Challenges of Shoulder Arthroplasty

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Challenges, Complications and Value Jonathan Levy, MD Shoulder & Elbow Surgeon Chief, Orthopaedic

Shoulder & Elbow Fellowship Disclosure: DJO Consultant; Assisted in development of Match Point System

Exposure Understanding anatomical landmarks Implanting glenoid component Surgical Planning How many

1 Challenges, Complications and Value Jonathan Levy, MD Shoulder & Elbow Surgeon Chief, Orthopaedic Surgery Holy Cross Hospital Medical Director, Holy Cross Orthopaedic Research Institute Director, ASES Shoulder & Elbow Fellowship Disclosure: DJO Consultant; Assisted in development of Match Point System Challenges of Shoulder Arthroplasty The Glenoid Planning glenoid component placement Getting Adequate Exposure Understanding anatomical landmarks Implanting glenoid component Surgical Planning How many surgeons template glenoids? How accurate are surgeons in placing our components? How many get CT Scans? 3D Recons? 1

What if Accurately plan surgery Correct Version Correct Inclination Identify where bone needs to be removed Identify where bone graft needs to be placed Could we

Most common cause of revision TSA remains glenoid loosening Glenoid Implantation Challenges Difficulty with exposure Intra-operative visualization Lack of

2 What if Accurately plan surgery Correct Version Correct Inclination Identify where bone needs to be removed Identify where bone graft needs to be placed Could we avoid complications? Most common cause of revision TSA remains glenoid loosening Glenoid Implantation Challenges Difficulty with exposure Intra-operative visualization Lack of reliable anatomical landmarks Glenoid bone loss or eccentric wear RSP Challenge -- Baseplate Everything Starts with the Glenoid! Starting point for all modularity of the reverse Build off the baseplate DJO RSP Baseplate Defined by central screw location Critical Step is to get the center axis point correct 2

3 Normal Glenoid (60%) Baseplate is inserted using center line, matching glenoid surface with baseplate Anterior Posterior Abnormal Glenoids Challenges when there is bone deficiency 40% of patients treated with a reverse Baseplate Insertion Abnormal Glenoid (40%) Alternative Center Line Posterior Bone Loss Tap Ream Insufficient Coverage Graft 3

4 What do TSA & RSP have in common? They both build of a central axis of the glenoid RSP TSA TSA its all about the glenoid Glenoid Component Position effects: Glenohumeral joint kinematics Soft tissue forces Contact pressures Stresses between polyethylene and cement Improper positioning Perforation of the glenoid cortical vault Compromise initial fixation Lead to TSA instability Predispose early failures RSP it all builds off the glenoid Glenoid Component Position effects: Scapular Notching Lengthening of humerus Impingement Points Location of baseplate screws for fixation Ability to utilize lateral glenosphere options Improper positioning Baseplate Failures (ie superior tilt lesson) Over lengthening of arm Impingement notching, etc. 4

5 Computer Assisted Surgery How accurate are we at TSA? Nguyen, et al (JSES 2009) 16 paired cadavers randomized to TSA by fellowship trained shoulder surgeons Traditional glenoid implantation Computer-assisted glenoid implantation 3D CT Scans Intra-operative tracking Computer assisted technique more accurate Mean absolute error Traditional 7.4 ± 3.8º Computer-assist 1.5 ± 1.9º 6 degree difference How accurate are we at RSP? Verborgt et al (JSES 2011) Compared ability to implant baseplate at neutral version with 10º inferior tilt 7 Traditional Implantation 7 Navigation Range of error Version 8º with navigation 12º with traditional implantation Tilt 8º with navigation 16º with traditional implantation 4 degree difference 8 degree difference Navigation improved accuracy of a reverse Glenoid Component Accuracy within 2 degrees of plan for tilt; 8 degrees of version 5

6 Navigation -- Kinamed Kinamed (Edwards, JESE 2008) 27 patients Tracking Proximal Humerus Coracoid Glenoid Surface Orientation Navigation Tracker on reamer Recorded changes in reference to native glenoid Inclination & Version Accuracy was 2.6º±2.5º Kinamed Position of Navigation System Scapula Reference Kinamed 6

Kinamed Glenoid Reference Glenoid Reaming Navigation takes TIME Nano Station Praxim (JSES 2009) 7 degree difference Randomized 2 groups of 10

138 min Navigation more accurate Average correction of retroversion Pre-op 15.4±5.8 Traditional 14.4±6.1 Post-op 3.7±6.3 Traditional 10.9±6.

