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In the latest edition of the series, leading surgeons discuss their use of Arthrex advanced surgical planning tools to optimize their total shoulder arthroplasty cases and provide practical tips and pearls they have learned with this innovative technology.

BreakThrough™ With Christopher Adams, MD—VIP™ System: Advancements in Planning

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Arthrex presents “Optimizing Reverse Total Shoulder Arthroplasty Through Advancements in Planning.” In this episode, host Christopher Adams, MD, and leading surgeons provide insight into the innovative use of preoperative planning and review relevant scientific literature. Joining Dr. Adams in the studio are Asheesh Bedi, MD (Chicago, IL), and Patrick Denard, MD (Medford, OR).

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BreakThrough™ With Christopher Adams, MD—VIP™ System: Advancements in Planning Episode 1: Making the Case 

Speaker  Hello, welcome to BreakThrough. Today we're going to be discussing making the case for preoperative planning for optimizing reverse shoulder arthroplasty with Patrick Denard from Medford, Oregon, and Asheesh Bedi from Chicago, Illinois. Gentlemen, thank you for joining us today. Speaker  Thanks for having us, Chris. Thanks, Chris. Speaker  Absolutely. So, Ashish, what has been your experience with planning? Speaker  Planning has been a real favorable evolution and integration into my practice. Chris. I think like many surgeons, you know, sometimes we're creatures of habit and we think that we do things well. And for me with shoulder arthroplasty, my impression was always that I was pretty good at appreciating anatomy and putting the pin in the right inclination and version. And then it was data and a number of key landmark studies that have pushed me to realize that we can be better. And that has been an appreciation of advanced imaging and VIP planning technology that can transfer to the operating room. And so for me, that's been incorporated into clinical practice, and that experience has mirrored the data. Speaker  So Patrick, could you discuss how planning fits into your practice. Speaker  Yeah. I think you should plan all your patients, right? Because it gives you, as Ashish mentioned, the appreciation of the anatomy, also the opportunity to essentially simulate that surgery before it occurs. So I plan all my patients, they come in, they have their CT scan, which gets uploaded into the system, allows me to analyze their pathology. And what's really unique about this system is I can take that plan to implementation within 48 hours with the use of guide, which is not available with other systems which require a patient specific or custom guide that has to be printed as costly and has a long lead time to delivery. Speaker  Thank you. Patrick. Now, Ashish, you briefly mentioned there are several landmark studies that have laid the foundation for preoperative planning. Let's take a deeper dive into those studies and how the literature has evolved over time. Speaker  Let's take an opportunity to review some of the key impactful literature with regard to preoperative planning and how it can impact our practice. I wanted to start with our first question, which is, do we even need advanced imaging and do CT scans matter? This article that was done by Pat Denard and Brian Werner and others, is one of the most impactful that talks about using advanced imaging for reverse shoulder arthroplasty. In this study, they looked at a pearldiver database of cases over ten years. What they found during that time was that the use of CT scan consistently increased for shoulder arthroplasty. But perhaps most importantly, when CT scan was utilized, it reduced the incidence of perioperative complications like dislocation or periprosthetic fracture. That, of course, has an important impact in terms of outcomes and minimizing morbidity for our patients. While a natural question from that is, if we have the CT scan and we have that three dimensional imaging, does it actually help us to place the implants better? A couple of wonderful articles by Joe Iannotti that really have been cited in the literature. This study with him and Eric Ricchetti, points out that there's an incremental improvement from two dimensional X-rays to three dimensional CT scans. The ability for the surgeon to appreciate a need for an augment is under realized with X-rays. The ability to place the PIN to correct version and inclination much less reliable. This