, you know, people say, Well, we could do America classy, but you will have 30% paying left, 20% paying left, But most of it will go away. And so again, you know things can ball up. And that wouldn't be acceptable to me. So I I had a feeling the rotator cuff was gonna be very damaged runs in there. He was very strong, though, on DSO I was planning on an atomic and I had a frank discussion with the patient about what would he be very, very disappointed in life. If he was back on the operating room table in five years with superior instability, failed rotator cuff rocking north annoyed and way needed to convert or revise completely to reverse. And he said, That's fine. You know, at this point in my life, I'd like to continue much possible as close to possible activities undoing. Okay, right. Let's see it. So So here is his a couple of different views of his Glenn oId. Um, I was, like, a look from the bottom up. Also, Um, show me a profile view. I'm looking, uh, you know, with the on the right side, you can see the glen on the polyethylene where I'm going to perforate, if at all. Or if I'm going to get engaged with that central quarter lock into the cortical bone. Um, can you talk just for a second? Maybe defines some of your goals for a Glenn White placement. What are some of the common, um, placements and angles you're looking for? How much? Seating Wendy's. And augment etcetera. Sure, we're trying to get it back toe. It's close to neutral. It's possible. You know, I think most people are and I myself am a swell willing to accept, you know, 10 degrees or less off retro version. Um, if they are, if they have some superior inclination, then I will try to correct that or leave. Ah, little extra bone on top. Um and, uh, it you know, the biggest. I think going back toe Dr Walsh with paper, which is the landmark article. You know, we worry about post your subluxation poster instability with these types of cases. Now, on the right side, you can see in the top two D c t scan. Here is all of this this osteo fight in Austria athletic bone has made all of this Patch Chua's. And so that's where you worry. Well, there's a little piece of plastic going to keep him from sliding out the back. And so these are the generations Bill. Dr. Levin, what do your your goals for Glenn oId placement and when would you? What level deformity would you consider an augment, for example? Um, 10 degrees of retro version, Pre op, eight degrees of superior inclination. Yeah, I I think that the general rule of thumb is, you know, you're you're looking for 90 90% plus of Glen oId seeding. Um, in most of finite element analysis and other studies, that seems to be a good rule of thumb. If you can't achieve that and it's less than that or you have significant, uh, Glenn oId retro version or Glenn oId erosion 15 degrees and beyond, then that's when I'm starting to think about using the augments. I think the augments have completely changed our playing field, Uh, in consideration of an atomic versus reverse. Remember, in Jill's original paper, you know his his concept before these augments was that if you had any significant B two that equal failure and therefore do a reverse. And now obviously we've we've thought a lot differently about these cases and having post your augmented options. None of us have 10 year follow up, and that's the problem. We'd like to have that, but I can show you one after the other after the other of post eerily subluxation humor I that I could not center prior to augment ycl N'Doye aids, and now they're centered two years, three years and the longest one I about now. I think it's five years that I've been using some systems post your augment Glenn Lloyds. So it definitely has changed the five year follow up. And that's what Dave just said he told this patient about Will it change the 10 year follow up? We just don't know. Alright. So, Dave, how are you going to execute this plan? You've done some planning here. Are you kind of an eyeball s? So I kind of know what my deformity is. I know where I wanna put my guide pin. Um uh, kind of surgeon, Or do you use P s I r What level of deformity? This is a pretty minor deformity. I assume you did this freehand. Yeah, I used p s I once just to try it two years ago, and I've been really use it again. I use landmarks, um, that I see in blueprint and try to dial my where my guide pin will go based off of that, um, and also, when I'm placing my guide pin with a very deft touch, that's and sometimes guys you into the exact right position and bounce off tortoises and put you where you wanna be on you confirm that then, with, um, you know, you're measuring guide or something else I don't ever take X rays on drop. Furtively I haven't found have been very helpful for me. Yeah, Okay. I really changed. Well, this I