Innovative New Treatments and Techniques for Shoulder Injuries: Patrick St. Pierre, MD

Innovative New Treatments and Techniques for Shoulder Injuries: Patrick St. Pierre, MD

Show Video

(gentle music) I'm Patrick Pierre and thanks Brett for introducing me and giving me this opportunity to talk to everybody. So, I'm at Desert Orthopaedic Center and mostly prior to know I do pretty much only shoulders now and so we're gonna talk about some of the newer things that are out in the shoulder world, talk about the things that I'm working on in particular and we'll have a couple of times for breaks to ask a few questions and we should have enough time at the end to field a lot of questions. So, say the questions or go ahead and add them to the chat and then we'll will follow that and we'll get to them as best we can.

So, I am part of the Sports Medicine Program at Desert Orthopaedic Center and I take care of the BNP Tennis Open when and if we can have it. So, certainly last year 2020, we didn't get to do it and it's still up in the air for this year but we also help with COD, Palm Springs Power and Palm Desert High School. Okay.

So, first, I'd like to start off with talking about anatomy so you can really understand the shoulder. And if you look on the left side, it's tendons of the bones of the shoulder and the shoulder joint is a ball and socket joint but the socket is very shallow and that's so we can get our hand everywhere in space. And for that to work and for us to use our shoulder and do everything that we wanna do, we need to have muscles that control that shoulder and keep it working, and that's what the rotator cuff is. And there's four muscles of the rotator cuff. There's one in the front called the subscapularis, the one on top which is the supraspinatus and two in the back which are the infraspinatus and teres minor. And inside the shoulder, so this is an arthroscopic view.

This is, I'm probing the labrum. So, people hear about labral injuries, that's the long head of the biceps and the bicep is is often injured in shoulder. In the front of the shoulder, there's some ligaments so I'm putting my probe on the middle glenohumeral ligament and now we can see the front rotator cuff muscles. So, that's the subscapularis. So, this is a pretty normal shoulder, this person had a pathology up above the rotator cuff so the insight is pretty good and that's that the insertion and that's an area that often has an injury. This is the front labrum.

So, when we hear about labral tears and shoulder instability when people tear their labrum, that's the injury and that's the Bankart lesions that we talked about, and then the ball and the socket. So, the cartilage should be nice and smooth and shiny just like that just like you see on the ends of chicken bones and turkey bones. This is now the top rotator cuff muscles. That's a supraspinatus, that's probably the rotator cuff muscle, it's torn the most.

And now as we come down the back, we're seeing the infraspinatus insertion on the back of the shoulder. Then we'll come back around and we're gonna look at the inferior labrum and the posterior labrum. So, it's pretty good. The view that we get of the shoulder when we go in with an arthroscope, when we can take pictures and take care of everything arthroscopically and now what's really good about this is it's minimally invasive and not so much of a burden on the patient. And then we go into the subacromial space.

So, this is the space above the rotator cuff. So, if you look at the pictures, the top bone is the acromion which you can feel on the top of your shoulder and underneath that, is the the bursa that we do most of our rotator cuff work in and it's kind of a room that's inside the shoulder and we'll be able to look at it. So, here we are up above the rotator cuff So what you're looking at in the bottom is the rotator cuff muscle over the top of the shoulder and then this is the bursa and it is very big. So, some of you may have had a subacromial injection or injection by us in the office and that's where we injected, we inject into that area in case there's inflammation.

So, he does have a little bit of inflammation in the rotator cuff. You could see how there's a little bit more inflammation but the rotator cuff is not torn. So again, those muscles help to secure it and to to keep the ball in the socket so when we raise our arm, the rotator cuff muscles are actually pulling down on the bone keeping it centered inside the glenoid or the cup of the shoulder. And they also do rotation, that's where they get their names. So, rotating in and out like this will be something that the rotator cuff would do. Now, when we talk about things that go wrong almost always in the shoulder, it involves three things.

So there's pain, there's immobility or loss of motion and then weakness. And these can come from traumatic events, it can also come from repetitive injury and oftentimes people just don't know, they come in and say, "I woke up this day and I was carrying luggage the day before" or "I cleaned out the garage" or "I did something but it wasn't anything that I haven't done a million times and I don't recall an injury." So, it can often be just repetitive injury that normal activities that we do all the time. Then there can be numbness and radicular pain and oftentimes when people start getting numbness especially if it goes down to the hand or what radicular pain means shooting pain down the arm, that's not really coming from the shoulder even though it may feel like it is it's usually coming from the neck. So, some of the things that I take care of, mostly the rotator cuff. So, the rotator cuff pathology's number one is rotator cuff or impingement syndrome.

So this is when people have inflammation of the tendon So, tendonitis of the rotator cuff, they can have bursitis and that's why we call it a syndrome 'cause it usually involves two or more things that are going on. As the injuries get worse, then they can develop rotator cuff tear. So, you could have partial tears and then complete tears and the problem with the rotator cuff is once that rotator cuff muscle is torn completely and it's pulled away from where it's supposed to be attached, then it's not gonna go back unless we put it back surgically.