follow up study by Doctor Iannotti took this to another level, where they looked at the value of three dimensional imaging and planning and our ability to place that pin. Speaker  In fact, just having the plan alone with standard instrumentation improved and narrowed that reliability of inclination and version to within five degrees of inclination and ten degrees of version across a wide variety of surgeons with variable level of experience when they use this additional five D targeter that reliability was only increased further. Again, some great literature that has come out that we can look at here. This is a great study that was done using preoperative three dimensional imaging and looking at whether, in fact, it changed choices in shoulder arthroplasty. You'll see the illustrious group of authors here, including surgeons like JT, Turkish and others. What you actually find here is when even experienced surgeons make their decision on X-rays, their agreement of what type of implant that they were using was actually, at best, modest. When we gave them incremental CT data, that reliability increased from 68% to 80%. But then when we gave them additional preoperative planning, their choice changed 30% of the time when you gave them additional demographics like age, even an additional 16% change. So highlighting the value not just of three dimensional imaging and targeting, but actually preoperative planning in choosing the right implant. Well, what about deviation from the planning software? If you do it beforehand as a virtual plan, do you tend to execute similarly or better? This well-done study by Matt Provencher actually showed in a meta analysis across a wide variety of implants and systems, low deviation from the preoperative plan, greater reliability with screw length and purchasing our optimal bone, and actually knowing when we might need an augment, and tending to use that augment to minimize bone resection and optimize implant position. Speaker  Finally, what's on the horizon for us? Does all of this preoperative planning actually help us to predict a better range of motion and better function after arthroplasty? This study by Keith Baumgarten using a different planning software points out that there's a lot of opportunity for improvement. In this study, they looked at the agreement between the preoperative virtual range of motion and in fact, what was assessed one year out from surgery for reverse replacement. And they actually found a very poor correlation between range of motion and impingement versus the true outcome. That is where as we look to the future, we have opportunity. This is the start of that great work by Pat Dennard that has started to look at functional outcomes after surgery and looking at the impact of preoperative planning. What's great for all of us is his study shows us that whether or not we use that preoperative planning tool, we can achieve favorable short term outcomes by our patient reported outcomes. But as we follow that out further and now have instrumentation like depth of Reim to execute our plan in the operating room, we have greater ability to assess improvement in longevity of the implant and function in the long term. Speaker  So Patrick, what are your thoughts on the literature and can you elaborate a little bit more on your recent publication? Speaker  Yeah, absolutely. So I think there's a couple of things you need to take away from this study. Number one, high volume surgeons write. All the people in this study were doing over 100 arthroplasties a year, so this may not apply to the Doc that's doing 10 or 20. Secondly, we are not looking at base plate position as outcomes only, and we know that the value of planning is really delivering the position of the implant. So we didn't look at that in this study. Lastly it's short term right. So we're really thinking about five years ten years with reverse now. So we actually may see some divergence later on. So when you take all that you really go, what's the downside. And there's no downside to planning as we've clearly gone over. Speaker  Well, gentlemen, this has been a great discussion on preoperative planning and the current literature supporting VIP as an innovative solution. Ashish and Patrick, thank you for joining us today to learn more about optimizing reverse shoulder arthroplasty through advancements in planning. Be sure to tune in to our other BreakThrough episodes, including highlights on the technique, play by play, challenging cases in the learning curves. Thank you for joining us.

