Dr. Gregory Gasbarro, MD, Orthopedic Shoulder Surgeon in the Orthopedic Specialty Hospital at Mercy Medical Center in Baltimore, Maryland, talks about shoulder problems and current innovations in shoulder replacement surgery.
Interview conducted by Ivanhoe Broadcast News in July 2022.
What kinds of things do you fix?
GASBARRO: It’s a great variety, and that’s why I went into this. I treat anybody from young athletes – high school, college, recreation athletes as they get older in their twenties and thirties – to older patients with arthritic conditions. I can treat patients up into their eighties and nineties for not only arthritis but also things like proximal humerus fractures or upper arm bone fractures.
What are the common injuries that would cause someone to have to come to see you?
GASBARRO: In a younger patient, it could be a labral injury, which is the lining of the ball and socket joint. If a patient dislocates their shoulder, that can be injured. In younger patients that are overhead athletes, throwers, you can also see injuries at the top of the labrum. They’re called SLAP tears. As you age, you have a lot of patients come in either with traumatic rotator cuff injuries, which are the tendons of the shoulder or even wear and tear injuries just from using their arm over the years. And then as you keep going, in the older patients is where you typically see arthritis and broken bones.
Can you describe what traditional shoulder replacement surgery looks like as compared to what you’re able to do now?
GASBARRO: A lot of research, effort, and time has been put into learning more about shoulder kinematics, the way the joint works normally and how it works in the arthritic state. The way shoulder replacements were done was to initially replace just one side of the shoulder, just the arm bone side and not do anything with the socket. As time developed and implant materials got better, not only was the arm bone being replaced, but the socket side was being replaced too. Initially, it went through several iterations. Especially on the socket side. Putting a piece of metal on the socket with plastic and finally evolving to just putting a piece of plastic with cement. Then, as those replacements were going in and patients were being followed over time, big registries were created to collect data and look at outcomes which allowed us to figure out “why are these failing?” And “are there reasons they’re failing based on the technique, based on the choice of the surgery that’s being done?” As things have evolved and imaging has evolved, CT scans have come into play to study the socket’s deformity. CT scans can give us a three-dimensional model of the shoulder with special software programs, and tell us specifically which direction the socket it’s facing. In an arthritic shoulder, the socket can be worn out centrally or it can be worn out towards the back of you. When you get a CT scan and you use three-dimensional modeling and virtual planning, you can tell exactly how much of that socket has been worn away. This has led to an evolution now of using technology to personalize these shoulder replacements and using personalized guides to complete the surgery. That is where this has all come in the last ten years now.
What’s the benefit of having a personalized socket and a personalized shoulder replacement?
GASBARRO: Durability and function. If you put it in the right way, it’s stable. You optimize the position of the implant, it will optimize the patient’s ability to get their arm around their back, rotate out to the side and get their arm up over their head. I believe those are the key factors in why I choose to plan every single one of my cases.
How is the decision made to go forward with a replacement? At what point do you know, replacement is going to be better than trying to do anything else?
GASBARRO: Everybody is treated non-operatively first. Things like, over-the-counter medications, home or formal physical therapy and cortisone shots, in 2022, the mainstay of what we use. When it gets to the point where you’ve tried those things over many months or years and patients aren’t getting any better, there’s no great intermediate option. And shoulder replacements overall are quite successful in relieving pain and secondarily, restoring function to the patient. We put everybody through the wringer and make them fail nonoperative treatment first. Then, if it gets to the point where they’re miserable, can’t sleep at night or perform daily activities, we mutually make the decision to proceed with the surgery.
Are there, in other joints, middle of the road options?
GASBARRO: Not with a high level of evidence. Things are always being developed, but there is not a lot of science behind them to date.
How much mobility is restored once the replacement is in?
GASBARRO: There are a lot of factors that contribute to the end result. Many times preoperative motion dictates postoperative motion. So, if you have an X-ray of a patient that has terrible arthritis, but they can get their arm over their head, then the likelihood of them getting their arm over their head after the surgery is much higher than somebody that can barely move. There are plenty of patients that after a shoulder replacement return to things like swinging sports. Such as golf and tennis. What we try to limit, especially in reverse shoulder replacement, is heavy, repetitive overhead lifting, that can be difficult to return too. However, there’s no reason that many patients can’t return to having almost full range of motion better than their other side in some cases.
Could you describe what a reverse shoulder placement is for our viewers?
GASBARRO: There are two kinds of shoulder replacements. An anatomic shoulder replacement replaces the ball with a ball, and the socket with a socket. You can only do that replacement if the rotator cuff or the tendons of the shoulder are completely intact and healthy. If they are not, then you must do something else called a reverse. There are other reasons to reverse such as a fracture. Others reason would be a chronic rotator cuff tear or a bad deformity on the socket that would not allow for a piece of plastic and cement to be durable over time. In a reverse, you flip the joint. You put the ball at the top and the socket on the bottom, and it changes the center rotation of the joint which changes the way the joint works. Different muscles are used to get your arm overhead. I do more reverse in my practice than anatomic total shoulder. That is a trend in the American Shoulder Elbow Society also.
Do patients feel the difference with the reverse?
GASBARRO: Not necessarily.
Are they placed in a different way?