So, by doing exercises, all that happens is it pulls that muscle farther and farther away. So, that's why most times when you have a big rotator cuff tear or something that's involved with interfering with your sports and the activities that you wanna do, then we often have to fix that. Then the rotator cuff arthropathy, so that's when it gets really bad. So, now you have a big and a massive tear of the rotator cuff and then the shoulder doesn't function at all or if it does, it's very, very weak. Then another set of shoulder injuries occurs with glenohumeral arthritis.

So, that shoulder arthritis very similar to what we see in the knee and the hip and the foot, the ankle and everywhere else in our body. So when arthritis occurs, the cartilage that sits on the ends of the bone starts to wear away and this can be totally separate and distinct from any rotator cuff pathology. So, some people can have arthritis without any rotator cuff tears but then people can also have rotator cuff tears along with their arthritis. Instability is something that usually occurs in younger people. So, when people have shoulder dislocations, it's often a result of a sport injury or a fall or motor vehicle accident or skiing. And when people talk about shoulder dislocation, that's very different than a shoulder separation.

So, shoulder separations are an injury to the AC joint which is up on top of the shoulder and this location is when it dislocates completely. When it happens to a young person, it's very commonly will recur. So, younger people that have one or two or three or more dislocations will often get surgery. My shoulder dislocated 40 times before I got mine fixed but eventually had to get it fixed and now it doesn't come out anymore. But in older patients, so people who are now in our age group in the fifties, sixties and seventies and eighties, if you dislocate your shoulder you're often going to have a rotator cuff tear as a part of it and we're treating as a rotator cuff injury. The bicep, bi means two, so there's two parts to the bicep.

And just like we saw on the video, the bicep will go into the shoulder and that's very commonly injured. In fact, the Europeans think it's a source of all major pain in the shoulder. And then the AC joint injuries as I mentioned before, A means the chromium which is the bone on top, C is for the clavicle. So, this injury up on top, we can get arthritis, we can get shoulder separations. And then finally, another very common thing is the adhesive capsulitis or frozen shoulder.

Although that's a very overused term and often people will say, "Well, you got a frozen shoulder." If they just have some loss of motion which may occur with rotator cuff pathology but a true thing, frozen shoulder is an auto-immune thing that we see a lot in diabetics and people with thyroid disease and their shoulder freezes up because the body is attacking the inside of the capsule. So, like we talked, well, we're gonna talk about some of the newer things that are available to us and that we're working on, and the first one we're gonna do is talk about this BioWick implant.

And this is a scaffold that we have to help us with rotator cuff repair. Now, this is something I've been a part of the advisory team so there are six of us across the country that have been involved in developing this even from the beginning and now, in production we're using it and we've done some studies and I'll talk about some of that before. So, the challenge with rotator cuff repairs is that there's a relatively high rate of failures and in the retear chat, it can vary from 11% to 94%.

So, we said, "Well, most rotator cuffs here on people do better but if we critically look at the shoulder and we do MRIs after even successful rotator cuff repairs, sometimes they didn't heal completely." And we're trying to get the heal and the maximum function in the best. And as you're seeing on the right, there's a big tear so it's gonna be very hard to get something like that to heal and as you can see on the slide, if it's a small tear, Most of them are going to heal but as we get to those bigger tears and even more so as we get the people who are further along in age, you're much more likely not to have your rotator cuff heal when you're 80 than you are when you're 50 or 60. Now, these can come from different mechanisms of failure. So, one is failure of mechanical features.

So, that would involve the anchors, the sutures, the different things that we use to repair a rotator cuff and sort back down to the bone. And then the biological failures is it means that the tendon just didn't heal. And sometimes we can do everything right but the tendon has atrophy or the tendon's older or the patient may be smokes or has diabetes and other factors that can interact with how well this is going to heal, and this is what we're gonna see on the MRI over there on the right. So, a lot of mechanical self has been worked on for years and now, we have great suture anchors. We figured out, we use now suture tapes instead of a single sutures 'cause the sutures would actually cut through the rotator cuff once the patients started working. So, these tapes are a little bit stronger, they're broader, they capture more fibers and tend not to cut through the tendon and many more.

And then, there's vented anchors and ways that we can get blood in stem cells. So, one way for tenants to heal better to bone is if we can get those cells that are going to promote healing and tendon healing. So, that's what we're really focusing on with this study and these patches.

So ,these patches have had started out and initially, we had patches that would go on top of the rotator cuff and then there were other anchors or other techniques like this Crimson Duvet where one surgeon would put holes in the bone to try to encourage these cells to come out, but there was really no control over where those cells went or how they worked or anything else like that so we're just kind of in a hope and a prayer to see if it would work. And then the patches that we use on top are often very difficult to put in. So, multiple anchors were necessary and it would take a lot more time. So, our BioWick implant, this is an implant that we anchor into the bone and then we have this patch.

So, you can see on the slide there's a white patch and that's really the scaffold. And we designed the scaffold to soak up blood and cells and then it was a certain size that would induce the tendon to heal. And then, the other really nice thing about it is it's a simple, reproducible technique. So, putting an anchor in is something that we all do as rotator cuff surgeons and we pass the sutures so nothing really changed except that this anchor was attached to the patch. I think I went too far. So, as I mentioned before, the initial patches were kind of put on top and that can help a little bit but the idea of this is that we would put the scaffold in between the bone and the tenant.

