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Name:
Reverse Shoulder Arthroplasty for Postgraduate Orthopaedic Exams
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Reverse Shoulder Arthroplasty for Postgraduate Orthopaedic Exams
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Evening, everyone, welcome to this evening's webinar on reverse showed total shoulder replacement by Professor EMOM. I'm sure it's going to be a very good topic for us all to learn about, and it'll be really important for your farke's exams. So the order of this evening is that we've started slightly earlier and we're going to finish at 730.
So this evening we probably won't get around to doing any fibers, but we're going to have a very interesting talk, followed by some questions from the audience, and we'll try and answer what we can. If anybody Mrs. the recording or part of it, then it will be available on our YouTube channel in a couple of days. So don't panic. You can watch it again.
So what I'll do is I'll hand over to Professor EMOM for the lecture. Thank you very much. Thank you very much, Nikki, and thank you, everyone for attending. It's a pleasure to be here. You know, and it's really impressive what the effort is meant to have provided for thousands and thousands of persuading surgeons globally.
I'm going to talk, you know, week I can talk about the vessel, the replacements for a few hours, but you know, I can try to summarize it into 40 minutes. I'm going to talk about concepts, concepts, innovations, history, biomechanics and complications of reversal. The replacement is a very important topic. I was asked the topic in my exam many years ago. It's now becoming very common, and the complications also has become common.
Complications have become common as well because of what we've been doing because we are doing more and more of this. So the reverse trend in this stroke, what I'm planning to do is actually a few answers. What we need to know what is the evidence, concepts, indications, complications, technical problems? I had actually maybe in the next talk, we can talk about prevention of complications.
And so but that might be not suitable at this time point. We all are seeing a lot of reverses in all our hospitals. It became a common procedure done everywhere. And what really matters to hospitals is different. What what really matters to managers, to consultants, to registrars, to companies trying to sell their implants and what we'll try to focus today on what actually is needed for your exam?
Tensile forces exam or an exit exam? There are stuff that we're going to go through that might be beyond the scope of the exam, but it's good to know you can skip it if you're not interested into that. A key concept. The what's really important for the exam is to understand the biomechanics of shoulder replacement.
It's actually there is a paper by Mason maths, and it's all about the mechanics of shoulder replacement it describing it in the pillar pillar whole concept, which has been highlighting the important aspects that we all should be thinking of while talking about this. So a key concept describing the mechanics of the normal shoulder is the concavity compression concept.
So in general, medicine itself describes this concept as a pole sitting in the concavity of a table. So the greater the depth, the connectivity, the greater are displacing force must be to dislodge that pole for a given compressive load. So in the normal shoulder, the rotator cuff muscles provides a compressive load. I'll show you a picture later, and this is close to rotator cuff deficient shoulders, leading to instability because there is unbalanced muscle forces in the glenohumeral joint.
Another important aspect here, also, which we have to understand fully is in the normal, which also was highlighted by Maxim and slap, it is the concept of the glenoid center line. So in a normal, you know, it's the same line as you can see in this picture represent. A line will be declared to the articular surface of the glenoid and directed, on average, approximately 10 degrees posterior.
So that reversion to the plane of the scapula like what you can see in an and so this center actually serves the centerline, serves as the pillar under which the humeral head rests so gleaming. Humeral and kapilow thoracic motion are coupled to maintain the center line beneath the humeral head throughout the full range of motion. However, in rotator cuff deficient shoulders, this unbalanced muscular forces were mentioned earlier, the slap relationship and the mechanical alteration can lead to pathologic wear patterns on the glenoid.
That's why you keep hearing shoulder surgeons talking about superior, inferior, anterior posterior, all global wear. So when you're doing a shoulder replacement, sadly no component should be placed alongside its center line. However, in some cases with bone loss, these components. A component placement in this plan is almost impossible. So in these cases, a stable base plate fixation can only be achieved by replacing the component along the alternate Illinois centre, as you can see.
Another important aspect as well, which describes this problem, is. There is actually looking at normal shoulder by mechanics, so if you see here in a curve official shoulder, there is the concept of impingement because the humeral head has displaced superior. And so you have what we call acetyl polarization. So the greater tuberosity and the chromium impinge together and lead to a chromium erosion or a stabilization.
So in patients who have lost the dynamic stabilizers of the rotator cuff muscle, the humeral head migrates superior and leads to abutment underneath the acromion. In these cases, using a fixed fulcrum, processes like a reverse shoulder replacement is the only option and can neutralize that dynamic instability. So because of what you because of the proximal migration here?
So with rotator cuff or thrombosis, that most well known classification, if you want to cite the classification in the exam, is the hamida class. The classification and classification is straightforward and easy. So it looks as a colonial distance in this one and 2 6 millimeter above and 6 millimeter below makes grade 1 and 2.
If you have access to liberalisation, that's grade 3. If you have narrowing of the given humoral joint, as you can see, that's great for. And there are two forms of date for and for b, and when you have collapsed, it will be grade 5. So if you want to cite evidence in the exam while having a case of rotator cuff arthroplasty, I think that's an easy classification to use if you want to.
So what happened here? You know, these patients are now more common. We see them all the time. This is a classic picture of rotator cuff axilo. See, you can see the stabilization, similar disruption of what is a similar position to line and hips. And this patient obviously will have pseudo paralysis and market limitation in movement.
What we should understand is this diagram, which is really an important diagram. The wide spectrum of disease that can be seen in rotator cuff or obasi, ranging from stability to instability to arthritis, and that happens over time. So when you see these patients, it's really crucial if you're seeing someone in a reverse situation or in a clinical situation, it's important to demonstrate your school is your thought process.
So but before we go into that, I'm going to briefly discuss the history of reversal, the replacement. So actually, the first one who introduced such implants is Charles near. However, the problem he had is that in these patients where there is deficient cost, there was high failure rate because the cuff was deficient. When the near prosthesis was used in patients with proper, intact functional cuff, they had good.
He had good outcomes. And what happened and then things developed over the years and surgeons started to realize the main aspect here is to achieve a stable center of rotation and that has developed over the years. As you can see in this video, actually, the first shoulder are supposed to, interestingly, was performed in 1993 by a French surgeon.
All surgeons. And over the years, surgeons were thinking of different concepts similar to the reverse shoulder replacement. They were looking at the, of course, learning from the most successful replacement we had, which is the hip replacement and trying to reproduce that. But the main problem of all these replacements, you can see interesting pictures here.
The main aim of all these replacements at the time was to have a stabilized center of rotation, but all failed because of the excessive torque and shared forces of the component bone interface. It was up to the man, the man who had no one has. Made a huge difference in shoulder surgery as much as Grumman. So Professor Boyle, Murray Drummond directed to engineers and a study in aiming at achieving the stabilized center of rotation.
He aimed for medial center of the utilization of the humerus, so that ultimately would decrease the shear forces on the glenoid component bone interface, improving the greater improving the lever arm of the deltoid, putting the deltoid at a superior biomechanical position in order to be able to move the shoulder without the need of intact tendons. And that was the first components by grumman, and this component has.
