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Shoulder Replacement for Postgraduate Orthopaedic Exams
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Shoulder Replacement for Postgraduate Orthopaedic Exams
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Upload Date:
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Language: EN.
Segment:0 .
OK good evening, everybody. Welcome again to our Wednesday evening webinar session. This is a combined session between US and UK. My name is Sean Henry, one of the mentors today we have Nicky Evans, Jo gouty and David Hughes with us supporting this today's session.
Today, we're very lucky to have Mr. Toby bowring. He is going to give us a talk on shoulder arthroplasty. He I am really looking forward to this talk. He's an expert in this area and I know that his talks are often very appropriate for the exam, which we're looking forward to.
We start with introduction today, shoulder hour and then we'll have a talk show and then some questions. We'll have some case discussions and tips for the FRCS, but we'll close already this time before sorry. Before I continue, I just want to introduce Mr berankis, a qualified Newcastle medical school, in 2000. He did his best to guys Thomas and then undertook his doctorate with prof.
Rogers in Emery at Imperial College London in 2006. Looking he looked at surgery in the rotator cuff. He is postgraduate. Training was in the Royal National orthopedic hospital in North London and spent his fellowship in nice and France with the shoulder specialist prof. Pascal Ballou. He's been appointed as a trauma orthopedic consultant at Hampton University Hospital in 2015, and he's the clinical director and practices shoulder and elbow surgery there.
His specialist interests are shoulder arthroscopy and joint replacements and shoulder and elbow trauma. I am very sure we are going to get an excellent talk from him and we're really looking forward to it. And without further complications, please go ahead. Thank you, Ryan, and the rest of the faculty for asking me, can you, can you hear me? Yes great screen, ok?
And you can see my screen. Great Yes. Yes, good. It's good evening. I'm Toby Barry. I work at the Hampton University Hospital in North East London. Shoulder arthroplasty is it may feel a bit of an enigma to a lot of you because, you know, compared to knee and hip replacements where you get exposed to them all the way through your training.
I suspect some of you may not have even seen a show replacement being done, and that was certainly my experience. And because of that, probably it's not. It's not well understood. I think compared to knee and hip replacements, we are probably about 20 years behind them, certainly in the sort of understanding what makes a shoulder arthroplasty.
Last but also I think in terms of the sort of postgraduate education. Anyway, hopefully after this, you will have a better understanding and feel more confident about dealing. The question about the policy in the Fox. I'm sorry.
We go so shoulder arthritis, there are lots of different types. That is sort of various causes of degeneration of the joint, which may lead onto requiring shoulder arthroplasty. So I don't know if this is going to work because I understand there's a lot of you, but I want to do is start with little quiz. And I think imaging is going to let one of you who puts their hands up.
Answer this question. We're going to go through a series of x-rays now we're showing different types of degeneration. I want to tell you to tell me what, what type it is. So anyone can want to tell me what's going on with the shoulder. If you kindly raise your hand in the participant section, we can then unmute you.
They were putting their hand up. Yes, we have. Hi, evening evening. Sorry yeah, to my name is AJ. It's pretty good. I can see it's of radiograph of the right shoulder of the mature skeleton.
I can see this is quite a sclerotic and irregular humeral head. And Uh, it's slightly highly migrated as well. The distance between the eye cream and humerus also seems to be reduced, though it seems to be a. Uh, it seems to be balanced. I would like to see the other view as well to check the house the glenoid, the Mason, the glenoid looks pretty normal, doesn't it?
Yeah OK, so what conditions do where just the funeral head is affected? It's the most likely. I think my first trip would be to avail of the funeral head, which made to only a fraction of the. Very good end of the humor I had. Yeah, very good idea. OK there's an error on this X-ray. Do you know what it is?
Right it's a tricky question, do you know what a grassy view is? Yeah yeah, I heard that, but I don't know the detail yet yet. It's a grassy view that is an AP of the Glen funeral joint, which is quite different to an AP of the shoulder. And yeah, with a grassy view, you should see clear space between the human heads and the glenoid.
Uh, which is not the case, this is more like an AP of the shoulder. Yeah, Yeah. So this is incorrectly marked as aggressive, you know, that's just something probably for the mix if you're not a very good. Well done. Thanks, Don. OK, let's move on to the next one.
Inflammatory arthroscopy? OK probably rheumatoid arthritis. And the key is, as I say, that there's a lack of Austria fights. The joint space narrowing is pretty symmetrical with primary area. You're always going to get asymmetrical narrowing of the joint because you're loading in one particular space where the cartilage is damaged more with inflammatory arthropods or the cartilage.
On the glenoid and the human side is essentially affected the same, so you get this symmetrical loss of joint space narrowing. The other feature, which may be is debatable, is unlike with air, you get periodic osteopenia, you get reabsorption, the bone. So rather than sclerosis, you get some reabsorbed reabsorption, although you know, that's maybe open to a bit of debate.
So that's this one would be an inflammatory arthritis. OK OK. Onto the next one. What about this one? And this was an issue to volunteer. And so this is a preview of the right shoulder showing reduced joint space between the humeral head and the glenoid with a goatee beard sign the.
Uh, AM slap AM space looks reasonably preserved, although there are shadows of loose bodies in there. I cannot comment on the siege from this view, so this is in line with the osteoarthritis of the right shoulder. Reggie, an yeah, as you quite rightly say, so the head is still centered on the glenoid, so we assume the cuff is OK. That's very characteristic.
I think it's the first time I've heard it as the go to be sign, but that is very characteristic inferior human head, osteophyte. And then, you know, typically you get more joint narrowing towards the center or posteriorly. You can't appreciate the posterior where you the. But yeah, very nicely describing tissue. Well done. Thank you.
And that's what you often see on these seats is that how much posterior where there is with these? We'll talk about that in a bit more detail later. This is the AP radiograph of the left shoulder showing the United proximal humerus and its United looks like in a quite vulgar position and also irregular shape with the reduced joint space. And it's migrated, proclaiming approximately as well. So I would label as a secondary due to a model United and possibly may be a sign of some avian.
Yes well. Very good, well done. Yes, so this is post-traumatic egawa. There is a classification called fracture sequelae, which particularly talks about the position of the GT because that has a big sort of it's a very determining factor in terms of how you treat these patients. If you are going to do an operation and we do see quite a lot of this.
Um, I'm finally this is I think this is the last one in this series. Anyone want to have a go at this one? I'd say this is quite difficult. And Michelle, you volunteered. Again, this is an X-ray of the right shoulder preview with symmetrical loss of joint space, but there is a formation of a still fighting filiale the preservation of the subacromial space. So the features are in some way showing secondary degeneration.
I wouldn't be sure what the primary causes for this, but if asked to choose, I would say still, this is osteoarthritis, probably. Very good. The key factor here is that you see this the glenoid has developed in Austria fire as well, and we only really see this with post instability. So if I put these up, this gives you a little bit more of an idea.
So these are patients who have had stabilization surgery and they all develop the very information sort of speaking of the glenoid. Again, you don't tend to see that. So much with primario. But that's just that's a tricky one. It's almost like the shoulders sort of growing its own procedure. Yeah shows proximal migration of the humeral head with a stabilization of the acromion.
There's lots of joint space and this is most likely after osteopathy. Late stage, I guess, is like a true shoulder surgeon. You've clearly been trained very well. I can say that because nischan used to be my registrar. So well done. OK, excellent. And we tend to talk about arthroplasty rather than arthritis.
But by the end of the spectrum of our therapy, you do very much get arthritic changes in Austria formation. So the management of arthritis? Uh, we obviously tend to try non OPT of treatments first. Shoulder arthritis is often a self-limiting condition in that patients will start to get pain from their shoulder as it becomes arthritic and actually change the way they use the shoulder and use it less.
And so we see a lot of patients present with sort of mild to moderate osteoarthritis. And it doesn't necessarily progress much beyond there. Interestingly, in traject, injections work very well. Steroids and and hyaluronic acid. We tend to try hyaluronic acid in the younger patients. The evidence is still doesn't show it's much superior to steroids, but patients like the idea of trying to reconstitute that cartilage.
Physiotherapy in primary OA is not particularly helpful, but with Cuff deficient shoulders. With this sort of pseudo paralytic movement you get, it can be incredibly helpful and actually restore a huge amount of function. Well before, I mean, you know, if you're talking about cuff deficiency or cuff tear, I throw up. That's a whole. And what you do about the rotator cuff in these patients, that's a whole other talk about super caps, reconstruction and balloons and those sorts of things certainly are not going to go into that today.
So this is just trying to keep this relatively simple, but there is something you can do to the biceps, as I'm sure you as you develop primary egawa in majority patients, you get posterior subluxation of the humeral head. You tend to wear away the posterior glenoid more than the anterior glenoid. And what happens with that is that you find a lot of them have this anterior joint or we think is anterior joint line.
Actually, you're feeling usually over the bicipital groove and the biceps becomes quite inflamed. And what happens is the biceps. Rather than going over the top of the head towards the glenoid, which should be heritable, be speaking as it becomes more posterior some blocks, the passage of biceps becomes more and more oblique, and it can kind of subscapularis creating a cleavage tear and be quite a source of pain.
So certainly in a handful of patients, you can do biceps tenotomy, and that will maybe buy them another few years before they require a shoulder replacement. And then obviously, the options after these sort of less invasive and non active treatments is to move on to arthroplasty. So then the question is which prosthesis, as you can say, that you can see there's I mean, like the knees, like the hips, like the elbows, we've gone through an evolution of.
Uh, different types and, you know, going from the nurse prosthesis in the 70s and eighties, which were not anatomical, didn't really fit the proximal humerus at all. Then along came the anatomical in the nineties, which seemed to work much better. The reverse is actually we tried reverses back in the 60s with four, which weren't particularly successful.
The second generation and third generation reverses came in about 20 years ago, and they now seem to be working, working quite well and lots of other things have been tried in between. This here is. Came out in France about 10 years ago, and they called it the snooker ball, which is it's essentially a bipolar hydrocarbon ball. This is here a, I call it, the Stanmore special.
Any of you who worked at Stanmore or may have seen this, essentially, it's a acetabular cup screwed into the chromium and the glenoid. So, yeah, so hopefully by the end of this tour, you should understand what the implications for which type of prosthesis are best. OK, first question, you know, how do you determine whether to do it, anatomical replacement or a reverse shoulder replacement?
And I think if you stick to these three components, you won't go particularly wrong for anatomical. You have to have near normal anatomy, intact rotator cuff and reasonably good glenoid bone. Um, whereas with a reverse, you can have distorted anatomy, you can have an absent cuff and you can have considerable glenoid bone loss. And so you're looking at that, you would think that the indications for anatomical are quite narrow and they are pretty much limited to primary primario and a vessel necrosis.
Although they even faster increases, we often don't replace the glenoid because the glenoid bone is going to bone, and cartilage is actually a good quality and tends to tolerate a metal or poorer carbon head or ceramic had reasonably well, whereas a reverse is far more versatile and actually that's illustrated in the NJR. Now we're doing considerably more reverses than anatomical, probably over 100% more.
Are the indications for reverses are now expanding relatively quickly? So I don't know. You know, I've been giving this talk for a few years now, and when I first wrote it, it seemed to be quite relevant the argument between a hemiarthroplasty versus a turtle shoulder. I'm not quite sure what's being taught in other parts of the country now, but generally we're moving more towards a total shoulder replacement.
