Dr. William Paterson reviews difficult primary reverse shoulder arthroplasty amid Wright’s “Tough Case Tuesday’ webinar Presentation featuring doctor’s George Athwal, Jay Keener, and Robert Tashain.
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We're very pleased to have Dr William Paterson with us tonight. Dr. Patterson is a board certified orthopedic surgeon specialize in the treatment of common too complex shoulder disorders. Dr. Patterson earned his medical degree from Rosalind Franklin University of Medicine and Science in Chicago, Illinois, where he was a member of the Alfa Omega Alfa on our medical society. Dr. Patterson completed his residency at the world renowned Campbell Clinic in Memphis, Tennessee. He did his shoulder fellowship at the Carroll Clinic and Baylor University Medical Center, where he trained the doctor, Suman Krishnan and Wayne Burkhead. Petra Patterson is a diplomat of the American Board of Orthopedic Surgery and a member of the American Academy of Orthopedic Surgeons. Dr. Patterson currently practices with Ortho Arizona, where he specializes in shoulder disorders and told her shoulder replacement. But it's also committed to exploring nonsurgical and minimally invasive approach is in order to produce best patient outcomes. Also with us tonight as our esteemed faculty panel, Dr George as well, Dr J. Keener and Dr Robert Tagine, Dr Atthe Wall is a professor of surgery at the University of Western Ontario handed upper Limb Center in ST Joseph's Healthcare. Dr atthe Wall is also a clinician scientist at Lawson's Health Research Institute program of Advanced Surgical Technologies. Dr. Kepner 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. Tash is a professor of orthopedics vice chairman for research at Ezekiel, our donkey and junior presidential endowed professor at the University of Utah School of Medicine in Salt Lake City, Utah. And finally, we're extremely honored to have a special guest panels with us tonight, and I'd like to turn it over to Dr Tagine for that introduction. Thanks, Tim. It's our honor. Tonight, toe have Dr Jill Walsh to be, uh, the guest faculty for our Webcast tonight. He really needs no introduction to anyone in the shoulder community. He's been an international thought leader and educator for over 30 years. Um J Georgia myself have all been lucky enough to spend some time with him in his clinic and are in France, and we're lucky and honored to spend some more time with him tonight. A czar guest for this webinar Um, it's early in the morning, and Leone and we really want to thank shield for joining us. Thank you, but no problem. Build want you pull up the first case. I will do that. All right, you guys, they're seeing my screen. Wonderful. Yeah, Case one is JB. He's a 78 year old, right hand dominant male who has had right shoulder pain for several years. The interesting part about his history is about 50 years ago, he had a head injury that caused left sided partial hem Ecclesia. Um, he uses a cane, and he has very limited function of his left arm for his right shoulder. He has failed conservative treatments and has limited range of motion. As you can see in the degrees, these are the X rays that we got. So I don't know if if we want to just go on to the cat scan or, um I don't know, J Do you want to take a quick shot at the X rays? Yeah. So this patient obviously has profound arthritis, and one of the things that stands out is the medial ization of the clinic. Emerald joint. So you got a lot of Glen oId Where? So this is fairly long standing process. Um, I think on the actually review, it's hard Thio see the front and back room of the Glen oId. But I get a sense that this is centered in terms of minimal poster subluxation on bits fairly well centered on the true AP view as well. So this is in stage osteoarthritis in a older patient with severe stiffness. I would definitely get a CT scan on this shoulder. How about you, Georgia? George, would you? C t scan is a routine part of your work up for this patient. He was saying earlier that his internet is able. Maybe maybe we're experiencing that. We may have lost him. Looks looks like it a little bit. Um, um I mean, I'll tell you. Yeah, for myself, J I would definitely do a CT scan. I think, um, you know when when you have medial ization beyond the corona, you know, media greater to veracity. Medial to the chrome. Ian, I think you have thio. And, uh, I guess one other question is, is there any role for Emory in this patient and again in the U. S? A lot of times, some surgeons will get m r I only or maybe get Emery plus c t scan. But I think this is, you know, the value of knowing what the cuff is probably as minimal, minimal value that you couldn't obtain on the c. T. By looking at the relative fatty degeneration, etcetera. I think doing an an atomic replacement probably is not, you know, not an option in this person because the medial ization what do you What do you think? Yeah, I tend to agree. I think you raise some very good points. Um, he's a little older. He's very stiff. Uh, he's gonna have a fair amount of muscle atrophy with limited vaults gonna be compromised. So you worry about fixation with an atomic replacement. I think those things. The other thing is if he uses a cane in that hand weight bearing on an an atomic replacement, it has to be protected a little bit more than a reverse. I would typically allow some weight bearing on a reverse. After six weeks, eso c T scan is going to help me plan and quantify, uh, my surgical procedure. But I think just his presentation in these X rays tell me that if I'm going to do something, It's gonna be a reverse. Sorry, guys. I was having some problems on the Internet. I think I'm back now. No problem. Um, well, once you move on to the c T scan to this was obviously the actual C T image. And this was my method of measuring his retro version kind of. Ah, conventional method. Um, and yes. Obviously, I wasn't even thinking Marie. I wasn't really interested. And if he had a little rotator cuff tear or a big one or not, I was thinking reverse from the very beginning, Um, looking at those x rays. So then these air the So I got a CAT scan and obviously submitted it for blueprint. Um, so these air the blueprint, images and measurements I think one of the things is to comment on is sometimes we forget about the form ity and the other plane, and you can see there's not only a retro. There's medial ization and retro version, but you're there's a fair amount of superior wears Well, so there's there's an inclination deformity. So these air fairly dramatic numbers. Retro version of 42 degrees inclination close to 20 severe subluxation It's a little surprising that the subluxation number came up that high, but this is a biplane of deformity was severely