Dr. Gregory Nicholson performs a recorded live surgery demonstrating an anatomic total shoulder arthroplasty for a B2 glenoid deformity utilizing Stryker’s Simpliciti Stemless humeral component and the Perform+ glenoid augment system.
Products: Simpliciti and Perform +
great. So why don't you run us through what you what you have set up for us? Can you guys see me? All right, great. We're at the Gold Coast Surgery Center this morning, uh in a water tower place in downtown Chicago. We've got a 62 year old male who's had about five years of unremitting shoulder pain. His original X rays were fairly typical are throw sis. And even the X rays that you see there don't show as well as when you see the ct scan, the actual cuts, how he started to get a bike on cave glenn, I'd start to have some poster human head extrusion. And the question is, what do you do with this gentleman? Uh And as Jill, just uh laid out for us, uh there are a lot of different options. Uh and I think it depends on what your what your surgical, your surgical skill set is, What your patient expectation is their age, their gender, what they're going to go back to. And how do we how do we correct that deformity? And let's not overcorrect it. So, um in the last three or four years, there's been more than 45 papers on B. two or B. three. Glenroy is different. Reaming techniques. How much vault can you violate? And the like. So, I don't know if we have the right answer. But today, uh we've got a plan and we're gonna show you a couple of things here. I want to post your Glenwood bone graft technique that I've uh developed and utilized. But also today, I think what we're gonna do is use the perform plus augmented glen wide and show you how to do that now. Uh George, have you gone through the power point there really quick? You know what we're gonna do is we're gonna put it up right now and we'll just go through it. So we're looking at the imaging right now, we can see the uh ap and accident review looks like a B to glen oid and we can go right to the C. T. Scan and there you can see it uh certainly retro averted a very large neo Glenwood, small paleo Glenwood. And and this is a typical Chicago guy. He's about 6 to 2 30 you know. Uh And I think one of the things that we forget about is once we got him on the table and got him asleep, we wanted to assess his passive external rotation, his passive internal rotation. Because it has a lot to do with the type of releases you may need to do and the access you get to the glow annoyed. But because of the complexity of this gentleman and his size and his yield just elucidated. I think uh an advanced imaging studies is imperative. And also the three D. Software and you'll see now kevin to er torneo right rep is gonna scroll through that bill, you are we on that. So I'm gonna move over a little bit, you guys won't see me but um as you can see as we went through this medium versus large. What size glenn oid do we need, How much correction do we want to have? I always try to aim for about minus five. I think the one thing we do not want to do in these folks is over correct them. Anti version is probably a really bad idea here. So we have a plan ification And we have a 25 millimeter or 25 degree I guess would be more important. Uh Medium sized Glenwood which you think will correct our deformity quite nicely on the glenn Oid side. On the humorous side, what's interesting for this gentleman is he does not have a lot of osteo fights. Uh And on the table, his passive external rotation was actually about 35 40 degrees. So um we've we've already got down to the sub scapular area so we're going to show you um how we're gonna do this. Are you guys ready? Can you, have you gone through the plan kevin, did you scroll through it George? Did you guys see that? Any questions I see that in the background of your, it looks like you got a bunch of screenshots. Is that routine for you to get sort of oriented during surgery to keep screenshots of your your planning? Yes. Yes. It allows us to kind of go back and forth. Um But you know as you guys know, once you're kind of in it uh it's a three D deformity as George has shown us it's not a symmetric deformity. And so sometimes you've got to alter your plan so you gotta plan a plan B and plan C. So we're gonna get down to it here. We've got uh and feel free George if ormat if I'm messing up let me know because I'm gonna violate every principle. Jill just taught you guys. So I'm you know, it's gonna be daunting to follow Jill Walsh and have to do an atomic total shoulder. Alright, so you just keep going Greg. But just to comment on the preoperative planning that that is a case that supports the idea that a preoperative ct would be very helpful because there's no doubt about it. Look at the preoperative x ray and you know, you have a B two glenn noi but it