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At Arthrex, our mission is Helping Surgeons Treat Their Patients Better™. We created this space to connect surgeons with educational content to enhance the preoperative planning experience. Learn how other surgeons are using the software and approaching important topics such as baseplate positioning and backside seating. We'll continue sharing short videos from other surgeons with you, highlighting unique cases and new features as they are released.

VIP™ Vision: By Surgeons, For Surgeons

Arthroplasty Shoulder

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In this exciting episode of VIP™ Vision, one of our veteran software users, Brian C. Werner, MD (Charlottesville, VA), provides a sneak peek at the next generation of our Virtual Implant Positioning™ (VIP) software, which is now available on iOS mobile devices. Dr. Werner presents a demo case to highlight some of the sleek new capabilities, including the center-of-rotation and subluxation features and 3D “fly-by” view, which can all be used to educate staff and patients. Also, stay tuned until the end to learn about the all-new VIP Experience.

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VIP™ Vision: Episode 1—The Next Generation With Brian C. Werner, MD

Hi, everybody. I'm Brian Warner. I'm a shoulder surgeon in Charlottesville, Virginia. And today we're going to talk about the next generation release of VIP, including some exciting new updates and upgrades. All right. So this is what the new VIP looks like immediately upon logging in, and you'll immediately notice some new upgrades. In addition to the dark mode, both the case list and how your cases are organized are different, and they represent a huge upgrade. I'll start first with how your cases are organized. You can have them in a table format like we see here with cases listed. But one of the new exciting changes that you also have this calendar format. And so in the calendar format you can see all your cases that are scheduled for a particular month. And then the cases will be color coded. And so there will be a yellow when there are a certain number of days out, and then red when they're in a pending case. And so I found that very helpful for myself to keep my cases organized. In addition, the case list is very easy to navigate. And so you can search for particular cases. You can search by surgery date. You can search by the status. What I found to be very helpful is I can also search by patient name if I know a particular patient is coming up, so I don't have to search through a long list of cases. An additional new upgrade is how the case upload process goes. So it's very simple to hit on new case. You'll notice that it loads much quicker. There's much faster computing speeds, so it's much easier to do. It's also a simpler uploading screen where you have less fields you need to fill in initially, and the CT scan uploading process goes a lot more efficiently. All right. So now we'll enter into a case to see some of the exciting new features. Within a case. You get a similar initial screen that shows you both the date of surgery and the date of CT scan, and basic information about the patient. You then can very quickly navigate to the View Plan icon, which is highlighted in blue to make it easy to find. You'll notice the cases load very quickly. So I like to organize this in terms of the left side of the screen. The center of the screen and the right of the screen. We'll start first on the left side of the screen. This is some familiar information that was present in the prior editions of VIP, but highlighted in a new fashion with some really good upgrades. So first, you'll see that we have both our native inclination and native version similar to what you're used to. However, these are mated with the coronal and axial CT scans as opposed to being present in a different part of VIP. These screens, with the native inclination and native version, allow you to make adjustments to base plate position for height sphere size, so you can size your sphere off the glenoid and also length of your post very simply before moving on with the rest of the case. So an additional feature on these inclination and version screens is the ability to measure distance and also measure angles. These are very easily toggled with the measured distance and the measure angle features. So if you click on measure distance you can see that you can use the little blue knobs to measure distance. And this can be done to decide where to place a component, how to place a component, or even to size a bone graft if you're planning on a bone graft. Very similarly, you can also measure angles. So if you're trying to decide if you need a particular type of AugMend or again, a bone graft to fill in a void, the angle measurement can be very helpful, and it's much easier to do on this version of VIP. Similar measurements of distance and also angle can be done on the axial CT scan, making this very versatile. So next we'll move to the middle of the screen. This is where you have your 3D flyby, which again is very helpful for both the surgeons, for the patients as well as the operating room staff to understand the plan. This also gives you your backside seating information. I think what's a helpful addition here is you can very easily see how you can minimize the backside seating information, but still have the seating information shown so that it does not obscure your fly by view. When you want to look purely at the fly by. So we'll then move to the right side of the screen. The right side of the screen is where you have all your implant controls, where you can actually plan out your case. Typically when I'm planning a case I start with spheres. And so the sphere feature allows you to select your sphere size and also your sphere lateralization. And so we won't be doing this exactly like I would plan a clinical case, but I typically would size a sphere based on the axial CT scan. You can see very easily that this patient needs either a 39 or a 42. And I typically lateralized you can see these very easy drop down menus where you can select a lateralized or an inferior offset sphere. Once we have selected a sphere, you'll notice that the joint tab appears, and we'll get into that in a few minutes. But that's a very exciting new tab that allows us an improved understanding of how the joint is positioned when we place our prosthesis. After selecting a sphere, typically my next choice is to look at what implants I'm going to choose. You can see very easily that these are labeled very nicely and very user friendly. You then can select your implant whether you want to do an anatomic or reverse. And if you're doing these which implant you prefer. I use a lot of augmented components. You can see it's very easy to select an augment, and that it loads very quickly from the same screen. You can also choose the size of the augment, whether you want a 10 or 20 degree augment. And then finally, you can also choose the length of your central post, which again I will typically select based on this axial CT scan. So moving on next to implant controls. This again is very easily labeled. And you can very easily choose how you want to place the implant for augmented components, which is what I typically use for reverses. I typically first will roll the component. And so that can be done either by selecting the amount of roll with the plus or minus keys, or you can type in the amount of roll that you want. For this patient with a reasonable amount of inclination inversion, I'll typically use a posterosuperior augment, which would place at 45 degrees. Then you can start to dial in your version, your inclination and your position, both anterior posterior and superior inferior. This is very easy to drag back and forth to accomplish this, although if you ever get it to a place where you're unhappy with location, you can simply hit refresh and it will restart it back to where the planners had placed it. So I typically will do my superior to inferior height first that we can decide based on this three dimensional image, which very nicely you can see the sphere outlined here in a white line. You can also look at the coronal CT scan to decide that, and then place it anterior to posterior and try to center the sphere based on that. We then need to dial in some additional version and inclination correction or loss of correction based on this glenoid. So we can do that very easily with the plus or minus keys. I typically will place the patients in a small amount of retroversion, usually somewhere 8 to 9 degrees of retroversion so that the central post is placed. Finally, then we can decide how much bone we're going to ream. We can adjust the patient medial or lateral. And so that's the amount of reaming we're going to do to achieve backside seating. You see for this patient we had to do a reasonable amount of reaming. But we're able to get 100% backside seating here. Our central post is placed very nicely. We have our sphere just flush or slightly inferior, so then can move on to see the amount of reaming that we do. One really nice feature of the new VIP that we have is that the Max GAP offset is automatically turned on when you log in, so it's not something we have to wait for to calculate or toggle it. What's really nice about that feature is it shows us not only the max GAP offset, but what I use it more for, for reverses is for the maximum depth. And so here anterior inferior we can see the maximum depth is 4.5mm. That tells us that just that point we reamed a maximum depth of 4.5mm. Everywhere else we reamed less than 4.5mm. Finally. Then we can proceed with screw trajectory for reverses. Obviously you wouldn't see this option in an anatomic. A nice new feature of this new version of VIP is that you that you don't have to go through quite as many steps to do screw trajectory. And so once we've decided on a screw, I'll say we'll start here with this screw. This I typically do is a locking screw. We simply select the locking screw and we can select our depth. We don't then have to choose any additional things. We don't have to click any additional buttons. It's automatically saved. So we can move right to the next one. Even after planning hundreds of plans, I still, in the older version of VIP would forget to hit okay and save my screw trajectory that I had chosen and often would have to go back. And so I found this feature to be very helpful. And so you have your full array of your locking options and your non locking options available to you. And it's very easy to very quickly go through and do your screw trajectory. I'd say it probably takes me 25 to 50% less time to do screw trajectory than it did on the older version of VIP. So once you've completed placing your implant and doing your screw trajectory, one of the exciting new features is this joint tab. And so you can click on the joint tab and see a number of additional measurements that you can interpret and use when you're deciding how to position your implants. The first is center of rotation. So this shows the native center of rotation for the patient and where the prosthetic center of rotation will be. It also shows the change in the center of rotation from native to prosthetic center of rotation. And those measurements are done in a three dimensional fashion. So it includes the AP plane, the superior inferior plane, and the medial to lateral plane. Additionally, you can also use this joint feature to look at subluxation. And so you can unhide subluxation that will bring you to an image. And that can show you both the subluxation visually. And then also there is a measurement of the native subluxation of the humeral head, which is measured in a three dimensional fashion compared to some of the other measurement methods which might not perform it this way. So finally, I wanted to show you this flyby feature, which is very helpful for surgeons, patients, and even the operating room staff to understand the surgery and what the plan is. Vip is part of the larger VIP experience, which includes automated pre-surgical texting. So the my VIP experience for patients. And that's directly linked to your surgical plan so that they're engaged in this VIP process. They're also the clinical tools that you can bring to the clinic, such as the interactive models, which my patients have found to be very helpful. Also the educational pamphlets and the social media kits. So I think it's important to consider VIP and the my VIP experience as a tool for both surgeons and patients. For surgeons. It's the preoperative planning. It's the reusable intraoperative tool, and it's the other tools to help you engage with patients for outreach and education for patients. They get the texting experience. They get the clinic models. They get the pamphlets. They also get this 3D flyby to really understand their surgery better and hopefully improve their outcome.

