- December 20, 2019
You know arthritis is one of those things that we kind of talk about but there’s lots of different types of arthritis. And so I thought I’d kind of go through this a little bit. We’ll talk about the anatomy the joint and some non-Op and operative strategies. But remember once you go to an hour through a joint replacement you can’t go back. So I think it’s important to talk about things we can do to avoid getting there. And we kind of understand that the shoulders of ball and socket joint. But it’s a very unstable ball and socket joint. So a hip socket stable shoulder. It’s one of those joints it’s almost more like you have a plate of bone. So it’s a unstable joint because the glenoid or the socket of the shoulder is relatively flat. So this joint not only is unstable but it’s also the most commonly dislocated joint.
And Ioannis will talk about that a little bit later. But it’s not really a true ball and socket joint. And the reason it becomes a ball and socket joint in a way is that the labrum adds about 50 percent of the depth of the socket. There’s a negative pressure in the shoulder. There’s this adhesion the fluid kind of holds it in and then you have this relatively wonderful kind of capsule and ligaments and muscles that all function around the shoulder. So for the shoulder we’re talking soft tissues. It is a soft tissue joint and there for rotator cuff muscles. And I love that and clinic and you guys have heard it too and God bless our patients had have Rotary cup problems or you know you hear all this when they come in and I still get a kick out of it but there’s four muscles that make up the rotator cuff and you don’t tear muscles really in the shoulder it’s more of a tendon injury you’re gonna tear your tendons.
That’s because they’re relatively a vascular structure. You don’t really get rotator cuff tears in people under the age of 40. That’s kind of one of those misnomers. I mean you can but most of rotator cuff tears occur and people my age so a fifty five year old. And something occurs and I’m in this boot now to eat, and crow because last year Jeff Stone fell and tore both of his calves, so Mark Frankle has both of his shoulders replaced. I was feeling young and sprightly because I didn’t have any orthopedic injuries. Here I am. So let’s talk about function and then and I thought John. That was a wonderful lecture that he gave. This is look out for this girl Coco Gauff used at Wimbledon probably the star of the summer she followed the playbook of kind of the Williams sisters You know and she beat one. Thing that’s interesting she started playing tennis and she was really little. On our shoulder Of course this year we’ve got a guy named Epstein who’s coming to talk about range.
I don’t know if you guys knew this but Roger Federer didn’t really start playing tennis until he was 18. So he was really good at sports but he didn’t start when he’s a little kid. So the question that always becomes you know how do you get good at a sport. And so if you come to our shoulder Of course you can listen to Epstein give his lecture so let’s talk about elevation. You know when you lift your arm up. One third of the motion is from your shoulder blade. Not from my ball and socket joint. So even if you have arthritis you can still lift your arm up the ball and socket joint seizes up much like the car engine it stops working but you can use your shoulder blade to elevate your arm. I kind of like this get to the the barnyard or into the garage and kind of figure this out.
But this is what the muscles do, so you’re kind of trying to figure the rotator cuff compresses a ball in the socket so your deltoid can work but all arthritis isn’t the same. And so there’s different ways to treat it but I think the biggest mistake people make is that you have an arthritic joint they go Hey don’t use it. Mistake. It’s actually quite the opposite. If you have an arthritic knee and arthritic hip and arthritic shoulder you want to exercise you want to stay active you want to keep moving the joint. It’s really counterintuitive. There’s a lot of supplements that are out there right now. You know I kind of my best friend growing up lives in Colorado you know and all these different kind of things. He likes allopathic medicine. So tumeric it’s this you know you can take it with pepper. It’s a natural anti inflammatory glucosamine conduit and sulfate and we heard about that a little bit earlier. But I think that it’s important to start these supplements early before the arthritis gets too bad.
