Dr. James Gregory examines revision shoulder arthroplasty of the glenoid with Doctors George Athwal, Jay Keener, and Robert Tashian in the finally of Wright’s “Tough Case Tuesday” Summer Series presentations.
SKU: 014240A We're very pleased to have Dr James Gregory with us tonight. Dr. Gregory attended Medical School of the University of Pennsylvania and his orthopedic residency at Rush University Medical Center. Dr. Gregory completed his shoulder fellowship at Washington University School of Medicine and is currently an assistant professor in the Department of Orthopedic surgery of McGovern Medical School at the University of Texas Health Science Center at Houston. Also with us tonight is our esteemed faculty panel, Dr George Athol, Dr J. Keener and Dr Robert Tashjian. Dr Atthe Walls, a professor of surgery at the University of Western Ontario, handed Upper Limb Center and ST Joseph's Healthcare. Dr. Athol is also a clinician scientist at Lost in Health Research Institute program of Advanced Surgical Technologies. Dr. Keener is a professor in chief of orthopedics and fellowship director of the shoulder and elbow service at Washington University Department of Orthopedic Surgery in ST Louis, Missouri. And Dr Tash is professor of orthopedics vice chairman for research at a secular donkey and junior presidential endowed professor at the University of Utah School of Medicine and Salt Lake City, Utah. And finally, we're extremely honored to have a special guest Panelist with us tonight. I'd like to turn it over to Dr Keener for that introduction. Thank you, Tim. This is our fourth and final installment, and we've saved a very tough topic for the last, uh, last session. This is Revision Illinois. We're very pleased to have Dr Javier Darryl Day. Uh, join us today. Thank you very much, Javier. Er, um, for those of you in the shoulder world, Javier needs no introduction. He's, uh, been a practicing Children. Although specialists in Atlanta for several decades. Uh, that doesn't mean he's old. That just means he's experience. And he knows what he's doing. Javier is very well trained, and he completed the Columbia Fellowship back when Dr Near was still a teaching. So hey, we are looking forward to hearing his opinions and him sharing his knowledge from his extensive experience. And we really couldn't have a better, uh, guest speaker or faculty for this last topic. So thank you. Have a year for joining us today. So with that, we're gonna have James kick off with his slides, right? You want circle kind of police, Pierre. Okay. So I appreciate the opportunity to talk with everybody today, and I put together four cases that I hopefully think will cover a variety of different spectrum of revision gonna pathology. And I'm honored to be here with the sustained, distinguished Panelists and hope people take a little easy on me so we'll get going, E So, First case. So this is a 75 year old who came to me after undergoing a reversal. Arthur plasticky with continued pain. Um, he had undergone multiple surgeries, including a license of adhesions, development of colonial stress fracture, and then underwent an O production internal. Hey, was two years out from that when he saw me with significant pain and very poor function. These are his X rays. So we've got a Grecian and AP First thing that strikes me is the Camille Plate that we've got here. We have significant superior inclination of our base plate. Then it looks like we've got some ice hostile Isis around almost down. It looks like you can see there's a little crack in his accumulate, which will better see another. Yeah. No, I mean, I was curious sense to the panel. How often have you guys done license of adhesions after reverse? Pretty rarely. Um, I think I've done it once or twice. Um, for those rare cases of extreme Bassett's this after replacement. Um, usually, it's something that I wouldn't do for several months. Um, dedicated rehab. I think in some of these patients with extreme stiffness, you have to worry a little bit about an indolent infection. I've seen a couple of SEAQ knees present that way, but it's not real common to tell you the truth is not a really satisfying surgery. In my opinion, I have had some some success with it, but I wouldn't say it's a game changer, but you do need to think about infection in the back of your mind. What do you think? Georgia? You have any experience with that? Have experienced with an atomic? But I don't think I've ever done for reverse on. I agree with you. Whenever I always think of a stiff, stiff shoulder that requires a revision operation, I'm concerned about the infection. Yeah, you mean I've done arthroscopic release probably twice in my career on an atomic total shoulder and you believe, three years exactly 32. But anyway, uh, so it's very rare. I mean, it's almost never necessary in with the reverse. I worry about component placement, whether something else going on infection. Always you worry about as well. But I don't think I'd ever tackle a reverse arthroscopic, Lee. So I think what I was going to do, that I'd be doing an open approach on possibly doing some kind of revision of the components at the same time. James, can you go back to the AP views on that view on the left, The true AP view. Obviously, there's some scapular tilt, so there's some deltoid dysfunction there. But you see that indentation in the soft tissue there? Uh, it makes you I mean, I've seen deltoid emulsions that kind of look like that. I'm just wondering his previous surgeries. Did he have, like, an open cuff repair? Or he had that open a chromium plating. Okay, they you know, you're basically reading my slides for me. So they took down his deltoid officer cro me in and then put that big old played on and, you know, didn't really repair it. And so he's got a huge deltoid avulsion, which contributes to his poor active motion. Yeah, tough case. A Z still heard of the Crimean or is he just kind of hurt all over? He heard that the chromium, because he's got a criminal non union, you know, broke through the plate. But he also hurt, so he's upset about his poor function. He's upset about paying over the chromium, but he's also upset about he's got a painful Arthur plastic in general. Just abuse me around the shoulder. Yeah, it's where that fracture is on the plate. I mean, that would indicate that it's it's in a chromium fracture. And it's not a capital spine fracture, you know. So those are the cases in which I just think the R F has such a significant complication rate, very little benefit that probably best treated non operatively. You could make an argument if it's the spine of this cap of an entire deltoid is off that perhaps you should fix it. But this year seems like it's kind of overkill. Interesting thing here is that the plate actually fractured. Typically, what you what I see with is that the bone becomes you lose fixation. And so what this tells us is that although the bone that is typically poor, that she has pretty good purchase into the Crimean to get a fatigue fracture of a plate without the chromium pulling off, which is usually what you see. Just interesting. Yeah, it is interesting. The fact they've gotten a criminal satisfactory. Begin with quality bone. So first thing I did with Dr King, you mentioned I sent him for an aspiration infection work. Negative. By the time he followed up, his screw had eroded through the skin on his Comey a plate. So now we had open hardware over his a chrome ian on DSM. Superficial, perilous