WEBVTT 00:00:00.000 --> 00:00:02.399 Imagine you're a professional under the age of 00:00:02.399 --> 00:00:06.059 60, active, perhaps still years away from thinking 00:00:06.059 --> 00:00:09.000 about retirement, and you've suffered a serious 00:00:09.000 --> 00:00:11.580 proximal humeral fracture that's a break right 00:00:11.580 --> 00:00:13.740 near the shoulder joint. A really nasty injury. 00:00:13.960 --> 00:00:16.739 Exactly. And you've had surgery to fix it, maybe 00:00:16.739 --> 00:00:19.300 what's called open reduction internal fixation, 00:00:19.420 --> 00:00:23.699 using plates and screws, or perhaps even a hemiarthroplasty, 00:00:23.879 --> 00:00:26.739 replacing just the ball part of the joint. Standard 00:00:26.739 --> 00:00:30.000 approaches, often. But critically, that surgery 00:00:30.000 --> 00:00:33.100 has failed. You're left with chronic, debilitating 00:00:33.100 --> 00:00:36.460 pain, maybe severe stiffness, and your shoulder 00:00:36.460 --> 00:00:38.420 just isn't working properly. It's not working 00:00:38.420 --> 00:00:40.859 the way you need it to. A devastating situation. 00:00:40.939 --> 00:00:43.000 So what do you do then? What are your options 00:00:43.000 --> 00:00:45.479 when those initial standard treatments haven't 00:00:45.479 --> 00:00:47.659 just not worked, but have arguably made things 00:00:47.659 --> 00:00:50.359 even more complicated? Well. It's one of the 00:00:50.359 --> 00:00:52.399 most challenging scenarios we actually face in 00:00:52.399 --> 00:00:54.780 orthopedic surgery. It must be. It truly is a 00:00:54.780 --> 00:00:57.399 difficult position for both the patient and, 00:00:57.399 --> 00:01:00.840 well, for the surgeon too, unlike The more common 00:01:00.840 --> 00:01:03.700 situations say treating degenerative arthritis 00:01:03.700 --> 00:01:06.000 in an older person who's perhaps less active. 00:01:06.400 --> 00:01:08.519 These are often younger, more demanding patients. 00:01:08.920 --> 00:01:11.799 They've already endured significant trauma. And 00:01:11.799 --> 00:01:13.959 then a subsequent surgical attempt that hasn't 00:01:13.959 --> 00:01:15.780 succeeded. So they've been through a lot already. 00:01:15.980 --> 00:01:18.920 A great deal. And their anatomy is often distorted. 00:01:19.659 --> 00:01:22.540 There's frequently significant bone loss. And 00:01:22.540 --> 00:01:24.459 the surrounding soft tissues, particularly the 00:01:24.459 --> 00:01:27.700 crucial rotator cuff and deltoid muscles. they 00:01:27.700 --> 00:01:31.040 might be quite compromised. So this isn't just 00:01:31.040 --> 00:01:33.879 a simple revision surgery. It's often a complex 00:01:33.879 --> 00:01:36.400 salvage procedure, and it's happening in a biological 00:01:36.400 --> 00:01:38.900 environment that's much less forgiving. And today 00:01:38.900 --> 00:01:40.680 on The Deep Dive, we're going to immerse ourselves 00:01:40.680 --> 00:01:43.579 in exactly that complex scenario. We're doing 00:01:43.579 --> 00:01:46.579 a deep dive into the treatment options for patients 00:01:46.579 --> 00:01:49.879 younger than 60 who face these failed initial 00:01:49.879 --> 00:01:52.260 surgeries, either that open reduction internal 00:01:52.260 --> 00:01:57.019 fixation, which we'll call ORIF or a hemi arthroplasty 00:01:57.019 --> 00:02:00.700 for these proximal humeral fractures. And specifically, 00:02:00.799 --> 00:02:02.859 our focus today is on a procedure that's become 00:02:02.859 --> 00:02:05.799 increasingly common for difficult shoulder problems 00:02:05.799 --> 00:02:09.139 generally. But it carries quite unique considerations 00:02:09.139 --> 00:02:12.509 in this younger sort of salvage context. Which 00:02:12.509 --> 00:02:15.430 procedure is that? That's the reverse total shoulder 00:02:15.430 --> 00:02:18.789 arthroplasty, or RTSA. Ah, yes, RTSA. As you 00:02:18.789 --> 00:02:21.129 touched upon, this is where the traditional mechanics 00:02:21.129 --> 00:02:23.969 are essentially flipped. The ball part of the 00:02:23.969 --> 00:02:26.930 joint is fixed to the shoulder blade, the glenoid, 00:02:26.969 --> 00:02:29.150 and the socket part is attached to the arm bone, 00:02:29.490 --> 00:02:33.090 the humerus. OK. And this design, it can leverage 00:02:33.090 --> 00:02:36.469 the deltoid muscle to provide function, effectively 00:02:36.469 --> 00:02:39.169 bypassing a damaged or deficient rotator cuff. 00:02:39.280 --> 00:02:41.360 Which is often the problem after these failed 00:02:41.360 --> 00:02:43.319 fracture treatments. Precisely. It's very common 00:02:43.319 --> 00:02:46.860 in this group. Exactly. So while RTSA has, well, 00:02:47.060 --> 00:02:49.479 it's really revolutionized treatment for things 00:02:49.479 --> 00:02:52.180 like rotator cuff terepathy in older populations. 00:02:52.180 --> 00:02:54.400 Absolutely. Applying it as a salvage procedure 00:02:54.400 --> 00:02:56.919 in younger patients after failed fracture fixation 00:02:56.919 --> 00:03:00.020 or heme arthroplasty. Yeah. That's a different 00:03:00.020 --> 00:03:01.919 proposition altogether, isn't it? It really is. 00:03:01.960 --> 00:03:03.699 It's a much higher stakes game, you could say. 00:03:04.180 --> 00:03:06.319 And the long term results, they haven't always 00:03:06.319 --> 00:03:08.659 been clear. which is why we're focusing today 00:03:08.659 --> 00:03:11.599 on this really critical long -term study. It 00:03:11.599 --> 00:03:13.460 was published in the Journal of Shoulder and 00:03:13.460 --> 00:03:16.800 Elbow Surgery, and this paper specifically examines 00:03:16.800 --> 00:03:20.120 the outcomes of using the salvage RTSA in this 00:03:20.120 --> 00:03:23.460 precise patient group under 60 failed previous 00:03:23.460 --> 00:03:25.960 surgery for a proximal humeral fracture. And 00:03:25.960 --> 00:03:27.439 you were involved in this research, weren't you? 00:03:27.500 --> 00:03:29.659 That's right. Yes, this research represents a 00:03:29.659 --> 00:03:32.159 significant effort to track these really challenging 00:03:32.159 --> 00:03:35.139 cases over quite an extended period. So tell 00:03:35.139 --> 00:03:37.659 us about the patients. Well, the study cohort, 00:03:37.659 --> 00:03:40.599 it consisted of 30 patients who met these specific 00:03:40.599 --> 00:03:43.900 criteria. Under the age of 60 at the time, they 00:03:43.900 --> 00:03:46.620 had the salvage RTSA procedure. OK. Their mean 00:03:46.620 --> 00:03:50.419 age was 52. And importantly, they had a substantial 00:03:50.419 --> 00:03:53.680 mean follow up period of 11 years. that range 00:03:53.680 --> 00:03:56.360 from eight right up to 18 years. 