limited bone stock. I think you're right. Inclination may be the problem, right? It's just Do you think this is a common? Uh I'm sorry, Jill, Do you often see, uh, inclination deformity this severe with Oh, a obviously cuff tear arthropod? The would produce a deformity like this. But what's your what's your experience with primary away? Yes. It's not a very typical primary away from me because off this superior inclination and also because off grade two or three fatty infiltration of the rata tah calf she passed binaries in fast binaries and subs. Cap are not so nice. As we can see on the previous slide on the two d two d slide, we can see some fatty infiltration, so it's not very typical from primary way. This stripper inclination is also a concern. Also, the human head. As you say, J human head is centered on the Cornel plan. But we can imagine that it will be difficult to correct both excessive reservation and superior inclination because off the poor bone stock under gonna it's time. So it's very, very tough. Case challenging case, I believe. Especially if as a patient as to use a can to walk to work. S o. I guess that will be very interesting. Point to discuss on the surgical strategy. Yeah, Bill, how far is he away from? Is he a very eyes? The effective cane Walker. Do you think he's gonna be going to a wheelchair sometime soon? His left sided deficits have been president for 50 years, so there was really not an indication that it was changing or worsening. Um, So I really wasn't worried about him necessarily ending up in a wheelchair anytime soon. Um, because it seemed to be quite a stable deficit. And the best part about his situation from that standpoint is he had excellent social support. He has a wife who helps take care of them and kids and grandkids. So he had plenty of people around which, maybe more comfortable, proceeding with surgery, knowing that he was gonna have good care. And it wasn't just gonna have to spend, you know, six weeks in a facility or something like that. So there is a question from the audience and the deal Direct this towards Jill. Uh, that anonymous attendee asks, what are your thoughts on accepting the inclination from the software? Uh, this is measured differently, depending on what software method you use. And the deviation, maybe in between methods may be up to 10 degrees. Just your thoughts on that. Yep. The nation is concerned. That's true. And the clear definition off inclination is angle between transverse axis of the scapula and glenn arrayed for PSA plane. We cannot see here very well the trickle, um, which is necessary to calculate the super intonation. And if you just follow the super Spinelli Vaasa, you may have 10 degrees difference if you have a correct Trigon Um um two door, the scapula trousers taxes. So I know that there may be some difference between software regarding generate inclination, and that's the reason why it's very important to know exactly what your software measure and how your software measure the super grenade Inclination s here. In this case, if you if you look the super has been addressed, Forsa it's not too bad. It seems that it's close to the rial transit success of this capital. But yes, it should be a concern for us to take into account a technique off Glen arrayed inclination measurements Don't Jill E. I mean, the other thing question would be if we're gonna do a reverse as opposed to an an atomic, that in terms of measurements, that's probably more important. Version vs inclination. Would you think that inclination is probably a more critical element in terms of correction for reverse as opposed? If we were doing an atomic, probably, maybe not. But we think retro version is probably more of an important correction. So if you're gonna air on one kind of to be cautious, would you maybe think about at least over correcting, um, inclination For if you were going to do a reverse, um, similar to it would be more concerned with retro version or under correcting retro version if we were going thio be doing in an atomic? Yes, that's very good question, Bob. That's true that with the reverse prosthesis, you can accept up to 10 degrees reservation where I asked for inclination. I really believe that we should try to avoid superior inclination with the reverse in orderto avoid early losing or nothing. So I really e focus on the inclination further reverse. And I always try to have zero degrees inclination with regard to the transit success of the scapula. All right, Bill. Uh, so, um, this is my, uh, blueprint plan. Um, you know, looking at this and especially, You know, like I said earlier, maybe I would have done something little differently. So, um, I did want to get it in zero degrees or, you know, completely correct that inclination down to zero. Um, maybe I, especially with someone who is going to be weight bearing. Maybe I would have. Now we've been done a little inferior inclination, but, um, in general, my goal with the reverse has usually been to try to get it to zero. Um, probably based on something that I heard dr will say at a previous talk. Um, so this was my plan. Um, I was planning on using a by our PSA. I did not think that using a metal argument would be able to get me the amount of, um, correction that I really wanted. And I think the okay, the next slide is already the Yes, I think some of the tricks that I use this is a pretty thick bone graft and some tricks that I used to decrease the thickness of the bone graft would be to add a little bit of retro version. I probably had maybe 10 degrees of retro version, maybe 15 probably 10. And then that'll thin the thin out the bone graft a little bit too. Like this is a perfect reconstruction. I have a question built here. I'm a little bit surprised about the perform reverse because using a perform reverse This subtle peg is not in the native bone. You just have the screw in the native Bowl. Andi. I saw here that you were using 6.5 frontal screw. So is it a concern for you for stability off the base plate? The fact that you have Well, I'll be 10 millimeter off the screw in the native bone, but nothing. No, no mini matter off the central peg. So I would be afraid about stability off the base plate if I cannot, um, put the the peg, the subtle peg in the native bone. So what are your thoughts thought for that? You say that you would probably not do that right now That does it mean that you use more peg base plate and screw base plate? Yes, sir. So my my typical by our PSA is a peg Central peg. In this case, I felt like I really wanted to use a thicker graft to give it some lateral ization and actually thought that the pig wasn't gonna be long enough. Um, plus, in the couple of cases that I have done using the perform base plate with Central Screw um, most of the