If shoulder arthritis has been causing you pain, this episode is your gateway to a pain-free life. Today, we learn from the best in the field, Dr Amit Sood, Chief of the Shoulder Service at Kayal Orthopaedic Center. Dr. Sood takes us on a journey through the intricate world of shoulder arthritis. He gives us a glimpse into how he diagnoses and manages this debilitating condition, elucidating on the anatomy of the shoulder joint.
We discuss not only the common symptoms and causes but also the various treatment options available. Dr. Sood shares his insights on the advancements in shoulder replacement surgery, with a detailed explanation of the pre-operative block and the benefits of outpatient procedures. His expertise on the precise placement of implants and the importance of preserving bone for potential revision surgeries is truly enlightening.
But what comes after the surgery? Dr. Sood emphasizes how we can live a full life post-shoulder replacement. By engaging in activities mindfully, we can ensure the longevity of the shoulder replacement and enjoy life to the fullest. Just like caring for a prized car, we need to treat our shoulder with care to enhance the quality of life. So, join us as we delve into the world of shoulder arthritis and its management, and equip ourselves with the knowledge to live a pain-free life.
If shoulder arthritis has been causing you pain, this episode is your gateway to a pain-free life. Today, we learn from the best in the field, Dr Amit Sood, Chief of the Shoulder Service at Kayal Orthopaedic Center. Dr. Sood takes us on a journey through the intricate world of shoulder arthritis. He gives us a glimpse into how he diagnoses and manages this debilitating condition, elucidating on the anatomy of the shoulder joint.
We discuss not only the common symptoms and causes but also the various treatment options available. Dr. Sood shares his insights on the advancements in shoulder replacement surgery, with a detailed explanation of the pre-operative block and the benefits of outpatient procedures. His expertise on the precise placement of implants and the importance of preserving bone for potential revision surgeries is truly enlightening.
But what comes after the surgery? Dr. Sood emphasizes how we can live a full life post-shoulder replacement. By engaging in activities mindfully, we can ensure the longevity of the shoulder replacement and enjoy life to the fullest. Just like caring for a prized car, we need to treat our shoulder with care to enhance the quality of life. So, join us as we delve into the world of shoulder arthritis and its management, and equip ourselves with the knowledge to live a pain-free life.
Hello and welcome to another edition of the Kaila Ortho podcast. Today is July 6, 2023, and we're very excited to have with us today Dr Amit Sud. Dr Amit Sud is the chief of the shoulder service at the Kaila Orthopedic Center and he's been with us here at Kaila Ortho for about eight years now. Welcome to the podcast, dr Sud. Thank you for having me. Dr Kail, we're so happy to have him with us today. Dr Sud is a highly trained and experienced shoulder expert in the field of shoulder surgery. Why don't you tell us a little bit about yourself, dr Sud, and your training as well?
Speaker 2:Sure, i actually grew up in the Chicagoland area and I went to the University of Illinois in Urbana-Champaign where I did my undergraduate training and, following graduation, i did my medical school training at the Medical College of Wisconsin and following that, i eventually made my way to the east coast, to New Jersey, where I did my orthopedic surgery residency training at what was called UMD&J before, which is called Ruckers Now, where I did extensive orthopedic surgery training. Following that, i did a specialized fellowship in shoulder and elbow at the Harvard Boston Shoulder Institute program, where I spent a year training with highly skilled surgeons in the Boston area, learning about more advanced techniques in shoulder and elbow surgery. Part of that fellowship involved traveling to France, in Europe, where I spent time training with some of the master surgeons in Europe as well, learning a lot of the techniques that they helped to enhance for surgeons throughout the world. I spent some time training in Nice, france, with Dr Pascal Wallo. I spent some time in Honesty, france, with Dr Laurent LaFos, learning very advanced arthroscopic techniques, and I also spent time with what's considered one of the grandfathers of orthopedic shoulder surgery, which is Dr Gilles Valls, in Lyon, france, as well, and it was truly a tremendous opportunity that not many orthopedists get to do.
Speaker 2:Usually you have to take time out of your own practice, once you've gone outside your fellowship, to go and travel and follow different surgeons throughout other parts of the world to learn advanced techniques.
Speaker 2:And I was fortunate enough, where it was a part of my fellowship, it was integrated into the program where I traveled there, lived there with the folks in the community, trained with the surgeons at the hospitals, both seeing patients and in the operating room, and really got to know them on a more personal level, where it wasn't just going to work with them, it was eating dinner with their family, going out, talking, having laughs and really getting to immerse myself in the culture. And it was an opportunity that I can't replace and I'll cherish that forever. Following that fellowship, i was fortunate enough to come back to New Jersey. I actually met my wife while I did my residency in New Jersey and she always tells me once a Jersey girl, always a Jersey girl. So she wanted to come back to New Jersey and I was fortunate enough to come to the Kale Orthopedic Center, where I've been ever since and I've loved it.
Speaker 1:It's no wonder we love your wife so much.
Speaker 1:I mean, what an experience to train in that part of the world, especially with those expert, expert shoulder surgeons, and certainly you've gone so much education and skill and expertise over the years that we truly consider you very much an expert shoulder surgeon, dr Sood, and you've taken care of thousands and thousands of patients for us at Kale Orthopedic Center over the last eight to 10 years and we're just so privileged and blessed to have you, thank you. Today's topic is going to be on one of the more common shoulder conditions called shoulder arthritis. We are going to be discussing with Dr Sood today the evaluation and management of shoulder arthritis. We're going to diagnose it. We're going to see how he evaluates patients presenting with shoulder arthritis, what signs and symptoms he appreciates when he has encounters with them. We will be discussing the conservative, nonoperative and surgical management of shoulder arthritis as well. So let's just dive right in and let's talk about a little bit of the shoulder anatomy so we can define the anatomy and then we can start defining the condition as well. Okay, sure.
Speaker 2:So the shoulder joint is comprised of the humeral head as well as a glenoid bone, and the glenoid bone is a part of the larger bone in the back of the shoulder, which is the scapula bone, and the humeral head is a part of the upper part of the arm or the upper part of the humerus, and it articulates with the glenoid. And my analogy for the shoulder joint is comparable to thinking about a golf ball and a golf tee, and so you look at the golf ball as being the. The humeral head is a golf ball and the glenoid is the golf tee, and, as you can imagine, it's a very unstable joint. In fact, the shoulder joint is the joint with the most range of motion in the entire body of all the joints, and so you can imagine what the golf ball is seeing on a golf tee is very unstable. You could just flick the golf ball and it could fall right off.