certainly didn't look like a 25 degree augment would be needed. That's absolutely, especially from the plane film. Right? Alright, so I'm a contrarian and I kind of do things differently than most people. I guess. I'm not a big fan of the lesser tubarao costo to me. But Nicholson's rules of the sub scapular various uh if I've released the rotator interval here And then I have more than 25-30° of external rotation. I feel I can do it to, not to me let me have my little drawing if you will and I think in fellows and residents, I don't know if this will show up. It might be too bright. It looks good but the sub scapular Harris is not rectangular. The sub scapular varies inserts. Wait a minute. I'm looking at it. Hold on. Can you guys see that the sub scapular, it's actually inserts at an angle like a Z. And then it comes back for the muscle. This is the lesser tubarao city which is a little gumdrop. It's not a ridge that rides the whole way. So with this type of subs cap and this kind of kind of motion, I'm going to take this down like a Z. Which gives me maximum length and we'll show you that. And so forces please. Yes and a little suction there. Uh you know, it takes a village to do an operation like this. I have Lindsay Ruderman, my P. A. On one side Jordan kansi and my raging Cajun fellow on this side. The master of gas dr Jeff partners upfront, keeping him relaxed so I don't have to struggle at the Glendale and have process here to hand me the wrong instruments at the wrong time every time with as a so I'm going to come across the top of the subs cap. Now the subs cap. This upper rolled border guys is the thickest part and it extends more laterally. So I'm going to now do a to not to me and I'm going to bevel a little bit through that tendon Almost as I'm thinking about doing an old near capsule er shift. I want to take the the subs cap almost off the capsule. So I'm going through about 45° and you can see that's all tended now down here at the muscle. Let me have the appendices please. And you're you're going straight perpendicular to the tenant but beveled relative to the long axis of the arm is what you're saying. Absolutely. Great, great point matt, I am going perpendicular attendant because the tenant is inserting at an obligatory on the lesser tubarao ct, you know, and you're and you're gonna and you're gonna separate your capsule from your subs cap right here, it looks like, right, you're gonna make that. So now I'm going perpendicular through the musculature there as you can see, it kind of pop away. So now I'm down to the capsule. So I've got this Z. So I want to make a sharp Now I'm gonna go right through the capsule just like matt Ramsey said, and this is going to give me about an eight millimeter flat apple laterally. I'll do it with a trans odysseus suture but it's gonna be a trans odysseus attended a tendon repair. So I'm hedging my bets, that's what it comes down to. But so now I'm gonna get way down here on the neck and release that capsule and just this little bit right there and there it goes now. The other thing this allows me to do guys is to see the upper rolled border of the sub scapula reason cross section right there. I'm done. Not only is it an east west repair, it's a north south repair so I can get it to the right spot. So tag stitch please. So I'm gonna put three tags stitches in so I can control the subs cap. So one at the top in the middle and one at the bottom. But that bottom is at the bottom of the tendon just above that muscular layer. And you can see how the bottom or the inferior aspect of the subs cap is very tethered right here. So, you know, Jill was talking about range of motion releases an exposure. Yeah, so now I've got this tag but you can see it doesn't really move so uh and you can see our capsule here. So let me have an elevator real quick. So I'm going to get inside the capsule right there and I'm gonna release very quickly right off that little osteo fight. And I think it's very, very important to get this off the neck mayo scissors so that you have full elevation. So I'm just gonna get inside the capsule right off the osteo fight. And now with external rotation, we're down on the neck there if you guys can see that. Can you get the light in there, a little bit of Greg or get you can you can you angle that this light in a little bit. Thank you. Let me see if I can. We're just having trouble seeing the bottom of the neck a little bit. Can you see that? Yeah, that's better. Thanks. He doesn't have a lot of osteopathy fights, but that's a pretty good one. But now I'm off. So I've got capsule off humorous now. Um let me have a Fukuda retractor. Uh not right now, it's coming. So we're gonna take this out now with the Fukuda in place, since we're pushing the head back, it will bring the axillary nerve a little bit on tension so I can feel