don't know if I want to. You know, this this is more of a It's a concept for reverse. What's completely changed? My, um, thinking on reverse and my outcomes have been very generous use of the scapular central line. But anyway, um, once you show what you did here in this case Mhm So, George, how do you get How you gonna manage the subs cap in a guy with 10 degrees of external rotation? Does that change anything for you? I mean, I'm appeal. I like to peel it off. We've done a couple of studies on it for me. That's the preferred way. It gives me a lot of versatility when you peel off, you commie realize it. You lot of lies to move it up to move it down. So e don't think it changed my life. So, Bob, your urine lto guys, surgeons similar toe. I am. Do you Are there any thresholds for rotational loss where you change your subs? Cap management? No, none 100% ost IATA me. I think what's most important in this guy as if his sub scapula rece fails. If that happens, he has a failed Arthur plastic. This isn't someone who'd be able to tolerate any lack of healing of this sub scapular Aris. And so in my mind it's you create the strongest construct that you possibly can and at least in my hands, not everyone's hands, not George's hands that they lost iata me with a repairs is what I would do. So now I I have not found that I've done anything different with regards to a plus, getting back to the initial history and physical exam like what Bill had mentioned. This is gonna be tough exposure and probably your boss, the Autumn E is going to actually improve. As Bill shown in their research, you're annoyed exposure to be able to do the work that you need to do. So I think the benefit is not only with post op healing and, uh, you know, uh, in a guy that's gonna be dis active with the shoulder, but also during the surgery or Glenwood exposure is gonna be easier with announced IATA me you're not going to just to be clear, Yeah, but there's no difference in outcomes, its anatomy Brosque autonomy. So, George, I will also say that there's no difference in outcomes in your prospective randomized studies. That's true. If you look at look at stem list to, it looks like 180 stem lists and there was no difference. Come on, that was a multi center. Also. Yeah, one of the things to keep in mind. You know, I'm a L T eo advocate, and there's a couple advantages that Bob mentioned. You know, George's right, if you do whatever you do but do it well and protect it afterwards, that's the bottom line, because there's probably is no clinical difference. But theglobe wide exposure is definitely easier now if I'm going to do a seamless implant. My lt I was not that big. I would not have done a seamless implant in the 64 year old because my hospital would smack my hands and say, Why are you putting expensive implants people over 60? But I have regulations have to fall by. But the Glenwood exposure is better and most importantly, that six week post op X ray. When I see that lto healed to them, attack ASUs. I don't have. I know that it's healed. I don't have to worry so much about sending them the therapy, letting them go a little bit harder. When I was doing peels in the beginning of my career, I kind of didn't know if I had a sub Scott problem or not. And the truth is, the physical exam for the subs cap after a So most an Atomic replacements has a lot of false positive findings because of the limitations of motion afterwards. So you think you take home message is is that you could do whatever you wish so and I mean, I've done a lot of I've done hundreds of osteo to me is the one thing I'll say is that when I've done an osteo to me on a on older woman, I've actually been Mawr concerned about fracturing when I'm putting my FA kudos in the back and their attraction back is the bones osteo pedic. But I think there's pros and cons to all three of them. I think a large number of Sergio you're trying to have the last word you said. You said you said have the last word today. And then you said. But when you see But everything before that doesn't count. So so none of the other literature regarding lto matters your just your study. I get it. E would like to point out that there is another prospective randomized trial that doctor Dr Atwell often quotes on. We likewise showed absolutely no difference. Comes up to Dr Levin. All right, he gets the last word. So what, Dave, how's this patient doing? Are you happy with the X rays? And how is he doing? He's doing very, very well. He has about 160 years Ford Elevation. I think some of that limitation is due to his bulk. Um, he has been media by 160 is perfect. What do you mean limitation? It's he get better than 100 60 and 6 ft five bodybuilder. Yeah, Pretty happy. Pretty happy for sure. All right. We've done one case in 45 minutes. Okay, Next