So, you can see on the top arthroscopic picture, the tenant so down... I don't think my pointer is working, and it's in-between, the arrow is pointing to the patch that's underneath the rotator cuff repaired. And that's going to induce that tendon to heal inside the bone as opposed to patches that were laid on top. So, this is also something that absorbs, it's a synthetic material but will go away so we don't have a foreign body that's gonna stay inside the shoulder. The arthroscopic pitcher that you see tho the right is one of my pictures and here I've let down the pressure of the water that we use while we're doing a rotator cuff repair. And you can see the blood starting to come up out of the bone marrow and into that scaffold.

And then once we sew the tendon down on top of it, it's going to compress that and it's gonna induce the healing to occur. And it's 80% porous and again, the fiber diameter is specifically designed from numerous studies that have been done to induce this tendon healing. And that's pretty much what I talked about as well. So, we wanna have something that's structurally engaged in the mechanical properties to induce that tendon healing to get that new tissue to heal and to help the rotator cuff heal. So, we started out with a sheep study.

So, even before this was launched, we wanted to test it in animals. And so, I was involved in the sheep study as well and we had controllers in groups that we would do the rotator cuff repair. So, in the sheep, we would repair these tendons and use the scaffold that you see on the picture to the left, and then we would repair normal tendons of the rotator cuff and then compare the two. And there were a number of different ways that we would look at it in different regions that we would look to see how well that scaffold would help not only right where the scaffold was but other places that it might be.

And we found that there was a higher percentage of tissue integration at the tendon bone interface, we had greater new bone formation which is what we want to see, we don't want that tendon growing into the bone. There were a higher number of perpendicular fibers that were growing into the tendon and then a higher level of collagen that we wanted at that tendon interface. And then, the implant was well-tolerated without any bad events. So, the body didn't reject this type of thing.

And here you can see the first thing the tissue is integrated. On the slide to the left, you can see in the bracket there was some gaping that was there where the tenant didn't grow inside and that was with our control group and then on the right, you can see where it says tendon-bone integration. That's where those tendons just melted right into the bone and that's with normal fibers that are called sharpey's fibers, that's what they look like on a microscope for a normal tendon healing and that's what we were able to obtain. And then, we also looked at how the body responded to it. So, these were inflammation and moving scores so it's all this kind of complicated stuff but we're looking to see if there were giant cells and different things that would occur.

And it was no difference between our treatment group and our control group. And then we looked at the biomechanical testing and our technique was very good. If you look all the way on the left, the control wound in a BioWick at seven weeks and then as it moved out to 12 weeks, our strength at 2000 Newtons was very, very strong. Stronger than most of the other report that studies rotator cuff repairs. And then when we compared this and we looked at it and we looked at all the different factors and use this correlation analysis this show and we had almost a perfect linear correlation between where we saw this inner improved tissue integration and new bone formation, we also saw greater strength with pullout on this rotator cuff.

So, then, we felt pretty good about moving forward and starting this controlled study and then because this is similar to previous rotator cuff repairs, we were able to release it. And then we started to study that now has been completed but it was prospectively done and we checked not only clinical scores but also we had them go back to do an MRI to see how that healed, and it was for 24 months, now everything has been completed and all this study is now in review and this is getting ready to be published. But again, we saw clinical improvement with our patients and also demonstration of a tendon healing back to the bone. So, this is the procedure. So first, so here's a rotator cuff tear, this is one of my cases.

So, I'm using the shaver to debris the bone 'cause we want to stimulate healing from that bone. And then, here's an all that goes in. So, this is done and this creates a path for our anchor 'cause the anchor that we're gonna use can be bio-absorbable or it could also be plastic and then there's also some that are just all sutures. So, we're trying to use anchors and not leave metal in the shoulder as much anymore. So, in fact, I don't use any middle anchors anymore but we tap it just like you would a wood screw and then here's our anchor.

You could see it's plastic and then inside, that was our patch or the BioWick which is the component. So, this goes in and it gets a nice secure tight fit inside the bone. And then if you notice the word BioWick, that is gonna tell me which direction the patch is going to be when I take this off 'cause you can't really see the patch. So, it is directionally oriented so now the patches on this side 'cause I want that to lay over the bone and then I'm gonna pass the sutures through this rotator cuff.

So, that's our patch and again, that's going to suck the bone elements and the stem cells out of the bone marrow inside and then I'm going to pass those sutures through the rotator cuff and tie that down. (faintly speaking) Here we go, so I'm gonna grab the suture. So, this is the technique that we do, I have these suture passers and I'm gonna pass the sutures through then we grab them.

The other suture that you see there was from the biceps that we did cause there was injury to the biceps. Then we tie down the sutures and then compress that rotator cuff back down to the bone. But as you can see, I tie this down, so this is like a fifth finger inside the shoulder so I can tie the knots securely. I'm going to press down on this rotator cuff and it's going to close that tendon over the top of the BioWick implant. And then, we'll go through sequentially and tie down all of these different sutures and these are really strong sutures that we can compress. So, here you can see the blood's coming out and then that BioWick implant's going to absorb that and hold that in position while we tie down all the rest of it and then once we also let up on the water pressure 'cause you can see there's hardly any bleeding that we see that's because I've filled this with water and that's holding the pressure down.