And if you can look here, all the principals government was aiming at by idealizing the center of rotation, so they're increasing the lever arm, if you look at this diagram, you can see this is a center of rotation here. The deltoid cannot function in that position. But when you meet the allies, the center of rotation and the stylized the center of rotation, you improve the lives of almost the glenoid.
Theoretically, he aimed the problem we had with the previous designs is you increase the share forces at the glenoid base plate, but by may, by idealizing the center of rotation. That thing has been better and that was in 1984. And so if you want to do a liver, if you want to do a diagram explicit in this, you can find that very clear here. Now we are actually doing more and more reverse shoulder replacements.
The main indication still covered obasi, but we can do it with for a cuff repairs, complex femur fractures, inflammatory arthritis failed, also blasted tumor surgery. It is the main revision option for any pain. Most failed proximal humeral surgeries. So these are what we see in patients with rotator cuff or obasi. You can see the federalisation here.
You can see the stabilization of the acromion in this classic presentation to one of the patients. So it is used for fractures. We and there are a lot of evidence supporting the use of reversal, the replacement. We looked at the reversal, the replacement for the younger than 60 years old as the revision procedure, which is a paper from Zurich. I was contributing to that.
One And we found that actually, if that's what have driven some surgeons now for doing primary versus, as you can see in a lot of places you're working in because of the increased complication rate in young patients with failed proximal fixation. You can see drastic pictures and the big failures there. So what are the contraindications? These are the general contraindications for reversal.
The replacement, the two absolute contraindication here would be deltoid deficiency and active infection. I would say active infection is the main one because with deltoid deficiency, there are surgeons doing tendon transfers and other associate the other simultaneous procedures in order to overcome the deltoid deficiency in cases with four of undertaking a reverse shoulder replacement. So in the exam, always be systematic.
History is all about clinical suspicion, asking about absolute contraindication, the likely concept of diagnostic clusters as proposed by the upper limb unit and writing to probable diagnosis. You have to include history, examination and investigation and special tests. With imaging, it's crucial to understand the pathology. It's really important to what we tend to do for all of them.
A CT scan. I do that. I tend to actually we have to. With CT scan, I'm looking at the bone stock. That's what you should highlight. We're looking at the version and we are looking at the bone loss because that dictates your treatment because you should be fully ready for these patients. This is a technique which is we proved it is more accurate in defining the glenoid version, and it's crucial to understand what type of glenoid and that's what you show in your exam if you are discussing in details.
And, of course, MRI not usually needed unless there is an indication for that. Nowadays, we have preoperative planning options, which enables us to understand where to put our components. We have a lot of tricks and how that would help. And this might not need that for the exam. So which approach to use? It's really important to understand which approach to use.
You know, if you ask me, what is the approach, I'm likely going to be asked in an effort as exam. It's possibly the data vector approach, and this is my preferred approach. You can be at the fully dedicated surgeon just doing the deal spectral approach. It is a versatile approach which you can extend and actually what I. What I would like to highlight to all of you here, whenever you're describing approaches, this is a little too big.
I'm not going to go through different bits of the Delta pectoral approach, but try to speak as if you yourself have done the operation before. Try not to say what you've seen in the books. Imagine you are telling a story or describing an approach to someone over the phone. I use phrases like I center my to better approach incision on the pectoral posture. I'll do my approach slightly lateral to the coracoid because there is evidence that this will enable me to have better access to the glenoid.
I often see I often release a person under Mr deltoid. Muscle identifies the cephalic vein. So if you keep telling this story all the time, you will make the examiner entertain while giving also the bits in between. Your description of every surgical approach should begin with a brief gambit on preparing the patient for surgery like, you know, having prepared and consulted the patient for the Senator.
I will do so. And so it sounds better to phrase it like that than go through every preoperative step verbatim like that. If the examiner wants to probe you on this, he or she will otherwise need to offer it up to you. So you must not forget to mention this. What's really crucial now? Our technical board, as you can see in the video, it's really important here to release the subscapularis.
If you're describing the Delta deltopectoral approach for a case of fracture, you don't do subscapularis tenotomy. You actually can go through the tuberosity the fracture because there is no need to do the tenotomy and actually in the exam, you might miss that, but it will make you look better and look more succinct and actually look more experienced while describing it that way.
And you can always mention landmarks and help to avoid the critical steps for if and you know, there are technical bits. So if you see someone with a fracture for fracture in the trauma situation and you want to operate to an eventual replacement, you can describe how I will position the patient on a beach chair. I'll take X-rays before I put on the drapes.
These are the things that would make you stand proud among your peers, which is actually what you should be aiming for. If you know something well, you should be aiming to achieve as much as you want. Here you can see the release of the labrum, and that's actually the delivery of the head with the reverse shoulder replacement. It's always for fractures.
It is always important to preserve the tuberosity. This is a very good exposure. And this is the head of biceps for exam purposes. I don't think you will need to go that far. So what I would and this is all, of course, preparing the glenoid. So what happened over the years since the Tremont design, although we said it is a more stabilized center of rotation, this was associated with problems.
This includes a marching rotation and stability, and limb lengthening and notching has always been a problem with reverses, and we're going to discuss it in details and stability has been reported to be as high as 30% in sacrament. Earlier designs are lengthening because of mythologizing and the stylizing. The components have also been a problem.
And then, frankly, surgeon in the US has popularized the concept of lateral. This might be beyond this might be beyond the exam, but it's good to know. Collateralization now we try to achieve. You can achieve localization either through on the glenoid side or the humoral side. And for both, you can either do it using bone grafts or metallic graft.
As you can see, this is by order, say, on the left side. So collateralization can be achieved through few things by reducing the neck shaft angle by using a curved stem and eccentric tray. This will enable you to achieve humoral sterilization glenoid collateralization either by you or say, or the biologic type or the metallic type. So we have different options, different components. What do you do for each of these?
Actually, more and more components are there now, but we have to understand the. Behind each of these and what you expect to achieve behind get annoyed and human and. As for anything else, there is no right answer. There is wrong answers. But the advantage of naturalization through the glenoid is that you can have less launching. You can achieve better rotation, you can achieve better shoulder control and less stability, but you will have reduced abduction and there is increased risk of glenoid losing.
The advantage of going on the humoral side is actually you are going to achieve better rotation. Still, less lengthening on guns are less notching better shoulder contusion while its disadvantages. This is also not associated with reduced abduction, so having the medial center of rotation will enable you to have better abduction. So what do we do?
So now we're going into the next few. In the next few minutes, I'm going to go through complications. I think there is an option now, especially with more and more shoulder replacement we're doing. You might have a scenario with the shoulder, complete with a reverse complication or not, but we'll go through it quickly. Complications initially reported to be high, and here it was mentioned that it is as high as 15% in this paper.
However, looking in depth on the application published in 2006, 3/4 of the 7,000 total shoulder surgery performed annually by surgeons who would do two or less a year. So actually, that's a huge limitation. And now we are. We think we're achieving better outcomes and less complication rates. There are complications for all types of stroke that are so bloody and there will be specific complications for each of the main shoulders.
