Paradigm Shift in Total Shoulder Arthroplasty Previously Recorded: Thursday, January 22, 2026, 1:30 p.m. ET
A new unique type of shoulder replacement that is bone preserving, less loosening and revisions, and allows patients to get back to all activities with no restrictions.
Presenter
Anthony Miniaci, M.D.
So, uh, we're now live. Um, good afternoon, everybody, uh, and thank you very much for being here. My name is Reggie La Roche, Assistant vice president for Baptist Health Orthopedic Care, and thank you very much for joining us today for our webinar, uh, The Paradigm shift in total Shoulder Arthroplasty. Uh, before we get started, uh, there's a quick reminder that the session is recorded, so if you experience any technical issues, uh, definitely please leverage the chat feature so our team in the background would be able to assist. Uh, now, it is my distinct pleasure to introduce today's speaker, Doctor Anthony Minacci, our Deputy Chief Medical Executive of Baptist Health Orthopedic Care, um, at Baptist Health Medical Group, and also the president of the American Shoulder and Elbow Surgeons. Uh, Doctor Miniaci is internationally recognized for his expertise in shoulder reconstruction and minimally invasive surgical techniques. And we are looking forward toward, you know, we're definitely looking forward to his presentation, uh, regarding total shoulder arthroplasty. Following the presentation, I will return, uh, to facilitate our Q&A. Um, so definitely please feel free to submit any questions throughout the webinar that you may have, um, using that Q&A feature. Uh, so now it is my honor to turn it over to Doctor Miniachi for today's presentation, Paradigm shift in total Shoulder arthroplasty. Take it away, Doctor Miniachi. Thanks so much, Reggie, and uh thank you, Baptist uh for organizing this webinar. But most of all, thank all of you who have actually tuned in to, to listen to this. You're gonna share with me a little bit of uh a passion of mine and, and uh we'll go sort of through a lifelong journey in terms of my thoughts about total shoulder arthroplasty, replacing shoulders in patients, and You know, what we've done differently and something which I think uh might change the paradigm in shoulder arthroplasty as we go forward. So that this is something which I have done for many years, um, and, uh, uh, it's, uh, started, uh, uh, with thoughts about the regular shoulder arthroplasty replacement. So that modern shoulder arthroplasty started in about the mid-1970s. It can be credited to Doctor Charles Nir out of Columbia. Uh, in New York, who, uh, designed some implants, which were sort of based at that time on the hip arthroplasty model. And uh what we had was a stem replacement with a spherical humeral head and then a plastic liner for the, the glenoid with fixed angles and sort of a monoblock type of system where we would cut the humeral head off, put the stem down the canal and have a head there with a piece of plastic. So it was, it was not really a true anatomic total shoulder arthroplasty, but something which we were using then for shoulder replacements. Over the years, we've learned that, uh, although patients have done well over the years, it's not without its problems. And, uh, some of the problems have been related to the implant designs, uh, the humeral head, the spherical, and we're gonna talk a little bit about the anatomy of the humeral head and why a spherical replacement might not be the best. And, uh, we wanna look at the things that can improve patients' range of motion, reduce their pain, reduce their, their failure rates. And then some of the issues that we have to face when we do reconstruct these arthritic shoulders, cause many of these arthritic shoulders end up with bony deformities. They get erosion of the bone, especially in the back part of the shoulder, so that, uh, problems such as subluxation, dislocation, centering of the humeral head, and malpositioning of the components creating soft tissue problems are things that we need to deal with. And we know that this is sort of the, the things because Even though we have done and gone through multiple design changes over time, so that some of these monoblock systems we found that we couldn't get the humeral head centered over where we would make our cuts, so what we did was we changed things so that we had variable changes on the head so that we could rotate it around. To get a little bit closer to the anatomic version. That's where the name anatomic came from because we said, well, you know what, before we couldn't get it to this spot, and you see the picture on the top right-hand corner here, you know, a monoblock system could end up with that, but you see, the humeral head is nowhere near where it should be, so that we had the ability to change this implant, so we can rotate it around so it was closer to where the anatomy should be. On the other hand, on the socket side, you know, this is nowhere close to what we wanna do in terms of the glenoid replacement. It's a piece of plastic sitting on the bone, and that, that getting the joint line in the right position was not helpful. So that we needed to start thinking, and this is where I first started thinking, you know, even though we call this anatomic total shoulder arthroplasty, we need to start thinking about the true anatomy of the shoulder because You know, this spherical head design and this plastic design of, of the, the, uh, humeral head, although it served us well for years when we had nothing else, doesn't really get away from a lot of the problems. So these larger heads not positioned in the right place, puts stresses on the rotator cuff musculature, and can result in failures of this. And we've sort of seen that, so that this is a, a, a study done out of the Australian registry, so that every patient that has a shoulder replacement gets documented in this. And they document their failures basically over time and the number of procedures that are done over time. So that the blue line here you see are the number of total shoulder arthroplasties that have been done, and the yellow line is the reverse shoulder replacement. So you can see that over time, the number of total shoulder arthroplasties is going down. Now, there's multiple causes for this, but one of the things is that, you know, that this operation here, the reverse seems to have more predictable results than this total shoulder arthroplasty, which means that something is wrong with