So, here's our final repair, that looks really good and then the BioWick is compressed underneath that and we use a knotless technique so we don't have knots on top and this works very, very well. So, this is very similar to most of the rotator cuff repairs we do. Now, we have a few different options, there's some suture anchors, we also have the PEEK and PEEK is a very special plastic that's inert that the body doesn't react to.

So, another thing that it often comes up and talks like this is using cells. So, play the rich plasma or stem cells to do this. So, platelet rich plasma is something that we do at Desert Orthopaedic Center and if you think about blood cells, there's really three major types. There's red blood cells that carry oxygen, there's white blood cells that fight infections and then there's platelets and platelets are cells that when you cut yourself, your body sends a bunch of platelets to form a clot and that's what makes up that clot. And within those platelets, there are growth factors and different things that are going to help things heal. So, this has been around since 1987 when it was first done an open heart surgery and now it's been used in many things.

So, ENT, dentistry, neurosurgery, it really just kind of took off. The problem with it is the insurance companies kind of caught into this and they were paying for all this PRP and so, now, they've really kind of stopped it to really prove that we have studies that do it and even though we have studies now that show it, oftentimes this isn't covered by insurance and patients have to pay unfortunately. But there are lots of studies that show that this can be effective for inflammation, osteoarthritis, tendon healing and decrease the use of narcotics and different things as part of our healing process.

So, again, these alpha granules they contain those growth factors and the growth factors can be a number of different things but this PDGF, which is a platelet derived growth factors stimulate cell reproduction and produces healing within that and then the other big one is transforming growth factor, TGF, which promotes the cell metabolism. Then, there are several others. So the nice thing about these granules is that it contains a lot of growth factors and these things all have cellular responses so they respond to the cells stimulus to make them work and also to the environment that they're in. So, when we get these things and they're compressed between a tendon and a bone, the body tells them that they're supposed to create tendon and allow this healing, which is really a pretty amazing source and our bodies are just incredible that we can take a tendon that's been torn off a bone, put it back down, get these growth factors and the body tells it to heal. And so, I'm still amazed at how will these things work in our body. And there's a whole process to how we create this.

So, we use the center fuse to separate the cells and we separate out the platelets 'cause if we inject just blood, then you're going to get a lot of red cells and a lot of white cells which aren't gonna be as helpful for the healing process. And then, there's different ways of doing this than to inject it. And for orthopedics, we use it a lot for tennis elbow, rotator cuff repair, into augment ACL reconstructions and meniscal repairs, osteoarthritis in knees, other tendon injuries like Achilles, tendon patellar, tendon injuries and even partial ligament tears.

So, these can be very, very helpful and there are clinical studies that have shown that. So, Allan Mishra, who's up in San Francisco was one of the first ones to show that the PRP was effective. This is another study in the hand journal showing that lateral epicondylitis with 22 and 28 were completely pain-free after the injection. And then, Peerbooms says another one article that was published showed that there was a significant improvement and although these studies came out especially for tendons around the elbows, there were other studies that showed that it wasn't as effective or that it was equivalent and unfortunately, these are the studies that the insures companies grab by the shoulders and say, "Okay, this shows that it's not work."

And there were a lot of problems with some of these studies. So, it wasn't a control group and there also isn't a control on the preparation. So, obviously there's lots of medical companies and they're doing different things to these platelets and they have to be a little bit different for patent infringement and all those types of things. So, now we have a big variation of what's going on and there really isn't a consensus yet or objective criteria to evaluate. So, now we have to deal with insurance denial but we can still do these at a fairly reasonable cost for people and get those things done.

That's something they want to desire. Stem cells are another thing. So we hear a lot about stem cells and stem cells are real sexy.

They're what's called purely potential cells that are available in fat and bone marrow. And the idea is that these cells can manipulate and can to change into either tendon or cartilage or whatever the body is telling it. The problem in the United States especially is we can't legally manipulate the stem cells.

So, if we had a way to tell the stem cell what we wanted it to become, that would really give us a big advantage. The opposition really comes from people that are looking that they think that this is the first step on a slippery slope. So, if we start manipulating stem cells, then we can start creating life and doing those types of things and some of these stem cells can be obtained from amniotic membranes from placentas from childbirth.

So, there's a lot of opposition for that but they're still being used and there are surgeons that are happy to charge 5 to 10,000 or even more dollars for this but they won't give you a guarantee. They just say, "Well, this could be a cool thing that work." And unfortunately there isn't a lot of objective data to support that. And probably at the most, it's equivalent to some of the other treatment options that we have. So, then you get a wallet biopsy and then you end up going and especially if you're doing it for things that we know we're not going to heal and it's really not being a good thing but we need better studies and we need to convince insurance companies that this is a good thing that we need to be able to do these for our patients.

And I think that we need as a country to kind of decide where we're going to go with stem cells and research on these types of things. So, what are other options? Let me take a little sip of water here. Do we have some questions on what we've done so far in the chat room? - [Erik] Nothing so far. - Okay, so what can we do if the rotator cuff doesn't heal and it's especially a problem in a young patient? And there are some other things. So, one thing I wanted to share with people is doing what's called a superior capsular reconstruction and when a rotator cuff is totally air repairable and this is a big tear.