Plus this, we use. All of them will have the common complications of infection, hematoma, losing type dysfunction, stability, fraction, nerve injury and all these. But for anatomic and hermes, the main complications that you should warn your patients and you as a surgeon should be aware is rotator cuff dysfunction. And of course, you will not lose. The anatomic showed the replacements.
Now there is an increased consensus of just doing a reverse for someone above the age of 75 because we know that the risk of the curve being dysfunctional is high. And so if you do, an anatomic showed the replacement for someone where you can see an intact cuff doesn't mean that the cuff is a cuff is fully functional, and that's it.
And also, there is risk that it will fail in a year, two or three years time. So why not go with the reverse immediately? For me, it is. Of course, we tend not to do him more now. But unless, of course, younger patients, there is other options like zero-carbon heads and stuff like that can help decrease the specific complication of glenoid erosion for reverses.
I'm going to go through the complications and tips and tricks in order to avoid them, which we'll go through them quickly. For the purpose of the exam notching, we looked at 259 patients. We found these are the complications in this multicenter trials. And of course, the main complication all of us would be worried about is infection, and having a scenario with an infected shoulder replacement is also something that you should be ready for.
We know from the evidence by Professor Gerber's the primary anatomic have 1% infection rate, while reverse has 5% Actually, you know, a good question. Should be asking yourself now is why reversers has a more complicated infection rates. Many reasons for that, possibly because these are older patients. They have large dead space.
There is absence of living soft tissue covers such as the rotator cuff. And another thing that was found in previous evidence is that multiple previous surgeries has been a risk factor for having an infection in any joint replacement. And the chances of you having multiple surgeries before a reversal to replacement is really high. The are the commonest organism B I can stay exclusive for shoulders.
The tricky part of diagnosis an infection in a shoulder replacement is this paper in 2006, and I remember every time I see someone who's always had shoulder replacement that appears to be infected. And I'm worried about. Fiction here, which is basically they have no mercy. 75 percent, they can have normal ESR and 86% normal life, there can be 93% while having an active infection going there.
So it is a clinical diagnosis with high suspicion, and that's something you should always bear in mind whenever you are facing with one of these patients, and this is strong evidence to cite in the exam. So what type of infection is there for acute infections? We can manage them by antibiotic. If you have infection, if you're doing a revision and that is infection, then while you're doing a shoulder replacement, you can do organism specific antibiotics and clinical observation.
If you have it in the first 30 days, we can still do the date approach by pathetic retention, just changing of the insert. If it is more than 30 days, you can still manage it as type two, or you can manage it as a two stage revision. If it is type for chronic infection more than a year, then two stage division. We looked at outcomes of 48 patients with very pathetic infections during my fellowship with Christian Gerber, and we found that using antibiotic loaded cements, Faisal provided successful infection rate in patients with this and with this in 90% of the time, and that has been now the most common approach of managing these.
We for the functional improvement. After doing a second stage using a reversal, the replacement has been observed and it is significantly higher than that after hemi or Simmons pacer used, definitely definitively. So what about notching what is not saying? I know all of you, if you're not doing a lot of shoulders, you hit the word notching all the time it does not think is actually a mechanical impingement between the Super medial aspect of the insert in the humoral side.
With the inferior scapula neck, you can see it better in this cadaveric video. So that's where notching is happening. So why not change is a big thing, and we keep mentioning it in all also classes of the old reverse shoulder replacement. It has been popularized and picked up by servo in 2004, and grading they proposed is a pretty easy.
So you have notching great one is here. Great two is actually when the launching is in contact with the lower screw grades, 3 is above the lower screw and grateful is under baseplate and obviously in great for this, there is the risk of market baseplate loosening, so it has been observed in graffman type to be as common as 88% In our study, we found it to be 35% in a multilateral system.
Does it make a difference? In our study, we didn't find any difference in clinical scores for range of Motion Pictures or range of motion. However, in others, they found that it continues to worsen and there is negative outcomes, and you can see that. Notion has been observed to progress over the years, and it has and looking at the clinical evidence, it is actually debatable.
So some mention it's not. There is no influence. Others mentioned there is negative influence on long term. So does it affect the outcome of shoulder replacements weed? The answer is we're not sure. So we need, as anything else, more research, but how can we prevent more change? I'll go through that quickly.
One thing you can do to prevent notching is to when you're positioning your sphere. You should position a bit inferior, because that will result in a less mechanical impingement between the Super medial aspect of the base plate with the inferior bit of the scapula and that will increase arc of movement. So that's also something we tend to do all the time now. Another thing I tend to do, which is recommended, is instead of putting your base plate like that, you do a bit of inferior tilt and that will prevent mulching.
Further, avoid excessive reaming because you are over idealizing the glenoid and finally implant choice. We have different options, like using bone grafts or using metal cups. The other things that you can use actually is use the central lateral center of rotation. You can increase the size of the green sphere. You can decrease the neck shaft angle when you're doing the procedure, you can see here when you use a lower shaft angle like 140 five, you're actually increasing the range of motion as per the study.
You can always decrease the cup depth because also that will prevent noshing use. Eccentric, gleaming spheres angled insert has been proposed by some, so including gold, these options altogether can ultimately lead to decreased notching. If you really worried about it when we actually are worried about it, because think about it, if you keep having noshing for long years, the grading will increase up there and can ultimately lead to unstable base plate.
So what about the stability? Stability has been a big thing with sacrament. It is common in anatomy, shoulder replacement, but in the end, sorry and reverses as well. It has been highlighted to be up to 30% in some reports, as mentioned earlier. And if you have someone with instability in the exam, like everything else, there are patients surgical and design related factors, patient related factors.
It's also had multiple surgeries the portal dysfunction compliance of patients, patients who are recurrent fallers epileptics. Should surgical related factors is also an important aspect, we tend not to blame ourselves as surgeons, but approach has been mentioned to be causing that. But we'll go through that as well. If you have moral discrepancy, malversation of the humoral components can cause as well.
Having a hematoma is a risk factor for instability as well. And of course, you have to maintain that tension. There are some reports saying that lateral approach might be associated with less stability. Having said that in deltopectoral approach, preservation of the subgame and having a superior approach as preservation of subset can help. Also, I think this approach is not really a great factor, as the Delta vector is the main approach for many shoulder surgeons.
Instability also, the surgical factors include humourless discrepancies, as I've mentioned, and you can see that you can risk placing the human component too low. So if you have a human loss, bone loss. And there is a high risk of having a dislocation there. And it's really important to understand this in fracture cases, which is somehow a bit more challenging and the Division of cases, while positioning of the components, all shoulder surgeons would aim for 0 to 20 degrees of electro version when applying a shoulder replacement.
There are a lot of surgical factors. Here is preservation of the soft tissue envelope, which is a surgical, important surgical aspect. In every surgery we do deltoid tension, you have to maintain the tension and that can be achieved by increased lateral offset design related factors, as we mentioned earlier. There are the designs can be associated with him with instability as well.
So how do you manage instability? If you see someone who's coming to your clinic or in the exam with instability, you have to assess the nerves and muscles. It's crucial. You have to do CT scans to rule out structural abnormalities like fracture, notching base plate fixation, failure component, muscle position and you have to exclude hematoma and infection preventionist crucial as well.