time, it does achieve what I feel like is excellent fixation. And you get the graft you use. This screw screw really sucks it down and typically has a very good purchase. Um, also, I felt like with the four peripheral screws. In addition, I feel like that gives me good fixation. However, certainly I have had a couple of cases where I attempted to use the Central screw, did not have good purchase and then went to a page instead. Um, but in this case in particular, especially with the plan telling me I needed for my plan of 35 Central screw um, I felt like the standard even long pig isn't long enough for that. Do you have? Do you have any limit regarding the thickness of the bone graft? I guess. Here you have probably 2025 millimeter bone graft, posterior and superior early. So, George, say that you can put some degrees off writer version 10 degrees. With the version, this will decrease the first day of thickness of the graft. Also, the superior part of the graph is going to be also very large. But what are your limit regarding the bone graft to use for BioWare essay? Well, I don't have any particular limits. This is This is the biggest one I've ever done. Um, So again, my goal was with the plan anyway, to get, you know, kind of a home run plan and the details during surgery, for example, like if I couldn't get as thick of a graft or the bone, the graph quality wasn't very good. If I had to mess with it, then I could change my inter operative plan based on the graph. But this this was my blueprint plan for what I was thinking was kind of like the best possible kind of situation for this patient before we see what you did, Jill What are your thoughts on thickness of the bone graft? What is your limit that you choose? And what sort of fixation do you choose to make that limit or obtain that limit? Well, we don't know exactly if there are any limits. Aziz, you know Pascal below doesn't hesitate to use 2025 million matter bone graft. I know that sometimes it's necessary for the very severe case like this case. But the key question here is about stability off the base plate. Because by using this kind off huge bone graft, you can certainly reconstructs a good learning bond stock. But I worry about the stability off the base plate. I need I want to have at least 10 millimeter off the pay or central screw in the native bone. E. I did some cases when through his 20 millimeter bone graft sickness, but my limit is usually I try to keep within 13 15 minimal and often time. If it is more, I do not hesitate to do a two stage, but from a two stage reverse with the first stage being Henry reverse to make sure that the bone graft hill and then come back and load the joint with email part. So whether in this case, it's a good indication or not for primary Hemi? Uh, I would say probably not. Because of the age the patient is 78 years old on. You certainly don't want to do to stage surgery for this patient. We I would accept to take a risk for the best place stability in this patient to avoid to stage surgery. But it's challenging, and the patient must be aware that there is a risk for I a risk for Leonard losing. I think we're 20 minutes in or should let's try to finish this case of bills, show us what you did. So that's what I did. And, uh, you know, again kind of looking at this. Um, maybe I could have got a little bit more inferior inclination on the sphere. Um, but, you know, maybe I got lucky, but thankfully, I did get the big graft and good, really good purchase with that central screw and four peripheral screws. Um, and you know, again, thankfully with, uh, I think his social support really helped him so that he wasn't on his own using that arm weight bearing too soon. He really had to help at home so he could let the graft hell before I let him wait there. Which was six weeks. Well, did you consider getting a guide for this case? So in these cases of, you know, severe erosions, we're trying too correct in a two plane deformity. Um, I think we think that weaken, do a plan and then make the plan kind of and act the plan in the operating room and then getting CT scans post operatively on a lot of these bone grafts for myself. Just to see how well I did post operatively I found him. Not as good as I would think I am. And so did Did you think about it in this case? And what air? Your maybe indications to get a guide if you don't use them Always. I don't use them always. I did not use it in this case. Um, my general indication for the guide is a tough be to when I'm doing an an atomic total with, uh, poster augmented so annoyed Polity. Um, for me, it's even more difficult to do that particular case without a guide. I think the guide is very helpful. Um, for this case and in general when I'm when I'm doing Ah, by our say, my part of my thought is, um, the graft, you know, using That's why I really like using bone instead of the metal. Augmon the bone compresses a bit. Thio fit the defect. Um, And again, you know, maybe I got lucky in this one. Um, but also, the blueprint plan does help me, Uh, you know, a zoo. You guys know there's part of the blueprint that tells you the access of dreaming and that can help you get the correct access, access and position for the guide 10. So I'd use the blueprint plan to help me place the initial guide. And, um, would you would you get a guide in this case? Yes. I get this guide for every single kid because it's a up for for me, for also for the federals to understand exactly what we do to make sure that we can correct the super intonation on the reservation and also one point interesting in this case is how to define the sickness of the bone graft bill. How do you interpret actively How did you define? How did you decide the sickness of the bone graft? You shape it, you shape it. How did you shape it? My, uh my local rep helped me, um, use the blueprint to measure the thickness. Um, so I knew what I wanted And inter operatively. Um, when I was fashioning the bone graft with the whole side of the human head essentially took as much bone as I could possibly get. Um, And then place it on the back of the basically and, you know, essentially using a ranger Thio Thio make it the exact dimensions that I that we had planned on. Okay, Yeah. I mean, another trick toe. Minimize the thickness of the graft is E C. The use of 36 39 sphere. Here. You could have gone up to 42 which sometimes it could be tough to get in there. But going up a size of sphere, you get the same on a range of motion. You can actually probably minimized or take a few millimeters off your draft. Yeah, good. Should move onto Case two guys. Yeah, so, thankfully, he's doing good. Case two is pl um his right shoulder. 