In Vogue…the Shoulder

Despite having to wait while spine and other specialties took the spotlight, the shoulder doesn’t have a chip on its, well, shoulder. It is quite mature…and maturing.

An Exciting Time for Shoulder Specialists

Dr. Ken Yamaguchi, the Sam and Marilyn Fox Distinguished Professor of Orthopaedic Surgery at Washington University School of Medicine in St. Louis, Missouri, notes, “Shoulder fellowships are one of the fastest growing fellowships around. It’s actually shocking how competitive it is to get a spot these days. But we need only look at the facts, one of which is that shoulder ranks just behind lower back pain as the top reason why patients seek out a doctor for musculoskeletal care. As shoulder problems are generally degenerative, and individuals over 70 are the fastest growing segment of the population, the volume should increase even further in the future. Additionally, patients are more sophisticated consumers now and tend to seek out shoulder specialists.”

The President of the American Shoulder and Elbow Surgeons, Dr. Evan Flatow, is also encouraged by the momentum in shoulder training. Dr. Flatow, the Chair of Orthopaedics at The Mount Sinai Medical Center in Manhattan, states, “Training is much more structured than in the past, with an established committee of fellowship directors who organize the application and match procedure to ensure that it is friendly to applicants. There has been significant attention paid to the issue of scheduling, i.e., programs are working together to ensure that interviews are not all held on the same day. That way, applicants can see all of the programs they are interested in before the offers are made.”

Dr. Louis Bigliani, the Frank E. Stinchfield Professor and Chairman of Orthopedic Surgery at Columbia University and past President of the American Orthopaedic Association, has helped to take the shoulder global. “We have seen shoulder surgery evolve into a worldwide subspecialty in the last few years, in particular due to the efforts of the International Congress of Shoulder and Elbow Surgery (ICSES). In 2007 we had a superb meeting in Brazil, with over 1, 000 shoulder and elbow surgeons in attendance; next year we will travel to Edinburgh, Scotland, for our 11th meeting. These events, along with the new shoulder training program in Asia, have helped to facilitate the transfer of scientific information and knowledge to fellow surgeons around the world.”

Shoulder Innovations and Research

Whether in the ORs of the American West or those at the tip of South America, today’s shoulder surgeons are learning a profusion of new techniques. Dr. Yamaguchi: “There have been significant innovations in all four areas of shoulder surgery, namely, trauma, reconstruction, rotator cuff surgery and joint replacement. Take percutaneous pinning of fractures, for example. While these injuries used to involve large, debilitating surgeries, the broken bone can now be reconstructed through a tiny incision. And because the shoulder is built for motion, it is important to limit the surgical trauma and minimize scar tissue. The only controversial issue with regard to percutaneous pinning is how bad of a fracture you can use it with. Some people say that a severely compromised bone may need more than several little pins. The fact is that percutaneous pinning is not easy, and we need better training, along with simpler instrumentation.”

Dr. Flatow adds, “Fifteen years ago most fractures were treated with joint replacement if the proximal humerus was shattered. Now, many of the shoulders that used to need replacement or plates and screws can be managed with percutaneous MI fixation in which we manipulate the fragments with pins and joysticks. There is a significant learning curve, however, which results in resistance by some orthopedists. And unlike elective surgery, fractures come in the door marked ‘trauma, ’ which makes everything more difficult because the cases appear at random. But if learned properly, it is a very successful operation.”

Dr. Flatow continues, “Two years ago my partner, Dr. Brad Parsons, along with Dr. Gerry Williams of the Rothman Institute, and Dr. Leesa Galatz, Dr Yamaguchi’s partner, presented the results of a multicenter study at AAOS. We pooled our cases and results with percutaneous fixation and found excellent results and minimal morbidity. In the days of plates and screws, if you had to operate again, there was a concern about avascular necrosis. We found that the initial surgery was less invasive and that if there were complications they were not serious. Now we are looking at the longer term results and are anticipating a low complication rate, good muscle strength, and healthy range of motion.”

As for the part of the shoulder that is “in charge of” stability and strength—the rotator cuff—it has many new options. Dr. Yamaguchi explains,

Rotator cuff tears are one of the most common ailments in all of medicine. Our data show that half of people over 70 experience rotator cuff tears. One treatment for this condition that has exploded is arthroplasty; surgeons can now do a reverse ball and socket prosthesis in which they cut off the humeral head and put in a prosthetic socket. This procedure has allowed us to take care of extreme rotator cuff problems, and has been an absolute game changer.

