Name: Technical Considerations in Anatomic Total Shoulder Arthroplasty
Uploaded: 2020-02-10T00:00:00Z
Channel: Arthrex
Description: Robert U. Hartzler, MD, MS (San Antonio, TX), reviews concepts critical to successful anatomic total shoulder arthroplasty outcomes.

<p>Robert U. Hartzler, MD, MS (San Antonio, TX), reviews concepts critical to successful anatomic total shoulder arthroplasty outcomes.</p>

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VID1-000746-en-US | A | Technical Considerations in Anatomic Total Shoulder Arthroplasty

Robert Hartzler

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Technical Considerations in Anatomic Total Shoulder Arthroplasty

So we're going to talk about indications, pre-op planning, which I think are the most important thing. And then just a bit on sub GAP management and post-op care. I think it's important to this is something that I picked up at Mayo to just consent all shoulder arthroplasty patients for everything that gives you the freedom. If you're planning on an anatomic to go to a reverse, if there's cuff problems or deformity, particularly of the glenoid that you can't manage. Hemiarthroplasty I don't typically consent patients for if I'm planning on a total. But that's the practice at Mayo, and I think that's just a good a good habit to get into, to give yourself freedom to do the right thing. I don't think that currently forcing an anatomic for, for most patients, if it does, if the anatomy doesn't allow you to do that is a good thing. And so freedom to go to reverse even though probably that's uncommon to do is a good thing. So in general anatomic TSA indications are narrowing I think. And most are relative. So there's a bit of art of medicine. In in deciding between anatomic and reverses can use anatomic for a variety of different disease states. You want to make sure that there's a good rotator cuff and a manageable amount of bony deformity. A few absolute contraindications infection neuropathic shoulder cuff deficient shoulder. But most of the indications now are relative. And so I'm just going to spend a little bit of time talking about how I think about these patients in my practice. Reverse for primary osteoarthritis is definitely trending. If you look at Australia and joint replacement registry data, you can see that yellow line reverse is going up. Anatomic is going down. That's definitely true in my practice. I think most high volume arthroplasty surgeons now are kind of Kind of reserving AnaToemic for the for ideal kind of patient characteristics, disease state characteristics and and and hedging towards reverse. If there's any problem with the cuff or deformity or age. So let's talk about so first let's talk about bad glenoid. Walsh showed 40% non glenoid non glenoid. So they're really common. You know this is a little bit of an old older study now. But you know we know that they had problems with a high high rates of complications and revisions in B2 glenoid. And if you I think you know, the 27 Retroversion 80% subluxation on axial CT is still a reasonable rule of thumb. If you want a measurement to be able to hang your hat on for too much deformity for an anatomic, it's difficult to correct version because of medialization and and and losing your bone stock and implant perforation. 3d planning helps a lot on that nowadays, but is still an issue for me. Posterior subluxation is, I think in general, a bigger concern. And, you know, the French surgeons have really promoted that difficulty in in managing posterior subluxation and going more towards reverses in those cases. And I think that that's something to really think difficult about. We think carefully about we definitely don't want to have to relearn the lessons of the French experience. Bad cuffs. How important is that in deciding about anatomic versus reverse arthroplasty in general? In primary, O.R. seems to be sort of protective of rotator cuff disease, or at least there's a lower prevalence in primary versus the general population. Doesn't seem to matter if there's a small supraspinatus tear, you can even leave that unrepaired. And it doesn't seem to affect outcomes. But fatty infiltration on CT scan seems to be associated with poor outcomes. So that's something that I look for. When you have this secondary cuff dysfunction phenomenon with with proximal migration, that that is a significant problem, but maybe not as much as we think 17% at eight at eight year minimum. Follow up time is a factor. Again, infraspinatus fatty infiltration and superior inclined glenoid. So those are all things to just sort of be cautious about. Diagnosis matters. Rheumatoid arthritis patients have more cuff problems, more problems with bony erosion and bone loss. And so, you know, you might say, well, we should lean away from AnaToemic, but the revision rate is low in those patients, probably because they're sedentary. I won't belabor this. You know, we talked about the problems with with prosthetic arthroplasty and young patients yesterday. So I'm really cautious about doing those in patients in their 50s and younger. Old age is a problem too. And AnaToemic. So there's more secondary cuff dysfunction problems, more bone loss problems. And so I think a general trend is we hedge away from AnaToemic and patients, particularly in their 80s, elderly patients can have problems complying with rehab, particularly protecting the subs. Gap. So that's another that's another consideration. And patients that are that are gait aid dependent