down there and get a sense of where the axillary nerve is. And in this gentleman it's way down there. So we're going to be pretty good. But you notice there's not a lot of bounce to this sub scapular Harris. So what we're gonna do is we're gonna release it in a 360° fashion uh somewhat that pascal Barlow kind of coined that phrase. So we're gonna put a pitch work for tractor their suction to me please. And you can see here's our rotator interval and is there enough light in there for you guys to see, let me know we could use a little bit more light. All right, it'd be nice if you had a light coming from superior better. That's better. So bobby please. So, we are doing an anatomical total shoulder. So we've got to get rid of the labrum. You can see he's got a big one here anterior early so I'm just going to with extreme prejudice, get rid of it and I'm just gonna ride the anterior ridge that is the glen oid and release this and I like to get this completely off the Glenwood neck. So drill guides and things like that can go down the next. So I know where I'm at. This is sometimes tedious because it's somewhat big. You typically do these releases before you do the humerus. This is correct. I'm gonna release the subs cap completely now. So this is the backside of the subs cap here in the super Sonatas for the subs cap fossil. Now. Right here you got to be a little careful. So what I'm gonna do, I'm gonna put that pitchfork retractor under the sub scapular larry's now and I'll we have to release this all the way around even though he's got post here, human head extrusion, we still have to release the poster unfair capsule. So I'm gonna walk around the capsule and it'll just keep walking Jordan. You're gonna have to pull a little bit therefore hang on let me just move this. Yeah, so it's all about little moves and and exposure and as we keep what can you guys see that as my head in the way. Can we get some light in there. What about your guys lights. Alright. Better. I'll try to stay out of the way here George. So give me the real quick so I'm gonna push the capsule and labor them down and my tips are gonna come in right at that interval between bone and labrum and then I'm gonna come out again and repeat as I walk around the glen oid, how far are you gonna go around the back? I'm gonna go to about 9:00 now people would say they're going to be post early unstable but remember we're changing the version here so you'll do the same releases no matter what Glenwood morphology you see, correct Because this also helps me get the head out of the way, you know, I have a way of getting the head out of the ways I usually cut it off first. Sorry now so there we go. Now if we look we've done come on out, there's always somewhat of an adhesion right here to the base of the core coin. So I'm going to change my scissor and release that and I'm gonna come under and here comes the key move. So Lindsay you're gonna hold that forceps please. I make all these releases 1st. Now we must release the inferior capsule, the sub scapular area so we want to find a little interval right here. Let's see. And so the capsules in my my forceps and I'm going to angle up behind the sub scapula towards the four o'clock position. So I'm gonna spread and snip spread and snip and just keep working and you'll watch the subs cap release and now that whole inferior area is released and now we've got some bounce to that. And then here's that inferior capsule earpiece which is don't go down here and get cavalier. But I think we can release that but doing it this way protects you from the axillary nerve. And then that allows my rectangular blade here to get on the inside of the subs cap, relax a little bit Jordan, please and get that sub scapular carries out of my way behind the blade. So now we're gonna take the cuda out and now it's time for the human head. Um We're gonna just do a little show you a little relaxing incision that we do so that we don't rip the super spy nodoz Or the sub scapular varies. So give me a small dara please. So we're gonna come over the top of the head here and forceps and again, George and matt, you can see here's the upper rolled border. The sub scapular varies. I'm just gonna do a little relaxing incision through the interval here and this is going to kind of open up like a flower, you'll see the biceps right there and you notice how the super Sonatas just rolled away so when I dislocate the head forward. This won't rip at the interval. Mayo's and then we can get around the long head of the biceps here and make you feel better because I'm gonna cut it. So there's our biceps, we know that's the top now and we'll get rid of that Jordan. Put your hand on the elbow for me, both of you people please. So I also wanted to descend alternately sit at the end of the case. Now I'm gonna elevate this capsule away