Dr. Yamaguchi elaborates, “It was developed years ago by Dr. Grammont in France and has been used in Europe for 15 years, and was approved in the U.S. about five years ago. I have had the privilege of being on a design team at Zimmer and working through the development process for one of their rotator cuff products.”

Dr. Bigliani adds, “In severe osteoarthritis of the shoulder, posterior glenoid (socket) bone loss poses a challenge to properly placing a glenoid prosthesis. We have been using a computer simulation to evaluate the extent of bone loss and deformity. We are also trying to determine how to evaluate the proper positioning and placement of the glenoid prosthesis such that stress is reduced across the implant. We obtain data from CT scans of the shoulder, put it into a computer and do virtual surgery. By putting the glenoid in different places and looking at the best position, we can determine deformity patterns and be better prepared for the OR.”

Dr. Flatow: “Many of the courses that my colleagues and I teach focus on how to select the right patient. We typically recommend the surgery only for older patients because if you put the implant in a younger person, it might wear out, break or loosen. While there may be appropriate times to perform the surgery on a younger patient—perhaps someone who is very active and seeking a higher level of functioning—that person should thoroughly understand the risks involved.”

And where would any joint be without arthroscopy? Dr. Yamaguchi says,

As recently as five years ago there were many surgeons doing large, open surgeries for rotator cuff repair. As arthroscopy has become more popular, however, most shoulder surgeons are comfortable with the approach. And now that the instrumentation has been refined, it is easier for those surgeons who have less experience with the procedure. The major issue now is that there are times that the patient doesn’t heal because of biological issues such as age. In the not so distant future, however, we can probably provide medications or growth factors to repair the site and enhance the ability of the rotator cuff to repair.

Elaborating on the repair issue, Dr. Flatow states, “There is some controversy surrounding the findings that many of these repairs don’t heal. We are one of the labs doing research into predicting the factors that control healing and are seeking ways to improve both the technical steps and the possibilities of newer biologic treatments. One of the projects in our lab, for example, involves turning stem cells into tendon cells. This is early scientific work by our colleague, Dr. Herb Sun, but we are trying to figure out many ways to grow and develop natural tendons biologically.”

Managing Patient Pain and Anxiety

Whether someone has a host of painful bone spurs, loose bone wandering around the shoulder, or an extreme loss of cartilage, there is help in the form of shoulder replacement. But, whether young or old, patients may be wary of such a serious operation. Dr. Bigliani: “I routinely hear comments from patients along the lines of, ‘Hip and knee replacements are routine, but the shoulder is still really hard to do.’ I tell them that as long as someone is properly trained in shoulder replacement, the results are consistently good. It is true that the shoulder is a more complicated joint, but much of the success of the procedure depends on postoperative rehabilitation and management.”

Regarding the efficiency of many shoulder procedures, the patient can be in—and out—of pain as soon as she can get in and out of the doctor’s office. According to Dr. Bigliani, “More and more orthopedic surgeons are converting to doing minimally invasive procedures on an outpatient basis. In my department we are probably doing more outpatient than inpatient surgeries at this point. This includes arthroscopy, rotator cuff repair, calcium removal, elbow arthroscopy, as well as some open procedures.”

In the pain relief arena, Dr. Bigliani and his team are going (safely) out on a limb. “One of the exciting things is that orthopedists are increasingly concentrating on pain relief. Here at Columbia we have an excellent orthopedic anesthesiologist—Robin Brown—who has championed interscalene blocks for anesthesia. This procedure, meant solely for shoulder replacement, involves leaving the catheter in the patient’s neck for 24 to 48 hours while pain medication is delivered. This way they avoid general anesthesia and have good pain relief and some movement in the hands. Patients typically leave the hospital faster and have a more pleasurable experience while there. These blocks can be tough to learn, however, so they are not very popular.”

Picking up on the increasingly popular evidence based medicine thread, Dr. Yamaguchi concludes,

The bottom line is that we need more evidence about what are really the best innovations that will translate to better patient outcomes.