11 years mean 00:03:56.360 --> 00:03:59.400 follow -up is significant. It is crucial because 00:03:59.400 --> 00:04:02.000 the true durability and the potential long -term 00:04:02.000 --> 00:04:04.620 issues of any joint replacement, but especially 00:04:04.620 --> 00:04:07.099 in younger, more active patients, well, they 00:04:07.099 --> 00:04:08.960 only really become apparent over many years, 00:04:09.099 --> 00:04:10.719 don't they? Absolutely. You need that long view. 00:04:10.819 --> 00:04:13.120 You do. So this study aimed to provide exactly 00:04:13.120 --> 00:04:15.729 that necessary long -term perspective. And this 00:04:15.729 --> 00:04:18.769 perspective is so vital because, as the paper's 00:04:18.769 --> 00:04:21.350 background really lays out, whilst many proximal 00:04:21.350 --> 00:04:23.649 humeral fractures can actually be managed non 00:04:23.649 --> 00:04:25.310 -operatively... That's true for the majority. 00:04:25.589 --> 00:04:28.310 ...the severe or displaced ones often need surgery. 00:04:28.769 --> 00:04:31.779 But when that ORE fails... Perhaps the screws 00:04:31.779 --> 00:04:35.180 back out, or the bony bits the rotator cuff attaches 00:04:35.180 --> 00:04:39.480 to, the tuberosities, they just don't heal. Or 00:04:39.480 --> 00:04:42.439 when a hemiarthroplasty fails, maybe due to the 00:04:42.439 --> 00:04:44.879 socket wearing away, the glenoid erosion, or 00:04:44.879 --> 00:04:46.959 just persistent pain from those tuberosities 00:04:46.959 --> 00:04:49.560 not healing. Well, you're left with a shoulder 00:04:49.560 --> 00:04:52.139 that's often far worse than if the fracture hadn't 00:04:52.139 --> 00:04:55.699 been operated on in the first place. That can 00:04:55.699 --> 00:04:58.720 happen. You see pain, severe stiffness, dysfunction, 00:04:59.439 --> 00:05:01.879 and often significant loss of bone or deformity. 00:05:02.000 --> 00:05:04.220 That's the reality, isn't it? It is. It's a grim 00:05:04.220 --> 00:05:07.100 landscape. And RTSA is considered here because, 00:05:07.339 --> 00:05:09.480 frankly, the other options are even less predictable. 00:05:09.680 --> 00:05:12.199 What sort of other options? Well, traditional 00:05:12.199 --> 00:05:14.540 things like trying to revise the ORIF, do it 00:05:14.540 --> 00:05:16.560 again, that's often just not feasible because 00:05:16.560 --> 00:05:19.139 of the bone loss. Or if you try it, it carries 00:05:19.139 --> 00:05:22.110 equally high failure rates in this setting. Revision 00:05:22.110 --> 00:05:24.769 hemi arthroplasty, replacing the hemi again. 00:05:24.930 --> 00:05:27.189 That's often contraindicated if there's significant 00:05:27.189 --> 00:05:30.110 glenoid wear. Or if the rotator cuff is clearly 00:05:30.110 --> 00:05:32.209 non -functional because those two porosities 00:05:32.209 --> 00:05:35.089 haven't healed or are gone. So the options are 00:05:35.089 --> 00:05:37.790 really limited. Very limited. So RTSA emerges 00:05:37.790 --> 00:05:40.870 as this potential solution. It uses the deltoid 00:05:40.870 --> 00:05:42.889 muscle as the primary motor for the shoulder, 00:05:43.170 --> 00:05:45.250 even though the underlying anatomy is highly 00:05:45.250 --> 00:05:48.790 compromised by the previous surgery and the original 00:05:48.790 --> 00:05:51.660 injury itself. So the key question this study 00:05:51.660 --> 00:05:54.899 really sought to answer was, what are the long 00:05:54.899 --> 00:05:57.779 -term consequences and indeed the benefits of 00:05:57.779 --> 00:06:00.879 applying RTSA in this specific highly challenging 00:06:00.879 --> 00:06:03.120 younger group? And the central tension, the sort 00:06:03.120 --> 00:06:05.620 of headline finding of the paper, it's quite 00:06:05.620 --> 00:06:08.060 stark, isn't it? It presents a real paradox for 00:06:08.060 --> 00:06:10.339 clinicians and patients who are considering this 00:06:10.339 --> 00:06:12.839 path. It is very much so. The study's primary 00:06:12.839 --> 00:06:16.000 conclusion is, well, it's unequivocal. Salvage 00:06:16.000 --> 00:06:18.420 RTSA in this younger cohort is associated with 00:06:18.420 --> 00:06:20.800 a very high complication rate. You simply cannot 00:06:20.800 --> 00:06:23.500 look at this data and ignore that reality. There 00:06:23.500 --> 00:06:27.639 is. And it's an important but. The equally important 00:06:27.639 --> 00:06:30.379 part of the conclusion, the part that offers 00:06:30.379 --> 00:06:34.019 maybe a glimmer of hope in a very difficult situation, 00:06:34.600 --> 00:06:37.060 is that despite this high rate of complications, 00:06:38.000 --> 00:06:41.360 the procedure can lead to worthwhile and durable 00:06:41.360 --> 00:06:44.360 long -term improvement in pain and function if, 00:06:44.379 --> 00:06:46.680 and it's a big if, if those complications could 00:06:46.680 --> 00:06:49.660 be successfully managed without having to remove 00:06:49.660 --> 00:06:51.800 the implant entirely. Okay, let's really unpack 00:06:51.800 --> 00:06:53.439 that because that's a statement that requires 00:06:53.439 --> 00:06:56.100 some careful thought, high risk, but potentially 00:06:56.100 --> 00:06:59.240 high reward if the implant stays in. Let's start 00:06:59.240 --> 00:07:02.399 with the reward side, the potential upside. What 00:07:02.399 --> 00:07:04.560 did the study find? In terms of the functional 00:07:04.560 --> 00:07:06.639 improvements, the subjective improvements for 00:07:06.639 --> 00:07:09.540 those patients where the RTSA was actually retained. 00:07:09.720 --> 00:07:12.199 OK, so for the 24 patients who still had their 00:07:12.199 --> 00:07:14.560 RTSA implant in place at the final follow -up, 00:07:14.600 --> 00:07:16.639 and remember, this is a mean of 11 years after 00:07:16.639 --> 00:07:18.420 the surgery. Right, long term. The functional 00:07:18.420 --> 00:07:20.740 gains were substantial, really quite substantial. 