Speaker 2:And the shoulder if you watch enough sports, you hear about shoulder dislocations all the time. So it's one of the most commonly dislocated joints. So it's very unstable, and so there's a big interplay between the muscles, tendons, as well as the bones to keep that shoulder stable. And because it's so unstable. It doesn't just rely on the bony anatomy for stability. There's a ring of tissue around the glenoid called the labrum, which provides stability for the shoulder joint. There's also capsular tissue Think of it like a balloon surrounding the shoulder joint that helps keep it stable as well. And there's a variety of different muscles and tendons, the most important being the rotator cuff muscles, which is comprised of four major muscles the sub scapulae, super spinaeus, infraspinaeus and teres minor, which help to keep the shoulder stable as well and provide range of motion for the shoulder joint.
Speaker 1:Yeah, so we talk about the dynamic and static stabilizers, right? So the muscles primarily make up the dynamic stabilizers to stabilize that construct. And then there are the static stabilizers the bone, the ligaments, the capsule, the labrum, things like that. I use the same analogy of the bone socket joint and the golf ball sitting on the tee. It's an inherently unstable, but if it weren't for those dynamic stabilizers to stabilize that joint, it would very easily dislocate or definitely sublux. So that's the anatomy of the shoulder joint. So, as far as arthritis is concerned, can you define that condition for our audience?
Speaker 2:Yes, There are different kinds of arthritis, the most common being standard primary osteoarthritis, or wear and tear arthritis as most patients call it.
Speaker 2:And on the surface of the humeral head as well as the surface of the glenoid bone, which are the two bones that I mentioned earlier, there's a softer, more smooth coating on those bones, which is the articular cartilage.
Speaker 2:So you can imagine or you know that the bone is a very hard and rough structure And so you don't want bone contact the bone. And so in every joint in the body we've evolved to have this articular cartilage at the ends of the bones to provide a more smooth surface of where they can touch and meet each other. And normal wear and tear or primary osteoarthritis involves the degradation or erosion of the articular cartilage, And what happens is, over time, you start to thin out on that cartilage And as it starts to thin out more and more it exposes the bone that's lying underneath and that's what's termed the bone on bone arthritis. So as you start to expose the bone you could imagine bone touching bone and it starts to grind and cause pain over time, and especially if it's involved on both sides of the joint or both bones that are part of that joint, the pain can be much worse.
Speaker 1:Yeah, and you know, arthritis, as we've defined in the past, is inflammation of the joint and, just like the other joints that we've discussed in the past, it's often associated with redness, warmth, pain and swelling in that joint. And of all the arthritic conditions in the body, for some reason shoulder arthritis seems to be the most debilitating, right for the most part. These patients really complain often of inability to sleep at night, and it definitely affects their quality of life, because all of us need to sleep and get a good night's sleep and, for whatever reason, when patients have shoulder disorders, very often they can't sleep at night, right.
Speaker 2:Absolutely. That's probably one of the biggest complaints that I get. Initially it starts out as having this sort of dull, too thick type pain that patients complain about and it can happen spontaneously and over time as the arthritis advances it could happen even at rest and again that sleeping situation where you're not even using it at night, you're just laying there and it can cause pain. But that's one of the most common presenting complaints. In addition to being unable to move the arm or use it for even basic functional activities like putting food up to your mouth to eat or brushing your hair or brushing your teeth or reaching into a cabinet, over time you get this functional limitation and pain associated with just doing basic household chores.
Speaker 2:The other thing is, as the arthritis advances you can also develop what's called a crepitus or clicking and popping of the shoulder and that really happens as you're road more and more cartilage over time and get that bone exposure and that can be very debilitating for patients and oftentimes it could be an audible click or snap that you can hear even examining patients in the office. And then, as time goes on, again the night pain is something that, again, not even using it, you're laying down going at night and patients complain that they can't sleep at night and to me that's the more worrisome symptom because if they can't sleep at night it affects them the next day. They don't have the same energy level, mentally they don't feel the same, at least depression, anxiety, etc. So once you start losing sleep we know that it's a more serious problem.
Speaker 1:Arthritis can obviously lead to pain in the shoulder, especially at night, some loss of motion as well, because you lose that nice articular cartilage and the joint starts to erode. But how do you know it's arthritis that's causing that? Can it be other things in the shoulder It?
Speaker 2:can be a variety of different things, like we mentioned on the anatomy, the soft tissue structures that are in the shoulder. So it can be pain can be caused not just by the bones but by those soft tissue structures. So you can have labral tears that can occur as well as rotator cuff tears or ligament tears that can happen in the shoulder. So it's important when the patient comes to the office that we do a thorough examination to figure out what exactly the problem is.
Speaker 1:Yeah, so it makes a difference, right, if a patient comes in, because patients with those conditions that you mentioned rotator cuff tears, labral tears and other disorders of the shoulder can also have night pain, right? So how do you distinguish in the office, based on physical examination and imaging, to determine what in fact is wrong with the patient, if it's truly arthritis or if it's a rotator cuff tear, a labral tear, a problem with their biceps tendon or all of the above?
