Dr. Gregory Carolan discusses revision arthroplasty of the humerus with Drs. George Athwal, Jay Keener, and Robert Tashjian during our “Tough Case Tuesday” 2020 summer series presentation.
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Theriot, hand in Upper Limb Center and ST Joseph's Healthcare. Dr. Keener is a professor in chief of orthopedics and fellowship director for the shoulder and elbow service at Washington University Department 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 with that doctor, Kenya, I'll turn it over to you to introduce our our special guest. Thank you, Tim. That was awesome. We're excited to have our second meeting today with us. We have a very special guest, Joaquin Sanchez Sotelo, who is not only a good friend but in excellent, very experienced shoulder surgeon. And I can tell you that we really couldn't pick a better person for today's events. He's really taught me a lot about revision shoulder replacements, specifically managing Hue, mural defects in hue, mural injury. So we're really excited to have Joaquin. He's a professor of orthopedic surgery at the Mayo Clinic. He really needs no introduction. Thank you, Joaquin, for being here, and we really appreciate it. So with you. Thank you You're very welcome. Thank you. So, Greg, once you kick us off Great. Well, thanks for inviting me. E was ableto kind of put together a few cases that I thought would highlight some of the concepts of funeral revision that we were talking about. Let me just share the screen here. Um and I hope that these cases kind of provide an avenue for discussion and for further enlightenment from our amazing panel of faculty. So e s means hopping in the first case. Um, first case that I wanted to kind of present was a case of a 57 year old gentleman. Came to see us had actually bilateral Glenda humor osteoarthritis with pretty advanced to wear. Hey was right hand dominant. He left it to have his right shoulder addressed. First, I did some preoperative planning and decided to go with reverse total shoulder, given his kill. Any deformity, um, used a halfway drug minute base plate with a flex. Them really was a uncomplicated primary procedure on the patients recovered uneventfully. Hey. Went on to have his other shoulder, which had very similar radiographic appearances, treated with a similar implant and was doing well. Unfortunately, he sustained in a fall he started developing, wrote to the young guy, started developing some a Taxila which turned out to be related to some vertebral Bassler insufficiency. He actually had stenosis of his bat Bassler artery in his brain, which was restricting blood flow, giving him some a taxi issues. So he presented Thio the office following a fall from standing on these air his ap in outlet views of his right shoulder. And I think, um, I love to kind of maybe take it off here and say, you know, what options do we think are available for for this injury for this patient? I don't know, Joaquin. Why don't you take this one? I mean, you've done a lot of research. John Perry. President fractures. Yeah. Thank you. You're So this is an interesting situation, because, um, in the face where we used to use standard length stems, this type of fracture may not necessarily carry the diagnosis evolution in as well. But in this fracture, because it's a conventional, you know, current shortest them. Some of the coating off the processes, um, in terms off it's in growth to the proximal humerus may have been compromised. So my concern is that the Asian may have a combination off fracture, which is not badly this place Onda also maybe a loose human component. Having said that, it could be possible that if there is enough in growth immediately on the cultural region where the fracture also occurred, this fracture could heal without surgery, and the patient may be okay. So I think is one of those cases where you have toe potentially get other views on, decide what to do. Um, you said that this happened three months after surgery. No, this is about one year after his primary, uh, nine months out after his Contra lateral side, which is functioning quite well. So one year later, maybe the stem subsided with the medial. Robin is still attached to it. And maybe the patient is gonna be fine without surgery. So this is one that I would probably not jumping the surgery right away. I will probably fall the patient a little bit over time with Texas and see how he does. One thing that could be done, which I haven't done, is to maybe do express under the stress, like very gently rotate the shoulder very gently. I'll see if you can see if you can convince yourself that there is abnormal motion between the proximal and distal requirements. But I've never done that, right. Yeah, I think E would probably consider non operative management here to I'd watch him closely with serial radiographs and and just see if it looks like it's healing or if there's any further subsidence of the human component or signs of shifting of the implant. But, I mean, I think it's reasonable to try this non operatively Attn. Least initially. Yeah, I think I would agree. I've seen several days now. It's interesting. The fracture line usually starts. If you look at the poorest coding, the poorest coding ends about, you know, separate and a half below the tray, but that the proxy bone actually heels to that porous coating. And the fracture occurs where it's not healed or that smooth part of stem distantly. And it's interesting now that I've seen a fair number of these, uh, these actually maybe a little bit more challenging to operate on for fixation because with these short stem implants that are metaphysical filling and the fractures of very high fracture to get captured into the proximal fragment is a little bit challenging with the standard proximate Here's place. It's very hard to get screws around the stand, especially if you put in. Are we put in a very robust shorts? Them so. But I think I would agree with Jay and Joaquin. I would give this a shot at non operative treatment first to see if this hills. The other point is that I think you are trying to make which I think is great is that the complexity of the re operation is much less. Let's see that the stem is lose, but the fracture heals. You revise the shoulder six months from now. Then it could be a straightforward human list. M exchange. Well, as if you would. Acutely, your temptation is to use play the screws, wires and the complexity of Operation Off increases substantially. George in this one. Would you? So for me, if I looked at this with a short stem, I wouldn't even be thinking about using plates and screws. I would just say, Just goto a little bit longer stem. You'll have rigid fixation. Fix the two ferocity like you normally would with a fracture and just bypass the area. And I think it obviously with a more standard lengths them You start to develop. You know, it's a huge amount of the humerus that if you had a fracture that was like this, then it's a different story. But does it change your kind of thought in the ones that you've treated that you've gone into to treat early? Uh, in the ones that you, uh, operated on? Do you have you gone in with the idea toe? Fix the mall and then if the stems loose, then replace it or say that you went in on this one and the stem was actually stable? Would you just pull it anyways and then and put in the longer stem for me? So I have It's interesting. This is the implant I choose to use. And so I've got a unfortunately got a fair, fair Siris of Harry prosthetic fractures at this level. Now, uh, it all depends on the size of the stem. So I wedged in a very thick flex stem where I had poor. Then I find that I cannot get screwed purchase. So then, in those patients, I'll