Dear CSS Members and Colleagues:
I am happy to share with you the reflections of a shoulder giant, Dr. Rick Matsen. His article entitled “Discovery” shares with us his “True North” and how we might navigate best treatments for our shoulder patients. His insights span years of experience and the emergence of new technologies, some of which he has conceived, and he makes some interesting statements about the current state of shoulder surgery. These are worthy of reflection and comment. For example:
About Shoulder Arthroplasty:
“Computed tomography scans are rarely necessary.”
“It is not necessary to correct glenoid retroversion when performing most total shoulder arthroplasties.”
“…a standard length smooth-stemmed humeral component can almost always be securely fixed with impaction grafting avoiding the problems associated with stress shielding, ingrowth prosthesis, cement fixation and prosthesis removal…”
“The goal of shoulder arthroplasty is to restore optimal mechanics, not to restore normal anatomy”
“The glenoid component remains the weakest link in shoulder arthroplasty.”
“There is not good evidence that current outcomes achieved with more “modern” approaches to anatomic total shoulder arthroplasty or reverse total shoulder arthroplasty are superior to those achieved a decade or so ago.”
About Shoulder Arthroplasty Infection:
Periprosthetic infection in shoulder arthroplasty presents differently than in the knee or hip arthroplasty.
“In failed shoulder arthroplasty Cutibacterium (formerly Propioni-bacterium) acnes is the organism most commonly recovered at the time of revision of failed shoulder arthroplasty-even in those revisions taking place years after the index procedure. Such infections typically present in “a stealth manner.”
Terre inconnue”: What we still don’t know:
“What determines whether a rotator cuff tear is symptomatic?”
“What evidence supports surgery for the treatment of rotator cuff conditions.?”
Is there evidence for superiority of new arthroplasty designs for shoulder replacement compared with older versions?
“Is there evidence that newer technologies such as computer guidance, patient-specific instrumentation, short stemmed or stemless humeral components, or augmented glenoid components, yield better clinical results in comparison with older approaches for osteoarthritis?”
Are increments in cost and complexity with these new designs and technologies “offset by commensurate increases in results realized by the patient?”
Are results (of reverse shoulder arthroplasty) performed by high volume shoulder surgeons relevant to the larger volume of low volume surgeons performing these replacements?”
Dr. Charles Mayo stated, “Age carries mental scars left by experience which shortens vision, but age carries wisdom.” While I am some years behind Rick, the mileage may be more important than the years, so I think I can offer a few comments about Rick’s statements:
Re Shoulder Arthroplasty:
Do we all currently believe that retroversion does not matter with conventional glenoid component placement? Do we not need CT scans? Biomechanics and clinical studies, such as Walch’s classification of glenoid morphology would argue that these considerations are paramount to a lasting outcome for TSA.
Do we think short stems and stemless implants, or perhaps designs allowing for convertibility to reverse, might offer a clinical and cost advantage for our patient’s requirements at time of future revision surgery?
Can we ever perform a prospective randomized study comparing older technology to newer technology in order to answer the question Rick poses about lack of superiority of new designs? Would this be ethical and relevant?
Mixed media such as Virtual Reality, Augmented Reality and Artificial Intelligence has revolutionized all business sectors including healthcare. Examples are aviation industry, the military, and all manufacturing. Why then would we not imagine that such technology can add value by engineering error avoidance, improving accuracy of surgery, and impacting inventory management and supply chain efficiency in shoulder arthroplasty?
Re Rotator Cuff Problems:
Do we not believe that traumatic rotator cuff tears are better managed with surgical repair? Doesn’t clinical literature generally reflect this? Is muscle trophicity associated with a chronic tear something to be avoided by surgical intervention in such cases?
The purpose of the Codman Shoulder Society is to look for such answers and find evidence as an antidote to nihilism. The intersection of business principles and surgical innovation provides an opportunity for us to increase value for our patients. After all, Codman said “Give me something that is different, for there is a chance of it being better.”
Please consider these words as we work together in coming years to bring clarity to these questions.
JP Warner, MD