All right, so we're going to get started here, and I think I know Dr. Clifto, one of our panelists here, had some travel issues, and I think he's been able to work us into his quite hectic travel back. But I wanted to thank our panel here. It's really a great group of people. It's going to be moderated by Julie Adams. Reid Hoyer, one of my partners at IndyHand, is also going to be joined by Chris Clifto from Duke, as well as Hannah Gift. And so we're going to be discussing shoulder and elbow pathology. We're going to bounce back between a couple of cases. So just like the other sessions, please feel free to ask questions in the chat, as well as in the Q&A, and we will try to interject those into the discussion as the cases are being presented. So this is really meant to be a more laid-back case presentation discussion of some difficult and interesting cases as we go here. So Julie and Reid, please take it off. I can just dive right in if that works. Good afternoon, everybody, and Brandon, thanks for inviting me to be here. It should be fun. So I'm starting off with an elbow case. Unfortunately, I guess I don't think I can advance either, so somebody can advance for me. Oh, I got it. So the first case is a 62-year-old woman. She's a director of a physical therapy department at a local hospital. Two days before she saw me, she fell and injured her elbow. No other injuries, no neurologic defects. Classic exam for a distal humerus fracture. Unfortunately, I was not able to get the plane radiographs, which I do apologize for, but here's her CT scan, and it shows really a low, common, intraarticular distal humerus fracture involving the capitella, but also the lateral aspect of the trochlea. And what I find really helpful in these injuries is three-dimensional imaging. So while the CT scan's helpful, I think this view where you subtract the ulna and the radius and really visualize the distal humerus is incredibly helpful. And I think these images help you kind of determine what your next steps are going to be. And I think first thing is to document the injury and identify what the bad parts are. So here, obviously, there's a capitella fracture. We also see laterally here a lateral epicondyle fracture, but the column is intact. There's comminution of the lateral aspect of the trochlea, including this small anterior trochlear piece and then an impacted posterior trochlear piece. And again, obviously, there's this obligate posterior-lateral impaction and comminution, which is almost always seen with these capitella injuries. So I think that the first stop along the road here is what are we going to do for this relatively active physical therapist with this dominant arm injury? And I'm happy to kind of pause, and we can pow-wow, or I could keep plowing through. So, Brenda, you tell me. I'll bite. I think this is, you've outlined beautifully some of the issues with these fractures, and I think this is unique. This is a patient who's a physiotherapist, and so almost certainly she's going to have an opinion, which is kind of nice, you know, because you can involve her in some of the shared decision-making. And I'm curious about the other panel members' thoughts about the not-so-recent and then the much more recent articles from Mike McKee and Nilu Degnan about distal humerus fractures in individuals over the age of 65 and some of the data surrounding that. There was a Canadian study where they sort of randomized patients to ORIF versus total elbow replacement and kind of opened up the envelope, and I always wondered, like, what did they do if they opened up the envelope and thought, oh, gosh, this is one I can fix, and it's randomized the replacement. And then a subsequent follow-up study that was published within the last couple of years, and it's sort of interesting how that bears on what we do with these. So I'm curious, your thoughts about that. Yeah, I think that those papers really, in addition to Mark Franklin's paper, pushed the envelope and sort of getting people thinking about total elbow arthroplasty for these injuries. But I think that it almost, the pendulum's swaying almost too far towards elbow arthroplasty, and I know personally, at least, I've sort of backed off elbow arthroplasty, especially, not quite the patient they're talking about, but even in patients over 65, I think that physiologic age is extremely important to consider, patient activity level. And then I also think that the implants that are described in those papers are not modern implants and not implants we use today. If you look at some of the x-rays, those are recon plates that were contoured to fit the distal humerus, there's non-locking technology, or sorry, there's no locking technology utilized. And I think that the implants we have now really allow us to fix a broader spectrum of these injuries than maybe we could previously. So I think it's important to consider, but... Yeah, those are great points. And I think if an ORF of a distal humerus goes bad, you know, you have an okay but not a perfect bailout, but if a total elbow goes bad, it goes bad in a big way. And, you know, again, if I think I can fix it, I do. So I'm curious from Hannah's standpoint, thoughts about this, and one of your colleagues, so to speak. Yeah, I think that's a really good point that she has just enough understanding to know kind of her different treatment options. You know, to be honest, I don't see a lot of total elbows and it's either that the physician doesn't trust the therapist, like thinks we go too hard and just says, you know what, let's just talk function and let's say, hey, it is what it is, or if it truly is not done a whole lot around me. So I don't have a ton of perspective to add to that. But I like your point that when they do go bad, it's ugly. Absolutely. Well, Julie, you set me up perfectly for my next slide. And I think that me and the patient together chose to proceed with open reduction intramuscular fixation and for the things that we just outlined, she's relatively young. One other thing that I consider is that arm dominance. And I don't know of any data that supports this or not, but I know it's very hard for patients to obey their weight-bearing restrictions with their dominant arm. I think it's much easier for them if it's their non-dominant arm, whether that has