76 year old male, right shoulder pain. For several years, he previously had had a successful left bio Arza that I did for, uh, severe clinical. More arthritis with a significant culinary deformity for the right shoulder. Um, failing conservative treatment developing quite a bit of stiffness at this point. He wants Arthur plastic for his rage, Told her. So he had these radiographs and he came to me with memories of both of his shoulders. At the very beginning. Eso I did have a memory on this particular patient, Bob. Anything interesting on the X rays? No, I mean, he looks he's got, you know, a significant amount of loose bodies around. You know, it looks like a primary osteoarthritis picture to me. And so this is Ah, a 12 depending on where you draw your line, but probably a a one or very mild. A to Glenn oId And I would, you know, I mean, I guess the decision about to do an imaging study would be You know, what? What is physical exam is like, so if the patients got good range of motion, if his cuff is strong and not painful or decent range, then I would probably just to a C T scan and probably planning an atomic replacement. Um, he's got a reverse on the other side, which you did from erosion. Or was that for cuffed efficiency? It was for erosion. So I guess the only worry would be if you did a reverse on the other side for cuff insufficiency. We know a certain percentage of people that have cuffed efficiency on one side. They probably have some rotator cuff disease on the other side, and so I'll be my only concern. But I would plan for an an atomic replacement based on these images. If Bill houses internal rotation on his reverse side, is he happy with his interpretation of his riverside? He's happy with it. It's It's not perfect. But for example, it was at about the hip to start with, and he was able to get in his back pocket. And one of his hobbies is shooting a pistol. I mean, this is the kind of patient who comes to my clinic every time with a pistol on his hip, Um, and he was able to do that with his left. He's left handed eso he was able to do that. So that was one of his big concerns with going through shoulder Arthur Plastic is he still wants to be able to draw his pistol. Yes, so he was able to do that. His internal rotation was not perfect on the left side, but he was happy with it. Sorry, being in Canada, we don't carry pistols around, are built. So if he's left handed, does that mean he draws his pissed? Does he place his pistol on his right hip and draw it with his left hand out? Or he's keeping on his left hip and draw it with his left side? It's on his left hip. Okay, so he drives it with his dominant side from his hip. That's just thought I'd clarified. Absolutely. I believe it's a very typical primary software is in this case with severe still fights, and also it's interesting to see that there are lose body in the long head of biceps groove that would be interesting and important or not. Do not forget that, because if you leave the biceps for these kind off primary start right is it's gonna be painful afterwards. So it's a good indication to perform also at the same time, uh, long head of by substandard 10 notices. And as George pointed out, internal rotation is important and we're sometimes a little bit disappointed with the internal rotation of our patients. And I believe that one of the main advantage off total Anatomy autocracy is that you get much better internal rotation, predictably, internal rotation. And I would probably think about total anatomy. Carter pressing for this patient because of that, getting mawr internal rotation is a cuff. Looks fine. I believe it could be a discussion that I have with a patient. Bill, can you go back to what his pre op motion was? So yeah, so I guess, um that you could just like what Jill said, you could potentially get more motion through an atomic. The other thing to consider is that say that his motion was actually fairly good so that if he had 140 or 150 degrees of elevation, sometimes my concern is of doing a reverse that those patients can sometimes be unhappy that if they may actually lose some motion by doing a reverse shoulder replacement if they already have relatively normal motion, but they just have a painful arthritic shoulder. Those patients can sometimes even if they don't hurt, can sometimes not be so happy because their motion is actually less not just internal rotation but even for elevation can sometimes be be worse. I don't know if, as George, George A. Have you seen that where patients have relatively good motion and then all of a sudden you do a reverse and they might. They have no pain, but there might be less than happy. Yeah, E. In the literature would show that with patients and massive rotator cuff tears with good preserved active Ford elevation and pain, that if you do a reverse on them, they're gonna be happy. But they're not nearly satisfied is the reverse for the painful, stiff lack of motion shoulders. So I agree. And that's what that was. My question with respect to the reverse on the cultural outside, because I find my ability to sometimes regretting interpretation is sketchy. Sometimes I hit a home run, and sometimes I don't and I can't typically explain why it doesn't work that work out sometimes. So if his internal rotations poor on his control outside really pushing an atomic. But all right, let s So did you had a CT scan in this case, and he came to me with an M r. I. So I presented the Emory images. Um, you know, maybe he's got a little bit of rotator cuff, so I thought I thought a lot about this one. I did get the C t scan to kind of help me make the decision on whether or not an atomic A supposed to reverse. Um, I was a little concerned about the superior Glenn oId inclination. Uh, to me, it didn't seem like as much. It wasn't as bad. I wasn't sure if this was kind of like his natural kind of soup. Clear inclination. And he just has more than the average person versus maybe some degree of erosion. Um, but again, you know, this this is one where I really went back and forth quite a lot in my head about what should I do? Um, and you know, for me, probably the biggest thing was he was happy with the reverse on his other side. And, you know, even he was a little worried about kind of because he was very educated about what was going on on his memory and CASS can and rotator cuff and all that. So eso we we kind of decided together, you know, to go ahead with with their rehearse. Um, it's interesting if you go back one slide that his he's anti averted. Four degrees. So the subluxation anti subluxation 46%? Uh huh. It's within the normal George between 45 55. It's a normal civilization. No, I agree. I was just referring to the use of the word posterior. Well, so 46 would be 4% answer within the normal range, right? And so that's also within the normal range of any version, up to five degrees of any