In patients who are over 60, 65 years old, we can do the reverse shoulder which we'll talk a little bit about in a few minutes. But when this happens in a younger person, we don't wanna put a reverse shoulder in somebody who's 35 or 40 years old. So, this is indicated for those types of patients without arthritis. Younger patient who's active and needs their shoulder but there's no way we can repair this rotator cuff, and this does happen.

So, we have graphs that we've, and as we've gotten better as arthroscopic surgeons and better techniques as you just saw with the BioWick and tying these knots and putting these anchors in. Now we've developed into using these graphs for superior capsular reconstruction. And now, we have knotless anchors that we can put in. We're not tying as much a knots and there's better ways of doing this to secure it and we'll show you that just a second.

So, Teruhisa Mihata is a Japanese surgeon. He was the first one to come up with this, and this was his publication. Thay Lee is a biophysicist who's a biomechanical engineering, Los Angeles. So, they got together and really came up with this and showing that they could repair or substitute for the supraspinatus by doing this and then reduce the amount of elevation and make the shoulder much more functional.

So, sometimes you can have a tear like the one on the left. You can see some rotator cuff tissue on the left and if it's mobilizable, we can repair that. But if it's all torn and it's all worn out and if there's arthritis, we really can't. So we get in and we measure using a measuring devices to figure out where we're gonna when I put this graft. You can see this is totally a bald head as opposed to the videos I showed earlier where this is all covered with a rotator cuff. And then we'll size and cut these grafts, We'll select where we're going to put our anchors and it's gotta be anchored on the inside at the top of the cup, which is the glenoid and then also on the outside.

So, we pass our sutures through these grafts and we pass it through arthroscopically and tie it down to get it to repair and really, I've been impressed with how will this work. It doesn't work for everybody but I have patients who are now five and six years out from these suprascapular reconstructions who still have had the ability to raise their arm and to be very functional. This will not give them strength though. So, as far as like putting a 10 pound bag of sugar up over their shoulder up into a cabinet, it doesn't give them that kind of strength but it gives them the ability to raise their arm and to do things that they're able to do. So, this is kind of the soft tissue reverse shoulder and it's an excellent option for younger patients and the results are promising and it doesn't burn any bridges.

So, if I can have a patient who's 40, 45 years old and I can do this on and we buy them 15 to 20 years until they get the reversal, then we did them a huge favor and it's a great way to treat this problem. A newer option which is just coming out is this Inspace balloon and so it's been designed to go in between the acromion and the humeral head when there's no rotator cuff. And this is what it looks like inside the shoulder, so you can expand this. And this was approved in Europe.

Back in 2010, they worked out some of the kinks, we started a clinical trial in the United States about three or four years ago, that's just concluded and we're hoping for a 2021 release for many people. So, this for someone who made be lower demand who is say in their eighties but they're not playing golf, not playing tennis and doesn't want to go through or doesn't have arthritis and doesn't want to go through the whole process of a reverse shoulder. This may be a nice, easier way to take care of this problem. It might also be indicated for someone who's really young. So, the 40 year old instead of maybe doing the superior capsular reconstruction if this works well, you can try this for a period of time but eventually the reverse shoulder provides much more strength and function of the shoulder.

So, what are the indications for the reverse shoulder arthroplasty? Well, in patients who have grossly deficient rotator cuff and developing arthritis as you see in that X-ray on your left, the ball is riding up it's arthritic and the rotator cuff is completely torn. And this was the first indication so I went to Europe in 2003 to learn how to do this and we started doing them in the United States in 2004. And it's amazing that their function and the results of these reverses have really improved. So, now, the reverses is the treatment of choice for failed joint replacements. So, somebody who's had an anatomic shoulder placed in other word, the rotator cuff doesn't function we take that one out and we put a reverse in. For people that have fractures, so people who have fallen and shattered their shoulder, we do reverse shoulder.

That's gonna work much, much better than any of the other techniques that we have prior to this. People with rheumatoid arthritis, massive rotator cuff tears even if they don't have arthritis. Patients with what's called the B2 glenoid are aware of the cup because when the cup wears and we don't have a lot of bone there, then doing the old anatomic shoulder wouldn't work because we couldn't fix that plastic cup very well to that native bone and also the ball would still tend to right out the back. So, the worst of reverse works great for that and then now not even elderly patients but even patients in their mid sixties with arthritis, I will tend to do a reverse shoulder 'cause then I don't have to worry about how well the rotator cuff yields but one thing that's key is they must have a functional deltoid muscle to make this work. So, here's a patient. So, my indication is when the patient can't raise his arm any higher than the tattooed lady can raise her leg, then there's time to do a reverse shoulder.

And reverse shoulders are really changed the way that we take care of shoulders in the United States. So, if you look back all the way on the left of that is back in 2004 and up through 2012 which is the the number of shoulder started to mimic what we do for hips and knees where they're much more shoulder or hips done in the United States than shoulders. And all of this is because of the reverse shoulder replacement and then the hemiarthroplasty or the partial shoulder now is decreased in use. So, we do this because they're working. Early results were much better than we expected and when we looked at the anatomic shoulders is now always as good as expected especially in in patients in their seventies, eighties and nineties because we know the rotator cuff wouldn't heal just like we've talked about the front rotator cuff muscle.