case you go moving. Okay. Number two, um, let's go to case too. Yeah. 71 year old female, right hand dominant. She has. Ah. Also authorities bilaterally left side more painful, getting progressively worse affecting sleep, which is usually the trigger that brings them in. I find, uh, prior us covered brilliance with different physician projections. Failed all that pretty limited mobility through Tereza elevation, 20 reason rotation thes air X rays. Um, she is probably could she could have probably gotten mawr motion. Uh, she is on lots of, um, mood stabilizers, if you will. So, you know, a little pain is a lot of pain on she's exam. I think maybe not be as representative of her architectural deformities as as an ordinary would be. This is our X ray, and I'm saying your CT scan, she's t scans here, starting to get on the left. You can see starting to get some b two, just barely. Um, it's measured at 10 degrees of retro version. Um, what word me more? Here was she's very poster released supplication as well per retro version on a software we use a 17 degrees, um, inclinations. 80 degrees and subluxation was 80 degrees. So the biggest biggest concern over was post tree instability again. So, Dave, what do you What do you think about doing an an atomic replacement? in an arthritic shoulder with 30 degrees of elevation motion eyes that Are you attributing that to her exaggerated pain reaction? Or do you think she's really that stiff? I think she I think she waas. I don't think she doesn't look like E. Think she's just tryingto exaggerate her her disability, if you will. Okay, yeah. How do you think our shooter cough waas And so that my only sometimes in these patients that are really painful you could have patients that come in with us to arthritis. And actually, their pain has nothing to do with their arthritis. It's actually there, cuff that bothers them and that you examine the rotator cuff. The rotator cuff is painful on bond. It has nothing really to do with the presence that they do have arthritis, that they may have had yours on. Bond was their cuff strong and not painful. Chuck was strong. Uh, how do you guys do that? I mean, I have a difficult time distinguishing, uh, in a patient with radiographic evidence of osteoarthritis. I mean, I always hear people saying the coffee strong. I just have a difficult time being certain whether it's tough for arthritis. a zehr. Some maneuvers that use that I just usually for me direct lateral based rotator cuff related pain in someone with primary osteoarthritis is not there. Typical presentation for me at least, that if you examine their rotator cuff with, you know, abduction and low degrees of abduction 30 40 50 degrees of abduction to test their super spontaneous, even though that's not perfect test that usually in someone with primary osteoarthritis. For me they don't have lateral based arm ping. That's the same that you would see with someone with the two centimeter full thickness rotator cuff tear. That worries me if I see that, because then I'm again more likely to get an Emory or some image ing study, because I wanna look at their cuff before we get in there to do a primary total shoulder and find a two centimeter cough there. So I'm not saying it's perfect, but something bill, do you have you? Do you feel over the years that you found patients that have arthritis? That they're symptom is primarily cuff instead of the Or do you think it's hard to tease out? I think it's pretty rare to have people that You know, of course, anything's possible. But, um, you know that you guys all know that they're arthritic. Pain is usually very reproducible, I guess in the rare case where you're really what you're really saying, I think Bob, is that your you got that patient where they're having mawr? An trilateral Subba chromium type pain. Um, And in that situation, you know, this one with 30 degrees of Ford elevation. It's kind of throwing everybody for a monkey monkey. Uh, for a loop here, wrenching This. So I'm not sure. I think that's kind of artificially, uh, bothering us. Um, And if that's really really motion, that's a problem. No matter what, that's a problem. The operating on her on doing any operation, unless you're doing a reverse because you think she sued a paralytic. So I suspect this is a pain generated problem. Likely mawr arthritic than cuff. But I hear what you're saying, Bob, I think the day that it wasn't, it sounds like your spider sense wasn't tingling means that you felt that the 30 degrees just lack of effort. But I think we've all examined patients where we feel like, you know, something's not right and those patients typically what I do and I don't hesitate as Bob said, to get memory to make sure something's right Like And you're gonna know after the years of examine