around that screw. So first thing I did was I deny, indeed, to displaying screws. There was no deep Carolyn's. I found that deltoid essence that we were noticing on the initial A P X rays. I tried to repair through bone tunnels with non observable suitors treated with I v antibiotics, Um, and then with the plan for a stage provision weeks later, because I don't want to do a big revision in the setting of ah, superficial peril infection. So here's when it came time for the revision. So what I found was a central defect. So he had that super inclination of his base plate. It was basically was well fixed, but I was able to remove it and leave a central cava tree defect on. But I was able Thio base can sell us Allah graph through the defect in the news. Say which basically help correct this version. Um, Then I used a san flex stem approximately tapas. You goaded stem with the 36 million hemisphere and Central trade plus six policy. Um, so that's why did initially three years post op. You can actually see, I think nicely. You could see incorporation of the in proportion of annoyed into his. Uh um, unfortunately, with his deltoid dysfunction, uh, he never really got very good range of motion. He had some pain relief from his preoperative presentation, but his a corneal nonunion and his deltoid dysfunction limited him. You didn't really gain much movement. You just had some painful. So, James, when you what was your thought on? Why did you revise the shoulder? I mean, do you do you think? Did you were you concerned about stem loosening or was the Glenwood Inclination your biggest issue? Because I thought I thought the fact that he was getting osteo license around the human component. I thought that that indicated is getting Polly wear potentially some notching or not notching, but potentially some impingement on the interest. Illinois. Um, right here. And so I thought that that could have been a source of pain on DSO. I knew I couldn't really fixes a corneal nonunion, and I tried to fix it, but I didn't really expect that to be successful. And so I thought, if I could give them anything in terms of generally eventually potentially preventing bony impingement on Major E Yeah, James, did you take cultures? At the time of revision, I took cultures not at the tide. Took cultures that the initial um I Indian aspiration, but I didn't e I did. I did Alfa defense again the second time, but I didn't taken hold. Cultures be interesting. I mean, I think you know, one question is you know, e think that X ray on the left shows I think on the medial aspect of the stem, I'm not sure if that's just kind of, um, you know, shadow. But it looks like it was loosened. And so that's the the stem come out pretty easy when you actually, uh, did the revision or No, it did. I mean, I didn't have to do in Aussie Autumn me, So I was able to just slide. It didn't come out. It wasn't grossly loose, But I was able thio just slide nasty to him around the side of it and then easily take it out on and simply, yeah, because that stem is notoriously like even in the UN cemented state extremely hard to take out S O s. Oh, yeah. I mean, that's kind of what I saw. Is that the license around the media card? And so I didn't think it be difficult to get out. And it was we were able to I've got a very stressful for doing an osteo to me to get out stems. And this one was very easy to get out. Um, So, George, I know you, I guess just to finish the thought was that Do you think that there's a There's a possibility that despite having Alfa defense in and aspirations that were negative, that this could have been a presentation off indolent infection that you treated with a one stage anyways by removing it, but it would it would it potentially might make sense that for the stiffness and poor function, etcetera, that maybe that that was that was the case. And I just It brings up the question of Should we be getting cultures on on what? Which revision should we be getting cultures on? And I guess, George, what would be your indication for a culture at the time of revision? Um, so So if I was thinking of doing a Wednesday division, um, and I wanted to play someone, so I guess let me go back. If it's is a mechanical cause for failure, I tend not to get cultures. If I have a suspicion of infection attending the cultures, if I have the option of retaining implants, then I actually do it arthroscopic biopsies because I want to be absolutely certain that if I could preserve an implant on one side or the other that I could do that safely and have my arthroscopic biopsies to prove that, um, with this case, I mean, if you go back, one slide and you look at the AP film or maybe two slides, three slides I've actually seen cases like this where you were on the one view. It looks like osteo Isis. Then if you look at the image on the right, you don't see it. And sometimes you get this artifact from the X ray. Um And so although I mean clinically felt that it was loose. Sometimes I've been tricked this way where I think that it's loose and then you get a couple X rays. You see, the next section actually looks pretty good. Um, the other comment I would make and I think Jay mentioned this earlier on is that there is a substantial amount of scapular tilt in this patient. And when you see scapular till it, I think our mind trains us to think that Glenn oId is securely inclined. But if you see the line of the Super Smiles Foster, I'm not Sir James. Could you put your mouse a little bit lower right there and follow that line? So that's usually an indication of somewhere around, you know, plus or minus 10 degrees from the inclination. So three inclination on this is it's probably a bit inclined, maybe five or 10 degrees, but certainly not excessive. And I think the scapular tilt is what gives that impression that you have a fairly profound, super early inclined base plate. Yeah, that's a good point. I've I've heard, uh, I've heard John Levy mentioned that when he on his a chromium stress fractures, he sees ah, fair amount of notching because they're they're hiking their shoulder so much there. Constant, relatively abducted on they get some abduction impingement, creating some watching eso Um, I guess there's one other issue here to talk about. It's kind of interesting. I don't know the right answer, but when you see deltoid failure in the setting of reverse, I don't know what what you're all success rate has been with with repair. But the reverse, obviously the arm is lengthened. The repair is going to be under tension. If you're thinking that you're going to revise this, um, to another implant later, let's say you don't think it's infected, but you're doing a deltoid repair. You're concerned about the component position. I wonder if there's a role for actually just doing a is removing everything and putting a little hit me Arthur plastics spacer in repairing the deltoid and then coming when you come back in revising it, um, to another reverse. That's where the components are better position, and you've given your delta a time to heal because it's not under attention from the arm lengthening. So obviously, this is a complicated case, and there's probably multiple pain generators and hard to know exactly, uh, what to do in in these scenarios. But I approach infection very much like George does. Eso If I there's a mechanical reason Thio for failure. I don't routinely culture at the time of revision. If I'm suspicious of infection, I do. And if I think I could retain the