You can certainly quote the Cochrane review, which was published in 2011. But just be aware it wasn't based on a huge amount. There are only two high quality objects comparing hemiarthroplasty and 2 to shoulder replacement. And that's, you know, so there's not a huge number of patients to demonstrate that the difference.
Certainly, the difference between the two when it comes to revision is quite considerable. And if you've put in a glenoid component and you have to revise it, you end up with a sort of hollow glenoid, which you'll have to fill with bone graft, glenoid tend to erode away the whole I'm sorry, I tend to wear wear away the whole of the glenoid and you end up with peripheral defects and often completely sort of destroy the glenoid.
And so that in a way almost Hemy can be trickier to revise if it were quite if that is required. Pre-op assessment of shoulders prior to arthroplasty is very important. Clinical examination will go into this a bit in a bit more detail is looking at the function of the cuff with emphasis on external rotated and subscapularis.
Deltoid function is. Certainly, if the patients had previous surgery and, for example, something like they've had a human fracture and they've had a previous. Previous delta to approach or even a delta is split. We often find that the a axilo ulnar nerve has been injured and they've lost quite a lot of.
A deltoids bulk anteriorly, actually, you know, although Delta is key for a good deltoid, is key for good shot of function. There's quite a lot of evidence to suggest that you can still function pretty well, even if the a deltoid is deficient, but it certainly should be noted CDC and MRI scan. It is very important for looking at bone stock on the glenoid side, especially assessing how much posterior glenoid where there is in primary area.
We do expect the rotator cuff to be essentially intact is quite unusual to have a cuff tear with primario and. Sometimes there are small defects. But not so good cuffed efficiency. But because the implications of having a damaged car cuff when you're trying to do anatomical have, if you do go in and find actually they've got a massive cuff tear, that's a real problem if you haven't planned to do a reverse as a backup.
And so we do tend to often do MRI scans for anatomical shoulder replacement just to reassure us that they're going to be no surprises. And then, of course, we always got to keep in infection the back of our minds, especially if it's revision surgery. I think I'm talking particularly about reverses when if you have had someone who's got rotator cuff disease and they may have had.
Two or three arthroscopic procedures prior to it. You know, repairs of tendons, repairs or tendons and so on. And obviously we hate infection in Arthur arthritis wherever it's done in the body. So just always keep that in the back of your mind that you may be dealing with potentially contaminated joint. And I think that goes also with steroid injections, you know, I. Always make sure the six months between a starting role, steroid injection and me doing a joint replacement on a patient because, you know, that is one of the risks factors for price infection.
Now technique, I mean, generally these days, I would say the majority of shoulder replacements are done through a data approach. It tends to give you very good access to the glenoid. Uh, and you can release subscapularis very carefully through it. It does a better approach if you're doing it anatomical and need to preserve the subscapularis deltoids splitting is.
Has been advocated previously, especially for fractures, because it gives you good access to the posterior aspect of the joint, so you can sort of pick up and manage the greater tuberosity, which tends to migrate security posture is superior because of the pull of the calf. You can't do it for replacement, really, and you do run the risk of damaging the axilo ulnar nerve and taking out the anterior the anterior deltoid.
Mm-hmm if anyone has seen a show replacement, you'll be aware of how challenging it can be to get adequate exposure of the glenoid and I suppose is just a technical point is you have to position the head and the retractors in a very specific way to allow you to get down onto the glenoid, which may be retrofitted already. So if you can't get sort of perplexed at the glenoid, you're going to find it very difficult to prepare it for your prosthesis.
You may have heard about these more modern options, we now have what we call platform prosthesis so that these are prostheses that are basically interchangeable between a anatomical and the reverse. Uh, and the terminology in lay and Lay's is relevant to that, so so platforms tends to be only in the metaphysical component sits above the shoulder or above the mattress sutures, actually.
Whereas this is one of the more original reverses and this is where the metaphysical component is, is actually sitting within the metathesis rather than above it. And the difference to that really is the biomechanics of the shoulder get changed. You have far more lateralization and fear is inferior with on. I'm not going to go into that in detail.
That's that's really quite a complicated component of the reverses. And I don't think you certainly don't need to know about that for physics. But I think if you're just aware of these terminologies, that would be helpful. Um, for a anatomical replacement, the subscapularis subscapularis repair is absolutely key. If your subscapularis repair fails, then you're anatomical replacement is probably going to last about 50% short of time.
And I'll go into that again in a minute. I tend to do use transverse sutures. There's lots of different ways of taking off subscapularis repairing it. Some some people do a lesser tuberosity osteotomy. But as I say, the key thing is to make sure you do a solid repair at the end. And the Piscopo now again, this is moving more into slightly more advanced knowledge, and this is very relevant to reverses, obviously in the show that you have very have essentially for internal agitators, you've got your subscapularis, your tiers major, your major and your little and Stasi.
But you've only got two external radiators, which are terrorism, terrorism, minor and impersonators, and with cultural property, obviously you can potentially lose certainly one, if not both external radiators and you end up with what's called an external rotation lag. And although the reverse will address the loss of elevation, I don't know if you can see this on the video. If you if you don't address the external radiators when they lift their arm up, their whole elbow and forearm falls forward.
And that doesn't necessarily return function in terms of getting your hand to your mouth and hands your head. So you've just got. We have now started doing these, episcopo, actually, the pisco was an Italian, he originally described this for obstetric palsy, but it works perfectly well and combined with the reverse. And you basically take off the d'Orsay and tiers major from the bicipital groove and wrap it around the other side of the humerus that comes around.
Rather than coming through the armpit into the front shoulder, you basically wrap it around the back of the humeral head and it turns it into external rotator. So as part of your preoperative assessment, prior to doing a reverse and someone with you must assess their external status and see how much external rotation they have. They often will have a lot of weakness, but they should be able to extend their right to actively.
If they don't, then you may well want to consider doing this transfer. Mason slightly more depressing part of why the replacements fail. Well, like any process, they can become infected. The rate of infection has been shown to be higher with reverses, that is probably because when you put in reverse, the human head, you then create a dead space above the human heads, which will obviously fill with hematoma, and that's probably a notice for infection.
But actually, as we move along and get better at these, actually the rates of infection are coming down dislocation. If that's an anatomical, it's usually because the cuff has failed. It does happen and certainly in the older patients with the sort of more frail soft tissue that is a possibility in reverse as obviously there's much less calf in it.
Again, it's a situation in reverse, this was it's become slightly more a historical problem now we've started liberalizing the sphere and the more stamps the mechanics are much more favorable to it being a very stable prosthesis. Uh, as I said, cuff failure can lead to not necessarily dislocation, but failure of the process it becomes.
Uh, becomes loose and you get this rocking horse effect, where if you have a functioning cuff, then obviously the humerus is the funeral component will be centered on the glenoid component, so you won't know the loading will be very central. As soon as you have a cuff deficiency, you will start loading the edge of the prosthesis and it becomes loose, and that's known as the rocking horse effect.
And then again, like other processes, you can have fracture leading to failure. Well, I'm. So there's a million question, how does a reverse shoulder replacement work? The classic works by inferior intellectualizing, the center of motion of the joint and making deltoid more competent in terms of lengthening the fibers so that they can exert greater force to elevate their.
OK and how does that bypass the issue of not having a rotator cuff? And so the rotator cuff, basically apart from centring the humeral head on the Dean or initiates the abduction or elevation of the arm and the glenoid being. Not fibers being lengthened then can perform this function in place of the rotator cuff.
OK well, you're saying all the right things, but it doesn't really answer the question about why a reverse works in and replaces the function of the rotator cuff. It's all about providing a fulcrum stable fulcrum, so. That is what the primary role of the rotator cuff is to create a fulcrum for the moment arm, which is the arm to rotate around so.
Rob, if rather than when your cuff is deficient, if you're deltoid contracts, you haven't got the fixed fulcrum, so the humeral head just moves my great superiority. And that is the key to reverse is that it's not really about changing the position of the center of rotation, it's about creating a stable fulcrum. It is a semiconductor constraint prosthesis, whereas a anatomical shoulder replacement, so is a completely unconstrained prosthesis.
If you put any, if you put two, you put two components of an anatomical shot replacement together and put any sort of shear force across them. They will come apart with a reverse. They can. Um, do it, it would remain stable with really quite a lot of shear force going across it. So if we go on to this slide, this is the back to the Star Wars special.
Yet that also works because it is a semi construction constrained device. It's got the cup is captive and it stops the head from dislocating or moving off its off its sensor at the center of rotation. So when you get asked how does it reverse work, you can talk about it in your AIIS and electrolysis this interpretation and it optimizes it, stretches out the deltoid, et cetera but you also should say it is a semi constrained device.
It's intrinsically stable. It provides fixed fulcrum in the absence of functionality to go off. I've put you here in mid-july, the sense of rotation. Now that was the original idea that Graham on when he introduced it in the second generation reverses in the 90s. That was the idea of stopping because prior to that, the glenoid component always got stable, had got loose and unstable.
But we've now found ways of catalyzing it will go on in a minute and you're by mid-july using it. The idea was would recruit more of deltoid into production, but actually we now think the external rotation and internal rotation, which the anterior posterior deltoid harp with are equally helpful.
I've just seen the time I'm going to keep going quite quickly as the reverse nears came up with the concept of the reverse in 1960. But because of having the sense of rotation outside the glenoid outside the bone stock, there were great shear forces push it through it and the glenoid component became loose and these were completely constrained devices. They had a completely captive hub.
You can actually just articulate them. And then he went through various different types in the 1970s. Then grandma came along in 1985 and talked about the media utilizing sense of rotation in towards the interface between the sphere and the glenoid, and that made it a much more stable. Or much less likely to loosen, I should say. So now we know we're very comfortable with the functional outcomes from reverses.
Mostly the main indication is cuffed the. Even if you don't have a property or arthritis, if you are a patient with a suit of paralytic arm, you can't they just cannot retrain their deltoid tuberosity work over a shorter excursion. You sometimes do have to do a reverse in the absence of significant arthritis. These are the glenoid is very amenable to sticking structural bone graft behind it to correct glenoid deficiencies.
So these patients here primary with massive retroviral loads of it's very difficult to put an anatomical shoulder replacement. You can do it, and there is now special augmented options, but it's very difficult to it can be very difficult to do until a replacement knees. And actually, it looks like a reverse is probably the better and more predictable outcome. Um, tumor is around the shoulder when you have to do large, large incisions of bone and tissue.
Some again, you're going to be often removing all the rotator cuff. And so some sort of strange device is will restore more function than trying to a heavy arthroplasty or a sort of anatomical. And then, as I think I said earlier in the elderly with arthritis, when you're worried about the quality of the rotator cuff, even though it may seem intact, it may be an option to do a reverse rather than anatomical.
So you, you do a good anatomical is going to be better than a good reverse in terms of restoring range of movement, especially on an internal rotation, which you tend to lose with a reverse. In this sorry, this is a picture of someone with pseudo paralysis where trying to elevate their arm and all they can do is really shrug the shoulder out because they can't activate the adults right any more than that.
Problems with the verses, just credit, go through the complication profile reverses, as I said, infection probably because of the dead space security dislocation. The Grumman reversed, which didn't utilize the center rotation, tended to stick the humerus right underneath the chromium. You then have a vector pull of deltoid, which is more lateral and more likely to dislocated by pulling it out and up.