patients, sometimes one just doesn't fall into a keyhole. And you get your spider sense goes up and you think, you know, I think I should further investigate this patient. Yeah, And you know, this is not that patient, though. There's not that patient. You have a hand on them. You're definitely rotating them. You're not feeling excess fork reputation, you know, they're not locked, engaged, getting, you know, humor, scapular, motion to compensate for the black That's almost enclosed. So I was not this patient at all. And so I felt that she was, uh she was kept intact and she was very young. If I remember correctly, she was 71 E. J. On this. Go back to if you could go back to those numbers from your blueprint. So, Jay, what are your cutoffs that you used to be able Teoh make a decision, Obviously that we're talking about an atomic Arthur plastic, but our other primary option in the 71 year old would be doing a reverse, and so are you more likely to make a decision based on numbers? Are you more likely to be on based on age, or maybe a combination of age and numbers? But how? What's your kind of in the back pocket when your in clinic you get these numbers, How you're directing that patient and are there some cutouts that you use? Yeah, that's a good question, because I think there's a big gray area. E think George mentioned the good point when your spider sense is going off and you you need to confirm that the cuffs. Okay, I think it's valuable. Check a memory here s o. E. So if I haven't, If I have an older patient and their motion is limited, eso limited for me is less. You know less than so. It's a stiff shoulder, not not a not a week shoulder. If their motion is less than 90 degrees and they're older than 70 the next thing I think about is there deformity. If they have a retro version deformity that's in the twenties, and I know I'm gonna be doing some raining. I'm worried a little bit because they're older, the quality of the bone, the longevity of the polyethylene. My threshold is a little bit smaller to do a reverse. In those cases, I usually tell the patient that I'm going to try to do in an atomic replacement because I think that that's e think that's more likely. I'm going to get a more consistently good result with a probably a slightly lower complication rate within an atomic. Although I fully admitted that that's controversial, and I'm making Inter operative decision based on how the cuff looks at the time of surgery. So I'm evaluating the excursion of the subs gap. I'm looking at the locator super spin. It is in the crescent. After I've cut the head, I actually bring the arm into extension and put my fingers on either side and just feel how thick the super spin aids is. So if the superstitious looks good and the deformities under 25 20 to 25 degrees, I usually do you own an atomic and I'm not really had a big issue. We published a Siris of patients under 70 proven cuff intact under I'm sorry. Over 78 years, less than 90 degrees of motion proven cuff intact that were retrospectively reviewed. There was 140 Atomics and something like 60 reverses, and we found no difference in their functional outcome. But we found a higher revision rate on the an atomic. So there were a six or seven revisions out of 140 within three years because of either cut failure or one instability case. So they do happen. But in general, um, you can get a good result if the cuff looks good in the bone. Deformity is not too bad. So 20 or 25 is your cut off And Bill, by the way we published that in our journal. I know. Hey, a quick question for the esteemed faculty and I just want a quick A percentage, no long winded answers. So how many times have you told a patient that you're going to do in an atomic total shoulder Arthur plastic with the potential to do a reverse? But you're really going in doing an an atomic what percentage of patients J has that actually happened where you told them you're going to do in an atomic, but you have the reverse in your back pocket is a backup. How many? What percent do you think that's happened in your practice? Um, probably 2%. Okay, George. Sorry. So I said, I mean, reverse my pocket, You're going into your going into the art of doing an atomic. But you've told the patient, you know, if something comes up, if the cuff isn't great, if it rare where and by yeah, 1 to 2%. So my point is for the young surgeons out there, this is a pre operative decision. The majority of the time there is rarely, rarely you're going to consent the patient for both. But it's rare that you're going to actually change what your pre op plan was. Based on interrupt findings. You've just heard that from the three esteemed surgeons. It's so, Bob, what are your numbers? Quickly? Because I think we got less than five minutes. I'm 25 25 to 30 but pretty much in that 27. I still use yields. Numbers of retro version greater than 80%. Poster 80. 