from the osteo fighting interior lee to give my subs cap a little bit of length. And again my sutures are gonna go here. So I have a trans odysseus repair but attendant attendant repair and also my saw blade won't cut the uh the subs cap. So that's a nice piece now because I did that little relaxing incision across the interval here, I can get the my dara behind the head, hold that for me, please. Thank you another dara please. So I I always say I have to be the one doing the extension here because nobody knows how hard you're pushing or pulling. And there we have the head section please. And now we see that go ahead. Do you have the arm resting on a mayo stand? I have a movable short arm board underneath here we we facetiously call it stubby. I need a half inch curved acetone please. And so now what I'm going to do, I see the color change and I'm going to score it because I wanted to come off where I wanted to come off, tell us about the color change. Well, I think it's just the osteopath, right? You can kind of see where that's gonna change. Now. The character of this osteo fight changes dramatically here, anterior early. It's much more firm. And you don't you don't wanna crack off your subs cap attack. So I'm gonna take that osteo tome now right under that little reflection after I've scored it and it'll hopefully come off, you know, and live surgery exactly how I planned. But that never happens around here, please. So, I'm a little careful here because I don't want to ruin my subs cap insertion here interior early. But you can see there's that little soft tissue reflection right there, forceps please. And this will also capsule reflection that you can feel. Yes, sir. There it is, Right, that map. So I'm gonna back off here because my subs cap is looking good. Let me see what I've got in that posterior inferior area. All right, let me have the austin. Please. Do you try to get all your osteo fights off at this point posterior early or do you wait till I get this off? No, I try to get to know. I'll fine tune it. Yes, but I'll try to get him off now if I can get to them. And like I said, he doesn't have a lot of Osteo fight. But you can kind of see now we have a natural head at least it looks a little bit more like a natural head. So you're gonna come back with something that looks like a pretty big head. It's gonna be we've sized it as a 50 actually, but we don't know. So a little trick. I'm going to take the dara and use the Corre coined as a shoehorn. Their baby Holman. Another little trick. Hold the wrist for me. Take a baby home. And and because of that relaxing incision, I've released the Super Spy Ennahda's and I'm going to Yeah. Do you have a one that's actually straight. Okay, so hold that. You got those two. Don't worry, I'll get it. It's not in. There you go. So now the most important part of this is bobby for me at least is three o'clock, 12 o'clock, nine o'clock. Because down here I can take care of business anyway, I want to but this is where the head needs articulate, especially when we're using simplicity. And we only have Yes. Mhm. Certain size and certain dimension suction please. So, I tend to take a bovie and give myself a visual line almost like mike pearls, Michael pearls paper that corroborated Jill and pascal's paper on neck angle where he kind of used almost a metal wire to get around the neck angle saw please. So you're you're trying to recreate normal inclination inversion. Here. Right, I am. I am indeed. And you're using your cuff attachments post dearly and superior lee as your guide in an atomic neck cutter. So here I go. So we're going to save the head A state. Um because we need this head for the poster glittery bone graft technique that I'm going to show you. So here's our head project's gonna not drop that looks like we got a little bit of soft. We're in the head back here, a little softy. That's okay. Now let me have the 50 trial this one. Yes we're gonna go back in just for grins and that's pretty darn good right now. Right. But we know we got some Glenwood issues mayo scissors please. And we're gonna clean up right now since I have some anima tous city here and just get rid of some of this burst. So that might be limiting my internal rotation back there. Okay, so pretty happy with that little tighten internal yet and that's a little worrisome because you know, we're gonna do something to raise the back right in this guy and you might make internal rotation more difficult so you might actually have to release more postaer capsule even though that sounds paradoxical. Alright, so let me have the Dera please. So we're gonna dislocate, remove the small and we're gonna dislocate remove the head and let's go to the fun part, the Glenwood. This is where you talk to your anesthesia colleagues and make sure that you know you've got them para paralyzed. Um