GASBARRO: Yes. The incision is the same. It’s a technical thing for the surgeon. The patients oftentimes will gain just as good a function as with an anatomic shoulder replacement. If you can do an anatomic, especially in a younger patient with a strong rotator cuff, that’s the preference. But the patient will not have a huge variation in how they feel after if a reverse is performed.
How much physical therapy is usually required to get them?
GASBARRO: It depends on the patient. Some patients decide not to go to therapy, and I teach them the exercises to do. Others like to go to therapy. And if they want structure and they want to go work with a therapist, I send them at six weeks after the surgery. Most patients around three months after a replacement are back to doing most of the things that make them happy.
Can you walk through the steps of performing the 3D surgery?
GASBARRO: The first thing is, when they come to the clinic, get a history. We get an exam and I always get an X-ray, which is a two-dimensional view from different angles to see what’s going on. After they’ve been treated nonoperatively, and if they’re deciding to then proceed with doing the surgery, we then order a CT scan that has a special sequence when you run them through the scanner that must be an input by the tech. This can then be transferred after it’s completed into the specialized software program. The software program then makes a three-dimensional model of the patient’s shoulder, and it spits out different data to me. For example, how much the socket is facing the back of them and how much the socket is facing the ceiling. I can see how much bone has been lost on the socket. Then, in that planning environment, I’m able to position and size the implants to the patient. Next, it takes it another step further and shows me arcs of motion that can be attained. I can do this several times and compare plans within the program and come up with the best plan for the patient. After that’s completed, we order a guide from the company. This is 3D printed and sent to us. It takes about two or three weeks. We sterilize it and then use the guide during the surgery that fits on the patient’s socket to get me in the right direction to do things.
How important is the guide to personalizing that surgery? Can you describe what you are doing with it to get that perfect fit?
GASBARRO: It is very important. The scapula, which is where your socket sits, is your wing bone. The wing bone is very mobile. It is held to your rib cage by muscle. Depending on how you’re sitting and on how we position you in the O.R., the wing bone can move. Because the typical pattern for severe arthritis is to wear towards the back of the socket, when you are in the surgery and you’re coming from an approach where you are looking at the front of the patient, you can get deceived as to where exactly the pin that you need to do all the work on the socket should be directed. When you use the guide, it is putting you down the best column of bone so you can have stability. It is also places you in the correct direction so you can correct the deformity of the socket. This way, it is stable, and it does not dislocate and also optimizes the function of the patient. If you just do it with your eyes, you can really get tricked into where you’re going.
Do most patients go back to things they would not have been able to do before?
GASBARRO: It is routine for an active patient that comes and has a terrible shoulder to go back to doing those things that maybe they’ve been avoiding for a couple of years.
Are you able to speak a little bit to Daniel’s case?
GASBARRO: He came to me in December of 2019 and had an X-ray of a horrible arthritic shoulder he had been living with for over two years at the time. We treated him nonoperatively first. I gave him home exercises to work on and a cortisone injection into the joint to try and relieve some of the pain. He ended up coming back to me later in the Spring of 2020, right when COVID was occurring. We sat down and he decided he was ready, because he had been living with this for over two years. The injection gave him partial relief for a temporary period of time, and he was looking for more of a permanent solution. We ultimately replaced his shoulder in June of 2020, about six to seven months after I met him. He has done very well. I have now followed him for over two years, and he is a patient that was very motivated to get better. He has returned to everything that has made him happy.
At some point, will this become standard of care other practitioners perform?
GASBARRO: That is the push. You have high volume surgeons and low volume surgeons performing this operation. To get everybody up to a higher performing level, I think this is a great tool to orient you during the surgery, to get you in the right position and to go into the surgery with a plan. When I enter into the surgery, I know the size of the components I’m going to use, where I’m going to position things, and how I’m going to orient things. For someone that is not doing this very often, it’s like doing your homework and studying for a test. It prepares you for the day of the surgery. There is no guesswork when you’re in the heat of things in the middle of the operation. I hope that we continue to push others to use this technology.
Is it that the technology is behind in shoulder replacement or is it just volume? There are more hips and knees done than shoulders?
GASBARRO: It’s a little bit of both. Hip and knee replacement has been around longer than a shoulder replacement. I think that what we have done a good job of in the last 10 to 20 years, is borrow some of the ideas from our hip and knee colleagues to the shoulder. Shoulder replacement is not something necessarily as a resident you get to see as often either. Hip and knee are something that you do over and over, repeatedly when you’re training as a resident. Shoulder replacement is not something you get a lot of reps on and experience is something you develop with specialized shoulder training and time.
Do you know how many shoulder replacements are done in the U.S. every year? Would you know how many are done with the 3D mapping?
GASBARRO: I do not know the percentage that are done with 3D but in total there are around 50 to 60 thousand shoulder replacements yearly. I know that hip and knee replacements are done over 10 times more often each year compared to shoulders.
Is there anything else that you would want to make sure people know?
GASBARRO: I think it is important when you are looking into shoulder replacement surgery to use all the available resources that you can find. Wherever you are locally, do your research and find out who is a high-volume shoulder arthroplasty surgeon who tracks their outcomes. Inquire if there are using preoperative planning when you meet with that surgeon. If they’re personable, thoughtful and provide a detailed plan, I think it is important that you seek these people out, whatever city you’re in, in order to optimize your outcome and your recovery.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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