impact on revision rates, I don't know. Just as you mentioned, I think that total elbow arthroplasty is a decent bailout. If ORF goes bad, there may be some increased risk of loosening and revision setting following total elbow arthroplasty. And I show a couple of papers here. But in general, I think that this could easily be converted, especially with this very low intraarticular where the columns are intact, it would almost be like doing a primary. And then just like you said, Julie, to me, looking at this, I could see how I could fix it. It's almost a subjective feeling of, okay, it looks like I can fix it. So those are the things that I thought about. Just really quickly, this is a similar case, but a different patient. So a little bit older, it's her non-dominant hand, and it's a little bit worse of an injury. You can see that the columns involved, the medial collateral ligament's out. And it's hard to see on these x-rays, but there's a significant articular combination. And this one, to me, especially if you look in this middle view here, these impacted very small trochlear fragments, I didn't see that I could be able to fix that one. And so she went on to a total elbow arthroplasty. So kind of back to our case, I guess the other thing to think about is if you decide you're going to fix it, then what are you going to do? How are you going to visualize the injury? What's your approach going to be? I don't know if Chris or Julie have thoughts on how they would tackle this one. Dr. Horwath, I'm curious. If you had this patient and you're considering a total elbow, I mean, oftentimes you have to do a lacrinone osteotomy to do the exposure. But obviously, that precludes you sometimes from doing a total elbow. How do you approach patients, those tweeners where you know you can only fix it if you do a lacrinone osteotomy? Yeah, I think that's a great, great question. And I guess lately, I've been a little bit less concerned about doing that with the locking plate technology. I mean, there's a few case tiers out there, people who have confined low distal humerus fractures and a lacrinone fracture, or someone's had a lacrinone osteotomy converted to a total elbow replacement. And there's even a technique where you do a step-cut lacrinone osteotomy and then fix it with surplus wires as an approach to the total elbow. So I think there's a couple of ways to kind of handle that. But I'll show you just to kind of keep moving forward here. My preferred approach for these is to not do a lacrinone osteotomy, actually, and to do a surgical dislocation of the humerus. And so this is a paper published, actually, recently in JSCS. They got to it before I could. But you can see that the visibility of the articular surface through the surgical dislocation as compared to the lacrinone osteotomy, and for these fractures that involve the front of the humerus, you can see the entire bone through a surgical dislocation of the humerus. You see less posteriorly, but for these anterior fractures, you can see the whole thing, as opposed to, for a lacrinone osteotomy, you're actually a little bit harder to see the front of the humerus. And I think this has been a great technique to use, and you don't have to worry about the lacrinone osteotomy anymore. You can still do a total elbow arthroplasty to this approach. And here's a case of mine showing what it looks like in surgery. It's basically an extended posterior lateral approach, the Boyd interval, and everything is stripped off the lateral aspect of the humerus. You can see this beautiful view of the front of the elbow, and hinged the elbow open on the intact medial collateral ligament. So this has been sort of my go-to now for these complex, low, and tracheal humerus fractures where I'm planning to fix it. Dr. Hoyer, can you share if you're doing a sort of osteotomy of the lateral epicondylar region, and you're taking off the collateral ligament with that, and then putting it back with a plate, or a screw, or a washer? I've seen that technique, or are you taking off the soft tissue and then putting it back? Yeah, I think that's a great question. For these, my experience has been for these bad ones, the LUCL is almost always evolved anyways. And so I'll just strip the already injured LUCL off as a soft tissue, and then repair it at the end. I think if the lateral collateral ligament is intact, though, doing an osteotomy makes the repair at the end probably significantly easier. But all of the ones that I've done, which is not that many, the lateral collateral ligament has been evolved as well. Okay, so I guess one other thing to think about is how you're going to fix it. Like I said, I thought I could visualize how to fix it, and I think that's important when you're approaching these injuries. If you don't think you can fix it before surgery, it's probably not going to get easier in surgery. And so for fixation methods, I think you've got to have all the tools in the toolbox available for these complex injuries. And so for me, this is a hybrid fixation approach. I really like having a posterior lateral locking plate. It gives you fixed angle screws to fix the capitellum. I think having headless compression screws from anterior to posterior, or fixing some of the smaller articular fragments, and I think it's very important to have fully or terminally threaded K-wires available for some of these small articular fracture fragments. And if you're able to bend them under the plate laterally, they almost function as like a thin fixed angle rebar, really increasing the strength of that K-wire. Any other thoughts on fixing these? There's some other tools out there like PLA pins, or I don't know, foot and ankle surgeons sometimes use those things, and they've been using capitellar fractures as well. Now, I think you made great points here, and not specific for this fracture, but more distal humerus C-type injuries, I've really gone to unichorical locking plates to hold provisional fixation. I found that's been a game changer as far as being able to get the plates on, holding fixation, being able to get your reduction. Not exactly for this, but that's probably the only other thing that I would add. Yeah, for sure. Like small plates holding things together as you build the puzzle back together. So here's what it looks like