6 patients in navigation group aborted due to technical problems What we have learned We are not as accurate as we think we are with free-hand

7 Kinamed Glenoid Reference Glenoid Reaming Navigation takes TIME Nano Station Praxim (JSES 2009) 7 degree difference Randomized 2 groups of 10 patients Navigation only used for k-wire placement Navigation took longer Longer average surgical time 169 vs. 138 min Navigation more accurate Average correction of retroversion Pre-op 15.4±5.8 Traditional 14.4±6.1 Post-op 3.7±6.3 Traditional 10.9±6.8 Difference approx 7-8 degrees Extra ½ Hour! 6 patients in navigation group aborted due to technical problems What we have learned We are not as accurate as we think we are with free-hand techniques Most studies show 6-8 degrees difference! Normal Glenoid Version up to 5 degrees of retoversion Free Hand surgical error can theoretically place version outside of normal range Navigation helps Within 2 degrees of accuracy Reference Points Challenging Time consuming!! Large capital expense for hospital 7

Patient Matched Instruments Key Benefits of Patient Matched Instrumentation Improved Pre-operative Planning/Templating Identify where to

screws Identify the axis for placement of glenoid Ease of Use Guide easy to place Practice on Model 3D Model gives preview of patient

8 Patient Matched Instruments Key Benefits of Patient Matched Instrumentation Improved Pre-operative Planning/Templating Identify where to place implants Maximize potential arc of motion Proper tensioning of device Improve accuracy of implantation Identify best bone for screws Identify the axis for placement of glenoid Ease of Use Guide easy to place Practice on Model 3D Model gives preview of patient Fast! Thank You Jonathan C. Levy, MD Shoulder & Elbow Surgery Holy Cross Orthopaedic Institute Fort Lauderdale, Florida 8

A Clinical Perspective Jonathan Levy, MD Shoulder & Elbow Surgeon Chief, Orthopaedic Surgery Holy Cross Hospital Medical Director, Holy Cross Orthopaedic Research Institute Director, ASES Shoulder &

9 A Clinical Perspective Jonathan Levy, MD Shoulder & Elbow Surgeon Chief, Orthopaedic Surgery Holy Cross Hospital Medical Director, Holy Cross Orthopaedic Research Institute Director, ASES Shoulder & Elbow Fellowship Disclosure: DJO Consultant; Assisted in development of Match Point System Value of Patient Matched Instrumentation Navigation Lessons We are not as accurate as we think we are Free-hand studies show 6-8 degrees difference! Navigation helps most within 2º of accuracy HOWEVER. Reference Points Challenging Time consuming!! Large capital expense for hospital Patient Matched Instrumentation Can be as accurate as navigation Ease of Use No additional steps No up-front capital expense for hospital How Accurate is MatchPoint? to be published in JSES 1

Cadaver Validation Study Cadaver Study of 14 Cases CT Scans obtained for each shoulder Pre-operative Plan using Virtual Model Patient Specific Drill Guide

Glenoid Center Point -- determined by selecting the smooth surface of the glenoid face and calculating its center Neutral inclination -- defined between the

10 Cadaver Validation Study Cadaver Study of 14 Cases CT Scans obtained for each shoulder Pre-operative Plan using Virtual Model Patient Specific Drill Guide Production How Angles Are Defined Scapular Plane -- defined by the glenoid center point, the angulus inferior point, and the trigonum spinae point. Glenoid Center Point -- determined by selecting the smooth surface of the glenoid face and calculating its center Neutral inclination -- defined between the glenoid center point and the trigonum spinae Inclination -- measured with respect to the neutral axis, Version -- measured with respect to the scapular plane. Surgical Planning 2