We now we've studied laterals, the sphere with sort of augments and and bone graft that seems to be less of a problem. loosening of the glenoid, you've got to make sure that you don't put the glenoid pointing upwards. And with rotator cuff arthroplasty, you can have a lot of superior glenoid wear. And so if you don't appreciate that surgery, then you end up point to the up and then you have these shear forces and it can just push.
The human component can actually push the glenoid out of position. Um, disassembly. This is more of a sort of interesting X-ray rather than key knowledge, but because of the rotation actually going on in the shoulder, you can unscrew prostheses and certainly the good bone stock is very important to prevent these, this problem occurring.
And then probably, I think this is one of the most relevant problems associated with the reverse shoulder replacements. Now These are cranial stress fractures, which are shown to happen in about 5% of people after a reverse. And just because you're putting on deltoid so hard after usually happens between six months and 18 months after surgery.
The chromium fails, and that's a real problem. And it's very it's very unusual actually for a patient to regain good function after that because you've essentially you've mentioned the anterior deltoid for surgery and we don't really know. Even though they tend to heal, the patient loses a lot of function. What often have persistent pain, and certainly the more recent work has shown that this is probably elderly with a low BMI is puts you in a high risk category for a stress fracture.
So those little old ladies where you might consider a reverse because you're worried about the rotator cuff actually probably want to rethink that because probably may want to be better sticking with anatomical to try and avoid this, this particular issue. So sorry to say it's slightly speeded up there at the end, but in sort of summary, exam point is definitely know the difference in primary owing to our property. For axilo, who showed replacements, you could think you've got to have near-normal anatomy, appreciate the posterior glenoid erosion that's done with the CT scan.
You want to demonstrate to your examiners that you understand that a rotator cuff has to be intact. And, you know, sometimes it's very difficult to examine patients with primary OR because their shoulder so sore. So that's why that's probably one of the rationales getting an MRI scan. For whoever replacements, the indications are broadening, it's being used much more now than anatomic cause.
Just make sure you have a good spiel in terms of describing the biomechanics when asked what, how a reverse works, having the sense of rotation from the bone to prevent the stabilization and loosening of the sphere is a constrained device providing a fulcrum and it has a knee instability. And also, as we've just been through, be aware of the complications both generic complications like infection, but complications that are specific to the prosthesis.
So the first question, I think probably some of you were thrown by the wording, but the majority of you got this right. So you cannot you can't do an anatomical show on some of the slap subscapularis tear and tear recurrent infection or cuff deficiency, but you can address retro versions. So glenoid retroversion is in primary 08 is a very common phenomenon. I would say the majority of people with primary IRA have a degree of.
Posterior glenoid bone loss, and that leads to increase retrogression, I mean, the glenoid we know is 8 degrees retrofitted anyway normally, but that tends to worsen with primary. It needs to be appreciated, but as I say, we have now the ability to augment the glenoid implants to correct that retrogression version. Anything up to about sometimes 20 degrees at some point, you know, you have so little bonus stock because there's so much regulation that you probably have to bail and do some other procedures, like a reverse.
But yeah, so one up for that next question. Again, I've sort of asked this in a double negative way, but which of these mechanisms is not a failure for a total shoulder replacement? And you quite rightly. Written the majority of you answered windscreen wiper effect. That's actually something to do with the biceps, which we see in Cuff disease.
But yes, the rocking horse effect is the failure of the rotator cuff, including the glenoid component disassembly. The prosthesis can come apart inside the shoulder infection, obviously, and loosening other causes. And finally, the Piscopo transfer again, the majority of you got this right, it is a slap d'Orsay and major transfer.
OK great, so that's the end of the polling close that down. I've got some, some cases to go through. And anyone who wants to go at practice favoring, I'm very happy to take them through. It will. Certainly two of them will be based entirely on my talk. So if you thought you shouldn't have a problem with it at all? Mr we've got some questions from our purposes.
OK, let's do the questions. I will ask them to you. I see them through the chat. So Uh, one of the audience is asking if we just left the subscapularis not prepared at the end. Would that give us enough external rotation rather than doing the Episcopal procedure?
Well, that's very good. So this is in reference to reverses rather than anatomical, yes, reverses. That's a really good question. Yes, there has been. Certainly, when I was on fellowship about eight years ago, we did try very hard to pare subscapularis at the end of reverse because we thought it actually helps they reduce the rate of dislocation.
But that's quite right. You're basically fighting against the external radiators. So there's now actually a move not to repair the subscapularis at all. And I now have not repaired a subscapularis with a reverse for the last, I think, three years. I have had no issue with instability. And you're going to maximize the function of the external radiators, which which is the problem with the reverse or the problem with the clinical outcome after the reverse.
OK and for me, asking how to reduce dislocation of reverse shoulder arthroplasty. Yeah, well, I think I think I was sort of talking about that if you've got your cranium here and you've got your reversing underneath there, the grandmoms star was to mid-july is the humeral head and the sense of rotation as much as possible to try and get the center of the rotation into the bone?
But as you go more and more underneath the cranium, the deltoid is going to be pulling more and more laterally. And that's why we think the. Reversed and 20 years ago, 15 years ago, dislocate is quite commonly. Now what we're doing is building out on trying to keep still keep the rotation within the bone.
But we build out of a combination of graft and augments underneath the glenoid base plate and also using only prosthesis on the human side, which tends to latch so that the humerus components and the humerus are turning to now sit slightly lateral to the cranium. So the pull of the deltoid is more medial, and that obviously increases the joint reaction forces in the stability of the prosthesis.
And how to reduce launching in by the position of the proponents in the reverse order, again, bye bye. The other thing that has happened is that you inferior is the glennis here now. And by building it out, you tend to reduce the chance of the glennis, the human component impinging on the scapula and causing notching. It still does happen. You know, we're not too concerned about scapula not showing.
It doesn't seem to be there have been some studies that indicate that the more skeptical nuts can get the poorer function the reverse has. But it doesn't seem to be a cause to failure. So we're not too concerned by notching. Brilliant and last question for now, is there any specific parameters you look on the X-ray for? To, um, to make a critique of reverse shoulder X ray?
Um, yes, I think that's a very good question. So the. I suppose you're looking at. The imaging of the a reverse is quite difficult to get good imaging because you're only really going to get the scapula in to the CT. You get a lot of artifacts, but essentially you want you want to make sure all the screws are in the scapula.
The rates of screens, the glenoid ideally should be inferior and it should be tilting down. Um, and obviously, if you've got good. If you've got bone graft underneath the Glen glenoid base plate, then you want to make sure that bone graft has incorporated and it hasn't been reabsorbed. I mean, that's I mean, that's one of the great things about these, these base plate structural grafts as they tend to heal so well.
And if now with reverses when it comes to revising them, it's very rarely the glenoid is a problem that's usually the human components become loose. And yeah, I suppose you want to the. You want to make sure that the human component is well, seated and that there is good fixation within your bone.
One thing I should just sort of going back to the previous question about and theorizing the glennis sphere, the authorization and Naturalization is very good. The only problem with that is we are seeing more complex because you're stretched, really stretching out the arm. And in some patients, they are getting nerve injuries, which do usually recover from fatigue. They can take quite a long time and it's pretty uncomfortable for them.
So it's just something to consider. Thank you very much. That's all the questions for now. And we have 3 to 3 participants for the Viva. So are we OK for time? Yes no, we're going for time. Just to reiterate, for the people taking part in the Viva, this will be recorded, but more for educational purposes.
So please, if you've got any, I know we don't know with the course of our Viva sessions, but just to remind people this will be recorded, but there will be very kind. Just take me through the. Personal features on this X ray, it's appeared much older. I'll give you that, what else can you see this going on here? So it looks like quite severe rotator cuff arthritic shoulder with the proximal migration, a stabilization of the acromion, and there is a bone on bone on the glenoid and it's quite proximal immigrated.
Also, it's quite inferior or to fight. And some systemic changes in the humeral head and the glenoid is not looking too bad in terms of a V or stiff right there. OK so, Tommy, how you would assess this patient if they came into your consultation room? To allow us the history, what is the presenting complaint and since how long and how they are affecting their day to day activities and any right handed nit handedness as we like right to left and what are their routine activities that they do any job?
And also do they do any recreation or hobbies? And are they on any medication past medical history in terms of people like to plan for surgery, then be an aesthetic review as well? And I would like to get an other view as well. And in my pre-op clinical request for a CT scan as well to assess for the bone stock on both sides. OK, looking very good. Just going back to their history is anything in terms of that sort of day to day function is anything particularly you would ask them about.
This is a they say this is a 75-year-old woman. Yeah to ask if the day to day activities like how much overhead activities and other activities they will to do or not able to do and what are their expectations out of this consultation today? Yeah OK. I'm and. What might you see on examining this patients who would like to examine by looking, starting the inspection, looking from the front side and back looking the rotator cuff muscles?
I presume it's approximately migrated. It seems to be prolonged or chronic condition. They will be, well, atrophied. I would like to check the functional deltoid, which will determine. Also, I'd like to check the function of other muscles like a trapezius. And let's say, in case the want to go for surgery and check the formal assessment of the function of the rotator cuff as well, and like to check the movement in terms of how much flexion, extension, rotation and abduction.
Well, component of the war component of the rotator cuff, would you be particularly interested in? It's the external rotation and external rotation. And how are you how do you assess external rotation? So it's merely in flexor-pronator and there is minus. So there are two ways. One is putting by the side and asking them to rotate against the force.
One yes, it's the Hornblower sign. OK? reduction and then external rotation the shoulder. And how did they go between those two? How so take it home design, which which rotator cuff muscle are you particularly assessing with those 416 flexor-pronator? I'm sorry that it's minor for the Hornblower site and the tenodesis for external rotation.
And by the side of the arm then asking for external rotation. OK very, very good. What are you going to offer her? OK, so 75-year-old woman, she's got some shoulder pain actually functions quite reasonably well preserved. What what treatment are you going to offer her to ask what she had until now, whether she had tried any physiotherapy, any injections, steroid or hyaluronic acid, and what effect she got with that?
And if it is not much effect, then most likely she is heading to have a reverse shoulder replacement because the UN actually seems to be quite hydrating. So I'm suspecting there will not be any rotator cuff for. To support the anatomical shoulder replacement. OK, that would be in five minutes. That would be 5 minutes. OK all right.
Well, let's because we're getting a bit late. Well, I'll stop you there, AJ I think you did that really well. So when you're I think when you're asked to explain what sort of history you take, you've got to the sort of three components really to the history taking is you've got to elicit their symptoms and how much pain they're in.
Um, you've got to work out how much dysfunction they have and that, you know, that's very important to ask things like hand dominance, who's at home with them? Are they by themselves if they got a partner or children or who helped them get by? And then the second matter is, is you're sort of when you see an X-ray like this, you're sort of thinking, OK, I think this patient might need a shoulder replacement then.
So then your third point is right. Are they a suitable kind of surgery? Are they fit? Are they are they compos mentis? Do they have good condition and they can sort of understand the implications of surgery and deal with the recovery period? So you just make that very. In terms of history taking and their supplies for, you know, whether you're doing a short replacement here, a knee replacement or a hip replacement, you know, just make it very clear that that's what you're trying to elicit from the history.
Well, the other thing I think with this is, is that, you know, clearly this has been going on for a very long time and always sort of make the point of asking whether they've had a previous surgery because they may have had a failed cuff repair previously. You know, that then makes you start thinking, OK, is this potentially an effective joint? I need to consider that prior to doing something like prostheses.