Arthrex presents “Optimizing Reverse Total Shoulder Arthroplasty Through Advancements in Planning.” In this episode, leading surgeons walk through key steps and share technique pearls on glenoid positioning and depth of reaming for glenoid component placement during reverse total shoulder arthroplasty. Joining host Christopher Adams, MD, are in-studio guests Asheesh Bedi, MD (Chicago, IL), and Brian C. Werner, MD (Charlottesville, VA).

BreakThrough™ With Christopher Adams, MD— VIP™ System: Advancements in Planning Episode 2: Technique Play-by-Play 

Welcome to breakthrough. On today's episode, we have a lady from Chicago, Illinois, and Brian Warner from Charlottesville, Virginia to share technique pearls on glenoid positioning and depth of reaming for glenoid component placement during reverse shoulder arthroplasty. As Brian, take it away. Thanks, Chris. So today Ashish and I are going to review a plan in VIP and also discuss the new depth of ream instrumentation. So if we take a look at our plan in VIP, we can see the patient's native version a native inclination. And that's often what I'll use to preliminarily decide which base plate I'm going to use for this patient. It looks like a standard MGS base plate will work quite well. Yeah. So Brian, first things first. As you're going through this plan, how do you decide on the base plate and do you use a post or a screw. So the base plate diameter I typically use a 24 millimeter base plate for essentially every single patient. For this amount of deformity, with relatively low amount of inclination inversion, a standard base plate will work pretty well for me. When I'm using the standard base plate, I typically go with a screw, but I really do like the post fixation. It works quite well. So if we look down over at the bottom right hand corner of the screen, we can see our different implant options. And so we have our base plate we can choose. We also have other base plate options. We then can decide on whether we're going to use a screw or a post. We can choose whether we're going to use an augment or not, and then also decide on the length of our central screw or our post. Yeah, I love that feature, Brian. It's so hard to see contact area and seating in the Or for you. How do you decide as you're maximizing that backside seating? How much bone of reaming is too much bone? So it's obviously a challenging balance between removing bone and getting good seating. And so there's a couple of different algorithms I like to use. Pat Dennard has suggested a great algorithm where he uses 15 degrees of Retroversion or more. He's often considering using an augmented base plate in that patient. And so then also we want to look at the millimeters or the depth of reaming that we're taking. I don't have a strict cutoff, but a general guide that I like to use is about five millimeters for depth of ream. If I'm reaming more than five millimeters, I'm leaning towards using an augment. And so we're pretty happy with our plan here. We've got good correction of our version inclination. We've got great backside seating at 93%. So let's move on and take a look at that depth of rim instrumentation. Trey just looking at the tray here. You can see at the top is your pilot reamer. That's going to be what's going to help to set that depth of rim that correlates with the plan you shared as you get to the next row. You have everything you need. If it's an anatomic replacement. On the left side are the secondary reamers for the vault lock. On the right side are the secondary reamers for your MGS base plate, and then a common drive shaft there at the bottom to work for both. So everything we need is here. And then a little closer look at this pilot reamer. You can see this makes it easy for your staff. You simply dial in that depth, and it correlates with a letter that correlates with your plan. And so for our VIP plan for this patient, we got a depth of E that was printed on the VIP plan. So you can see here we've dialed in the pilot reamer to E. So let's take a look at this in action and see it on the patient. So we have our cadaveric specimen. We have a great and fast exposure of the glenoid. We're using the five D targeter as we typically would anyway to get the central pin in place. Then we bring in our VIP pilot reamer for this cadaveric specimen. We set it to C. That's what was needed for depth of ream on this patient, and then we place it over the guide pin and do our depth of ream. Yeah, this is great, Brian. It has a positive stop. That of course correlates with that letter C. As you'll see the reamer will go through here. But it'll stop at that preset depth. And then you have this view you can see right there the bottom of that hole. That's ultimately what's going to become flush here with this secondary reamer. You can see the positive stop at the back of that reamer that correlates with that pilot hole. And then the fins on this secondary reamer that do the work. In the past, you didn't have that positive stop to give you that feedback here. But at this point this is going to ream right down to the base of that pilot hole. And so compare this to some of your cases before you had depth of ream, you can see how excellent of a job that it does. And so if we look here it minimizes the amount of reaming we need to do so that we're not getting into the subchondral bone. So you can see that we didn't violate any of the subchondral bone at all. And then also that pilot hole is reamed away after you're done with the reaming. So you can see no pilot hole. So this really maximizes the amount of seating you get, the amount of reaming we do but also minimizes the amount of bone removal. Yeah I love that, Brian. It basically is your positive confirmation that you've gone to the right depth and it's flushed, but you have a great subchondral surface to support your base plate. Let's take a look also at how this works with our augmented base plates, and how this system can work there in a sawbones model. Excellent issue. So if we see here we've already used our five D, Targeter and VIP to place our central pin. We then use the VIP pilot reamer to drill our pilot hole, similar to how we saw in the previous section. Now we need to take a little closer look at that augmented VIP reamer. You can see that we have the depth stop that will give us our positive stop and then the angle of the augmented reamer. And so those will be really important as we translate our plan. Yeah. And then as you pointed out Brian, you want to have that black line on your angled reamer align with your area of, of deformity where you want to place your wedge. In this case, we're angling postero superiorly where that defect always or often is. So now we can take a closer look at how fantastic a job it did at reaming. And so importantly, first you'll notice that there's no subchondral bone that's been violated on this sawbones model. The subchondral bone is pink. Another important thing to notice is that when you're doing this, this pilot reaming with the augmented system, you're going to see a little bit of that pilot hole after reaming. And that's expected. That'll be eliminated after you ream for your central post. Gentlemen, that was a great demonstration. So what would you say is your main take home message? Yeah. Thanks, Chris. I definitely think there's a few key points for me. You know, as VIP technology has evolved, it initially started kind of as a preoperative planning tool. And I think this instrumentation has been transformative to change that from planning to execution in the operating room. And I completely agree, Ashish. I think for me, in addition to that, it's making it a reproducible case every single time. We have great planning tools, we have great instrumentation, we have great implants. And now it's something that's reliable and reproducible every single time. It's the transfer. Technology has really helped my practice. Thank you again. That was great. Now to learn more about optimizing reverse shoulder arthroplasty through advancements in planning, be sure to tune in to our other breakthrough episodes, including highlights. I'm Making the Case, Challenging Cases, and the Learning curves. Thank you for joining us.