Brian C. Werner, MD (Charlottesville, VA), highlights the value of using Virtual Implant Positioning™ (VIP™) preoperative planning for his practice and patients.

VIP™ Vision: Episode 2—The Value of Preoperative Planning Using the VIP System With Brian C. Werner, MD

Hi, everyone. Welcome. My name is Brian Warner. I'm a shoulder surgeon with the University of Virginia Orthopedics in Charlottesville, Virginia. And I'm going to discuss the value of preoperative planning and how VIP works. So I think the most important question to ask as a surgeon, beginning to, to use preoperative planning is why is preoperative planning valuable anyway? I trained and during my fellowship, without any preoperative playing at all, other than playing radiographs and quickly upon entering practice, realized that was probably not optimal for patients. And so I began searching for a preoperative planning platform and then arrived at VIP. I really found that the addition of preoperative planning through VIP completely and totally changed my practice. And most importantly, planning alone. So uploading the CT and performing the plan in VIP on the computer improve the accuracy of pin placement. There's been a number of studies, one of which is pictured here that shows a plan alone, improved pin placement, then the use of a transfer guide or a targeter further improves placement, and that again has been demonstrated by several studies. Intraoperatively. It helps us achieve the desired glenoid location. But I think most importantly for me, it reduces variability. When we're in the operating room, there's a lot of things going on, and so I'm trying to reduce variability and make things more predictable. And so VIP makes both anatomic and reverse shoulder arthroplasty and more predictable and reproducible operation. So how does planning help me? I think that planning overall is key to performing the best possible surgery that I can for the patient. Just uploading the plan and looking through the plan on VIP and rotating the scapula around allows me to more completely understand the patient's patho anatomy and understand their version, their inclination, and the amount of medialization. It also helps me choose the appropriate implant. I've had several patients that I thought were appropriate for an anatomic shoulder arthroplasty. I upload their plan into VIP and notice they have much more significant bone loss than I thought, more medialization than I thought. Or I began to to start doing a correction for correction for AnaToemic Tuberoplasty and realized it would require much too, too much reaming. And so then I settled on using a reverse shoulder arthroplasty. And so it has changed the implant in a number of cases for me. And I've also found that using the Targeter as a transfer guide, as I mentioned it reduces variability. It gets me closer to correct in the operating room and really, really helps reduce variability. It also increases my confidence. This is still important now over 1000 shoulder replacements later, as it was with my first couple of shoulder replacements. Confidence is everything in the operating room. So how does VIP work? It starts with a CT scan. So I'll talk a little bit later about how to implement CT scans in your practice. But first the patient needs to get a CT scan. After that is uploaded there's a number of ways to upload it. It can be sent directly, or your technology consultant can get a CD and upload it. It's about a 48 to 72 hour turnaround before the plan is sent back to you from the engineers. I think the important thing about taking a 2D CT scan and giving it to Arthrex to upload a VIP is it's then corrected to a 3D CT scan. This corrects the axial CT scan into a scapular plane and then calculates version inclination. This is done using the gold standard. Freeman's line. And it's really powerful. If you ever have the opportunity in your own PAC system to correct in the scapular plane, the version inclination can change substantially. The other advantage then, is that the engineers at Arthrex provide you with a preliminary plan. I often will adjust the preliminary plan, and I treat it as preliminary, but it gives you a great place to start and so it saves you as the surgeon some time on the back end, so that when you're doing your plans, you have a starting point, and so you often are only making minor adjustments. Then once you've finalized, it's almost ready immediately for your use. So then how does VIP affect my decision making? It affects me both Preoperatively and Intraoperatively. Preoperatively I mentioned a little bit, but it helps confirm the appropriate implant type. I'm someone who likes to place an anatomic implant when I can for appropriate patients, but I found a number of times based on x rays and 2D CT scans. Once I've uploaded and had their 3D CT scan, I've realized as soon as I'm starting to position that implant that an anatomic glenoid might not be the most appropriate thing for the patient, and changed to a reversed shoulder shoulder arthroplasty implant just based on the plan alone. It also decides how much deformity I can safely correct. This goes for both anatomic and reverse shoulder arthroplasty. Certainly there are some acceptable ranges for implant version inclination, not necessarily the subject of this talk, but it decides for me or allows me to decide how much I can safely correct without overreaching or overmedicalising intraoperatively. It's the best way that I have to accurately position the central pin. Typically, I will place a little bovie mark where I think the pin should go based on my preoperative plan. The targeters still often changes that slightly. It also gives me a guide for version inclination, which often prior to VIP was a little bit of guesswork for me. So how do you discuss VIP with patients? I think the most important thing is having that is having a discussion with your patients, showing them that you, as the surgeon, feel that it's valuable for you to perform the best operation and valuable for the patient to get the best outcome. I highlight the importance and the value personally to the patient. I don't have a nurse or one of my athletic trainers do it. I do it myself. I then emphasize that VIP, VIP allows me to individualize the treatment for the patient's pathology, and that a 15 or 20 minute CT scan can have a lot of value for the patient. Patients also like the idea of performing the surgery on a computer first before performing it on them. And so I'll often mention that to patients who do I get it on? I get it on all anatomic shoulder arthroplasty patients because often glenoid version is underappreciated. Then I will get on the majority of my reverse shoulder arthroplasty. And every year I'm increasing the percentage of patients that are getting reversal arthroplasty that I'm getting a CT scan on. But certainly any patient without any axial imaging at all. So patients without an MRI or anyone even with an MRI where I've identified significant bony deformity. So thank you very much. Hopefully that gives you a little introduction to VIP and why I find it valuable.

Justin W. Griffin, MD (Virginia Beach, VA), discusses backside seating considerations for anatomic and reverse total shoulder arthroplasty using the Virtual Implant Positioning™ (VIP) preoperative planning system.

VIP™ Vision: Episode 3—Backside Seating Considerations With Justin W. Griffin, MD

Hi, I'm Justin Griffin from Virginia Beach, Virginia. I'd like to talk to you today about how to optimize your implant seating utilizing the Virtual Implant Positioning system. The goals of shoulder arthroplasty are to decrease pain, limit complications, and optimally make these last a long time. We'd like to make our fixation great so that the longevity is improved. This changes when we have specific patterns in shoulder wear that create bony deficiency. Sometimes we need to move towards a reverse shoulder. Sometimes we need to augment with metal, and we have to make hard decisions on how to augment or correct certain shoulders. Some of these challenges come with specific wear patterns, specific version in the shoulder, and inclination patterns that we can discuss today. We'd like to avoid failure in. Many of these failures come with improper planning. So the virtual Implant Positioning system allows us to plan our backside support. The goal of that is to minimize micro-motion and loosening and breakage, and to minimize the ream for the patient so that we avoid having to revise the shoulders in the short term to hit a home run. We really have to plan this before surgery. Everything happens in our mind before we get into the operating room, and VIP allows us to do that very nicely. Posterior glenoid bone loss creates a unique challenge, and we have to really try not to read too much bone in order to put the implant in a proper position. You can see here that I'm analyzing whether I can get this implant properly into the patient without taking too much bone. So we have to stock our toolbox. We can consider a Riemann run. In this patient we consider partial correction. We can consider a high side ream, posterior bone grafting, augmented shoulder replacement, or even a reverse. So let me tell you a few aspects of what I'm looking for when I'm considering my component seating in a total shoulder and an anatomic shoulder arthroplasty. I'd really like to ideally get 90 to 95% backside seating in VIP, as you can see here. We can tell whether or not we're all the way down the green shows us if we're contacting bone in a reverse shoulder, I may go for less. I may shoot for 80% backside seating. The dangers of incomplete seating are real. We'd like to avoid rocking. We'd like to avoid edge loading, and specifically we'd like to avoid loosening. Complete seating might not be necessary. If you look at the world's data on this, you don't necessarily have to get to 80 or 90%. Some studies have shown us that even without complete seating, the patients may still do well in the long run. So some of the steps that I use first, I'd like to bring this out of Retroversion. We're trying to get to less than ten degrees optimally. So in this patient with a native 14 degree retroversion, I don't want to sacrifice any bone here, but I'd like to get it to less than ten. And if you get it to less than ten, if you look at Doctor That is work, we can avoid osteolysis in the long run. The next thing I do is I bring this out of inclination. We've recently done some work with our registry study to look at this, and noted that two year outcomes, when we get those patients down to less than ten degrees of inclination, there's a significant improvement in their postoperative constant score at two years. So I do think it's important to take some of that pressure off the rotator cuff and bring those patients out of superior inclination, and we show that the degree of correction is as important as how bad it was in the beginning. The next step I take is I position the base plate so I can get 80 to 90% contact at the backside of the implant. Complete seeding is not necessary again, to achieve implant stability. If you look at the studies demonstrating 43 month follow up with no significant radiolucencies around those partially cemented glenoid component, but in a perfect world, we'd like to get to 95% or more backside seating. And the reason for this is if you look at the effects of reaming on the glenoid, if you look at the data, if we ream too much glenoid, our survivorship goes down and we can end up with more radiographic loosening than we would like in the long run. And this results in migration of the glenoid component and decreased survivorship. To mitigate these concerns, we'd like to minimize the glenoid rim by using an implant that matches the patient very well. And ideally we want this to be less than 3.5mm but no millimeters insignificant. So my particular algorithm is an A1 glenoid. This is really a chip shot. You should be able to get 100% seating here. And A2 glenoid. We may want to think about flattening that versus putting in a reverse shoulder depending on the rotator cuff tendon. And a B1 glenoid. If we can perform some high side reaming and put in a total shoulder, that's probably ideal. And in those cases, we may be able to accept 90% or slightly less of backside seating and a Walsh B2 glenoid. This is where it gets more tricky. We might be able to highside ream if we can get the patient to correct to less than ten degrees, but we don't want to take too much bone, and certainly in B3 and see glenoid, we have to think really carefully about whether we want to put in a reverse shoulder in those patients. So what about in a reverse shoulder. So positioning of the sphere in the base plate are related. Sometimes I'll put up the sphere and look at its relationship to the inferior glenoid. You can see on this patient on the right I performed a bone grafting procedure on this B3 glenoid to restore the lateral offset and the joint line. My next step is I bring this to zero degrees of inclination with a 135 implant, which is my preference. The version is really not quite as crucial based on the world's literature in reverse shoulder. I shoot for 80% backside seating or more, but we can accept less. So how much contact is necessary? Well, if you look at the studies, Doctor Frankel has done some very nice work on this, and we want to accept what's necessary. But ideally, I'd like to have one centimeter of my post in Native Bone. This study showed that you could really accept a very small amount of backside coverage was still good implant stability as long as you have good screw and post fixation. So augmented MGS seating is really no different. We're looking for optimal position. You can see in this particular plan I've rotated that posterior superior to fill the defect for this challenging glenoid. So this is really a balancing act between bone preservation and bony replacement for our patients. So in summary I'd encourage you to plan every case with VIP. Ideally we want to optimize our backside contact. And those numbers are a little bit different in total. And reverse shoulder arthroplasty when necessary. We use augments and consider bone grafts and severe deformities. Thank you for your attention.