this procedure if we're moving away from it. And a lot of the reasons are sort of cited over here. So everybody thinks that it's the glenoid side, the plastic socket, that's the issue. But some of the soft tissue injuries, the dislocations and instability, and the glenoid loosening are the major components of failure of this. And so that we need to be able to reduce those if we're going to improve our total shoulder arthroplasty design. So over the years, we've really focused on the glenoid and glenoid loosening because that's one of the major components. But remember, I told you that soft tissue failures are related to some of these problems with the design of the implant itself. So what we need to understand is that the humeral side as well has significant implications on the failures, even on the glenoid side, because The, the shape and size of the humerus can lead to soft tissue failures, can lead to glenoid loosening, and I'm gonna go through all of that with you today so you understand how the two, the glenoid and the humerus are interrelated in terms of the failure of the glenoid side as well as the soft tissue failures that we're seeing. So that even though we focused mostly on the glenoid side over the years, the humeral side is becoming more and more important, and people are starting to recognize that. So that's where I think that uh in the year 2026, we are considering and have considered and have done this over time, a redesign of these concepts. So that, uh, I, I think that we need to get away from this traditional spherical design, which is what the more common shoulder replacements, uh, even many of them are done today are all spherical. And I think that we need to get back to true anatomy. And so that when we call these anatomic shoulder replacements, A truly anatomic replacement would have an ovoid head, because if you look at the head of, if you look at the head of the humerus here down in this picture here, you can see that it's shaped more like an egg than it is like a sphere, like a ball. And the question is, does that really matter that much? And we're going to talk a little bit about that because I'm going to show you that the humeral design has significant effects on the overall stresses and failures that we see. So, you know, everybody says, wow, how come nobody knew this before? Well, we have known this before. And so that you can see through the literature for over the years that we've known that the shoulder is not a sphere. And that, that this is some work that I did many years ago looking at the improvements in the fit over ellipsoid and oval shapes. To the humeral head, and you can see that the humeral head is not spherical, and so that uh when you look at these designs, if you take something which is an ovoid head, it has 3.3 times a better fit over a spherical design. And so you say, well, does that really matter? And so that the answer is yes. There, there's research that's been done over the last number of years, showing that if you have an anatomical aspherical head, something which is more ovoid in shape, that it restores the center of motion. It gets the anatomy to where it needs to be, it improves the stability of the joint, and FEA studies, which means measurement of the stresses on both the glenoid and in the humeral side, are 8 times less when you have something which is not spherical, uh, over a spherical design, so that it, it is important. And this is probably one of the best studies that has been done recently, looking at all of these different factors where they compared uh biomechanically, a spherical head here versus an a spherical head here to see what the differences were. And you can see overall what it did was it improved the range of motion, it improved the center of rotation, and it improved the stability. So I like to sort of simplify things and just imagine, OK, so that here we have a soccer ball in the front, on the top part, and a football on the bottom part. Now, our true anatomic humerus is more like a football than it is like a soccer ball. Although the shoulder replacements that we've been doing for years are like a soccer ball, so that when you roll a soccer ball across the floor, the center rotation stays in that one spot. When you roll a football across the floor, I think you know this, because it's not spherical, it center rotation undulates as you go forward. And that's how our shoulders normally move. So that if you take a sphere and you put it into a design here where it's supposed to go up and down as it moves backwards and forwards, then the only way to get this line to go up and down is to push this ball to the front and to the back, which then puts more stresses on the glenoid side. So what happens is, is that that as that implant sits in that position and it moves back and forth, it puts more stresses on these areas, and we're gonna talk about that in a little bit. In addition, if you think about it, if it's a spherical design, then what happens is no matter in this position, or if you rotate it in this position, the distance that it has X is the same because it's a, it's a complete circle. But if you take this implant here, it's obviously narrower in this range than it is in the up and down range. And so that what happens is, is when you rotate that one outward and inward, that you have 4 millimeters less in that position of the arm than you do in the other position of the arm, which puts less stress on the muscles. And one of the biggest failure problems we have is the failure of the muscle that we cut to get into the shoulder. And so that we're putting 4 millimeters more pull or tension on the subscapularis muscle when you externally and internally rotate the shoulder, just by the shape of the head. Forget about any pull from the muscle itself. So you can see that biomechanically, this has a significant improvement in the biomechanics around the musculature around the shoulder. So, we understand then that a non-spherical humeral head is beneficial. So what about on the glenoid or on the socket side? So that, uh, you know, our traditional, which we've discussed already, is this piece of plastic sitting on this bone here that we put in, and a spherical head on this side. And this is now a newer concept that I sort of came up with, and now, you know, this is not new anymore, even though we call it newer, but it's, you know, it's hard to adopt in medicine. Medicine is very conservative. And people don't adopt