and let me have the cut surface protector. May have dropped this in a little too deep. But that's okay? There we go. Alright so everybody's got to be on the same page here. So I'm gonna slide my hold this for me please thank you my arm board up underneath. Oh no, we may have a problem. You just came off. Well, technical difficulty. Hold on. Can you see it? So john do you typically prepare the humorous first or go right to the Glenwood? I cut the head off and then I go straight to the Glenwood. I don't prepare the humorous but I can't get my head off your honor yourself. I cut the head off first. Cut her off her too. This stubby issues cleared up. We are. So now what we're gonna do again, exposure issues, quick squirt irrigation please baby home and again. So I put a homing in at the superior aspect about six o'clock, A little bit of a sunroof, lets the light in. Four sips and mass and Greg. You don't you're not using a PS I hear or anything. You're just translating. You've got mentally in your head. No, no, we've got a guide. We've we've done uh some some labrum, little little cinnamon on that and that is delicious. Just kidding with some fava beans. Yes, so little orthopedic butane routine here to get that release and now we're going to see that beset elevator please would you do there? You just put your hands behind the glen oid and just spread the poster caps made some space. There is a little trick I'm going to get rid of This cartilage that hasn't seen any action in about 20 years and it's gonna not look so retro averted anymore. Roger. That's your angle ones. We we might need a little change in the vantage point of the camera. Okay? We'll do that. Uh bovie please. So we want to clean up the edge. Right? Especially if we have a plan ification guide because you gotta get the cartilage in the labor room off because the feet, Can you guys? Let's take a look. Yeah, I see what you're saying, George. I'm looking at it. We need to probably bring that camera guys a little bit different orientation. Can you get this way? Yeah, that's getting better, getting better, getting worse. They'll get there. Can you can you zoom There we go. Alright, we'll get you all right. So let me before we do that, let me have the human head to towels. Coker, can you guys see this? We're gonna go right here right here right now. No, no, no, no. We were doing something different. Can you guys show me this? My fingers mm hmm Over here. Mhm. Right here, over here. Ah over here! Over here, over here. There you go. Alright, so if you notice here is the human head, the human head has been sitting on the glenn Oid for years and years and years. So this surface matches the neo Glenwood surface. Okay so we're gonna take a a Coker and lindsey go ahead and grab the other as our saw guy. Let me have the saw and this is how you start. Save that. So now we have taken the ark of the of the sphere and we're gonna put this surface against the Glenwood surface. Now we're gonna have to trim it a little bit. But this is your poster Glenwood bone graft to reconstruct the neo glenn Oid back to the level of the paleo Glenwood. Okay but we're not gonna do it. But I just want to show you how we're gonna do that. So we'll get Jordan's hand out of the way you do you ever use the three D. Printed glenn Oid to help you pick the part of the human head to cut? I have not done that. But where's my where's my bone? So I just gave you you mean something like that. I think we need to get back. We need to see your hands. Yeah, here we go. Something like that. You mean it looks beautiful and I you know I've done nothing except just and I could shorten that arc right because George you showed us this is not a symmetric deformity, its posterior inferior for the most part. So there you go. And I mean it really is a match fit. Now I'll show you down here. Low, let me have some Russians. So here's the facility and I think you guys can see that clearly. Hopefully I'll tell you what we're gonna do a couple of things. Let me have the do you have a bigger pitchfork? So our our time is pretty good yet. We've still got time. We're gonna put the big pitchfork in here suction at the bottom. Please twist open a little bit for me. There you go. So now we're kind of around the world. Quick squirt. Do you have the humorous and internal rotation? External rotation? And it's actually an external rotation right now against my chest Russians and my my graft. Any chance we can move the camera just a little bit more from the Russian forceps. That's it. Alright. Uh Okay can you get in this angle, hang on, they're gonna move for us just a bit. You may you may have to come down over my shoulder, give me a run through real quick while they're repositioning. Good morning. Mhm. Keep suctioning their jordans now were getting their four steps again Jordan you have to