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, MD Zimmer Patient Specific Instruments (PSI) for Reverse Shoulder Arthroplasty: Rationale and Overview Anand Murthi, M.D. MedStar Union Memorial Hospital Baltimore, MD Goals of Reverse Shoulder Arthroplasty Pain relief Function restoration Stability Durability Zimmer July 28, 2014 Page 1
Complications in Reverse Shoulder Arthroplasty Radiolucencies* Instability* Infection Glenoid loosening* Hematoma Humerus fracture (in op) Acromio/Scap fracture (Boileau P, Old J, Pinedo M, Zumstein MA. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011 Jan;20(1):146-57.) * Directly influenced by glenoid placement Glenoid Component Malposition Common challenges Glenoid bone loss, erosion and deformity Lack of visibility; challenging exposure Lack of reference; scapula movement Resulting difficulties Pre-operative definition of pre-morbid anatomy Defining the optimal implant and its location Executing the surgery, bone preparation and implant placement Potential complications Dislocation Loosening Notching Excessive poly wear Glenoid Pathology - Value of 3D Imaging Assess version Assess OA posterior/inferior bone loss Assess CTA superior/central bone loss Assess revision cavitary bone loss X-rays and 2D imaging have many problems with inaccurate assessment (Hoenecke HR Jr, Hermida JC, Flores-Hernandez C, D'Lima DD. Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty. J Shoulder Elbow Surg. 2010 Mar;19(2):166-71.) Zimmer July 28, 2014 Page 2
Longevity of a total and reverse shoulder prosthesis largely depends on correct positioning and fixation of the glenoid component. Positioning Location of the center (AP and SI dimensions) Location of joint line: avoiding medialization Version, inclination and rotation angles Post placement within glenoid vault Fixation Support bone preservation Baseplate contact area Maximal screw length Bi-cortical purchase Avoidance of critical structures Zimmer PSI Shoulder Focus on Reverse Shoulder Arthroplasty (RSA) due to: Addressing potential RSA complication rates Increasing demand for RSA procedures RSA patient population trending younger Goal of Zimmer PSI Shoulder: Improve accuracy of positioning and fixation of glenoid baseplate Maximize performance Cleveland Clinic Results Effect of PSI for Achieving Desired Location of the Glenoid Component 31 Pts RCT (Note: This PSI study conducted with non-zimmer glenoid components, primary TSA) (Michael D. Hendel, MD, PhD; Jason A. Bryan, MS; Wael K. Barsoum, MD; Eric J. Rodriguez, BS; John J. Brems, MD; Peter J. Evans, MD, PhD; Joseph P. Iannotti, MD, PhD. Comparison of Patient-Specific Instruments w ith Standard Surgical Instruments in Determining Glenoid Component Position: A Randomized Prospective Clinical Trial. J Bone Joint Surg Am, 2012 Dec 05;94(23):2167-2175.) Zimmer July 28, 2014 Page 3
Cadaveric Study Results Zimmer PSI demonstrated to reduce variability in baseplate component and screw placement for RSA Base plate accuracy better than 5 of variation to plan for both inclination/version (69% PSI vs. 29% Non-PSI) Screws placed within 7 of variation to plan compared to the non-psi technique (88% PSI vs. 22% Non-PSI) Aggregate analysis of cadaver studies on Zimmer file including 29 shoulders using Zimmer PSI (TR-TG120709-01 Warsaw Cadaveric Lab 2012 and TR- FB121026-01 Chicago PSI Shoulder Cadaver Lab November 2012). Three Elements of Solution Element One: 3D Planning Software Element Two: PSI Bone Model Element Three: Patient Specific Instrument Guides PSI Shoulder Process 1 2 3 4 CT Scan Surgeon Plan PSI Guides Quality 5 6 7 Shipping Sterilization Surgery 8 Recovery Zimmer July 28, 2014 Page 4
Preoperative Planning Overview Zimmer Patient Specific Instruments (PSI) for Reverse Shoulder Arthroplasty: Surgical Technique Ryan Krupp, M.D. Norton Orthopaedic Specialists Louisville, KY PSI Shoulder Pre-op Report: Baseplate Planned Position Baseplate Sagittal View Baseplate Transverse View Zimmer July 28, 2014 Page 5
PSI Shoulder Pre-op Report: Glenoid Reaming Glenoid Reamed Surface Sagittal View Baseplate Post Length: 15mm PSI Shoulder Pre-op Report: Fixation Screw Length Screw Insertion Anterior View Screw Insertion Coronal View PSI Shoulder Instrument Guides Pin Guide Roll Guide Ream Guide Screw Guide Zimmer July 28, 2014 Page 6
Intraoperative Video Zimmer Patient Specific Instruments (PSI) for Reverse Shoulder Arthroplasty: Case Study Anand Murthi, M.D. MedStar Union Memorial Hospital Baltimore, MD PSI Shoulder Case Review 75 y.o. female chronic right shoulder pain Pseudoparalysis VAS = 9 Left RSA 1 year ago doing well Right stage 4 CTA Zimmer July 28, 2014 Page 7
Imaging PSI Shoulder Imaging PSI Shoulder Imaging Zimmer July 28, 2014 Page 8
PSI Shoulder Imaging PSI Shoulder Imaging PSI Shoulder Imaging Zimmer July 28, 2014 Page 9
PSI Shoulder Imaging PSI Shoulder Imaging PSI Shoulder Imaging Zimmer July 28, 2014 Page 10
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PSI Shoulder Surgery PSI Shoulder Surgery PSI Shoulder Surgery Zimmer July 28, 2014 Page 12
PSI Shoulder Surgery PSI Shoulder Surgery PSI Shoulder Surgery Zimmer July 28, 2014 Page 13
PSI Shoulder Surgery PSI Shoulder Surgery PSI Shoulder Surgery Zimmer July 28, 2014 Page 14
PSI Shoulder Surgery Zimmer Patient Specific Instruments (PSI) for Reverse Shoulder Arthroplasty: Case Study Ryan Krupp, M.D. Norton Orthopaedic Specialists Louisville, KY 60 Y/O RHD FEMALE H/O POLIO > 50 YRS SEVERE OSTEOPOROSIS SEVERE PAIN AND WEAKNESS LEFT REVERSE TSA 2011 FE 60/ER 20/IR LB 3/5 STRENGTH Zimmer July 28, 2014 Page 15
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Transverse view, superior part of baseplate Measure = 4.46 mm Sagittal view at contact area with the base plate Sagittal view of the 3D model Zimmer July 28, 2014 Page 19
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QUESTIONS? 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, MD Zimmer July 28, 2014 Page 22