actually do non operative management or, as you suggested, go right to a revision standard length implant. Say if, say, if we knew magically that this was a loose stem, I would agree with you I would go to ah longer stem. But if I usually tend to get a C T scan on these, and I just look at the fracture fragments and if the napkin ring of bone around underneath the trays intact, I would believe that there's a stable implants, and in this case, I think I could try to fix this if I wanted to. But I think this one, I would treat non operational. This looks pretty lined up. It's almost like a little bit of a loose I am nail. The tip of the stem is kind of wedged into that die offices, and it looks pretty stable. That dives is I think this would have a fairly good chance to heal. Joakim, would you kind of going into this one if you say that for whatever reason, you needed to do surgery that he said he was just not tolerating it. The patient was having too much pain or whatever the situation is, and he just wasn't tolerating non up and he went to surgery. Would you think about fixing this first as well? No, I think. Like if I, um if I convince my shoulder the fracture will heal, I would probably let the fracture hell on, then deal with the loose human component 3 to 6 months later and then do a standard division to a longer. It's them. I think that's what I will do. One of the issues also is, if you haven't revised, spend money is actually, well, ingrown. Immediately potential. You can leave the or with a little bone immediately. You know, it can be difficult to excavate sometimes. Yeah, it's a free broken pieces don't have control is not easy. Do you guys think that? Do you think I think that if this fracture was treated conservatively and it heals, is the risk of this location now increased? Because the humans is shorter on the politicking? Is more vertical or is that not a worry? That's a really good point. I don't know the answer, but the in theory that would be concerned about that. Obviously you've lost some soft tissue attention eso and also the police No more vertical Russia could escape with just because trying to various nice thing is let's look like a 42 head. And, uh, did you put any Is this a lateral ized head? It xlat relies on the base play e. I mean, you got a good chunk of liberalization and what I find sometimes with these they just if you hear this non off, just be so much scar tissue because, I mean, I don't I don't move these people. I keep him in a sling for six weeks. I don't even do pendulum. Maybe I should. But I think they get stiff and so they develop a lot of a fair bit of contractor around there. I think that's a good point, though, That about instability. I've seen that in the primary setting, where someone has a various Mallya union that a short stem was placed to try to not get along stem and the implant was put in various. And then that patient then went on to having instability instead of dealing with the mallee united kind of proximal humerus and putting a standard length stem that would then restore than normal inclination angle. So, you know, the tendency is okay, Well, it's easier to put a shorter stem in. But there's an error, I think, in that, because then the anatomy of the reverse is going to lead to potentially having higher rate of instability. It's funny, because I just had that case, a patient that had a mile position component in severe virus on the surgeon who kept increasing the blogosphere size more and more and more. But the body I kid, you know, it was like almost vertical. Didn't matter how much you rather allies it escape out. So I realized the human side only, and he was actually just by changing maybe 20 degrees of the intonation of the police. So that's that's a very good point. The exact same problem I had a patient had analogs half press that a composite that fell and bent their stem into a various angle and I couldn't get her stable. Yeah, I tried everything. I salute you. I did that. Bob Tajin Sutra everything. Uh huh. All right. Let's Let's keep rolling, Greg. Yeah, So we chose Not operative care is what came was mentioning. I don't get stressed views, but I do let them do little pendulums and see how they feel. And I find if they're unstable, that causes quite a bit of pain. If they're relatively stable, they don't seem to have that much pain. So it kind of helps me with my clinical exam with these cases. So we he was also undergoing this neurosurgical work up for this arterial insufficiency of his brain. So it was really non operative care. But unfortunately he fell again again. He was having these no neurologic symptoms with ataxia. He had another fall and presented about three or four weeks later, after we chose not to care with this injury pattern, and you talk more about that. But I felt that this now had a dis continuity between the proximal distal aspect of the human shaft. And I felt that there was, um, in my hands limited role for open reduction internal fixation. But I don't know if that if that bears discussion or we proceed forward with what I decided to dio, I think in this situation it looks like that medial cow color pieces pulled away from the stem. You probably have a loose stem here. In addition to the segmental fracture eso I would probably revise the whole thing rather than a cigarette. Uh, I e no question one of the problems before we go on with these cases that thes patients that fall, they keep falling. I had some of these that they keep breaking this story, have a patient with a chronic alcoholic on, you know, I keep going longer and she kept freaking underneath. It's just it's just so hard. So I think the neurologic treatment is actually very, very important because I was killed sticky, falling and breaking. Yeah, and they kept blamed. They It was a great discussion because they team caring for him thought he was infected, that he had a pair of prosthetic infection and that's why he was falling because he was sick from the from the infection. And truly it was this neuro nurse surgical issue that ended up being treated. So, um, just to move on. So we decided that I didn't feel open direction from vexation was going to be successful for this patient. He was quite a large guy, and I felt revision with a longer stem was certainly appropriate. Before you show us your pictures, who would manage this with a cemented in planet. Who would manage this with a precedent plan? I want to breastfeed. I would do Press fit is well, primarily because the distal cornices air. Very good. I would probably at this point, I would probably still do it cemented, but I would consider the revive. How about you, Jordan? I mean, I've always done these cemented, but I would consider using a press it because I think the court of Cesaire good. And I think it be get some distant fixation, then put some wires around the proximal aspect that my classic has always been cemented. Long stand model block, fracture, stem. But I would definitely consider a precedent. Long time here. Do you in George to prevent cemented stablization when you do that, Or do you You don't care. Really? So I'm sorry to ask me that again. So cement this conversation to the fracture line. Do you care that that happens? And you do anything to prevent it? E just try to put the Smith and especially doughy very, very so that it's very, uh e try my best not to get this meant to interdigital. And I try to use futures and, Sir Collage. I use a wire to obtain the reduction of the fragments. Like looky. And then I use suitors to maintain it because I find the fiber tape is gonna maintaining it, but not obtaining fragment fixation. How would you? Do you have any interest? Voice Cement Association? Because I have a without big time where sometimes