Speaker 2:It initially starts out with a good history. I think just by talking to the patient you can learn a lot about what the problem really is, and so it's important to, as a physician, talk to the patient, hear what they're saying and process that. There's a lot of different factors to consider. Was it traumatic? Were they skiing downhill and all of a sudden they fell? Were they're playing basketball and fell? or riding a bike and fell and landed onto the shoulder and then developed pain In that situation? if they didn't have pain before, i'm less likely to think that arthritis is a problem, and maybe they disrupted one of the soft tissue structures that we talked about with the shoulder. If they fell and dislocated their shoulder and went to the emergency room and one of the doctors had to put it back in place, depending upon the age of the patient younger patients it tends to be associated with labral tears. As a patient gets older, when you dislocate your shoulder, we tend to see rotator cuff tears as a more common associated pathology. So all these things I have to take into consideration when I talk to the patient. In addition, we always take x-rays when the patient comes to the office. I get more concerned about arthritis as the patients are a little bit on the older side but again we're seeing it more and more at a younger age as well, with this post-traumatic arthritis that can develop. So we take x-rays in the office and we evaluate the bony architecture and we look at the ball in the socket or the golf ball in the golf tee that we mentioned earlier and we see is there a space between the two bones? and it? has there been degradation of the cartilage that's on there? One thing that we see if there is degradation of the cartilage is that the bones start to move together. So you see the humeral head touching the glenoid bone and oftentimes, as the arthritis advances, not only do the bones touch together but we see other findings on the x-ray as well, for example development of osteophytes or extra bone formation on the x-rays as well. And the body does that in response to the stress that develops across the joint because of the loss of the cartilage. And so the body responds by trying to grow this extra bone and distribute the stress across a greater surface area, not knowing that it's actually causing more of a problem for the patients and that could inhibit the range of motion and cause clicking or popping. And once I hear the patient complaining of clicking or popping in the office, i know that either it's unstable, either it's shifting in and out of the joint or potentially these osteophytes causing that noise, and so we're able to pick that up on the x-rays.
Speaker 2:In addition to listening to the patient, we also do an appropriate physical exam. I will start by touching the patient both over the biceps tendon as well as the acromioclavicular joint. Those are some common areas where we see associated pains. We want to rule that out as a source of pathology. We also test range of motion, and we test both active range of motion as well as passive range of motion. And by checking the passive range of motion I'm able to see if the patient is either stiff or just unable to move the shoulder. So if they can't lift up their shoulder but I could lift it up for them I know that they're not stiff. That's just a lack of range of motion secondary to either pain that they're having or that maybe they tore their rotator cuff and can't physically elevate the shoulder. If my passive range of motion is similar to the active range of motion, then I'm more concerned about stiffness, and that's a whole different variety of conditions I can develop, for example, frozen shoulder that you can develop and cause stiffness in the shoulder. So we do a thorough physical exam.
Speaker 2:We also do strength testing.
Speaker 2:So we test a different rotator cuff muscles and tendons that are on the shoulder And the four different rotator cuff muscles that I mentioned earlier the subscapularis, which is on the front part of your shoulder. When that contracts it results in internal rotation. So we're always testing internal rotation strength to test that specific rotator cuff muscle. I also check for forward elevation strength, which is for the supraspinatus rotator cuff tendon, as well as external rotation, which is for the infraspinatus rotator cuff tendon and the teres minor rotator cuff tendon. So, based on strength testing that tells me the integrity of the rotator cuff tendons and gives me information. I also check for instability of the shoulder to see if the shoulder wants to slide out the front or the back of the shoulder and even if it doesn't slide, if any provocative maneuvers cause pain in those directions which leads me to potentially having a labral pathology in that shoulder. I also raise their arm and check for signs of any impingement or bursitis by raising the arm and internally rotating the arm to see if there's any symptoms of impingement Right.
Speaker 1:Well, i think all of this is very, very important, but probably the most important thing that you identify is whether or not the patient has arthritis.
Speaker 1:because there are a lot of soft tissue problems that you see on a daily basis in treat labral tears, biceps, tendon injuries, rotator cuff tears. But I think the game changing finding is when you identify that there is arthritis that exists in addition to all those things, because as soon as we identify that arthritis exists in that joint, it changes our conversations with our patients Right. So if it's an isolated soft tissue problem so for instance then in the knee, if there's a meniscus tear or an ACL tear typically we'll address that soft tissue problem arthroscopically in a sports medicine type procedure. Once we identify that arthritis is also present on the X-ray or MRI, it changes our conversations with our patients. It's important for the patients to understand that we don't just treat those soft tissue problems when there's arthritis. we have to do something bigger, more definitive, where we take care of the arthritis as well as the soft tissues at the same time. Why don't we just inform our patients how you would address somebody that presented with arthritis in the shoulder? What is the first line of treatment for those?
Speaker 2:patients. We always try and start with a conservative management for the patient. When the patient first comes in and we identify that they do have arthritis, we want some pain relief and that's usually the first presenting complaint that they come with. And, as you mentioned earlier, osteoarthritis is inflammation of the joint and pain relief is designed towards decreasing that inflammation. So if there's not any medical contraindication, we recommend oral anti-inflammatories to reduce the inflammation and help with the pain and hopefully help with some of the night pain that some of them might be experiencing or pain with daily activities. Also, we always recommend some physical therapy for the patient. Oftentimes they're limited with a range of motion or have an element of weakness, and we want the physical therapists to work with them to optimize the range of motion as much as they can and also decrease the pain as much as they can.
Speaker 2:The goal of physical therapy is to help stabilize the shoulder. Because they're bone-on-bone at that point or have eroded a lot of their cartilage. Even any element of micro instability can cause pain across the shoulder joint. So what we want to do is get them into physical therapy, strengthen the rotator cuff muscles and also in turn, that provides stability for the shoulder and decreases that micro motion and can help decrease the pain for the patient.
Speaker 2:We also try, if the patient chooses to do so, cortisol injections which can be administered both in the joint as well as outside the joint to help with bursitis. I usually will do a combination of both. If I feel like there's a lot of impingement related pain or bursal sided pain, i will do a subacromial space cortisol injection in the office. If a lot of the pain is being derived from within the joint itself, where the arthritis is, i will do a cortisol injection into the glen and hemorrhage joint where that articulation is. It's very important to be precise with that injection and oftentimes it can be difficult to do In the office. I will do it under fluoroscopic guidance to make sure that I have it in the correct location so that when the patient gets the medication they get the most relief from that injection.
Speaker 1:Yeah, i think it's important for patients to understand there are different areas that we inject in and around the shoulder.
Speaker 1:It's important to identify if the problem lies within the bowel and socket joint, that your doctor injects the bowel and socket joint as opposed to the area above the bowel and socket joint.
