10 Apr All Things Shoulder Replacement with Dr. Todd Wurth – Facebook Live
Dr. Wurth, Tell Us A Little Bit About Yourself And What Specialties You See Here At Bone And Joint Institute:
Dr. Todd Wurth: I’ve been in Franklin since 2004 straight out of training so this is my first and only job ever. Obviously our practice has changed a little bit over the last several years but my sub-specialty is upper extremity, so I do shoulder to fingertips – that’s what I did my fellowship in. I still do general orthopaedic surgery but my area of specialty is upper extremity.
Before We Get To Shoulder Replacement, Lets Backtrack and Talk About How We Get There With Arthritis in the Shoulder:
Dr. Wurth You get arthritis from different things. Obviously we have general osteoarthritis that people develop, basically your wear-and-tear arthritis. There is inflammatory arthritis, whether that be rheumatoid arthritis, psoriatic arthritis or something like that. The very common one we see is post-traumatic arthritis, someone that has injured a joint. In the case of the shoulder, perhaps they dislocated the shoulder and when they dislocated their shoulder, they injured the cartilage. That may have happened when they were a teenager and then by the time they’re 40 or 50, if they had an injury to that cartilage, that results in post-traumatic arthritis where the shoulder joint begins to wear significantly.
With Injuries And Arthritis, What Are Some Treatments That You Can Offer Before Surgery?
Dr. Wurth: With any arthritis, we go with nonsteroidal anti-inflammatory medication (NSAIDs) is pretty much your first go-to. You can consider injections – corticosteroid injections – that are done prudently and not too often. I typically tell people “Try to keep an injection to once every six months if possible in any one particular joint.” If you get them too frequently, then it can speed up the arthritic process. Other options such as PRP injections are possible that they can help if it’s early in the arthritic process. Other avenues such as stem cell treatment, that’s just not there yet. That’s not been shown to try to “regrow.” A lot of people do stem cells thinking they’re going to regrow cartilage and that technology is not there yet.
If NSAIDs and Injections Don’t Work, What Else Is Talked About?
Dr. Wurth Leading up to that, another thought people often will discuss is physical therapy. If I’ve got someone who has a significantly arthritic shoulder I typically don’t send them to therapy. Now, don’t get me wrong, I want to make sure we keep the rotator cuff strong and have a functioning rotator cuff. But as a shoulder – like any joint – becomes arthritic, as it becomes more arthritic it becomes stiffer. So if you just try to push through and get more motion, you’re just going to aggravate the arthritis so I usually don’t recommend doing that.
How Do You Know It’s Time To Have Surgery For A Total Shoulder Replacement?
Dr. Wurth: As far as when to do surgery, that’s a common question. People say “Hey, should I get my shoulder replaced.” My answer to that is when the shoulder – when it starts preventing you from doing the things you want to do with your daily life or the things that you need to do with your life, that’s when you think about doing the replacement. And you have to take other things into consideration like your age, medical comorbidities and that kind of stuff. But, when it starts to effect your life, it’s a good option when everything else has failed.
Can You Talk About The Different Types of Shoulder Replacement?
Dr. Wurth: We do shoulder replacement for basically three reasons. One, arthritis. Two, we do it for something called pseudoparesis in situations where patients might not have a functioning rotator cuff or have a nerve-related disorder that has rendered their rotator cuff ineffective, they may come in and they have an inability to lift their arm. But as long as the other larger muscles around the shoulder are working – the deltoid, the latissimus, the pectoralis major – then we have surgical options that will accommodate that. And then the third situation that we do replacements is for fractures. A lot of patients come in and they’ll have a bad fracture that involves the attachment of the rotator cuff or the head of the humerus is split and you have a lot of articular pieces, we’ll do a shoulder replacement for that.
I get questions a lot, there are two basic types of shoulder replacements. There’s an anatomic shoulder replacement and then there’s something called a reverse total shoulder replacement. A lot of people don’t totally understand what that is so I brought a model. (We’ll start out with anatomic). When we do a shoulder replacement, basically the shoulder and humeral head is replaced. So to do that, the normal head, we’ll cut that head off and it’s arthritic. We’ll drill down inside the bone and we’ll put a component down inside the bone and then we’ll replace the humeral head with a metal head that is matched perfectly for that particular patients. On the socket side, in a patient that has a good, functioning rotator cuff, then we’ll replace the arthritic socket – of the glenoid – with a plastic component like that. And so basically it’s metal on plastic and that gives you relief of your symptoms.