85% poster subluxation. I'm doing a reverse under those numbers. I'm going to do an an atomic and that 80% subluxation using Blueprint subluxation, and I'm using retro version based on blueprints. So the problem is that that's why I'd be willing to bump it up to even 85 because we know subluxation is over. Called on three D. Same thing with retro version that, you know Jill's 27 can turn into 30 on on Blueprint because we get a couple extra degrees from three D. Planet two D subluxation is 80% on volumetric three d subluxation. Using like a mathematical volumetric formula. 80% equals 90%. If you're gonna use Blueprint and apply Jill's 80% rule, you're cut off should be 90% on Blueprint, based just purely in mathematics. Comparing two D two volume the same thing with version so that the 27 degrees of retro version there's multiple studies. April published her study looking at version that shows about a three degree or four degree increase, compared from three D to two d. So I think you gotta understand, like this 17 degrees of retro version. Using Friedman's line on A to D. C. T. Skin. That's probably gonna be 13 14 degrees of retro version. So it's interesting. So that's why I actually don't use the numbers anymore. What I do is in this patient with Austria threatened to be too. I'm gonna put him into Blueprint. I'm gonna try to do a standard polyethylene reading the highest side. See what I get. I can't go to a 15 degree wedge and correct it under five degrees if I can't go 25 degree wedge. So I'm gonna actually do the surgery. I'm not doing this for you, as I'm doing internally. Rather than having the numbers ahead of time determine what I'm gonna dio. And what's your goal of version? Less than five between 05 and between minus 10 and plus 10 off, uh, superior. So you're from that theory. You're gonna put the patient into anti version because zero degrees. We know on three D from A to D. I'm just saying, you know that there's a discrepancy between two d and three d. So tell me what your thought is to put someone into zero degrees of retro version with an anatomical. It's not retro version. That would be neutral then. So yeah. So my goal is to get between three and five, right? So I think that's that's the best. Biomechanically speaking. If you look at anything, that's if you look at this, anything is round and this is the Glen oId and I put the gun away at neutral. It's going to stay. Have come cavity compression as soon as I leave it at 10 degrees and tilt. That's gonna promote poster subluxation. So based on just understanding of biomechanics, it would make sense to correct them. Okay, kicking his head. I mean, you can What's that? So go ahead, Jake. I know. I know you've published a paper on, uh, leaving them, like, partially corrected and swinging the human head, but certainly just based on biomechanical principles, if we're going to do it, I think I need to. Full correction. Yeah. I don't swing the head very often, George. And I think what I think we're biomechanical data shows. Um, there's a major change happens in the cement bone interface beyond 10 degrees. So, E, I think defining your threshold at 10 degrees, possibly up to 50 tina select cases is very reasonable. Um, the study that we published is, you know, be careful of 15 is enjoying our has already shown us that a 15 degrees of increased radio Lucent line. So it's a 15 is definitely I agree with you in 10. I wouldn't go to 15. I would then follow that up with Mattson showed that the 15th and the same thing. We should know the same. I mean now these are intermediate survivorship. This is 3.5 to 4 years survivorship. But the radio Lucent lines are Justus good as concentric Glenn noise eso. The question is, you know, Jill's been smarter than us and more prophetic than us for years. What did these shoulders look like at eight and 10 years? I think that's a valid point, but in terms of like, he's correct it to zero. He's correcting 20 All right, I'm saying that his previous data that showed that that when they were left on Lee partially corrected it was a problem. But I think we're going to see actually pretty good survivorship between, um probably up to 10 and 15 degrees of retro version. And you know, if somebody starting out at 5 to 10 degrees of retro version in their native and you're correcting into zero, I think Bob's point is valid, I mean your relative and averting them compared to what they're used to be. So I think this is a really unanswered question. We know what happens by mechanically to the shoulder beyond 10 to 15 degrees. The question is, do you really have to get to neutral? Because I hear a lot of thought leaders on the podium saying, My goal is zero degrees, and I