Speaker 1:For instance, a lot of patients present with night pain from rotator cuff pathology or a condition like bursitis or impingement that Dr Seud was referring to. Those injections typically would take place outside of the shoulder joint and those injections are typically given from the side or the back of the patient to that area where the bursa is. But when patients have shoulder arthritis or problems inside the shoulder, like labral tears or long head of the biceps tendon injuries, those injections have to be performed inside the joint and it's difficult to inject the shoulder joint itself, and so at the Kaila Orthopedic Center we use imaging technology such as ultrasound or fluoroscopic guided technology to make sure that when we're injecting the shoulder joint we're actually inside the shoulder joint, exactly where we want to be, so that the patients get the most relief. In addition to the injections of cortisone, are there other types of injections that you can treat our patients with for shoulder arthritis?
Speaker 2:Yes, there's orthobiologic. So in the office I do do platelet-rich plasma or PRP injections, as is commonly called, where we take the patient's own blood and it's not a lot of blood, only about 15 cc's and we do it right there in the office And we actually use a centrifuge machine to extract the platelets from the blood and we inject that into the shoulder as another option for pain and also another option compared to cortisone injections?
Speaker 1:Yeah, certainly, regenerative medicine is popular these days, and orthobiological therapy utilizing autologous conditioned plasma and platelet-rich plasma is very helpful in decreasing the inflammation in the joint, which can definitely contribute with alleviating our patient's pain. So, besides the injections in physical therapy and anti-inflammatories, are there any surgical procedures that can be done to help alleviate some of these patients'?
Speaker 2:pains. There are arthroscopic procedures that have been described. They're not designed for long-term relief because over time arthritis does tend to progress. There is a certain population that can benefit from it. Sometimes we'll see younger patients where there's the development of arthritis but it hasn't gotten to the point where it's bone on bone or they have large bone spurs And, as you can imagine, some of these younger patients don't want to commit to a full shoulder replacement at that time.
Speaker 2:And so there are arthroscopic techniques where we go in and basically we're cleaning up the shoulder in a way and any inflamed tissue or loose bodies that might exist in the shoulder we remove that.
Speaker 2:Oftentimes the capsule can be very tight of the shoulder which is compressing the humeral head against the glenoid.
Speaker 2:So we'll do a capsule or release at that time where we sort of cut around that balloon that I described earlier or the capsule and that helps to loosen it up a little bit and get the bone of the humeral head maybe less tension onto the glenoid. Oftentimes with arthritis there's also associated biceps tendinitis And you can also do a biceps tinnadesis we call it at the time of the arthroscopy, where we basically remove the insertion of the biceps from the labral tissue and we tack it down into the humeral bone So we keep it from sliding where a lot of the irritation and the inflammation develops. Also, if there are any small bone spurs, we could use a burr and remove those bone spurs at the time of arthroscopy as well to try and limit the impingement that they can get and limited range of motion that can develop from having those bone spurs. So an arthroscopic procedure is an option as a less or more minimally invasive procedure for patients who are appropriate candidates if they're younger and aren't to the point where they can commit to a full shoulder replacement.
Speaker 1:Yeah, and sometimes a lot of us that do arthroscopy will find a patient that's relatively young, has a beautiful looking shoulder joint but unfortunately suffered a trauma and has now a big pothole in the articular cartilage of the glenohumal joint or the balsakha joint. And that's a difficult situation where you have a young patient, sometimes 30, 40 years of age, beautiful anatomy, intact rotator cuff, biceps, labrum, everything's perfect But there's a big pothole in the glenoid or in the humeral head. missing cartilage and bone is exposed. Fortunately, some of the vendors that we use offer instruments that allow us to use some procedures, like a microfracture, where we combine that with the regenerative medicine that we talked about to try to regrow the cartilage and fill the defect.
Speaker 2:Yes, absolutely So. Just like a regular road that we drive down, if there's a single pothole in the street, they don't replace the entire road right. So this happens after every winter in New Jersey, where they come in the spring time and fill in those potholes. And the same concept applies to the shoulder, where if it's just a small little defect or a pothole in the shoulder, we don't need to replace the entire shoulder. In that situation There are other options that are there.
Speaker 2:Microfracture, as you alluded to, is one of them, and what we want to do is essentially fill in that pothole. So there are multiple ways to do that. Microfracture is one technique where, arthroscopically, we go in in a very minimally invasive fashion and we make smaller holes within the base of that pothole, and when we're in there doing the arthroscopy we're putting a lot of fluid into the shoulder and it prevents the backflow of blood. But once that fluid pressure is gone at the end of the procedure and we actually test this after we make the little holes at the base of the pothole we eliminate the fluid from the arthoscope or the camera that we're using during the procedure And what you see is bleeding that comes back in through those holes And, as the patients were covering, what happens is that that bleeding induces the formation of scar tissue to kind of form in within that pothole over time to fill that defect, and so that's one technique that we use, which is the microfracture technique.
Speaker 2:There's also a newer techniques where you go in and we harvest a piece of the cartilage and take it to a lab And that lab grows these chondrocytes. And once we grow those chondrocytes we come back and we implant that into the pothole. So we put into the pothole with the fiber and glue that holds it in place And we're trying to use the body's own natural cells of the cartilage to try and fill in that defect. So not just with scar tissue but hopefully with some cartilage, and that's another technique that we utilize as well.
Speaker 1:Yeah, so clearly the future of orthopedics is regenerative medicine and healing disease, joints and repairing structures, as opposed to replacing and reconstructing torn structures as well. Right, so that's an exciting up and coming field, and right now, in 2023, i guess the best we can do with these defects is the microfracture and the procedures that you've outlined. But let's go to the next stage now, where the patient's arthritis is too advanced and is now a candidate for something more definitive. The surgical procedures we've discussed thus far have been mainly palliative, in effort to buy time, because none of them are really guaranteed. Even the field of regenerative medicine is not where it's going to be in the future. Still, to this day, it's not really possible to regrow normal articular cartilage with like the cartilage we were born with, and so We tend to do these procedures to buy time To a point in in time when the patient is more amenable to undergo a more definitive procedure.
Speaker 2:So once the degradation of the cartilage or the arthritis becomes more advanced, we do was called a shoulder replacement or an anatomic shoulder replacement for for primal acerothritis. What we do is we basically resurface the ball part of the Shoulder joint, which is the humeral head, and we also resurface the Glenoid, which is the golf tee part of the the shoulder joint. And basically what we're doing is similar to, again, the road analogy where If there's too many potholes on the road You can't just go in an individual philic pothole. Even if you drive across, it's still gonna be a very bumpy road. And so basically we're going in and we're surfacing the entire surface of both parts of the shoulder joint to provide a more smooth articulating surface.