00:07:20.939 --> 00:07:22.819 Looking at objective measures like the constant 00:07:22.819 --> 00:07:25.379 score, which is a widely accepted functional 00:07:25.379 --> 00:07:27.959 assessment for the shoulder. Yeah, the mean relative 00:07:27.959 --> 00:07:30.060 constant score improved dramatically. It went 00:07:30.060 --> 00:07:32.959 from a very low preoperative baseline of just 00:07:32.959 --> 00:07:38.040 25 % up to 58%. Wow, a constant score of 25%. 00:07:38.379 --> 00:07:41.180 That suggests a shoulder that's barely functional, 00:07:41.399 --> 00:07:43.879 doesn't it? Causing significant disability. Absolutely. 00:07:43.980 --> 00:07:47.199 It's very low. So jumping to 58%, that's a really 00:07:47.199 --> 00:07:49.579 clinically significant improvement. It doesn't 00:07:49.579 --> 00:07:52.600 necessarily mean, I suppose, a return to a completely 00:07:52.600 --> 00:07:55.300 normal pain -free shoulder, like before the injury? 00:07:55.519 --> 00:07:57.980 No, generally not. But it suggests a move away 00:07:57.980 --> 00:08:00.459 from severe disability towards a level that might 00:08:00.459 --> 00:08:03.860 allow for many activities of daily living, perhaps 00:08:03.860 --> 00:08:06.480 even some light work. That's exactly right. That 00:08:06.480 --> 00:08:08.660 magnitude of improvement really indicates just 00:08:08.660 --> 00:08:10.980 how severely compromised these patients were 00:08:10.980 --> 00:08:13.860 before the RTSA. And what about how the patients 00:08:13.860 --> 00:08:16.600 themselves felt, the subjective view? Yes, the 00:08:16.600 --> 00:08:19.319 subjective shoulder value, the SSV. This captures 00:08:19.319 --> 00:08:21.319 the patient's own perception of their shoulders 00:08:21.319 --> 00:08:23.319 function, usually as a percentage compared to 00:08:23.319 --> 00:08:26.439 a normal shoulder. That also saw mirroring. improvement. 00:08:26.560 --> 00:08:29.199 It rose from a mean of only 20 % preoperatively 00:08:29.199 --> 00:08:32.899 up to 56%. So they felt a marked improvement 00:08:32.899 --> 00:08:35.139 in how useful their shoulder actually was to 00:08:35.139 --> 00:08:37.799 them day to day. They did. A very significant 00:08:37.799 --> 00:08:40.220 perceived improvement. And range of motion. That's 00:08:40.220 --> 00:08:42.519 often terribly limited after failed fracture 00:08:42.519 --> 00:08:44.919 fixation, isn't it? Especially lifting the arm 00:08:44.919 --> 00:08:47.360 up. Yes, and significant improvements were seen 00:08:47.360 --> 00:08:50.720 here too. Active anterior elevation, so lifting 00:08:50.720 --> 00:08:53.679 the arm forward, increased from a mean of just 00:08:53.960 --> 00:08:57.279 45 degrees preoperatively. Very restricted. Very. 00:08:57.639 --> 00:09:00.379 Up to 106 degrees at follow -up. Okay. That's 00:09:00.379 --> 00:09:02.940 over the horizontal. It is. An active abduction 00:09:02.940 --> 00:09:05.120 lifting the arm out to the side went from 42 00:09:05.120 --> 00:09:08.639 degrees up to 99 degrees. Again, functionally 00:09:08.639 --> 00:09:11.000 important gains. Crucial gains, especially getting 00:09:11.000 --> 00:09:13.500 over that 90 degree mark for elevation and abduction 00:09:13.500 --> 00:09:15.980 that's so important for reaching and performing 00:09:15.980 --> 00:09:19.000 many basic tasks. And pain. Pain scores also 00:09:19.000 --> 00:09:21.759 saw significant reductions and perhaps surprisingly 00:09:21.759 --> 00:09:24.840 even strength improved notably. Really? Strength 00:09:24.840 --> 00:09:27.500 improved too. Yes. The study highlights that 00:09:27.500 --> 00:09:29.799 all of these functional and subjective improvements 00:09:29.799 --> 00:09:32.820 were statistically highly significant. We're 00:09:32.820 --> 00:09:37.039 talking p values less than 0 .0001. So very unlikely 00:09:37.039 --> 00:09:40.960 to be due to chance. Extremely unlikely. Less 00:09:40.960 --> 00:09:44.220 than a 1 in 1000 chance that these observed improvements 00:09:44.220 --> 00:09:47.830 were just random variation. That level of statistical 00:09:47.830 --> 00:09:50.730 significance really underscores the robustness 00:09:50.730 --> 00:09:52.889 of the finding, at least for those patients with 00:09:52.889 --> 00:09:55.110 retained implants. And you mentioned the follow 00:09:55.110 --> 00:09:58.730 -up was long -term, a mean of 11 years. Did the 00:09:58.730 --> 00:10:01.370 paper comment on whether these functional gains 00:10:01.370 --> 00:10:03.690 held up over that extended period? Did they last? 00:10:03.830 --> 00:10:06.169 Yes. And that's a really key point about the 00:10:06.169 --> 00:10:08.669 durability, isn't it? The study specifically 00:10:08.669 --> 00:10:11.370 looked at the outcomes over time, and it confirmed 00:10:11.370 --> 00:10:13.570 that the functional gains achieved at earlier 00:10:13.570 --> 00:10:16.139 time points, they were largely maintained. even 00:10:16.139 --> 00:10:18.860 beyond 10 years postoperatively for the patients 00:10:18.860 --> 00:10:20.980 whose implants remain in place. That's encouraging. 00:10:21.340 --> 00:10:24.000 It is. It suggests that when salvage RTSA works 00:10:24.000 --> 00:10:26.259 in this population, it could provide a lasting 00:10:26.259 --> 00:10:28.379 improvement, which is crucial given the younger 00:10:28.379 --> 00:10:30.379 age of these patients. They need something that 00:10:30.379 --> 00:10:33.879 lasts. OK. So the potential upside is clear. 00:10:34.960 --> 00:10:37.720 Significant, durable functional recovery possible 00:10:37.720 --> 00:10:42.500 for a severely damaged shoulder. But now, now 00:10:42.500 --> 00:10:44.360 we must confront the other side of the quail. 00:10:44.940 --> 00:10:47.379 The side that makes this procedure such a complex 00:10:47.379 --> 00:10:50.419 clinical decision, that very high complication 00:10:50.419 --> 00:10:52.440 rate you mentioned earlier. Yes. What were the 00:10:52.440 --> 00:10:54.360 numbers the study reported there? Well, this 00:10:54.360 --> 00:10:56.620 is where the challenge really lies. The study 00:10:56.620 --> 00:10:59.340 found that 18 out of the 30 patients in the cohort. 