change, surgeons don't adopt change very quickly until they see longer-term data. So this inlay concept is we don't put the, the sphere on the bone, we put it inside the bone. So that what it does is it shares load from the bone to the polyethylene to the plastic as you go forward. Now, I just want to clarify some concepts because there's, uh, sometimes people confuse this inset inlay and onlay, and they don't understand what it is. So I just wanted to show you that. All these new Glenoid designs are not the same. The onlay is sort of the traditional design that we've had for many, many years. And what happens is you remember I said that you get a lot of loading on the edges because the, the ball wants to move back and forth on this. The inset design is sort of halfway between what we call an inlay concept, which is buried inside the bone and sharing load with the bone, so that this one sort of is buried in the bone, but not quite as far, and the further you move this into the bone, the closer you get to the inlay concept, and the further you move it away from the bone, the closer you get to the onlay concept. So this is somewhat in between. So this is, so the inset is better than the onlay. But it's not as good as the inlay when it comes to sharing the stresses and loading the and sharing with the peripheral bone that you have. And so, uh, the concept of what we're trying to get away from is what we call this rocking horse phenomenon. So there was a study that uh was done in South Carolina, which looked at this very concept. And what they did was they compared spherical heads against uh uh uh uh non-spherical heads against an inlay glenoid, and non, and spherical heads against an non-lay, and you can see that back and forth motion which the shoulder normally sees when it goes through a range of motion. What it does is it rocks on this plastic and it puts stresses on these edges, which allows the implant then to get looser over time, and that's why they call it the rocking horse. Well, what you can see with the inlay concept, this doesn't happen because the head slides across the bone and it slides across the plastic, so you get more shear stress, but you don't get that rocking horse phenomenon. And so that this study, which was done many years ago, um, in South Carolina, looked at that concept and they took this to 4000 cycles of an onlay glenoid in a spherical head versus an inlay glenoid in a non-spherical head. And at 4000 cycles, none of those with the non-spherical head and the inlay glenoid loosened, but all of them loosened, and they loosened probably at uh Uh, at a mean cycle of about 2000 cycles, they were all loosened, and so that you can see that the design of the implant itself has direct impact on the loosening and stresses that are seen in those shoulder replacements. And this again just demonstrates exactly what's happening. So this is the onlay, uh, what we're doing now, the traditional anatomic, and this is the inlay, what I'm talking to you about today. And you can see that the onlay, the stresses are all at the edges of the implant, the rocking horse phenomenon. And here, you can see the regular shoulder because the shoulder moves back and forth, you'll see stresses there. But when you put the inlay in, the stresses are almost identical to what we're seeing in the normal anatomic glenoid when it moves across, and it shares loads so that when you look at these, you can see that an onlay actually has increased stresses over the native glenoid. OK? So this is what's happening in the normal glenoid and the stresses on the edges. And if you look at the inlay, you can see that the stresses are the same as we see on the native glenoid, but it shares loads so that the bone takes some of it, the plastic sees some of it, so that it's much less stress on that implant, which means that probably it loosens uh at a, at a much less rate. So that's why we sort of came up, and this has now been going on for about 20 years, this concept of a truly anatomic shoulder replacement as opposed to the sphere and onlay. Because it would improve the biomechanics and reduce the stresses with the design of the implant by itself. So without doing anything different, it's just changing the implant itself, it reduced the stresses significantly. And uh so then the question comes, well, you know, one of the biggest issues that we have, and I told you about at the beginning, was that this severe glenoid deformities, which come with the more complex cases, does it work in that? And so that, uh we first had to do and proof, proof of concept, and this was done many years ago. This was my first series of patients before anybody had ever seen this implant or done it. And we did this uh in, in um 29 patients and 31 consecutive shoulders, and patients had primary osteoarthritis. And what we found was, is that if you looked at Uh, what we looked at was patients with concentric versus the eccentric glenoids, so that the eccentric ones were the ones with bone erosion, the concentric ones were the ones that hadn't eroded bone yet. And you can see that overall, they all did identical. And this was sort of at a shorter term, obviously, about a 4-year follow-up. Uh, and what you could see, which was really the interesting point was when we looked at the range of motion. That we we're seeing ranges of motion that we weren't used to seeing in both the concentric and eccentric. And we thought, wow, this is better range of motion than I've ever seen with any of the other type of shoulder replacements that they did. So that we compared our ranges of motion with all the other implants that exist out in the literature, and you can see this is the non-spherical head here. And what the range of motion is in both external rotation and forward elevation compared to all the other implants that have been reported over time. You can see that there was at least a 20 degree improvement in forward elevation and probably about a 15 to 20 degree improvement in external rotation just based on the design of the implant itself. So, everybody says, well, that's great, that's all biomechanical studies, and, you know, what are the clinical outcomes, and, you know, not just your clinical outcomes, everybody wants to know. So that over the years, you can see there's a number of papers that have been reported, not just my own, that basically report all the same things, that there's improved patient outcomes in all of these cases, regardless