Brian C. Werner, MD (Charlottesville, VA), demonstrates planning in the Virtual Implant Positioning™ (VIP™) system. The VIP reamer features a positive stop to ensure reaming to the VIP plan.&nbsp;

VIP™ Vision: Episode 4— Introducing the New VIP Depth of Ream Instrumentation

I'm Brian Warner from Charlottesville, Virginia, and today I'm going to demonstrate planning a VIP case that we will then use to demonstrate depth of Reme instrumentation. First, I'd like to look at the patient's native inclination and native version. For this patient. They have one degree of inclination eight degrees of native retroversion that will help me decide what implant I'm going to use for this patient. I think it's very reasonable to use a standard MGS base plate. I typically will use a 24mm base plate and prefer a screw when I use a standard MGS. Next, I like to size the sphere, and so I typically will choose the sphere in this axial view, making sure that it covers both anterior and posterior, at least flush, anterior and posterior. And so this looks about a 36. And that seems to cover pretty well. The final thing I like to size before moving on to controls is the length of the screw or the post. Typically that's going to be between a 25 and a 30 for me. Now we'll move on to implant controls. I like to start first looking at the axial. Typically I'll leave the patients in a little bit of retroversion for several reasons, the first of which is because it does not affect clinical outcomes, the second of which is because a little bit of RetroFusion between seven eight degrees of retroversion for most glenoid will allow the post or the screw to be completely contained in the vault. Then we'll typically look at the coronal plane. I like the sphere to be flush or a millimeter inferior. And so that can be adjusted right now on the coronal plane. I can also look at the 3D to confirm this. But if we look at this position here we can see the line shows that we're flush or just inferior. And near the sphere is sitting flush or just inferior. We can also in this axial view adjust the anterior or posterior position of the base plate. I typically like to center it as best I can. It seems pretty well centered. Finally, then we can adjust our depth and we can move it lateral or medial until we get good backside seating. I'm shooting for close to 100% backside seating, but I'm not necessarily committed to 100% backside seating. I often like to pair this with the max gap offset, so that I'm balancing the amount of bone that I ream with the amount of backside seating that I can achieve. We would then proceed to using the screw trajectory feature to choose the length of our screws and the angle for our non-locking screws. This depth of reaming, this 3 to 4mm of reaming that we'll be doing in this case will then be transferred to the final VIP plan provided to you as a surgeon with the letter that you can then transfer onto your pilot reamer so that you match the depth of reaming in your VIP plan with what you achieve. Intraoperatively. So next I wanted to introduce you to the VIP Glenoid Reamer tray. It's a pretty simple tray. I just wanted to highlight a few things in the tray. First we have our VIP Pilot Glenoid reamer. Next we have the secondary Reamers. Secondary Reamers for the VaultLock and also for MiGs. And then the standard reaming equipment from the other trays that you're used to. I wanted to show you a little detail on the VIP pilot reamer. You'll see a series of letters on the pilot reamer. And this indicates the depth of ream from your VIP plan. This can be dialed to what your VIP plan calls for, simply by turning the shaft and watching the line which will correspond to the letter from your VIP plan. If you accidentally go too far or need to reset it, this is something where you can simply pull back and spin it and then restart again back at a. I will now demonstrate in a cadaver the use of the VIP glenoid reamer. We've done our standard exposure and capsule releases and have an excellent view of the glenoid. I'll now place my guide pin for my standard MGS base plate using the VIP targeter as is typical. Our depth for the VIP pilot reamer is set at C per our VIP plan. Here I'm using the VIP Pilot Reamer to create our pilot Ream hole. So next we will use our secondary MGS VIP reamer. You'll note the key difference between this VIP secondary reamer and the standard MGS reamer is the flat smooth hub. Next we'll use our secondary VIP reamer and this will ream until there's a positive stop. Now our reaming is complete. You can see that the pilot ream no longer shows, and so we can be very confident that we've now matched the depth of reaming from our VIP plan so that we can get the backside seating. We were planning for our MGS implant. We would then proceed with our standard MGS implant technique of reaming for the central screw post and placing the base plate. I'd now like to highlight for you the one key difference between using the VIP reaming system for a standard MGS and an augmented MGS. We're using a sawbones to demonstrate this. We've already placed our central pin, and we'll use the same VIP pilot reamer in order to do our do our pilot ream. Here is the secondary VIP reamer for the augmented MiGs. You'll note it has the elevated nose to provide a positive stop when it enters into the pilot hole. And again, this has a nice positive stop when you've completed your reaming. We have now completed our secondary VIP augmented MiGs reaming. You'll notice a key difference from the standard MiGs compared to the augmented MiGs, is that you'll still see some depth from the pilot ream. This is because of the nose sticking off of the augmented VIP MiGs. Secondary reamer. This will be eliminated when you ream for your central post.

Jeffrey Tuman, MD (Eugene, OR), discusses how to use the Virtual Implant Positioning™ (VIP™) preoperative planning system to determine placement of the augmented Modular Glenoid System (aMGS) component during complex reverse total shoulder arthroplasty.&nbsp;

VIP™ Vision: Episode 5—Augmented MGS Positioning for Complex Glenoid Morphology With Jeffrey Tuman, MD

Speaker  Hi, my name is Jeff. I'm an orthopedic surgeon from Eugene, Oregon. Today I am going to be reviewing a clinical case to help highlight how VIP helps me manage more complex glenoid deformity. Here you can see we have a 73 year old male with chronic right shoulder pain. His activities of daily living were affected, including sleep. His forward elevation was 130 degrees. External rotation was 30 degrees. What we see here on his X-rays are severe glenohumeral osteoarthritis. There is evidence of a B2 glenoid deformity and posterior humeral head subluxation. We have a CT scan which demonstrates that as well with significant B2 deformity present. Factors to consider. How do I correct deformity, minimize glenoid reaming and have optimal stable implant positioning? How do we assess whether or not there's excessive glenoid inclination? Particularly important if we're planning to do a reverse total shoulder arthroplasty. And for me, the way we do that is through VIP planning. So here's the case that's uploaded on VIP. And I'm going to walk you all through how I would plan this case first. What I do is I like to look to see what we are dealing with. And here we can see VIP has us at about a ten degree inclination, native inclination and a 22 degree native retroversion. So we're dealing with more of a biplanar glenoid deformity both needing to correct inclination and retroversion because we are planning to do a reverse arthroplasty. Next, what I like to do is go to our implant controls, and I like to set what my goals are. Speaker  So here my goal of inclination is at least zero. And version I'm going to set to approximately. Ten degrees of Retroversion. And we can adjust from there as needed. So now we know what we're shooting for and now we can Help position. And I think quickly what we'll see here is that with this standard base plate, we're not going to be able to correct our deformity and also minimize reaming and go to state and get a good stable position of our base plate. And so pretty quickly, we can see we're going to need to change to an augment. And I'm going to select a full augment based upon the amount of deformity present. So now we're going to go back to implant controls. And we're going to work on positioning this base plate exactly where we want it. And we're going to shift this a little more anterior. We're going to shift this a little more inferior. And now we're going to work to position this such that we're happy with where it is and achieve the backside seating of the base plate that we would like. And with the augment, it's very common that I can achieve close to 100% backside seating, base plate contact with the glenoid with fairly minimal reaming. And what we'll start to see here is now we're getting closer to 100% seating. Speaker  We'll shift this a little more anterior to ensure that our post is going to be in a good position based upon down here. And now I'm pretty happy with the correction, the base plate seating. And just to demonstrate, we can adjust the roll which allows us to correct both planes of deformity. And so you can see where what I call the apex of the of the augment is, allows us to both correct inclination and version to approximately ten degrees of retroversion with minimal reaming. And now I can take this plan and translate that into the OR. And I've found that to be extremely helpful. So our goal is to take our VIP information and translate that directly into the operating room. Here you can see we're utilizing the baseplate guide to assess our contact and correction of a deformity. We have our pin in place, which allows us to then place our base plate in an excellent position. Here you can see my post-operative X-rays. Assessing these. You can see we have our base plate that's well positioned with excellent contact. We have correction of our retroversion to how we had planned it through VIP. We have a well positioned Inclinator Glenosphere. And this patient is now approximately two months post-op. He is doing excellent. He is pain free. His function is also very good. And he's extremely happy with the outcome of his surgery. Thank you.