If that doesn't work, then that shoulder will not be able to function and they won't be raise it up and then we get more complications and more failures because of loosening. So, the subscapularis even if we do it, there are late failures and oftentimes we need to switch people to a reverse. And there've been some great studies, this is a great study by April Armstrong who's a friend who's at Penn state and they did EMGs and ultrasounds and looked at these subscapularis.

So, these are very experienced shoulder surgeons repairing everything afterwards and they found that half the patients had chronic innervation even when repaired. And often, there were more commonly the subscapularis which is probably the most the important thing. And if that fails, then you don't have a functional shoulder joint and it's an unconstrained system. So, you see that ball and show that's what a total shoulder would look like.

And if the rotator cuff is working perfectly, that will work great but if it doesn't, then it will pop out. So, this is a patient who had a subscapularis repair and actually this is my patient and the shoulder came out and he couldn't raise his arm anymore so we went back and converted that to a reverse shoulder and now he's playing golf and doing everything. So, here's an example of that bone where that we were talking about. See the ball, the front of the shoulders to the right, the back is to the left and that's going out the back. So now, most people will use the reverse shoulder to fix this and make it a more stable shoulder.

And if we look at comparisons between the two, more and more we're seeing same amount of complications, same results with the reverse and the anatomic shoulder. When we looked at sports, so this is a group out of a hospital for special surgery in New York city. They had an 86% present returned to sports with the reverse and only 65% with a hemiarthroplasty. Here's another one looking at ages. So, reverses under 65 years old, very high survival rates with 99% for two years and 91% or five years. And now, I think that we're getting so good at this and most of these shoulders are gonna last at least 20, 25 years.

And then, this is another study out of the... I think it was the Cleveland Clinic that showed that their return to activity was as good with the reverse and they could get back to high demand activities, and that's really been my result. I see faster recovery with a reverse shoulder equal return to golf, swimming and no radiographic clinical failures at 10 years for these primary results and more revisions of the anatomic shoulders that I've done then reverses. And when I looked at a small cohort of two years between September 2011 to 13, we did 165 of these.

They're constant scores that they escort, these are clinical scores that we looked at. All of those things improved had a very low complication rate and then were able to return with 78% returning to golf, swimming, tennis, and weightlifting. And the thing I love about it is, it's a very reproducible surgery so I can get these things and those putting the ball on the inside and securing it with those crews that you can see makes it very solid. And I really knock on wood I've have not had anyone fail with that type of fixation that didn't already have multiple revisions or bone loss and were really tough cases to start with.

And it's very reproducible and you can put it back on and if you talk to patients that have had this, not everybody but most of them are back to doing a lot of things. We also talk about a rehab program. So, we really focus on a rehab program so that you can do these exercises and using therapy and using using the wall just to be able to do this.

And for patients who may be on here that have seen me or had surgery, they know that we really focus on this. But this is what we can get back to. So, this guy, he's got a reverse shoulder and the right side and he's back to a five handicap. And this is the amount of the sand trap. I think most people would be happy with that.

And this guys a little bit slower. So, here's lifting weights even took two dumbbells because one was not enough. Here he is doing flies and he's back then was about five years out from his reverse and now he's 10 years out. Patients doing planks and here's the general. This is one year out from his surgery and then on the right, he's five years out from the surgery. So, you see that the results don't diminish with time.

So, he can still maintain active lifestyle and working out as this gentleman has done but as you can see here, he's doing push-ups formerly he wasn't tired. So he made me the video from the other side as well. This gentleman, this is as far as range of motion so he swims all the time. You can see the range of motion with his shoulders. So, it's the right shoulder.

I think it's a little delayed in using the zoom video here but you get the idea that he's got good motion. This gentleman is in the pool and you can say he's doing breaststroke but how about doing freestyle and overhand crawl? He's gonna go right back. So, these are all with perverse shoulders and they can be very functional as long as you do the rehabilitation program.

And that's why we do this. This gentleman, you can go on our West side and a lot of these videos are on the website and he's got a Bowflex program that he's gone back to just six months out from his replacement. And if you think about that reverse, he's got a reverse in the West side but he's able to do those flies. So, I do anatomics when I have a patient who has got arthritis but he's got excellent rotator cuff function and minimal glenoid deformity and usually somebody who's under 60 years old.

And then, I used the reverse for almost everything else. So now, probably 90% of the searches that I do or more are the reverse shoulder arthroplasty and we've been very happy with those results. And when I'm talking to other surgeons, because still 70% of shoulder replacements are done by surgeons doing less than 12 a year. Now, we don't have that problem here because there's primarily only two people in the Valley that do them with Dr. Saven and myself. And I'm still doing with over 200 a year and he's doing over a hundred.