intraoperatively. You can see this kind of hybrid fixation technique where that posterior lateral plate, a bunch of headless compression screws, and then this small impacted posterior trochlear fragment is really held with these two K-wires put into the lateral side, and then the K-wires are then bent under the plate, so they're not going to migrate. And I really like to have these terminally threaded wires. I think fully threaded K-wires would be nice, but they're hard to find, and these are available in some off-the-shelf sets, also helps things from migrating. So I think I wanted to ask our therapy colleagues a few, or get them involved here because, you know, obviously getting this patient back to full activity is going to be really important. That therapy is going to be really important for these injuries, and so Hannah, you know, this is, to me, the limiting thing is going to be the lateral clavicle ligament. I would love to hear your thoughts on some of these patients, though. Yeah, that ligamentous component is definitely going to guide our rehab more than the fixation piece, and I think you have a picture here, but that supine approach is really the preferred way, where supine gravity is actually assisting in locating that joint, and it also allows the dynamic stability of the triceps. Like, if we're doing elbow flexion and extension and seated, we're not really getting any tricep dynamic stability. We're more just getting an eccentric bicep lowering, so being supine helps with the stability, helps with the patient comfort and avoiding too much compensation, but then helps with the tricep dynamic stability piece of it, and then from a therapy approach, just remember that there are dynamic stabilizers that we might be able to activate. Like, so for the wrist extensors, where they originate, it helps with the dynamic stability as well, so other ways that we can maybe even do, like, a submaximal isometric to the wrist extensors to help stabilize as well, but when we're doing that supine piece, the patient really has to understand when we go into extension, we want to be pronated, and then as we come back down, or we can come into that supinated position, we really want to avoid the extension with the supination, so you really have to have videos on their phone and a lot of education on what they're feeling and the difference between what is pain, what is stiffness, and what is apprehension, because they really need to listen to that elbow as they're starting to move. Yeah, 100% agree with that, and I think this has been a really important part of my protocol for treating these patients, is this supine overhead motion, and in addition to all the things you said, I think patients have a real time, a real hard time understanding what varus and valgus is, but if they have their arm up overhead, it doesn't matter, because no matter how the elbow is positioned, the the ulna is always going to be in line with the humerus, whereas if it's at their side and they have their elbow away from their body at all, that is going to add a varus component to it, so what about splinting? What do you like to do for splinting for these patients? Well, I usually go with what the doctor recommends, but usually it's some kind of posterior long arm is at 90 degrees. Usually they recommend a neutral rotation. If they have an LUCL repair, I'd prefer it to be in pronation if I had my way, but generally I do what is recommended if I can't get a hold of the referral source at the time, and then I also, if they have a hinge brace that can lock, I'm great with that option as well. Yeah, I personally, I really like the static splints rather than the hinged elbow braces. To me, the hinged elbow braces almost always end up in the wrong spot. The hinge is kind of like not in line with the elbow, and especially if the patient has a bigger arm and it's not long enough and those kind of things, so I'm a big fan of just a custom orthoplast, 90 degrees, and have the patient come out minimum of four times a day, more like six times a day if possible, and then what about getting them out of the splints altogether? When do you think about just getting them moving? So stability is always going to guide the process, but generally I would tell them they're probably going to expect four to six-ish weeks, but stability kind of guiding that process. Yeah, that makes perfect sense to me as well. I don't know if Chris or Julie have any thoughts on therapy afterwards for these? Yeah, you know, my just first thought is that I often am very concerned about getting these to heal and then I'll worry about getting the motion a bit later if I have to pick one thing. We have a question from the chat box. I think to Hannah, what if the patient is stiff and you can't get them in a pronated forearm position was the question. Yeah, so and that goes back to like them knowing what their elbow feels like and making sure they know the difference between movement and any kind of apprehension, but obviously we want to get them in whatever pronation they can, but if all they can do is neutral, then just making a shorter arc of motion and potentially making them a almost an exercise splint that gives them like a max, like do not extend past this point. So if they can't get to that point, I can make sure they're only extending to maybe minus 45 just to be safe to get the benefit of range of motion, the benefit of joint motion within a blood flow without me having to worry about them overdoing it at home. All right, well, this is the end of the case for me. Here she was at five months. She did incredibly well, probably because she's a therapist and she made me look good. So I think moving on to Dr. Cliftoe's case, unless there's any other questions about this one. It's a great case. Great motion. One more question from the chat box, your preferred method of repair of the LCL in this patient. Did you use a suture anchor? Did you use bone tunnels? Yeah, for these ones, I think that, especially when there's a case like this, I think it's best to use a suture anchor. I think it's best to use a suture anchor Did you use a suture anchor? Did you use bone tunnels? Yeah, for these ones, I think that, especially when there's that combination laterally, I tie it over the plate. And so having a posterior plate there