version for him. A one. So I went to plan here with this one. A budget. What you plan here is a primary reverse with some kind off major decision off the planet. I know that Bob also like to media lies the Glenn. I'd So in this case, uh, I would worry about notching contact between the created and on the scapula. Pila. So does it happen often time in your experience to major allies, the base plate and Major Liza Glenn. I'd or this is just because off good cuff in this case. And you wanted to preserve the cuff. My my thought was to correct some degree of the superior inclination without going all the way down. Um, and then I I really like the lateral eyes. Glennis fear. So with the keeping the sphere below the level of the glen oId and then using a lateral eyes Glennis Fear. You know, I feel like that really helped, um, minimize the notching. Um, you know, again. And this is another case where, you know, maybe if I was planning it again now, maybe I would have done a little bit differently. Maybe a little bit more lateral ization, but my kind of goal with the base plate positioning was too. Um, not over correct. The superior inclination, but corrected to what was probably a more normal range. Mhm. Jay, what are your thoughts in this case? How would you approach this one? E think that Yeah, I think again I would struggle a little bit with, uh, an atomic versus reverse. I think you bring up a really good point, George about how he's how his internal rotation function is on the other arm. Um, that's it's important, because if it's very limited, that would probably push the envelope towards an an atomic. Um, but I think you know, he's got some small arguments to do a reverse here. He's got some mild cuff disease on his emerge. He's over. Small argument. Yes. Okay, so I just wanted to clear, is he? If you add everything up, I mean, I think that those small arguments become larger. Uh, one of the one of the interesting things about about this study. This case, that is, I think, very valuable discussion point is the first case, the global lateral ization. What? I'm sorry. The lateral ization on the Glenroy planning was 13 millimeters are 13 or 14 and in this case, we're actually media lies one millimeter. And obviously the deformity is more pronounced on the first case. But you've got a wide range of planning goals here in terms of your Glenwood position. And he's made up for some of that medial ization with a lateral ized Glennis fear. But still, I don't I think it brings a point that we don't know the sweet spot in terms of amount of global lateral ization that we should shoot for. And I think that to get to Jill's point, there's great value view in assessing the range of motion. So I will plan several different Glenn oId positions. Um, some with a bone graft, some without with just reaming. There is abduction impingement. So with abduction or extension or external rotation, how much blockage of the motion is there? And that helps me pick the amount of lateral ization that I want either through the Glynis Fear or through less reaming. I think that's really important. Here is reem toe 90% seating and you can probably get by with a little bit less reaming. Check the range of motion across several iterations and figure out where the motion is not limited and then stop there. So So we've got two cases distinctly different bone deformities. But we've got a 15 millimeter difference in Glen oId planning based off the morbid joint line. And that just goes to show you that we really don't know exactly how much global lateral ization is correct. It's probably variable from patient to patient, but there is great value incest in assessing range of motion with your plans to make sure that whatever your plan is, you're not having abduction impingement to prevent that notching phenomenon that you mentioned. So what would you do in this case? Would you do a bio? Are, say, like, AnAnd Atomic? A superior wedge I would do I would I would plan in this case at neutral version and neutral inclination, I would not tilt it securely. I'd read to 50% base plate support. I checked the range of motion with a standard Glynis Fear. If there was, if there was abduction impingement, if I didn't like the motion, I would use a plus three Glynis Fear, as Bill has here, if I still had construction impingement, I do a bio r s A. To minimize that motion. Or I would consider an augment eso generally over age 70 the bone quality and the human heads not the best. So I have a lower threshold to use an augment rather than bio Arce. But I think that's that's that's individual from patient to patient. So I would use my range of motion to dictate how much Latinization I need in the construct to prevent the abduction impingement motion. I mean, I do something very similar where you just incrementally lateral eyes until you get the range of motion that you're happy with Exactly. Right. All right. Let's see what you did. Well, so this was a case where I started using the central Screw and didn't have great purchase. So I bailed to the central peg and there are four you know, for peripheral screws in there. Um, you know, I felt like the plan helped me get a good reconstruction. And in terms of his outcome, he's he's pretty close to equal on both sides, and he's happy with it. And, uh, he can he can shoot his pistol. So that's a good thing for him. You never want Thio e really needed to make sure he did good. Eso bill, I would argue that you got your tilt. Sorry, J. Go ahead. No, I just I just I think you've you've actually corrected your tilt a little more than you planned, Which is if you look at it in reference to the beta angle. That looks really good. I would be very happy with that post op film Yeah, And so, yeah, I think you know, potentially during surgery, I was thinking about a little bit more than the plan, you know, but yeah, Thank you. So this would be I would say, this is about as close to a traditional Graham on style base plate and position is you could probably get there's maybe a couple millimeters of liberalization, but it looks like his outcome is good, or at least so far with what you have. And, uh, but it still has five that still has five more millimeters of liberalization than a standard grandma. Because it's two millimeters built in the base plate and you put a plus three in. So it's about five. It looks It looks like a classic Ramon, though I agree. S o, I guess. Um, yeah. I mean, I I would agree with deal that I'm I'm more of a dreamer in certain cases. And I would be more inclined if this was maybe a 75 year old female with osteoporotic bone with kuffar through apathy that I would tried to push her more medial and loose as opposed to lateral ized with the biochar esa or with a with a augment. Um, For a guy like