So, you're gonna be able to go to somebody who does a lot of these replacements and you wanna be able to do something that you can rely on and I think the surgeons who don't get to do as many should do the reverse because it gives you equal results and it's important to get really good at one arthroplasty. So, another option is the Mako robot and this is something that I've been involved in. So, the robot is what you see here and it's been used in hips and knees and I'm one of five surgeons across the world that are the primary consultants on designing this. And we're still a couple of years away because this takes a lot of planning but what that robot is gonna do when we as surgeon will do the approach and we'll get in and expose the bone but then the robot will then go in and make the cuts based on the CT scans that we had already planned. So, as a surgeon, I would go and use the CT scan and would plan the surgery and then we program that into the robot and then when we get into, into surgery, then we would register everything so that the robot knows where the body parts are and then that tool will then go in and make the cuts or make the drill holes with exact accuracy so that we know that it's exactly what we wanna do. Now, oftentimes I think surgeons who do a lot of these surgeries won't necessarily need the robot for something that's pretty routine but when I get cases that are revisions or people with really severe bone loss, I can see this as being very, very helpful in the future.

So, here's a few more results. This guy has had two reverses and he's playing basketball and throwing the football. So for me, it's a no brainer, if I can do the reverse, I'm going to do it that way.

So, we've spent 45 minutes going through what I have ready to present. So, success rate for the BioWick, that's what our clinical studies showed that there was... And we still don't know the MRI results which are probably gonna be the most important. So, I don't want to misquote something for that but our clinical results have been over 90% success rates with this tendon healing. So, if I can use a BioWick as a part of my rotator cuff repair, then I will but some of that's based on insurances too because some insurances cover it, some insurances don't. And unfortunately, we're the victim of whatever insurance program that you may or may not have.

I think the use of growth factors with the BioWick is a great idea and I've gone to the company about doing more research and developing it. So, if you put the BioWick in and either you have it pre impregnated into the BioWick or we have injectables that we would inject into that and then the scaffold holds onto that. I think that would be great. That's certainly something that I've been an advocate for but we're just waiting for the companies to put up the money to do more research and I think they're just waiting to see how the BioWick goes on. So, right now, as far as the selling factor on is we're just telling patients that the growth factors and the different stem cells and stuff that are coming out of the humeral component is what's providing that. So, partial shoulder replacements.

That is what that hemiarthroplasty was. And there were a number of reasons why hemiarthroplasties were done pretty frequently 10 to 15 years ago. Number one is especially with surgeons who didn't do a lot of these replacements and there was a time when probably 80 to 90% were being done by people who did less than 10 to 15 a year. The exposure is very difficult. And if you can't get the cup exposed really well and sometimes that's hard on people with bad arthritis, then the surgeon would say, "Well, I can't get there, I'm gonna just do a partial replacement."

And then replace the head but not replace the cup. And they worked, they helped, but there were not as good as doing a total shoulder replacement. So, we know from a number of studies whether it's an anatomic shoulder or a reverse shoulder but a total shoulder will do better than a hemiarthroplasty. And although there was a time when the hemiarthroplasty was the treatment of choice for people without a rotator cuff because the rotator cuff, as I discussed the rotator cuff needs to keep that ball centered in the socket. Well, you can't put a plastic cup if the ball doesn't stay center because when the patient's moving their shoulder, it's gonna loosen that and make it fail. So, we used to do more hemiarthroplasties but I can tell you I haven't done a partial shoulder replacement in at least eight years.

I think I did a couple when I first got here 10 to 12 years ago, but I haven't done any sense. So, the next question is what procedure do you recommend when the rotator cuff is 60% separated underneath instead of torn on top? So, that's an MRI finding that you may get. So, you get an MRI, you got shoulder pain and the MRI shows that there's what's called an articular surface. So, if we have the rotator cuff like this and it's over the top of the joint, so where it inserts on the bone here is where the tear is but the top is still intact and that occurs. And sometimes, it's because of what we call internal impingement. So, if that occurs, sometimes patients will get better with just doing a debridement or really the first thing we do is do an injection, do rehab and see if that'll get better.

There are times when, if we go in and the patient just hasn't gotten better, so the indication to operate on that person is that they haven't gotten better with rest injections, physical therapy and they can't get back to their activity, they can't get back to doing the sports that they wanna do or practice sports or playing golf or they can't sleep at night because every time they roll on that shoulder, then they get pain, then we'll operate on it and this is actually a procedure that I've done BioWick on. So, you can go in and place the BioWick on the undersurface of it. Slow down the rest of the rotator cuff on top of that, and then that will heal or you can do a rotator cuff repair without doing a BioWick.

There's a little bit of argument among the shoulder surgeons about what technique's better 'cause sometimes you'll try to leave that top portion intact and just do the repair and then slow things down or some people will say it's better to just go ahead and complete the tear and sew it down. So, that's controversial and probably up to the surgeon to decide what's the best thing. If it's 60%, maybe it's better to try to leave the top part intact and do the repair. If it's 90%, I think you're better off just completing it and just repairing it as you would any other rotator cuff repair.

How well are these procedures covered by Medicare? So, rotator cuff repairs, shoulder replacements, those are all covered by Medicare. Now, some people have different Medicare plans. So, there are some like the Medicare advantage plan and there are some other plans that will do supplements and I'm not so sure they really help fill the whole thing. So, if you have straight Medicare and you're covered for all the different components of it, then usually these things are covered completely 'cause we at Desert Orthopaedic Center, we accept Medicare. Sometimes if you have Just the plain straight Medicare and so you decided, "Well, I really liked that concept of doing the BioWick."