of the amount of wear or uh on the glen, we're gonna get into that in a little bit here. They have better range of motion. A lot of these patients were returning to work and full activities, things like weightlifting, which we would preclude them from returning to with a standard shoulder replacement. And over the years in all of these studies, nobody was reporting glenoid loosening, which was one of the biggest complications and problems that we see with our traditional implant. And so that, that we started thinking, wow, we have something here. Now, for those of you who know how the system works, you know, systematic reviews are done when something has been around for a long time, they can review a number of papers that have been done. And so you sort of know that you've made it into the thought processes of surgeons when there's systematic reviews going on. So that this is no longer a fat I say, so that people looked at this concept of an inlay glenoid, and inlay, even with a spherical implant in place. And I want you to notice a couple of things here. First of all, these were all done and you can see that half of these patients had what we call B2 or greater, which means they had a significant bone erosion. Uh, but, uh, uh, when you look at the revisions with comparative systematic reviews with our traditional anatomic shoulder replacements, at, at a 7 to 10-year rate in a, in a regular shoulder replacement that we're talking about, our standards, that's the spherical head, and then on, the revision rate is about 17%, and with significant problems in terms of lucencies around the implant. If you look at the inlay glenoids over a period of time, the revision rate is 1.3%. So a tenfold reduction in the revisions for this implant at the same time frame. So that got me excited because it shows you proof of concept and all the biomechanical work is actually coming to fruition. So the big issue we have are the ones where like half the time, we see these cases where we have erosion of the, the humeral head falls backwards, it starts to erode the bone, and the more bone erosion, the higher the grades, and so that these are a significant problem because over time, these are the ones that loosen more frequently, that the patients are not as satisfied, and we see a lot of loosening on the X-rays, so that uh we've established a lot of different options for these over the years. And this population group here, this younger patient who's highly active, almost 75 to 80% of the time, get this. So these are our highest risk patients because they have a high activity level, they have significant bone loss. They're the worst-case scenario. So I started doing these patients when we saw proof of concept initially, because there was really no, nobody would offer this patient here who wanted to continue weightlifting a regular shoulder replacement. So we sort of said, well, there's nothing to lose here, the patient understands it. And so we started doing these patients a number of years ago to see if this would actually work for them. So that instead of doing our traditional things where we'd sort of ream down the high side, put bone graft in there, put augmented glenoids in, or do reverse shoulders, instead of that, we sort of tried to shift the paradigm and said, I'm going to do an inlay glenoid with a non-spherical head. So for those of you who don't know, or for those of you who do, you know, this has become the more common procedure that's done, the stepped augment for this posterior glenoid where, where we have a big wedge built into the back, and what we do is we put this in, and now even under, under robotics and computer control to sort of get it in the right spot, so that you can drill this pin, ream it out, and you can see that there's where the erosion is, and you want to sort of put this back in the center here. And these are the implants that are designed. However, if you look at this, in the early phases, these patients are doing great. As you follow them over time, what happens is they start to fall apart, and especially when they have big things. So that this was one of the first implants that was done out there. And you can see when the bone erosion is greater than 16 degrees, that what happens is these ones fail at a very high failure rate. And so I think that this type of implant is doomed for failure over time. And it's not the first time that we've done this, so that, you know, I've been around long enough to know that. Uh, way back in the uh 80s and 1990s, 1980s and 1990s, uh Bob Cofield out of the Mayo Clinic came up with these designs, a metal back and a, a full polyethylene one where they reconstructed the bone posteriorly. And you can see that in the longer term follow-up of those patients, these started following up and they started to go away from these. And so that rather than going to this type of replacement, I think that we need to be asking ourselves, you know, are we reinventing the wheel with these new augmented Glennox and repeating our mistakes, which I think is what we're doing, we're going to have problems with these in about 10 years from now. So, if you look at biomechanically, you know, the reaming of bone versus putting these in, you, there is no question that the stresses that this implant sees are much higher than our standard replacement, and it's not a good idea. And so then again, for me to simplify, You know, just the way I think about it, just imagine that your glenoid is like this scenario here, OK? So that what's happening is the force of nature here is the ocean, and it pushes all this stuff back. So what happens is you get this erosion, and the house that was sitting on the edge of that, that's like your humeral head, then falls into that defect. So what we're doing, With our new augmented glenoids is we're trying to fix that defect, and what we do is we fill that area so that now we sort of level things out again. But what you've got to remember is that the forces of nature are still there, and so that these forces are going to continue to push against this, and over time, this is probably going to fall apart again. So that's my concern with some of those augmented glenoids. So that's why I sort of took this on and I sort of said, OK, you know what? We've had, we know that a non-surgical humeral head is better. We know that an inlaid, inlaid glenoid is better. So that for these patients with a significant posterior subluxation and humeral head