Speaker 2:And What we do for an anatomic shoulder replacement is on the humeral head or the golf ball part of the shoulder joint, we use a metal sphere to Provide a more smooth surface for articulation at least of the humeral head component, and on the glenoid part of the shoulder We replace that with a plastic component. So basically at the end of the procedure you have smooth metal articulating with smooth plastic, and so you don't have that bone-on-bone grinding sensation and you don't have bone spurs, because the bone spurs are limited at the time of surgery As well. So you have smooth metal articulating with smooth plastic and it's a very smooth range of motion. You don't have that clicking and the popping and the pain that you had preoperatively.
Speaker 1:So it's essentially replacing the ball and socket joint. You, you're giving the patient a new ball and a new socket, and the new ball made out of metal, the new socket, made out of plastic, feels no pain, right, so you're it's. The analogy I like to give in other joint replacements is like capping a tooth type of thing. We still keep the patient's bone, but we put a new cap on it. The cap is now feeling no pain, it's a. It's a nice, smooth, shiny surface And it's a stable construct. How long have shoulder replacements been around?
Speaker 2:They've been around It's since the 1950s, but they've evolved over time and originally it started out as a salvage procedure, in particular, especially with the reverse shoulder replacements, and they were used primarily to treat Complex fractures that existed as well as different tumor conditions that exist in the shoulder, unfortunately, in the beginning had a high failure rate, to be honest with you, and we've gone through multiple generations of implant designs now Where they're very stable and initially they had very long stems and we're actually using a lot of metal to replace just a small piece of bone just to keep that stable, especially in the humeral component, and We're using a lot of cement in the plastic component to hold that in place and keep it from getting unstable over time or loose and over time. But obviously, as technology has advanced you you know We we don't really put in a lot of metal now when we do shoulder replacements. It's actually very, very minimal and most patients are surprised when I show them in the office on an x-ray Or pictures of the implants how much metal there really is and it's far less than a hip replacement or a knee replacement. It truly is a resurfacing procedure that we do and Oftentimes I would say the vast majority of the shoulder replacements that I do. They don't even involve any stems.
Speaker 2:There are these small press fit components that we put in. They're really adhere to the bone and and and allow for the bone to grow into the implant to provide stability over time. So we're not even removing much bone to begin with and we're putting in a minimal amount of metal in terms of the plastic component, the. The implant that I particularly use Doesn't even involve the use of a lot of cement. It still involves a press fit component to rely on the majority of the stability and a very, very small amount of cement that I use To keep that in place.
Speaker 2:Again, just because of the way that the technology has advanced, these are very, very stable implants and the survivorship The ten year survivorship is approaching 96% in a lot of studies. So these implants are lasting a very, very long time and of course, part of it is, you know, treating the shoulder well after you get it, just like any other joint replacement. You want to treat it well, but they they are lasting a very long time and I tell patients when I give them a shoulder replacement The goal is for them to have it for the rest of their life.
Speaker 1:So let's demonstrate what we're talking about to our patients. Let's Present the model of the shoulder replacement system that you use and we'll talk about the anatomical Parts of the shoulder and what gets replaced. So, dr Su, why don't you explain to our viewing audience exactly what we're looking at here?
Speaker 2:so this is the shoulder joint and Analogous to the golf ball, sitting on a golf tee. This is the humeral head bone and that's the golf ball component, and here's a socket that I mentioned or alluded to earlier, which is the golf tee.
Speaker 1:So let's talk about that. So this is the golf ball and this is the golf tee. So this is an example of how small the golf tee would be, and that's the analogy we often give for the shoulder joint. So if you saw this tee in this position and the golf ball sitting in this position, that's very much analogous to a golf ball on a golf tee and you can see that's inherently a very unstable Construct. The cup of the ball and socket joint is so small and the ball is so big. But the only reason this shoulder becomes stable is because of the dynamic Stabilizers, the rotator cuff muscles that we alluded to before, and also because of the bony constraints from the, from this Articulation, as well as the labrum and the capsule that keeps this bone socket joint stable and together. So that's the analogy of the bone socket joint of the shoulder and this smooth white surface on the end of the bone.
Speaker 2:That's the articular cartilage that I mentioned earlier. So you know, here's the, the rougher bone that is comprised of the entire humerus And this is the coating at the end of the bone, which is the articular cartilage, and that's the smooth part of the shoulder. And if you look at the glenoid as well, which is right here, there's a ring of tissue around the glenoid which is a labral tissue, and central to that is also articular cartilage. So it's the same smooth white coating that you see on the humeral head And so you have smooth articular cartilage on the humeral head That's articulating with the smooth cartilage on the glenoid yeah, so the labrum is like he discussed, a Fibro cartilaginous structure that circumferentially wraps itself around the entire glenoid.
Speaker 1:It's essentially a Thickening in the capsule at its insertion that, along with the capsule, helps to stabilize the Bone socket joint from dislocating. So that is a normal shoulder joint, normal ball and socket joint. But in the face of arthritis what happens?
Speaker 2:So we get degradation or erosion of this smooth cartilage that you see here, and so, as, as that starts to thin out and erode, you get exposure of this rougher bone that you see here Which comprises the rest of the humerus, and so that bone again is rough and as that becomes exposed, that is what arthritis is.
Speaker 2:And when we take an x-ray in the office You see that the joint space is narrowing because this articular cartilage creates a space between the two bones. And when we take an x-ray in the office we only see the bones, we don't see the cartilage. So when we look at an x-ray, we see that there's a space between those two bones and The classic bone-on-bone term for arthritis that patients always hear about is that as that Carilage starts to wear out, we don't see that space anymore, and so we see the two bones starting to go towards each other and touch each other, and as this smooth white surface starts to erode, we see that on the x-ray the to the exposure of the bone Becomes obvious and and that's what leads to the thinning that you see on the x-ray right.
Speaker 1:So what are we looking at here, dr Sud?
Speaker 2:So this is an example of how a shoulder replacement would look like and, as I mentioned earlier, we're not removing a lot of bone and we're not putting in a lot of metal or plastic for that matter.