you have things perfect. And then when you're preservation, the spin cement, it starts to come out. You know, e for fractures like this. I don't have any tracks, but, Greg, don't do it. I'm sorry. Go ahead. E was just gonna say that three only other. The trick that I've had is obviously the arm is in a deduction and external rotation. That's probably the hardest part. So there's a lot of torque that's being placed across your reduction when you're putting this in, I think for us to get an an atomic reduction, it's still hard when the arm is in, you know, in neutral rotation. But then you put the thing in a deduction. External rotation, all that forces placed across your looky wires or Souter tape. And so, for me, um, I will actually get my reduction place All my fixation, but I'll take a large reduction clamp and I'll put it back across the fracture site, even after all my fixations there. And leave that in place while I'm extra a deducting, external rotating. So it's almost it's it's extra fixation that I wouldn't necessarily have in there getting, you know, squeezing on the fracture site. Thio hopefully counter act those forces of external rotation. Other than that, I don't really have any other tricks. The one thing I would mention, I'm sure Greg did this is that with that proximal lateral fragment that's got the deltoid attachment on it so instinctively when we sometimes do fracture work, we spent a lot of time exposing the fracture fragments. In this certain case, I would really not do that. I would really try to maintain that Delta insertion laterally because that's going to give us attention or stability. Yeah, I was going to say I think the best way to avoid cement extra visitation is not to use cement. E love that trick. That's awesome. That allows us Thio proceed forward with one point. Greg Yeah, yeah, I get one point. Excellent. Alright. So I took the advice, uh, about that everyone gave me, um, you know, it was his court disease were excellent. And so what I decided to use was a revived stem. Um, I did revise Revise the Glennis fear when I was in there. Just mostly because I was in there. I had dislocated, uh, give me a better exposure for everything I did use a nine millimeter stem, which was at the time. I still believe it is the narrow stem, because I couldn't literally pass it any further distantly than this. I wanted to use a longer stem, but it got so tight and his, uh Smith that could not get anything passed there. So we were able to do that. I did use some psychological cables. Help, you know, maintain the reduction. Really? Before I did, my reaming are sounding on Ben. I did use the scoop piercer collage cable to grab that medial cal car piece. Um, so right, Can I can I ask you about your steps? Because So we're all for Georgia myself that for using cement, it's really obtaining the an atomic reduction first and then, um, placing the implant and actually even reaming with the reduction performed. So it's like doing it in the intact state. In this case, did you read the distal part first, prior to placing your reduction of your fragments and then reduce the implant and then put the implant in? Or did you put the implant in the distal segment and repair the the proximal segment around it? What was the kind of what was your steps in terms of strategy? So I removed the implant, which was currently in there, which is obviously loose on easy to remove. I then used the sounder to kind of get a provisional reduction by skewering the proximal and distal fragment. Then place the cables around the hue mural shaft both, you know, after exposing everything, making sure wasn't grab the nerve approximately the middle of the distal, and then and then attention it. And the Cynthy system has these little, um, clips that you kind of clip down and take the tension or off. So I didn't tension it crazy. But attention enough, like you mentioned, help avoid those stresses when you're trying to rotate, reduce and and trial. Once I did that, I took the sounder output a try. Elin reduced it revised the Glennis fear. Like I mentioned left, I thought the base play was a good position. And then when I was ready to perceive forward, I placed the rial stem. And then I finally attention the cables finally on, then went to my reduction of the Glen of funeral joint in my examination afterwards is that answer? Um, it sounds like the proximal part was a little bit more looser in terms of your fracture fixation to make sure that you could bypass all those segments of bone with your stem into the distal fragment first and then kind of tension the top, which is kind of a little bit different than how we would normally do it with cementing it, Joaquin, to use the same strategy with how you place the stem. Yeah, I would probably depending on how low the factories. The problem sometimes is that the alignment of the stem distantly can dictate um, al reduction approximately a million that if you have extend that it's a lining the canal in a way that doesn't allow to wrap properly approximately. You can be in trouble because you have to stay beautiful place and then you just cannot get the fractured toe you obtain. But in this case, because there is a wider canal approximately in the study, that, however, usually is perfect. One challenge I have had and I have a conflict of pictures with this system is that you cannot trialing off the realist m. So being picky about getting your length right, it's actually very important. And I find it difficult because he goes into minute increments. So sometimes you think you're gonna get the rial where the trial went on. It may remain. Maybe another centimeter proud or go too deep. You already bought your length. So there's something to be aware. Um, they pay special attention to your trialing so that you know for sure you have the length, right? I think this is distantly nice part to revive is if you have a larger distal segment, you can use a smaller proximal segment as well, in order to reduce those Tubarao cities around it. I know if you guys had a lot of experience using the different size proximal segments, but it's kind of nice to avoid what you're talking about about you. Did you have any thinks about some mentalist, Stan Fixation. You mentioned that that's what you would do also, in this case and your special tricks we have uncovered, I don't think so. I think I would probably prepare my distal a segment first and not be too concerned because you have such a small caliber proximal body. Not not be too concerned about being able to reduce the Cal car piece in the Tu ferocity back. But the distal the distal prepped, I think, is for me the key. I think with this system it takes a little bit of time to get experience knowing, uh, but you're not going to split the humorous because the dreaming and the trialing is very important toe choose the right diameter of the stem. That's the biggest challenge in this case. You don't worry about it so much because the distal bonus so good. But if you try to use this stem, I think we see this in some of your later cases where the court is Cesaire thin. You worry about, um, fracturing further distal with your with your hue mural Prep eso That's probably been my biggest learning curve with using the revive stem is knowing knowing exactly how much reaming I need to do. Just get a good press fit distantly without fracturing further down. Um uh, just one quick question, Greg, this looks great. By the way, that proximal greater to brasi piece. Did you? Do you? I mean, it's important that obviously keeps, um, post your cuff attachments. I think if you use a nice, smaller body segment, you can reduce the tube. Ferocity is well, Did you purposely reduced and fix like that with suitors? Or what do you like