For patients who do not have a functioning rotator cuff, the rotator cuff the job is basically to keep the ball to the socket and it provides stability to the joint. So if you don’t have a functioning rotator cuff, when you life your arm up, the humerus rides up on this other bone and they can’t pull it up. And so in that situation, we consider doing something called a reverse total shoulder replacement. On the reverse total shoulder replacement, on the socket side, rather than having a plastic insert to recreate the normal joint, we’ll place something called a base plate on it. The base plate is metal, it has a metal cage that goes into the bone behind it, and typically we’ll augment that with screws to provide initial stability. The bone will grow through the holes in the cage so basically the prosthesis kind of grows to the body and provides long-term stability. On top of that base plate, we put this component called a glenosphere. So basically, the ball comes on the socket side and on the humerus side, we can use that same stem and that same cut but rather than having a ball, we’ll insert a (different) component so now the plastic is on a different side. When you reduce the shoulder, you can see that you have stability to the shoulder so you don’t need that functioning rotator cuff, and so the other large muscles around the shoulder will bring the arm up without the presence of a rotator cuff.
That’s an excellent option. The one thing I will say, reverse total shoulder replacements, by and large, are easier to rehab than a standard shoulder replacement. With a standard shoulder replacement, you have to repair a part of the rotator cuff on the way out. Basically, you have to release part of it to get the prosthesis in so you repair that on the way out. So you have to protect that during the rehab process. For six weeks, you’re in a sling and a pillow and then we begin active range of motion at six weeks. I do basically the same thing with reverses – although we don’t have to worry about a rotator cuff repair with that necessarily although I will repair the rotator cuff if there are portions that are reparable even with a reverse – but the stability of the implant allows it to rehab a little bit better.
So why don’t we do reverses for everybody? I base it on a couple things. In the United States, reverses are basically outnumbering anatomics but I still think a well-functioning anatomic shoulder replacement is better than a reverse, particularly with internal rotation reaching behind your back, reverses are a little bit harder for that.
In my practice, I tailor what I do to my patients and their needs.
What Types of Technology Do You Use When In Surgery?
Dr. Wurth: So I use CT guided navigation for placement of the glenoid component. And what I mean by the glenoid component, it’s the socket side. Basically what we do is we obtain a CT scan pre-operatively and it’ll give me a 3D image of the glenoid on a laptop or a tablet and I can rotate it around and put the component exactly where it needs to be. In shoulder replacements, if it’s going to fail it’s going to fail or loosen typically on the socket side so you want it in the very best position you can get. The pre-operative CT will allow us to have the patient’s anatomy. In surgery, I attach a little tracker called the coracoid, and then I have a little handheld tracker that will touch different areas of the anatomy. And then I have, interoperatively, live guidance via CT. I can place, I can perform a drill and place the screws with live CT guided navigation. Particularly in instances where you have a lot of bone loss, there are augments that we can do that the prosthesis for the glenoid side will have buildup with the metal and it will take up for that loss of bone. The CT guided navigation just allows you to tailor the implant to the patient and that gives them the best option for long-term success.
Can You Talk A Little Bit About How The Comprehensive Care at Bone and Joint Institute Really Helps The Patient From Start To Finish?
Dr. Wurth: Ours is a little bit unique in that, it even starts with the physicians. We’ll have patients come in, maybe from out of state, and they’ll see one provider and it’s not uncommon that I’ll have one of my partners come down, maybe they don’t do total shoulder replacements and they’re in a different specialty but they have a patient who comes in there to discuss a shoulder replacement, they’ll ask us to come down and talk to the patient. We made adjustments like that the same day.
The other thing is is that we have CT availability in our office so we can get the CT scan in our office, we have the templates and software here. We do shoulder replacements typically as outpatient surgery … and then we have our full physical therapy group afterwards and so they can obtain all of their post-operative care here as well.
To watch the full segment with Dr. Watson from Facebook Live, click here.
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