We can inject the shoulder and we’ve talked about that but the most important thing I tell my patients is keep exercising don’t stop. I don’t even know what pickle ball was this is a goofiest game that has come up but it’s very pious like all the rage that patients come in and there’s like tournaments and leagues and it’s crazy. So let’s talk about arthritis. They’re all arthritis is not the same. There’s lots of different types of arthritis and some of them are systemic mean it’s not just the joints that are involved it’s the entire patient. So the most common is osteoarthritis. This is what we see in our practice but rheumatoid arthritis is out there.
This is Phil Mickelson. I think he has psoriatic arthritis but these inflammatory processes affect the entire body. And before we had these defeat disease modifying agencies are really sick people. Now they’re out doing great things but it’s amazing what a medication can do. And it is eliminated. Those patients need to go to the orthopedist they go to the rheumatologist. There’s rotator cuff arthropathy. We have failed cuffs. You can get AVN from traumatic type problems or drinking too much or too many steroids and unfortunate a lot of cancer survivors get AVM because part of the regimens for cancer treatment oftentimes involves high dose steroids. You can see septic arthritis from infections. And that’s really not quite as common. But one thing I want to show you here is this is a way to get a proper extra of the shoulder. This is what’s called a true AP of the shoulder so you can see the joint and you can see on the X-ray picture.
This is an obliterated joint. So then we can look at C.T. scans and they add a lot of information for us. So I think a C.T. scan with arthritis it’s not necessary the MRI with arthritis I’d like to see the C.T. scan rheumatoid that joint is destroyed before we had these medicines to stop it. It was this sit over him just ate into the cartilage, ate into the bone. It just destroys the entire joint. And these patients would end up in wheelchairs and crippled by the time they were in their 40s. Luckily that isn’t the case today rotator cuff arthropathy is something that we used to not be able to treat too well because we didn’t have means to do it. Now we have newer shoulder arthroplasty that can deal with it a vascular crisis still a problem very painful. They don’t do as well if I replace a shoulder on someone with AVN.
They’re not as happy as my other patients. They still have problems. And so I think this is kind of let’s see that that is actually a surgery that was done in the 1970s that was called the do capsulorrhaphy. You took a big roofing staple you nailed the subscap to the Glenoid. No more dislocations but in fact the problem with that is people got arthritis later in life. This is a non-union meaning the bone has not healed. This is a challenge whereas to treat because the bone and some of the older patients no longer can be fixed the blood supply has been compromised. So you’ll probably go to an arthroplasty. So let’s talk about a valuation exam. Ioannis did a wonderful job. I thought so this because this was me. Well not really me I’m not Kevin Durant but you could see that his poor Achilles tendon just ruptures and there it goes poor guy.
And so Kevin Durant also talking about Prince George’s County My wife is from Greenbelt and Johns there. Kevin Durant grew up in the area. He could only bench press about 100 pounds at the combine for basketball. Everyone’s looking I’m like This guy’s not going to be a great basketball player. So let’s talk about physical exam. We have Ioannis do a beautiful thing. I like to get photographs and videos of patients that undergo art the policy. But the problem is what Ioannis alluded to that you tried to do the pass of motion with arthritis it doesn’t go arthritis the joints seizes up you have basically a square peg in a round hole doesn’t work. So most of the motion is coming from the shoulder blade so you can do surgery and so everyone comes and everyone is arthroscopy is kind of what people want to talk about because it sounds like no it’s outpatient it’s easy.
You know I don’t have to have a big operation. I don’t need my joint replaced but it really doesn’t do too well for pain relief. So you can scope someone’s shoulder who has arthritis but it’s really never the greatest answer for me and I rarely do it these days sometimes you get a younger patient but the recovery is a lot more difficult than they might imagine. It’s not going to solve the problem of the loss of the cartilage or the irregular joint surfaces. So I would tell you that that’s probably not a great idea. Don’t encourage your patients to have that because most of time it doesn’t work too well. Arthroplasty is across the board going to win but it’s a limited time so it’s like buying a car once you do your art plus you’ve got 15 years. And if once you get to the end of that you’re going to have to have a really big operation.