implants, I do do a lot of scope biopsies. Thio get tissue because I think that's a better way to rule out infection. Multiple people have shown us that, including Bob eso Javier Or do you? Do you routinely culture all revisions? I do, you know, and I don't You know the aspirations don't work because the organisms air stuck into the biofilm, so I don't really pay much attention. That one thing I do do pay a lot of attention to with the it's frozen section. So although frozen section on all these cases and look a number of polish for high powered field and that kind of guys Mia's well. So if I have a very benign looking prosthesis, you know, I see some mechanical issues and then I get, you know, just very few Polish for high power field. I'll proceed with a revision prosthesis, and then they'll take cultures. And then I'll usually, if I have any suspicion, it all. I usually put that patient on oral antibiotics until the cultures come back and then they come back positive. I'll treat him for six weeks with I v antibiotics, depending on the violence of the organism. If I do the frozen section and it looks like it's grossly party lent or it has, you know, a lot of Polly's per high power field, and then I'll put a spacer in and then come back later, treat him and get the final cultures, and then usually come back about three or four months later and and revised the thio another reverse. I think deltoid repair really is, um is sort of wishful thinking. More than anything else, you know that muscles under tension and and basically, you know, I used to do it. I, even for a while, of putting graft jackets over to see if that would help. It is well, and nothing really seems the work. It's just, you know, the world is fighting against you. But I think what you have to remember is, um, even in patients who can't elevate the arm, the ability to rotate and use the arm below shoulder level. If you relieve their pain and restore some rotation in that patient, they'll be much better often than what they were. So it's definitely worth the effort to revise them, just like you did, James. Yeah, um, two things that we just Sorry. Go ahead, Bob. No, I was just gonna say, just to finish out the deltoid issues, I think the mawr common scenario that we often face our patients that don't have a reverse shoulder implanted yet so that they've had some open surgical procedure cuff failure. Um, and there's some level of deltoid dysfunction that's present. And, um, or they've had the cuff insufficiency and that they have a primary middle deltoid head rupture, which we know can occur. Just this, you know, as a native, you know, entity without necessarily having prior surgery. I guess that probably case we've seen a lot more than maybe the reverse that needs to get revised. That already has a deltoid related issue. And so I guess my question would be, you know, to the panel would be in those cases, they, uh, native shoulder or native in a sense that's had prior surgical repair for the rotator cuff has some level of deltoid dysfunction. Um, do you one stage it so you go in and do your reverse and do either kind of side to side implication or trying to bring it back or grafting or whatever your decision due to stage it? And then, um, similarly, um, say that that the deltoid is so far gone. What is a reasonable amount of deltoid loss for you to still proceed forward with a reverse shoulder replacement? It's just anti ahead alone. It's anti head that moves into the middle head or kind of extending even beyond the middle head of the deltoid. What is kind of a A. It is still a reasonable on muscle that you still consider doing a surgical a reverse for the patient to improve pain relief in function. Georgia, I'll start with with So if they have painless lack of function with Delta auditions I'm a little bit concerned about that. I would probably stage that I would do a reverse, see how they well they did. And if they didn't do well, then I do a flip pick If they had pain. I agree with Javier, like if you could take a patient's pain away and give them good rotation, I would do that. I would not do the foot peck, uh, in association with the reverse. I tend to do it stage so I do the reverse first, and I tell them that they're arranging ocean recovery is going to be unpredictable, but their pain relief will be predictable and in a way to, um, And so that's how I approach that one. Um, I would do it staged afterwards. And the other thing that is interesting. So and Javi is absolutely right that we actually looked at our reverse patients after we had done surgery on them and follow them out. Less than 1% of the time is spent above 90 degrees of active for elevation. 99% of their day is spent below 90 degrees, so if you could give good rotation, good paid for emotion below 90 degrees. I still think they have a high satisfaction. Right, Javier, how would you? How do you approach kind of your your patients with, uh, you know, failed open cuff. There's some level of deltoid dysfunction. It's usually some rent that's there with, uh, you know, divot. That's there. And then, um, probably the other cases are ones they've had open Prior Delta petal approach for whatever. You know, uh, you know, a proximal humerus fracture, something like that. That then this kind of lost an entire section and head of the deltoid or even in revision setting. How do you approach those two separate eso depends on it. Depends on the status of the rotator cuff. So I just saw patients today. Four month follow up for that exact sin area where he had complete loss of the entire middle heads of the deltoid current large rotator cuff, tear and, uh, you know, obese. Uh, 48 year old woman, you know, So but no arthritis. And so I took her to surgery, did lights of adhesions revision decompression shit for decompression and did a cuff repair. And she came back today at four months. Extremely happy. She can rotate. She could reach her x l a. She could reach your mouth and she could reach up her because she's got a good subs cap and she she got 30 degrees of elevation. But she got 3/5 strength so supine she could raise the arm up happy, you know, told me that about 10 times. So I think if you can fix the cuff, try and do that. I didn't even attempt to do anything to the Delta yourself. Well, she had innovated deltoid as well, so different. Now, if you have that scenario and it's irreparable cuff and you're looking sicker, there's nothing there to work with. I think that you need, you know, if I have ah, isolated loss of the middle head of the deltoid or anti your head of the deltoid, I'll consider doing it because if the entire heads down, they still abduct and kind of bring the arm out sideways and you use it and have some function you know, at at Children level in the same with, uh, if you know the middle head's gone, they could still have some forward elevation. They lose the two of those on a massive rotator cuff that I just don't see you have much to work with. Very few patients would be, you know, candidates for fusion. But I mean, probably the breed Mont do little or nothing on those kind of patients in my hands. And maybe that's the patient George that you were talking about. We're doing the transfer and that if you have kind of gone all the way around the side, then you're talking about Boston's tech transfer toe. Try to help him. We have a We have a question from the listeners before we move on to case number two just, we'll just quickly scan the panel. Any indication to