this, though, who is male with an osteo arthritic pattern instead of a cuff arthropod the pattern where potentially the bone is better. Even though you say in the glen Oh, you didn't have great kind of purchase without Central screw. I predictably think that his bone quality would be better, potentially lower risk for a crow meal related issues. And so I would agree with kind of trying to push him out laterally. I still like to be able to get metal on bone, but I would probably have used if I was doing it. This is perfect, but I would use, like, a 42 sphere so even larger on this patient that might push me out a little bit more. And then if I was using the reverse two, I just used the plus four lateral ized. You know, the 10 degree tilt or plus four spear that they have that would then give you a couple more millimeters. So probably in the same ballpark is where your final lateral ization is on this one. But, um, you know, if it was any more superior inclination, I agree with Jay it looks like you probably got lower than that 10 degrees that you plan for. It looks probably closer to neutral that if it was any more than that, I would have probably used the super full wedge. Um, you know, 15 degree full wedge to be able to correct that and on day push you out. Okay, I think I've changed the way I used the Central screw. And I think I've decreased by incidents off, uh, having to switch up, meaning that if I used the central screw to actually suck in the base plate, I find that there's a higher chance if it's dripping versus if. I used the insertion directo push in the base plate and then let it screw in. That's Google captures that media vault and then pulls in rather than get abutted against the media vaulting strips. And so I've changed my technique or low and had a much lower incidence of having to switch to a different implant after the 65 through. This looks great. One thing I've learned. One thing I've also learned to Georgia's point is, if you have osteoarthritis as Bob mentioned a lot of times, the clinic vault is fairly hard, and I've learned to take it. That central boss, the bone in that area is very hard. I've learned to take that central reamer and and just do a little roto Rooter to expand it a little bit, because that allows you as you're trying to see your screw and you're not getting hung up the boss, the central post is or the bosses not getting hung up on the bone. And also tapping the far cortex of your screw beforehand allows allows it, in my experience, to strip a little bit less. But you have to. You have to change your prep based on bone density a little bit. I think it's helpful to expand that central tunnel a little bit, but this looks very good. Remember, in the set there's, ah, hard bone drill. So that's another key aspect that if your rep for the people that are on that if you're used to using perform and you have a hard Glenn oId, there is another drill for the hard bone drill that gives you I forget. If it's a millimeter, I can't remember exactly how much more it gives you, but this is exactly the case where using the hard bone drill for the Central Post or the Central screw is probably, um uh, really important. Excellent. Alright, Case three. Bill, You're rocking it. Yeah, que three d m. 78 year old, right hand dominant male with left rather than right shoulder pain for a few years. Still conservative treatment, reasonably maintained elevation, obviously. Some lack of external rotation, internal rotation, these air his radiographs bill Has this shoulder had surgery before? No, sir. In the interest of time, Bill, do you? What do you want to take? Just kind of describe what you think is important in these X rays, and we'll just move on? Sure. Clearly, he's got severe osteoarthritis, probably with at least some degree of Glen oId, maybe superior erosion deformity. I'm concerned about the rotator cuff. Um, in an older gentleman like this with this degree of medial ization England deformity again, I'm thinking reverse. Um, I s o he got the cat scan to help again. You can clearly see that Dr Walsh was saying the severe rotator cuff. Um fatty infiltration. Eso Even if his cup is intact, it's not functioning. Clearly, he's got a significant to Glenroy deformity again. This is my, um, kind of conventional way of measuring it and the blueprint, um, so again, reasonably centered head, but with the superior inclination and media erosion deformity. Uh, pretty similar to that first one I really love using bone to make up that gap. Um, and how, Joe, how would you classify that going away based on the walls? Classifications? Yeah, because off civil introversion your measure on the two d you can respect that. It's a type d Glenna it with more than five degrees introversion. What is surprising is that the sweetie blueprint measurements show one degrees retro vision, so it's a little bit surprising, but it's just really measurements. It's not anymore to D Measurements. So and I would say, with three D measurements that it should type A to A to Glenn arrayed meaning seven central erosion of the Glen arrayed looking at the city's camp interesting with the degree of fat infiltration. Yeah, true, I Wish Way should not speak about primary statewide. It if there is such a savior fighting situation because it's very unusual to see this kind of fighting situation for primary status. So if it is not typical primary statewide is we should not use the A B c D. Classifications. So, George, how would how would you plan this? What would your beer goals of base plate position E. I mean, I plan. I think you and I plan very similar. Where? Ah, place I start off a place in the base plate. Low Azaz Bill is down here, um, and looks like with zero degrees aversion. ITT's kind of going down the pike down the pipe. And so then, in this circumstance, what I'd do is I'd probably aim for a bio. Arce. I place the base plate and then I do a range of motion assess my motion to ensure that I'm happy. And I must admit, I don't care. E mean, I care about flexion and abduction, but I care mawr about interpretation. I care more about abduction, and I care more about extension. I find those there is that I want to optimize. And so then, uh, incrementally lateral eyes until I'm happy with my range of motion and whether that means a bio arce or increased thickness of the graft or switching from a 39 to 40 to scare. So in this particular country that looks like a grasp in this. In this, in the image of the bottom, right, the bone looks reasonable. Um so my first go to would be a bio are, say like an autologous bio are safe from the head. What if your bone quality is not good in the human will have When you're in there doing surgery, what's your what's your strategy? So in those circumstances, I typically have the perform base