Speaker 2:So the part of the cartilage that was thinned out and exposed We removed. So we removed the part of the bone, and only the part of the bone That's that's degraded and causing pain. We don't need to remove any more than that. And what we do is, once we remove that bone, we replace that with a nice smooth metal implant and, as you can see, it's a hemisphere, it's not a full sphere. And again, we're only replacing that part that had the articular cartilage on it. We're not removing any more bone or replacing any more bone. It's literally just the part that had the exposed bone underneath from the Articular cartilage erosion.
Speaker 2:So this is how it would look like on the humeral side, on the glenoid side. We put in a plastic component and Basically what we do is we remove whatever remaining cartilage is there that really isn't doing much for the patient at that point and we replace it with a smooth plastic component and it's placed Press fit with only a small amount of cement and we put that into the bone and it's a very stable implant and That causes it, the glenoid component, to have a smooth plastic component to it. So once we've completed the shoulder replacement, we have this smooth metal part on the humerus, articulating with the smooth plastic part on the glenoid bone, and You don't have that bone-on-bone contact anymore. Great, amazing.
Speaker 1:How do you do a shoulder replacement? I mean, typically is this done in the hospitals, it done as an outpatient.
Speaker 2:Oftentimes it can be done as an outpatient, and that's where medicine is going is outpatient genre placement. Oftentimes patients wake up with no pain. Prior to undergoing a shoulder replacement, vast majority of patients get a pre-operative block by the anesthesia team, so they get an injection and They basically numbs up the arm and the body doesn't feel the the arm anymore And and that means that the body doesn't experience pain. What that allows is, during the procedure, the patient doesn't require much anesthesia to keep them asleep. The body's not experiencing the pain, their their pulse isn't elevating, they're very comfortable and when patients wake up, they wake up in no pain. So it allows them to go home and not have to stay in the hospital, necessarily overnight, unless there's a medical reason to keep them in the hospital. Obviously we would do that, but that's why the vast majority of shoulder replacements are able to go home is because they're comfortable, they wake up, they have no pain and they're able to recover at home, which is the ideal situation for many patients.
Speaker 2:It's done in a minimally invasive fashion. It's it when I talk to patients about a shoulder placement, initially a lot of them haven't heard about it, so they don't know how it's done or or or what we do and it sounds Like it's a very, very big procedure, it's actually done through one incision. So we make one incision in the front part of the shoulder several inches long, but it's one incision. It's not on the side, it's not in the back, just one incision in the front. And When we do the exposure we're dividing the muscles and just opening up the plane to the shoulder and and we're able to expose it Within 10, 15 minutes. It really doesn't take much time. To gain the exposure to the shoulder We do identify the subscapularis rotator cuff tendon and that part I take down.
Speaker 2:And Once I take the subscapularis rotator cuff tendon down and we have to visualize the entire shoulder joint from the front, once I have full exposure I remove again only the part of the bone that's arthritic. It doesn't have cartilage on it anymore. Usually I'll start out by exposing the humerus or the humeral head on the arm part of the bone or the upper part of that bone. So we expose the humeral head part of the bone and we just remove the part of the bone that doesn't have a cartilage on it anymore. And as I mentioned earlier, you know I've transitioned to not using these big stem implants with a lot of metal. I always evaluate the bone intraoperatively and as long as the bone quality is good and the vast majority of the patients have sufficient good bone quality to be able to use a stemless implant, and so that gets put into place and Exposure of the glenoid or the socket part of the shoulder is is is can be challenging at times for a lot of surgeons And that's why, in the hands of someone who's experienced it can, it can go very quickly, which is always the ideal situation, with less anesthesia time.
Speaker 2:You know, i'm able to prepare the glenoid and put the plastic part of it within several minutes With precision.
Speaker 2:Now, with the technology that we utilize intraoperatively. That technology involves the use of getting a preoperative CT scan that we do prior to surgery and With that CT scan I Import those images into a computer software program which regenerates the shoulder in a 3d anatomic model and Based on that anatomic model I'm able to design a custom guide that I use to to prepare the glenoid surface while I'm in surgery. Precise placement of the guide, pin off that guide is Everything with the surgery, because even if you're off by a few degrees, it can change the outcome of the patient. So precision is very, very important for the placement of the guide pin and preparation of the glenoid component. That guy that gets made gets placed right onto the glenoid and it's custom. So if it's perfectly like a glove onto the glenoid, once it's perfectly onto the glenoid I advanced the guide pin into the glenoid and, based off that one single pin, i'm able to do the entire part of the procedure that involves the glenoid.
Speaker 1:I'm so excited to know that, in the area of shoulder replacement surgery, you're utilizing the technologies that we've been using for years now in the area of hip and knee replacement. Customized, patient specific joint replacement surgery is something I'm very, very passionate about, and using high-resolution cross-sectional imaging modalities like MRI and CAT scan to make sure that we're giving each and every patient the perfectly sized position and aligned implant is So important in ensuring excellence in joint replacement surgery and outcomes as well for our patients. So let's demonstrate what you do in the area of shoulder replacement surgery to our patients, how you customize each and every joint replacement. Okay, so what am I looking at here, dr Sue?
Speaker 2:So, based on that CT scan that I mentioned earlier, where we recreate a 3d model on a computer, i designed the the implant that I used during surgery to to allow for the correct placement of the guide pin, and What we do is preoperatively, once I plan it on the computer software, there's a 3d printed model that gets recreated to To shape the actual glenoid that the patient has, as well as the implant that I want to use during surgery. So here, on your right hand, you see an example of a 3d printed model of a patient's glenoid bone or the socket part of the shoulder joint, and You see the little divots. There's three divots on the front and one in the back, and The guide that I designed using the computer program has four Hands, you could imagine, or prongs that that fit onto the glenoid like a glove.
Speaker 1:There's three prongs in the front, one in the back, and I am able to Position it exactly where I want during surgery And and that's how the guide is printed- So, for instance, on this Model of this patient's Glenoid, this is the guide that you will create to snap on to that patient's glenoid Intraoperatively, just like that Yes, correct, and that's got the guide holes in it so that you know where to drill your pins in preparation for your glenoid reaming. So, for instance, this this is a model now of the patient's Native glenoid that's degenerative and worn and this guide will literally snap on, just like this, intraoperatively. You could see how it literally finds its happy place and it's perfectly positioned right there for you intraoperatively. And through that guide, you have these drill holes that you'll shoot some pins, k wires, to allow you to continue the reaming process.