Then that might be something that would be charged as a separate thing, but most rotator cuff repairs are paid for fully by insurances. What happens to the BioWick patch over time? And it does eventually dissolve. So, it's a synthetic made patch but it will be absorbed by the body and usually by three to four months after the surgery, it's gone because it's already done its job. It takes 12 to 16 weeks for a tendon to grow into the bone and that's really all that I want that patch there for. And if that, in fact we think the patch actually contributes to faster healing. So, if we get that to heal faster than if it goes away, that's even better.

The site to show these shoulder exercises. That is a great question. So, if you go to, that's our website for Desert Orthopaedic Center and there'll be a tab across the top that has providers.

And then you click on that and then you'll see all the different providers that we have within Desert Orthopaedic Center. If you go and click on my name, then you'll go to my page and within that page, there's some articles that I've written in, some other things, some testimonies from patients and then we also have some videos of people doing the home exercise program. So, that's a great way to do that. And then if you do come in for surgery, then we'll also go over that with you. I have a great a physician's assistant named Jim Roselle and he helps me with seeing patients and both of us will go over all of these exercises and different things to different stages for your repairs.

And then there's the question about frozen shoulders as it is. So, truly adhesive capsulitis where we see the inflammation and it is an auto-immune response, that's why we see it so much in diabetics and in people with certain thyroid diseases because diabetes is an autoimmune response. Your body is attacking the cells inside the pancreas and it stops creating insulin and thyroid disease often works the same way. So, we see true frozen shoulders a lot with those types of patients and sometimes the frozen shoulder will just occur out of the blue.

Sometimes it's trauma driven. So, someone will hurt their shoulder and develop what would be a normal rotator cuff syndrome for everybody else but for them, they develop this frozen shoulder. And when you get are true frozen shoulder thought that you're limited, some people will say, "So, if I have a rotator cuff problem, I may only be able to get up to here as supposed to getting all the way up to here. True frozen shoulders, they're stuck here and they can't move their arm out to decide and they certainly can't go behind their back.

So, that is an auto-immune reaction and sometimes in the initial time or initial phase where the frozen shoulder is really more painful than frozen, we often do injections and we can do corticosteroid injections and there's a slow release and corticosteroid injection. It looks to be very promising for frozen shoulders that will just slowly release the cortisone. So, people with diabetes, it doesn't raise your blood sugars and it really works well for that.

Yeah, someone mentioned their Kaiser copay for the reverse shoulder, it was $200. Yeah, whatever insurance, all of these insurances plans are different, they have different things so, I'm not an insurance expert and whatever the copay is, better a part of it and it might be. So, when we submit for surgeries, our schedule or we'll go ahead and submit to your insurance company so that you'll be able to find out or you can call them up and find out what their... (indistinct) Here's one with a patient of mine who said that he did, so, seven months after his surgery, he played 18 holes of golf and he was totally pain free. "Tennis is two weeks away."

that's good to hear on one of them. I hope to do well with playing tennis. And then typical recovery room. So, that kinda ties into that. So, the recovery time from a reverse shoulder, we keep people in a slang for four weeks but they start doing their exercises immediately after their surgery. So, usually we give them some really basic exercises for the first five days, we use a plastic bandage that allows you to take a shower so you bathe the next day.

Now, these surgeries especially with COVID, we're letting people go home the same day of surgery and it's actually worked very, very well this year. The patients that have gone home immediately because our anesthesiologists have blocked the nerves coming out of your neck so you don't feel any pain during surgery, you wake up with any pain, they didn't go home with any pain. And then when the block wears off, which usually in the next day, then you're at home, you're icing your shoulder, you've had some of eat or drink so you can tolerate the pain pills. Well, if I had time to get into narcotics but I hate narcotics. As some of the main, I had just had both my hips replaced, I didn't take any narcotics.

They don't work. They go to your brain, they give you a brain reward that distracts you from the pain but we used to think that it did help patients get through but what's happened is that our brains love that reward. And even though the patients are often constipated and feel nauseous and they don't really like the feeling, the brain loves the narcotic and very quickly figures out that to get through the narcotic, the patient has to have pain and it sets up chronic pain in the brain that mimics the pain that they're having so you never know when the pain goes away.

So, that's how we created a nation addicted to these things. So, most of our patients take less than 10 and usually it's for the first day or two after the block has worn off and then we transition right to Extra Strength Tylenol, and I'd say most people when we see them four or five days later after surgery, they're off of narcotics, they're on Tylenol and they're doing just fine. Further recovery though, as you go on. So, my golfers are chipping and parting usually at three to four months at full golf for five to six months. Results are different for everybody though. It's very hard to standardize.

There are some people that really work hard at their exercises, there are some people that have more problems, they had a bigger rotator cuff tear and certainly, one thing that I certainly see is that patients who have not used their shoulder for a long time, so it's been a year or two of just putting up with severe pain, they're avoiding it, they're not using their shoulder. It takes them longer to recover because all their muscles had atrophied and haven't done as well. So, I think that's it. Again, if there's no other questions, actually we're right at five o'clock.

So, thank you all for your attention. I see we got a pretty good crowd and if you do have problems like these, then come and see us at Desert Orthopaedic Center, I'm more than happy to see you and take care of you and take care of whatever the specific problem that you have. (gentle music)

2021-03-28 14:12

Show Video

Other news