Well I think, again, your examination was very good. Patient like this will interesting actually will probably have quite good function. They have created a perfect acetabulum from there that the underside of their cranium. This is what we call a shoulder hip or a ship joint, and you wouldn't if you became pseudo paralytic as soon as you.
And my great still ahead superbly is unlikely you would have been able to do this to the acetabulum, so they've cleared it. This patient's clearly retrain their deltoid and is actually probably got reasonably good elevation. And I suspect they've presented now because although they've got a reasonable range of movement, they're sore because everything arthritic and there's nothing. So, you know, just to say that, you know, be that the patient has to protect range of movement or they've maintained good, good function.
This varies hugely between people, and it often varies depending on how good a physiotherapist they've seen as well. The other thing to mention on. Uh, en observation is look for a bicycle. Look at that biceps, they may work, she may. She may well have ruptured her biceps, or she may have a Popeye sign, as well as the waist rotator cuff musculature and make a real fuss about how you would examine external rotation.
You quite rightly said it's unlikely that maybe they can't get into a position to do a horn blows, but I would. I would put that elbows into the side, accelerated their hands manually and ask them to hold it there. And if often what happens, I show you my video is that they have reasonable passive range of. But as soon as you let go of the hand, the hand just flops around across their tummy that tells you that they've got really no external protectors.
Very good. Well done. This is a 65-year-old retired accountant, as I say, a retired lawyer, and he has had primary over his shoulder joint for the last. Five years, which has been managed reasonably successfully with steroid injections, but he is now struggling and the steroid injections.
Can you just tell me how you would counsel him for having a shoulder replacement? Go through the consent process, take, take, take us through the consent process for and for a shoulder replacement came to the patient, but there are different treatment options which are injections, physiotherapy and probably all treatment has failed.
Now So the other option is the surgery in which we replace the joint. And I will show him the probably a picture as well or X-ray as well, and that it will be we will change the head and replace them and the side. There are some risks involved as well. The one is the first is infection.
There will be a scar. His pain will improve. But I can't guarantee that how much range of movement he will get for that. And then there is a risk of nerve injuries because we will be operating very near to the neurovascular, state and neurovascular bundle. The other thing is that which nerve is most likely to be injured if that?
Exhilarated, you say no. Yeah, OK. Yeah, we know. And also that this may get in later. This may get few news as well, and he may need another surgery as well. OK um, any other complications you can think of. And also it can also dislocate as well.
Anything else? Right OK, fine and OK, so you're now in theater with the patient on the table. He's he's asleep and prepped, ready to go. Just what approach would you use for Anton shoulder replacement and just tell me how you would do the approach? I used, the better approach. The Allen, the patient will be in a slightly proper position by land, but will be the coracoid process, and I will go laterally deltoid tuberosity after taking the skin subcutaneous tissue.
I will look for the fat to see the cephalic vein. I will let a light movie mobilize it laterally towards the deltoid. I may have to get some tributaries and I will make my way with the finger, with between the deltoid and the major, and then I will dissect the Delta fascia and that subscapularis. I have to.
I would like to preserve the subscapularis, so I will take the lesser tuberosity with the subscapularis and expose the head and. Uh, what would be the landmarks for telling you where the subscapularis is because you, you go in, there's a lot of inflammatory tissue around.
It's all a bit scarred up because of the arthritis. I would look biceps biceps long ahead of biceps because it will be between the lesser and greater tuberosity and lesser tuberosity will be a OK and a thing in feroli, which tells you the inferior border of the subscapularis. That's the. Inferior border of subscapularis.
Yeah, the I will just go to the Petrulis major in session. OK, all right. Fine OK. And that's fine. All right. Well, I think we'll probably stop there with that one. That that was good. Is that five minutes?
That was good, Mohammed. I think the key with if you ask consent form is or go through the consent process, you've got to keep a couple of things in mind. You've got to keep the idea of shared decision making. OK and I can't remember what it's called now, the Montgomery ruling. Oh, Yes. So you've got to make sure that the patient is fully aware of that.
A shoulder replacement is not going to save their life, but it will change their life. So you you must always consent them in a way that they feel like they are being empowered to. They're given all the information about the operation and the outcome, the recovery, that sort of thing and that.
They are then allowed, they are then able to go ahead and make a decision based on that information. So, you know, you got all the right complications. Maybe it could be a bit more fluent, you know, but you need to say, OK, so we're going to do a shoulder replacement. We can do a shorter placement on you. If we don't have a shoulder replacement, you're probably going to continue to get pain and loss of function, which might get worse over a period of time.
We can continue to manage that as best we can with the combination of oral analgesia, injections and possibly physiotherapy. But with a shoulder replacement. It you will come into a hospital, you it will be inpatient care. You will stay in hospital for two or three days afterwards, your arm will be in the sling. It will take you six months, so it will take you six weeks to regain reasonable day to day function.
Your shoulder will continue to improve for up to a year. 90% of patients who have this operation are very happy with the outcome. The other 10% either have a problem, which is amenable, maybe between. Two and 4% of patients who have this operation are probably no better or slightly worse than they were before the operation. That way you have demonstrated the examiner that you have you've been through that modern consent process to just just, you know, again, these are generic skills they apply to consenting for any, any operation.
And you don't have to. Um, you know, design is not going to pick you up on not being exact on the timeline, but you just need to go through not just reading out the complications, which is what we used to do. But you need to give them painting them the whole picture of what the process of coming into was to have the operation is in the recovery period.
The that's a picture approach, very good. The skin incision centered on the coracoid, you quite rightly identify the vein and retracted it laterally. After that, it becomes, you know, you can start to tell who's done this procedure more recently and who hasn't. But just have a look at it, maybe in hop and failed or another sort of operative manual.
When you go through the superficial muscle adult deltoid and major, you know, talk about identifying the coracoid and the conjoined tendon. You go to the conjoined tendon you want to get retractor underneath the conjoined tendon that actually protects the break or practice, actually, if you retract, if you tried over the tendon, you tend to stretch out the brake or bit.
You would say. You can also add components like I will put stitches in subscapularis before I release it, so I don't lose it into under the conjoined tendon. And you, as you said, you use the bicep to groove is the most important landmark when you're doing the approach to the shoulder because that it's very easy to find because you see major inserting just lateral foot, the inferior border of subscapularis if you heard of the three sisters.
The so these are three blood vessels that run along the bottom of subscapularis, and they're the second vessels. And they indicate the board of subscapularis. And they usually you need to tie them off or diethylamide them before you, before you divide them. Otherwise they blew it up. So, yeah, I would just have a little bit more try, you know, when you're asking technique or is try and describe it as though you've done it lots of times in practice, you know, in the exam situation, it's more difficult, but this sort of little bits you can add which sort of customized, personalized.
We get. Mr tell me what you can see on this. Veto so this is a clinical photograph showing patients left arm, which is showing a pharmacist on the medial aspect of the elbow with a muscle bulge in the superior aspect, probably showing a reversible sign. Great good.
OK, so this is a 35-year-old plumber who was trying to stop a heavy object was falling off a table. What would you like to ask him about in the history? So well, the again, the mode of injury, as you said, he was a mechanism to again, he was his hand dominance.
And I then would explain to him that the most and then examine him and confirm the diagnosis of a by distal biceps tendon rupture by performing the test. OK all right. What are you going to do? How are you going to cancel him for the treatment going forward? So I would explain to him that the options going forward are to do nothing and do some physiotherapy and let it heal by itself, or the other option is to treat it by an operation.
The conservative treatment is likely to lead to loss of about 30% of the biceps and maybe more, whereas in the operative option. Can you expand a bit on loss of bisects function? What do you mean by that? So the main functions of the biceps is it is a strong supernatural, the forearm in flexion of the forearm. And so that's the main function.
Loss to the flexion strength is lost to lesser extent, but the Super strength is largely lost if we treat it conservatively because the tendon will not heal in the right position, whereas the function is more likely to recover with an operation where we attach the tendon through a drill hole in the radius at epimysium tuberosity. There is still the operation are again like any other operation infection.
Mainly largely, but there's lots of nerves that travel around here, and the lateral cutaneous nerve of before, yeah, is at risk here, and I think at least 10% of the patients get that, but it recovers later on in my book is more which ulnar nerve is at risk. Um, well, during the dissection of the tendon, the median nerve is at rest when we are fishing the tendon from the Super part of the incision.
What about what? And the other one, which is more at risk when you're reinserting the tendon into the radius? probably entering process. OK what are the complications from surgery? And so again, there is like any other tendon repair, the risk of the repair failing and reduction risk. And apart from that, there is a risk of.
And the risk of stiffness or reduction in the loss of function. And not able to get the full strength. So you say stiffness, what might cause stiffness around the elbow with this sort of operation? The sometimes if when we the patient present late and we are beyond two weeks, it's difficult to suture the tendon back. So we have to flex the elbow to get it, get the tendon to the bicycle tuberosity.
In which case then we keep them in flexion for some weeks and then gradually stretch them out. Have you done a repair? I was just in a few partly done one, but you know, how would you repair the tendon back into the bone? Would you reattach the end the bone? So we use the single insurgent technique from anteriorly, we subpoenaed the Fort Lee and then make a hole to different diameter holes and then pasando button and flip it.
We stand. Yeah, that's five minutes. Brilliant yeah, you did that, very well done. Yeah I mean, quite rightly so. I gave you the information about his occupation. You are straight away about hand dominance. The key, I think you said biceps function will be reduced. Actually, you don't tend to lose very much flex and strength at all because breaking loose compensates.
And you've got the other part that you want to just head straight for the loss of supination you lose about. You lose between 50% and 70% of supination strength. And that's the problem with these guys who do manual jobs using screwdriver, that sort of thing. If you lose supination strength that it can be very disabling, quite right on good goods, on the complications that the nerve that can get injured as posterior interruptus nerve as you usually as you pass the undo button, you have to pass a passing pin through the hole in the radius and out through the dorsum of the forearm and you can catch the posterior nerve that way.
OK, so I didn't know and the complication actually more with to the old fashioned two incision Boyd Anderson technique was the formation of who just keep that in mind as part of your. But you know, you would have scored pretty high with that. I think you did that very fluently well. Thank you. We get.
OK I think I might have questions now over to you guys, right? Fantastic thank you very much, Mr Barry. Yeah so I think it's 9 o'clock now. So I know there are people coming out of the fast. So if people need to go and go and eat it, probably time to bring this to a close. There's a really grateful for a fantastic talk tonight.
Apple admits it has come up quite a lot in the exam, so and this obviously this talk is going to be on our website, the fastest mentor YouTube channel and the OK, so please, please look at refresh yourself with it beforehand. Again, we've approaches. There's lots of delta. Proactive approach is a really important approach. Very a very favored one with examiners, particularly the vyver and the basic science, because it can go one of two ways.
You can even ask you how to approach a funeral microfracture or doing an anatomical shoulder. So there are subtle ways to know who's done it and who hasn't done it. And there are certainly videos out. If you haven't seen it, appreciate somebody as difficult to go and see it. If you haven't had a chance to do enough for them, job the fantastic talks on YouTube of how to do all sorts of different approaches.
So I reading unfold is one way of doing it. But if you have a very visual brain, it's always good to have a look and see how someone's done it online. I know Mr. van rensburg, who has talked to us before, has got fantastic video on YouTube for it, so I recommend having a look at those. Again, zain, thank you very much for everyone coming today.
Appreciate a lot of people results today as well, so fingers crossed people had a good have were successful. Otherwise, we're here to support you and get you through this. So don't worry. OK so without further ado, we'll say goodbye and wish everyone a good night. All right, any. McCabe by good luck, everyone.