We wrote about the lateral thrust and the lateral flow test. These are the tests I would use when I'm doing a reversal, the replacement to make sure we can. We have a stable processes in place. So if you're shown an X-ray of a dislocated shoulder vessel, the replacement, I would opt for close the deduction under anesthesia and follow up with by 6 weeks of immobilization.
We have to investigate further and possibly you might have to exclude infection at all times. You have to identify from all the factors we mentioned what might be the cause here before opting for revision surgery, you have to understand the reconstruction of soft tissue, human remains discrepancy and the version. And then if you have few lens discrepancy and less than 2 centimeters you can just increase the clean sphere, as you can see in this picture.
Or you can use a bone graft if it is bigger. One important complication that has been cited a lot is baseplate failures. It is. It was very common before, but it's less common now with more modern designs. Common causes include poor initial fixation stabilizes and infection can take several forms, as you can see here. Screw fracture face plate failure with screw fracture dissociation as you can see between the base plate and the glenoid hemisphere.
And for each of these, you have to understand what's going on. You have to prevent a while doing it and then it can be managed accordingly. But this has decreased significantly. I have a whole composite proposal that when you do the inferior tilt of the base plate, you achieve less glenoid failure and you achieve less notching all designs, all modern designs that are using blocking screws.
That's why we're seeing less face plate failures. Of course, single versus two stage revision based on the infection or not. And technical notes can be your management plan. What about prosthetic fractures? It's becoming more and more common. The risk is cited to be as high as 2.8% Now it will. It's actually, I think, very periprosthetic fractures on humerus will be the new pandemic.
We see a weekly peripatetic fractures in the hips and knees. That's because we've done thousands and thousands of hips and knees. Now the fact that we're doing more shoulder replacements everywhere, we are going to see more and more of these right and cofield the 1995 they used a similar classification system to help type A type B at the step and type c, the scale of the fracture.
There is different ways of managing each. Most importantly, when you're doing a shoulder replacement, you have to avoid external forces for external rotation. Excessive reaming you. I personally don't use a tremolo or spider on any of the devices. You have to be extra cautious and careful and. And there are also glenoid fractures in our study, looking at 5 years, if we had for you for a better periprosthetic fracture on the human side to prevent this sort of Lloyd fractures, you have to start dreaming beyond the subculture of bone and start screaming before contact with the bones.
What I would say to prevent it. So what about the. You have different options. You can if you have during doing a shoulder replacement, what we tend to do. We use base plate screws to stabilize the fracture. You can use other screws to stabilize the fracture and then put your base plate on top. You can reorient the central plot into a more robust bone with compression, especially with those with compression centers through a portal.
Noise implantation in tenotomy revised to a reverse at a later date is another option. Are dysfunction can happen 0.1 percent, which is lucky, and this is a catastrophic complication if it happens. Hematoma formation more common in reverse, as I said, because there is bigger space there in reverse. There is. There is usually multiple procedures done before and it is a problem with hematoma formation.
It can ultimately lead to infection. And as I've shown you before. It's hard to diagnose infection and shoulders from clinical aspects. Lots of complications here. Thromboembolic complications less than 1% for DVT and is less than 0.5% There is a lot of advances in shoulder replacement and there is more to come, including virtual reality and machine intelligence.
We have to, you know, if you are having adverse, if you are discussing reverse shoulder replacements, which is a common option now for rotator cuff neuropathy, for fractures and for different scenarios, it would be important, actually, I would ask the and basic sciences clearly, what is the reversal, the replacement and how you do a reversal and about biomechanical aspects. It is important to understand all these for the purpose of the exam.
Sorry for taking long. Remember when you are discussing anything in the exam, your day one consultant, you don't do a procedure for the first time once a day, you say. If you have to discuss something you don't know, say the principles are 1 to 3. If you're a consultant to a weird procedure, having a for hours or doing microfracture or doing code decompression for arthritis, all these procedures are not written in the book, and there is no general consensus.
No one actually care what your boss does. There are a lot of common wrong answers, but there is no right one and common is common here. If you're asked to do. If you asked to discuss the rebels. And you want to draw whenever you can draw, that will make your life easily. If you don't know, say, I don't know and thank you.
Thank you, Professor imaan, that was a very comprehensive lecture with lots and lots of top tips for your exam. I was asked about this in basic sciences as well, so make sure you're quite clear on why you do a resource and the basic mechanics of it. And what happens when you laterals it and things all of that stuff and drawing it is excellent. It just helps focus your mind, and the examiner can see that what you're talking about.
And it also gives you that little second, if you have a bit of a brain freeze because of the exam, then getting your pencil and your bit of paper and starting to draw will Help Center your thoughts a lot as well. Yes, I couldn't agree more. And actually avoid eye contact with the examiner because it is stressful as well. So and you're not rude to looking there and you can use less words.
It's relaxing. You know, in my exam, I've put a lot of stuff, even if there isn't a proper drawing in my mind. Great, thank you. OK, so a question has popped up from panagiotis Merida's and his book why is abduction decreasing when we laterals? So if you realize it's so obnoxious decrees, because actually still with the toyed with the media center of rotation, that deltoid is at a better functional position because they have the center of rotation and you increase the liver almost the deltoid so you can have a better function.
Having said that, even with that last components, you can still have good abduction, but if generally speaking, you'll achieve more abduction with the medial components rather than localized components. OK I hope that answers your question. Are there any more questions, but quite a small group. So if you do have one, you can raise your hand and you can ask yourself if you want to.
Anyone got any? I have question, actually. OK, so in the case of trauma, prof. If, like a patient below 60 years. And there is a comminuted and the approximate humerus fracture, and you decided to do an arthroplasty when you will do him and when you do reverse shoulder, it's an excellent question. And the answer is actually dependent on the patients themselves and the type of the fracture because you know, you can be committed with a reverse shoulder because, you know, it's not very helpful.
If someone is younger and you do a helmet and you, you're not going to achieve significant range of motion. So if someone is 40 years old, I'll definitely it's unlikely I'll be doing a helmet also. Plus the. Sorry, I'll be doing the reverse. I'll be opting more towards a heavy arthroplasty. But in the 50 to 60 age group, I know, and the evidence is quite clear in that regard is reverse is better than heavy.
Also, plus the. In in this group of patients, what's the worst outcome you can achieve in these patients is actually opting for fixation. And you know, that fixation will definitely fail. And then revising it later on, as we've demonstrated in our study offshore. Q, thank you. OK, any final questions before we wrap up this meeting?
No, can't see any hands raised. OK, good. All right, guys, so thank you very much, prof. That was an excellent lecture. And yeah, I certainly, you know, learnt a little bit from that. And yeah, you guys can all watch it again. It'll be available on the website. Usually in a couple of days or so.
Yeah and share with your colleagues because it was excellent. And you know, it's kind of thing you get asked in the exam and it's just been presented really concise and straightforward for you. And if you present it like that in the exam, they're going to go, oh, this guy knows what he's doing. So thank you, everybody. I'll if I can ask all the candidates to leave and the mentors will just say five minutes to do a debrief, and please join us next week for shoulder arthroplasty.