revise the Crow male fracture? Javier, in this patient? No, no, it failed once. He's gonna fail again. Yeah. Uh, no. Only if it was a spine fracture for May J. Yeah, I agree. Just the location of the fracture. I probably would not have fixed it at first. And the spine fractures are there different players? I would. I think it's worth fixing those. I've never revised the failed our f of the spine fracture, but I imagine if there's not too much bone resorts in at the fracture site. You could consider that. But we know that people with a chromium insufficiency prior to reverse do well and even the ones with the post op chromium fracture. As long as it's not involving the base of the spine or the, you know, base of the chrome Ian or medial spine they do. They tend to do pretty well. They lose a little bit of elevation motion, but I don't think that's enough of an argument to fix it, so I would not able advised it, either. Segue. Case number two I thought this one because it was a central contained defect. This is how to address revision clinically deformity. I grafted the central defect and could easily gain central food purchase. So Case number two So this is a 67 year old underwent a right reverse for 2015 presented me three years after the index surgery, had really, really pretty good active Ford elevation, but have significant pain with a deduction. So we heard whenever his arm was down by his side. No pain with a deduction or movement around the arm when he was elevating it. No history of instability. And so here are his X rays, So same thing we've got to AP views way, see superposition of the base plate. We appear to have appropriate inclination, but there's a certain amount of bone in proportion of Illinois way, which makes sense when he's hurting when he's a deducted. Um, it looks like he's in pinching his Glenroy tray or is metaphysical force humorous? I proportion is finally okay. This is excellent. It's a J. How would you approach this one? Um, well, I think James has kind of nailed it. The base plates high, and sometimes that's well tolerated. If if you're a Missouri medium and your 253 £100 and you've got a big a big biscuit underneath your arm, you're not really spending a lot of time abducting. So sometimes, um, that's pretty well tolerated, but, um, I would approach this with a C T scan. I tryto better objectify where the base plate is. You can see just where the central screw is and, uh, the reference of the base plate to the superior, literally that it's high. Now the question is download. Where's the native joint line? Because some of that bone is probably reactive, hetero topic bone. But I get a C T scan of the shoulder. Um, if you're concerned about the hue mural implant, Uh, sometimes on these revisions Uh, not so much in this case, but instability cases. If the implants put in too low or there's a length issue, you get full length humorous films. I don't think I would do that in this case, Um, S O I would probably get a C T scan. And you know, I think it's reasonable to revise this on, Duh. Revising the base plate with the thought of retained retaining the human component if it's well positioned, Sometimes you get in there and you find that the versions way off or or if it's not a platform system, you have to revise this them. Anyways, eso those were those were kind of my initial thoughts. Is this a striker? Uh, a strike? It looks like a striker. Sometimes, uh, it's got 135 degree head neck angle. Yeah, Sometimes you can keep the base plate. And if there's Glynis, fear modularity options where you can either latter lies or or have some east interest. ITI to bring the head center down. You don't have to revise the base plate, but I've seen a few of these that are way off, and there's actually they're actually fairly easy to revise because there's enough real estate of Glenroy Bone in Fear, Lee that you can get primary fixation. So I've seen that a couple of times, but never we ever considered just doing a notch plastic. So just going in there and removing that bone is that an option? I think it's an option if the base plates recently well positioned, especially if you can add a little bit of lateral ization on the Glennis fear or some eccentricity. But and you know, when you get in there, you're gonna find a lot of Polly wear in fairly. You're gonna find a ridge of bone. You can certainly bird that bone down if you carefully exposed the in fear of Illinois in exchange the poly. But you know you have to make some type of a judgment if you think, um, if you think that's gonna be enough and that's hard to do sometimes inter operatively. But I have done that on cases where there's Mawr bone projecting laterally But I think in this case, I would be concerned about that. It probably consider, uh, either modularity options on the head or advising the base plate. Uh, would you do anything different? So I look at the left hand ax right there and that that component is already contract is already pretty lateral eyes. You know, something worried about putting in a Glenn was fear that was bigger or more lateral eyes. But I agree that sometimes you can if you have any centric one that you can rotate downwards and cover, you know, the inferior part of the Glen oId rim. And perhaps between that and removing some bone there, it's possible to do it. But sometimes it's a mess down there, you know, with with Polly wear and the inflammatory response a patient has to it so often, the bones of worse condition than you expected to be from the X ray just because of all the, uh, Polly debris. And then they're the microfiche reaction to it. So I think more often than not, you wanted improvising the whole thing. Um, what did I dio? That's the whole thing. So when I got in there, I found that that stem was 20 degrees and averted. You can kind of get a hint looking at his axillary x ray back here. Eso I felt it was appropriate to revise that stem. I was prepared to retain it and try to just provides the late But I ended up doing the stem was well fixed, so I ended up doing an aust IATA me. I create a little estrogenic frosty fracture that was non displaced. And then I actually found his base plate was loose so that basically it was completely loose. It was very easy to remove. E was actually, as you pointed out, I was able to use the inferior Glenroy, which was relatively well preserved and then used a full wedge based augments, um, to help. Correct appropriate position, inclination. Pretty good purchase of our central screw your base plate position Looks great, James. I think this is a good indication for the augment as well Give yourself you're gonna you know, you're gonna have bone loss. A purely obviously. So you can make that up fairly nicely with these augments. Um the great existent. Sorry, sir. Go ahead, J, I'll go ahead. E I was gonna ask you so J, in this case of with a loose space. But when you consider getting cultures at this time Indra operative, I would I would culture that because I wouldn't expect Anabel rent position base plate to be loose, so I would probably culture it. Um, I would do frozen sections as well, because I have to make a decision at the time of surgery. And I'm gonna advise this or am I Do I think it's infected? Um, but I don't know. The utility of frozen sections is debated. I think there's probably a role in borderline cases, but I would I would culture it. I would wash it out as if it were infected. Changed my gloves, changed my gowns, get a new table in the back and