plate. So whether it's the plus six or the full wedge, so do you think looking at this deformity that this patient has to be able to correct 20 degree tilt that you could use a 15 degree performed full wedge where the maximal thickness on the full wedge is eight millimeters? To me, if I measured out that, I mean I would be even a little concern that that's over 10 millimeters. So, using the traditional bio Arce cut guide, if you're gonna use that from the right cut guides, 10 millimeter graft, that would be even pushing the limits with regards to that. So e, I think the truthfully the wedge base plate in my hands is perfectly matched for almost the natural. Glenn oId like to correct the natural blended with its inclination. So, uh, if I have to bail to the agenda, have to accept some, uh, unfortunately, I have to bail to the augment. I don't have to accept some medial ization. What do you think about Allah? Graft. Um, I tend not to use a lot of Allah graft. I find in my hands what we have for Allah brackets. Terminal head. It's so hard. I have a very difficult time molding it. And like the nice thing about the autographed in the human head as you impacted, it compresses down and almost gives you a patient specific graph with the federal head Allah graft. It's very hard to get it to compress down. So I've used it. A few revision cases. I've not been ecstatic about it. I mean, I do keep it. I ordered for most of the revision cases, but I prefer to use, uh, autologous is possible. Idea crest or district? Laughable. Yeah, I think Bob, you raised a good point because there are some deformities when you when you place your base plate and you get to what you think is the acceptable version and inclination, and you start to ream. You quickly realize you're getting very medial enough and you're getting fairly medial. Then you've got a decision. Well, I don't wanna go anymore. Medial. How bad is my deformity here? And there are some deformities that an augment won't won't feel obviously. And I think that's the point you're making. And the question is, if your bone inter operatively is bad, how often do you use Allah graft? I use it not routinely, but I use it. Probably 30% of my bio are S A S or Allah graft. And I know you have good experience with that. And as George mentioned, it's a challenge because the bone I use ephemeral head and the bone is very hard. So you have to spend more time making sure that the backside of the graft matches the deformity. And then what I usually do is put the is put the graft in puts, um, que wires in. And actually I reme Kanye lated thgraf to kind of prepare the face. But the challenge is getting the backside to match well, because it's not going to compress all that. Well, so, um do you have any tricks? Thio? Sorry. Go ahead. Oh, no. Let's say I don't I don't use the Allah graft as much as J and primaries. They use a lot more visions, but definitely I have it available. And I have used it in primaries. Um, one of the tricks, I guess for me to get the graft to fit correctly in the bio are say, is that I will, um, prepare my Glenn oId. So get a nice bleeding surface. Do it. Paschal talks about drilling the Glen oId to be able to get not only just burning but drilling to be able to get bleeding and then positioned in my K wire drill my central post hole, prepare my graft of what I think it is. Then I'll actually take the doughnut of the graph, not on the base plate, and I'll put it inside the Glen oId. And I'll take the drill that I used and put the drill back into the hole and then rotate the graft on the drill itself to be able to find the optimal orientation. And then I'll mark the graft. I'll mark the Glen oId and then I take it and put the graft onto the base plate and then and put it into the glen, right? So it really lets me trial the graft in a 3 60 version. Thio optimize the position to get into the place that I like about. That's a great idea. I think I've not done that. I think I will next time. My point I was gonna make is that many times when we see erosion like this, we're concerned about primary fixation of our base plate in this eroded Glenn, I'd, but I want to draw your attention to the image on the top, right? This is a sclerotic annoyed, So it's a it's eroded. It's thin, but it's gonna have very hard, hard bone. So this goes back to what genuine you mentioned about considering maybe giving it a little bit of a windshield, opening up the whole a little bit. Consider tapping things like that because I think the primary bite on this implant and use the standard instrumentation is gonna be great on this particular Illinois. Yeah, great. Let's see. Let's see what you did. I would in terms of choice of baseball Yeah. Worry about to say, Jay, I think I mean, I think that that this is the point that Dr Walsh brought up earlier. You know, the the question is, do you need your post in the native bone eso for this? In this situations, I typically use the reverse to base plate that has a long post. Or you could use the perform base plate with the post, and I I would want to have some of that in the native bone. Um, this looks great. And if the patient wins the race between graft healing and implant loosening, he'll be fine. But if you don't have any of your native post in the bone, you get concerned about later subsidence of the implant. So, um, can you talk? I agree with you. Can you talk a little bit about Hugh Meral? Uh, Phil Canal fill with this implant. It's been shown. Probably You wanna be a minimalist in terms of Canal Phil because of the adaptive bone changes that happen. Bill, Um, do you, um I noticed you like to use longer implants, but how do you choose the size in terms of Canal Phil? So I think that this is a recommendation from someone on this panel to go up until there's some rotational stability. Um, you you rotate the brooch and it rotates the humorous thio Stop at that size. Um, so that's my usual plan. Uh, in a in a severely osteo product female patient, for example, that that's probably going to be closer to filling the canal. Compared to someone like this gentleman who had a little bit better quality bone where e mean, I feel like I didn't quite feel the canal. Obviously it's touching a little bit that lateral cortex. But, um, you know, I probably could have put in maybe one more bigger size or something like that in this particular case. And And I do like the long stems, I I feel like it really helps me get, um, a better, uh, reconstruction. I think it helps avoid the potential for very serve Al Ghous. Um, I guess maybe I'm more of a kind of traditionalist in that regard, but I like to do also will. For that, for the humorist is to use a long, uh, the long compactor in order to stay in line with Di physics with the email access and then use