Thank you very much.
Segment:0 .
Evening, everyone, welcome to this evening's webinar on reverse showed total shoulder replacement by Professor EMOM. I'm sure it's going to be a very good topic for us all to learn about, and it'll be really important for your farke's exams. So the order of this evening is that we've started slightly earlier and we're going to finish at 730.
So this evening we probably won't get around to doing any fibers, but we're going to have a very interesting talk, followed by some questions from the audience, and we'll try and answer what we can. If anybody Mrs. the recording or part of it, then it will be available on our YouTube channel in a couple of days. So don't panic. You can watch it again.
So what I'll do is I'll hand over to Professor EMOM for the lecture. Thank you very much. Thank you very much, Nikki, and thank you, everyone for attending. It's a pleasure to be here. You know, and it's really impressive what the effort is meant to have provided for thousands and thousands of persuading surgeons globally.
I'm going to talk, you know, week I can talk about the vessel, the replacements for a few hours, but you know, I can try to summarize it into 40 minutes. I'm going to talk about concepts, concepts, innovations, history, biomechanics and complications of reversal. The replacement is a very important topic. I was asked the topic in my exam many years ago. It's now becoming very common, and the complications also has become common.
Complications have become common as well because of what we've been doing because we are doing more and more of this. So the reverse trend in this stroke, what I'm planning to do is actually a few answers. What we need to know what is the evidence, concepts, indications, complications, technical problems? I had actually maybe in the next talk, we can talk about prevention of complications.
And so but that might be not suitable at this time point. We all are seeing a lot of reverses in all our hospitals. It became a common procedure done everywhere. And what really matters to hospitals is different. What what really matters to managers, to consultants, to registrars, to companies trying to sell their implants and what we'll try to focus today on what actually is needed for your exam?
Tensile forces exam or an exit exam? There are stuff that we're going to go through that might be beyond the scope of the exam, but it's good to know you can skip it if you're not interested into that. A key concept. The what's really important for the exam is to understand the biomechanics of shoulder replacement.
It's actually there is a paper by Mason maths, and it's all about the mechanics of shoulder replacement it describing it in the pillar pillar whole concept, which has been highlighting the important aspects that we all should be thinking of while talking about this. So a key concept describing the mechanics of the normal shoulder is the concavity compression concept.
So in general, medicine itself describes this concept as a pole sitting in the concavity of a table. So the greater the depth, the connectivity, the greater are displacing force must be to dislodge that pole for a given compressive load. So in the normal shoulder, the rotator cuff muscles provides a compressive load. I'll show you a picture later, and this is close to rotator cuff deficient shoulders, leading to instability because there is unbalanced muscle forces in the glenohumeral joint.
Another important aspect here, also, which we have to understand fully is in the normal, which also was highlighted by Maxim and slap, it is the concept of the glenoid center line. So in a normal, you know, it's the same line as you can see in this picture represent. A line will be declared to the articular surface of the glenoid and directed, on average, approximately 10 degrees posterior.
So that reversion to the plane of the scapula like what you can see in an and so this center actually serves the centerline, serves as the pillar under which the humeral head rests so gleaming. Humeral and kapilow thoracic motion are coupled to maintain the center line beneath the humeral head throughout the full range of motion. However, in rotator cuff deficient shoulders, this unbalanced muscular forces were mentioned earlier, the slap relationship and the mechanical alteration can lead to pathologic wear patterns on the glenoid.
That's why you keep hearing shoulder surgeons talking about superior, inferior, anterior posterior, all global wear. So when you're doing a shoulder replacement, sadly no component should be placed alongside its center line. However, in some cases with bone loss, these components. A component placement in this plan is almost impossible. So in these cases, a stable base plate fixation can only be achieved by replacing the component along the alternate Illinois centre, as you can see.
Another important aspect as well, which describes this problem, is. There is actually looking at normal shoulder by mechanics, so if you see here in a curve official shoulder, there is the concept of impingement because the humeral head has displaced superior. And so you have what we call acetyl polarization. So the greater tuberosity and the chromium impinge together and lead to a chromium erosion or a stabilization.
So in patients who have lost the dynamic stabilizers of the rotator cuff muscle, the humeral head migrates superior and leads to abutment underneath the acromion. In these cases, using a fixed fulcrum, processes like a reverse shoulder replacement is the only option and can neutralize that dynamic instability. So because of what you because of the proximal migration here?
So with rotator cuff or thrombosis, that most well known classification, if you want to cite the classification in the exam, is the hamida class. The classification and classification is straightforward and easy. So it looks as a colonial distance in this one and 2 6 millimeter above and 6 millimeter below makes grade 1 and 2.
If you have access to liberalisation, that's grade 3. If you have narrowing of the given humoral joint, as you can see, that's great for. And there are two forms of date for and for b, and when you have collapsed, it will be grade 5. So if you want to cite evidence in the exam while having a case of rotator cuff arthroplasty, I think that's an easy classification to use if you want to.
So what happened here? You know, these patients are now more common. We see them all the time. This is a classic picture of rotator cuff axilo. See, you can see the stabilization, similar disruption of what is a similar position to line and hips. And this patient obviously will have pseudo paralysis and market limitation in movement.
What we should understand is this diagram, which is really an important diagram. The wide spectrum of disease that can be seen in rotator cuff or obasi, ranging from stability to instability to arthritis, and that happens over time. So when you see these patients, it's really crucial if you're seeing someone in a reverse situation or in a clinical situation, it's important to demonstrate your school is your thought process.
So but before we go into that, I'm going to briefly discuss the history of reversal, the replacement. So actually, the first one who introduced such implants is Charles near. However, the problem he had is that in these patients where there is deficient cost, there was high failure rate because the cuff was deficient. When the near prosthesis was used in patients with proper, intact functional cuff, they had good.
He had good outcomes. And what happened and then things developed over the years and surgeons started to realize the main aspect here is to achieve a stable center of rotation and that has developed over the years. As you can see in this video, actually, the first shoulder are supposed to, interestingly, was performed in 1993 by a French surgeon.
All surgeons. And over the years, surgeons were thinking of different concepts similar to the reverse shoulder replacement. They were looking at the, of course, learning from the most successful replacement we had, which is the hip replacement and trying to reproduce that. But the main problem of all these replacements, you can see interesting pictures here.
The main aim of all these replacements at the time was to have a stabilized center of rotation, but all failed because of the excessive torque and shared forces of the component bone interface. It was up to the man, the man who had no one has. Made a huge difference in shoulder surgery as much as Grumman. So Professor Boyle, Murray Drummond directed to engineers and a study in aiming at achieving the stabilized center of rotation.
He aimed for medial center of the utilization of the humerus, so that ultimately would decrease the shear forces on the glenoid component bone interface, improving the greater improving the lever arm of the deltoid, putting the deltoid at a superior biomechanical position in order to be able to move the shoulder without the need of intact tendons. And that was the first components by grumman, and this component has.
