Lewis Shi, MD, presents - Evaluation and Treatment of Shoulder Pain, New Options - Reverse Shoulder Replacement.
[MUSIC PLAYING] SPEAKER: Good afternoon. Thank you very much. So my topic is on reverse shoulder arthroplasty. But I like to start off with a few slides about shoulder pain and how my approach to shoulder pain should be. I have nothing to disclose. So as you guys know, orthopedic burden in the U.S. is very high. And shoulder pain, after back pain and knee pain, is the third thing that come to the emergency department. So right now, as I still have your attention, I want to talk a little bit about symptoms that merit immediate referral from the primary care physician to the orthopedic surgeon. So dislocation, fractures, these are certainly things that we should be seeing sooner than later. Certainly, if you have a documented trauma, and you have an acute loss of function-- so things that I'm thinking about include a rotator cuff tear. So obviously is not as urgent as a fracture, but if it is an acute rotator cuff tear, we probably prefer seeing these sooner than later. Certainly infection, indicated by pain at rest, fever, and chills-- these are things that we really ought to be seeing as well as tumors, obviously. So this is my algorithm for shoulder pain, for adult patients with shoulder pain. History of physical exam. Imaging. Differential diagnosis. So these are the four things in my mind as I evaluate a new patient coming to my clinic, depending on their age and their presentation. Generally I think about rotator cuff. These are more people in their 40s and older. Very rare in people in their 20s and 30s. Extremely rare. These present a weakness. They may or may not have a trauma. Instability or any labor pathology. These are younger patients, often are related to sports injuries. They may have dislocation, subluxation. They may have a sense of apprehension that their shoulder is not quite in place. Next, frozen shoulder. Adhesive capsulitis. This should be in everybody's differential. It's often missed by my residents as they evaluate these new patients. These may be patients in 30s, 40s, and 50s. They have decreased passive range of motion. And they may or may not have trauma. And they certainly may or may not have diabetes. Certainly there may be a higher chance of diabetes, but often not the case. And then arthritis, certainly. These tend to be older patients. Decreased motion, progressive pain. The patients in the younger range of this population may be laborers. And they may have some post-traumatic arthritis. So let's go through each one very briefly. So rotator cuff. What I tell my patients that there are basically two layers of muscles in the shoulder. There's the deltoid. And then there's the rotator cuff, which a thinner layer muscle deeper down in the joint. And the way that they understand it is that the function of the rotator cuff is keep the ball on the socket. All right. That's really the way I explain the shoulder anatomy. And then obviously, there's the rotator cuff in front, top, back, and way back. So those are the different parts of the rotator cuff. And then to the right, there are images of a drawing of a rotator cuff tear. And then arthroscopic pictures. So that at the bottom is-- this is the humeral head. This is supraspinatus. This is a full-thickness rotator cuff tear. I should not be able to see inside the joint. But during this picture, there's a tear. This layer of tissue torn off from the humeral head. So my job during surgery to fix this arthroscopically is to get this back down to here. So labral tears. If the patient has instability. The labrum serves as the anchoring point for different things, such as the capsule. So in this picture right here, this is the anterior capsule. Labrum is attaching. There's attachment of the capsule. And as patients-- the labral tear-- they may have detachment of the capsules. They become more unstable. And this is a similar picture. This is in front. If they dislocate anterior, this labrum-- even after you reduce it, you have detachment of the labrum. And then frozen shoulder. Normally the capsule is approximately two millimeters thick. It's white. Uniform in color. If they're inflamed for whatever reason they develop frozen shoulder. And then the capsule can be up to eight millimeters thickness. And on gross inspection, they're very inflamed. And then certainly arthritis. You have decreased joint space. You have ostephyte. You have lose body. And you have decreased range of motion. Now at the intersection of these first and last diagnoses, you have this concept called cuff tear arthropathy. So you have rotator cuff tear-- patients no longer have anything that's-- Normally, rotator cuff comes over and attaches right here on the greater tuberosity. Here, when you have a chronic rotator cuff tear, you don't have any tissue up top anymore. So then, as I mentioned, the function of the rotator cuff is to keep the ball on the socket. If you don't have any rotator cuff up top, the function of the superior rotator cuff is to push the humeral head down. If you don't have that any more, then the humeral head starts riding up. You can see this picture. It's starting to actually form a joint under the surface of the acromion. As a result, you form arthritis as well. So this is cuff tear arthropathy. It's relatively common. And it's often in patients with neglected rotator cuff tears. And this is this concept that I'll talk about later on, as a treatment, using reverse shoulder arthroplasty. So I tell my patients, we orthopedic surgeons, we're pretty simple people. There are not too many options we offer patients. We talk to them about-- in all my diagnoses, activity modifications. They can change your lifestyle. They can take some oral anti-inflammatories. That's option number one. Then they can do some therapy. And then they can do injection. If these three things fail, then they go on to surgery. We obviously go to school for a number of years to learn how to do the surgery. But that's the last resort. So for therapy, obviously very important. The goal is to restore function, strength, and motion. And we progressed to a home therapy program. I think it's very important for patients understand that you send them to the therapy, once or twice a week. The other five, six days a week, they should be doing home exercises. So these are some of the handouts the therapist may be giving to patients. Injection certainly is a very important part of your practice and my practice in helping patients, treating them conservatively. And for shoulder injection, this is a sub-acromion injection I do. I often do a little bit more a posterior lateral. I may aim for maybe this spot right here, rather than directly posterior. Because the goal is to get the Kenalog, whatever, cortisone, into the anterior bursa. So often I find posterior lateral may be a little bit better than posterior. If there's concern for rotator cuff tear, if you worry about this patient