Segment:0 .
OK good evening, everybody. Welcome again to our Wednesday evening webinar session. This is a combined session between US and UK. My name is Sean Henry, one of the mentors today we have Nicky Evans, Jo gouty and David Hughes with us supporting this today's session.
Today, we're very lucky to have Mr. Toby bowring. He is going to give us a talk on shoulder arthroplasty. He I am really looking forward to this talk. He's an expert in this area and I know that his talks are often very appropriate for the exam, which we're looking forward to.
We start with introduction today, shoulder hour and then we'll have a talk show and then some questions. We'll have some case discussions and tips for the FRCS, but we'll close already this time before sorry. Before I continue, I just want to introduce Mr berankis, a qualified Newcastle medical school, in 2000. He did his best to guys Thomas and then undertook his doctorate with prof.
Rogers in Emery at Imperial College London in 2006. Looking he looked at surgery in the rotator cuff. He is postgraduate. Training was in the Royal National orthopedic hospital in North London and spent his fellowship in nice and France with the shoulder specialist prof. Pascal Ballou. He's been appointed as a trauma orthopedic consultant at Hampton University Hospital in 2015, and he's the clinical director and practices shoulder and elbow surgery there.
His specialist interests are shoulder arthroscopy and joint replacements and shoulder and elbow trauma. I am very sure we are going to get an excellent talk from him and we're really looking forward to it. And without further complications, please go ahead. Thank you, Ryan, and the rest of the faculty for asking me, can you, can you hear me? Yes great screen, ok?
And you can see my screen. Great Yes. Yes, good. It's good evening. I'm Toby Barry. I work at the Hampton University Hospital in North East London. Shoulder arthroplasty is it may feel a bit of an enigma to a lot of you because, you know, compared to knee and hip replacements where you get exposed to them all the way through your training.
I suspect some of you may not have even seen a show replacement being done, and that was certainly my experience. And because of that, probably it's not. It's not well understood. I think compared to knee and hip replacements, we are probably about 20 years behind them, certainly in the sort of understanding what makes a shoulder arthroplasty.
Last but also I think in terms of the sort of postgraduate education. Anyway, hopefully after this, you will have a better understanding and feel more confident about dealing. The question about the policy in the Fox. I'm sorry.
We go so shoulder arthritis, there are lots of different types. That is sort of various causes of degeneration of the joint, which may lead onto requiring shoulder arthroplasty. So I don't know if this is going to work because I understand there's a lot of you, but I want to do is start with little quiz. And I think imaging is going to let one of you who puts their hands up.
Answer this question. We're going to go through a series of x-rays now we're showing different types of degeneration. I want to tell you to tell me what, what type it is. So anyone can want to tell me what's going on with the shoulder. If you kindly raise your hand in the participant section, we can then unmute you.
They were putting their hand up. Yes, we have. Hi, evening evening. Sorry yeah, to my name is AJ. It's pretty good. I can see it's of radiograph of the right shoulder of the mature skeleton.
I can see this is quite a sclerotic and irregular humeral head. And Uh, it's slightly highly migrated as well. The distance between the eye cream and humerus also seems to be reduced, though it seems to be a. Uh, it seems to be balanced. I would like to see the other view as well to check the house the glenoid, the Mason, the glenoid looks pretty normal, doesn't it?
Yeah OK, so what conditions do where just the funeral head is affected? It's the most likely. I think my first trip would be to avail of the funeral head, which made to only a fraction of the. Very good end of the humor I had. Yeah, very good idea. OK there's an error on this X-ray. Do you know what it is?
Right it's a tricky question, do you know what a grassy view is? Yeah yeah, I heard that, but I don't know the detail yet yet. It's a grassy view that is an AP of the Glen funeral joint, which is quite different to an AP of the shoulder. And yeah, with a grassy view, you should see clear space between the human heads and the glenoid.
Uh, which is not the case, this is more like an AP of the shoulder. Yeah, Yeah. So this is incorrectly marked as aggressive, you know, that's just something probably for the mix if you're not a very good. Well done. Thanks, Don. OK, let's move on to the next one.
Inflammatory arthroscopy? OK probably rheumatoid arthritis. And the key is, as I say, that there's a lack of Austria fights. The joint space narrowing is pretty symmetrical with primary area. You're always going to get asymmetrical narrowing of the joint because you're loading in one particular space where the cartilage is damaged more with inflammatory arthropods or the cartilage.
On the glenoid and the human side is essentially affected the same, so you get this symmetrical loss of joint space narrowing. The other feature, which may be is debatable, is unlike with air, you get periodic osteopenia, you get reabsorption, the bone. So rather than sclerosis, you get some reabsorbed reabsorption, although you know, that's maybe open to a bit of debate.
So that's this one would be an inflammatory arthritis. OK OK. Onto the next one. What about this one? And this was an issue to volunteer. And so this is a preview of the right shoulder showing reduced joint space between the humeral head and the glenoid with a goatee beard sign the.
Uh, AM slap AM space looks reasonably preserved, although there are shadows of loose bodies in there. I cannot comment on the siege from this view, so this is in line with the osteoarthritis of the right shoulder. Reggie, an yeah, as you quite rightly say, so the head is still centered on the glenoid, so we assume the cuff is OK. That's very characteristic.
I think it's the first time I've heard it as the go to be sign, but that is very characteristic inferior human head, osteophyte. And then, you know, typically you get more joint narrowing towards the center or posteriorly. You can't appreciate the posterior where you the. But yeah, very nicely describing tissue. Well done. Thank you.
And that's what you often see on these seats is that how much posterior where there is with these? We'll talk about that in a bit more detail later. This is the AP radiograph of the left shoulder showing the United proximal humerus and its United looks like in a quite vulgar position and also irregular shape with the reduced joint space. And it's migrated, proclaiming approximately as well. So I would label as a secondary due to a model United and possibly may be a sign of some avian.
Yes well. Very good, well done. Yes, so this is post-traumatic egawa. There is a classification called fracture sequelae, which particularly talks about the position of the GT because that has a big sort of it's a very determining factor in terms of how you treat these patients. If you are going to do an operation and we do see quite a lot of this.
Um, I'm finally this is I think this is the last one in this series. Anyone want to have a go at this one? I'd say this is quite difficult. And Michelle, you volunteered. Again, this is an X-ray of the right shoulder preview with symmetrical loss of joint space, but there is a formation of a still fighting filiale the preservation of the subacromial space. So the features are in some way showing secondary degeneration.
I wouldn't be sure what the primary causes for this, but if asked to choose, I would say still, this is osteoarthritis, probably. Very good. The key factor here is that you see this the glenoid has developed in Austria fire as well, and we only really see this with post instability. So if I put these up, this gives you a little bit more of an idea.
So these are patients who have had stabilization surgery and they all develop the very information sort of speaking of the glenoid. Again, you don't tend to see that. So much with primario. But that's just that's a tricky one. It's almost like the shoulders sort of growing its own procedure. Yeah shows proximal migration of the humeral head with a stabilization of the acromion.
There's lots of joint space and this is most likely after osteopathy. Late stage, I guess, is like a true shoulder surgeon. You've clearly been trained very well. I can say that because nischan used to be my registrar. So well done. OK, excellent. And we tend to talk about arthroplasty rather than arthritis.
But by the end of the spectrum of our therapy, you do very much get arthritic changes in Austria formation. So the management of arthritis? Uh, we obviously tend to try non OPT of treatments first. Shoulder arthritis is often a self-limiting condition in that patients will start to get pain from their shoulder as it becomes arthritic and actually change the way they use the shoulder and use it less.
And so we see a lot of patients present with sort of mild to moderate osteoarthritis. And it doesn't necessarily progress much beyond there. Interestingly, in traject, injections work very well. Steroids and and hyaluronic acid. We tend to try hyaluronic acid in the younger patients. The evidence is still doesn't show it's much superior to steroids, but patients like the idea of trying to reconstitute that cartilage.
Physiotherapy in primary OA is not particularly helpful, but with Cuff deficient shoulders. With this sort of pseudo paralytic movement you get, it can be incredibly helpful and actually restore a huge amount of function. Well before, I mean, you know, if you're talking about cuff deficiency or cuff tear, I throw up. That's a whole. And what you do about the rotator cuff in these patients, that's a whole other talk about super caps, reconstruction and balloons and those sorts of things certainly are not going to go into that today.
So this is just trying to keep this relatively simple, but there is something you can do to the biceps, as I'm sure you as you develop primary egawa in majority patients, you get posterior subluxation of the humeral head. You tend to wear away the posterior glenoid more than the anterior glenoid. And what happens with that is that you find a lot of them have this anterior joint or we think is anterior joint line.
Actually, you're feeling usually over the bicipital groove and the biceps becomes quite inflamed. And what happens is the biceps. Rather than going over the top of the head towards the glenoid, which should be heritable, be speaking as it becomes more posterior some blocks, the passage of biceps becomes more and more oblique, and it can kind of subscapularis creating a cleavage tear and be quite a source of pain.
So certainly in a handful of patients, you can do biceps tenotomy, and that will maybe buy them another few years before they require a shoulder replacement. And then obviously, the options after these sort of less invasive and non active treatments is to move on to arthroplasty. So then the question is which prosthesis, as you can say, that you can see there's I mean, like the knees, like the hips, like the elbows, we've gone through an evolution of.
Uh, different types and, you know, going from the nurse prosthesis in the 70s and eighties, which were not anatomical, didn't really fit the proximal humerus at all. Then along came the anatomical in the nineties, which seemed to work much better. The reverse is actually we tried reverses back in the 60s with four, which weren't particularly successful.
The second generation and third generation reverses came in about 20 years ago, and they now seem to be working, working quite well and lots of other things have been tried in between. This here is. Came out in France about 10 years ago, and they called it the snooker ball, which is it's essentially a bipolar hydrocarbon ball. This is here a, I call it, the Stanmore special.
Any of you who worked at Stanmore or may have seen this, essentially, it's a acetabular cup screwed into the chromium and the glenoid. So, yeah, so hopefully by the end of this tour, you should understand what the implications for which type of prosthesis are best. OK, first question, you know, how do you determine whether to do it, anatomical replacement or a reverse shoulder replacement?
And I think if you stick to these three components, you won't go particularly wrong for anatomical. You have to have near normal anatomy, intact rotator cuff and reasonably good glenoid bone. Um, whereas with a reverse, you can have distorted anatomy, you can have an absent cuff and you can have considerable glenoid bone loss. And so you're looking at that, you would think that the indications for anatomical are quite narrow and they are pretty much limited to primary primario and a vessel necrosis.
Although they even faster increases, we often don't replace the glenoid because the glenoid bone is going to bone, and cartilage is actually a good quality and tends to tolerate a metal or poorer carbon head or ceramic had reasonably well, whereas a reverse is far more versatile and actually that's illustrated in the NJR. Now we're doing considerably more reverses than anatomical, probably over 100% more.
Are the indications for reverses are now expanding relatively quickly? So I don't know. You know, I've been giving this talk for a few years now, and when I first wrote it, it seemed to be quite relevant the argument between a hemiarthroplasty versus a turtle shoulder. I'm not quite sure what's being taught in other parts of the country now, but generally we're moving more towards a total shoulder replacement.
You can certainly quote the Cochrane review, which was published in 2011. But just be aware it wasn't based on a huge amount. There are only two high quality objects comparing hemiarthroplasty and 2 to shoulder replacement. And that's, you know, so there's not a huge number of patients to demonstrate that the difference.