I'm pretty careful about doing anatomic. So some people have even promoted why why are we even doing any anatomic anymore. So a few reasons to keep doing anatomic. Most most at least from the surgeons perspective. You know we say well our best anatomic beats the best reverse. It can look and feel more normal. And there's some evidence that if you look at patients who have one of each, that the anatomic are better from an objective standpoint of range of motion and functional outcome scores. In my practice, the anatomic look better. If I look at their pain scores. You can see on the left anatomic versus reverses on the on the right and functional outcomes. That's probably a selection bias though, because I'm selecting, you know, the the best patients with the least disease and the right age for AnaToemic over reverse. This idea of the best anatomic beating, the best reverse I've I've started to actually really question whether that's true. There's there's another study with same same idea. Look at patients with one of each. And even though the anatomic or objectively better 70% of patients preferred their reverse. And I, I don't think I have any patient whether I did one side, whether I did the anatomic or the reverse, whatever they have one of each that they like the anatomic better. It's really strange to me. I even have a patient who had an infected anatomic revised to a reverse outside. Then I did the anatomic and they still like the reverse better. And their anatomic has better range of motion and they don't know why. They just feels better for some reason. So I think that's something that we should be studying carefully in the in the future. Just, you know, with regard to patient satisfaction, there's unique complications with reverse. If you get acromial fractures, if you get instability, you know, those are challenging problems to handle that are unique to reverse over anatomic. You know, we can, in contradistinction to the French point of view, manage be glenoid. This study by Jay Keener with a goal of 80% coverage, 10 to 15 degrees final retroversion and corrective reaming, have good outcomes in short term mattsson's technique of leaving them retroverted also seems to be fine at short term in managing those B type glenoid. So for me right now, anatomic I think is best in patient with primary OA, with with minimal glenoid deformity and a good rotator cuff and a in a sort of a narrow age range, and I lean toward reverse for many other patients, pre-op planning I think is a really big deal. And I use this I would say I'm addicted to pre-op planning and and 3D guides in my practice. I think it's a big step forward. We definitely know that this affects decision making, and in selecting anatomic versus reverse, we know that using a transfer device improves the accuracy of the glenoid placement. I'm not going to show this whole video, but this is like a two minute video on how I plan shoulder arthroplasty cases. And I go, I have their history in front of me. I have their x rays in front of me. I have their CT in front of me, I have their 3D planning, and I spend a lot of time really carefully making sure that that I'm both choosing the right operation and implant placement very carefully. So straightforward. Primary oh isn't always what it seems. If you look at 2D and 2D and 3D CT imaging, there can be subtle, subtle deformity that you want to correct. There can be size of glenoid issues, particularly really small glenoid that you That you wouldn't know about if you weren't doing 3D planning. 3d, 3D planning and transfer technology allows us to manage bad deformity cases with a lot of confidence. And so I think that that's something that if you're if you're not using in your shoulder arthroplasty practice, you should really consider doing SpeedScap. We talked about this a little bit yesterday. There's level one evidence for doing anything in terms of Tenotomy, peel and LTO. I think this is really one issue that you can use surgeon preference on. There's pros and cons for each one. I like LTO in general because of bone to bone healing and monitoring that, but it is harder. And I think peel in general is the most versatile and technically straightforward thing to do and to teach that. Probably pick one of those and do it well. And I think one caution is with the subscapular nerves. That's something that I've been more cautious on, not blindly sweeping around with my finger in that area because you can get a healed sub scap that's denervated. That is a problem. Apex repair, if you want to look at that in the lab, I think that's a great thing to spend time doing. It's an awesome repair. Very good rate of healing with peels, particularly with a pretty aggressive post-op rehab protocol. A couple of repeat slides. I'm conservative again with rehab. Forward bend. Elbow range of motion at passive external rotation. Zero has been really good for me and good getting good results in AnaToemic and I'm protecting the subs GAP really carefully even with that monster apex repair technique. Patrick and Alex showed that if you delay passive range of motion after AnaToemic with an LTO, that you get better healing and that correlates a healed versus non healed LTO correlates with better post-operative outcomes. So I think care with the subscapularis is definitely warranted and a conservative rehab approach will give good results. Thank you.

Technical Considerations in Anatomic Total Shoulder Arthroplasty

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