pull a little bit and twist open so bringing my graft in. Look at that, I mean that that is an absolute almost perfect fit. We trim this a little bit and then use two screws. But if this person was 52, Maybe not 62. I might think about a biologic uh which is his native bone. Okay and you can see how it right here look at that interface. But we're gonna do an augment. Alright so plant ification. Let me have our our guide again model. So here's our pathologic model and our marks for our guide. So hopefully I've done a good job releasing and we're gonna make this fit, Jordan's take this one and I'm gonna take the Fukuda, hold that for me brunch. Thank you. Let me just get a few things here. This is the key to victory. There you go. Let me have the guide please. So we have a P. Which marks posterior. Hold down. Thank you lindsey. You might have to relax on your retractor a little bit john how often do you application specific instrumentation? That's a fellow decision. So if the fellow if the fellow actually plans and then he gets the P. S. I. But so I'll probably use it maybe one case a day. Okay so yeah. And so how many how many joints are you doing today? 6 to 8, wow. So why not more than once time to check the right case. I would do it on all of them if I had a time moment. But how about yourself are using P. S. I. S. Not much honestly. Again it's um you know I I've always I found that I can at least translate. I pre operatively plan and then all right, let me have my bolster back please kind of recreated in the O. R. And that's worked out. Okay, Jeff just check and see if you can get me if he's a little get a little tight thanks. So, I'm struggling a little bit, even though we've marked and made our feet lindsey come out with your home and there we go. It's important that we get it right, so, George, you're gonna take that for me. I've got this one. Thank you. There we go. All right, let me have the pen, please. It's a little touchy that hurts. Mhm. Mhm. And we're gonna drill now. R. D. Rotation pin and you can see here on the guide it's marked. So everything will be based off our guiding off this. Now we're gonna remove the guide and now we're gonna ream the neo blindside, That's the problem. No worries, nobody panic, twist uh forceps, please. There we go. Alright, so, let me have this. So your job is to do that. Okay? And Lindsay I'm gonna relax you a little bit. So there we go. Hold this one to hold this 12 double duty. So we don't wanna we don't wanna hit this too hard. We just want to almost sand right that girl annoyed. So what you're doing here is you're dreaming the anterior portion of the solenoid correct. And I would do this even if I'm doing the poster girl annoyed bone graft because it really shows you where that is where the where the drop off is and you're dreaming to the pin Your guide pin. I'm That's a great question matt and this is kind of a little bit by feel, right? You know, there's no stop on this. You certainly don't want to get too big, You don't you don't want to remain below, so you're you're reaming extends beyond your guide pin. I think the goal is just to remove the entire hemisphere, correct? Alright, so now we're gonna take our our wedge reamer And we're gonna set this at 25 because that's what our plan was. And if you can see that, so our d rotation, we're gonna go down the pin. But the d rotation pin goes in the hole and that is critical relax here for a sec because we just don't have the exposure. We've got him better relaxer, Jeff. All right, let me just see little arm position issues here. I need that right there. Okay, you got to really get your hand on on top and you gotta twist and pull, you know, get your hand on it like a man. They twist and pull there you go. Sometimes it's education by humiliation. You guys know that come on now. So they're okay. Did you see that how it went in? That's a good feel. But you really gotta hold on tight here. Okay. Mhm. Let's see if we can get you a little bit different. There. There we go. Let me see what you got. I got you. So, if the plant ification is correct, There's not a lot you have to do there. It just kind of sands and sculpts that. Okay, so now our checker is going to go down mm hmm. Hold this for me again. Thank you. And we've got to make sure we're seated. Let me have um let me have an elevator because you don't want to be hanging in the air here and we are down and that looks nice and we're right on our pen. So now we have our guide so that we don't get off track again. R. D. Rotation pin. Very important, we're going to go through the checker. I think that the rotation pin is a key because even with that uh the neo remember bouncing against the retractor because you have your d rotation pin, you're not worried about switching or rotating the wedge. Get the edge of the wedge of the right spot. So