Arthrex presents “Optimizing Reverse Total Shoulder Arthroplasty Through Advancements in Planning.” In this episode, leading surgeons discuss using advancements in preoperative planning and highlight their clinical experience with an illustrative surgical case presentation. Joining host Christopher Adams, MD, are in-studio guests Anthony A. Romeo, MD (Chicago, IL), and Brian C. Werner, MD (Charlottesville, VA).&nbsp;

BreakThrough™ With Christopher Adams, MD—VIP™ System: Advancements in Planning Episode 3: Innovative Solutions

Welcome to breakthrough. Today we're going to be discussing challenging cases in innovative solutions with preoperative planning for reverse shoulder arthroplasty with Brian Warner from Charlottesville, Virginia and Tony Romeo from Chicago, Illinois. Gentlemen, thank you for joining us today. Thanks for having us, Chris. Thanks, Chris. Absolutely. So, Brian, let's start with you. In what patient population have you found planning most beneficial? Chris, that's a great question. And to be honest with you, it's transitioned a little bit over my practice. But now I'm at the point of planning every single case reverse or anatomic. Interesting. So, Tony, when is preoperative planning most valuable to you? I think preoperative planning is most valuable when there's more significant deformity of the glenoid. So if you lost the posterior wall or the anterior wall, or when you have these three dimensional deformities, both inclination and inversion are involved. But just as Brian said, once you get comfortable using it, you want to use it every case to make sure you're doing it as best as possible. In fact, I'm going to give you an example. I have a wonderful case from Patrick Denard, and I'll show you how the preoperative planning can be very helpful. This is a case of a 67 year old, right hand dominant lady who has had shoulder pain for several years and has failed to do well with conservative management. She has a BMI of 44, but she's only five foot three, so relatively small bone. Her range of motion is severely limited with zero external rotation. Her forward elevation is only to the level of her shoulder, and her internal rotation is just to her hip, so she's significantly disabled with the shoulder. And what we can see on these radiographs, the true AP and the axillary lateral is that she has no remaining joint space. So she has arthritis and some deformity on the glenoid side. But it's not enough to make a call on how difficult this case may be. C.t. Scan in fact, shows the deformity is primarily in the version. So she has increased retroversion and that the bone loss is not too significant. And that's helpful for us when we have this ability to plan ahead. It gives us many different options. We can put the right size glenoid baseplate into position. We can then cover it with the proper sphere. And as we've learned over the years, lateralizing the sphere is very important. For most women, it's 4 to 6mm, and for most men it's 6 to 8mm. For us to optimize the ability for the humerus to clear the scapula and provide a impingement free range of motion. And as you see, with this implant, we're able to minimize the amount of inclination and version deformity that she has. This is a live video of the surgical procedure. And as you can see here, Doctor Denard is making that head cut. It's a free handed head cut. But he checked it with a cutting guide, and he's done a complete capsule release on the humeral side and on the glenoid side, which has allowed him a direct access to the glenoid preoperatively. We had the plan. He's able to put a 2.8mm titanium pin right in the correct position. And this is followed by the actual angled reamer, which is put into position to ensure that the deformity is corrected. And again, it's primarily in the form of Retroversion. Finally, he's got a checker to make sure that he's prepared the glenoid properly. And once that's confirmed, he can again mark the position where there's the most amount of glenoid bone loss. He'll then finalize that preparation by drilling for the post. And then he aligns the base plate with the actual position that's prepared with the plant. Now the important thing here also to notice is that there are two places the screws can be. They can be standard so that they're straight up and down or oblique. If in fact there's some variation in the position of the glenoid base plate. And then once you put that in a place where you get the best fixation on the glenoid, the screws go in typically non-locking screws inferiorly and locking screws anteriorly and posteriorly. And then finally the sphere over