acts as a way to tie your sutures over. There's not a place to put an anchor. Bone tunnels can be utilized, but again, sometimes there's, with the combination over there, you sort of like eyeball where you think it's supposed to be and then pass it posteriorly through bone tunnels and tie the suture over the plate. Great. All right, so I guess we'll do the next case. So we're going to shift gears a little bit here. This is something that I'm really enjoying in my practice is tendon transfers around the shoulder. So Dr. Hoyer, maybe we can go through this together and we can kind of, you can prick your brain about what you would do. So this is a 52-year-old construction worker who was referred to me because he had a massive rotator cuff tear, but mainly he had almost no external rotation and was able to do his duties as a construction worker. So this is his MRI. And for those who are more junior on this, you can see you have a massive rotator cuff tear. Your tendon on the upper left side is retracted to the level of the glenoid. And most importantly, if you look at the image all the way on the right, the infraspinatus is almost completely atrophied. So Reid, what's your, Dr. Hoyer, what is your go-to for this type of patient? Yeah, I mean, this is, obviously this is a tough problem. And I think that for me, this would be almost certainly a tendon transfer in a younger patient without arthritis, as opposed to going right to a reverse shoulder replacement. I'm sort of intrigued about the newer things available, including the balloon, but I really don't understand quite how that works. And so I would probably try and scope this patient, repair whatever cuff was available to repair. Although, as you mentioned, there's significant atrophy of the posterior superior rotator cuff. And so I would be leaning towards a, probably a lower trapezial tendon transfer would be my go-to today. I still don't really know. I'm sure you're going to talk about it, but I really don't know when to do an SCR. And I don't know that I believe that it works either, even though there's a couple of cases, a series of patients showing decent results from a couple authors. So, but for me, this would be a lower trapezial tendon transfer. All right. Awesome. So just a couple of quick definitions for it. I'll move through this quickly. Massive irreparable rotator cuff. It involves two tendons, usually extensive to the subscapular teres. It's retracted to the level of glenoid and over five centimeters of retraction, either anterior posterior or medial lateral, and advanced fatty infiltration of the muscle tendon. So this is just a great study by Gerber looking at 33 patients with clearly a classifications of two or three. They essentially found that in two years, you have a 92% failure rate versus less fatty infiltration, and you have less than 25% failure rate. So the reason why this patient is hard is there's clearly a higher grade than two or three and he's a manual laborer. So indications for tendon transfers, and this is just kind of a big overview, but massive rotator cuff tear with weakness, functional strength and loss, antagonist muscle, intact deltoid, good bone for fixation, and most importantly, compliant patient with node-bundled humeral arthritis. And you know, just a little nuance, they have to have pretty good passive range of motion in my experience, even though, well, Gerber's study from Al-Assad who shows that the contrary. But Dr. Horwich, to answer your question, this is a nice schematic I found describing when to do each type of tendon transfer. So anterior, obviously it's the pec major. If you have a posterior superior like our patient has, it's the lat or the trap, and your isolated supraspinatus with retraction is your SCR. But we're not going to talk about SCRs here, but you have to have an intact infra and usually intact subscapularis to actually do a SCR. So this is just the earlier study by Gerber, which defined the lat-dorsi transfer, which was the first transfer. And we didn't do it with this patient, but it's kind of come out of vogue. But essentially what it did was it reconstitutes the posterior force, allowing the latissimus dorsi to function to actually rotate and suppress the humeral head. So here's a nice schematic. If you see the top two squares, when you transfer the tendon, you can actually put it into the posterior superior portion of the humeral head, which allows it to function like an intact posterior superinfraspinatus. So the outcomes were really good. They had 74% good to excellent results, significant increase in range of motion, forward flexion, and there's been a couple studies actually showing that this has been a good outcome. But as we have evolved, we've come up with different techniques. And El-Hassan has really pioneered the lower trap transfer, which his initial studies showed that he had 111 patients with paralytic shoulders, which initially was a contraindication to do a tendon transfer. Some of them had brachial plexus injuries, and all 33 were irreparable. But he came up with the concept that you have a more anatomic line of pull with the lower trap than you do for patients with the lat. And he said that was mainly used for massive posterior superior rotator cuff tears, and specifically patients lacking external rotation. So here's some of his earliest schematics kind of showing the pull of the trap to the posterior superior humeral head. So great outcomes, 97% had improved pain, subjective shoulder scores improved, all PROs improved, and now it's become the preferred method for all tendon transfers, honestly. So this is our case here, and Dr. Hoare, maybe you could talk about how you use your surgical technique, where your incision is, and do you do these arthroscopically assisted, or do you do them with a mini open? I initially, the first couple I did, I did a mini open, and it's actually really, really easy to do arthroscopically assisted, though. So I've gone to this almost exact setup, I think it's a beach chair, the patient's got to be way lateral, so you can see the entire scapula, and that tendon's inserting onto the medial inferior aspect of the scapular spine as it meets the scapular body, and so, you know, a four to six centimeter incision, depending on the size of the patient, right there where you can