We recently had the opportunity to interview Dr. Michael Cushing and learn more about his background and experiences using InSet® Systems from Shoulder Innovations in his practice as an orthopedic surgeon.
An edited version of our interview led by David Blue follows.
David Blue:
Thank you for joining us today. Would you please share your background, including how you became involved in healthcare and specifically orthopedics?
Dr. Michael Cushing:
I first became interested in orthopedics during high school. I sustained a knee injury while training for a triathlon, and my experience with the orthopedic surgeon who treated me was very positive, which ultimately influenced my career direction. Later, while swimming in college, I experienced a shoulder injury that also required surgery. Both of those interactions with orthopedic surgeons had a profound impact on me and confirmed that orthopedics was the path I wanted to pursue.
David Blue:
What attracted you to shoulder as a specialty?
Dr. Michael Cushing:
My own shoulder injury played a role, and being a collegiate swimmer meant that many of my teammates dealt with shoulder problems throughout their careers. That experience sparked my initial interest, which continued to grow through residency and the guidance of mentors I connected with well.
From the outside, the shoulder may appear to be a relatively simple joint based on its bony anatomy, but it is actually quite complex. That complexity made it more intriguing and challenging to me, and it is ultimately what drew me toward the specialty. The more I studied and immersed myself in shoulder surgery, the more my passion for it continued to grow.
David Blue:
What continues to motivate you in shoulder surgery, and what do you find most rewarding?
Dr. Michael Cushing:
What keeps me motivated is simply that I love what I do. I know it is a common saying that if you love what you do, you never work a day in your life, and I truly feel that way. I enjoy every day at work, including my longest days in surgery, because I am doing what I love.
Shoulder arthroplasty is probably my greatest passion, but what keeps me most interested in shoulder surgery as a whole is the continued advancement of the field. What I have witnessed since I began in 2002, including the introduction of reverse shoulder arthroplasty in America in 2004, has been remarkable. The way reverse shoulder arthroplasty has evolved as we have continued to learn and refine our approach is extraordinary, and it is still changing today. We are continuously finding ways to improve outcomes, not only in arthroplasty but also in rotator cuff repair.
It is the constantly evolving nature of shoulder surgery that makes it so exciting. Over the 24 years I have been involved in this field, it has truly been a privilege to be a shoulder surgeon during such a dynamic period of growth and innovation.
David Blue:
How did you first learn about the InSet® system, and what prompted you to evaluate it?
Dr. Michael Cushing:
My very first surgery when I entered practice in 2002 was a total shoulder replacement. That same patient returned to me 21 years later with a failed glenoid. He was otherwise doing well, but the glenoid component had failed, leaving me with a very large glenoid defect and minimal remaining glenoid bone. Ultimately, I had to place a custom base plate and convert his procedure to a reverse shoulder replacement.
That case prompted me to think carefully about what could be done to prevent glenoid failure, or at least reduce the risk of it occurring. It was through that process that I came across the InSet® glenoid and felt it was a compelling option. My hope is that it will not present the same challenges that have been associated with standard glenoid components.
David Blue:
What was your learning curve like when transitioning to the InSet® system? How does it compare to learning other shoulder systems?
Dr. Michael Cushing:
Throughout my career, it has been interesting to reflect on how my practice has evolved. This will now be the fourth system I have used, and I have always made a change when I felt another company offered a meaningful advancement or was ahead of the curve in terms of innovation.
As far as the learning curve is concerned, it was not difficult at all. The instrumentation is very straightforward and simple, which contributes to how accessible the system is to learn. That simplicity also connects to their one and two tray system, which we may discuss further, but it makes the overall process very efficient. It is a very easy system to learn.
David Blue:
Have you noticed an impact of the one tray TSA and two tray RSA setup?
Dr. Michael Cushing:
The first time I used the InSet® system, my scrub tech was amazed at how simple it was and how few trays were required. He was accustomed to setting up six or seven trays, and he actually said he felt he could set up this system on his own. He was genuinely excited about that.