Julia Lee, MD (Fresno, CA), highlights the value and techniques of using Virtual Implant Positioning™ humeral planning in total shoulder arthroplasty patients.&nbsp;

VIP™ Vision: Episode 6—The Value of Humeral Planning Using the VIP™  System With Julia Lee, MD

Hi, everybody. My name is Julia Lee. I'm a shoulder elbow surgeon in Fresno, California. I'm here to talk to you guys about the value of humeral planning in the VIP system. So we'll go from there for me. Why is humeral planning valuable? There are certainly cases where the pathology is more on the humeral side rather than the glenoid side. So understanding what the humerus looks like and how you can plan your implant based on that is very important. It allows me to have a better understanding of the proximal humeral anatomy. It helps me understand where to resect a little bit better. And it's also very important for me to be able to see where my osteophytes are. So I know how much I have to remove where they are and kind of plan for that in my overall approach. For me also, it helps me figure out what size I want for the implant, whether it is an anatomic and I'm trying to recreate the center of rotation, or if it's reversed, and how big of a cup I can go with based on the patient's humeral anatomy. So if you look over here, this is a patient of mine. And if you want to take a look at his x rays, he has an AP and an axillary view on here. If you look at the AP view it seems pretty benign. He's got a bad arthritis with some medialization of the glenoid, but it really doesn't show the whole picture. If you look at the axillary view, you can see that he's got very large osteophytes around the entirety of the humeral head. And most importantly, if you don't have humeral planning, you will miss the osteophyte that's going behind the glenoid as well. Having humeral planning here really helps me with my surgical approach. Helps me make sure I have a couple extra steps to make sure I need to have a retractor in the joint before I can dislocate it. And sometimes, even in these cases, you need an osteotomy to be removed the osteophyte prior to dislocating the joint. So having something like humeral planning can help me visualize that and help me have a better plan to my surgery the day of going forth from here. In terms of an anatomic application, I do think that having humeral planning here allows you to better select the size of your humeral head, which helps you better understand how long your Corkscrew has to be. So you better understand the anatomy. And it's great because it helps you really recreate that center of rotation very well. You can see that on your plan, and then you can also see that hopefully executed in your post-operative x rays as well. Even in terms of reverse applications, it helps you understand which size you should be using for your stem, whether it's a short stem or a long stem. Having a good idea of what size you should be using is very helpful for surgical planning. It can also tell you how deep you want to inset that stem, so you can have an inlay or a fleshlight position of your component. And also for me, if you're using combination liners or if it's a smaller patient or a bigger patient, to be able to figure out how big of a cup you want to use to better inset that component. So very important to have just a better surgical plan, have better outcomes, and have an easier time at surgery with humeral planning. So we'll go over some tips and tricks as well on how to use humeral planning in the VIP system. And so for me, I always want to take a look at the humeral head first. For me, I personally rotate the head to the correct side of anatomy. So if it's a right side, I make sure I rotate it to where it looks like on the right side. For left side, I rotate it to what it looks like on the left side, and I always choose my the resection of my humeral head cut first, and that's usually how I start. I can see the different osteophytes that are present. I can see what size I need for my trunnion. If I'm doing anatomic, I can see what size I need for my cup, if I'm doing a reverse. And from there I can rotate the model around so I can actually see what the cut looks like in 3D. You can see the anterior aspect, you can see the posterior aspect, and you also have a really nice screen on the left side that helps you see what it looks like on a 2D CT scan as well. So that's very helpful in terms of sizing. And from there, there are different things that you can do to rotate to make sure you're not overhanging your implant. You can also see make sure you're not perforating the cortex. So different things that you can check using the humeral head planning section. So let's go from here. Let's take a look at a couple examples that I have for you. So this is usually the screen that shows up when you first log into your VIP account. As you can see this particular patient we are planning an anatomic component. And this is the glenoid part of it. They have their inclination as well as their version on that left side over here. And their glenoid side has already been planned. So let's move over to the humerus. I usually start with the right side first. This is the 3D rendering of their of their humerus. And for me this is the right side. So I need to switch it over to the correct anatomy. And from here, after switching it to the correct side, what I do is I put that humeral head completely back on because I want to see what I should be seeing at the time of surgery. From here, I can determine on your left side over here, the resection level so you can see what it looks like, how much humeral head that you are taking. So for me, that looks about right. Right there. That's the humeral head cut that I'm planning on taking. So let's take that humeral head off. And there we go. You can see that humeral head cut right there. Then I come over to the left side. And what you see here, there is a green circle. And that green circle is the center of rotation. The yellow crosshairs that are middle is really, truly the center of rotation of the patient's native anatomy. With my humeral head cut, what Arthrex has done in the VIP system is you're looking at the purple crosshairs. So you want to get that purple crosshair to match the yellow crosshair as much as you can to make sure that you're matching the patient's native anatomy as much as you can. As we all know, anything about 2.7mm more makes it where you're not restoring their anatomy appropriately. So from here, I want to make sure those purple crosshairs to match that yellow side. What we want to do is perhaps changing the The component position to better match that. So I think that looks really good. This is size for 41 millimeter trunnion. And I like that size. That looks pretty good. With the 41 millimeter trunnion you have two different head options. And over here you can look at the two different head options. You can see at 41 by 16 and a 41 by 18. And both of those you can see restore of that center of rotation rather well. For me personally I undersize these if I can, just because I do not want to put extra tension on the patient's rotator cuff. Other things that you want to look at, if you want to check your radial mismatch between a small, medium, large and extra large glenoid component and your humeral head size, they have a nice little chart here that can show you what works based on your implant selection and coming back to this particular image. Other things that you can look at. You're looking at the cage screw. So the cage screw function is over here. You can see where the cage screw is. This is a small that's in there. Now we can take a look at the medium going up a size that looks okay. But you certainly do not want a large. If you're perforating Vortex at all, you're going to have a nice little warning message there. So we want to size down. And for me, I think a small component looks pretty good there. Looking over here in the middle, what you can do, you can do an anterior posterior translation over here. It will tell you if you're overhanging the humeral head too much, either anterior or posterior. So you can move that to get a better idea of where you want your ideal component to sit. So I think this sits very well looking over here. This on the right side I think it sits very well as well. I like that recreation. This is what you're going to see on the x ray. I like the way that that would look. Centered rotation is stored very nicely on that left side over here. Just remember I need to take off the osteophytes at the time of surgery. So I think this looks very nicely positioned for a humeral head component. So after you have planned your humeral head in the humeral planning section, you can actually take a look at the joint overall. So this is a nice screen to take a look at the component and how it sits. So on the left side over here we are looking at the patient's native anatomy. This is their original 2D CT scan. And on the right side over here you can see the anatomic that you have planned for the patient. So a couple of things to point out. Overall looks pretty good pretty good in terms of restoring the patient's anatomy. There's an osteophyte down through here that we will definitely take off at the time of surgery, so that's something to consider. Over here you see these crosshairs also. It says that the delta is 9.7. So this is a reconstruction of the center of rotation in 3D anatomy. We don't know exactly how this affects function overall at this point in time. But this is something that we are looking into with the research development team. Hopefully understanding better how this 3D center of rotation affects patient outcomes. Other things you want to consider in this particular view is looking at the patient, the patient's arm. It may be positioned slightly different than what they would be able to actually achieve in real life based on their body habitus. So something else to consider, but definitely an overall good view of what an anatomic replacement would look like in your patient after surgery. So these are a couple examples of how Arthrex VIP humeral planning has helped me with my patients and my cases. Check it out for yourself at Arthrex. Thank you very much.

Albert Lin, MD (Pittsburgh, PA), demonstrates his best practices using the VIP™ system’s reusable, patient-specific transfer technology.