feel the scapular spine, and then I'll scope the patient first, do a debridement, confirm that, you know, this is not going to be fixable. If possible, you know, if you can fix some of the infraspinatus, try and do that, although oftentimes you try and do that, and then by the time you get back in there to look at your lat transfer, like the thing's already pulled out, so don't spend too much time trying to fix those, and then I like to fix the tendon to the humerus first, and then pass it through the trap tendon. Yeah, I mean, that's the exact same technique I do, and surprisingly not as difficult of a procedure as you would think it would be. You usually find the trap pretty well, and usually there's no infraspinatus, so it's really easy to tunnel, and I'll go to the next slide here, but we use an Achilles allograft, and exactly like you said, we suture it to the humeral head, and then we kind of tension it over to the lower trap, which works really well, and I have to say that for my patients with no external rotation, this has been a great procedure, and especially for the young active laborer. What's the youngest patient that you would do a reverse on for similar pathology? Hard for me to put a number on it. I mean, I think the youngest is probably in their 40s that I've done a reverse on, but I think it's got to be a unique situation, so I think with the rotator cuff and a good joint, massive rotator cuff and a good joint, I'm probably, you know, if they're in their 50s, I'm probably trying to talk to them about this procedure. The hardest part to me about this procedure is the next eight weeks, though. Oh, yeah. So, what's your postoperative protocol? That's a great point. I put them in an abduction external rotation brace for eight weeks, and it's, like, some patients have done fine with it, but I've had a couple patients that are, like, absolutely miserable, and they call on me almost daily for the first couple weeks, and every time they see me, they're like, when can I get this brace off? So, I don't know if you have any tips I can incorporate. No, it's the same thing. It's like the same initial studies with the SCR, right? Like, patients feel pretty good, pretty well, because this puts a big hunk of tissue in it. It usually recenters the humeral head if there's elevation, which actually gives patients a lot of pain relief, and a lot of times, they want to move too fast. So, always trying to talk to patients about slowing down their rehab and just being patient and allowing them to really heal that allograft, and then 12 weeks post-op. This is just his video from the clinic. Let's see if I can get it to play. That's the right side, and just, you know, it's more remarkable how well these patients can do when the procedure works, and there's this external rotation where you didn't have any prior. So, yeah, it's a fun procedure that works well for the right patient. Any thoughts about the rehabilitation? Hannah, your thoughts? Yeah, I think the, I mean, the communication with the therapist is going to be huge, especially just knowing, like, we cannot overstretch these guys, and just knowing, like, passive range of motion does not mean stretching necessarily. So, as we start to start the rehab process, we have to kind of find the right person that understands tendon transfer rehabilitation, because we're taking a lot of the principles from the hand and just putting it into the shoulder, but we have to make sure we're not overstretching anything, which is a hard concept at, when we're so used to treating, like, rotator cuff repairs and things like that, but I agree they're miserable, and then they're just so happy after the fact, but just the education, the pain education, and then just the, them have to, having to trust the process is so hard in that early part of it, so just putting more faith in just trusting the process, but I honestly don't see very many of them, so I don't have a ton of specific examples to provide. Another question. Go for it. Sorry, Julie. Sorry, go ahead. I was just going to say, I really like this procedure, because it sort of, it makes sense to me, as opposed to the SCR, I think as hand surgeons, doing tendon transfers is something we're used to doing, and we understand, you know, taking a muscle that has a different function and using it to replace something that's missing, and so this is something that I think is intuitive, and it makes sense compared to, like, the superior capsule reconstruction, which I still have trouble wrapping my head around. We answered the question about the youngest patient you might do a reverse on, rather than this procedure. What about the oldest age? Patients, active, healthy, minimal arthritis. When would you consider this, as opposed to doing a reverse? Dr. Hury, you want to answer that first? Yeah, I think that that involves a lot of, you know, involvement of the patients, the shared decision making. I think that the reverse is very predictable. Recovery, I think, is much easier in the initial phases, but then you have an artificial joint and all the potential negatives that come with that, so I don't know. I think if a patient came to me and asked for this, I would dive deeper, but if they're in their, you know, late 60s, early 70s with a massive cuff tear, it's not something that I'm going to, like, bring up for most of those patients, I don't think. Yeah, I think a lot has to do with their function level. Like, a construction worker isn't going to do well with a reverse, but someone who's in their 60s who wants a quicker rehab, because the hardest part, like Reid was saying, is the rehab for these patients. They just hate being in a sling for eight weeks. I don't know about you, Reid, but my reverses are completely out of the sling at two weeks at this point, so patients love that, and you just have, it's more of a shared decision-making model with those patients for the versus versus tendon transfers. Great. One more question, sort of related to this. We talked a bit about large rotator cuff tears, cuff tears with retraction. Recently, there's been a lot of interest in folks who've had rotator cuff repairs, which is different than this case, which was irreparable, with concomitant decompression of the suprascapular nerve. Curious if you guys would like to comment on