00:10:59.600 --> 00:11:02.240 That's a substantial 60 percent. 60 percent. 00:11:02.500 --> 00:11:04.960 Experienced one or more postoperative complications 00:11:04.960 --> 00:11:09.059 following their salvage RTSA. 60 percent. Wow. 00:11:09.389 --> 00:11:11.370 More than half of the patients undergoing this 00:11:11.370 --> 00:11:13.610 specific procedure in the study experienced a 00:11:13.610 --> 00:11:16.389 problem afterwards. And how did these complications 00:11:16.389 --> 00:11:18.970 then translate into needing more surgery or, 00:11:18.970 --> 00:11:21.029 you know, worst case scenario, failure of the 00:11:21.029 --> 00:11:23.149 implant itself? Well, the rate of revision surgery 00:11:23.149 --> 00:11:26.450 was also high. The paper reported that 11 open 00:11:26.450 --> 00:11:28.450 revisions were either performed or planned to 00:11:28.450 --> 00:11:30.730 be performed in 10 of the patients. 10 out of 00:11:30.730 --> 00:11:34.509 30. Yes, representing 36 % of the original cohort. 00:11:35.289 --> 00:11:38.129 And these revisions, they often occurred relatively 00:11:38.129 --> 00:11:40.870 late. The average time for the index salvage 00:11:40.870 --> 00:11:44.029 RTSA to the revision procedure was 71 months. 00:11:44.190 --> 00:11:47.190 71 months. That's nearly six years later. Almost 00:11:47.190 --> 00:11:50.110 six years on average. So over a third of patients 00:11:50.110 --> 00:11:53.090 needed another significant operation to try and 00:11:53.090 --> 00:11:55.590 deal with issues arising from the RTSA itself. 00:11:56.250 --> 00:11:58.789 And what about the ultimate failure rate where 00:11:58.789 --> 00:12:01.090 the implant just couldn't be salvaged and had 00:12:01.090 --> 00:12:02.909 to come out? The study defined failure quite 00:12:02.909 --> 00:12:04.990 stringently actually. It included explantation 00:12:04.990 --> 00:12:07.389 of the RTSA that's removing the implant entirely. 00:12:07.509 --> 00:12:10.200 Right. conversion back to a hemiarthroplasty, 00:12:10.240 --> 00:12:13.340 which is a rare and often problematic step, or 00:12:13.340 --> 00:12:15.720 insertion of a cement spacer, which is typically 00:12:15.720 --> 00:12:18.139 a temporary measure, often used to manage deep 00:12:18.139 --> 00:12:20.580 infection. So by that definition, six patients 00:12:20.580 --> 00:12:23.740 out of the 30, that's 20 % of the cohort, were 00:12:23.740 --> 00:12:26.379 classified as failures. One in five. One in five. 00:12:26.519 --> 00:12:28.779 This is a significant number. It represents one 00:12:28.779 --> 00:12:31.419 in five patients where the salvage RTSA just 00:12:31.419 --> 00:12:34.419 did not provide a lasting solution and the implant 00:12:34.419 --> 00:12:36.600 ultimately had to be abandoned. So let me just 00:12:36.600 --> 00:12:40.120 recap that. for a younger patient under 60. With 00:12:40.120 --> 00:12:43.259 a failed fracture fixation or heme arthroplasty, 00:12:43.419 --> 00:12:46.700 considering a salvage RTSA, they face roughly 00:12:46.700 --> 00:12:49.639 a 60 % chance of some kind of complication. Correct. 00:12:49.779 --> 00:12:52.519 A 36 % chance of needing another revision surgery 00:12:52.519 --> 00:12:55.000 down the line, possibly years later. Yes. And 00:12:55.000 --> 00:12:57.700 a 20 % chance that the whole procedure will ultimately 00:12:57.700 --> 00:13:00.620 fail, requiring removal of the implant. Those 00:13:00.620 --> 00:13:02.799 are the figures from this study, yes. Those are 00:13:02.799 --> 00:13:05.840 really sobering statistics. They absolutely highlight 00:13:05.840 --> 00:13:08.419 the high -risk nature of this specific procedure 00:13:08.419 --> 00:13:11.830 in this. specific patient group. Now, given these 00:13:11.830 --> 00:13:14.129 risks, the paper also looked at factors that 00:13:14.129 --> 00:13:16.169 might predict who is more likely to have these 00:13:16.169 --> 00:13:18.149 complications or perhaps less successful outcomes. 00:13:18.889 --> 00:13:21.090 What were the key associations they identified? 00:13:21.309 --> 00:13:24.269 Yes, this is critical, isn't it? For informing 00:13:24.269 --> 00:13:27.009 patient selection and, indeed, surgical planning, 00:13:27.649 --> 00:13:29.590 the study found a strong association between 00:13:29.590 --> 00:13:31.629 the number of previous surgical procedures on 00:13:31.629 --> 00:13:34.070 that shoulder and the likelihood of postoperative 00:13:34.070 --> 00:13:36.750 complications. That makes sense. It does. Patients 00:13:36.750 --> 00:13:38.570 with more prior surgeries were significantly 00:13:38.570 --> 00:13:41.549 more likely to experience issues. The p -value 00:13:41.549 --> 00:13:45.299 was 0 .005. So, highly significant statistically. 00:13:45.500 --> 00:13:48.179 Yes. It really underscores the cumulative damage 00:13:48.179 --> 00:13:50.159 that happens with each operation. You get scar 00:13:50.159 --> 00:13:52.320 tissue, altered anatomy, potential compromise 00:13:52.320 --> 00:13:55.600 of blood supply, the soft tissues. It just creates 00:13:55.600 --> 00:13:57.980 a much more hostile environment for further implant 00:13:57.980 --> 00:13:59.960 surgery. Right. The more times you've been in 00:13:59.960 --> 00:14:01.879 there, the harder it gets to achieve a good result 00:14:01.879 --> 00:14:05.240 the next time. What else significantly increased 00:14:05.240 --> 00:14:08.600 the risk? A documented history of infection prior 00:14:08.600 --> 00:14:11.789 to the salvage RTSA. That was another major predictor 00:14:11.789 --> 00:14:14.669 of complications, and this was striking. All 00:14:14.669 --> 00:14:16.610 seven patients in the study who had a history 00:14:16.610 --> 00:14:19.610 of infection experienced post -operative complications 00:14:19.610 --> 00:14:22.490 after the RTSA. All of them. Every single one. 00:14:22.870 --> 00:14:26.570 The p -value there was .048. Just a powerful 00:14:26.570 --> 00:14:28.529 reminder that eradicating infection, especially 00:14:28.529 --> 00:14:31.110 around orthopedic implants, is incredibly difficult, 00:14:31.129 --> 00:14:33.549 and a history of infection significantly escalates 00:14:33.549 --> 00:14:36.210 the risk of it recurring or other related complications 00:14:36.210 --> 00:14:38.590 happening with the next surgery. So if infection 00:14:38.590 --> 00:14:40.690 was part of the reason the initial surgery failed 00:14:40.690 --> 00:14:42.970 in the first place, carrying that history into 00:14:42.970 --> 00:14:45.710 the RTSA setting, it almost guarantees future 00:14:45.710 --> 00:14:48.149 problems based on this data. It carries a very, 00:14:48.149 --> 00:14:50.970 very high risk, yes. The nature of the previous 00:14:50.970 --> 00:14:53.389 failed surgery also seemed to matter. How so? 00:14:53.529 --> 00:14:55.970 Well, salvage RTSA performed for a failed heme 00:14:55.970 --> 00:14:58.710 arthroplasty was associated with a higher overall 00:14:58.710 --> 00:15:01.629 complication rate compared to salvage RTSA performed 00:15:01.629 --> 00:15:05.669 after a failed ORF. OK. Specifically. 