to do for the tuba? Rossi fixation in this setting, I do. I use like a North Accord like a highly, you know, high strength suitor, and basically do standard heavy Arthur plastic fracture. Technically, I tried thio by grabbing the tube ferocity that the bone tendon junction repairing that down to the proximal aspect of the prosthesis and also to the humorous if it all possible and I was able to preserve adding a small piece, you can see that on the on the lateral here. And then I do have some, I think later post ops. I think you could certainly see some healing of that to ferocity. Fragment. There Um and that's really my concern in the post operative phase. Like, how aggressive can you be with patients when you're you know, when you're trying to protect that to Brasi, And then how important is it in the setting of of a collateralized reverse total shoulder? Um, but I I feel if the bone is there and I think you kind of see it up here, uh, if you preserve it, I think you're you're better off. Is that something that most got the most of the panel is doing Still? Absolutely, Absolutely. I mean, for me, I would absolutely tryto preserve the greater absolutely. Try to preserve the lesser If I couldn't. I would then consider either constrained polyethylene or probably in a PC. I think I wanna fill that volume. And so I do not hesitate to do a small what I call a baby a pc, Uh, or and then a customize constrained Polly the really challenging the really challenging cases when it comes to to barasa t. And this is a little bit outside of this case, is when you have a two barasa Team al union and you try toe. If you've done some type of ah Huma RL reconstruction, and you try to pull that to Barasa t back. A lot of times it won't go where you wanted to go. And that could be when you're crossing wires in this height of the human is that you guys find their younger or not. Do you normally find, you know, I've never done that? I've always I used to Cynthia's cable pastors as well, and I always hugged the bone, and so far I haven't been burned. But I think it's really that's a part of the case. I never let the resident or the fellow do. I always pass those cables myself, especially in the danger zones. What do you think, Joaquin? Do you think it's important to dissect that? You know Tom Norris has a beautiful cadaver study that shows that if you stay superior on inferior to the petition Masatoshi attachment, you're almost always very, very safe. So I always look at where the lab is on go proximal and distal. I don't find it unless I have to go lower or if it's like a real revision where everything is just card down. But I have the honor of policies after revision showed a couple. So I think in these eso these two inferior, wiser, certainly at the level of the radial nerve there below the level of Lotus Imus. And so my trick to get these actually exposed that while the fracture still free fragments. So I book opened the fracture and use a periodical toe lift the soft e. Think your network decision has to go down towards almost breaking us. I'm sorry. So I try to book open the fracture to expose the nerve. But I think I have an unstable internet at the cottage. Don't worry. Okay, Zoe. Beautiful Greg. Beautiful taste number two. Just the one thing that what can you mentioned? The most important part of this was he did have an angioplasty of basil or artery, and then he actually stent in the basilar artery, which I thought was pretty cool. He's asymptomatic from his neurologic deficit because I was afraid. We do all this and he falls again. And then we're back to where we were before hand. So concept to make sure that the reason he fell was addressed. And I think we were able to do so. Alright, case to this is in This is a fallen. So this is a 86 year old female came into the emergency department, falls down the stairs already and dominant. She'd had a press fit. Henry Arthur Plastic for unknown reasons in the past for her history, her history. She has a mild dementia in the family was interested in pursuing everything that could be done to help this woman Onda according to them. And the reports that we're getting from the facility she lived that she was independently living in a facility and was using this shoulder prior to her injury. Um, that's clinical picture. Uh, she came into the emergency department, so these were the best images I that I was able to obtain for her injury. And I know they're not ideal, but, um, I'll be happy to describe them with what I see, Which is a, you know, Perry implant fracture distal to the to the tip of the of a press fit stem within a appears to be an anterior on human dislocation of the prosthesis. I did get a C T scan as well to evaluate the Glen oId Andi. I feel that that shows relatively preserved Glenwood Bone with a anti clearly dislocated prosthesis with an acute Perry prosthetic funeral shaft fracture. Right when you're talking with the family. Was there any sense that the shoulder was a problem before? I mean, does she have reasonable function, which she complaining of pain much before the injury? Yes, I I was sort of convinced that I was referred to me by one of my colleagues, and I was pretty convinced a chronic dislocation. But But we actually got notes from the facility where she was saying she was using the shoulder. There was no deformity that anyone had ever reported. And I think clinically or picture I was such that if that was the deformity, I think that would have been noticed. But yeah, the the discussion was that she was functioning. She was independently living. They didn't want this to rob her of her independence, this injury. So treatment options. Bob, how're you gonna handle this? 86 years old. Reasonable bone stock, but probably severe osteopenia in the glen oId um, very prosthetic fracture. What do you think? I think it gets I mean, so it's interesting that if this was a chronic dislocation. Um, at some level, you could consider non operative treatment for this. Even though it is, it is a pretty severe injury. I've seen these hell, and it's interesting. Ed McFarland has this talk on Perry prosthetic fractures, and it is amazing. He he treats everyone non operative Lee. There's a it's almost there's not a single patient with the Perry prosthetic fracture that he doesn't initially treat, and he has some just amazing pictures that show these people going on to healing. And so, granted, she's 86. She's got poor bone quality. She may go on toe non union, but with this being an acute injury to the shoulder, I think you have to do something. And so I would say that you know your options are too. Try to reduce the shoulder and then fix it. Or to just take everything out. And that's probably where I would go, because I think you're likely to lead Thio more chronic instability of the shoulder. It'll probably just fall out again. If you did that, um, from soft tissue insufficiency, I'd pull the stem and then piece back together thehyperfix with the same techniques that you used in the last kind of case on then, for this one, I mean again, I would probably use a long stem cemented implant and partly that the her level of osteoporosis, especially distantly, would make me a little worried to use a un cemented stem. Joaquin, you might feel differently that you've had a lot of experience with this in poor bone. But I'd be worried about shattering further the rest of our humorous. So I think a nicely placed long stem cemented implant. I don't think you need to augment it with a bone plate. I think if a long as you get good, uh, good bomb approximately, I think will be reasonable if you're deficient in that zone. So it was just paper that was surrounding that human implant. Then you've got a problem. Then I think you've got to use