subluxation and bone erosion, that maybe something like this actually would be less expensive, it's simpler, and it can preserve bone. So I know a lot of you out there who are thinking, well, you know, is this really a good idea to be putting, you know, in a glenoid, which is retroverted, an inlay glenoid, does this really work? Well, my friend Jerry Williams started to do this and published a series uh way back in 2016 of these patients where he'd used this inlaid glenoid. With significant and good results with these patients, which sort of like led, led credence to my idea that we could do this for all these patients. And then if we add a non-spherical head, this would be even better. So people always ask, they say, well, you know, what you're dealing with is a head, which, you know, if you look at the socket here, and the socket is here, and the center of the head is here, this should be up here. They say, what do you do? How do you treat that if, you know, if that's some luck, do they all come back in position? So we did a study then looking at that. And so we, we took uh 30 consecutive patients and looking, so you see there's a socket, there's the humeral head, there's the post-op, you can see it's all centered, and these things stay there forever. And so that no matter which way we measure them, they all move back to the center point and they stay there for a number of years. And if you look at the patients' outcomes, and then looking at those young active people, so that I became the doctor for many of these guys who came to see me because You know, they, they had significant shoulder arthritis but didn't want to have a regular shoulder replacement. So over the years, we accumulated a number of elite weightlifters and we did a number of shoulders. And you can see 75% of them are eroded glenoids, and, and a lot of these patients, and most of the patients went back to their activities over time. You could see their hummoid heads reduced into the 50% position, and their ranges of motion and clinical outcomes were excellent and have maintained so over the years. And I'm going to show you sort of a couple of cases. This is one guy you can see here who has posterior erosion, posterior humeral head subluxation on both shoulders. And you can see his ranges of motion preoperatively, he had -5 of external rotation, which means he could hardly get it away from his body and couldn't lift it up to his shoulder, only 85 degrees of forward elevation. And you can see this is the guy here postoperatively, who has full range of motion and he's very happy with his result. He was a Cleveland Indians fan, it's the World Series against the Cubs. The only thing he wasn't happy about was that we didn't beat the Cubs that year. So, this is another patient, and uh this is a guy who came to see me who was uh very serious about powerlifting, and uh wanted to go back and wanted to stay in powerlifting because, but he had significant reduction in range of motion and couldn't compete at the highest levels just because he didn't get the ranges of motion. So we did both of his shoulders, so he had one, and then the 2nd 16 months later, and this is his first competition afterwards, which was the World Powerlifting Championship. And you can see that on all the lifts, he's, he's setting world records, so that he set that first year, which was 18 months from his first one and 12 months from his second one, he set 4 world records for total weight and for all the different competitions that they do, and became the world record and the world champion in that powerlifting. Uh, and since then, uh, he's, he's now, uh, become the world powerlifting champion in the Masters category for 8 years consecutively and set like world records every year. Now, the important thing was that he came back to see me because he had a different problem, uh, in his AC joint. And so we were gonna go back and do something there, and I asked him permission to sort of look inside his joint to, to have a look at it. So this is his arthroscopy picture cause he was still having no problems in the joint. So there's a reflection, there's the metal portion, no loosening there. And you can see there's the plastic, no loosening there. But the amazing thing is, is that at 7 years, you can see that there is no wear on that polyethylene, on that plastic, because this thing slides across there and acts normally. And that's not what we would normally see at 7 years with the regular polyethylelene implant. So, a few years ago, we did this study, we looked at it, and this is a systematic review that we looked at all the different treatment options for patients with complex bone loss. And we looked at ones which, which were less than 5 years follow-up and ones that were were greater than 5 years. So, one of the things that you can see is that less than 5 years follow-up, all the things like asymmetric greening, bone grafting, the augmented glenoids, reverses, the non-surgical humeral heads, they all had pretty good results. Except for these hemiarthroplasties and ream and run type of sets where they'd only ream the glenoid and then put a hemiarthroplasty in place, something like they're doing for pyrocarbon these days. So those ones had the highest revision rate, but everything else here did pretty well. When it got to higher than 5 years, you could see that the non-spherical head and inlay glenoids had no revisions for loosening, no subluxations, and they were the best. The second best were the reverse shoulder arthroplasties, although you can see that they're starting to have some problems, a little bit of lucency, so that you can see that of all the different options for patients who had complex bone loss, this non-surgical humeral head with an intact cuff is probably the best component. So the final question that people always ask me, well, you know, you're using it, so that's, OK, maybe I'll give you that, you can use this in young active athletes, and that's what it got first done for, and it was, uh, most people are out there doing it. But what about this patient here? You know, the 78 year old lady who we know is gonna have soft bone, and this is, doesn't have a big stem on it, and so that, But you gotta remember, this is, this is fixed in a different way. It preserves all the bone underneath this piece of metal here as compared to some of the other stemless type implants. And so that, uh, we wanted to compare to see if we could use it in this patient