Shoulder Arthroplasty, Reverse Replacement On the Rise
Within the orthopedic world, shoulders are the superstars these days. According to new research, the use of shoulder arthroplasty is on the rise, as is the changeover to treating many complex fractures with reverse replacements instead of hemiarthroplasty. Edward Craig, M.D., M.P.H. is an attending surgeon at Hospital for Special Surgery (HSS). Dr. Craig, who also holds an appointment with Weill Cornell Medical School, tells OTW, “We are seeing an increase in shoulder arthroplasty relative to other large joints because of better technology, more widespread surgeon education, and more predictable and durable implants. In addition, there is a substantial upsurge in reverse shoulder replacement. We have two publications in the pipeline on the national utilization of reverse shoulder and the national utilization of reverses for fracture of the shoulder versus other types of shoulder replacement.”
“When total shoulder replacement was designed it was done so that it looked like and functioned as a normal shoulder, i.e., with a metal ball resting against a plastic socket. However, while this relieves pain, some patients do not have any healthy soft tissue, specifically the rotator cuff, to facilitate movement. The dilemma was then what to do when someone is in pain and needs a new joint but has no healthy soft tissue to either stabilize or move it.”
Dr. Craig, who has co-designed an anatomic shoulder and a reverse prosthesis, says, “The surgical use of reverse prosthesis seems to be increasing both for arthritis and fractures; in the early years of reverse shoulder arthroplasty the reported complication rate was higher than the anatomic shoulder and thus warranted appropriate caution and careful patient selection. But as surgeons have learned more and as implant technology and instrumentation have improved and become more predictable, the complication rates have fallen. The reverse has not had as long of a track record as the anatomic design, however, so we must continue to monitor it closely for several years.”
“The inherent concept in the reverse prosthesis is one in which the positions of the metal ball and plastic socket are ‘reversed’ and the implant itself had more stability and thus could be utilized in the absence of the stabilizing rotator cuff. The other critical piece was that the rotator cuff was not essential for movement…it’s moved by the deltoid muscle, a muscle which functions well in most people even if this is a non functioning rotator cuff.”
“When we looked at the national use of reverse shoulder arthroplasty, we found that the most recent nationwide inpatient data was from 2011 and that there were 70, 000 shoulder arthroplasties in the database. More than a third of shoulder replacements were reverse prostheses. And while the majority of reverse replacements were for arthritis and rotator cuff problems, at this point in the U.S. at least one out of four complex shoulder fractures are treated with a reverse replacement. There has been a big uptick in this because when someone has a complex shoulder fracture, the normal rotator cuff tendon attachments of the bone stay attached to the bone and it is the bone that breaks. In order for the patient to regain function of the arm they must have a healthy rotator cuff attachment to the bone and the bone of the shoulder must heal to the rest of the humerus, which heals as part of the fracture. If it doesn’t heal then the shoulder functions as if there is a deficient rotator cuff, thus compromising both movement and stability.”
“For years, when someone had a complex fracture of the upper humerus involving the ball of the ball/socket joint you needed to put in an artificial ball hemiarthroplasty. We looked at the national utilization of reverse shoulder arthroplasty versus hemiarthroplasty for proximal humerus fractures. We found that there were 8, 000 proximal humerus fractures, of which nearly 30% were done with a reverse shoulder prosthesis. And interestingly, if you look at the reverse versus the hemi for fractures, the results are at least as good as hemiarthroplasty results and in some studies are better. Interestingly, the reverse is statistically more likely to be done in small, rural, nonteaching hospitals.”
“The reverse prosthesis is an attempt to make up in prosthetic design for both pathologic joint and soft tissue in a design that doesn’t look like a normal shoulder. It works great, but it doesn’t work like a normal shoulder. The ability to lift the arm is not always predictable with the reverse. And while it has revolutionized how we treat many complication shoulder problems, there remains the fact that it is more expensive than the anatomic design. I do think that over the next five years we’ll see the cost come down.”