Allah graft and that I've done a couple of these where I've used ah, large inter Kaleri segment of Allah graft. So the two barasa fees are still okay and you can repair it. There's about 7 to 10 centimeter area of missing humorous and then the distal part, and so I'll use a long stem with an Inter Kaleri federal shaft and then fix the Tubarao cities approximately and then distantly, um, cemented into place and use a step cut to be able to get some rotational stability. I haven't plaited those. And again, that might be a knish. You longer term. But I figured what the cement fixation the step got have been okay, so that would be my plan going in if the middle segment of bone was missing. I mean, I don't see any. I'm not sure. Is my Internet okay? Yeah, I apologize. Yeah. So I think for me whether I would really get the family involved in this, I think it's reasonable to manage. Just not operatively because my surgical treatment, whether this goes onto a delayed union or non union is still the same. Um, whether I do it acutely or delayed, if the family disagrees with that, they want something done urgently. Then I'm happy to go on to dio emergence in operation. And what would that be? E trying office like it depends on her level Dementia apartment. I'm sorry. Go ahead. So it for me it depends on her level of dementia. The more dimension she is, the less likely I'm up to operate. But I mean, if the family wants Thio, I would revise us. And what would you do, George? With the human side, I think with the human side, I want to get an idea of this is acute or chronic dislocation. If it was a chronic dislocation, shoes functioning honestly, I would consider plate and analogs half struck sandwich. If this was truly an acute dislocation, then I'd probably revise her to a long stem submitted, reversing the reason I prefer cement in this case just because her her bone is pretty weak distantly and I'd like to get primary solid fixation. I find a cement. I could get that, especially if the bone is going to be the president applications we distill to the isthmus and the best bone to get the president is right at the level Isthmus only have a short segment of press fit before the canal dilates. So for me, it's a cemented implanted in this scenario. I think a couple off comments, if I may, you go back one extreme. Uh, the shortages off the list of humans, as you can see, are very, very thin between the canal is very capacious on. Uh, this patient is saving 16. She probably is not gonna live for another 10 years. But when usually cemented the stem, I try not to use a polished cemented them in this situation, because you use one that is polished is much more unusually unstable. You have to use also a bigger extension. You don't have a finish them on like 13 mirrors amendment. So you have to be careful about your implant choice if you're gonna go cemented because again, she say this is what she wants. 72. You could see yourself with a loser. Spend in six more years just because it's not originally stable. E think for a long stem cementing this application. Probably augment with a structure on. Then additional. You have to use a model block fracture, stem and model blocks. Fracture. Stem has. It's not a cylindrical display. It's got grooves in it, so it provides some rotational stability. But also, I believe there is a recent biomechanical study. Also looked at the diameter of stuff. You want to maximize the diameter muff your cemented stem eso you get the Maxim surface area maximum rotation because you want to get off the center rotation? The narrower your stem is the more torque the moment arms very small. So you wanna get a nice, long, big fixed and then on, especially the first reverses, like the Delta three, You know, it was fully polished. So once you have no personal support, it just a spin in the cement because it was so certain. Move E. I might be a contrarian. In this case. I suspect that this is a chronic dislocation and I would I would probably played her fracture, um, and give her a arm that doesn't hurt and probably had similar function to what she had before. Because I know getting that stem out is going to destroy what's left and you're gonna be left with this large distal segment. And you either have to do something as Bob mentioned, uh, some inter Kaleri graft or I'm not gonna do in a PC and an 86 year old with dementia with a life expectancy of probably a couple years, you could do a diet to steal fit. Um, I think I'd be a little concern. Was Bob mentioned about the bone quality distantly so think you've got a lot of options here, but I would I would I would bet that this is a chronic dislocation and I would if I was my hand was pushed to do something. I'd probably just do a plate cable, play construct. You're not the contrary and I agree with you. That's what I would have done. So if I felt this was a chronic dislocation, I do the exact same thing Clayton struck. But if it's a cute, then I would consider something else. So with you, if you're thinking about considering this being a chronic dislocation, that fracture may probably hell without even the plate. But I will never myself more toe, you know, no surgery now. The only problem is that because the dislocated service locked in position all the rotational portion of the skull fracture sites, that's a short I mean, there's some fragments there, but at the level of just a fragment, it z fairly trans verse on. And you know what the literature shows in short, Trans verse union on hiring on union. So just be clear. So George and Jay, you would have played it. This obviously assuming it's dislocated, dislocated you played it in position just to give her some functional stability and pain relief. Yeah, I probably would have. I would try to reduce the shoulder and see if it looks like an acute injury. But I suspect, uh, that that it's more of a chronic dislocation. If it's an acute injury, I think that build the argument to to consider doing a reverse eso would have that option in the room. But I'm being concerned about her bone quality in a chronic dislocation. I think you're gonna find once you do the exposure. Sorry. I think what you're gonna want you to the exposure of the Delta petrol approach. You're gonna be able to identify whether it's acute or chronic. We'll probably see a lot of humor. Throw sis if it's acute. And if it's chronic, I would agree with Jay. That's what I would do. But, I mean, she's She's 80 some odd years old. She's low demand. She's demented. So I think, as a friend of mine once said, sophisticated operations for sophisticated patients. Dr Kepner, that's a great line. J love it. All right. So I could move on to what my I chose. I was very concerned about semantics, Travis ization on this one as well. So I decided to have cement available and just like Bob said. And J. And George said that it was paper thin, basically taking the proximal so on the approaches. Like George said, it was right there through the Delta petrol approach was right. There was some core coy. There was a big hematoma. Hey, Martha, assist. So I felt that it did have the findings consistent with acute dislocation. So and we did have reverse available. We were thinking about playing it in the dislocated position, but once I saw the acuity to it, I fared well. We could probably give her even a more stable, functional, low demand shoulder. By revising this, I was planning on using a similar technique with the revived stem, but the bone just was socked onto that proximity frag, and I really was no no chance of taking it out. So we kind of dissected away the deltoid origin preserve that and we used a We had a cemented available, but we used a long stem press fit Revive Stem This on the limited user released. This is the