who has perhaps osteoporotic bone. So what we did was this study here, which, uh, Um, uh, this was done out of the University of Rochester in New York. Ilya Voloshin, a good friend of mine, so what we did was compare the, the ovoid head with the, uh, preservation of bone versus a couple of other stemless designs versus stemmed, uh, designs, short stem and long stem. And what we found, just to summarize things is that the ovalhead, with the way it's prepared, had the same type of, and it didn't matter what the bone marrow density was, it was the same as the stemmed implants. So that the fixation doesn't matter in these older patients, as it does with some of the other stemless implants, which, if the bone is too soft, you can't use those implants. So basically, you can use this on everybody. So, that's what I do now. Uh, for every patient with an intact rotator cuff, I have this as my go to, an asspherical humeral head. And an inlay glenoid design. So it's my primary total shoulder arthroplasty, because I think it's truly anatomic. And I think that, you know, what we did pay attention for years was the humerus design, and I think that this ovoid design makes a huge difference because it reduces the stresses that the plastic sees. But then the design of the plastic also contributes to the fact that it doesn't loosen, it doesn't rock, and so that there are significant biomechanical advantages. Uh, and the stresses that the soft tissues sees are significantly improved with this. So that, what it does is it preserves all options because it preserves bone on the humeral side, it preserves bone on the glenoid side. There's clinical and biomechanical data to support it. And so that's what I do. So I think that this now is becoming more and more accepted. I think that you can see that other companies are looking to replicate this design. And I think that this will be where we head with uh total shoulder arthroplasty to solve some of our problems. So with that, I'll thank you and I'll turn this back to Reggie. And if any of you have any questions, I'm more than happy to entertain them. All right. Thank you so much, Doctor Miniachi. That was definitely uh insightful, forward thinking. There's a lot of developments when it comes to shoulder shoulder arthroplasty and um it was definitely informative. Uh, for those that, uh, do have questions, definitely please, uh, leverage the Q&A feature, uh, to that. get those in there. Uh, we do have some that came through the chat, uh, so we'll move into that Q&A portion right now. So first question is, uh, Doctor Minacci, if you're able to compare and contrast the anatomical TSA versus the reverse TSA, um, so, off to you. Yeah, and I, I think that One of the, one of the reasons the reverse shoulder replacement has become much more popular, and you can see the lines, if you remember back to that. That uh slide that I showed you where in Australia, the numbers of reverse shoulder arthroplasty are going up and the anatomics are going down, is that The reproducibility in the surgeon's hands is much easier to do with a reverse shoulder replacement because what happens is, is that, you know, the reverse shoulder replacement, you're, you're pretty much snapping it together. And so that technically, believe it or not, it's a little bit easier than an anatomic shoulder replacement. However, you have to understand that complications still exist and things like acromial stress fractures, dislocations, instability, and loosening are still not uncommon with reverse shoulder replacements. In addition, I don't think You know, there are some patients that get great range of motion, but the average patient range of motion with a reverse shoulder arthroplasty is about 150 of forward elevation, which means, and I tell my patients, you know, you can get the hand to the top of your head, uh, but, uh, getting your hand behind your back, uh, sometimes is a little more difficult, so that they lose internal rotation, so that they don't get as good rotation with an anatomic shoulder replacement. So patients, uh, surgeons who do it, and patients who have them, anatomic shoulder arthroplasties can result in better functional motion and better functional results than overall average reverses. Great. Thank you for that. So even in thinking about, let's say like patients now, so from a patient profile, um, you know, who benefits, who, who may not. So when you think about the ovo motion, the inlay, glenal construct, we're talking about primary OA, younger, active patients, minimal deformity, um, who would be a great candidate and who would not be a, a, a great candidate just based on what you've discussed. Yeah. So, as you saw, we started, we started off, like the people who have the highest activity level, uh, but oftentimes, they have bone erosion are the younger active patients. And, uh, but they seem to benefit the most because, you know, I think that most of us still are a bit reluctant, especially if the patient is very young, to be putting a reverse shoulder in place because, you know, then you have to deal with revisions of a reverse, which are much more difficult to do than having an anatomic shoulder replacement in place. Uh, so that, that was sort of my initial series of patients because I figured if it didn't work in those, then I could, I always had an option to go to. But I think that, uh, for me, as long as the rotator cuff is intact, you know, I do to patients what I would do to myself. And if I had an intact rotator cuff with osteoarthritis in my shoulder, whether I had minimal deformity or whether I had significant bone erosion, I would want what I just talked to you about. And that's why, you know, and I feel confident in telling patients that that that's what I would have done to myself. Perfect. OK. Uh, another question came in, um, I guess, uh, this comment is, I'm a bilateral shoulder patient, I'm in need of replacements. Clinically, when the TSA is done, is biceps tendinosis performed during this replacement procedure? Yeah, so the biceps tenodesis is something where, you know, the biceps tendon sits in a groove. Uh, that, uh, is just outside the shoulder, and then it goes into the shoulder. And that groove, when patients get osteoarthritis of the shoulder, that groove gets what we call little osteophytes or spurs, and oftentimes it rubs against the biceps tendon. And so, um, if you, like, if it's perfectly normal, there are situations where you can leave it