VIP Vision™: Episode 7—VIP™ Targeter Best Practices

Doctor Albert Lin from the University of Pittsburgh. I'm a sports and shoulder surgeon, and today we're going to look at the features of VIP planning on the glenoid side with the use of the five D targeting device. So as you can see here, we've illustrated a few places for retractor placement for glenoid exposure. So I'm going to take you through how I perform capsular releases to get adequate glenoid exposure. This is a Fukuda retractor. Some people use a retracting the back or a curved type instrument in the back. Here. You want this at the 7:00 position of the glenoid. This retractor is a sharp Hohmann retractor that's placed right above the the biceps. And this is the tenodesis or anonymized biceps, as you can see right here, that I'm illustrating right at the 12:00 position. So a couple steps regarding the capsule release. Typically after the substance has been released, there can be remaining interval capsule right in this region. This is your CHL and the remaining capsule. And so we're going to go ahead and just release that. So we've released the rest of the SQL in the interval. The next step here is to release the ML. This can usually be found on the deep surface of the SpeedScap. And you can see with my my tonsil instrument. Here I've distinguished the area of the ML in the muscular portion of the sub GAP. And so we're going to keep this spread like this I usually would release with the bovie. But for obviously for cadaveric demonstration we're going to cut this with a knife. And this will release the rest of the ML. Like so. All right. Once that is fully released, we kind of make sure that the entire capsule has been released on the under surface of the sub GAP and from the glenoid. So both the XL, the interval as well as ML have now been released. So after that's released, I usually then shove the sub GAP into the subs GAP fossa. This then will show the remaining ijl, which has not been released off of the inferior aspect of the glenoid. We've now released the QL, the interval, the QL, the retractor. Now the SpeedScap has been pushed into the fossa. This leaves the remaining ijl intact here. And typically in an actual case, I would put my finger in this interval between the SpeedScap and the QL. I can typically feel the axillary nerve, and then I would bovie right on top of my finger to completely release the entire hammock here of the ijl. We're going to essentially now release the entire ijl off of the off of the glenoid. All right, so we've now fully released the entire capsule, including the entire ijl from anterior to posterior in a reverse, I will circumferentially release all of the capsule in an anatomic. You probably want to stop around 7:00 or so, so you don't introduce estrogenic posterior instability. In reverse, we can take the entire capsule and you can see a little bit of this remains right in the in the hole of the Fukuda here. And so we're going to release the rest of this as well. And so now we have a full capsule release. We should be able to get great exposure of the glenoid. We've now gained full exposure of the glenoid. I've taken the labrum off. One of the important things about the the targeting device is that you should not remove any of the osteophytes, because often the legs, one of these five legs are going to be overhanging on the osteophytes. So it's critical that you leave them for the targeting until you fully prep the glenoid implant, and then you can remove them afterwards. Now I always have the PDF file that shows the legs here from A, B, C, D, and E. You can see that there are numbers that also are associated with those as well. And you can see that the 17 and 15 are anteriorly overhanging the anterior glenoid. I also, in most circumstances, also like to try to get a posterior leg overhanging as well as that gives a nice positive stop. There are certain individuals who have very large glenoid. It's not possible to do that, but if I can get three around that, I think that's more of an ideal configuration. And so based on the plan here, as you can see with the numbers, the 17 is going to go directly anterior. The 15 is going to go anterior inferior. And the 17 is going to go directly posterior. One of the things that can be illustrated with this guide is that, you know, I like to put the two anterior ones on first and then rock the the rest of the targeter on. I actually think it's most useful when you use both hands on this in order to fully seat the the guide, and you can see that we're fully seated here. This matches our plan completely. I'm actually using this guide is pretty robust as well. I'm actually using it somewhat as a retractor even though I have great exposure here. I have the retractor in the right orientation, particularly with the Fukuda. I'm using the entire targeter to posteriorly retract as well, giving us great exposure here. The other double check is you want to look and make sure that all of the feet of the targeter are on the glenoid. So the ones that are overhanging are overhanging, and the two which are not, in this case the 18 and the 17 are on the face of the glenoid. I'm double checking here looking everything is down. So we know that this is fitting exactly where the plan is. Now you can see in this particular case we can do this with the posterior retractor in because our exposure is exposure is great in certain tight individuals, you can actually use the guide as your full retractor posteriorly. So you can remove the Fukuda retractor in here if it's in the way. And then we're going to drill our guide pin. Our flexible guide pin. It's important to note that this is a pretty long guide. You know I always have both of my hands on the targeter while an assistant is drilling the pin. This allows me not to kind of move this pin. Great. Perfect. A nice, nice feature of this guide pin is that it's flexible. And so I can actually slowly kind of bend this out and remove the guide wire. But this is exactly where our targeter has placed our plan, which we initially had demonstrated on the VIP planning system. Now in the prior case, the glenoid was relatively straightforward. But for a more complex case, including a deformity, we can order a 3D Sterilizable glenoid model along with the 5G Targeter. You can see in this particular case that there is pretty significant retroversion, as well as inferior inclination of the glenoid, allowing us to be able to assess our guide pin placement more accurately. Intraoperatively. This model replicates the patient's anatomy perfectly, and so this is good for deformity cases, as well as cases in which you might consider bone grafting. The 5G targeter can essentially be placed on this model. This is a double check for your starting placement intraoperatively. And there's a pre-drilled hole that accommodates the guide pin as well. And again, this can be matched up to the patient's anatomy during the case to ensure that our execution of the plan is, as we had anticipated, with our VIP plan. Lastly, I want to show you a nice feature of this bone model. You can see that this guide pin goes completely through the model. There's many ways to do a bone graft, My preference is to actually match up the humeral head to the glenoid, as both surfaces should match perfectly. I'm talking about the articular margin of the the humeral head. Cut to the glenoid, and if we're using bone graft to match the deficiency or make up the deficiency, we can actually have an assistant hold the bone graft or hold the humeral head cut in place, again matching the contour of the of the glenoid. And then we can then drill into the bone graft with somebody holding the bone graft in place. And this should match and accommodate the deficiency completely. You can then take off the guide pin with the humeral head all in one, and then using the circular reamer or circular saw set, you can then drill an asymmetric bone graft to make a perfectly matched bone graft for a deformed glenoid.

Matthew Levine, MD (Frederick, MD), discusses how to use the Virtual Implant Positioning™ (VIP™) preoperative planning system to determine placement of the Univers VaultLock® augmented glenoid during complex anatomic total shoulder arthroplasty. Dr. Levine then walks through the execution of the plan using precision transfer technology.

VIP Vision™: Episode 8—Planning an Augmented VaultLock® for Complex Glenoid Morphology

Hi, I'm Doctor Matthew Levine from Frederick, Maryland. Today I'd like to share and walk through a complex shoulder replacement case that really highlights the benefits of using the VIP pre-operative planning software with the associated transfer technology. This will really highlight how you can appropriately address a complex anatomic shoulder replacement case. Today we're going to look at a 66 year old right hand dominant female who has had long standing shoulder pain. She lives on a farm and her husband is a physician. Because she lives on the farm, she's continued to use her shoulder but has constant pain when she does so. She has tenderness at the anterior joint line, but not at the greater tuberosity. She has 130 degrees of active forward elevation. Passively, we can get her up to 150 degrees, but she has crepitus and pain. She externally rotates to 30 degrees, but has well-preserved internal rotation to the Thoracolumbar junction. Her strength is normal, but she has pain in all planes of testing of her rotator cuff. As you can see on her X-rays, She has significant medialization on the grassy view and on the axillary view. You can see where she has some posterior retroversion, as well as some bi concavity in the posterior aspect. The CT scan better defines the amount of retroversion as well as the posterior wear, to help in pre-operative planning for this case. Clinically, we've decided that we want to proceed with an anatomic arthroplasty, but we know she has a bit of a complex glenoid in your VIP system. You now know that she has 21.7 degrees of retroversion and about five degrees of inclination. If you want to do a standard VaultLock component, you're only going to get about 55% backside seating. As you adjust the position of that implant to get full backside seating and then check your reaming, you have to ream six and a half or seven millimeters to get the appropriate backside seating. Clearly, that's going to violate your subchondral bone Other implant options include the universal glenoid. But even at 87%, you're going to over lateralize your joint line. In this particular case, an augmented VaultLock with a 25 degree left augment is probably going to be the best fit as you adjust from 4.5mm of reaming, which is still a bit much, you can change your inclination down to one, and you can probably adjust your version to ten. And then as you bring it out to about three millimeters of reaming, you still have 94% backside seating. And with 3.5mm, you have a 98% seated implant. Great stability with correction of a complex anatomic deformity. You can then move on to your humerus. When talking about my humeral head cut, I like to make it fairly close to the rotator cuff insertion. So as we increase that cut length, you'll see that you've realized that center of rotation and that implant is probably a bit small. So as we go from a 41 to a 43, you also would probably want to go to a 4318 head. And you can restore your center of rotation on the humerus. This also gives you an assessment of what to expect with your cage screw. And here a medium cage screw is probably going to be a better fit. Now that you've finished your humeral planning, and we know the appropriate implant for the glenoid, with 3.5mm of anterior reaming, we can now transition to our transfer technology using depth of ream to make sure we execute our plan the same way we've planned it. Let's walk through each step of the execution. The transfer technology in this system is really critical in making sure that you can execute exactly what you've planned. As you transition to execution, you can see that the VIP targeter allows you to sit flush on the glenoid, ensuring that you have a good exposure and allowing some retraction of the humeral head. This allows you to confidently place your center pin exactly where you planned it, and here you can see that you have posterior wear on the glenoid after the center pin is placed. The VIP depth of reem feature is set to the pre-operative plan, and the pilot reamer has a positive stop that ensures you do not violate the subchondral bone. Once you've completed the pilot reamer, you can see here that anteriorly you've left a little more bone to be reamed, whereas posteriorly, with her retroversion and posterior where you're going to ultimately reem less bone. The next step is VaultLock nautilus reamer for the anterior surface to define the flush surface, which you base your angled reaming on. Once you've reamed the anterior surface, you can see that there's a ridge defined posteriorly. The secondary angle reamer sits flush on your anterior surface, and then reems the posterior surface to match the angle of your angled polyethylene component. Once you've reamed the posterior surface. You can then trial and then see where you have two distinct surfaces that will provide good subchondral support while minimizing the reaming required. Here you can see the final product. Secure fixation using VaultLock techniques. With time zero fixation and the implant positioned exactly the way your pre-operative plan has prescribed. Here you can see the post-operative x rays. Where we've restored the inferior arch. We've positioned the center of rotation back where the tuberosity sits lateral to the acromion. And on the axillary view you can see where we've restored the posterior, where using the augment on the polyethylene component clinically, she comes in with almost full forward elevation on the left side. She says that it's now her good arm. She can still easily reach behind her back and has good external rotation. She's back to all of her work on the farm and is very happy, having maintained an anatomic replacement instead of a reverse.