a short stem because we will I'm or on metaphysical stability. So the long compactor is useful to find the correct access. But then the short stem is enough, I believe, for metaphysical stability. But that's another way. Just another way. The other question E. I was just gonna ask the panel. How often eso when I first trained on verse, I never removed any osteo fights off the gun out, and now I'm pretty. I look a range of motion. I try to remove osteo fights on Glenn. I just started with Bill Jill. Bob Jay, Do you guys remove osteo fights on the Glen right? Or do you leave absolutely especially inferior? Or, if there's any anything close to in pinching anterior posterior? Absolutely. Is everyone the same? They lost your fights off, right? Yeah, on the purple of planning. We see that often time we need to remove some post A are still fights to avoid impeachment during extension or extend irritation. But on the other hand, once your base plate is screw in is in, it's extremely difficult to remove the past iosco fight, so also I like to remove post Aosta fight to avoid impeachment. Often time I don't, because if you remove your post a a retractor to put the base plate in, you cannot anymore remove the Paseo so fights. And sometimes keeping that post curiosity if it really helps your exposure because you can refute your a tractor on it. Yes, the question is whether we should once the sphere is in or the base plate is in, whether we should remove their self fights before putting this fair. Uh, but I don't routinely perform it. Also, maybe we should I don't know, Bob Jay. You guys remove Austin fights in the bloodline. Yeah, I wouldn't say. One thing that I've been more aggressive about is I think I appreciate the Aussie fights more now that I doing range of motion assessment. But I also very aggressively released sharply Thean fear capsule in the lateral part of the triceps off the Glen oId rim. So with my finger over the nerve, take a knife and just undercut that. And I think I have a better appreciation not only for the where the bottom of the Glen White is, but any projecting osteo fights. I can kind of feel him under there, So I do like to remove the inferior ones. I often will remove the post here one after the base plate is on, but I try not to be too aggressive in the back because I don't want I don't want to create a fracture that goes under my base plate now after it's in place. But I think that's important. Actually lost a fight. Removal Bob, What do you think? No. Ideo, I think on Thean theater ones are important for me is because sometimes it can fool you with regards to where the native guano it is. And so the problem is, if you talk about this, it could almost make your base plate too low, which I know it sounds kind of not what we worry about, but if if you over distal eyes, that could be a problem, especially with nerve related issues, etcetera. So I try Thio, you know, pre operatively. Look at the images, see if there's a four or five millimeter osteo fight and fairly remove it. Prepare the Glen oId and then, if there are large osteo fights in the back to try to remove them, you know, I think it's different than what we normally would do, which is in primary osteoarthritis were ATTN. Least I was taught always lead the Glen oId Austria fights because of the concern of removing them with them potentially lead to instability. And so I think that, you know, many of us are kind of ingrained in their head Is to not remove osteo fights in the Glen oId because of what we learned with primary osteoarthritis. Do you? Are you George in a in a case of a primary away? Do you ever remove osteo fights on the Glen oId of doing an an atomic doing an an atomic right? I think you kind of hit the nail right there where I was trained. You didn't remove osteo fights in the Glenwood you kept them on unless they were entering. You're worried about the subs, cap, But now I switched to being exactly like you guys. I look, I feel along the inferior rim, and if there's one overhanging I removed them. I removed him on the back. And if they impinge in internal rotation or four inflection, I improved removed on the front. Now also, I think George one last comment about the Post was that that you are talking is that, um and you know, just to make the comment is that going back in on a revision? A lot of times? Some the If you're revising a base plate that you actually think is loose, sometimes the only thing that is actually ingrown is the post. And it could be so well and grown that you can barely get Thean base plate out. And so I think it points to mawr of the importance of having some type of in growth, especially in these large bone graft cases. Because even if it does resort a little bit, the likelihood that you're gonna get in growth is probably pretty decent. And if you just have the threads of a screw, it's concerning that you wouldn't you wouldn't have that's or just another yeah, kind of point to the same issue. I think that's I mean, my I've had some personal experience with that where I've used uh, type of threaded post base plate Monta Block in a revision scenario which came loose because I had bone grafted the vault and the only part of the base plate that was in contact with the host bone was a smooth, polished model blocks, crew and bone. As we all know, bone doesn't heal to a polished surface. And so, as Jay said, what was that race? I lost the race on both of those cases where the bone grafting incorporate fast enough. And so I'm personally I'm a fan off mano block base play with host bone contact but saying that I know there's a good friend of mine, Marty Blaine in Alberta, who does Bio Arce using the perform with no essentially screwed compression. He's had good results with it. I personally don't have experience, but he's an excellent surgeon and he follows his patients, and he's been able to do that with his primary bio. Our say so. I think there is a role there, I think, just more to learn, but certainly in revision situations with Allah graph, I have not had good luck with that, all right? I think Bob Dylan, close this out. Oh, I wanna, you know, thank Bill for joining us. These were three great cases, Andi, I think hopefully I mean, I learned a lot and hopefully everyone else, uh, that was listening in and on. The panel even has been able to learn from kind of going through these cases. Um, we are, uh we're also very lucky that Jill was able to join us for this. This has been great discussion, and I hope he enjoyed it as much as we did. Yeah, thank you for being. Congratulations, Will. Those were fantastic cases on. Congratulations for your surgery. Thank you very much. Bill. Thank you for sharing. Your case is with us. It Zanon er, thank you very much, guys. I really appreciate it.