11 Cadaver Validation Study Cadaver specific guides produced Using the guide, several planned holes were drilled into the glenoid face Trajectory of the holes were compared to the planned pre-op positions Post-surgical CT Scans Post-operative pin directions segmented into best fit cylinders for each pin and compared to preoperative plan Results Results As good (if not better) accuracy compared to reports using navigation Translational Accuracy of 1.01mm ± 0.66mm Accuracy of inferior tilt of 1.16 ± 1.18 Accuracy of glenoid version 3.10 ± 2.03 RSP (14 specimens) Translational accuracy of 1.19mm ± 0.69 mm Accuracy of inferior tilt of 1.24 ± 1.24 Accuracy of glenoid version 2.58 ± 1.65 TSA (6 specimens) Translational accuracy of 0.58mm ± 0.31 mm Accuracy of inferior tilt of 0.96 ± 1.08 Accuracy of glenoid version 4.32 ± 2.46 Match Point System Conclusion Surgical Planning on Virtual Models High level of accuracy in reproducing plan in a cadaver model As accurate (if not more) than published results of navigation for shoulder arthroplasty Plan ahead not in OR Faster option compared with navigation Familiarize anatomy with 3D Model 3

Small Patients Margin for error low Glenoid

excessive retroversion, posterior subluxation,

Virtual Surgical Planning Software becomes

assessment of potential motion, impingement

Steps of Use CT Scan Using Defined Protocol

12 Which patients might benefit from this technology? Small Patients Margin for error low Glenoid Deformities RSP 40% of all glenoids TSA excessive retroversion, posterior subluxation, severe glenoid wear (~20% TSA) If Complete Virtual Surgical Planning Software becomes Available Role for all RSP Pre-operative assessment of potential motion, impingement points, etc. Steps of Use CT Scan Using Defined Protocol Upload onto Surgicase Software Once loaded, Plan Surgery Steps of Use 3D Printout Model & Guide Delivered Practice on Model Easy to Place Intra-op 4

13 Discussion Reverse Shoulder Arthroplasty Goal optimize glenoid baseplate fixation Preference to Inferior Tilt Unclear role of changes in Version Total Shoulder Arthroplasty Goal neutral or normal glenoid version 0-7 degrees of retroversion Avoid Superior Tilt of Implant Associated with rotator cuff tears Correction of Excessive Retroversion Let s See Cases! Thank You Jonathan C. Levy, MD Shoulder & Elbow Surgery Holy Cross Orthopaedic Institute Fort Lauderdale, Florida jonlevy123@yahoo.com 5

14 PATIENT MATCHED INSTRUMENTATION FOR TOTAL AND REVERSE SHOULDER ARTHROPLASTY Dr Jonathan Herald Shoulder Surgeon Sydney Australia Disclosure Consultant for: Smith and Nephew DJO Global Case Study 1

69 y/o RHD female with c/o right shoulder pain Pain began while playing tennis in Dec 06 Pain started gradually while playing 3-4 times per week Continued to play and pain persisted Late Feb 07 pt

15 69 y/o RHD female with c/o right shoulder pain Pain began while playing tennis in Dec 06 Pain started gradually while playing 3-4 times per week Continued to play and pain persisted Late Feb 07 pt was lunging to get a ball, missed, and had acute onset of severe pain and weakness Gradually increasing pseudoparalysis + night pain PMHx/PSHx: Pituitary adenoma, hypothyroidism, hypercholesterolemia, lumbar decompression for spinal stenosis All: NKDA Meds: Accupril, ASA, Prednisone, Synthroid, AndroGel, Lipitor, Tricor, Vit B12, Vit B6, Niaspan PE. Psuedoparalysis Ix. Preop CT scan 6 Confidential SurgiCase connect software 2

16 7 Confidential SurgiCase connect software 8 Confidential SurgiCase connect software 9 Confidential SurgiCase connect software 3

17 10 Confidential PMI guides and bone models 11 Confidential PMI guides and bone models 4

18 Thank you 5

19 4/7/2014 Patient Specific Instrumentation DJO MatchPoint and its role in Reverse Shoulder Arthroplasty Mr Mark Falworth MB BS FRCS(Eng) FRCS(Orth) Shoulder and Elbow Unit Royal National Orthopaedic Hospital Stanmore, UK Disclosures - DJO Surgical Consulting Services / Honorarium - Arthrex Consulting Services / Instructor Overview Why navigate? What we have tried - Naviagtion Where we are going - PMI. 1