Patrick J. Denard, MD (Medford, OR), highlights recent publications that have impacted his step-by-step approach to preoperatively planning complex reverse total shoulder cases.&nbsp;

VIP™ Vision: Episode 9—Research-Based Algorithm for RSA Planning

Welcome to VIP vision. I'm Patrick Denyer from Medford, Oregon. I want to share with you my research based algorithm for planning in RSA. So I'm going to share with you how I use the VIP system to plan RSA. Vip system is a web based platform. It's very data driven. There's lots of information on this particular platform, and one of the highlights is a reusable guide, which allows reduced cost and time to execution from plan to implementation in the operating room. And that's coupled with depth of instrumentation as well. So I'm going to go through my steps in planning for reverse shoulder arthroplasty. First of all, I like to assess the deformity. Secondly, I want to size the sphere. My next step is to determine the base plate position. Then I assess base plate contact and reaming. With that position I will augment as needed from there. Lastly, I do central fixation and screw length and then move on to humeral planning. Okay, so my first step is to assess the deformity. I like to just get a big picture here of what's going on. Really I want to see the forest for the Trees. Look at my x rays if I have those available. If I don't have those x rays available. A nice trick is to go to the original views, remove the implants, and assess the deformity. Here you can see I have a B2 glenoid. So I have posterior erosion of the glenoid with posterior subluxation the humeral head. This is going to drive me to a reverse arthroplasty. In this particular case, it will also give me a sense of the superior deformity I'm dealing with. Next I'm going to size the sphere. My primary goal here is to avoid anterior overhang of the glenoid sphere. We have a couple of studies now, both looking at the axillary view and at the sagittal wide view, which show that if we have anterior overhang we limit internal rotation. So in particular I like to size from anterior to posterior to avoid that overhang because we really want to maximize internal rotation. So you'll see here I'm going to look at this from a couple of regards. First off I'm going to look at the axial view on the bottom left. And then secondly I'm going to look at this white outline on the three dimensional view. And here we can see the 36 will overlap. So I'm going to go down to a 33. Next I'm going to position the base plate. I have three goals here I want to restore the joint line. I want to avoid superior tilt. And I want to avoid glenoid overhang. Okay. Again I'm going to avoid it anteriorly. But here I'm going to avoid overhanging in particular inferior. So I want to restore the joint line I'll try to use my normal anatomic landmarks the paleo glenoid. In this case I want to avoid superior tilt of the base plate to maximize fixation, but it's important to remember that normal superior inclination is about ten degrees. And I'll show you how I address that in this case. And then I'm going to avoid inferior glenoid overhang because that increases the risk of stress fracture. For every millimeter increase of inferior overhang the risk of stress fracture goes up in our data. So first here you see I'm going to look at version I'm looking at version in the lower left. And I'm going to set that so that it that it goes out mats and centering point right out the anterior vault. I'm aiming for that point more than I'm aiming for, actually going for an absolute number, because normal version is about seven degrees. And my primary goal here, aside from restoring the joint line, is to get fixation. And my fixation will be maximized by going out to that point. Once I have version set, looking at where I want the base plate. The next thing I'll do is address inclination. And here you can see we have seven degrees of inclination. And I'm going to set that at four degrees. That'll just give me a couple of degrees of inferior tilt. So I want to avoid superior tilt. But I have in my mind that normal superior tilt is about ten degrees. So we're respecting that or slightly correcting that in this case. And you also notice that I'm avoiding inferior overhang. I have just a little bit of overlap on this white circle. But I'm not destabilizing dramatically because if I destabilize again, that's where I'm going to increase the risk of stress fracture. And at this point, I'm not really medicalizing I'm just setting where the base plate is going to go. The next step is to assess base plate contact and depth of ream. Now I have two goals here. I want to get 75 to 100% contact. What do I mean by that? If I have a central screw, 75% is probably acceptable. The data on AugMend says that 75 to 100% should be your goal. So I'm going to go for that type of contact. I'm going to try to do this with avoiding reaming. Now there's not set guidelines for reverse shoulder arthroplasty. But we know the depth of subchondral bone is about 3.5mm. So when we reverse we have a little more tolerance. And I want to minimize my reaming to less than five millimeters. So I picked the position of where I want my base plate first. I can adjust lateral and medial. And then from there I can check my max GAP offset. In this case it's 6.5mm. And you can see that my seating Ceiling is only 16%. Now, I know that a ten degree argument will reestablish about four millimeters of the joint line, but a 20 degree argument will reestablish almost nine millimeters of the joint line in the back of the implant. So that's what I'll be picking in this case, because I want to fill that up. That's where I'm going to augment as needed to really get that maximum contact. Now my goals here are to get long, superior and inferior screws. And I want to do that by having proper orientation of my AugMend because we have two options. We have a standard AugMend which is designed for superior deformity, which will go along superior and inferior screws. And then for a posterior deformity, as in this case, I'll use an oblique augment, which slightly clocks the implant more posterior and provides long, superior and inferior screws. So here I'll move from a standard MDS base plate to a full augment. I'm going to go up to the 20 degree oblique. And then I can apply lateralization if desired because I can lateralize two millimeters on the base plate, and then I can lateralize four millimeters on the sphere at maximum. So I first of all restore the joint line. And then I can go out lateral from there. And here you can see once I do that my contact has increased to 96%. So in this case I think that will be very acceptable for fixation. Next I want to do central fixation and get my screw length okay. My goal here is to go bicortical with central fixation. Data shows both with a post and with a central screw. That implant fixation is improved at time zero by going bicortical. My second main goal is to get a long inferior screw screw. Length is important for fixation, and that's really important when we're going lateral, because we place more force on the base plate and the inferior screw is most important. I want to get screws anterior and posterior as well, but I want to particularly avoid violating the scapular spine or suprascapular notch with my superior screws. So I'm typically going to go with a bicortical locking screw up top. So here you see on the axial view down here I can adjust my central post. If I go down to a 25 I'm going to be contained. A 35 is a bit too long, but a 30 is nice and bicortical. Next I'll look at my peripheral screws and I'm going to adjust here. Typically it's a 36 inferior sometimes a little bit longer. Once I have that into place this will be a non-locking screw that I will place first. I will then select locking screws in the other locations. Anywhere from a 16 to 20 anterior and posterior is typical. And then superiorly you can see here I'm looking at the suprascapular notch. If we sometimes have a long screw, we can go toward that notch. And you can see before as well that I was avoiding going toward the scapular spine. When I'm placing my base plate with an augmented implant, I really like to have a single compression screw first. You do get compression when you get impaction of the base plate, but I like to get additional compression with a non-locking screw, as I said inferiorly, and then I will lock in after that. The other thing that I really like doing this for is that this will improve my efficiency. So not only have I selected my implants, but during the surgery, I can pull my screws and have those ready to go, which really saves me a lot of time in the operating room. So a couple of minutes here will save me several minutes in the operating room of waiting. The last step is humeral planning. This is a newer feature in reverse shoulder arthroplasty. My primary goal here is simple. That's to get an inlay humeral cup. Why is that? We talked about distalization on the glenoid side, but on the humeral side. There is good data that shows that if you have inlaid humeral cup, you have less distalization. And that again lowers the risk of stress fracture. Post-operatively. In one study that we did, the risk of stress fracture was much higher, almost three times higher with an onlay compared to an inlay. So I'm going to go with a 135 implant. I like to look at the inner circle. As you can see that's also valuable for anatomic. And I can adjust my cut up and down and then select the appropriate stem size. So I'll see here where I want to make my cut. Looking at the anatomic landmarks. And I can select my stem size from there. In our early data that's not published. We found that we're typically within one stem size. So again I have a lot of improved efficiency by knowing what the potential size is going in. And I can go back and forth between the standard stem or a short stem based on what fits the best for this particular patient. In this case, that's a standard length stem size five, and I can save my plan and be ready to go to the operating room. Thank you.

Brian C. Werner, MD (Charlottesville, VA), highlights the value and techniques of using the latest features of the Virtual Implant Positioning™ system in total shoulder arthroplasty patients, including range of motion, osteophyte removal, and multi-plan approval.&nbsp;

VIP™ Vision: Episode 10—Overview of Range of Motion, Osteophyte Removal, and Multi-Plan Approval Features