the top. This is a relatively small patient. And despite the fact that we used a 33 glenoid, we have all the options available with regards to the augment to be able to adjust to the deformity of her bone. Then we'll finalize this with the proper size humeral stem, making sure we go down to the 135 35 degree angle mark. And we want to get excellent fixation of the proximal rim of these devices with the short stem. We'll look and see where the offset is if there's a slight amount of offset in a posterior direction. We have two millimeters of offset that allow us to ream for the cup and the proper position. And then I like to take the reaming and use that bone to actually bone graft at the time of placing the implant. Then the subscapularis repair is planned either with a tension bridge technique or with a speed gap type repair, and they both work excellent in terms of being able to provide a double row trans osseous equivalent. Repair of the subscapularis. Relying on some of the biomechanics and clinical results that we've seen with other rotator cuff repairs. The final component is impacted into an inlay position, and then we'll reduce this onto the sphere to check for an impingement free range of motion, and then finally repair the subscapularis using virtual implant planning. Having proper exposure. We end up with x rays that demonstrate the components to be in an outstanding position. You can see the humerus is on the lateral aspect of the humerus canal. The greater tuberosity is lateral to the acromion, which is going to give excellent position for the deltoid. And then the sphere with the augmentation has corrected the deformity and fixed securely with the screws and the post. Tony, that was a great presentation. So how often do you feel the need to change your plan during the surgery due to a challenging scenario? Or let's say an anatomic variation? You know, Chris, when you get comfortable with the virtual implant positioning system or VIP, you actually can kind of predict ahead of time those spots where you might have to make a decision one way or the other. But in reality, the vast majority of cases, once you have the VIP plan in place, we follow that and we use that actually as verification that the procedure is going well. We have the implant in the right spot and we're doing the correct geometry for that patient. Now, I notice Pat used a locking screw through the augmented portion of the base plate. Tony, what are your thoughts about using locking screws versus compression screws for augmented base plates? You know, Biomechanically, it's been hard to tell if there's much of a difference. They both work great. I think many of us like the idea of using a compression screw at the inferior part of the fixation. We like really seating that well along with the post or screw. If you're using that in the center position and then the other three anterior, posterior and superior, I think it's really dealer's choice. You can either use a locking screw or a compression screw. Personally, I like to use a second compression screw superiorly, and then my anterior and posterior screws are locking screws. Thanks, Tony for sharing that with us. So Brian, what is your process for planning in regards to sizing? So I think that's one of the important features of VIP and why I like using it for reverse arthroplasty, because you can really individualize the size for each patient. We have a wide array of sizes. And so what I typically will look at is the axial CT scan and size the sphere so that it's covering and flush anterior and posterior. That will help optimize impingement free range of motion. Yeah, I think we're very fortunate to be able to go down to a size 33 and then also have 36, 39 and 42. So we have a wide variety of sizes for our smaller patients. I agree with Brian that if you look at the anterior posterior distance, which is usually the more narrow of the two, that should define your sphere, and then you want to make sure from the on face view that you put it in the superior, inferior position. It's the lower part of the glenoid. So the glenoid sphere is overhanging at that inferior portion. Again, having these smaller sizes allows us to match up properly with our patients. Gentlemen, thanks for sharing your experiences with these challenging cases and how to optimize reverse shoulder arthroplasty. Now to learn more about optimizing reverse shoulder arthroplasty through advancements in planning, be sure to tune in to our other breakthrough episodes, including highlights on making the case, technique, play by play, and the learning curves. Thank you for joining us.