Speaker 2:Yes, this guide allows me to place one central guide wire in the center of the glenoid in the correct position and again, even a few degrees can make a big difference in the outcome for patients. So this allows for the precise placement of that guide pin and off that guide pin to be able to prepare the entire glenoid and implant the final component.
Speaker 1:Wow, that's so exciting to know you have this advanced technology and shoulder replacement surgery as well. Our patients are truly getting the best of the best in your hands, for sure. So what are we dealing with here? What am I holding here, dr Sud? So this?
Speaker 2:is a model of the proximal humeral bone and here you see that the humeral head has been resurfaced with the implant and there are two different ways to fixate this part of the component. The more traditional way, or the way that I used to do it, was using a longer stem and it had a porous coat here which allows for the in growth of the bone and stability over time, and we used to put that down the canal of the humeral bone, which provided a good fixation and tight fixation for stability. But as technology has advanced, we don't need to use as much metal anymore and so I've converted primarily to using a stemless implant, as long as the bone allows for it and we don't need to use the stem. So here's an example of that, for instance. So this is an example of the of the stemless implant.
Speaker 1:Comparing contrasting to this.
Speaker 2:And so we prepare the, the proximal humeral bone. We don't need to prepare the canal like we used to for the other implant, and because the technology that we have, and the good on-growth or in-growth porous technology is able to provide very secure fixation and the failure rates on the humeral component are low, and even once we've transitioned to the stemless implant, i've yet to have a single failure with this type of device.
Speaker 1:I love it. I love it just like other fields of orthopedic medicine. It's all about preserving bone right, preserving bone being minimally invasive. In the area of joint replacement surgery in particular, we always have to think about the potential next to operation and in the area of shoulder, the humerus is a small bone relative to, for instance, the knee and and we've done a podcast about ankle replacements as well, and Dr Rappaport alluded to the fact that it's very, very important to make sure that he preserves every little bit of bone around that ankle. The shoulders got to be quite similar in that we're dealing with very little bone stock, especially around the glenoid and even the proximal humerus as well, and it's really critical for you to try to preserve bone, especially when, potentially, the patient may require some type of revision surgery down the road. So these less invasive implants are becoming more and more popular, i'm sure.
Speaker 2:Yes, they are, and the whole idea is to preserve the normal anatomy and the normal bone as much as possible.
Speaker 2:And you're absolutely right, we always want to think about the next step.
Speaker 2:It's easy to do it initially, but if, for some reason, we need to go back in, we need the bone stock to work with and if we were in a situation where we remove too much bone, there's nothing to work with when we go back and and you're right, the shoulders very similar to the ankle, where there isn't that much bone, it's not like a big hip joint or a big knee joint and so there really isn't much bone and we want to preserve as much as we can initially.
Speaker 2:And it's important because there's a lot of important soft tissue structures that attach to that bone too. For example, on the on the proximal humerus side, where we put the, the ball part of the component, the, the rotator cuff tendon, is attached all around that bone to the tuberosities on that proximal humerus. So the greater tuberosity has the super spinaeus, the infraspinatus, and on the back part is a teres minor, and on the lesser tuberosity on the front part of that bone, the subscapularis has its attachment so we want to maintain those attachments so that the shoulder can function as normal as possible after the operation.
Speaker 1:100% so typically. Dr Sudd, how long does the shoulder replacement take you in the operating room to perform?
Speaker 2:The standard total shoulder replacement will take me about 45 minutes to complete.
Speaker 1:So is everyone that presents to your office with shoulder arthritis a candidate for an anatomic total shoulder replacement.
Speaker 2:There's a. There's several things that we look at. One of the most important things that we look at is the integrity of the rotator cuff tendons, because the the a good outcome for a shoulder replacement surgery depends on not just the bone but also the soft tissue structures that surround that bone, and so it still relies on intact rotator cuff function for it to function. So we always check, based on physical exam as well as MRI in some situations, to check for the integrity of the rotator cuff tendons, to see you know, once we replace the bone with these implants, can it still function, and so that's always an important thing to look at preoperatively.
Speaker 1:If somebody has a small rotator cuff tear, will you still be able to do this type of shoulder replacement?
Speaker 2:I will and and it's not not common but in a lot of situations I'll repair the rotator cuff tendon at the time of the shoulder replacement surgery. And again, this is for very, very small tears where I don't want to commit to a reverse shoulder replacement, which is something we'll get into in another podcast, which is a different type of shoulder replacement. But if the patient has good integrity of the remaining rotator cuff tendons and it's just a small tear and overall they have good strength on exam, i will repair small rotator cuff tears at the time of a shoulder replacement to try and preserve the anatomy to be as normal as possible. And that's what we want. We want to preserve the anatomy and just replace the bone that we removed without making any significant anatomical changes for the patient.
Speaker 1:So you mentioned that it takes you about 45 minutes to do this operation. Typically, when they're done, most patients will be discharged the same day. Some patients, for medical reasons, may get admitted overnight, but for the most part they're discharged the same day. And what's life like after that? what is a typical rehabilitation course for these patients?
Speaker 2:Surprisingly, the post-op or the pain after shoulder replacement is not as significant as patients might think. In fact the consensus would be it's far less than even an arthroscopic rotator cuff repair where we're not removing any bone or putting in any major, you know metal implants. And again patients get the block preoperatively so they're able to go home very comfortably and make the appropriate transition to any pain and medication that they might need. And I would say in terms of all my patients, the ones that get shoulder replacements and the ones where I do arthroscopic rotator cuff repairs, labor repairs etc. I find that my shoulder replacement patients need far less pain medication and are far more comfortable after surgery. Usually they're placed into a sling and I keep that sling in place for about four weeks after surgery and that allows the rotator cuff tendon to heal. And again, as I mentioned earlier, i take down the sub scapularis rotator cuff tendon to gain exposure to the shoulder. So we want it to heal and the protection is mainly for that rotator cuff tendon because the implants that we put in are very stable. You could almost begin moving it right away. After about four weeks we begin physical therapy.