Hi, I'm Brian Warner from Charlottesville, Virginia, and welcome to VIP vision. Today we're going to review some of the exciting new features in VIP 8.0. One of the first new features is the ability to do multiple plans. And so we can save multiple plans and then also get targeter settings for multiple plans for some of those challenging or in-between cases. When you're trying to decide between anatomic and reverse or maybe different size spheres in reverse, you can have all those targeted settings available for you at the time of surgery. Next, we have Osteophyte removal and this is really helpful not only in the anatomic setting for making sure you get the appropriately sized head on your plan, but also in the reverse setting for removing osteophyte so you get a more accurate depiction of the impingement free range of motion. And then finally, as I alluded to, we have the range of motion features. So you can see the impingement free range of motion for all of your reverse plans. So I think the best way to kind of show you all these features is to do it in the setting of a case presentation. So this case is a 61 year old right hand dominant male who, like most of our patients, has had many years of shoulder pain. He's had three prior surgical procedures for instability over 30 years ago, and these were all open procedures. Like most of our patients, he's had a number of injections with declining benefit over the past few years. And he's an outdoorsy type of guy. He likes fishing and gardening. He's status post a right shoulder hemiarthroplasty 15 years ago with very limited function. And so he has some hesitancies about what arthroplasty can accomplish for him. His X-rays are there on the left. You can see his anchors from his prior instability surgeries also has very large glenoid and humeral Osteophytes his left shoulder exam. He has 100 of forward elevation, extra rotation of zero, limited internal rotation and some weakness in his rotator cuff. So I thought this was the perfect patient to choose for this because at least on his radiographs, I think he'd be appropriate for an anatomic type shoulder arthroplasty. However, with three prior surgeries that violated his sub scap, I'm a little worried about his subs gap. And so it's going to be an intraoperative decision for me whether I do an anatomic or reverse arthroplasty. So let's go now to the live planning so I can highlight some of the new features of VIP 8.0 with this patient. So first I wanted to introduce you to the new user interface for VIP 8.0. I want to direct you to the right hand side of the screen here. That shows you case details, and there's a couple of helpful new features that really should help with planning. First, it now carries through the patient name the patient sex the age if you input the patient's birthday laterality and the native subluxation. And so some of these are features that I like to use when I'm kind of deciding what size Glenna sphere, for instance, whether I'm deciding anatomic versus reverse subluxation can help. And so some of these demographic or native features for the patient are really helpful in planning. And now it just sits right on this case detail screen. We then move on next. And we have our implant selections. And so instead of having to dig through and look for those, those sit really nicely. Now on the home screen where you can see both your glenoid and your humeral implant selections. And so for our glenoid planning, the controls are very similar to what we've had before. So we have our implant options. We have our implant controls that were already used to and then our max gap offset. And so for this patient like typical, I'm trying to minimize the amount of reaming while correcting any version or inclination issues. We also have our humeral side. And so humeral side planning obviously something that we're now very familiar with. Some of these controls, although they're all there, have changed a little bit in their location. You'll notice that the humeral planning screen that used to be three different panels, is now two main panels within kind of overlaid panel here that you can minimize to focus on these other two. As you remember from the pre-operative x rays, this patient had a very large osteophyte. And to kind of streamline some of this planning a little bit, I removed a lot of the Osteophyte Osteophyte removal is done with this Osteophyte removal tool. So you can see we have different radiuses that you can do, and you can simply click along here to remove Osteophyte you can do that on the humeral side. I can show you also, you can do it on the glenoid side. Another nice feature to look at in a plan like this, where you've already removed Osteophyte, is to change your visibility, and so you can bring the osteophyte back up if you want to see how much osteophyte there was. And so for this patient, you can see in blue how much osteophyte we've removed already. And that certainly helps you size your anatomic implant better. And so we'll hide that just for the rest of the planning. And you can see here that the the humeral planning goes in a little bit more of a streamlined fashion. We have our net cut, which is what we typically do surgically first, then our implant sizing and then our implant positioning. Finally, after we've positioned it, we can choose our cage screw. Also brought now easier to access. If you're someone who likes to adjust the native torsion or the torsion of the implant, that can be adjusted somewhat as well. And so very streamlined planning for anatomic adding in osteophyte removal. And so for this patient, if you remember saying he's had three prior surgical operations through his sub Scap. And so I'm worried typically I make a decision beforehand. But I'm worried about anatomic versus reverse based on the quality of his sub scap intraoperatively. So I want to be prepared to do a reverse arthroplasty. Also, I think that highlights one of these kind of unique situations where having multiple plans is very helpful. So we can go up here to the planning screen and see we already have three different plans ready for this patient. And so we have our anatomic plan. And then we also have two different reverse plans, one with an augment and one without an augment. And certainly you don't have to have an anatomic plan if it's someone that you're planning for reverse anyway. You could have different amounts of lateralization. So you can pair range of motion. If you're in between sizes, you could plan for the two different sizes and make sure your base plate is positioned appropriately. For that, it gives a nice summary of what implants are used for each plan, but then you can also change the name of the plan for something that you remember when you're going to your final screens. And so I have these named for anatomic and then my reverse without an augment and my reverse with an augment. And so I like augments a lot. So we'll choose our augmented patient or our augmented plan just to take a look in a little bit more depth about what we've done. So you can see our summary here shows us all of our different implant selections. Our glenoid plan is going to be very similar to what we've seen before, with all of our different options available to us. Same on the humeral plan. Although that's condensed down to two screens. All the same information that we had before is available to us for for planning on any of these screens, we can do osteophyte removal, I think on the reverse screens. Osteophyte removal is sometimes easiest in this three dimensional plan, because you can see how osteophytes would affect your impingement if we change the visibility again, like we did on the anatomic. On the reverse, we can see that there are both very large glenoid osteophytes and very large humeral osteophytes. And that would be removed at the time of surgery. And certainly we should remove them at the time of planning. So we get a more accurate depiction of our range of motion and how our implants will look. Speaking of range of motion, let's take a look at range of motion for this patient so we can go to range of motion I just do want to hide. And you'll notice when we go to range of motion it automatically removes those osteophytes for you. And so when we go to range of motion we get a nice summary screen here. That summary screen is going to show us our range of motion for all of our reverse plans. The active plan, which is our augment plan, is going to be the one where the numbers appear in white and they're easiest to see, but we can easily toggle in between plans and see that our highlighted range of motion is now for our non-augmented reverse. And so we'll focus on the augmented reverse. We can see that our range of motion numbers are a little bit better for the augmented reverse and for most of our different range of motion measures. And that's likely because the augment is allowing us to lateralize a little bit more because we're not reaming. We can see our different impingement points, and we can look at each of these range of motions in isolation, or we can play all the different range of motions at once to appreciate where it's impinging, to see if that's something we can improve with implant positioning, sphere diameter lateralization if needed, or osteophyte removal at the time of surgery so that we maximize our range of motion for any of our individual plans. Once we're happy with all three of our plans, we can go to our approve screen. We can then, like we did before, choose to just approve the glenoid side or our glenoid and humeral side. Once we've done that, we can then select two of the three plans to finalize that will get targeted settings for at the time of surgery. So let's go back to our patient. So here's our patient at two years post-operatively, we decided on a reverse shoulder arthroplasty for him because his the quality of his subscapularis was not great. We got an excellent outcome. Great forward elevation, great abduction, really incredible internal rotation at two years post-op, great looking positioning of the implants. This just highlights some of the really key features in VIP 8.0 that are going to help us to optimize our planning, and that will in turn help optimize our patient outcomes. And so we now have multiple plans, which is really helpful if the time of surgery making you confident going in that your plan for whatever you need with osteophyte removal. And then finally we have range of motion feature, which is a really exciting addition to VIP 8.0. Thanks for joining me for VIP vision.

Tim R. Lenters, MD (Grand Rapids, MI), highlights the latest metal segmentation feature in the Virtual Implant Positioning™ system while planning a challenging glenoid revision with significant bone loss using the Augmented Modular Glenoid System.