19 out 00:15:05.669 --> 00:15:08.870 of the 23 patients who had a failed hemiarthroplasty 00:15:08.870 --> 00:15:11.750 went on to have complications after their RTSA. 00:15:12.009 --> 00:15:15.090 That p -value was 0 .014. That's interesting. 00:15:15.370 --> 00:15:17.250 Why might that be? Well, it's an interesting 00:15:17.250 --> 00:15:19.929 finding. It might suggest that the reasons why 00:15:19.929 --> 00:15:22.149 the hemiarthroplasty failed in this particular 00:15:22.149 --> 00:15:25.509 cohort, perhaps severe tuberosity resorption 00:15:25.509 --> 00:15:28.169 or significant glenoid erosion, were on the socket 00:15:28.169 --> 00:15:30.950 side. Right. Did these create a more complex 00:15:30.950 --> 00:15:33.389 biomechanical and soft tissue challenge for a 00:15:33.389 --> 00:15:36.000 subsequent RTSA? compared to the issues you typically 00:15:36.000 --> 00:15:39.279 see after a failed ORF, like screw cut out or 00:15:39.279 --> 00:15:41.820 simple non -union. That resonates clinically. 00:15:42.100 --> 00:15:44.440 Dealing with poor bone stock on both sides of 00:15:44.440 --> 00:15:46.899 the joint? Potentially significant soft tissue 00:15:46.899 --> 00:15:49.399 deficiency after a failed hemi? That does sound 00:15:49.399 --> 00:15:51.200 much more challenging than revising a failed 00:15:51.399 --> 00:15:53.600 plate and screw construct, generally speaking. 00:15:53.759 --> 00:15:56.600 It often is, yes. Did the study also look at 00:15:56.600 --> 00:15:59.799 implant -specific factors? Did the type of RTSA 00:15:59.799 --> 00:16:03.139 used matter? Yes, they did. They found an association 00:16:03.139 --> 00:16:05.259 between the use of older generation implants 00:16:05.259 --> 00:16:08.379 specifically. They mentioned the Delta III RTSA 00:16:08.379 --> 00:16:11.679 design and a higher complication rate. OK. 17 00:16:11.679 --> 00:16:13.799 out of the 20 patients who received that specific 00:16:13.799 --> 00:16:17.299 Delta implant experienced complications. The 00:16:17.299 --> 00:16:21.159 p -value was 0 .018. Now, the authors rightly 00:16:21.159 --> 00:16:23.379 acknowledge the limitations of a retrospective 00:16:23.379 --> 00:16:25.820 study, and obviously surgical techniques evolve 00:16:25.820 --> 00:16:28.299 over time. Of course. But this finding does hint 00:16:28.299 --> 00:16:31.059 that advancements in implant design and perhaps 00:16:31.059 --> 00:16:33.139 the surgical protocols associated with newer 00:16:33.139 --> 00:16:35.700 implants might well influence the outcomes. That's 00:16:35.700 --> 00:16:38.120 a crucial point for clinicians, isn't it? Being 00:16:38.120 --> 00:16:40.440 aware that the results reported might be influenced 00:16:40.440 --> 00:16:42.700 by the specific generation of the prosthesis 00:16:42.700 --> 00:16:44.740 used and the techniques that were contemporary 00:16:44.740 --> 00:16:47.389 at that time. The paper also noted a particularly 00:16:47.389 --> 00:16:49.990 high infection rate within the study cohort itself 00:16:49.990 --> 00:16:52.850 after the RTSA. Yes, the overall rate of infection 00:16:52.850 --> 00:16:56.450 post -salvage RTSA was noted as 27 % across the 00:16:56.450 --> 00:17:00.279 whole cohort. 27 %? That seems very high compared 00:17:00.279 --> 00:17:02.980 to primary RTSA for other reasons like arthritis. 00:17:03.200 --> 00:17:06.299 It is high. And it further highlights the compromised 00:17:06.299 --> 00:17:09.380 state of these revision shoulders. Hmm. Consistent 00:17:09.380 --> 00:17:11.500 with the other findings, factors significantly 00:17:11.500 --> 00:17:13.880 associated with this post -operative infection 00:17:13.880 --> 00:17:16.339 included, again, the number of previous surgeries 00:17:16.339 --> 00:17:20.299 and obviously a prior documented infection. The 00:17:20.299 --> 00:17:22.440 study did note, however, that their management 00:17:22.440 --> 00:17:25.019 protocol for dealing with infection before performing 00:17:25.019 --> 00:17:28.960 the RTSA, typically a staged approach using antibiotic 00:17:28.960 --> 00:17:31.759 -laden cement spacers, that appeared effective 00:17:31.759 --> 00:17:34.039 in controlling the infection before the RTSA 00:17:34.039 --> 00:17:36.059 was put in, which aligns with other research 00:17:36.059 --> 00:17:39.170 in the field. But controlling the infection beforehand 00:17:39.170 --> 00:17:42.250 doesn't eliminate the risk of it recurring or 00:17:42.250 --> 00:17:44.309 other complications cropping up once a large 00:17:44.309 --> 00:17:46.869 foreign body, the implant, is placed back into 00:17:46.869 --> 00:17:49.269 that environment. So even doing everything right, 00:17:49.349 --> 00:17:51.990 using staged procedures with spacers to clear 00:17:51.990 --> 00:17:54.549 a pre -existing infection, it doesn't wipe the 00:17:54.549 --> 00:17:57.190 slate clean. There's still a high risk of complications, 00:17:57.589 --> 00:17:59.670 including infection, after the RTSA in these 00:17:59.670 --> 00:18:01.930 complex cases. That's what this data suggests, 00:18:02.109 --> 00:18:05.339 yes. Yes. The risk remains elevated. OK. Beyond 00:18:05.339 --> 00:18:07.819 just complications, were there specific factors 00:18:07.819 --> 00:18:10.799 linked to inferior functional outcomes? So even 00:18:10.799 --> 00:18:13.500 if the implant remained in place, did some patients 