Volunteering in the Ukrainian War Zone
Recently, a retired Army colonel and associate professor of orthopedic surgery took a leave of absence from Brown University to help Ukrainians and, in a way, honor his heritage. On his own dime and his own time, Roman Hayda, M.D., co-director of orthopedic trauma at Rhode Island Hospital, decided to travel to Ukraine to get a better understanding of the medical care provided to war casualties both civilian and military. Dr. Hayda tells OTW, “I served my last 10 years at Brooke Army Medical Center in San Antonio, Texas. During that time I took care of injured soldiers with complex injuries as the senior orthopaedic traumatologist and helped to establish policy in addition to being deployed, so I gained extensive knowledge of war injury. These injuries invariably involve tissue loss and are prone to infection. On the flip side those who sustain these injuries [are] usually healthy young and highly motivated injured in service of their country. When the conflict in Ukraine arose during the course of the year, I began searching for ways to help. I made contacts in the Ukraine, and over about 2.5 months they assisted me to visit military and civilian hospitals in Ukraine ultimately travelling to Lviv and Kyiv.”
“I did not perform surgery, but instead saw patients as a consultant and met with the surgeons in both cities. At the Kyiv military hospital I lectured to their roughly 50 surgical residents on my experience of war surgery and in Lviv I lectured at a regional meeting of surgeons. The majority of casualties had extremity injuries, and many were in the subacute stage of treatment. They had sustained were open fractures of the upper and lower extremities with various degree of bone and sot tisue loss; many patients were in external fixators or traction. The challenge, as one might expect, was infection.”
“These injured soldiers, much like U.S. troops, have a surprisingly positive attitude and they want to get better and return to the front with fellow soldiers. This is not always possible, of course as these are complex injuries requiring lengthy treatment and recovery. Incomplete recovery is common. Although the surgeons were qualified they had limitations. In part because they do not have great access to the innumerable resources and implants that we have. They do not have access to sophisticated physical therapy (PT) that we in the U.S. normally do right at the start of recovery or advanced prosthetics. In the Ukraine, PT is rare and late; it’s also hard to do PT when someone is in an external fixator which are used to limit implant related infection.”
When not visiting hospitals, Dr. Hayda said that he had an opportunity to see the deeply moving memorials for those killed during the protests on Maidan. “These amazing memorials showed the range of ages, professions and areas that these victims came from within Ukraine. I also noticed widespread volunteer action in support of the troops. Although I didn’t have a chance to do a comprehensive review of the medical care system in the Ukraine, I found that the level of care can be advanced by improved implant resources, informational exchange with surgeons, therapists, and prosthetists experienced in war casualty care, and battlefield communication and evacuation resources.”
John M. “Jack” Flynn, M.D. Named Chief of Orthopedic Surgery at CHOP
John M. “Jack” Flynn, M.D., a nationally prominent specialist in pediatric orthopedic surgery, is the new chief of the Division of Orthopedic Surgery at The Children’s Hospital of Philadelphia (CHOP). Dr. Flynn is the most recent president of the Pediatric Orthopaedic Society of North America. He told OTW, “Being associate chief for nine years allowed me to share in all strategic decision-making and serve in a fiduciary capacity for division finances. During this time, we hired many new physicians and surgeons, developed many innovative programs and began offering our services at new sites in the region. In any organization or business, the person who is second in command usually has a large amount of influence, but rarely has the final say in the decision. They often have ear and the trust of the group in a way that the leader cannot. Spending almost a decade in this role allows me to truly understand the visions and needs of those in our division in a way that will best allow me to serve them.”
Looking a year into the future, Dr. Flynn said, “The Division of Orthopaedics at CHOP is in great shape, and certainly is not a ‘turnaround’ project. We are one of the biggest, and arguably the best, Division of Pediatric Orthopaedics of the country, often topping the list in the national magazine surveys. There are exciting opportunities in the next year as the hospital opens extraordinary new facilities in Philadelphia, King of Prussia and the Brandywine Valley. Our division will develop orthopedic programs close to patients in these areas. It will give us a chance to further bring ‘the right care to the right patient in the right place at the right price, ’ which will be critical in the changing healthcare marketplace. There are also excellent opportunities to enhance our robust clinical research program, improve patient satisfaction with outpatient visits, and bring on new surgeons to offer unique services not readily available in our region, such as brachial plexus palsy care, hip arthroscopy, among others. It is an exciting opportunity to go not from ‘good to great’ but instead, ‘great to greater.’”