try to put this new implant in a sterile as I can. Um, I don't know. What would you do, George? Would you culture it exactly? I mean, I agree with you. It's pretty rare Thio to find a loose Glenroy basically s Oh, I think I would agree with you. I would do a, um, culture at the same time. I do aggressive irrigation department probably treated like a one stage and put him on I V antibiotics until the cultures come back. Mhm. But this looks great. Bass player looks perfect. It does look good. I had a patient like this. It was a renal dialysis patient. And the bass player was completely displaced. Sure, she was infected. We went into, you know, revising and got in there. And it was Paul Polly wear, you know, And, uh, frozen sections were negative for any type of bacteria, and cultures came back negative. So, I mean, it does happen for different Polly, where I would agree with probably more likely to be infection. You gotta be very suspicious of it. But sometimes that can happen. You know, thes augmented base plates for the revisions in the primaries that tend to use, you know, autographed photograph from the human head. But I think these air really very versatile in these kind of defects. James, with this, So is the Cirque Lodge there securing your tube rosti factor? No, it's a currently osteo bi. Okay. And so you're to grasp the fact it is pretty high, though, right? It looks like it's very high. It's right. It's right here. Yeah, eso. It's just essentially, I went back to the first of the pre op film. Yeah, that one. Just so the only thing I'd say about this is this is the striker base plate. I'm almost positive they tried to replicate the D. J O N Plan. And so I don't think that there's a central post or any in growth central fixation. It's all screw fixation. And so I personally think that that there's probably a to see a loose base plate with This would not make me as concerned with regards to infection simply because I think if you've got any type of mechanical problem with inside the shoulder, you're probably a much higher risk for having this base plate loosen as opposed to something with an in growth post or central kind of fixation. So, um, whatever it's worth it, you know, there's nothing for those screws to grow into. It's just, you know, stainless steel or titanium. And so, um, it's something I would think about that if you're gonna when revising a base plate that is all screw fixation with no uh, in growth post that you might have a higher risk of having a loose base plate without infection. Um, the only other thing is like if you look at your you can see your your left handed image on the left side. And then if you scroll forward to your post op that you're chromium humorous distances probably increased by, you know, double. And I think that's probably or at least 1.5 that you clearly lowering your sphere. But I think it's also, um, the type of humor Elim plant that you've used. And so that s O. The only other consideration is I think this looks great. But if this was, say, a 75 year old female, um, I might get, you know, osteo product. 75 year old female. I might get a little bit worried with bringing her down that far from where she started and maybe consider something Mawr kind of in Les instead of online toe may be uploaded, but those I don't know, those would be my only thoughts. I think it looks great, though, so I was pretty happy. Patient was pretty happy for a six week post op visit, and he was out, told me he went hunting and went was in a deer stand and something was falling off the deer stand. So he reached out his like ammo box or something. Um, so you know, I thought I was putting him into tight, but clearly not. So we ended up revising him. I found that his human stem was actually loose, so I advised him to a daffodil president stem. I think in retrospect, that greater to brasi fracture that I didn't make too much of, I think compromised enough of his fixation of that metaphysical stem that it it didn't really work. That putting them. Uh, no eso I picked this one because this was superior inclination of basically a superior Illinois bone loss category defect. But we didn't really have to address it because we had enough real estate in purely to just basically play it as it lies. Eso we didn't really have toe to do much beyond usedto basically to address this plan. So case three This was a 64 year old male with hemophilia who underwent a total shoulder in 2009 did well initially and then gradually had worsening pain limb to function. Now he's got 10 out of 10 pain. Very poor active motion he's got will preserve passive motion and significant rotating weakness. Here's his initial X rays in 2009 s so we can see what looks like a field components Looks like, you know, people have position, maybe a little bit high dial high. But the Glenroy it appears to be, well, positions or the country component is well positioned. 2019. Can you go back? Yeah, so was he's got an anchor in his greater to Barazi. So he's had a cuff repair. Was that done prior to the time of the replacement? Do you know or at the same e Don't know whether it was done before, but he had, He said after surgery he had excellent function, so I don't think grossly insufficient time. A human head looks like it's touching the a chromium there, you know? Yeah, Glennon components high also, which would also probably promote the human head from going on. You see, the keel is almost at the level of the Super Hispanics fossa and and these were put the initial The surgery was in 2009 right? There's initial post op X rays. You see, the state. The state staples on the right, actually, but you don't see the smooth. You know, this is for user benefit. Once, two weeks later, then no. Yeah. So in general Bob, what? Your thoughts on doing an an atomic replacement in a patient who has had a previous cuff repair. If you think they're cuff is intact and they they don't have proximal migration, Um, do you? Does that concern you at all? It does, And I've I've gotten to the point where it's extremely uncommon for me to do in an atomic shoulder replacement someone that's had prior rotator cuff repair despite having kind of a memory. Even that shows that they've got a healed rotator cuff just because of the overall quality of the rotator cuff. Integrating into the into the you know greater to ferocity. It's interesting that last week I saw patient who she was post from a rotator cuff repair, and she was perfectly well centered memory. It was perfectly well heeled, and her motion was excellent, but mostly it was internal rotation. That was great. And so I told her this exact same thing that, you know, we went through this, that I normally would do a reverse shoulder replacement for her. Specifically, I am going to do in an atomic because I'm afraid that I'm probably gonna lose motion with her if I do a reverse. And she might very well be unhappy. S o. I think there are cases. We're doing a reverse. I can Atomics. Reasonable. But I'll be honest, like nine times out of 10. I'm doing a reverse. How about you, J? I've done it and I'm concerned about it. I don't know what the right answer is. I think that I would I would definitely one image ing that showed not only the cup was intact, but the Muslim bellies were healthy. They would have to have good preoperative range of motion. But I've done it and I've not. I've not been burned that I know of, but it is a concern. I don't know. You know, it's an interesting thing to talk about. Well, I