00:18:13.500 --> 00:18:16.859 do less well functionally? Yes. The type of prior 00:18:16.859 --> 00:18:19.059 failed surgery also seemed to impact the level 00:18:19.059 --> 00:18:21.779 of functional recovery achieved. The study found 00:18:21.779 --> 00:18:25.119 that salvage RTSA performed for a failed secondary 00:18:25.119 --> 00:18:27.720 hemiarthroplasty. What does secondary mean here? 00:18:27.839 --> 00:18:29.519 It means the patient had already had at least 00:18:29.519 --> 00:18:32.539 two previous surgeries before the RTSA was even 00:18:32.539 --> 00:18:35.589 considered. So perhaps ORIF then HEMI, or HEMI 00:18:35.589 --> 00:18:38.589 then revision HEMI, before the RTSA. Okay, multiple 00:18:38.589 --> 00:18:41.009 prior surgeries. Exactly. And in those cases, 00:18:41.150 --> 00:18:43.869 the salvage RTSA resulted in significantly inferior 00:18:43.869 --> 00:18:46.230 active abduction, lifting the arm out sideways 00:18:46.230 --> 00:18:48.750 compared to salvage RTSA for a failed ORIF. How 00:18:48.750 --> 00:18:50.769 much inferior? The mean abduction was just 77 00:18:50.769 --> 00:18:53.750 degrees after failed secondary HEMI versus 116 00:18:53.750 --> 00:18:56.730 degrees after failed ORIF. That difference was 00:18:56.730 --> 00:18:59.190 statistically significant. P equals marrow point 00:18:59.190 --> 00:19:02.289 zero two three. Okay, so multiple previous surgeries 00:19:02.480 --> 00:19:05.539 And then, specifically, a failed hemiarthroplasty 00:19:05.539 --> 00:19:09.140 before the RTSA seems to result in significantly 00:19:09.140 --> 00:19:11.700 less ability to lift the arm out to the side 00:19:11.700 --> 00:19:14.400 compared to someone who maybe just had a single 00:19:14.400 --> 00:19:16.940 failed aura half as their only prior surgery. 00:19:17.160 --> 00:19:19.559 That's a finding, yes. That reinforces the idea, 00:19:19.599 --> 00:19:22.119 doesn't it, that the cumulative negative effect 00:19:22.119 --> 00:19:24.940 of prior interventions really impacts the final 00:19:24.940 --> 00:19:27.140 functional result you can expect. Absolutely. 00:19:27.369 --> 00:19:29.849 And furthermore, salvage RTSA performed after 00:19:29.849 --> 00:19:33.210 that failed secondary hemiarthroplasty also yielded 00:19:33.210 --> 00:19:35.930 significantly inferior mean active abduction 00:19:35.930 --> 00:19:39.670 compared to RTSA following a failed primary hemiarthroplasty. 00:19:39.869 --> 00:19:43.529 So worse than just one failed hemi. Yes. 77 degrees 00:19:43.529 --> 00:19:47.829 versus 107 degrees. P value 0 .049. So again, 00:19:47.849 --> 00:19:49.849 it points to the compounding difficulty introduced 00:19:49.849 --> 00:19:52.329 by multiple previous procedures, particularly 00:19:52.329 --> 00:19:54.730 when a failed hemiarthroplasty is part of that 00:19:54.730 --> 00:19:56.789 patient's history. And what about external rotation? 00:19:57.009 --> 00:19:59.089 The ability to turn the arm outwards, that's 00:19:59.089 --> 00:20:00.970 notoriously difficult to recover after these 00:20:00.970 --> 00:20:03.269 proximal humeral fractures, isn't it? Especially 00:20:03.269 --> 00:20:06.130 if those tuberosities, the rotator cuff attachments, 00:20:06.430 --> 00:20:09.390 don't heal properly. Yes, and this study confirmed 00:20:09.390 --> 00:20:13.009 that observation. Even with an RTSA place. They 00:20:13.009 --> 00:20:16.009 found significantly better active external rotation 00:20:16.009 --> 00:20:19.109 when the greater tuberosity had healed properly 00:20:19.109 --> 00:20:22.410 prior to the RTSA or was successfully incorporated 00:20:22.410 --> 00:20:24.569 into the reconstruction. Okay. Compared to when 00:20:24.569 --> 00:20:27.150 it was resorbed, essentially dissolved away or 00:20:27.150 --> 00:20:29.130 had been resected during previous surgeries. 00:20:29.289 --> 00:20:31.750 What was the difference? A mean of 21 degrees 00:20:31.750 --> 00:20:34.470 of external rotation if the tuberosity was healed 00:20:34.470 --> 00:20:36.829 versus a very limited three degrees if it was 00:20:36.829 --> 00:20:40.210 resorbed or resected. That p -value is .025. 00:20:40.349 --> 00:20:42.430 Only three degrees. That's very little outward 00:20:42.430 --> 00:20:45.109 rotation. Very little. And it highlights that 00:20:45.109 --> 00:20:47.549 while RTSA is often described as bypassing the 00:20:47.549 --> 00:20:49.730 need for a functional rotator cuff for elevation, 00:20:50.490 --> 00:20:52.950 the state of those tuberosities still plays a 00:20:52.950 --> 00:20:55.329 crucial role in trying to restore external rotation, 00:20:56.049 --> 00:20:57.730 which is often poor in these failed fracture 00:20:57.730 --> 00:21:00.410 cases, precisely because tuberosity healing is 00:21:00.410 --> 00:21:03.029 so problematic. And did the paper link that poor 00:21:03.029 --> 00:21:06.170 tuberosity status to the failed hemi group? Yes. 00:21:06.490 --> 00:21:08.829 It specifically notes that in seven out of the 00:21:08.829 --> 00:21:11.990 eight patients who had failed secondary hemiarthroplasty, 00:21:12.390 --> 00:21:14.809 the tuberosities were either resorbed or resected. 00:21:15.309 --> 00:21:17.990 And that strongly contributes to their poor abduction 00:21:17.990 --> 00:21:20.250 rotation results compared to the other groups 00:21:20.250 --> 00:21:22.589 in the study. That lobbage is really important, 00:21:22.670 --> 00:21:24.950 isn't it? It's not just about the implant mechanics. 00:21:25.369 --> 00:21:27.970 The residual anatomy and the biological situation 00:21:27.970 --> 00:21:30.470 resulting from the previous failures significantly 00:21:30.470 --> 00:21:33.109 influenced the outcome, even for a complex procedure 00:21:33.109 --> 00:21:36.980 like RTSA. Let's briefly touch on implant survival 00:21:36.980 --> 00:21:39.200 itself and maybe what they saw on imaging on 00:21:39.200 --> 00:21:41.880 the x -rays. Sure. The study provided survival 00:21:41.880 --> 00:21:44.519 estimates using Kaplan -Meier analysis, which 00:21:44.519 --> 00:21:46.500 is a standard statistical method to estimate 00:21:46.500 --> 00:21:48.900 the probability of an event like revision or 00:21:48.900 --> 00:21:51.380 failure happening over time. Okay. They reported 00:21:51.380 --> 00:21:53.420 an overall survival rate of the RTSA without 00:21:53.420 --> 00:21:57.259 needing a revision of 69 % at 10 years. 