Hi, everyone. This is Lucas Voss with Becker's
Healthcare. Thanks so much for tuning in to
the Becker's Healthcare podcast series. It's great to
have you today. Excited and thrilled to be
back for part two of our series with
doctor Aaron Chamberlin, a board certified orthopedic surgeon
with the Intermountain Orthopedic Specialty Group. And I'm
excited to continue our conversation around the evolution
of shoulder surgery today and also dive in
on advancing shoulder care with the enhanced intact
tissue sparing surgical technique. We'll hear a little
bit more about that here in just a
little bit. Doctor Chamberlain,
great to have you again. Thanks for being
back.
Thank you. Good to good to see you.
Good to be with you again, Lucas. Yeah.
Absolutely. Excited to dive into a little bit
more detail from our first conversation here.
We've seen a lot of attempts over the
last couple of years to develop a
successful
subscap sparing approach, really.
What has your experience been with these previous
techniques? Where is this space at now?
Yeah. So I I first,
explored the idea of subscap sparing many, many
years ago in an attempt to try to
help some of my patients where,
their ability to heal a subscapularis
repair would be is diminished due to some
patient comorbidities or immune
system deficiencies or medication management. So where I
I'd explored historically with historical implants, the subscap
sparing approach, which largely involved using a stem
implant
and then, you know, trying to
do our best to
execute some of the steps along the way,
which
without appropriate instrumentation,
it just it was very time inefficient. It
was extra time under anesthesia for the patient.
Required a lot of extra steps to try
to verify that what I was doing intraoperatively
was,
you know, exactly what I'd planned and intended
to do from a surgical technique standpoint. We
would never wanna compromise
an outcome just to try a technique. And
so, double and triple checking everything with historical,
just implants and lack of instrumentation just took
us quite a bit longer.
What I've seen evolve and what we've done
with the,
the new evolution and intact,
enhanced subscap sparing tissue sparing technique If we
try to address the steps that really,
we needed some extra aids to help us
navigate and execute some of the steps, some
of the key steps in the in the
shoulder replacement, specifically the humeral head cut where
we're not able to completely visualize and see
the humeral head. We're able to use instruments,
to, more quickly and efficiently and accurately
perform that step. The other thing that's changed
is is, you know, we've we've now,
migrated as a profession largely to stemless implants.
And so that changes the technique a little
bit from historical,
where we would use the stem and intramedullary
canal for alignment. Now the, the stemless
implant can be placed in a variety of
locations,
which can add flexibility, but also,
adds some variation potential, which in in a
negative way where we wanna be reproducible.
And so adding instrumentation
and developing instrumentation help, be reproducible and accurate,
and that is has been a a very
positive evolution from from where we were historically.
Now you are an innovator by passion,
but also by trade. You've been part of
the development
of Intact. You were very involved in in
the development of it itself.
What sets it apart right now from other
approaches that some of them that you've just
described?
Yeah. So what we've done now is we've
compared to before where some other, iterations have
tried to repurpose existing instrumentation
in a way that was less than optimal,
to try to help execute the subscap sparing
approach. We've really changed and started from, you
know, the beginning again and said, what instruments
do we need to design,
to try to make this, happen, in a
more efficient and, reliable and predictable,
manner. And so we've we've changed the instrumentation.
We've changed retractors. We've designed retractors around this
to help the surgeon,
gain what, you know, visualization they need. We've
changed,
as I mentioned, we used to do subscap
sparing mainly with just stemmed implants and using
the interventricular canal. And now we've we've changed
and altered that to,
kinda meet the mark, in the current utilization
of of stemless implants. And so being able
to accurately reproduce, we place a stemless implant
on the humerus,
is is the other, one of the other
key features.
The last thing that I will say that
I think is a real,
game changer, for those that have tried subscap
sparing,
they'll tell you that the most challenging part
of the procedure is how you manage
the humerus. And and the the the instruments
that I've mentioned where we can now more,
timely and efficiently
perform a humeral head cut without taking the
subscap off or place the humeral implant more
reproducibly are key steps. But the kind of
maybe one of the bigger, changes is we've
we've developed a mechanism by which we can
access the glenoid through a transhumeral approach.
So we don't need to move the humerus
out of the way and retract it. We
can just go right through the humerus, which
opens up the the the realm of possibilities
of what types of glenoid
pathology we can manage,
because it it, you know, it it improves
our ability to access the glenoid,
in a way that doesn't rely just exposure
and some of the other factors out of
our control.
So I I think it's it's been a
really rewarding experience to work with the design
team and try to understand,
what problems do we identify by leaving the
subscap on and how do we design instruments
and and leverage the implant of the intact
to be able to execute that.
I wanna jump back to something that you
just touched on. You talked a little bit
about the glen and your marrow piece here.
When you see a patient that has glenoid
meridural joint pain specifically, how do you determine
whether that subscap sparing technique
like Intact is appropriate for that patient?
So,
currently, my my surgical indications are around, you
know, patients who have routine,
primary glenohumeral osteoarthritis.
So it's just, you know, loss of cartilage
in the glenohumeral joint. Their shoulder, otherwise, is
is normal, and then they've got a rotator
cuff that's attached and functioning well.