that. Is it useful? Is it not useful? Any thoughts? And so, that's part of the CAM procedure, right? Complete arthroscopic management of shoulder pathology, and I personally don't do it a lot. I don't, I understand, I understand the thought process behind it, right? Like, if you have a retracted rotator cuff, there's a potential that it's retracting and pulling on the suprascapular nerve, and a neurolysis might actually help for pain relief, but I don't know. I don't feel like my patients I've done that have gotten enough relief from the neurolysis for me to feel like it's done anything. What about you, Reed? Yeah, I don't, I still don't know the indications for it exactly. I think that when patients come to me, and they've seen somebody else, and they come with a diagnosis of suprascapular nerve palsy or whatever on the EMG, then I'll incorporate it into the cuff repair. I think that, you know, you know, potentially, Julie, it would be something where, like, someone has traction on the suprascapular nerve, and the cuff tear is not repairable, and you're doing this tendon transfer. Is that a case where we should be thinking about doing a suprascapular nerve decompression? Because we're not unloading, I mean, if you repair the cuff, theoretically, you're taking the tension off the suprascapular nerve, whereas in this type of procedure, you're not doing it. But it hasn't seemed to affect the outcome, so I don't know. I don't know the answer. Yeah, I think I share your, your lack of clarity about the utility. Somebody was saying something. No. Nope. All right. Are we moving on to arthroplasty? Sounds good. Okay. So, switching gears here. This is a 57-year-old guy who was initially treated someplace else. It says I'm controlling it, but it's not working. There we go. For proximal humerus fracture, and I'll show you the injury films here in a second. He's schizophrenic. He lives in an adult home, and he presents to the ER after a fall with these injuries, and I think it just, this isn't where I got involved, but I think it'd be interesting to kind of see what people would think about doing for this injury at this time. Again, 57-year-old, relatively low-functioning, has a surgical neck humerus fracture. Chris, what are your thoughts right now before we get going? So, without having a CT, it doesn't look like there's a head split, And this looks like it's just an isolated surgical neck, if I got that correctly. I think it's, I think for, let's call it that, an isolated surgical neck fracture. So, you know, I'm kind of old-fashioned. I'd probably try to treat this non-operatively first. This doesn't seem like the right person for it, but it's still a hanging arm cast, will work every once in a while for these patients. And for the isolated surgical necks, my go-to, especially for this type of patient, is actually human mailing. I find that it's a pretty low morbid procedure and that they do really well with. And there's different, you know, I know we're not talking about human nailing, but, you know, people complain about shoulder playing, but you could do different techniques to kind of get away from that. So that'd be my go-to for this person. So initially non-op, but if kind of pushed to, you'd fix it, right? Okay. Yeah. So the other surgeon initially treated non-operatively as well. And then the patient came back six weeks and presented with these injury, these films that follow up. And so to me, I think like at this point, initial non-op treatment, not the wrong thing to do by any means, but I think a course change is probably required now. And I think in addition to, you know, I guess I should have included on here a nail. So include in ORAF, let's include a nail as an option. Do you think this summarizes kind of the treatment options now, Chris? Yep, absolutely. Yeah. All right. So I agree that I would probably fix it. You would do a nail. The surgeon chose to do a reverse shoulder replacement. And here's a PACU film at eight weeks from that surgery. So in addition to the... Quick interposition, if we have time, a patient was initially seen at time zero and then at six weeks. Just some questions for the panelists about if you'd prefer to see him a little quicker than that or sometime in the interim. Yeah, for sure. I mean, I usually try to see these patients after maybe three weeks and I try to get therapy started around the three-week mark and get updated x-rays, make sure nothing's displaced. It's not too early at that point to kind of easily shift course. Yeah, I'm every three weeks if I'm trying it non-operatively and then six weeks if I make it through the non-operative course. So I think the thing I wanted to point out on this PACU film is that the entire proximal humerus has been excised. So all the two... Because of the surgical neck fracture, none of the tuberosities were repaired. They weren't osteotomized and repaired around the verse of the entire proximal humerus was excised. And so when the patient came back two weeks later, this is what it looked like. And I don't need to pimp you guys on risk factors for instability, but I think there's a few things to think about in every case. Instability of the reverse total shoulder is one of the most common complications. And anywhere from like one and a half to 30%, depending on the series, probably somewhere around 5% of patients who get a reverse are going to have a dislocation. And so understanding what are the risk factors I think is really important. And there's a whole lot of them, but in general, if it's for a fracture or prior surgery, it's going to have a higher risk of instability. Soft tissue tensioning is a big component and therefore excising the tuberosities following a fracture, in my opinion, is the wrong thing to do in 2022. Also want to look for implant positioning. This thing might be a little high, potentially bony impingement could be a problem here. And then finally, there's a thing called the deltoid wrap effect, and that is lost when you have excision tuberosity. And so what is the deltoid wrap? Well, the deltoid as it contracts applies a medially directed force to the glenohumeral joint. And it works in the native humerus, as you can see in the lower box D that's circled in red. The deltoid applies a medially directed force and also works in reverse total shoulder