And if you can look here, all the principals government was aiming at by idealizing the center of rotation, so they're increasing the lever arm, if you look at this diagram, you can see this is a center of rotation here. The deltoid cannot function in that position. But when you meet the allies, the center of rotation and the stylized the center of rotation, you improve the lives of almost the glenoid.
Theoretically, he aimed the problem we had with the previous designs is you increase the share forces at the glenoid base plate, but by may, by idealizing the center of rotation. That thing has been better and that was in 1984. And so if you want to do a liver, if you want to do a diagram explicit in this, you can find that very clear here. Now we are actually doing more and more reverse shoulder replacements.
The main indication still covered obasi, but we can do it with for a cuff repairs, complex femur fractures, inflammatory arthritis failed, also blasted tumor surgery. It is the main revision option for any pain. Most failed proximal humeral surgeries. So these are what we see in patients with rotator cuff or obasi. You can see the federalisation here.
You can see the stabilization of the acromion in this classic presentation to one of the patients. So it is used for fractures. We and there are a lot of evidence supporting the use of reversal, the replacement. We looked at the reversal, the replacement for the younger than 60 years old as the revision procedure, which is a paper from Zurich. I was contributing to that.
One And we found that actually, if that's what have driven some surgeons now for doing primary versus, as you can see in a lot of places you're working in because of the increased complication rate in young patients with failed proximal fixation. You can see drastic pictures and the big failures there. So what are the contraindications? These are the general contraindications for reversal.
The replacement, the two absolute contraindication here would be deltoid deficiency and active infection. I would say active infection is the main one because with deltoid deficiency, there are surgeons doing tendon transfers and other associate the other simultaneous procedures in order to overcome the deltoid deficiency in cases with four of undertaking a reverse shoulder replacement. So in the exam, always be systematic.
History is all about clinical suspicion, asking about absolute contraindication, the likely concept of diagnostic clusters as proposed by the upper limb unit and writing to probable diagnosis. You have to include history, examination and investigation and special tests. With imaging, it's crucial to understand the pathology. It's really important to what we tend to do for all of them.
A CT scan. I do that. I tend to actually we have to. With CT scan, I'm looking at the bone stock. That's what you should highlight. We're looking at the version and we are looking at the bone loss because that dictates your treatment because you should be fully ready for these patients. This is a technique which is we proved it is more accurate in defining the glenoid version, and it's crucial to understand what type of glenoid and that's what you show in your exam if you are discussing in details.
And, of course, MRI not usually needed unless there is an indication for that. Nowadays, we have preoperative planning options, which enables us to understand where to put our components. We have a lot of tricks and how that would help. And this might not need that for the exam. So which approach to use? It's really important to understand which approach to use.
You know, if you ask me, what is the approach, I'm likely going to be asked in an effort as exam. It's possibly the data vector approach, and this is my preferred approach. You can be at the fully dedicated surgeon just doing the deal spectral approach. It is a versatile approach which you can extend and actually what I. What I would like to highlight to all of you here, whenever you're describing approaches, this is a little too big.
I'm not going to go through different bits of the Delta pectoral approach, but try to speak as if you yourself have done the operation before. Try not to say what you've seen in the books. Imagine you are telling a story or describing an approach to someone over the phone. I use phrases like I center my to better approach incision on the pectoral posture. I'll do my approach slightly lateral to the coracoid because there is evidence that this will enable me to have better access to the glenoid.
I often see I often release a person under Mr deltoid. Muscle identifies the cephalic vein. So if you keep telling this story all the time, you will make the examiner entertain while giving also the bits in between. Your description of every surgical approach should begin with a brief gambit on preparing the patient for surgery like, you know, having prepared and consulted the patient for the Senator.
I will do so. And so it sounds better to phrase it like that than go through every preoperative step verbatim like that. If the examiner wants to probe you on this, he or she will otherwise need to offer it up to you. So you must not forget to mention this. What's really crucial now? Our technical board, as you can see in the video, it's really important here to release the subscapularis.
If you're describing the Delta deltopectoral approach for a case of fracture, you don't do subscapularis tenotomy. You actually can go through the tuberosity the fracture because there is no need to do the tenotomy and actually in the exam, you might miss that, but it will make you look better and look more succinct and actually look more experienced while describing it that way.
And you can always mention landmarks and help to avoid the critical steps for if and you know, there are technical bits. So if you see someone with a fracture for fracture in the trauma situation and you want to operate to an eventual replacement, you can describe how I will position the patient on a beach chair. I'll take X-rays before I put on the drapes.
These are the things that would make you stand proud among your peers, which is actually what you should be aiming for. If you know something well, you should be aiming to achieve as much as you want. Here you can see the release of the labrum, and that's actually the delivery of the head with the reverse shoulder replacement. It's always for fractures.
It is always important to preserve the tuberosity. This is a very good exposure. And this is the head of biceps for exam purposes. I don't think you will need to go that far. So what I would and this is all, of course, preparing the glenoid. So what happened over the years since the Tremont design, although we said it is a more stabilized center of rotation, this was associated with problems.
This includes a marching rotation and stability, and limb lengthening and notching has always been a problem with reverses, and we're going to discuss it in details and stability has been reported to be as high as 30% in sacrament. Earlier designs are lengthening because of mythologizing and the stylizing. The components have also been a problem.
And then, frankly, surgeon in the US has popularized the concept of lateral. This might be beyond this might be beyond the exam, but it's good to know. Collateralization now we try to achieve. You can achieve localization either through on the glenoid side or the humoral side. And for both, you can either do it using bone grafts or metallic graft.
As you can see, this is by order, say, on the left side. So collateralization can be achieved through few things by reducing the neck shaft angle by using a curved stem and eccentric tray. This will enable you to achieve humoral sterilization glenoid collateralization either by you or say, or the biologic type or the metallic type. So we have different options, different components. What do you do for each of these?
Actually, more and more components are there now, but we have to understand the. Behind each of these and what you expect to achieve behind get annoyed and human and. As for anything else, there is no right answer. There is wrong answers. But the advantage of naturalization through the glenoid is that you can have less launching. You can achieve better rotation, you can achieve better shoulder control and less stability, but you will have reduced abduction and there is increased risk of glenoid losing.
The advantage of going on the humoral side is actually you are going to achieve better rotation. Still, less lengthening on guns are less notching better shoulder contusion while its disadvantages. This is also not associated with reduced abduction, so having the medial center of rotation will enable you to have better abduction. So what do we do?
So now we're going into the next few. In the next few minutes, I'm going to go through complications. I think there is an option now, especially with more and more shoulder replacement we're doing. You might have a scenario with the shoulder, complete with a reverse complication or not, but we'll go through it quickly. Complications initially reported to be high, and here it was mentioned that it is as high as 15% in this paper.
However, looking in depth on the application published in 2006, 3/4 of the 7,000 total shoulder surgery performed annually by surgeons who would do two or less a year. So actually, that's a huge limitation. And now we are. We think we're achieving better outcomes and less complication rates. There are complications for all types of stroke that are so bloody and there will be specific complications for each of the main shoulders.
Plus this, we use. All of them will have the common complications of infection, hematoma, losing type dysfunction, stability, fraction, nerve injury and all these. But for anatomic and hermes, the main complications that you should warn your patients and you as a surgeon should be aware is rotator cuff dysfunction. And of course, you will not lose. The anatomic showed the replacements.