69 % 00:21:57.259 --> 00:21:59.569 free of revision at 10 years. Correct. Now, if 00:21:59.569 --> 00:22:01.650 you define survival more strictly using failure 00:22:01.650 --> 00:22:04.269 as the endpoint, remember that was explantation, 00:22:04.410 --> 00:22:06.869 conversion, or spacer insertion. Right, the really 00:22:06.869 --> 00:22:08.869 bad outcomes. Then the survival rate was higher, 00:22:09.170 --> 00:22:12.910 79 % at 10 years. OK, so roughly four out of 00:22:12.910 --> 00:22:15.150 five implants were still in place at 10 years, 00:22:15.410 --> 00:22:17.450 even if some had needed revisions along the way. 00:22:17.690 --> 00:22:20.809 That's right. Now, whilst these rates are certainly 00:22:20.809 --> 00:22:24.369 lower than often reported for primary RTSA performed 00:22:24.369 --> 00:22:27.390 for, say, degenerative conditions in older patients. 00:22:27.430 --> 00:22:31.819 Sure. They do provide a realistic benchmark for 00:22:31.819 --> 00:22:34.920 this specific, highly challenging salvage indication 00:22:34.920 --> 00:22:38.079 in a younger population. That's important context. 00:22:38.259 --> 00:22:40.279 And what did the x -rays show over the long term? 00:22:40.380 --> 00:22:42.940 Any common findings? Yes, a very common finding 00:22:42.940 --> 00:22:45.640 on the radiographic side was inferior scapular 00:22:45.640 --> 00:22:48.180 notching. Ah, yes, notching. This is where the 00:22:48.180 --> 00:22:50.019 metal component on the arm bone, the humeral 00:22:50.019 --> 00:22:52.559 component, can rub against the lower edge of 00:22:52.559 --> 00:22:55.099 the shoulder blade socket, the glenoid. It was 00:22:55.099 --> 00:22:57.460 present in a very high proportion, actually 92 00:22:57.460 --> 00:22:59.539 percent of patients with retained implants in 00:22:59.539 --> 00:23:01.740 this study. 92 percent. That's almost everyone. 00:23:02.240 --> 00:23:05.220 Almost everyone showed some degree of it. However, 00:23:05.799 --> 00:23:08.619 and this was quite a key finding, the study found 00:23:08.619 --> 00:23:10.680 that the presence or even the severity of the 00:23:10.680 --> 00:23:13.519 scapular notching was not statistically associated 00:23:13.519 --> 00:23:16.619 with inferior functional or subjective outcomes 00:23:16.619 --> 00:23:19.480 in this specific cohort over the observed period. 00:23:19.640 --> 00:23:22.359 That's surprising because notching is often cited 00:23:22.359 --> 00:23:25.829 as a Potential concern for RTSA longevity and 00:23:25.829 --> 00:23:27.950 outcomes, isn't it? It is often discussed, yes. 00:23:27.990 --> 00:23:30.470 Yeah. But in this difficult salvage setting in 00:23:30.470 --> 00:23:32.829 these younger patients, this paper suggests it 00:23:32.829 --> 00:23:35.450 wasn't the primary driver of poor results, at 00:23:35.450 --> 00:23:38.009 least not within the time frame studied. Interesting. 00:23:38.210 --> 00:23:40.650 Anything else on the x -rays? They also noted 00:23:40.650 --> 00:23:42.869 radiographic lucent lines around the humeral 00:23:42.869 --> 00:23:45.049 component, the part in the arm bone, in about 00:23:45.049 --> 00:23:47.549 25 % of patients. And what do those lines mean? 00:23:47.890 --> 00:23:50.089 Well, lucent lines can sometimes indicate loosening 00:23:50.089 --> 00:23:53.269 of the implant or stress at the bone implant 00:23:53.269 --> 00:23:55.670 interface, and these lines were significantly 00:23:55.670 --> 00:23:58.470 associated with using that older Delta III implant 00:23:58.470 --> 00:24:02.049 model, and also with the need for subsequent 00:24:02.049 --> 00:24:04.950 revision surgery. So that further supports the 00:24:04.950 --> 00:24:08.069 idea that implant design and achieving stable 00:24:08.069 --> 00:24:10.890 fixation at the bone implant interface really 00:24:10.890 --> 00:24:13.130 does play a role in the long -term outcome. Right. 00:24:13.630 --> 00:24:15.930 Now before we wrap up, it's always important, 00:24:16.049 --> 00:24:18.210 as the authors themselves noted, to consider 00:24:18.210 --> 00:24:21.140 the limitations of any study. What were the key 00:24:21.140 --> 00:24:23.960 caveats they highlighted for this research? Well, 00:24:24.019 --> 00:24:25.680 they pointed out quite rightly that it was a 00:24:25.680 --> 00:24:28.660 retrospective study. That means they looked back 00:24:28.660 --> 00:24:31.180 at data that was collected over time, which can 00:24:31.180 --> 00:24:34.279 introduce certain biases compared to a prospective 00:24:34.279 --> 00:24:36.599 study where you follow patients forward under 00:24:36.599 --> 00:24:39.720 a very strict protocol. There was also inevitably 00:24:39.720 --> 00:24:41.599 in a long -term study like this a percentage 00:24:41.599 --> 00:24:43.779 of patients who were lost to follow up about 00:24:43.779 --> 00:24:47.359 11 % in this case. And sadly another 11 % died 00:24:47.359 --> 00:24:49.559 during the study period, which is expected given 00:24:49.559 --> 00:24:51.799 the time frame but can affect the overall power 00:24:51.799 --> 00:24:54.799 and completeness of the analysis. They also acknowledged 00:24:54.799 --> 00:24:57.400 the relatively limited sample size 30 patients 00:24:57.400 --> 00:24:59.990 in total. which meant they had limited statistical 00:24:59.990 --> 00:25:02.509 power for doing very detailed subgroup analyses. 