longest stem they had on. Guy was concerned about the distal fixation, but there was this pedestal If I go back to the other X rays, it was interesting, right at the at the tip. Wherever this arrow is, there was a big pedestal of bone. And I found, once I punctured through that, it actually gave me a really good fixation with With the press fit there was almost like a canal, like a collar inside the canal that I was ableto as I was trialing. I was like, Wow, this is actually ah, lot better than I thought it was gonna be. And so we decided less is Mawr sort of. We just kind of put the stem in. We figured to be low demand. We repaired the deltoid to the prosthesis. Proximate. Almost like a tumor prosthesis. Um and I am. It was stable. We didn't get a lot of good follow up on her, you know, we did. We did a proximal um, a standard base plate with a 39 plus 3 36 plus three lateral eyes. Glennis Fear I did have to build up length on the tray because I didn't have a long, long enough stem to get stability. But as I build it up on the tray, I was able to provide a stable shoulder and the patient was relatively functional. We saw her three months post op aan den. She ended up sort of starting a spiral. I believe, from this injury on Ben, she had expiring in the nine months post op. I never didn't really steer again. I had looking the records and she went to hospice and expired peacefully. But I thought, I don't know if you know, would you Would you consider putting a constraint polyethylene in her? I would have, but it was actually relatively stable. Once I built a little bit of length up and I was able to preserve the deltoid I think you mentioned earlier. Sometimes bringing those two ferocity is around, kind of take up that space and kind of tension. The deltoid out. I think by having the Delta origin off, you're able to kind of tension that a little bit as well maybe give some inherent stability. I don't know if that's a weird concept, but no, I think I've had called these Double D's. I've had bad problems with dementia and dislocation. So if you're demented, you get a constraint. Polly it in my practice, just from some experience they have, they find ways to do this, locate their shoulder. Yeah, I called the nursing home grab. They grab their. I think they grab their shoulder to pull him out of bed and they pull it forward. So then they are one of our tests. We call the nursing home move or the bureau pushed, grabbed me, try to pull forward on it, it pops out. Then they're getting constraint liner or they're getting a lot more liberalized blends here. E think that happens. I think it was grabbing that Putting forward e you really help this patient because, you know, this located fractured bone is pretty painful. So it was nine months, but my months of no pain. So I think you did a very good job in terms off, making her very comfortable for, you know, her life. Thank you. And I think the conversation with the family was extremely important. As Georgia mentioned early, everyone mentioned I mean, it really was, you know, a limited kind of gold surgery, but I feel in the end was definitely the right thing to do for. And I don't think the surgery began her decline. I think the injury was kind of the predating issue with her cognitive decline in her her health issues that are following Nice. Yeah. All right. So wait 15 minutes for case three. All right, this is going So this this is actually just an example of the patients that get referred. I don't know if you guys have seen these nice rotator cuff anchors. As you get closer onto the sub control bone, it appears to give better fixation. But this is not the patient we're talking about. Eso a 69 year old gentleman, uh, painful reverse total shoulder done by another surgeon. Refer to see me because of pain. Insidious onset, two years out. Decreasing function with no injury. His images are here. Um, he presented with, uh with the press fit reverse total short Arthur plastic. That was painful. I felt his Glennis fear was tilting superior. Lee, there was some lucent lines around his humor. RL stem. Um, I was concerned mostly for infection. Give his insidious onset of pain, and we didn't aspiration 1600 white cells and he actually grew Merce out of that aspiration culture. So I guess one question is, what's the you know, the next step for in your guy's hands for this problem? How old's the patient? He's 69 years old, Okay, Pretty functional guy. Sure. You know, the big I guess you've already done all the work up. The big question is you've got a bacteria. Presumably you've got sensitivities on the bacteria as well on the aspiration. Granted, it's merciless. So it's more virulent. Organism, you know, is this the question is one stage versus two stage. And, you know, the biggest drawback of a two of a one stages if you don't have an organism. And so in this case, you've got an organism, potentially with sensitivities. You start the right antibiotics at the time was during surgery, you put antibiotics for that bacteria in the cement. Is this something where you would consider doing a one stage operation? Um, for me, traditionally it's been to stage and probably honestly, I would still do it to stage. But maybe I'm making the wrong choice because the survivorship of one stage is actually technically better than two stages. If you look at the re infection rates. So I think, um, I don't know. I would ask the guys, Joaquin, would you be, uh, considering one stage? So, to be very honest, I have never done a one stage. Andi, I feel bad about my patients because, like you, I think I should give it a chance or infections. His department is completely against it, so they bias the patient against it anyway, so it's difficult to do. But if there is one candidate distribute the one provided he's also healthy. Otherwise, you know diabetes, you know, complained patient on dso on. But I have no experience. Uh, the literature analysis is tricky because there's probably a selection bias, meaning that they're probably selecting the business from one stage of have a non organism, healthy forces and so on. I've never done it. Have you guys don't want to stage George and J. I've done of several one stages in a couple of scenarios. Usually the patients are older, whether it's physiologically older, chronologically older, and I'm worried about several anesthesia hits. Number one number two is I like to see a less virulent organism. I'm much more willing to do. Ah, single stage benefits, SEAQ knees or something like that. I think if it's 69 he's healthy and he's got M R s A, I would feel more comfortable with the two stage procedure in this situation. The one stages that I have done have worked well on, but I think I have pretty narrow indications. Um, Martin, what in the world stages a today stay on for life from? No, I typically treated him not with suppression, just on the typical aggressive wash out at the time of the surgery. Antibiotics cemented stem, um, on Gueye be antibiotics and then we usually take them off. I've had good luck with that. Our I D department doesn't feel like you need to chronically suppress these patients, but I know that's controversial. E I have the exact same experiences j so typically lower demand older patients. I'll dio one stage where I want to just get the operation done. I actually do put him on six take cultures again. At the time of their vision, I put him on six weeks of I V antibiotics, and then depending on the infectious disease consultant, the other put them on sixth 12 months or lifelong oil suppression. Typically, these patients are on about a dozen medications anyway. So if I add one and the biotic doesn't add much sugar overall, a medical regime, um, another kind of quick question for you as just to