may have a tear, rather than just impingement, intact cuff, and bursitis, then I would ask you to reconsider injecting. And certainly it may be indicated in some patients. But if you're considering surgery to repair the cuff, then we prefer the patient have not had an injection previous. Evaluation of arthritis starts at examination. X-ray. You can see there's significant loss of joint space, loose bodies, osteophytes. This is the anatomical solution. A total shoulder replacement. What do I mean by anatomical? Wherever the humeral head was, we restore the normal anatomy of the patient. So we replace it with a cobalt chrome. And then on the socket part, we put in a polyethylene plastic. So this is the anatomical solution. This has been going for the past 30, 40 years. Now we have cuff tear arthropathy-- the concept I talked about. When you don't have a rotator cuff, then you cannot do an anatomical solution for a non-anatomical problem. So as I talked about, there are two layers of muscle in the shoulder joint. The function of deltoid is keep pulling the humeral head up. And the function of the rotator cuff is to keep the humeral head in place, or more importantly, to counteract the deltoid to pull it down. If you no longer have the rotator cuff working, then you result in this unidirectional pull, so the humeral head is going upward. Again, this is the concept of cuff tear arthropathy. So one of the surgical solutions is called a reverse shoulder arthroplasty. And as Dr. Angeles mentioned, it's very simply put. It's reverse. Where the socket was, you put a ball there. Where the ball is, you put a socket there. So this is a non-anatomical solution. It's a constrained prosthesis. So you can see in X-ray right here, where the humeral head now riding higher up, your deltoid is losing tension now. It's a little bit lax than before. And you have arthritis here. And then this replacement-- the socket, you have the ball there. So you changing, your medializing the center of gravity. And you're making the arm just a little bit longer than what it was in this position. So you're tightening the deltoid. So that your center of gravity is more medial. Your lever arm is bigger, so that you're able to use your deltoid again. So this is what a prosthesis looks like. This goes down in the humerus. So the interface is still cobalt chrome to plastic. There's a component that goes into the socket, then two screws to hold it in place. And then the conisphere, is a hemisphere that fits on top of that. And then this component goes down into the humerus. And then the articulation is formed. So the evolution of this. This came out of Europe, this innovation, in the mid '80s. There's been many generations of this product. In the early '90s was when, more or less, the current design arrived. And you see, previously they used different products. The size of the hemisphere was different. And then you went through a lot of iterations before we get to the most recent design, which is more or less like this. This was approved in the United States in 2003. So only about 10, 12 years ago. Certainly in Europe, they've been doing this for about 10, 15 years longer. The indication for this, as I talked, is cuff tear arthropathy. Because as we understand, as we started learning about the reverse, how they behave, we're expanding our indication. Because some of these other problems, like really bad fractures, non-unions, revision cases-- patients just don't do as well. So then we are starting to use reverse for some of these other indications. Now some of these are contraindications. Originally it was approved for patients 70 and older. But as we are getting better and better at these, we're starting to do them in younger and younger patients. But if there's someone in their early 60s or 50s, I would have to think twice about are there other, better solutions, such as non-operative treatment, to try to hold them off as long as we can. Because this is not as robust as anatomical solution and total shoulder. If you don't have a deltoid that's working, obviously-- You rely on a deltoid to hold this tension in place. So if you don't have a deltoid, then this is contraindicated. Infection, certainly. And weight-bearing requirements. I have Vietnam vet, who's a double amputee, who needs to basically use his arm to weight bear to transfer. And he's begging me for this. And I'm not sure that he's the best candidate for this. So a few pictures interoperatively. This is a right shoulder. This the glenoid. The humeral head is under the deltoid here. This is the back of the glenoid, the front of the glenoid. And this is the glenoid that we're going to prepare to put the implant on. This is the base plate, that we talked about. Some of the base plate designs have four screws. Some of them have two screws. Either two or four will work fine. And then you put this in the right place. And then you put the hemisphere on the base plate that engages. And then you have a plastic component and the metal that goes down the humerus. So briefly about what to expect as you counsel patients, as we talk to you about getting a patient ready for surgery. This is about 2 and 1/2 hour surgery. About 150, 250 EBL. You can do these under strict regional or regional plus general. Generally my patients stay in the hospital two or three days. They go to rehab for social reasons. They don't need to go to rehab-- because they're in a sling-- for about four weeks afterwards. But if they don't have anyone taking care of them at home, they go to rehab. And then therapy starting maybe second half of the first month, or second month. And then we start with shoulder strengthening into the second or third month. There's really no activity limitation from my perspective, but there's reasonable weight limits. So I certainly don't want them to weight bear through this. Especially in the first couple of months. And then I tell patients, any arthroplasties, antibiotics, prophylaxis for dental, and endoscopy procedures for lifetime. So complications. This is something we should end on. Dr. Frankl, a very well-established shoulder surgeon in Tampa. And he published his experience with 300 reverses. And his complications with them were 10%. So in less experienced hands, certainly, we're talking about complications ranging between 5 and 20%. So this is certainly higher complication rate than anatomical shoulder replacement. Dislocation, disassociation, base plate failure, chromium fractures, et cetera. So in summary, patients with arthritis and deficiency of rotator cuff-- this is certainly a challenge. In the last 10 or 15 years or so, we have this new technology called reverse arthroplasty that we can consider after patients fail conservative treatments. Total shoulder replacement is not indicated for reverse. There's evidence that there's very good intermediate outcome. And patients are relatively happy. But there are significant complications, even in inexperienced hands. Thank you very much.