So we like to put that off till later sometimes in very old patients will just cut the shoulder out people like go Oh my God. But if you have someone who’s sick not healthy can’t rehab. That may be an answer in a resection or maybe it was an infected case an infectious arthritis and finally a fusion of the shoulder. The only time we really do that is when the nerves don’t work when you’re electrical wiring system is gone. I said the last three I did were from young men who were jilted or their girlfriends cheated on them or something happened terrible. They were going to kill themselves and then they shot themselves with a shotgun in the shoulder instead. And that takes out the nerves. You confuse the shoulder and all three of the guys that have recently done are back working one guy works fixing jet skis. So he’s better. He’s found a nicer lady this time.
So let’s talk about arthroplasty. So arthroplasty is really gold standard. And we have to look at when we’re doing our exam is what’s the status of the rotator cuff. Because in osteoarthritis you’ve got a great rotator cuff. In fact it almost protects the rotator cuff. We know that patients who have osteoarthritis have a 5 percent chance of having a rotator cuff tear by the time they’re 60 whereas a normal human like this guy Dr. Papp who probably has about a 60 percent chance of having a rotator cuff. So the arthritis itself protects a rotator cuff rheumatoid arthritis. They tend to get rotator cuff tear because it’s a destructive process. And then in traumatic cases the rotator cuff is scarred. If I broke my shoulder falling on it like God forbid, I fall off the stage but if I broke my shoulder and it healed I’m stiffer.
And those patients don’t do quite as well with the traditional total shoulder passes because they’re stiff so there’s tense that you don’t have to write this down. This is this more of a sort of but I always make like you have to have either a 10 or 12 step program for most thing in life. This is how you do it total shoulder 10 step program. But I think that the main thing is that anything we do surgically we have a strategy. When we go about it. And so first we want to make sure we get adequate radiographs. We want to make sure we get adequate C.T. scans and then this is kind of what we do. I mean this is art the policy. What’s amazing is that this is actual surgery very little bleeding you know what’s amazing to me is it’s unusual that I’ll ever have to do a transfusion for a shoulder replacement.
But the key to doing a shoulder placement is really seen into the socket. And we do a series of detractors but when we’re done you can really see what we have to do when we’re doing this procedure. Most of our implants these days if you look to the to the left of this that’s on the right up here. But we’re using titanium stems cobalt chrome balls and we still use a plastic socket that gets grounded in the reason it’s a little quick as I had monster energy that morning so was a little faster doing my surgery which helps to get done quicker during the day. So I think that glenoid exposure for us as shoulder arthroplasty surgeons is really what’s critical. And so that is what makes us better. So you know if you do I do about two hundred and fifty shoulder replacements a year so I do this all the time. I mean I really do. Basically, two operations at this point one is a shoulder replacement.
The other’s a rotator cuff repair so I can keep it simple but you know we have to get this exposed in the way we do it was by putting these retractors in to kind of see the socket. So we use these large home in these instruments to really expose the glenoid and it’s almost like a Chinese finger trap if you put too many instruments and it gets too tight. And I had a Chinese surgeon with me and I was like you know I’d say doctor Wang You know you want to put too many like a Chinese finger trap and he goes to me what’s Chinese finger trap. So I didn’t realize that Chinese finger traps or something. It’s almost like French fries. I think it’s pommes frites Right.
So you know I said no you know lie a little. And he kind of looked at me like I was crazy. But when we’re doing this we want to have just enough for tractors to see it. And usually it’s about three so you can see right now we’re using an electrocautery so all this is done with an electric knife and that keeps the bleeding down also and you’re going to remove the inflamed and overcome the inflamed capsule. And we put these retractors in and we gradually remove all the disease tissue while maintaining the muscle. So we’re taking out the lining but not the muscles. And we have our tractors in and we work till we can see and choose the three were tractors that we have in so in the end we have this nice exposure we can see the glenoid and we can place our shoulder arthroplasty.