get your experience. The patients that you've done two stages for, or even one stage that have failed that have then gone on to requiring another surgery because of persistent pain. Loosening of the implant, obviously persistent infection. Has it been your experience that those bacteria have been mawr or less virulent? And the only reason I say this is that my presumption personally as a surgeon would be that oh, more virulent. These are the ones that are actually gonna be a higher risk of for failure. But for my personal experience, it's been exactly the opposite that if I go into aggressive debridement, wash them out, give him appropriate antibiotics, you get a puss forming bacteria that those are the ones that actually you clear their infection, the ones that I've had that have lingered that have gone on to a loosen stem or whatnot later on 235 years has been a piak knees infection. So, um, or indolent bacteria that have done a full two stage. But maybe because the things so indolent that I can't rid the shoulder of the bacteria and it would be good. Thio, come here. What, you guys thoughts are okay. How about you? Yeah. You know, I was thinking about your question, which is usually is very insightful. And I am I don't remember a single patient off mind that I have to be operating enough start to a stage, even though I have patients with persistent pain, but I haven't proven that they're still infected, so I haven't forced them to hurry operation. Having said that, when we look at the rate off positive cultures in the stage in the second stage waas 15%. But those patients went on correct oppression, and we don't operate on them again. Um, so I don't remember a patient off mind that I have done another operation off to a stage. That doesn't mean that they're not infected. I haven't toe prove that their ongoing pains because they still bacteria in there. Maybe because of lack of follow up or otherwise. Bob, that's a really good question in my experience. I truthfully, I've never had somebody that I think was reinfected after a two stage procedure. I have seen one patient that had humor, all loosening, that I ended up having to revise, and I presumed that she was infected. But she was missing her to Barasa teas, and I think she just loosened over time. It was a couple of years later that she presented with pain and again in the shoulder so so e, because the experience is the same. No re operation for recurrent infection, right? Right, E. 11 thing I have learned is not to re culture them. If I e go back in on the second revision, I mean on the revision when at the time of re implantation, I don't think it's valuable to culture them unless it looks suspicious. You know, there's something if if there's did you get in there and it's the tissue doesn't look good, or there's obvious, uh, cloudy fluid or something like that. But I have not read cultured at this assignment at this time of re implantation. Routinely, I don't know if that's right or wrong, but I think you know, we all know that uh, ree. Culturing culturing implants in general can give you a 15 to 30%. Um, positive, you know, culture results. And, you know, I I just don't see the value in that. Honestly, I haven't been burned thus far, and I've done a fair number of two stage revisions for infection. George any any. Have you had any two stages fail? I'm embarrassed to say this. I haven't. And I was thinking about when you asked the question. Uh, not that comes to mind on my memories. Poor. I mean, uh, and that I probably have, but nothing that comes to mind where I had a two stage field I have had the same problem is Joaquin where at the time, the second stage, I take five cultures and five come back positive. And I've done a big Allah graph press that a composite and I do culture them. And maybe I shouldn't. I take five or seven. I've taken odd number, and I followed them, make sure they grew up within seven days and have greater than 50% positive results. And in those patients, I put him on six weeks by the antibiotics, followed by aural suppression for anywhere from 3 to 6 to 12 months, and I haven't had one loosen yet. That comes to mind. And I think I would remember if I saw one of those patients. Um, I would argue if those were infected, George, that that would fail. But maybe we should revise those numbers from 75 to 80% successful to 100% successful. No, I don't I don't think we know the answer because some patients to have pain on, we just don't. We just don't know if the reason for the pain is ongoing. Infection. I bet you there are a few that are along the same pathway. And I don't agree that more common with see, Agnes, that the patient has still ongoing pain that lingers. And you just don't know why you blame it on the two surgeries, the little stories, whatever e guess it depends on how you judge success, right? Is it re operation or pain or functional outcome? So e think weaken. We're running a little low, but so I felt with the Vera an organism, he was again like Joaquin said the infections these doctors were like, No way, no way No way. And the patient, you know, was very clear. So we did respect, um, the intra operative culture digging from Mersa. Um, and I think most of the things I was talking about are not really Purdon here, but we did, uh, make a spacer with We had to add some banco powder to the to the antibiotic has only had Tober mice and and gentle mice, and neither of which was sensitive to bacteria. So we treated him with eight weeks of an ivy and about Vivanco. His CRP returned normal. He had really not a lot of pain, but its function was quite poor. And we did do a PSA Nova Shore analysis to evaluate for persistent, very prosthetic infection. That might be an interesting discussion. Um, how people are using that and their practice today for Perry Prospect joint infection. But, um, what would you all considered to do now for this gentleman with emergency infection that we think has been clinically cleared? Um, so I mean for me, I don't use nova. Sure. If the patient had an inflammatory markers that were elevated at the time of infection, I used the inflammatory markers to determine that the infections eradicated and then I do not do cultures as day does. If the patient had the diagnosis, infection of the first revision and inflammatory markers like SMC, retro producer, not elevated. Those are the ones that actually consider doing an arthroscopic biopsy before I do my second stage. But in this particular case, I think this is gonna be a I would say I don't want to say the word routine, but a fairly routine. You got a good to barasa t. It looks like you got a little bit of bone loss on the inferior aspect of the Glen. I could probably get a CT scan, and in this case, I'd probably try Thio blueprinted. So the advantage. If this CT scan looks like a normal shoulder, you can kind of sneak it through the blueprint, and it won't classified as a revision and all these blueprint. So in this case, you see, like certainly up high, there's good bone. So I'd probably consider using an augmented implant, and I probably dialed the augmented federally so that's exactly what I did. And I One of those parts about the two stage was I thought I'd get more information about the Glen oId by doing a two stage and then seating it with the spacer and rather than see teeing it with his base plate on before I took it off. But I did try to blueprint this, George, and it didn't work. It gave me an air message. So this is this is a year or two ago, so maybe now the technology is better, but I was hoping that would give it to me, but yeah, I did feel that there was some pretty good bone, actually in fear, like a little pedestal in fear, Lee. And then at the top, there was also a good anterior court