Precision without Wisdom.

A must read!

The recent publication of Precision without Wisdom by University of Washington shoulder fellow alumnus Tassos Papadonikolakis argues that contemporary surgical innovation has become systematically decoupled from clinical judgment, long-term evidence, and ethical accountability. In its 98 pages, the book draws on surgical history, philosophy (particularly Aristotle), innovation science, and healthcare economics to make its case. It is organized into nine chapters with an epilogue and afterword, covering the historical arc of orthopaedic innovation, the failure modes of modern technology adoption, the distorting effects of industry funding, the promise and dangers of artificial intelligence, and the ethical responsibilities of surgeons and institutions.

The central thesis is straightforward and well-stated in the preface: the crisis in medical innovation is not a shortage of intelligence, technology, or capital — it is a crisis of orientation. Papadonikolakis frames the book as an argument for balance: between precision and judgment, between progress and restraint, and between enthusiasm and humility.

This is a book for the thoughtful surgeon and for all others who are concerned about optimizing the appropriateness and cost/effectiveness of the technologies we use in caring for our patients.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link)
The total shoulder arthroplasty (see this link)
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link)

Shoulder rehabilitation exercises (see this link). 

Technique vs technology: managing a B2 glenoid in an active 67 year old woman. 9 year followup

It is said that "technology is something we buy and technique is something we learn".

In that light, let's consider an active woman in her mid sixties from Alaska presented with activity limiting shoulder pain and stiffness as reflected by her Simple Shoulder Test

Her radiographs at the time of presentation are shown below. Her axillary "truth" view shows posterior decentering of the arthritic humeral head on a posteriorly eroded glenoid with a degenerative cyst.

After discussion of non-operative management, anatomic total shoulder, reverse total shoulder and the ream and run procedure, she elected the latter.

No preoperative CT scan, MRI, or 3D planning was carried out. The procedure was performed under general anesthesia without a nerve block; no patient specific instrumentation was used; the biceps tendon was preserved; the glenoid labrum was preserved; the glenoid was conservatively reamed - just enough to create a single concavity; no glenoid component was used; the smooth (non-ingrowth) standard length humeral component was fixed with impaction autografting; and an anteriorly eccentric humeral head component was used to provide posterior stability.

Followup radiographs showed that her humeral component was stable without evidence of stress shielding and that her anteriorly eccentric humeral head was centered in the glenoid on the axillary "truth" view.

At nine years after her ream and run at the age of 76 she reported the ability to perform all 12 of the Simple Shoulder Test Functions and added that she recently spent 30 days canoeing many miles down then Chandalar and Yukon Rivers in Alaska, going 35 miles the last day. While the photos below are not from her trip, they show a bit about these two rivers.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link

Follow on twitter/X: https://x.com/RickMatsen
Follow on facebook: https://www.facebook.com/shoulder.arthritis
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link). 

Do advanced technologies for total shoulder arthroplasty lead to better clinical outcomes?

Advanced Templating for Total Shoulder Arthroplasty

The bullet points of this review are listed below:

1. Longitudinal clinical and radiographic success of total shoulder arthroplasty (TSA) is critically dependent on optimal glenoid component position.

2. Historically, preoperative templating utilized radiographs with commercially produced overlay implant templates and a basic understanding of glenoid morphology.

3. The advent of 3-dimensional imaging and templating has achieved more accurate and precise pathologic glenoid interrogation and glenoid implant positioning than historical 2-dimensional imaging.

4. Advanced templating allows for the understanding of unique patient morphology, the recognition and anticipation of potential operative challenges, and the prediction of implant limitations, and it provides a method for preoperatively addressing abnormal glenoid morphology.

5. Synergistic software, implants, and instrumentation have emerged with the aim of improving the accuracy of glenoid component implantation. 

6. Additional studies are warranted to determine the ultimate efficacy and cost-effectiveness of these technologies, as well as the potential for improvements in TSA outcomes.

The authors are careful to point out the need for clinical outcome data to support the use of these new technologies:

"Longitudinal data on clinical outcomes and component longevity are necessary before widespread adoption of these augmented glenoids can be recommended."

"It remains largely unknown how preoperative planning impacts operative efficiency, cost-effectiveness, and preoperative and operative time commitment. Lastly, a learning curve is likely present."

"These results suggest modestly increased accuracy of glenoid placement in the hands of high volume shoulder surgeons, although the added cost of PSI must be weighed against outcome, usability, and anesthesia time."

"Widespread adoption is limited by financial barriers, increased operative time, training burden, and lack of long-term outcomes. "

"Prospective randomized controlled trials are necessary to assess the long-term clinical results of different templating strategies and adjunctive arthroplasty techniques. These studies are warranted to determine the ultimate efficacy and cost-effectiveness of these technologies, as well as the potential for improvements in TSA outcomes."

This review complements another recent publication:

Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty 

These authors point out that publications regarding anatomic total shoulder arthroplasty (TSA) have consistently reported that they provide significant improvement for patients with glenohumeral arthritis. 

New TSA technologies that have been introduced with the goal of further improving these outcomes. The number of new technologies is increasing dramatically.

Some of the new technologies are preoperative computed tomography (CT) scans, 3-dimensional preoperative planning, patient-specific instrumentation, stemless and short-stemmed humeral components, as well as metal-backed, hybrid, and augmented glenoid components. 

The benefit of these new technologies in terms of patientreported outcomes is unknown. 

They reviewed 114 articles presenting preoperative and postoperative values for commonly used patient reported metrics. The results were analyzed to determine whether patient outcomes have improved over the 20 years during which new technologies became available. 

Their analysis did not identify evidence that the results of TSA were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes. 

The figures below show the average preoperative to postoperative change in the different outcome measures for studies published over the last two decades. The linear trend line is shown. The two horizontal lines represent the lower and higher values for the minimal clinically important difference (MCID) reported for the outcome measure.

They concluded that additional research is required to document the clinical value of these new technologies to patients with glenohumeral arthritis. 

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).