intact. But more often than not, there is damage, disruption of the biceps tendon, injury to it, degeneration. So that if the patients have, and, and I usually get an MRI and I examine them carefully, but by and large, I would say more than 90% of the time, the biceps tendon is involved and it needs a biceps tenodesis. But that, to be honest with you, um, doesn't change the functional results too much. Understood. And you, you mentioned a little bit about the imaging. So when, let's say if you're planning, let's say the in the inlay, uh, glove, like what pre-op imaging findings or morphology factors most influence your decision. Yeah, so, you know, CT scanning, which is coming a little under a little bit of scrutiny nowadays because all the CT planning that we're doing. You know, there's a, uh, an article recently showing about the, the radiation exposure for patients and the potential, especially in younger patients, the potential of developing later sarcomas in life, so that we have to be a little bit careful about what we're doing. Uh, for, for me, because a lot of the planning is done intraoperatively, I need to know a couple of things. One is, is, you know, do they have bone erosion or not, which I can tell on an MRI and where the humerroid head sits. And then, Is their rotator cuff intact, which, you know, you can see it on CT scan, but I get a much better picture of it on MRI. So what I do is I default to an MRI for these patients for my planning because I can get all the information from an MRI. I don't need to do a CT. Gotcha. So from a, let's say rehabilitative standpoint, are there any limitation or precautions initially post, um, for post-op rehab? Yeah, and I think, you know, patients, you know, and I have this discussion with, you know, all my patients when they come because You know, everybody thinks, oh, this is a much lesser operation, but we still have to cut the subscapularis muscle to get in, so we've got to let it heal. We've got to let the biceps tendon heal, especially if you do a tenodesis. And so that, uh, even though the implant, you can start using it right away. You can't use the muscles right away until they heal. So that what I usually do is I limit them to sort of very passive motion for the 1st 3 weeks, like, they can't drive and do that, that kind of thing. At 3 weeks, they start with more of an uh passive-assisted motion program. And it's not until 6 weeks where they start to Do, um, uh, stretching and strengthening exercises to start working on it. What I tell patients is that, you know, their recovery is sort of like a slow, gradual recovery until 3 months and then it takes off. So from 3 to 6 months, uh, is when the big recovery occurs. Now, granted, not everybody's the same. And so I tell them not to be disappointed if it takes 9 months, and the older we get, the longer it takes. So, um, I usually, once they, once they have good motion and have recovered their strength when I examine them at 6 months, if they have good strength and their range of motion is where I'm happy and their X-rays look great, I let them go back to full activities, whether that's weightlifting or not. OK, understood. Uh, another question came in, um, I guess, uh, how does your glenoid technique differ, uh, for a B2 glenoid versus that versus a non-eroded type. Um, they may be referencing that, uh, the augmented version. Yeah, so the, the, the technique is. Pretty much similar, the instrumentation, where you put it and all that. What you have to recognize is that when you have bone erosion, you have now what we call a retroverted glenoid, OK? So that it's now pointing a little bit more posteriorly. And so, and then usually, because the humeral head is sat in that back socket a little bit, there's usually a ridge there. And so, when you're, when you're putting it on a non-eroded glenoid, the instrumentation sits on the glenoid face and you can make your little hole in your little slot, if you will, for the, the polyethylene to fit right into that slot. What you have to make sure of is that because you have a ridge there, you have to make sure that the backside of the implant of the uh instrumentation is sitting on the glenoid, so that it, cause it rocks on that ridge. So you can either sort of ream down the ridge, or you can just make sure that the backside is, is down on the bone, so that when you put your polyethylene in, it has to be surrounded and covered. By bone. If you sit it proud, what happens is it rocks, and then it acts more like an inset as opposed to an inlay, uh, because it sits a little bit proud. So that you don't, you know, you wanna try and sit it as far down as possible. You know, I think that probably a millimeter proud at the back is not such a big issue, but it's, uh, a millimeter proud will see more stresses than, uh, totally flush. Those are technical issues for the surgeons out there, I think. Mhm, gotcha. So I guess when it comes to, let's say, uh, some of the soft. Tissue area, so you know, how you handle the subscapularis management of that, um, you know, with the system of the tenotomy versus the peel, the lesser tuberosity, osteotomy, you know, how have you adjusted that technique based on your implant design and rehab strategy? You kind of touched on it, but just to evaluate a little bit more. Yeah, so, you know, I'm old enough to say that I have done all of those. So I, I went through, you know, I started with the tenotomy many years ago cause that's what uh Uh, my mentor was doing and teaching and then went to the Peel to sort of try and protect that and started using anchors to fix that. And then, um, you know, it became, well, you know, those soft tissue things are not as good as what we call an osteotomy, where you cut the bone and then reattach the bone. And then over time, I think, you know, surgeons realized and the literature realizes that none of them made any difference, that they all sort of do about the same. For this specific technique, I think that the, for me, the tenotomy, and that's why I've gone back to it, has been the best. Because what happens is it gets me good soft tissue, uh, side to side repair. If you use a lesser tuberosity osteotomy with this, what happens is if you make too big an osteotomy, so that, if you're gonna do an osteotomy, you have to make a very small sliver so it doesn't go into the head. Because remember, you're preserving the proximal humerus. So if you do an osteotomy and you take away some of the head, you