replacement. But if the tuberosities are excised, the deltoid, depending on the implant you're using, the deltoid can actually apply a destabilizing force to the glenohumeral joint and actually pull the shoulder out of concentricity. And so excising tuberosities is not good. And then the other thing I just wanted to mention was assessing the glenoid and addressing the glenoid and reverse instability. This is a really great paper to check out. It's out of Stanford. And they looked at 11 patients who had surgery for unstable reverses, and five of the 11 re-dislocated following the revision surgery. All of them were only managed on the humeral side. And so if you're doing revision surgery for unstable reverse, you got to do something to make the ball bigger, push the shoulder out more lateral. Just like in the native humerus, you got to adjust the glenoid side as well. So just to kind of make your story... When you're revising the glenoid side, what size glenosphere would you normally go to? I think if you're doing it for reverse, I'd make it as big as the system can be. I think you want to make it big. Because the goals, I think, change a little bit. And the last thing you want to do is what happened to this guy. And so two days after he had that post-op x-ray, they go back and they make the humerus longer. He comes back in five days later. He's re-dislocated. Then they go back in two days later. Now they make the ball bigger and make the humerus longer and get some cultures, one of which was one of one were positive for C. acnes. And then he comes back in a week after. And at first, when I was looking at this x-ray, I'm like, something looks not quite right. And then when you look at the x-ray lateral, all is clear. So because he tried to put a bigger ball in, probably didn't have good exposure. And now it didn't get the Morse taper engaged. And now the glenosphere is dissociated. So this is what prompted a referral to me. And so I guess at this point, Chris, what are you thinking? What are your thoughts and next steps for this guy? Reset. This guy has a positive culture of C. acnes. Get all the hardware out, put a spacer in there. Make sure he clears that. And then just restart, like get a new CT scan, see what type of implant you need to try and give this guy stability. And also just meet the guy for yourself because it looks like his past medical history had a history of schizophrenia. You got to make sure that this guy actually can have a reverse and function well with it because you'd be surprised. I mean, as you know, people do really well with the xanthobic spacers, essentially for the patients that are noncompliant, acts like a large hemi. And they actually have like decent motion. They get their range of motion up to 90 degrees sometimes and works pretty well. Yeah, I think that's a great option. That's not what I did, but I would not argue 100% at all that that's not the right thing to do. And I think there's some debate whether C. acnes can be treated in one stage or two stage revision. Certainly the worst case scenario is if you one stage it and it's infected again. So you can get faulted for that. So I think, you know, laying out like what's wrong with this. One, it's infected. Obviously it's unstable and the reasons it's unstable are what we laid out before. There's no soft tissue attachments. There's no delta wrap. I'm not sure about, you know, the glenosphere size or lateralization. Can we make it bigger? Are the implants loose? Has the infection affected bony engross? And then what about the glenoid positioning? And so this is what I was thinking is single stage for me for this. But again, I think two stage is absolutely reasonable. And then how do you address the delta wrap effect? Well, you gotta have some, add some bone or metal that restores the tuberosity. And allograft prosthetic humerus is one way to do that. So I'm definitely revising the humeral component. I'm going to look at the base plate. I'm going to make the ball as big as I can and probably push the humerus as far away from the glenoid as I can. So as much lateralization as possible. This is what it looked like intraoperatively. Everything came out easily. There's no bony engross. There's no overt signs of infection. To me, looking at this, the base plate was significantly higher than I'd normally like to see. So I revised everything. This is the new glenoid base plate going in. There's plenty of bone in this case to do a single stage revision. And then there's multiple systems. Many systems are now allowing for lateralization. This particular system allows for a really big ball and significant lateralization. So there's going to be no bony impingement that is going to be obviated as one cause of instability in this patient. And then here's the allograft prosthetic composite. So the stem is cemented into the allograft component and then a step cut is made after you determine your version. And there's some data suggesting that this is going to improve or result in good patient outcomes, probably because you're restoring that deltoid wrap. The benefit of this over a tumor prosthesis is simply cost. It's probably a little bit more technically challenging, but probably one third the cost. And so if you are in a system that is thinking about cost, then that's something to consider. Chris, have you used like tumor prostheses? Yeah, for this patient, I would go to a tumor prosthesis. I just feel a little bit more comfortable with that prosthesis. I really like how with the tumor prosthesis, you can actually build your tension incrementally, which I think is great for these patients who have a history of instability. But that's a great job you did there. That looks awesome. A couple of questions and comments. I noticed you were able to find enough bone to put in a new base plate. I'm curious if you could comment on impaction grafting of the glenoid if you're struggling. And then a second question from the chat box. Cy asks, I think the dislocation of the implant is due to adductor pull on the distal bone, according to Graham Apley from Roehampton in England. Any comments? To the first question, I think the impaction grafting is an absolutely great option if you have a contained defect. I think if the defect is uncontained or involves the rim of the glenoid and you