Certainly, the difference between the two when it comes to revision is quite considerable. And if you've put in a glenoid component and you have to revise it, you end up with a sort of hollow glenoid, which you'll have to fill with bone graft, glenoid tend to erode away the whole I'm sorry, I tend to wear wear away the whole of the glenoid and you end up with peripheral defects and often completely sort of destroy the glenoid.
And so that in a way almost Hemy can be trickier to revise if it were quite if that is required. Pre-op assessment of shoulders prior to arthroplasty is very important. Clinical examination will go into this a bit in a bit more detail is looking at the function of the cuff with emphasis on external rotated and subscapularis.
Deltoid function is. Certainly, if the patients had previous surgery and, for example, something like they've had a human fracture and they've had a previous. Previous delta to approach or even a delta is split. We often find that the a axilo ulnar nerve has been injured and they've lost quite a lot of.
A deltoids bulk anteriorly, actually, you know, although Delta is key for a good deltoid, is key for good shot of function. There's quite a lot of evidence to suggest that you can still function pretty well, even if the a deltoid is deficient, but it certainly should be noted CDC and MRI scan. It is very important for looking at bone stock on the glenoid side, especially assessing how much posterior glenoid where there is in primary area.
We do expect the rotator cuff to be essentially intact is quite unusual to have a cuff tear with primario and. Sometimes there are small defects. But not so good cuffed efficiency. But because the implications of having a damaged car cuff when you're trying to do anatomical have, if you do go in and find actually they've got a massive cuff tear, that's a real problem if you haven't planned to do a reverse as a backup.
And so we do tend to often do MRI scans for anatomical shoulder replacement just to reassure us that they're going to be no surprises. And then, of course, we always got to keep in infection the back of our minds, especially if it's revision surgery. I think I'm talking particularly about reverses when if you have had someone who's got rotator cuff disease and they may have had.
Two or three arthroscopic procedures prior to it. You know, repairs of tendons, repairs or tendons and so on. And obviously we hate infection in Arthur arthritis wherever it's done in the body. So just always keep that in the back of your mind that you may be dealing with potentially contaminated joint. And I think that goes also with steroid injections, you know, I. Always make sure the six months between a starting role, steroid injection and me doing a joint replacement on a patient because, you know, that is one of the risks factors for price infection.
Now technique, I mean, generally these days, I would say the majority of shoulder replacements are done through a data approach. It tends to give you very good access to the glenoid. Uh, and you can release subscapularis very carefully through it. It does a better approach if you're doing it anatomical and need to preserve the subscapularis deltoids splitting is.
Has been advocated previously, especially for fractures, because it gives you good access to the posterior aspect of the joint, so you can sort of pick up and manage the greater tuberosity, which tends to migrate security posture is superior because of the pull of the calf. You can't do it for replacement, really, and you do run the risk of damaging the axilo ulnar nerve and taking out the anterior the anterior deltoid.
Mm-hmm if anyone has seen a show replacement, you'll be aware of how challenging it can be to get adequate exposure of the glenoid and I suppose is just a technical point is you have to position the head and the retractors in a very specific way to allow you to get down onto the glenoid, which may be retrofitted already. So if you can't get sort of perplexed at the glenoid, you're going to find it very difficult to prepare it for your prosthesis.
You may have heard about these more modern options, we now have what we call platform prosthesis so that these are prostheses that are basically interchangeable between a anatomical and the reverse. Uh, and the terminology in lay and Lay's is relevant to that, so so platforms tends to be only in the metaphysical component sits above the shoulder or above the mattress sutures, actually.
Whereas this is one of the more original reverses and this is where the metaphysical component is, is actually sitting within the metathesis rather than above it. And the difference to that really is the biomechanics of the shoulder get changed. You have far more lateralization and fear is inferior with on. I'm not going to go into that in detail.
That's that's really quite a complicated component of the reverses. And I don't think you certainly don't need to know about that for physics. But I think if you're just aware of these terminologies, that would be helpful. Um, for a anatomical replacement, the subscapularis subscapularis repair is absolutely key. If your subscapularis repair fails, then you're anatomical replacement is probably going to last about 50% short of time.
And I'll go into that again in a minute. I tend to do use transverse sutures. There's lots of different ways of taking off subscapularis repairing it. Some some people do a lesser tuberosity osteotomy. But as I say, the key thing is to make sure you do a solid repair at the end. And the Piscopo now again, this is moving more into slightly more advanced knowledge, and this is very relevant to reverses, obviously in the show that you have very have essentially for internal agitators, you've got your subscapularis, your tiers major, your major and your little and Stasi.
But you've only got two external radiators, which are terrorism, terrorism, minor and impersonators, and with cultural property, obviously you can potentially lose certainly one, if not both external radiators and you end up with what's called an external rotation lag. And although the reverse will address the loss of elevation, I don't know if you can see this on the video. If you if you don't address the external radiators when they lift their arm up, their whole elbow and forearm falls forward.
And that doesn't necessarily return function in terms of getting your hand to your mouth and hands your head. So you've just got. We have now started doing these, episcopo, actually, the pisco was an Italian, he originally described this for obstetric palsy, but it works perfectly well and combined with the reverse. And you basically take off the d'Orsay and tiers major from the bicipital groove and wrap it around the other side of the humerus that comes around.
Rather than coming through the armpit into the front shoulder, you basically wrap it around the back of the humeral head and it turns it into external rotator. So as part of your preoperative assessment, prior to doing a reverse and someone with you must assess their external status and see how much external rotation they have. They often will have a lot of weakness, but they should be able to extend their right to actively.
If they don't, then you may well want to consider doing this transfer. Mason slightly more depressing part of why the replacements fail. Well, like any process, they can become infected. The rate of infection has been shown to be higher with reverses, that is probably because when you put in reverse, the human head, you then create a dead space above the human heads, which will obviously fill with hematoma, and that's probably a notice for infection.
But actually, as we move along and get better at these, actually the rates of infection are coming down dislocation. If that's an anatomical, it's usually because the cuff has failed. It does happen and certainly in the older patients with the sort of more frail soft tissue that is a possibility in reverse as obviously there's much less calf in it.
Again, it's a situation in reverse, this was it's become slightly more a historical problem now we've started liberalizing the sphere and the more stamps the mechanics are much more favorable to it being a very stable prosthesis. Uh, as I said, cuff failure can lead to not necessarily dislocation, but failure of the process it becomes.
Uh, becomes loose and you get this rocking horse effect, where if you have a functioning cuff, then obviously the humerus is the funeral component will be centered on the glenoid component, so you won't know the loading will be very central. As soon as you have a cuff deficiency, you will start loading the edge of the prosthesis and it becomes loose, and that's known as the rocking horse effect.
And then again, like other processes, you can have fracture leading to failure. Well, I'm. So there's a million question, how does a reverse shoulder replacement work? The classic works by inferior intellectualizing, the center of motion of the joint and making deltoid more competent in terms of lengthening the fibers so that they can exert greater force to elevate their.
OK and how does that bypass the issue of not having a rotator cuff? And so the rotator cuff, basically apart from centring the humeral head on the Dean or initiates the abduction or elevation of the arm and the glenoid being. Not fibers being lengthened then can perform this function in place of the rotator cuff.
OK well, you're saying all the right things, but it doesn't really answer the question about why a reverse works in and replaces the function of the rotator cuff. It's all about providing a fulcrum stable fulcrum, so. That is what the primary role of the rotator cuff is to create a fulcrum for the moment arm, which is the arm to rotate around so.
Rob, if rather than when your cuff is deficient, if you're deltoid contracts, you haven't got the fixed fulcrum, so the humeral head just moves my great superiority. And that is the key to reverse is that it's not really about changing the position of the center of rotation, it's about creating a stable fulcrum. It is a semiconductor constraint prosthesis, whereas a anatomical shoulder replacement, so is a completely unconstrained prosthesis.
If you put any, if you put two, you put two components of an anatomical shot replacement together and put any sort of shear force across them. They will come apart with a reverse. They can. Um, do it, it would remain stable with really quite a lot of shear force going across it. So if we go on to this slide, this is the back to the Star Wars special.
Yet that also works because it is a semi construction constrained device. It's got the cup is captive and it stops the head from dislocating or moving off its off its sensor at the center of rotation. So when you get asked how does it reverse work, you can talk about it in your AIIS and electrolysis this interpretation and it optimizes it, stretches out the deltoid, et cetera but you also should say it is a semi constrained device.
It's intrinsically stable. It provides fixed fulcrum in the absence of functionality to go off. I've put you here in mid-july, the sense of rotation. Now that was the original idea that Graham on when he introduced it in the second generation reverses in the 90s. That was the idea of stopping because prior to that, the glenoid component always got stable, had got loose and unstable.
But we've now found ways of catalyzing it will go on in a minute and you're by mid-july using it. The idea was would recruit more of deltoid into production, but actually we now think the external rotation and internal rotation, which the anterior posterior deltoid harp with are equally helpful.
I've just seen the time I'm going to keep going quite quickly as the reverse nears came up with the concept of the reverse in 1960. But because of having the sense of rotation outside the glenoid outside the bone stock, there were great shear forces push it through it and the glenoid component became loose and these were completely constrained devices. They had a completely captive hub.
You can actually just articulate them. And then he went through various different types in the 1970s. Then grandma came along in 1985 and talked about the media utilizing sense of rotation in towards the interface between the sphere and the glenoid, and that made it a much more stable. Or much less likely to loosen, I should say. So now we know we're very comfortable with the functional outcomes from reverses.
Mostly the main indication is cuffed the. Even if you don't have a property or arthritis, if you are a patient with a suit of paralytic arm, you can't they just cannot retrain their deltoid tuberosity work over a shorter excursion. You sometimes do have to do a reverse in the absence of significant arthritis. These are the glenoid is very amenable to sticking structural bone graft behind it to correct glenoid deficiencies.
So these patients here primary with massive retroviral loads of it's very difficult to put an anatomical shoulder replacement. You can do it, and there is now special augmented options, but it's very difficult to it can be very difficult to do until a replacement knees. And actually, it looks like a reverse is probably the better and more predictable outcome. Um, tumor is around the shoulder when you have to do large, large incisions of bone and tissue.
Some again, you're going to be often removing all the rotator cuff. And so some sort of strange device is will restore more function than trying to a heavy arthroplasty or a sort of anatomical. And then, as I think I said earlier in the elderly with arthritis, when you're worried about the quality of the rotator cuff, even though it may seem intact, it may be an option to do a reverse rather than anatomical.
So you, you do a good anatomical is going to be better than a good reverse in terms of restoring range of movement, especially on an internal rotation, which you tend to lose with a reverse. In this sorry, this is a picture of someone with pseudo paralysis where trying to elevate their arm and all they can do is really shrug the shoulder out because they can't activate the adults right any more than that.
Problems with the verses, just credit, go through the complication profile reverses, as I said, infection probably because of the dead space security dislocation. The Grumman reversed, which didn't utilize the center rotation, tended to stick the humerus right underneath the chromium. You then have a vector pull of deltoid, which is more lateral and more likely to dislocated by pulling it out and up.
We now we've studied laterals, the sphere with sort of augments and and bone graft that seems to be less of a problem. loosening of the glenoid, you've got to make sure that you don't put the glenoid pointing upwards. And with rotator cuff arthroplasty, you can have a lot of superior glenoid wear. And so if you don't appreciate that surgery, then you end up point to the up and then you have these shear forces and it can just push.