00:25:02.769 --> 00:25:05.170 And finally, they noted that there might be inherent 00:25:05.170 --> 00:25:07.789 differences between the patient groups who initially 00:25:07.789 --> 00:25:12.049 had ORIF versus those who initially had hemiarthroplasty, 00:25:12.269 --> 00:25:15.009 perhaps related to the original injury severity 00:25:15.009 --> 00:25:17.710 or bone quality that weren't fully captured or 00:25:17.710 --> 00:25:20.329 adjusted for in the analysis. Those are standard 00:25:20.329 --> 00:25:23.009 but important limitations to bear in mind when 00:25:23.009 --> 00:25:25.250 we interpret the findings of a study like this 00:25:25.250 --> 00:25:28.319 one. Taking all of this information together 00:25:28.319 --> 00:25:31.920 now, the significant potential for functional 00:25:31.920 --> 00:25:35.180 improvement on the one hand, contrasted with 00:25:35.180 --> 00:25:37.319 that very high risk of complications and failure 00:25:37.319 --> 00:25:39.779 on the other hand, particularly in the context 00:25:39.779 --> 00:25:42.869 of previous surgeries and prior infection. How 00:25:42.869 --> 00:25:45.789 does this paper really frame the overall clinical 00:25:45.789 --> 00:25:48.049 decision making for this challenging group of 00:25:48.049 --> 00:25:50.509 younger patients? Well, I think the paper strongly 00:25:50.509 --> 00:25:53.190 reinforces that salvage RTSA in this population 00:25:53.190 --> 00:25:55.230 is absolutely not a straightforward procedure 00:25:55.230 --> 00:25:57.829 with any guaranteed success. It is clearly associated 00:25:57.829 --> 00:26:00.670 with substantial risks. And those risks are particularly 00:26:00.670 --> 00:26:02.890 influenced by the patient's prior surgical history 00:26:02.890 --> 00:26:06.150 and any history of infection. However, the buddy 00:26:06.150 --> 00:26:09.069 again. The study also presents quite compelling 00:26:09.069 --> 00:26:11.329 evidence that for those patients where the implant 00:26:11.329 --> 00:26:14.210 can be retained, it does offer a level of pain 00:26:14.210 --> 00:26:17.230 relief and functional recovery that may simply 00:26:17.230 --> 00:26:19.890 not be achievable with the other available salvage 00:26:19.890 --> 00:26:22.309 options. If there are any other options left. 00:26:22.609 --> 00:26:25.809 Precisely. It underscores the fact that in these 00:26:25.809 --> 00:26:28.730 severely compromised younger shoulders, all the 00:26:28.730 --> 00:26:31.630 options are difficult. None are without significant 00:26:31.630 --> 00:26:35.279 drawbacks. RTSA, despite that high complication 00:26:35.279 --> 00:26:38.579 rate, emerges as a procedure that can work. But 00:26:38.579 --> 00:26:41.259 it demands really careful patient selection and 00:26:41.259 --> 00:26:43.539 a preparedness, both from the surgeon and the 00:26:43.539 --> 00:26:45.759 patient, for managing the potential issues that 00:26:45.759 --> 00:26:48.200 are quite likely to arise. It really sounds like 00:26:48.200 --> 00:26:50.599 it's often a procedure of last resort, then, 00:26:50.960 --> 00:26:53.259 chosen perhaps out of necessity when other options 00:26:53.259 --> 00:26:55.759 have failed or aren't viable, accepting that 00:26:55.759 --> 00:26:57.920 high likelihood of future problems in exchange 00:26:57.920 --> 00:27:00.880 for the potential for significant, albeit maybe 00:27:00.880 --> 00:27:03.579 imperfect, improvement in a shoulder that is 00:27:03.579 --> 00:27:06.259 otherwise debilitatingly painful and dysfunctional. 00:27:06.460 --> 00:27:08.799 I think that's a fair summary. It forces a very 00:27:08.799 --> 00:27:11.440 difficult conversation, doesn't it, about managing 00:27:11.440 --> 00:27:13.980 expectations and accepting a significant level 00:27:13.980 --> 00:27:16.920 of risk. Exactly. The improvements shown in the 00:27:16.920 --> 00:27:19.119 study are real, and they are meaningful for patients 00:27:19.119 --> 00:27:21.759 starting from such a low baseline with severely 00:27:21.759 --> 00:27:25.579 failed shoulders. But they come at a cost, frequently 00:27:25.579 --> 00:27:27.799 requiring further surgical intervention down 00:27:27.799 --> 00:27:30.220 the line to manage complications, and with that 00:27:30.220 --> 00:27:33.400 non -trivial chance around 1 in 5 of ultimate 00:27:33.400 --> 00:27:36.579 failure requiring implant removal. Well, this 00:27:36.579 --> 00:27:39.220 deep dive has certainly illuminated the complexities 00:27:39.220 --> 00:27:42.279 and the critical data surrounding salvage RTSA 00:27:42.279 --> 00:27:45.400 in this very challenging patient group. If this 00:27:45.400 --> 00:27:47.559 discussion sparked some insights for you, or 00:27:47.559 --> 00:27:50.119 perhaps clarified this difficult clinical scenario, 00:27:50.279 --> 00:27:53.059 please do consider leaving us a rating and perhaps 00:27:53.059 --> 00:27:54.859 sharing this deep dive with a colleague who might 00:27:54.859 --> 00:27:57.039 find it valuable. Yes, we appreciate you joining 00:27:57.039 --> 00:27:59.339 us for this in -depth look at a complex problem. 00:27:59.579 --> 00:28:02.279 And finally, a thought to perhaps mull over, 00:28:02.539 --> 00:28:04.700 drawing directly from the factors identified 00:28:04.700 --> 00:28:06.990 in this paper. we've discussed. Given that the 00:28:06.990 --> 00:28:09.690 study found things like a higher number of previous 00:28:09.690 --> 00:28:12.809 surgeries and prior infection were so strongly 00:28:12.809 --> 00:28:16.170 linked to complications, and that factors like 00:28:16.170 --> 00:28:18.730 tuberosity healing and the specific type of failed 00:28:18.730 --> 00:28:21.410 prior surgery impacted the functional outcomes, 00:28:22.730 --> 00:28:25.990 how much of the ultimate success of salvage RTSA 00:28:25.990 --> 00:28:28.430 in these challenging younger patients is actually 00:28:28.430 --> 00:28:30.670 determined not just by the technical execution 00:28:30.670 --> 00:28:33.769 of the RTSA surgery itself. Right. but perhaps 00:28:33.769 --> 00:28:36.430 even more so by the surgeon's ability to meticulously 00:28:36.430 --> 00:28:38.210 select the right patients in the first place, 00:28:38.390 --> 00:28:41.430 to rigorously optimize their condition preoperatively, 00:28:41.710 --> 00:28:44.490 especially managing any hint of infection, and 00:28:44.490 --> 00:28:46.630 then possess the experience and the infrastructure 00:28:46.630 --> 00:28:49.450 to effectively anticipate and manage the almost 00:28:49.450 --> 00:28:51.589 inevitable complications when they do arise. 00:28:52.049 --> 00:28:54.309 It suggests the outcome might be less about the 00:28:54.309 --> 00:28:56.329 implant or the index procedure in isolation, 00:28:56.549 --> 00:28:59.170 and much more about the comprehensive long -term 00:28:59.170 --> 00:29:01.990 management of a complex previously operated and 00:29:01.990 --> 00:29:03.210 often compromised shoulder.