We recently had the opportunity to interview Dr. Fotios Tjoumakaris 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. Fotios Tjoumakaris:
When I started medical school, I had this idea that I’d become a cardiologist or go into something related to the heart because I loved the physiology — how the heart works and how the body functions. But by the time I reached my third year and started clinical rotations, I realized that the actual experience of caring for cardiac patients didn’t speak to me as much as I expected.
At that time, I was also dealing with my own orthopedic injury. I had torn my ACL and was figuring out how to manage surgery while still being a medical student. A friend of mine suggested I look into an orthopedic rotation, so late in my third year, I decided to check it out. And it just resonated with me. The types of problems you treat, the patients you serve, and the focus on helping people return to active lives and regain function really drew me in.
I liked that the issues were often clear-cut, and the treatments were not only effective but also biomechanically fascinating. The use of technology in the field, along with the exciting developments ahead, made it even more appealing.
The idea of restoring movement and helping people get back to what they love was what ultimately inspired me to choose this path.
David Blue:
What attracted you to shoulder as a sub-specialty?
Dr. Fotios Tjoumakaris:
I enjoyed treating knee and shoulder problems, but the shoulder in particular really stood out to me. It has the greatest range of motion of any joint in the body and relies on a complex interaction between several components: the surrounding nerves, the rotator cuff muscles, the dynamic stabilizers, the cartilage, the joint’s geometry, and the labrum. All of these elements work together to bring some degree of stability to what is actually the most inherently unstable joint, allowing us to place our hand in space. After studying all the joints, I found the shoulder to be the most biomechanically fascinating.
Over time, my practice naturally evolved to focus more on shoulder care. That included treating instability in younger patients, rotator cuff disease in aging patients, and shoulder arthritis in individuals ranging in age from their 30s to their 80s.
When I was first training, we didn’t have great solutions for certain conditions, especially for patients with massive cuff tears. Back then, we were still doing CTA heads and hemiarthroplasties, even for relatively young patients with arthritis. But over the last 20 years, the field has changed dramatically. Reverse shoulder arthroplasty has really come to the forefront, and now it probably accounts for 70 to 80 percent of the shoulder replacements I perform. It’s been a truly transformational period in my career.
The shoulder continues to be deeply interesting to me, and a lot of the research I’ve done—especially on postoperative outcomes—has focused on that area.
David Blue:
What were your initial impressions of the InSet™ Shoulder System?
Dr. Fotios Tjoumakaris:
I think we’ve always struggled with the question of how to best care for the young arthritic patient. One of the biggest challenges has been achieving durable glenoid fixation. Over time, fixation becomes less reliable, and we’ve historically been hesitant to place glenoid implants in younger patients because of those concerns.
That was a major issue I wanted to help solve. I was seeing patients who had undergone hemiarthroplasty or ream-and-run procedures not doing as well in my practice. Often, I was having to revise them to total shoulder replacements within just two or three years, which clearly isn’t ideal.
The key question became: how do we achieve glenoid fixation that has a chance to truly last and withstand higher loads? Younger patients often aren’t as compliant with postoperative restrictions, so their implants need to hold up under more demanding conditions. That’s what led me to explore the InSet™ glenoid.
I was drawn to the concept Dr. Steve Gunther put forward, the “manhole cover phenomenon,” which involves achieving solid fixation within a rim of cortical bone rather than relying on the deeper cancellous bone. I thought it was a really smart idea. The biomechanics at time zero looked extremely promising, and it aligned with the problem I was trying to solve.
Once I began using it, I saw how well it worked in active younger patients such as 45 to 50-year-old weightlifters. I naturally started thinking, why wouldn’t this also benefit slightly older patients, say in their 60s or even 65?
That led me to explore the broader implant portfolio, particularly in the reverse space. I started looking into what options were available for reverse procedures, things like augmented glenoids and implants with more lateralized offset, or degrees of a neck-shaft angle. And over time, that part of my practice began to grow as well.
David Blue:
What has been the feedback received from patients regarding their outcomes or comfort after surgery using the InSet™ system?
Dr. Fotios Tjoumakaris:
First and foremost, I think even the humeral side has also been excellent. I originally gravitated toward the implant for the glenoid, but I’ve found that I really appreciate what it offers on the humeral side as well.
The humeral fixation has been solid, and I like the way the stem is designed to be placed. Even in larger patients, you don’t have to go as vertically down the humeral canal, which gives you more flexibility during implantation. Additionally, the ability to use an eccentric head allows you to position the head in a way that feels more anatomic, which I think contributes to better balance overall.