think because I mean, if you know, if you like reading about an atomic Arthur plastic in the setting of a full thickness rotator cuff tear, it would suggest that the outcomes of an an atomic replacement are not influenced by the status of the rotator cuff, meaning the presence or absence of a terror. Even in Paschal's, you know, paper that him and I think it was it was Brad. I think that maybe was butch, that showed that it was the muscle quality of the infra spin. A tous was predictive with regard to the function of the an atomic. It had nothing to do with the presence or absence war, the presence of a repair or not a repair at the time of an an atomic shoulder replacement Joanne Audie and Tom Norris. You know the same thing in their data and but did the same to Yeah, but I'll be honest anecdotally for me every single time I've done an atomic replacement and done a rotator cuff repair. The patient comes back, and either they're painful and weak or I gotta convert him to a reverse. So I hate toe practice anecdotal medicine, but I'm like, I'm not going to go there again. And you know, you do it kind of a couple of times, and you're like, I'm not going back. And Javier, what? What's been your experience with that kind of very similar very similar to yours, you know? So you know, we used to always say the anatomical is indicated in in, uh, intact and reparative cuffs. E think that's true. So if a patient has a tear the time of surgery better off this with the reverse to start with. If I had a patient who had, like, a small cuff repaired years before and the imaging looks good like they've got good muscle bellies and it looks like the end of the, you know, healed Fine. I'll think about doing an atomic in those patients. I also feel like the cuff is gonna let you know during surgery sometimes whether you're making the right choice or not, because you started doing external rotation and the cuff tears off and let you know that was parchment there. And so So I team up for both, and I tell them if if it's I just say if it's poor quality during the time of surgery, we're gonna do a reverse, and so I don't go through the details. But if I'm actually rotating and dislocating and it tears off, they're going for a reverse. It looked like 10 years later, in 2019 um so we can see if you look at the metal or the little regulation markers of the keel on the extra in 2009 you can see that significantly migrated in 2019. So we don't really see those as well on the axillary. What we see them translated more post yearly thing. They were here. They are centered in the glen. OId looks like they've moved most clearly, so it looks like one component is possibly loose and has migrated. Posters superior. Another thing I look at is if you go back to you, look at the position of the greater to Broschi in reference to the lateral aspect of the Caribbean. So go back when slide if you could. And you see there's about a centimeter to breast about a centimeter latell to the corona and you see the next film that's me realized on so many times. In this case, you were really good because you can see the Glenroy failure. We've had cases where the Glenwood actually looks pretty good, but what's happening is it's just slowly migrating, and even though it looks good, we know it must be loose or slowly becoming loose. just by looking at the two bras too. So I got a C T scan on this. Um, this is a cut on the left is the in proportional Glenroy, which you can see the Glenwood Component appears. You know the position, Superior Lee, you can see that, uh, the clinic component appears to be completely uncontained. And so it's worn out of the poster super aspect of Illinois, which is consistent with what we saw. Radiographs. So it looks like a loose, gonna component, significant pusher, Superior Conroy, bone loss, um, and likely rotator cuff failure based office. Sam. So here's what I did. So this guy is, as I mentioned, severe hemophiliac. So it was an ordeal. Getting him optimized for surgery, you know, preoperative invention. You know, factor seven for, you know, several hours and then mission outwards. So when I got in there is his preoperative infection. Work up again was negative. I did take cultures on drop. Really, Given the loosening, I had thermal had telegraphed available to address the bone. Um, if I thought I needed it, but I was actually able to do this in one stage. I use a little bit the alternates Capital Line to get fixation with my central screw, as able to reference the infra portion of Glen oId and use a half wedge base plate, um, to and I'll have to post your support to post your super portion. The based played a little bit uncovered, but I had approximately 80% coverage at the base plate. Eso I felt pretty confident with that. I didn't want a two stage in because I don't want to come back and someone with significant medical capabilities. Um, so you know, I used to have so fitting stem, but I'm pretty happy with the fixation was able to get in with a challenging clinical deformity. Mhm. So I've got a SYRIZA about 10 patients like this, and many of them were frail like this guy, where they show up in their their high risk for surgery. And I've gone and done arthroscopic excision of the Glen oId biopsy culture at the time to see if they're infected and they've done pretty well. What was this guy's function pre out very port. So he had, I think, 60 degrees, 80 degrees of active Ford elevation. Andi Way had actually I you mentioned that Because that was the interval step. I actually wasn't this guy, but I've done that before us. Well, and, uh, you know, it's been mixed results is cuff weakness and poor active for television That though I ended up deciding to go with the reverse, But I think that's great. Interesting. If you go back and look so if you look in a C T scan, he's actually surprisingly, is infra spices. Subs cap have almost almost no fat infiltration. When the image on the left just a surprise. Yeah, yeah, you know, it depends, I think, on what the functions like what the patients like and risk Andi. You could also do that The stage procedure, you take the glen or it out. You do your biopsy to find out whether you have an infection or not. And then you can judge whether the patient is gonna be happy that way or not. And if he is, you can let sleeping dogs lives. We say here in Georgia, or take him back and do the reverse later. Yeah, I think I mean, for me, the arthroscopic Leonard component, Great pain relieving operation, at least personally. And I know that people have had kind of different opinions with regards the effectiveness of it. But I think it's been, um, tremendous. You get a all that debris out. Oftentimes a Glen Oise cracked in half or it's sheared off. And, um, from a functional standpoint, though, I haven't necessarily found very much improvement for patients that they're still weeks still can't raise their arm. But, like you said, if someone starting out with decent function, 90 degrees of elevation and then maybe it's just a big pain issue low demand, I think that I agree it's a great operation. Um uh e I think I've got about 10 or 12 of very similar to Javier. And it was My indication was either the Glen was loose or they have a painful shoulder that you're gonna go in to do the cultures on to take the five biopsies and the Inter operatively ahead about three of them that we identified that the Glenwood was loose and if I looked at all of them, about 50% of them did well, 50% of them will end