cortical rim. So I thought it was reasonable for for re plantation. Um, they wanna comment about the Glen oId or I think there's reasonable bone there. The question is, should you just, uh, can you use the standard base plates? You could put a little graft in there or not. Um, I think you may be okay with just some slight reaming and using a standard base plate here. Um, if you think the infections eradicated, I don't have a problem using a graph, but I would just be one of those ones that would expose it very well. And see how big the cava Terry defect is. Um um, you may get get by with just a standard base plate. I would probably consider reverse to base plate in this case of give me more points of fixation. But you could use a perform, um, base plate as well. Um, if I grafted, I would use the reverse to base plate. I think, um, I'm not the the exact Is that an exact text spacer? Yeah, I've gone thio interesting because most of these infections or grand positive bacteria and I don't like the spacer because the Tober covers mostly gram negative. So I've gone to using the right medical molds and making a flex stems basically and using bank of mice and powder for that reason. But, I mean, that's neither here nor there. I don't know if it really matters on the effectiveness of eradicating the infection doing that, but I know in Canada this this space shirt costs $2700. So for us, it's a really big hit in the socialized healthcare system. Yeah, it's expensive here in the U s is well on the spit, the spacer modes. If you don't own the molds, the right medical charges, like $1000 compared to 20. I think it's close to 3000 for the exact tech spacer at my hospital. At least I used to use the element of special, which has been recalled. It was 2500 for just a mold. What? Quick, expensive cement. All right, let's see what you did. Let's see the action by surprise un cemented s. So I was able to use a standard, basically used the reverse. So the perform reverse. Uh, I felt with my, you know, my image and was able to get good fixation into the base of the of the Glen oId with that long center screw. And then with my little pedestal and clearly and in fear, like I thought I could really set that basically on there. And it actually went extremely well and did not draft. I did have, you know, pro dance available. I had bone graft available, but I didn't feel like I required that on, But I did it on the human side. I did perform a long stem press fit revival 1 30 on. But I was very happy with the with the outcome of this radiographic album. At least you know that's interesting. I've never used this stem in the setting of previous infection. Not, and I think it's probably just fine. But these are the cases I almost always cement and use antibiotics, cement. And at this time of re implantation, I don't know if it matters at all. But maybe that's part of the reason why I have not seen a recurrence of infection with a two stage implantation. Bob, do you usually cement the's in the setting of previous infection or yeah, but I'm still large mentor for the humorous anyways for that, So it doesn't really on that on a perverse. So I think it's a moot issue for me. But, yeah, I put it, uh, cement and put antibiotics in it. I think the bigger question for me was whether you're gonna be able to make this implant work on the base plate. And there's definitely some bone loss in the Glen oId and I guess, anecdotally for me, the Glen noise that I've had the biggest trouble with are the ones with the failed. Loosen Reverse that that those are the ones that are the most destructive for me, with limited options, even an elusive IND an atomic, because the answer vault wall has not been violated, typically by a standard and atomic Leonard component that you still have preservation of that answer vault wall that allows you to bone graft and then put a reverse in. But because the reverse purposely violates the interval wall with the central peg and oftentimes a screw, but mostly the post, then oftentimes that wall is compromised. And then you've got a real problem for fixation if you if you don't have that. So I think it's great that you are able to use the standard implant. But those have been the most challenging cases for me is a failed loosen reverse because really, the once the interval wall is compromised, then you're talking about alternate center line, and whether or not you feel comfortable doing that with this implant versus the d. J O implant, that's a whole nother kind of topic. But whatever it's worth it, that would be That was the biggest kind of issue or concern that I had on this case it looks great. The other comment I will make is that I have no experience in removing this implant, you know, But in the patient that might have a current infection, One of the consensus that if you have to remove it, it almost means an Austrian Mito processes. So in these situations have tended to use a long stem like standard length, but approximately coded and then bongers around it because I am fearful or how to remove the implant. The heavenly movement yet, But I'm worried always. I've removed four of Tom's. So the original, uh, right medical stem that, uh, Dr Norris, uh, created all of them for infection. I actually just removed another 12 weeks ago and I watch it. Eso this one was truly infected to the point where it was just a little bit loose. So I still needed to make a vertical lost iata me, and that was enough for me to actually get the stem up. But in the other cases, I've had to make a full window. And even in that situation, because it's been in grown into the poster wall, um, it can you could be staring at the entire front of the implant and still be challenged to be able to get the thing out. So this last one, I was really super happy that I just needed to make a, you know, a vertical lost IATA me. But in the other something it's not, not easy, and, you know it's partly it's the shape of that implant has that groove shape in it and bone and grows into those grooves, and then it zits really hard to be able to get. You know, it's almost like it's a double fit between the implant and the bone eso. Anyways, e think you mentioned that the new implant has coating only in the upper 20% of the standing e that we should use that university. I think because there's more than enough in growth and then you don't have to go all the way, that it makes a big difference. I provide some some of the longer stem ones, and I could tell you that certainly is challenging that I have to do a window. But a trick is especially with something like a Lima implant that's got those kind of grooves is to stick a K wire from the top down the grooves. So use a styling pen or K wire to fly down the group. So you get the poster cortex, and then it breaks that sort of inter digitization that goes circumvention at the implant, you know, and I totally if you can get intermediary. I totally agree. And the only issue with some of these older people that have had it, it's they get that bone that heals up to the top part of the metal. And it's almost like paper that surrounds that top part. And so, as you try to kind of do this from up top, it just all goes away and then you're left with no humorous and so biomet by modular all over e or e think I think it's, uh I think we're five minutes over. I mean, got a great cases, Greg. Really. Congratulations. Those were great cases. And thanks for being a good sport and presenting and put this all together. Uh, and Joaquin, you know, special for J. Bob and I have you here. You're a good friend and really a mentor. And many of these guys don't know, but I did my fellowship with you. So it's really special to have you on eso. Thank you for being here. Feels like family. Yeah,