we're gonna leave that in poster inferior. So now we do the peg holes, we're gonna leave those in because they so I'm lining that up quite nicely. Mhm. And then once we've got our pedals, we're gonna take the whole instrument out. But leave the center. I got this for you suction to me real quick. Now I'm gonna have to re drill this one because we're so deficient there. So hold that for me, let me have the drill again, yep with any of them. Any of the small ones. No coming out there and I've run into this a couple of times posterior inferior lee where the defect is the greatest. Mm hmm. Okay. And you took the just don't worry about cleaning it. So I'm gonna have to freehand this, but I'm going to go right back in the hole because it's not deep enough, mm hmm. All right, quick sport irrigation, please. Got it. And now we're gonna we're gonna drill our center post hole, which is a much bigger. Hang on, hang on, hang on, hang on. And you guys can see our prep here. Okay, But we're still a pretty good fall off their posterior and fairly. We've got cement ready to roll guys. Alright, and if I could put that in there, that'd be great. Looks easy. There we go. So now again everything was based off the D rotation pin. Here's my the pin from the guide. So we're gonna drill that bigger hole and this is our central peg hole. Let's remove the pin please. And we're gonna take the pin out. Now we're gonna put our trial in and you can see we've got an angled guide or gripper so we can get it in. And with these cutouts you can see if you're down or not. So I've got this, I've got this. Yeah. Alright. Mallet please. So we're just usually it's a little temperamental, you gotta bone tamp. Thank you. Okay, don't they have something on the system for this And here we are. And the cutouts show us that we are down and I don't think we've excessively overcorrected our version. Remember our plan indication told us it was gonna be -5 and that looks pretty good. So, uh that went in pretty good. So that may have to stay in. So the FDA hopefully is not back in the back there with the trial mallet, please. All right. And now it's about again, talking to your anesthesia, colleagues getting everybody on the right on the right uh page here because we're gonna have to Yes, he's processes going to mix cement. I'm going to lavage this out to have a thrombin soaked sponge. I got it Greg, you're doing great for time. We got about 10 minutes we'll be in pretty good shape. I I like, I like Jill Walsh, love akil, but he gets in europe, this is available in a kilo in the United States is only available in pegs, the perform plus. So I'm uh I'm Akil guy and we can debate that all day. But but I, so I try to pack my my cement holes with a thrombin soaked sponge. You can use ceo to thrombin epi whatever you want, but I want to try to stop that bleeding. Well, well this is the first time projects ever mixed cement? So we'll see how it goes. So while we're waiting? Uh George is the exposure still good enough. Are we in good shape there? Are you guys Seeing what we need? It looks good for me? So again, Interestingly enough, I did a post here Glenroy bone graft on a 52 year old power lifter. In august with this technique, he fell down the stairs the week of thanksgiving. He came in to see me, his glen oid had been extirpated out of the out of the bone and was anterior and he'd torn his subs cap. We went back in the Glenwood, we took out the two screws we took out but the bone graft had completely healed. We were able to cement back in a keeled component with healed bone. Now the retro version I was completely resolved and we repaired as sub scapular varies so at 5.5 months this bone graft was completely healed and it had restored bone stock for me. That's my end of one. Okay, that's anecdotal but it was pretty cool. We're just gonna get a case series of those. Let us know what Yeah, I hear you man. I actually have you mean power lifters who fall down the stairs? I've got that serious. Where do you typically if you have a second, where do you typically put your screws in your bone graft? Great, great question. Hold this. Well I don't want that cement to harden. Now I put them in dead, straight, perpendicular, right into the face right here and bury them under this can sell a surface to compress the industrial surface because the key will be right here. So they're they're perpendicular to the face. Alright, so let's do it. Can you see that guys? So I'm gonna put this some cement in the posterior inferior one because it's hard to get there and then the superior and then the inferior. Let me have a freer please thank you, give this back to you. Mhm. Now we don't really have a little You got that bone, that small bone tamp you had? Let's see if that'll work well, that's awesome. Good let's go for some cement again please. I'm trying to