The staff as a whole has been very receptive to the system. There are also significant cost savings associated with it, particularly on the sterile processing side.
Overall, it has been a great experience. It saves costs, reduces shelf space requirements, and makes the entire workflow much smoother and the setup considerably easier.
David Blue:
Are there any key benefits have you observed since adopting the InSet® system?
Dr. Michael Cushing:
There is a lot! Starting with the InSet® glenoid, and really the base plate as well, the flat back of the prosthesis with anteriorly built-in augments is something I find particularly valuable. It gives you the sense that you are achieving 100% backside support every time you ream. On the InSet® glenoid side specifically, the ability to perform biplanar correction has been a notable advantage, though it is worth noting that biplanar correction is achievable with both systems.
With the reverse shoulder system, the lateralized-lateralized construct is a design approach that simply makes a lot of sense to me. The overall “anatomic” reverse design philosophy is well thought out and logical.
With both systems, I am seeing excellent results. I love the way the imaging looks post-operatively, and overall it has been a significant improvement to my practice and, most importantly, for my patients.
David Blue:
What has been the feedback received from patients regarding their outcomes or comfort after surgery using the InSet® system?
Dr. Michael Cushing:
The post-operative experience has been very encouraging. Patients are reporting minimal pain following surgery, typically at their first post-operative visit. In terms of outcomes, the anatomic shoulder replacements are producing excellent range of motion results. Even with the reverse shoulder replacements, where internal rotation has traditionally been a concern, I am finding that patients are achieving better and better internal rotation as their final outcome, which translates to improved overall function.
David Blue:
Shoulder Innovations prides itself in having surgeon-driven innovation. How would you compare your experience with SI to other companies you’ve worked with?
Dr. Michael Cushing:
One of the things I have appreciated most since transitioning to Shoulder Innovations is the culture of the organization. From the executives down to the representatives and the other surgeons I have met within the Shoulder Innovations community, it has been a very positive experience throughout.
Another thing that really stands out to me is that the company is very surgeon driven, and I believe that makes a significant difference in the advancements you see. There is a genuine interest in every surgeon they work with, and the emphasis placed on collecting and acting on surgeon feedback is probably the most notable aspect of that culture.
David Blue:
If you were sitting down with a fellow surgeon who was ready to use InSet® for the first time, what advice would you share with them?
Dr. Michael Cushing:
That I have been very happy with the system and feel that the results have been better than what I was seeing previously.
What initially brought me to Shoulder Innovations was the InSet® glenoid, and every time I have implanted it, it has been rock solid and stable. That stability is exactly what you are looking for when it comes to glenoid longevity.
Beyond the glenoid, the reverse shoulder system has also been excellent. It offers a number of features that distinguish it from other systems, and I believe those features provide a significant benefit to patients and contribute meaningfully to outcomes. The anatomic reverse design, as we discussed, is a particularly important part of that.
David Blue:
Do you have any technical tips or insights that could help a surgeon using the InSet® system for the first time?
Dr. Michael Cushing:
There are two things that come to mind. First is regarding placement, with the glenoid, I position it slightly higher in the glenoid, ending up approximately one millimeter above the midpoint. That is intentional, as that is where you want it. With the reverse base plate, placement tends to be approximately one millimeter below the midpoint.
In terms of glenosphere positioning, I prefer to have it sit at the inferior border of the glenoid, though being one millimeter above that is also acceptable. I find that the 132.5 degree humeral cut helps prevent notching, which is an important consideration.
My second technical tip is using the 132.5 intramedullary cutting guide. I have used a free hand cut for 23 years. With the “anatomic” reverse design, to truly get the lateral-lateral positioning, I feel the cut needs to be reliably at 132.5. So I have been using the intramedullary cut guide reliably, to achieve what the system was designed to accomplish.
Dr. Michael Cushing is an orthopedic shoulder surgeon in Georgia