Bone and Joint Institute of Tennessee’s board-certified shoulder specialists Ian Bryam, M.D., Christopher Stark, M.D., and Todd Wurth, M.D., recently sat down to discuss the evolving field of CT-guided shoulder replacement technology and the significant advancements being made.
Wurth: CT-guided shoulder surgery involves obtaining a preoperative CT scan, and it allows us to more closely evaluate a patient’s specific anatomy. That really comes into play in patients who have significant wear, whether the wear is from arthritis, trauma, or if they had a fracture. The CT-guided technology, particularly in the current software that we have available, allows us to place the socket side of the implant, with respect to shoulder replacement surgery, exactly where we want it. That’s a game changer, because the weakest link in shoulder surgery in the past has been the socket. Oftentimes on the ball side, you tend not to have as many issues with loosening as on the socket side, so ensuring the stability of the implant on the socket side of the shoulder is key. As a surgeon, you want to get that implant in the appropriate position that helps to balance the shoulder and also decreases the risk of loosening in the future, which oftentimes will require revision.
Byram: In order to use this technology, you have to have CT scans. We order CT scans for patients who meet the specifications necessary for the software. Then the scan gets uploaded into a system, which we then have access to on our laptops, and we can then plan for a surgery. One other added benefit of this system is your surgeon is planning your surgery well before they walk into the operating room and is spending that additional time on it. Before we even begin your surgery, we can change the angle, the version, the depth to which we put an implant, and spin the scapula around in every direction to look at it in any possible way. Then our preoperative plan gets put on a USB disc drive, which gets uploaded into, essentially, an iPad that’s sterile in the operating room. Our instrumentation in the operating room is linked to the CT scan so we can see in real time what’s happening. So, as I am putting in a screw, for example, or moving away bone in order to put the socket on, that gives me immediate feedback as to the depth and the direction I need to move my hand. It’s much like how pilots use flight controls. It allows you to know exactly where you are in space, and it removes some of the human error from any surgery that we know exists. Lastly, another benefit is that we can change our plan intraoperatively if something comes about not having to do with the bone, whether it be rotator cuff, soft tissue, or something that wasn’t a part of our original plan. It allows personalization and adaptation. It’s not robotic surgery; it’s still one of us doing the surgery. It just gives us an added tool to be even more accurate and precise.
Stark: When it comes to shoulder replacements, there are two kinds: anatomic shoulder replacement, which basically looks like a normal shoulder, and reverse shoulder replacement, which is particularly used for bad fractures, or people who have had bad rotator cuff pathology. Candidates for a CT-guided replacement may have arthritis, possibly shoulder injuries as a young person, inflammatory arthritis and rheumatoid arthritis, or fractures around the shoulder. Generally for these patients, replacement is our best option. We look at each patient and their symptoms. There is not a specific age range for these surgeries, but generally we recommend shoulder replacements on people who are older than 50-55 years old. However, we do shoulder replacements on young people when we have to, even as young as 20s and 30s when we don’t have an alternative. Another benefit of this technology is that one of the concerns with replacement is how long it will last. If we can do our job better at the beginning with these better components and better tools, they’re lasting much longer.
Wurth: Whether or not the patient stays in the hospital depends largely on the patient’s insurance. Currently, Medicare requires an overnight stay, and private insurances do not. A lot of that, though, depends on the patient and whether or not they have preexisting medical conditions. We’ve performed outpatient total shoulder replacements, and patients have really liked that. I’ve had great experience sending patients home with a plan for post-operative pain relief, and that is definitely the way of the future. Medicare will be coming along in the future because it’s a cost- savings scenario. As far as after surgery, I typically will place both my anatomic-shoulder-surgery-replacement patients and my reverse-shoulder-surgery-replacement patients in a sling abductor pillow for the first week. There are certain aspects of the reverse replacement that we don’t have to worry about as much as we do in standard shoulder replacement, as far as repair goes, so I give them a little bit more leeway. After the first week, I’ll allow them to take the pillow portion off and just use the sling, and they increase their activities as tolerated. It allows them a little bit more mobility. For patients that have a standard shoulder replacement, which we call anatomic shoulder replacement, I maintain them in their abductor pillow for six weeks. We have to protect one of the tendons that we repair on the way out, so we do that for six weeks. When it comes off, we start working on active motion, incorporate strength in that weak tendon, and take it from there.
Byram: We’re fortunate to have partnered with Williamson Medical Center to have this technology available, and we’ve really been one of the leaders in this type of surgery, not only in this small region, but even throughout the Southeast. Between ourselves and Dr. Thomas, we do a large number of shoulder replacement surgeries, which are not that common. Hip and knee replacements have been common procedures for many years, and shoulder arthroplasty has really taken off over the last couple of decades. So, not only do we have this technology and use this technology, we are really innovators and leaders in this field, and it’s nice to have multiple partners who are all familiar with it so that we can work together as a team to take the best care of our patients as possible. Stark: To chime in on that, I’ve learned a lot from my two partners on either side of me, doing a lot of talks around the country, and doing a lot of research on this. Working with my partners allows me to learn their tricks, and, hopefully, they learn some of mine. Not many groups do that – we actually work as a team, and I think it’s one of the things we’re most proud of here is we work together, just like we’re doing this together. We’re better as a team than we are individually.