20 4/7/2014 Why use Patient Specific Instrumentation? Optimal glenoid baseplate position will optimise outcome. Limited surgical exposure; anatomical landmarks not visible. Variable glenoid morphology. Conventional instrumentation can be unreliable when managing patients with atypical glenoid morphology. Minimise outliers in patients with atypical anatomy or in the revision setting. The alternatives; computer navigation Improved accuracy of glenoid positioning in TSR with intraoperative navigation; a prospective randomised clinical trial. Kircher J, Wiedemann M, Magosh P, Lichtenberg S & Herbermyer P. JSES Improved accuracy in glenoid positioning in the transverse plane when correcting retroversion (Eclipse, Arthrex); - navigation group: 15.4 o +/- 5.8 o degrees pre-op to 3.7 o +/- 6.3 o post-op - no navigation group: 14.4 o +/- 6.1 o pre-op to 10.9 o +/- 6.8 o post op The alternatives; computer navigation Improved accuracy of glenoid positioning in TSR with intraoperative navigation; a prospective randomised clinical trial. Kircher J, Wiedemann M, Magosh P, Lichtenberg S & Herbermyer P. JSES Improved accuracy in glenoid positioning in the transverse plane when correcting retroversion (Eclipse, Arthrex); - navigation group: 15.4 o +/- 5.8 o degrees pre-op to 3.7 o +/- 6.3 o post-op - no navigation group: 14.4 o +/- 6.1 o pre-op to 10.9 o +/- 6.8 o post op Accuracy of placement of the glenoid component in reversed shoulder arthroplasty with or without navigation. Verborgt O, De Smedt T, Vanhees M, Clockaerts S, Parizel P & Glabbeek F. JSES More accurate (Anatomical Shoulder, Zimmer); Mean version; 8.7 o of anterversion compared to 3.1 o in navigation group [Ideal - 0 o ]. Mean Tilt; 0.9 o compared to 5.4 o in navigation [Ideal -10 o ] 2

How to be equal or better than navigation but quicker and cheaper?

21 4/7/2014 The alternatives; computer navigation Conclusions of navigation - More accurate But - More time consuming - More expensive - Long term outcomes? How to be equal or better than navigation but quicker and cheaper? How are we going to hit the target? Patient Specific Instrumentation DJO MatchPoint Cadaveric trial 3

4/7/2014 Patient Specific Instrumentation

Instrumentation Instrumentation Cadarevic

Superior Offset Inclination DJO Cadaveric Trial

22 4/7/2014 Patient Specific Instrumentation Cadaveric trial Patient Specific Instrumentation Cadaveric trial Patient Specific Instrumentation Cadarevic trial results and comparisons Retroversion Superior Offset Inclination DJO Cadaveric Trial Navigation No navigation 3.4 o 1.7 mm 0.2 o 4

4/7/2014 Patient Specific Instrumentation Cadaveric trial results and comparisons DJO Cadaveric Trial Navigation No navigation Retroversion 3.4 o 3.1 o 3.

9 o - Accuracy of placement of the glenoid component in reversed shoulder arthroplasty with or without navigation.

21-26 - Improved accuracy of glenoid positioning in TSR with intraoperative navigation; a prospective randomised clinical trial.

23 4/7/2014 Patient Specific Instrumentation Cadaveric trial results and comparisons DJO Cadaveric Trial Navigation No navigation Retroversion 3.4 o 3.1 o 3.7 o 8.7 o 15.4 o Superior Offset 1.7 mm Inclination 0.2 o 5.4 o 0.9 o - Accuracy of placement of the glenoid component in reversed shoulder arthroplasty with or without navigation. Verborgt O, De Smedt T, Vanhees M, Clockaerts S, Parizel P & Glabbeek F. JSES Improved accuracy of glenoid positioning in TSR with intraoperative navigation; a prospective randomised clinical trial. Kircher J, Wiedemann M, Magosh P, Lichtenberg S & Herbermyer P. JSES DJO MatchPoint Reverse TSR When is Patient Specific Instrumentation needed? Primary Cases (Routine or Atypical Glenoid?) Post Septic Arthritis Dysplastic glenoid DJO MatchPoint Reverse TSR When is Patient Specific Instrumentation needed? Primary Cases (Routine or Atypical Glenoid?) Biconcave glenoid 5

24 4/7/2014 DJO MatchPoint Reverse TSR When is Patient Specific Instrumentation needed? Revision Cases Case Presentation DJO MatchPoint - Case Presentation Mrs PJ - 76 year old female - Left hand dominant - Septic arthritis of total hip replacement - Multiple joint involvement - including shoulder - Active infection excluded from shoulder before consideration of TSR 6

25 4/7/2014 DJO MatchPoint - Case Presentation Materialise case-report DJO MatchPoint - Case Presentation Materialise Case Report DJO MatchPoint - Case Presentation Materialise Case Report 7