Arthrex presents “Optimizing Reverse Total Shoulder Arthroplasty Through Advancements in Planning.” In this episode, leading surgeons share their experiences and the educational tips and pearls they learned while incorporating preoperative planning into their practice. Joining host Christopher Adams, MD, are in-studio guests Patrick J. Denard, MD (Medford, OR), and Anthony A. Romeo, MD (Chicago, IL).&nbsp;

BreakThrough™ With Christopher Adams, MD—VIP™ System: Advancements in Planning Episode 4: Lessons Learned

Welcome to breakthrough. Today we'll be discussing pearls for Reverse Shoulder arthroplasty with Patrick Denard from Medford, Oregon and Tony Romeo from Chicago, Illinois. Gentlemen, thank you for joining us today. Thanks for having us, Chris. Thanks, Chris. Absolutely. Now, with any innovation, we all know there's a learning curve. Patrick, what is your top pearl for? Glenoid base plate positioning. I think study after study has shown, right, that you are going to have the best base plate position if you use a guide or a patient specific instrumentation. So really that's predicated on having good exposure. You got to have a good straight view of the glenoid. And for me if I'm struggling, that's all about going back and releasing the humeral side, making sure I can get a straight line approach. But once you have that, if you have a guide, you're going to get it right almost every time. Tony, what about you? Well, as Pat said, inevitably in the operating room, you have to have the exposure. But before the operating room, if you can actually visualize the three dimensional structure of the glenoid with a pre-operative plan, and then take that plan and put the glenoid where you'd like it, and then be able to take that and bring it into the operating room with the targeting device. That's going to be the secret to making sure you put it in the right spot. Excellent exposure. A preoperative plan and then delivering it at the time of surgery. So those are some great pearls. Now, Patrick, how important is the turnaround in timing of the preoperative plan? I think that's one of the things that really distinguishes the VIP system and targeting device from other systems out there is you can go from plan to implementation 48 hours. Other systems, you have to get a customized guide that's expensive. With the VIP targeter, you can go right from plan to the case in 48 hours or less. Now, Tony, as you've gained experience with the augments, what are some orientation and positioning pearls? Yeah, the augments have been a wonderful addition to the system because before when we had these bone defects, we had to use the patient's bone typically. And it's a bit unpredictable metal very predictable and fits right into our pre-operative Preoperative plan. And so when we have an augment where we're trying to correct the inclination because it's a patient with cuff tear arthropathy, it's very nice to be able to put that augment superiorly and make sure that we correct it down to zero. In that situation, we'd love to have those screw holes in line with the axis of the glenoid. So that's the standard way that it's developed. One at the top, one at the bottom, and then anterior and posteriorly, as well as the central post. However, if that deficiency is more into the corner. So like instead of the 12:00 position at the 1030, 10 or 9:00 position, our schools are now not going to be with the axis of the glenoid. Fortunately, we have a system where the augment also has an oblique screw hole alignment. So as that augment goes more posterior, you can get the screw holes to be in line with the glenoid and maximize your fixation with the screws. That's really interesting. Now Pat, what about humeral planning? Yeah, humeral planning is a new feature for us. And I think what's really nice about that it's just another layer of giving you confidence going to the operating room, right? Just like we were doing the glenoid. Now we can go to the humerus, get a sense of the size of the implant that's going to potentially give you improved efficiency. Also, in cases that are more complex, like deformity, we can address that and see if we can get a stem in. So I think it's been a great addition to our technology. Now this has been an incredible discussion. But nuances of tensioning are always on a surgeon's mind. Can you both provide your pearls on tensioning and range of motion with our viewers? Tony, let's start with you. You know, this whole issue with regards to tensioning goes back to the very beginning, when it was initially developed by Grammont. And you asked how tight do you put it? Many surgeons say I put it as tight as I can, so I can just barely reduce it. That makes sure that it's stable. But the design was different. It was a steeper inclination at 155, and it came underneath the glenoid. And