VIP Vision™: Episode 11—Metal Segmentation for Revision Planning

Hi, my name is Tim. I'm a shoulder surgeon in Grand Rapids, Michigan. I've been using the VIP system now for over ten years, and I'm happy to share a case presentation that highlights some new features of the planning software. The planners can now perform metal segmentation on your surgical plans for use in revision cases of existing implants. So what previously used to require potentially several surgeries, with the first surgery being removal of an existing implant to allow us to obtain a clean CT scan, that first step is no longer needed with metal segmentation features of the VIP system. I'd like to use this case to highlight some of those features on the platform. My patient is a 68 year old. She's fairly low demand female. She had a reverse total shoulder arthroplasty five years prior to her presentation with me. She describes one month of progressively worsening pain in her shoulder, and she has also had a few falls over the last year, although none of these falls led to a significant worsening of either pain or function of her shoulder. I was able to find her x rays from her early postoperative period. She has a reverse total shoulder arthroplasty with a lateralized glenoid sphere. It seems to be an appropriate position in terms of the RSA angle, as well as in relation to the inferior scapular neck or x rays. On presentation to me, show a catastrophic failure of the base plate with fracture of all three of the fixation screws, and in my mind, I felt it was essential to rule out the possibility of an indolent infection, despite her history of some falling onto the shoulder. I did do an infection workup. Her inflammatory markers were normal, including the SED rate, the CRP, and her white count. I also aspirated the shoulder to culture and the cultures did not grow. Any organisms at three weeks or vitamin D level was also checked and found to be in the low range of normal. The CT scan was also obtained and I found it somewhat challenging to observe what sort of bone was remaining into the glenoid vault on this axial cut. I can just appreciate that there's bone loss and maybe some residual bone inferiorly. The coronal image shows a fairly large defect here, and raise some concerns about my ability to utilize a standard implants for this reconstruction. I did decide to upload this image to VIP software to see if potentially, I'd be able to utilize a standard implant for this reconstruction. So at this point, I uploaded the study to VIP, and we'll go through sort of a live planning session to demonstrate the features of the system. You can see the old existing implant is green. You can see the existing screws in the vault. The planners have been able to identify those structures and highlight them with these blue outlines. The surgeon can easily toggle visualization of these features with this little window on the right side, and this will make the implant disappear. And what you see then is what's left of the scapula. And it's fairly obvious that there's a very large posterior defect in this glenoid vault, sort of an uncontained wall defect. The vault is missing. You can see there's maybe a little bit of bone remaining in the base of the coracoid process. There's a nice column of bone anteriorly and maybe some bone inferiorly. You also can see that perhaps the scapular spine is available to use asphyxiation. So in my mind at this point I had really three options. One option would be to utilize the scapular line for fixation, to try to sink the post of the base plate down the spine of the scapula. Second option in my mind was to use Grammont principles and Medialize. And inferiorly lies the sphere to try to minimize the shear along the back side of the implant. And then my third option would be to develop and manufacture some sort of a custom implant, which is my which would be my least preferred option. So my first option was to look at use of the alternate scapular plane. And if we bring that implant in, what I thought was the alternate scapular line here you can see the post is seated in the base of the scapular spine. The windows on the left side here can show you what sort of bone is available on either side of your central post, and there seemed to be a nice quarter of bone in this position. The top window gives you sort of a coronal view, and here you can start to appreciate where the glenoid might reside in relation to the inferior scapular. And I did have some concerns with the position of this implant. I was worried about this bone posterior inferiorly that the humeral cup might impinge on that bone. And so this looks like it might be an option in terms of fixation of the center post. I did have some concerns about the overall position of the glenoid in relation to this inferior glenoid neck. So I looked at another option, which would be more of a Grammont principle to digitalize and medialize the sphere. And you can see in this position, if I remove the sphere itself, the base plate seems to be seated reasonably well. I have 53% backside contact with just a non-augmented base plate. The post seems to be seated in a nice area of residual bone, both on the axial plane as well as on the coronal plane. The sphere looks to be in a better position in relation to that posterior inferior scapular neck. And so in my mind, this seemed like a very reasonable option. I did want to utilize some other features on VIP. So if we look at the range of motion module, we can see that in this position there may be some issues with impingement of the humeral cup against some remaining bone around this sphere. And so it would be useful, I think, at this point, to utilize the Osteophyte removal tool to remove some of that bone and see if we can improve the range of motion. You can use that tool from this window. So I'll go through some of those steps right now. Remove some of these potential sources of impingement. We can reassess the range of motion following this bone removal. And this is something I would do in surgery if I see sources of impingement. I'll just simply take a roger and remove some of these problem areas. But once we do that, we can reassess now the range of motion we'll bring in the humeral component one more time. There's a nice abduction. We've improved her abduction. External rotation seems to be moving more freely without impingement until 41 degrees of external rotation. Internal rotation seems free. So I thought this would be a very good reconstruction. At this point, I finalized the surgical plan by hitting the subscribe button. Prior to surgery. So the planners were able to develop a surgical plan. These images show the 3D targeter on the patient's scapula, and you can see we could get four of the peripheral legs to seat very nicely, with the standard two legs wrapping around the front rim and the two other feet sitting on the face of the existing glenoid bone. And I was surprised, somewhat surprised to see how well this transfer technology worked in the patient, and how well the surgical plan mimicked the actual anatomy that was encountered at the time of surgery. At the time of revision, I did use some bone croutons to graft some cavitary defects from the screw tracks. I did not encounter any evidence of a chronic infection. There was no biofilm. There was no Seroma noted. I did take five sets of tissue cultures, understanding that this might represent a chronic infection, but I felt I was able to achieve a durable reconstruction that mimicked my surgical plan very nicely. You can tell that based on the overall position and fairly with a little bit of overhang of the sphere in relation to the neck. I think the center post nicely aligns with the floor of the suprascapular fossa, and I like my position on the anterior posterior plane as well, with the sphere sort of covering that posterior glenoid rim. So at latest follow up the patient shows a stable reconstruction with improving clinical metrics. I do believe that the newest capabilities of the VIP system allowed me to plan this case, and feel comfortable with the use of standard implants. Vip turned what could have been a challenging and uncomfortable situation into a definable problem with a definitive solution. I encourage you to make use of this system if you see failed shoulder implants. I believe it will help you plan your surgical plans and optimize your patient outcomes. Thank you for allowing me to present this case.

Sri Pinnamaneni, MD (St Louis, MO), highlights the latest metal segmentation feature in the Virtual Implant Positioning™ system while revising a failed aTSA to an rTSA.

VIP Vision™: Episode 12—Metal Segmentation for aTSA Revision Planning

Hello everyone. My name is Doctor Sharif Pinnamaneni. I'm an orthopedic surgeon that specializes in shoulder elbow surgery at the Orthopaedic Center of Saint Louis. And I want to present a interesting case to help highlight the VIP metal segmentation software. This is a patient that presented to my office. Really pleasant lady, 81 year old female who had an anatomic total shoulder replacement completed in 2006 and subsequently she presented to my office in just approximately a couple months ago with some worsening left shoulder pain with decreased range of motion. She has multiple medical problems, multiple surgeries including a left anatomic total shoulder replacement completed many years ago in 2006. Multiple medications and her social history is listed below. When I'm examining her, she has significant limitations in motion and significant dysfunction and pain, and so she only has forward flexion to about 40 degrees, abduction of 40 degrees, minimal internal external rotation. As I'm examining her, she has clear anterosuperior escape with prominence in her anterior glenoid of where the implant is. These are x rays of that office visit, and you can identify how the humeral head here is overstuffed. Additionally, on lateral views, you can really identify how there's maybe some mild superior migration, but overall it looks well fixed. And so she has clear exam findings for Pseudoparalysis. She can't live with this and has trialed conservative management. So at this point she really has no option outside of a reversal, shoulder replacement or conversion to reversal or shoulder replacement. So the next step here would be to get a CT scan to really identify the bony anatomy of this patient. So you can identify these coronal views here that are significant superior migration of the humeral component on the glenoid. By blocking the the superior migration is really hard to identify the level of the calcar to identify the bone loss in the calcar and glenoid vault. This is an axial view. And you can identify the humeral head being superiorly migrated, but also the glenoid. It's really hard to identify on these axial views the glenoid vault, the bone quality, and if there is a contained versus an uncontained defect. Additionally, distally here you can really identify how much of the humeral canal is filled by the humeral stem. This is a sagittal view here. What I'm trying to identify here is what is the bone look like. And can I accommodate a reversal or shoulder replacement. And this is really hard to see. Now scrolling through this again you can really identify the amount of scatter that you have, especially anterosuperiorly around the implant. And despite having the most advanced metal subtraction softwares, this really does not give you enough information to identify whether or not you can accommodate a reversal or shoulder replacement. What the bone quality looks like, and also help you plan preoperatively on where the implant should go. And so this is where the VIP metal segmentation software has really changed the game for me, especially in these really complex cases. Here you can identify this patient CT scan that's been put through the VIP metal segmentation software. Once you remove the metal you can really identify what that glenoid looks like. And here it looks like there's this posterior superior humeral head bone loss. There's a contained defect. And there's actually looks like there's going to be excellent bone here. And that's something that I would not have been able to identify on the CT scan. The metal segmentation software allows me to do that. So now I can go on and plan this based on my usual metrics of amount of medialization lateralization and amount of bone that I want to take, and so on. This, I was able to plan a stable implant with four peripheral screws or a standard implantation. I can also, going through the axial cuts, identify how much of the peg actually fills that contained defect, which is something that's unique to this system, because you can identify that and see if you need to place any additional bone or augment with some any cadaver bone or bone augmentation. Another highlights, and arguably, for me, one of the most important things during revision surgery is the humeral component. The humoral component oftentimes represents the majority of the case, and so being able to remove a well-fixed humoral component can be the most challenging complex portion of a revision. Total shoulder arthroplasty. The metal segmentation software here really identifies a couple of different things you can identify on the left, here on a two dimensional view. What implants currently in place? This is highlighted by the turquoise line here. Additionally, you can identify overlay that based on what the native bone is and then what the planned implant is. Now this is a unique offering that is unique to the market. And so this allows you to understand what was there, what is there and what's going to be there. And so here what am I trying to identify. And so what I'm trying to identify is how do I get the stem out with removing the least amount of bone possible. And so when I look at the implant that's currently in place, I can see that there's a intact calcar I can see that the greater tuberosity is intact. I can see that the stem is actually filling the canal. And so these are all things that I'm thinking about that allow me to plan the surgery better. For example. Now I know that if I can delaminate this area on the medial calcar and maintain the calcar, if I can minimize the greater tuberosity bone removal, and I can place a straight osteotomy going down the current implant stem, I might be able to get this out without taking too much native bone. And so that's what I'm planning on doing. Not only does this help you plan how to remove the current implant and give you the profile in a two dimensional view, but it's actually the VIP. Metal segmentation allows you to overlay all three of these native bone, current implant, and future implant, all on a three dimensional view as well, which is a unique product offering. And you can see here it helps me identify not only what I see on a two dimensional view and correlate that. It helps me understand what the two dimensional view looks on a three dimensional view. The final portion of the planning is you can remove the prior metal using the metal segmentation software and really put the final implant in. So in this patient that's exactly what happened. You know, I got lucky. I was able to maintain the calcar use a curved osteotomy around the medial calcar I was able to maintain the greater tuberosity and use multiple small osteotomies in a bur. I was able to use a straight osteotomy, just like I planned on my pre-operative plan on the VIP metal segmentation software, I was able to retain the greater tuberosity, the mediocalcar, and I was actually able to use a smaller stem in a combination of the glenoid planning and the humeral planning. The metal segmentation software on the VIP system has really helped me plan for surgeries better, particularly in these complex surgeries, but it's also helped me recreate what I plan intraoperatively and then help achieve a more personalized, custom post-operative outcome.

At Arthrex, our mission is Helping Surgeons Treat Their Patients Better™. We created this space to connect surgeons with educational content to enhance the preoperative planning experience. Learn how other surgeons are using the software and approaching important topics such as baseplate positioning and backside seating. We'll continue sharing short videos from other surgeons with you, highlighting unique cases and new features as they are released.