26 4/7/2014 DJO MatchPoint - Case Presentation Assessment of the first 3 MatchPoint s DJO MatchPoint; Post-operative CT Processing Clinical Review Method 8

27 4/7/2014 DJO Reverse MatchPoint Results Patient 1 DJO Reverse MatchPoint Results Patient 1 DJO Reverse MatchPoint Results Patient 1 9

28 4/7/2014 DJO Reverse MatchPoint Results Patient 1 DJO Reverse MatchPoint Results Patient 1 DJO Reverse MatchPoint Results Patient 2 10

29 4/7/2014 DJO Reverse MatchPoint Results Patient 2 Very abnormal base of corocoid DJO Reverse MatchPoint Results Patient 2 Very abnormal base of corocoid DJO Reverse MatchPoint Results Patient 2 11

30 4/7/2014 DJO Reverse MatchPoint Results Patient 3 DJO Reverse MatchPoint Results Patient 3 DJO Reverse MatchPoint Results Patient 3 12

4/7/2014 DJO Reverse MatchPoint Results Patient 3 DJO MatchPoint; Post-operative CT Processing

same scan protocol as the pre-operative scans used for MatchPoint System.

DJO MatchPoint; Post-operative CT Processing Post operative CT processing The position of the

The three following measurements were defined: - Deviation of the Insertion Point of the glenoid

31 4/7/2014 DJO Reverse MatchPoint Results Patient 3 DJO MatchPoint; Post-operative CT Processing Post operative CT processing Post op CT Scans - The post-operative CT scan is undertaken using the same scan protocol as the pre-operative scans used for MatchPoint System. - The post-operative scans were taken within 2 weeks of surgery. DJO MatchPoint; Post-operative CT Processing Post operative CT processing The position of the post-op glenoid baseplate was compared to the planned position. The three following measurements were defined: - Deviation of the Insertion Point of the glenoid baseplate (3D distance measurement) - Deviation of the Version Angle (2D angular measurement in the axial plane) - Deviation of the Inclination Angle (2D angular measurement in the coronal plane) 13

4/7/2014 DJO MatchPoint; Post-operative CT Processing Post

glenoid implant registering was the position of the

MatchPoint; Post-operative CT Processing Post operative CT

processing surgery date Patient- ID Deviation insertion

45 4.15 0.26 9/23/2013 OEU13-QEM-RUN 1.21 5.76 6.

32 4/7/2014 DJO MatchPoint; Post-operative CT Processing Post operative CT processing The main criteria for accurate glenoid implant registering was the position of the central screw (angle, length, screw thread) DJO MatchPoint; Post-operative CT Processing Post operative CT processing DJO Reverse Match Point TSR Post operative CT processing surgery date Patient- ID Deviation insertion (mm) Version( ) Inclination ( ) 10/10/2013 DEU13-KUB-JOX /23/2013 OEU13-QEM-RUN /12/2013 OEU13-UZU-MUB average stdev

4/7/2014 DJO Reverse Match Point TSR Post operative CT processing surgery date Patient- ID Deviation insertion (mm) Version( ) Inclination ( ) 10/10/2013

61 DJO Reverse Match Point TSR Post operative CT processing surgery date Patient- ID Deviation insertion (mm) Version( ) Inclination ( ) 10/10/2013 61

33 4/7/2014 DJO Reverse Match Point TSR Post operative CT processing surgery date Patient- ID Deviation insertion (mm) Version( ) Inclination ( ) 10/10/2013 DEU13-KUB-JOX /23/2013 OEU13-QEM-RUN /12/2013 OEU13-UZU-MUB average stdev DJO Reverse Match Point TSR Post operative CT processing surgery date Patient- ID Deviation insertion (mm) Version( ) Inclination ( ) 10/10/2013 DEU13-KUB-JOX /23/2013 OEU13-QEM-RUN /12/2013 OEU13-UZU-MUB average stdev Cadaveric study Thank You 15

Zimmer Patient Specific Instruments (PSI) for Reverse Shoulder Arthroplasty

Zimmer Patient Specific Instruments (PSI) for Reverse Shoulder Arthroplasty Ryan Krupp, M.D. Norton Orthopaedic Specialists Louisville, KY Anand Murthi, M.D. MedStar Union Memorial Hospital Baltimore,