really compress that. Alright, prayer you're not shy with the cement. Well, you know it's it's it's there for a reason I guess just squirt out all of it. Oh I know, I know so okay, here we go, the hardest part of the whole case, you gotta twist that open, I've got to get that lined up and kind of get it pushed and if I can get the 22 out of the three pegs in there, I'm good. Let me have the impactor please lindsey relax on your retractor. Alright, jordans, you gotta twist open buddy. There we go. Nice, hang on now there you go, I got you here. Mhm. Alrighty suction. Can you guys see that one day? I'm gonna angle you down a little bit on the anterior inferior attracted the banker just a little bit more of a poll and we'll see it really nice that one right there. Yes, we are clearly freer please. Prayer. So we're clearly down all the way here all the way there. I knew there's gonna be a little gap here just because of the way the reamer was working but clearly down all the way. So that's wonderful. Now the biggest issue is not to knock your glenn. Oid out. Okay so baby Rich and a bone hook please. Well yeah but you know, give me the give me the impactor II. Actually if I'm doing a keel I actually like to hold on to it for an extended period of time. Let me have it again. Just twist open. You know because it is the only thing that's you know the cement is there to prevent micro motion so that the the peg in grows. But I think it's pretty good fixation. So if we do our job right we'll be okay baby Rich and a bone hook. You know I want to get to know graphed around the center peg. I don't it makes it hard to get it in. I like that feel of it popping in. Hold that for me. I'm gonna grab I'm gonna get that bone hook into the middle of the simplicity implant. Maybe there we go so I can pull lateral and sneak that out around from around the humerus not hitting the back of the Glenroy and I'm going to gently so George you're gonna pull that and I'm going to drop that my stubby down new terra please. Mhm yep. And Lindsay you're coming out so I'm gonna make sure she's off the poly suction please. Now let me have the 50 x 19 head and a baby home. And so this is important. Remember we thought that they were a little tight in internal rotation. Right? And I want to make sure that that's not going to continue to help me. All right, stay in, come out lindsey. Stop everybody, stop, head came off. Okay come out Lindsay. Ah sarah that never happens baby home And again so this baby home is a really nice trick under the cuff clearly. Okay let's try it again. There we go. Okay so Jordan's gonna stay in so we can see let's get the GLP out. We're gonna pull up on the sub's computers and you can see he's falling a little posterior. That doesn't worry me a bit. I'm worried about his internal rotation but as you guys can clearly see he's got easily 45 so I like 45 and 45. Little little bounce back and then another retractor please. Yeah that's fine, we're gonna pull the peck out of the way and the strap and I want to see what my sub scapular Harris is doing. And here we have excellent Jordan put your hand under the elbow for me please. So he's gonna put that in the mid to anterior axillary line. Heavy forceps please. Mm hmm. And so here's our here's our upper rolled border of the subs cap marked by our sutures. So you can see how that's gonna lay down and come as matt said, it's going to come right over it suction on the line because I don't think we'll have time to show you the subs cap repair Greg. Will you do anything if you notice some posters? Subluxation of the head? Do any rotator interval application or do you just great question matt. I always always repair the interval. And what do I mean by that? I'm going to repair my subs cap but I'm gonna put two number two esteban's from the front of the top to the top of the front out laterally. So it's an L shaped repair Of my subs cap, extra strength and that and I do it in about 30° of extra rotation. It completely eliminates that post your subluxation. So we're at about time, George and matt and bob. I so we'll we'll continue on here. We'll all we're gonna do is put the the sutures in, we're gonna put the implant into the nucleus. The nucleus in. We're gonna use a 50 x 19 head like our planet fication the balance is super. I hope you can see that sometimes. Looking inside the Glenwood is not easy. Let me have a self retaining retractor that went superb. That was great. Thank you so much for doing that. So I thought there's a couple of tricks there that, you know, pull on the sutures. Please. You guys enjoy the rest of the meeting. I hope this, this inaugural ASAP meeting is, uh, is awesome. Thanks Greg. Thanks Greg. Great job. Thanks guys. Take care, careful on the slopes. We, hey, we're having a special on clavicle fractures. So if you've got, you know,