don't think it needs to be that way. Um, how do you feel about reaming that much with exposing sub Condra bone to the point where and, you know, in Jill's long term, Siri's the biggest predictor with regards to failure of the Glen Oy had nothing to do with actually the correction have to do with so using augment. So I need an augment to correct to between zero and five, because I'm not going to read the high side to correct Take 23 million Gurbanov. Absolutely not. And the studies that you were referring to J. R. On the cement mantle, right? So there's more to do with instability, loading characteristics and eso one parameter we look cement cement mantle in an isolation. It may go up to 15 degrees. But there's other parameters. Other measurements, other metrics out there. Um so I think, as you said, I mean each person's entitled review. We have a lot of thought leaders saying you want to correct the 0 to 5 degrees you have less than people are saying less than 10 degrees yet studies that show variability of 15 degrees. The one thing we will know is as we go forward, if we know what we're putting it and we're following our patients up in 10 or 15 years, we're gonna have probably that's gonna lead us into the right direction. So what we're doing here by actually putting in the right place or whatever we feel we wanna put him is gonna lead, uh, to the answer. Hey, George. Question from the chat room. If native retro version is six degrees on average, why not have that? The goal to correction be that my my analogy for that it's similar to to be a slope at three degrees. We correct to build slope to zero, right? So it's so I wanna have a nice flat surface. So I'm not correcting 20 I'm correcting toe between zero and five So if I get to five degrees of retro version with an augmented implant, I'm gonna stop there. I don't go to zero I go to under five e Think, uh, this is a great, great thing. This is a behind the to slope a slope of three degrees. You get a correct three degrees. Do you feel like you're on a like that blind date? And you just kind of been left at the table by yourself? Way we're out of time. That was bringing it over. Hey, what do you do? What you do, e. I love hearing all this. I've hoping to show you my last case, because that's the most interesting one. But, um, your last should have been first time. Yeah, I started. You know, we're gonna be talking that much, but we did, uh, use a little bit of a wedge on. Brought it back from back to the center. Eso This looks like what you would have done. You would have probably augmented them in the back. Given that the 17 of retro version to be able to correct 17 down to five or less, I can't imagine being able to do that. just with high side reaming to be probably pretty hard to do that. Yeah, I don't high side e never. I said, Reema. I graze at the most. I'll graze the Glen oId whether Reamer, whether it be a reverse or in an atomic or I'll take a carbon or move the cartilage. But I really do think subcultural bone integrity is what's going to keep the Glen polyethylene or Glennis fear from subsiding. We're loosening. I think that's one of the big things we've learned over the last five or 10 years. What do you think of those radios? Some lines. Sorry. So what do you think of those radios? The lines? Yeah, that one. I think she so she were slink for about a week. I think eso I was not very happy about that. She's still hot. She's been completely stable. Um, clinically. But I don't like them. Certainly. And the radio government has not changed. Fortunately, I think we should probably wrap this up. I think, uh, that was actually a lot of fun. I'd like to thank Dave like to thank Bill. Um, Bill, do you have any closing comments? Uh, I think this is a great forum on bond. Uh, you know, I think the point is that, you know, I do all kidding aside, uh, to go straight to the what you did in the operating room and show the post op X rays. I hope people aren't disappointed that we didn't spend a lot of time on that. There's a lot of principles of shoulder Arthur plastic that go into the decision making to hopefully get the best outcome for your patients and eso. That's why there was so much time tonight spent on some of those other factors. And there's so many controversies. The final. My final thought is, as I say, Thio, you know, people all the time is we have so many more questions than we have answers. And despite all the incredible work done in shoulder Arthur plasticky, the next generation is gonna you guys, the Dave Shook Liz and the rest of you have lots of things that you can help teach us gray hair and no hair guys. So thanks for having me. It was a really, really honored to be your inaugural guest. Uh, guest faculty member. Thanks, guys. Published October 9, 2020 Created by