The human component can actually push the glenoid out of position. Um, disassembly. This is more of a sort of interesting X-ray rather than key knowledge, but because of the rotation actually going on in the shoulder, you can unscrew prostheses and certainly the good bone stock is very important to prevent these, this problem occurring.
And then probably, I think this is one of the most relevant problems associated with the reverse shoulder replacements. Now These are cranial stress fractures, which are shown to happen in about 5% of people after a reverse. And just because you're putting on deltoid so hard after usually happens between six months and 18 months after surgery.
The chromium fails, and that's a real problem. And it's very it's very unusual actually for a patient to regain good function after that because you've essentially you've mentioned the anterior deltoid for surgery and we don't really know. Even though they tend to heal, the patient loses a lot of function. What often have persistent pain, and certainly the more recent work has shown that this is probably elderly with a low BMI is puts you in a high risk category for a stress fracture.
So those little old ladies where you might consider a reverse because you're worried about the rotator cuff actually probably want to rethink that because probably may want to be better sticking with anatomical to try and avoid this, this particular issue. So sorry to say it's slightly speeded up there at the end, but in sort of summary, exam point is definitely know the difference in primary owing to our property. For axilo, who showed replacements, you could think you've got to have near-normal anatomy, appreciate the posterior glenoid erosion that's done with the CT scan.
You want to demonstrate to your examiners that you understand that a rotator cuff has to be intact. And, you know, sometimes it's very difficult to examine patients with primary OR because their shoulder so sore. So that's why that's probably one of the rationales getting an MRI scan. For whoever replacements, the indications are broadening, it's being used much more now than anatomic cause.
Just make sure you have a good spiel in terms of describing the biomechanics when asked what, how a reverse works, having the sense of rotation from the bone to prevent the stabilization and loosening of the sphere is a constrained device providing a fulcrum and it has a knee instability. And also, as we've just been through, be aware of the complications both generic complications like infection, but complications that are specific to the prosthesis.
So the first question, I think probably some of you were thrown by the wording, but the majority of you got this right. So you cannot you can't do an anatomical show on some of the slap subscapularis tear and tear recurrent infection or cuff deficiency, but you can address retro versions. So glenoid retroversion is in primary 08 is a very common phenomenon. I would say the majority of people with primary IRA have a degree of.
Posterior glenoid bone loss, and that leads to increase retrogression, I mean, the glenoid we know is 8 degrees retrofitted anyway normally, but that tends to worsen with primary. It needs to be appreciated, but as I say, we have now the ability to augment the glenoid implants to correct that retrogression version. Anything up to about sometimes 20 degrees at some point, you know, you have so little bonus stock because there's so much regulation that you probably have to bail and do some other procedures, like a reverse.
But yeah, so one up for that next question. Again, I've sort of asked this in a double negative way, but which of these mechanisms is not a failure for a total shoulder replacement? And you quite rightly. Written the majority of you answered windscreen wiper effect. That's actually something to do with the biceps, which we see in Cuff disease.
But yes, the rocking horse effect is the failure of the rotator cuff, including the glenoid component disassembly. The prosthesis can come apart inside the shoulder infection, obviously, and loosening other causes. And finally, the Piscopo transfer again, the majority of you got this right, it is a slap d'Orsay and major transfer.
OK great, so that's the end of the polling close that down. I've got some, some cases to go through. And anyone who wants to go at practice favoring, I'm very happy to take them through. It will. Certainly two of them will be based entirely on my talk. So if you thought you shouldn't have a problem with it at all? Mr we've got some questions from our purposes.
OK, let's do the questions. I will ask them to you. I see them through the chat. So Uh, one of the audience is asking if we just left the subscapularis not prepared at the end. Would that give us enough external rotation rather than doing the Episcopal procedure?
Well, that's very good. So this is in reference to reverses rather than anatomical, yes, reverses. That's a really good question. Yes, there has been. Certainly, when I was on fellowship about eight years ago, we did try very hard to pare subscapularis at the end of reverse because we thought it actually helps they reduce the rate of dislocation.
But that's quite right. You're basically fighting against the external radiators. So there's now actually a move not to repair the subscapularis at all. And I now have not repaired a subscapularis with a reverse for the last, I think, three years. I have had no issue with instability. And you're going to maximize the function of the external radiators, which which is the problem with the reverse or the problem with the clinical outcome after the reverse.
OK and for me, asking how to reduce dislocation of reverse shoulder arthroplasty. Yeah, well, I think I think I was sort of talking about that if you've got your cranium here and you've got your reversing underneath there, the grandmoms star was to mid-july is the humeral head and the sense of rotation as much as possible to try and get the center of the rotation into the bone?
But as you go more and more underneath the cranium, the deltoid is going to be pulling more and more laterally. And that's why we think the. Reversed and 20 years ago, 15 years ago, dislocate is quite commonly. Now what we're doing is building out on trying to keep still keep the rotation within the bone.
But we build out of a combination of graft and augments underneath the glenoid base plate and also using only prosthesis on the human side, which tends to latch so that the humerus components and the humerus are turning to now sit slightly lateral to the cranium. So the pull of the deltoid is more medial, and that obviously increases the joint reaction forces in the stability of the prosthesis.
And how to reduce launching in by the position of the proponents in the reverse order, again, bye bye. The other thing that has happened is that you inferior is the glennis here now. And by building it out, you tend to reduce the chance of the glennis, the human component impinging on the scapula and causing notching. It still does happen. You know, we're not too concerned about scapula not showing.
It doesn't seem to be there have been some studies that indicate that the more skeptical nuts can get the poorer function the reverse has. But it doesn't seem to be a cause to failure. So we're not too concerned by notching. Brilliant and last question for now, is there any specific parameters you look on the X-ray for? To, um, to make a critique of reverse shoulder X ray?
Um, yes, I think that's a very good question. So the. I suppose you're looking at. The imaging of the a reverse is quite difficult to get good imaging because you're only really going to get the scapula in to the CT. You get a lot of artifacts, but essentially you want you want to make sure all the screws are in the scapula.
The rates of screens, the glenoid ideally should be inferior and it should be tilting down. Um, and obviously, if you've got good. If you've got bone graft underneath the Glen glenoid base plate, then you want to make sure that bone graft has incorporated and it hasn't been reabsorbed. I mean, that's I mean, that's one of the great things about these, these base plate structural grafts as they tend to heal so well.
And if now with reverses when it comes to revising them, it's very rarely the glenoid is a problem that's usually the human components become loose. And yeah, I suppose you want to the. You want to make sure that the human component is well, seated and that there is good fixation within your bone.
One thing I should just sort of going back to the previous question about and theorizing the glennis sphere, the authorization and Naturalization is very good. The only problem with that is we are seeing more complex because you're stretched, really stretching out the arm. And in some patients, they are getting nerve injuries, which do usually recover from fatigue. They can take quite a long time and it's pretty uncomfortable for them.
So it's just something to consider. Thank you very much. That's all the questions for now. And we have 3 to 3 participants for the Viva. So are we OK for time? Yes no, we're going for time. Just to reiterate, for the people taking part in the Viva, this will be recorded, but more for educational purposes.
So please, if you've got any, I know we don't know with the course of our Viva sessions, but just to remind people this will be recorded, but there will be very kind. Just take me through the. Personal features on this X ray, it's appeared much older. I'll give you that, what else can you see this going on here? So it looks like quite severe rotator cuff arthritic shoulder with the proximal migration, a stabilization of the acromion, and there is a bone on bone on the glenoid and it's quite proximal immigrated.
Also, it's quite inferior or to fight. And some systemic changes in the humeral head and the glenoid is not looking too bad in terms of a V or stiff right there. OK so, Tommy, how you would assess this patient if they came into your consultation room? To allow us the history, what is the presenting complaint and since how long and how they are affecting their day to day activities and any right handed nit handedness as we like right to left and what are their routine activities that they do any job?
And also do they do any recreation or hobbies? And are they on any medication past medical history in terms of people like to plan for surgery, then be an aesthetic review as well? And I would like to get an other view as well. And in my pre-op clinical request for a CT scan as well to assess for the bone stock on both sides. OK, looking very good. Just going back to their history is anything in terms of that sort of day to day function is anything particularly you would ask them about.
This is a they say this is a 75-year-old woman. Yeah to ask if the day to day activities like how much overhead activities and other activities they will to do or not able to do and what are their expectations out of this consultation today? Yeah OK. I'm and. What might you see on examining this patients who would like to examine by looking, starting the inspection, looking from the front side and back looking the rotator cuff muscles?
I presume it's approximately migrated. It seems to be prolonged or chronic condition. They will be, well, atrophied. I would like to check the functional deltoid, which will determine. Also, I'd like to check the function of other muscles like a trapezius. And let's say, in case the want to go for surgery and check the formal assessment of the function of the rotator cuff as well, and like to check the movement in terms of how much flexion, extension, rotation and abduction.
Well, component of the war component of the rotator cuff, would you be particularly interested in? It's the external rotation and external rotation. And how are you how do you assess external rotation? So it's merely in flexor-pronator and there is minus. So there are two ways. One is putting by the side and asking them to rotate against the force.
One yes, it's the Hornblower sign. OK? reduction and then external rotation the shoulder. And how did they go between those two? How so take it home design, which which rotator cuff muscle are you particularly assessing with those 416 flexor-pronator? I'm sorry that it's minor for the Hornblower site and the tenodesis for external rotation.
And by the side of the arm then asking for external rotation. OK very, very good. What are you going to offer her? OK, so 75-year-old woman, she's got some shoulder pain actually functions quite reasonably well preserved. What what treatment are you going to offer her to ask what she had until now, whether she had tried any physiotherapy, any injections, steroid or hyaluronic acid, and what effect she got with that?
And if it is not much effect, then most likely she is heading to have a reverse shoulder replacement because the UN actually seems to be quite hydrating. So I'm suspecting there will not be any rotator cuff for. To support the anatomical shoulder replacement. OK, that would be in five minutes. That would be 5 minutes. OK all right.
Well, let's because we're getting a bit late. Well, I'll stop you there, AJ I think you did that really well. So when you're I think when you're asked to explain what sort of history you take, you've got to the sort of three components really to the history taking is you've got to elicit their symptoms and how much pain they're in.
Um, you've got to work out how much dysfunction they have and that, you know, that's very important to ask things like hand dominance, who's at home with them? Are they by themselves if they got a partner or children or who helped them get by? And then the second matter is, is you're sort of when you see an X-ray like this, you're sort of thinking, OK, I think this patient might need a shoulder replacement then.
So then your third point is right. Are they a suitable kind of surgery? Are they fit? Are they are they compos mentis? Do they have good condition and they can sort of understand the implications of surgery and deal with the recovery period? So you just make that very. In terms of history taking and their supplies for, you know, whether you're doing a short replacement here, a knee replacement or a hip replacement, you know, just make it very clear that that's what you're trying to elicit from the history.
Well, the other thing I think with this is, is that, you know, clearly this has been going on for a very long time and always sort of make the point of asking whether they've had a previous surgery because they may have had a failed cuff repair previously. You know, that then makes you start thinking, OK, is this potentially an effective joint? I need to consider that prior to doing something like prostheses.
Well I think, again, your examination was very good. Patient like this will interesting actually will probably have quite good function. They have created a perfect acetabulum from there that the underside of their cranium. This is what we call a shoulder hip or a ship joint, and you wouldn't if you became pseudo paralytic as soon as you.