can't have most of the base plate sitting on native bone, then I would probably, then I would probably, I guess my approach would be to do a two-stage in that setting. Because I'm going to, in this case where there's no native humerus, you could go to the lateral clavicle. But I think that after having had a few of those bone graftings fail late, relying on metal is probably a better approach. And this is completely my opinion, but I have gone to custom-made implants with significant bone loss. But a central defect, I think impaction grafting is a great option. And that can come from iliac crest, off-the-shelf femoral head, ortho-lateral clavicle is a great local graft that can be utilized. But if it's a big uncontained defect, metal. And then can you reread the second question again? Sorry. Sai's question was, I think the dislocation of the implant is due to adductor pull on the distal bone, according to Graham Apley from Roehampton in England. Any comments? Yeah, adductor pull. I don't know. I guess I have to look at that paper. I'm not sure. I think that Certainly the tension is off from the, you know, resection. Yeah, I think there's multiple, multiple reasons that these things dislocate. And I think trying to understand and address as many as possible is key to getting a good result. So I think if you just address one thing, you're going to potentially not be happy. And I think the key things I wanted to point out for this case were not just lengthening the arm. So don't just lengthen the humerus. That's not going to give you what you want. And then think about the deltoid wrap effect in particular. And so at one year later, no recurrent instability, and I have a There we go. The allograft actually heals to the native humerus. I think that this is a great, great time to talk about therapy for these, because in my mind, the goals of this are much more limited than when a patient comes for a cuff tear arthropathy. I think the goal is to give the patient a stable humerus that's pain-free to let their elbow and hand work. But Heather, any comments on not necessarily this case, but the unstable reverse in general from your standpoint? I think your point of discussing goals is a huge thing of them understanding what the goal of the surgery was, and that we never promised them like the most mobile, most strong shoulder. We promised them a pain-free functional shoulder. And in this case, in particular, I think just based on his other factors, I think we would focus a lot on just simulating daily activity, simulating dressing and bathing and preparing meals and actually creating a functional atmosphere to show him how to modify that based on. So it'd be a very traditional functional approach as opposed to really giving a home program, isolating the stabilizers and that kind of thing. Great. That's all I have for that. That's a great case. While the game is loaded up, what do you think of the alternate scapular line? Do you like that for when you're trying to get a stable base plate? Yeah, I think 100% is another thing to think about is going where the bone is. And I think it depends on what implant you're using, but if you can get the fixation of your central post into the alternate scapular line, that can bail you out of a lot of problems and potentially avoid... For those of you who don't know what that is, it's essentially you antivert your implant. You try and get to the confluence of the scapula, kind of where the spine meets the body. And that's usually a nice place for a good solid bone if it's trying to get your post or your screw in. It's been really helpful in my practice as well. Okay, so we'll change back. We actually have one question here before I think we probably are going to wrap it up. Views on healing of the allograft with cement and reinforcement of an allograft with a plate as an alternative in that last case? That's a great question. I think that most people today are adding a lateral plate to the allograft for additional improvement. For additional improved rotational stability. I think for the smaller ones, especially if it's more approximate like this, this has a step cut. So it's a step cut that provides rotational stability. And I don't know. I guess I think adding a plate makes sense in some ways, but it also you're attaching a plate to a dead piece of bone and you know it's only going to heal at the bone interface and it's only going to revascularize for a few millimeters. And so I think it might make you feel better, but I'm not sure how much additional rotational control it actually adds and as compared to the step cut. I think if it's a longer graft and it's more diaphysial, it's going to take longer to heal. Adding a plate is probably something I would consider more commonly. Dr. Cliftoe, any alternative thoughts or any thoughts as you potentially use cement in some of these cases? Yeah, you know, I find the cement just kind of like Reed mentioned, heals pretty well. Like you get to have just a little bit of cement and it keeps some rotation and allows you to still have healing over top of it. I routinely use it for even my proximal humerus fractures just at the implant interface with the bone and then I fix the tuberosities around the cement and usually heals pretty well. So I like Reed's technique and how we use that. Great. Brandon, are we out of time? We are out of time. Thank you, Julie, Reed, Chris, and Hannah. That was a great session, very complex cases and amazing outcomes. Thank you for all your insights on all of those topics. Also, as this closes out the entire course, I wanted to thank all of the faculty today. My co-chairs, Paige and Chris, the ASSH staff as well, especially Selena and all that you participants here for joining today and making this very successful and engaging course. There will be a survey coming out as well as instructions for claiming your CME. So please let us know your thoughts as well as be sure to claim your CME from today. I hope everyone has a great weekend and for those on the East Coast, I hope you stay safe, warm, and with electricity. So I hope everyone has a great weekend.

orthopedic cases

shoulder pathology

elbow pathology

tendon transfers

reverse shoulder replacements

distal humerus fracture

total elbow arthroplasty

rotator cuff tear

surgical techniques