take away some of your fixation of your implant. So, I don't like to do the osteotomy. Uh, what I do is I use a hybrid repair of the subscapularis, I, the, the superior half or so, uh, or 2/3, you know, it's very tenderness and, and you get a, a robust repair. And then I have an anchor which I use for my biceps tenodesis down distally, and then I use the sutures from that to repair the inferior third of the subscapular. So it's sort of a hybrid anchor versus side to side repair. Uh, uh, and I've been doing that. For these patients over time, but I can tell you that my failure rate of subscapularis is very low with this technique, and I think it's More related to the fact that the implant size, because it's narrower as they rotate their shoulder, that, that, the stresses on the subscapularis are much less. And we actually, uh, with some of the engineers at FAU have started an FEA study looking at the muscular uh forces that occur with the different shape implants and, and are seeing some very interesting data to start with. We're good. Um, like I said, guys, if there are, are any more questions, please continue to feed them through. So, I guess one of the things, uh, Doctor Miniachi, in terms of looking ahead and just based on your, based on what you've seen in your, in your years and kind of what you're seeing now, uh, what outcome measures do you think best capture the success of the implant that you discussed? Um, whether it's, you know, return to sport, work, Yeah. So, I, I, you know, I decided that if we were gonna do this, we needed to get patients back as close to normal. So if we were going to say, hey, we're trying to replace your shoulder to as close to normal as possible, the patients wanted to do that. And so that I don't, after I am happy with their result in terms of their range of motion, their strength, I don't restrict anybody from any activity, so that, uh, you saw, you, you, you saw, I put his video on the screen for you to see because that's the, the worst-case scenario in terms of stresses on your shoulder, or the guy who's powerlifting that amount of weight. And, you know, he's now like almost 10 years, and uh has, has not come to revision, is not having any loosening, any problems. So, if he can do that, then the rest of us can do all the activities that we please. And so that, uh, that's one of my major goals is allowing patients to go back to what they really want to. So that, whether it's tennis, overhead sports, you know, or it's something as, as minor as golf, you know, which you can go back to with the other replacement. I don't limit anybody in their, in their activities. The second thing is, is that there is an appreciable difference in the ranges of motion that patients get with this implant compared to even other anatomic shoulder replacements or what they call anatomic. So some of our other designs that exist out there, these patients get a better range of motion. And I think everybody knows that when they do them, they can see that the patients actually end up with a better range of motion. So, I think range of motion and function, Uh, and when you have adequate pain relief, cause I'll be honest with you, other anatomic shoulder replacements get great pain relief. And so I can't say that this gets you better pain relief because they all get better pain relief. But this one here specifically has better range of motion and better functional recovery than other replacements. Perfect, perfect. Will it help with pickleball? That was my question. I'm just, yeah, uh, you know what, the pickleball, you just better be worried about your Achilles tendon. Forget about, uh, your shoulder. All right, uh, another question that came in before we close out. Uh, how does a non-intact rotator cuff affect this procedure? So I have um a number of patients who who have small To medium tears that were younger, that we did a rotator cuff replacement in addition to this. Uh, I tell the elderly patients, so, you know, greater than 65 years of age. Um, we discuss it, and I tell them that, you know, at this stage, most people would recommend a reverse shoulder arthroplasty, because if the rotator cuff doesn't heal and it fails, then you have a different issue. But if they're very active individuals and they want to go back to some other sport, I have done rotator cuff repairs in addition to this replacement. So, if it's a non-reparable rotator cuff tear or there's significant atrophy, Uh, with retraction of the tear, then I think that unfortunately, and they're older patients, then I think unfortunately, they're destined for a reverse shoulder replacement. So that's basically the two things that I do, you know, is this is my shoulder replacement if the rotator cuff is intact or if I can repair the rotator cuff in a younger patient. Uh, otherwise, um, I do a reverse replacement. So that, this is my two options. OK, perfect. All right, I think we, we've hit the end of the questions that have uh have been submitted thus far. But, you know, I definitely wanna give you the opportunity for, you know, closing remarks or final remarks just to kinda summarize your points and just kinda, you know, keep people thinking, um, regarding this procedure and to continue to explore, uh, everything that we have going on here at Baptist Health Orthopedic Care and elsewhere, uh, for, for future information. No, I'm just uh uh thankful for all of you to allow me to present this. This is, as you can tell, this has sort of been a lifelong Uh, journey for me. And, you know, at the beginning, uh, uh, what I was saying was a bit heretical. People were looking at it saying, is he crazy? What's he doing? And it's nice to see now that, uh, you know, this is becoming more and more accepted. And I think that people are starting to recognize that, you know, this actually might be the solution and a simpler solution for a lot of our, uh, difficult reconstructive problems that we see in patients with primary shoulder arthritis. So thanks everybody for showing up. Excellent, excellent. Well, thank you very much, Doctor Miniaci. The presentation was amazing. Uh, thank you all for uh the opportunity for joining us today. Um, and if you do have further questions and would like more information, uh, regarding the presentation, uh, please visit us, uh, Baptist Health Orthopedic Care within our Baptisthealth.net, uh, site and, you know, reach out and we hope you have a wonderful rest of your day. Enjoy. Thank you.