Speaker 2:I teach a very intensive home program that I want patients to do on their own as well as physical therapy and I tell everyone that you know they use physical therapy as a guide but I really want them to do a lot of the exercises at home every day, multiple times a day, to prevent stiffness and regain that range of motion and get the strength back. Well, i could go to the gym with a personal trainer two or three times a week, like patients do with physical therapy, and if I come home and I don't exercise I'm eating potato chips, not really dieting. Well, they're exercising. I won't really see the gains with that personal trainer. But if I use that personal trainer, i come home and I exercise on the side, i have a good diet, i'm trying to eat right. All of a sudden I'll see those gains at an exponential rate.
Speaker 2:And so I tell patients when they go to physical therapy yes, i want them to go, because it's very, very important in the beginning to have that help to move the shoulder, because it can be uncomfortable sometimes And patients just need that help. But I want them to come home and do the exercises on the side as well And that's when they get that exponential recovery, fast recovery with range of motion and strength, and so I teach a very intensive home program And they're basic exercises that they do, but I want them to do them frequently And as consistently as possible, and all my patients have. You know, i don't have any issues with compliance because these are basic exercises. At home does not require any equipment, they just need the commitment to it And when they do these exercises, overall the recovery is pretty quick And the goal is to achieve full range of motion. You know, usually around six to eight weeks is where I want them to have the full range of motion.
Speaker 1:So how long do you tell your patients it takes to fully heal from this operation?
Speaker 2:I tell everyone I can take, I give an approximation of about three to four months of recovery. I mean I tell everyone, just like any standard joint replacement, that they're going to expect improvements for even upwards of a year. But the biggest gain is going to be that first three to four months And at that point they'll feel very comfortable doing most of the activities that they were doing prior to the development of arthritis.
Speaker 1:And with respect to outcomes and patient expectations, what do you typically tell them? their expectation should be with respect to restoration of function, range of motion, return to sports activities of daily living, et cetera.
Speaker 2:In terms of range of motion, my expectation is that it's as close to what's normal for them as possible And where the contralateral shoulder or the other shoulder might be, or where it was prior to the onset of the arthritis. So the goal is to achieve as full range of motion as possible In terms of activities. That's the beauty of joint replacement surgeries. We want patients to get back to doing as much as possible. We don't want to limit too much. We want them to live their life and enjoy and do the things that they want to do pain-free. There's just a couple of things I recommend they avoid, which is excessive force or axial force through the shoulder. So if they're able to accommodate, maybe avoid doing heavy push-ups or heavy bench press exercises or military presses. It doesn't mean that they can't work out at all, they still can. It's just that maybe take some of the load off the shoulder. But in terms of doing sports activities or recreational activities, they could pretty much do everything that they want to do.
Speaker 2:And do I have some patients that go back to doing push-ups and bench press and do great, absolutely. But in general we want to avoid too much excessive force And my analogy again to that is having a nice car. And if you have a very, very nice car, a fast sports car, you look at one of the days that you drive it. Right, you're going to drive it on a nice sunny day on a smooth road, but it's a car. Technically it can go anywhere. You can go off-roading with it on a gravel road if you want to, but you don't. You want to treat it well, and so my analogy to patients is I'm giving them a nice car, which is their shoulder, and I just want them to treat it well. It doesn't mean you can't do certain things, just that If you have a nice shoulder replacement, take it out on a nice sunny day on a smooth road and treat it well, and the goal is for it to last forever.
Speaker 1:Yeah, i mean it's just like any other joint replacement. We want patients to be able to restore their quality of life And that's why, in fact, we're doing the operations. But don't abuse it. Every once in a while, if they have a knee replacement, they want to run on it. Run, but don't run marathons with your knee replacement. But if you have to run to play a pickup game with your kids basketball or whatever by all means run, enjoy it.
Speaker 1:But try not to choose to participate in sports or exercise activities that will potentially lead to premature wear of the construct And, with respect to the shoulder and also other joints, high impact aerobic activity tends to potentially increase the risk of wear and tear. But by all means, we're doing these operations so that our patients can restore their quality of life, live life to its fullest and, just for the most part, use common sense in that regard. In general, especially in the area of hip and knee replacement surgery, we favor fluid-like exercise regimen, and the shoulder is quite similar. Just try to avoid that high impact, the push-ups, et cetera, but certainly golf, tennis, things like that, swimming I'm sure you encourage all those exercises, right, Absolutely, and for the most part, most patients are extremely satisfied.
Speaker 1:Being told that, and just to get out of pain, especially at night, and to be able to have a good night's sleep because your shoulder is not bothering you, is so rewarding I'm sure that shoulder replacement surgery in your area of expertise is probably, i would say, the most rewarding procedure you do. Is that true?
Speaker 2:It absolutely is, and almost immediately postoperatively, especially the patients that had that night pain that we were talking about earlier. Vast majority of the time the patients come to their first postop visit and they say that within one or two days that night pain that they had completely goes away. It's a different kind of pain because they're recovering from an operation But that deep, dull, toothache-type pain that they were experiencing before is completely gone And to them the recovery or any minimal pain that they have from the operation itself, that's a trade-off they're willing to take all day, every day, because it's minimal compared to what they were experiencing preoperatively.
Speaker 1:Well, as I alluded to earlier in the podcast, dr Sud, i will forever be indebted to your wife for being a Jersey girl and to bringing you back home from France.
Speaker 1:We're just so blessed to have you at the Kaila Orthopedic Center. You know how I feel about you and your skill set, especially as well in the area of shoulder surgery. You are a master shoulder surgeon. You've cared for thousands and thousands of our patients over the years and helped them restore that quality of life that they were yearning for, and so we're very appreciative of your excellence and your expertise, and I just want to sincerely thank you for joining me on this podcast today, and I truly look forward to having you back again to discuss many other shoulder ailments, such as rotator cuff tears, labral tears, biceps tendon conditions, ac, joint separations and the reverse total shoulder arthroplasty that Dr Sud referred to earlier. So thank you so much. We hope that this podcast was very informative to you and your family and friends, and if you found this helpful and entertaining and informative, we would appreciate you subscribing to our Kaila Ortho channel. Thank you, have a great day.
Speaker 2:Thank you, thanks so much, thank you.