Now there is an increased consensus of just doing a reverse for someone above the age of 75 because we know that the risk of the curve being dysfunctional is high. And so if you do, an anatomic showed the replacement for someone where you can see an intact cuff doesn't mean that the cuff is a cuff is fully functional, and that's it.
And also, there is risk that it will fail in a year, two or three years time. So why not go with the reverse immediately? For me, it is. Of course, we tend not to do him more now. But unless, of course, younger patients, there is other options like zero-carbon heads and stuff like that can help decrease the specific complication of glenoid erosion for reverses.
I'm going to go through the complications and tips and tricks in order to avoid them, which we'll go through them quickly. For the purpose of the exam notching, we looked at 259 patients. We found these are the complications in this multicenter trials. And of course, the main complication all of us would be worried about is infection, and having a scenario with an infected shoulder replacement is also something that you should be ready for.
We know from the evidence by Professor Gerber's the primary anatomic have 1% infection rate, while reverse has 5% Actually, you know, a good question. Should be asking yourself now is why reversers has a more complicated infection rates. Many reasons for that, possibly because these are older patients. They have large dead space.
There is absence of living soft tissue covers such as the rotator cuff. And another thing that was found in previous evidence is that multiple previous surgeries has been a risk factor for having an infection in any joint replacement. And the chances of you having multiple surgeries before a reversal to replacement is really high. The are the commonest organism B I can stay exclusive for shoulders.
The tricky part of diagnosis an infection in a shoulder replacement is this paper in 2006, and I remember every time I see someone who's always had shoulder replacement that appears to be infected. And I'm worried about. Fiction here, which is basically they have no mercy. 75 percent, they can have normal ESR and 86% normal life, there can be 93% while having an active infection going there.
So it is a clinical diagnosis with high suspicion, and that's something you should always bear in mind whenever you are facing with one of these patients, and this is strong evidence to cite in the exam. So what type of infection is there for acute infections? We can manage them by antibiotic. If you have infection, if you're doing a revision and that is infection, then while you're doing a shoulder replacement, you can do organism specific antibiotics and clinical observation.
If you have it in the first 30 days, we can still do the date approach by pathetic retention, just changing of the insert. If it is more than 30 days, you can still manage it as type two, or you can manage it as a two stage revision. If it is type for chronic infection more than a year, then two stage division. We looked at outcomes of 48 patients with very pathetic infections during my fellowship with Christian Gerber, and we found that using antibiotic loaded cements, Faisal provided successful infection rate in patients with this and with this in 90% of the time, and that has been now the most common approach of managing these.
We for the functional improvement. After doing a second stage using a reversal, the replacement has been observed and it is significantly higher than that after hemi or Simmons pacer used, definitely definitively. So what about notching what is not saying? I know all of you, if you're not doing a lot of shoulders, you hit the word notching all the time it does not think is actually a mechanical impingement between the Super medial aspect of the insert in the humoral side.
With the inferior scapula neck, you can see it better in this cadaveric video. So that's where notching is happening. So why not change is a big thing, and we keep mentioning it in all also classes of the old reverse shoulder replacement. It has been popularized and picked up by servo in 2004, and grading they proposed is a pretty easy.
So you have notching great one is here. Great two is actually when the launching is in contact with the lower screw grades, 3 is above the lower screw and grateful is under baseplate and obviously in great for this, there is the risk of market baseplate loosening, so it has been observed in graffman type to be as common as 88% In our study, we found it to be 35% in a multilateral system.
Does it make a difference? In our study, we didn't find any difference in clinical scores for range of Motion Pictures or range of motion. However, in others, they found that it continues to worsen and there is negative outcomes, and you can see that. Notion has been observed to progress over the years, and it has and looking at the clinical evidence, it is actually debatable.
So some mention it's not. There is no influence. Others mentioned there is negative influence on long term. So does it affect the outcome of shoulder replacements weed? The answer is we're not sure. So we need, as anything else, more research, but how can we prevent more change? I'll go through that quickly.
One thing you can do to prevent notching is to when you're positioning your sphere. You should position a bit inferior, because that will result in a less mechanical impingement between the Super medial aspect of the base plate with the inferior bit of the scapula and that will increase arc of movement. So that's also something we tend to do all the time now. Another thing I tend to do, which is recommended, is instead of putting your base plate like that, you do a bit of inferior tilt and that will prevent mulching.
Further, avoid excessive reaming because you are over idealizing the glenoid and finally implant choice. We have different options, like using bone grafts or using metal cups. The other things that you can use actually is use the central lateral center of rotation. You can increase the size of the green sphere. You can decrease the neck shaft angle when you're doing the procedure, you can see here when you use a lower shaft angle like 140 five, you're actually increasing the range of motion as per the study.
You can always decrease the cup depth because also that will prevent noshing use. Eccentric, gleaming spheres angled insert has been proposed by some, so including gold, these options altogether can ultimately lead to decreased notching. If you really worried about it when we actually are worried about it, because think about it, if you keep having noshing for long years, the grading will increase up there and can ultimately lead to unstable base plate.
So what about the stability? Stability has been a big thing with sacrament. It is common in anatomy, shoulder replacement, but in the end, sorry and reverses as well. It has been highlighted to be up to 30% in some reports, as mentioned earlier. And if you have someone with instability in the exam, like everything else, there are patients surgical and design related factors, patient related factors.
It's also had multiple surgeries the portal dysfunction compliance of patients, patients who are recurrent fallers epileptics. Should surgical related factors is also an important aspect, we tend not to blame ourselves as surgeons, but approach has been mentioned to be causing that. But we'll go through that as well. If you have moral discrepancy, malversation of the humoral components can cause as well.
Having a hematoma is a risk factor for instability as well. And of course, you have to maintain that tension. There are some reports saying that lateral approach might be associated with less stability. Having said that in deltopectoral approach, preservation of the subgame and having a superior approach as preservation of subset can help. Also, I think this approach is not really a great factor, as the Delta vector is the main approach for many shoulder surgeons.
Instability also, the surgical factors include humourless discrepancies, as I've mentioned, and you can see that you can risk placing the human component too low. So if you have a human loss, bone loss. And there is a high risk of having a dislocation there. And it's really important to understand this in fracture cases, which is somehow a bit more challenging and the Division of cases, while positioning of the components, all shoulder surgeons would aim for 0 to 20 degrees of electro version when applying a shoulder replacement.
There are a lot of surgical factors. Here is preservation of the soft tissue envelope, which is a surgical, important surgical aspect. In every surgery we do deltoid tension, you have to maintain the tension and that can be achieved by increased lateral offset design related factors, as we mentioned earlier. There are the designs can be associated with him with instability as well.
So how do you manage instability? If you see someone who's coming to your clinic or in the exam with instability, you have to assess the nerves and muscles. It's crucial. You have to do CT scans to rule out structural abnormalities like fracture, notching base plate fixation, failure component, muscle position and you have to exclude hematoma and infection preventionist crucial as well.
