Facebook Live: Ian Byram, M.D. on Shoulder Replacements

Dr. Byram, can you tell us about yourself? 

I am originally from Raleigh, North Carolina. I went to the University of North Carolina at Chapel Hill for both undergraduate and medical school, where I met my wife. My wife and I got married the week before we started residency at Vanderbilt, which is how we ended up here in Nashville and have since had three boys. At the end of residency, I decided to pursue specialty training in shoulder, elbow, and sports medicine in New York at Columbia University Medical Center. When I finished that up, I came back to Nashville and joined our practice. 

Can you tell us a little bit about arthritis in the shoulder?

Arthritis, generally speaking, means the loss of cartilage in a joint. Whether it’s in your hip, knee, or shoulder, when that cartilage wears away, you no longer have the two smooth surfaces articulating. I often tell patients it’s like having worn out tires on cobblestone, rather than having new tires on a freshly paved street. When that happens, the normal mechanics of the joint are disrupted. You might develop stiffness, meaning you can’t move your arm in the same positions that you used to. You might also develop pain. Some people describe it like a toothache, just sore, but not necessarily acute. It slowly over time grows. The shoulder in particular, has the greatest range of motion anywhere in your body. That is because it is a large ball in a very shallow socket. So when any mobility is restricted, it’s pretty noticeable. 

What are the non-surgical options that you offer for arthritis? And can you tell us a little bit more about total shoulder replacement? 

Broadly speaking, there’s two types of arthritis. There is inflammatory arthritis, which is your rheumatoid, gout, and psoriatic. Then there is wear and tear osteoarthritis. With the inflammatory arthropathies, we often get a rheumatologist involved. In these cases, the arthritis is medically treated – whether that’s with medications taken orally or an injectable. With wear and tear arthritis, we also often try non-surgical options. In fact, that’s generally the mainstay of initial treatment. Anti-inflammatories and ice, can really help. Physical therapy or home exercises can also really help focus on maintaining and maximizing that flexibility and strength. Patients always ask me, “when do I need to get my shoulder replaced?” The answer is when you tell me, not when I tell you. What that means, is that your pain may get to the point where these other modalities just aren’t working, so you’re seeking a better, and more permanent solution. That is where shoulder replacement can really be beneficial. Essentially what that procedure is, is rather than the worn-out ball and socket, we take a metallic ball and a plastic lining on the socket, and that is a standard, or an anatomic, replacement. There’s another type of replacement called a reverse replacement. With this, we’re still replacing the ball and the socket, but we do it in a reverse fashion. So the ball is on the socket side, and the socket is on the previous ball side. 

Is there an advantage to one versus the other? Or how do you decide which you get? 

That’s my job to help you figure that out! If you are rotator cuff deficient, or if you have a significant amount of bone wear, or a bad fracture, Those are all the times when we would generally consider a reverse replacement. This used to not be very common, but as it’s grown, and as it’s been in the United States for longer, we have become more comfortable with this type of prosthesis. It has a much lower complication rate than it used to have 15 to 20 years ago. It’s no longer just a salvage procedure, but in some cases is the primary procedure. 

At the Bone and Joint Institute of Tennessee, we’re all about cutting edge. What are some of the technologies that you use during the planning or actual surgical process to assist you?

We are very much about cutting edge technology, research, and data. I have many of my patients enrolled in a study where we follow them longitudinally. In light of this, we often try new technologies that are fortunately well-established now. This technology allows us to use a CT scan that we took before surgery, then upload that into a system, which then allows me to look at it during surgery. It allows me to look at the scapula, which is the socket side of the joint, and put the implant in the perfect place. It is a very small amount of bone to begin with, then when you add the wear, it makes a small piece of bone even smaller. It allows us to put the piece in a very precise fashion. In the past, the technology would essentially end after the CT scan, and you would try to emulate that once you got into the operating room. However now, I’m able to use that CT scan, connect it to the technology, and actually look at it during surgery to place the piece correctly. As I move my hands 10 degrees to the right or 10 degrees to the left, I see that on the screen and I see it on the patient. This allows me to recreate our exact preoperative plan. This ends up with more precision, and hopefully better outcomes. 

After surgery, do you need therapy? And if so, what does that look like? 

Of course, every patient is different, so we can tweak this for the pathology or what the reason is for the replacement. In general, you are in a sling for about six weeks. We start therapy about a week after surgery. That is when you start to gain progressive motion. Strengthening will then usually start about six to eight weeks out. We will also often have you see an occupational therapist early on during this process as a one-time visit. They help you with determining how to get the sling off and on, feeding yourself, bathing, dressing, things of that nature. Education is incredibly important throughout this whole process. Education is part of the whole comprehensive care that we provide here. If you get to the point where you’re ready to have a shoulder replacement, you have a pre-operative assessment, where we assess any medical needs that you may have and address those on the front end. If you’re on a blood thinner, when you need to stop that, different medications, when you need to start or stop those. We also have you attend our Total Joint Class, which is the same for hip and knee replacements as well. We have some of our nursing staff that help walk you through that process. After all of this is done, we will do the procedure, sometimes even in an outpatient setting. After your surgery, you can have your physical and occupational therapy here. To be able to combine all of that together has really been great for my patients. It’s been something that I’ve really enjoyed. It helps minimize any communication gaps. 

What can you tell us more about the comprehensiveness in the team approach that the physicians have here? 

Being able to take it from diagnosis, to conservative non-surgical, or surgical treatment, then therapy, all under one roof is really a great benefit. Of course we have patients come in from out of town, and so we’ll do part of the process here, and then you can do your therapy back in your hometown. We follow a protocol that we’ve been working on as a group. To that point, I have partners that also perform the same procedure, and we all meet regularly to make sure that we’re all on the same page and following the same protocols so that our patients can get a uniform, excellent experience. 



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For more information about shoulder replacements, call Bone and Joint Institute of Tennessee at (615) 791-2630. You can also schedule an appointment online.