when we went to more of an anatomic structure, it was 135. Even the reduction maneuver was slightly different. And what we've noticed, particularly over the last ten years, is that we put in looser or more lax than we did at the beginning when we were using the different styles, but it's still, when it goes through a range of motion, can't impinge on the scapula, it can't gap off of the sphere. And we can achieve that by placing our glenoid in the right spot and then lateralizing it so we avoid the scapula. And that was really some important technology that needed to happen at 135 inclination and lateralization of the sphere. And that in fact allowed us to put it in a slightly more lax position, which gave us the opportunity for more range of motion at the glenohumeral joint. And yet we avoided increased instability of the glenohumeral joint. Pat, what about you? Yeah, I think just echoing what Tony said, if you look at the literature on dislocation after 135, it's extremely low, right? So for me, I'll confess, I do very little trialing. It's all about planning in advance how much lateralization I'm going to have that 6 to 8mm of lateralization on the glenoid side with a 135, you're really doing more of an anatomic reverse. And if I do that and I have confidence at the time of surgery, then I'm not going to have an instability event. Now, Tony, in regards to patient satisfaction and overall patient experience, what are you doing in your practice? Well, patient experience begins as soon as the patient walks into the door. They have to be greeted properly. They should be put in a room by a medical assistant who knows about your practice. And then once a decision has been made that a shoulder arthroplasty is necessary, they should be educated on exactly what that is and their questions should be answered. Many of our patients still do not know the difference between an anatomic and a reverse, and using models that actually show the two different designs is very helpful. And then we can refer them to websites such as the Arthrex orthopedics site, which has areas available that are really valuable for the patient. I have some of my own. Pat has a wonderful website too, where patients can go after they leave the office to continue to become educated. And then finally, we assess our providers and how they are getting the right message to the patients through press Ganey scales, which our patients will fill out, tell us how we're doing as well as online reviews. And we take those and we continue to evolve and improve our practice to maximize that patient experience. That was wonderful, Tony. So, gentlemen, any final thoughts on the future? A couple of things. I mean, I think first of all, you just have to be on board, right? Because you're going to see all of this continue to evolve over time. And if you're behind the curve, you're really not going to see what's going on in the future. A second thing that I'm really excited about is range of motion. Currently, the systems out there really are not assessing range of motion properly. They really have little value because they don't take into account the scapula. So as we develop technology that will account for that, I think you'll actually see a translation into being able to have that range of motion assessed preoperatively to actually being clinically meaningful. Tony, I think what's really amazing to me is the fact we've had the reverse prosthesis for now, 20 years since 2003. We are still learning how to do this for each of our patients. In other words, patient specific design and patient specific implants based on what is going to give them the best function. We're still learning exactly how to do that. In addition to the overall patient care, we're doing more and more of these cases on an outpatient basis, and that's a really significant improvement for both the way our patients feel about the surgery and the environment in which we do these cases. And the technology continues to evolve in terms of the way that we can actually make our cuts on the humoral side. And then some of the newer devices that we can use both on the humerus and glenoid to make sure our patients get the very best implant. This has been an incredible discussion. Gentlemen. Thank you again for joining us today. Thank you. Thank you Chris. To learn more about optimizing reverse shoulder arthroplasty through advancements in planning, be sure to tune in to our other breakthrough episodes, including highlights on making the case, technique, play by play, and challenging cases. Thank you for joining us.

In the latest edition of the series, leading surgeons discuss their use of Arthrex advanced surgical planning tools to optimize their total shoulder arthroplasty cases and provide practical tips and pearls they have learned with this innovative technology.