So the other thing I wanted to talk about a little bit is that this is a traditional shoulder arthroplasty but for you guys. Probably only 30 percent at this point of the shoulder arthroplasties done or the traditional shoulder arthroplasty because of the reverse shoulder so the reverse prostheses is what we use when the rotator cuff is bad so the reverse is much more versatile in the sense that I can do a total shoulder for an anatomic shoulder replacement but the reverse will work for a deficient rotator cuff for a post-traumatic case they’ll work for a revision case it’ll work when you have bone loss of the socket it is much more versatile and 70 percent of the shoulder is done in the United States are now reverse shoulders and the other thing that I’ll mentioned about this is that with my traditional shoulder arthroplasty and a little bit more concerned about my post-operative care.
Traditionally we’ve done six weeks in and immobilize her now with my reverse shoulders after two weeks they can start using their arm I don’t send me the therapy yet but I let them take their sling off they can go to the shower they can they can Bay they can drive their car they can play on the computer they can do all of those things because it is relatively stable it’s a much more stable design. And if in fact I did repair the subscap and it failed with the reverse shoulder it won’t be a problem if I do a subs gap and it fails on a total shoulder it’s a real problem. So the reverse shoulder can be done and some people are even doing it now in patients over 80 because they don’t want to have to have those individuals be in an immobilizer or for six weeks because whether you’re immobile or for six weeks or a boot for three months there’s nothing worse and crawling into the shower in the morning to get ready for work. And I had to learn about that which was kind of a unique experience.
So this is a reverse shoulder. It’s a long deltoid pectoral incision we expose a shoulder we do the head cut we remove bone but I think that at the end of the day whether we do a reverse or an anatomic. The Glenoid component becomes the most important of all. OK. So. Another thing that is really important is rehab for an anatomic total shoulder width policy your physical therapist is your best friend.
You my patients like their therapist more than they’d like me they’ll like how I saw John or I saw so and so and they because you guys spent a lot of time with them all the physical therapies out there do a great job and the patients really kind of bond and they hate it when they transfer to different therapists like the biggest thing I hear as a doctor is I was seeing John and I saw Johnny last week and Ioannis didn’t know anything about my case. They love seeing the same therapist they don’t like it when they get bounced around to different people. So when I have patients I try to have them go and kind of get a relationship with their therapist.
But I think it’s very important. The one thing we’re protecting is that subscapularis repair is very important to protect the repair of the subscapularis. And you don’t want them to do any really heavy lifting until three to four months out from their operation. And so. You know. Basically the first day after surgery when I say we begin therapy is really elbow wrist and hand motion and then at the two weeks from my reverses I’m letting them do computer work. I can drive their car with the total so I’m a little bit more stringent. And then at three months you know we’re basically kind of getting them going. So I think that in general it’s a wonderful operation like anything in life. Unfortunately, there are complications. And so just briefly infection is very rare but one of the things that’s very important and this goes for all surgery.
I have my patients use benzoyl peroxide wash because you know the acne that lives in the skin and that bacteria’s more common and shoulders but they just go to the drugstore and get it. But if you have surgery on your shoulder your face your head neck benzoyl peroxide wash is wonderful. The actual incidence and shoulder replacement is one of the lowest because it’s a very vascular area. It’s less than 1 percent. The infection rate in children are the policy loosening happens with time. So loosening usually starts to happen around 15 years unless you’re very aggressive. And then finally dislocation can happen and usually that happens early when you don’t follow protocols. Nerve injury thank God is very very rare. And finally, some people get stiff and I think that’s not proper rehabilitation afterwards. So in any event I thank you very much for listening and we’re going to move on to talking about the instability of the shoulder and I’m gonna be able to have Dr. Pappou who come back up here and talk to us about that.