up getting revised. So, James, can you talk a little bit about the alternate center line and how you find it in the O. R. And like is are there some tricks that you can use to find the that column a bone that you're looking for? Maybe just for the for the for the audience. Yeah, And so the idea is, you're really Instead of the normal kind of perpendicular to the normal Glenroy face, you're going to really try to get your center pin or the access of your center of your base plate through the high quality bone where the established by Mrs Scapular body. And so that's gonna be more an averted than your normal, um, access. And so what I do is I slide my finger around anti early and do it under PAL patient. And so, basically, you know, I can feel where that column of bone is with my finger and I'll shoot my guide wire. You know, freehand essentially and kind of palpate with my guide wire. As I get down and estimate the quality of our the depth of the vault that I have with my guide wire. Compare that to the length of the boss that I have on the back of the base plate. and determine whether I'm gonna have enough to actually get a screw past the boss. And in this patient I did. So I felt comfortable doing a one stage. If I don't, then I would do a two stage. But that's, you know, you're basically trading the version of your base plate pay putting, um, or an averted for getting better bone, which is very helpful in revision situations like this. Yeah, I agree. I think you raised several good points. It's it's helpful toe palpate along the anterior Illinois ball. I like to sound of the vault, so if I think I have the right access, I'll use a two millimeter drill and I'll just bounce my way down and feel the depth now. Interestingly, usually you have thio in fairly tilt the base plate Thio, aim the screw or the post up towards the confluence of the scapular spine with the body. In this case, you didn't do that, but a lot of times, not only is it an inverted, but it's it's a little bit in fairly tilted to angle up, but but there are some some you know. Obviously, Floro is not gonna help you a lot, but that's sounding the vault to find that deep bone. Um, tract is very helpful with a small caliber drill, and then you put your guide pin in and you do all your Glenn White prep over that. If you if you had luck using a post Central post using the ultimate center line technique, because I'll be honest me personally, I haven't that. I think, you know, obviously, Mark was the one who describe this, and he was using a central screw construct as opposed to a central post. And I have I have kind of felt that I'm either I miss it, Do you know what I mean? And clearly going out the back of the scapular spine is a very is a bad place to be because your fixation and, you know, with your If you're so anti averted, then you're really you're relying on almost nothing in the back of the Glen oId, and you're probably at high risk for failure. So e guess that would be 11 question that I have for you and the other is a lot of times when we're using the alternate center line, it means there's substantial bone loss, and we're using that technique to be able to put a standard base plate in, which means that were significantly medial ized with the placement of the base plate. And so I guess, um, you know, the D j O implant. The benefit is that they have a tremendous amount of lateral ization that they can place on the sphere to be ableto compensate for that, um, medial ization. But other implant systems, including right, we have some. It's not as large with that system. And how have you kind of thought about needle ization, lateral ization, and then the ability the use of a post versus a screw. So I'm not sure what the right answer is. Every time I've done an alternate center line, I've used a central screw because I want that far cortex, uh, fixation on that and really want good compression. Um ah, lot of times, because the bone in the front is actually reasonable and you're an averting with you when you ream a little bit, you've actually got some adequate bone to support your implant. I wanna have it least 50 60% mawr if I can, uh, in this case, um you don't have obviously opposed. So you're not gonna have on growth in the vault. But you've got a boss, and I think that there is a least partial on growth onto that. And then lastly, I think your point about medial ization is very relevant and I will try to use I have used in thicker base plate, like the augmented thesis metric Lee Thicker base plate and then used a lateral eyes. Glynis fear on those cases because otherwise you the whole thing is kind of buried fairly medial under the conjuring attendance. So I think if you can get some lateral ization through your base plate into the Glynis Fear, I think that that that that that is ideal, but the alternate centerline can bail you out. But it's very tricky knowing how toe to put it in. Right. So it does take some experience. Um, looking at the extras here on the left, where you see the super spin it is fossil line. Um, I think the alternate satellites probably just just inferior to that. And so what I found is that when um, I use the alternate center line, I typically have to use e collateralize. But after being eccentric sphere, especially if I'm using a high head neck cut next time using a 1 45 or 1 55 degree in plant, you have to dial this fear down to bring this fear down because my base plate is high in anti verdict. Yeah, it is your right. Yeah. So I e think although you got great bone purchase your I probably would say that the alternate centerline is probably just a little bit higher than where your base plate is here. Um, yeah, and I had, you know, I could I had to try to match the defect. And so I felt if I tilted it to inferior there, I would compromise my fixation on the wedge portion base plate into the defect. And so then I knew I was going to have toe. I think I was running out of fixation if I would have unfairly tilted it too much. And so I tried Thio think the best thing I could, leaving it at a reasonable inclination. And, you know, I think you can argue. Maybe I'm a little bit superior, Lee inclination there, but, you know, ended up Okay. Nice thing about this base plate is the poorest on growth. I mean, I've been very impressed with the poorest on growth of this. If you just talk us through your press fit long stem versus cemented stems What is your preference, James? It's obviously did you use the limited steps? I love the president. Long stems. I like, particularly the ones that are approximately coded. Um, instead of fully coated because, you know, I like to try toe minimizes much stress, feeling as I can if we're kind of fully coated the whole way down. But I like, I mean, I think they're quicker. I've been very happy with the dictation. I just prefer bony on growth versus mm fixation. Because, I mean, I don't thes stems that I've been using Don't have a long track record, but I'm very optimistic. Short term in terms of loosening on dso in my mind and with the ability to adapt them. So if something happens and you need to go back and lengthen it, you can take out the central screw. You can. You can lengthen the component. You can adjust the version. Um, whereas, you know, long cemented stem you cemented in. You bought it basically on DSO. I like the ease of revise ability of the metaphysical proportion Metaksa portion as well as the modularity of it. So I've been pretty happy with this system. Just