And my great still ahead superbly is unlikely you would have been able to do this to the acetabulum, so they've cleared it. This patient's clearly retrain their deltoid and is actually probably got reasonably good elevation. And I suspect they've presented now because although they've got a reasonable range of movement, they're sore because everything arthritic and there's nothing. So, you know, just to say that, you know, be that the patient has to protect range of movement or they've maintained good, good function.
This varies hugely between people, and it often varies depending on how good a physiotherapist they've seen as well. The other thing to mention on. Uh, en observation is look for a bicycle. Look at that biceps, they may work, she may. She may well have ruptured her biceps, or she may have a Popeye sign, as well as the waist rotator cuff musculature and make a real fuss about how you would examine external rotation.
You quite rightly said it's unlikely that maybe they can't get into a position to do a horn blows, but I would. I would put that elbows into the side, accelerated their hands manually and ask them to hold it there. And if often what happens, I show you my video is that they have reasonable passive range of. But as soon as you let go of the hand, the hand just flops around across their tummy that tells you that they've got really no external protectors.
Very good. Well done. This is a 65-year-old retired accountant, as I say, a retired lawyer, and he has had primary over his shoulder joint for the last. Five years, which has been managed reasonably successfully with steroid injections, but he is now struggling and the steroid injections.
Can you just tell me how you would counsel him for having a shoulder replacement? Go through the consent process, take, take, take us through the consent process for and for a shoulder replacement came to the patient, but there are different treatment options which are injections, physiotherapy and probably all treatment has failed.
Now So the other option is the surgery in which we replace the joint. And I will show him the probably a picture as well or X-ray as well, and that it will be we will change the head and replace them and the side. There are some risks involved as well. The one is the first is infection.
There will be a scar. His pain will improve. But I can't guarantee that how much range of movement he will get for that. And then there is a risk of nerve injuries because we will be operating very near to the neurovascular, state and neurovascular bundle. The other thing is that which nerve is most likely to be injured if that?
Exhilarated, you say no. Yeah, OK. Yeah, we know. And also that this may get in later. This may get few news as well, and he may need another surgery as well. OK um, any other complications you can think of. And also it can also dislocate as well.
Anything else? Right OK, fine and OK, so you're now in theater with the patient on the table. He's he's asleep and prepped, ready to go. Just what approach would you use for Anton shoulder replacement and just tell me how you would do the approach? I used, the better approach. The Allen, the patient will be in a slightly proper position by land, but will be the coracoid process, and I will go laterally deltoid tuberosity after taking the skin subcutaneous tissue.
I will look for the fat to see the cephalic vein. I will let a light movie mobilize it laterally towards the deltoid. I may have to get some tributaries and I will make my way with the finger, with between the deltoid and the major, and then I will dissect the Delta fascia and that subscapularis. I have to.
I would like to preserve the subscapularis, so I will take the lesser tuberosity with the subscapularis and expose the head and. Uh, what would be the landmarks for telling you where the subscapularis is because you, you go in, there's a lot of inflammatory tissue around.
It's all a bit scarred up because of the arthritis. I would look biceps biceps long ahead of biceps because it will be between the lesser and greater tuberosity and lesser tuberosity will be a OK and a thing in feroli, which tells you the inferior border of the subscapularis. That's the. Inferior border of subscapularis.
Yeah, the I will just go to the Petrulis major in session. OK, all right. Fine OK. And that's fine. All right. Well, I think we'll probably stop there with that one. That that was good. Is that five minutes?
That was good, Mohammed. I think the key with if you ask consent form is or go through the consent process, you've got to keep a couple of things in mind. You've got to keep the idea of shared decision making. OK and I can't remember what it's called now, the Montgomery ruling. Oh, Yes. So you've got to make sure that the patient is fully aware of that.
A shoulder replacement is not going to save their life, but it will change their life. So you you must always consent them in a way that they feel like they are being empowered to. They're given all the information about the operation and the outcome, the recovery, that sort of thing and that.
They are then allowed, they are then able to go ahead and make a decision based on that information. So, you know, you got all the right complications. Maybe it could be a bit more fluent, you know, but you need to say, OK, so we're going to do a shoulder replacement. We can do a shorter placement on you. If we don't have a shoulder replacement, you're probably going to continue to get pain and loss of function, which might get worse over a period of time.
We can continue to manage that as best we can with the combination of oral analgesia, injections and possibly physiotherapy. But with a shoulder replacement. It you will come into a hospital, you it will be inpatient care. You will stay in hospital for two or three days afterwards, your arm will be in the sling. It will take you six months, so it will take you six weeks to regain reasonable day to day function.
Your shoulder will continue to improve for up to a year. 90% of patients who have this operation are very happy with the outcome. The other 10% either have a problem, which is amenable, maybe between. Two and 4% of patients who have this operation are probably no better or slightly worse than they were before the operation. That way you have demonstrated the examiner that you have you've been through that modern consent process to just just, you know, again, these are generic skills they apply to consenting for any, any operation.
And you don't have to. Um, you know, design is not going to pick you up on not being exact on the timeline, but you just need to go through not just reading out the complications, which is what we used to do. But you need to give them painting them the whole picture of what the process of coming into was to have the operation is in the recovery period.
The that's a picture approach, very good. The skin incision centered on the coracoid, you quite rightly identify the vein and retracted it laterally. After that, it becomes, you know, you can start to tell who's done this procedure more recently and who hasn't. But just have a look at it, maybe in hop and failed or another sort of operative manual.
When you go through the superficial muscle adult deltoid and major, you know, talk about identifying the coracoid and the conjoined tendon. You go to the conjoined tendon you want to get retractor underneath the conjoined tendon that actually protects the break or practice, actually, if you retract, if you tried over the tendon, you tend to stretch out the brake or bit.
You would say. You can also add components like I will put stitches in subscapularis before I release it, so I don't lose it into under the conjoined tendon. And you, as you said, you use the bicep to groove is the most important landmark when you're doing the approach to the shoulder because that it's very easy to find because you see major inserting just lateral foot, the inferior border of subscapularis if you heard of the three sisters.
The so these are three blood vessels that run along the bottom of subscapularis, and they're the second vessels. And they indicate the board of subscapularis. And they usually you need to tie them off or diethylamide them before you, before you divide them. Otherwise they blew it up. So, yeah, I would just have a little bit more try, you know, when you're asking technique or is try and describe it as though you've done it lots of times in practice, you know, in the exam situation, it's more difficult, but this sort of little bits you can add which sort of customized, personalized.
We get. Mr tell me what you can see on this. Veto so this is a clinical photograph showing patients left arm, which is showing a pharmacist on the medial aspect of the elbow with a muscle bulge in the superior aspect, probably showing a reversible sign. Great good.
OK, so this is a 35-year-old plumber who was trying to stop a heavy object was falling off a table. What would you like to ask him about in the history? So well, the again, the mode of injury, as you said, he was a mechanism to again, he was his hand dominance.
And I then would explain to him that the most and then examine him and confirm the diagnosis of a by distal biceps tendon rupture by performing the test. OK all right. What are you going to do? How are you going to cancel him for the treatment going forward? So I would explain to him that the options going forward are to do nothing and do some physiotherapy and let it heal by itself, or the other option is to treat it by an operation.
The conservative treatment is likely to lead to loss of about 30% of the biceps and maybe more, whereas in the operative option. Can you expand a bit on loss of bisects function? What do you mean by that? So the main functions of the biceps is it is a strong supernatural, the forearm in flexion of the forearm. And so that's the main function.
Loss to the flexion strength is lost to lesser extent, but the Super strength is largely lost if we treat it conservatively because the tendon will not heal in the right position, whereas the function is more likely to recover with an operation where we attach the tendon through a drill hole in the radius at epimysium tuberosity. There is still the operation are again like any other operation infection.
Mainly largely, but there's lots of nerves that travel around here, and the lateral cutaneous nerve of before, yeah, is at risk here, and I think at least 10% of the patients get that, but it recovers later on in my book is more which ulnar nerve is at risk. Um, well, during the dissection of the tendon, the median nerve is at rest when we are fishing the tendon from the Super part of the incision.
What about what? And the other one, which is more at risk when you're reinserting the tendon into the radius? probably entering process. OK what are the complications from surgery? And so again, there is like any other tendon repair, the risk of the repair failing and reduction risk. And apart from that, there is a risk of.
And the risk of stiffness or reduction in the loss of function. And not able to get the full strength. So you say stiffness, what might cause stiffness around the elbow with this sort of operation? The sometimes if when we the patient present late and we are beyond two weeks, it's difficult to suture the tendon back. So we have to flex the elbow to get it, get the tendon to the bicycle tuberosity.
In which case then we keep them in flexion for some weeks and then gradually stretch them out. Have you done a repair? I was just in a few partly done one, but you know, how would you repair the tendon back into the bone? Would you reattach the end the bone? So we use the single insurgent technique from anteriorly, we subpoenaed the Fort Lee and then make a hole to different diameter holes and then pasando button and flip it.
We stand. Yeah, that's five minutes. Brilliant yeah, you did that, very well done. Yeah I mean, quite rightly so. I gave you the information about his occupation. You are straight away about hand dominance. The key, I think you said biceps function will be reduced. Actually, you don't tend to lose very much flex and strength at all because breaking loose compensates.
And you've got the other part that you want to just head straight for the loss of supination you lose about. You lose between 50% and 70% of supination strength. And that's the problem with these guys who do manual jobs using screwdriver, that sort of thing. If you lose supination strength that it can be very disabling, quite right on good goods, on the complications that the nerve that can get injured as posterior interruptus nerve as you usually as you pass the undo button, you have to pass a passing pin through the hole in the radius and out through the dorsum of the forearm and you can catch the posterior nerve that way.
OK, so I didn't know and the complication actually more with to the old fashioned two incision Boyd Anderson technique was the formation of who just keep that in mind as part of your. But you know, you would have scored pretty high with that. I think you did that very fluently well. Thank you. We get.
OK I think I might have questions now over to you guys, right? Fantastic thank you very much, Mr Barry. Yeah so I think it's 9 o'clock now. So I know there are people coming out of the fast. So if people need to go and go and eat it, probably time to bring this to a close. There's a really grateful for a fantastic talk tonight.
Apple admits it has come up quite a lot in the exam, so and this obviously this talk is going to be on our website, the fastest mentor YouTube channel and the OK, so please, please look at refresh yourself with it beforehand. Again, we've approaches. There's lots of delta. Proactive approach is a really important approach. Very a very favored one with examiners, particularly the vyver and the basic science, because it can go one of two ways.
You can even ask you how to approach a funeral microfracture or doing an anatomical shoulder. So there are subtle ways to know who's done it and who hasn't done it. And there are certainly videos out. If you haven't seen it, appreciate somebody as difficult to go and see it. If you haven't had a chance to do enough for them, job the fantastic talks on YouTube of how to do all sorts of different approaches.
So I reading unfold is one way of doing it. But if you have a very visual brain, it's always good to have a look and see how someone's done it online. I know Mr. van rensburg, who has talked to us before, has got fantastic video on YouTube for it, so I recommend having a look at those. Again, zain, thank you very much for everyone coming today.
Appreciate a lot of people results today as well, so fingers crossed people had a good have were successful. Otherwise, we're here to support you and get you through this. So don't worry. OK so without further ado, we'll say goodbye and wish everyone a good night. All right, any. McCabe by good luck, everyone.
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