In terms of range of motion, at least anecdotally, I’ve seen encouraging results. I’ve been using the implant for about a year and a half now, and I’ve been placing it in some of my more challenging patient populations. Even in those cases, I’m seeing improvements in range of motion that stand out compared to what I might typically expect.
I’ve been very satisfied with the results so far.
David Blue:
Can you describe your experience using ProVoyance surgical planning software, and how it has impacted your preoperative planning?
Dr. Fotios Tjoumakaris:
I had quite a bit of experience with surgical planning software, especially since I had been using Blueprint from Tornier. So the transition felt very natural—it was familiar and easy to adapt to.
I’d say the new system offers a few more bells and whistles compared to Blueprint. Performance-wise, I think it’s a bit more accurate, particularly when it comes to planning for augments and managing soft tissue balancing. It also adds value on the humeral side in terms of preoperative planning.
Overall, ProVoyance has been great. The transition from Blueprint to ProVoyance has been smooth and we’ve had a really positive experience using it so far.
David Blue:
Have you noticed an impact of the one tray TSA and two tray RSA setup?
Dr. Fotios Tjoumakaris:
I can tell you that the surgical techs are much happier without having to deal with as many trays! And from a cost perspective, especially at the end of the year when you’re doing a high volume of arthroplasty, whether it’s total shoulder, total knee, or total hip, it really adds up. Our surgery center now handles all of that, so we have more control over the cost structure.
Fewer trays mean less processing and less sterilization, and every tray costs money to process. So reducing the number of trays significantly improves throughput and translates to real savings for the surgery center. From the staff’s perspective, our employees see that efficiency as a bonus — it may literally impact their end-of-quarter incentives.
From the surgeon’s standpoint, it contributes to higher margins for the ambulatory center. Since reimbursements have remained relatively flat, it’s become more about what we can do to reduce the expense side of the equation. So between the streamlined instrumentation and the cost savings from reduced processing, it makes a big difference.
David Blue:
If you were sitting down with a fellow surgeon to talk to them about this technology for the very first time, what would you tell them?
Dr. Fotios Tjoumakaris:
What really stands out to me first and foremost is that bone preservation. If I ever need to come back and do a reverse procedure five, ten, or fifteen years down the line, the inferior part of the glenoid is still intact. It’s pristine and provides a great foundation for seating a future implant. That alone makes a strong case for this approach.
Secondly, the glenoid fixation is incredibly reliable. Once it’s in, it’s solid. I tend to place them a bit higher than I would a traditional onlay implant, and even then, the fixation remains excellent.
So between the bone preservation and the dependable fixation, it just makes sense to me. And for younger surgeons who are comfortable replacing shoulders in patients in their 60s or 70s, but maybe are hesitant about doing so in more active patients in their 50s, this is a great solution.
Even in cases with significant glenoid deformity, like a Type C glenoid or a B2, I’ve had success. With the use of augments and the flexibility in implant placement, you can still achieve excellent fixation, even in those more challenging scenarios.
David Blue:
Do you have any tips or pieces of advice that you would give other surgeons if they were using the system for the first time?
Dr. Fotios Tjoumakaris:
Honestly, when it comes to total shoulder arthroplasty, glenoid exposure is everything. For me, that’s the key. Making sure there’s a solid cortical rim of bone around the glenoid is essential for achieving a good inlay, and that’s where your exposure technique really matters.
Using ProVoyance preoperative planning software helps ensure the glenoid is wide enough to accommodate even small stem implants, especially if you plan to place the implant a bit higher. As you know, some patients have glenoids that taper as you go more superior, so if you’re going higher with your placement, you want to confirm that you’re still within solid bone to get a proper inset. Proper planning is crucial.
For very narrow glenoids or those with shallower vaults, where you might have considered using a keel implant in the past, the InSet™ system gives you flexibility. You can go as small as a 22mm implant, and if you need to ream slightly more on the high side, you can get up to an 8mm implant as well. That range of options makes a big difference. It allows you to get soft tissue balancing right without over-reaming and compromising the bone quality in the vault.
Overall, I think it’s a really strong, almost one-size-fits-all approach when it comes to glenoid preparation and reaming. That’s been incredibly helpful in my experience.
David Blue:
Do you have any closing thoughts today?
Dr. Fotios Tjoumakaris:
I continue to evolve in how I use the InSet™. I’ve gradually expanded the indications, and so far, the results have been really positive, including with the reverse arthroplasty system. I’m genuinely excited to see where the technology goes from here!
Dr. Fotios Tjoumakaris is an orthopedic surgeon in Egg Harbor Township, New Jersey