another question from the audience. So when you anti vert and use the alternate center line, do you adjust the version of your human component? James, why do you take that one and J. Why don't you take that one to after? I don't I still typically. But if the patients got intact, um, enter soft tissue, meaning an intact pack will still put the reverse in 20 degrees of retro version. Have someone soft, tissue deficient and clearly meaning if they don't have a pack. And I'm worried about, um, and answer instability that will put him in a zero degrees of retro version. I have typically increased the retro version on the stem when I've used an alternate center line. I don't know if that's faulty reasoning, but I think if the Clinton spheres pointed mawr anti rly, I've traditionally tried toe rotate the humorist a little more post cheerily just to keep it aligned better. But I don't think anybody knows exactly what the right answer is there. I don't I don't know if you've adjusted that. What do you guys think? I do it for the same reason, but it just logic, you know, more than really dance. It seems to me that if you re travertine slightly mawr than it matches better. Well, mhm. So, James, do you think, um, you know, back if you were doing this surgery with Dr Galax or Doctor Yamaguchi back in the day and you had a loose, short stem, uh, they would probably go with a standard long stem, but metaphysical feeling, um, prosthesis or possibly use that same prosthesis and cemented, Um, What do you think the advantage of this stem is over? Maybe cementing a standard links DeMint. I think the advantage of this stem versus submitting a standard length stem is, um I think the bony on growth provides potentially more. I'm not as worried about loosening it. Right. If you can get past the initial kind of on growth or initial in growth of the bone into the stem, then it's gonna be well fixed for a long, long time. I think the downside is potentially stress shielding And so I try Toe get fixation is approximately as I can, you know? So I I try not to go fully coated if I can avoid it. Um, but yeah, I mean, I think a cemented long stem is perfectly viable, you know, its's tried and true, and it's very successful. But I think this one, um and it's easier to try. Ally, it's easier to adjust the modularity of it. In this example, you can see I used a different size proximal body versus stem so used to size 11 kind, approximately eight official body versus a nice size nine stem. Just because I felt that that filled that Metaksa portion a little bit better, I don't You know, I think dealer's choice in my mind. But I tend to prefer bony and growth just for for a long term fixation. I don't have to worry about not listening. Yeah, what if the patient came back three months later with a draining wound and they were infected and you needed to respect it? Which would you rather revise? A cemented 100%? I'd rather revise this. I mean it. Just like you know, I mean a cement. You got every little piece of cement out if it's infected, right. And that's gonna be a nightmare if that goes all the way down that arm. And so this one especially if your if your fixation is approximately you could just osteo atomized the humorous take it out and then like it in the other case puts her claws, wires around it. And you still got a solid sleep, A bone that you can use. Um, Thio Go back Thio Where a cement. You can get a lot of atresia of the bone. You could get in. It could be a nightmare. Trying to revise long cemented stones. You obviously haven't had to revise one of them. E was gonna say for me, I'm gonna play Devil's Advocate If if this is a well ingrown long stand press fit and we have a long stemmed cemented for me a long time cemented is a much faster and easier, easier revision for me personally, um, I know Bob, you feel the same way. Yeah. I mean, I agree that the this could be tricky when you have in growth into the mid shaft portion of the humerus. Um, it could be it could be hard, because even after osteo autumn izing, uh, with you know, the humorous, even a fair amount, um, the back of the implant is still in grown into the actual humorous and so you can even sometimes have the window. These and you still can't get around the back of the implant, and they can still be ingrown. And so the setting of infection, I think, is, is, um if it's a if it's a separate of infection, then the implants loose, and that's it, Doesn't you know, I totally agree. But even if it's a low grade indolent infection, but there's been good in growth of the implant, they could be a little tricky to take out. And I you know, I totally agree. So taking cement out stinks. Um, I will say right. Medical, in their revision implant system has tremendous implants to be able to actually take out cement. Um, there was a and I don't know if George and J and Bobby, if you've used their revision system where, um, they're they have a drill, and then a tap that then goes into the distal cement mantle and cement plug and the first time I used it. I was like, you know, this has never worked. I've tried it in the past of using, you know, trying toe, you know, threat in a threaded Steinmann pin, etcetera down into it. And it never seems to work. And and then I did it the first time in the whole club came out everything perfect, the whole cement mantle. Distantly, I was like, Okay, this is a one off thing. I'll be honest. It's, like, probably have used it a dozen times. And I have yet to fail to use that system to be able to get the distal plug out. So forever. Do you have a vision tomorrow? I know. I'm not. I'm not. I'm not gonna fail tomorrow, would. But I think it's an important thing to talk about because it's in the system. Got. And you Really? If people are there, are listening, have a revision that need to take cement display. It's a great tool. They've got some great back. Um uh corrects reverse. Corrects that fit inside the humerus, which typical reverse curates are built for a femur not necessarily built for humor. So oftentimes they don't actually fit so whatever it's worth. A little plug in the system, I tell you know, for me, the less humorous I need Thio manipulator machine, the better. So I'm going for the shortest Them I could go every time. And And if I and I've been impressed with these, uh, these new stems that, uh, you know that they get a good grip and you can you can put him in a nun cemented case that, you know, in revision cases, you can use the months amended and get good fixation in the cases where the bone quality is not that good. I will, you know, get doughy cement, stick it around the prosthetic stem and stick it in all together. So I'm not getting entire shuffle of cement. It's to try and minimize the amount of humorous that's involved because I'm always thinking about that next case. You know, if you go back on this one and just to think about revising a long stem like that, if it's well fixed, it could be a real nightmare, you know? So you worry about the destruction you're gonna have of your humorous, you know, and you see these cases occasionally with the total Huma RL replacement and they start out, you know, with longer, longer stems. So I think it's wonderful that hobby actually concluded. And that's a perfect segue. It's actually 10 o'clock, and I think we're at the end of our fourth episode for summer. Siri's eso. I'd like to thank James for putting these cases together. Uh, thank you for sharing this. Thanks for having me. It's great.