We wrote about the lateral thrust and the lateral flow test. These are the tests I would use when I'm doing a reversal, the replacement to make sure we can. We have a stable processes in place. So if you're shown an X-ray of a dislocated shoulder vessel, the replacement, I would opt for close the deduction under anesthesia and follow up with by 6 weeks of immobilization.
We have to investigate further and possibly you might have to exclude infection at all times. You have to identify from all the factors we mentioned what might be the cause here before opting for revision surgery, you have to understand the reconstruction of soft tissue, human remains discrepancy and the version. And then if you have few lens discrepancy and less than 2 centimeters you can just increase the clean sphere, as you can see in this picture.
Or you can use a bone graft if it is bigger. One important complication that has been cited a lot is baseplate failures. It is. It was very common before, but it's less common now with more modern designs. Common causes include poor initial fixation stabilizes and infection can take several forms, as you can see here. Screw fracture face plate failure with screw fracture dissociation as you can see between the base plate and the glenoid hemisphere.
And for each of these, you have to understand what's going on. You have to prevent a while doing it and then it can be managed accordingly. But this has decreased significantly. I have a whole composite proposal that when you do the inferior tilt of the base plate, you achieve less glenoid failure and you achieve less notching all designs, all modern designs that are using blocking screws.
That's why we're seeing less face plate failures. Of course, single versus two stage revision based on the infection or not. And technical notes can be your management plan. What about prosthetic fractures? It's becoming more and more common. The risk is cited to be as high as 2.8% Now it will. It's actually, I think, very periprosthetic fractures on humerus will be the new pandemic.
We see a weekly peripatetic fractures in the hips and knees. That's because we've done thousands and thousands of hips and knees. Now the fact that we're doing more shoulder replacements everywhere, we are going to see more and more of these right and cofield the 1995 they used a similar classification system to help type A type B at the step and type c, the scale of the fracture.
There is different ways of managing each. Most importantly, when you're doing a shoulder replacement, you have to avoid external forces for external rotation. Excessive reaming you. I personally don't use a tremolo or spider on any of the devices. You have to be extra cautious and careful and. And there are also glenoid fractures in our study, looking at 5 years, if we had for you for a better periprosthetic fracture on the human side to prevent this sort of Lloyd fractures, you have to start dreaming beyond the subculture of bone and start screaming before contact with the bones.
What I would say to prevent it. So what about the. You have different options. You can if you have during doing a shoulder replacement, what we tend to do. We use base plate screws to stabilize the fracture. You can use other screws to stabilize the fracture and then put your base plate on top. You can reorient the central plot into a more robust bone with compression, especially with those with compression centers through a portal.
Noise implantation in tenotomy revised to a reverse at a later date is another option. Are dysfunction can happen 0.1 percent, which is lucky, and this is a catastrophic complication if it happens. Hematoma formation more common in reverse, as I said, because there is bigger space there in reverse. There is. There is usually multiple procedures done before and it is a problem with hematoma formation.
It can ultimately lead to infection. And as I've shown you before. It's hard to diagnose infection and shoulders from clinical aspects. Lots of complications here. Thromboembolic complications less than 1% for DVT and is less than 0.5% There is a lot of advances in shoulder replacement and there is more to come, including virtual reality and machine intelligence.
We have to, you know, if you are having adverse, if you are discussing reverse shoulder replacements, which is a common option now for rotator cuff neuropathy, for fractures and for different scenarios, it would be important, actually, I would ask the and basic sciences clearly, what is the reversal, the replacement and how you do a reversal and about biomechanical aspects. It is important to understand all these for the purpose of the exam.
Sorry for taking long. Remember when you are discussing anything in the exam, your day one consultant, you don't do a procedure for the first time once a day, you say. If you have to discuss something you don't know, say the principles are 1 to 3. If you're a consultant to a weird procedure, having a for hours or doing microfracture or doing code decompression for arthritis, all these procedures are not written in the book, and there is no general consensus.
No one actually care what your boss does. There are a lot of common wrong answers, but there is no right one and common is common here. If you're asked to do. If you asked to discuss the rebels. And you want to draw whenever you can draw, that will make your life easily. If you don't know, say, I don't know and thank you.
Thank you, Professor imaan, that was a very comprehensive lecture with lots and lots of top tips for your exam. I was asked about this in basic sciences as well, so make sure you're quite clear on why you do a resource and the basic mechanics of it. And what happens when you laterals it and things all of that stuff and drawing it is excellent. It just helps focus your mind, and the examiner can see that what you're talking about.
And it also gives you that little second, if you have a bit of a brain freeze because of the exam, then getting your pencil and your bit of paper and starting to draw will Help Center your thoughts a lot as well. Yes, I couldn't agree more. And actually avoid eye contact with the examiner because it is stressful as well. So and you're not rude to looking there and you can use less words.
It's relaxing. You know, in my exam, I've put a lot of stuff, even if there isn't a proper drawing in my mind. Great, thank you. OK, so a question has popped up from panagiotis Merida's and his book why is abduction decreasing when we laterals? So if you realize it's so obnoxious decrees, because actually still with the toyed with the media center of rotation, that deltoid is at a better functional position because they have the center of rotation and you increase the liver almost the deltoid so you can have a better function.
Having said that, even with that last components, you can still have good abduction, but if generally speaking, you'll achieve more abduction with the medial components rather than localized components. OK I hope that answers your question. Are there any more questions, but quite a small group. So if you do have one, you can raise your hand and you can ask yourself if you want to.
Anyone got any? I have question, actually. OK, so in the case of trauma, prof. If, like a patient below 60 years. And there is a comminuted and the approximate humerus fracture, and you decided to do an arthroplasty when you will do him and when you do reverse shoulder, it's an excellent question. And the answer is actually dependent on the patients themselves and the type of the fracture because you know, you can be committed with a reverse shoulder because, you know, it's not very helpful.
If someone is younger and you do a helmet and you, you're not going to achieve significant range of motion. So if someone is 40 years old, I'll definitely it's unlikely I'll be doing a helmet also. Plus the. Sorry, I'll be doing the reverse. I'll be opting more towards a heavy arthroplasty. But in the 50 to 60 age group, I know, and the evidence is quite clear in that regard is reverse is better than heavy.
Also, plus the. In in this group of patients, what's the worst outcome you can achieve in these patients is actually opting for fixation. And you know, that fixation will definitely fail. And then revising it later on, as we've demonstrated in our study offshore. Q, thank you. OK, any final questions before we wrap up this meeting?
No, can't see any hands raised. OK, good. All right, guys, so thank you very much, prof. That was an excellent lecture. And yeah, I certainly, you know, learnt a little bit from that. And yeah, you guys can all watch it again. It'll be available on the website. Usually in a couple of days or so.
Yeah and share with your colleagues because it was excellent. And you know, it's kind of thing you get asked in the exam and it's just been presented really concise and straightforward for you. And if you present it like that in the exam, they're going to go, oh, this guy knows what he's doing. So thank you, everybody. I'll if I can ask all the candidates to leave and the mentors will just say five minutes to do a debrief, and please join us next week for shoulder arthroplasty.
Thank you very much.
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