They don't have a lot of extreme deformities
with bone resorption or or anything like that,
but they've got, you know, some routine osteoarthritis.
With that, any any patient that fits within
that category in my in my practice, I
would consider this for.
The the benefit of it is by by
not detaching and then reattaching the subscapularis,
the risks that are associated with that, like
not healing the subscapularis
drops substantially.
And and in addition to that, I'm able
to help my patient recover a little more
quickly. And so,
for any patient with run of the mill,
glenoid humor loss or arthritis,
I will consider that. I will say that
we're early enough in the learning curve. There
are some patients where it may be challenging.
So for surgeons who are listening who might
consider this in their own practice, I would
say, you know, patients with a significant amount
of glenoid,
deformity,
where they might be considering a reverse shoulder
replacement or substantial amounts of osteophyte formation or
bone spur formation on the humeral side that
might be challenging to remove
in a predictable way by working under the
subscapularis, I think, would be some other considerations.
You mentioned one important thing here, which is
really key, I think, the learning curve. Right?
I think that's hap that happens with every
new procedure, every new technique that comes into
the into the marketplace, into health care, whatever
it may be.
Can you walk us through what sort of
your first few enhanced intact cases looked like
for you? What was your experience there? What
did recovery look like for your patients? What
was that learning curve like?
Yeah.
I think that's really key to consider. And
as I mentioned before, we really wanna make
sure that as we're considering a new technique,
we are trying to solve a problem for
the patient to help their outcome,
and we don't want to
sacrifice any potential, you know, positive outcome just
for a technique. And so I think what
we're,
what in my own experience with my learning
curve, I focused on, number one, patients who
don't have a lot of deformity where, technically,
I have a clear understanding of the anatomy
I'm working with,
despite not taking the subscapularis
off. And when I got started with this,
I started with some of the first few
steps just to kinda make sure I was
comfortable. I had a low threshold to use
more X rays in the in the Operating
Room where I would check and double check
what I was using with the instruments,
and making sure that I was,
you know, performing or executing the step as
I would as I plan to. And so
when I put a cutting guide up and
I would before I made the humeral cut,
I would check it with an x-ray and
make sure it looks like, I would expect.
Or before doing a final implant placement in
the Operating Room, I would get an x-ray,
rather than wait until the recovery area. But
the nice thing about the intact enhanced technique
is that during the learning curve, I I
and I did this, but I would go
as far as I felt the patient's anatomy
would allow me to go and my my
learning curve would allow me to go. And
if at any point, if it became clear
that it'd be better off to just take
the subs cap off, I went ahead and
I did that. By by starting out with
the technique,
you don't burn any bridges to then just,
your bailout procedure is what you've always done.
And so I think that's a that's a
key part in the early part of learning
curve is give yourself permission to take more
time in the Operating Room, get X rays
in the Operating Room, and then realize that
you can bail out to what you've always
done,
at any point, depending on your learning curve.
Well and, again, it benefits the patient. It
trickles down to the patient outcome, which is
ultimately the biggest piece that you've mentioned. The
patient is the central part of this. We
wanna make it easier, which is so important
for it. Yep.
As more surgeons adopt these techniques, it's more
widely adopted across different ASCs in the country.
What do you think the future of anatomic
shoulder shoulder atherplasty
will will look like with that subscapularis
sparing innovation?
Yeah. As we as we continue to, proceed
down our learning curve and and see how
patients, you know, can recover more quickly, get
back to work more quickly, and and we
don't have to concern ourselves with the subscapularis
healing after surgery, I think we're gonna see,
I think, more of a demand, on the
patient's side. And I've had some patients already
come to my office, and they need a
shoulder replacement. They'd ask, can you do this
without taking off the rotator cuff? Because they
they they understand, and they've read, and and
understand that it's a much shorter recovery period.
It's less complication regarding the subscapularis.
So I think we're gonna see more patient
demand. We're going to see more surgeons learning
and needing to become more comfortable with the
technique as far as the differences in surgical
exposure.
But I do see I see that it's
gonna become,
a bigger part of our practice more generally.
The interest is high from the patient perspective,
and I think we can make a good
use case for it. I do think with
innovation and technology, we probably will see a
continued evolution of the instrumentation we have. So,
you know, as as more digital guidance or
navigation opportunities become available, we might see that
help us with some of the steps that
we've designed instruments around, and and that will
only help us become more efficient and more
accurate and precise as we work. But I
do see,
us you utilizing more surgeon technological
aids as we move forward.
And we did talk, specifically about the patient
experiences in our first episode as well. If
you've missed it for the audience, it is
available on demand as well. Highly recommend you
listen to that. Again, we talk quite a
bit about the patient experience and and the
expectations that patients have today, which is certainly
critical to the these techniques and advancing these
techniques. Doctor Chamberlain, it's so great to have
you. Thanks again for taking some time and
sharing your insights with us today. It's great
to have you. Thank Thank you very much.
Good to be with you, Lucas. Absolutely. And
we also want to thank our podcast sponsor,
DePuyis and Thies. You can tune in to
more podcasts from Becker's Healthcare by visiting our
podcast page at beckershospitalreview.com.